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…