"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

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

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

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

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

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

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:

http://thecentralline.org/?p=642

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

http://www.slate.com/id/2227082/pagenum/all/#p2

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

http://www.kevinmd.com/blog/2009/09/free-market-health-care-exist.html

-ER Doc

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