A young man came in about 3:00 in the morning worried he had overdosed on medicine for pinworms. He said he was standing in front of a convenience store when a passerby noticed him “itching my butt.” The other man told the patient he probably had pinworms. The other guy also said he just happened to have some pinworm medicine, which he offered to my patient. After taking one of the pills, my patient started getting worried he had overdosed, though he had no symptoms. He came to the emergency department and brought the pill bottle with him.

What he said he took was Worm-Ex. It is a broad-spectrum antiparasitic. This formulation was from Mexico and was specifically made for treating roosters used in cock fighting. Hence, the rooster logo on the nice yellow pill.* The bottle was clearly marked (in Spanish): For Veterinary Use.

The ingredients in the pill can also be used to treat parasitic infections in people so there was not a real worry about toxicity from taking medicine designed for animals. Also, the pills were for treating a rooster so you can rightly assume the dose was well below what one would prescribe to a human who needed to take the same medicine.

I explained to my patient that he had no reason to worry. The medicine was safe for humans to take and he took a very low dose. Though he had been unwise to take the medicine given to him by some guy in front of a convenience store, it was not dangerous and he need not worry at all about the consequences of his unwise decision.

This did not reassure him at all. He insisted that we pump his stomach as he was sure he was going to be poisoned. I questioned him some more as to why he was so worried. He insisted he had only taken one of these pills and nothing else. He assured me he had not wanted to hurt himself.

I tried all the logic I could think of to get him to see that, if he just took one of these pills, he had nothing to worry about. No matter what I said, he kept insisting that he was poisoned and needed his stomach pumped. By the time this went on for a while, I started to wonder if anything he was telling me was true. The idea that someone would see you itching your butt in front of a convenience store in the middle of the night, diagnose you with pin worms and just happen to have pinworm medicine to offer you just seemed too crazy to be true. But, was what really happened just as crazy? We will never know because he adamantly stuck to his original story and persistently refused to be reassured that he was not poisoned. He left a very unhappy patient with a very puzzled doctor.

A middle-aged man with a black eye and scrape over his cheek sat on the gurney, obviously upset. He said he went into the local McDonalds to take a dump. Just as he was settling in to do his duty, a “crazy guy” he had never seen before broke into the stall hollering at him and accusing him of some insult.

The crazy guy got even more upset when my patient denied what he was being accused of and hit him across the face.

It was clear my patient’s face was not seriously harmed, so I asked if he had been injured anywhere else. In response, he pulled the sheet off his lap and showed me a large gash in his leg and a big blood clot on the end of his penis.

My mind started to spin. Something didn’t make sense. The man’s pants were clearly not cut, but he had serious injury to his genitals. I actually opened my mouth to ask him to explain. Then, I remembered an important detail and shut my mouth again. The patient had told me right at the beginning that he was attacked while taking a dump at McDonalds. In that situation, his pants might have been removed from danger but he would have been even more vulnerable.

I have never seen a penis injury like this before. The knife cut the foreskin in two and nipped off the very tip of his penis. It was still bleeding quite a bit.

We cleaned him up. I stitched the laceration on his leg. I put some stuff called Surgicel on the bleeding part of his penis. It helps promote clotting. And I had him hold pressure on it. Then, I made arrangements for him to be taken to a larger hospital for evaluation by a urologist. I really have no idea what sort of treatment they might recommend for this injury. If you cut the tip of your finger off like that, you just need to keep a dressing on it and it will heal up fine. But a nipped penis? I have no idea.

So, lesson learned: keep your pants up when you are taking a dump at McDonalds.

My patient was a 60-year-old woman with lower abdominal pain. Her evaluation led to a CT scan which showed a very large pelvic mass, thought by the radiologist to be worrisome for ovarian cancer.

I frequently tell people we don’t diagnose cancer in the emergency department, which is technically true. But in a case like this, where it is very likely to be cancer, I have to be honest with the patient about what I have found. I pulled up a stool at the bedside and calmly told her what the scan showed. I clarified that it was most likely cancer and that I had made some phone calls to arrange to send her to see a gynecology/oncology specialist to get a definitive diagnosis and start her on the treatment she might need.

As the gravity of my news set in, she started to quietly weep. She was a nurse and understood, better than most of my patients, just what she might be facing. She quickly got hold of her emotions and then said she would not be taking me up on my offer to transfer her to see the cancer specialist. Her husband had cancer, she said. He was due to start his next round of chemotherapy the following day and she needed to be there to care for him. She had no time to care for herself. She would just go home and deal with her own problems when she could.

As I sat at her bedside, I was really moved emotionally. I saw a person who understood that delaying her treatment could lead to her death. But she cared more about her husband’s welfare than her own and felt she really had no choice in the matter.

I discharged her with the information about the specialist, with hopes she would find a way to go and get the consultation she so badly needed. I was unusually sobered and emotional when she left. As I recognized the effect this was having on me, I tried to understand why this affected me so much more than I would have expected.

One part of it, I am sure, was just the beautiful selflessness. All she cared about was taking care of her husband. Also, I could really relate. I am about her age and am married to someone I care about much more than I care about myself. I think her situation really hit close to home, leaving me very empathetic, with all the associated emotions.

Fortunately, this story has a happy ending. She came back a few days later. She had gotten her husband all set with his chemo and rounded up some social support as well. She went on to have surgery and was told it was not cancer, after all. So, fortunately, this story doesn’t have a tragic Shakespearean ending like I originally feared it would.

A thirty-five-year-old man with a history of drug and alcohol abuse as well as mental illness, eloped from a long-term residential rehab facility in Georgia. He flew to our fair, California city to watch WrestleMania. I don’t know if he enjoyed the show or not but while here, he relapsed and fell into drinking excessively and taking methamphetamines.

This landed him in our emergency department, from which he was sent to psychiatry. There, he was evaluated and discharged. The psychiatrist said he could not be held against his will because he was not a danger to himself, a danger to others or gravely disabled. She noted he was sorry for what he had done. He promised to go to the airport, fly back to Georgia, return to his rehab and resume care with his psychiatrist.

If he really did make that promise to the psychiatrist, he didn’t follow through. In the subsequent week, he was kicked out of three different hotels because of problems caused by his excessive drug and alcohol abuse.

He was readmitted to our emergency department during my shift. In addition to being addled from methamphetamines, he also had severe conjunctivitis or eye infection. Both of his eyes were so swollen, red and yucky with dried discharge he was unable to open them. Usually, conjunctivitis is an annoyance. This man’s eye infection was particularly bad because his methamphetamine use caused him to dig and pick at his eyes constantly. He was aware enough to feel the irritation in his eyes but not aware enough to stop digging at them.

When we met, he was sleeping on a gurney in the hallway. I prodded him and called his name. He moaned and shifted a bit but was unable to talk. He was also unable to open his eyes because they were, literally, glued together with crusty yellow discharge. I had to pinch his upper and lower eyelids and pull them apart in order to see his red, swollen eyes underneath.

My plan was to observe him until his drugs wore off and then discharge him with antibiotics.

Over the next several hours, his mental status gradually improved and he was finally able to converse. He told me about coming to California because he loved WrestleMania. He admitted he had been drinking and doing drugs and, though he said he was sorry, he also admitted he had no plans to change any of his present behaviors when he left the emergency department. He also had no plans to return to Georgia any time soon. He denied having suicidal ideas, though he acknowledged that what he was doing was bad for his health. Though he was better, he was still not able to open his eyes or walk.

During this time, his mother called from Georgia. She demanded to talk with every staff person who would talk to her. Finally, it was my turn.

The mother made several demands. First, she wanted her son admitted to our hospital. To that, I explained he didn’t have any medical condition that would justify a medical admission. No one would admit him just because he was doing stupid things that were not good for him. As soon as he could walk, he would be ready for discharge.

She then demanded he be sent to psychiatry. She knew about his previous admission to that unit in our hospital. She told me the psychiatrist who discharged him said if he didn’t follow through on his promise to fly back to Georgia it would be proof he was a danger to himself and he would need to be committed.

I told her taking someone’s rights away is not something to be done lightly. We don’t do that just because someone is making very bad decisions, as in the case of her son. He would not be going back psychiatry.

She next insisted we call the police, have them take him to the airport and force him to get on the airplane home. I was amazed when I couldn’t get her to see there was no way the police would do that.

The mother consistently refused to accept any of my responses to her demands. She kept saying things like, “You just don’t understand. His life is in danger if you don’t do this.”

Things with the mother went from bad to worse when her son refused to get on the phone with her. “I don’t want to talk to her,” he said.

“Tell him I won’t scold him,” she assured me. That was not enough to get him on the phone with her.

I was unable to discharge the man before my shift came to an end. Though he had been in the emergency department for fifteen hours, he was unable to walk unassisted to the bathroom and he still could not keep his eyes open. I had to admit him.

After a day in the hospital, he was well enough to leave. The admitting doctor spoke to the patient’s mother on the telephone before discharging him. During that conversation, the mother threatened to sue the doctor and the hospital if they released her son. In part because of that threat, the doctor agreed to keep the patient one more day until the mother could fly out from Georgia to get him, which is exactly what happened. He was sent home the next day with his mother.

As I come up with stories to share with you, I often pick them to exemplify different challenges we face as emergency physicians. Here is an example of something we face not too infrequently: a patient we couldn’t get rid of.

The evening shift doctor had seen her initially when she complained of vaginal bleeding and anemia. He found she was not bleeding and her blood tests showed no anemia. She was discharged just as we were changing shifts. I was warned that she didn’t want to leave and might give me trouble.

Sure enough, about an hour after I took over, the nurse came to me and told me the patient was still nauseous and was not up to leaving. I ordered some nausea medicine.

An hour later, I asked the nurse why the patient had not left the department. I was told she was unable to get a hold of anyone to give her a ride home. I asked that she be put out in the waiting room to await a ride. This is standard procedure when we are busy. The bed is needed for another patient and there is nothing wrong with someone waiting for their ride in the waiting room.

About three hours after I came on duty, she was finally out in the waiting room. But not for long. I soon was advised that she had feigned passing out and had to be brought back into an examination room. When I saw her, she was clearly pretending to be unconscious. I was too busy to deal with her at that time. I left her with the nurses to recheck her vital signs while I hurried off to take care of other, more pressing patient concerns.

Soon, I was able to spend some time reviewing her situation so I could decide what to do next. She was a relatively young, healthy lady. Her vital signs and laboratory tests were normal. She had already been in the ED for almost seventeen hours and nothing wrong had been found. She needed to leave. Still, always haunting the back portions of an emergency physician’s mind is the question: What might I be missing?

At this point, I had only two choices: force her to leave or admit her to the hospital. I mentally ran through both of those options in my head. We admit people to the hospital to receive medical care not available as an outpatient. This patient was in no need of such care. I couldn’t ask the admitting doctor to see her if it was clear there was nothing wrong with her. I had no choice but to accept a certain liability and send her out, even if she didn’t want to leave.

First, I had to wake her up. I was sure she was faking her unconsciousness. I proved this with an ammonia capsule. This is the modern equivalent of smelling salts.* A concentrated liquid ammonia compound is held in a small, thin-walled glass vial surrounded by an absorbent material. The vial is broken by being compressed between two fingers, releasing a strong ammonia smell. It is placed under the nose of the “unconscious” patient. No conscious person could continue to pretend to be unconscious when one of these is placed under his/her nose.

As I expected, her first reaction to the ammonia was to hold her breath. Tears then started forming in her eyes. When she was not able to hold her breath any longer, she turned her head to get her nose away from the capsule. I followed her, keeping the annoying, irritating stimulant under her nose until she was forced to talk to me.

“Why don’t you want to go home?” I asked.

“I don’t feel good,” was all she could come up with.

“I am sorry, but you are going to have to leave. Do you have anything you want to ask me?” She had no reply so I instructed the nurse to discharge her.

She had occupied a bed in our emergency department for almost eighteen hours by the time she walked out. How sad that someone’s life would be so messed up that lying around an emergency department pretending to be ill was better than anything else she had going on.

*https://en.wikipedia.org/wiki/Smelling_salts

After 27 years of working in a big, urban hospital, I switched to a small, community hospital. The biggest adjustment for me is the difference in access to resources. In the big city, we had access to all the equipment and specialists that might be needed. We rarely had to transfer patients out to other facilities for additional care. Now, I do not have all those supports and it can be stressful.

For example, a young Hispanic couple brought their 1-year-old daughter to our small, community hospital at three o’clock on a Sunday morning. They were concerned about bruising and swelling around her right eye. She had been born with a clouding of the cornea – the clear part on the front of the eye. However, the parents had been told their daughter’s eye was otherwise normal.

The parents said the bruising and swelling started the day before and had gotten worse. She had not been injured and appeared to be in no distress. The father even pointed out that it didn’t seem to hurt her when he pressed on it. She was behaving completely normally.

Looking at her eye, I could see that the cornea was, indeed, cloudy. The conjunctiva, the white part, was also a bit red. There seemed to be no pain or tenderness although there was bruising, as the parents had noticed. Bruising and swelling often indicate trauma. However, I did not detect swelling and there was no reason to suspect child abuse based on the way the parents and big sister behaved.

All that aside, there was clearly something wrong. She had proptosis. Her right eye was bulging out farther than the left one. Neither did it seem to move normally, though that was a bit hard to test in a one-year-old.

Acute proptosis may be caused by infection. If you get infection around your eyeball, the swelling causes the eye to push forward abnormally. In this situation there was no history of fever or other signs of infection. And, again, the kid was acting perfectly fine. It seemed impossible she had an infection severe enough to cause proptosis and still feel well enough to play normally with her sister.

My dilemma was: “Does this kid have something acute going on that needs me to transfer her to another hospital for care tonight? Or, is this something that can wait until Monday morning when she can see her primary care doctor and be referred to a specialist?”

I decided the only way to know was to scan her. This presented another challenge. A CAT scan would probably give me the information I needed, but we try to avoid CAT scans in kids because of the ionizing radiation it exposes them to. The earlier in life you get radiation, the more likely it will end up causing cancer many years down the road. An MRI scan would be a safer test since it would not cause exposure to radiation, but there was no MRI in our small hospital at night or on weekends. In order to get that test, I would need to transfer her to a bigger hospital where they had MRI available. However, the whole purpose of getting the scan in the first place was to help me decide if she needed to be transferred!

I finally decided it was important enough to justify getting the CAT scan done at our hospital. It showed a mass behind the eye that the radiologist said could be either a hemangioma or a sarcoma. A hemangioma is an abnormal and benign wad of blood vessels that you are born with. A sarcoma is a tumor that is usually malignant. Either of of the two would cause the baby’s eye to be pressed forward.

My impression was that if the baby was born with a hemangioma, the doctors would probably have picked up on it when they evaluated her cornea. I think the mass was a tumor that had been developing slowly. As it gradually pushed the eye forward, a little vein ruptured causing the non-tender bruising the parents noticed.

Though the situation was serious, there was no reason to transfer her to a higher level of care in the middle of the night.

The poor parents. Though I did my best to explain the situation, I don’t think they really understood what they were up against. They took off to put the baby back to bed.

A young man and woman were having an argument. She pulled out a switchblade knife with intentions of using it on him. He wisely turned and started to run away. Just like in the movies, she snapped the blade open and threw it at him. It struck him squarely, burying the three-inch blade deep into his back. He collapsed to the ground, moaning in pain. Someone at the scene tried to pull the knife out but, being unable to do so, called 911.

Our evaluation, including x-rays and scans, failed to demonstrate any evidence of serious injury. He was taken to the operating room where the knife was removed by a spine surgeon.

The blade could have stabbed his lung, spinal cord, esophagus, windpipe or a large blood vessel like his aorta. But, it happened to hit him in just the right place so that only skin and muscle were cut and the point of the knife was buried in the bone. All of these tissues would heal nicely. I’m sure the same could not be said about his relationship with the girlfriend.

The Deadest Person

It was the end of my shift and I was just leaving Slidell Memorial Hospital in Louisiana when I was called back. The paramedics had just alerted the Emergency Department that they were on the way with a severely injured trauma victim and my help was needed.

The patient was about thirty-years-old and was not wearing a helmet when he crashed his motorcycle into a car at high speed. He was thrown under another car, which ran over him. A voluntary ambulance crew picked him up and rushed him to our emergency department, performing CPR.

Since the patient was not breathing, I was assigned to intubate him by placing a tube into his windpipe so we could ventilate his lungs with oxygen. As other members of the team quickly performed their assigned duties, I easily passed the tube, secured it in place and then started to blow oxygen down the tube. What happened then caused everyone to stop what they were doing. With each push of oxygen down the tube, he started to puff up. His neck expanded and air bubbled out of a cut near his eye. His abdomen started to expand, then his scrotum. Each time I pumped in air, his scrotum puffed up a bit more until it was the size of a grapefruit. When I pinched the enlarging scrotum, air was forced out of a large cut over his hip. He was pronounced dead.

An autopsy done the next day showed multiple fractures of his extremities and spine. In addition, he had at least four things that would have killed him: His head was completely dislocated from his upper spine. His left lung was completely ripped off with extensive damage to all the other organs in his chest. There was a huge hole in his diaphragm, which separates the chest cavity from the abdomen. His liver was completely demolished. His pelvis was severely crushed. All of this explained why he had puffed up as we blew oxygen into his wind pipe. The oxygen went down the windpipe and into his chest cavity. It then passed through the hole in his diaphragm into his abdomen. The crushed pelvis allowed the air to continue down into the scrotum and out the hole over his hip.

This was the deadest person I have ever taken care of.

The Insanity of My Addiction

Paramedics were called to a house where a twenty-six-year-old man was having a severe allergic reaction after injecting methamphetamines. He told the medics he didn’t think it mattered what he mixed the meth in before injecting it. So, since he had some handy, he had used grape juice. Soon after injecting the juice-meth mixture, he started to feel terrible and called 911.

The medics found him in severe distress with fast heart, low blood pressure, swollen face and diffusely red skin. They correctly diagnosed a severe allergic reaction resulting in anaphylaxis and appropriately treated him for the same. By the time he got to the emergency department, he was feeling a lot better.

When I talked with him, he confirmed he had injected meth mixed with grape juice and he didn’t seem to think there was anything strange about having done so. He said he had done the same in the past, and he was sure the problem that day was caused by dirt in the cup he used to make up the mixture.

When I asked how often he used meth, he answered, “How often do I not use meth?” I asked him if he wanted to be smart with me or if he wanted to give me serious answers so I could take good care of him. He said he was not being smart. He used all the meth he could get ahold of.

Since a severe allergic reaction like this can be life-threatening, we watched him for several hours. None of his worrisome symptoms came back, so I went to talk to him before he was discharged. I pointed out that most people would not think it was a good idea to inject grape juice into their veins. He reiterated that he thought it was contamination that caused his problem. I pressed him, again, that it was unwise to inject things not designed for that purpose. He thought for a moment and then agreed, saying, “That’s just the insanity of my addiction.”

Fireballs of the Eucharist

Early in my emergency medicine training, a woman came in screaming because of severe abdominal pain. She told the nurse she suffered similar pains in the past because of “fireballs of the Eucharist,” which we interpreted as fibroids in her uterus. She said she had not had a period for three months but was sure she was not pregnant as her periods were always irregular. She was so upset by her pain that we had a hard time getting more information from her. From the way she looked, I thought she was dying from a ruptured ectopic (tubal) pregnancy or something terrible.

She said she needed to move her bowels but was unable to do so after the nurse helped her onto a bedpan. By then, we had an IV in but she was not responding to pain medicine. In fact, she seemed to be getting worse. She screamed, “Somethings coming out down there!” I slipped on gloves and slid my fingers in her vagina. What I felt puzzled me so much that I was startled and pulled my hand back. “What?” I asked myself. I put my fingers back in to reevaluate. Now I was sure. A head!

I hollered for help and, just as I had the baby delivered, the pediatrician and obstetrician arrived to take over care of the mother and the baby. The baby was probably about two months premature. However, it was pink and crying, which is very good news for a newborn. I told the lady that she had a baby and she cried, “Oh, no! I don’t want a baby!”

At the time, my wife was at about the same stage of pregnancy with a baby that we very much wanted. That made me all the sadder for the lady and the baby.