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