A 35-year-old man came in saying his shoulder became dislocated when he passed out from his sugar going too low. Besides diabetes, he had Ehlers-Danlos Syndrome, which causes very loose joints, among other things. He said he had suffered from dislocations like this many times in the past and told us exactly the dose of narcotics it would take to relieve his pain in order to get his shoulder back into joint.

We gave him the amount of pain medicine he asked for but were then not able to get the joint back in place, even after multiple tries by me and by the orthopedist I called to help me when I had been unsuccessful.

We gave him more and more medicine until he finally fell sound asleep at which time, the shoulder slid right into place. It was noted while he was unconscious that his shoulder was so loose, it could just slide in and out of place with minimal pressure. We put it in place and applied a shoulder immobilizer.

When he woke and called for more pain medicine, the shoulder was out again and it became clear he could move it in and out of socket at will. He had been holding his joint out of socket and feigning his pain in order to get narcotics.

Early in the morning, a couple brought in their three-week-old baby girl. She was not breathing or moving. We started CPR, placed IVs and put a tube into her windpipe to breath for her. This is a big challenge in such a little person but all went smoothly. We then gave her medicines to get her heart beating again. It seemed like she was stabilizing when she just crumped and died, in spite of all we could do to save her.

Having little kids die is always hard. The pediatric intern was in tears and everyone was upset. The family seemed in shock. I did the best I could to help everyone deal with their emotions but I only had so much time as I had to turn back to my busy emergency department and get on to the needs of the other patients. The family was given as much privacy and peace as was possible to allow them to begin to grieve.

When someone dies, the charge nurse calls and talks to the coroner who decides what to do with the body. The body is released when there are no worries about why the patient died, no need for an autopsy and the patient’s doctor will sign the death certificate. Alternatively, the coroner can take custody of the body until the cause of death has been determined, usually through an autopsy.

In this case, the coroner decided the baby probably died of naturally causes and the body could be released. I spent quite a bit of time on the phone telling him I wasn’t comfortable with that decision. I told him we didn’t know why the kid died and they should do an autopsy. I specifically mentioned we had no way of knowing the kid had not been abused.

He wouldn’t change his mind and released the body. The parents refused permission for an autopsy. I was frustrated but felt I had done all I could do.

A few days later in the paper, there appeared an article stating that they arrested the baby’s father for killing her. I guess the radiologists noticed old rib fractures on the chest x-ray. That led to an autopsy that showed a skull fracture as well. There was no evidence of trauma on the outside of the body that would have given us a clue. That is not unusual for babies with trauma.

This case shows many of the challenges we face as emergency physicians. The medical part of the case was challenging. It is hard to provide critical care to such a little person. If the medical care is difficult, the social elements were even more so. Many of these challenges are out of my control, which leads to frustrations. In this case, had there been no visible rib fractures on the x-ray, no justice would have been done. This realization is very painful to me and makes the emotional part of my job even more challenging.

I have a couple of stories to tell you that have to do with clothes.

Always Fashionable.

The first patient was a twenty-two year old man who was drunk and crashed his car while racing. He came by ambulance, escorted by the arresting police. He was strapped to the spine board, swearing at and flipping off everyone who tried to help him. He was thrashing around so much we had to sedate him in order to perform studies on him to be sure he was not injured internally.

Several x-rays, scans and hours later, he was ready to go to jail. When he stood to go, it was clear he needed some help with his pants. In order to expose his legs, the medics had slit his long, baggy pants up the front of both legs from the hems to the waistband. When walking, they flopped around has legs so much I was afraid they would trip him. I had him lie back down, grabbed my trauma shears and cut the pant legs off about the level of the hems of his boxers. When he stood again, it was clear they were so loose might fall down when he walked so I grabbed some strips of gauze and tied a loop between the front two belt loops and synched the waist to keep it up around his hips. I was feeling really good about my efforts on his behalf until he stood again to go. The last thing he did before they handcuffed him with his arms behind his back was to grab the waistline of his newly formed shorts and tug them down off his hips so he could be fashionable as he headed off to the hoosegow.

Super commando

There is no rule saying everyone must wear underwear. Yet, I can tell you after many years of seeing people in various stages of undress that the vast majority of people in our society do so. The term for going without underwear is “going commando.” In the emergency department, when I picture going commando, I picture a dirty homeless man or a woman in a very short skirt who was beaten up by someone she expected to pay her for some services rendered. Let me tell you about one patient going commando that was a unlike any other I have ever seen.

She was a nineteen-years-old trauma patient who came in, as they usually do, all strapped down to a spine board. She was nervous but pleasant and cooperative (unlike the first guy) and was dressed in a large, thick, white terrycloth bathrobe. As we got the straps off the board and started to examine her, we realized she had nothing on under the robe at all.

The story was that she got in an argument with her boyfriend. He got mad, bolted to his car and took off. She ran out, got in her car and sped after him without bothering to get dressed. She then drove in a crazy manner that lead to the crash. Fortunately, she was not seriously injured and was soon released into the custody of the waiting Highway Patrol.

Someone referred to her as going commando to jail. Then someone else joked that she was actually going “super commando” as she walked out, hands cuffed behind her back, wearing only her white terrycloth robe.

The triage nurse at the front desk makes a brief note of a patient’s chief complaint. Here are a few unusual ones.  These patients didn’t have anything interesting wrong with them but their complaints were noteworthy.

Big Time Wrestler

A professional wrestler was uninjured during his bout at the fair grounds. Afterwards, someone hit him on the back of the head with a bottle and he was brought in by ambulance, still in his wrestling costume and strapped to a spine board. He denied any symptoms. “I’ve had three concussions and I know I don’t have one now,” he assured me. He seemed to have no injury and was discharged.

Bit by a Dead Hamster

A woman called the emergency department and told the nurse a family member had been bitten by a dead hamster. She was wondering what they should do.

Bus Ride Too Far

An elderly man got on the bus to go from one town to another about 70 miles away. He fell asleep and missed his stop. He snoozed for another two hundred miles. When he finally woke up, he got off the bus in our city. Having no way to get back to where he really wanted to be, he called 911 and was brought to the emergency department.

From Hickeys to Bruises

A thirty-five-year-old woman came in complaining that her boyfriend had struck her on the back and elbow. The only abnormalities on her physical examination were the multiple hickeys she had on her neck. When asked about them, she said they also came from the boyfriend but “before this all started.”

Wanting to Look Good

A 74-year-old woman took ill and hurried to the emergency department. She said she came in sooner rather than later because she didn’t want to be a bad-looking corpse.

Caught His Penis In the Mattress

A nineteen-year-old said he cut his penis when he rolled over and caught it in the spring of an old mattress.

“It must have been a really old mattress,” I observed.

He later admitted he was “messing around with my girlfriend” when it happened but was too embarrassed to admit it.

Bit by His Cousin

A 4-year-old boy was brought in by his grandmother. He was complaining of pain in the penis.

She said she placed the boy and his 5-year-old cousin in the bathtub to bathe. The boy splashed water on his cousin. That made the cousin got mad and he bit the patient on the penis.

The boy’s penis was swollen and purple.

Certified Wart-Free

A man in his twenties came in for a certification that he had no venereal warts. His ex-girlfriend had told his present girlfriend that he had given the previous girlfriend genital warts. His present girlfriend was refusing to have sex with him until he presented her with a certification that it was safe.

Here are a couple of fun activities I heard about by taking care of patients with less than good judgment. If you are bored and looking for something fun to do, you might try one of these creative activities.

Dry Ice Russian Roulette

A 13-year-old boy came in who had multiple lacerations and pieces of glass under his skin, which he suffered while playing a game. He and his friends put water and dry ice in a bottle then quickly closed the lid tightly. They then passed the bottle quickly around like a hot potato until it exploded. My patient was unlucky enough to have been holding the bottle when it exploded.

Try These Pills

Two twelve-year-old boys came in from a group home. One of them had run away from the home and while away, met a girl with a bag of unidentified pills she claimed to have found in a garbage can. He took the pills from the girl and snuck them into the home when he came back. He then shared them with his buddy in crime. They swallowed some of the pills. Others they crushed and snorted into their noses.

Somehow, the people at the home found out and dragged them in to make sure they were not going to be poisoned by their ingestions. After listening to the recent runaway tell his story, I asked him if he was embarrassed telling me what he had done.

He said, “No, because it’s true.” I listened in amazement. He took unidentifiable pills from someone he didn’t know who said she found them in the garbage. He then swallowed and snorted them and he couldn’t see why the doctor might think he was an idiot.

A forty-three-year-old man was admitted to a different hospital in our community. There, he was found to have abdominal pain and fever. A CAT scan of his abdomen showed a mass in the pancreas and he was scheduled for further testing to determine appropriate treatment.

In order to have the test done the next day, his doctor ordered that he not have anything to eat or drink after midnight. When he asked for water, the nurse reminded him the doctor didn’t want him to have any. When further demands for water brought the same results, the patient got mad and signed out of the hospital against medical advice. Rather than leave the premises, he went down to the emergency department and pitched a fit, yelling and throwing furniture around the waiting room.

Police were called. They handcuffed the patient. Rather than take him to jail, however, they took him outside, called an ambulance, filled out a psychiatric commitment form and sent him to our emergency department.

When the patient arrived, he was not confused but was very nasty and uncooperative. When I tried to get him to tell me why he was in the emergency department, he gave me flip, evasive answers and told me to ask the people who took him there. He also demanded water to drink.

After getting very little from him that would help me understand what was going on, I called the other hospital and was filled in on the events prior to his arrival at our emergency department.

What was I to do with him? Since he was on a psychiatric hold, I couldn’t discharge him. I either needed to do further medical testing or send him straight to the psychiatric emergency department.

While I was struggling with my decision, he went crazy. At first, he only thrashed around on the bed. Because of the violent behavior he had displayed at the other hospital and toward the paramedics, he had been placed in two-point leather restraints: a thick leather band around one wrist and another around the opposite ankle, both secured to the bed. These kept him on the bed but he still had two limbs free.

As the nurse and I tried to calm him and get him to relax, he started hollering for a drink of water then started violently rocking the gurney back and forth. Each time he would throw his weight form one side to the other, two wheels of the gurney would lift a little farther off the floor. With each rock, his momentum took him a little closer to tipping over. All this time, he was hollering, “I want a drink of water!”

When the nurse and I intervened to keep the gurney from tipping over, the patient spit straight in the nurse’s face.  Then, he tried to hit and kick us with his free arm and leg.

This turned what had been a measured, calm response to his obnoxious behavior into a full take down. I was standing at the top of the gurney by his head. To keep him from spitting on the nurse again, I grabbed his sweaty, greasy head and pushed his face into the mattress. I held it there as others grabbed his free arm and leg and placed them into leather restraints as well. A sheet was placed across his chest, under his armpits and was tied to the top of the gurney. A specially designed spit mask was placed over his head, allowing him to breath but forcing him to keep his oral secretions to himself.

At this point, I would have just washed my hands of him – literally and figuratively – and sent him to psych. There was just one little problem. He had a temperature of 103 degrees! He obviously needed more medical evaluation.

After a few minutes, the patient tired of his thrashings and settled down. He even started acting almost like a normal person. He relaxed and agreed not to attack anyone. Three of his five restraints were removed and he was given a drink of water. Blood and urine tests were done and I made arrangements for him to be admitted to the hospital to figure out why he had a pancreatic mass and a fever. I am sure they will figure out what is wrong with his abdomen but I wonder if they will figure out what was wrong with his head.

About four o’clock in the morning, we got a ring down for a multiple victim pediatric trauma. That is a strange time of night for kids to be out and about so our curiosities were pricked, wondering what the story would be.

As it turned out, the kids in the car had been visiting their father for the holidays. Mom had picked them up and was driving them home when they were in a nasty single-car crash on the freeway. The paramedics brought all four of them to us: the mother and her three kids.

My first patient was the big brother, age ten. He had been seated in the front seat next to his mother. It was immediately obvious that had a broken femur (thigh bone.) An x-ray confirmed the fracture but we had to do a lot of other studies to make sure he had no other serious injuries. He was very cool and brave given the pain he was in and the excitement of being in a car that rolled over on the freeway.

My next patient was the eight-year-old sister who was pretty banged up and also needed studies to make sure she had no serious injuries. After testing, she got admitted to the hospital for observation though nothing life threatening turned up on the testing. She also was very brave.

The three-year-old brother was hardly injured because he had been in a car seat. He was released to relatives. Their drunken mother also had no serious injuries and was released to Highway Patrol to go to jail for drunken driving.

Anyone who gets arrested for drunk driving has good reason to be bummed out. Besides those feelings, can you imagine how that mother felt knowing that her decision to drink and drive had resulted in her children being injured? No wonder she was crying as they led her off in hand cuffs.

The paramedics who brought in this middle-aged patient said she frequently calls 911 with the same symptoms. This time, however, neither dispatch nor the medics could understand her. Her husband allegedly refused to talk to the medics and police who responded to the emergency call.

When I interviewed the patient, she said, “Yes” to every physical complaint. Except for having a cough, it was obvious her condition was not new. I was unable to understand why she specifically felt she needed to come to the emergency department that night.

According to the patient’s medical record, she suffered for years with daily episodes of debilitating muscle spasms. Typically, her back muscles would tighten and then the spasms would spread to her extremities. This usually occurred in early mornings. The patient had been unsuccessfully treated with various muscle relaxants. Multiple blood tests, CT scans and MRIs were all normal. Finally, a blood test came back positive for Anti-GAD 65 antibodies, and the patient’s regular doctor diagnosed her with Stiff-Person Syndrome. However, no treatment relieved her symptoms.

It’s a real challenge taking care of a patient like this in the emergency department. If someone has some strange disease we have never heard of before, we wonder what bad complication the patient might have and what testing might be helpful. We don’t want to admit the patient to the hospital unnecessarily, but we are nervous to send the patient home, thinking we might miss something.

In this case, we tested her blood and urine and did a chest x-ray to make sure she didn’t have some sort of infection. All turned out normal. Eventually, we were able to get her husband to come in and vouch that she was at her baseline “normal.” He took her home.

What is Stiff-Person Syndrome? Stiff-person syndrome (SPS) is a rare neurological disorder. It is characterized by muscle rigidity in the trunk and limbs and a heightened sensitivity to noise, touch, and emotional distress, which can set off muscle spasms.

Abnormal postures, often hunched over and stiffened, are characteristic of the disorder. People with SPS can be too disabled to walk or move. They are often afraid to leave the house because street noises, such as the sound of a horn, can trigger spasms and falls. SPS affects twice as many women as men. It is frequently associated with other autoimmune diseases such as diabetes, thyroiditis, vitiligo, and pernicious anemia. Scientists don’t yet understand what causes SPS, but research indicates it is the result of an autoimmune response gone awry in the brain and spinal cord. The disorder is often misdiagnosed as Parkinson’s disease, multiple sclerosis, fibromyalgia, psychosomatic illness, anxiety or phobia.

A definitive diagnosis can be made with a blood test that measures the level of antibodies against glutamic acid decarboxylase (GAD) in the blood. GAD is an enzyme involved in the synthesis of an important neurotransmitter in the brain.

Check out http://en.wikipedia.org/wiki/Stiff-Person_Syndrome for more information on this amazing and sad condition.

An eighty-six-year-old lady came in by ambulance with a report of having passed out at home.

When I walked in the room, her two sons were at the bedside. I recognized both of them. Rafael had been a tech in our emergency department years ago. His brother, Cesar, called me by name as I approached them. He had also worked at our hospital in the past. The two were very attentive and gave me their mother’s history.

The patient’s initial evaluation was pretty straightforward. She denied any pain or losing any blood. She had been pretty healthy her whole life. She was pale and her blood pressure was low.

I got busy trying to figure out what was wrong with her. As anticipated from her appearance, she was very anemic. I needed to figure out why her blood count was low and do something about it. When we put a tube down into her stomach, it brought back blood so I figured her anemia was caused by a bleeding ulcer. I ordered a blood transfusion and continued looking for other problems.

As test results and vital signs showed she was getting worse and worse, I shared the information with the patient’s sons along with my increasing pessimism she was going to survive. All the time, I was doing everything I could to save her. At one point, we had fluids, blood and medications running in six IV catheters.

As we approached the end of my shift, the patient took a turn for the worse. The nurse noted her abdomen was distended. I checked her and, sure enough, her belly was blown up like a balloon and very firm. A quick peak with an ultrasound confirmed it was full of blood.

This changed things. Bleeding ulcers are a medical condition, cared for in the hospital by internal medicine specialists. A belly full of blood is a surgical condition. But the patient was not stable enough to even think about operating on her. She was going to die.

Even though I knew no one would operate on her, I asked a surgeon to come and see her to make sure we’d done everything we could do to save this woman’s life. The surgeon came, saw the patient briefly and told the sons there was nothing that could be done.

With the picture of futility now clear, the sons had to decide whether to have us keep making heroic efforts to save their mother or to just make her comfortable as she died. They were clearly troubled by this and still undecided when the patient was ready for transfer to a bed in intensive care. As the sons stood to leave the emergency department, I walked up to Cesar, shook his hand and gave him an abraso: the kind of hug Mexican men give each other. When I turned to Rafael, he fell on my shoulder, wrapped his arms around me and sobbed. Then, rather than release me like Cesar had done, he held me and cried. So did I.

When they walked out, I returned to my writing area, trying to get myself under control to finish up my charting. A co-worker asked how I was doing. I was surprised when I used the word “fun” to describe the experience. What I meant was that it was an emotional, human interaction made even more intense because it was with people I knew. It really was a “fun” experience.