Top Three ER Patients that Make You Go Hmmm

July 19, 2009
Anything but the needle doc

Anything but the needle doc

I have had this post on my mind for quite some time but it has come to the forefront due to some of my recent patient encounters. There are certain things in Emergency Medicine which are so strange and become even stranger because of the fact that it seems they are found in all other emergency rooms. Its kind of like someone getting a 1500 calorie fastfood meal and then ordering a diet coke – it doesn’t make sense and yet people everywhere seem to do it.

The first type of patient that causes many of us to just wonder – sometimes out loud – people with multiple tattoos, usually very large ones at that and often with the added variety of body piercings, who refuse to get a shot. Why you might wonder? Because they say they don’t like needles. It makes us wonder if their tattoos were painted on with a brush or maybe the kind you get out of a bubble gum machine. Piercings though – that’s like having a 10 guage needle stuck in you repeatedly – and often in some very sensitive areas as well. For the non-medical out there, we use needles that are at least half that size and sometimes only one third.

The second patient group that leaves us scratching are heads are those that come in with “vomiting”. This group is often divided into two categories: the truly sick and those who aren’t. Those who aren’t sick baffle us because they routinely insist on vomiting on the floor even though typically the waste basket or vomit-bin/bag/etc is literally within easy reach. I used to think that such people would never do such a thing at home, but after doing some EMS ride alongs and seeing some of the conditions that some people live in, I understand that they probably just vomit on their own floors/couches/chairs/etc as well.

As for those who aren’t so sick, its amazing how often they come in complaining of nausea while they munch on Doritos and drink some nasty grape soda or other carbonated sugar poison. One day I’m just going to lose it and tell them that maybe if they weren’t treating their stomachs like toxic waste dumps that they wouldn’t be nauseated. But usually, I just take the polite road and encourage them to do a bland diet for a few days and that they will likely feel better.

The last group that comes to mind – although their are a few others out there deserving of mention – are those that come in with a complaint that just started. “I have a sore throat”. How long have you had it? “Oh, it just started about 30 minutes ago”. Or, “my child has a fever”. When did it start? “I just checked their forehead 20 minutes ago and it felt hot so I rushed him in”. Granted if the patient has some extreme history, like they had epiglottitis or febrile seizure, I would certainly understand and do my best to reassure them – but come on.

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Creepy Love and Other Relationship Oddities of the Week: I

July 18, 2009

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From time to time in the ER, we have the unfortunate experience of seeing relationships so foul that they can only be called “creepy love” as a nurse so aptly put it one night. It is just the sheer volume of people that we interact with that necessitates, to some degree, that we see all sorts of oddities. To narrow it down to just a few is so hard that I decided this would only be one part in a mini-series. Prepare to be horrified.

Creepy Love #1  goes hands down to a mother and son team that came in last night. The son, a young man of 19 years, presents with mom because his testicles hurt. Ok, nothing weird so far. Before I go in the room, I see mom step out as he gets gowned, something totally expected. I figured she would stay in the waiting room till he got discharged. Wrong.
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As I start the exam, Mom returns. I tell her from behind the curtain that we are about to examine the private area and if she would be comfortable returning later. To my surprise, they both – almost simultaneously – say no. So, she comes back to watch me examine her boy’s family jewels.  Afterwards, we come to the a set of questions of what he was doing when his balls started to hurt.  I am totally amazed as he goes into a detailed description – again in front of Mom – of how he was making out with a girl for “a really long time” without hitting the pay-off at the end. So, I told him that most likely he was suffering from a case of  “blue balls” – or testicular vasocongestion in medical speak. 
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Mom very creepily laughed at this point and told me that this is what she had suspected as well. I thought to myself, “If she starts talking about how this kid’s Dad used to get blue balls when they were still a fledgling couple – I am outta here!”  Usually young men cross the – Mom, “this is kinda private” – line around 15 years old. 16 wouldn’t be weird. 17 is pushing it. College age is already weird. But 19 going on 20 is just creepy (this guy is about to start junior year in college).
 
Creepy Love #2: Young woman – 25 years old – presents to the ER after having a fall the night before when she was plastered. There is a gentleman (used very loosely) in the room with her who appears to be in his 50’s. I’m thinking Dad, but I learned a long time ago to not assume anything in this area (We’ve all been there before – “So, this must be your Mother right?” Patient’s wife replies in a very insulted tone, “Mother? I’m his wife“. Ohhh – can the Earth please open up and swallow me now please).
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So, I casually wait for a moment to ask the man, “And you are?”. He replies that he is a “good friend“. Another lesson that I have learned is that “good friend” can also mean any one of many things. Apparently, Mr. Good Friend was with this young lady at the bar last night and drove her home. So, I’m thinking maybe he lives on the same street – saw his neighbor trading sober for hammered and kindly offered to take her home. No, that would be too normal. This was all about the creepy.
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So, since she had fallen in her less-than-sober state, I needed to check certain areas of her that were still clothed. I told her to get gowned and that’s when the creepy-meter hit red. I walked out of the room to let her get undressed – and he didn’t.  Now I know you’re thinking, it isn’t necessarily weird for an older man to date a younger woman less than half his age, and that in some ways it can be totally socially acceptable. Believe me, this wasn’t one of those cases.  
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The last couple for this post wasn’t a creepy one at all, just a sad one. 55 year old man comes in with chest pain. There is a woman with him who looks like she fell from the ugly tree and hit every branch on the way down as well as ate bark. But I really do believe that beauty is partly from within and not only skin deep – so I really didn’t think much of it. Until I started the interview.
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Everytime this guy would try to answer a question, this woman would literally scream at him and say he was lying. Then she would tell me something else. He didn’t seem to fight it, so I could only assume she was right. It was more typical of the way an angry mother would correct her delinquint son, but this was husband-wife dynamics.
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When we got down to the social history, the guy turned out to be a regular drinker. Imagine that. I mean, who wouldn’t want to be sober to deal with a delightful woman like her everyday? To understand this dynamic better, I researched the net and found this interesting article: Top 10 Signs She’s a Bitch. Oddly enough, the first comment to that article was written by a man who called himself F@&k Me who wrote: “what happens when you’ve been married to one for 17 years, and just can’t take it anymore?”. I guess my patient was asking himself the same question everyday as he cried into his drink.

Some People Have Nine Lives Too

July 12, 2009
Medical Cynicism 101

Medical Cynicism 101

I remember someone giving me a book to read called The House of God when I was in medical school. I imagine that a lot of you have read this book as well. I thought that it would have been a better book had it not digressed so much into sex and I never really finished it for that reason. Looking back now at the some of the book’s ideas, especially that of the GOMER, a lot of it really rings true.

There are certain people that come to the ER that seem to command little to no empathy from all ER staff. They go by different names but they seem to make their way to all ER’s irregardless. They just don’t die, no matter what they – or someone else – does to them. They survive such extreme conditions that would kill even the most hardened average person a long time ago. And they just keep on ticking away.

I saw one such person in the ER this weekend. A staffer at the ED told me that he knew him well as he used to see him regularly when he owned a liquor store. The guy apparently had 6 kids with 6 different women (another f#^&er setting up franchises I noted), and was clearly proud of it when I asked him. This time, he was driving his motorcycle at about 100 MPH down the highway, weaving in and out of traffic, until he lost control. His bike slammed into the median strip ditch at this insane speed and he went flying into a field where he landed on his back. Of course, he wasn’t wearing a helmet. Would you or I have survived an accident like this? No. We would have died when the bike hit the ditch or even before that maybe. Did it kill him though? Not even close. He ended up with a broken collar-bone and first rib. He went home after a short observation period in the hospital.

Or not so long ago, when I saw a raging @$$hole in the ER demanding that I give him a prescription for ritalin. I had already looked into this guy’s long list of abuse (cocaine, meth, alcohol, narcotics, benzos, etc.) as well as the previous notes describing his charmingly prickish personality and habit of physically attacking those who disagree with him.  So, I explained to him as politely as I could (while maintaining a safe distance) that this was not something that we ever did and that he needed to speak to his doctor if he felt he should be on it. He threatened me and used enough profanity to make someone from the Sopranos blush, and then left the ER.

He was so angry at so many people that he decided that enough was enough and he was going to die. He took an overdose of someone else’s Vicodin and Xanax and locked himself in his room at the house he was staying at.

An hour later, one of his house mates came to check on him because he was “unusually quiet”.  No answer and so he broke down the door only to find his “friend” lying facedown on the floor with two empty pill bottles near-by. He tried to wake him up and then called EMS. They arrived within 5 minutes – 5 minutes where no one was doing any CPR on this 37 year old man. He had to have been dead for at least 30 minutes before EMS even layed hands on him. They worked him for 15 minutes with nothing and brought him back to me.

In the ER, we worked him for another 20 minutes and just before I called time of death, wouldn’t you know it – his heart started beating again. I really don’t know what happened to him eventually, but how could a man who has been totally dead for at least 30 solid minutes to one hour get anything back is beyond me.

If it was some kid who had drowned in a pool and was given CPR by mom and then brought to us he would have been dead of course. Its the people that seem to be the most vile that survive. The ones that you hope make it are never the ones that do make it. Their stories are tragic. As for these people, I honestly believe that they are anaerobes like bacteria.

They seem to actually thrive when they don’t have oxygen or other elements essential to life for the rest of us. They fall off a building and the next day they are walking out of the hospital after they have drained the life out of everyone they have come into contact with – which may in fact be their secret. Maybe there is some truth to Vampires after all?

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Coping Skills Don’t Come in Pill Form

July 9, 2009
Just swallow

Just swallow

OK, I promise to write more often (thank you all for the kick). June and July are always mega-busy as everyone tries to go on vacation, and then you get a Dumass doctor fired and it just makes things that much harder on everyone.

One of the saddest commentaries on the modern world that I see on an all too regular basis is the absolute lack of coping skills in the growing generation. We had generation X and then Y, and I guess they’ll need to call this generation W for whiners. Too pampered while growing up that they have no idea how to manage their own problems after they very effectively create them.

Case in point. This past weekend, I had the unfortunate experience of seeing LT on three separate occasions for what he described as “anxiety or a panic attack”. LT was a promising college football recruit out of his competitive high school district. I have no doubt that he was getting his bum kissed all the way through high school and well into college until he blew out his knee.

He went to surgery for his ACL, but being that LT had always had others to take care of him, he ended up with an infected knee and a PIC line. The nurses in the ED came to know him well as he would often roll into the ER for his scheduled IV antibiotics after midnight while drunk and with a different girl on his arm. And things would only get worse …

Soon after, one of his girlfriends got pregnant and decided she didn’t want him in her, or the newborn boy’s, life. On one of his drunk escapades, he got into a fight with some guys on a street corner. For some reason though, he was the one arrested (they were all the same ethnicity by the way). Since his knee was no good now, he also lost his scholarship and with it, the stream of girls who had followed him around.

So now he had only one girl left and a growing list of problems. So poor LT thought he was going crazy and came to the ER. There he received an rx for Paxil and some Ativan to help him calm down. Little did I know that he would be back a short 10 hours later. He told the nurse that the doc he had seen earlier “hadn’t taken the time to talk to him”. He was surprised to see that it was still me though and quickly backtracked by saying that what he meant was that he hadn’t had enough time to fully explain his problems.

So, I listened patiently to him as he told his sob story. Afterward, I explained to him once again that he was not crazy but that he had several issues that he would need to address one at a time (just like the rest of us mere mortals). He didn’t seem to like my suggestion as that entailed actual effort on his part. I resisted the urge to ask him if his girlfriend wipes his butt for him as well.

The next day he showed up yet again, this time saying that he felt chest pain. I was obligated to do more of a work-up this time – which was completely negative 80 minutes and $5000 later. I had no desire to see him again in what remained of my ridiculously long shift and hit him with the B-52. When his mother, I mean girlfriend, came to pick him up he was already half-way to his “happy place”.

Thinking I was done, I actually rested. But less than 2 hours later the police showed up with an inmate who had swallowed shampoo and some toothpaste in a suicide attempt. I asked him why he had done that, and he said that he couldn’t handle being in jail anymore. He was put in jail 3 days earlier for DUI. I thought to myself, “you really don’t know what being uncomfortable is all about – yet.” Then I got out the gastric lavage.

I don’t think he had bargained on getting a garden hose put into his stomach without sedation. But he just couldn’t get it through his mind that he needed to find a way, other than medicine to “knock him out”, to cope with prison life. The whole “do the crime, do the time” thing just didn’t compute in his mind.

The future scares me.

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