I heard an overhead announcement for assistance to the ambulance bay and went out to see if I could help. The police were there. They had a suspect they could not get out of the patrol car.

As I peered into the back seat, I could see part of the patient. He was hogtied which means he had handcuffs on wrists and ankles and all four were fastened together behind his back. He was thrashing and screaming incoherently. Somehow, he had thrown himself onto the floor of the patrol car and wedged his head under the back of the front seat. Because he was naked, all I could see through the window was his bare buttocks and his balls sticking up between them.

It was pretty tricky to get a naked, sweaty, fighting, crazy person dislodged and out of the car. After we got him onto the gurney, I noticed he was not moving. We quickly moved him into a room for assessment and treatment. He had a low pulse, no blood pressure and was not breathing. We were quickly able to get him through this situation and he was fairly stable when he went up to intensive care. With all his thrashing, he had dislocated his elbow. A toxicology screen showed only cocaine in his blood. All of this from taking drugs.

I told you that story so I could tell you another one:

The ambulance arrived with a thirty-year-old man in police custody. While being arrested, he crammed little packets of white powder into his mouth and started to chew and swallow them. I don’t know if he was acting crazy before he downed the drugs but by the time he arrived in the emergency department, he was out of control.

He filled the paramedics’ gurney, being a tall, large-boned and very obese man weighing close to 500 pounds. He was thrashing, confused, and sweaty. His heart was pounding. He was naked from the waist up and his hands were cuffed behind his back.

Everything we needed to do for him was made difficult because of his size, sweatiness and fighting. First, we rolled him from the ambulance gurney face down onto one of ours. After we put four point leather restraints on him, we removed the handcuffs. It took two people on each extremity plus several more on his trunk to control him at this stage. We were then able to roll him onto a different gurney so he was now face up. His legs were secured to the bottom of the gurney and his arms to the top above his head.

The next step was to get an IV started. Even in leather restraints, the patient was still flailing so, I ordered intramuscular sedatives to begin the sedation process while the nurses tried to start an IV. Then, I turned my attention to other patients, leaving the nurses, techs, security officers and police to care for this guy.

A few minutes later, the nurse came and told me she had not given the patient the sedatives because he was “playing opossum.” Since it was my impression that he was in a drug-induced, incoherent state, I didn’t understand how he could be faking it, so I went right to the bedside. Sure enough, my fears were justified. The patient was in arrest. His pulse was 30, he had no blood pressure and he was not breathing.

He needed a tube passed down into his windpipe to protect his airway and allow us to breathe for him. Huge people like this can be nearly impossible to intubate so I faced this with some trepidation. Fortunately, we were able to get this done without too much trouble. Once he was intubated and we were blowing oxygen into his lungs, his blood pressure and pulse came up and we were able to prepare him for transfer to intensive care.

I don’t want to get weighed down with the medical issues here, but let me say there were plenty of things suggesting this patient was going to die.

So both of my patients were under arrest for taking drugs. Their legal problems, however, were the least of their worries as their drug use might have lead to their deaths.

This is a story of a patient I took care of in the intensive care unit (ICU) during my training. As luck would have it, this young man was hit by lightening right outside the hospital. Medics arrived at the scene almost immediately and found him in ventricular fibrillation, an erratic heart rhythm that can result from a large electrical shock. This rhythm is ineffective in pumping blood. The resultant lack of circulating oxygen rapidly leads to brain damage and, eventually, to death.

Just like in the television dramas, the medics gave the patient a quick cardioversion shock, which caused his heart to return to a normal pumping rhythm. They then bundled him up and brought him into the hospital.

In the emergency department, the patient’s heart was beating fine. Though still unconscious, he was coming around enough to thrash about and he vomited a very large amount of undigested food all over himself, the gurney and the floor.

Now, I have a lot of experience with vomit. I have vomited many times. I have been with family members many times when they have vomited. In the emergency department, having patients vomit is just a way of life.  So, to be noteworthy to me, a particular episode of vomiting must be pretty amazing. This one was.

The patient’s vomitus was filled with discs of pressed meat about the size of a mouth. It was clear he had recently eaten a deli sandwich by biting and swallowing big hunks without chewing any of it. This left the round pieces of meat intact when swallowed. They came back up the same way. I had never seen anything like that before.

Now back to the lightening strike victim. We sedated him to keep him from thrashing around and admitted him to the ICU. Since his heart rhythm was now stable, the big question was whether he had suffered brain damage during the time his heart was not beating. We would only know that when he woke up, if he woke up.

The next day, we took him off of sedation so we could start to assess his mental state.  Our initial reaction was of disappointment. Though the medics had saved his life by rapidly getting his heart beating again, it was obvious he had suffered brain damage. The patient gave us his first name and asked for food, but he was clearly not normal. Since the patient came in the hospital with no identification, we asked him about his family.  He could only come up with the first name of his sister. Another indication of his brain injury was that he seemed completely unconcerned about his situation, content sitting in a hospital bed getting all the food he wanted.

The following day a young woman came to the hospital. She read in the newspaper about our unidentified lightning strike victim and wondered if it were her brother.

After talking with her for a minute, I felt comfortable taking her in to see our patient. I was filled with some trepidation, wondering how she was going to handle it when she realized he was brain-damaged.

It was immediately obvious they were siblings. As she walked into the room, she rushed to give him a hug and he called out her name. It was a touching scene, but my emotions were complicated. I wondered how I was going to help her recognize his loss of mental faculties. How would she handle the realization that her brother was not what he used to be?

As soon as things calmed down a little, I gently shared with the sister our observations about her brother, describing what we believed to be brain damage caused by his time with no oxygen flowing to his brain.

As I talked, she got a puzzled look on her face. When she finally got the big picture, she kind of laughed. “Oh, no,” she said. “This is the way he always is.” He then got dressed, she took him home and they all lived happily every after.

This shows how his metal necklace burned his skin when it was heated up by the lightening. He also had a burn where his bicycle was leaning against his hip.

The psychiatric emergency department at our hospital notified us they were sending a patient with chest pain. Everyone who recognized her name knew we were in for a challenge.

This middle-aged woman had been to our emergency department many times and was always difficult to deal with. She has serious medical problems but also serious psychiatric problems. This makes treating her especially challenging.

When she arrived, I went into the room and politely introduced myself, as is my habit. I asked her about her chest pain, the pains in her legs and her recent falls. She had a pleasant demeanor and looked comfortable as she described pain in her legs that made her unable to walk. Her physical examination showed no indication of serious injury.

I explained the tests I recommended to make sure she was not having a heart attack or blood clots in her lungs: electrocardiogram, chest x-ray and blood tests. She agreed. I then told her I was not going to be giving her any narcotics.

“That’s fine. I’m not here for drugs. I’m not a drug addict,” she said in a sweet voice.

I was glad she agreed with me and told her the nurse would be right in to get the tests started. I began to walk out of the room.

“Just a minute, doctor. What are you going to do for my pain?” she asked.

I reassured her we would give her all the medications we usually give someone who might be having a heart attack or blood clots but we would not be giving her any narcotics. I turned again and walked out of the room.

Then she went off. She started to scream at me at the top of her voice using every foul word you could think of.  At the same time, she grabbed anything she could get a hold of and yanked on it. First, she ripped the phone cord out of the wall and threw the phone on the floor. She jerked the monitor cables out of the monitor and threw them on the floor.

We responded to the noise of her screams and the sound of the phone hitting the floor and prevented her from pulling the courtesy curtains out of the ceiling. After we moved things out of her reach, she pulled off all of her clothes and threw them on the floor. Eventually, unable to get a hold of anything else, she started throwing her immense weight back and forth in the gurney, trying to tip it over. Since she was so extremely obese and was rocking so violently, she almost went over but was prevented from doing so by staff.

So there she was, an extremely large woman, butt naked, rocking violently, trying to tip her gurney over and screaming obscenities at the top of her lungs.

Her insults were mostly directed at me. She accused me of being a bigot and not giving her pain medicine because she was black. She yelled she was being treated like a slave on the plantation. She shouted if she were white or Hispanic or Asian, we would be giving her pain medicine. Her screams included the foulest swearing she could come up with and filled the whole emergency department, upsetting other patients and visitors. Staff had a hard time taking care of other patients and doing necessary duties like talking on the phone because her obscenity-laced screams were so distracting.

Extreme conditions require extreme responses. When people are violent and put themselves and staff at risk of physical injury, something has to be done to prevent this. In such unusual circumstances, we may need to put heavy leather straps around both ankles and both wrists then tie the patient down to the gurney. This was such an occasion. It took four security officers and several other staff members to get her into four point leather restraints. She refused all medical care and, even tied down, was able to keep staff from covering her naked body. I wanted to sedate her, but she said she was allergic to each sedative I proposed. All we could do was keep her in the middle of the room so she couldn’t grab anything. She screamed non-stop for the half hour it took us to make arrangements for her to go back to emergency psychiatry.

Once arrangements were made, she rolled out the door. I had assumed security would have at least tied a sheet over her but their efforts to do so had been unsuccessful. Her enormous thighs and gut covered her private parts, but her pendulous breasts were fully exposed. She left, still screaming at the top her lungs, “No pain meds for fuckin’ niggers,” over and over again.

One of the most important things I do as an emergency physician is reassure people. True, I occasionally do something that might save someone’s live. I frequently provide treatment to help people feel better and assist in a more rapid recovery from injury or illness. But most of the people I take care of don’t have a serious condition and can go home with little or no treatment. All they need is to understand they will be fine. They need reassurance.

Most people in this situation are glad to have an explanation and happy to be reassured. They are relieved to know their chest pain is not coming from a heart attack. They are thankful to know they don’t have a broken bone or appendicitis.

I get frustrated when I determine that someone has nothing worrisome but he or she refuses to accept my explanation and reassurances. I have found it nearly impossible to satisfy such a patient.

Here are two stories of people who were completely unsatisfied with my explanations and reassurances:

Fainted

A sixteen-year-old boy fainted after spraining his thumb. The most common reason for someone to faint after a sudden, painful event is what we call a simple faint. There are some bad things that can cause fainting but all of them are very rare in an otherwise healthy youngster. After asking this patient some questions and looking at him carefully, it was clear to me he had just fainted and would be perfectly fine.

I spent quite a bit of time with the patient, his mother and siblings. I explained how I came to a conclusion that he had only fainted and why I felt comfortable sending him home.

As I finished my explanation, the mother put her head down and shook it, apparently displaying some dissatisfaction with what I had said. I asked if there were some problem. She said, “No,” and resignedly added she would take him to be checked by his own doctor.

At this point, the sister got upset and angrily said if the patient left and became “comatose or died,” she was “going to come and get” me.

The brother then became irate and hollered that this was a “charity hospital and no one is going to do anything for you here.”

I tried to discuss the situation with these family members but they were not interested in any more discussion. They all stormed out without waiting for their discharge papers.

Nausea, Vomiting and Diarrhea

A fifteen-year-old boy came in by ambulance with nausea, vomiting and diarrhea. The paramedics had started an IV so I ordered some intravenous fluids and medicine for the nausea. I then continued seeing other patients who had been waiting longer and were more likely to be ill.

When I finally got to the room, the patient told me he started vomiting and having diarrhea after eating nachos for dinner. He had looked weak and his mother thought he was going to pass out, so she called the ambulance. However, after the IV fluids and medicine I had given him, he was now feeling fine and had no more symptoms. His examination and vital signs were normal.

I explained to the mother what I found and why I thought her son had food poisoning or stomach flu. I reassured her he would most likely be fine in a day. I promised to prescribe medicine for vomiting and diarrhea in case he needed it at home, and again reassured her that he was going to be fine.

This is my basic speech to reassure people when they have gastroenteritis. Most people are glad to have such an explanation. Not this mother!

As I spoke, she filled with angry indignation. He had almost passed out! How could I just look at him, not do anything and know he was going to be fine? I had not even done any blood or urine tests on him!

I started my explanation over again and reviewed my thinking with her. He was a young, healthy boy who was very unlikely to have anything serious the matter with him. He had symptoms that are really only consistent with one of two minor, self-limited illnesses. He had a normal examination and vital signs. He had responded to the treatment he got and was feeling and looking fine.

The more I explained, the madder she got. She was just not going to believe that her son, who almost passed out, could be sent home without any tests being run. I asked her what tests she would recommend running. Of course, she had no idea about what tests one might run and the fact that I asked her just seemed to make her even madder. If I had done some sort of tests and told her they were normal, she would have been happy. The irony completely evaded her that she would have had no idea if the tests were really able to find any problems in a patient like this.

At this point, she refused to talk to me. I asked if she had any other questions or if there was anything else we could do for them. She didn’t reply and fixed her steely gaze on the wall behind my back.

The patient did have a question but when he tried to ask me, she told him to just shut up. He tried again and again she told him to shut up and not say anything as they were going home.

I told her the nurse would bring the prescriptions. She said she didn’t want any prescriptions. I told her they were coming anyway and she could do with them what she wished. They left without the prescriptions or discharge papers.

Not G-Rated
My patient was a 39-year-old man who presented in police custody. He wouldn’t talk to me but the police said he they had been called to the home of a twenty-year-old woman who said someone tried to rape her. The woman was drinking at her home with the man. She told police he put his hands around her throat to force her to engage in oral sex but she fought back and bit him. When police arrived at her place, they found her roughed up and upset. A testicle was sitting on her living room floor.

She told them who the body part belonged to and where he lived. Medics, who had been called to the scene, put the testicle in a plastic bag, placed it on ice and brought it to the emergency department in case it could be reimplanted.

When police got to the man’s house, they found him lying on the couch in pain. They brought him into our emergency department for care before he went into custody.

The man’s injury was very interesting in that none of the scrotum was missing. She had pinched the testicle so strongly that it literally popped through the skin, leaving a linear laceration on the front of the scrotum through which the testicle had been pushed out.

We numbed up his scrotum, irrigated the wound and stitched him up. He went off to jail with fifty percent fewer testicles than he had when he got up in the morning.

The woman was also brought in for evaluation. As the word circulated through the emergency department that a woman had bitten off a man’s testicle in order to keep from getting raped, the staff was impressed. Our immediate response was to be moved with compassion for her and pride that she had stood up for herself. She was kind of a hero.

Everyone there was on her side and wanted to be with her emotionally. However, she was just the nastiest person to interact with. She was drunk, dirty and smelly. She was so foul in body and personality that it was impossible, after interacting with her, to continue to have any fond feelings towards her at all.

Her evaluation showed she suffered bruises and scratches but was in no need of medical treatment. The police took her home.

We later found out the woman was a prostitute and the man was on parole after serving seven years on a prior conviction for forced oral copulation.

Here is a redacted copy of the article in the local paper about this event:

Man loses testicle, held in assault.
By XX, Paper Staff Writer
A 20 year-old Sunnyvale woman told police she reacted in self-defense when she bit off the testicle of the man who sexually assaulted her.

A  Municipal court judge on Tuesday ruled XXX, 39, must now stand trial on one count of forcible oral copulation.

The woman, who was drinking at her home with XXX on September 29, told police they may have kissed, but when XXX put his hands around her throat to coerce her to engage in oral sex, she fought back and bit him.

“She thought she was going to die,” said The Department of Safety Detective.

She suffered major bruises around her neck and on her shoulders, scratches and minor bruises on her back and arms, and abrasions on her knee, police reported.

After the woman called police, officers found XXX at his home and rushed him to The Medical Center.

XXX was paroled from prison in February after serving seven years on a conviction for forced oral copulation, according to state Department of Corrections. He remains in jail in lieu of $250,000 bail.

I went to see a 31-year-old man who was complaining of headaches and a bump on his scalp just above the forehead. The bump on his scalp was unusual. It was red and tender. It looked and felt kind of like an abscess though it is unusual for someone to develop an abscess on that part of the scalp.

A good way to find out if a bump in the skin is an abscess is to poke a needle into it and aspirate with a syringe to see if any pus comes out. I recommended this to the patient and he agreed.

I got a needle and syringe then wiped the bump with an alcohol swab. I poked the needle into the skin over the bump and pulled back on the plunger. I then slowly advanced the needle, watching for pus. I knew if the needle hit the skull and no pus came back in the syringe it was not an abscess.

But, the needle never hit the skull. Just as I realized this, the syringe started to fill up with liquid. It was not the yucky, thick pus I was expecting from an abscess, but clear, colorless liquid. Cerebral spinal fluid. The fluid that bathes and supports the brain inside the skull. I had poked a needle through his skull!

Shaken, I told the patient what happened. I then ordered x-rays, which clearly showed there was no skull under the lump.

I made arrangements for the patient to be watched in the hospital since I had potentially contaminated his cerebral spinal fluid. This put him at risk of an infection around the brain.

As it turned out, he got no infection and was later diagnosed as having an eosinophilic granuloma or Langerhans cell histiocytosis. This rare condition caused the replacement of normal skull tissue with a tumor that caused the bump on his head.

http://en.wikipedia.org/wiki/Langerhans_cell_histiocytosis

I pick up the chart of a man in his early forties. “Rectal pain” is the chief complaint.

When I enter the room, the patient is standing in the corner, dressed in a hospital gown and looking rather glum. I introduce myself and ask how I can help him. He mumbles enough of a non-specific answer for me to understand he has something stuck in his rectum that he can’t get out.

I invite him to bend over the exam table as I turn to get some gloves.

Turning back to him, gloves on hands, I pull the gown away from his backside. Sticking out of his anus is the end of a broomstick about a foot long. This surprises me somewhat. I touch it and the patient moans in pain.

“How long has this been in there?” I ask.

“Mmmmm. Four days,” is the reply.

I explain to the patient that we clearly need to give him pain medicine and also something to help him relax before trying to get the stick out. I then excuse myself and pass orders on to the nurse to get this started.

Once the patient is medicated, I return to the room and, again, don gloves. This time, the patient is comfortable enough that he only moans as I pull the stick out. Interesting. The other end of the stick is wrapped in twine. I’m trying to figure this out when the patient looks up at the stick and groggily asks, “Where’s the rest of it?”

An x-ray reveals the outline of a large, penis-shaped dildo stuck in the patient’s rectum. Now, I think I understand what happened. The patient wanted to get the dildo farther into his rectum, so he put it on the end of a broomstick. However, the broomstick was smaller than the inside of the hollow dildo so he wrapped the stick with twine until it fit snuggly inside the dildo and would not come off.

What he failed to consider was what would happen when the dildo was all the way up inside his rectum. Once his anus closed down over the dildo onto the broomstick, it was stuck and couldn’t be pulled back out again.

The poor guy, too embarrassed to seek help, had been sitting – or not sitting – around the house for four days, in miserable discomfort, with that thing stuck in there.

I will blog more in the future on rectal foreign bodies as it is a recurrent and interesting subject in the emergency department. Sometimes, we are able to get them out in the ED. Other times, as in this case, we are unable to do so. In those situations, we call the surgeons. With the patient asleep, and with access to tools they have in the operating room, the surgeons are often able to pull the object out. But, not always. Sometimes, as in this case, the surgeon actually has to cut the abdomen open for removal.

Please don’t ask me why people do this. I never ask. You will just have to use your imagination or go online for more specific information.

While Chair of our department, I had occasion to review the medical records of one of our patients. This review prompted me to write the following memo to our doctors:

This patient has been seen many times in our ED for various complaints. She usually reports an injury, as you will see below. In spite of these visits here, she always checks in with a Reno, Nevada address. She is frequently prescribed narcotics. Please keep this in mind as you have occasion to deal with this lady in the future.

Here is a list the dates and chief complaints she gave when registering:

2/92            dental pain

9/91            car crash

1/95            twisted ankle yesterday

3/95            car crash

3/95            fell last night while taking the trash out

7/95             slipped on newly waxed floor yesterday

11/95            car crash

3/96            fell onto shoulder

4/96            fell from ladder

7/96            dental pain

8/96            fell getting out of the tub

11/96            garage door hit head and neck

1/97            fell off snowmobile yesterday

4/97            fell off ladder 2 days ago

5/97            hit with a 2 by 4

6/97            fell attempting to put bolt in an engine

7/97            hit ribs on truck hood when fell off a plastic chair

8/97            fell off ladder yesterday

9/97            fell off ladder yesterday

10/97            struck in ribs by car door opened by granddaughter

10/97            fell off ladder today (17^th)

10/97            fell off ladder two days ago (30^th)

11/97            slipped and fell yesterday

1/98            fell off ladder two weeks ago

2/98            fell on U-Haul ramp this morning

4/98            slipped on linoleum floor two days ago

5/98            slipped on stairs last night

7/98            fell from chair

7/98            fell onto rocks yesterday

9/98            fell onto buttocks yesterday

11/98            slipped yesterday and hit chest on counter

2/99            bumped chest wall on edge of chair two days ago

4/99            fell against a corner of a refrigerator at 4:00

5/99            slipped and fell at Laundromat

7/99            slipped and fell in kitchen two days ago

8/99            fell down steps yesterday

9/99             fell from ladder yesterday

10/99            fell down stairs yesterday

12/99            fell in bathtub yesterday

2/00            fell off ladder yesterday

3/00            dropped box of books on wrist yesterday

10/00            fell from ladder

“Doctor? I’m going to die.”

I don’t know if she feels it from within herself or if she reads it on my face.

“Yes.” I mumble, dropping my head, unable to continue to look into her eyes.

“No!” bawls her mother, falling forward and pulling my patient up against her.

She is in her mid-forties, round-faced and hump-backed from the steroids she uses to control the symptoms of her lupus erythematosus. She woke up in the middle of the night with severe chest pain radiating to her back, unable to feel or move her legs. Within seconds from the time the medics unload her onto our stretcher, I know she is dissecting her thoracic aorta, the large artery carrying blood from the heart to the rest of her body. In like manner, I also know there is nothing I can do to keep her from dying. In order to combat the feeling of futility brought on by this realization, I launch into a frantic effort to save her.

I order two large IV’s, blood tests and x-rays. I place urgent calls to the surgeon and radiologist. The results of this effort lead only to frustration. The surgeon says he can’t do anything until I get a CT scan that demonstrates the problem. The radiologist can’t do the scan until the patient is more stable. She is dying.

More frantic calls are placed looking for a thoracic surgeon willing to come in and do something heroic. Again, no one will come until I have a scan showing a dissection. But her blood pressure is too low to send her for the scan.

I order lab tests looking for something I can do to help her. The results only reinforce my feelings of powerlessness. Anemia, acidosis. She is not responding to the fluids and medication I am giving her to try to keep her blood pressure up.

As her blood pressure drops further and her acidosis worsens, she slips into unconsciousness. All of my efforts frustrated, I give in to the inevitable and shrink back into acceptance. I pull the curtain closed behind me, leaving her with her family. They hold her and weep as she quietly slips away.

I weep too. I weep and it hurts. I have failed! No wonder I try so hard to avoid facing death. No wonder I choose to resuscitate rather than let life go quietly away. If she had only lived to get to the operating room or intensive care unit, I would have done my part successfully, even if she died later on. As I face her death, premature and unfair, I am forced to face my inadequacies and the cruelty of life.

I have to go be alone for a while as I deal with my emotions. Soon, I am able to shake off the feelings. I wipe away the tears, pick up the next chart and charge off to see my next patient.

When I was a resident at Charity Hospital in New Orleans, I took care of a young man who came in worried about being poisoned. He lived with his mother in a public housing apartment building. He was hungry when he came home from work that night so the pan of red beans and rice on the stovetop looked good to him. As he was finishing them off, his mother came in the room. With an alarmed voice, she asked, “Why are you eating those red beans and rice?”

They had been having trouble with rats in the kitchen so she put rat poison in the pan of leftovers and left them on the stovetop with hopes of poisoning the rats.

As soon as he found this out, he came to the emergency department to be treated for his rat poisoning. Fortunately, this type of rat poison is not very toxic to humans so he was fine and needed no treatment.

Another such case happened to me more recently. A 42-year-old man came in saying he had taken a gulp of what he thought was Gatorade.  As soon as he tasted it, he recognized it was not his Gatorade but “floor degreaser” a friend at work had poured into a Gatorade bottle for him to use at home. Again, he was not harmed by his ingestion.

Still, who would put rat poison in food on a stovetop and leave it? Who would put a clear blue-colored poisonous liquid in a Gatorade bottle and have it in his car along with the Gatorade he was drinking?