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.

The Dissection

Written by Tad. Posted in Kooks

In honor of Halloween, I wanted to share a case that came into Charity Hospital when I was resident there. It is one of the most bizarre cases I ever came across and impossible for me to explain.

A woman in her twenties was brought in by ambulance. She was almost comatose because of a combination of drugs and alcohol. She had been found by her roommate naked in bed with “something wrong with her eye.” What we saw was that someone had taken a scalpel and dissected her eye. The lids had both been cut off in a circle around the boney edge of her eye socket. The fatty tissue, eye muscles and everything else around her eyeball had been carefully removed without damaging the eyeball itself. It was clean and the bleeding had been controlled just as it might have been in the operating room. All that was left was her eyeball, still hooked on by the nerve running back into her skull. Her pupil reacted normally, so the assumption was that when she woke up she would have normal vision. However, she would not be able to move her eye or keep it moist by blinking. The specialists said that nothing could be done to save the eye. She would have to have a perfectly good eye removed and some sort of a skin graft placed over the open tissue.

I never heard if they ever found any suspects or more clarification of why or how this happened. Another item to add to your list of reasons to not get smashed on drugs and alcohol.

A Woman from Utah

Written by Tad. Posted in Kooks

A woman from Utah was visiting a friend in New Orleans when they had some sort of a falling out. For reasons unknown to me, this falling out resulted in her being committed to the Crisis Intervention Unit (CIU) at Charity Hospital, where I was spending a month to learn more about psychiatric emergencies. I was told that her three-year-old son was taken into protective custody when she was committed to the psychiatric unit.

As I talked to her, it was impossible to really understand what had happened to her. Nothing she told me made any sense and she contradicted herself as well as the reports I received from the ambulance personnel and nurses. She had Borderline Personality Disorder. “Borderline” doesn’t mean “almost a problem” but means more like “almost completely nuts.” There was no effective treatment for personality disorders so it was not clear to me what the psychiatrists were going to do for her. She was still in the CIU when I finished my shift and went home.

When the patient’s mother in Utah found out the patient had been committed to the psychiatric ward, she called the local leader of her church and asked him to intervene to win her daughter’s release. A friend of mine, Doug, was an ophthalmology resident at Charity Hospital and a member of the same church. He was asked by the local church leader to go see if he could get the patient out of the psych ward. When someone was willing to take responsibility for the patient, the people in the CIU were only too happy to let her go. Doug took her to a mid-range hotel not far from the hospital. He used church funds to pay for a room and gave her additional money for food and incidentals. Once the mother knew the patient was free, she bought a ticket for her daughter to fly back to Utah. The patient was told that someone would come and take her to the airport the next morning.

Later that night, while at a dinner at the church with his family, Doug got a call from the manager of the hotel. He was told the woman had taken the money she was given and had purchased booze with it, which she was using to try to seduce any man who passed by as she swam naked in the hotel swimming pool. The manager told Doug the woman was no longer welcome at the hotel and he needed to come pick her up.

When Doug got to the hotel, the police were there but refused to take the patient into custody because the hotel manager was not interested in pressing charges. The only thing that Doug could think to do was to try to get her back to the CIU. When it was clear that the police were not going to hold her, she told Doug to “F— off” and set out down the street, with clothes on, I believe.

I have no idea what happened after that. It certainly made me appreciate that Doug was willing to do so much to try to help her. It also made me very empathetic for the mother and left me to only imagine what kind of grief this crazy woman had caused her family because of her mental illness. As I have said so many times over the years, “Mental illness is just the worst.”

 

Assaulted in Waiting Room

Written by Tad. Posted in Kooks

A.L. was a 65-year-old man who came in complaining of having been assaulted. This was not any ordinary assault. It took place while sitting in our waiting room. But, wait. Let me start at the beginning.

For the last three years, A.L. had been assaulted many times by “private investigators.” They used a gas to render him unconscious, then inflicted trauma to his legs. Most of the time, the trauma was localized to his calves but, lately, they had moved above the knees. They didn’t actually land blows on him but would grind their palms into his flesh, causing localized pain and swelling. He said they did this to avoid leaving any bruises as evidence. When he woke, he always found new areas of swelling and tenderness, which he could identify by carefully feeling the flesh of his legs.

These assaults happened almost daily and sometimes up to four times per day. They could happen anywhere, including in the parking lot walking into the hospital. Often, he was alone, as when he was working in empty offices at night where he was trying to run his janitorial service. They could also happen when others were around, as in the ED waiting room. He was even assaulted while in bed with his girlfriend. When I asked him how it could be possible that someone could gas and assault him while he was sitting in our crowded waiting room, he said, “They are very sneaky. They have their methods.” The fact that no one else had ever seen this happen did nothing to cause him to doubt it took place.

He provided excruciating details about the techniques used to assault him. He meticulously described how they did all of this without leaving any evidence. He said they had, within the last month, changed to a different type of gas as they were afraid he might be getting immune to the effects of the gas previously used.

Since he was always unconscious when these attacks happened, I asked how he knew who was doing it and why they were doing so. He said he knew because he once “came to” just as they were leaving and he saw the bushes outside move as they rushed away.

When asked why someone would be doing this to him, he was evasive. It was clear he believed someone felt wronged by him and that these attacks were retribution for that wrong. He refused to elaborate on what that wrong might have been or who was having the private investigators assault him.

He said he had been to the police many times and they refused to take him seriously, which upset him. He also admitted he had been to our emergency department many times for the same thing and, again, had not felt supported in his struggles.

After talking to him for about twenty minutes, fascinated by the details and long course of his delusions, I asked him what he thought I could do for him in the emergency department. I had to ask this question several times before I got a specific answer because, rather than answer the question, he would just go back and repeat details of the assaults.

Finally, he said he wanted me to put casts on his legs so “they” couldn’t inflict any more injuries. He wanted help getting a single medical care provider who could see him each time he presented so that person could document, over time, the various injuries he suffered at the hands of his assailants.

He seemed to understand when I told him I would not be able to cast him. However, I could respond to his second requests by referring him to get a primary care provider.

Up until this time, our conversation was very calm and agreeable. That all changed when I finally told him he had paranoid delusions. That really set him off. He started to holler and swear at me, saying he was not delusional. He had evidence of everything he was telling me if someone would take him seriously and not just blow him off as everyone, up to that point, had done.

I finally had to pull out the line I use at times like this. “You know these things are true and I can’t convince you otherwise. But I also know they are not true and you can’t convince me they are. So, we will just have to leave it at that and it’s time for you to go.”

I told him his discharge papers would include directions for contacting a mental health provider and I encouraged him to do that. He left very unhappy. I had no hope he would follow my recommendation.

A few weeks later, I saw this same gentleman, again. He came in with exactly the same story and, of course, had made no effort to get any mental health assistance. I felt so sorry for him but there was, literally, nothing I could do to help him. Even listening to him didn’t help when he saw that he was not believed.

Check out this article to better understand fixed delusions. This describes my patient very well.

https://en.wikipedia.org/wiki/Delusional_disorder

 

Big Bloody Guy

Written by Tad. Posted in Kooks

The other night, a woman rushed in asking for help getting her injured boyfriend out of the car. She said he had been drinking with friends when they called to say he had been stabbed and needed her help. When she got there, he was covered with blood, nearly unconscious and unable to stand. The friends helped her load him into her car and she rushed him to the hospital.

A nurse and a tech went with the woman to her car. There, they found a man slumped in the front seat. He had dried blood all over his face and soaked into his clothes. He moaned as they moved him into a wheelchair and pushed him into the emergency department.

When I entered the trauma room, I saw a tall, big-boned, muscular man covered in blood. His head was thrown back in the wheelchair and he was moaning. Though conscious, he did not respond to staff’s questions or instructions. His size and passive posture led to a quick conversation about how to best get him out of the wheelchair and onto the gurney. I bent over and, talking closely into his ear, firmly encouraged him to help us get him onto the bed. That was enough to get him to stand and move over to the gurney, where he fell back, moaning, his eyes closed the whole time.

I then stepped back against the wall at the foot of the bed while the nurses and techs got him undressed, placed him on a cardiac monitor, recorded some vital signs and started IVs.

Just then, the trauma surgeon walked in and asked me what was going on. I told her he had been stabbed, he seemed to be very drunk and we were in the process of evaluating him for possible serious injuries.

Suddenly, the man, who had hardly been able to hold his head up, leapt from the gurney, hollering loudly. He pulled the IVs out of his arms, yanked the monitor leads from his chest and tore off his gown. Throwing everything on the floor, he stood, naked, in the middle of the room, blood running down his muscular arms from where he had pulled out the IVs. Everyone was amazed at his miraculous transformation. He had suddenly gone from being a nearly unconscious rag doll to an erect, angry man who was hollering, swearing and waving his arms threateningly. Staff immediately stepped back away from him and pressed against the walls of the room, wondering what might happen next.

At first, his profanity-laden tirade was directed at no one in particular. Soon, he focused on me. Though his eyes had been closed and he had been acting incoherently, it became obvious he heard what I told the trauma surgeon and was very upset that I assumed him to be drunk.

He walked forward and got right up in front of me. Waving his arms wildly and pointing at his bloodied face, he screamed at me for saying he was drunk and not paying any attention to his stab wound.

I can’t say I was not afraid but I just stood, statue-still. I stared him straight in the eyes and did everything I could to not respond to him at all. Not getting a reaction from me, he turned and walked around the room, hollering at others who stood, lined against the walls. He picked out a nurse in the farthest corner, called her a “bitch” and gestured threateningly at her.

Recovering their wits somewhat, some of the staff tried to calmly talk him down. He paid no attention to them. He continued to pace the room, completely naked, with dried blood all over his face and fresh blood dripping down his arms. At times his ranting seemed incoherent. Then, he would say something like, “Look at me! Standing here buck-naked in fronta y’all. What the
f—?” All the time this was going on, his poor girlfriend was sobbing in the hallway outside the trauma room.

Eventually, he seemed to tire of it all and started looking for his clothes. Several of us encouraged him to let us evaluate him to make sure he was not seriously injured. This, he refused, demanding to be given his bloody clothes so he could leave.

This presented a difficult ethical question. When he came in, it seemed he was impaired. A person in that condition could not wisely refuse medical care. If he had tried to leave, it would have been appropriate to restrain him until we were sure he was either okay or competent to assume the risks of leaving against medical advice.

Now, I had a very different patient. He was alert, talking clearly in full sentences, and able to pick me out as the one who insinuated he was intoxicated. What was my responsibility? Did we need to tackle and restrain him to protect him from making a bad decision and leaving? Should staff be put at risk in order to make sure he didn’t leave until it was clear he was alright?

By then, security officers had arrived, waiting for my instructions on to how to deal with this man. I had to decide. He was big, strong, upset and covered with blood. I knew it would be a nightmare to try to take him down. Rather than put staff at higher risk, I told everyone to let him leave if he wanted to. It took him quite a while to get dressed as he kept getting distracted and continued hollering at people. Eventually, however, he walked out.

The next day, I got the following email from one of our physician assistants, referring to this same patient:

Hello Dr. Tad,

A patient presented to the ED today to apologize for his behavior during his most recent ER visit. He was very sincere, and wanted to apologize for his horrific behavior. He is very sorry and appalled at himself, stated he is not normally like that, and continued to profusely apologize, asking to please have me pass on how remorseful he was.

Sincerely,
C.M. PA-C

 

 

 

 

Too Many Pushups

Written by Tad. Posted in Kooks

A 15-year-old boy got in trouble at football practice. As punishment, his coach sentenced him to do 150 pushups over the weekend. His mother was assigned to monitor him and make sure he was compliant.

On Monday, he was unable to move his arms, which were in severe pain, and he noted that his urine was darker than normal. All of this concerned his mother, who brought him to the emergency department. This story of over-exercising, followed by excessive muscle pain and dark urine was worrisome to me. Quick blood and urine tests confirmed my suspicion. He had rhabdomyolysis.*

The excessive use of the muscles of his arms and shoulders caused enough muscle damage that a protein, myoglobin, was released from the muscles in such large amounts that it turned his urine dark. If not treated, that same protein could be toxic to the kidneys. This patient had to be admitted to the hospital to get pain medicine and IV fluids until his muscles healed and the myoglobin was cleared from his blood and urine.

Over-exercising is one of the more common causes of this condition. As far as I know, I have never seen it just from over-use of the upper extremities. Since your legs have so much more muscle mass than your arms, it is a lot more likely for this to develop after over-use of the legs. For example, we often see prisoners who do squats over and over until they develop rhabdomyolysis. They come in from jail with leg pain and dark urine and have to get admitted to the hospital.

I wonder if my patient’s coach will assign 150 pushups as behavior modification again.

 

*I posted a case previously about rhabdomyolysis. Please see Dancing with the Stars in a previous post.

Also, for more information, check out this Wikipedia article: https://en.wikipedia.org/wiki/Rhabdomyolysis

 

Mr P., Again, Again

Written by Tad. Posted in Kooks

I am so sorry. Looks like this was still not working for some people. Here it is again. I am confident it will work this time. Thanks for your patience.

One the doctors I work with forwarded this article to me. It was written by Otis Warren, an emergency physician. It paints a great picture of a specific patient but also of the bigger social problems associated with public alcoholism.

Enjoy!

http://content.healthaffairs.org/content/35/11/2138.full

 

Copyright © 2014 Bad Tad, MD