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

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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

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

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

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

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

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