NPO

NPO stands for "nothing by mouth." Patients are kept NPO before a procedure or if they are very sick incase they are at risk of aspirating their food.

A man came in around midnight with a chief complaint of "I need a chest tube." I asked him how he knew this. He said that he was in a fight that day, and has had bad chest pain and shortness of breath. He went to an urgent care at 10 pm, and they diagnosed him with a pneumothorax (hole in lung). They told him that he needed to go to our trauma hospital to get a tube in his chest to reexpand the lung. I asked him what the delay was....what he was doing for the last 3 hours. He said he knew we weren't going to let him eat before the chest tube, so he went out to have a nice big steak and a few beers before the procedure!

This reminded my attending of an even better story. A man walked into the ER holding his abdomen. It was quickly identified that he had been shot in the stomach. He gave no details, and was taken to the OR emergently. In the OR, they found a hole in his stomach. Visible in the hole was fresh chicken nuggets and fries! When the surgeon asked him about the nuggets post op, the patient said "last time I got shot you guys didn't let me eat for days, so I went to McDonald's before coming here." It takes a tough, dumb mo fo to head to micky dee's being shot in the abdomen.

-ER Doc

Racial Sensitivity

I know we've posted about controversial subjects before, specifically Race/ethnicity. Well, here we go again. I can't recall if I've brought this up before on this forum or with colleagues, but either way, this is another example of how people can get very racially inappropriate when they are MANIC.

A 40-ish Black female was brought in by the police, because she walked 10 miles to attack her ex-husband's new wife with a weed-eater. This lady was extremely agitated from the minute she arrived, pacing back and forth and being rude. The first thing she told me was how she was going to sue the police. "Usually they ask me if I want the handcuffs in the front or in the back, but this cop put them in back without asking. Then he put me in the back of the car and wouldn't turn on the A/C. My hair was sweatin' and now it's gettin' all nappy. Just look at it."

"Ma'am, I'm sorry about that, but I don't think there's much I can do about that right now."

"Yes there is. Get me a G-dd-mn hairdresser right now!"

"Sorry, this is a hospital, not the beauty shop. What else might I be able to help you with?"

"I need some more food." Her dinner tray was barren. She had eaten everything.

"Well, we will serve some snacks here in a couple of hours."

"I didn't even like that dinner. I can't eat this chicken-fried bullsh!t that you all serve up in here. All I eat is catfish!"

This continued for a few more minutes until she ran to the phone and called 911 to place me under citizen's arrest.

-Psych Doc

Open Modeling Position- Requires large prostate

As a second year medical student, our medical school paid homeless drunks for allowing students to practice various skills. These skills included pelvic exams, rectal exams, eye exams, & history and physicals. On this particular day, I was extremely nervous b/c we were all learning how to perform rectal exams. They split the rectals into groups of five (total of 80 plus students). Each group performed their first rectal on one patient. The patient recieved 100 dollars per 5 rectals or 20 bucks each finger. Many of these patients smelled of alcohol, had no teeth, had mental illnesses, and were addicted to IV drugs. In my eyes, it was very strange and messed up that we paid the same people each year so they could go buy booze and drugs.

Our patient was a 58 year old male with no teeth and suffered from Hepatitis C. He was a perfect patient b/c he had an enlarged prostate (I assume this is why he was selected over all the other candidates- still wonder if they had tryouts). We all lined up outside the door, and the doctor came out of the room to give us instructions.

He said, "I recommend double gloving on this guy b/c he's got Hep C. When you come in, get some lube on your finger and insert. Then, push deeper to feel the prostate. Sweep around like this (just imagine a doctor pointing with his index finger and then doing a spin with the finger as a pivot) and get a good feel of the prostate. Any questions?"

We were silent as we pondered on how to rotate around our finger to sweep the prostate. One after the other, my fellow medical students went in the room and quickly came out 5 minutes later with their heads down to the floor. So, it was my turn- I knocked on the door (like he didn't know I was coming). I said "Hello sir, it's good to meet you. I'm Student Doctor Sensitive and here to do your rectal!" The homeless guy just got a huge smile on his face and turned around and dropped his smelly,dirty pants onto the floor. I confidently double gloved (just in case of the Hep C) and put lube on. I spread his butt cheeks and pushed hard like the doctor instructed me to and then spun around my finger to feel something. I'm not sure what I felt b/c I was trying to hurry.

As I was taking my finger out of his rectum, Mr. Homeless turned around and smiled sheepishly with his missing, broken teeth and said "I like you, you are charismatic!" At that point, I became alarmed b/c he enjoyed these rectals a little too much. I quickly removed my soiled finger, tossed the glove in the trash, and walked with my head down (as the two before me had done). I still wonder if Mr. Homeless said the same thing to the others that day, but I am pretty sure he still lines up for his 100 bucks of satisfaction. Still gives me chills.

-Doc Sensitive

Memorial Day Nightmare

The above is a real pic of one of our trauma bays from last night...

I don't know who I pissed off to work trauma on Memorial Day. Tons and tons of BAD accidents, the vast majority of which were preventable. As always...drugs and alcohol were the problem.

The day started out with a motorcycle accident at 2pm. The man was already drunk, got on his bike without a helmet, and didn't even make it out of the parking lot before he drove into a parked car at close to full speed. He had a good sized head bleed. What really pisses me off is that he had his 4 year old daughter in the apartment with his drunk girlfriend.

Then we had an ATV accident that brought in 2 sisters and their 2 kids, all of whom were on the ATV. Bad injuries. The worst part is one of the adults was 4 months pregnant. Who the hell gets on a 4 wheeler pregnant!

When it rains it pours. Overnight about 6 motorcylce collisions, 4 ATV wrecks, 1 diving accident, 12 car accidents, 2 assaults, and 1 shotgun to head. They ALL had either drugs or alcohol on board...except for the 2 people that died. It's amazing...the trolls always live and the innocent die. One female and friend lost control of her car in the rain and smashed into a pillar. The blunt trauma left them without a chance. Their family lived out of state, so I had to tell two different mothers about their childs death over the phone. The other near death was a man smashed by a bus on his way to work. 2 chest tubes and 18 units of blood later...I had to make the dreaded phone calls to family about the accident.

Appreciate your kids today...

-ER Doc

The Pain of Cheating

A nice young guy came in with a complaint of foot pain after being run over by a car. The story was pretty interesting. He couldn't find his live-in girlfriend. After a few hours, he decided to go to her uncle's house where she hangs out a lot. The uncle wasn't there, but her car was. When he went into the bedroom he found her in bed with another man! Of course she tried to blame it on him. They argued in the lawn, and she decided to leave. She got in her car, and as he tried to chase her down she decided to just run over him! Besides the broken heart, he just suffered a broken foot. Worst part is that he has her name tattooed over his chest. We tried to come up with ways to transform the tattoo into another word....but "Maria" doesn't leave much to work with.

My attending had a similar story....but I think way better. A 30 something year old man walked into the bathroom and found his girlfriend getting it on hot and heavy with another WOMAN in the shower. He was distraught and decided to jump out of the window of his 2nd story apartment. When he arrived to the ER he was asked if he knew where he was. He replied, "Yeah, where people who do stupid shit like I just did end up!"

My attending said he wanted to give him an extra point on his GCS score for such a clever response. Personally I think he should loose a man card for getting upset at finding his girlfriend with another woman. That's most men's dream. He should have joined them. He would have spared all the broken bones for one happy bone.

-ER Doc

Dream Interpretation: Elevator

Dear Psych Doc,

I have a recurring dream for years that I hope you can help me with. In the dream, I am riding an elevator in a tall building. I am going up...and the elevator starts to break. Instead of falling, though, it starts going up uncontrollably. It goes faster and faster till it explodes out of the roof (kind of like in the original Willy Wonka and the Chocolate Factory). When I am in mid air, I awaken sitting up in my bed screaming and sweating. I am afraid of heights...could this have anything to do with the dream?

-ER Doc

Dear ER Doc,

I'm sorry to tell you that fear of heights has nothing to do with it. Your brain is too smart to let you think it's something that simple that is causing your anxiety.

Theory #1: In Freudian symbolism, the elevator "shaft" represents your penis. You feel the elevator car (your man-seed) starting to break and rumble. After reaching a certain threshold (known to men as 'The Point of No Return'), the load is unstoppable. It shoots out the top of the building, making your pajama bottoms all sticky.

Cure #1: The way to prevent this is to keep your pipes clean. It's like you have Augustus Gloop stuck in there and you've gotta keep it moving. Just tell some nurses you have an Everlasting Gobstopper that needs licked, and you will prevent all future nighttime desecration of your undergarments.

Theory #2: You have a gay man crush on Gene Wilder and you want to be alone in a small glass room with a guy who dresses fruity and your old homeless granddad.

Cure #2: See Cure #1.

-Psych Doc

Sharpest Patient

A 28 yo male arrived to the ER on a stretcher after being found in the front lawn of the hospital seizing uncontrollably and unresponsive. I arrived into the room as the nurses were removing all his clothing. First, they took off his pants and underwear. Then they proceeded to remove his shirt.

Low and behold a surprise for all of us...in black sharpie ink, the following was on his chest: "Name is ______. Seizures. DOB 10/25/80. Takes Dilantin 100mg 3x a day. Haven't missed any meds. No drugs or alcohol. Call xxx-xxx-xxxx for additional info. Thanks."

Since I work at a large public hospital, it looked like a picasso painting. Wow! Finally a patient with some intelligence. Thanks to the magic sharpie, we called his wife from the number written on his chest and found out that he has uncontrollable seizures refractory to all current medical care. He took a train to our hospital b/c an outside hospital told him that we could do something for him, but seized before making it inside! He got admitted and hopefully was treated so that he can finally take a shower to wipe off his chest!

-Doc Sensitive

MORE Rectal Fun

A 78 year old man came into the ER because a flashlight was lodged in his rectum. He said he was working on a ladder...naked... and fell to the floor. The flashlight apparently was upright and found itself into his butt.

I have gotten to the point to were I just go with the story and don't ask as too many questions. It's not worth it to fight for the real deal if it is not going to change the outcome. But the surgeons wanted the truth. They told him there was no way he was naked working on a ladder and fell onto a flashlight. Then they (inappropriately) told him they would not remove the flashlight without the truth.

Reluctantly...the patient replied "Look doc...I am a lonely old man." That was enough to satisfy the a** surgeons.

Patient and flashlight recovered well.

-Doc Sensitive

More Trauma

A 17 year old boy was transferred to us after an attempted suicide. Family said he was outside playing football with his friends. He came home....was drunk...told everyone he knew they didn't want him alive...and went into his parents bedroom. Next thing they heard was one shot of a rifle. He put the riffle under his chin and tried to kill himself.

He didn't die...but he pretty much blew off his face. It was one of the most unbelievable sights I have ever seen...and I mean that in a bad way. He aimed the gun up instead of back, and the riffle destroyed his chin, mouth, facial bones, eyes, forehead, etc. Amazingly he was intubated at the other hospital. I don't know how. You could see parts of his brain from the open bony defects. His face was basically a big crater gushing blood. Neurologically, he was intact. When sedation would wear off, he would reach for his tubes and move his arms. Cat scan just showed a small bleed in his brain from the skull fragments.

There are so many points we could discuss here. What could drive a young normal kid to this??? Why was he drinking??? And of course...gun control! I will let you guys discuss these in the comment section. Right now I can't. After spending hours trying to tie off all the bleeding vessels in his crater face...I just need this image out of my head so I can sleep.

-ER Doc

So Thats What Obama Was Talking About...

A 13 year old boy was transferred to our trauma center yesterday for neurosurgical evaluation. He fell off the back of a golf cart and suffered a skull fracture with a small amount of bleeding in his brain. The docs at the outside hospital did a great job copying his chart and burning a CD with all of his cat scans. When he arrived I paged neurosurgery. Just as I was expecting....they wanted a new cat scan of his head and neck before they saw him. I explained to them he had a CD with his scan from 2 hours ago that was perfectly fine, plus there was no need to radiate a child unnecessarily. They balked at this, said they needed one to be able to look on their computer system whenever they needed, and said they would not see him until the scans were done. So after much debate....a couple thousand more dollars in tests and more radiation was eventually ordered.

Yesterday policy makers announced a new plan on health care reform that is aimed to reduce wasteful spending. One way proposed to do this is to eliminate ordering duplicate or unnecessary tests. This was a great example on how we waste money in medicine. I am all for this kind of reform....but its going to take way more to make a big impact on health care. I think we should also start with end of life care....but we will save that for another day

-ER Doc

Shouldn't have had that V8

People overdose on lots of things. Sometimes it's intentional (either they want to die or just get someone's attention) or unintentional. Most of the intentional ones get to see the psychiatrist; some of the accidental ones do too. When this happens, they get cleared in the medicine ER then sent to the psych ER. What follows is an actual report from the nurse in the medicine ER on a patient coming for a psych eval.

46-year-old homeless white female, found down in the field with unidentified male. The female responded to Narcan (a drug that blocks the action of opiates), but the male did not and coded in the ER and died. EMS reported finding heroin paraphernalia on the scene. They were also drinking beer mixed with tomato juice.

It's that last vital piece of information that threw me for a loop. I guess they thought that the tomato juice played a factor in the overdose. Or maybe that the tomatoes were tainted with Salmonella and he died of acute sepsis.

Either way, kids, the next time you see that commercial, just remember: V8 kills.

-Psych Doc

Ken Doll

A 17 yo nonverbal, mentally handicap male arrived to the ER accompanied by his elder mother with the chief complaint "Ken doll is missing."

I went to evaluate the patient and the mother said "I haven't been able to find the Ken doll that he plays with for days...I think he swallowed it." I replied, "Does he have a history of eating large objects?" The mother said, "Well, he periodically eats things if you don't keep an eye on him." I then replied, "What has he eaten in the past?" The mother stated, "Well, last week a VHS tape went missing and after a couple days I noticed some black magnetic tape hanging out of his bottom." I was puzzled, "Really, did you go see a Doctor?" She replied, "No, I saw the tape hanging there and just slowly started pulling and got about 6 feet of tape out of his bottom." I was astonished but continued with the history, "So has he been acting different since the Ken doll went missing. Such as vomiting or no bowel movements?" The mother looked toward her son, deep in thought... "Come to think of it. He has vomited a couple times and has not gone number two for at least two days."

Reassurance did not help...mom SWORE he had to have eaten the 12 inch Ken doll. Then...the patient became acutely ill. He started to look more and more like an acute abdomen, and X rays showed an obstruction. Surgery was consulted, and he was taken to the OR for an exploratory laparotomy. The findings were pretty amazing. It seemed as though he bit off the head of the doll, swallowed it, then went for the extremities one by one, then finished off with the torso. Kens head was lodged in the small intestine! Eventually, they got the rest out, and this missing person case was put to rest. Another good reason why boys shouldn't play with dolls!

-Doc Sensitive

Respect Or Tolerance?

Please forgive me if this turns out to be a little rude or insensitive....but I just worked 30 hours of trauma and am a little beat.

Thanks to the swine flu, a nice 13 year old boy was home during the day instead of at school. He was riding his scooter and was hit by a car at about 35 mph. He was hurt pretty bad...his skull was cracked open leaving a track open to the brain. There was a lot of bleeding as the skull is very vascular. We consulted the neurosurgery team and face team immediately to try to get him to surgery asap to give him the best chance possible.

When his mom arrived, she was appropriately distraught. I explained to her the injuries and the need for emergent surgery. Before I could finish the word surgery, she had cut me off to say loud and boldly "I am a Jehovas Witness and I want to sign right now that he can have NO blood." I told her I 'respected' her beliefs, but there was a good chance that her son was going to need blood or blood products to live. It didn't phase her, and she was pulling out her pen. I then told her that we would do our best not to use blood, but in the state we live in parents cannot deny kids the right to blood transfusions in emergent situations. So....she then wrote it out herself on a piece of paper and put it in the chart.

We are taught ethics in med school....and the blood issue with Jehovas Witnessess is very familiar. It usually isn't a problem unless its with children. I am not a total ass. When I am with my muslim friends...I am sure to order pizza without pork, even thought they are drinking beer. When I am with my Jewish friends...we go somewhere kosher, and I even bring coupons. One of my dearest patients in the past was a Jehovas Witness....and I made sure he got through his entire complicated hospital course without blood.

But this night it just hit me the wrong way. I wasn't rude to her. I didn't tell her we all sin in our different religions so I didn't understand why she wouldn't let this "sin" go so her child could live. I just muttered the same ole "I respect your....." But I don't think its respect any more. Its tolerance. We tolerate things that are different than we believe...and in the end just try to do our job. That night it was to keep HER child alive.

-ER Doc

Skittles

A 45 yo male arrived to the ER looking disheveled and telling the nurses he needed a CT scan of his head because something was definately wrong with him. The nurses came up to me and said "Please go see that guy because he's annoying all of us."

So I go evaluate the man. He looks like he hasn't showered in months, hair all over the place, and holding a stick for walking.

Me: "Sir, what brings you in today?"

Patient: "Well, my head hurts like hell and I've been hearing voices and eating these Lortabs like their f**king skittles." (Lortabs are pain killers that basically have tylenol and hydrocodone in them)

Me: "Sir, you have been eating lortabs like skittles? How many have you had in the past two days."

Patient: "I don't know....about 2 bags of skittles worth"

The patient had a normal CT scan and had elevated liver enzymes indicating that his liver was damaged from too much Tylenol in the Lortab. He was started on the antidote for Tylenol toxicity and had an uneventful hospital course.

Moral of the story....medicine is not candy

-Doc Sensitive

stuck pin

44 yo obese female arrived in the ER with chief complaint "pin stuck." Patient had no significant past medical history and actually looked well kept compared to the others in the ER that day. I was very curious as to what "pin stuck" meant.

Me: "What brought you to the hospital today?"

Patient: (figiditing with hands and looked nervous) "Well I lost my sewing needle."

Me: "Okay, were did you loose it?"

The patient proceeds to lift up her shirt and points to her lower abdomen. I got the overhead light and concentrated the light on where she was pointing but didn't see a single mark on her stomach.

Me: "Are you sure it's right there. How do you know it's there?"

Patient: "Well, I was sewing some clothes in bed and fell asleep and when I woke up, my needle was missing. Now I have a sharp pain in my stomach. I could feel it earlier in the day but the more I pushed... I think it went deeper. Now it really hurts, especially when I walk"

I honestly thought this lady was pulling my chain or something, but she was pretty large so it was possible. I ordered a KUB (stomach xray) to see if there was a needle, and sure enough she had a large sewing needle stuck in here subcutaneous tissue. It was so deep, though, that I had to consult surgery. They ordered a cat scan which showed the needle just barely penetrating the peritoneal tissue. She ended up going to the OR under fluro where she had the needle surgically removed.

I don't think she will be sewing in bed anymore!

-Doc Sensitive

Drugs Are Bad

A colleague of mine, usually very calm, found me in the doctor's lounge the other day. He was in a bit of a panic. He requested that I sign a prescription of Tamiflu for him..."just in case this swine flu thing gets out of hand." He seemed really concerned, so I signed his script. Then...he asked for something a little stranger:

Him: "Also...do you think you could sign this script for Norco 10/325 for me?"

Me: "Uh....what?? Why??"

Him: "Well, my wife and I are going on vacation next week. I wanted to get some just in case she falls and sprains her ankle."

Me: "Uh...no! I recommend if that happens she take some Tylenol and you assess her....maybe take her to a clinic."

Him: "Oh yeah...good idea...thanks."

A few minutes later, I was sure to drop off a pamphlet from our local drug and alcohol addiction center in his locker.

-ER Doc