I want a great-grandchild

Recently I took care of a 16 year-old who stated she was experiencing vaginal bleeding and had not had her menstrual period in “about 2 months”. The patient was accompanied by her grandmother who stated the patient had a positive result on a home pregnancy test taken 2 days ago. “It was the best money could buy!” Both the patient and her great-grandmother were concerned for the vaginal bleeding. Since the timing of the patients last menstrual period and her current vaginal bleeding raised my concern for an ectopic pregnancy, an evolving pregnancy that is growing outside of the uterus, which is a dangerous life-threatening condition, I ordered some blood work and a pelvic ultrasound to assess the patient’s condition. As I interviewed the patient I inquired if this pregnancy, her first, was planned or unexpected. Both the patient and the grandmother (who looked like she was about 50) assured me that this pregnancy was planned. “She’s getting married in 2 months!” the grandmother informed me. Upon further questioning the patient had dropped out of high school, earned her GED, was planning on marrying her 16 year-old sweetheart, and they felt they were ready to start a family -- even though neither one of them had a job. Grandma didn’t appear to be rolling in the dough either. I was supportive and I congratulated the patient on earning her GED. I also encouraged her to go back to school to gain a marketable skill after her current pregnancy. After an hour when the patient’s studies had been completed, I returned to the exam room to inform these ladies that the patient had no pregnancy in her uterus, no pregnancy outside her uterus, and, furthermore, had no circulating pregnancy hormone in her blood. The patient was not pregnant despite the reported positive test at home. The patient took the news well, and I told her that since she wasn’t pregnant it might be a good idea to start birth control and get a career started before starting her family. Unfortunately grandma was not interested in that advice and she told me “I’m ready for a baby!” Then she proceeded to reassure her 16 year-old granddaughter she could start trying to get pregnant right away. I walked away literally shaking my head wondering why grandma was pushing so hard to get this teenager pregnant and thereby assume an enormous responsibility that would last the rest of her life. Why not let this girl enjoy the rest of her childhood before reproducing. At least let her get a job so that she could support the child rather than expecting the government to provide care. A few minutes later my nurse came to tell me that grandmother had really blown up when the nurse had repeated my advice – this nurse had also been a teen-aged mother and knew what she talking about. Apparently grandma was tired of having other people tell her grandchild what to do – that was her right – and she and the patient stormed out of the ER. Presumably to go find the patient’s future baby daddy and get back to work attempting to reproduce.

Holy noodles!

Everyone who has worked in an ED for any amount of time is going to accumulate stories about people who enjoy putting various objects in their god-given orifices to gain whatever thrill it offers. I cannot imagine the full extent of who is stuffing what where on any given night because in the ED we only encounter these people on the occasion that whatever they decided to introduce into their bodies becomes impossible for them to retrieve at home. I estimate that we only encounter a small sampling of the foreign body inserters since I imagine the larger population manages to retain control over their artificial sexual supplements. The “victims” often show up in the ER complaining of abdominal pain, but it is rare that they’ll admit to the triage nurse that the source of their abdominal discomfort is an object in their rectum or vagina that never was meant to be in there. In fact, they are often reluctant to confide in their doctor what is creating their distress. Instead they will often wait until an abdominal X-ray reveals a large bottle of distilled water resting not so comfortably in their bowels. They will feign surprise “oh my! how did that get in there?” or claim a random accident “I slipped in the shower and fell on it”, or, my personal favorite, they blame someone else “my wife stuck it there – I didn’t know what she was doing!” OK. How the hell would someone NOT know how a 1 liter water bottle got lodged up their ass? And how does falling on a water bottle magically make it fly up their butt? I have fallen on a lot of things in my life, but they didn’t end up up there. And finally, what the hell was going on that they lacked the awareness that their wife was shoving a large inanimate object where the sun doesn’t shine???
Anyway. My favorite story was actually treated by a friend of mine who saw a patient that had accomplished an amazing (by some standard) feat. He had succeeded in shoving about 20cm of a pool noodle into his rear-end. Yes, I am talking about those long Styrofoam floatation devices used by the aquatically-challenged. I seriously doubt that they were ever marketed as or intended to be used as tools for the “sexually adventurous”, but people do get creative. I only hope this particular noodle was not pulling double duty by performing its primary function while lodged in this guy’s butt. To make this particular story even more impressive this patient had not only wedged 20cm of pool noodle into his behind, but he folded it IN HALF prior to insertion and thereby was enjoying a DOUBLE DOSE of pool noodle!! I don’t even think he tried to lie and say he slipped in the poolside shower and landed on it. I believe he was one on the ones whose wife placed in his butt while he was “completely unaware”.
WARNING!!! PLEASE DO NOT TRY THIS AT HOME!!

I don’t need a work excuse

This past Monday was a typical busy Monday in the emergency room; I was literally running from room to room taking care of patients. Just when I would begin to think I was getting caught up and getting things under control the paramedics would bring in a patient in who had low blood sugar and was actively seizing or someone in severe respiratory distress unable to breathe. In the middle of all the insanity that exists in an emergency room on a Monday I hustled into an exam room to evaluate a patient with foot pain. It only took a few minutes to interview this patient, determine he was suffering from an episode of gout, and formulate a treatment plan. Initially when I had been taking his medical history he denied having any medical problems, but when I started to talk about pain medications he admitted that he took vicodin, soma, and xanax daily. I was a bit surprised since this 47 year/old man had just told me he had no medical problems. Upon further questioning he revealed that he was on pain medications for chronic low back pain and degenerative disc disease. Fine. After giving him my lecture on the dangers of chronically using and becoming addicted to these known drugs-of-abuse, I added a strong anti-inflammatory to his regimen to treat his gout. I also recommended that he elevate his foot as much as possible for the next few days and I asked him if he needed a work excuse for 2 days of rest. Imagine my surprise when this 47year/old healthy male with no medical problems except chronic back pain informed me that he didn’t need a work note because he was on disability! He didn’t have to work because some idiot doctor had signed disability paperwork for this individual who was perfectly healthy. During my exam he had no evidence of back pain or discomfort, and, other than his current episode of gout, he had no physical impediment whatsoever! Sure he had back surgery, but many people have had back surgery. I had back surgery 20 years ago and I am still working. I never even thought to apply for disability. Unfortunately, during all these years of work I have been contributing tax dollars not only to improve our schools and roads, but also to support this perpetrator of disability fraud and the millions of others like him throughout the country. Today, while schools are closing and teachers are increasingly overburdened with larger class sizes, minimal support staff, and decreasing resources, money that could be improving the education of our future generations is supporting drug-abusers who legally obtain their drugs of choice (soma, vicodin, and xanax) by getting prescriptions from unethical providers and having tax-payers pay for them. Today there are “working-poor” who are struggling to maintain multiple jobs and provide for their families without any health benefits. Throughout their struggles their tax dollars are supporting individuals who are too lazy to work and instead prefer to parasitize society for a free ride. Why are we supporting these individuals? Why aren’t we saying “No, you are not disabled and you need to get a job!” Who do I call do report these fraudulent abusers of our strained social services program? And who is going to curtail the practices of unethical providers who give the individuals prescriptions and sign their disability paperwork for a nominal fee? It’s sad the medical profession has allowed these practitioners to flourish. I only hope that with a better national healthcare registry we can finally track the prescribing practices and drug use of this subset of society who are constantly draining our already scarce resources.

Enjoy your Steak

Since the beginning of time man has procured food through hunting and gathering. Whether they were taking down a wooly mammoth, cultivating a vegetable garden, or shopping at a mega warehouse store with millions of products people find a way to feed themselves. Sadly, for a significant part of the population hunting and gathering involves panhandling food on streets, visiting soup kitchens, and, when everything is closed and people are off the streets, scouring alleys behind restaurants to locate discarded tidbits.
A year ago I had a 50-ish year-old homeless person arrive in the ER in acute respiratory distress. She was quite anxious, frothing at the mouth, turning blue, and really working hard to breath. All she could say was that she had got “a piece of steak stuck in my throat”. After I alerted the pulmonary specialist that we may need to scope this patient, I prepared my crash cart, gave the patient some sedatives, and went hunting for the offending piece of food with my laryngoscope. I didn’t have to look far; I discovered something lodged in her esophagus partially obscuring her windpipe. I quickly grasped it with some forceps and, to my amazement and the entertainment of all the staff that were present, I proceeded to withdraw an enormous chunk of slimy, grisly, fatty meat that did not in any way resemble a steak. The patient immediately felt better and her respiratory status improved. She was able to describe that she found this hunk of discarded meat while “dumpster diving” behind a restaurant. Since it was too gristly to chew with her 4 remaining teeth she had attempted to swallow the 5 inch piece of meat whole thinking it would be digested in her GI tract. It was an interesting theory but a dangerous practice. On more the one occasion I have had to code a patient who turned purple, passed out, and arrested at restaurants or in their home. I have attempted to put breathing tubes down patients’ windpipes to ventilate them during the code only to find large hunks of poorly chewed food, often steak, clogging their airways. After removal and ventilation their color would improve, but typically after suffering prolonged periods with no oxygen they would not regain cardiac function and I would have to pronounce them dead. Point is if you’re gonna enjoy a steak then do it slowly by chewing well before swallowing, and, just in case your enthusiasm overcomes your common sense, have your family trained to perform the potentially life-saving Heimlich maneuver. Oh yeah- if you only have 4 teeth then stick with soft food!

it burns when i pee

another one for the list of ER moments that suck:

telling a 16y/o girl that the painful "tears" on her vagina that burn when she pees are not abrasions from her tight jeans like she thought but are actually a horrible case of herpes that she contracted from her 18y/o boyfriend with whom she is having unprotected sex -- the first boy she has ever boinked. i had to explain that herpes is a viral infection that will rear it's ugly head intermittently for the rest of her life. nothing like getting an incurable lifelong disease from your first boyfriend. i also got to tell her that the stinky yellow vaginal discharge she is experiencing is from the gonorrhea her boyfriend had also passed along to her.

unfortunately her mother did not speak english and after i explained it 3 times in spanish she still could not understand how her daughter got this infection since "she told me she doesn't have sex". sorry mom, but yes she is having "relaciones sexuales" and it is with a very dirty boy. i also had to explain that she also needs to go to a public health clinic and get tested for syphilis and HIV since her boyfriend has obviously been around the block a few times and she is at risk.

mom was stunned, but my poor patient was crying her eyes out and trying to cope with the horrible news. i did share the good news that at least she isn't pregnant.

i only pray her HIV test is negative.

I want peaches!

There’s nothing like taking care of a patient who uses their medical acuity as a bargaining chip to manipulate doctors and nurses. I had a patient come to the ED recently complaining of generalized weakness and fatigue. This patient had kidney disease, and he was intermittently on hemodialysis. He was a very thin malnourished man who looked like personal hygiene was a foreign concept and any attempt at self-care was unfathomable. I was concerned about his health status and wanted to do some blood work to check his electrolytes for potentially dangerous abnormalities. His initial ECG was normal so I was less concerned for immediately life-threatening abnormalities, but I was still concerned for evolving conditions. Unfortunately this patient was one of those “difficult to get access” patients meaning getting an IV in this guy was a lot of work. After several of my best nurses failed to gain access I was called to the bedside to place an IV. This was not an uncommon situation, but the fun thing with this particular patient was that he was refusing any more attempts until “I get some dinner”. Now I understand this patient was probably hungry – he certainly looked like he hadn’t been eating well- but the ED isn’t really well-equipped to cater to nutritional needs of patients. We operate an emergency room. I can’t think of one situation where providing a meal-tray could avert a life-threatening problem. We do try to be accommodating as much as possible, and when a patient is medically cleared we try to provide them with whatever food we have available. However, trying to determine if a patient has a life-threatening condition while they refuse to cooperate isn’t the most fun thing to deal with in a busy ED. My nurse was able to get him a meal tray in an attempt to bribe him to let me place an IV line and obtain blood for analysis, but he took one look at it and asked “where are my f$#king peaches – I want me some f$#king peaches”. Great. I don’t keep peaches around the ED. Why do people come to the ED asking for help and then make impossible demands which impairs the delivery of care? I felt like telling him “look buddy- you came to me”. I finally coaxed him into letting me put an IV in his external jugular vein and that’s when things got even more interesting. Try sticking a needle in someone’s neck while they are maintaining a running litany of profanity and threatening you with physical violence if you don’t succeed “because they already stuck me enough!”. Of course the IV blew. Blast. The patient didn’t carry out his threats, but he stepped up his swearing and continued to demand peaches. Another meal tray later and I was able to coax the patient into one more IV attempt even though I still hadn’t been able to procure any peaches. “I still want me some G-D peaches!” thank god that attempt was finally successful – blood was obtained, fluids were given, and the patient’s medical status was stabilized and laboratory abnormalities were addressed when the results returned. All accomplished despite the patient’s multiple attempts to block delivery of care. The patient was admitted to the hospital for extreme failure to thrive and malnutrition, and a special request was submitted for peaches on the patient’s dinner tray.

“Don’t tell him that!!”

I had gentleman come to my ER the other night complaining of pain in his lower abdomen as well as nausea and vomiting for the past day. He looked pretty uncomfortable and his lower abdominal tenderness was slightly more on the right side raising the concern for acute appendicitis. I wouldn’t say he had a classic presentation – he had no fever or anorexia , and his tenderness did not seem like a slamdunk appy – but his symptom complex was suggestive. In the past patients like this could be monitored for evolution of their symptoms with close surgical follow-up. However in this day of litigation combined with the ease and availability of obtaining a CT scan, it is almost mandatory to perform this imaging study. The majority of modern surgeons won’t even examine a patient unless a CT scan has been obtained. Even in cases of a classic appendicitis presentation when there seems to be no doubt clinically regarding the diagnosis surgeons appreciate the imaging study to prevent operating on the occasional patient who has mesenteric adenitis or right-sided diverticulitis which can mimic appendicitis and do not require surgical intervention. Imaging also helps define any complications such as perforation which assists with operative planning. In the case of my patient there were many reasons to pursue imaging to evaluate the cause of his abdominal pain however he was concerned about the cost. At $7-10K to scan the abdomen and pelvis his concern was understandable. Not to mention the radiation exposure which is not trivial in these CT scans. The patient revealed that he was only able to obtain part-time employment at his factory, and, unfortunately, he was not eligible for health benefits. It is sad that he was willing to work and actually had a job, but thanks to a poorly functioning healthcare system that leaves huge gaps in coverage of our population this patient was going to have accept responsibility for a huge hospital bill. Since the patient’s wife was in the examining room with him, I inquired if she was working and had access to benefits. She responded “I don’t work”. Now come on- it’s easy to blame the system when people are making the effort and still are not covered, but where is the personal responsibility. I suggested to the patient’s wife that she go get a job somewhere like K-mart or target. Maybe it’s not glamorous and the pay isn’t fantastic for low-level positions, but I have relatives and friends who maintain this type of employment solely for the benefits. It might not be worth a pay-cut if you already have a job with good compensation, but if someone is not working then some pay is more than none and the health insurance alone can add several hundred dollars worth of benefits to your monthly salary. Try going out and purchasing health insurance privately as an individual – it’s expensive. I had to pay $250/month for a basic HMO when I was a young healthy waiter struggling to put myself through school. I had to work 3-4 extra shifts each month to afford limited insurance, but at least I was covered. I have never gone without auto insurance, and I think the same thinking should be applied to health insurance. Sure it’s easy to blame the government, but ultimately the individual is responsible. And there are options. When I suggested to my patient’s wife that she get a job I explained that she would probably only have to work 30hours/week to qualify for benefits. She replied “don’t tell him that! I don’t want to work!!”. She didn’t want to work. Even for 30 hours a week. She probably logged in more hours than that watching TV. I mean come on – even if she was raising children she had a husband who was only working parttime and there had to be time to split the household responsibilities and still work for 30 hours/week. This is the not the 50’s when men worked and women stayed at home. In today’s economy anyone who can work should be seeking employment, appreciating the opportunity to earn a living, and contributing to our progress as a society. I always wanted to work, and I started working fulltime when I was 15 years/old. Most of my life I have held down 2-3 jobs simultaneously and gone to school. It is difficult for me to comprehend how someone can not want to work especially when their family has no medical insurance and one medical problem could present financial distress ranging from draining a small savings account to forcing a family into bankruptcy. Unemployment is a luxury only the independently wealthy can truly afford. Think about it.