The Picture Album

I love doing psych consults so much that I just did an extra elective. Something cool about hanging out with "real doctors" and seeing all the medical/psychiatric interactions. Or something. Anyway, I find that most consults are pretty interesting, and I've seen every imaginable kind of delirium, suicide attempt, drug withdrawal, etc. Or so I think. It's those stories outside of my normal comfort zone that make it to this blog.

Warning: Those with kids, especially moms, especially if you're a pregnant mom, be forewarned. You may not want to read this one.

Getting a psych consult to the Labor and Delivery floor can never be good. Usually it's some case of post-partum depression/psychosis, usually requiring a report to be filed with appropriate child welfare agencies, moms with 10 kids and no way to care for them, etc. Today, it got dialed up to an 11 for me.

A G6P3 21 y.o. female presented 2 days ago with acute pelvic pain. She was at 34 weeks' gestation. Sono showed intrauterine demise of the fetus. While waiting to spontaneously deliver, she got very labile, asking to go to a different hospital, etc. Basically, she was angry that the primary team didn't just surgically remove it. Seems reasonable to me, but damned if someone shows some normal human emotion in a hospital or else psych gets called in.

I saw this lady the day after she delivered. She is understandibly sad, tearful, and grieving. Her life had not gone according to plan, as evident in her age, 6 pregnancies, and 3 total miscarriages now. She reported her prenatal care, psych history, support network, etc., as I obtained a complete history and mental status exam. I gave her referrals to several different grief counselors and recommendations for meds and follow-up.

As I was wrapping up the interview, she asked me if I wanted to see pictures of her baby. I felt this twinge in my gut, telling me to say no. No human part of me wanted to see a dead baby. However, I knew it would be better for her therapeutically to show interest in her plight in this way. The patient needed her doctor to do this. To connect with her. It was going to be hard.

She brought out a small album. Her and her mom had put a new little red dress with a matching cap on the baby. They took 6 or 8 pics. Different poses. Closeups of face, hands, feet included. At first glance, it looked like a normal newborn album. But the reality of it all could be seen in the skin color and turgor. I was able to manage "She's beautiful" or somesuch, quickly tied up any loose ends, and left her room.

I just hope I helped her in some way. Because those pictures are gonna stay with me for a while.

-Psych Doc

Give Me Back My Child!

A 27 year old male came in for multiple lacerations. Let's called him Patient Dumbass. He had been doing PCP that day. Apparently, when he does PCP, he gets very "touchy."

While Patient Dumbass was fried out of his mind on PCP, he went over to visit his friends who had a 9 month old child. Apparently, when Patient Dumbess does PCP, he gets very "touchy." He decided to hold the baby, and became very touchy since he was high. This freaked the parents out, and they wanted him to hand over the baby. Well Patient Dumbass didn't want to let go of the cuddly lil' booger, so in normal PCP fashion he held on to the kid and tried to take off. With the baby in his arms, Patient Dumbass ran straight through a glass door, causing injuries to himself and the baby.

Word from the Childrens Hospital was that the baby would be just fine. The police weren't interested in Patient Dumbass, so I deemed him "a threat to himself and others," and he was shipped to a local psych hospital. I don't really think his issues were psychiatric but more just drug related, but there wasn't much I could do and I didn't want to just discharge him.

-ER Doc

Pregnancy Headache

Warning: Sad case for any pregnant readers.

A 23 year old, 16 weeks pregnant female came in with headache, vision changes, and right sided weakness. With pregnant females, we are always very conservative. But in this case, we had to do a cat scan. She was obviously having a big brain bleed.


Before her presentation with the bleed, she was completely healthy. We think she had a AVM that had always been asymptomatic. To date, she and the baby are still alive.

Weird thing is we had the same case in our ER 1 week ago, except the patient was 33 years old and 26 weeks pregnant. She wasn't as lucky.

-ER Doc

Borrowed Post, Condom Inhalation

While blog rolling recently, I found an interesting post from a blog called Life in the Fast Lane. Its from a group of Australian EM Docs.

Anyways, this post is about a women who inhaled a CONDOM! Wow. Had to be a stripper. Why else a condom during fellatio? At least now I can ask my patients with a cough, "Have you been sucking d**k lately and a load fired so strongly the wrapper came off?

Here's a copy of the post and the link.

------------------------------
27-year-old lady presented with persistent cough, sputum and fever for the preceding six months. Inspite of trials with antibiotics and anti-tuberculosis treatment for the preceeding four months, her symptoms did not improve.

A subsequent chest radiograph showed non-homogeneous collapse-consolidation of right upper lobe.

Videobronchoscopy revealed an inverted bag like structure in right upper lobe bronchus and rigid bronchoscopic removal with biopsy forceps confirmed the presence of a condom.

Detailed retrospective history also confirmed accidental inhalation of the condom during fellatio.

-ER Doc

Expensive Day

Today was the beginning for me to start repaying my student loans from college and med school. I haven't even been out of residency one month! More importantly, I haven't even been paid yet! Expensive day to say the least. Only 29 more years and 11 months to go at least.

-ER Doc

The Little Things

Where I work is action all the time. Today I intubated 2 people, 1 central line, sent 3 to the ICU, 1 chest tube, etc. But sometimes it's nice to get one of those classic cases that are simple, but offer the patient relief. Here are a couple of examples


1) A 76 year old female came in with severe dizziness. It had been getting worse over the last few weeks. Immediately all the bad stuff started going through my head like stroke, electrolyte imbalances, etc. But when I looked in her ears...look what I found!

















She said she thought she lost a cotton swab Q-Tip about a month ago. Looks like I found it. Treated her with some antibiotics and she should do fine. Probably the only 75+ year old I have been able to send home with dizziness.

2) A mom brought in her 18 month little girl in for a "red eye." Mom was convinced it was pink eye. Not a bad thought, but when I looked at the eye, I saw no signs of pink eye. Her eye was red, but just didn't look like conjunctivitis. And she was kind of guarding her eye with her hand. So I told the mom I wanted to stain the child's eye to make sure she hadn't accidentally scratched her cornea, causing a corneal abrasion. The mom thought I was crazy, and it took a lot of convincing for her to allow me to do the exam. Low and behold, this is what I found! (Similar image from online. Not actual image from patient didn't want to make her have to take a picture after her enduring me staining her eye for the exam)



Poor thing probably scratched her eye with her nails. She should do fine as well.


Neither case was exciting, but they weren't everyday things for my practice and they offered patient's actual treatments with good outcomes. In a very high acuity ER, this is nice.

-ER Doc

2 Diagnoses for the Price of One

OK, enough about the farting. Let's get to a story that involves the other hole down there!

A 50-year-old lady came in by EMS status post 2 seizures at home. She had missed her medicines the last couple days, so it was no big deal that she was seizing. I ordered a dilantin (seizure medication) level to know how much medicine to give her.

Surprise to me...the nurse had ordered a urine test. And what came back in it?? Trichomoniasis in her urine! Usually this is tested by a swab of the vaginal discharge during a pelvic exam. When you see it swimming in the urine, you have a nasty case of the trich.

So this 50-year-old got dilantin for her seizures AND a loading dose of metro for her trich.

Patient after I told her she has a STD: "I'm gonna kill my husband!"

Me: "I understand, ma'am. I just ask that you please do it next to a different trauma center."

Her: "Deal!"

-ER Doc

Patient Quote of the Day (and an insite to doctor farting)

I had a 30 year old Hispanic Panic male patient last night that was being seen for chest pain. He ushered me in the room after our initial, loonnnngggg visit.

Me: "Yes sir, what can I do for you."

Him: "Hey Doc, can you get me some air freshener?"

Me: "Huh? No we don't carry air freshener in the ER. Why?" (Astounded look on my face b/c I just coded 2 people and this guy is asking me for air freshener??)

Him: "Oh. I just have to fart and I didn't want anyone to smell it."

With a pissed off look on my face, I told him to just let it rip, and then let one rip myself as I walked out of his room.


I know plenty of docs, maybe even myself at times, who choose patient rooms to fart in. Usually we get to hit the can maybe once in a 10 hour shift, so definitely don't have time to go to the bathroom to pass gas every time the cafeteria food makes its way down the colon. We usually choose either unconscious or altered patients rooms, homeless patients rooms (b/c they smell themselves), or really obese patients rooms (b/c they will be the prime suspects).

-ER Doc

Abdominal Complaint

A pleasant 45 year old male presented to the ER with a complaint of abdominal distension. He had no past medical problems. He was released from jail about 3 months prior after years of being locked up.

He was concerned because his stomach had been getting larger since he got out of jail. He went to an urgent care clinic 3 days before coming to the ER. The "doctor" at the urgent care told him that he was retaining fluid in his abdomen, probably because of liver/kidney/heart failure, and gave him lasix to help get the fluid off. No tests were made to help him get to this diagnosis.

I wasn't that impressed with his exam. No peripheral edema. No heart murmur. No fluid in his lungs. No skin changes concerning for liver failure, and no fluid wave in his abdomen. I told him we would do some tests to get to the bottom of things.

Nurse: "So what do you think is the matter with him."

Me: "I think he has enjoyed to much McDonalds since getting out of jail and has just gotten fat."

Nurse: "You are such as asshole doctor. You always think the worse for these poor patients. That man is probably dying from liver failure and you just think he is fat b/c you wish you could eat more McDonalds and let yourself go. Your such an dickhead....but damn I want you. Please take me now" Just kidding. She didn't say anything, just chuckled and looked at me like I was an idiot.

So....the tests came back. Normal kidney function, normal liver function, no heart failure, no fluid in his belly per ultrasound. Diagnosis= pot belly. He was relieved. I recommended diet, exercise, and stopping the lasix.

-ER Doc

EMR

One of the most valuable tools of electronic medical records his being able to review a patients previous visits quickly. I saved this note from residency b/c it was so funny. It had to be written by an off service resident, b/c there is no way an ER resident would write in such detail (hence all my short hand). Anyway, the resident does a great job of painting a picture of this glorious patient.

---------
HPI: 48 yo WF with past med history of extensive alcohol and drug abuse, bipolar disorder, Hepatitis C cirrhosis, and hypertension who presents after being found down at the bus stop across the street from this hospital. Patient reports that she woke up this morning and drank 2 bottles of wine and injected heroin subcutaneously, per her daily routine, and then set out on a bus ride to buy more wine and ask people for money. After buying the wine, she spent a few hours behind the hospital asking people for money. Then she went to the bus stop across the street to catch a ride back to her apartment. This is the last thing she remembers before awaking in the ambulance while being transported to the ER. Patient denies any fever/chills, nausea/vomiting, chest pain, loss of bowel or bladder incontinence. She does report she becomes very ill when she stops drinking, and has had seizures and hallucinations in the past while withdrawing from alcohol. Pt has reported to the ER countless times over the past 5 years for a series of injuries both from assaults and falls, and has been found down and treated for alcohol intoxication and withdrawal in the past. She is also wheelchair-bound secondary to a R hip injury which she sustained in 2007.

-ER Doc

Heatlhcare Dollars Part 2

OVER-TREATING:
Bingo....here is where the money goes down the toilet. End of life care.

From the article..."More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project. Yet the numbers show that's not what is happening: The average time spent in hospice and palliative care, which stresses comfort and quality of life once an illness is incurable, is falling because people are starting it too late. Hospitalizations during the last six months of life are rising. Treating chronic illness in the last two years of life gobbles up nearly one-third of all Medicare dollars."

Half of what we see in the ER is old nursing home gomers trying to die but their families won't let them. So lets just keep fighting so demented old grandma can sit in her chair in the nursing home some more and see them briefly on holidays. It is ridiculous.

Cancer sucks. If you have bad cancer and you are 75...and the treatments aren't working...hang it up and spend your time being comfortable.

I heard a story from a surgeon the other day: An illegal immigrant was shot while committing a crime. He was a vegetable in the trauma ICU. There was no one to "legally" execute a withdrawal of care for this ILLEGAL CRIMINAL IMMIGRANT, so he stayed on a ventilator in the ICU for a year....gobbling up who knows how much money. Finally after a year, the hospital ethics committee and a court agreed to pull the plug on the guy...and he passed shortly after. Glad my tax dollars are well spent.

Long story short.....let's rethink end of life care. Get past all the sensitivities and lets make some progress.

-ER Doc

Healthcare Dollars: Part 1 of 2

Here are a couple of interesting MSNBC articles....one about over-testing, and the other about over-treating. Both articles claim that we waste billions of dollars every year by over-testing and over-treating patients. Well....no shit Sherlock! Here are my takes on the subjects.

Part 1 OVER-TESTING:
Yes....we over-test a lot. It is called defensive medicine. But it is not JUST because we are afraid of getting sued. Nobody wants to get sued. I am sure it totally screws with your head. Just having to present in M&M conference in residency would fuck up my head for weeks. No doctor, especially ER doctors, want to miss something. In the ER you margin of error is supposed to be zero in the few minutes you have with a patient.

I am in a tort reform state, and lawsuits being capped has not slowed me or any of my colleagues down in our testing. We don't think..."Oh well, now I can only get sued 200k for this patient so I might as well send him home and risk it." No....its that WE DON'T WANT TO GET SUED PERIOD. We don't want to screw up. We don't want to miss things. There has to be a balance in the testing. But it seems as soon as we don't order that "unnecessary" test...we get screwed.
---side note...why do other docs (not me b/c I don't), order so many damn UAs??? You don't have to order a urine test for every ER patient guys).

Patients want to be tested. I don't know how many times I have heard, "But you aren't going to test my blood?" from a patient. No genius, I don't need to order blood work to see that you have cellulitis. I don't need a CXR or blood work to see that a 35 year old patient with no fever and who looks good has bronchitis. But try explaining that to a patient. They will either doubt you, or you will explain it soooooo many times throughout your practice that you will get so sick of explaining it and just order the damn tests.

So if you want to lower costs...don't just give us tort reform BUT protect us from being sued period (unless it involves complete breaching what a reasonable physician would do or if we act outright dangerously). THEN we can practice evidence based medicine. But you are going to have to protect us first.

-ER Doc

No Good Deed

I'm sure you've all heard the phrase, "No good deed goes unpunished." I'm sure this happens in all medical specialties, but this adage has been especially true for me recently. Every time I go out of my way to do anything but prescribe meds for my patients, they start to take advantage of me. Each time that I think I can help somebody by filling out disability forms, working with their caseworker/therapist, or helping them get medication assistance through pharma programs, etc., they come back asking for more stuff that manipulates the doctor/patient relationship.

Misuse of Rx meds is another issue I've blogged about. Today you will see both issues come together like a tarball in a gulf pelican's ass.

I have been treating this guy with Bipolar/Anxiety disorders for a year now. He also has a significant opiate dependence history, but that has been stable thanks to the methadone clinic. The guy has his ups and downs, and usually bounces from job to job, mostly stocking/warehouse type stuff. Aside from some social anxiety, he's done really well. No manic or depressive episodes since I've treated him. He's still young and didn't seem to have much direction. Until last week.

He came in for a regular appointment last week. He seemed pretty level-headed and was very pleasant. He hasn't worked for a while but is planning to go to community college next term. He asked me if I would write a letter to the college, indicating that I thought he would benefit from various classroom accomodations. I was really impressed by his new goal and he seemed to have a good outlook. While such a letter is extra work and no pay for me, I was glad to do it. Besides, an education could keep this guy off welfare for a few years. I gladly typed up a letter this morning, faxed it to the school's disability services, and sent a copy snail-mail-style to the patient.

This afternoon, I hear the registration clerks and the nurse laughing hysterically. The patient had called in with this story.

"I was wondering if Psych Doc could write me a new prescription of Xanax. I accidentally spit in the bottle." He went on to describe how he dips snuff, and he sometimes uses empty Rx bottles to spit in. He claimed that he reached over, grabbed a bottle and spit in it before he realized it wasn't an empty bottle. He said all the pills were ruined.

I have heard some great "I lost my Xanax" stories in my time bout this one beats them all. I asked the nurse to call him back and let him know that I would not give him an early refill on prn xanax. There's no way he spit so much he ruined a whole bottle. And what are the odds that it was the Xanax bottle that was open (not Prozac, etc.)

To paraphrase the nurses' conversation.

"Sir, you have a med contract and Psych Doc won't give you early refills."

"What am I gonna do?"

"I suggest you get in that bottle and salvage all that you can."

"But there's all kinds of matter in there."

"Well, you're the one that puts that nasty dip in your mouth. I'm sure you didn't spit enough to destroy them all. Try to do the best you can until your next refill is due."

"Okey dokey."



-Psych Doc

Confusing the Census Bureau

First, let me say congratulations to my colleagues. I wish them the best of luck. Just glad they are in a different hospital so they can't abuse me with a bunch of crap consults. For me, it's the 4th year of psych residency. Luckily, this means slightly less work. I think. But my program has a history of deceiving me.

A guy came in for refill on his antipsychotic. Reality testing seemed to be going fine. He was pleasant, oriented, not suicidal, denied hallucinations, etc. That is, until I asked him about agitation/aggression.

"I do pretty good except when I'm outside in the heat," he said. "Cherokees can't handle the heat."

Let me back up for a second and tell you that the guy across the table is obviously (to me at least) African American. So I was shocked by his comment. So shocked that I thought, "Wow, then why did they build all those tepees without air conditioning?" and "I bet it sucked hunting those bison" and "Why didn't they just hang out around the Bering Strait instead of migrating all the way down to the prairie?" and about a million other questions popped into my head.

Instead, all I could muster was, "Wow, I never knew that."

"Yeah, most people don't know that about us Cherokee. I'm also Dutch, German, and Jew."

I gave him my best "Whatchu talkin' bout, Willis?" gaze, and didn't say anything.

He said, "That's right. 1% Jew."

"Okay, if you say so. Here's some Abilify. See you in a month"

-Psych Doc