Tuesday, December 29, 2009

A day in the life...

I will admit that sometimes I forget about this blog. Maybe it's because I think I have nothing to share. Thank goodness ER doc keeps updating this thing. I've had a pretty good couple of days to report, so here is a report from one day at the county clinic.

1. Overheard this discussion betweeen a new patient and the nurse (I didn't see this patient, the other resident did).

Patient: "My mom kicked me out. I am staying at Motel 6. I spent Christmas at ***** hotel - it's for dealers and whores!"

Nurse: "Why did she kick you out?"

Patient: "She says I've been neglecting my son. How can I neglect him if I'm not even there?"

2. New patient presents with anxiety. No psych treatment history. Anxiety problem started a couple of weeks ago. The only situation that makes him anxious? Urinating into a cup in front of his probation officer.

I'm sure it had nothing to do with having a possibly dirty UA. Especially after you've already been in prison. You should be pretty used to performing bodily functions in front of peers.

3. New patient, 20 year old kid. Chief complaint "I think I'm addicted to Adderall."
Me: "What can we do to help you?"
"I need a prescription for Adderall."
Right away, I have decided I won't be prescribing any schedule IIs to this dude. I went through the interview, and he just kept on giving me reasons not to. Uses ecstasy, meth, LSD, cannabis on a regular basis. Has purchased Rx stimulants from friends and off the street. No job. Dropped out in 9th greade. His goals are: 1) Record some of my music 2) videotape myself skateboarding, burn it onto DVDs, and sell them on the internet. Arrested x1 for possession of weed. Denies any history of violence/suicidality.

I let him go on and on, way longer than scheduled 30 minutes because I was documenting like crazy. He had some anxiety, no mood component or psychosis. I offered medical treatment that did not include stimulants (or benzos), and he started to get pissed. "I need to go out and get some fresh air. Can I leave my stuff here?" I told him that the interview was over and to please take the stuff (new patient forms) and complete them in the waiting room.

Next thing I know, Granny comes back and starts advocating for placing him on stimulants. "He's been clean for 2 weeks."
"Really? How do you know? He told me he did meth and weed last night."
"No he's been in jail for 2 weeks for possession of methamphetamine."
So now I know that he's lying to me about jail.
She also says she has to sleep with a deadbolt on the door because he assaults her.
Lying about assault history.
All this and she wants me to prescribe a med that he admittedly abuses, and will likely increase aggression.

After I let Granny vent all of her anger toward her worthless grandson out onto me, I gave her a referral to Al-Anon.

Just a day in the life. Check back later about a 12 hour shift in the psych ER.

-Psych Doc

Monday, December 28, 2009

Iron-ic Seizures













A 34 year old male came in for a burn. Poor guy was ironing when he had a seizure. He knocked the iron to the ground then landed on top of it, making the 3rd degree burn to his back seen on the left. It sucked because he was therapeutic on his seizure meds, meaning he was taking his meds the right way. He ended up having to undergo surgery due to the depth of the burn

-ER Doc

Sunday, December 20, 2009

Just Another Manic....Sunday?



Sundays are usually pretty slow days in the ER....especially during football season. Today, though, was the exception to the rule. It wasn't just busy...the department was full of sad cases. Here are a few:
  • 64 year old female on blood thinners was putting up Christmas decorations, slipped, and fell. She had a large head bleed. The family will likely withdraw care
  • 21 year old male was fixing his parents fence when the power lines somehow fell on him. He had severe electrical burn injuries, aspiration pneumonia, and is going to require multiple fasciotomies...if he survives
  • A nice 19 year old hispanic male.....on dialysis!
  • 37 year old female with newly diagnosed pancreatic cancer
  • 44 year old female with newly diagnosed hepatocellular carcinoma
  • 54 year old male with no past medical history came in with back pain and leg weakness. Ended up having a large epidural abscess and osteomyelitis
  • 2 heart attacks
  • 2 motorcycle accidents, 3 motor vehicle rollover accidents
  • 1 gun shot wound to the chest
  • 47 year old make, obese, diabetic, on dialysis, bilateral below the knee amputations...today gets a diagnosis of fournier's gangrene (horrible necrotizing infection of the scrotum)...so now he won't have testicles either
  • A 45 year old with left upper extremity weakness. Normal CT brain....MRI showed an acute thalamic stroke
Very atypical Sunday. Time for a drink.

-ER Doc

Friday, December 18, 2009

Sue Me For What??

33 year old male came in to the ER b/c he felt like he couldn't urinate. He said for the past 2 days he was barely able to pee, and he felt like his bladder was extremely full. I put the ultrasound probe over his lower abdomen, but didn't see a distended bladder.

Next step in a male with this complaint is to do a rectal exam to check for prostatitis. I explained it to him, and he dropped his pants and I proceeded. Normal prostate. He swore, though, that his bladder was full. I was more worried about other things at this point. His abdomen was pretty tender. Was he having an appy with referred pain? Maybe something more serious going on that's causing irritation in his lower abdomen, like diverticulitis? He refused to let me proceed without fixing his "peeing problem." The only thing left to do was to place a foley. We did just that, and very little urine came out. Sit was confirmed that his bladder was basically empty.


But man.....was he pissed! He was screaming that I raped his asshole for no reason and shoved a tube up his penis. I explained over and over that it was all medically necessary, but to every employee that walked by he shouted that I shoved my finger in his ass and a tube in his pisser.


His urine came back with bacteria and mucous...suspicious for prostatitis. But his white count was elevated more than I was expecting (about 18k). So I decided to get a cat scan of his abdomen. His scan showed a perforated diverticulitis...and he needed IV antibiotics and surgery. My shift was over and I signed him off to one of my colleagues. My colleague said that this guy continued to complain to everyone about his rectal exam. He was now determined that since his diagnosis was perforated diverticulitis, he never needed the rectal exam in the first place and that he wanted to sue me for violating him.


I understand rectals are a pain in the ass....I don't enjoy doing the test myself. It's the worst part of my job. But this guy needs to freaking chill. I believe there was a Family Guy episode about this same thing.


-ER Doc

Wednesday, December 9, 2009

Why Is My Poop So Big

My favorite triage note from today:

"10 year old female accompanied by her mother. Mother brought her daughter in because she has been having large bowel movements. Patients mother states her daughter is only having one BM per day and it is formed, but she is worried about the size of her stool. "


-ER Doc

Thursday, December 3, 2009

Thumbtack Mishap

Warning: Sad story ahead

A father noticed his young child was choking. He ran to go help his son by performing the Heimlich maneuver. After about the fifth thrust, his son became dramatically worse. When the child arrived to the ER he was dead. We noticed a lot of crepitus in his swollen neck. Autopsy results showed a thumbtack that perforated his trachea. The theory is that the boy swallowed the thumbtack and the effects of the Heimlich maneuver propelled the tack through his trachea. The back of the tack was sitting right where no air could pass, with the sharp part piercing a false track. The dad did everything he should have. I feel horrible for him.

Hard case to swallow...no pun intended.

-ER Doc

Sunday, November 29, 2009

Suprise Packing


Recently an unresponsive Hispanic female was brought in after a MVC to our trauma center. She was intubated and the normal trauma protocol was followed. We normally get routine pelvic Xraysin trauma. In this case, there was a very interesting finding. Forgive me that I don't know how to draw arrows...but if you look in the middle of the pelvic ring you will see something that looks like a ball of pebbles. At first I thought it was just hard stool. But the radiologist read it as unknown foreign bodies.

So when the patient got sicker and we couldn't figure out what was going on, the surgeons decided to see what exactly that possible foreign body was. Turned out it was about $10,000 dollars worth of cocaine stuffed inside of her. It was removed and IV antibiotics and time did the trick.

-ER Doc



Sunday, November 22, 2009

Chief Complaint of the Week


Sometimes we hear medical terminology and associate it with what we think it sounds like. I had a patient who did suck that last week.

Phlebitis is defined as inflammation of a vein. My patient came in because she had been around fleas and wasn't feeling well. She was afraid she might have been bitten by the fleas and caught a case of "Flea-Bitis." Classic.

-ER Doc

Wednesday, November 18, 2009

Magic Needle

A 24 yo large Hispanic male arrived in the ED carrying plain film X Rays from an outside hospital. Since he only spoke Spanish, I went over and pointed at his films so I could at least see what was going on before the translator arrived. To my surprise, he had a sewing needle in his left thigh. I couldn't wait to hear how the needle implanted there.



When the translator arrived, I asked him "How did the needle get into your thigh?"

He said, " I'm not sure."

I then asked him, "Don't you remember that LARGE needle going into your leg. You had to feel it when it happened."

He said, "No, but about two weeks ago I started feeling a sharp prick every time I walk. Maybe the needle was in my pocket and it just went in. Or maybe I laid on it."

I was puzzled as to how a large sewing needle got stuck in his thigh. I examined his thigh and he didn't even have a mark on him. To this day, I am scratching my head. We gave him an appointment to see a surgeon to have it removed.

-Doc Sensitive

Monday, November 16, 2009

More Weirdness










Some more weird complaints from patients from my last moonlighting shift in the boonies:

Patient 1: Chief complaint of "I think I have forceps coming out of my vagina!" Oh course everyone was cracking up before I went into the room. The patient stated that she had a c section done a year ago. Since then, she had pain and pressure to her lower abdomen. She was convinced the doctors left forceps in her uterus and they were slowly falling out. I did the vag exam, and of course no forceps. But....Before I left the room I got some forceps from the drawer, gooped them withe some jelly, and brought them out of the room with my gloves on. I had a shocked looked on my face and told the nurses, "Look! She really did have forceps in her snatch!" I couldn't hold my laughter for long and they quickly figured out the joke.

Patient 2: Was actually a phone call to the nurses. The person called at 3 am b/c she cut her dogs toenails too much and they were bleeding. She was frantic and didn't know what to do. My nurse told her to call a vet. She said all vets were closed. So my nurse said, "So go to sleep!" and hung up the phone. Greatness

-ER Doc

Thursday, November 12, 2009

What do vegetable juice, milk, and worms have in common?

The answer? My patients! Here are a couple of word-for-word triage notes from a recent shift:

Patient 1:
Patient states she thinks someone put something in her vegetable juice this am at 0500. She says that she woke up and drank the juice and shortly after she felt "like my stomach was swelling up and then I had nasty orange diarrhea". Pt states she then drank 1/2 gallon of milk and then had the more diarrhea, this time a lighter orange. Pt appears in no acute distress in triage. Pt states she feels fine now.

Patient 2:
Patient with chief complaint of "I have an abscess on my head and i found a worm in it."

-ER Doc

Monday, November 9, 2009

Milk the Balls??


A 27 year old male came in withe the chief complaint of testicular pain. On exam he had extremely enlarged, red/purple testicles. There was active drainage, he was febrile and tachycardic, and the infection had spread to his lower abdomen and thighs. It was basically a surgical emergency.

Usually this kind of infection stems as a complication from diabetes...but not in this guy. No past medical history. So what could it be?? The story is very hard to believe. His girlfriend told him that she heard "milking the prostate" can feel really good and make your man parts larger. Problem is they didn't know what that meant or where the prostate was. They KNEW the prostate wasn't in the penis, so it had to be in the testicles. So...they got a needle and syringe INJECTED MILK into his scrotum! Ouch.

I try to educate my patients as much as possible on things. I don't always do a good job when its really busy. But this time I was sure to explain what "milking the prostate" really is.

Poor guy lost both of his testicles from necrotizing fasciitis. Milk doesn't always do a body good.

-ER Doc

Thursday, November 5, 2009

Reminder


Working in a county hospital emergency department reminds me everyday that our healthcare system needs reform. I saw a patient the other day that was a sad example of this.

The patient was a hard working handyman who had been recently diagnosed with metastatic cancer. He had noticed a lump on his ribs a month prior, and it was discovered that lump was actually metastatic cancer to his ribs from a gastrointestinal source. He was in the ER for worsening pain. I looked through the computer to see what follow up appointments he had, and I noticed he was to be see in palliative care clinic in the next few weeks. Right then I knew his prognosis. Patients don't go to palliative care for cancer treatment, they go there so their pain can be controlled as the cancer spreads until they die. I talked to him and his wife for a bit, and could tell they still had hope of possible treatment. The past month had been a shock for them, as it would for any of us.

So let me get this straight... an honest, hardworking man who struggled to support his family now has an incurable cancer that was found only after it spread and became noticeable.... YES. We see it all the time. Why wasn't it caught earlier? Only if this patient had a primary doctor who noticed he was having months of weight loss (a classic historical point in cancer patients) or was anemic and needed further workup. If only he had a routine screening colonoscopy for a man of his age. Unfortunately, a lot of the time hard working people who support their family cannot afford health insurance, and in the end they sacrifice.

Health care in this country is the greatest example of the haves versus have-nots. I don't want to paint the picture that people who don't have healthcare are poor and homeless. They have jobs and families but just cannot afford the high cost of medical coverage. I see them every shift in the emergency department. It costs more to take care of a patient who has had a stroke because of untreated chronic hypertension than it is for that patient to have a primary doctor and take daily blood pressure medication. We practice reactive, not preventative medicine. Reactive medicine not only increases health care costs, it hurts people. I am not saying we need a socialist system, but people should not have to choose between medical care and supporting their family. That we should all agree on.

-Nice Doc

Tuesday, November 3, 2009

Sleep Walking



We all know that sleep walking can be dangerous...but I never thought of this happening. The cat scan shown is that of a poor patient from yesterday. 29 year old make walked in confused, wide based gait, and bruising around his eyes (racoon eyes).
Classic picture of someone with an epidural hematoma, and that's what he ended up having. His girlfriend said he was sleepwalking and accidentally fell down the stairs...about 22 of them. They had a gate on the stairs to prevent this, but I guess it didn't work. He quickly declined and had to go to the operating room to drain the blood. So far he is still alive and he should do ok.

-ER Doc

Friday, October 30, 2009

Think Gland



While I am mostly in clinic during this year of training, I do cover our psychiatric "urgent care" one day per week. Most of the time, the patients in that clinic are fairly stable and just need med refills. This week, I saw the sickest patient that has ever made it to that clinic. He was a 21 year old male, already on Medicare (so that means he is legitimately ill), but I still have to laugh about this. What I have in quotes below is word-for-word what he wrote on his patient questionnaire. I didn't change the spelling.

HPI: "Abilify 10 mg for my think glands it clears it. Zantex For my Enziety promblems helps me For Breaking out in stuttering in throwing up."

The interview was even more interesting. He was discharged from our inpatient unit 9 months ago for assaulting family members, had moved to another city to live with an uncle and was being prescribed the above medications (Abilify for his thinking gland and Xanax/Zantex). He moved back here to live with his grandfather. He had been out of his medication for 4 days. I asked him how he had been getting along without his meds and he replied, "I've been self-medicating by drinking 40s and watching cartoons. Cartoons really help me chill." I wish now that I had asked him which cartoons.

I tried to get him to tell me more about his thinking glands, his stuttering and vomiting issues, etc., but he was getting frustrated. "Look doc, I know you're trying to help, but I already said all I gotta say on that paper right there. I just need to get my meds. Give me some credit, man, I've made a 360 degree turnaround from when I was hospitalized right here a year ago."

The icing on the cake was when I asked him what he wanted to do with his life. "I want to go to college, probably be a doctor. Definitely something medical."

I hope his think gland can handle med school. Mine barely did.

I have to do this blog just to keep my think gland from exploding.

And no, I did not give him Xanax. Or Zantex. But I Abilify-ed the sh!t out of him!

- Psych Doc

Thursday, October 29, 2009

Viva America

Everyone, welcome a new guest blogger...NiceDoc. He really is one of the nicest people I know. As far out as his story might sound, I have experienced the same thing 2 different times in the last year. Enjoy, ER Doc
------------------------------------------------------------------------------------------------------------------

It was thirty minutes before the end of my shift. I had almost tied everything up and was planning on leaving on time for once. Out of nowhere, paramedics burst through the doors of the ER with a very sick patient. The patient was a 400-plus pound intubated Mexican man. No one in the ER knew he was coming in. We always get an alert when an ambulance or helicopter are on their way to us. With this case there was no report, no one called ahead, NOTHING! As the paramedics came closer, I noticed something out of the norm. All of the paramedics were Hispanic, and the writing on their uniforms were in Spanish. "This can't be what I think it is," I thought.

So as we got him into our critical care room, we learned that he was in a Mexican hospital for the past week and his family was disgruntled with the care he was receiving there. The doctors tried to transfer him to us a couple of days prior, but our hospital refused (It's not a law that we have to accept transfers from other countries). So after being rejected, his family paid a large some of pesos to rent a jet to fly him to the states, and had a helicopter waiting once they landed to transfer him to our hospital. That explained why we didn't receive any advanced notice of the patient. It was an illegal transfer, and the chopper just landed on our roof!

Not only was the patient critically ill and on the ventilator, he was unstable. The only history we had was a patient summary from his hospital stay in Mexico...and it was hand written in Spanish. His oxygen saturation was low despite being on the vent, his blood pressure was low, and his heart rate was through the roof. He had medications hanging through an IV, but the IV wasn't working! It was a mess. Eventually we stabilized him, and he made it to the ICU.

What's going to happen to the Mexican hospital? Nothing. They don't abide by our country's hospital ethics laws. What's going to happen to the patient? I don't know, but I do know that we just inherited all the substantial medical costs to take care of this unfortunate gentleman... and I left my shift and hour and a half late :)

-NiceDoc

Tuesday, October 27, 2009

Perverts


A couple of male patients kind of weirded me out today. Both married med in their 50s.

The first needed a prostate exam to rule out prostatitis. He said he never had this exam done. After the exam, he thanked me and said it was the most action he had gotten in awhile, and said he couldn't wait to tell his wife that he was right... putting something in there doesn't hurt that bad. I asked that he wait until he gets home to tell her that.

The second needed a foley to measure his post void residual volume. I have NEVER met a man who enjoys getting a foley....but there is always a first. He thanked the nurses over and over again, stating that it felt so great and that he hasn't "gotten any" in over a year. He laid back and relaxed and asked for a cigarette!

No wonder I found my self washing my hands more than normal today.

-ER Doc

Saturday, October 24, 2009

The Best Medicine--Your Husband


A 65 year old female arrived via ambulance with a heart rate of 220 and feeling very dizzy and lightheaded. After a 12 lead ECG, it was determined that she had a rhythm called supraventricular tachycardia (an arrhythmia originated above the ventricles resulting in a very, very fast heart rate).

I proceeded to give her the standard treatment... a fast acting medicine called Adenosine. I gave her 6 mg IV push and the heart rhythm never changed. I then gave her 12mg IV push and saw the characteristic long pause on the ECG (looks likeasystole )...which is the medicine "resetting" the heart back to normal. After the long pause, however, the heart went back to 220 beats a minute. I debated shocking her, but decided to give her someAmiodarone b/c the second ECG looked more wide complex then the first. After I gave her 150mg Amiodoarone her heart rate slowed down to the 160s, but had yet to revert back into a normal heart rhythm.

I left the room to check on another patient when the nurse pushed the code button and started screaming for help. I immediately ran back into the room expecting to see my patient inasystole... but instead found the patient's husband passed out on the ground. Unknown to us at the time, the husband had a habit of passing out in medical situations. After tending to the husband, I looked back up towards the wife. To my delight the husbands vasovagal episode scared the patient so much it caused her vagus nerve to fire strongly... which reverted her back into normal sinus rhythm!!!! She had failed three different drugs, but in the end all it took was her husband to pass out.

I told her to bring her husband to the hospital the next time she goes into SVT.

-Doc Sensitive

Tuesday, October 20, 2009

Cold Foot

Funny story from a colleague about a cold foot:

A patient from a neighboring country had a vascular problem with her foot. The prognosis given to her foot was grave, and she wanted a second opinion. Someone from her family recomended our hospital (which again is in another country) as her saving grace. They packed up and got in the car and started to drive. For some odd reason, they put her foot in ice for the drive to "stop the infection from spreading." So they drove, and drove, and drove (passing many large cities and hospitals on the way) for about 20 hours to our hospital....all with the foot in ice. So needless to say when she arrived her foot was hypothermic, black, and dead.

Not much could be done at that point. I guess second opinions can be overrated.

-ER Doc

Monday, October 19, 2009

Stolen Material

Here are a couple of things I read that I had to share. The first is from a blog call "The Central Line." It is a blog done by the American College of Emergency Medicine. The second is a comment from one of our readers Bubba. Again...not my material.

-------
#1
Non-Clinical Clinical Prognostic Indicators


Good Prognosis:
-Your doctor hasn’t seen you yet, and you’ve been waiting for (insert average wait time) hours.
-You’re in a bed in the hallway.
-Your complaint consists of “months” or “years” of pain/nausea/headache/X Y Z.
-You’ve come to the emergency department for a second opinion, despite multiple subspecialist evaluations.
-You answer yes to every symptom the doctor asks you about.
-You get a blood draw, but no IV.
-The only medication you’re given is tylenol.
-Your doctor says the words “probably” and “virus” in the same sentence.
-You are talking on your cellphone, playing a game, or chit-chatting.
-You are talking on your cellphone, playing a game, or chit-chatting and the doctor has to ask you to stop.
-You “just wanted to get it checked out.”
-Your primary care doctor sighs on the phone when the emergency physician calls him or her.

Bad Prognosis:
-You get not one, but two IVs.
-You remark, as my GI bleeder did last night, “Boy, I’ve never been to a hospital so attentive and efficient!”
-You get your own personal doctor to take you to the CT scanner.
-Multiple doctors, nurses, and staff greet you in your room.
-The triage nurse walks you to your room and points at you while speaking to the doctor.
-You get a room all to yourself.
-You get a monitor.
-Your monitor keeps beeping, even though you’re not doing anything.
-Your doctor keeps checking on you.
-Your doctor sticks a finger in your bottom.
-You don’t argue with the doctor about getting this treatment or that one.
-You are kind, good-natured, and have been a good person in this life.

-------
#2
Bubba said...
I will seek and find you.. I shall take you to bed and have my way with you. I will make you ache, shake & sweat until you moan & groan.I will make you beg for mercy, beg for me to stop. I will exhaust you to the point that you will be relieved when I'm finished with you. And, when I am finished, you will be weak for days. All my love, The Flu


-ER Doc

Friday, October 16, 2009

Flu Rant!

I am so sick of the Swine Flu. I know kids are dying and it's scary. I'm not going to say the normal "people die from the flu every year" thing. I do believe this thing is worse...but damn I am sick of it.

It's not the people who are really sick that's bugging me. It's that EVERYONE thinks they have the flu. I primarily work at a big county hospital for residency, but I also work in a children's hospital, an urgent care, and a small rural ER (moonlighting gigs for extra money). EVERY single one of them is filled with people daily who want to be tested and treated.

They don't care about my clincal assessment of them. They don't care that testing for the flu is basically worthless...they want the test. They want to call and tell everyone they have the swine flu. They swear their neighbor has it or the shopping cart they used had it. They could care less of my training and clinical acumen. They know what they have and what they want. I try and try to talk rationally and teach them the recommendations and pathology, but they don't care. I spend time and energy and it doesn't matter. And if I succeed and talk them out of it, I get negative patient satisfaction scores.

I know what sick people look like from the flu. They are hypoxic, febrile, have rigors, and having breathing problems. Slam dunk cases that will be treated or admitted. But a year ago....we would NOT be running all these tests and treating all these iffy cases. We would call them URIs or viral syndrome or bronchitis and let them be. This country is going to run out of Tamiflu....and then....

"Shoo Shoo Retarded Flu"--The Howard Stern Show

Thanks for letting me rant,

-ER Doc

Wednesday, October 14, 2009

Till Death Do Us Part


An 85 yo man and 84 yo female married couple arrived to the trauma bay after a head-on-collision in which the man entered the freeway going the wrong direction. Both of their injuries were critical. The man sustained a severe pelvic fracture, and his wife had a hemothorax (blood in the chest cavity). The wife was more critical than the husband, so we intubated her and placed a chest tube to drain the blood.

Shortly after placing the chest tube in the wife, she became bradycardic and lost a pulse. After about 30 minutes of resuscitation, she died. Afterwards, I went over to the husband to reassess him. He kept asking me "how's my wife?" I couldn't answer him. I proceeded to get the CT scans that he needed. He again kept asking everyone "How's my wife?" At that point, we debated not telling him until he got to the floor. He kept asking and then said "We have been married for 65 years." We told him....and it seemed he let go. He died later that afternoon, shortly after he was told that his wife passed away.

-Doc senstive

Friday, October 9, 2009

Saying no to drugs


I remember when I was a kid hearing Nancy Reagan saying "Say No to Drugs." I deal with this every day in clinic. I'm not even talking about ice, smack, weed, crack, bumpin' a rail, etc. I mean the honest to goodness, legal prescription stuff. Every day I have to talk with patients who are abusing there benzos. Residency training programs are a great place for benzo abusers, because the residents cycle in and out, and nobody takes ownership of bad situations, therefore problems just get passed along. Even though our patients sign medication contracts, they still try to abuse the system.

Since I have recently begun clinical rotations, I have been stuck in numerous predicaments such as this. Patients abusing their priviledges. Psych Doc draws a line in the sand. Patient retaliates. Some examples.

Patient #1 presents for refill on her valium. She was fired from another clinic in our system for repeatedly overusing valium, calling for early refills, and on one occasion, showing up totally stoned on weed. My attending physician told me that I got to be "the bad guy" and take her off valium. We had a fairly pleasant discussion, however she did inform me that if I didn't prescribe it, she would send her grandpa to Mexico or Canada to get it. She also told me she should be able to smoke weed whenever she wants. On the way out of clinic, she screamed "Psych Doc is a Demon from Hell!" That didn't exactly brighten my day, but it did provide the name for my fantasy football team this year.

Patient #2 I inherited on Klonopin 1mg TID. She insists that it is QID, though it's been prescribed TID for > 6months. She ran out early. She could barely stay awake during the nursing assessment. Once again, I get to be the bad guy, cuz nobody else wants to set limits. I tell her we're going to taper her off Klonopin over 4 months because she's been abusing it. She asked, "Is there a higher authority than you?"

I resisted the urge to answer, "Maybe God would qualify" but decided I would leave that to my surgical colleagues. Instead I replied, "Do you mean like a patient advocate?" to which she answered in the affirmative. As she wrote down the advocate's name and phone number that I provided, she was so stoned that she couldn't operate a standard ballpoint pen. She then slammed the door on the way out, went into the waiting room and told the other patients, "Good luck with Dr. Asshole."

I am so frustrated with the users. As one of my attendings used to say to these patients, "Excuse me, but do I look like a vending machine?" I really try to do what's in the patients' best interests. Use the lowest possible dose (all meds, not just benzos). Avoid polypharmacy. Prescribe high risk meds when appropriate.

Some days I wonder why I went to med school.

Say "Thank you" to your doctor today.

Regards,
Dr. Asshole aka Demon from Hell aka Psych Doc

Saturday, October 3, 2009

Cuts like a butter knife


A 45 yo strange looking female arrived to the ED with chief complaint of "bright red blood per rectum." I went into the room and asked her "What brought you in today?"

She kind of avoided eye contact but matter of factly stated, "I have been constipated for the past three days, so I took a butter knife from my kitchen drawer and I used the knife to alleviate my constipation. After the first bowel movement, I noticed blood in the toilet. I am not very concerned, but my family made me come in to ensure nothing serious was happening."

Sometimes, it's difficult to maintain a professional demeanor. I had to put the chart over my face to avoid smiling and laughing at this poor patient. I had many questions I wanted to ask, such as "Is this a normal dinner discussion in your family? Wouldn't you keep that a secret?" Nevertheless, I decided to avoid any additional questions because I didn't really want any answers.

I did a though anal exam with an anal scope to look for deep cuts in her anus. Thankfully, it appeared nothing was seriously injured in her butter escape hole. I discharged her with a script for a stool softener and gave her strict ED warnings to avoid butter knifes.

I can believe its not butter!

-Doc Sensitive

Thursday, October 1, 2009

Honored to Serve


A 92 yo male arrived to the ED complaining of severe abdominal pain. Upon examination, I could immediately tell that he had a severe surgical abdomen because he displayed rebound and guarding on physical exam. When I asked if he had any past surgeries or medical problems, he said "Son, I got shot by a German artillery in WWII when I was young. Besides that, I dont have any medical problems." I was rather interested and asked him what he did during the war. Turns out he was a fighter pilot.
He was a very humble and nice man. I knew his chances to survive were slim after I saw his upright chest x-ray illustrating free air under the diaphram. I called the surgeons and soon forgot about him. For some reason I recently searched his name on Google, and learned about him through his obituary. He was a true hero.

As an ED physician, you often encounter certain patients that make you wonder what kind of person they were to touch your life so genuinly- even if briefly. I'm not sure why he stuck in my mind. Maybe it was that he reminded me of my grandfather. I wanted to know more about his career and what "the war injury entailed." More importantly, I wished he was still farming and alive to tell the rest of his WWII stories. In a way, I feel honored to have served him during his last days, just as he served his country and the world during WWII. He served a greater good and higher power then I can ever dream to serve- salute and cheers.

-Doc Sensitive

Tuesday, September 29, 2009

"Awesome"


Ok...a change in subject. I feel like I am sitting on the floor of the senate after reading all those comments. Great to have an involved debate though.

So....a story about a funny trauma case. Saturday night, 230 AM. The bars had just closed. EMS called to warn us they were bringing in a gun shot wound...to the TESTICLE!! Ouch. A 23 year old pulled a "Plaxico" by carrying a gun in his pocket to the club. He accidently fired the gun in his pocket, and the bullet went through his testicle into his thigh.

He presented in a great mood actually. He was drunk and calm. His testicle was hanging outside of his sac by its cord, obviously dead. When he was asked if he had any medical problems, he replied "You mean besides being awesome!? Then no." Not the typical response you would expect from someone with their left nut hanging outside its cage. He was taken to the OR and the testicle was removed.

Two days later I saw the gentleman in the ER again. This time it was daytime, and he was sober. He presented with severe constipation, presumably from the narcotic pain meds he was prescribed. After 2 enemas and a bottle of mag citrate, we had him feeling "awesome" again.

-ER Doc

Monday, September 21, 2009

Compassionate death?

I recently spent some time in another country that has socialized medicine and thought I would share a story that illustrates the differences b/w our system and socialized medicine:

72 yo deaf and demented male from a nursing home arrived looking pale, diaphoretic, and not responding to voice commands. The gentleman looked very critical, and my instincts were to get ready to intubate him. However, my attending on duty looked at the patient and realized his quality of life was very low considering that he was deaf, at the end of his life, and living in a nursing home. He told me to not intubate the patient(even though no family members were present). I then got an EKG illustrating a very wide complex tachycardia with high t-waves suggestive of hyperkalemia (high potassium). I drew a state venous blood gas which confirmed a high potassium level of 7.0 (normal is less than 5).

When the potassium gets very high, it can cause the heart to stop beating if is not corrected. I brought the EKG to the attending with the lab result of the high potassium and asked him if he wanted me to push calcium gluconate with IV glucose/insulin (the treatments for a high potassium). He said, "No. His condition is already very critical because he is in urinary retention and has an acute abdomen. We need to just let him die peacefully."

It was quite shocking b/c in America we would have intubated him and performed heroic measures, but it begs the question- "Why do we save everyone and not take into account individuals quality of life? Would I want to be treated if I was demented and lived in a nursing home? Is it more humane to just allow people to die peacefully?"

Rather then giving him calcium and glucose/insulin, I gave him Morphine for comfort. He died peacefully about an hour later.

-Doc Sensitive

Sunday, September 20, 2009

Shoulder Pain


Shoulder pain is a very common chief complaint in the emergency department. It's also a pretty easy work up and disposition. This case was no different, but the story behind it was classic....

So the patient was a 30 something year old male. He complained of bilateral shoulder pain. Further history revealed that it had been worsening for 2 years. When I asked him if he had any clue what could be causing the pain....he had a pretty good reason:

"Well doc, ya see it's like this. I like to go down on my girl friend. I spend a lot of time down there. I mean like 4 to 5 hours at a time. When I'm down there, I have my hands stretched above my head to play with her nipples. I think all that time with my arms up messes up my shoulders. I don't think all the meth helps either."

It was one of the only times in my short career my jaw dropped during an interview. Totally caught me off guard. I discharged him with a prescription for some NSAIDs and advised he takes breaks while he's "down there."

After his classic quote, I noticed he had really bad teeth. I wonder if it was from the meth or from.....

-ER Doc

Monday, September 14, 2009

MADD (Moms Actively Drunk Driving)


Sad night....24 year old female was drunk at around 10 pm Friday night. She was driving around 50 mph in a residential neighborhood and drove into a house. When EMS got there, they noticed an 8 month old baby in the back seat. To make matters worse, mommy was so drunk she couldn't figure out how to strap her child in properly.


There's more....no drivers license, no insurance. And...this was her 2nd DWI! Instead of asking about her baby, she asked me to call her boyfriend, who was still at the party. Instead I called CPS and the Police.


Alcohol level.....194.


The baby is ok, thank God.


-ER Doc

Thursday, September 10, 2009

Dream Interpretation: My Blanket


Dear Psych Doc:

I have had a LONG string of not remembering my dreams lately. I think it is b/c subconsciously I know you will interpret them for everyone to hear. Finally....I had a dream and remembered it. It was kind of dumb.

The background to the dream is as follows; I have had a blanket since junior high that is awesome. Everyone who stays the night wants to use it. It has the perfect material consistency. I'm not a total dork....I don't sleep with it every night. My wife and I have a comforter so it's not like I have to have it to sleep. I usually use it when on the couch or need extra covers and such. It is striped green and white...not even my favorite colors.

So my dream took place with me on vacation visiting friends from early childhood that I haven't thought of in 15 years. My green and white blanket was with me. I walked a few blocks to go to the grocery store, and for some reason I brought my blanket. On the way home from the store I noticed I left the blanket, so I turned around to hurry back to the store. Before I made it to the store, I noticed two lady's with my blanket. They molded it into a horse and made it look like a pinata. I asked for my blanket back, and they offered me $500 for it. I felt like that was too much money, so I said they could have it for $300. Soon in my dream I regretted the decision of selling my blanket. The rest of the dream I searched for the lady's I sold the blanket to. I don't remember anything after that. What the hell is the matter with me?

-ER Doc

Dear ER Doc,

Welcome back to my office. First, let me explain the blanket. The blanket is a common transitional object used by a toddler during the separation phase from the mother. The blanket signifies a representation of the mother that comforts the child when the mother is away, therefore easing the transition into individuality. In many ways, adolescence is a lot like being a toddler, so I can see that the blanket could be your "teenage" transitional object.

This also sets the time frame: 15 years ago, you were a teenager, a time that you remember your blanket and your mom providing you security.

I think that the 2 old ladies probably refer to your 2 "old ladies"- whoever fulfills the 2 dominant female roles in your life right now. Could be your current and ex girlfriend or current girlfriend and mom. You feel as though they are battling for your attention. Whatever it may be, you're refusing to let go of something in the past. You're holding onto some behavior or personality trait that reminds others of a teenage boy. I'll let you figure that out.

As for the horse/pinata part, that's just a fantasy. You wish you had genital anatomy the size of a horse. And you want women to beat you like a pinata because you're into S & M.

-Psych Doc

Tuesday, September 8, 2009

Cash Baby


A mother brought in her 8 month old baby today for "breathing difficulty." She stated that for the last 2 months her child had been breathing worse and worse. He had a non productive cough and no fever. They had been to her pediatrician multiple times. Despite treatment with medicines, including breathing treatments, the child was getting worse. When she went to see her doctor today...she realized the baby had lost 4 pounds in the last 2 months...so she decided to come to the ER for a second opinion.

Up until his presentation today, no one had ordered a chest x ray. A similar CXR to my patients is pasted above.

So the diagnosis was easy. Swallowed a coin. Consult for endoscopy....


But if ya think of it....this doesn't really make sense. The kid has been losing weight so I am confident that the coin was probably the culprit. But how does a baby that small swallow a coin? We are taught that a coin that is swallowed but doesn't make it to the stomach is a surgical emergency. But presumably the child swallowed this coin 2 months ago?!?! That means by now the child would have been septic, had a perforated or eroded his esophagus, the list could go on and on.


So....I'm stumped. Don't know if the swallow was recent and a red herring to what was really going on, or if he swallowed it 2 months ago and is some kind of miracle baby. He was admitted to the hospital to have the coin removed and further workup. I'll have to follow up and see what comes out of it.


-ER Doc


Thursday, September 3, 2009

Greed


Below is a link of a blog post from a different website. I think it brings up important points that we don't hear enough of:


The next is an article on the basis of how physicians get paid....the relative value unit (RVU):


For those of you who are interested in medical care and the "free market," here is an interesting take by a leader in medicine:


-ER Doc

Wednesday, September 2, 2009

Cake


Here is a copy of a nurses triage note from the other night.

"Patient presents to triage complaining of tooth pain. He has obvious tooth decay and was already seen at an outside facility last night for the same complaint. He has prescriptions in his hand from that visit which he has not filled. He is asking for utensils to eat his 3 large pieces of cake that he has with him, a place to do his laundry, and also requesting to be allowed to sleep and shower in an inpatient bed. Explained to the patient that the hospital cannot provide laundry or residential facilities and offered the patient information about local area shelters. Patient declined and responded by shoving a piece of cake in his mouth and wiping hands on his soiled shirt. Nurse X"

Needless to say...I don't think we got good patient satisfaction scores on this one. If we only had a shelter and plastic forks in the emergency department...

-ER Doc

Friday, August 28, 2009


Anonymous said...

I am a "green" R.N and just pulled a 36 hour shift in a very understaffed hospital. I was tired, emotionally spent and considering my career choice. After reading your blog and seeing the way you use humor to deal with the day to day happenings it rekindled my faith and reminded me that I wasn't alone. Thank you.


Re Anonymous: I really appreciate your comments. In medicine, we see a lot of sick things...and even more sad things. It is emotionally and physically grueling. This is especially true for the young docs (residents) and "green" nurses b/c we start out in understaffed and county type places. We really don't help people as much as we would like. There are many reasons for this. One is b/c of things that are out of our hands...like social and financial constraints or the resources available. Other reasons are as simple as the people who flood us who "aren't sick" and have secondary gain usually outnumber those that truly need help. That being said...in psychology humor is regarded as a mature defense mechanism. Sometimes the only way to get through a situation is to laugh at it. Humor as a defense mechanism takes feelings that are uncomfortable to talk about "straight up" and allows us to express them in ways that don't hurt others and at the same time help us. (Albeit I tend to do this sometimes in sick ways and go too far, but that's me and my problem, not most peoples.)

The patient you are referrering to was a good example of this. She was horribly sick in the head, smelled terrible, high maintenance, had been in the ER daily for 4 days, and drained ALL of our staff. She made me mad at her, mad at society, and just mad in general. I honestly didn't want to take care of her again. But I found something funny about it and knew I could share it with you guys. All of a sudden I wasn't as mad anymore.....

Thanks for your understanding anonymous.

-ER Doc

Wednesday, August 26, 2009

Chief Complaint: My Cat's Burning


Here is a direct copy of a chart I saw when looking up a patient's past history:

Chief Complaint:
Patient presents with
  • "My Cat's Burning"

HPI: Patient very difficult to interview and giving strange inappropriate responses to questions. Shouts, "AIDS!" long pause "Gonorrhea!" long pause "you want to see my penis?" long pause "My cat's burning and I need someone to look up under me." Finally interpreted to mean that she has burning when urinating for several days. Also complaining of vaginal pain and burning. Unsure if she's had any discharge. No abdominal pain, nausea, or vomiting.

-You can't make this stuff up!

-ER Doc

Friday, August 21, 2009

Misconceptions

It seems that some people out there have misconceptions of what psychiatrists can do. One of my attendings warned me about this last year, but now that I'm in clinics, I believe him. For some reason (probably Hollywood), a lot of the public believe that psychiatrists can read minds. Several recent events, including the gun post by my colleague, bring this to light.

I was at the mechanic the other day. I knew I needed some work done on my brakes, and I was getting a quote. Meanwhile, I made small talk with the brake guy while he was telling me all that I needed. Of course, I felt like he was trying to sell me more than I needed. I went with the minimum service. He said something like, "I bet that your psychiatry training helps you out with negotiations like this," implying that somehow I knew that he was trying to scam me. I did, but it had nothing to do with my psych training.

Another example is when someone recently mentioned that a way to keep guns out of the hands of suicidal/homocidal people is to make them undergo a psychiatric evaluation. Of course there would be a lot of logistic concerns (which psychiatrists would do it, who would pay, etc.) But what I want to make clear is that Psychiatrists can NOT read minds. I can only help you if you want help. If you are lying to me, maybe I can figure it out, but I probably can't. Sure, I may be able to tell if you're depressed or hearing voices. I can obviously tell if you're manic. But I can't tell if you're going to kill unless:
1. You tell me you're going to or
2. Your family/friends/police heard you make those statements or
3. Other aspects of your personal history (which you can lie about anyway) send up a red flag.

The third aspect of all this is what really hits home. I recently found out that the father of one of my daughter's classmates died. It made me confront my own mortality; I had seen him a few days before. He was fairly young and appeared happy and healthy. He did NOT look depressed. I figured he had a heart attack or car accident. Then I checked the medical examiner's website. He committed suicide. This was a person who on the surface had a loving family, a successful career, wealth, you name it. These are all protective factors for suicide that almost none of the patients that I treat at a county hospital possess. Who knows what his own personal demons were. But the point is: I'm sure nobody saw this coming.

I can't stop thinking about the hole that he left for his wife, kids, and friends. My initial sympathy turned to anger due to the selfishness of this action. That night, I told my family I loved all of them and promised to never do such a thing. It has been haunting me for a week now. Even though I didn't really know him, it touched me deeply. I am a mental health professional. I am supposed to help people like him.

Please, if you are having thoughts of suicide, or know someone who may be, please get them the help they need.

Sometimes they don't seek help on their own.

And don't expect a random psychiatrist walking down the street to read their mind.

Anyone can fake it.

Anyone can lie.

And I wouldn't know.

-Psych Doc

Thursday, August 20, 2009

Daddy's Little Girl??

Interesting shift in the "Children's" ER the other day.

Patient 1: Fifteen year old female presented with a sore throat. She also wanted a pregnancy test b/c she was late on her period. When I walked in the room....I saw a young female with tattoos on her neck and arms that said "bad ass." + nose and lip ring. Overall she was a sweet girl. She was concerned about being pregnant (which she wasn't...thank goodness). She did, though, have gonorrhea in her throat. The kicker...her t shirt said in big letters "Daddy's Little Girl." Having daughters myself, this saddened me. Let's just say we had a little heart to heart.

Patient 2: Fourteen year old female presented with abdominal pain. She was with her FOUR MONTH OLD child. She had been pregnant 2 times before, one resulting in an ectopic pregnancy. Again... this girl was fourteen years old!! She admitted to doing cocaine, marijuana, and "occasional" alcohol. Her last period was 4 months ago. Long story short...pregnancy test was positive, and she was transferred to the adult ER for another ectopic pregnancy workup. We consulted social work b/c she just didn't seem fit to be caring for her four month old.


-ER Doc

Monday, August 17, 2009

More Fun With Guns

Latest victim of a gun shot wound was a 46 year old male who was shot by his...FOUR YEAR OLD SON!!!

Story was that an 18 year old was teaching his 4 year old brother how to "target shoot" from the back of his pick up truck. When dad came outside, the 4 year old turned to show him what he could do and accidently fired a bullet through his dad's spleen and esophagus.

Who's to blame in this one??

-ER Doc

Sunday, August 16, 2009

Wall of Saddness


A 22 yo male arrived via EMS after being in a head on collision at highway speed. There were already 2 fatalities on the scene. According to the paramedics, the patient was found 30 feet away face down with agonal breathing. He was intubated at the scene and brought into the ER as a Level I trauma activation under the code name of Alpha. The patient was in bad shape. He had a large skull defect, cerebral spinal fluid coming out of his right ear, & unequal pupils. These are signs of SEVERE brain injury...but he was being kept alive by residual brain stem function and the ventilator.

After we stablized him, three sets of parents arrived and were put into the family waiting room. I called the chaplain because none of the parents knew about the fatalities. We had no way to identify our patient besides his personal belongings. Our patient, the last alive and barely holding on, had a unique belt on.

I went into the family room to talk to the parents. I said "I am sorry to break the bad news but we had two deaths at the scene. The one survivor is here and is in very critical condition."

All I could hear was screaming and sadness. One family member asked, "Who is the young man alive?" I said, "Sir, we have no way to identify him except that he has a unique belt on." Then one hopeful set of parents started crying and said "Does it have a nickname and silver trim?" I said, "Yes." The parents then shouted "That's out son!"

The other parents were crying in agony. It was probably the worst night of my medical career. Trying to maintain composureI said, "You can come back to see him in 5 minutes, but he is in critical conditon with a serious brain injury."
The parents soon came back and identified him. Unfortunately the CT Scan illustrated irreversible brain injury with a cervical spine fracture. Again, I had to break the sad news to the family.

With more strength and courage than I could ever imagine, the mother said "I want to donate his organs so someone else can live. He wouldn't want to live like this." I was shocked b/c so far in my career, I've seen most make end of life decisions that maintain someone on a ventilator, prolonging the inevitable. I made the call to the transplant center and he became an organ donor. I left the hospital that day with a wall around my heart to seperate my emotions from reality.

I eventually forgot about Alpha until I received a letter in the mail one day from the transplant center. It said the following: "Dear Dr. Sensitive, Although Alpha died on June 1, 2008, we were able to harvest his liver, eyes, kidneys, & tendons. Because of your referral, 12 people were either saved or helped by Alpha's tissues. We are extremely grateful, and on behalf of our patients we thank you."

My wall came down and my emotions came back. Thus far I dealt with that night by building a wall, but now Alpha was a real person to me. I went home that night and googled his name. I found out that he was 2 minutes from his house, his girlfriend was following behind him, and she saw the entire accident. I discovered that he had a My Space Page and looked through it. It was strange to see him as a person, and I was saddened that his life was cut so short. However, through his death and his courageous mother, he saved the lives of 12 others.

-Doc Sensitive

Friday, August 14, 2009

Fact Check

Nice article I found on misconceptions with the Health Care bill. Link is provided if you are interested.

http://www.newsweek.com/id/211981?GT1=43002

-ER Doc

Monday, August 10, 2009

Allergies

Below is a copy of a "allergy list" from a recent patient, with only the hospital name taken out. It goes with one of my rules that "the more allergies the patient has the less likely the said patient is sick. " Also, the spelling is priceless. The only pain med this guy wasn't allergic to was demerol. Uh huh....




-ER Doc

Healthcare Reform and a Scary Fact

We haven't broached the politics subject yet....but figured now is as good of a time as any.

The US Securities and Exchange Commission Filings reported that profits for the 10 largest insurance companies increased from 2.4 billion to 12.7 billion from 2000-2007, while the number of uninsured increased 19%. Kind of hard to explain that one. And we are supposed to believe the rhetoric that if a public option exists the private insurers wont survive. Come on. Not to mention that the average salary for the CEOs of these insurance companies is 11.4 million!

Here is a link from a fellow blogger that has lots of the most up to date information and videos on the health care debate. View if your interested.


-ER Doc

Wednesday, August 5, 2009

Tough Love


A 32 yo male arrived via EMS in full cardiac arrest without a pulse. Despite our best efforts, and despite us coding him for over an hour, we pronounced him dead in the wee hours of the morning.

We all scratched our heads because this young man looked healthy, clean cut, and didn't appear to be an IV drug user. We went to the family waiting room and broke the bad news. It was tragic to all, including the nurses and doctors because its always hard to have a young person die.

Later in the evening, the hospital chaplin spoke with the girlfriend regarding their last moments. The girlfriend stated : "He had been looking at girls all night long and pissing me off. When we went to leave the bar he did it again, and I punched him in the chest and he took two steps and fell over."

When I heard the story I was shocked because I didn't believe someone could die from one punch! After some research, however, the condition is called "commotio cordis," results in V-tach, and can cause immediate death. Everyone should think twice before checking out girls in a bar!!!!

-Doc Sensitive

Monday, August 3, 2009

A Strange Case of Indigestion

This is a case that goes back to my intern year, where a portion of my Internal Medicine rotations were at an outpatient clinic. A 60-year old male came in for a routine checkup. He had most of the usual problems: hypertension, GERD, T2DM, etc. It seemed like a routine med-refill visit, until he asked, "Doc, I think I need some of that Mylanta."

Like a good little intern, I had already reviewed his med list. This seemed easy enough. "Sir, you're already prescribed Nexium. That should take care of everything."

"But I really think I need Mylanta," he said.

"Okay, if you really want it, I can't stop you. If your reflux acts up, feel free to buy some over the counter," I replied.

"But Doc, you don't understand. I have a new lady friend who's 20 years younger than me. I don't have the ability to give it to her as much as she wants."

"Oh, you must mean Viagra."

- Psych Doc

Sunday, August 2, 2009

Rural Medicine

It's my 3rd year of residency. One of the perks about 3rd year is you are allowed to moonlight. Moonlighting is basically working outside of your residency part time and earning some semi-real cash. I actually started the last few months of my 2nd year at an urgent care....but this weekend I started at an Emergency Department in a rural hospital. The shifts are generally 24-48 hours b/c you can get some sleep since the volume is low at night. I was the only doc in the whole hospital all weekend...kinda scary

I'm a city guy...so this weekend was kind of an eye opener. I enjoyed the greenery on my drive in with all the cows and horses in the pasture. I quickly learned that not having a truck made me out of place....and the "Yes We Can" Obama sticker didn't go over well. The patients were generally very friendly and nice....which
was a pleasant change.

One patient was a bipolar manic gentleman off his meds. In the city, this kind of case is very easy to admit. In the country, it was a big ordeal... even involving the "sheriff." This guy was very agitated and wanted to smoke. The nurses refused to let him go outside since it was a non smoking hospital and he was under a medical warrant. I felt bad for him and wanted to keep him calm, so I volunteered to break the rules and accompany him while he smoked outside. He sat on the curb....but didn't pull out a pack of cigarettes. Instead he pulled out a bag of home grown green stuff and a white wrap. He rolled it and smoked a joint right in front of me! For some reason I was shocked weed is smoked in rural communities.

Next an old man came in after hitting his head. The story behind it was much more interesting: He was getting up in the middle of the night to get a drink when he walked into his "hanging bull skull!" Yes...a skull of a bull hanging in the living room. He passed out. When he woke up he tried to wake up his son to take him to the hospital. He kept banging on his son's locked door...but he couldn't get him to wake up. So he decided to go outside with his shotgun and fire it outside his son's bedroom window. That seemed to wake him up!

Speaking of guns....we got a heads up call from the local authorities that some kids were driving up and down their street firing a rifle repeatedly. They wanted us to know just in case someone got hurt. What's with country folk and guns? I've never even held a gun.

Overall....I had fun. I surprisingly like the outskirts and look forward to what's next. Only in the country.....

-ER Doc

Monday, July 27, 2009

Rabbit


As a 3rd year medical student I was learning how to properly insert Foley catheters. I was green and really didn't pay close attention during the teaching labs because we used fake penis's and vaginas.

One of my first rotations as a 3rd year was in psychiatry, and a patient developed urinary retention from her psychiatric medications and needed a Foley. I was very excited because this was my first "live patient." I entered the room and saw a 40 something patient holding a stuffed rabbit, petting it, and talking to it. So I stepped up to the patient, and the nurse handed me the kit. I placed the lube on the end of the Foley and spread the vaginal lips and pushed the foley into the "proper hole." I continued pressing and then used my fingers to get a better look. As I continued using my fingers, I noticed the patient moaning....so thought I was hurting her. I continued trying to insert the foley but kept finding resistance. As I pressed, the patient moaned to her rabbit. The nurses started laughing. I continued to struggle but finally asked the nurses, "Okay, this is my first Foley... why is this not going in?" The nurse said, "Student Doctor Sensitive, you are rubbing her clitoris and she seems to be enjoying it." The nurse then grabbed maneuvered hand to the urethra, and it went in without a problem. It was embarrassing for inadvertentlystroking her rabbit....but at least I made a patient happy for once!

-Doc Sensitive

Tuesday, July 21, 2009

Wooo Wooo Rocket Lube



Monday morning....9 AM. Call from EMS was they were en route with a 33 year old male who was uncontrollable. When they arrived, there were 4 police officers holding this man down. He was shaped average, white, and wearing only boxers. His eyes were wide open and he kept screaming "Wooo, Wooo Rocket Lube" as the cops kept trying to hold him down.

Here is what EMS said. "We got called about an unruly man in his apartment. The call was from a man he met an hour before on the internet. When the man showed up at his apartment to do whatever they were going to do, he said his new friend was flipping out. When we showed up, he was jumping uncontrollably on the bed screaming like he is now. There were candles lit and bottles of Rocket Lube were everywhere."

We started bolusing the guy with ativan to try an calm him down. He had 4 cops and 4 techs all holding him down, and restraints on every extremity. It became too much. After 50 mg of ativan he was still uncontrollable, so we induced a medical coma and intubated him. After he was intubated the nurses started to put a foley in. When they removed his boxers...the man was wearing 2 rubber cock rings!

Monday morning mind you....

So ten minutes later this guy was up bucking the vent and almost breaking through the restraints. Long story short...to keep him sedated he ended up needing a propofol drip at 100mcg/min, ativan 40mg/hr, and fentanyl 200mcg/hr. This is an unbelievable amount of drugs just to keep someone sedated. A normal person would die from a fraction of this. I was astonished. His drug scream was + for Methamphetamines. I've never seen a meth case like that before. Hope I don't again.

Monday morning....unbelievable.

-ER Doc

Sunday, July 19, 2009

Deja Vu

Yesterday I had a guy come in who tried to kill himself by an attempted overdose. Run of the mill for our ER....except his name was Michael Jackson and he was 50 years old!! It was creepy seeing that on the board. Even more ironic....he was white too? This guys drug of choice was seroquel (antipyschotic), though. His OD was non toxic and I eventually transferred him to psych.

I had another lady come in by ambulance about 50 years old. Her goatee was thicker than mine. I try to see the ambulance patients right away to help the nurse decide if they need a bed or can go to the waiting room. This lady was freaking out. Screaming to me she needed her pants off. I asked her why, and she said b/c of all the itching in her legs, vagina, butt, and stomach. Then she told me how the worms were crawling out of her and started screaming. She kept trying to get her clothes off...which would have been devastating to everyone around. She had many other weird complaints, like discharge from her anus.

Being in such a big hospital....we have a separate ER for female (ob/gyn) issues. I begged the paramedics to take her to that section and only to mention the vag itching as the chief complaint. It was my 11th hour and I couldn't hand that kind of crazy right then. About 20 minutes later the female ER called to send her to us. They said they checked her out and the itching was from the patient pooping all over herself. I accepted her...then assigned her to the intern. She eventually ended up in psych as well.

Disaster averted!

-ER Doc

Tuesday, July 14, 2009

Squatting

I do some moonlighting for a local urgent care group. Here is an email that was sent out recently regarding a patient that had been making his way around the clinics. Goes to show ya even in the private sector you the weirdos will find you...

"This patient has been to several clinics requesting physicals from female doctors and midlevels. Specifically, he is requesting rectal exams while squatting. Dr. X has confirmed the phone number he gave us is not a working number. Please do not examine him."


Here's to you...Mr. Squatting while using your insurance copay to get off man.

-ER Doc


Friday, July 10, 2009

Clinic Fun



Okay, I know I've been slacking off lately. Maybe it's because I'm in clinic now, so there's not quite as many crazy ER stories. In clinic, the craziness and irrationality is still present, but on a smaller scale. Just thought I would provide some anecdotes from one week of working in an outpatient psych clinic for the county.

One day a week is child/adolescent clinic. Every other patient is a photocopy of this one. 7-10 year old boy comes in with mom. Mom complains that kid is acting up in school, getting into fights, suspended, etc. At home, he throws telephones and potted plants while calling mom the "C"- word. Dad has been in prison all the kids life. Mom never re-married but has had some boyfriends. Mom wants to throw some mind - altering drugs down the kid's throat and hope everything gets better.

Last week, I'm seeing a followup. 50-ish white female with anxiety after a near fatal car wreck that put her in a coma for a few weeks. She had on a T-shirt that said "pimpjuice" and that's all I could think of during the entire visit. I didn't know until today when I was looking for a graphic that it is an energy drink, a Nelly song, etc. If you have anxiety/depression and you think your life sucks, then take life seriously and throw away the dumb t-shirts. Just my opinion.

Yesterday, I was reading through a lady's new-patient questionnaire. She mentioned that she had trouble controlling her "dietbetes". I asked her what that meant and she said, "It's because of the insulin. If I don't eat, I feel bad. So I have to eat more than I should so the insulin doesn't make me crash. I've gained 50 pounds since I got diabetes." I guess she never thought of just taking less insulin. Or she has a crappy doctor (in addition to me).

Also yesterday, a 400+ pound guy comes in for a pain management referral. Basically the pain management docs want a psychiatrist's "street smart" opinion as to whether the person might have potential for narcotic abuse or addiction. On this guy's self-reported review of systems, he wrote down "can't masturbate". I understand that this is a quality of life issue but I asked what that has to do with chronic pain and he said, "Oh nothing to do with pain, I just can't reach down there anymore. Also, I can't wipe my own ass." The guy lives with his 80 year old mother and no one else. I did not ask him who actually does the wiping.

-Psych Doc