Diabetic Type II

Written by Tad. Posted in Kooks

Some people really want their doctor to know the exact details of their symptoms. This often leads to extended written accounts of details patients believe will help with their diagnosis. Here is a reproduction of a written note a patient brought in to help outline his symptoms. If you have a hard time following it, I do to. In the end, we found nothing wrong and the patient left without a diagnosis. As I sent him off to follow up with his primary care doctor, feeling sure he had no emergency, I wondered if someone, someday, will find a strange medical condition to explain the symptoms or if it was all just mental. This is not an unusual thought as I discharge people. It seems mental to me but I don’t know everything.

 

Diabetic Type II
Off meds long time
#’s run in 200’s

Wed 7/6

3:30 AM

-woke up dizzy
-sat on edge of bed
-got online and video chat so people could watch me, make sure I was OK

4:00 PM

-eyesight got strange
-couldn’t see part of right side of vision. close one eye can see OK. close other eye see OK. both eyes – missing right side view

4:30 PM

-right side of lips (top + bottom) went numb for a little while. right arm and leg got weak and shaky
-only lasted a little while then lips ok again + arm/leg ok too (no shaky)

4:45 PM

-nauseas – didn’t throw up – just wretched

5:30 AM

-headache left front behind eye
-took Naprosyn Sodium (just one)

6:00 AM

-went to sleep
-eyesight still messed up

10:00 AM

-woke up feeling better
-no headache
-eyesight ok (but bright spots)

Wed

-bright spot/line in right eye fading but still there
afternoon       -small headache
-took Naprosyn – headache faded away

1 periods of dizziness

Crazy Brother

Written by Tad. Posted in Kooks

A young woman brought her brother in for psychiatric evaluation. She told me he had been acting strangely and gave me her written account of what had been going on. She was a bit compulsive in the way she documented things and, you can tell, was not primarily English-speaking. Still, if you can be patient enough to read through this, you will get an interesting insight into this man’s mental illness and the trouble it caused his family.

When the sister said she was comfortable that they were all safe with him at home, we discharged them with information on how to get him some psychiatric help.

Here is a recreation of the “log” she kept and shared with me:

Log – JC (I am not using his real initials) – Summary

One Page Summary – August 2016

Patient Info:

Name:            JW

Age: 37

Phone:

Address:

Weight: 150 lbs.

Height: 5’8”

Education: BA degree Nuclear and Computer Engineering from UC Berkley in 20–

Career: Started working for S——— in 2016

Lives with: Wife, 4-year-old son, mom-in-law

Medications: none. Currently refuses to see any doctors.

Drugs or Alcohol uses: none. No history of drug or alcohol abuse

2013-2016

When he was working at a computer chip company, he said to the family that his boss taps his phone, knows where is was going, someone is watching and needs to close the blinds and install security cameras. Family had talked to him and lay out all the reasons why his boss would not do such thing. He was convinced at first. Family asked him to quit and he quitted, and stayed home with baby son and mom-in-law for about 2 years. He seemed fine most of the time but every few months, he will bring up issue of being watched and his phone being tapped.

June 2016

Started telling family that his in-laws are hurting-poisoning him and irritated that rich people controlling everyone and buying everyone’s mind, so everyone is scared to speak up. We talked to him but he cannot be convinced. He has these strong feelings about one week and increased to couple of times per week. He then said that it is his wife, B, who is hurting and poisoning.

July – August 2016

J has symptoms of bipolar disorder which includes: daily extreme mood changes, strong feelings of irritability and anger, avoid friends and social activities, decline sleep, having delusional thoughts, persecutory paranoia, episodes of hypomania daily and mania almost every other day. He refuses that there is anything wrong with him and everyone including doctors are all against him. He said he does not have paranoia because he is not that type of people. He now strongly feels that his wife is harming him, including poisoning him, throwing stuff to his head. He yells at her almost daily for hurting him and threatens to hurt her and the son if they try to hurt him.

6/6/2016 Sunday 12 PM

He held down P (the son) to put alcohol on his scraped knee. He insist that there are microwave length that controls all this. We argued very loud and he accused me of killing people, accused B of using atomic bombs and army trucks.

7/15/2016 Friday 10 PM

He took a picture of his scraped knee and insisted that it was serious, badly swollen, internal, microwave laser tissue penetration. Need to report to Obama. Everything is bought and everyone else is scared to say anything, everything is cover up including doctors. Everyone needs to be educated to a high-level and accessible. I don’t want to live a scared life like you all. You are all brainwashed.

7/16/2016 Saturday 8 AM

He posted on Facebook “Imagine life in a country that is constantly at war, surveillance, and creates artificial news. There’s gotta be a better way and I know I’m not the only one that feels this way.”

7/17/2016 Sunday 9:30 PM

He posted on Facebook “Thank you everyone for your care and kindness. I will keep a positive thinking going forward.”

7/18/2016 Monday 2 PM

Posted “Feeling cool about Usesome” which is an article about high-ranking intelligence officer making artificial news and destroying massive mankind.

7/20/2016 Wednesday 4 PM to 8 PM

He posted on Facebook “Got sick? Got resistors, capacitor, F T?”

7/23/2016 Saturday 12 AM to 3 AM

He and I talked for over two hours about various topics from “What do you think of B, rich people ruling everything, interviewing for the new job is beneficial because involve learning new thing, what if Mom and Dad and I were taken advantage, what would I do?” I told him that “That must be a scary feeling.” He said “Never mind” and changed subject. I asked him how his knee, what did the doctor say. He did not answer me.

7/24/2016 Sunday 12 AM

He posted on Facebook “<3ing.” Kicks bathroom door open and held up fist to B, eyes wide open. He said “You poisoned me, you and your coworker poisoned pool water and made me go into pool with P. My legs are handicap now. I don’t want to you.” B said violence is not going to help and sat down to talk to him. He calmed down and B was able to talk to him in a calm way. He listened and talked, lasted over an hour, then went to sleep.

7/25/2016 Monday 9 PM

He mixed cement and worked on the basketball hoop at 9 PM at night, shouting to B to help and asking mom-in-law to stay inside. At midnight, posted on Facebook a bunch of Chinese sentences that no one can make any sense. Like random Chinese words being put together to try to say something evil inside of someone.

8/2/2016 Tuesday throughout the day

P is sick. He said someone pressed button. J asked P to eat, P has no appetite and didn’t want to eat. He told P if he didn’t eat, he can die. He said at one point to P that P only needs to learn math and English and don’t need to learn anything else because he can teach him everything else.

8/4/2016 Thursday day

He said he was hypnotized, someone shot him. Caused by phone microwave. Felt that hair had blown by wind so he was hypnotized. Must be B who used pollen. She gets pollen everywhere. She is together with high school friends and large corporations like cops, FBI. He went out with P and Dad and ran into bad freeway traffic, he said someone messed with us. Someone messed with mom too because mom ran into traffic going home after work.

8/5/2016 Friday morning

He yell at B and said to sell the house, B caused T to pull wisdom teeth, she caused T to move away from San Francisco. He stopped after P started crying. I talked to him right after this episode and he acted normal. He asked me if I have already gotten my wisdom teeth off, I told him no because it was just a consultation. He said that they are getting ready to leave the house to bring P out.

8/6/2016 Saturday

He had a long talk with Mom mainly complaining about rich people ruling everyone else. There are smart people sifting all the stupid people out. Stupid people receive small incentive, so they comply and work like slaves. He was calm and had no episode.

8/7/2016 Sunday 9 PM

On the car ride home, he complained to B about her being a betrayed person. After arriving home he and P played and P accidentally poke J’s eyes. J said to P, you are trying to hurt me, I will kill you so you can’t hurt everyone in the society. He pulled B out of bed, dragged her down two flights of stairs and pulled her into the kitchen and pointed to a cockroach and accused her of poisoning him. After B tell him that it is not an issue when there are insects around, and Mom-in-law said a few positive things to calm him. They sat down and he saw her looking through her phone and he told her not to call 911. He asked if they are going to get a divorce and whether she is contacting a lawyer. He said “we can talk about it here and you don’t have to talk to lawyer.” Mom-in law-said it’s late and they should all go to sleep. He insisted to sleep with P in P’s room. She sleeps in their own master bedroom. Everyone went to bed. From 12:40 AM to 2 AM, he texted to a Family Group chat “Be careful, and evil is acting up again. My wife just put something in my drink. The family history going back hundreds of years are all traitor. Targeting all Chinese people, kissing ass to non-Chinese people, be careful, this 200-year-old issue still happens today, don’t fight within each other, needs to collaborate together. Is everyone around just sick for a long time?” When B was getting ready for work in the morning, he came to her room and said “I’m checking what the traitor is up to.”

8/10/2016 Wednesday morning

Mom called J and first he said “Don’t worry about me. Everything is fine.” He brought P out to the playground and museum and asked mom-in-law to join too, as if nothing happened last night.

8/10/2016 Wednesday 8:30 PM

I had an hour-long conversation with him. He said B together with other unknown people from high school poisoned him for years. He asked how we feel, he said he can’t explain it, it’s just feel different. He said she brings in drugs from somewhere/someone and dosage is not severe enough to kill him but enough to make you feel different and will last 20+ years. This all came from 200 to 5000 years ago that the tradition of poisoning continues to this day. There is a group of highly educated gangster related and rich people summoned people from China to come to the US and get citizenship and turn in people for them. B is brought into that group whose job is to turn J to the highly educated people. That’s why she poisoned him. He said he already reported to FBI and Obama. He said he wants to try to make B get out of it but she is too much in already. He said he is telling me and the family because he wants us to be careful. When asked if he feels angry or frustrated, he said some time but he can’t do anything about it so just let it be. When I asked he was sad, he said no because he smiles every day. He said he wants P to be highly educated so that he will know there are people around to hurt him.

8/12/2016 Friday 3 PM

I suggested he sees a marriage therapist because his current relationship with wife, he refused and said the root cause is that she needs to stop poisoning me. Then midnight he went to her room and said she is always awake, “every time I wake up in the middle of the night, this girl is awake.”

8/15/2016 Monday 5 PM

When he came home from work, he said someone throw stuff on his head, and he went to shower right away.

Said the same as yesterday about someone throw stuff on his head. When Mom-in-law was away from the house to get groceries, he started yelling at B that she is harming his family, harming his uncle, and said parents are scared of B. And then he said to P, “if you hurt my family, I will kill you.”

8/17/2016 Wednesday 8 AM

Wrote on family group chat that someone threw stuff on his head. He said he felt something that breaks/spread apart as it lands on his head.

Limo Ride from Pismo

Written by Tad. Posted in Kooks

A telephone call came into the emergency department and was transferred to the charge nurse. The caller said that a coach for the US Olympic Tennis Team was on the way to our emergency department and that he should be given VIP service when he arrived. She told me about the call and we both wondered what this might mean.

A while later, a middle-aged man arrived who was complaining of flank pain. As I talked with him, I realized this must be the person referenced in the mystery call. I couldn’t make any sense of this because the patient was not what you would picture an Olympic tennis coach to be. He was weird, pale, obese and dumpy. He gave a disjointed story of being diagnosed with kidney stones at various different hospitals around the country as he traveled with his coaching responsibilities. I had a hard time tying this all together in a way I was comfortable with. Nonetheless, I proceeded to make him comfortable and evaluate his flank pain.

Sometime later, a man arrived who identified himself as a limousine driver. He had a bemused police officer with him. They were looking for our Olympic tennis coach-patient. The driver said that the patient had contacted him in Pismo Beach and agreed to pay for a ride to our fair city, a distance of about 200 miles.

The patient pulled out a wallet, showed that driver it was full of cash then asked the driver to hold onto the wallet as the patient said he would be drinking in the back of the limo and would appreciate the driver keeping an eye on it. The patient jumped in and the driver headed off, happy to be paid for the nice, long trip.

When they got here, the driver was directed to the Fairmont Hotel. The patient asked the driver to wait for him while he ran inside to see if the people he was to meet were there yet. The patient went into the lobby and the driver patiently waited.

When the patient didn’t come back, the driver went inside and asked the staff if they had seen his customer. They said he had come in, asked where the nearest emergency room was and had exited out the back door. The driver pulled the wallet out of his pocket and found it was full of paper: no money. His customer had pulled a switch after showing him a wallet full of cash.

The driver then realized he had been had and called the police to help get some justice.

I was too busy to appreciate much of the interaction between the patient, the driver and the police officer. I understand the cop took a report and the driver left, angry and with no money.

I eventually figured out that the patient had no history of kidney stones and everything he told me was probably a lie. I have no idea where he went or what he did next after he left our emergency department.

 

Tardive Dyskinesia

Written by Tad. Posted in Kooks

My patient was a thirty-five-year-old man who came in by ambulance. He had a condition called tardive dyskinesia. It is a movement disorder that can develop in some people, often a side effect of some psychiatric medications. He had the most terrible case I have ever seen. Whenever he was awake, he had uncontrolled movements of his entire body. Not just wiggling but actually thrashing. Every single minute, he writhed in bed, throwing his arms and legs around so much that we had to put pads on the side rails of the bed to keep him from injuring himself.

He was a Kaiser member, and sees a neurologist who specializes in movement disorders. He is also a regular visitor to their emergency department. He ended up in our emergency department because, when the medics were called to his house, he told them he was so sick of his constant movement that he wanted to die. That prompted the police to put him on a psychiatric hold and all patients in our county that are on a psychiatric hold must come to our hospital.

I had never before seen anything so severe. I ordered laboratory tests and got some information from Kaiser before I was comfortable that he didn’t have anything new or dangerous going on. I then formed a plan to help control his movements enough that he could go to the psychiatric emergency room. We did this by giving him injections of medications. One medicine, benztropine, is used for various types of movement disorders. We also give him lorazepam, which is a tranquilizer.

When he got enough medicine, he finally quit moving and fell asleep. However, as soon as the medicine started to wear off, he started moving again. A little at first, then as soon as he was wide wake, the thrashing would start again.

When he was settled down to what he said was his baseline, I sent him over to psychiatry. However, in a few minutes, we got a call from them saying they were unable to deal with his constant movement and were sending him back to us. I eventually had to admit him to the hospital to be seen by a psychiatrist as an inpatient.

I looked on YouTube to see if I could help you get an idea of what this poor man was living with. Here is one example, which is similar to, though very much milder than what my patient had:

https://www.youtube.com/watch?v=Qf3I6t8fuA8

 

Trump for President

Written by Tad. Posted in Kooks

We frequently have to decide if an elderly patient has an altered mental status. This can be a bit tricky because the patient might be a little “off” at baseline so sometimes, we have to try a little bit harder to determine if the patient is altered or not.

The other night, the intern (doctor in training) told me an eighty-year-old woman was confused because she was not able to give the exact date. After meeting her, I asked her if she knew where she was and she named, exactly, our hospital.

I asked her if she knew the date. She said, “No,” without even trying. When I pressed her, she gave the year, off by only one.

I then asked her who was the President of the United States. “Obama,” she answered confidently.

“Who is going to be the president next year?” I then asked.

“I have no idea.”

Well, who are you going to vote for, Trump or Clinton?”

“Trump.” Again, with confidence.

“You are the first person I have ever met who supports Trump. Why do you think he would make a good president?”

“Because he is very rich and has a beautiful wife.”

Since my purpose was not to delve into her politics, I stopped the interview there. If she knew those two facts about the man running for president, it was hard for me to believe she might have any significant confusion.

 

A Loaded Basketball

Written by Tad. Posted in Kooks

A 23-year-old non-English-speaking Vietnamese man came in with a scalp injury. Through an interpreter, he said he was playing basketball earlier that evening when he ran, head-on, into the basketball standard. He careened off and ran into a nearby fence, which he also hit with his head before landing on the ground.

His friends took him home, shaved the area around the cut and made a compress of tobacco, which they placed in and around the wound. They then decided he should get it checked out and brought him to the emergency department.

When his laceration was numbed and explored, a piece of metal was felt in the wound. X-rays and a CT scan showed a bullet embedded in his skull. He also had underlying brain damage. I called a neurosurgeon to take him to the operating room to repair of his injury.

When confronted with evidence that he had actually been shot, he stuck firmly to his basketball story. I noted that he didn’t exactly fit the profile of a basketball player. He was just over five feet tall and was wearing flip-flops.

Could he have been shot while playing basketball and not realize it? More likely, he was involved in some sort of shady activity that resulted in his being shot and just didn’t want anyone to know about it.

We Make a Mess

Written by Tad. Posted in Kooks

The other night, we had a serious trauma patient come in. She was eighteen-years-old and crashed her car off the freeway into a ditch. She was unconscious and severely injured. The whole team moved together to try to save her. I helped an emergency medicine resident pass a breathing tube as the surgeons put in IVs, gave her blood and stabilized her for CT scan and the ICU. I read in the paper two days later that she had passed away. This is what the floor looked like in the trauma room after she left:

IMG_1479

“Housekeeping to the Trauma Room” is a pretty common page heard overhead.

 

Rape and Threats of Suicide

Written by Tad. Posted in Kooks

When a rape is reported somewhere in our county, police investigate and, if they think a forensic rape exam is indicated, the patient is brought to our emergency department for that exam. The victim is not seen by our emergency physician unless some issue comes up that the specially trained Sexual Assault Response Team (SART) nurse is not able to deal with.

Recently, while the SART nurse was doing the exam, the patient said that being raped had made her suicidal and, when she got back home, she was going to kill herself.

This information was passed to me and I went to talk with her. She was emotionally upset, as you can imagine. She admitted to saying she was going to kill herself but she had just said it because she was upset, not because she was going to follow through on the threat. She just wanted to go home.

This put me in a tough position. By law, if I think patients are suicidal, I have to place them on a psychiatric hold and get them to our psychiatric emergency room for help. If I don’t do so, I have broken the law. This also offers a challenging moral dilemma. If I sent such a person home and she did kill herself, I would certainly be at fault and would feel terrible about it.

We see people all the time who come in on a hold with clear documentation of suicidal behavior who totally deny it once they get to the emergency department. They either change their minds or they lie because they just don’t want to be on a hold. Was this patient like them or was she really just upset and misunderstood by the SART nurse? I had to decide whether to believe that she had just said something that she didn’t mean and let her go home or put her on a hold and send her to emergency psychiatry.

After talking to her for quite a while, I told her I was obliged, under law, to send her to psychiatry to get her help that would not be available if she just went home. When I told her that, she pleaded and begged to be allowed to go home. When that didn’t work, she went ballistic and started hollering and screaming that she was just going to leave.

When she went off, the staff called security. Soon, three big guys in blue uniforms were standing at the door of her room, which only made her more hysterical.

You can imagine how bad I felt. First, she is raped, which is horrible. Now, instead of the calm, understanding environment we try to provide victims of rape, we are threatening to tie her down to a gurney with leather restraints. It made me feel really bad, though I recognized I made the right decision, given the circumstances presented.

Fortunately, she quieted down and went peacefully off to talk with the psychiatrist. When she got there, she was calm and cooperative. She told the psychiatrist she felt safe and was glad she was there. She acknowledged she really needed help.

 

Sincere Apology

Written by Tad. Posted in Kooks

I was just looking back at my last few posts. They are pretty sad. I decided to share this with you as it lifts my heart a bit.

This is a letter that was mailed to our department from a patient. I think it speaks for itself:

To the Emergency Room Staff of The Medical Center

My name is John Smith. I was a patient at your hospital the night of July 4th, 2008. I am writing this letter to apologize for my verbal and physical abuse to the members of the staff working that night. I have to admit that I do not remember much of what happened that night due to being extremely intoxicated. I am told that I made threats to kill and that I was spitting on staff members. I cannot capture with words how sorry I am for saying those hurtful things and spitting on people that were only trying to help me. I am extremely embarrassed about my behavior and will be paying for it for a long time to come. You guys have a hard enough job as it is and the last thing you need is some drunk kid making that job even harder. I obviously was having a problem with my drinking and it turned me into a person that I never want to be. I have a long road to recovery ahead of me. I understand that forgiveness might be out of the question for some of you, but I hope that in time you can find it in your heart to forgive me. I would never knowingly want to hurt anyone that is trying to help me and feel a great amount of shame for acting as I did. I just want to say sorry and thank you, thank you for helping somebody who needed it whether they knew it or not.

 

Paper or Plastic?

Written by Tad. Posted in Kooks

We see a lot of methamphetamine-crazed people in our emergency department. One such guy came in the other night. He was in his twenties and was so crazy he had to be held down by multiple staff, police and medics. He was sweating profusely and his stringy hair was in his face. His heart was racing, he was thrashing and he was hollering, though the only word you could understand started with “F.”

He got our usual treatment: leather restraints on all extremities, sedatives, and a close evaluation to make sure nothing else was going on.

All such patients are assigned a “sitter.” This is a staff member who has no other responsibility than to watch the patient to make sure he is safe. When I went back a few minutes later to check on the patient, the room reeked of stinky feet and the poor sitter was stuck there, unable to leave the room. The patient’s shoes and socks were so bad, they had been taken off and sealed inside double plastic bags. I am sure that helped, but his bare feet were also very stinky so the room was no less unpleasant.

I recommended the sitter place plastic bags over the patient’s feet and tape them around his ankles. This he did, with great result in clearing up the air. I couldn’t resist the temptation to take a picture.

IMG_1565

Copyright © 2014 Bad Tad, MD