Wednesday, April 29, 2009

The Butterfly

All....please welcome a new member to our blog. "Doc Sensitive" is one of the most perturbed residents I have ever met. He has enjoyed the blog...and would like to share a few stories of his own. Here is his first post:

A 38 yo male arrived via ambulance to one of the trauma bays after being hit by a car while walking across the street. When I arrived to evaluate the patient, he stunk of very cheap beer and was screaming in agonizing pain.

Me: "Sir, what happened today?."

Patient: "Well, doc, I was walking across the street with my forty ounce tucked under my jacket and a f***ing car hit me in my a**! Then I flew across the street like a butterfly and landed on my arm and leg!" Now my arm is f**king hurting and my forty ounce is smashed all over my jacket."

Me: "Sir looks like your not much of a butterfly!"

Patient and nurses laughed, and he ended up having a broken arm and pelvis but recovered without any complications....except for a brief bout of alcohol withdraw.

-Doc Sensitive

Twilight Zone

In the psych ER, most of the patients are kept in a large open room so they can be monitored. There are a few beds in private rooms that are reserved for people that are medically ill (i.e. with foleys or ostomies, see prior posts) or sometimes for patients who are extremely loud and disruptive. These rooms are, for the most part, vacant.

When you walk into the unit, you have to pass right by these private rooms. I showed up for call one night and heard somebody singing that "Day-O" banana boat song. I went to get some coffee before starting the shift then walked onto the unit. "Day-O" had stopped by now. I walked past the first room, and I heard this loud bark that scared the crap out of me. It wasn't the volume that startled me, but the direction it came from-it was low to the ground, just like a Rottweiler would be.

I looked over my shoulder, and things just started getting weirder. There was a huge black woman with no legs, who still probably weighed over 300 pounds. She was scooting around on the floor, a la Eddie Murphy on Trading Places, except this lady didn't have a skateboard or sunglasses. To make matters worse, she was obviously on her period, and she was leaving a brownish-red trail like breadcrumbs so you could see everywhere she's been. It reminded me of when your dog has worms and drags his dirty ass all over your carpet.

As soon as we made eye contact, she said "How you doin', Boo?" I walked away to hear her seranading me with another round of "Day-o."

-Psych Doc

p.s. "Shoo, Shoo, retarded flu"

Monday, April 27, 2009

What do Abilify, Tylenol, and Swine Flu have in common? really....but they had to do with a few of my patient's today in the pediatric ICU

1st patient was a 2 year old who got into his ten year old brothers abilify (antipsychotic). First of all....I am pretty much against ten year olds being on those kind of meds...but that's really Psych Doc's field so my opinion shouldn't be taken too seriously. Anyways...he took about 25 tabs of the antipsychotic. He will be really sleepy for a few days, but should be ok.

2nd was a 17 year old female who just gave birth to her first child 3 days prior. Mix that with some post partum depression, and you have an extra strength tylenol overdose. 20 tabs according to her. I was biased when I heard 20 tabs...and figured the toxicity wouldn't be bad. I was dead wrong. Fulminant liver failure soon took over! Hopefully with treatment we intervened in time.

3rd was an 11 month old transferred from another hospital intubated from respiratory distress. Story was he was fine yesterday, then woke up this morning with a high fever and trouble breathing (no past med history). Went to the hospital and failed breathing treatments, got worse, and ended up being intubated. They did a viral test...and he tested positive for influenza A. I haven't seen influenza A be positive for there a good chance this could be Swine, but still unclear. Cultures were sent to the CDC, and the news was not notified so you aren't seeing us on the news yet! I hope those isolation gowns we wear that you can pretty much see through can block transmission of the germs...

-ER Doc

Saturday, April 25, 2009

Stupid phone call of the week.

Last night, a woman called the psychiatric ER, saying "My 14 year old grandson is walking down the street with a noose around his neck and pointing a loaded rifle at little kids. Do you think I should call the police?"

Huh, ya think?

Psych doc

Friday, April 24, 2009

Chew Your Food! A recent patient of mine was a 14 year old boy not breathing after choking on....a hot dog. Parents said he has always had a problem with eating his food too fast. They had told him that day to slow down on his hot dogs. He got tired of listening to it, so he took his food to his room. They went to check on him later on...and he was on the floor blue and apneic.

He was intubated at arrival to the ER. Poor kid ended up needing a bronchoscopy to remove the rest of the hot dog, and his lungs suffered from florid pulmonary edema. Thankfully in the end he recovered and didn't have any neurovascular deficits....which shocked me.

For all the young ones out there....moral of the story is to chew your food. Or as my 7 year said when I told her about this..."you should always listen to your parents."

-ER Doc

Wednesday, April 22, 2009

Medical Complication of the week

I recently did a psychiatric consult for depression on the medical floor. The patient was a late-30s male, weighing in at around 350 lbs. He has diabetes and heart failure. Been hospitalized numerous times in the past few months because of various infections, which have required partial foot amputations and IV antibiotics.

The guy actually had a job (an oddity for the county hospital) up until January when all this started. He let his brother move into his apartment to help take care of him. After his last hospitalization, he was ready to go home but needed several more days of IV antibiotics. They arranged for a home health nurse to go to his house daily to give his dose.

The guy came back now with a bad GI infection. Again, several more days in the hospital and he's ready to go home with IV antibiotics so they called for a Home Health consult. The evaluation from Home health said: "Home health cannot assist this patient at this time. 2 weeks ago, we went to his home to begin his treatment. We knocked on the door, and his brother said, 'Come back later, I'm too busy using drugs right now.'"

Psych doc

Letter To The Nurse

In a LARGE county hospital....wait times can be very long. Many times patients will be brought from the waiting room to the actual department and still n0t be seen for hours. Other times, they might be worked up but then not see their doc or nurse again for a LONG time. We try not to do this, but sometimes resources are strapped and we are bursting at the seems....and it just happens. Here is a letter left behind from one of my colleagues patients. Letter is transmitted word for word.

"To the nurse: I had to go. I am 6 hours past my meds schedule. Doc said not a heart attack or stroke! I removed my IV and took off my leads. Thanks so much for being so kind. Please mail my discharge papers. Thanks, ____"

If only all patients could be this cool.

-ER Doc

Monday, April 20, 2009

"My Feet Are Bleeding From The Inside"

A middle aged black women came into the ER at about 4 am on a Wednesday night. Her chief complaint was "my feet are bleeding from the inside." I looked through her medical history, and she had been to the ER four times in the last week for the same thing.... so the "ok this lady is crazy" thought was going through my head.

When I went to go see her, she was a very pleasant but concerned smelly patient. She stated that her feet were bleeding from the inside. She knew this because they were getting darker and darker. She admitted to being seen multiple times for this....but no one had figured it out. Her symptom was accompanied with foot pain if standing too long at work.

I examined her feet. They were indeed very dark. So were her sandals though. So...being the astute young physician I am....I went to get some magic solution to get the "blood off." I grabbed some alcohol pads, and showed the patient that when I cleaned her feet with alcohol, her feet were no longer dark. She didn't quite understand this, so I had to tell her kinda bluntly that her feet were just dirty...not bleeding. After much teaching, I thought she understood. When my attending saw her was apparent that I didn't do much good.

I couldn't find a billing code for dirty feet. I think we should make one though b/c we see a lot of this. I also wish we could bill for being dumb.

-ER Doc

Friday, April 17, 2009

Father Of The Year

During rounds on the Pediatric Intensive Care Unit (PICU), I witnessed a surprising site. We were going to see a 4 month old on the ventilator for a bad case of RSV. Usually the long sliding glass doors to the room are open so the nurses can view the patients and their monitors. On this day, the door was closed.

2 load knocks and we slid the door open like usual. Leaning over the crib was the dad's big bouncy girlfriend....naked. Behind her was the patients dad, hammering his girlfriend from behind. Both were sooo in the moment they hadn't heard the knocking our notice us entering. Our attending loudly said "we will be back when you finish," and we took off....scarred for life.

What is even sicker is the room has a long couch against the wall. Why bend your women over the crib with you baby in it on the vent when you could at least use the couch.

-ER Doc

Monday, April 13, 2009

Dream Interpretation

As a new segment, Psych Doc will be interpreting some of my (ER Doc's) weird dreams. Should be entertaining to hear how screwed up I am.

Dream #1: Psych Doc....recently I had a dream that struck me as weird. I was in a sports bar hanging out with midgets. We were watching lacrosse (which I have never watched or played in my life). The lacrosse teams had averaged size adults and midgets on the same teams playing one another. Why would I dream about things so random and that I know so little about....the midgets and lacrosse?

-ER Doc

Interpretation #1: Well, ER Doc, it sounds like lacrosse is a symbol for something else that recently occurred in your life or a place you visited (that you have never experienced before). The midgets probably represent the types of people that you encountered in this new, strange place. I'm sure you respect little people, buy you can't help be a little bit curious about their lifestyles. Little people have been considered mysterious for thousands of years throughout literature, for their magical powers. They have led people to pots of gold and destroyed magical rings in the fires of Mount Doom.

I think that most likely you recently visited a gay bar. It's something you've never experienced, but you know it's popular on the East coast and there is potential for physical activity with other men (all indicative of lacrosse). The midgets represent all the colorful characters there, that you have only dreamed about in fantasy books. You were always curious about them, but now they are both fascinating and frightening at the same time. The average-sized adults represent those men, like yourself, who are curious or "on the down-low."

This is a very common dream, reportedly experienced by celebrities such as Clay Aiken.

Just remember that gay sex, just like lacrosse, requires all responsible participants to wear protective equipment.

Disclaimer: No offense is intended toward Little People. Please do not bombard with negative comments or send Matt Roloff to my house.
All insults toward lacrosse and Clay Aiken are fully intended.

-Psych Doc

Wednesday, April 8, 2009

Nursing Home Nightmare

One frequent presentation to the psychiatric ER is aggression in an elderly patient. Usually, a nursing home gets tired of dealing with a demented patient, and somehow they are able to send them to psychiatry. Usually there is an allegation of "aggression" or some such. More likely, they just think our social workers can work miracles and find another nursing home overnight.

Lucky for them, there is a psych ER in this county. Imagine your elderly loved one being sent by EMS to a unit where half the patients are depressed, manic, or psychotic, and the other half high on cocaine or meth.

A recent incident was especially troubling, though not entirely uncommon. First, I will try to capture the phone call between the Nursing Home (NH) and social worker (SW).

NH: Do you guys treat aggressive nursing home patients?
SW: Yes.
NH: Can you adjust their meds so they don't hurt our staff?
SW: Yes.
NH: We have an 80-year old female with dementia that is "being aggressive". We'd like to send her there.
NH: By the way, her son wants her placed in another nursing home. Can you assist with that?
SW: Uh, no. If that's really why you want her to come here, then no, we can't accept this patient.
NH: Okay, Bye.

Whaddya know, 5 minutes later the patient shows up with EMS. Of course, the NH had loaded her up and called for administrative approval while she was in transit. This was a classic dump at 4:30 on Friday afternoon. This means the patient gets to stay all weekend, because there is no social worker on weekends.

When the patient arrived, her condition was terrible. The nurse who triaged her had tears in her eyes. I knew something was up, so I went to see her immediately. Elderly, well dressed lady in a wheelchair, pleasant, but demented. The medial (inside) part of both elbows had ulcers from where they rested on the wheelchair arms. There's no way she's "being aggressive"- she couldn't even lift her arms off the wheelchair armrests! Her toes were stuck together, it had been so long since she was given a bath. There were pieces of gauze on some open wounds on her shins, but the gauze had been there so long that the scabs had enmeshed the gauze and you couldn't pull it off without causing severe bleeding.

The patient was admitted to the medical floor for treatment of multiple metabolic problems as well as those listed above. The NH was reported to the appropriate authorities.

I didn't tell this story to gross anybody out. I've been struggling with this for a few weeks. However, I realized there are 2 important reasons for this post. First, before you place a loved one in a nursing home, check the place out. Visit, get references, do all you can to investigate.

The second reason is, while we do tell funny stories on our blog, our intent is also to give some insight into healthcare in this country as well as into the lives of doctors. Some people have left comments below, ridiculing psychiatrists and ER. The thing is, the funny stories are easy to share and make this lifestyle easier to bear. For every story I share that involves a funny moment, I have ten stories that I could share about the pain that I experience along with my patients and their families. And I love all of them.

Psych doc

Fun With....Colostomy Bags???

It is hard to freak me out....but I have to admit this one does it. A man in his 50's with HIV came in b/c of pain around his colostomy bag. For those of you that don't know, some patients have to have a surgery where their intestines are brought to the outside of the stomach wall and left open to poop on the outside of the abdomen into a bag b/c of a problem more distal in their intestines.

Figured it would be easy....go take a look at the bag and the surrounding bag and see if there are any erosions or bleeding around it. I was surprised by what I found. There were red, raised, ulcerated, and friable lesions on the skin around the whole and coming from the intestines going into the body. These looked just like....HERPES! I thought no way this is possible. So took a quick swab and sent it for a test. Sure came back as herpes. When I told the gentleman about it, he wasn't very surprised. His explanation was pretty straight forward: Men give him money, and in return he takes off the bag and lets them have sex with his colostomy hole and intestines!!

Horrible, disgusting, and should be against the law with his HIV status.

Friday, April 3, 2009

Cock Rings

40 year old man came in by EMS with chief complaint of "cock ring being stuck." He was in a ton of distress. This gentleman had put his penis and testicles through the cock ring. Of course....he said it was his girlfriends idea. They were being intimate, and at some point they had a fight and he didn't get to finish. That's when he noticed it was stuck.

This was no regular cock ring, if there is suck a thing. This thing was huge, and made of metal. It had been stuck for 13 HOURS before he called EMS. He had been trying to saw it off all day to avoid going to the ER. So all day his penis and testicles had been swelling and getting larger and larger. This guy was in a TON of distress. I have never seen testicles so swollen. They were probably the size of cantaloupes. I really thought he would loose function down there.

So we called maintenance and got a saw. We put some plastic between his testicles and the ring to avoid burning, and started sawing. This was some heavy duty metal. It was quite a scene. I was sawing, and about 3 nurses were fanning him down with water, holding his balls, pouring cold water on his balls, etc.

After about 2 hours of trying in the ER, this poor pervert tired out from all the pain and stress. He ended up going to emergency surgery b/c he couldn't take it anymore. They put him down and used a heavy duty saw they had in the OR, and afterwards he did quiet well.

I don't know much about cock rings, but if they make plastic ones it might be a good idea to go with that over metal.

-ER Doc