A 31-year-old woman came in with right eye pain, decreased vision and light sensitivity for eleven days. She had been pounding a screw driver with a hammer to try to open a lock. As she did so, a piece of metal broke off and hit her in the eye. She experienced a lot of pain and could see blood inside her eye. It was not clear why she had not sought care earlier or why she finally came in.

Her vision was decreased in the right eye and I could see a hole through the iris (colored part). An x-ray showed a large piece of metal (foreign body, in doctor talk) in the middle of her eye. I called an ophthalmologist and admitted her to the hospital so they could operate on her, take the metal out and deal with the developing infection.

A case like this brings up interesting questions about human behavior. I think pretty much everyone would look at their eyesight as being very important and something to be protected. It seems clear to me that someone pounding metal who gets a pain in the eye and can see blood inside the eye would immediately assume the eye had been injured by a hunk of flying metal. Putting this all together, I would also assume that most people would immediately seek medical care. Indeed, we see people all the time who have an injury of some kind and head immediately to the emergency department – even if it is something minor like a sprained ankle. 

So, why did this woman with pain and blood in her eye wait eleven days to come in for care? Most of the time, I don’t ask why an individual would make what seems like an unwise decision. Such questions might be perceived as being judgmental and would not change what I need to do for the patient. 

On those occasions when I have asked or the patient volunteered their reasons for a delay in coming in, they give reasons like this: fear of doctors, worry about the cost, having no ride, thinking it is going to get better or thinking it wasn’t really that bad. Such reasoning doesn’t always lead to bad decisions. If you have a cold or a minor sprained ankle, it is very unlikely there will be a bad outcome without medical care. But people use these same reasons to delay seeking care for serious illnesses like heart attacks, strokes, or a serious injury to the eye.

Cat Feces

A 51-year-old man came in by ambulance. When I walked in the room, I immediately noted a foul smell. An Emergency Medical Technician student working with me that day took the patient’s vital signs and then started undressing him so he could be fully evaluated. 

When the student took the patient’s socks off, he noticed there was cat feces on the patient’s foot. So, it was clear where the foul smell was coming from. What wasn’t so clear is how the patient could have stepped in cat poop at home, smearing it on his foot and between his toes, and then put his socks on before calling the ambulance to come to the hospital. 

Hit Twice on the Freeway

This 34-year-old man was stopped in his car on the side of the freeway when he was struck from the rear by another car at unknown speed. He didn’t seem to have been injured in the crash so he got out of his car to see what was going on. While standing by his car,  he was knocked to the ground by another passing car. He was treated in the emergency department for abrasions, lacerations and a severely fractured ankle. 

Shot to Remove Your Memory

I told a lady I was giving her a “strong medicine to get rid of your inflammation.” She objected, thinking it would take away her memory because she confused “inflammation” with “information.”

While I was serving as the Chair of our emergency department, one of my duties was to keep the medical staff advised of certain patients who presented with particularly challenging situations. Here is a memo I wrote to our staff about a man who, after recovering from injuries to his left leg, kept it immobilized in a cast or splint even though his doctors told him it was not in his interest to do so. He continued doing this so long his leg started to suffer from muscle wasting (atrophy) and joint stiffness, which could become irreversible. 

This patient may have had some sort of Munchhausen Syndrome, a condition where people misrepresent their illness or even hurt themselves to continue to get medical attention. He also might have been trying to damage himself so he could blame it on his work injury and get permanent disability. Who knows what his motivation was but here is his story, retold in my memo, which I have revised for confidentiality.

Date:               30 October

To:                   Emergency Physicians and Physician Assistants

From:              Dr. Tad

Subject:           Mr. Williams

This is a 45-year-old man who, in May, had an operation to repair a left heal fracture. He subsequently suffered a left knee injury at work. 

He has been followed by a podiatrist (foot doctor) and an orthopedic surgeon. He has come to our emergency department ten times in the last six weeks saying that, unless his left ankle and left knee are put in a cast, he has too much pain and can’t use his crutches. His knee and heel are apparently completely healed from his previous injuries. Still, he has insisted on having his leg immobilized in a cast or splint for so long that his muscles are wasting away because of atrophy.

One of our doctors took the time to call his doctors. This is what she found: The orthopedic surgeon said that, as the patient became more mobile with rehab and showed significant improvement in his knee injury, he began a pattern of going to the emergency department of another hospital in town and insisting he needed a long leg splint, which he usually got. When the orthopedic surgeon would see him, the splint would be removed, but the patient would be back in the emergency department a few days later. It got to the point that the other emergency department would refuse to put on a splint and send him on his way. That is when he started coming to our emergency department. 

His insistence on immobilizing his leg has led to atrophy and joint stiffness. The orthopedic surgeon eventually dismissed him from his care, as the patient would not cooperate with the treatment plan. His podiatrist agreed that immobilization was not in the patient’s best interest and also no longer sees him.

Please keep this in mind as you have occasion to provide medical care to this patient.

In our society today, people go to the emergency department for about anything they might need. If you look back through my blog postings, you will see stories of many ridiculous reasons people have come to see me. 

One service we provide in the emergency department that most people wouldn’t think of is finding someone a place to stay. Sometimes, this is just a shelter for the night. Sometimes, people can’t be sent home. Because of social, physical or mental problems they really can’t return to wherever they came from. In such cases, we look for a reason to admit them to the hospital for medical care. If they are not in need of such care, we have to find them some place to go. We call this “placing” a patient. 

Here is a revised memo sent from one of our social workers to the Medical Director of our hospital about a young man who was driving everyone crazy trying to “get placed.”

Hi Dr. T,

I wanted to update you on the patient I came to talk with you about 2 weeks ago. He is a 23-year-old man who is a paraplegic (paralyzed from the waist down) and absolutely functions independently. I have placed him in two boarding houses in the last few weeks, but he has been kicked out of each one. He refuses to stay in a shelter. He was asked to leave the Helpful Home Board and Care last week. He was supposed to pay his rent within 3 days of admission. He failed to do so, saying his social worker (me) told him Medicaid or our hospital would cover this expense. 

This patient continues to lie about everything and has contacted Adult Protective Services (APS), the police department, and the fire department several times a day over the last week. He tells them I specifically told him he should call 911 and be taken to our emergency room. This is very frustrating for me, as I have received multiple phone calls from these agencies all day, every day about this patient, who continues to try to manipulate our system. The bottom line is that this patient was living independently for three years and then started going from skilled nursing faculty to skilled nursing facility, staying for 90 days, so his Social Security benefits would not be in jeopardy. He knows the system! He then presents to emergency rooms, wanting to be placed. I have placed him twice. He is non-compliant with independent living and is rude to staff. He is more independent than he appears to be and is severely lazy. It is his decision to be lazy.

He has a very dependent personality and believes this is our problem, not his. Several social workers from two hospitals in town have spoken with him about how he needs to take some responsibility for himself. We have given him resources for shelters, board and care homes and skilled nursing facilities. He has income from Social Security. The problem now is that he is not going to go away. He will continue to present himself to our emergency room, call APS, the police department and the fire department daily until he gets what he wants, which is to be placed. As mentioned above, I have placed him twice, but he has burned his bridges and I do not want to continue burning my bridges with the facilities I work with. The emergency room is informed that they should not admit him for placement reasons, but of course they will continue to see him for alleged medical complaints. My supervisor is well aware of this case and the problems the patient has been causing our staff, other hospitals and law enforcement agencies.

You may get a call as well from APS. Everyone who has assessed him here and at the other hospital agrees he functions independently, but he is very lazy, entitled and doesn’t want to take responsibility for himself.

Sincerely,

M.D., MSW

A young man came in as a trauma patient after having been stabbed multiple times. At first glance, the worst injury was a large slash across the front of his chest. However, it only involved the skin and didn’t penetrate into the chest. So, it was really just “a mere flesh wound.”

A small laceration on his face was much more worrisome. The cut was on his cheek just below his left eye. His eye was bulging forward, what we call proptosis. Though he could see well, he was unable to move it normally.

Further evaluation of his facial injury showed the knife had penetrated his check and broken through the bone just blow the eye. It passed through the orbit, which is the space in the skull the eyeball sits in. Then, the knife entered into his brain. The proptosis was caused by bleeding in the orbit, filling the space between the skull and the eye with a blood clot. The eye and nerves which allow for vision had been missed by the knife, so his vision was unaffected.

His chest wound was cleaned and stitched in the emergency department. He was then admitted to the hospital for further evaluation and care by the ophthalmologist and neurosurgeon.

Usually, kids with abdominal pain and vomiting do not have worrisome medical problems. Most of the time, they have eaten something that didn’t agree with them or have a stomach virus. But, there are some serious conditions that give kids abdominal pain and make them vomit. An emergency physician has to think of the bad things every time, in order to make certain that nothing life-threatening is missed.

An example of such a serious condition is intussusception. This happens when a part of the intestine folds into an adjacent part. This “telescoping” causes strain on the walls of the intestine and its blood supply. The damage to intestinal tissues can cause blood and excess mucous in the stool. The classic stool of patients with intussusception is described as “currant jelly,” meaning dark purple and slimy with mucous. If intussusception is not diagnosed quickly, the bowel can become severely obstructed and the involved section of the intestine can die, leading to the need for emergency surgery or even death. Intussusception is something that, though rare, should not be missed by an emergency physician.

Often the diagnosis and treatment of intussusception are accomplished with a barium enema. Barium is a liquid preparation that shows up on x-rays. When intussusception is suspected, the child is sent to the radiology department and the radiologist gently squirts barium through the anus into the intestine, while taking x-rays. If an intussusception is present, it shows up on the x-rays and the diagnosis is made. Often, the pressure of the barium being injected into the colon causes the intussusception to be “reduced,” meaning the intestine is pushed back into normal position. In such cases, the diagnosis and treatment take place at the same time. When a kid comes in with abdominal pain and vomiting, the emergency physician has to decide if the chances are high enough for intussusception to call in the radiologist from home to do the barium enema.

I have only made the diagnosis of intussusception twice in my long career.

Ryan was a previously healthy, 16-month-old boy who had been having abdominal pain and vomiting for three days. He had been seen twice in that time by pediatricians who treated him for dehydration and sent him home. On arrival in our emergency department, he had a large, black stool covered in slime. Given that history, it was clear to me he needed a barium enema. I called the radiologist, who came in from home and confirmed my diagnosis. Unfortunately for Ryan, the intussusception was not able to be fully reduced. I had to admit him to the hospital to be cared for by a surgeon.

Such a case makes me feel really good. I identified a sick kid. I thought of the right disease. I ordered the correct test. This led to timely and appropriate care. It is just the kind of case that makes emergency medicine so fulfilling and rewarding.

The very next night, I saw another little boy, about the same age, also with vomiting and abdominal pain. He had a distended abdomen and had passed a stool that was dark and covered in mucous. You can imagine how this played with my decision making. In all my years as an emergency physician, I had only diagnosed intussusception one time and it had been the night before. Could this even be possible? Yet, all the signs were there and I called for the barium enema.

The radiologist was pleasant but skeptical. Intussusception is unusual enough that, earlier in the day, the radiologists had all sat around together and looked at the x-rays from my case. So, this radiologist knew I had made that diagnosis the night before. Essentially, he was questioning my need for another barium enema, suspecting my diagnosis the night before had me over-call the need for another one tonight.

I acknowledged his justifiable skepticism but said something like, “Last night, we got lucky. Tonight, this kid read the book.” By this, I meant that he had all the things a textbook would say to watch out for in intussusception. He agreed to come in and, just like the night before, made the diagnosis of intussusception. Again, he was unable to reduce it with the barium enema, so I admitted the patient to a surgeon for further care.

As far as I know, I have only seen two patients in my career with intussusception. And they came in on consecutive nights. What are the chances of that?

My mother-in-law says, “Things always come in threes.” I don’t believe that but I can’t help notice coincidences in my practice. Usually, it involves looking for different patients with similar illnesses or injuries. In this first case, it was infant twins who shared three identical abnormalities.

Mom brought in her fraternal (not identical) twin daughters for fevers. They had been sick about the same period of time. I diagnosed both with urinary tract infections. It was kind of a surprise that the two of them would come down with an infection like that at the same time. I also noticed they both had umbilical hernias and were tongue-tied. Umbilical hernias are hernias at the belly button. They are not at all unusual in kids this age but it was certainly an interesting coincidence that they both had them. To be tongue-tied means that the frenulum (the small fold of skin beneath the tongue) is too short or tight. This keeps a person from being able to stick his or her tongue out normally. It is usually treated with a minor procedure where the doctor numbs and snips the frenulum, releasing the tongue to stick out normally.

It seemed to me quite a coincidence that both of these sisters had the same three abnormalities.

Speaking of coincidences…

One night, a young man was dancing. While doing so, he thrust his arm into the air, causing a dislocation of his shoulder with the arm stuck straight up in the air. Shoulder dislocation is a pretty common injury we see in the emergency department. That it happened when he was dancing was really unusual as the shoulder usually dislocates because of a fall or other injury that involves more energy. Also, a shoulder dislocation usually results in the patient’s arm hanging down at his or her side. Having it dislocate so it is locked with the arm pointing straight up in the air is also very unusual. I gave him pain medicine and sedatives. I was then able to easily get his arm back in the socket again.

Two nights later, another young man came in with his shoulder dislocated and stuck up over his head. Rather than dancing, this happened when he rolled over in his sleep. It sounds crazy but there are people whose shoulders can just pop out of joint, even from rolling over in bed. Usually this joint instability arises from previous dislocations which damage the supporting structures of the joint leaving it subject to easily popping out. This often needs to be corrected with surgery. Again, they usually present with the patient’s arm down to his or her side. That he also had his shoulder locked with his arm pointing up only two nights after the other guy is quite a coincidence.

You can imagine my mother-in-law would have had me keeping my eyes out for that third shoulder dislocation with the arm pointing up in the air, but it never happened.

Police were called to a home where a naked 27-year-old man was causing a disturbance. He reportedly threw a dresser at the police when they tried to subdue him. To keep him safe and protect those caring for him, he was hogtied. To hogtie someone, the police cuff the wrists behind the person’s back and cuff the ankles. Then, the wrist cuffs and the ankle cuffs are connected together, behind, with a third set of cuffs, forcing the subject into a position with his back arched and his ankles fastened to his wrists behind his back. After restraining this man, the police loaded him in their squad car and headed for the emergency department.

I was called out to the ambulance loading dock because the police and ED staff were having trouble getting him out of the back of the police car. Hogtied, naked, sweaty and still fighting, he had thrown himself forward, off the back seat. His head was wedged under the back of the front seat with his rear up in the air. All I saw when I peeked into the car was his naked butt with his scrotum sticking up by his crack.

When we finally got the man onto a hospital gurney, I noted he was not moving any more. A quick check showed he had no pulse and was not breathing. This changed the nature of our situation profoundly. Instead of controlling a drug-addled patient, we had a patient in cardiac arrest.

We moved him immediately off the loading dock into the closest room in the emergency department where the police reluctantly removed his cuffs. I was then able to quickly assess him and give some orders including starting CPR, inserting an IV and getting him on the monitor. Since he was not breathing, I immediately passed a breathing tube into his windpipe and got him on a ventilator. As we got all that done, his heart, which had actually not stopped but had just gone to a very slow rate, was now fast and he was starting to wake up. Though that was good news for him, it also required immediate sedation so he would not pull out his IVs and breathing tube.

A more careful examination showed him to have abrasions on his extremities where the cuffs had been placed and a dislocated elbow, which had probably been suffered at some point during the fight to restrain him. After I stabilized him for admission to the ICU, I got his elbow back in joint and splinted. His testing was all negative except for methamphetamines in his urine.

An emergency physician, by training (and, for me, by nature) wants things to be simple and straightforward. Often, patients show up with anything but simple and straightforward complaints. Sometimes they even come in with detailed notes laying out the course of their symptoms. I am sure they think that lots of details will help the doctor get to the bottom of whatever is making them ill. In reality, at least for me, the more complicated it is, the more I am sure I will NOT get to the bottom of it.

Here is a reproduction of a note I was given by a woman one night. My reading of this is not, “I need to pay attention to all of these details.” Rather, it is “This patient clearly has more problems to deal with than asthma.” Whether it is stress or some underlying personality or psychiatric problem, I see this note as evidence that I have no chance of fixing her problems in one visit to the emergency department.

Obviously, I have changed the names and details to protect the patient’s identity.

Sally A. Williams

CONFIDENTIAL

Asthma

• Current symptoms:
  • Chest feels warm
  • Some back pain while lying down (also pinched cervical nerve)
  • Still tired and hard to get out of bed
  • Terrible dreams where I am fighting to wake up
  • Hard to get to sleep
  • Hard to stay awake during the day even when using CPAP at night
  • Use rescue inhaler with limited success
  • Started Prednisone 25milligrams on 10/29 at 9:00, with slight improvement
  • Prednisone 10mg on 10/30 at 3:00 a.m. with slight improvement
  • Prednisone 15mg on 10/30 at 1:00 p.m. with limited improvement
  • Saturations run 92 to 99, with pulse high at 100-110 (Normal saturations 98-99)
  • Saturations worse the lower I lie in bed
  • Pulse rose to 126 beats approximately 7:00p.m. on 10/30/12
  • Flow Meter done on 10/29 and 10/30 measured 350-375
  • Feet swell if I am upright for even short time, very painful by night (taken off of Aldactone 25 mg by Dr. Jones in July 2012)

HISTORY

• Started Metoprolol 25 milligram ½ tab 2 times on 9/22/12
  • Became tired and started sleeping a lot
  • Sleep was disturbed
  • Advair 500/50 didn’t seem to completely work
    • Felt winded
    • Couldn’t seem to catch my breath
  • High humidity made it worse
  • Hoarseness usually became worse about 4:00 p.m. to 7:00 p.m.
  • Started to use rescue inhaler every few days
  • Last slight flu was August 2012
  • Saw Dr. Jones on 10/19 and she changed medicine to Diltiazem 110
  • Previous private patient of Dr. Smith – diagnosis was mild asthma but worsened greatly by colds and flu and general anesthesia
  • Previous private patient of Dr. Allen – diagnosis of unknown etiology for feet swelling

Zoloft for nighttime to help keep me calm due to stress of not being able to find a job?
Aldactone 25mg. 2x

10/30/12

A 47-year-old woman came into the emergency department one evening. The “Chief Complaint,” as recorded by the nurse, was “Pain in the neck for 3-4 years. Wants x-ray done.”

She told me this all started about three-and-a-half years ago when she woke up in the morning with a “slit” in her left neck. She said she didn’t really think anything about it at the time. Since then, however, she has been having several troubling symptoms, making her think a chip had been implanted in her neck that night. She had been seeing strange flashes of light. Other than that, her symptoms were vague. She said she had “weird things happening all the time.” She had some vague discomfort in the neck but not really any pain. This was the first time she had sought medical attention for this problem. She couldn’t give me a reason why she decided to get checked out that day. She would not offer any idea of who might have implanted a chip in her neck or why. She had no medical history other than hypothyroidism. She denied any history of mental illness or substance abuse.

Her physical exam was unremarkable. Her neck was normal. I noted a lack of any scar. She behaved completely normally with no evidence of obvious psychiatric disorder.

There are many reasons for me to not believe what she was saying was true. I didn’t believe in a “chip” that could alter her behavior. I saw no reason someone would sneak into her bedroom one night and implant a chip in her neck. I don’t know how someone would do so without her waking up. I don’t know why she would not have freaked out if she woke with a slit in her neck that appeared while she slept. I don’t know how having a chip under her skin would cause her to see flashing lights and have all kinds of weird things happen to her. Though I didn’t believe she had an implanted chip I did believe she thought it was true.

So, my diagnosis was “delusion.” Here is one definition for a delusion: an idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder.

This fits her perfectly. Her belief certainly was idiosyncratic. She firmly held it to be true. Most people would generally agree her belief was not in keeping with reality. She was not open to any rational argument used to try to convince her otherwise.

What kind of delusional patients might an emergency physician deal with? I had an elderly man who believed all our laws were invalid since they were not based on English Common Law. I have seen several people who believed they had chips implanted in them by the CIA. I have seen patients who have delusions of religious persecutions. Toxic vapors and molds pervade the delusions of many patients. People irrationally believe their neighbors are pestering them. Delusional parasitosis, where people believe they are infested, inside and/or out, by vermin is rather common. I had one patient who was convinced our doctors were using “Mexican children” as “guinea pigs,” performing unnecessary tests on them. People sometimes feel persecuted or, the opposite, have delusions of grandeur where they think they are very important and due more respect than they are provided by society. They sometimes believe they have an illness causing their symptoms, even an illness not known to medical science. They sometimes have body image issues. Sometimes these delusions are wide-ranging and associated with paranoias. In other cases, they are limited and specific. Delusions can range from offering mild amusement to the outside observer, to severe, socially incapacitating conditions.

As with any medical abnormality, a doctor caring for such a patient wants to provide treatment. Many treatments have been shown to help with delusional disorder, though with various degrees of effectiveness. Treatments include medications and various types of behavioral therapies. One big problem in getting them help is they don’t want psychiatric help. They know what they are suffering from is not a psychiatric problem and they resent any insinuation they are crazy. So, they are often resistant to any recommendations for psychiatric intervention.

With that background, how should I deal with this patient? Within a short time of talking with her, I was sure she was delusional and I was not going to be able to “fix” her problem. I focused on listening, making sure she knew I was on her side. I recognized that one of the reasons she had come in was to get “an x-ray.” I was sure no imaging would show a chip in her neck but, in order to show I was interested in helping her, I ordered an ultrasound, explaining to her why I thought that would be better than a regular x-ray in identifying something that might be implanted in her neck.

When the ultrasound report came back negative, it was time for her to leave. I went over things, explaining that any chip in her neck would have shown up on the ultrasound. The problem with this disorder is that, by definition, it is resistant to logical evidence. I knew she would leave with her delusion intact, even with my reassurances about her ultrasound. I told her she needed to make an appointment with her primary care physician for further evaluation and treatment.

Some might say that punting to the primary care doctor is a lame way for me to escape a difficult situation but this patient needed a lot more help than what she might get from one visit to the emergency department. In reality, I had no treatment to offer her.

How the patient reacts to all of this helps determine how honest I would be with her. If she says, “Thank you very much” and leaves, I am done. But sometimes these people will not do that. Often, they have been to many doctors, including their primary care doctor and no one has done anything. Sometimes they say something like, “I know I have a chip in my neck but you just think I’m crazy!”

When I am pushed into this situation, I usually resort to is something like: “I can tell you are upset and I understand why. You know you have a chip in your neck and I know you don’t. There is nothing I can do to get you to believe there is no chip and there is nothing you can do to get me to believe there is. So, we are just going to have to agree to disagree and you will need to look elsewhere for further care.”

Even after that, often the patient will just start over again with their arguments trying to convince me. Sometimes, they will get angry and storm out, threatening to sue me or report me to the Medical Board. I never know when I enter into this last part of the visit whether the patient will walk out quietly with my sympathy or angrily with shouted threats.

Being an emergency physician, I never know what happens to delusional patients I have seen. How many of them work things out and get back to normal? How may carry on with their delusion giving them some trouble for a long, long time? How many degrade and become diagnosed with severe mental illness? I never know.