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.

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.

Copyright © 2014 Bad Tad, MD