When I got to work at 11:00 PM, I was greeted by loud screams coming from two women recently arrived in the emergency department. Since they both spent the night with me, I would like to describe them as an interesting exercise in compare and contrast.
The first patient was nineteen. She had been drinking and had caused some public disturbance, so police were called to the scene. In these situations, the police have the choice of arresting people and taking them to jail or turning them over to the paramedics to bring to the emergency department. In this case, the patient was put on a psychiatric hold and sent to us. In the emergency department, she continued to scream and cause such a disturbance that the previous doctor on duty ordered her a strong sedative. Soon after my arrival, she was sleeping soundly and I removed the leather restraints that had been necessary when she had been disruptive.
She was a thin young woman who might have weighed a hundred pounds. She had interestingly colored hair, lousy tattoos and scars on both of her wrists and forearms where she had obviously cut herself in the past. After carefully checking her out, I decided all she needed was to sleep off her excess alcohol ingestion and the sedative she received for her uncontrollable behavior and screaming.
The second lady was thirty-five-years-old. She, also, had been delivered to us after causing some sort of commotion in the community. When she arrived in the ED, she was screaming so loudly and shrilly that she was nicknamed “The Pterodactyl” by the doctor on duty. She, too, was given a sedative.
While the first woman looked anorexic, this short lady weighed at least three hundred pounds. Once she fell asleep, she caused almost as much commotion with her sleeping as she had earlier with her screaming. Because of her obesity and her sedation, she snored badly. Her breathing was like a constant series of snorts. Each inspiration caused her huge body to jump and her fat to jiggle. As with the first lady, I determined she just needed to sleep off the drugs she had taken as well as those she had been given.
While the first lady quietly slept, the second lady’s breathing caused quite a disturbance. It was loud and annoying. More importantly, it was so labored it made everyone nervous she was either going to have her oxygen levels drop dangerously low or stop breathing altogether.
A tool made perfectly for this situation is called a nasal trumpet.* It is a soft rubber tube lubricated with KY jelly that is gently passed into the patient’s nose. When in place, the inside end sits down behind the tongue and the outside end, which spreads like a trumpet’s bell, rests against the nostril. The nasal trumpet prevents snoring by allowing air to pass more easily behind the tongue.
In this case, it worked wonderfully. The patient winced and reached for it when I put it in her nose, but she immediately fell back asleep, breathing comfortably and allowing every one to relax.
At intervals throughout the night, however, she would rouse somewhat and, vaguely aware something was in her nose, reach up and pull out the nasal trumpet. She would then go into the same labored, worrisome breathing pattern she had before. So, I would replace the trumpet.
This is how we passed the night. The little lady sleeping soundly and quietly. The big lady snorting, moaning, and flopping around on the gurney. They were in the hall across from my documentation area so we could keep a close eye on them.
Every hour or so, I would check to make sure they were not getting worse, hoping for some improvement in mental status that would allow them to be discharged.
A few hours into this, I looked up and saw the big lady had aroused enough to sit up. She still had her eyes closed and, to my horror, had pulled off all her clothes. Her areola, the circular areas around the nipples, were as large as dinner plates. Even though she was sitting up, however, you could not see them because her huge breasts were hanging down and pressed against the tops of her thighs. Her large belly covered her crotch. So, though she was naked, none of her socially sensitive parts was visible. She couldn’t stay in the hall in that condition so we moved her to a room. For the next few hours, she kept trying to get out of bed and pull off her clothing. The whole time, she kept her eyes closed and would not respond to instructions. We assigned someone to sit with her so she would not fall and hurt herself when trying to get out of bed.
About 6:00 in the morning, the little lady sat up, asked what had happened, requested a drink of water and very nicely went off to emergency psychiatry. The other lady was still there, waiting to wake up, when I went home at 8:00.
* This is what a nasal trumpet looks like:
This shows how it fits in place, allowing air to pass behind the tongue.
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