My patient was an elderly man who tripped and hit his head in a minor fall. It was only a big deal because he was taking the blood thinner, Coumadin, to keep his artificial heart valve from clotting off. People on this medicine can bleed into their brains and die after minor trauma that would normally cause no serious injury at all.

As feared, within minutes, his minor fall turned into a deadly hemorrhage around his brain. Though we did everything we could to reverse the effects of the Coumadin and save his life, it was clear that he was in big trouble. I enlisted help from the appropriate specialists then made arrangements for him to be admitted to the hospital.

When I went into the family room to tell waiting family members the bad news, who was sitting there but a friend of mine from church? The patient was his father.

Delivering bad news to family is always a bit dicey. When you throw in a personal connection, it makes it more difficult but more interesting and potentially more rewarding too. Our interactions in the family room were warm and satisfying. My friend understood his father was going to die and thanked me for my efforts in his behalf. I took him to be with his father.

The patient went on to die the next day so his whole huge family started heading into town for the funeral. My wife, as president of the women’s’ organization at church, contacted the family to offer assistance. Besides arranging for rolls and dessert for 200 people for the family dinner at the church, we also offered our house to help them put up members of their immediate family. The wife, her two daughters, two sons-in-law and three grandkids stayed in our three spare bedrooms until the funeral was over and they headed back to Las Vegas.

Who would have guessed, as I headed into the trauma room that night, that it would lead to having my house full of family members mourning the loss of my patient?

I frequently tell people they should stop smoking. To me it is kind of a ridiculous thing to do. Everyone in our society knows it is stupid to smoke. When I ask people why they smoke, among the most common responses are “I’m stupid” or “I’m trying to quit.”

Needless to say, when I invite them to join the 85% of adults in California who don’t smoke, I feel it is a waste of time. They know they shouldn’t smoke. Most of them wish they didn’t smoke. If they were going to quit, they would. What good would it do for an emergency physician to tell them to stop?

The other night, I went into a patient room and introduced myself to a middle-aged man who said, “I know you. You were my doctor last year and you told me to stop smoking. I haven’t had a cigarette since then and I really appreciate you encouraging me to stop.”

Wow! I was really set back by that. Now I can use that as encouragement to continue to jab people about their smoking. Good luck to me as I try to keep up my efforts and good luck to all smokers as they try to quit.

Globus 1

A man in his mid thirties claimed he repeatedly had food stick in his esophagus. It started ten years earlier when he took a big handful of vitamins at one time and he couldn’t get them to go down. He had to force them out by sticking his fingers down his throat, causing him to forcibly vomit. He had experienced many such episodes since then and said it could happen with eating something as simple as a poorly chewed almond.

People with abnormal narrowing of the esophagus may have problems like this. However, this guy had been told his esophagus was normal on a recent x-ray swallowing study.

After hearing this history, I felt pretty sure he did not have a physical problem. As I watched him, this impression was reinforced. He appeared nervous, uptight, and very weird. He gave in-depth, detailed descriptions of all his symptoms. When I was talking, he would stare off into space with an anxious look on his face, holding his hand on his chest. Lost in his own thoughts and concerns, he would then interrupt me to add some new detail of his condition. He would get up mid-sentence, whether his or mine, go to the sink, stick his fingers down his throat causing himself to bring up a small amount of saliva which he would point at and say, “See!”

He paid such little attention to my explanations that, had it not been so fascinating, I would have been annoyed. Finely, I had to be blunt. “We are sending you home now. I just need to know if you want me to refer you to a doctor here or if you are going to see your doctor in the city where you live.” I had to ask him several times before he gave an answer rather than just repeating things he had already said or going to the sink and pushing fingers down his throat.

Globus 2

A middle-aged man came in by ambulance after almost choking to death on his saliva while driving. He said he was saved only after he managed to get a Hall’s cough drop in his mouth. The menthol vapors allegedly opened his chronically congested nasal passages so he could better breathe through his nose, saving him from certain death.

He had a long history of ankylosing spondylitis* which caused fusion of his entire spine so he was not able to bend or rotate his trunk or neck. He also had a long history of unexplained weight loss.

For a year, he had trouble breathing out of his nose. He also had recurrent choking on thick saliva. Unfortunately, no doctor had been able to explain this or offer any beneficial treatment.

My immediate impression was the guy was crazy. He looked distracted when I was talking. Looking down, he plugged one nostril with a thumb, took a little sniff to see if it were open and then repeated the same with the other side of his nose. This he repeated several times during our interview.

I’ve been saved many times in emergency medicine by stopping to ask if my impressions are wrong or if I might be missing something. My impression was that this was all in his head but I forced myself to re-examine my perceptions in this situation. The patient was very skinny. His stiff spine and abnormally stooped posture gave him a creepy appearance and caused him to move in a strange way. Could he also have something that might cause him to choke to death?

I excused myself and went to the computer to look closer at his medical record. I confirmed the history he gave me. A recent CT scan showed normal airway anatomy and a swallowing study showed no abnormality. He also had an unremarkable evaluation by an ENT specialist. This supported my impression he was suffering from a mental and not a physical problem. The only other thing I needed to know was if he could swallow or not.

I got a cup of water and took it to him. He said he was unable to swallow because his saliva was too thick. I told him to drink anyway.

He hesitatingly took the cup and pressed it to his lips. A slight amount of water entered his mouth.

“Good. Drink some more.”

This time he actually took a small sip.

“Drink it all.”

And he did. With no problem.

I tried to help him see that his perceptions were not logical and had no basis in anatomy or medicine.  I did this in a gentle and understanding but straightforward way. He would accept no reassurance nor reconsider his impressions that he was at risk of dying from nasal congestion and choking on thick saliva. He was truly afraid if he went home he would die. As he begged to stay, the poor man painted such a miserable picture, I was unable to kick him out.

For the rest of the night, he slept on a gurney in the hallway. A couple of times, he got up to tell me “it” was happening. He would demonstrate “it” by sticking out his long, snaky tongue covered with saliva he had collected in his mouth. I would get him another drink of water and he would go back to his bed.

In the morning, he left with plans to drink water, take Hall’s as needed and follow up with his doctors.

Take a look at http://en.wikipedia.org/wiki/Globus_pharyngis which points out that people get this sort of thing and it is all in their brain. A broader Google search was also interesting to me.

* http://en.wikipedia.org/wiki/Ankylosing_spondylitis

I was called to the trauma room in the middle of the night.  The medics were just moving a patient from their gurney onto ours. They reported he had been drinking and maybe doing other drugs at home. His family had seen him fall onto a glass table, breaking the glass and cutting his forehead.

During transport, the patient was excessively agitated and combative. Besides being strapped down to the spine board with the usual trauma straps and brace on his neck, he had leather restraints on all of his extremities and had been handcuffed to the board by police called to the scene.

He was a heavy, middle-aged man. His clothes, face, arms and bare feet were covered in blood. He was swearing and mocking everyone who was trying to help him. He spit in the face of one of the paramedics who was trying to stop the bleeding by pressing gauze against the large laceration in the middle of his forehead.

This sort of situation causes lots of problems in the emergency department. The patient may actually have serious injuries that might not be identified if he does not allow appropriate testing. Something has to be done to gain control of a very uncontrolled situation.

After calling out a list of instructions to the staff, I took his bloodied right arm, twisted it to keep it straight and held it to allow Fernando, the nurse, to start an IV. It was all I could do to keep him from pinching me with his bloodied hand while facilitating the catheter placement into his vein. Fernando then injected him with lorazepam, a potent tranquilizer.

The first dose had no effect. He was still thrashing and hollering. After the second dose, I was able to relax my hold on his arm. A third dose allowed us to start a more thorough, head-to-toe evaluation, looking for serious injuries. Though more relaxed, he continued to be uncooperative and demand to be let free.

Suddenly I noticed something changed. He went stiff, stopped breathing and started to turn purple. I told everyone to stop what they were doing so I could figure out what was going on. Everyone was immediately quiet with intense attention focused on his new condition.

I looked at the cardiac monitor and checked his blood pressure and pulse. No answer there. Next, I tried a “sternal rub.” This means making a fist and digging a knuckle into the front of the chest, purposefully causing pain. He did not respond. He was getting more purple.

As I quickly considered what to do next, the patient let out a huge breath, tried to sit up and screamed, “Psycho!” at the top of his lungs. He then fell back on the gurney and laughed hysterically.

I was almost frozen by the complex set of emotions that welled up inside of me. I was obviously relieved to know he was all right. I was filled with that indignation anyone feels when he recognizes he has been played the fool. I also could not help but see how funny it all was, in a sick and sad way. Drunks are profoundly sad yet they do and say things that are unavoidably perceived as funny. I found myself moved to laugh at something that was really very sad.

He continued to laugh and laugh, apparently enjoying the fact that he had played a very good trick on us all. He then allowed us to sew up his face and scan his head. He spent the rest of the night with us, mostly sleeping. By morning, he was sober enough to skulk out of the emergency department and head home.

Last week we did a neck story. Let’s do another this week.

A man called 911 and said he stabbed his girlfriend. When the medics arrived, there was no man. They found a twenty-five-year-old woman, unresponsive, with a needle, hooked onto a syringe, stuck in her neck.

Medics often find drug paraphernalia when addicts go unconscious after shooting up. In this case, no paraphernalia was found and there didn’t seem to have been anything in the syringe. In route to the ED, the patient suddenly woke up and went crazy in the back of the ambulance.

She was like no woman I have ever seen. She was a body builder who admitted to taking steroids, and she had HUGE muscles. Seriously, she was so totally muscle bound she was unable to put her arms down to her side! She walked like she had a watermelon between her legs. Her breasts were small and tight under her sports bra, and her muscles and tattoos were very visible under her wife-beater T-shirt.

The patient was intoxicated, but that didn’t seem to explain all of her very strange behavior. She claimed to not remember what had happened to her. She reported nearly uncontrollable feelings of rage causing her to feel like punching the wall or another person. She continuously paced around, unable to sit still.

A police officer came in to take a report. His reaction to the situation was a good measure of the strangeness of it all. The patient acted so abnormally and gave such bizarre answers that the officer became frustrated and gave up trying to understand what she was saying. He left, telling us to call him back if she began making more sense.

The patient’s very unusual, androgynous appearance added to the effect of her bizarre behavior. She was clearly a woman. But, she was so masculine, muscled and tattooed it was hard not to stare at her. She looked like a freak and acted like one, too. It made me wonder how much her craziness was caused by acute intoxication, underlying mental illness, or by the steroids she was taking.

We see lots of people who harm themselves. The most common ways of doing so are taking an overdose and cutting. Sometimes the cutting is in troubled people trying to let off stress rather than really trying to kill themselves. Often the cutting is more a cry for help or to get attention rather than a truly serious attempt at committing suicide.

Only occasionally do we see someone who really seems to be serious about killing himself by cutting. One such patient was a troubled young man who took a box cutter and cut his neck from one ear, across the front, over his Adam’s apple, to the other ear. He refused to say why he had done so.

The cut was really amazing. It was a serious attempt at suicide that cut down to but not into every vital structure he had in the front of his neck. I could look into the cut and see his carotid arteries, jugular veins, thyroid gland and larynx (voice box.) Somehow, he managed to perfectly expose all of these structures without injuring them other than a nick in the thyroid cartilage, which is what causes the Adam’s apple bump.

As I gazed into his wound, I was struck with how much detail I could see in his anatomy. Then it struck me there was no blood! After he cut himself, he ran through large sprinklers in a park. By the time he arrived in the emergency department, the bleeding had stopped and the wound had been washed clean in the sprinklers. It looked more like an anatomy specimen than an injured person.

He was taken to the operating room where the wound was carefully explored to make sure there were no important injuries and put him back together. He then was transferred to psychiatry.

All three of our kids had the same kindergarten teacher. Mrs. Goldsmith was great. One of the things I learned from her was the importance of children learning to recognize patterns.

Pattern recognition allows us all to function in life. Experience teaches us what to expect and that allows us to fluidly move through life.

When we don’t find what we expect to find, it sets us back.

One time, one of our nurses was interviewing a young woman at triage. On the nurse’s list of questions was, “Do you have any pain in your ears?”

The patient replied, “I don’t have any ears.”

When the nurse didn’t know how to take the response, the young woman pulled back her hair, showing that, indeed, she had been born with no ears. Who would have expected that?

Let me tell you about a time when I didn’t find what I was expecting to see. A young woman came in complaining of lower abdominal pain. I asked her all the usual questions and examined her, including feeling her abdomen. I then informed her that I needed to do a pelvic exam.

She told me that would not be possible, as she had no vagina. I am not sure if I was too proud to listen to her or if the idea that a young woman would not have a vagina was too bizarre for me to take seriously. Either way, I just blew off her response.

When the nurse had the patient all set up in the stirrups, her legs and crotch covered by the sheet, I stepped in between her legs and grabbed the speculum. I put some KY jelly on it and pulled back the sheet. I am sure I must have looked really stupid as I peered up between her legs, lubricated speculum in hand, and found nothing. Well, not really nothing. She had normal external genitalia and pubic hair. But there was no opening into a vagina.

After recovering from my shock and embarrassment, I apologized to the young woman and did what I should have done earlier: I asked her some more questions.

She had been born with no vagina. Further investigations showed that, inside, she had a normal uterus and ovaries. When she was a little girl, this caused her no problems.

After she became an adult, she consulted doctors to see if they could fix her problem. She had been told that a functional vagina could be surgically created for her but there was no way to do so and preserve her uterus. She would be able to have sex but never able to have children.

She really wanted to have kids so she had declined the offered surgery with hopes that someday, she might find a way to have a vagina and keep her uterus, allowing her to get pregnant and bear children.

So, she faced an interesting dilemma. She was unable to have sex or get pregnant because she had no vagina. Yet she refused to have a vagina created, holding onto the hopes that someday she would be able to get pregnant.

It has been twenty-five years since this experience. I wonder what happened to her. I also hope I have become more humble and skilled in dealing with situations where I find, or don’t find, what I am expecting.

Last week, we did an eyeball case. Let’s do more this week.

Exophthalmos is a condition where the eyeballs bulge out of the eye sockets abnormally.* It is frequently associated with hyperthyroidism.

One night, I saw a woman who had such severe exophthalmos that the eyelids caught behind one of her eyeballs. This caused the eye to protrude even farther. As a result, she was not able to close or move the eye. I had to gently press her eyeball back into its socket and work the eyelids back over the front of her eye.

*

This is an image from the Internet, not my patient.

The other eyeball patient was a one-hundred-year-old lady who fell out of bed in the middle of the night. She hit her face on something and ruptured her globe, which is the medical term for the eyeball. Her eye was so bulged out and had so much chemosis** (swelling of the surface of the eye) that, like the first patient, the lid was caught behind the eye so she couldn’t close or move it. The entire front portion of the eye was full of blood.

She was admitted to the hospital to have the eye removed.

**

Again, not my patient.

I walked into the Accident Room of Charity Hospital in New Orleans. A young man sat in one of the old, wooden, high-backed wheelchairs they used at that time*. He was thin and pale. His shoulder length hair was greasy and unkempt.

He sat still and showed no emotion. His left eye was covered with a large paper cup, which had been taped in place by emergency staff. Under the cup was the wooden handle of an old ice pick, the point of which had been thrust into his eye. The cup had been placed over the handle to prevent it being bumped, possibly making his obviously serious injury worse.

I asked him what had happened. In very flat and unemotional words he told me he suffered from psychotic depression and had wanted to die for a very long time. He recounted how he had seen a show on public TV that showed cross-sectional images of the brain. This made him realize his brain sat immediately behind his eyes. He reasoned that poking an ice pick into his brain would clearly kill him. So, he planned to drive an ice pick through his eye and into his brain, in order to die.

He denied being in any pain unless he moved the eye, which he found difficult to do. He said, as far as he could tell, his vision was OK.

When I gently lifted the eyelid open, I could see an old, dirty, rusty ice pick entering the lower part of his eye. The rest of the eye, above the ice pick, seemed to be working fine.

I had three problems. The most immediately life-threatening was brain injury. He was right in recognizing the brain does sit behind the eyes. The bones of the orbit, which surround the eyes, are thin and could easily be pierced by even an old, dull ice pick. From the looks of how far the ice pick seemed to have entered his head, it looked like he probably had stabbed himself in the brain.

My next worry was his eye. Though his vision seemed to have been unaffected so far, I was concerned that trauma and potential infection might threaten his vision.

The third problem, very real but not so acute, was his depression and suicidal ideation.

There was no good way to fully evaluate either his brain or his eye with the ice pick in place. I was afraid to pull it out without addressing the possible brain injury, so I called the neurosurgeon who went with me to the CT scanner. The neurosurgeon placed one hand on the patient’s forehead, grabbed the ice pick handle with his opposite hand and gently pulled, twisting slightly to get it to let go.

After the ice pick was removed, the CT scan was done which showed no bleeding or other problem in the brain that required neurosurgery.

I then made arrangements for ophthalmologists, the eye doctors, to see the patient. They took him to the operating room where they cleaned out the wound. They found only a small nick in the lower part of the globe, which they cleaned and repaired. The patient was then admitted to the hospital for a few days to make sure no complications arose. Afterwards, he was transferred to the psychiatric ward.

This poor man must have been at the end of his rope to get the nerve to do such a horrible thing. He really wanted to die and, by all rights, he very well could have.

However, when he stabbed himself, he hit just low enough that, rather than puncturing the eyeball, it was displaced upwards. The ice pick passed under the globe, missing the vital parts of the eye, so his vision was not affected.

A small hole in the bone of the orbit would heal with no treatment. Ironically, the part of the brain he punctured, the frontal lobe, is probably the most forgiving part of the brain to damage. So, rather than dying, he ended up fine with no permanent damage done at all.

I certainly hope his psychiatric care ended with the same good results as his medical care did. I think that was not too likely, as this sort of depression is very hard to treat.

*

I found this in Google images. It is exactly like the wheelchair my patient was sitting in that sad  day.

Pseudocyesis is the medical term for a mental disorder that causes a woman to believe she is pregnant when she is not. I am not sure how common this is but I have seen it several times in my practice.

I have cared for several women who were so disabled by Pseudocyesis that they are in the hospital all the time. They are well known to staff in both the Emergency Department as well as Labor and Delivery where they go insisting they are in labor.

Here are a couple of specific cases I have recorded:

Pseudocyesis Case 1

A 27-year-old woman presented at triage saying that her water broke, she was in labor and was about to deliver. She was rushed right up to Labor and Delivery where an examination, pregnancy test and ultrasound proved she was not pregnant. She then admitted she had been seen at another hospital earlier that same day where they told her she was not pregnant. The Labor and Delivery staff sent her back down to the emergency department to evaluate her abdominal pain.

My examination and laboratory tests failed to uncover a reason for her abdominal pain. This didn’t bother her because she didn’t care at all about her abdominal pain. She continued to insist, in the face of all the evidence, that she was pregnant and in labor.

I did my best to convince her, which was not possible. I then tried to reassure her, which was also impossible. I finally resorted to the speech I use in the rare situation where someone cannot be convinced after all I can do. I said something like, “I know you are not pregnant and there is nothing you can do to convince me that you are. You know you are pregnant and there is no way I can convince you that you are not. We are just going to have to agree to disagree.”

After giving my speech, as sympathetically as possible, I turned to walk out of the examination room. She then started to scream, saying the baby’s head was pushing out.

Though frustrated, I stopped, went back in with the nurse and examined her down there again. When I found nothing, she finally left, continuing to complain of feeling the baby coming out and saying that we had done nothing to help her.

Pseudocyesis Case 2

A 51-year-old woman came in by ambulance complaining that her water broke. She claimed to be one month pregnant, which was making her nauseous. She admitted to having had a negative pregnancy test at her doctor’s office earlier that day.

She insisted to me that she was pregnant and demanded to know how far along she was. She said she had seen the fetus and the umbilical cord “with my eyes closed.”

I told her it would be very unlikely for her to be pregnant being 51 years old and having a negative pregnancy test. Upon hearing that, she got irate and started to swear and yell at me, refusing to let me examine her. As she walked out she threatened that if she lost the baby because I didn’t provide her with needed care, she was going to sue me.