Fireball

Written by Tad. Posted in Kooks

A 28-year-old man came in with his mother complaining of chest and abdominal pain after drinking a whole bottle of Fireball Whisky on an empty stomach.  I had never heard of this sweet, cinnamon-flavored alcoholic drink but got the rundown from Xavier, the millennial physician assistant with whom I was working.

As I understand it, Fireball is not really whiskey at all but a cheap liquor that tastes like Red Hots. I understand it is looked down upon by serious consumers of whiskey. The fact that he drank the whole bottle, at home, alone, caused the young staff carrying for him to scorn him, behind his back, of course. The response seemed to be somewhere between, “What did you expect?” and “You deserve it.”

After talking with him and examining him, I was comfortable that he did just have a stomachache caused by his imprudent ingestion. I reassured him and told him I was going to have the nurse come bring him some medicine to make him feel better before he went home.

“Is it natural?”

“I’m sorry?”

“Does the medicine you’re going to give me come from natural sources?” he clarified.

“It comes from a big pharmaceutical factory. There is no reason to expect that anything we might give you here would be ‘natural,’” I answered.

This upset him and he told me he was astounded that we would offer anyone medicine without knowing about the origin of its ingredients.

I then pointed out the irony that someone would drink a whole bottle of Fireball Whisky, which is clearly not natural, yet refuse medication offered by a doctor because it was not “natural.”

“What are you getting at?” he asked.

At this point, his mother piped in, trying to help him understand. He turned, shook his finger at her and told her to stay out of his business. Their conversation quickly turned into an argument and I walked out the door.

I ordered his Maalox, in case he changed his mind about taking something “natural,” and processed his discharge papers.

Which Way is Home?

Written by Tad. Posted in Kooks

While doing my emergency medicine training, I worked in a hospital in Slidell, Louisiana. There, I helped care for a middle-aged woman who was passing through town when she, her young adult son and his wife stopped in town for lunch. Coming out of the restaurant, the lady fell and injured her ankle. X-rays showed a fracture so I splinted her leg, got her some crutches and gave her a dose of pain medicine. She was discharged with a prescription for more pain medicine and instructions to follow up with her doctor in Mississippi. We helped her get into the back seat of the car and prop up her leg. Off they went.

About four hours later, the nurse came to me to ask for help. The lady’s son was there, asking if we could give his mother another dose of pain medicine to help her get home, where they could fill her prescription. It had been my impression that they were headed straight home when they left the emergency department, so I was really puzzled as to where they had been.

It took a while for me to get the clear picture of what had happened and it is still hard to even believe. Rather than head north on I-10, which would have had them in Mississippi within a few minutes, they went south. Thirty-seven miles later, they had crossed the causeway over Lake Pontchartrain and arrived in New Orleans. There, I-10 turns west. When they got to Baton Rouge, 81 miles later, they finally recognized they were going the wrong way. They turned around and by the time they got back to Slidell, the lady’s pain medication had worn off and her ankle was killing her so they stopped in for her next dose.

Going south instead of north on the interstate could happen to anyone. But how could someone drive, in broad daylight, on a 24-mile bridge over a lake, through a major metropolitan area and continue for another hour and half before recognizing that he was heading the wrong direction?

I told you that story in order to tell you this one:

A 53-year-old woman was taken by ambulance to the emergency department in San Jose, California. She had been found driving the wrong way, at 2:00 in the morning, on a freeway going through town. The highway patrol felt she had a medical problem so they sent her to the hospital rather than take her to jail.

The lady was primarily Russian speaking so her broken English and accent made it a bit hard to understand her. In addition, she had schizophrenia. This made it hard to figure out what part of her story was real and what part was a result of her mental illness. So, her story didn’t seem to make any sense and it took quite a while to understand just what had happened to her.

She lived in Yuba City with her brother and elderly mother. Yuba City is about forty-five miles north of Sacramento. The day before, she had driven to Sacramento to visit her brother who was a patient at the UC Davis Medical Center.

After her visit, she had headed west and south for 120 miles to San Jose rather than drive the 45 miles north back to Yuba City.

By the time she got to San Jose, she recognized she was lost. She got scared when she saw the low fuel light go on in her car. Then, “a spirit” appeared in her car and did something to the car. She ended up on the wrong side of the freeway because of the presence of the spirit. That is when she was discovered by highway patrol.

Since she had no medical problems, she sat in the emergency department until the social worker arrived in the morning. The social worker was the one who finally was able to make sense of the whole story. She called the brother, still in the hospital, who confirmed the patient had left there the day before. She called the mother and talked with a sheriff deputy who had been called by the family to help find the lady when she didn’t return to Yuba City after visiting her brother. Her family was very relieved to find that she was alive and well in San Jose.

The woman was obviously not in any condition to drive home. Since her brother was in the hospital and her mother didn’t drive, the patient was put in an ambulance and sent back on the three-hour drive to Yuba City. The car was towed home and the department of motor vehicles was advised of a need to reconsider her driving privileges.

 

 

Three Drunks, Again

Written by Tad. Posted in Kooks

It seems like I have so many drunk stories that one might think this is a blog about drunks. Oh well, here are some more.

Drunk 1

My patient was a twenty-one-year-old who was excessively drunk. The medics pointed out that she had “pathmarks” on her forearm. These, I was informed, indicated how many drinks she had consumed. Sure enough, on her left forearm were hash marks: three groups of four connected by a cross hashes then two singles. Seventeen drinks. Marked and worn, I assume, as a badge of honor. How much honor is there in becoming unconscious and barfing all over yourself? At least I added a new term to my vocabulary: pathmarks.

 

Drunk 2

A fifteen-year-old went to the mall with her friends. I don’t know exactly what happened at the mall (or, wherever she really went,) but she arrived in our emergency department about midnight so poisoned from alcohol that she had to have a breathing tube placed in her windpipe and be put on a ventilator to breathe for her. She went to pediatric intensive care where she still was the following night. As I have mentioned many times, the blood alcohol level to be legally drunk in our fair state is 80. Hers was 659. I have seen above 700 a few times but never in a kid. Amazing. Kids (and adults) do the dumbest things.

 

Drunk 3

Most of my drunk stories are sad or amusing. This was truly horrible: A fifteen-year-old girl went drinking after school with friends. She got so drunk she passed out and didn’t remember what happened to her. She was later found, bleeding and in pain, with lacerations in her vagina from having been raped. That was really terrible to take care of.

 

 

 

 

 

Thirty-two to One

Written by Tad. Posted in Kooks

Emergency department staff deal with a lot of stressful situations. We kind of get used to it, after a while, so most of it doesn’t get to us. Only rarely is something so emotionally traumatic that it really rocks the whole department and each staff member personally. Let me tell you about what I think if one of the most stressful things we encounter in our job.

As I was walking in for my shift, there was a huge commotion going on in Room 6A. I quickly learned they were trying to resuscitate a nine-month old baby boy who had been found unresponsive at home by family members.

I put down my ice chest and Timbuk2 bag and slipped in to see if there was something I could do to help. It is hard for me to adequately describe what was going on. This is as stressful a situation as arises in the emergency department. A baby is dead or trying to die. Everyone is doing everything possible to save a little life with so much potential. Every thing that needs to be done on such a little thing is more difficult than in most adults. IVs are hard to start. The breathing tube is hard to get into such a little windpipe. CPR is difficult to do correctly. It is really challenging and the stress brings appropriate emotions to the surface.

At the bedside were two emergency physicians, an emergency medicine resident (specialist in training,) and two pediatricians. In addition, there were nurses, emergency department technicians, clerks, radiology technicians, and other curious staff. At one point, I counted thirty-two people in the room. I then walked out into the hall and counted sixteen more there, mostly cops and paramedics. You can imagine what a crazy scene that is and that nothing else was going on in any other part of the emergency department.

The team worked well together but, in spite of all of their efforts, there was no response and no signs of life. The resuscitative efforts were ended. That left the emergency physicians with the painful job of telling the family their baby was dead, which is one of the hardest things we ever have to do.

After the shift ended, those caring for the baby had a debriefing session where they could talk about things a bit and make sure everyone was OK. Since we almost never find that necessary, this illustrates how unusual and stressful a baby’s death is for us in the emergency department.

In deaths that are obviously from natural causes, we encourage family members to come see the patient before the body is carried off to the morgue. But in situations like this, there is always the suspicion of non-accidental death so the police treat everything like a crime scene. They won’t let any family members near the baby. That makes it really hard for the family and also for staff to start to come to a resolution. It is really tough.

 

Is this You on TV?

Written by Tad. Posted in Kooks

At work this week, I took care of a middle-aged man who, as he left his house to go to work early in the morning, was beaten about the face and stabbed. He had three serious stab wounds on the L side of his abdomen and flank. The middle one had guts hanging out of it, which is a clear indication for going to the operating room. The surgeons have to cut him open, look around inside, clean every thing up, put things back in place and, most importantly, check for injuries to the bowel and other organs. Oh, and sew him back together again.

As the patient went off to the operating room, I walked out of the trauma room into the hall. I was approached by two young police officers with their standard question in such situations: Does he have life-threatening injuries? They need to know this because the way they proceed with the crime investigation is different if they think it might be murder as apposed to just assault.

After I told them the patient would probably be OK but there was no guarantee, one of the two officers asked me if he could ask me an unrelated question. He then took out his phone, pulled up several pictures he had taken of a talking head on TV and asked, “Is this you?” As he scrolled through the pictures, he told me that when this guy came up on TV, he thought, “That has to be that doctor in the emergency room!” He then took a bunch of pictures because, by his own admission, he was so excited about it. He was paying more attention to the picture taking than to the show so he was not even able to say who the TV said the guy was.

He seemed pretty disappointed when I assured him I was not the guy on TV. “I can see the resemblance,” I said, mostly to make him feel better. “But I am a lot more handsome than he is.” The cop laughed, as did his partner who added that he agreed.

It was pretty funny and I was surprised that a cop, who I would never have even recognized, would have been taking pictures of someone on his TV because he thought he was taking pictures of me.

 

Three guys in the Solarium

Written by Tad. Posted in Kooks

We used to put drunks in the little anteroom at the ambulance entrance. I lovingly called it “The Solarium.” The word “solarium” comes from the Latin, sol, meaning sun. I think I picked that name with obvious irony, given I only work at night.

Usually, the drunks would just sleep there until they woke up and could walk. One night, three drunks who were parked in the solarium didn’t follow this predictable pattern. I recorded the interesting problems that each presented.

First was a skinny, young guy with scrapes on his knees and elbows. He was brought in by ambulance after he was found on the ground, intoxicated. He was too drunk to safely walk but he kept trying to get out of bed. We were worried he might fall so he had to be restrained for his protection. When his ankles and wrists were tied to the bed, he went ballistic.

It is not unusual for us to have to restrain and sedate intoxicated people for their protection. I ordered a shot of droperidol, a commonly used sedative.

He relaxed a little after the shot but soon got more agitated. I thought he just needed more droperidol. He was given another shot but got even worse after that was given.

I then wondered if he were having what is called an extra-pyramidal reaction, a common side effect from this medication. The antidote for an extra-pyramidal reaction is a shot of Benadryl, which he got.

Rather than settle down, as I had expected, he got worse still. The Benadryl was repeated. He got even worse still. His pulse went up to 190. He was sweaty and agitated and wouldn’t talk. He pulled violently against his leather restraints.

I was then worried he might have some other medical condition, rather than just being drunk. Laboratory tests and a toxicology screen were ordered. His alcohol level was 215. (Remember that 80 is driving limit in our fair state.) That is high but I didn’t think it high enough to explain what was going on. Everything else came back normal.

Eight hours later, he sobered up and said he freaked out because he just hates to be restrained. He got himself dressed and walked out perfectly fine.

 

Next was a sixty-year-old man with huge belly. He was also brought in by ambulance for intoxication. He was unable to talk clearly.  He was watched until he was perfectly awake but still had unintelligible speech and could not walk. I noted a broken-down wheel chair at his bedside so wondered if he usually was unable to walk. He couldn’t tell me and he had never been to our hospital before so we had no old records on him. I offered him paper and pencil but he was not able to write, either. I then was concerned because I was not able to determine if this condition was from some old problem like a stroke or if he might be having some new, worrisome illness. What a nightmare!

I ordered tests on him that all came back normal. He still was not able to talk. I made a plan to just keep an eye on him over night and see if social services could find out something about him in the morning.

Eight hours later, he was sober enough to communicate. He told me he was fine and walked well enough to be discharged. He left, pushing his wheelchair in front of him.

 

Finally, I had a man in his 20s who had walked into jail then collapsed, unable to stand or walk. The jail nurse refused to accept him and the arresting officer loaded him into her patrol car and brought him to us.

The officer said he had been walking and talking when she arrested him and she felt he was faking. After I examined him, I was also suspicious he was pretending. He wouldn’t stand or walk but woke up when smelling salts were placed under his nose. When we forced him to stand, he let himself go to ground. We picked him up and put him back in the bed to sleep. Later, the officer called me when he climbed back onto the floor. When instructed to do so, he got up and crawled onto bed without any difficulty but would still not stand or walk.  The poor officer was super frustrated. She wanted to just give him a citation and leave him but, because she didn’t know his name, she was not able to just cite and release him. She had to sit with him all night long until he was sober enough to get up and walk out to the patrol car, still refusing to give his name.

 

Three Drunks

Written by Tad. Posted in Kooks

Never Too Young To Start

Our 11-year-old patient left home with his 13-year-old cousin to go visit friends. When the mother’s boyfriend went to pick them up, he noticed they were not acting right. After asking a few questions, he learned they had been drinking tequila. The boyfriend took them home and put them to bed. Later, when the mother arrived home, she was unable to wake her son. So, she called the paramedics who brought him to the emergency department. He was unconscious, unresponsive and was found to have a blood alcohol level of 168, which is double the legal level for adult drivers in our state. He had to be admitted to the pediatric intensive care unit and watched carefully overnight.

 

Open Bar at Your Local Emergency Department

Paramedics brought in a very drunk 54-year-old lady at 11:00 PM. Her blood alcohol level was 302. Remember, in our state, a blood alcohol level of 80 will land you in jail for driving under the influence.

Our usual practice in these situations is to keep a close eye on the patient until she sobers enough to call for a ride or leave on her own. At 3:30 in the morning, she seemed to be getting worse rather than better. I guess we didn’t watch her as carefully as we should have because, when she tried to get up to walk, a vodka bottle fell onto the floor. Her repeat alcohol level was 450.

 

A Man Stands Up for His Constitutional Rights

A man was arrested for being drunk in public. The police brought him in to get cleared to go to custody. When I asked him if he had been drinking, he said, “I’ll have to take the fifth* on that.”

* Paraphrased from Wikipedia:

In the late nineteenth century, liquor was often sold in bottles which appeared to hold a quart but, in fact, contained 2, 3, or 4 fluid ounces less than a quart and were called “fifths” because they held about a fifth of a gallon. The fifth was the usual size of bottle for distilled beverages in the United States until 1980.

 

Don’t Try This While Drinking

Written by Tad. Posted in Kooks

Designated Passenger

I had two patients from a single car crash. He was the driver and she was the front seat passenger. Neither was wearing a seat belt. She told us that he was very drunk and went to get in the car to drive away. Though she was also drunk, she was afraid to have him drive while being so drunk so she jumped in the car with him “to make sure he was OK.” He caused a crash in which they were both seriously injured and brought to the emergency department.

We, in the emergency department, are all in favor of designated drivers but I am pretty sure that the people who came up with the idea of a designated driver did not were not thinking of a Designated Passenger.

Hot Tubbing

A middle-aged man had so much to drink before climbing into the hot tub at the hotel that he soon slumped under the water and nearly drowned before other guests noticed him. They pulled him out, started CPR and called 911.

Because of the effects of the alcohol and the near drowning, he had to be placed on a ventilator and be admitted to intensive care. He had a significant chance of having permanent brain damage or even dying because of the lack of oxygen to his brain while he was under the water.

 

Gambler’s Fallacy?

Written by Tad. Posted in Kooks

My wife, Shari, forwarded me a link to a segment on NPR about Gambler’s Fallacy. In short, Gambler’s Fallacy refers to our brain’s tendency to see patterns in random events then thinking those patterns can predict future events.

A simple example is a gambler betting on whether a flipped coin turns up “heads.” Each coin flip has a 50:50 chance of resulting in “heads.” If, in a series of flips, “heads” come up several times in a row, the gambler thinks the next one just has to be “tails,” even though heads is still a 50:50 chance in each flip. The gambler puts all his money on “tails” since, after so many “heads” in a row, the next throw just has to be “tails.” He looses his money when “heads” comes up again.

An interesting example of the Gambler’s Fallacy played itself out in our emergency department last week.

I was seeing a 9-year-old girl who had abdominal pain for three days. From her examination and laboratory tests, it looked for all the world like she had appendicitis. Coincidentally, her 12-year old sister had just had her appendix taken out that day in our hospital.

My patient got sick the day after her sister. Her family had just kind of ignored her complaints because she had not seemed very ill and everyone’s attention was drawn to the sister who had been admitted to the hospital for surgery.

Eventually, Mom and Dad brought her to the emergency department wondering if she might also have appendicitis. Everyone taking care of her saw that she had the symptoms of appendicitis and that her abdomen was tender like you would expect in someone with appendicitis. But no one was willing to take her to the operating room and cut out her appendix because her sister had just had the same operation. It was such a big coincidence that it made everyone uncomfortable.

Still, the 9-year-old was too ill to send home, so she was admitted to the hospital for observation. The next day, it was clear she needed an operation. Operate they did and, sure enough, found her to have appendicitis.

So, two sisters both came down with appendicitis within a day or two of each other and both had an operation and were in the hospital at the same time.

Here is the link to the NPR story on Gambler’s Fallacy:

http://www.npr.org/2015/12/29/461352879/how-the-bias-known-as-gamblers-fallacy-effects-our-lives?utm_source=npr_newsletter&utm_medium=email&utm_content=20151229&utm_campaign=npr_email_a_friend&utm_term=storyshare

 

Barf

Written by Tad. Posted in Kooks

I have been thinking tonight, for some reason, about vomit. Not just vomit but also vomiting. I think I will give an overview of my life’s experience with vomit and vomiting and some highlights, if you will, of my medical experience with the same.

Our daughter-in-law, Elizabeth, claims to have never barfed in her life. I have vomited so many times that it just seems to me like a normal thing to happen to all humans. Usually vomiting is caused by eating something bad (“food poisoning”) or an intestinal virus (“stomach flu”) that you catch from another person.

It is so common that I am amazed when people come into the emergency department and think they are dying because they are vomiting. Or they want to know exactly why they are vomiting and are amazed when I am unable to tell them.

I remember the first time our son, Philip, vomited. He was about a year old. We were sitting in church and out it came, all over. I grabbed him up, put my hand over his mouth and ran out, vomit dripping behind us. I remember looking at him later in the day and feeling so sorry for him. I knew he would be fine but still felt bad for him, especially being so little and unable to understand what was happening.

When our daughter, McKenzie, was about the same age, she vomited grape juice on the dining room floor, which left a purple stain that was with us until we got new carpet.

Our daughter, Hilary, always seemed to vomit when we were traveling. She spent the night vomiting into a stinky pit toilet on a night fairy in Thailand when she was about eight. We never even knew she had done so until morning, when she gave told us about it. She did the same on Christmas Day in a yucky airport bathroom in Peru.

The first truly memorable vomit I remember as a medical student came when I was working at the Veterans’ Hospital. I was caring for an elderly patient who had a blockage in his rectum. Nothing could go out down below so he was vomiting stool. I would have been totally grossed out by the idea of vomiting poop but watching someone actually do it was pretty hard for a new medical student to take. I remember really feeling sorry for him as we tried to provide him some relief.

Blood causes the most exciting vomit. People with ulcers can vomit some blood, which can sometimes be dangerous, but liver patients are the ones with really scary bloody vomit. They develop esophageal varices which are swollen, engorged veins running around the lower esophagus. The blood in them is under an unusually high amount of pressure and, if they bleed, they really bleed. I am talking about huge volumes of pure blood, gushing out, uncontrollably. When this happens, it is about as scary as anything I have to deal with as an emergency physician. Someone like this can die, and die fast, so a huge effort is launched to control the bleeding and replace what is being lost. It is not unusual in this situation to end up with blood all over the patient, the bed and bedding, the curtains and walls and the healthcare providers. This is exciting vomiting.

I recently posted on this blog about the boy who had pancreatitis and we only discovered the cause when he vomited a huge pile of wriggling, waxy-looking round worms. He admitted he had vomited worms at home but had flushed them. He didn’t tell anyone because he was embarrassed. Everyone there was truly grossed out by vomiting worms.

Another noteworthy episode of vomiting came from the only patient I have ever taken care of who was struck by lightening. He was in his twenties and had apparently just finished eating a luncheon-meat sandwich before being struck by lightening while seeking shelter from a big thunderstorm.

He was lucky enough to quickly have his heart returned to a normal rhythm. As he was coming to, he vomited, which is not unusual in such a situation. What was unusual was that the sandwich meat all came out in rounds, the size of his mouth, with jagged edges from where his teeth had bitten off the meat. The fact that the meat was still in these rounds proved he had swallowed the meat without having chewed it. When he recovered, we discovered he was developmentally disabled, perhaps explaining why he would wolf down a sandwich without chewing it.

All little babies urp up their milk. This bothers some new parents who bring the baby in to the emergency department worried it might be something serious. Most of the time, it is not serious but sometimes it is. One vomiting condition that can develop in little babies is pyloric stenosis. The muscle around the opening from the stomach to the first part of the small intestine is too thick and keeps the baby’s food from passing out of the stomach. These kids get real vomiting, not just urping up. In is often described as “projectile vomiting,” to differentiate it from normal baby barfing. My parents say that when my little brother had this, he vomited so badly and lost so much weight that they were afraid he would die. Once the diagnosis is made, this is easily treated with a minor surgery and the baby is back to milk and normal baby barfing again.

I see and hear people vomit every day at work. Still, as you can see above, not all vomiting is created equal.

Copyright © 2014 Bad Tad, MD