My patient was a middle-aged man who was severely mentally retarded. He was able to do some things like walk and feed himself but was unable to talk. His caretakers brought him in for a paronychium, which is a small abscess under the cuticle of the finger.

The treatment for a paronychium is to drain it. It is usually done by cutting between the cuticle and the nail, lifting the edge of the cuticle and expressing the pus.

We formed a team: the caretaker, the nurse and I. They held his hand as I made a little cut and squeezed a pretty good blob of pus out from under the cuticle and onto the nail. As soon as the patient saw the pus, he broke his hand loose from their hold, stuck the end of his finger in his mouth, sucked the pus off and swallowed it.

It happened so fast and was so unexpected that we were at first startled, then way grossed out. The patient was completely unfazed.

I had a twenty-year-old man come in worried about an infection in his penis. While recently incarcerated, he had agreed to let a fellow inmate perform surgery on him. An incision was made in the skin of the shaft of his penis. The “scalpel” was a toothbrush handle that had been sharpened by rubbing it on concrete. The incision was made without antiseptic or anesthesia.

Once a hole was made in the skin, a plastic ball, taken from a roll-on deodorant, was pushed up under the skin. The skin was then somehow held together until it healed over, securing the plastic ball under the skin against the shaft of his penis.

The patient explained that he did this in order to improve his sex though it was not clear if it was supposed to make it better for him or his partner.

The patient had subsequently been released from custody and wanted the plastic ball taken out. I easily removed it, using antiseptic, anesthesia and a scalpel not made from a toothbrush handle.

We rarely have pediatric deaths in the emergency department and some of my most painful emergency physician memories are of having to tell parents their child is dead.

We had a three-year-old die this last week. The father brought him in lifeless. We started CPR, put a tube in his airway to press oxygen into his lungs and gave injections of adrenalin to try to get his heart started again.

As do most dead people, he stayed dead. He was one of those “syndrome kids.” He was born with severe physical and mental abnormalities. As a result, he was destined to die and early death like this. That realization blunted the pain in seeing him dead. The pain was also dulled by the realization that he was really dead when he arrived and there was nothing I could have done about it. Still, it was heart wrenching to be with the father as he held the body of his unfortunate son.

While we were trying to revive the patient, I noticed he had obviously been given some sort of a red, sugary, fruity cough syrup sometime before he died. He had vomited so it was all over his face and in his hair. I inadvertently got some of it on myself and the smell of it kind of haunted me for the rest of the shift.

My patient was a man who had torsion of his testicle, resulting in the testicle being dead and needing to be removed surgically. I called the urologist in to see and admit him for surgery.

After seeing the patient, the urologist came up to me and told me the patient had refused to talk to him about surgery or even to let himself be examined.

This really puzzled me. Since the patient was primarily Spanish speaking, I asked if the urologist had used an interpreter. He said the patient’s English was good enough that an interpreter was not needed. This made me nervous. I told him if the patient were refusing surgery, it would make sense to use an interpreter to make sure the patient really understood the risks associated with his decision.

Anyway, as it turns out, the urologist had looked for a patient named Garcia and had gone into the room of a different man named Garcia who was there for chest pain! True, this man primarily spoke English but he also had nothing wrong with his testicle and was not about to talk to anyone about getting his cut off! Fortunately, we were able to identify the mistake, get the urologist to the correct Mr. Garcia and get the right man admitted for surgery.

He was a most pitiful man. He was about sixty-years-old and had suffered a stroke in the past. He was in the emergency department after being found down drunk and unable to walk. Because of his previous stoke, he had a big challenge walking – even with his cane. It didn’t take too much booze to make him quite unstable. He needed no medical treatment and didn’t even need to be in the emergency department at all.

We frequently let people like this sleep the night in the hall, partly from empathy and partly from worry they might injure themselves in a fall or being hit by a car after they leave. The problem with this man staying was that he was so stinky. He was wet with several doses of his own urine, which made him smell most awful. He filled the department with a burning, foul stench. It was not fair to other patients, their families or the ED staff to have him around.

With such patients, we usually offer to let them shower and then find them some clean clothes to wear. In this case, he refused to take a shower or get new clothes. When told he had to leave if he didn’t clean up, he said he would just wait in the waiting room. I told him that was not an option because he was too smelly. So, he grabbed his cane and walked out into the cold, dark night. He chose to stay wet and foul rather than accept the offer of a hot shower, clean clothes and a warm place to sleep the night. It really makes you wonder what makes some people tick, doesn’t it?

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.

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.

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.

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.

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.