Her Pants Were Too Tight

Written by Tad. Posted in Kooks

My Patient of the Week was really a Mother of the Week. On Wednesday night, I cared for a fourteen-year-old girl who came in with a report of having been found unconscious with her pants down. My evaluations allowed me to feel comfortable she was very drunk and not ill in any other way. In doing so, it was hard to not notice this drunk-as-a-skunk pubescent teen had neck tattoos. I couldn’t help but ask myself, “What the heck kind of a parent would let his fourteen-year-old daughter get neck tattoos?

My plan was to watch her closely until she woke up and then call in the Sexual Assault Response Team (SART) to do an exam on her. Soon thereafter, I was told her mother had arrived. The nurse came up to me and told me the patient was awake and pulling out her IV and the mother wanted to know when she could take her daughter home.

When I went into the room, I found a woman about thirty-five years old with an infant girl on her lap. Other than the sparkles in her eye shadow, there was nothing particularly unusual about her appearance.

I reviewed the known facts with the mother. Her daughter had been found abandoned by her “friends,” unconscious because of drinking too much alcohol. Her pants had been pulled down and there was no way for me to determine if she had been molested or not. I recommended a SART exam be done to make sure her daughter had not been sexually assaulted.

First, the mother turned to the girl and asked her if anything happened to her. When the girl said, “No,” the mother passed that answer to me. I pressed the mother, pointing out there was no way her daughter could know what happened as she was unconscious. The mother then asked the girl how she could know nothing happened and the girl just repeated that nothing happened.

Since the mother was unable to convince the child she needed a rape exam, the mother then turned to rationalization. The first thought Mom used to minimize the significance of all of this was to say that nothing could have happened because the girl’s pants were so tight there was no way anyone could have gotten them down.

The whole conversation was too convoluted for me to be able to reproduce it all but it was amazing to see how little concern the mother showed, how she tried to present everything in the most positive light and how she let the girl decide everything even though the girl was clearly impaired and irrational. After I pointed this out to them and made clear the implications of their decision to leave, off they went, apparently undisturbed by anything that had happened or been said.

 

Bleeding Scrotum

Written by Tad. Posted in Kooks

Our Patient of the Week was 29-years-old and had to be taken down by the police with a Taser (which stands for Thomas A. Swift Electronic Rifle.) He had a long history of psychiatric problems. That night he had been drinking and maybe doing drugs before he slashed his scrotum with a razor. The paramedics reported he was talking “in several languages” but he would not talk to me.

He had very bizarre behavior and had to be tied to the gurney with leather restraints on his ankles and wrists. He made it very difficult to get a good look at his scrotum but I was able to see he had several cuts through the skin with no evidence of any injury to underlying important structures. The bleeding had pretty much stopped.

My evaluation included confirming that he was, indeed, known to be crazy and making sure he was not in need of treatment for any metabolic problems. When I offered to sew up his scrotum, he refused so the nurse dressed it as best she could.

In the mean time, the police who had been called to the scene had learned he was wanted on several warrants so they placed him under arrest. They took him and his dressed scrotum to off to jail.

Not long after he left, the emergency department charge nurse told me she had taken a call from the nurse at jail saying the patient’s scrotum was bleeding and they were sending him back. Though I was pretty sure he didn’t need to come back, I was not too surprised that a nurse at the jail wouldn’t be comfortable with a bleeding, crazy scrotum.

When he returned, he had a little blood in the dressing and no active bleeding. This confirmed my impression that he would have been fine just staying where he was. This time he let me put some stitches in the cuts. Truth be told, it was mostly for sake of the jail nurses.

We have such a focus on first aid in our society that people have a hard time believing that no cut has to be sutured. We do suturing for two reasons. One is to make for a smaller scar. I would say it was not too important in this case. The second is allow the cut to heal up faster which I am sure was of some benefit to him. But, the fact is that, given enough time, ALL cuts will eventually heal. We often hear people worried that if the cut is not sewn, it will lead to infection. Again, the truth is that suturing a cut actually increases the risk of infection.

 

How Long Have You Been in the Hospital?

Written by Tad. Posted in Kooks

One night, I had an amazing patient. It is hard to do justice in a note like this just how amazingly bizarre he was. He came in by police at about 6:00 in the morning. I sat and listened for maybe half an hour while he told me his story.

He developed complications of gastric banding surgery. He was in a Veterans Administration hospital in city across the state for six months before being transferred to a VA hospital close to us where he had been for a year! He told me about how the police had arrived at his hospital room the day before as the doctors pulled out his IVs and drains. He was taken in hand cuffs to jail where he was booked on warrants for old misdemeanors. He told the most pitiful story of illness, innocence and victimization.

As I read through the papers that came with him, there was quite a different story. He was believed to be a sociopath who was malingering in the hospital in order to not go to jail for his felony warrants. He told them he was unable to eat anything so they were giving him total parenteral nutrition (TPN), which means everything you need for survival intravenously. When he was found to be gaining weight, they searched his room and found hidden food. The report went over other crazy stuff they had been putting up with for a year and half with the guy.

On the way to the jail, he told them he felt ill so they took him to another hospital near us where he got evaluated, cleared and sent on to jail. As soon as he got to the jail, the nurse who evaluated him decided he was too sick for jail and refused him, sending him to us. So, after a year and a half in a hospital, being deemed safe for discharge then going to a second hospital where he was deemed safe for jail he is now in my ED. For an emergency physician, this is a nightmare.

I looked at all of his stuff and sent him back to jail. I am told he refused to walk or to sit up on the bench in the custody van so he was taken back on the floor of the van, handcuffed to the underside of the bench. I am sure that was not the last time we will be seeing this guy.

 

I Have Lice

Written by Tad. Posted in Kooks

The other night the paramedics brought in a woman with burns on most of her scalp. The medics said when they got to the residence, the patient was screaming hysterically. They could see a fire had been burning in the fireplace and some partially burned wood was scattered out onto the hearth. The fire appeared to have been recently put out and there was water in and around the fireplace as well as on the carpet, the couch and the patient. When the medics asked the patient what happened, all she would say was, “I have lice!” The best they could guess from looking at the scene was she had put her head inside the fireplace to burn her hair in order to get rid of the lice. Water had then apparently been used to douse her and the fire.

By the time she arrived in the emergency department, she had stopped screaming because the medics had given her morphine. Now she could not keep her eyes open and was unable to answer questions.

She certainly painted a pathetic picture. She was very obese, had no teeth and her tongue kind of stuck out as she snored. Some of her hair had obviously been cut off near the scalp before this event. Most of the scalp and her ears were burned.

I reviewed records from previous visits, which showed she was diagnosed with schizophrenia. Her urine drug screen showed she had taken phencyclidine, also known as PCP or angel dust. That is just the worst combination: a drug that makes you crazy taken by a crazy person.

The burns were not severe enough for her to be admitted to the burn unit so we cleaned her up, dressed her head and sent her to the psychiatric emergency department.

What is that Smell?

Written by Tad. Posted in Kooks

The medics told us he was about sixty years old and lived in his car. He had gotten out of the car and collapsed, unable to get back up. He was apparently on the ground for several hours before passersby discovered him.

The medics said they had tried to get all his clothes off but had been unable to do so because, they felt, his flesh was rotting underneath and some of the overlying clothes were sticking to him. They said the horrible smell coming from him was rotting flesh, not feces (a more common cause of stinky people coming to the hospital.)

As we finished undressing him, it was clear the medics were only partially correct about the source of his bad smell because his pants were full of feces. In addition, his clothes were so dirty they were shiny, slick and just tore apart rather than needing to be cut off. It was obvious something was going on under the sleeve of his left arm, which the medics had not been able to uncover. When I got to that area, I held my breath, cut the sleeve of his shirt at the wrist then tore it to the elbow and pulled the cloth away from his forearm. As I did so, a huge pile of maggots fell down off a large mass on the back of his forearm and onto the floor. Everyone gasped and the emergency technician standing by me screamed. The combination of the putrid smell and the sight of the maggots crawling on his raw flesh and the floor was absolutely disgusting.

I looked around for the intern I had brought in the exam room with me and he was nowhere to be found. When I later asked him why he left, he said he was sorry but he had to leave because he was about to lose it. I laughed at him but totally understood since I actually felt nauseous myself.

As soon as we could tell the patient was medically stable, we sent him to the shower where two unfortunate technicians had to shower him to get rid of his excrement and wiggly guests. We then made arrangements for him to be admitted to the hospital.

 

The Man Didn’t Die

Written by Tad. Posted in Kooks

I had a forty-year-old man come in with perfuse rectal bleeding. He had a polyp removed from his colon two days before. He said there was no problem during the procedure but he had spent the next night in the hospital for some reason and just gone home twelve hours before he rolled into Room 15.

His pulse was fast and his blood pressure was low, signs of hemorrhagic shock. He had piles of clotted blood between his legs and it was starting to drip on the floor and was tracking up the bed under him and on the sides of his back. To complicate things, he was as fat as a whale. In fact, he was so fat, he had a tracheotomy in the front of his neck so he could breath.

Now, all of this was bad enough but he informed me he was also a Jehovah’s Witness and would accept no blood products. Usually, someone who is in hemorrhagic shock and gets no blood transfusion dies.

I took a quick peek at him and it became rapidly clear that, because of his morbid obesity and his shocky state, it was going to be nearly impossible to get an IV in him. This was urgently needed to give him fluids, even if he would not take any blood.

This is why I went into emergency medicine and I went to work. I started calmly barking orders and telling my support staff what I needed them to do to help me. I tried unsuccessfully to get a large intravenous (IV) line under his collarbone into his subclavian vein. He was just too fat to be able to get the needle at the proper angle and deep enough to hit the vein. I tried to use the ultrasound to look for his internal jugular vein but was unable to find it because his neck was too fat. He also was too fat to use any landmarks on his neck to direct my needle so I couldn’t use that approach. In the mean time, I had called the gastroenterologist, telling him to come in and scope the guy to get the bleeding stopped. I felt this was our only hope. I called the intensive care unit physician to get him an ICU bed and I called the trauma surgeon to come help me with the IV. Basically, I was pretty sure he was going to die so I called everyone so no one would wonder why I had just sat there and let him die.

Fortunately, for the patient, two good things happened. First, just as the trauma surgeon got there, I was able to get a huge IV into his right femoral vein so we could get some fluids in him. I was only able to do this after the nurse pulled his belly towards his head so I could get into his groin and get access to the vein. The second stroke of good fortune was the bleeding seemed to have slowed, if not stopped. So, by the time he went up to the ICU, his blood pressure and pulse were stable. If he was going to die, at least it wouldn’t be in the emergency department. I did everything I could and it worked out well. Good story.

I will never win a customer service award for this one, though. The guy, along with presenting a HUGE challenge to caring for him because of his religious beliefs and his morbid obesity, he was a huge whiner, too. I finally got so sick of him asking me if what I was going to do would hurt that I told him to shut up. I said something like, “Sir, you are about to die. Everything I am doing is to try to keep you alive. You have to assume it is going to hurt. Just shut up and let me try to save your life.” I felt bad about it and he continued to whine so I don’t know if it did any good. When he wasn’t whining, he was talking on the phone telling his mother goodbye or mumbling praises and prayers to God. Very interesting.

As it turns out, he didn’t die. In fact, he came back one night the next week to see me again. He told me he got his bleeding fixed by the gastroenterologists and was discharged a couple of days later. He came back in to see me again when he had some pain that freaked him out. Fortunately, he was fine and went home. Still, it gave me a chance to apologize to him for being short with him but also to explain my fears he was going to die and the effect it had on me. He accepted my apology and thanked me as we shook hands before he left for home. It was a nice kind of interaction we don’t get too much of in emergency medicine.

 

14-Year-Old Designated Driver

Written by Tad. Posted in Kooks

A fourteen-year-old girl was the driver of a car that was involved in a motor vehicle accident. She was driving the car at a high rate of speed on the freeway. When the highway patrol went to pull her over, she tried to outrun them and ended up running into the concrete divider of the freeway. She and her passengers were brought in as trauma patients.

The driver was severely injured as were the two severely intoxicated adult male passengers. The patient was admitted to the hospital with her jaw broken in two places, a severe ankle sprain and lacerations on her face. Her blood alcohol level was negative so she had not been drinking but she seemed to be a poor choice for a designated driver.

98-Year-Old Lady Chews Off Her Fingers

Written by Tad. Posted in Kooks

This is, word for word, the note I wrote on this patient’s chart:

Family members called the ambulance when they found the patient chewing on her fingers today. The patient is demented, bedridden and completely dependent for all of her care. She was reportedly more agitated lately including spitting and chewing on things like her blankets. She had no history of self-mutilation but today the patient’s temporary caretaker found her chewing on her hands. The daughter, who normally cares for the patient, is ill herself and hospitalized elsewhere.

On the left hand, fingers 2 to 5 (index, long, ring and pinky) have extensive soft tissue damage. The fifth finger is essentially chewed off with just a strip of tissue left attaching it to the hand. Bones are visible in the other fingers with considerable amount of soft tissue damage present.

The patient went to the operating room for amputation of the fingers.

Impaled on Tree-trimming Equipment

Written by Tad. Posted in Kooks

A young Hispanic man came in telling the nurse he had fallen and been poked in the buttock four days before. He was worried the wound might now be infected.

When I reviewed the story with him, he corroborated the nurse’s note, adding nothing else. Though I speak Spanish fluently, I didn’t have the vocabulary to understand just what it was he landed on. I decided it probably didn’t really matter.

At my instruction, he pulled down his pants and rolled over. He showed me a puncture wound on his left buttock. It was healing nicely and showed no signs of infection.

As I went to reassure him there was no infection, a little something prompted me to wonder if there might be something else going on. I asked him if he thought it possible that a piece of whatever he landed on might have broken off inside him. He answered affirmatively and I sent him off for an x-ray of the area. I had the idea there might be a small chip of metal under his skin causing him some discomfort.

A few minutes later, the x-ray technician called me in to have a look at the x-ray. She was as amazed as I was to see the outline of a metal bar almost an inch in diameter that looked like a round file. One end was right under the skin where he had the wound. The other end disappeared off the film heading towards his pelvis.

We called him back to x-ray where more films showed the metal went clear up into his pelvis. The other end of the file was sitting right in the middle of his bladder!

When I went to show him the x-rays and explain my plan to get it out, I asked him if he had been having any blood in his urine to which he sheepishly admitted.

I called the urologist to our assistance. They took him to the operating room and put him to sleep. They passed a scope into his bladder and took pictures, which he later shared with me. They showed the file coming up out of the floor of his bladder like an empty flagpole. He then cut into the patient’s buttock, grabbed the file with some pliers and, with some effort, pulled it out. The scope was then reinserted to make sure no repair was needed. He was kept in the hospital for a couple of days and left, good as new.

When I see things like this, I frequently ask myself, “What if…?”

He landed on this huge bar with such force it went up through his skin, the muscle of his buttock and the floor of the pelvis before it broke off. It entered the pelvis just off the midline. Had it passed through the center, it could have destroyed many important midline structures. The base of the penis with its blood supply and nerves important for erectile function, the urethra where the urine passes from the bladder to the penis, the prostate, and the rectum were all at great risk in an injury like this. He might have suffered some injury that could have caused him a lot of trouble for the rest of his life. Instead, he was just fine. I wonder how much he appreciates what good luck accompanied the bad luck that caused his injury that day.

Abruptio Placentae

Written by Tad. Posted in Kooks

The nurse called me into the room. A thirty-year-old woman had come in by ambulance. She told the nurse she was four months pregnant and had suddenly started to bleed heavily from her vagina. She was not having a lot of pain.

When I walked in the room, she was lying on the gurney in a hospital gown that was rapidly becoming soaked with blood. Playing around the bed were the patient’s two daughters, about three years and eighteen months in age. They seemed to have enjoyed the ambulance ride and were unbothered by the excitement and all of the blood.

A lot of things happen simultaneously when I face this sort of situation. One look helps get a feeling for how sick the person is. Then vital signs come as an IV is being started and blood tests are being ordered. All of this is happening while I am talking to the patient, listening to her and feeling her abdomen.

Once I get the important information I need and get the treatment and testing started, I do a pelvic exam, which is really where the money is in a patient like this. This lady had a very large vagina and it was packed with a ton of blood and blood clots. I used a big pincher called a ring forceps with balls of gauze-wrapped cotton to remove the blood and blood clots. Over and over again I reached in, scooping blood and blood clots out which splatted onto the absorbent pad I had spread on the floor.

Eventually, I was able to get enough of the blood out to see she was still bleeding but the opening up into the uterus (womb) was still closed. That told me that even though she was bleeding heavily, she was not presently aborting. Now I knew what I needed to tell the obstetricians when I called them.

We got her vital signs fixed with IV infusions. We got blood ready for a transfusion. The obstetricians came down and did an ultrasound that showed an eighteen-week-old living fetus. They examined her down below again and found she was still bleeding. All of this pointed to abruptio placentae, which is defined as the premature separation of the placenta from the uterus.

So, the patient had a perfectly healthy baby, which she wanted, but she was going to bleed to death unless it was taken out of her. The way the OB attending physician put it to the patient was something like, “We want you to be here to take care of the two girls you already have rather than dying trying to have a third.”

The poor lady was in tears as she concented to going to the operating room to have her pregnancy aborted to save her life. Her husband was working in San Francisco and couldn’t be reached and she said she had noone else to come and support her or help her with the girls.

By the time she went to the operating room, she was stable. The girls stayed with us until morning when a social worker could come and try to get some help for them. The lady was sad but I am sure she was grateful to get medical treatment that certainly saved her life.

All of this made me think about what Rick Santorum said about why a woman shouldn’t have an abortion even if she were raped. He said something like, “It is her baby and she should accept it and love it.” I wonder if he would have advised my patient to just go ahead and die rather that have an abortion to save her life. It was very sad and very painful for that woman to have to make such a decision but it was really the only justifiable decision to be made, in my opinion.

 

 

Copyright © 2014 Bad Tad, MD