Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 19-year-old came in with discomfort in her vagina. She said she had used her mother-in-law’s “old douche bag.” She said she was afraid her nephew, who had been playing with the bag earlier, put marbles in it. She was afraid she might have marbles in her vagina. Her husband checked her, feeling for a marble earlier today. He said, “There is something up there that doesn’t belong there.” I removed a cat-eye marble from her vagina.

A 50-year-old man came in after a three-foot-long board was dropped onto him. The board had a nail sticking out of it, which was stuck into the scalp on the top his head. He had walked to a neighborhood fire station where the medics were called. They transported him with the board carefully secured in place. I just pulled it out.

A 37-year-old man stepped on a screwdriver that went clear up through, poking out the top of his foot.

A 15-year-old was brought in by ambulance after being hit by her 10-year-old sister with a can of Pringles.

A 26-year-old female presented at 6:00 in the morning complaining of being weak and tired after being up all night drinking whiskey at a party.

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 46-year-old man working to make a wall of rebar which gave way and fell over, pinning him underneath it. He had a one-inch diameter piece of rebar running through his right biceps. He was soaking wet from the water that was used to cool the metal as it was cut on each side of his arm to free him from the structure.

A 24-year-old lady was driving in reverse in her driveway when she looked in the rear-view mirror and saw her children playing behind the car. She freaked out, jumped out of the car without putting it in park, and was promptly knocked down by the open door. The car also continued and knocked over both of the children, running them over all of them. Fortunately, none was seriously injured.

A group of teens rolled their car while driving in reverse in a parking lot of a shopping mall.

The daughter of my elderly patient with diabetes said, “I woke up and found her on the floor unresponsible.”

A 54-year-old woman was sitting in church when she developed “power in my vagina” which moved up into her heart and caused chest pains.

More Bad Tad Meanwhile next time!

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 74-year-old man claimed he came in to be seen “sooner rather than later” because he didn’t want to be a “bad looking corpse.”

A young man fell on an arrow, which stabbed him up under the chin. It passed through his tongue, the roof of his mouth and into his nasal cavity.

A young woman came in complaining of a “bad infection in my grinder.” I had never heard a woman refer to her vagina as a “grinder” before and have not been able to find such a definition anywhere, even in the likes of Urban Dictionary. Maybe I am just not street wise.

I asked the son of an elderly man if his father had any medical problems. He said, “He has something wrong with his arm.” I pulled up the patient’s sleeve to reveal a dialysis shunt. So, chronic renal failure on dialysis turned into “something wrong with his arm.”

More Bad Tad Meanwhile next time!

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. I would like to do a little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.
Twice I have had to dig little beads out of the craters in teeth caused by severe cavities. One was in a child and one was a 22-year-old man.
A 20-year-old man came in with a complaint of uncontrollable farting when he gets nervous.
A 22-year-old female was hit in the thigh with a lime that was shot from a gun. I had heard of potato cannons before but never one that had been modified to shoot citrus.
A 38-year-old man came in with a heavy metal ring on penis, which was purple and markedly swollen. I was unable to cut it off (the ring) with anything we had in the hospital. Some passing paramedics saw what was going on. They left and came back with bolt cutters that did the job.
In one shift, I saw had 17-year-old patients who claimed that they couldn’t get pregnant because their husbands “always pull out in time.”
More Bad Tad Meanwhile next time!

I was called into the room to see a young, healthy woman who had abdominal pain, vomiting and diarrhea for several days. I found her to have abdominal tenderness and low blood pressure. She was clearly ill. Of specific concern was that her finger tips were blue, a clear sign something bad was keeping her blood from flowing well. It was not at all clear just what would be causing her illness. I told her, her mother and her boyfriend I was worried and I reviewed with them what I was going to do to get some answers and start treating her.

My first focus was on the abdominal pain, vomiting and diarrhea. I ordered pain medication, fluids and antibiotics in case she had an infection. I was thinking maybe her low blood pressure and the poor circulation to her fingers were just from being severely dehydrated. But, we are always thinking of more unusual, bad reasons our patients are sick, so I ordered more tests than I would normally have done. I also had the charge nurse move her to the room right next to my work area so I could keep a close eye on her.

Her lab tests confirmed she was sick but didn’t answer any questions as to why. I wanted to get a CT scan of her abdomen but because her blood pressure was so low, it was not safe to send her to the Radiology Department. Second best, we did an ultrasound at the bedside. It didn’t show anything in her abdomen but, very much to my surprise, it showed a huge pericardial effusion. That is a collection of fluid between the heart and the sack the heart sits in. It usually occurs because of inflammation and, if it is large enough or develops too quickly, it can press on the heart, keeping it from filling adequately with blood. This could cause low blood pressure and poor blood flow to the fingertips.

The treatment of a pericardial effusion is to pass a big, long needle through the skin in the upper abdomen. It is directed up under the ribs, into the heart sack. The hope is that sucking that fluid out will give the heart a better chance to fill with blood so it can pump more efficiently, raising the blood pressure and fixing the circulation.

Draining a pericardial effusion is done very rarely but, if done quickly and correctly, it can be life-saving. I spread antiseptic over her chest and abdomen. I passed the needle up under her ribs into her chest and was immediately able to start drawing fluid out with a syringe. With the ultrasound, I could see when I had removed it all. Unfortunately, I could also see that, even after the fluid was out, her heart was beating very weakly. Taking the fluid out didn’t help her at all.

Now, at least, I had my diagnosis. Cardiogenic shock. That means the heart is beating so weakly it is unable to keep blood moving well enough to get oxygen into all of the tissues. I then was able to concentrate on her heart as I continued treating her.

Unfortunately, she continued doing poorly. Her blood pressure got so low she went unconscious. I intubated her and ordered multiple medications to keep her blood pressure up enough to send her for the CT scan of her abdomen. I still didn’t understand what could cause vomiting, diarrhea, abdominal pain and cardiogenic shock.

He blood pressure improved just well enough for me to risk sending her to Radiology. The CT scan showed inflamed intestines. Nothing else. It looked like she was probably very ill with a virus. That would cause her intestines to be inflamed and give her pain, vomiting and diarrhea. A virus can also inflame the outside covering of the heart, causing the pericardial effusion. Worse, it can inflame the heart muscle itself, causing viral myocarditis, which can cause the heart to beat weakly. Though I had not found anything I could easily fix, at least I had a picture of what was going on. I didn’t feel like I was missing anything.

While all of this was going on, I had also been making phone calls to get her admitted to the hospital. I talked to our cardiologist who said the patient should go to the bigger hospital in the large city a few miles from us. When I contacted them, they said she was too sick and should go to a “university hospital.” The closest place like that to us had no beds and would not accept her. The next closest place was so busy, I could never even talk to a doctor. Finally, I got ahold of an intensive care doctor at a big university hospital about two hours’ driving time from us. He was very helpful, giving me recommendations on how to treat her as we got ready to fly her to where he was.

Unfortunately, I soon learned the helicopters were grounded because of weather. I knew if she went by ground she might die en route. I also knew if she stayed here, she was certainly going to die.

All this time, she just got worse and worse, eventually requiring CPR. I stood at the bedside with the ultrasound probe over her heart. When it stopped beating, we would do CPR for a while and give her adrenalin injections. This would keep her heart beating weakly but when the effect of the CPR and adrenalin wore off, her heart would stop and we could do it again.

Her mother was kneeling on the floor next to me, holding her daughter’s hand, and begging her to live. Her upset, but remarkably under control, boyfriend was by her head. At one point, the boyfriend’s mother came in as well. She put one hand on the patient and one on her son and prayed, asking God to intervene in the patient’s behalf. I stood there with them, feeling I had done everything possible but that she was certainly going to die.

For almost two hours we were there like that. The patient was too sick to be admitted to our hospital and too unstable to be transferred. She got everything I could possibly use to pull her through, but her heart just kept getting weaker and weaker. I was standing there, watching the family cry and pray as her heart slowly gave out. There was nothing I could do about it. Eventually, her heart stopped completely and she was pronounced dead.

I felt physically and emotionally spent. After the family had some time alone with her, I went in and talked with them. I explained what I thought had happened. I reviewed with them what I had tried to do for her. I cried and said I was so sorry for them.

By the time this was over, I could hardly do anything else. I had a hard time focusing my attention elsewhere because my mind would immediately circle back to this case. Though I am good at leaving my work at the hospital, I was not able to do so in this case and it took a long time for me to work through my feelings and get back to normal.

A measure of how difficult this case was is how it affected the emergency department staff. For a couple of weeks, people who were involved with her care were talking about how challenging it had been. For about that same time period, every time I would come in for a shift, the other doctor would say something like, “Hey, I heard about that case you had…” Everyone was talking about it.

So, a young lady that may have just had the stomach flu, died from cardiogenic shock. It could happen to anyone. Why did she have such bad luck? Why did I have the opportunity to be the one with her and her family while she died? Just my luck. Good or bad?

I have seen some pretty bad hair in my years in the emergency department. I am not talking about a style, cut or color not to my taste. I mean gross hair. I have seen lots of people with lice. I have also seen people with problems caused by their belief they had lice when they did not. One woman dug at her hair so much trying to dig out her nonexistent lice that she turned the back of her hair into a giant dreadlock ball. One man burned his scalp when he lit his hair on fire trying to get rid of his lice.

The other day, my patient was a young man who was in the emergency department for something completely unrelated to his hair. As I examined him, however, I couldn’t help but notice he had an Afro pick so entangled in his hair that it was, at first, difficult to tell what it was. He didn’t offer an explanation for how he ended up in this situation.

I asked him if he wanted me to help him take the pick out. He seemed appreciative of the offer. He also agreed to let me take a picture of it and share it with you. With some work, one of our ED techs was able to work the pick out, leaving a giant dreadlock ball for him to deal with later.

We addressed his other concerns and he left, with his newly liberated pick.

Some clarification about what you are seeing in the picture: This is the back of his head. The pick’s handle is pointing straight up. The tines of the comb are enmeshed in the hair, some of them showing below, pointing to the right. A staff member’s hand is on the patient’s right shoulder.

Here is an image from the internet that shows, basically, what the pick looked like.

Working in the emergency department can be dangerous. It is a stressful place for everyone. Many patients are impaired from drugs and alcohol. Mentally ill patients frequently end up in the emergency department. Gun shots have even been fired while I was working in my emergency department.

I have been an emergency physician for over thirty years. During that time, I have been yelled at and threatened. I have been spit at several times, once right in the face. But I have never been physically assaulted – until recently, when I was actually knocked down by a patient. I was not injured but I was surprised at how much this bothered me. I realize the older I get, the more at risk am to being assaulted. Also, to do well in a high-risk environment, one has to kind of fall back on the “it can’t happen to me” defense. Once it has happened to you, it is harder to effectively use that. I was really shaken by this. Enough that it contributed to my decision to retire, a bit earlier that I had planned to. It was important enough that I want to tell you about it.

Staff alerted me that a patient having a seizure had just arrived. He was being wheeled into the room the same time I entered. I saw a healthy-looking young man, about twenty years old, sitting up in the wheel chair. He was clearly faking having a seizure.

For some reason, faking seizures is a pretty common way for people to try to gain attention. Some of them are pretty good fakes but an experienced emergency physician can often tell, at a glance, the patient is not really having a seizure. I shared my impression with my staff. That allowed them to relax and move ahead with stuff like getting vital signs and attaching the patient to the monitor. I went to take care of another patient while all of that was being done.

When I went back into the room, the patient was behaving normally. His brother-in-law was with him and helped give me the following history. The patient had just come from another hospital where he was admitted to intensive care, a breathing tube was passed down his throat and he was treated with multiple medications to get him to stop seizing. The patient and his family were unhappy with his care so they signed him out and brought him to our hospital in the neighboring city. The patient complained, “All they did was just knock me out.” He admitted he had not been taking his seizure medicine before he had the seizure that took him to the other hospital.

I started with his vital signs and a physical examination, which were normal. To evaluate someone who is having seizures, I might have ordered blood tests, a urine drug screen and a CT scan of the brain. However, since he had just come from another hospital, I thought testing might have already been done. I asked the patient for permission to request records from his previous visit, thereby avoiding unnecessarily repeating tests.

Before too long, the report was faxed over from the other hospital. It was pretty amazing. He had arrived having seizures and had been given several medications to stop them. None worked. As a last resort, the patient was paralyzed and put under general anesthesia. A breathing tube was passed into his windpipe and he was placed on a ventilator. All laboratory testing was normal, as was the CT scan of his brain. Up in intensive care, they let him slowly wake up then pulled the breathing tube out. He promptly refused further treatment, signed out against medical advice and left the hospital.

Within a couple of hours, he was back in their emergency department, seizing again. Once more, he was given medications to stop his seizures. They repeated all of the labs and the CT scan. When no medications stopped his seizures, they decided to paralyze and intubate him again. Before they did, he stopped seizing, refused further care, and signed out against medical advice a second time. That’s when he came to our hospital. So, in the last twenty-four hours, the patient received two complete seizure work-ups. All was negative.

Seizures are hard on the brain. Someone who has been seizing a long time usually does not wake up right away. It could take hours before returning to normal mentation. For him to stop seizing, wake up and immediately walk out of intensive care made me wonder if he had been faking all along. Regardless, he was not having seizures in my department. All he needed to do was go home, take his medicine and follow up with his doctor.

As is my habit when discharging someone, I went into the room and sat on a stool at the foot of the gurney. I calmly explained what I learned and why there would be no reason for us to do any additional testing or provide him with any treatment. As what I was saying began to sink in, he started hollering and swearing at me. He stood up, called me several nasty names, pulled off his monitoring pads and yanked the IV out of his arm.

He announced he was leaving and I could see he was in no frame of mind to listen to me anymore. So, I stood, moved to the door and pulled it open for him to go. As he walked by me, he took a big swing at my head. Reflexively, I pushed the door into him to protect myself. The door knocked him back and kept his roundabout swing from landing a blow. He quickly recovered and came back swinging, knocking me down onto the gurney. Fortunately, his brother-in-law jumped between us and pushed him back against the wall, giving me a chance to roll off the gurney onto the floor. I then scrambled out the door on the other side of the room.

I was not injured but I was shaken. I am sure he would have hit me if I had not been able to use the door to protect myself and if his brother-in-law had not been there to hold him back.

I can’t help but think he was a troubled person. I assume everything that happened at the other hospital as well as his assaulting me as I tried to give him discharge instructions were as a result of underlying mental problems. It makes me wonder how long it will be until he attacks someone else and whether that person will be as lucky as I was to escape serious injury.

This is a complaint that a patient submitted to Customer Service at the hospital. Customer Service sent it to me as Medical Director of our emergency department. When I would get such a complaint, it was my responsibility to look at the medical record, talk with any staff involved and reply to Customer Service.

Just for background: a spinal tap is a common procedure performed on children and adults in the emergency department. It is done to make sure they don’t have spinal meningitis, which is a serious brain infection which can kill or seriously injure the infected person if not treated repidly. To preform a lumbar puncture, a kid has to be held tightly while a little area on the lower back is numbed up. A small needle is passed between two bones in the spine to take out a sample of fluid that is then sent to the laboratory to look for signs of infection. It is not fun for the baby, the parents or the doctor. It is also not an operation nor experimentation.

This is one of many similar complaints this man made to Customer Service. Most were about Hispanics not being treated appropriately in the hospital. His complaint was so wacko, it was hard to even take it seriously as I formed a response.

Here it is. Other than removing names, it is copied word for word from his Customer Service complaint form.

Subject: Human Experimentation and Medical Malpractice on Mexican Children

Attn: Chief Administrator, The Medical Center

RE: Spinal tap surgery performed on 2-3-year-old Mexican Child by M.D. (non-surgeon) & assistant.

1. Location: Emergency Room A (close to entry/exit)
2. Time: 2-3 a.m. (morning), 2 September
3. Condition: Non-surgical, non-hygiene; inhumane – young child screaming throughout experiment.
4. Physician: Dr. M. and other emergency room associate (at least one.)
5. Please note: Child and Parents spoke no English.
6. Please note: After this inhumane butchery, Dr. M. and company celebrated for an hour between 3 and 4 a.m. in the morning. (This is the second experiment/celebration we are aware of by Dr. M. & et. al.)
7. Immediate suspension w/o pay, arrest, imprisonment, prosecution and revocation of medical license are mandated for public safety.

I have additional notes from my conversation with the patient, however they are covered here.

Maybe you are tired of hearing stories about drunks, but I am afraid any blog about emergency patients is going to be full of stories about drunks. We see so many drunks it takes a pretty amazing drunk to be remembered many years later. Here is a sad one I will never forget.

An elderly woman was found in her home, intoxicated, with a half-empty vodka bottle at her bedside. It was not clear who had called the paramedics. She had no complaints and said she was in no need of medical care. She had been verbally and physically abusive to the paramedics before she arrived. She had to be restrained in the emergency department to keep her from striking our staff.

She was very thin, half naked, intoxicated, disheveled and wet with urine. She was very uncooperative and refused examination and treatment. She demanded to be let out of the restraints.  When I pointed out that she was too drunk to be trusted out of restraints, she adamantly denied being intoxicated, saying she was a Mormon and didn’t drink alcohol.

This was an interesting defense to use on me. Though she obviously had no way of knowing it, I am a practicing Mormon. This makes me very aware that most Mormons live by health standards that forbid the use of alcohol. Using Mormonism as a defense for her present situation might have worked on someone else but was clearly not going to work on me. Also, as an emergency physician, I am very familiar with signs of alcoholism and am very good at telling who is drunk. It was obvious to me that she was both an alcoholic and acutely intoxicated.

I then did what I usually do with such people: wait. I checked on her frequently, expecting that, with time, she would sober up, allowing me to be assured she had just been drunk and not in need of medical care for some other problem.

As she sobered, she admitted she had been drinking but she denied being drunk. Every time I tried to talk with her, she got upset and threatened to “cut (my) balls off.” She refused to call for anyone to come take her home.

It took all night for her to sober up.  When she was ready to leave in the morning, she continued to refuse to call for a ride. She was provided with dry clothes and allowed to leave. As she was walking out, I couldn’t resist the temptation to say to her, “Have fun reading your Book of Mormon.”

She stopped, angrily spun around and flipped me off before turning on her heels and walking out.

Vomiting Blood

A 22-year-old man came in saying he had been vomiting blood for several hours. He also had abdominal pain, felt weak and dizzy. He had never had anything like this happen to him before and had no significant past medical history. He looked uncomfortable and a little pale. His abdomen was tender, his heart was beating fast and he had blood on his clothing. (See below.) All of this made me worried he was bleeding internally, probably from an ulcer in his stomach.

I told him I was going to ask the nurse to start an IV and draw some blood tests. I also explained the need to put a tube through his nose into his stomach to see if he were still bleeding. He agreed to this potentially life-saving course and I went on to see my next patient.

A few minutes later, I was approached by the nurse. As she was getting ready to pass the tube into his stomach, she got additional history. The patient had eaten nothing in the last twenty-four hours but Flamin’ Hot Cheetos. I then took a second look at the “blood” on his pants and tested it. No blood. Just pure Flamin’ Hot Cheetos juice.

So, instead of a potentially life-threatening hemorrhage, he had a bad stomach ache from eating too many Flamin’ Hot Cheetos. We gave him some IV fluids and some medicines to make him feel better. We sent him home, admonishing him to be a little more wise with his diet in the future.