"The Patient is the one with the Disease"

We get used to sadness and death in the ER. Most of the time I detach myself so I can keep coming back. Like the book The House of God says, "The patient is the one with the disease." That basically means don't get too emotionally involved. Sometimes, though, the stories of the day are too much. Here are 4 sad ones from a recent shift.

1) An 86 year old female comes in altered from her nursing home. Yes, most nursing home patients live with altered mental status, but this was different. I won't get into the details, but basically she was raped and abused. Her body was mangled and she had a large subdural (collection of blood in the brain). She didn't have a DNR...but was I really supposed to code this poor lady full throttle?

2) A 43 year old female was brought in by air ambulance in full traumatic arrest. She lived on a lake. It was a cold and rainy night. Her car broke down on the bridge. She then slipped off the bridge, and was hanging on for her life for 15 minutes before help arrived. When help was near, her muscles gave out and she fell. She hit rocks then slid into the water. She stayed afloat for 30 minutes. It was too far down and too dangerous for anyone to try to get her by foot. By the time the helicopter got there, it was too late. She drowned. But because it was a cold night her core temp was 27 degrees Celsius. So we had to code her until she was warm enough to be pronounced dead.

3) Another elderly abuse case. A sweet old lady who had her facial bones punched out. Whenever an elderly person is being pushed in by EMS with the police surrounding them...it's never good.

4) We were told an asthma patient in full respiratory arrest was coming in. The patient was a 33 year old female. She was at home with her 10 year old daughter when she went into respiratory distress. Her daughter called 911. No one else was at the house, so EMS had to take the daughter in the ambulance with them. En route, the mom lost her pulse and respiratory drive. EMS had to start CPR and intubate the mom in front of the child. EMS told us that the child had NO other family. Not an aunt, not a grandparent, just the two of them. We coded her for an hour and a half....but we couldn't get her back. I haven't seen the autopsy report yet, but it had to be a massive pulmonary embolism. Out of all them...this was the hardest one to say those nasty 3 words..."Time of Death."

-ER Doc

Who's the Daddy??

A 31 year old white female presented with chest pain. Her heart rate was very fast, and it was determined she had SVT. She needed to be admitted to the hospital. No biggy.

Until...the pregnancy test came back positive. I went to go tell her the news (didn't know if it was going to be good or bad news for her). Her boyfriend was in the room. After I told her she was pregnant, her and her boyfriend had a long, entertained, Jerry Springer like discussion trying to figure out who the father was.

The lady was trying to become a surrogate mother. She had been inseminated AND had been having sex with the boyfriend (I bet that's not allowed when you are trying to be someones surrogate), so it was going to be impossible to figure out who was the daddy without DNA.

To top things off...she was a chain smoker and her drug screen was positive for marijuana, opiates, and benzo's.

Lesson to be learned: choose your surrogates closely.

-ER Doc

Depressed with this Throckmorton's Sign?

Throckmortons's sign: position of the penis in relation to unilateral disease. Throckmorton's sign is a slang term used jokingly by medical professionals. A positive "Throckmorton" sign is when the patient's penis lies to or points to the side of the body wherein lies the abnormality on a plain X-ray of the Pelvis

-A 45 year old male presented with hip pain after trying to kill himself by jumping from a balcony. He said he wanted to die because he was depressed. This xray, though, makes me wonder why he was so depressed. He has a huge throckmorton's sign. You think he would be getting lots of love. This is the first throckmorton's sign I have seen that couldn't even fit on the whole xray. Besides his broken heart, there were no fractures. He was sent to psych to see why he would be so sad with such a huge schlong.

-ER Doc

Psychosis

I guess there are a lot of theories about psychosis. Does it stem from psychodynamic conflict? Is it purely biologic? Is it a combination of factors? I am in a more biologic training program, but a case I saw this week shows you where there is at least a gray area.

Mid-20s male comes into clinic after recent discharge from psych unit (first hospitalization). The guy has had 3 big psychotic breaks in the past few years, all of them related to his current girlfriend. With his first girlfriend, he began to think she was cheating on him. He got really paranoid and eventually attacked her. Admittedly, this alone is not enough to say he's psychotic-maybe she really was unfaithful.

Second girlfriend he dated, everything was going okay until he started to believe she was someone different. Not only that, he believed that she had undergone a sex change. She left before much more happened.

Now he comes to clinic with 3rd girlfriend (also with his sister in tow, which was awkward). The guy had begun to believe that when his GF was washing dishes or touching any long, cylindrical object, she was making a subliminal comment to him about his masculinity. He described how his girlfriend denigrates him by reaching for the cookie jar. He demonstrated this in my office by grabbing my canister of disinfectant antibacterial wipes and stroking it off. Even if his girlfriend touches an oven pan, that somehow sets him off.

He told me, "I even went and had sex with a few strippers. I asked them if I was big enough, and they said it was. I don't know why, but I have too much anxiety about my small penis." He later admitted that he is paranoid around pretty much everyone, and stays at home and to himself. It seems that when he gets into an intimate relationship, he can't escape his self-doubt and it escalates to a psychosis. The guy does no drugs, confirmed by drug screen and all family members present.

At some point, I think every guy not named John Holmes went through some period where he questioned whether or not he was properly equipped. But this is too much.

Freud woulda loved this guy. Next time I'm gonna ask him about his momma.

-Psych Doc

Cell Phone Rant

I remember the days when people were scared to bring their cell phones in the hospital. They were afraid to set off the monitors and cause all kinds of harm. Most would at least shut them off, or go outside to talk. My....how things have changed.

Daily, I walk into a patient's room and have to wait for them to get off the phone. "Hey man...the doctor just came in. Let me holla at you later. Yeah. Yeah. Uh huh. No. I know. Haha. Hey, can I call you back, the doctor is still waiting. Hey doc, hold on a second while I finish up." That's pretty much the conversation I hear about 8 times a day. If its not that, its the loud ass ring tones that blast in the middle of my history taking or physical exam. Forget them not answering the phone or sending it to silent. Nope. I have to wait for them to answer and finish. Even text messaging or game playing takes precedence over my exam.

Yesterday I was suturing a 7 year old boys forehead, and his mom was sitting outside the door shouting on the cell for all to hear. "Hell yes kinfolk! As soon as I get out of here I'm gonna drop him off at my cousins. I got my blunts all rolled up. You better come with yours rolled up too! We gonna get so high tonight. I got the fatties bitch!" Great mom. It's no wonder the kid had the vocabulary of a 3 year old.

That same day...I had a patient wanting a phone book to deliver pizza to his room. We didn't have a phone book. He had his cell phone right there waving it in my face, but of course didn't want to dial '411. Then, when it was time to discharge him with his prescription for Bactrim (four dollar prescription), he flipped out. How dare I give him a script and not just the pills...because of course he couldn't afford the four dollar medicine. "Sir, you have a cell phone and you wanted to order a pizza....I think both of those cost more than your script will, right?" I cannot post his reply due all the cuss words. Let's just say my Press Ganey scores sucked for that day.

-ER Doc

Medical Dictionary (SEE COMMENTS SECTION FOR EVEN MORE!!)

I was talking with my ER friends about the interesting slang patients use for various diseases/conditions/things, and thought I'd share them. Please respond with more interesting translations!

High Blood = Hypertension

Low Blood = Hypotension

Risings = Abscess

Fell out = Syncope

Double Pneumonia = Bilateral Pneumonia

Hydrocortisones for pain= Hydrocodeine

Spider Bite= Abscess

The Sugar = Diabetes

Vomicking = Vomiting

Wet= THC cigarette dipped in formaldehyde

Square= normal cigarette

Blunt= Marijuana

5s = Regular Vicodin

10s= Stronger Vicodin

"Hi Anal Hernia" = Hiatal Hernia

Thick Blood = High Cholesterol

The Shakes = Seizures

"My Girl Got Me" = STD

The Drips = STD

Fibromyalgia = Undiagnosed psych disorder

-Doc Sensitive/ER Doc

71

Too old to do what? That is the question....

I see A LOT of very elderly patients. Most come from nursing homes, which is always challenging. I see many elderly patients who are very active. They are probably the most fun patients. They have a great outlook on life and are usually very humorous.

Fist patient to tell you about was a 71 year old female who came in for arm pain. She had an obvious forearm deformity. The X Rays were already taken before I saw her. She had a broken arm. "Ma'am, how did you injure your arm," I said. With a very straight face looking me straight in the eyes she replied, "I punched my granddaughter in the head." I immediately thought oh shit! I pictured having to call CPS and Adult Protective Services, getting this lady a geriatric eval for dementia, and all kinds of painful stuff. But then I asked her how old the girl was....thank god she was 18. And apparently, she deserved to be hit. I put her in a splint, and she said she was done boxing.

Second patient was a 71 year old male veteran. He came in for chest pain, and only because his PCP made him come in. He was convinced he was "healthy as a horse" and didn't need to be there. Chest pain questions are pretty routine. We always ask about alcohol, smoking, and drugs. Sometimes I feel bad asking seniors about drugs....like I am disrespecting them. For this gentleman: Smoking...NO. Alcohol...NO. Drugs...Not cocaine anymore, but marijuana...Yes. Ecstasy....Yes! I was obviously taken back. He said, "I probably got a bad blunt that made my chest hurt. I was around in the 60s and 70s, and it was second nature to use back then. Never felt the need to stop. Is that a problem, Doc?" He was admitted for his heart attack.

-ER Doc

More Rectal Fun...Homemade Pleasure

A 45 yo male arrived to ED walking with his legs wide apart and refusing to sit down in the triage chairs. Instead, he elected to stand up in a semi erect stance and demanded to see the doctor. The nurse wrote the following triage summary: "45 yo male in moderate distress here for a 2 day history of a homemade dildo in his rectum."

I have retrieved many objects from rectums including flashlights, apples, old spice bottles, glass bottles, and many lost commercial pleasure devices. This, however, was my first "homemade" device.

Sir, "I'm Doc Sensitive. How can I help you today?" Of course I knew exactly why he needed my help b/c I read the nurses notes.

The poor man was laying on his side and didn't want to face me... butt stated "Doc, I'm extremely embarrassed about this... but my girlfriend came over one night and told me she wanted to fulfill one of her fantansy's and brought over a plastic dildo she made herself and said that she wanted to have sex with my a**. So I was like, okay, why not. She then strapped it on to perform anal sex on me and all of a sudden she screamed out... 'Uh, I can't get it back out!'"

This guy had spent the prior TWO DAYS trying to remove it with various other foreign objects... including a spoon and a wrench, but was unsuccessful. He finally gave in and came to our hospital. The surgeons took him to the operating room, and they successfully removed a 12 inch first class homemade dildo. He left the hospital the next day without his girlfriend's dildo, or his manlihood.

-Doc Sensitive

PS: For more posts like these, check out our "Most Popular Posts" section on the right and look for titles about Rectal Fun

Snake Bite

A 25 year old disheveled male arrived to the ER and handed me a piece of paper with the following written in messy handwriting: "A snake bit my dick."

I laughed in my head and and said, "Sir, why do you think a snake bit your penis?"

He anxiously replied, "Because it burns and has two things that look like snake fangs!"

I then proceeded to look at his penis and quickly identified the lesions as herpes. I told him that he was not bitten by a snake, but infected with a STD that is passed on by unprotected intercourse and it would require antiviral medications for his whole life.

I asked if he had any questions. He replied, "Do you know what kind of snake bit me?"

He was not going to be convinced! I attempted two more times to explain what an STD was and how it was treated. I gave him a script for acyclovir and told him to follow up with the health department. I also advised him to stay away from that snake that bit him.

-Doc Sensitive

Close to Home

Special treat tonight. Psych Doc times 2.

Had a really unique scenario in clinic yesterday. Was looking at my afternoon schedule and I recognized a name that I know from long ago. I saw this guy's name and it was associated to a memory of his face and some relation to my life 15-20 years ago. I check in the waiting room and it's the same guy I pictured. I think I probably played ball against him in high school or something. Very weird cuz my residency is 350 miles from where I grew up.

I spoke to the nurse and she agreed to let another physician treat him.

I am interested to hear from other health care professionals, including nurses, doctors, and others. Have you ever treated a patient that you know (even very superficially) from an external environment? In psych, avoiding this scenario is pretty standard, due to countertransference/confidentiality issues, etc. But I wonder how others handle it.

Political sidenote. Usually my colleague is more vocal than I. But I gotta say something about Rush Limbaugh. He said we shouldn't donate to Haiti relief because 1) the contributions will probably be filtered through and used by the democratic party and 2) Obama is only supporting Haiti in order to unite light skinned with dark skinned blacks. Also, Pat Robertson says that Haiti is being punished because they made a deal with the devil. Look, I am a simple, very white Christian redneck, and these are some of the most offensive things I have ever heard. What is America supposed to do? Nothing?

Sports sidenote. I love the NBA. Former season ticket holder for 2 years (team to remain un-named). I love guns (owned them more than 20 years.) That said, what are you thinking, Gilbert Arenas? If a normal, non-NBA person brought a gun to the stadium, they would be screwed. If you want to keep them away from your kids, buy a safe. Don't take them to work. Just dumb.
Peace and Love, people.
-Psych Doc