Strange Side Effects

True report by patient who is about to be discharged from inpatient psych unit: "I don't like so much Risperdal. It makes me sh!t like clay." Despite numerous attempts to allow her to expand on that description, all she can come up with is, "It is like clay. I don't know what else to say."

Another adult outpatient >50 years old that I saw recently said "I think I have ADD." He was already on 60 mg BID Adderall from an internist. Of course, he met hardly any criteria for ADHD. 9th grade education, no GED, and a history of alcohol and marijuana abuse. 50 years old and works as a mechanic. No depressive symptoms. The only reason he wanted it was to increase productivity at work. I offered some Wellbutrin. "I don't want that, I know somebody who took that and gained 100 pounds. What about some Adderall? My PCP has been prescribing it for 12 years."

FWIW, Wellbutrin causes hardly any weight gain, and sometimes causes weight loss, especially when added to SSRI for treatment resistant depression.

He told me, "I'll just keep getting it from my private PCP. I thought I could go through the county system and get it prescribed for free."

-Psych Doc

Worms

Long time, no see. I guess I must see pretty funny stuff all the time, but by this point, I am immume to it. I have been doing some moonlighting, but in all honesty, it is much less acute than the county hospital where I train. Nevertheless, here are some moonlighting cases.

1. Psychotic older guy comes in because he is watching kids get on the school bus. Not so bad, right? Well, what if he was totally naked. At 8 in the morning. Standing in the street. He walks into the office doing some kind of breakdancing moves. Gyrating his hips. He is looking at my computer monitor like he hears music coming from it. I asked where the music was coming from. He said "From my d!ck." I tried to get some kind of history from him, but to no avail. I finally asked, "Is there anything that we can do to help you?"

"Yeah, prescribe me some pu$$y".

2. A lesson for all the non-psych docs that follow the blog. 30 year old female with history of depression presented from a rural county ER. She was complaining of worms coming out of her head. She had large scratches and excoriations on her forehead and scalp because she was trying to get the worms out. Also, spiders had laid eggs in her neck. She could not walk without holding onto a wall. She kept repeating "10 steps North, 4 steps West." and "Katie is a pretty girl". She was not oriented to person, place, situation. Only psych history was some treatment with Prozac. Further history (provided from transferring hospital) noted that she had been picked up by police 4 days ago for a DWI warrant. Had none of these symptoms until day 3, when she was taken to the ER.

What is the diagnosis?

No, it's not Prozac withdrawal.

Let's try Delirium Tremens.

I sent her to the local ER immediately, they loaded her up with benzos, and she came back 8 hours later.

Mental status exam: perfectly normal.

To all you med students and board eligible docs out there, you're welcome, because if you read this, you just got a question right on some B.S. exam

-Psych Doc

Out of Jail Free B/C It Stings When I Pee!?

In a previous post, I ranted about people who are brought to the ER in police custody because after they were arrested they had a medical complaint.

Most of the time the police have to bring them because they complain of something like chest pain. They usually get discharged quickly. But the police did NOT need to bring this guy in.

Me: "Hello sir. What did started bothering you today after you got arrested that you needed to come to the Emergency Department before going to jail?"

Patient Inmate: "Man....it stings when I pees. I think it is because I sleep with too many whores."

Me (Pissed off that the police would bring him in for that when they know that can be handled by the jail doctor): "That's why they brought you here!? We will give you some meds...be sure not to catch anything in jail!"

-ER Doc

Why I Like Working In The Hood

I have talked in the past about why I choose to work in the less affluent neighborhoods. The hospitals aren't fancy and the patients don't have great, if any, insurance. There are no frills. But the cases are great. In affluent areas, the patients generally are not as sick. So the ER isn't used to the good stuff, the nurses are less experienced with sick patients, and it's just not as fun. So yes it's a little less money in the hood but too much fun to pass up.

My group has a mix of hospital settings, from fancy to flat out ghetto. I usually split my time with the ghetto hospital in the hood to the poor-to-middle-class hospital in the nicer hood. Tons of sick patients. Today....I got to do stuff some ER docs never see.

1-Pericardiocentesis: Post dialysis CPR in a 45 year old male. Regular code meds (epi, atropine) were not working. I put the ultrasound probe to his heart and there was a huge tamponade (blood in his pericardium constricting his heart from beating). So I grabbed the 18 gauge spinal needle and 20cc syringe, and stabbed him in the heart with it! I have been waiting to do that for a long time. I withdrew about 20 cc's of blood, and wallah there's your heart beat!

2- Thoracotomy (Cracked Chest): Not a procedure I would generally do. The survival rate is less than 1% and it really isn't advocated anymore.

A 25 year male was coming in CPR after a gunshot wound to the chest. If I was alone, I would not have cracked his chest. But....the other doc on (my boss and hero) is a trauma guru and loves to crack chests, so I figured I might as well take advantage of the situation and do the procedure with a pro.

Within 2 minutes of the patient's arrival, I had cut down and spread the ribs apart, grabbed the heart, opened the pericardial sac, and started repairing the big ass hole in his right ventricle. It was freaking awesome. As soon as I had that hole put together, he got a strong heart beat back. He did not end up making it, but hopefully the experience will save someone else in the future.

-ER Doc








(not an image from my case but a google image)

One Tough 13 Year Old

A 13-year-old African American male came in by EMS for altered mental status. The history was very vague. All they knew was that he got hit in the head and didn't really respond after that.

He was no more than 5 feet tall and 100 pounds....tiny little guy.

Mom arrived and said that she didn't know what happened. She said he spends most of the time in the streets, smokes marijuana daily, and only drinks alcohol on weekends! He also had a big tatoo on his arm that said "I Don't Play." Remember....this kid was 13!!! Hell I am from the hood myself but don't remember any 13-year-olds this hard

He ended up just having a bad concussion. He was transferred to the local children's hospital where he can teach the other kiddos how to keep it real.

-ER Doc

Intubate Me X 3

Sorry for the lack of recent posts. I have been on a string of nights and getting ready for boards, and as usual my co bloggers are MIA. Here are a few notables from the shift I just ended. The common denominator was they all got intubated.

1) A NINETY-SIX year old female came in as a CPR. When the EMT heard that a 96 year old code was coming in, he prepped the bed in the white morgue bag so she would be placed in the open bag on arrival. One of the funniest things I have ever seen.

Of course, her children in their 70s wanted everything done. I had to intubate her b/c of it, and called the code as soon as it was medico-legally possible.

2) Drunk driver goes down the wrong side of the road and has a head on c0llision. He gets intubated due to being basically comatose. Ended up having a large liver and head bleed. Thankfully the only one he hurt was himself.

I am really starting to hate drunk drivers with a huge passion. Within the last 2 years, TWO of the best physicians I have known have been killed by drunk drivers.

3) Another drunk.....he drank himself into a coma. Blood alcohol level was 501. That was the 2nd highest I have ever seen. He was having trouble breathing, was vomiting, and had no gag reflex....so he got intubated as well.

Can't wait to see what Saturday night brings me!

-ER Doc

That IS a Medical Problem

There are about 6 questions I need to ask when I see a patient:

1- What brings you in?
2- What medical problems do you have?
3- Do you take any medicines daily?
4- Have you had any surgeries?
5- Do you smoke, drink, or do any drugs?
6- Are you allergic to anything?

The rest is just gravy. I am REALLY getting annoyed with question # 2 lately. I have tried phrasing it many different ways...but people for some reason don't think that high blood pressure, high cholesterol, or diabetes are medical problems anymore.

They will say NO they don't have any medical problems, but when I ask do you take any medicines daily, they will reply yes for my high blood pressure! Well genius that's a medical problem, not a gift from your grandmother.

Recently I had a patient say she had NO medical problems at all. No matter how I asked it she said no. I kept prodding b/c she looked like she had lots of problems. I found a previous discharge summary, and below were her actual medical problems listed:

• High blood pressure
• HIV
• Diabetes
  
• Gout
• Anemia
• Hypothyroidism
• GERD
• Schizophrenia
• Cervical Cancer

Guess what....those count!

Now I just say "do you have any medical problems including high blood pressure, diabetes, high cholesterol, chronic stupidity, etc??" It's getting annoying

-ER Doc

Well That's Just Not Fair

I wanted to post this a few days ago when the story came out...but I have been very busy.

A new study by George Washington University Scholars showed that it costs women nearly twice as much as it does men to be obese. Researchers tabulated the cost of medical bills, employee sick days, health insurance, lost productivity and even the need for extra gasoline to fuel cars carrying heavier passengers. In total, they found that the average yearly cost of being obese in America is $4,879 for a woman and $2,646 for a man.

I'm all for bringing up more reasons to have the fatties loose some pounds. Day in and day out in the ER, the majority of cases I see can either be attributed to or complicated by obesity. Now we have a study that brings up the obvious...being fat costs more money. Sometimes it takes saying the obvious to make an impact.

The reason, though, why it costs women more to be fat??? The study says it is because they get paid LESS than their fat male counterparts. Now that sucks.

Now for my liberal side....it is HARD to eat healthy when you don't have a lot of money. It costs a hell of a lot more. That's not an excuse for not exercising or controlling portion sizes...but there needs to be better regulations on what goes in food and their needs to be more AFFORDABLE healthy options. I was poor until moonlighting in residency.....that dollar menu used to be very appealing.

Now enough of the serious stuff. Let's get some funny comments about why it costs more to be fat. If you are sensitive, don't read.

-ER Doc

BTW, it doesn't take as much as you would think to be classified as obese. To calculate your BMI, click here. (Mine is 23...booyah!)

Discharge to Jail

All too often arrested people come to the ER and get a "get out of jail free" card. I take great pleasure when justice is served.

On weekends, we get tons of accidents from drunk people. Last week, 3 of my drunk drivers were taken to jail. It was a great feeling. Usually the police officers don't wait around for the patient to be discharged, so they get off the hook for the most part. After a night full of drunk MVCs and stabbings, it was nice to see some people leave my ER with cuffs on!

Just as bad are the people who get chest pain when they are arrested. Today I had a 41 year old male who "started to have the big one" after being arrested for shoplifting. Normal EKG and discharge to jail!

Drink...Drive...Go to Jail!

-ER Doc

To and Fro the Government

Case 1: To the Government

A 57 year old female came to the ED with COPD exacerbation. She didn't even require home oxygen yet, but stated that she just started receiving medicare and disability for her COPD! After she told me this, I asked her if she still smokes. Of course the answer was yes. I then replied something smart ass'ish like "Wow it sure is nice of the government to pay for your cigarettes and your medical problems that you caused for yourself." She didn't appreciate that. Oh well.

Case 2: From the Government

A 19 year old female came in for "nausea." When it came down to it, she had a + pregnancy test yesterday and wanted confirmation that she was pregnant. Why did she need confirmation??? Well she asked that I fax her records to her Army recruiter. She was supposed to report to boot camp the following day. She was very happy she was pregnant and didn't have to go to boot camp. My suspicion is that she got pregnant on purpose b/c she changed her mind about the army.

-ER Doc