WrestleMania

Written by Tad. Posted in Kooks

A thirty-five-year-old man with a history of drug and alcohol abuse as well as mental illness, eloped from a long-term residential rehab facility in Georgia. He flew to our fair, California city to watch WrestleMania. I don’t know if he enjoyed the show or not but while here, he relapsed and fell into drinking excessively and taking methamphetamines.

This landed him in our emergency department, from which he was sent to psychiatry. There, he was evaluated and discharged. The psychiatrist said he could not be held against his will because he was not a danger to himself, a danger to others or gravely disabled. She noted he was sorry for what he had done. He promised to go to the airport, fly back to Georgia, return to his rehab and resume care with his psychiatrist.

If he really did make that promise to the psychiatrist, he didn’t follow through. In the subsequent week, he was kicked out of three different hotels because of problems caused by his excessive drug and alcohol abuse.

He was readmitted to our emergency department during my shift. In addition to being addled from methamphetamines, he also had severe conjunctivitis or eye infection. Both of his eyes were so swollen, red and yucky with dried discharge he was unable to open them. Usually, conjunctivitis is an annoyance. This man’s eye infection was particularly bad because his methamphetamine use caused him to dig and pick at his eyes constantly. He was aware enough to feel the irritation in his eyes but not aware enough to stop digging at them.

When we met, he was sleeping on a gurney in the hallway. I prodded him and called his name. He moaned and shifted a bit but was unable to talk. He was also unable to open his eyes because they were, literally, glued together with crusty yellow discharge. I had to pinch his upper and lower eyelids and pull them apart in order to see his red, swollen eyes underneath.

My plan was to observe him until his drugs wore off and then discharge him with antibiotics.

Over the next several hours, his mental status gradually improved and he was finally able to converse. He told me about coming to California because he loved WrestleMania. He admitted he had been drinking and doing drugs and, though he said he was sorry, he also admitted he had no plans to change any of his present behaviors when he left the emergency department. He also had no plans to return to Georgia any time soon. He denied having suicidal ideas, though he acknowledged that what he was doing was bad for his health. Though he was better, he was still not able to open his eyes or walk.

During this time, his mother called from Georgia. She demanded to talk with every staff person who would talk to her. Finally, it was my turn.

The mother made several demands. First, she wanted her son admitted to our hospital. To that, I explained he didn’t have any medical condition that would justify a medical admission. No one would admit him just because he was doing stupid things that were not good for him. As soon as he could walk, he would be ready for discharge.

She then demanded he be sent to psychiatry. She knew about his previous admission to that unit in our hospital. She told me the psychiatrist who discharged him said if he didn’t follow through on his promise to fly back to Georgia it would be proof he was a danger to himself and he would need to be committed.

I told her taking someone’s rights away is not something to be done lightly. We don’t do that just because someone is making very bad decisions, as in the case of her son. He would not be going back psychiatry.

She next insisted we call the police, have them take him to the airport and force him to get on the airplane home. I was amazed when I couldn’t get her to see there was no way the police would do that.

The mother consistently refused to accept any of my responses to her demands. She kept saying things like, “You just don’t understand. His life is in danger if you don’t do this.”

Things with the mother went from bad to worse when her son refused to get on the phone with her. “I don’t want to talk to her,” he said.

“Tell him I won’t scold him,” she assured me. That was not enough to get him on the phone with her.

I was unable to discharge the man before my shift came to an end. Though he had been in the emergency department for fifteen hours, he was unable to walk unassisted to the bathroom and he still could not keep his eyes open. I had to admit him.

After a day in the hospital, he was well enough to leave. The admitting doctor spoke to the patient’s mother on the telephone before discharging him. During that conversation, the mother threatened to sue the doctor and the hospital if they released her son. In part because of that threat, the doctor agreed to keep the patient one more day until the mother could fly out from Georgia to get him, which is exactly what happened. He was sent home the next day with his mother.

She Won’t Go Home

Written by Tad. Posted in Kooks

As I come up with stories to share with you, I often pick them to exemplify different challenges we face as emergency physicians. Here is an example of something we face not too infrequently: a patient we couldn’t get rid of.

The evening shift doctor had seen her initially when she complained of vaginal bleeding and anemia. He found she was not bleeding and her blood tests showed no anemia. She was discharged just as we were changing shifts. I was warned that she didn’t want to leave and might give me trouble.

Sure enough, about an hour after I took over, the nurse came to me and told me the patient was still nauseous and was not up to leaving. I ordered some nausea medicine.

An hour later, I asked the nurse why the patient had not left the department. I was told she was unable to get a hold of anyone to give her a ride home. I asked that she be put out in the waiting room to await a ride. This is standard procedure when we are busy. The bed is needed for another patient and there is nothing wrong with someone waiting for their ride in the waiting room.

About three hours after I came on duty, she was finally out in the waiting room. But not for long. I soon was advised that she had feigned passing out and had to be brought back into an examination room. When I saw her, she was clearly pretending to be unconscious. I was too busy to deal with her at that time. I left her with the nurses to recheck her vital signs while I hurried off to take care of other, more pressing patient concerns.

Soon, I was able to spend some time reviewing her situation so I could decide what to do next. She was a relatively young, healthy lady. Her vital signs and laboratory tests were normal. She had already been in the ED for almost seventeen hours and nothing wrong had been found. She needed to leave. Still, always haunting the back portions of an emergency physician’s mind is the question: What might I be missing?

At this point, I had only two choices: force her to leave or admit her to the hospital. I mentally ran through both of those options in my head. We admit people to the hospital to receive medical care not available as an outpatient. This patient was in no need of such care. I couldn’t ask the admitting doctor to see her if it was clear there was nothing wrong with her. I had no choice but to accept a certain liability and send her out, even if she didn’t want to leave.

First, I had to wake her up. I was sure she was faking her unconsciousness. I proved this with an ammonia capsule. This is the modern equivalent of smelling salts.* A concentrated liquid ammonia compound is held in a small, thin-walled glass vial surrounded by an absorbent material. The vial is broken by being compressed between two fingers, releasing a strong ammonia smell. It is placed under the nose of the “unconscious” patient. No conscious person could continue to pretend to be unconscious when one of these is placed under his/her nose.

As I expected, her first reaction to the ammonia was to hold her breath. Tears then started forming in her eyes. When she was not able to hold her breath any longer, she turned her head to get her nose away from the capsule. I followed her, keeping the annoying, irritating stimulant under her nose until she was forced to talk to me.

“Why don’t you want to go home?” I asked.

“I don’t feel good,” was all she could come up with.

“I am sorry, but you are going to have to leave. Do you have anything you want to ask me?” She had no reply so I instructed the nurse to discharge her.

She had occupied a bed in our emergency department for almost eighteen hours by the time she walked out. How sad that someone’s life would be so messed up that lying around an emergency department pretending to be ill was better than anything else she had going on.

*https://en.wikipedia.org/wiki/Smelling_salts

Proptosis in a Baby

Written by Tad. Posted in Kooks

After 27 years of working in a big, urban hospital, I switched to a small, community hospital. The biggest adjustment for me is the difference in access to resources. In the big city, we had access to all the equipment and specialists that might be needed. We rarely had to transfer patients out to other facilities for additional care. Now, I do not have all those supports and it can be stressful.

For example, a young Hispanic couple brought their 1-year-old daughter to our small, community hospital at three o’clock on a Sunday morning. They were concerned about bruising and swelling around her right eye. She had been born with a clouding of the cornea – the clear part on the front of the eye. However, the parents had been told their daughter’s eye was otherwise normal.

The parents said the bruising and swelling started the day before and had gotten worse. She had not been injured and appeared to be in no distress. The father even pointed out that it didn’t seem to hurt her when he pressed on it. She was behaving completely normally.

Looking at her eye, I could see that the cornea was, indeed, cloudy. The conjunctiva, the white part, was also a bit red. There seemed to be no pain or tenderness although there was bruising, as the parents had noticed. Bruising and swelling often indicate trauma. However, I did not detect swelling and there was no reason to suspect child abuse based on the way the parents and big sister behaved.

All that aside, there was clearly something wrong. She had proptosis. Her right eye was bulging out farther than the left one. Neither did it seem to move normally, though that was a bit hard to test in a one-year-old.

Acute proptosis may be caused by infection. If you get infection around your eyeball, the swelling causes the eye to push forward abnormally. In this situation there was no history of fever or other signs of infection. And, again, the kid was acting perfectly fine. It seemed impossible she had an infection severe enough to cause proptosis and still feel well enough to play normally with her sister.

My dilemma was: “Does this kid have something acute going on that needs me to transfer her to another hospital for care tonight? Or, is this something that can wait until Monday morning when she can see her primary care doctor and be referred to a specialist?”

I decided the only way to know was to scan her. This presented another challenge. A CAT scan would probably give me the information I needed, but we try to avoid CAT scans in kids because of the ionizing radiation it exposes them to. The earlier in life you get radiation, the more likely it will end up causing cancer many years down the road. An MRI scan would be a safer test since it would not cause exposure to radiation, but there was no MRI in our small hospital at night or on weekends. In order to get that test, I would need to transfer her to a bigger hospital where they had MRI available. However, the whole purpose of getting the scan in the first place was to help me decide if she needed to be transferred!

I finally decided it was important enough to justify getting the CAT scan done at our hospital. It showed a mass behind the eye that the radiologist said could be either a hemangioma or a sarcoma. A hemangioma is an abnormal and benign wad of blood vessels that you are born with. A sarcoma is a tumor that is usually malignant. Either of of the two would cause the baby’s eye to be pressed forward.

My impression was that if the baby was born with a hemangioma, the doctors would probably have picked up on it when they evaluated her cornea. I think the mass was a tumor that had been developing slowly. As it gradually pushed the eye forward, a little vein ruptured causing the non-tender bruising the parents noticed.

Though the situation was serious, there was no reason to transfer her to a higher level of care in the middle of the night.

The poor parents. Though I did my best to explain the situation, I don’t think they really understood what they were up against. They took off to put the baby back to bed.

Stabbed in the Back

Written by Tad. Posted in Kooks

A young man and woman were having an argument.She pulled out a switchblade knife with intentions of using it on him. He wisely turned and started to run away. Just like in the movies, she snapped the blade open and threw it at him. It struck him squarely, burying the three-inch blade deep into his back. He collapsed to the ground, moaning in pain. Someone at the scene tried to pull the knife out but, being unable to do so, called 911.

Our evaluation, including x-rays and scans, failed to demonstrate any evidence of serious injury. He was taken to the operating room where the knife was removed by a spine surgeon.

The blade could have stabbed his lung, spinal cord, esophagus, windpipe or a large blood vessel like his aorta. But, it happened to hit him in just the right place so that only skin and muscle were cut and the point of the knife was buried in the bone. All of these tissues would heal nicely. I’m sure the same could not be said about his relationship with the girlfriend.

 

The Deadest Person

Written by Tad. Posted in Kooks

The Deadest Person

It was the end of my shift and I was just leaving Slidell Memorial Hospital in Louisiana when I was called back. The paramedics had just alerted the Emergency Department that they were on the way with a severely injured trauma victim and my help was needed.

The patient was about thirty-years-old and was not wearing a helmet when he crashed his motorcycle into a car at high speed. He was thrown under another car, which ran over him. A voluntary ambulance crew picked him up and rushed him to our emergency department, performing CPR.

Since the patient was not breathing, I was assigned to intubate him by placing a tube into his windpipe so we could ventilate his lungs with oxygen. As other members of the team quickly performed their assigned duties, I easily passed the tube, secured it in place and then started to blow oxygen down the tube. What happened then caused everyone to stop what they were doing. With each push of oxygen down the tube, he started to puff up. His neck expanded and air bubbled out of a cut near his eye. His abdomen started to expand, then his scrotum. Each time I pumped in air, his scrotum puffed up a bit more until it was the size of a grapefruit. When I pinched the enlarging scrotum, air was forced out of a large cut over his hip. He was pronounced dead.

An autopsy done the next day showed multiple fractures of his extremities and spine. In addition, he had at least four things that would have killed him: His head was completely dislocated from his upper spine. His left lung was completely ripped off with extensive damage to all the other organs in his chest. There was a huge hole in his diaphragm, which separates the chest cavity from the abdomen. His liver was completely demolished. His pelvis was severely crushed. All of this explained why he had puffed up as we blew oxygen into his wind pipe. The oxygen went down the windpipe and into his chest cavity. It then passed through the hole in his diaphragm into his abdomen. The crushed pelvis allowed the air to continue down into the scrotum and out the hole over his hip.

This was the deadest person I have ever taken care of.

 

The Insanity of My Addiction

Written by Tad. Posted in Kooks

The Insanity of My Addiction

Paramedics were called to a house where a twenty-six-year-old man was having a severe allergic reaction after injecting methamphetamines. He told the medics he didn’t think it mattered what he mixed the meth in before injecting it. So, since he had some handy, he had used grape juice. Soon after injecting the juice-meth mixture, he started to feel terrible and called 911.

The medics found him in severe distress with fast heart, low blood pressure, swollen face and diffusely red skin. They correctly diagnosed a severe allergic reaction resulting in anaphylaxis and appropriately treated him for the same. By the time he got to the emergency department, he was feeling a lot better.

When I talked with him, he confirmed he had injected meth mixed with grape juice and he didn’t seem to think there was anything strange about having done so. He said he had done the same in the past, and he was sure the problem that day was caused by dirt in the cup he used to make up the mixture.

When I asked how often he used meth, he answered, “How often do I not use meth?” I asked him if he wanted to be smart with me or if he wanted to give me serious answers so I could take good care of him. He said he was not being smart. He used all the meth he could get ahold of.

Since a severe allergic reaction like this can be life-threatening, we watched him for several hours. None of his worrisome symptoms came back, so I went to talk to him before he was discharged. I pointed out that most people would not think it was a good idea to inject grape juice into their veins. He reiterated that he thought it was contamination that caused his problem. I pressed him, again, that it was unwise to inject things not designed for that purpose. He thought for a moment and then agreed, saying, “That’s just the insanity of my addiction.”

Fireballs of the Eucharist

Written by Tad. Posted in Kooks

Fireballs of the Eucharist

Early in my emergency medicine training, a woman came in screaming because of severe abdominal pain. She told the nurse she suffered similar pains in the past because of “fireballs of the Eucharist,” which we interpreted as fibroids in her uterus. She said she had not had a period for three months but was sure she was not pregnant as her periods were always irregular. She was so upset by her pain that we had a hard time getting more information from her. From the way she looked, I thought she was dying from a ruptured ectopic (tubal) pregnancy or something terrible.

She said she needed to move her bowels but was unable to do so after the nurse helped her onto a bedpan. By then, we had an IV in but she was not responding to pain medicine. In fact, she seemed to be getting worse. She screamed, “Somethings coming out down there!” I slipped on gloves and slid my fingers in her vagina. What I felt puzzled me so much that I was startled and pulled my hand back. “What?” I asked myself. I put my fingers back in to reevaluate. Now I was sure. A head!

I hollered for help and, just as I had the baby delivered, the pediatrician and obstetrician arrived to take over care of the mother and the baby. The baby was probably about two months premature. However, it was pink and crying, which is very good news for a newborn. I told the lady that she had a baby and she cried, “Oh, no! I don’t want a baby!”

At the time, my wife was at about the same stage of pregnancy with a baby that we very much wanted. That made me all the sadder for the lady and the baby.

 

A Wild Night in the Accident Room

Written by Tad. Posted in Kooks

A Wild Night in the Accident Room

I did my emergency medicine residency training at Charity Hospital in New Orleans. It was a big, inner-city teaching hospital that was always very busy with lots of sick people to take care of. Most of the surgical and traumatic problems were taken care of in the part of the emergency department known as the Accident Room.

One night, while I was on duty in the Accident Room, gunshots blasted out followed by screaming. People scattered in all directions. Others froze, too afraid to go anywhere. Soon, there was a swarm of police pressing in with guns drawn. I was kind of freaked out but also very curious about what was going on.

As it turned out, a prisoner who was there for medical care had asked his guard to let him go to the bathroom. When one of his hands was free, he jumped the guard, got his gun, pistol whipped him, fired off two shots and ran away with the gun. One of the bullets wounded an innocent bystander who had only come into the hospital to poop.

After things settled down, I took care of the injured cop who felt really bad about having let the guy get away. I also took care of three people who were trampled in the stampede that followed the gunshots. It took several hours before people were not afraid to leave the hospital as they thought the escapee might still be outside somewhere. That was a wild night.

 

Fifty-Three Things Wrong

Written by Tad. Posted in Kooks

Frequently people with complicated past medical histories come into the emergency department for care. If they have an organized list of their problems, it is really helpful. We want to keep their past history in mind as we evaluate the new problem that brought them to the emergency department today.

At other times, people are hypochondriacs or just weirdos and their list is really not helpful. It can be fascinating reading, however. Here is one such list. I reproduced it as exactly as I could.

 

Currenty told I have the following wrong

  1. Prostate Cancer
  2. Broken back and I spent 2 days in VA hospital and told nothing they could do due to many breaks
  3. Diabetes type 1 was on 12 units of insulin and now at 25 units. Started type 2 in 2003 and became type 1 in 2009. one injection in am and one in pm.
  4. Degenerative disc disease
  5. Peripheral neuropathy
  6. nerve neuropathy
  7. Osteoporosis vertebroplasty
  8. Both eyes operated on for cataracks
  9. Fatigue
  10. Feet go numb and once turned blue due diabetes.
  11. Multiple age indeterminate compression deformities diagnostic code abnormality
  12. Several calcification within pelvis which likely represent phleboliths.
  13. Ureteral calculi cannot be excluded sub acute end plate deformity at L1, L2, L4, L5 with associated enhancement
  14. Enlargement of prostalic.
  15. L3 and L4 bilateral neroforaminal stenosis.
  16. Degenerative changes causing central canal and bilater neuroforamind stenosis at L4 and L5
  17. post operative changes of left laminotomy at L5 and Sl.ss
  18. Mild compression deformities at L5, L2, LI.
  19. cant walk too for before getting tired
  20. Right hand drops things. Left does it too but not as much as the right
  21. Very bad time going to sleep and sometimes have nightmares and wake up sweating around the neck.
  22. Side effects of meds I took caused me to loose my wife and son. Now separated.
  23. Anger sometimes very bad when I take the meds.
  24. Urinate a lot due diabeties and have to wear depends. Have to eat 5 to 6 meals a day due hunger pangs and get weak if I don’t eat to point I feel like I may faint.
  25. Diabetes started 5/13/03 type 2 and 2009 turned to type 1.
  26. Wife MS started 4/20/09 and had to spend a week in hospital
  27. ED since I got diabetes.
  28. new meds don’t work.
  29. Use cane to walk straight.
  30. Handwriting iffy to bad at times.
  31. Spondylolysis
  32. compression at SI nerve root
  33. Somatoform disorders
  34. Lumbar spasms
  35. peroneal neuropathy
  36. Partial thromboplastin
  37. Spurs at C4, C5, C6
  38. disk ogenic end plate marrow signal changes at C5, C6and alio for a minal narrowing
  39. always feel tired and fatigued
  40. Incurable lymphedema
  41. Cellulitis
  42. PTSD
  43. Congenitial interbody fusion
  44. Bright flair signal in left frontal sub cortical whit matter in brain.
  45. Bulging at L4, L5 level of the ventral surface of the thecal sac.
  46. lumbosacrale spine
  47. 3 nodules in lungs
  48. Diffuse asteopenia.
  49. When I lose sleep for two or more days I become very weak and may take another day or two to get better. One week I got 7 hours of sleep for the whole week. Almost dropped dead from that series of lost sleep.
  50. Hit many times with hyperglycemia and hypoglycemia. Last 3 yrs none occurred.
  51. blood glucose once hit over 500 now average 90 to 200 no matter what I do Meds make the numbers all over the place.
  52. once slept for 24 hours another day 23 hours felt very weak and out of it.
  53. PTSD

Three Penises

Written by Tad. Posted in Kooks

The other morning, I had to take care of three penises before lunch. That was an unusual concentration of penis problems so I decided to share them with you.

The first was a thirty-year-old man with a “drip” or discharge from his penis. Of the three penis complaints, his was the most common for us to deal with in the emergency department and, as a result, the easiest. For about a day he had been having a thick, green discharge from the end of his penis with some burning when he urinated. He admitted to having unprotected intercourse with someone he was sure had passed this little present on to him. This sort of discharge is usually caused by gonorrhea so I treated him for that as well as chlamydia, because they so often travel around together. He was advised to notify all of his sexual contacts and a report was sent to public health.

Penis number two was a twenty-year-old who came in saying he caught the end of his penis in his zipper. This had caused a little cut that would not stop bleeding. Sure enough, he had a little cut and it was still oozing but it was clear he was lying about how he got it. An uncircumcised man who catches the end of his penis in his zipper will almost always catch the end of the foreskin. Most of the time, this just causes a painful pinch but it can cause a small laceration. The end of the foreskin can also get caught in the zipper so deeply that the patient is unable to get it out. I have seen more than one man come in with the zipper, cut free from the old pants, caught on the end of his penis and tucked down into the pants he was then wearing. We have little tricks to get the foreskin out of the zipper without doing any more damage and such a patient is always quite appreciative once he is extricated.

It was immediately clear that this man had not caught his penis in his zipper at all. His laceration was in the frenulum of his penis. This is a thin connection between the bottom of the glans (head) and shaft. It is down underneath the foreskin and very protected from any errant zipper. The frenulum is frequently damaged from too exuberant sex, which is most certainly what happened to this man, though he persistently denied it.

There are several tricks for getting a pesky little cut like this to stop bleeding. Most will stop with just some good pressure. When this doesn’t work, the next thing I try is a little injection of local anesthesia with epinephrine (adrenaline.) This causes constriction of the blood vessels, which helps stop the bleeding. If that doesn’t work, I put one or two little stitches into the cut. That always fixes the problem. This guy didn’t need the stitches and went off happy that his penis was no longer bleeding. Makes me wonder if he thought we still believed his zipper story or not.

Penis number three is saved for the last because his was the most unusual and difficult to care for of the three. He was a seventy-year-old who was unable to pee. His doctor recently told him he was passing a kidney stone. In the past, he had a kidney stone stuck in the end of his penis and he had to go to the emergency department to have it pulled out. He said he could now feel a stone half way down the shaft of his penis and that that was probably the reason he couldn’t pass urine.

Evaluating his penis was difficult because he had a small penis and was quite obese. The shaft of his penis was almost covered by the fat of his mons pubis (hair-covered skin above the penis.)

The most straight-forward way to fix a penis plugged by a stone is to pass a Foley catheter through the penis and into the bladder. The catheter pushes the stone back into the bladder so the patient can pee. Then, the patient can then follow up with his urologist to have the stone removed.

A while after I asked the nurse to pass the catheter, she came back saying she was unable to do so. The patient had phimosis, which is a scarring of the foreskin so it cannot be retracted off the glans. With a combination of the patient’s obesity, small penis and phimosis, there was no way the nurse could get to the opening of the urethra to pass the catheter into it.

This kind of situation is a urological emergency. The patient is unable to void and he needs to empty his bladder. However, because I was working in a small-town emergency department with no urologist on call, I had to do something. One option I had was to poke a needle through the patient’s lower abdominal wall and pass a catheter straight into his bladder from there. The other option I had was to do a dorsal slit of the patient’s foreskin. This was more aggressive effort to gain access to the opening into the urethra, and it was the approach I decided to take.

First, I used a local anesthetic to numb up his entire penis. I then cut back through the foreskin, trying to expose the glans and find the opening to the urethra.  This ended up being much more difficult than I expected it to be. It had been so long since his glans had seen the light of day that the foreskin was scarred down completely to the underlying glans. I had to insert a forceps a little way, make a small slit in the foreskin, then repeat, all the time controlling the bleeding and making sure not to cut anything but the foreskin. Eventually, I was able to identify the urethra and, with quite a bit of difficulty, get a little catheter passed up into the patient’s bladder. His relief was immediate.

By this time, I was convinced that his scarred down foreskin was the real cause of his inability to void. However, to be sure, I sent him for an ultrasound of his penis and bladder. No stone was detected which confirmed my diagnosis.

The patient went home with the catheter in place and a referral to a urologist. He will need to have a circumcision to fix his problem for good.

Copyright © 2014 Bad Tad, MD