Tuesday, November 30, 2010

Divine Intervention 2

A 41 year old black female comes by EMS in full cardiopulmonary arrest. She had been "down" for at least 30 minutes before arriving to the ED. EMS had no return of circulation en route. I coded her for another 30 minutes b/c she was young. There was never of a pulse despite multiple rounds of epi. This lady had NO signs of life. There was nothing I could do to save her.

I have no clue what she died from, but that's not the point of this post.

I went to go break the news to the family. As usual, I was accompanied by a nurse and a chaplain. When I arrived to the room, there were about 10 family members holding hands in a circle praying. They were saying "amen" to the prayer leaders pronouncement that the Lord will bring her back and that it was already done.

It was a really awkward moment b/c I had pronounced her dead but they were still praying as if she was alive or had a chance. I just kind of stood there at the door. I didn't know if I should go hide, interrupt the prayer and tell them to stop b/c there was no use, go pretend like I was still working on her, or undo the body bag and actually start working on her again. I don't even know what I believe in anymore....but what if I was ruining a miracle??

I felt like I was in the middle of them and divine intervention. I knew there was nothing left to do for the patient, but man did I feel like I was playing God all of a sudden.

So I asked the chaplain to call me when they were done, which turned out to be less than a minute later. I broke the news, and they freaked like no family I have ever seen. There were broken walls, plants, and doors. The patient's mother ripped my white coat after grabbing me and shouting at me to get back in there and save her daughter.

So.....my question is what should I do if I walk into a family room to tell them their loved one is dead while they are praying for a miracle. Please, no comments on how we play God in medicine all the time, that's not what I am getting at here. More of how to get out of this awkward situation.

-ER Doc

Friday, November 26, 2010

Gobble Gobble

Thanksgiving evening... Swallowing foreign bodies are very common on Thanksgiving. This one was a first for me.

A 49 year old male came in after swallowing his partial dentures. He swallowed them right into his lung! He says he was eating his turkey too fast and bam....aspirated his fake teeth. Usually foreign bodies will go into the right mainstem bronchus, but this guys went into the left. Here is his actual X Ray:

What makes this even funnier?? How about that the guy did the SAME THING 2 years prior. Here is his X Ray from then, when his dentures went to his right lung.

I guess history really does repeat itself!

-ER Doc

Sunday, November 21, 2010


TWO different tazerings, if that's a word, in the SAME shift.

Patient #1: A 33 year old male, upstanding citizen, allegedly high on PCP was attempting to steal a car. The police quickly got involved and tried to arrest him. But the PCP gave him superhuman strength. After EIGHT police officers could not contain him, they tazered him. One tazer, no response and he kept coming. Second tazer, no response and he kept coming. Third tazer, and he dropped dead.

He was brought to me as a full cardiopulmonary arrest. There was no saving him. The combination of the catecholamine surge from the drugs and the tazers was too much for his hear. And of course his family is making a huge deal about it and wants to sue the police. In my opinion, they should of just shot him.

Patient # 2: Same night about 4 hours later a 37 year old male was admitted for altered mental status and DKA. He was in full alcohol withdrawal, but also his metabolic system was also in terror from the DKA. He had a foley in place to monitor his urine output. He was on tons of fluids and insulin for the DKA, but he was also on an ativan drip for his agitation and alcohol withdrawal.

Eventually he became too hard to control as well. As I was ordering more sedation, or hospital police showed up. Problem is....there is no reasoning with an altered person from drugs or alcohol.

The patient ran out of the room naked into the halls, RIPPED out his foley and started attacking the police with it!! So the police tazered him in the middle of the ER. It was awesome.

-ER Doc

Monday, November 15, 2010

Psych Doc Interprets ER Doc's Patient: Blue Balls

I had a 43 year old white male come in for penile pain. He was accompanied by his wife. They seemed like very nice, affluent people.

So I asked him what happened....I wasn't expecting the response I got.

Mr. Blue Balls: "I tried to freeze my penis off 2 days ago by leaving ice packs on it."

Me: "Uhhh...ok. Why did you do that?"

Mr. Blue Balls: "I don't know."

So I proceeded to take a look at the damage. When he dropped his pants. I noticed his testicles were gone. His wife told me that 2 years ago he cut off his testicles HIMSELF. Never said why....always would just say I don't know. She said he was never diagnosed as psychotic or bipolar or schizophrenic. She said he was just diagnosed with being severely depressed. I've seen some really depressed people, and none of them had self mutilated their genitalia!

His penis had 2nd degree burns. It will turn out better than his nuts did. I called our psych team to come out for an eval (team of trained professionals but not physicians). I figured they would deem him a threat to himself and get him admitted to a psych center. Nope. They said he seemed genuinely regretful and set him up with outpatient counseling. Of course, he couldn't tell them why he did it either. So I was left with no choice but to discharge him.

So Psych Doc....what's your interpretation? How much denial is this family in? Should he have been committed?

-ER Doc


Wow. First off, I hate to question other professionals, but I can't see how this guy didn't get admitted to a psych unit. He meets "Danger to self" criteria more clearly than a lot of the drug overdoses we see. And he's done similar, serious things twice now.

He may or not have been psychotic; however, I would think that if he had been, the evaluating team would have seen it (as would you and the family.) He could have been briefly psychotic, i.e., under the influence of drugs.

My hunch is that this guy has some sexual deviation that is very socially unacceptable. In other words, he probably has urges to commit violent sexual acts. This guy doesn't hate himself; he hates his intrusive, impulsive sexual thoughts. The symbol of the sexual deviance, his own genitalia, have become his enemy.

I have had two male patients that have hinted at things like this. Both of them have intrusive thoughts of molesting kids. One of them admits that when he sees teenage girls at the mall, he visualizes himself raping them. Then he thinks about where he could bury them. Both of them have asked for chemical castration. They both know that these kinds of thoughts are morally and socially unacceptable, which causes them a lot of distress and feelings of shame and guilt. They have problems with depression and anxiety, and both swear they have never acted on these thoughts.

Your patient likely does need some intense outpatient counseling. He may be an outwardly very pleasant, kind, and peaceful person. But the demons are hidden in there. I hope he can afford some good therapy. And I hope that the neighborhood kids stay away from his house.

-Psych Doc

Saturday, November 13, 2010

A Twisted Case of Constipation

(Warning....for non medical readers, you will have to google a lot on this post as it has a lot of medical jargon)

I had a 83 year old male present with constipation and a "knot" to his neck. He was in good shape and health for being 83 years old.

Anyways, his belly felt a little more distended and tympanic than I was expecting for constipation, but he looked really well. Every part of me wanted to just give him an enema, make him poop, and send him home. But because of the mild distension I decided to get an abdominal series (a series of X Rays of the abdomen and chest).

What did I find in the X Ray?? The abdomen looked OK, but his chest X Ray showed a huge lung mass. I then did a full workup, and a cat scan showed diffuse metastasis to the liver, intestines, and bones. That "knot" to the neck was a cancerous lymph node

Next I reviewed his medical history. 6 months ago he was seen in the ER for chest pain and shortness of breath. A X Ray at that time showed a nodule in the lung, and a cat scan was recommended by the radiologist. The patient was admitted to the hospital by the ER Doc. For some reason, the hospitalist decided to a pulmonary embolism work up. His creatinine was a little high so he didn't get a cat scan but a worthless V/Q scan. The V/Q scan was negative and the patient was discharged.

The patient's doctor was never notified about the abnormal chest X Ray. The PATIENT was never notified about the X Ray. And now the patient has horrible cancer. Lots of things went wrong. The hospitalist had 1 diagnosis in mind and chased it....and was wrong. The patient couldn't get the cat scan with contrast, but he could have had a regular cat scan to evaluate the nodule. Even if the hospitalist didn't do the cat scan during admission, he should have informed the patient and the patient's doctor.

I hate to place blame on other doctors. I am sure this was multifactorial. If the ER doctor would not have admitted the patient, it would have been his job to inform the patient's primary doctor about the nodule....but that wasn't the case. The facts in this case are clear. And the prognosis = death.

-ER Doc

Tuesday, November 9, 2010

Society's Wh%$#

Today, I was working in the Psychiatric Emergency Center. A patient that I had not seen walked over to me, said he couldn't breathe, needed to go to the medical ER, and get a nebulizer treatment. Keep in mind, he got out of a chair and walked about 20 feet to tell me he couldn't breathe. When I told him I would order a PRN rescue inhaler, he said, "Nah, I don't need that, I have a nebulizer machine in my belongings." (When patients come onto a psych unit, all their items are stored in a secure area.)

I asked him why he needs to carry a nebulizer everywhere he goes. He said, "Well, I never know when I'll have trouble breathing. And, I never know when I'll find some crack." So this guy taught me something new today: When you open your airways, crack gets you even more high. Needless to say, your Medicare dollars paid for that nebulizer.

This story is good if it stopped right there. But oh no, my droogs. He proceeded to tell everyone how he had HIV and was "Society's Wh*%&" (a derogatory term for a woman who has sex in exchange for money). During his maniacal rant, he asked the nurse if he could see Psych Doc again. "Why?", the nurse asked. "He already said you can have some Albuterol."

"Well, it's just that I haven't been taking my psych meds like I'm supposed to," he stated. "Can Psych Doc come back out here and spank me for being a bad boy?"

I love this job.

-Psych Doc

Monday, November 8, 2010

Football Baby

I love football. Modern day gladiators! The NFL has really been cracking down on viscous hits and has been taking closed head injuries more serious, which is great. Hopefully there will be a trickle down effect to college and high school football.

A 15 year old QB came in after a hard hit to the head. He lost consciousness and was confused after. Neuro exam was essentially normal. He didn't remember the event but was alert and oriented. Here is a similar cat scan of what he had:

As you can see by the bright white blood.....he had a little head bleed. I was shocked. The kid looked great. He ended up doing just fine. But still amazing to think high school, JV football can cause this kind of injury.

-ER Doc

Thursday, November 4, 2010

Random Post

Sorry for the lack of posts. I have specialty boards coming up in 2 weeks so have been busy studying. In Emergency Medicine, we have a lot of tests. After residency, we have our specialty written boards. If we pass that, then we have oral boards. After all that we can be considered "Board Certified" in Emergency Medicine. To maintain that, we have to keep up with a small refresher test based on current literature every 2 years. So...right now I am a fully licensed regular doctor, residency trained in EM and "board eligible."

Anyways, work has been boring lately. No great saves to talk about.

I did have 2 patient's today that both had trich (STD) on random urine tests. It was funny b/c they were both in their 60's. One male and one female, in rooms right next to each other. I wondered if they had hooked up in the past, but due to the HIPPA police I couldn't ask.

I had another lady that I diagnosed with Scabies. When I told her I would be sending her home with medicines, she was pissed b/c she had to actually BUY the medicines. She said she had no money to buy them, and I basically told her to figure it out. Of course she didn't like that. So I asked who paid for the cell phone she had been texting on. She replied, "My sugar daddy, but he's in Florida now b/c he is a truck driver." I suggested that her sugar daddy pay for them. She was ok with that as long as I called Sugar Daddy for her and explained to him that she did have a medical condition that required treatment. I guess he isn't a very trusting Daddy.

-ER Doc