No One Can Be Struck by a Car

The emergency department computer won't allow it

The chief complaint was “struck by car.” The patient was shaken, with bruises and scrapes, but essentially fine. This was work-related — she was a delivery person carrying packages across a street — so I felt the need for a formally correct diagnosis. I was also in a rush because, emergency department.

I typed “struck by car” into the discharge diagnosis window.

Nothing.

Right. It’s probably not “car”, probably “automobile”?

I typed “struck by a * ” and got:

Struck by alligator
Struck by alligator, initial encounter
Struck by alligator, sequela
Struck by alligator, subsequent encounter

And down the rabbit hole I went.

“Struck” by an alligator? I could see bit, mauled, savaged, amputated, drowned, frightened — but “struck”? Is this a thrown alligator?

Back in the good old days (I’m talking 2018 or so), an ER doctor would see a person hit by a car and type “hit by car”, or “pedestrian struck” — whatever seemed logical — in for a diagnosis. Importantly, the computer was lazy and would allow this. The baton would then be handed off to the billing goblins over at Gringotts, who would figure out which diagnostic code to assign from the list of International Statistical Classifications of Diseases and Related Health Problems. A formal ICD code would be attached to the chart, and someone would pay the hospital, and eventually the doctor.

Then came … improvements. No longer could a doctor diagnose a patient with a finger fracture. The ICD gods now prefer fracture, 4th proximal phalanx, closed, initial encounter. (Do you really think I know which finger is the 4th? Do you? I mean, I could figure it out … assuming I started counting from the correct side …)

More improvements loom. The World Health Organization says that “ICD-11”, or the 11th rewrite of the list that debuts this year, will be used for everything from documenting folk remedies, to tracking COVID-19 vaccine uptake and antimicrobial resistance patterns. And when the WHO says “ICD-11 will do this”, that really means, “the computer will make me do this.”

Back to my patient who had, whatever the computer thought, indeed been struck by a car. I tried typing just “struck by”. I got just four suggestions covering the entire menu of options from A to B: alligator, baseball, baseball bat, basketball. The options for C and D immediately followed:

Struck by chicken
Struck by cow
Struck by crocodile
Struck by crowd with subsequent fall
Struck by dog
Struck by dolphin
Struck by duck

Actually, of course, I got more than this: For each thing a patient might, per the computer, be struck by, there are the same four options for providing additional detail:

Struck by duck: Nice and simple. I decline to elaborate further.
Struck by duck, initial encounter: If for some reason I’m feeling generous to humorless epidemiologists who might care, I can specify that this is indeed the first time we’re addressing the incident with the duck.
Struck by duck, subsequent encounter: It’s a struck-by-duck bounceback. “Doc, this duck is still jammed headfirst in my ear! You said it’d work its way out over time, but it’s been three days!”
Struck by duck, sequela: “Sequela” is Doctorspeak for “later consequences of.” So maybe the patient now has PTSD: “Doc, every night I see that mallard rocketing towards me, and I wake up screaming!”

Struck by, from A to Z

The list above included, from A to D, every “struck by” option. Alligator to duck, this is the list (per the Epic electronic medical record of 2022) of the only things patients are allowed to get struck by. Struck by dolphin? Welcome to our universe! Struck by door? Never happens.

It gets worse. Brace yourself for the entire “struck by” alphabet, from alligator to … volleyball. (That’s right: There’s no zebra. Is it an oversight? Or systemic discrimination against land-based fauna? Read on to decide.)

E: Sorry, there’s no E. No one is every struck by anything that begins with that letter. (Egg? Elk? Elbow? Elevated train? Nope).

F: Under F, struck by starts out promising with a generic falling object. No doubt ICD-11 will clean that up, that’s way too easy. But the computer also offers multiple falling object sub-categories. It’s almost impossible to move on, mentally or emotionally, from the very first:

Struck by falling object due to accident to nonpowered inflatable craft.

Your patient is on an “inflatable craft.” So a dinghy, or a floatie. It’s nonpowered, so it only moves as fast as she can paddle it, or maybe as fast as she can drive it forward kicking her legs in the water.

Then — there’s an accident! An object falls!

From where does this object fall?

Quit trying to make sense! Don’t look at the grammar either! Onward!

Think of where objects fall, or fall from. You might think of a ladder or a roof, a construction site or a warehouse, overhead shelves or trees or the sky itself. The Epic discharge diagnosis menu recognizes none of those scenarios. Instead, it is obsessed with convoluted, marine-based events. In fact, other than the plausible-sounding (though rare) struck by falling object in cave-in, Epic / ICD-10 offers exclusively water-based “struck by falling object” scenarios. Here they are in their entirety; they all involve an “accident” happening “to” a:

fishing boat
merchant ship
passenger ship
sailboat
water skis
watercraft

Imagine a chicken, on water skis … Nope, we don’t have time for that. Onward! In addition to various falling objects-at-sea, under F one can also be struck by a field hockey puck, a field hockey stick, a football, or furniture. That’s it.

G: golf ball, golf club, or goose. That’s it.

H: hit or thrown ball, or horse. That’s it.

I: ice hockey puck or ice hockey stick. That’s it.

L: Struck by lightning. That’s it. No llama. No lady. No lizard or lizards (see below). No lacrosse ball and no lacrosse stick.

M: Macaw! That’s it.

N: Nonvenomous lizard. Nonvenomous lizards (plural). Nonvenomous snake. That’s it.

PATIENT: See doc, I was caught in a kind of a riot at PetSmart. A disgruntled employee was shouting, and she just started throwing lizards at me and the other customers! And I got struck!
DOCTOR: Hmm, I see. Were you struck by a single lizard, or plural lizards?
PATIENT: Two or three. Maybe two.
DOCTOR: Hmm, I see. And were these venomous lizards, or nonvenomous?
PATIENT: Does it matter? None of them bit me, they just struck me. I was pelted with lizards, you see.
DOCTOR: I understand, but the World Health Organization actually wants to know whether, when you were struck by lizards, they were venomous or nonvenomous.
PATIENT: I believe they were venomous.
DOCTOR: I see. Well. There actually is no option to select “venomous” for a lizard.
PATIENT: Did you try plural, “lizards”?
DOCTOR: I tried both.
PATIENT: How about generic “lizard”, without getting into venomousness status?DOCTOR: Nope.
PATIENT: How about “struck by reptile”?
DOCTOR: Hmm. There’s “struck by other nonvenomous reptile” …

Onward!

O is up next. There is some redundancy with object (no longer falling), and then there is orca.

Struck by orca is an ICD-10 category! I can’t get struck by car, but I can get struck by orca? What the flipper is going on?

After orca there is an entire “struck by other” category.

Struck by other birds comes up first. Note the plural: You can’t be struck by one bird, only many. Unless it’s a chicken, duck, macaw, parrot or turkey (see below).

To round out the struck by other options, in order and in entirety, we have fish, hit or thrown ball, hoof stock, mammals, marine mammals, nonvenomous marine animals — I’m not making this up! — nonvenomous reptiles, psittacines, and sports foot wear.

Let’s bring it home, the last 11 letters of the alphabet, in order and in entirety: Parrot, pig, raccoon, sea lion, shark, sharp object, shoe cleats, skate blade, soccer ball, soft ball, tennis racquet, turkey, turtle and volleyball.

For my part — as I struggle to find a sensible, computer-approved diagnosis for my patient who was struck by a car — I don’t mind because I know this level of diagnostic specificity will generate spectacular research in the future. Think of the things our best research minds will discover: An epidemic of blunt trauma involving sea lions, orcas, and other non-venomous marine animals; evidence that lacrosse is exponentially safer than field hockey; a shocking rise in macaw-based assaults … Trust the science!

(An abbreviated version of this article was published in Emergency Medicine News.)