I had a forty-year-old man come in with perfuse rectal bleeding. He had a polyp removed from his colon two days before. He said there was no problem during the procedure but he had spent the next night in the hospital for some reason and just gone home twelve hours before he rolled into Room 15.

His pulse was fast and his blood pressure was low, signs of hemorrhagic shock. He had piles of clotted blood between his legs and it was starting to drip on the floor and was tracking up the bed under him and on the sides of his back. To complicate things, he was as fat as a whale. In fact, he was so fat, he had a tracheotomy in the front of his neck so he could breath.

Now, all of this was bad enough but he informed me he was also a Jehovah’s Witness and would accept no blood products. Usually, someone who is in hemorrhagic shock and gets no blood transfusion dies.

I took a quick peek at him and it became rapidly clear that, because of his morbid obesity and his shocky state, it was going to be nearly impossible to get an IV in him. This was urgently needed to give him fluids, even if he would not take any blood.

This is why I went into emergency medicine and I went to work. I started calmly barking orders and telling my support staff what I needed them to do to help me. I tried unsuccessfully to get a large intravenous (IV) line under his collarbone into his subclavian vein. He was just too fat to be able to get the needle at the proper angle and deep enough to hit the vein. I tried to use the ultrasound to look for his internal jugular vein but was unable to find it because his neck was too fat. He also was too fat to use any landmarks on his neck to direct my needle so I couldn’t use that approach. In the mean time, I had called the gastroenterologist, telling him to come in and scope the guy to get the bleeding stopped. I felt this was our only hope. I called the intensive care unit physician to get him an ICU bed and I called the trauma surgeon to come help me with the IV. Basically, I was pretty sure he was going to die so I called everyone so no one would wonder why I had just sat there and let him die.

Fortunately, for the patient, two good things happened. First, just as the trauma surgeon got there, I was able to get a huge IV into his right femoral vein so we could get some fluids in him. I was only able to do this after the nurse pulled his belly towards his head so I could get into his groin and get access to the vein. The second stroke of good fortune was the bleeding seemed to have slowed, if not stopped. So, by the time he went up to the ICU, his blood pressure and pulse were stable. If he was going to die, at least it wouldn’t be in the emergency department. I did everything I could and it worked out well. Good story.

I will never win a customer service award for this one, though. The guy, along with presenting a HUGE challenge to caring for him because of his religious beliefs and his morbid obesity, he was a huge whiner, too. I finally got so sick of him asking me if what I was going to do would hurt that I told him to shut up. I said something like, “Sir, you are about to die. Everything I am doing is to try to keep you alive. You have to assume it is going to hurt. Just shut up and let me try to save your life.” I felt bad about it and he continued to whine so I don’t know if it did any good. When he wasn’t whining, he was talking on the phone telling his mother goodbye or mumbling praises and prayers to God. Very interesting.

As it turns out, he didn’t die. In fact, he came back one night the next week to see me again. He told me he got his bleeding fixed by the gastroenterologists and was discharged a couple of days later. He came back in to see me again when he had some pain that freaked him out. Fortunately, he was fine and went home. Still, it gave me a chance to apologize to him for being short with him but also to explain my fears he was going to die and the effect it had on me. He accepted my apology and thanked me as we shook hands before he left for home. It was a nice kind of interaction we don’t get too much of in emergency medicine.

A fourteen-year-old girl was the driver of a car that was involved in a motor vehicle accident. She was driving the car at a high rate of speed on the freeway. When the highway patrol went to pull her over, she tried to outrun them and ended up running into the concrete divider of the freeway. She and her passengers were brought in as trauma patients.

The driver was severely injured as were the two severely intoxicated adult male passengers. The patient was admitted to the hospital with her jaw broken in two places, a severe ankle sprain and lacerations on her face. Her blood alcohol level was negative so she had not been drinking but she seemed to be a poor choice for a designated driver.

This is, word for word, the note I wrote on this patient’s chart:

Family members called the ambulance when they found the patient chewing on her fingers today. The patient is demented, bedridden and completely dependent for all of her care. She was reportedly more agitated lately including spitting and chewing on things like her blankets. She had no history of self-mutilation but today the patient’s temporary caretaker found her chewing on her hands. The daughter, who normally cares for the patient, is ill herself and hospitalized elsewhere.

On the left hand, fingers 2 to 5 (index, long, ring and pinky) have extensive soft tissue damage. The fifth finger is essentially chewed off with just a strip of tissue left attaching it to the hand. Bones are visible in the other fingers with considerable amount of soft tissue damage present.

The patient went to the operating room for amputation of the fingers.

A young Hispanic man came in telling the nurse he had fallen and been poked in the buttock four days before. He was worried the wound might now be infected.

When I reviewed the story with him, he corroborated the nurse’s note, adding nothing else. Though I speak Spanish fluently, I didn’t have the vocabulary to understand just what it was he landed on. I decided it probably didn’t really matter.

At my instruction, he pulled down his pants and rolled over. He showed me a puncture wound on his left buttock. It was healing nicely and showed no signs of infection.

As I went to reassure him there was no infection, a little something prompted me to wonder if there might be something else going on. I asked him if he thought it possible that a piece of whatever he landed on might have broken off inside him. He answered affirmatively and I sent him off for an x-ray of the area. I had the idea there might be a small chip of metal under his skin causing him some discomfort.

A few minutes later, the x-ray technician called me in to have a look at the x-ray. She was as amazed as I was to see the outline of a metal bar almost an inch in diameter that looked like a round file. One end was right under the skin where he had the wound. The other end disappeared off the film heading towards his pelvis.

We called him back to x-ray where more films showed the metal went clear up into his pelvis. The other end of the file was sitting right in the middle of his bladder!

When I went to show him the x-rays and explain my plan to get it out, I asked him if he had been having any blood in his urine to which he sheepishly admitted.

I called the urologist to our assistance. They took him to the operating room and put him to sleep. They passed a scope into his bladder and took pictures, which he later shared with me. They showed the file coming up out of the floor of his bladder like an empty flagpole. He then cut into the patient’s buttock, grabbed the file with some pliers and, with some effort, pulled it out. The scope was then reinserted to make sure no repair was needed. He was kept in the hospital for a couple of days and left, good as new.

When I see things like this, I frequently ask myself, “What if…?”

He landed on this huge bar with such force it went up through his skin, the muscle of his buttock and the floor of the pelvis before it broke off. It entered the pelvis just off the midline. Had it passed through the center, it could have destroyed many important midline structures. The base of the penis with its blood supply and nerves important for erectile function, the urethra where the urine passes from the bladder to the penis, the prostate, and the rectum were all at great risk in an injury like this. He might have suffered some injury that could have caused him a lot of trouble for the rest of his life. Instead, he was just fine. I wonder how much he appreciates what good luck accompanied the bad luck that caused his injury that day.

The nurse called me into the room. A thirty-year-old woman had come in by ambulance. She told the nurse she was four months pregnant and had suddenly started to bleed heavily from her vagina. She was not having a lot of pain.

When I walked in the room, she was lying on the gurney in a hospital gown that was rapidly becoming soaked with blood. Playing around the bed were the patient’s two daughters, about three years and eighteen months in age. They seemed to have enjoyed the ambulance ride and were unbothered by the excitement and all of the blood.

A lot of things happen simultaneously when I face this sort of situation. One look helps get a feeling for how sick the person is. Then vital signs come as an IV is being started and blood tests are being ordered. All of this is happening while I am talking to the patient, listening to her and feeling her abdomen.

Once I get the important information I need and get the treatment and testing started, I do a pelvic exam, which is really where the money is in a patient like this. This lady had a very large vagina and it was packed with a ton of blood and blood clots. I used a big pincher called a ring forceps with balls of gauze-wrapped cotton to remove the blood and blood clots. Over and over again I reached in, scooping blood and blood clots out which splatted onto the absorbent pad I had spread on the floor.

Eventually, I was able to get enough of the blood out to see she was still bleeding but the opening up into the uterus (womb) was still closed. That told me that even though she was bleeding heavily, she was not presently aborting. Now I knew what I needed to tell the obstetricians when I called them.

We got her vital signs fixed with IV infusions. We got blood ready for a transfusion. The obstetricians came down and did an ultrasound that showed an eighteen-week-old living fetus. They examined her down below again and found she was still bleeding. All of this pointed to abruptio placentae, which is defined as the premature separation of the placenta from the uterus.

So, the patient had a perfectly healthy baby, which she wanted, but she was going to bleed to death unless it was taken out of her. The way the OB attending physician put it to the patient was something like, “We want you to be here to take care of the two girls you already have rather than dying trying to have a third.”

The poor lady was in tears as she concented to going to the operating room to have her pregnancy aborted to save her life. Her husband was working in San Francisco and couldn’t be reached and she said she had noone else to come and support her or help her with the girls.

By the time she went to the operating room, she was stable. The girls stayed with us until morning when a social worker could come and try to get some help for them. The lady was sad but I am sure she was grateful to get medical treatment that certainly saved her life.

All of this made me think about what Rick Santorum said about why a woman shouldn’t have an abortion even if she were raped. He said something like, “It is her baby and she should accept it and love it.” I wonder if he would have advised my patient to just go ahead and die rather that have an abortion to save her life. It was very sad and very painful for that woman to have to make such a decision but it was really the only justifiable decision to be made, in my opinion.

When I tell people I work in the emergency department, they usually think first of taking care of injuries. Trauma is only a small part of what I do. One night, I printed out the ED census, listing all the patients in our ED at that time. Here is a review of that list which gives you a good idea of what is going on in my life when I am at work. It was about 6:30 PM. Here is a list of the patients and what was going on with them at the time.

62-year-old lady with chest pain. It is very difficult to get her history. Multiple blood tests were sent to the lab. Her potassium came back hemolyzed so it had to be redrawn and resent. We are waiting for that at this time. I am considering whether she needs admission.

22-year-old sent here by clinic doctor with high suspicion of pulmonary embolus (blood clot in the lung.) Multiple blood tests were sent to the lab. She is in CAT scan at this time. She will probably need to be admitted for anticoagulation.

54-year-old lady with chest pain. It is very difficult to get her present and past history. Multiple lab tests, EKG and chest x-ray have been ordered. I am planning on admission.

73-year-old lady from nursing home with possible seizure and cyanosis. She has had no history of either in past. I had to call the nursing home for more information from the nurse there about what happened there. I then interviewed her son when he showed up. Her x-ray shows a pneumonia. I am considering admission for pneumonia with cyanotic episode. Her CAT scan is pending at this time.

34-year-old lady with large abscess on her abdominal wall from shooting drugs. The physician assistant didn’t feel comfortable she could adequately drain it. The patient has been given multiple doses of intravenous narcotics until she could be comfortable enough for me to finish draining and packing it. She will probably be able to go home.

30-year-old lady who was in a car crash. She is very upset and complaining of neck pain among other pains. It took almost an hour to get her registered so neck x-rays could be taken. She is in X-ray now.  Her emotional situation and delays in getting her registered required me to visit the bedside multiple times. She will probably be able to go home, assuming her x-rays are normal.

31-year-old lady who passed out and has chest pains. After chest x-ray, EKG, labs and reevaluation, I considered work up for pulmonary embolus but she is being discharged.

57-year-old man with chest pain and numbness of his legs. He has complicated present and past histories. I had to review his labs, x-rays and old chart. I had to medicate him to get him out of pain. He has been admitted.

14-year-old girl came in as a trauma alert from a car crash. Her x-rays and a reevaluation are pending. She probably will be able to go home.

22-year-old man with infection of operative sight. He has had lab tests and a surgical consult with consideration for readmission.

61-year-old man with chest pain. He got an EKG, x-ray, and blood tests and has been admitted. We are waiting for him to be assigned a bed so he can go upstairs.

74-year-old man with head and neck pain. He is getting a CAT scan and lab tests.

42-year-old lady with pains from car crash. She is the mother of the 14-year-old. She will be discharged when her daughter is ready to go.

33-year-old lady with very complicated present history of headaches, chest pains, vomiting and numbness like what she had with her stroke. It is very difficult to get the history. She had multiple labs, EKG, chest x-ray, CAT scan of her head and extensive review of her old chart. She is admitted.

40-year-old lady with vaginal bleeding and feared pregnancy. She will be discharged if her pregnancy test is negative. Will need a pelvic ultrasound and obstetrics consult if it is positive.

72-year-old man visiting from the Philippines with multiple complaints arising from not getting adequate care for his hypertension and diabetes. He had multiple labs, EKG, chest x-ray and ultrasound of his leg. He is admitted.

53-year-old lady with atrial fibrillation (irregular pulse) with a pulse rate of 180. She has a complicated history. She had multiple labs, EKG and a chest x-ray. She required multiple doses of multiple drugs in an unsuccessful attempt to control her heart rate. I talked with intensive care resident as we considered putting her in Intensive Care. Her pulse is now controlled enough that she will be admitted but not to ICU.

62-year-old lady with chest pains after a car crash. She is getting x-rays and labs. She may need a CAT scan and a trauma consult depending on the results.

43-year-old lady with severe allergic reaction. She is being observed after having been given intravenous drugs.

32-year-old man with abdominal pain. Laboratory tests and surgery consult were obtained. He is admitted to the operating room to have an appendectomy.

52-year-old lady admitted with weakness and shakes from alcohol withdrawal. Multiple lab tests were done and intravenous drugs were given to control her symptoms. Her disposition will depend on lab tests results and how she responds to treatment.

50-year-old man came in by ambulance after injuries from an altercation. He just arrived and has not been seen yet.

24-year-old lady with pelvic and abdominal pain worrisome for pelvic inflammatory disease. Her lab tests are pending. She may need a pelvic ultrasound and a gynecology consult depending on the results of her tests.

75-year-old man with head and neck pain. He just arrived and has not been seen yet.

We have a couple of swallowers who are frequenting our ED recently. One is in the inpatient psychiatric unit at our hospital. The other is in a closed psychiatric facility in the community. They both are very crazy and act out by swallowing anything and everything they can get a hold of. This usually leads to them coming to the ED for evaluation. Sometimes we just send them back to let the swallowed item pass. At other times we have to arrange to have someone go in after it, depending on what it is and how far down it got.

The lady in our hospital is under one-on-one observation. At her side at all times is a sitter whose job it is to keep her from swallowing anything. The other night, the patient leapt onto the sitter, pulled a pen out of her hand and gulped it down. Of course, they called and sent her to the ED for evaluation. I got an x-ray to see if had passed all the way into the stomach or if it was still in the esophagus.
The pen was mostly made of plastic, which doesn’t show up on x-ray. The only evidence of its presence was the little metal part at the tip that holds the ball in place. It was in her esophagus and showed that the pen had been swallowed back end first and was about half way down. I called the gastroenterologist and arranged for them to see her first thing in the morning.

I told the patient she was going back to her inpatient ward and she got really upset. As soon as I turned to go back to my paperwork, she leapt out of the gurney, bolted to the nursing IV cart, opened a drawer, grabbed two hands full of items out of the cart and was just about to get them to her mouth when she was stopped and restrained. She went back to psych hollering and screaming.