Double Overdose

Written by Tad. Posted in Kooks

A forty-year-old man was sleeping on the living room couch. Around 3:00 in the morning, his family tried to wake him to send him to bed. They called 911 when they were unable to arouse him. When the paramedics arrived, they found him unresponsive, not breathing and with very small pupils. They diagnosed opiate overdose and administered a shot of naloxone, which blocks the effects of opiates. He immediately woke up. That confirmed their diagnosis and removed the immediate risk to the patient.

In the emergency department, he admitted he had taken too many of his opiate pain pills (Percocet,) which his primary care doctor prescribed him for chronic foot pain.

At that time, he was fine because the naloxone was blocking the effects of the opiates. My main concern then was that the naloxone usually wears off before the opiates. If that happens it is possible for such a patient to lapse, again, into life-threatening unconsciousness. To prevent this possibly happening after discharge, we observed him for a couple of hours to make sure he would not go unconscious again and stop breathing at home. He had no further problems and was discharged about 8:30 when his father came to pick him up.

I later learned that he spent the day with his family then, that night, again fell asleep on the couch. This time, for some reason, the family decided to let him sleep. In the morning, they found him dead, presumably from another overdose.

Unfortunately, addiction to prescription opiates is common and on the rise in our society. This young man nicely fit the demographics of the epidemic: men between 25 and 54 years old. Not only are more people dying from prescription opiate overdose. Heroin use, which had been falling for years, is also on the rise. Addicted people turn to heroin when they are unable to get prescription medications or they become too expensive. Hence, deaths from heroin overdoses are also on the rise.

If you are interested in reading more, here is a reference to my favorite medical reference, Wikipedia, and another from the Centers for Disease Control and Prevention.

https://en.wikipedia.org/wiki/Opioid_overdose

http://www.cdc.gov/drugoverdose/data/overdose.html

 

 

Red Flags

Written by Tad. Posted in Kooks

Low back pain is very common. It is the most common medical reason for people in America to miss work. It is so common that when people ask me why they have back pain I feel like answering, “Because you are a human.”

Being such a common condition, back pain is also a common reason for people to come to the emergency department. We see everything from people with strains caused by lifting something heavy to people who have low back pain every waking minute of their miserable lives.

There is not much we can do in the emergency department for most people who have low back pain: Provide temporary relief of the pain. Give reassurance. Write prescriptions. Give advice for further care at home.

Mixed in with all of this regular back pain, there are people who have something really bad happening. This is a great example of what makes my job so challenging and interesting: I have to recognize the rare “bad” back pain among all those “regular” back pains.

To identify low back pain that might be caused by something serious, we look for what we call the Red Flags of Low Back Pain. Basically, the red flags are clues there is some pathology in the spinal column that puts the spinal cord at risk of injury. For example, decreased blood supply can cause a “stroke” of the spinal cord. Other injuries are caused by pressure against the spinal cord from things like cancer, an abscess or a herniated disc.

Patients with these red flags need further investigation that is not warranted in the vast majority of patients with low back pain. What raises a red flag for me? Cancer patients with new back pain, old age, fever, loss of tone in or numbness around the anus, problems emptying the bladder, among others.

One night, a 47 year-old lady came in with a four-day history of low back pain with pain and numbness down her left leg. She said she had never had anything like this and had never before seen a doctor for back pain. She was miserable. She leaned to the left when she walked and was unable to walk at all without holding onto something. She said she had no control of her urine and stool. As part of my exam, I stuck my finger in her anus. She had no tone and was unable to pinch down on my finger.

I hope I did a good enough job of explaining the red flags to help you see why I was seriously concerned this patient had something bad causing injury to her spinal cord. I needed to make arrangements for her to be admitted to the hospital, be seen by a neurosurgeon and have an MRI done to identify the badness causing her problems.

I paged the neurosurgeon on call and told him my patient’s story. He surprised me by calling her by name. He said he had recently admitted her to another local hospital. All the tests done there were normal and, after being in the hospital for a couple of days, the patient miraculously got better and walked out.

I went back to the patient and told her of my conversation with the neurosurgeon. I explained we would give her no more opiates for pain and that there was no reason for her to be admitted to our hospital that night. On hearing this, she leapt out bed, flipped me off and briskly walked out, swearing at me as she went.

There is no way for me to know how this lady ended up with red flag symptoms. How did she know all the bad things to lie about? How did she learn to fake having no anal tone? Was she faking to get opiate pain medications? Did she have Munchausen Syndrome?* I really don’t know and your guess is as good as mine.

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

 

Sayings from the South

Written by Tad. Posted in Kooks

While we traveled around, getting my medical training, we lived in the south for several years. Being born and raised in the west, I was not used to the colorful adjustments many people in the south have made to English, or at least, the ways they speak that are so different from the way I grew up speaking. That caused me to be aware of things people said that I thought were interesting. Now, years later, as I look back at what I thought was interesting, it is as much a comment about my naïveté as how people, many of them poor and uneducated, spoke.

Here are a few interesting examples of things people said that I found worth keeping a note of:

An 84 year-old man came in with a severe nose bleed. He was very upset and told the nurse, “I’m bleeding to death! Get a doctor in here that will give me a shot of coagulant.” (There is no such thing as a “shot of coagulant.)

A young woman came in complaining of a “bad infection in my grinder.” (vagina)

A lady with seizures told me she was on “Die-lay’-tuns” and “Tri’-ger-talls” (Dilantin and Tegretol)

A patient walking along the side of the road told me he “div” into the ditch to avoid being hit by a car. (dived or dove)

“I had rech up for a pair of shoes and my chest started to hurt.” (reached)

A man, complaining about his girl friend not being able to have an orgasm said, “She’s cum hung.”

“I droove over to my cousin’s house.” (drove)

An 88 year-old lady who didn’t want her sweater turned inside out got upset with my efforts to help her with her clothes and said, “Don’t put it inerds, outerds.”

 

 

Friends with Headaches

Written by Tad. Posted in Kooks

About three in the morning, two patients came in complaining of headaches. They were placed in different rooms. Their situations were amazingly similar. They both: 1) had a long history of severe headaches but had not had such a bad one in several years

2) were visiting siblings from out of state

3) had severe cardiovascular side effects to Imitrex, a non-narcotic headache medicine

4) had headaches triggered by food allergies and admitted to dietary indiscretion leading to this current event

5) were asking for a shot of the narcotic Demerol and a prescription for Vicodin.

They were told that they would only get a shot if they had someone to give them a ride home. The man said his sister was in the waiting room. He walked to the waiting room, saying he was going to find her. He was seen walking out alone and getting into an empty car.

The female patient also walked out, saying her brother was waiting for her outside in a white Volvo. She soon returned saying he was not there. She assured the nurse that he would be right back and it would she please administer the shot. When the nurse declined, she went to make a phone call but said there was no answer. Next, she asked if there were any vending machines. When she was directed to them, she walked out and was seen jumping into the car where the man was waiting. They drove off together, unsuccessful in what was clearly a ruse to get narcotics for feigned headaches.

I don’t know why in the world they would both use exactly the same story at the same time to try to get opiates in the emergency department. This exemplifies the complexity of the lies someone will fabricate to try to get a fix.

Two Gunshot Victims

Written by Tad. Posted in Kooks

About six o’clock in the morning, we got a call from an ambulance that they were bringing in a pediatric gunshot victim. I asked myself, “A little kid shot this early in the morning? What the heck?”

In our trauma system, “pediatric” means up to age 18, so I immediately started picturing a seventeen-year-old gang banger shot in the line of duty. This thought was disturbed by a clarification from the nurse: a nine-year-old shot in both legs. That is really strange and left me wondering what the story would be behind this one.

As the trauma team began to assemble in the trauma room in preparation for the arrival of the little gunshot victim, an overhead announcement was heard: “Minor trauma in the department now.” That is said when a trauma patient comes in by private car, rather then by ambulance, and presents to the triage desk in the front of the emergency department.

This patient was also a gunshot victim and the coincidence made me think, immediately, that these two events had to be somehow associated with each other. I assumed we had two victims from the same firefight.

I met the man just as they were going to move him from the wheelchair onto the hospital bed. There was a hole in the top of his athletic shoe with a bit of blood oozing out. He was middle-aged and of slight build. He was in a lot of pain and was very upset. He told me he was getting ready to go to work when his gun accidentally went off. I was unable to get him to explain why he had the gun while getting ready to go to work or why there was a bullet in the chamber. “It was an accident, I swear!” he hollered over and over again.

I tried to reassure him as we started in on all of the treatment he needed: get him undressed and get his shoes off; start an IV for fluids, pain medicine and antibiotics; get an x-ray of the foot; get some more information about just what happened; find if he had any medical history and if he needed a tetanus shot.

As all of this was getting started, the boy came in. He had been shot with a single bullet as he lay on his side in his bed. The bullet entered one of his legs just below the knee, tore off a huge hunk of flesh, shattered the shinbone and passed into the other leg, breaking that shinbone, as well, and lodging just under the skin. We entered into the same plan of care for this gunshot victim.

When I went back to the bedside of the man, I learned that he shot himself through the foot with a high-powered rifle. There was a nasty hole through the middle of his foot leaving one of his toes almost detached. I also learned from the police that, after going through his shoe and foot, the bullet had also gone through his floor and come out of the ceiling in the apartment below, striking the nine-year-old boy as he slept in his bed.

To clarify, I went back to the bedside of the little boy and greeted the mother who was just arriving in the room. She spoke only Spanish so I served as her greeter, translator and explainer. She corroborated the story that a bullet had come down out of the ceiling, striking the boy as he slept in bed.

Both patients were admitted to the hospital. They both needed to go to the operating room to have their injuries surgically repaired. Both would probably end up with some sort of disability because of the accident. Both may well be emotionally scarred as well.

As I was finishing things up, word came back through the police that the wife of the man who was shot in the foot reported he had written a suicide note and had his rifle out with intentions of killing himself when it accidentally went off into his foot. If he was depressed before, how much more depressed will he be now?

Norm, Meet the Kids

Written by Tad. Posted in Kooks

Norm was a “regular” in our emergency department for many years. He was recently found down on the sidewalk in front of a liquor store and couldn’t be resuscitated.

Hearing he was dead reminded me of an interaction I had with him years ago.

Before our kids were in school, Shari volunteered for the local food bank. Every Wednesday, she and the kids delivered bags of donated groceries to shut-in elderly people in need. When my schedule allowed, I went with them. One day, as we made our deliveries, we ran into Norm. He provided my young children with an insight into life that they never would have had in our home.

We pulled our Camry up in front of the next house on our delivery route. It was in an older area of town with rundown businesses next to old houses inhabited by a less fortunate swath of society.

Following their normal pattern, Shari and the kids grabbed the bag of groceries and went to the door. While I waited for them, I looked over and was somewhat surprised to see Norm sitting on the ground leaning up against the building. He was drinking with another man I didn’t recognize.

We happened to have an extra bag of groceries so I called out to Norm, addressing him by name. He got up and staggered over to the car. He stuck his head through my open window and leaned his forearms on the door. He was not at all threatening, but he pressed a bit too far into my personal space and forced me to lean back farther in my seat.

It was about then that Shari and the kids returned from making their delivery.  Their conversation stopped and they, somewhat warily, climbed back in the car. The kids listened quietly and watched closely as their dad had a conversation with a dirty, scroungy, drunk man.

I offered Norm the bag of free groceries. He declined it. Then hit me up for money. I told him I was really glad to give him food but that I would not give him money because I knew he would use it to buy booze. That irritated him, so I started the car and told him we were leaving.

As we pulled away, the silence in the car broke. My kids were amazed that I knew Norm and could even call him by name. They wanted to know what he and his companion were doing there on the street. They were surprised he had no interest in food. Our son asked why his hands were so swollen.

I was able to explain that Norm drank too much alcohol. I pointed out other ways he looked and acted differently than people they were used to seeing. It painted a pretty graphic picture that I think was a good lesson for my kids.

 

Two on the Floor

Written by Tad. Posted in Kooks

The other night, the paramedics brought in a patient that was nervous and paranoid. He was a schizophrenic and admitted to being off of his psychiatric medications for some time. He said he was hearing voices and having thoughts of suicide. I explained someone would soon take him over to the emergency psychiatric ward for help. He agreed to wait. I did his paper work and went to see my next patient just around the corner.

She, too, was a schizophrenic, off her medicines and talking of suicide. Unlike the first gentleman, however, she had behaved so aggressively towards the police and paramedics that they had to restrain her. They did this by putting leather straps on her wrists and ankles and tying her to the gurney. We call this “four points,” meaning four points of restraint, one on each extremity.

By the time I went to see her, she was a lot calmer. I asked if she would behave if we took her restraints off. She assured me she would. As I started to release the restraints, one of the paramedics gave me a look like, “You’ll be sorry!” I released her restraints, reminded her or her agreement to cooperate and left while staff took her vital signs and got her registered.

Very soon, I heard screaming and detected agitation coming from her room. When I got there, she was face down on the floor. The nurse said she had refused to stay in bed and, as soon as she stood up, purposely went to the floor without hurting herself.

Let me help you picture what I saw as I looked down at her on the floor. She was a large woman. She had no clothes on under her hospital gown so her entire backside was visible as she lay sprawled out on the floor at the entrance to the exam room.

She pretended to be unconscious but I knew she could hear me as I told her she had violated our agreement and would now have to be put back in restraints. Hearing this, she immediately jerked herself onto her back. At the same time, she pulled the hospital gown away so her entire naked front side was now visible for the world to see. It appeared she tried to use her nakedness as some sort of a weapon when she was not happy with what was going on.

By this time, at least eight people were at the bedside including two police officers that happened to be in the department. Since the patient refused to get up, I instructed everyone to grab an arm or leg so we could safely get her back on the bed and into restraints.

That is when she really went off. She screamed at the top of her lungs and swung and kicked at us. Unable to get her arm loose from me, she grabbed my pants and tried to pinch my leg. As she flopped on the floor, she tried to pull her gown completely off.

When everyone had a secure hold of her, I called out, “One, two, three…” to coordinate lifting her back on the bed. We maintained our grip while someone went to get the restraints.

Suddenly, I looked over my shoulder to see that the first patient I told you about was now in the room. He was hollering as loudly as the lady was. Having heard her distress, he decided she was in trouble and needed his help. “I’m Federal! I’m Federal!” he repeatedly hollered as he grabbed some of those still trying to restrain the lady. “Let go of her! I’m Federal!”

Unfortunately for him, one of the people he grabbed was a police officer. In a flash, the officer released his hold on the female patient, turned, took the man down, and pinned him face down to the floor.

“Why are you doing this to me? Get your knee out of my back! Let go of me! I’m Federal!” the patient loudly protested. The police officer hollered back at him to shut up.

All of a sudden, I started to laugh. I couldn’t help it. It was too bizarre to even believe. One naked woman screaming and fighting in front of me on the gurney. One man screaming and fighting on the floor right behind me. It was just too crazy.

The woman, who now had her feet in restraints, turned to me and asked, “Why are you laughing?”

“I’m sorry, but it’s just funny,” I said.

“You are the shittiest doctor I ever had in my life,” she said as I was finally able to release her arm, which was now restrained at the wrist.

Soon, both patients were in four point leather restraints and sedated. I hope they were able to get the help they needed when they got to psychiatry.

 

Three Patients for the Social Worker

Written by Tad. Posted in Kooks

We don’t have a social worker available to us on the night shift. When we have a patient who is ready for discharge but really needs the help a social worker could provide, I recommend that he or she wait until morning when the social worker gets in.

One night last week, I went home at the end of my shift leaving three patients waiting for the social worker. That was unusual and prompts me to tell you about them.

Lady from Seattle

The paramedics brought us a lady in her seventies. A Good Samaritan found her wandering around, confused, at the bus station. The police were called. They then called paramedics who brought her to the emergency department. The medics told me she had come on the Greyhound from Seattle looking for her son. She had been reported as a missing person, having left her nursing home in Seattle without telling anyone where she was going. The medics suspected her son didn’t even live in our fair city.

The patient said she had no medical complaints. She was a bit strange and had a speech impediment, but knew she was in a hospital in California. She said she had come looking for her son, though she didn’t have any contact information for him. I had no ability, in the middle of the night, to find her a place to go. So, we made her comfortable and she slept until the social worker got there in the morning.

The social worker found out her son did live here. Though he was not expecting his mother, he was glad to come to the hospital and take her to his home.

Open Heart Surgery Man

This guy was in his sixties. Two weeks earlier, he had open-heart surgery to replace a heart valve. On discharge from the hospital, it was arranged for him to go to a nursing home to recover. He came to the emergency department after leaving his skilled nursing facility earlier in the day. He told me he left because “a nurse and I didn’t see eye to eye.”  He said he was not recovered from his surgery and wanted to be readmitted to the hospital until he was able to fully care for himself. When I asked him just what problems he was having, he pulled up his shirt and indignantly said, “Well, you can see this is not healed yet.” The scar he showed me running up the center of his chest was healing perfectly well. There was no sign of infection or any other complication. So, I told him there was no reason to be readmitted. However, I also told him the social worker might help him find a different option for getting the care he felt he needed. I suggested he sit in the waiting room until she arrived. As I watched him leave, I wondered what the real story was. Had he gotten upset with the nursing home and chosen to leave? Or, had he done something to get kicked out? He was irritating enough that I figured either of these could easily have been true.

As it turned out, his doctor at the nursing home had decided he didn’t need to be there any longer and had discharged him with plans to go stay with his brother. The patient didn’t want to do that so he came to the hospital to be readmitted. The social worker made arrangements for him to get to his brother’s house and off he went.

 

Mary Kay Man

The third patient was a man about seventy-years-old. He came in complaining of various problems and wanting to be admitted to a nursing home. He was a homeless alcoholic and nearly blind. He had an irritating, unpleasant personality and was dirty, unkept, scraggly and smelly. Then he told me he sold Mary Kay cosmetics. When he told me that, I found it hard to believe anything he said. “Who the heck would buy Mary Kay from this guy?” I asked myself. The nurse pointed out he had a whole bag of new Mary Kay products among his personal belongs, which certainly left me wondering.

When it was clear he needed no medical care, he, too, went back to the waiting room to wait for the arrival of the social worker in the morning.

As it turned out, the social worker knew this guy well from many similar previous encounters. She learned he lost his housing when he was put in jail. He came to the emergency department that night because, recently released from jail, he had nowhere to go and thought being put in a nursing home would be the easiest way to get off the streets.

The social worker give him some direction to find housing. She also clarified that he had a legit, online Mary Kay business. That helped me understand how he could sell Mary Kay without completely wrecking their brand image.

 

Bounce Back from a Motel Room

Written by Tad. Posted in Kooks

A middle-aged woman was discharged from the hospital after a three-day stay for treatment of injuries suffered in a car crash. Less than twelve hours later, she was back in our emergency room.

She told me her son took her to a motel room and told her they would spend three days watching TV there until they could get into “the condo.” After settling into the motel, the son left to go out for something and did not return. In trying to get to the toilet alone, she ended up on the floor and was unable to get up. So, she called the ambulance, which brought her back to the hospital.

I clarified she was there only because of not being able to care for herself and not for any new medical problem. I told her we would make her comfortable on a gurney in the hallway until morning when someone from social services could see what might be done to help her.

Feeling comfortable with that plan, I placed her at the bottom of my priority list. Normally, I would have given her little attention for the rest of the shift.

Some time later, I went into a room and smelled cigarette smoke. I asked the people on one side of the room if they had been smoking, which they credibly denied. The other lady in the room was a severely demented nursing home patient who would not be able to smoke if she wanted to. Where was that smoke coming from?

As I walked back into the hall, I noticed an orange Bic lighter on the sheet next to the lady from the motel. I approached her and asked if she had been smoking. Slowly and dramatically, she pulled her hand out from where it had been hiding between the bed and the wall. In it was a lit cigarette. Mind you, this is in California where you basically can’t smoke in any public building. On top of that, this is a hospital! And right in the center of the emergency department! We occasionally catch someone smoking in the restroom, but I have never seen anyone brazen enough to smoke right in front of us.

Anger and indignation welled up inside me. I have never been good at hiding my feelings and in this case, I did not even try. I felt it important that the lady know I was completely disgusted. I said something snotty as I took the cigarette away from her, doused it with water and threw it into the trash.

A couple of hours later, I heard heated voices coming from the area where her gurney was parked. I looked up and saw a young man in conversation with her. I assumed, correctly, that he was her son. Before I could get over to talk with them, I overheard some of their loud conversation including sentences like, “Get me the fuck out of here!” and “Just shut up!”

I wish there were some way for me to paint an adequate picture of the interpersonal pathology displayed between these two people. She showed clear signs of having a personality disorder. Everything was about her. All she could do was be indignant and nasty because she didn’t have everything exactly how she wanted it. She even lit up another cigarette and sat puffing away while her son berated her for behaving worse than his three-year-old.

I tried to intervene but soon realized I was not going to have any positive impact on the way they were dealing with each other. All I could do was give them their options: leave or wait quietly until social services could see her in the morning.

She demanded he take her to the hotel. He insisted she try to get some help. In the end, he took her away, cursing and complaining. I hate to think of how things went when they got back to the motel.

Alcohol, Valium and What?

Written by Tad. Posted in Kooks

A 67-year-old man was brought in by ambulance after being found unconscious with empty alcohol and pill bottles nearby. A review of his old emergency department visits showed he had a long history of drug and alcohol abuse.

He was so intoxicated there was concern he would stop breathing. So, he was intubated, which means a tube was placed into his windpipe and he was placed on a ventilator. However, other than a high alcohol level and Valium in his urine toxicology screen, nothing else turned up on his emergency department evaluation to explain his altered level of consciousness.

The intensive care consultant who came to see him wanted a CT scan of his brain. Even though there was no evidence the patient had suffered any trauma, the consultant wanted to make sure he didn’t have bleeding in his brain that would explain why he was so out of it.

Everyone was totally surprised when this picture showed up on the scan:

IMG_1230

Here is a close up:

IMG_1231

Let me help you understand what you are looking at here. This is a side view of the patient’s head. Only the bones show clearly. It can be seen that a nail entered his head from the front, in the middle of his forehead. As it passed back (from right to left on the image,) it went through the skin of the forehead, into the skull and through the frontal sinus, which is an air-filled space in the skull right above the eyes. The nail went in with enough force that it continued through the frontal sinus and stopped with the head of the nail pressed against the back of that same sinus. At the same time, the tip of the nail broke into the space where the brain sits. As it went in, it apparently missed injuring any important structures, sliding right under the bottom of the brain. The tip of the nail then continued out of the brain compartment and ended up in the sphenoid sinus, another air-filled cavity in the skull, back behind the nose.

A recheck of the patient’s forehead, where the nail would have entered, showed no open wound. A recheck of his old visits showed no mention of a nail in the brain. In fact, when the patient was seen two months earlier for a similar spell of intoxication, he had also had his head scanned and there was no nail there then. Because the nail did not seem to have injured his brain, it was felt that the patient’s unconsciousness was due to alcohol and Valium.

The next day, the patient woke up. He said he didn’t know he had a nail in his head and had no memory of any event that might have left him with one. He also denied any headaches or other symptoms that might be caused by having a nail in his head.

The patient was seen by a neurosurgeon who felt that, if having a nail in his skull did not bother the patient, there was no reason to remove it. The patient was discharged with referral for drug and alcohol counseling.

I am sure no one will ever understand exactly what happened. However, the best guess is that some time in the previous two months, the patient was shot in the head with a nail gun. It had been long enough for the puncture wound on the forehead to completely heal over so there was no sign left on the outside.

Beyond that, we have only more puzzling questions. Was he shot on accident at a construction work site? Did someone shoot him on purpose trying, unsuccessfully, to kill him? Did he shoot himself with a nail gun, trying to kill himself? Was he so drunk he really didn’t remember the event or was he lying when claiming to have no knowledge of what happened?

How could you get a huge nail shot into your head, have it penetrate your skin, frontal sinus, inside of the skull around the brain and out into your sphenoid sinus and never develop headaches or an infection? A truly amazing story that is hard to even believe.

 

Copyright © 2014 Bad Tad, MD