The Medical History

Taking a medical history in the ED is often a challenge. Usually this is because people don't know their own medical problems or have any clue, for instance, that drinking a twelve pack of beer a day is, well, unhealthy.

There is also the patient who is just stupid (click above to see my previous post entitled, "You Appear to Understand English").

Tonight I had the third of the dreaded triumvirate of "poor historians"... The "too much information" patient. It goes like this...

Me: "Ma'am, tell me why you are here tonight."
Patient: "Well, many years ago..."

Ugh...

Positive Cheetos Sign

As bad as ED jobs are, dealing with life and death, drug overdoses, drug seekers, neuron synapse misfires (idiots), social misanthropes, and the like, there is one thing that would at least make this job a little easier...honesty.

I am not a policeman, so I don't care how much coke or meth or GHB or God knows what you ingested. Just tell me. Granted, I will do everything in my power not to let you drive and kill someone, let alone one of my family. I don't care how much alcohol you drink, cigs you smoke or bags of pork rinds you consumed on your 1800 cal ADA diet. Just tell me. It will most likely save a lot of consternation down the road.

There is also an honesty of omission as well. You don't have to tell me about the car wreck in 1994 when you got whiplash, which now causes you to walk funny leading to the pain in your hip which radiates directly to the doctor. I know none of this is true. You also don't need to tell me about your reflex sympathetic dystrophy flare up, total body pain, or acute exacerbation of fibromyalgia made worse by the chronic fatigue . These I don't need to know about.

Which brings me to the Cheetos. When you bring little Johnny or Samantha or some crazy made up name that even you can't spell, (really, this happened-a mom and dad brought their child in and we couldn't get the child in the computer because neither of these parental units took the time to learn how to spell the ten syllable three hyphen two accent mark name they had bestowed on this lamb they had brought into the world) don't tell me they haven't eaten anything or held down any liquids in 4-5 days. I may be slightly naive, but I can tell from the 20 lb diaper soaking with urine, extreme drool coming from the mouth, and fingers and hands covered with that oh so wonderful powdery cheezy goodness we all know as Cheetos residue, you are lying to me.

Hence, a positive Cheetos sign.

Nurse, discharge this one immediately.

The Child as a Battering Ram

Once every few months I get an angry mom presenting to the ED with their child. The child is usually a girl though not always. The complaint is that "Her father might have molested her."

Inevitably the story then unfolds of the nasty breakup or divorce and the ongoing custody battle. The child, usually pre-verbal or just verbal (two or three years old in other words) is prompted with leading questions about what happened "at daddy's house".

"Did daddy hurt you?"
"Did daddy touch you there?"

Then the mother (and usually the maternal grandmother), quite frantically, bring their child in for me to act as judge, jury, and executioner to the absent father. They are sure that the father is a molester and has no right to ever see the child again.

I am obligated to do an external genital exam which always is traumatic for the child, and obligated to talk to the Child Protective Services people. Their reaction is always the same. A groan and an agreement to visit the child in the home and check on the allegations.

And back and forth we go. What a spot to be in. I can't ignore the allegations and the child is caught in the middle. People actually have to pass a test to get a driver's license but can just go have a child. Hooray. Oh, and for all you folks who earnestly want to have a child but are having problems with conception I recommend starting to use crack or heroin... Works every time.

Acronyms

I was inspired by my friend at "Addicted to Medblogs" (click title above to navigate there) to add some new acronyms to her list. Acronyms are useful on the ED board to let the ED staff know what the chief complaint of a particular patient is without spelling it out for the passers-by to see and puzzle over.

"CP" is chest pain, "SOB" is shortness of breath etc... Here are some others invented for the patients not fitting nicely into a medical pigeonhole...

"SPAK"- Status-post ass-kicking.
"GOK"- God only knows.
"WADAO"- Weak and dizzy all over.
"FDGB"- Fall down go boom.
"BBFB"- Bone broke, fix bone.
"AMFYOYO"- Adios MF, your'e on your own (i.e. discharge this waste of carbon).
"SLAS"- Seizing like a squirrel.
"AHD"- Acute haldol deficiency.

More later.

Supper Nanny Needed (ten years ago)

A frumpy forty-ish woman walked into the ED about 20 minutes after her son arrived by ambulance. There was no father around and I suspect that to be the case at their home too. No matter, this young hoodlum, 13 years old, had been out drinking vodka and, as befits an alcohol rookie, he got quite sick. Evidently this was in the presence of mom, and when he got bat-shit crazy she called EMS.

The drive to the ED was partly heard over the radio...

"Unit 38 en route non emergent with a 13YO male, altered, combative, 5 minutes ETA, vitals, and airway intact, restraints to wrists..."

In the background the young man could be heard...

"Get the F*** offa me... F*** you you A**holes..."

We were ready with about six people when EMS pulled in. There are some big thirteen year-olds out there and you never try to subdue a patient with less than 5 people. That just risks injury to the patient and the subduers.

This knucklehead was acting the perfect fool, cursing, threatening, and generally making the ED loud and unpleasant for the rest of our patients even in his four-point restraints. I came into the room with as commanding a presence as I could muster and grabbed the young man by the chin and forced him to look at me.

"What did you take?"

"Vodka, man, vodka... get my FOOT off my DICK!"

"Any pills? Any cocaine? Any crystal?"

"No dude, F*** you, I'm SOOOOOO drunk, get me the F*** outta here?"

There's a great old drug called droperidol. The FDA gave it a black-box warning because it has been linked to some deaths through a cardiac rhythym disturbance in certain susceptible individuals. Nevertheless, if you screen patients for the rhythm with an EKG then place them on a cardiac monitor then you can still use this drug. It's an anti-psychotic in higher doses and has strong anti-emetic properties as well. In short, it makes combative assholes shut up and sleep it off without puking.

We do not give this drug as a punishment. That's illegal. But when a patient like this comes in and disrupts the entire ED, drains off security and nursing resources, and prohibits adequate evaluation by his idiocy it is, in fact indicated.

After about five minutes the droperidol had this kid in sleepy land. It's a good thing I checked for other substances of abuse because the patient had overdosed on tylenol too. Probably he got hold of some pain pills; Lortab, Percocet, Tylenol 3, and had popped a handful to enhance his buzz. Problem, they all have large doses of tylenol in them. Tylenol will kill you slowly in overdose by poisoning your liver. It's a horrid, nasty death.

This kid got sent down the road to the pediatric hospital. He needed monitoring and treatment for his tylenol poisoning (which we had initiated at our facility), and, when sober, a psychiatric evaluation.

In all of this the true culprit was apparent however. The worthless POS mom. She actually laughed a bit when she saw how messed up her son was and proceeded to yell at him in front of me and the nurses (we were all very impressed). When I told her he had to be sent by ambulance to the local pediatrics hospital she gave me the old shoulder shrug. "Whaddya gonna do?" seemed to appear in a cartoon bubble above her head.

I love droperidol.

I Don't Know What to Say

A young mother brought in her 4 month old at 1am this morning with fever. The child had been seen by his pediatrician just 12 hours previous and had been placed on an appropriate treatment regimen for otitis media. The mother had gone to the pharmacy and picked up the antibiotic prescription (covered by the state) but had failed to buy either tylenol or motrin.

"That's money for bills," she said, "I can't afford tylenol".

Well how in God's name can you afford this bill?!??

I thought about calling Child Protective Services but held off at the last minute. I thought about asking the following: Do you have a car? A cell phone? Call waiting on your home phone service? Cable television? But I didn't. I sat and talked with the mom and got the feeling at the end of the interview that she truly wasn't capable of understanding the poor choices she was making about her child or about her money. I did drop a note to her pediatrician to ensure close follow up, but what the hell? Poor kid.

Helpful Hint Regarding Body Piercings

For some young, fit, and healthy people a body piercing or two can add a certain ammount of skanky allure. I mean in a heroin-chic kind of way (not the take home to mom way).

However, if you are a hirsute fat woman, having a bunch of metal in your face is, well, amplifying the fact of your hairy obesity. Putting a metal stud through your clitoris or through your labia just makes the bile rise in my stomach. "It quite o'ercrows my spirit" (aplogies to original author). Really. Stop. Please.

Tiny Bob

A tiny Bob Marley look-alike walked into the ED the other night after being 'cut' by his girlfriend. Tiny Bob was 21 and had dreadlocks and the whole look going on. He wasn't badly hurt but he was very worried about his rep with his home-slices. He also didn't want me to sew up his cuts or stick him with needles.

In the meantime the police came into the room and Tiny Bob tried to be the good guy and take all the blame for the cuts he received at the hands of the angry girlfriend. He told them that he hit her first and she was just trying to defend herself. This story was inconsistent with the wounds he received (for one he was stabbed in the back of the thigh, no doubt as he was running away), but he stuck to it. The result was that he got arrested for domestic assault, and with the record he already had, he will probably go to prison.

The second result was that his girlfriend was also arrested for assault with a deadly weapon after she showed up in the ED with a small cut to her finger. Good thinking Tiny Bob.

The coup-de-grace for the interaction took place as I was sewing up his four lacerations...

Me: "So, do you like Bob Marley?"
Patient: "Who's dat?"
Me: "You know, the famous reggae singer?"
Patient: "What's dat?"
Me: "You know, Jamaican music?"
Patient: "Jamaica??"
Me: "Are you a rastafarian?"
Patient: " What's dat?"
Me: "You know, the religion some Jamaicans have... that's where dreadlocks come from."
Patient: "Dreadlocks???"
Me: "Yeah, the way you have your hair, it's called dreadlocks..."
Patient: "Huh?"
Me: "I guess you just like your hair in that style, huh?"
Patient: "Yeah."

Even though Tiny Bob was didn't know Bob Marley from Adam, was not a fan of reggae, was not a rastafarian, and didn't know what dreadlocks are, I'm fairly sure he smokes a lot of pot.

"I Was Raped"

If you come into the Emergency Department with a chief complaint of sexual assault many things will occur.

First the police will be notified and they will come and interview you. Second, an evidentiary collection for sexual assault will be performed along with a standard exam. Finally, you will be offered counselling, pregnancy prophylaxis, and STD prophylaxis.

In the course of the evaluation it is necessary for me to ask you what happened and to record it in the medical record. My job is to be a medical detective; the police do the police-work.

Now I'm well aware of the hot-potato nature of this topic, but I don't care anymore really about what the latest definition of "rape" is or whether it is a crime of power, anger, hatred, or sex (or some combination of these).

Guess what? With the obvious exception of someone slipping you a mickey and sexually assaulting you while you are drugged, going out with your friends, getting hammered, meeting some guy, dancing with him, then waking up in a strange room with your pants off, a pounding headache, and a vague recollection that you may have had sex does not constitute rape. It's merely stupid.

Lost a Holiday

Sorry to be repetitive. No Christmas cheer this year. No Christmas spirit. Just a dude stabbed in the neck, a bunch of kids with flu or something like it, and a bunch of out-of-town patients who were either depressed about Christmas or out of their percocet or both. Gotta get the holiday thing down better. I'm a huge fan of Christmas and New Year's and this is the first year in my life that I never felt the spirit and was glad to take down the tree.