Lady With Sheets and Other Stuff

Had a good one the other day. This lady came in with her husband with symptoms of something which turned out to be nothing. He was sort of an over bearing type and, although she had genuine medical problems, was also a card carrying hypochondriac. I saw the card.

But the point of the story is the sheets she brought in with medical history, meds, allergies. I realize 911 had a previous post on this, but the information on these was incredible. She was allergic to 32 medications, musk scent, every single food dye (even green), potatoes, carrots, tomatoes, fruit packed in its own juice, and gravy (yes, gravy). She also had had 22 surgical procedures performed, and was taking 16 medications. I honestly could not stop looking at these sheets. How could someone have been exposed to 32 medications, much less be allergic to them? Now, she did have medical problems, namely diabetes and heart disease, but 32! And what is it with being allergic to gravy. God gave us gravy to enjoy and to slop biscuits in, not to be allergic to it. The sheets showed a tremendous exposure to the medical world, probably 1/2 our fault for throwing meds at her and 1/2 hers for demanding them and then not liking or tolerating them. And then again she could be just unlucky.

OTHER STUFF

Anxiety or just being stressed out is not an emergency. Granted, the feeling may be disconcerting, but out of the 45,000 or so patients I have seen, I haven't had an anxiety death. Maybe I have just been lucky. But I did have a 25ish year old female type run up to the nurses station while I was finishing orders on a respiratory distress patient who I had just intubated and was getting her ready for the unit. The MI patient had just gone to the cath lab and I was about to get to another chart, when she informed me that if someone didn't give her friend something quick, she was going to have a FULL BLOWN PANIC ATTACK. I mean with the carpo-pedal spasms and rapid breathing and everything. "Oh, my gosh" I said and ran from the critically ill patients room to help this poor lass. No, I'm just kidding. I didn't do that. But I did tell her friend to just stop talking, that all her talking was starting to bother me, and I gave her friend the required vitamin X. She lived, and we didn't even have to put a brown paper bag over her face. Ain't medicine a beautiful thing.

Suggestions for Those Placed Under Arrest

I had a fine young citizen brought in by the police recently for "clearance for jail". He had a little laceration on his brow delivered either by the arresting officer or the ground, and had been pepper-sprayed. He was, well, a little drunk. Funny how those things seem to go together, drinking and trouble with the law, someone should do a study.

"Bill" had been down at the Kwik-Mart causing a disturbance and the police had arrived and tried to shoo him away. He was more interested in running his mouth and threatening the officers though, so they arrested him. Here's where the lesson begins.

Rule #1: If asked by a policed officers to 'go home' or 'go away' do not respond with, "Fu** you you f**king pigs", and do not spit on them.

Rule #2: When handcuffed and placed in the back of the squad car do not bang your head against the safety screen or kick your feet against the windows. I know it's hard to believe, but this will not cause the police to stop the car and let you go. Instead you will get your legs cuffed and a nasty dose of pepper spray to the face.

It was at this point that I met "Bill" last night. The whole ED heard him come through the door dropping the F-bomb and threatening to have all of us arrested (citizen's arrest of course). He was also threatening to sue us all, huge surprise. He was all red in the face and was crying like a nine-year-old. He also smelled like a still.


Me: "Hello sir, how may I help you."

Patient: "Get these f**kers off of me!! I want to press charges NOW!!! SOMEONE LET ME PRESS CHARGES NOW!!"

Me: "Uh, someone get this guy a phone," (wink to my nurse), "Sir I have to fix this cut on your head."

Patient: "How could this happen to me?" (blubber, whimper) "How can he arrest me? I want to press charges! (kick, spit, kick)."


At this point I called for the haldol and ativan as this guy was flailing around, causing a disturbance for the whole ED (lots of kids there), and requiring four nurses and myself to keep him from face-planting off the gurney. As drunk as he was he did not have the right to refuse the laceration repair or the chemical restraint. Soon after the haldol and ativan he was nice and asleep.

We then had a "BAL Lottery" which I won (that's four dollars to the plus side for me). Guesses were from the low 200s to 299 (my guess). The guy clocked in at 309, not bad for a 26 year old. I'd give him another three years and if he keeps in practice he might be able to top-out over four-hundred and still be able to curse, spit, and walk.

I sewed his laceration and told the officer that as soon as the guy could put one foot in front of the other that he could go to jail. I had done a CT of his head to make sure he had not been badly injured with the blow and it was fine. He wont remember any of it but he will wake up in jail with a pounding headache, blood all caked in his nose, and urine soaked pants. King me!

You'll Shoot Your Knee Out

Nail guns. It's construction season and in the last three weeks I've seen three nail-gun injuries. This guy above had to be taken to the operating room to remove this nail from his lower thigh. Luckily it didn't hit anything important. The reason I couldn't get it out in ED was that the head of the nail had disappeared deep into the muscle and objects like this are notoriously hard to find without the aid of Xray and the ability to open the wound. In this case it also had to be opened for wash-out as the nail had carried part of this guy's jeans deep into his thigh.

I didn't get a picture of the nail-gun injury that was more impressive than this, but I did take care of a guy who came in with a 2X4 nailed into his index and middle fingers. He was a great patient and sat in the bed without even asking for any pain medicine. I was able, in his case, to digitally block his fingers and remove the nail and the board. He too had escaped permanent injury.

Nail guns = job security.

You'll Shoot Your Eye Out

Young Ralphie Parker wanted a Red Ryder BB Gun for Christmas and he eventually got one (click the title of the post to read about Ralphie). He nearly shot his eye out as his mother and his teacher (Miss Shields) had warned.

I took care of a young man recently who was shot in the eye at close range by a 'friend' with a BB gun. You can see the BB lodged in the right orbit in the Xray. The kid had light perception only from this eye and he had an 'open globe injury' meaning the eye itself was punctured. Other physical findings of note; a misshapen pupil, severe pain, a large hyphema, and a large scleral laceration that carried into the inferior outer portion of the cornea.

I called our eye surgeon immediately and he came in. He was unable to operate on this young man as, on CT scan, the missile was shown to be deep in the vitreous of the globe. The patient was transferred by ambulance to the nearest facility with a retinal surgeon on call. Hopefully he will do well but it is unlikely that he will ever regain full vision in the injured eye.

Trivia: What was the red-haired bully's name in A Christmas Story?

Scut Farkus.

Spacer

I need to put a nothing post in between the last and the next so we can resume our light banter in a decorous fashion. Today in the ED I saw nothing interesting except a sweet little girl with her hand stuck in a decorative vase. The vase enclosed the whole arm almost up the shoulder. The parents had tried butter and lots of pulling but had no success in removing it. A hammer quickly fixed the situation and I sent her on her way. Very satisfying. I almost felt like an orthopedist.

Virginia Tech Massacre

I hesitate to even write this post but to the extent that I can bring a bit of a medical perspective to the massacre in Blacksburg then maybe I can be forgiven.

First. As someone who works very closely with EMS and less so with the police, and as someone who knows a whole lot about Columbine (for reasons I can not explain here) please let me implore you to dismiss those who seek to throw blame on the police or the emergency system out of hand. In emergency situations and emergency medicine in particular (both pre-hospital and in-hospital) we train for stuff like this, but since school shootings, believe it or not, are still vanishingly rare, our time is better spent training for major motor vehicle crashes or natural disasters or even a chemical weapons attack. As far as I know the response of the police, paramedics, nurses, and physicians yesterday was above and beyond excellent.

Second. I have met people, and sometimes I meet more than one on a single day, who consider their lives forfeit. Usually these people simply wish to kill themselves, but sometimes they want to kill others. Simple fact, if I'm interviewing them then they have a shred of humanity left and have a chance to recover. We are so conservative about this on the medicine side that usually the mere mention of suicide or homicide buys you an involuntary 72-hour stay at an inpatient psychiatric facility. However, once you don't care whether you live or die and you decide to keep it secret then there is precious little that anyone can do to stop you in whatever it is that you are planning.

Whether it is tossing yourself from a hotel balcony with the television cameras rolling and writing your last "fuck you world" all over the pavement in your own blood, whether it is driving a truck full of homemade high-explosive to a populated downtown intersection to blow it up, whether it is planning for years to hijack a plane full of jet-fuel and crash it into the World Trade Center, or whether it is sneaking a couple of semi-automatic pistols onto your college campus and executing your classmates, you will probably succeed in transferring your pain to others. Pure black emptiness.

In my personal experience I learned this from a patient that I spent 10 hours with as he recovered from an "unintentional" opiate overdose. He managed to convince me, his wife, and the psychiatrist that he was simply trying to sleep and that there was no need to hospitalize him. We eventually discharged him and he killed himself that night.

I guess it comes down to this; if you believe that we make choices and have free will (even if it is affected by genetics and environment) then blame the shooter, if you believe that we are 'programmed' (either by genetics or our environment or both) then go look for someone else to blame, and realize as you do, that if we are merely 'programmed', then blame, any kind of blame, makes no sense.

The Pants Tell the Whole Story

Can the smartest woman in the world fix health care? Not if she chose these pants. "Woof, woof!"

Ode

Just a quick post for my coffeehouse fans:

I just love it when some tech or nurse comes up to me, oh, at 3:00 a.m. in the middle of a hellish shift and says "look at the bright side, you only have 4 more hours". This is the equivalent to saying to someone "look at the bright side, I am only going to stick you with this HOT POKER for four more hours". I don't think that person would say "great!, I thought you were going to poke me for 5 hours".

A Haiku:

Only four hours left
Oh great, another jerk-off
Night shift, hot poker

P.S.

ETOTHEIPI, could you send me one of your severed feet. The next time I kidnap someone I could use use to up the ante and show the family I mean business.

Fun With Feet

Free piece of advice (sort of like 80% of my professional advice): if you have diabetes and you get a boo-boo on your foot, even if it doesn't hurt, get it taken care of. Do NOT let the wound get infected and eat into the bone, that is, unless you really enjoy hopping.

Got a foot in the lab today and I thought people may want to know what happens to your body parts when they get taken off of you.

So, here's how it is. First, cut off foot. Next, wrap in red bio-hazard bag, but forget to secure the opening so blood leaks on the hospital waiting-room carpet (true story). When the foot gets to me, I like to have a little fun. I put the appendage into the -80 degree freezer overnight. Why? Because frozen human tissue cuts exactly like wood on an industrial bandsaw. The following day, I open the freezer to a wonderful sight - a rock hard, ulcerated foot. Then to the aforementioned bandsaw. I make a sagittal cut, aiming the blade at roughly the gap between the 2nd and 3rd toes, and saw through the ankle joint. Smells like burning lamb chops. If I see a focus of osteomyelitis, I'll buzz a thin cut that gets fixed, paraffin-embedded, microtomed, stained, and looked at under the microscope.

The rest of the foot? This gets tossed into a vat of formaldehyde until the case is signed out. Then I chuck the whole mess into another big red bag that gets incinerated along with the placentas, colon cancers and aborted fetuses.

What a f***in' job!

Charity Doc Taking a Breather

A fellow ER doc has had enough (at least for a while). Click on the above title to read about our friend at Fingers and Tubes in Every Orifice and the nit-picky, incessant crap that has forced him to take a break from medicine. We have covered the same ground here but it can't be said enough: America's doctors are fed up, and, while the general public may not care or shed a tear, it takes at least 7 years to train one. In all the talk about the health care crisis we are usually only mentioned as part of the problem. Fine, many of us will simply remove ourselves from the equation and then we will see how much worse a 'crisis' can get.

Fun With Narcan

On the overnight shifts I often get called to the CCU for codes and such. One night recently I was forewarned by the respiratory tech that an overdose patient was in respiratory failure in the CCU and would probably need to be intubated.

The critical care attending was in Russia on a trip and had asked one of his internal medicine buddies to cover for him and the coverage doctor had no interest, and, quite frankly, no business, taking care of this patient.

I arrived at the bedside to find a disheveled middle-aged man quite incoherent and with oxygen readings which were indicative of respiratory failure.

Me (to the nurses): "So what did this guy overdose on and who called EMS?"

Nurses: "Methadone; He was 'found down' in the shelter."

"Found down" means just what it sounds like, some schmo is found on the ground and when the paramedics arrive everyone already present gives the old 'Italian Salute" (shoulder shrug).

One thing about methadone is that it lasts a hell of a long time (at least 24 hours), and, without getting into pharmacokinetics and discussions of drug half-lives it is enough to simply realize that it's basically liquid heroin and is prescribed both for chronic pain and for heroin addiction.

Since it lasts so long it is possible to reverse its effects either in the field or in the ED with a drug called "Narcan" AND have the narcan wear-off while the methadone takes the patient to respiratory failure and la-la land again.

Narcan is a pure opiate antagonist. In other words it completely counteracts all the effect of opiates in the human body. Opiates cause euphoria, respiratory depression, coma, and, as an end result, death in overdose. Narcan, given in the appropriate setting, is like an 'on switch' in the patient.

Usually, since those given narcan are in the habit of using opiates, the effect of narcan is not appreciated. In a word, you have just stomped on a huge buzz (never mind that the patient was 'walking towards the light' when given the narcan). I have had some of my medics beaten-up by patients saved from the brink of death by narcan as it does precipitate ACUTE OPIATE WITHDRAWAL (which is a lot like the wicked witch touching you with a wand and giving you the worst case of the flu ever recorded).

So, long story short, the patient in the CCU did wake up with narcan and the nurses thought I was a genius for about 5 minutes. Then we noticed he wasn't moving his arms and had no purposeful response to painful stimuli in the upper extremities. Question; At 3am, with this patient flailing about in acute withdrawal and possibly paraplegic, what do you do? The answer is not, "call the internist".

This patient became mine for the next two hours as I intubated him, put him in a cervical collar, put him on a propofol drip for sedation, and did CT scans through his C and T spines. I was concerned that when he was 'found down' that he may have taken an unwitnessed dive off the top bunk at the shelter. His scans were pristine and he eventually started moving his arms. I have no idea why he didn't move them to begin with and I no longer care.

Dispatch From the Privy Council

Having disposed of the pseudoissue of circumcision, we shall move onto more important matters.

At our annual confab meeting (held in aforementioned secret location) we determined the following:

Resolved:
Big money cannot be made in medicine and it sucks your soul.

Solution:
1. Build time machine.
2. Invest in real estate in currently hot resort town in 1984.
3. Be rich.
4. Avoid medicine at all costs.

The resolution passed unanimously. We then finished the seventh pitcher of beer.

When successful this blog will vanish. Out.

Secret Annual Confab Update

Dear Readers,
The three principle authors of M.D.O.D. will be meeting tomorrow in a secret location. We will post from this location and update you on the weighty decisions we reach, which will, since we are members of the Trilateral Commission, affect you all in ways you can not imagine (especially if we buy cheap tequila). Until then, we remain, your humble servants.