I recently took care of two interesting cases that came from the jail on the same night. You never know what will come into the emergency department and the jail is a very interesting source of our patients.

 

Keep Patient Away from Toilet Paper

A 39-year-old man came in from custody for evaluation. He had tried, unsuccessfully, to hang himself with some sort of a plastic ligature. He was found to be uninjured and was sent back to jail… but not for long.

After getting back to his cell, he spent some time twisting toilet paper into a rope of sorts, which he used to try, again, to strangle himself. He was returned to the emergency department and, again,  was found to be uninjured.

When I discharged him to go back to jail on a suicide watch, my instructions were, “Keep patient away from toilet paper.”

I wonder if they followed my instructions.

 

Something Unnatural in the Eye

A 33-year-old woman came in complaining of left eye pain. She told me someone had “put something unnatural” in her eye a year ago and she had been having eye pains, like a knife stabbing into it, every since. She had never seen a doctor about it. The reason she was there that night was that she had been arrested and, during medical screening at jail, mentioned it to the nurse. The nurse sent her straight to the emergency department in the middle of the night for evaluation.

Vision problems are a fairly common complaint in the emergency department. Eye pain can be a symptom of a serious eye problem so we always take this complaint seriously.

As I approached the patient, she was sitting comfortably with a piece of gauze loosely taped over the eye. She had 20/20 vision and my examination of her eye didn’t reveal any abnormality. I could see no reason for her pain.

As I asked her for more details about getting something unnatural in her eye, she replied with vague and unhelpful answers. When I asked if she had any past medical problems, she denied any. Her demeanor made me suspicious she had a psychiatric problem but she denied that as well.

Still wanting to make sure I was not missing anything, I went to the computer to review her past medical history and previous visits to the emergency department. This showed that she did, in deed, have a history of anxiety, bipolar affective disorder and psychosis as well as drug and alcohol abuse.

As I went back to talk with her again, I summed things up in my mind. A vague history of someone putting something unnatural in her eye. Pain for a year without seeking any medical attention. Normal visual acuity and eye examination. Pain that made no sense for any eye disorder of which I was aware. A history of psychiatric problems, though denying so.  It was pretty unlikely she had an eye disorder that needed to be identified by me in the middle of the night in the emergency department.

I released her return to jail with a recommendation that they schedule a routine visit with an eye doctor.

 

 

This is transcribed exactly from a paper a patient handed me when asked about allergies. I didn’t have time to ask about just what happened when she took each of these medicines but can you imagine trying to prescribe a medicine to her with any hopes she wouldn’t have a reaction?

 

Bad Side Effects List

(I may have overlooked something)

aspirin

atarax

amitriptiline

all antihistamines

baclovent

buspirone

Benadryl

Bonine

Cisapride

Clonidine

Diltiazem

Darvon

Ditropan

Dalmane

Halcyon

Elavil

Flexeril

Lopressor

Metoprolol

Morphine

Maxide

Naprosyn

Penicillin

Pilocarpine

Betoptic

Robaxin

Sulfa

Tagamet

Vasotec

Xanax

Isoptin

Estrogen

Codeine

Cipro

Erythromycin

Cephalexin

Lidocaine

Noroxin

Miconozole

Macrodantin

Ambient

Imipramine

Metronidazole

Dicyclomine

Septra

Doxycycline

All antidepressants

Buspar

Paxil

Soma

Melatonin

 

 

A 47-year-old man came in with so many complaints that, after I listed them, there was no more space to write on the chart. Here they are:

Exposed to various contaminations: oil, paint, varnish, and ZEC for several days.

Banged his knuckle.

Trouble with ventilation: the heater in his house contaminated with fumes.

Comet cleanser used to clean the sink caused fumes that caused him to almost pass out.

Tide and garden chemicals that were by the heater were pumped through the heater.

Left nasal pain for 2 days since he picked it.

Painters’ soap up left nose.

Spitting up “crap.”

Varnish comes in through the windows from outside the house because of the cold weather.

Contaminations in food, coffee and water.

Vomiting and coughing up brown varnish.

Numbness in hands.

Spitting up soda after using Comet.

Finding pockets of air with varnish in them all around the house. Unable to ventilate the house so it just keeps coming back in.

Washer and dryer cause his body to vibrate.

Gets sick while smoking cigarettes and marijuana.

Feels better after putting hydrogen peroxide on his hand.

Decrease in bowel transit time.

Has “fatigue points” on his legs that are sore.

His van clogs up with “smog cast” that he can’t clear out.

We all search for patterns in life. It is the way our brains allow us to navigate this crazy, complicated existence. As I have saved interesting cases over the years, I have been sensitive to certain patterns, coincidences.

Here are some stories that are not that amazing, on their own. But the coincidences are just too good to not notice and celebrate.

 

Two Febrile Seizures

Some young children suffer convulsions when they have a fever. It is not really known why this happens or why it doesn’t happen to older children or adults. Fortunately, it is a benign condition though it does scare the socks off of uninitiated parents. It is not a rare condition but most children who have a fever obviously do not suffer seizures. If one sibling in a family has had a febrile seizure, there is an increased risk that other siblings might also have one.

One night a young mother and father brought their two children into the emergency department for evaluation after both suffered febrile seizures the same day. I was wondering how in the world you would calculate the likelihood of that happening but it is amazingly unlikely.

 

Sparks Girl

I was taking care of a seventeen-year-old girl. She was a troubled soul being cleared for methamphetamine abuse so she could go to custody. The officer said she was a runaway and would be going back to Sparks, Nevada as soon as they could make the arrangements.

When I heard that, I told her I used to live in Sparks. I said, “I went to Alice Maxwell Elementary School.”

“So did I,” she said. Then she told me she lived on Sbragia Way! That is only three blocks away from our old house on 1165 Vance Way.

Now, what is the chance that I would have a patient who went to Alice Maxwell and even stranger that we would put it together?

 

Twins

Last week, in the middle of the night, I was hustling around seeing patients. When it was time to go see someone new, I noted two new patients had been placed in beds 1A and 1B, next to each other in the same room. I also noted they were both 3 month-old babies with fever. “Twins,” I thought.

Then I noted they had different last names. Of course, that slowed me down so I decided to check dates of birth. One was born 5/20 and the other 5/21. “Twins, one born just before, the other just after midnight? But with different names?”

Next, I decided to check the street addresses as a quick check. Wow. They both lived on the same street. As I went in to talk to the mother of the two kids, a boy and a girl, I was really interested to see what the story was.

In room 1A, I found a single mother with a baby girl. “Where is the other baby?” I asked. The mother gave me a confounded look and I am sure I was giving the same sort of look back at her. This forced me to do what I should have done in the beginning, check carefully until I understood what was up. Yes, different names, born one day apart, both with fevers, both lived on 8^th street. But, Lucinda Garcia lived on 6353 8^th Street and Jose Ramirez lived on 2735 8^th Street! So, at the same time of the night, two babies with fevers, Hispanic names, born on consecutive days and lived on the same street were placed in the same room for me to care for. It is an amazing coincidence. Call me weird but I really like that sort of thing.

 

The medics brought in a middle-aged woman who was in cardiac arrest. Her husband had found her down and called 911. The medics found her in arrest, started CPR, injected her with adrenalin and brought her to us.

When medics bring in such a patient, it causes quite stir in the emergency department. Pretty much everyone stops what he is doing and goes to help. The patient has to be transferred onto our gurney, chest compressions continued and oxygen has to be blown down into the lungs. The patient has to be hooked up to the cardiac monitor and checked to see if there is any sign the heart has started beating again. All of this has to be done as fast as possible and the more hands helping, the faster it gets done.

As everyone was pitching in doing all these things for this lady, I turned my attention to her airway. It was obvious right away that, during CPR, she had vomited and there was liquid vomit in her mouth and the back of her throat. I suctioned that out, looked in with a laryngoscope* which is a curved, lighted blade designed to move the tongue out of the way to be able to see the vocal cords**. Once the cords are seen, a tube can be passed through them in order to get oxygen-carrying air down into the lungs and keep vomit out***.

As soon as I had got the tube in place, I turned my attention to the patient’s heart. I asked that CPR be paused while I looked at the monitor, listened for heart sounds and felt for a pulse. Not finding any evidence the heart was beating, I put an ultrasound probe on the chest wall, over the heart, and confirmed no cardiac activity. She was dead.

I took a minute to look over her, to make sure I hadn’t missed anything. I thanked everyone for helping so efficiently, then went to write a note about what had happened.

As I was sitting at my desk, the registration clerk came to me and told me the patient’s husband had arrived with a boy who looked to be about twelve years old.

“He knows,” she said.

In reply to my quizzical look, she told me the husband had asked her if his wife was alright. When she told him she had not been taking care of the patient but she would have the doctor talk to him, he turned to the boy and said, “She’s dead.”

After the husband and son were escorted to the Family Room, I went to meet them. I introduced myself, made sure he was the husband, then told them she was dead. I told them the medics had done everything they could to revive her but that she was already dead when she got to us.

“No!” the man hollered as he stood and threw his head down into his hands. “No!”

He then collapsed back onto the couch and moaned with his eyes closed and his hands on his pained face.

The boy leaned over his father, put one hand on his arm, patted him gently on the back and said, “It’s OK, Papa. It’s OK.”

Going and telling someone that his or her loved one is dead is one of the worst parts of my job. I never know what to expect. I certainly was not expecting this and it made my interaction with them especially poignant.

* This is an image of such a scope:

** Here is what I see when I get a good look at the vocal cards. The endotracheal tube is passed between them, through the opening.

 

***Here is what the tube looks like.

Last week I posted about a woman so obese she couldn’t be taken out of the ambulance to try to resuscitate her from cardiac arrest. Today I share another obesity-related story.

My patient was a man in his early twenties. He was complaining of having trouble sleeping at night and having sores “by my penis.”

As for his first complaint, it was pretty obvious he had obstructive sleep apnea, a common condition where the airway closes down at night causing people to wake frequently. It is usually not life-threatening but it makes people miserable by keeping them from resting. It is much more common in obese people and this kid was massively obese. I made arrangements for him to be referred to the sleep clinic for evaluation.

To evaluate the sores by his penis, I pulled the sheet down and saw what I thought was a huge, inflamed scrotum hanging down almost to his knees. However, when I pushed his belly fat up to get a better look, there was no penis by the scrotum. That’s when I realized that what I originally thought was his scrotum was actually his mons pubis, the area where  pubic hairs grow. I could then see that his sores were caused by inflammation of the hair follicles of his pubic hairs, or folliculitis.

With two hands, I lifted the mons up off his thighs and looked underneath it. Then, I could see a little penis and scrotum way down between his legs.

Amazing.

Amazing and very sad.

 

 

 

 

A 56-year-old lady went down on the floor at home and was unable to get up because she had injured her foot. It took eight medics and firefighters to get her out of her home, onto the ambulance and into the emergency department. They transported her on the floor of the ambulance, as they were unable to get her onto an ambulance gurney.

Spine boards were used as ramps to get her from the floor of the ambulance to an emergency department stretcher, which could hardly tolerate the weight. She was incontinent of urine and stool and was so foul smelling she stank up the entire emergency department.

After she was cleaned up and a medical evaluation was performed, she was admitted to the hospital because she was not able to get up and around on her injured foot.

I am not sure what happened to her during her hospitalization but two days later she was back at home and took ill again. This time, she was found unresponsive and the medics tried to keep CPR going while they loaded her, again, onto the floor of the ambulance and brought her to the hospital.

When they got to the emergency department this time, she was still in cardiac arrest. Since it was would have taken too much time to get her into the emergency department, one of my partners went out to the ambulance to try to revive her. His efforts were in vain as he was unable pass a breathing tube or start and IV. She was pronounced dead in the ambulance.

Last week we did crazy teen drivers. Here are some more crazy car stories.

Crushed by Daughter

A 44-year-old man was standing in front of his house when his daughter pulled into the driveway. She lost control of the car as she pulled in, striking the father. He was crushed between the bumper of the car and the wall of the house. He had multiple factures and other internal injuries that had to be repaired in the operating room.

 

Double Bad Luck

A 34 year-old man was driving his car and was rear-ended by another car. When he got out to check the damage, he was knocked to the ground by a third car as it passed. He was transported to the emergency department for evaluation and care of multiple injuries.

 

Poor Get Away

A paraplegic man purposefully ran his wheelchair into a slowly moving car. When the driver of the car stopped and got out to see if the man in the wheelchair had been injured, an third man car-jacked him and took off with his car.

The paraplegic and his wheelchair were unintentionally injured when struck by the car so he was unable to flee with his partner-in-crime. He was brought to the emergency department by ambulance for treatment of his injuries before being taken to jail.

 

How Did You Do That?

Several teenagers were brought in for evaluation after a car crash. When I asked the driver what happened, she said they rolled their car while driving in reverse in a parking lot of a shopping mall. When I pressed her to help me understand how in the world someone could possibly roll their car while backing up in a parking lot, she didn’t seem to understand why I was so puzzled.

 

Where Is It Safe to Park Your Motor Home?

An 18-year-old sober woman was driving about fifty miles per hour on a neighborhood street when she ran into a motor home, which was parked in a driveway.

 

Luck of the Draw

An 18-year-old man came in by ambulance. The medics reported the car he had been driving was going over 100 miles per hour when it hit a pole, apparently without braking. They said the car was literally cut in half with the two parts approximately 150 feet apart. The patient was very drunk and had cuts and bumps but nothing life threatening. The other occupant of the car had been pronounced dead at the scene.

 

 

Fair warning: not G-rated.

My patient of the week was a sixty-five-year-old man. He was thin and disheveled. Though it was  the middle of the night, he wore  huge sunglasses that covered his regular glasses. He kept peering out over the top of both of them to look at me as we talked. My interaction with him just amazed me. I think the best way I can do it justice is to  reproduce the nurse’s note, exactly as she wrote it:

Presents with complaint of pain under left shoulder blade, coughing up grey sputum, pain in penis and general weakness for six days. States he was seen in clinic a few days ago and given codeine cough syrup that doesn’t feel it’s helping him. States he’s been using Enzyte, the male “natural” enhancement drug ordered from TV for 1½ months and feels it may be causing his issues with his penis. States he went to a “Party Place a few nights ago where they have little holes in the wall and was able to obtain an erection and received oral sex from another guy and maybe that’s where I caught something on my penis.”

This is right out of the nurse’s note. I can’t make up things like this.