Here are three true stories about something that happened to the patient before he or she arrived in the emergency department.

Ambulance Taxi

A 69-year-old man was out in public and needed a ride so he called a cab. When the cabby refused to take his watch in payment for the planned ride, an argument ensued and the cabbie left. The man then fell to the ground and feigned being ill. A passerby took pity on him and called an ambulance that took him to the emergency department. He told me what happened and asked that I find him a board-and-care home where he could live. He had no medical complaint and expected no medical care.

Resurrection with Oxygen

Our emergency department is the base station for the County Emergency Medical System. This means paramedics call us if they need any guidance.

One night, I took a call from frustrated medics. They were on the scene with an eighty-five-year-old lady who had been seen by reliable bystanders to be down and not breathing for two hours. The medics got there and found her to be dead. When they wanted to pronounce her dead and call the coroner, a daughter, who was present, objected. She wanted the patient transferred to the university hospital and placed on oxygen for three days. She claimed to be a nurse and said she had experience causing her to believe this therapy would help her mother.

The medics put the daughter on the phone and I talked with her. I tried to get her to see that her mother was dead and there was nothing that could be done about it. She didn’t want to believe me and was not happy when I instructed to medics to call the coroner.

Ipecac Followed by Water

When I was practicing in Alabama, I worked in a hospital that also served as the medical command for the County Emergency Medical System. At that time, any treatment given by the paramedics had to be ordered by the doctor at the hospital. If the medics wanted to give a medicine to a patient in the ambulance, they had to call us for permission to do so.

One night, I got a call from the medics saying they had a patient who had just overdosed on pills. As was the procedure then, I ordered a dose of a medicine called syrup of ipecac, which was given to cause the patient to vomit. After the medicine is taken the patient was supposed to drink several glasses of water until the onset of vomiting. So, over the radio I ordered, “ipecac followed by water.”

Soon they arrived at the hospital and I was puzzled to find the patient was wet. The medic gave the patient the ipecac to drink then threw a glass of water over him.

A young adult man came in as a trauma alert. He was very drunk and obviously injured. The alcohol-induced lack of cooperation made his trauma evaluation difficult and complicated. He had to be sedated to keep him from harming the staff while we removed his bloodied clothing and performed tests to rule out serious injury. Eventually, all of his x-rays and scans came back normal and he was left to sleep off both his alcohol and the sedatives he was given.

Some time later, I heard a commotion and went to see what was going on. As I rounded the corner into the hallway adjacent to his room, I saw the patient, naked except for the protective collar he still had around his neck, standing in the hall. His IV tubing was trailing behind him into the room and he was hollering curses at everyone who was trying to get him to go back into the room and onto the gurney.

Immediately in front of him, sitting on a gurney in the hallway, was a young family: Mom, Dad and a seven-year-old daughter. When the drunk, crazy, naked guy came out of the room into the hall, he was standing right in front of them, hollering with dried blood on his face, arms and chest. The poor family looked like they were watching a horror film, frozen with eyes and mouths agape. The parents were so stunned they didn’t even think to protect the little girl from this amazing site.

A pair of Sherriff’s deputies happened to be guarding a prisoner nearby and quickly took the patient back into the room. They pinned him, face down, on the gurney and handcuffed his hands behind his back until hospital security arrived and got him into leather restraints.

I later learned the patient had awoken and asked the nurse where his Chihuahua dog was. When the nurse told him he came in with no dog, the patient blew up, tried to strike the nurse and cried that his dog was the only thing he had in the world. He then got up and headed off to find the dog. That is how he ended up naked and screaming in the hallway.

A few hours later, he was ready for reevaluation. I took off his collar, rechecked his neck and sent him off to look for his dog, sober and dejected.

One of the main jobs I have in running the emergency department is what we call “disposition.” That means getting people out of the department so others can come in and be cared for. Most of the time, this is simple. They either go home or they get admitted to the hospital. Some times, it is not so simple and takes a lot of work, time, creativity and patience to find a good place for someone to go. Here is a story of one such patient.

A 68-year-old man presented from a board and care facility. He was reported to be hyperventilating and not able to talk appropriately. He had a history of developmental delay and schizophrenia.

I found him agitated and hyperventilating. I ordered laboratory testing and sedation.

After being sedated, he responded to questions with answers like, “Elvis Presley” and “Bing Crosby.” He also started singing Christmas songs and other songs like “When They Call the Roll Up Yonder” and “Mine Eyes Have Seen the Glory of the Coming of the Lord.”

Because he had caused so much trouble at the board and care home, the managers refused to take him back. I had to find somewhere else for him to go.

I will present a time line that shows what I had to go through and how much time it took in order for me to get this guy out of my emergency department that evening.

5:05             The patient arrived in our emergency department and his work up began.

8:40             His labs came back normal. He was calm and cooperative. I called Emergency Psychiatry and

with the charge nurse. He said he would call back.

9:00             The Emergency Psychiatry charge nurse never called back so I called him again. He told me to call

back and talk to the doctor.

9:10             I called back and talked with the doctor, who told me the patient was not a good candidate for their

facility and recommended I try to find another psychiatric facility that would take him.

9:30             I talked with the charge nurse at a local psychiatric facility. She said she would call me back.

9:50             I talked with that charge nurse again. They refuse to take the patient in transfer. They offered no

reason.

10:00           I talked with someone at another local hospital with a psychiatric facility. They said they would

get back to me.

10:20            I talked with them again. They also refused patient.

10:20            I talked with the patient’s doctor in a city about an hour away who refused to take the patient in

transfer. He recommended I send the patient to our psychiatric unit.

10:30            I talked, again, with the charge nurse at Emergency Psychiatry who accepted the patient.

10:40            The charge nurse at Emergency Psychiatry called me back and asked that I document all of my

efforts to place the patient elsewhere.

11:10             The patient leaves for Emergency Psychiatry.

So, it took six hours and ten phone calls to make sure this man was safe for discharge and find a place for him to go. You can imagine what a disruption this was to the care I was trying to provide to all my other patients and how frustrated I got. This is an example of what I have to endure to do my job.

About 4:30 in the morning, I heard an overhead announcement, “Help at triage for a patient to Labor and Delivery, right now!” It was repeated with a true sense of urgency.

The last time I heard a similar page, I went out and caught a baby, just before it hit the tile floor in the waiting room.

This time, rather than finding a woman about to give birth, I found an anxious looking triage nurse and an even more frantic father-to-be. I was told the patient was still out in the car and the baby was coming.

Now, this would be exciting enough at the best of times, but the hospital is doing construction right now. So, there is no way for a car to pull up near the entrance to the emergency department. I grabbed the supply pack we use for precipitous deliveries and yelled at someone to get a wheelchair. I then hurried off, already some distance behind the father.

In order to get to the street, we had to run out the door to the curb, along a temporary sidewalk flanked by construction fencing, down an even longer sidewalk and then through a final walkway between more temporary barriers. As we came to the end of the passageway, which opened onto the street, I turned to make sure someone was following with a wheelchair.

When I turned back around, I was disturbed to not see the father. I quickly scanned the temporary patient drop off area. No one was in any of the cars. Where had he gone?

A holler drew my attention up the street where a minivan was parked around the corner, just out of my sight.

When I finally got to the minivan, the patient refused to get out, saying, in her Ethiopian-accented and limited English that the baby was coming out. I quickly sized up the situation. Her fundus (top part of the womb) was still high and no fluid seemed to be wetting her pants or the car seat. I told her it looked like she was OK and she had to get out of the car so we could help her.

With prodding, the patient allowed us to slowly help her out of the minivan and into the wheelchair, which was now parked in the flowerbed next to the curb. With some effort, as she would do nothing to help herself, we got her feet up on the little footrests. Then, I took control of the wheelchair and we headed back the way we came towards the emergency department.

The patient was clearly in distress. She was not holding on or doing anything to keep from being dumped on the ground as we went cross-country in the wheelchair through the flower beds, over the sidewalk, across the street, up the temporary sidewalks and around corners. I realized I needed to be a bit careful so that I didn’t dump her out of the chair onto the ground.

Fortunately, she stayed seated until we got her to the trauma room and the only open bed in the unit.

The staff got the patient up on the gurney and pulled off her stretch pants. I grabbed some sterile gloves and was just pulling them on as the baby squeezed out onto the gurney. I grabbed him and started drying him off while the respiratory therapist suctioned his nose and mouth.

For someone who rarely delivers a baby, the most anticipated thing is to hear it cry. A good strong cry means that the baby is not going to need any immediate care from me. After a couple of weak tries, this little boy was hollering just like I wanted to hear. Then, I was able to relax a bit, hand him off to a nurse and turn my attention to the mother. Soon, they were all off to Labor and Delivery.

It was not my doctoring that made the difference in this situation. I am sure that none of the other staff would have been so confident and aggressive in expediting the patient’s extraction from the car or her cross-country trip into the hospital. However, without that, the baby would almost certainly have been delivered into the mother’s stretch pants in a dark minivan or trodden flowerbed. Everything would probably have turned out all right anyway, but I was glad for the patient that she delivered on the gurney in the trauma room with us all there ready to handle any medical emergency that she or her new baby might have had.

A seventy-four-year-old woman was brought to the ED by her daughter. I approached them and introduced myself. The patient didn’t look at me or respond. She stared off in an angry or disgusted way. So, it was the daughter who told me the patient’s story. She said her mother’s behavior had been bizarre for the past five months. This included not paying her rent, and accusing her daughter of being abusive and stealing from her. The daughter said her mother had even threatened to kill herself.

During the previous week, the patient’s grandchildren, of whom she had custody, had been taken into foster care by Child Protective Services. Since then, the patient had been telling people her daughter had kidnapped the girls. Then, when the patient began running back and forth in the streets, saying she had nothing to live for, the daughter brought her to Emergency for help.

After listening to the daughter recount this story, I interviewed the patient with the daughter in the room. The patient said she was the guardian of two young grandchildren who the daughter had sent to Washington without her permission. She stated that her daughter and the daughter’s boyfriend were verbally abusive and had been taking unfair advantage of her financially. That day, while getting off a bus, she saw her daughter and a teenage granddaughter drive up and get out of their car. They started to yell at her, so she tried to run away. The daughter allegedly grabbed the patient and pushed her into the car. The patient said she had an ache in her arms and shoulders from being roughed up. She had no medical problems and she denied being suicidal.

I examined the patient and found no serious injury or any evidence of a medical problem that would cause bizarre behavior. I was not sure which of the conflicting stories to believe, so I did what any good emergency physician would do: procrastinate. I went to see someone who needed more urgent medical care and put off deciding what to do about this woman.

It was a good thing I decided to wait.  A while later, a second daughter arrived.  She said the first daughter was trying to make their mother appear insane. She was apparently doing this in order to get custody of the granddaughters who were in the patient’s custody. This second daughter seemed believable and her story was in agreement with the patient’s. When I looked for the first daughter, she was nowhere to be found.

I notified Adult Protective Services. A police officer came and took a report. He told the patient how to file for a restraining order against her accusing daughter. Since the patient had no need of medical care, we discharged her with the second daughter who said she could keep her safe.

Backed Over by a Good Samaritan

A 62-year-old lady was lying in the road in the middle of the night. A man, driving by in a car, saw her as he drove by. He stopped and backed up to render assistance. He was so excited that, as he did so, he accidently ran her over. One witness said that after he realized what he had done, he freaked out even more and drove forward, driving over her again. The patient did not remember any of this. It was not clear why she was lying in the street at 2:00 in the morning. She suffered extensive injuries requiring hospital admission and surgery.

Remember to Put the Car in Park

A 24 year-old lady was driving her car in reverse in the driveway. She looked in the rear view mirror and saw her two children playing behind the car. She freaked out and jumped out of the car in an effort to protect them from the moving car. Unfortunately, she did so without putting the car in park. The open car door immediately knocked her down. The car continued in reverse and the open door knocked over both of the children before coming to a stop across the street. Fortunately, none was run over by the car. The driver suffered only a badly bruised knee and the children were all unhurt.

Run Over Twice by Same Car or Could This Really Have Happened?

A two-and-one-half-year-old boy came in by ambulance. His mother said she saw her car slip out of gear with no one in it. The car was parked on an incline and rolled down the hill, running over her child who was playing behind it. The car then went up an opposing hill where it stalled out then rolled back over the child again, continuing back up the hill on which it started. She said she was able to move the child before the car came back down the hill when it would have run over him a third time. He suffered multiple severe injuries.

About 4:00 in the morning, the paramedics brought in a twenty-six-year-old man who had been beaten by bouncers who kicked him out of a bar where he had apparently caused a commotion. Police, called to the scene, may have also added to his injuries when he became combative with them.

He was a thin man who was very drunk and uncooperative. He had clearly been beaten about the face, which was swollen, discolored and scratched. He had bruises and scratches on his shoulders, back, arms and legs. He refused all efforts to calm him down. He was uncooperative as we tried to convince him to let us evaluate him to make sure he had no serious injuries. No matter what was said to him, he would strike out at the questioner and say something like, “F— you!” Almost every sentence or proclamation included the “F” word.

Since he was not competent to refuse care, I could not just let him leave as he asked to do. At this point, I had to make a decision. If there was little likelihood of a life threatening injury, we could restrain and/or sedate him until he sobered up. However, if his injuries might be life threatening, then I would need to do more to diagnose and treat him. Since this patient was so uncooperative, I would have to use more aggressive means to control him so he could be x-rayed and scanned.

I decided to just keep an eye on him. I asked the patient if he had anyone sober who could come and take him home. He said he did. I asked him who. He said, “My fuckin’ parents!”

“Your what?” I asked. He repeated his disrespectful answer. Then, he sat up, looked me in the face and went off on me personally. He started by telling me he could tell I was a “fag.” He pointed out my blue eyes (I actually have green eyes) and my ponytail as evidence that I was “a queer.” He then said, using most offensive words, that he could tell that all I really wanted was to have sex with another man but had never been able to do so. “I can tell just by looking at you!”

I walked away from him so he didn’t have me as a target for his nastiness but it was not helpful. He talked with everyone the same way. He said foul, hurtful and untrue things about Hispanics, blacks, women, everyone. He was taken out of the trauma room, placed in a regular room and was assigned someone to sit and keep an eye on him.

A while later, I started to wonder if I had made the correct decision about just letting him sober up. Rather than relaxing and falling asleep, as most drunks usually do, he just got more obnoxious. He refused to stay in bed and he actually became more violent. While standing in his boxers at the bedside, he screamed that everyone there had touched his private parts and molested him. He said he was leaving. Four security guards and a sheriff deputy stood in the hall outside his door. They asked me what they should do about him.

The patient was still way too drunk and injured to be allowed to leave. Yet, my impression remained unchanged that he could safely be observed until he was sober. I told the officers to put the patient in four point leather restraints and then stay out of his sight so he was not tempted to insult anyone.

A while later, I was informed that his parents had arrived. I went in the room, wondering what I would find. They told me he had no medical problems and confirmed that he was an alcoholic and had been through rehab several times. As we talked, the patient would interrupt, repeating his accusations about having been sexually molested while under our care.

“Oh, shut up!” his father scolded.

I explained that their son was being held, against his will, because he was injured and too drunk to be safely discharged alone. I told the parents they could take him home if they were willing to take responsibility for him. Otherwise, our plan was to keep him until he cooperated with the scanning and x-rays and was sober enough to be sent out alone.

The parents didn’t even need to discuss the situation. They declined to take responsibility for him and went home.

The patient finally fell asleep. He woke up a couple of hours later and was much more pleasant. Now, it was “Yes, sir” and “No, thank you.” He agreed to x-rays, which, fortunately, didn’t show anything broken.

When it was time for him to be discharged, he wanted to know where his wallet and cell phone were. No one had seen either of these items when he came in and we were unable to find them. As I was giving him his final discharge instructions, I was very careful to not say anything judgmental. However, when he accused us of stealing his belongings, I pointed out that, perhaps, he had some responsibility in keeping track of his items.

As he turned and walked out, he said, “You are a douche bag and I hope you die today.”

A twenty-six-year-old man with mental problems was taken by his family to emergency psychiatry. Before they could get him inside, he broke away and ran off. The sheriff was called. They chased him down and, in order to subdue him, shot him with a TASER. By the time they got him under control, he was not breathing and they rushed him in to us. We did our very best to revive him but were not able to do so.

The worst part of my job is telling people their loved one is dead. When I got to the family room to do my duty, I met a middle-aged mother and several other people who turned out to be siblings, cousins, uncles and aunts. I briefly reviewed what had happened then told them he was dead. When this happened, the mother, who was sitting right in front of me, screamed, threw herself on the floor and started to flail around. Everyone else (and I mean EVERYONE) immediately pulled out their cell phones and started dialing. One aunt, as she dialed, pointed to the mom and said something like, “Can’t you get someone to do something for her?” A younger brother, also while trying to dial, started hollering at the sheriff deputy who was standing in the hall outside the room, blaming him for the death. It was the most surreal situation, standing there, watching everyone dialing and talking on his or her cell phone while the grieving mother moaned on the floor.

I finally pointed out to every one in the room that all they were doing was calling on their phones while the mom was crying on the floor. I recommended they put away their phones long enough to give her some comfort. There was some half-hearted effort to respond to my recommendation.

I told them I was very sorry then excused myself to go back to seeing my other patients. A while later, as I was writing up a note on the computer across from the dead man’s room, I heard the mother, from behind the curtains, hollering in Spanish, commanding her son to get up and walk.

I work in a place where we may see patients from almost anywhere in the world. This richness in humanity is one of the reasons I have stayed working at the same place for almost a quarter of a century. Interacting with people from all over the world is interesting and enriches me. It also presents significant challenges

A Bangladeshi man brought in his elderly mother for evaluation. He made some notes, which he gave to me so I could understand what had been going on with her. He said she had been suffering for forty years with these problems. She had just arrived from Bangladesh a few days before and he brought her in for evaluation. Here is the note he gave me, transcribed as best I can from his neat handwriting:

* IF SHE FEELS HUNGRY, GETTING DISSYNESS.

WANT TO EAT MORE, BUT CANNOT.

EVERY HALF AN HOUR EATING.

JUST LITTLE AMOUNT, WAANT TO EAR MORE.

* BURNING INSIDE STOMACH/ GAS, HOT

* FEELS VOMITING BUT COULDN’T THROUGH UP.

* STOOL IS HARD/ GOING TO THE RESTOON ONCE EVERY AFTER ¾ DAYS

* CAN’T EAT ONLY RICH FISH, VEGETABLE

* IF TAKE PRE-COLEDG (stool softner) GOING TO THE RESTROOM NORMALLY.

* VERY WEAK, SHECKING.

****SLEEP IS NOT ENOUGH/ 4-5 HOURS EVERYDAY

* 4-5 YEARS AGO, GOT LOT OF EXAM FROM HERE. DOCTOR SAID, COULDN’T GET SERIOUS.

ANTHING, ONLY STOMACH/ PARS ARE VERY WEAK

* WANT SOME VITAMINS

You can see that this sort of presentation would be a challenge for any doctor but, as an emergency physician, I need to see through the forty-year-old things and make sure I don’t miss anything that needs to be discovered today. These people and this note represent a part of what makes my job so interesting.

I wanted to share with you all an amazing medical story that hit close to home for me, though I had nothing to do with it myself.

Our middle daughter’s best friend is Jessi. She recently married a young man named Trevor who was in the throws of trying to get into medical school. He was a healthy young man who had been training all summer for a triathlon.

They were at a family reunion at Bear Lake in northern Utah. He was standing in shallow water next to a ski boat, surrounded by cousins, when he collapsed. Those closest to him kept him from going under the water and hoisted him into the boat.

One of the cousins was a nurse and a second had just recently taken a CPR class. They found him to be unresponsive and with no pulse so they started CPR. This continued for about fifteen minutes until the medics got there. They found him to be in ventricular fibrillation, which is a chaotic heart rhythm that is ineffective in pumping blood and soon leads to death. Fortunately, when they shocked him, just like you see on TV, his heart started beating normally again. He went back into that same deadly rhythm one more time in the helicopter on the way to the hospital. He was shocked again back into a normal rhythm.

I first found out about him when he was in the ICU with his temperature being kept artificially low and in an induced coma. My daughter called and wanted to know what his prognosis was. I told her it was grim. Most people who suffer a cardiac arrest die. Most of those that survive do so with brain injury from lack of oxygen from the time their heart was not beating. I wanted to tell my daughter there was no hope but realized it was time for hope so I didn’t share with her my true, fatalistic expectations.

Trevor remained stable until it was time to warm him up and see if he would awaken. Everyone was hopeful as he immediately started to follow commands and ask what had happened. He soon managed to bend his head down close enough to his restrained hand to pull the ventilator tube out of his windpipe. He then looked up at the nurse and asked, “Where is Jessi?”

By the next day he was eating and asking over and over again, “What happened?” as his short term memory was gone. The next day he was remembering better and was able to be involved as they made the decision to give him an implanted defibrillator. This is a machine, like a pace maker but designed to shock him from inside if his heart goes into that death rhythm again.

Trevor fully recovered. He is in medical school and the father of the child Jessi was carrying when this all happened. This is really an amazing story with an almost unbelievable ending.

I can put myself in the place of the emergency physician who took care of Trevor. I am sure as he was taken out of the emergency department and up to the ICU, the doctor had to be asking if they had really done any good in reviving him or if they had just kept alive a brain-injured nightmare.

In the emergency department, we don’t usually see the whole story and have to keep emotionally distanced to a certain degree as we deal with this sort of difficult situation. This event gave me a chance to be emotionally involved in a way I would never have been able to had this been one of my patients. It helps renew my optimism and not see every patient who survives cardiac arrest as a future vegetable in a nursing home.