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

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
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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

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

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

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

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.

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#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.

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#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

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

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

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

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

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