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.

************************************************************************************

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.

*************************************************************************************

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.