A Bloody Freaking Mess

Woe unto you if you piss off the wrong woman. She may sneak up on you with a knife and plant it in your neck. A few minutes later you may find yourself drowning in your own frothy blood with a medic cutting your neck with a scalpel to stick a tube down your trachea to save your life.

Then, though you are not aware of this, I get to see you and figure out that the knife punctured your lung and your large airways, and that the tube in your neck is not serving to breath for you. Then about 7 people will stick you with needles and I'll cut your neck again to reposition the tube and give you 4 units of blood and do CPR on you and get your pulse back and fly you to the trauma center after your brain has died and your pupils are fixed and dilated and you hopefully get to donate your organs to people in need.

Death in an Hour

It is uncommon that someone dies in the Emergency Department who wasn't already well on their way to dying in the field. It is even more uncommon to watch someone die right in front of you and do nothing other than perform "medical management" (fluids and medicines).

I took care of a woman last night who was sent in merely because her pulse rate was too high. Mrs. Hall was sent from a nursing home where she was a resident and her husband was at her side. She had advanced Alzheimer's disease and hadn't been able to communicate with anyone in almost two years. Prior to that time she and her husband had decided that she did not wish heroic measures to be used to save her life when the occasion arose. In other words, she had a valid "Do Not Resuscitate" order executed prior to my meeting with her.

I still don't know what happened to Mrs. Hall. She came in with a pulse of 140. I assumed she was dehydrated and probably had a urinary infection. Given that she was non-communicative however, we proceeded with a very thorough workup. "Do Not Resuscitate" does not mean "Do Not Treat"... That's for hospice patients. I was sure we would find a pneumonia or even a pulmonary embolism or something that we could fix. We did not.

Mr. Hall was at her bedside the whole time. As I did what I thought I had to do to reverse and treat this poor woman, she got worse. Her heart rate went up despite IV fluids, she began to sweat profusely, her breathing rate increased but the breaths themselves became more shallow. Finally, her heart rate began slowing. She was dying, and dying quickly.

Her husband was very courageous. As I explained to him that she had, perhaps, minutes to live without heroic measures, he did not change his mind about her DNR order. He did not give into the very strong temptation to have me intubate her and do all kinds of stuff that wouldn't have mattered anyway, but might have given her a few more hours or days in her state of limbo.

In fact, she breathed her last not two hours after her arrival. Her husband cried and told her he loved her as she died. All of us around the bed were moved. He let her go and, I truly believe, her soul is joyfully alive somehwere out of the prison that was her body.

What happened? I think she either had a huge heart attack after her first EKG was done, had a huge pulmonary embolus, or had massive internal hemorrhage from a thoracic or abdominal aneurysm. It doesn't matter. Whatever it was took her quickly, and, as I explained to the husband, even if he had changed his mind about the DNR order nothing I did was going to change a thing. Humbling. Christmas is it?

Emergency or Not an Emergency?

Great idea for a new Hollywood game show. Prime time. It's called "Emergency, or Not an Emergency?"

The moderator would be someone of great fame, talent, and class. Wait, let's make it a no-talent, weird, washed-up dude... Louie Anderson perhaps. Members of the audience would choose a suitcase held by a beautiful model. Inside the chosen suitcase would be a scenario commonly encountered in the Emergency Department. Here's one from the other night... "My baby cried more than usual last night and her color is just not right."

The audience member would then get to choose whether this was a true emergency or not (it's not). If they got the first scenario correct then they could proceed to other scenarios, banking ten grand at a time and having the option to stop with their winnings.

About 10% of the cases would be true emergencies... that would approximate our experience in the ED. Nevertheless, I think most people would lose early when they guessed that "I've had back pain for eight years but it's worse today" was a true emergency.

"His Balls Haven't Moved in Two Days"

Imagine my surprise while, in the course of explaining to a very sweet 84 year old woman that her husband was in heart failure, was intubated and chemically sedated, and would need to go to the intensive care unit to recover, she interrupted me and said, "You know his balls haven't moved in two days."

Now it may be obvious to you reading this that she meant '"bowels", but it wasn't obvious to me for about three or four seconds, during which time I think an upturning of the corners of my mouth occurred, and I thought to myself how sweet it was for her, at 84 years old, to notice.

The "Throckmorton Sign" Explained

We are an immature bunch for the most part. It turns out that with Xrays of the male pelvis or hip region that the penis can often be seen hanging left or right. Legend, not research, tells that the side the penis points to is the side of the fracture or 'lesion' as we say.

Further, a dude with a Throckmorton sign on the left who actually has a fracture or significant finding on the left side is said to have a "positive Throckmorton sign". If the penis points away from the injured side then it is called a "reverse Throckmorton sign". Also, if there is no injury to the patient then you have a "false-positive Throckmorton sign". This, of course, allows us to talk about the famed "Throckmorton sign" in all possible scenarios. A good dick-joke is never to be missed.

Of course, some males are so endowed as to impress the doctors and nurses with the immensity of their ding-dongs. In this case one might speak about a "Hugely positive Throckmorton sign" or a "Tremendously false-positive Throckmorton sign".

The above Xray demonstrates a normal pelvis and hip in a 27 year old white male who had fallen off a ladder. The patient reportied pain initially on the left side. Therefore this is what's knows as an "Oh my goodness, WOW! Hugely false-positive reverse-Throckmorton sign."

The Contest

Continuing the "alcohol and rectal foreign bodies" theme, I will add this little story. Early one morning a few years ago, a skinny gentleman came to the ED complaining that he had something stuck in his ass. He was intoxicated, and did not seem that uncomfortable, either with the anal foreign body, or the situation. After reviewing the xrays and talking to the gentleman, it turns out he had the entire attachment to a vacuum cleaner stuck up there. You know, the one that gets into those hard to reach areas in your furniture. His drunk buddies had bet him $40 that he couldn't fit it in. Even on the way to the OR, all he could say is "I won the bet!". Yes, you did.

The Obligatory ED "Rectal Foreign Body" Post

Okay. Yes, we sometimes see patients who have put things up their butt and can not get them out. Here's a little bit I wrote about a recent patient.

I noted the other night at work that shaving cream can be dangerous. It seems that American manufacturers have neglected to put a safety warning label on the cans. As you can see from this Xray, some of the lower priced brands can acutely migrate up one's ass (necessitating removal in the operating room). We are not sure if this was mentholated cream or not, nor are we sure if it was the 'gel' or simply the foam. I will at this point avoid such obvious puns as, "Wow, that was a close shave!", and "Looks like he got to us just in the nick of time", or "It seems this gentleman was a little behind in his personal hygiene". This is not a can lying on someone's belly, it is well and fully disappeared behind the external anal sphincter. As you will also note, the plastic top to this can is on the business end, making removal even more difficult. In fact, the surgeon had to pull the little rubber stopper out of the bottom of this can in order to insert a gripping instrument to pull the can out. There was, in fact, a shaving cream fountain in the OR coming out of this guy's ass. The final lesson for everyone? If you are homeless and drink a lot, do not hang out with other homeless drinkers who are, strangely, giving you their alcohol while snickering and trying to hide a can of shaving cream from your view.

Another Acorn Falling Near the Tree

Saw a patient, ten years old, who had just been seen by his pediatrician. Turns out the mother of this little gem had been kicked out of the pediatrician's office for cursing and throwing a tantrum. Seems she wanted junior to get antibiotics for his cold and, after a prolonged explanation from the pediatrician with charts and graphs and stick figures and all words cut down to three syllables or less, she still did not understand that viruses are not treated by antibiotics.

So this patient, who already had been diagnosed with bipolar disorder and pre-adolescent obesity, got what his mom wanted. I gave in. I was too busy and I actually didn't think it was unreasonable to try a short course of antibiotics on this child as he had been sick with cough and cold for two weeks. Many doctors believe that after 6 days of upper respiratory symptoms that the viral illness has probably paved the way for a bacterial superinfection. Anyway, that's not the point.

This mom was barely controllable. When I told her that I would prescribe zithromax she told me that her son's unique and fragile constitution responded only to non-generic zithromax and to be sure not to write for generic. Fine! Crazy bitch.

Fast forward one hour. The local pharmacist called me. This same woman was now at the CVS and was not happy. Turns out she thought that the only way to get brand name zithromax was in what has come to be known as a "Zpak". The pharmacy did not have any "Zpak"s, but did have the brand drug in individual tablets. This banshee was convinced that the pharmacist was trying to pawn-off generic zithromax on her and was calling me to complain.

If I had the ability to reach my hand through the phone line I would have strangled her. This would have had three benefits: First, the pharmacist would have felt better. Second, I would have felt better. Third, her tub-o-lard kid would, after a short period of pseudo-grief, have felt better.

My Friend the Hero

I have a friend just returned from Iraq. He's been there 7 or 8 times now since the war started. He's a special operations guy and therefore he deploys for shorter periods which usually involve intense combat. My wife and I had dinner with him and his wife last night. Let's call my friends Mike and Sarah for convenience's sake.

Mike is being awarded the silver star for valor in a previous deployment (click on the above link to see the kind of things one has to do to earn a silver star). After this deployment he's being awarded "something higher than the silver star".

Mike is nothing if not humble and modest. He has killed, I conservatively guess, hundreds of "insurgents" in close quarters combat. I know this because, while he will not tell where or when, he will tell enough for me to be sure that he is getting shot at on a regular basis, and, since he just returned in fine health, that he shoots better than those shooting at him.

I know this is off the subject of medicine but I have to say thanks to Mike. Whatever you may believe about the reasons for the Iraq war, Mike simply saluted and went. In the course of his multiple deployments and in the course many chats in our driveways I am convinced that the people he kills are death-worshippers. I am convinced that if they had the opportunity to kill me or my wife or my kids or the jew down the street that they would do it with fanatical zeal and without hesitation. What a conundrum. An enemy who is happy to kill us and happy to be killed.

Thanks Mike. Thanks for killing them there. Thanks for putting yourself at risk for me and my family. Thanks for giving me and my family a buffer zone in which I can pretend the world is basically good and I can hang my Christmas lights on my house and buy presents for my kids for a special morning two weeks from today.

Thanks Sarah, for being such a good neighbor, such a good wife to Mike, and such a good mom to your kids. And Sarah, thanks for modeling bravery to us all. How do you manage not to jump every time the phone rings or a strange car drives up our street? You are both stronger than I can imagine. You are both what all Americans should aspire to be.

Hello Taxpayers

A 19 year old illegal alien from Mexico came into my ED last night by ambulance. What I meant to say that a 19 year old guest worker/visitor/(insert politically correct term of the day here) came into the ED etc..

Up front, this guy's life is now shit. He was in a bad car wreck and is paraplegic as a result. This wreck occurred two weeks ago while he and 5 others were driving across the country for work. The car hit a tree. Pablo fractured his lumbar spine and also had intra-abdominal injuries. He was treated at the nearest trauma center and released to family. His treatment included two major surgeries, one of which was a stabilization of his fractured spine.

Last night he was septic from a bad urinary infection. I suspect that his bladder was not functioning properly after his injury. He was very ill and needed to be admitted to the hospital for IV antibiotics and further study. He was immediately in the post operative period so he HAD to go back to the hospital that operated on him 12 days ago.

The reason for this is that our facility has no trauma or neurosurgical capability and besides that, there is a generally accepted rule that one surgeon does not clean up another surgeon's mess. It's a bad idea for many reasons not the least of which is a liability one.

The only way to do this was to fly him there so we did. 150 miles by helicopter. No insurance. No viable way to rehab and recover after he is discharged again. No skills. No education. He doesn't speak English. Tragic all around. And thank you American taxpayer for footing the bill both through your increased tax burden and through the increased premiums you pay for insurance as the cost of health care increases (for many reasons, including Pablo).

At the end of the day we have a young man from Mexico just trying to make some money who came to this country illegally. If he had crashed his car in Mexico he probably would have died. As it stands he will live in a wheelchair with no means to support himself in a country where he does not speak the language. He will live with some "in-laws" who could not afford the money to pay for a cab home from the Emergency Department. Come to think of it he will probably get a disability rating and be supported by the taxpayers. A tragedy on many different levels.