The woman was middle aged. Her presenting complaint was “Eye Problem.” She was ill-kept, making me think she might be homeless. She said she had been having “parasites” coming out of her eyes for a long time. At first, they were right inside her eyes and now, they were in the eyelids. Sometimes they were black and other times they were white, shaped like a string, probably when they were laying eggs. She had seen many doctors before but no one had ever been able to help her. It was unclear why she had decided to try again that night.

I talked to her for quite a while, looked at her eyes and skin, and then gave my honest impression. Her complaints didn’t fit any sort of parasite infection I was familiar with and I was not going to be able to help her. I told her it was probably all in her head, though I could be wrong and maybe some day somebody would discover with what she was infested.

I shared with her information on finding a doctor in a clinic, reassured her and sent her on her way.

The very next patient I went to see was listed as “Rash.” In the room was a man who was about the same age and apparent social status as the lady with the eye parasites though I made no connection between the two. He launched into a prolonged story about being infested with mites. He told me how they migrated around his body, showing up in different places at different times and looking different as they moved around and came out of his skin.

When I had heard enough and looked at his “rash,” I started into my “you may have something but it is probably all in your head” explanation when I was interrupted by someone in the hallway outside the room.

“He don’t believe us! He ain’t gonna do nothin’ for us!” It was the lady! They were living together on the streets and had developed a shared delusion about being infected with parasites.

I went over things with them, again, and they left, complaining that nobody ever believed them.

Here is a link to our old friend, Wikipedia, to explain that this sort of shared delusion is a well-described condition: http://en.wikipedia.org/wiki/Folie_à_deux

This reference has a couple of case studies that provide insight into how this can present itself: http://www.minddisorders.com/Py-Z/Shared-psychotic-disorder.html#b

A twenty-nine-year-old woman came to the emergency department complaining of numbness and inability to move her legs when she woke from a nap earlier in the day. She had pain in her neck and back, and was unable to feel anything from her waist down. She also had numbness of her hands.

She had been in a car crash four days earlier. After the crash, she was seen and evaluated at another hospital. She had no numbness or weakness at that time.

Though this story made no sense to me, I was still worried and launched into an aggressive evaluation that included x-rays and consultations with a neurologist and a neurosurgeon. Every thing came back normal.

I gave her a shot for pain and soon she was completely normal. She walked out of the emergency department in no distress.

The second crash victim was a forty-seven-year-old man who complained of having chest pain for years. He blamed the symptoms on a car crash he had ten years previously. He had been seen in the emergency department many times for the same problem. He had also been seen many times by his primary care physician, a gastroenterologist, a pulmonologist and an orthopedist. He had x-rays, CT scans and MRIs, none of which showed any pathology. He had seen many different doctors for this same problem and was sick of it. He came to the emergency department that night for us to get to the bottom of his problem. He didn’t want any pain medication. He wanted to be diagnosed and fixed.

He described the pain as being in his lower ribs bilaterally but worse on the right. He said it felt like his ribs were broken apart and were tearing into his intestines and diaphragm.

Examining the patient and getting his story were all I needed. There was nothing I could do in the ED that night to find the cause of symptoms he had suffered for years and for which he had already had many negative tests. However, I was unsuccessful using this logic to reassure him he had no physical problem.

In order to show me he really had a problem, he stood, raised his shirt and pulled in his abdominal muscles. Being a thin man, this caused his lower rib margins to stand out. They were a little asymmetrical. This, to him, was evidence of pathology he knew was there.

I finally had to resort to the line I use in situations like this. I said something like: “I am sorry. I don’t believe you have a physical problem and you cannot convince me you do. I am also not going to be able to get you to agree with me. So, we are just going to have to agree to disagree.”

Off he went, miserable and sad, and completely unwilling to entertain the idea that all of his suffering might be coming from his mind.

Last week, I told about falling off my mountain bike and making it to the hospital with obviously injured left shoulder and leg. I had just arrived at the emergency department at the end of my last posting.

I swooned as soon as they pushed me into the treatment room. That passed pretty fast once I was flat on the bed. An IV was quickly started in my hand and I was injected with morphine. I didn’t like the way it made me feel but I was very glad to have the pain controlled.

Getting my x-rays was the worst part of my ED adventure. Even after morphine, it was torture to get my arm in the correct position to diagnose my posterior shoulder dislocation. Most shoulders dislocate forward or anterior. Mine had dislocated backwards. I had read about posterior shoulder dislocations, but it is so unusual that none of my emergency medicine colleagues I talked with could actually remember having seen one before. It also explains why my efforts to reduce it on the mountain were unsuccessful.

It was nice being taken care of by my friends. The emergency physician and nurses took special care of me. The trauma surgeon heard I was there and poked his head in on me.

Once the diagnosis was made, they put me out and the orthopedist pulled on my arm. He thought it was back in and ordered more x-rays but, as I came to, I could tell very clearly it was not. I told him so and, even though I am a doctor, he still sent me for x-rays to check. That led to more of the same painful positioning for more x-rays.

When I got back to the room, the orthopedist came and told me it was still dislocated. I resisted saying, “I told you so.” He then said he was pretty sure he could put it back in without more medicine because I had already been given so much. As soon as he started to pull, my hollering convinced him he was not correct. The next time they put me under, they were more successful and I woke up with my correctly positioned shoulder held in place with a sling.

The x-rays of my knee didn’t show an obvious fracture so I was discharged with my leg in an immobilizer. My wife took me home and I got into the house and bed without too much trouble since I was able to limp on the bad leg as I walked with only one crutch.

Then next day, I had an MRI. It showed good news for the shoulder: no specific injury. But the news for the leg was bad: non-displaced tibial plateau fracture. The tibia is the shin bone and its plateau is the large part that forms the knee joint. So, I went to non-weight bearing for six weeks! That would be bad enough if I could have walked on crutches but, for the first couple of weeks, I had to use only one crutch. That meant that, to get around, I have to crawl (using just one arm and one leg,) use a wheel chair, or hop. Since we have a tri-level house, I was basically stuck in my bedroom where all I could do was hop from the bed to the toilet and back again.

It was interesting how being laid up worked on my head. All I could do was lie in bed and worry. I worried about being constipated from taking narcotics and lying in bed. I worried about getting addicted to the pain medicine. I worried about a blood clot forming in my swollen, immobile leg. I worried that my leg would never be the same again and I my active life as I knew it had come to an end. I pictured my self an addicted, constipated cripple on blood thinners. To make all of this worrying worse, I had trouble sleeping because of the pain and discomfort of the sling and immobilizer so I had plenty of long nights to contemplate my bleak future.

Fortunately, all worked out well for me. I missed nine weeks of work but, no constipation, no blood clots, no addiction. Back hiking and riding my bike. Just a setback that has helped me be more empathetic towards others in similar situations.

A few years ago, I went for a mountain bike ride in the Soquel Demonstration Forest in the Santa Cruz Mountains. I was several miles up into the ride when I hit a tree and ended up on the ground. As my head cleared, I was in severe pain. I had a lot of pain in the left shoulder and couldn’t move it but there was nothing that felt like a fracture. I diagnosed a dislocation. The left knee hurt like heck, too, but was also not obviously fractured. I managed to get up and I could walk, although with a bad, painful limp.

Once assessing my physical condition, I assessed my assets and liabilities, as I had to decide what to do next. It was early on a Friday afternoon in February but was one of those perfect California winter’s days. Though it was not at all cold at the time, it would not be fun spending the night up there.

I decided that sitting and waiting for help was not an option. In retrospect, that was a good choice since I didn’t see a single person as I hiked out and there were no cars in the parking lot when I finely got there. If I had waited for help, I would have been up there all night. It was early in the afternoon in February but was one of those perfect California winter’s days. Though it was not at all cold at the time, it would not be fun spending the night up there.

Next, I had to decide whether I was better of with or without my bike. Though I couldn’t peddle it and could only use one arm, I decided to use it as a crutch and see how I did.

As I started hobbling up the hill, leaning on my bike, I realized I would be a lot more comfortable if I could relocate my dislocated shoulder. I have relocated many shoulders, including one on my friend on the ski slopes, so I was sure I could do my own. I put the bike down, grabbed my arm, bit down hard and tried to twist my shoulder back into place. This resulted only in a huge scream of pain. I gave up and, as soon as I could see straight again, continued on. As I went, I talked myself into believing I really could reduce my shoulder if I were just tough enough. I put the bike down again. I really focused all my attention on overcoming the pain and getting that shoulder back in joint. This time, I really pushed and twisted but with the same disappointing result.

After that, all I could do was just keep on going. When it was uphill, I walked, pushing the bike with my good arm and using it as a crutch. When it was downhill, I got on and coasted. Though this makes sense, the getting on and off was the worst part of it all. I couldn’t bend my left knee and any leaning over killed both the knee and shoulder. I was worried about loosing my balance and going down again as I struggled to get on and off the bike. I got so tired I was really tempted to lie down and take a break but my shoulder and knee had gotten so stiff and painful I was really afraid I would not be able to get up again once I was flat on the ground. So, when I had to, I rested by sitting on the bar of the bike but mostly I just forced myself to keep going.

It took me about two hours to get back to the parking lot, then I had to get the bike on the rack and drive about an hour from there to get to my hospital.

As soon as I could get a signal on my phone, I called my wife, told her I had hurt my shoulder and asked her to meet me at the hospital. She arrived first and was waiting for me at the loading zone in front of the emergency department. She was surprised when I told her I needed a wheel chair as she was just thinking of a shoulder injury.

They were waiting for us when she wheeled me into Room 2B. As soon as they pulled me up next to the gurney, I swooned. I think my adrenalin kept me going up until that time. When I was finally in a safe place, my autonomic nervous system let down and I almost passed out.

Next week, I will tell you about what happened next. I have told you about so many of my patients, I guess it is only fair to tell of my experience as a patient in the emergency department.

I am amazed at people who sit in the ED waiting room for hours with some complaint that would not seem to justify the inconvenience. Sometimes, they honestly do not know whether or not their condition is serious but other times, I get the feeling patients stick around just because they are not quitters. They come, they register, they wait.

On one such occasion, I went to see a man in his early twenties with a complaint of vomiting three times after eating fish. The nurse’s note said he had no medical history and the symptoms were now all gone. I wondered what I would learn about why he had chosen to wait over six hours to be seen.

He told me he was a temporary worker at Google, which provides free food for all its employees. He said it was his impression the food provided the temps was of inferior quality to that provided to the regular Google employees. Once, in the past, he had vomited after eating the fish at work. Today, he hesitated before taking the fish but decided to take the chance. Soon thereafter, he vomited and headed straight to the ED. He said no one else who ate the fish was ill. After talking to him, it was still unclear as to why he chose to wait so long to be seen since all of his symptoms were now gone.

I gave him my usual explanation about vomiting and/or diarrhea and I reassured him there was nothing for him to worry about since he had no more symptoms.

He seemed unhappy with my explanation so I asked some more questions. I then learned he had actually complained to Google in the past about getting sick from eating the fish. Google told him they would do a survey to see if there really was a problem with the food. This did not satisfy him at all.

The reason he was unhappy with my approach to his vomiting was that he wanted something he could use to “go after Google.” I am sure my disgust must have been visible, though I kept myself from telling him what I thought of his intentions.  I told him I was unable to help and excused him.

Brother. Don’t people have better things to do?

Skinnier Than Most Prisoners

Police cars need to have a way to be able to roll down the back windows of their squad cars to provide ventilation while preventing any suspect from escaping through the open window. In our fair city, they address this need by placing a metal plate horizontally across the rear window. It is placed so the window can be lowered to let air pass above and below the plate but not allow a suspect to escape.

One night, I took care of someone who challenged this time-tested system of keeping captives from jumping out of the police car window. An officer was driving down the street with a man in the back seat. The suspect was so skinny, he crawled out of the back window, squeezing over the plate and falling out of the moving police car. As the officer realized his charge was squeezing his way to freedom, he freaked out and crashed his car. Both men came in by ambulance. The suspect had minor injuries from hitting the ground. The officer had to be treated for injuries suffered in the crash.

Three for the Price of One

A 30-year-old drunk driver ran into the back of a parked police car. This drove the police car forward, striking down the officer who, was standing in front of his car, and a pedestrian he was ticketing. The driver, the police officer and the pedestrian were all injured and came by ambulance for treatment in the emergency department.

Hold on Tight!

A 31-year-old undercover police officer pulled over a car driven by a suspect. He reached in through the open window and grabbed the driver, who then started to drive away. The officer was pulled off his feet and dragged away by the moving car. He finally managed to get a hold of the steering wheel and directed the car off the road where it ran into a hedge and came to a stop. Officer and suspect were both brought in by ambulance. The suspect was uninjured and the officer was discharged with bruises and scrapes.

A 22-year-old lady with no medical history presented with lower abdominal pain and shortness of breath. She had been seen the day before by one of our physician assistants who diagnosed her with bronchitis and prescribed erythromycin. She came back because she was getting worse.

When I went in the room, I saw a trim young woman who was hyperventilating and clearly in distress. As I talked with her, she relaxed and became quite comfortable. Her physical examination was normal except for an obviously distended abdomen. Just as I went to examine her abdomen more closely, it tightened up and she started to hyperventilate again. Getting the big picture, it became clear to me she was in labor. Her contractions were causing her pain and distress leading to hyperventilation. She had no breathing problem at all. She was about to have a baby.

When I shared my impression with her, she became very upset. She said there was no way she was pregnant. She had normal periods every month and could not possibly be pregnant.

As she told me this, her abdomen softened and she relaxed. I realized I could be wrong so I excused myself to go and get a Doppler, which is an electronic listening device that can detect blood flowing and turn it into sound. When I placed it over her abdomen, the rapid swoosh, swoosh, swoosh of a baby’s heartbeat was clearly audible. I told her she was, indeed, going to having a baby.

“No!” she screamed, and started to sob. I tried to comfort her, which was not helpful. I told her we were sending her up to labor and delivery. She made no response but continued to cry.

As she was leaving, I asked if there were anyone with her. Between sobs, she told me her mother was in the waiting room, but cried, “Don’t tell my mother!”

“You think she’s not going to find out?” I asked. She collapsed back on the gurney and sobbed uncontrollably. Off she went to labor and delivery.

When I told the mother the news, she was subdued but didn’t seem really surprised. When I asked her if she had not noticed her daughter getting big, she said, “We just thought she was gaining weight.”

This bike has been leaning against the wall behind the emergency department for weeks. It must have belonged to someone who came in and either stayed in the hospital, left without it or died. It was dark when I took the liberty to take these pictures with my phone but you can get the idea of how it was decorated.

I looked up and saw a new patient listed on the white board. The complaint written by the nurse was “urinating green.”

“I wonder what he has taken to make his urine have a green color,” I wondered to myself.

In the room, I found a 38-year-old man who told me he penis had been turning green for five days and it was getting worse. He complained of burning when he urinated. The rest of the history was unremarkable.

I asked him to show me what he was talking about. After examining him, found nothing wrong and told him it looked normal to me.

“It only happens after I piss,” was his response.

I handed him a urinal and turned by back while he urinated. When he was finished, I turned back around and again inspected him. When I pointed out that it still looked normal, he said, “You gotta see it in the sunlight, Doc.” Since it was about 4:00 in the morning that was not an option so I went back to asking more questions.

As it turned out, about a week prior to his visit, he had unprotected sex with someone he viewed as suspect. Since then, he had been worried he might have caught something from her and had been watching for evidence of infection. This had worked on his brain to the point that he was having symptoms and seeing things that were not real. I reassured him and sent him on the way with a recommendation that he use condoms.

In the emergency department, I frequently have need to aggressively get control of patients in order to get tests that might save their lives. At the same time, aggressive control carries risks so I often face tough choices of how to best control a patient for his benefit. At work one night, I had to go to CAT scan (CT) twice. It is just down the hall from the emergency department but I almost never have to go down there. It was very unusual to have to go twice in one shift. I had to go there to help control two challenging patients who both had potentially life threatening conditions.

The first guy I had to go see was in his twenties. He came in telling me he was nervous and had palpitations after taking cocaine and methamphetamines. His heart was beating fast and he was jittery but was thinking normally.

In such cases, we usually just give them something to help them relax. We watch them for a while until they are better and send them home. This guy, on the other hand, just got worse and worse. Even after being given the sedatives I ordered, he began hallucinating and his agitation increased. Over a relatively short time we gave him a ton of medicine and he finally fell asleep. Minutes later, he woke up fighting, agitated and pulled out his IV. Then he fell back asleep.

One rare complication of stimulant drug abuse is a brain hemorrhage caused by the elevated blood pressure and excess agitation. I felt I needed to scan his head to rule out a hemorrhage but he needed to sit still for a few minutes in order to perform the scan. As soon as we tried to move him to the scanner, he would wake up and thrash around again. We gave him so much medicine I was afraid he would stop breathing but whenever he was moved he became too agitated to sit still in the scanner.

Finally, at the recommendation of one of the nurses, we got a spine board and strapped him down like he was a trauma patient. We wrapped straps around his body and tape on his head and neck. We then took him to CT. Once he was given some more medicine and was left on the CT table for a few minutes, he relaxed and we were able to get a scan that showed his brain was OK.

All of this was a huge pain but, in the end, all of his tests were normal except for the cocaine and methamphetamines in his urine. Over the next several hours, he didn’t wake up so he had to be admitted to the hospital for further observation and care.

The second guy provided almost exactly the same challenge but in a very different situation. Right at the end of my shift, a young man came in after having had a seizure. He was two weeks out from having an arteriovenous malformation* (abnormal blood vessel) removed from his pons** (lower part of the brain). He had been doing well after his surgery until that night when he had a seizure. He was still unconscious when the ambulance got him to us.

We did our initial assessments and treatments in record time and the nurses headed off with him to CT. They soon called saying he was thrashing around. I had sent them with instructions to give him a sedative if he seized again or wouldn’t sit still. They had followed my instructions but he hadn’t responded to the medicine. I gave orders for more medicine. That didn’t work either. They were unable to scan him, as he wouldn’t lie still.

I hurried down to CT with another nurse and more medicine. I was finally able sedate him adequately to get him to sit still just long enough for the scan. It showed he had bled into his brain at the surgical site.

It was very challenging to get him to sit still. But it was a big bummer to see the hemorrhage. It had caused the seizure and the agitation, and was also probably going to lead to his death.

So, in the first case, the patient brought his problems upon himself by taking too many stimulant drugs. His CT was normal and he would probably be fine. The second guy had the really bad luck of bleeding after brain surgery. His CT was positive and he was certainly going to have a bad result. It shows why it is so important to be able to get control of such patients to get their studies so any needed care can be provided in a timely fashion.

* http://en.wikipedia.org/wiki/Arteriovenous_malformation

* http://en.wikipedia.org/wiki/Pons