Barf

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 ferry 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.