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.

his first GSW

had my youngest gunshot wound victim the other day.
7 years old!
his friend had just received a BB gun and a one of the first shots ricocheted off a metal fence and hit my patient in the chest. the patient looked fine and his wound was pretty unremarkable, but x-rays quickly revealed a BB embedded in the middle of his lung!
oops.
didn't puncture his lung bad enough to show up on x-rays, but he still got to ride in an ambulance when i transferred him to the children's hospital. he was cool as a cucumber the entire time - it didn't phase him at all.
hopefully this will be his last GSW.


of all the things i wouldn't want to be allergic to...
i had a patient (quite uncomfortable) who complained of having a itchy and painful allergic reaction to (drumroll) spermicide on a condom
ouch!

Stuffers

Working in an urban ER exposes you to all aspects of drug use, marketing, and abuse. I’ve had patients shooting up heroin in the ER, dealers are always hanging around outside ERs offering their products, and every other patient has a substance abuse problem. Body packers or “mules” are brought in by border patrol after they are discovered smuggling drugs into the United States in their stomachs. These patients are usually from South America, Central America, or Mexico, and they have swallowed many latex packets the size of large grapes that are filled with heroin or cocaine. After arriving in the US they are picked up by their contacts and the drugs are collected when they exit the body with the assistance of laxatives. Our job in the ER usually is to perform whole bowel irrigation which is a fancy way of saying we give them Go-lytely which is an osmotic agent they causes watery diarrhea to evacuate the bowel of all its contents. The border patrol agent usually handcuffs the patient to their bedside commode and nature takes its course. The real problems arise when one of these packets rupture and spill their contents into the bowel where it is rapidly absorbed into the blood stream leading to a massive overdose. A similar phenomenon occurs more commonly with body stuffers (as opposed to packers). These patients have swallowed their goods as they were being arrested by police to avoid charges of possession. They are usually under the assumption that since their crack or crystal is in a baggie they can save it and will be able to retrieve it later. Unfortunately simple sandwich baggies are rarely air-tight and the drug can still be absorbed - often with disastrous results. I had a 25 year-old patient brought to the ER by medics after he swallowed a baggie of unknown contents while trying to evade the police. The patient initially appeared well to the medics, but his heart and blood pressure became quite elevated enroute to the ER. He then began seizing as his body responded to a massive influx of amphetamines that he had swallowed. The patient was still seizing when he arrived in the ER and I gave him large doses of benzodiazepines as well as sedatives to control the seizures. I also quickly paralyzed and intubated him meaning I placed a tube was in his windpipe and put him on a breathing machine to protect his airway and ensure oxygen delivery to his brain and other organs. This young patient was admitted to the ICU and monitored carefully. After 2 days he was extubated (the tube was removed) and he was taken off the ventilator. He was able to breathe for himself, but unfortunately due this patient’s prolonged seizures he had suffered an anoxic brain injury – he basically had a stroke from not getting enough oxygen to his brain while he was seizing. He was what people call “a vegetable”. He had intact primitive functions such as breathing and respond to painful stimuli, but he had no higher brain function and couldn’t perform any meaningful activity. At 25 years old a young, otherwise healthy man had effectively committed suicide when he ingested that baggie of drugs to avoid what probably would have been a short incarceration for possession. The patient was eventually transferred to a long-term care facility specializing in patients with neurological problems ,and he will probably spend many years, the rest of his life, receiving care and therapy with minimal progress.
How's that for depressing? sorry but it was a long week...

congratulations!!

tonight i was examining a patient who came to the ER with complaints of low back pain. part of her work-up included a rapid pregnancy test, and the patient was quite suprised to find out that she was with child. i ordered all the usual "oops, i just found out i'm pregnant" labs with a pelvic ultrasound to make sure her pregnancy was in her uterus. while awaiting the ultrasound i performed a pelvic exam to get a look and her cervix, and i was dismayed to see some fluid coming from her uterus which appeared to be a precursor to a miscarriage. i kept a straight face and sent her off to ultrasound. about 30minutes later my ultrasound tech came running up to me,

"doctor, she's gonna have a baby!"

"she's not having a miscarriage?"

"no she's 38 weeks pregnant!"

oops...

i quickly went to the patient's room to share the good news.

"good news! you're gonna have a baby!"

"i know, you told me my pregnancy test was positive."

"no, you're gonna have a baby NOW!"

the patient was stunned to learn that her low back pain was the beginning of labor and she had had no idea that she was even pregnant. unfortunately when you weight 350 pounds an extra 30 can easily go unnoticed, but i would think the abscence of a menstrual period for 9 months would have tripped alarms at some point!

after letting the patient call her husband to share the news, i transferred her to labor and delivery where she could continue birthing her baby that had zero pre-natal care.

Bad people happen to good people

I often see assault victims who were injured while they were "minding my own business". typically they are either drunk, belligerent, or covered in gang tattoos. sometimes they are all 3 and there is no doubt that they doing something other than minding their own business. occasionally i do see victims who were actually innocent bystanders...

Pleasant gentleman was taking out the trash late at night after work. as he went to the dumpster behind his building he unknowingly interrupted a break-in in progress. He was shot once and the bullet travelled through both thighs. Luckily it was a clean shot with no nerve, muscle, or bone damage, but still…one minute he was diligently performing his job and the next he was a gunshot wound victim.


Nice 14 year-old kid was walking home from football try-outs after school (lives in one of the less desirable parts of the city) when he was stabbed in the arm by an older teenaged thug. In-and-wound right above elbow. Patient arrived tot he ER bleeding profusely from a brachial artery wound and he also lost ulnar nerve function due to laceration. He was sent to the OR for surgical management, and he can forget playing football this season.

3 bridesmaids were brought screaming into the ER after they were shot during a drive-by shooting of a wedding in progress. Enough said on this one...

Still Smoking...

Several times each shift I encounter an older male or female with emphysema from prolonged smoking who is brought in to the ER after calling 911 because they are short of breath. (really- you’re having trouble breathing after smoking for 30 years? Go figure). By the time they get to me they are often starting to feel a little better after getting nebulized albuterol and supplemental oxygen from the paramedics. I throw in some steroids and more breathing treatments in addition to some antibiotics if they are hawking up a lot of phlegm, and if they still can’t walk around without dropping their blood oxygen saturation I admit them to the hospital (again) for more rounds of treatment. My personal favorite was a fairly obese woman, probably 350 pounds, who was brought in by medics regularly for altered mental status due to hypercarbia – meaning she had destroyed her lungs so much that she could barely breathe enough to exhale and off-gas all the carbon dioxide her prodigious body was producing. Too much carbon dioxide leads to hypercarbic narcosis which is an altered mental state that further impairs the ability to breathe and the patient spirals down from there. This patient would arrive to the ER and get intubated (time after time) so that we could mechanically breathe for her and reduce her sky-high carbon dioxide levels. The really sad thing was that the patient’s sister (who also is a smoker) would see the patient getting sicker and sicker and would try to get the patient to call 911, but the patient would persistently refuse because she knew she wouldn’t be allowed to smoke in the hospital. So the patient’s sister would watch carefully while they patient chain-smoked herself into a stupor – often still with a lit cigarette between her lips or fingers- before calling 911 for a trip to the hospital and another lengthy and costly ICU stay. I have walked into exam rooms to see a patient and have almost choked because my patients were giving off fumes so bad I could swear they had just smoked a pack in the room. I’ve had to apologize and open the door so I could breathe enough to complete my history and physical exam and decide how to treat the patient. Then I would leave the room gratefully breathing in (relatively) fresh air only to discover that I could taste the sickening flavor of tar on my lips and smell the smoke on my scrubs just from being close to these people. They smoked so much it stained their fingertips, impregnated their hair, and gave them breath that would cause me to gag when I had to examine their oral cavity (when your patient’s breath smells worse than their ass you know you’re in trouble). I can’t judge to harshly because I smoked while growing up, but after seeing the long term effects that have destroyed so many people- some of them very endearing and pleasant patients- I am glad I dropped that habit before I developed emphysema and had to make weekly visits to the ER for shortness of breath.

You swallowed a what?

Yesterday was an especially brutal shift in the ER. We have been short a doc on the schedule for the past 4 days. Since there are only 4 docs covering a 24hour period in a our community ER, losing 25% of our coverage is a pretty big hit and we were all working overtime. Anyway, I’ve been busting my butt, skipping the gym, going into intense work-mode to get through this short period of work-hell, and I was actually doing pretty good. Aside from a brief melt-down in the middle of my shift when I somehow managed to use the f-word 6 times in one sentence (it can function as a noun, verb, adjective, and adverb) I mostly held it together. Everything was rolling along Saturday afternoon with the typical assortment of young women complaining of vaginal bleeding and elderly men presenting with chest pain when one of my nurses yelled out the thing I never enjoy hearing “doctor, there’s a baby who can’t breathe!”. No hesitation, no drama. I got my ass in that room and found a 2 month-old boy gasping for air and turning blue. Quickly activating my team, we got an IV in and I intubated the kid which quickly stabilized his condition. A stat chest x-ray revealed bilateral pneumonias which were the underlying cause of his respiratory failure. After starting antibiotics and arranging critical care transport to the children’s hospital ICU I walked back to my work station, sat down, and then it hit me – this kid was the youngest patient I had intubated. My eyes actually started to tear-up when I realized how close he had come to dying, and the full gravity of my position hit me. It’s one thing to resuscitate adults and elderly people who have lived a long life, but being responsible for the life of a 2 month-old in critical condition is a whole different experience. I took a deep breath, said a silent thank-you to the doctors who had trained me, and got my butt back to work.
Unfortunately during the 30minutes I had spent stabilizing the 2 month-old a tour bus must have unloaded into our ER because suddenly there were about 16 new patients clamoring to be seen by the doctor. Sometime after seeing a 45 year-old guy with chest pain who was as white as sheet after he unknowingly crapped out most of his entire blood supply presumably from his stomach ulcer and diagnosing an unfortunate 1month-old with bacterial meningitis I got a call from medics in the field who were bringing in a women who called 911 after swallowing her toothbrush. Yes, you heard me right – she swallowed her toothbrush. WTF? How vigorously does someone have to be brushing their teeth to ram their toothbrush down into their esophagus? Why didn’t her gag reflex kick-in before she ended up with dental products invading her GI tract? And most important, was it an electric toothbrush? I had a thousand questions, and I couldn’t wait until she got to the ER so I could find what had happened. After several anxious minutes of anticipating this patient’s arrival, she showed up and it quickly became apparent that the biggest factor contributing to her foreign body ingestion was some liberal ingestion of ilicit chemicals. No surprise in our ER. This patient was sitting on the medics’ gurney zoned out on benzos or opiates or probably both, and she calmly explained to me that she had eaten too much for dinner earlier and had decided a little artificially-induced purging would be a great idea. Unfortunately she must have abolished her gag reflex years ago, god only knows how, and thanks to her inebriation things quickly went south, literally. One minute she’s happily tickling her tonsils and then oops- where did my toothbrush go? Oh shit, that’s not going to feel so good when it comes out the other end. My GI specialist was thrilled when I called him in the middle of the night to come to the hospital and retrieve the toothbrush my patient had misplaced. He wasn’t too surprised. Apparently this was the second ingested toothbrush of his career. Not that I ever doubted there would be two similar idiots in the world, maybe they were twins separated at birth. The extrication went well. The Reach toothbrush that went were no toothbrush was intended to go was recovered and unfortunately released back into the custody of the patient. She gratefully reclaimed it and was appropriately amazed that it had almost made it into her stomach. Undoubtedly she will resort to more shenanigans involving toothbrush-induced vomiting next time she takes valium and eats too much dinner.

Aspiring alcoholics

I’ve had more than enough teenage girls show up in my emergency via ambulance wasted and out of their minds after a weekend (or school-day) binge. Alcohol abolishes their inhibitions and exaggerates their underlying borderline personality disorder unleashing the terror of uncontrolled and unedited adolescent angst. I have had them screaming “f$#k you stupid f%#king f$#kers, I f$#king hate your f$#king guts!” at the top of their lungs while crying hysterically with their – always black- eyeliner streaking down their faces. It’s fantastic for morale in an over-crowded ER often filled with sick children and elderly patients. On more than one occasion I’ve had multiple teenaged offenders performing duets of profanity – as soon as one would start screaming how her life sucks and she hates everyone another drunk in another part of the ED would wake up and add her opinions of how her life sucks worse and she hates everyone in the entire universe. As each one attempts to outdo the other it escalates into a deafening stereo performance of anger, frustration, and hate - juvenile anguish in surround sound. What’s not to love? These potty-mouthed princesses must surely be a source of pride and joy for their families – too bad it’s against the law to you-tube their behavior to the world, or better yet post a little video on their facebook profile for all their friends to enjoy.
Occasionally I have been a little slow with chemical sedation thinking we could keep them calm and complacent as they sleep off all the alcohol they had consumed. Unfortunately I had a soft spot for the wasted teenagers, and I was somewhat optimistic they would behave themselves– a naïve and dangerous perspective for an EM doctor. It never works. You can’t reason with a drunken adult, and it’s even worse a drunken teenager who already believes that anyone over the age of 18 can’t know anything about anything. Now I just sedate them at the first sign of belligerence and let them metabolize their indulgences without any drama. Chemically –induced complacency helps to avoid all kinds of unpleasantness. These teenaged drunks are labile powder kegs that can explode with no observable trigger. In 1 second they can go from resting comfortably oblivious to the world, and the next second they are screaming epitaphs, ripping out their IV catheters, and jumping out of their gurneys to sprint down the hall ass to the wind flinging blood all over the place while threatening bodily injury to everyone who is risking their own health and well-being to get them back under control. You may think it isn’t hard to subdue a 16year-old girl, and theoretically it isn’t, but try it with an uninhibited drunk who is bleeding all over you and who isn’t afraid to use her fingernails and teeth. Not fun. And to top it all off, you have to subdue them without hurting them while they are kicking and screaming and trying their best to hurt you. It’s not an easy task.
Once I get my drunken teenagers chemically or physically restrained – often both- I like to put them in the room with the dirtiest, smelliest, crunchiest drunk that is sleeping it off in the ED. I want these aspiring adolescent alcoholics to get a glimpse of their future if they continue on their paths of self-destruction. I don’t think they often get it, but once in awhile one of them will wake up sober with a killer hangover ready to be discharged to home. As they put on their cold clammy pissed-in hip-hugging jeans, they get to witness their decrepit, disheveled, malodorous roommate who has also soiled themselves. Sometimes they make the connection – this smelly, crusty lady is an adult version of them and one day that will be passed-out in their filth while another “innocent” teen-ager gapes at them with horror. You can lecture a teenager for hours, and, unfortunately, due to normal human development they all insist nothing wrong could ever happen to them. But a picture is worth a thousand words, and occasionally one of my patients will take note and recognize the scary possibility that their life could become that of the filthy, toothless, tragedy of reality that is sleeping in the next bed.

chronic pancreatitis

I had a patient come to ED last night complaining of abdominal pain with nausea and vomiting. This 32 year/old female claimed to be suffering from chronic pancreatitis that was so severe that she could not work and was subsequently collecting disability. In case you don’t know, the pancreas is responsible for producing many of the digestive enzymes that are released into the gastrointestinal tract to help breakdown food. Inflammation of the pancreas, pancreatitis, is most commonly caused by gallstones or excessive alcohol consumption which creates a condition were the digestive enzymes are released into the pancreas itself inducing a state of auto-digestion of the pancreas which can vary in severity and symptoms and usually include severe abdominal pain with nausea and vomiting. There are other much less common causes of pancreatitis including scorpion stings and “cryptogenic pancreatitis” (can’t figure out what caused it). This patient denied a history of gallstones and alcohol and told me her doctors had been unable to find a cause. As I reviewed her records I confirmed that she had been to our hospital on many occasions for abdominal pain with several admissions for pain control. The discharge summaries described unremarkable work-ups with only occasional mild elevations in the patient’s measurable pancreatic enzymes. However, the summaries were remarkable in their descriptions of this patient’s demands for very specific pain and anti-nausea medications. The patients insisted on the medications that are known to induce euphoria (get you high) and she demanded they be given intravenously (for a better high). At the same time she refused traditional interventions for pancreatitis such as a nasogastric tube which is placed through the nose to decompress the stomach. She also refused anti-nausea suppositories which are very affective medications placed in the rectum when a patient cannot tolerate oral medications. Now refusing to have things shoved up your nose and bottom may not sound too unreasonable, but typically patients that are suffering from a case of pancreatitis that is severe enough to warrant hospitalization are usually so miserable that they will try anything to feel better. Not this patient. When she arrived in my ED she was accompanied by her mother, and she appeared quite distressed. She was intermittently writhing in pain, stopping occasionally to retch but was unable to vomit. The mother informed me that she too suffered from a chronic pain syndrome and went to the same pain management clinic as her daughter (great- now chronic pain is genetic?!?). I ordered a panel of labs to elicit the cause of the patient’s pain and assured her I would give her medications for her pain and nausea. Of course the patient wanted to know which medications I would be giving her, and I told her “strong pain medications”. However the pain medications I ordered were not narcotics and had no euphoria or sedative qualities. When the lab reports returned they were stone cold normal with no evidence of pancreatitis. This absence of findings did not surprise me, nor was I surprised when the nurse reported that when he went to administer the patient’s pain medication and she found out it was not a narcotic she stated “it’s not going to work” even before getting the medication. The patient continued to carry on with her writhing and retching. Actually she only writhed and retched when she had an audience (especially when her father was at bedside), but when a nurse or I entered the room unexpectedly she was always resting comfortably for the seconds until she realized she was no longer alone and then she would be wracked by paroxysms of pain. Her performance was good enough to get an Oscar nod, and her poor father was certainly distressed by her theatrics. After I reported the unremarkable results of her studies and prepared to discharge the patient I offered her a dose of the medication she so desperately wanted. As I confronted her with the evidence of a benign work-up I pointed out that her behavior in the ER was concerning for drug-seeking. After I let her yell at me for 2 minutes I calmly pointed out to her father that when she was distracted her seemingly intractable nausea and retching completely disappeared. The patient really didn’t like this statement and told me “as soon as you leave I’m gonna start puking again!” and she immediately returned to her non-productive retching. OK- she just had her Oscar nod revoked.
Who knows how many ER visits, hospitalizations, CT scans, and procedures this patient underwent for her “chronic pancreatitis”. I learned that the pain management doctor she and mother visited was arrested for prescription drug-trafficking. Warning- big red flag. And somehow this patient had been put on disability so that her drug addiction, her entire life, is being supported by taxpayers’ money. What a great system. In addition to her frequent hospital visits for what is largely a fictitious disorder, taxpayers are also paying for her to go to pain clinic and get large amounts of drugs which ensures she will stay addicted to drugs and continue her lifestyle for what will probably be 3-4 decades. Her and probably 10’s of thousands of others…

Why are you here?

New mother and father come to ER with their 1 month-old baby and mom tells me:

“my baby is having large bowel movements after she eats”

and that’s a problem because…
most people get worried when their kid doesn’t poop.
of course the kid looked fantastic and the parents were reassured, but I have a feeling i’ll be seeing a lot more of these new parents over the next year.
People should have to read a book and take a test on childcare before they are allowed to reproduce.

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an 18 year-old girl arrived in the ER via ambulance.

She called 911 after becoming dizzy and nauseated while enjoying the rides at the county fair.

What?
Isn’t that kind of the point?!?
If I didn’t get dizzy on the Scrambler I’d want a refund.

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30 year-old intoxicated female arrives in the ER tearful and stating:

"i just want to go home!"

so why are you here?

"the police told me i could either go to the ER to get sober or go to jail."

?!?
the choice was obvious to me...
(this happens A LOT more than you would believe - can't really blame the PD since they already have their hands full and don't have much time for people who are wasted in public. unfortunately that means i get to play "babysit the obnoxious drunk")

911 taxi service

Recently an 18 year-old girl was brought to the ER by ambulance stating her left arm hurt and that she was feeling quite anxious. The patient was assessed by our triage nurse and since there were already about 5 patients in waiting to be seen, this patient, who did not have a life or limb threatening condition, was appropriately sent to our waiting room until a bed was available for further assessment by a doctor. Within several minutes of sitting in the waiting room the patient’s father showed up, became quite angry, and started yelling at the front desk staff. The father demanded to know why the patient was not already in an exam room. “She came in an ambulance!” He had a point, the patient did indeed arrive in an ambulance, but the paramedics revealed that the patient had actually driven to within 1 block of the hospital and then pulled over and called 911 to take her the final block. Instead of driving 90 more seconds she had waited 6 minutes for medics to arrive and transport her the final distance. As I reviewed the patient’s electronic medical record I found that the patient had been seen in the ER the day before for a skin rash. The patient had waited in the waiting room and then had received a medical screening exam by a physician’s assistant. At that time the examining physician determined that shedid not have a condition requiring emergent treatment, and he advised the patient to use an over-the-counter lotion and follow up with her primary care provider. Apparently the patient decided that another screening exam would be inadequate so this time she decided to arrive in the ER by ambulance so that she would be seen quickly and not have to wait in the waiting room. The patient and her father were furious that her ploy had failed and now she would have to wait - just like everyone else. Apparently dissatisfied with his daughter’s care the patient’s father went outside and called 911 to transport the patient to another ER for assessment. Boy was he pissed off when medics informed him that their responsibility was to transport patients to the nearest available ER capable of treating the patient, and they were not a free taxi service that could drive patients around while they shopped for an ER where they would not have to wait. Since the nearest ER was the one where the patient was currently located the medics stated they would not transport the patien. Obviously the patient and her father were not planning on paying for the patient’s medical care or transportation, so they felt comfortable completely abusing a system that is designed to initiate stabilizing care for critical patients and transport them quickly to a location where they could receive definitive care. Abusing this system and these care providers by using them as a personal taxi service in an attempt to move in front of other patients who had arrived at the ER by private vehicles is not an uncommon occurrence. It occurs several times each shift that I work. Patients are never responsible for the costs, either because they have medicare, private insurance, or veteran’s benefits, or because they simply do not plan on paying when they are billed. It’s amazing how many people aren’t intimidated by the threat of collection agencies. Instead of visiting their primary care physician or a community clinic which would be more appropriate for their complaints they come to an emergency room to receive treatment. If they do receive care it is going to cost them(or at least be billed to them) many times the amount they would pay for the same care at a clinic simply because the cost of operating an emergency room is much higher than operating an outpatient clinic. However, since they are not responsible or will not be taking responsibility for the bill they show up anyway demanding immediate attention and treatment -- often in an ambulance, thereby wasting money and resources without any regard to the crisis in medical costs and resources that exists today.

What’s that smell?!?

Last night I took care a patient who arrived in the ER complaining that she had “a ball in my cootchie”. Despite my initial thought, it turned out she did not put a round object into her va-jayjay, but she actually had a large painful mass on her labia. Apparently this patient had had this mass for about 10years and it would come and go without getting too large or painful. About 2 days ago the mass tripled in size and started to cause excruciating pain while sitting, walking, peeing…just about anything was painful for this poor lady. While examining her I confirmed that shewas suffering from what is known as a Bartholin’s gland cyst, a common condition which is caused by a clogged duct in the labia that leads to accumulation of fluid and pus. I explained to my patient that the treatment for this painful lesion was to make an incision with a scapel and drain all the pus out after which I would place a tiny balloon catheter in the incision which would remain for 6 weeks and allow the cyst to drain continuously so the fluid would not reaccumulate. Very few females relish, understandably, the thought of having someone cut into their flower, even with local anesthetic, and since her cyst was one of the largest that I had ever seen we decided to perform the procedure under sedation. I would give the patient medicine to put her to sleep for 5 minutes and when she woke up the procedure would be done and she would never remember it. Now I have drained many, many pus-filled abscesses and most of them smell quite foul, but imagine a cyst that has been growing and receding over 10 years, a pocket of pus that had been putrefying and curdling and increasing it’s disgusting factor over time. Now imagine cutting that thing open and releasing the decaying putrid pressurized fluid into the atmosphere. As soon as I made the incision and the pus started pouring out I knew we were in trouble. My nurse turned green, retched a little, and then fled from the room. Stoically I clenched my jaw and continued draining the abscess by gently probing the cyst with forceps to release all the septated pockets of funk from their biological cave and drain more pus thereby filling the confined room with some of the foulest odors known to man. About that time the little old lady who was sharing the room and was being evaluated for altered mental status (more altered than her baseline dementia) arrived back from getting her head CT. Upon entering the room and catching a whiff of the smell from hell she suddenly woke up and started screaming “what’s that smell!” “what's that SMELL!” Rather than explain to this poor demented that lady that she was experiencing a decades worth of enclosed and anaerobically putrefying bacteria and cells that had been unleashed into the environment like the opening of an old Egyptian tomb I called my ER tech and had the patient rapidly moved to to different, less malodorous, room . The old demented lady kept screaming "what's that SMELL!" all the way down the hall until she arrived in her new quarters. My nurse finally returned to the room wearing a benzoin-enhanced surgical mask to block the funk that now lay over the room in an almost visible haze, and I was able to rapidly complete the procedure and clean the patient’s wound. Shortly thereafter my patient regained consciousness, and, as she quickly became aware of her surroundings, she exclaimed “WHAT is that smell! That’s terrible! Oh my God, what is that! Is that from me??” Uh-oh. Rather than traumatize her further after her ordeal I simply reassured her that the horrible odor she was experiencing was actually the product of the little old lady who had an especially foul bowel movement, probably from all her protein drinks, and she had to be quarantined in another room to protect the rest of the ER. The patient gave a sigh of relief, felt much better with my explanation, and was discharged home blissfully unaware that her female anatomy had been harboring one of the foulest pus pockets known to man.

9 year/old to the Rescue!

Last night I took care of a 50 year-old male who was brought to the ER by paramedics after he lost consciousness at home. Apparently this patient was at home alone with his 9 year-old grandson when he fainted. The quick-thinking 9 year-old helped his grandfather to the ground and then called 911 to get medical support. He also called his mother and grandmother who split up to take care of the child and go to the ER to check on the patient respectively. As I was assessing the patient whose mental status was altered on arrival to the ER I suspected, among other things,that a drug overdose was the cause of sluured speech and slowed responses. I gave him a medicine called narcan which is an antidote for opioid overdoses and he showed mild improvement in his mental status. I stabilized the patient and initiated the normal labs and imaging needed to evaluate an altered patient which included a urine toxicology screen and alcohol level. After leaving the patient’s bedside I took a few minutes to review his old records on the computer and, sure enough, he had had a similar ER visit less than a year ago after overdosing on soma and vicodin. The patient’s work-up revealed nothing remarkable other than a tox screen confirming exposure to opiates as well as benzodiazepines (valium, xanax, etc). the patient’s clinical status remained stable with continued improvement in his mental status and when his wife arrived in the ER she confirmed that the patient did take vicodin, soma, and xanax daily for his chronic back pain. After I finished conversing with the patient’s wife, my nurse pulled me aside to inform me that she recognized the patient and the wife who had both arrived on the same day of the patient’s last admission after they both overdosed on the same medications. The remarkable thing is that, once again, it was the same grandchild who had called 911 to alert medics about his grandparents’ condition.
In a perfect world no child would be exposed to such poor examples and suffer such responsibility, but in reality it occurs every day. Children are suffering while being raised by families in which substance abuse is passed down through the generations. Often this form of child abuse is not even recognized because these pill-popping addicts feel legitimatized because their drugs-of-choice are “medications prescribed by a doctor”. As I attempt to educate these patients about the dangers of this form of drug abuse, I can tell my advice is falling on deaf ears. Even though there have been numerous programs aired on television outlining the growing epidemic of prescription drug abuse, people remain in denial of their problem and fail to see their obvious similarities to street-drug users such as heroin junkies. Instead they insist they have a medical condition that warrants these dangerous medications, and they swear they would be unable to function without their medications. Sounds like the definition of a junkie to me. Meanwhile their children and grandchildren are growing up in a world where they are responsible for calling 911 when their guardian, the person who is supposed to be responsible for the child, passes out after overdosing on the pain medications they should never have been prescribed for long-term treatment in the first place. So much for teaching our children well to let them lead the way in the future.

um...I'm sorry, but this is an EMERGENCY room

young female comes to ER complaining of neck pain...

me: I'm sorry your neck hurts, were you in an accident?
her: not really, i was pulling on my weave but it was stuck on real good and now my neck hurts!
me: ???

middle-aged female complains of pain in her knees...

me: how long have you been having pain?
her: 6 months
me: did you injure them recently?
her: no
me: is the pain worse today?
her: no
me: are you having difficulty walking?
her: no
me: so what brings you into the ER today?
her: i just wanted someone to look at them
me: ???

old guy comes to the ER stating he wants an enema...

me: does your belly hurt?
him: no
me: does it feel distended?
him: no
me: do you feel like you have to go to the bathroom?
him: no
me: why are you here?
him: i didn't take my laxative today and i didn't have a bowel movement so i want an enema.
me: that's it?
him: yes
me: ???

worst part of this story is that he called 911 and came to the hospital by ambulance, and then, after an enema, he wanted me to order an ambulance to take him home because "i don't want to bother my son that i live with and besides my insurance will pay for it!"


POINT: next time you are the in the EMERGENCY with an actual emergent condition please remember that your overwhelmed doctor is desparately trying to get to you, but first he has to wade through the endless tide of bs complaints that are clogging up ERs across the country.

me: ???


ps: "???" is the polite shorthand for WTF

Don’t forget the syrup!

Every ER doctor and nurse is going to have a collection of stories about patients who have inserted objects into their rear-ends, apparently for purposes of pleasure, and then were unable to extricate these objects. These “foreign body” stories often provide a brief period of amusement during what is usually a hectic and/or grueling shift in the ER, and they also give us doctors interesting anecdotes to share with our families the next day. It’s not always funny though. Sometimes the “lost” object may be so far gone into the “nether regions” that it evades our attempts at retrieval and the patient has to be transferred to the operating room. General anesthesia and further attempts at removal sometimes culminate in surgery to open the abdomen and colon to take out the offending object – kind of like a bizarre version of a c-section. Helluva way to end a night of self-pleasure; abdominal surgery is a pretty high price to pay for a self-inflicted condition that could have easily been avoided with a little common sense.
Recently I had a gentleman in his 40’s arrive in the ER complaining of abdominal pain. While interviewing him to investigate his condition he admitted to inserting an object in his rectum earlier that evening and he was now quite concerned after being unable to expel it despite numerous attempts. I could feel a firm mass in his lower abdomen so I obtained an abdominal X-ray to get a better idea of what was going on and to make sure he hadn’t perforated his colon. The X-ray revealed an object in the sigmoid and descending colon that was too large and irregularly shaped to be a garden variety dildo that we usually see in the ER. After administering medications for pain and anxiety so that the patient would be relaxed I was able to feel the object during rectal exam. Despite several minutes of coaching the patient to push while I attempted to manipulate the object we were unsuccessful at delivering the object. Apparently it was hung up on the patient’s coccyx and would not go any further. Frustrated, but not giving up, I had the patient reposition himself on his hands and knees and resume pushing while I directed the exodus of the object which was now hanging free of the coccyx. Since it was no longer hung-up the object was rapidly expelled from the patient’s rectum (almost as if it wanted out), and I successfully delivered a quart-sized Aunt Jemima bottle still full of syrup. Ugh! All I could think about were those TV commercials where an animated matronly Aunt Jemima giggles sweetly and encourages you to buy her syrup to sweeten your pancakes and waffles. I don’t think she ever promoted her product by asking people to buy her, take her home, and stick her up their butt. Yuk! Poor Aunt Jemima, I’d hate to hear what she’d have to say as she approached the asshole of death (“aw hell-to-the-nawh! You are NOT putting me in there!! you better turn this around RIGHT now you crazy sonuvab#tch!). And what was this innocent breakfast condiment thinking while she was trapped for several hours with her face shoved up against his spleen suffocating in his pungent colon (“get me the F*#% out of here!”)-- I can almost hear her muffled screams echoing off the walls of his large intestine. I’m not really sure why anyone sticks objects up their rear-ends, but, come on, what type of sadistic pleasure do they get from reaming themselves with poor ole Aunt Jemima? The best part of this story is that, due to hospital protocols to reduce liability, all tissue or objects that are removed from the human body have to be sent to pathology for identification. Bored pathologists have to file reports of their findings such as “object is consistent with syrup bottle”. At least the object is confiscated and the patient can’t reuse it and end up in the ER again; that is until they lose something else up their butt. Of course the patient had to eat his pancakes plain the next morning, but at least he avoided the OR and exploratory abdominal surgery.

You know you’re in trouble when…

The nurse tells you to “have fun with this one!” when you are on your way to see a patient…
I try and remain optimistic.
Her chief complaint was “having spells”. As I entered the room I noticed a normal-looking obese female sitting calmly in a wheelchair in no apparent distress so I asked her:
“how can I help you today Ms. W?”
when she failed to answer promptly her very sweet and attentive 18 year-old daughter began to give me the details. However I quickly stopped her and told her I wanted to hear from the patient first and then I would want the daughter’s version. So again...
“how can I help you today Ms.W?”
“Oooouuuuwwwwwyyyyyyoooooooouuuuaaaaaaiiiiiiiiiiiihhhhhhhhhhhhhhhaaaaaaaaaa….”
I still don’t know what the hell she was saying or trying to say, but it sounded a lot like she was attempting to speak “Whale” like the little blue fish Ellen Degeneres played in the movie, Finding Nemo. Anyway, after about 10 painfully long seconds of listening to “wwwwwaaaaahhhhhooooouuuu…” and trying to keep a straight face while watching Ms.W contort hers like silly putty as she dragged out every syllable of a word I never did figure out, the words “psych consult” popped into my head and I turned back to the daughter…
“OK, your turn. Fill me in.”
Apparently these are the spells Ms.W has been having. She would, at random times, alternate between speaking Whale (or whatever she was doing) and then speaking like an auctioneer on crack. So after I examined the patient and ascertained that nothing dangerous was going on, I reassured her daughter, stepped out of the room, ordered some basic screening labs, and called my psychiatry team to please come assess this morbidly obese female who was trying to communicate with whales.

improving the human condition or battling natural selection?

I am an emergency medicine physician. A lot of people don’t understand what that means. When I tell someone that I am a doctor they invariably ask “what kind?” to which I reply “emergency medicine”.

“what?”
“I work in an ER”
“oh. I see. So what kind of doctor are you going to be?”

Guess what people. Emergency Medicine is a specialty. We don’t have offices or schedule appointments; we just show up for our shifts in the ER and take care of whatever happens to roll in through our doors. Or, as is often the case with stab, gunshot, and overdose victims, whatever is dumped off on our loading dock. Every shift is different. Sometimes I find it exciting with cases that challenge my intellect and ability to multitask while managing several critical patients at the same time. At other times it is almost overwhelmingly monotonous as I examine the 12th 4 year-old kid with a fever and runny nose that I have seen that shift while trying to stay alert at 3am so I don’t miss the 1 kid out 100 who is actually sick.

Saving lives happens daily. Sometimes it is dramatic and may involve a patient in respiratory distress ready to arrest or a patient with severe hemorrhage from an arterial bleed that is shooting blood across my emergency room. Other times it occurs quietly when I resuscitate a patient with evolving sepsis or initiate treatment for a patient with a pulmonary embolism.

That capacity to “do good” is always present. Relieving pain from symptomatic gallstones or getting a patient with appendicitis to the OR for surgical intervention is always satisfying. The amusement factor in the ER is also quite high with patients getting themselves into predicaments like sticking a pool ball in their mouth and then being unable to get it out or, more often, putting something in their body from the opposite end and then finding out they cannot retrieve it. But, in spite of the satisfaction of treating disease and helping people out of their sticky situations, I often wonder how much good am I really doing? Every shift that I work is also riddled with patients who suffer from disease of their own making. They have substance abuse problems, social problems, and emotional instability with little insight and, often, almost no desire to help themselves. They rely heavily on emergency services as their primary source of medical care. All they seek is stabilization or a quick fix so that they can continue to lead lifestyles that invariably put them right back in the ER.

Every shift that I work involves taking care of chronically, often severely, debilitated patients who have suffered from head injuries, strokes, or just old-age and dementia. Often I see these patients on a weekly basis to treat whatever infection or problem they are currently suffering from. The families demand that I “do everything you can, I don’t care what it is” to save the unfortunate patient who often does not even realize what is going on and has no quality of life whatsoever. Such is the unrealistic expectations of the American public.

Every shift that I work has many opportunities to “do good”, but likewise, in a busy ER where the action rarely abates, there are often even more opportunities for mistakes. Miss one lab, one X-ray, or one physical finding and you could completely miss the diagnosis or administer improper treatment. In today’s litigious society being right 99.9% of the time is not good enough. With that success rate you may still mistreat one patient out of a thousand. I treat an average of 400 patients a month which means that even if I function at 99.99% then every three months I could be at risk for a career-threatening or even career-ending lawsuit. When you consider the inherently chaotic nature of a busy ER where I can be pulled away from the 12 patients I am managing simultaneously to go run a code-blue in the ICU for an hour you can understand the pressure involved in this line of work.

In addition to all this pressure, in spite of the satisfaction of having appreciative patients who have received excellent care, as an ER doctor I am forced to deal with the “repeat offenders” the drunks, druggies , and chronically ill patients that no one can “fix”. I do the best I can. I treat, stabilize, discharge, or admit for further management, but invariably they return in a week or two with the same problem. When I see these patients I have to ask myself “am I really ‘doing good’? Am I improving the human condition by treating these same patients over and over or am I struggling against the forces of nature and battling Darwinism and theory of natural selection?”

I don’t anticipate ever having the answer to that question. I’ll continue working at the job I love; I’ll continue enjoying the rewards and satisfaction while fighting the challenges and angst. And I’ll document my progress in this blog. This venue is my chance to share my small world with whoever wants to experience it. It may be a small world but multiply it by 10’s of thousands of EM doctors throughout America and the implications of what I see on a daily basis are quite sobering.