I’m sure everyone would agree – handovers are perhaps the most risky parts of ED medicine.

In our hospital we have a policy that all patient handovers apart from overnight ones are made to the duty consultant – lucky me!

Yesterday I was given a very interesting patient as a handover – a previously well lady in her 30’s with acute arm ischaemia but fortunately the vascular surgeon was on his way and would review her within 1-2 hours of the handover and didn’t want any further Ix just heparin Rx.

I thought I had better personally check on this lady, who I noted was in sinus rhythm and asked a few questions of which the only real significant points obtained was that a week ago she was in the garden shed and suddenly got pain in her 5th toe which went red and had localised paraesthesia develop within a few hours, and these symptoms had persisted. Indeed her toe was a bit bruised looking.

Could that have been a red back spider or snake envenomation? But no… there is no way that could fit in with an ischaemic limb and her clotting factors including fibrinogen were normal.

Let’s have a look at the arm then…

despite 20mg iv morphine over the past 1hr, she screamed when I attempted to palpate her radial artery of her mottled hand…

time to cut my losses… vascular surgeon coming anyway …. seems consistent with subclavian artery thrombosis – given a PH neck pains – guess she might have a cervical rib or other thoracic outflow obstructing mechanism.

time to go and see all the other patients and attend to the multitude in the waiting room who had already waited 4-6hrs – and assist with that LAMP on the lovely old lady who had broken her wrist.

Vascular surgeon turns up and pleasantly enough points out – its NOT subclavian artery thrombosis – she has emboli to most of her limbs – didn’t you get the history of intermittent claudication? didn’t you check all her pulses?

AAAARRRGGHH! I HATE HANDOVERS, ESPECIALLY WHEN YOU ARE BUSY!

At least no harm was done and she was managed appropriately in the ED and referred in a timely manner – what else could one ask for?

Still seems pretty weird though that a health lady should start flicking off emboli all over the place – at least it explained the sore toe!