We receive this transfer from an outlying hospital for a neurology evaluation. The patient is in his 30s and was out at the bars when he was hit in head with beer bottle during an altercation.
Since that event, he has complained of dizziness, headache, loss of vision in one eye, pain all over his body, and repeatedly running out of pain medications. He had multiple CT scans and an MRI looking for causes of his symptoms at the referring hospital. All were normal. He also had multiple x-rays and physical exams without positive findings.
He went back to the emergency department and was reportedly “pissing himself” and “s**tting himself” – as in he was sitting on the couch watching a movie and didn’t know he urinated on the couch until his girlfriend told him that she felt something wet on the floor. Also reportedly only knew that he soiled himself when he went to take a shower and noticed his underwear contained a present.
The ED physician at the transferring facility took good notes. The medical records showed that at the first visit, he was on his cell phone yelling at police why the person who threw the beer bottle at him wouldn’t be charged with a crime. After he got off the phone, he reportedly told a nurse that he had to have a “serious injury” in order for it to be further prosecuted. A cut to the head from a beer bottle wasn’t classified as a “serious injury.”
The patient never seemed to have soiled clothing in the ED and he was able to walk back and forth to the bathroom without problems – even though he couldn’t tell when he needed to go to the bathroom. He also failed several tests for malingering in the hospital that sent him to us.
I had to smirk just a little when I watched the well-tattooed muscular patient transfer from the ambulance stretcher to the bed holding a cell phone to his ear … and wearing an adult diaper that the previous emergency department had placed on him for the ride.
The neurologist discharged him from the ED after finding no abnormalities … and after he failed the same tests for malingering in our ED.
I’m getting worried about going to work lately. First it’s this phone call. Now, it’s the following:
Mrs. WhiteCoat happened to be at the hospital seeing a patient and I get a call from Daughter WhiteCoat in the ED.
“Ummm … Dad? Yeah. Um Junior WhiteCoat got stung by a bee and I think he’s having an allergic reaction. Should I use the EpiPen?”
In the background, I hear my son screaming bloody murder with alternating “No no no no no no” and gibberish.
“OK, where did he get stung?”
“In the backyard.”
“Noooo. What part of his body got stung?”
“Oh. His finger.”
“Why do you think he is having an allergic reaction?”
“It’s really swollen.”
“Is he having any trouble breathing or throwing up or anything like that?”
“No. Just his finger.”
“How about you put some ice on it for about a half hour. If anything changes, call me back.” Then I thought about my wife’s allergy to bee stings. “Oh. And why don’t you get the EpiPen out of the closet just in case.”
“It’s OK. I already have it.”
“Good.”
A half hour later, I called back to hear a bunch of yelling in the background. Ah. Everything back to normal.
Only later did I learn that Daughter WhiteCoat was standing over Junior WhiteCoat like a modern day version of Psycho ready to stab him in the aorta with the needle. [cue this music]
We’re hiring a babysitter for the next couple of months.
We recently had a 22 year old patient come in from a bad motorcycle accident. Road rash all over the place. Wasn’t wearing a helmet. As we began to examine him, it became evident that he had a spinal cord injury. He had priapism and reduced rectal tone. His legs weren’t moving. MRI showed a T6-T7 injury.
It was even more sad learning how the injury occurred. He told the paramedics that he was riding his motorcycle at a high rate of speed using one hand to steer and using the other hand to talk on his cell phone. On a speeding motorcycle. He was making plans to meet a friend that evening to go out to the bars and “get some.” The only thing he “got” was a lot of IV medications, a neurosurgical consultation, and a hospital bed.
Now he’s forever more likely to “get a lot less” due to a lapse in judgment.
Is answering that message from your BFF this instant really worth the thought of dying … or of sitting in a wheelchair the rest of your life?
Don’t text and drive.
UPDATE AUGUST 28, 2010
The day after my original post and one of my first patients of the shift last night was a 21 year old young lady who gashed her head open when she was driving down the street at 40 mph and she hit a parked car … while she was texting.
The 22 year old didn’t think the wheelchair would happen to him. This patient didn’t think the crash would happen to her. No one gets behind the wheel and expects to get into a major car accident.
Someone just told me about Oprah’s campaign about texting and driving. Read about it.
It’s not a question of IF something bad will happen to you, only WHEN it will happen to you.
Don’t text and drive.
Over the police/EMS scanner in the ED we hear the following 911 call:
“I need an available unit to respond to 359 Main Street … 359 Main Street … for a report of a black and white raccoon that won’t come out from beneath a bed.”
I thought the same thing that you’re thinking. Black and white raccoon? Ummmm … does it happen to have really bad smelling farts?
We didn’t hear any more chatter over the scanner about the incident, so we were left wondering. Then a police sergeant happened to come to the ED later that night to take a report from a battery victim and we asked the sergeant about the call.
None of the officers on duty wanted to go on the call because they were thinking the same thing everyone else was thinking, and no one wanted to get sprayed in the face or have to Taser a skunk. Eventually one of them went to the scene and cautiously looked under the bed with his flashlight.
The “raccoon” ended up being an old blanket.
The person making the call was a little old lady in her 70′s. After the officer pulled the blanket from under the bed, she kept telling the officer “I’m not crazy, you know. I’m not crazy.” Sorry, ma’am, but when you have to make that statement more than once, it creates a rebuttable presumption that you are indeed crazy.
Thinking that zebras and raccoons can mate and produce a viable offspring that hides under beds … well … um … you all can be the judges.
See the satellite edition with more news briefs from around the web over at ERP’s blog – ER Stories.
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When states cut funding for mental health, where do all the patients go? You guessed it. Sacramento emergency departments are getting “swamped” by mental health patients. Visits for mental health illnesses are up 30% in the past year. Inpatient psych treatment centers close inpatient beds, then tell the community to call 911 or go to the nearest emergency room. About one patient every 30 minutes are taking that advice. Yet the county wants to cut more services – requiring a federal court to block them from doing so last month.
You take away our malpractice reform, we take away your database of doctors. Illinois removes online database listing physician crime convictions, physicians who were fired by a hospital and physicians who were forced to make medical malpractice payments. The database was required as part of Illinois’ medical malpractice reform bill, but since the Illinois Supreme Court overturned malpractice reform, it also got rid of the requirement for the database. Now only disciplinary actions are listed.
The president of the Illinois Trial Lawyers Association got into the act, too, being quoted as saying “That anyone would want to keep that information from the citizens of Illinois is appalling to me. Patients deserve to know whether their doctor poses any dangers to them.” Guess you should have thought about that before striking down tort reform. By the way, does the Illinois State Bar Association have the same database? Don’t clients deserve to know whether their lawyer poses any dangers to them? Yeah. Didn’t think so.
Does the admission of guilt and early offer of compensation reduce the costs of medical malpractice? The University of Michigan believes so. Ted Frank at Point of Law has his doubts, but does note that such a policy would decrease the amount of money going into the lawyer’s hands.
5’5″ 300 lb patient falls off of operating room table because velcro straps won’t hold him. Now the hospital is getting sued.
In other news, hospital names velcro strap manufacturer and McDonalds as codefendant in case.
“Florida has the highest rate of malpractice premiums in the U.S., and Miami is the highest in the state,” says Florida Attorney General Bill McCollum during a campaign speech. “As a result, the percentage of doctors practicing is among the lowest in the nation.” Nope. No connection there.
Do seniors come to the hospital for warm meals and companionship? Researchers enrolled 118 seniors to get coaching visits plus deliveries of food for a month after they had been discharged from the hospital. Nurses visited homes two days, seven days, 14 days and 30 days after discharge to ask patients if they’d scheduled appointments with their doctors and to make sure they were taking medications as prescribed. The number of patients readmitted within 30 days dropped from 23.3 percent to 2.7 percent. Providing hot meals alone dropped the readmit rate by almost half.
Was the closure of St. Vincent’s Hospital due to financial mismanagement? Lawsuit will find out. While heading toward more than a billion dollar budget shortfall, hospital execs paid for a $278,000 golf outing, took home salaries of $1 million, spent $17 million on management consultants and had more than $100 million in “unspecified spending” for just one year.
Here we go again. Radiologists berating clinicians for ordering too many x-ray studies.
In other news, look soon for the American College of Radiology to publish whitepapers on how to judge the amount of coronary artery occlusion by palpation of pulsations in the patient’s chest, how to interpret a radiologic study without recommending further radiologic studies, and how to get out of lawsuits alleging that not enough radiologic testing is ordered.
Kudos to ACEP President Angela Gardner who was just elected as one of the 100 Most Powerful People in Healthcare (free registration required). Barack Obama was #1, Kethleen Sebelius was #2, and Nancy Pelosi was #3.
I admit being a partisan toward ACEP, but awards like this are the reason. I don’t agree with all ACEP policies or actions, but I also think that ACEP does a great job advocating for both emergency physicians and emergency patients. As I scrolled through the Top 100 list, the only other medical society members present were people from the AMA and the American Board of Internal Medicine. No other medical specialty societies were represented.
A patient came into the hospital after being bitten several times on the hand by a squirrel.
What caused the squirrel to bite her, you ask?
Well it seems that the patient was in the park and saw the squirrel “limping.” So the patient scooped it up in her handbag and brought it home with her so that she could help the squirrel recuperate.
After further examination, the patient apparently thought the squirrel had broken its leg, so she wanted to fix it.
First, she gave the squirrel some Benadryl to sedate it. Never did figure out how she got the squirrel to drink the Benadryl. Maybe poured it into an acorn?
Then she tried to make a splint out of Popsicle sticks to tape to the squirrel’s leg. The squirrel wanted no part of it. The feeling of popsicle sticks being taped to his leg woke him from his slumber and was not appealing to him, so he bit the patient several times on the hand.
At that point, the woman dropped the squirrel and came to the emergency department. Said squirrel probably then limped to the fridge, got a beer and sat down to watch the Cubs lose again.
Frankly, if someone doused my head in Benadryl and then tried to tape a couple of sticks to my legs, I’d bite her, too.
A 55 year old patient comes in with itching to her scalp – so bad that it is setting off her migraine headaches.
She’s been to her family physician twice already and was first prescribed antibiotics for a scalp infection, then was prescribed steroid lotion for the inflammation. She was feeling worse.
When I examined her, she had several bite marks to the base of her neck and over the ears. You could also see the dried hydrocortisone cream in her hair. Then I saw movement and I pulled out the insect pictured.
What is the diagnosis and what is the treatment?
UPDATE AUGUST 25, 2010
OK, you all are too smart. Head lice, it is.
I had never seen a live head louse before and had to look it up on the internet. I knew it wasn’t a bedbug and suspected it was a louse because of the couple of lice nits on the patient’s hair.
Treatment recommendations vary.
Shaving the head is a radical but curative approach.
The American Academy of Pediatrics recommends copious amounts of amoxicillin, then Augmentin if that doesn’t work just came out with an excellent clinical report on head lice last month (.pdf format).
Pediculicides (chemicals) such as “Quell,” “Nix” and “Rid” are still the mainstay of treatment according to this paper. Benzyl Alcohol also works well. While oils have been used to remove lice, the report states that their effect is not reproducible. Occlusive agents such as petroleum shampoos, mayonnaise, and herbal oils “have not been evaluated for effectiveness in randomized, controlled trials.”
A dessicator can be used to blow hot air on the lice to kill them – with good results. Using a blow dryer to try this at home will cause live lice to become airborne and spread all over your house. Don’t do it.
EMedHome.com recently published a set of pearls about urine drug testing that included several things I wasn’t aware of.
Did you know that …
Urine levels of “ecstasy” (MDMA) need to be quite high before they will be picked up by the urine drug screen since the tests have a low sensitivity for MDMA?
Zantac, Prozac, and labetolol can all cause false positive results for amphetamines?
Zoloft and Daypro can cause false positive drug screens for benzodiazepines?
Several benzodiazepines are difficult to detect on urine drug screens – including Librium and Versed?
Levaquin, Cipro, dextromethorphan (common in OTC cough meds), rifampin, and verapamil can all cause false positive tests for opiates?
Standard urine toxicology screens do not usually detect Vicodin, Tramadol, Fentanyl and Percocet?
Ingestion of one poppy seed bagel can cause a false positive opiate test?
Most drugs are undetectable 3 days after use?
Links to some of the cited articles are here, here, and here.
By the way … if you came across this post in a web search on how to beat drug tests and now think you’ve got it made – don’t worry. There are plenty of other ways that doctors can tell whether or not you’re using drugs.
Antibiotics for viral infections are a big pet peeve of mine. No. Make that a huge pet peeve.
Some doctors prescribe antibiotics for coughs and stuffy noses because the patients want them. If you’re one of those patients who think that antibiotics make your coughs go away, or clear up your stuffy noses, or somehow make your sinus headaches vanish, or if you’re a doctor who prescribes antibiotics for these symptoms, this post is for you.
You’re killing people with your dumb demands and/or your inappropriate prescriptions.
MRSA stands for methicillin resistant staphylococcus aureus. There is regular staph aureus – that bug is pretty much fading into the sunset and being replaced by staph aureus on steroids. Because so many people are requesting/using antibiotics for non-bacterial infections, the bacteria in their systems learn how to beat the antibiotics – in effect, making the antibiotics useless. For example, in our area, Levaquin is frequently prescribed by many doctors for obvious viral infections. Then, when people have a urinary tract infection, almost half of the strains of E. coli – the most common urinary tract pathogen – in our town are resistant to Levaquin and Cipro and all the other drugs in that family that would normally kick E. coli‘s butt. We have had several patients who had simple UTIs turn into serious systemic infections because they were initially treated with Cipro or Levaquin for their urinary tract infection and the antibiotics didn’t help.
Now there’s a super duper bug that’s coming to a town near you. According to a recent article in Lancet Infectious Diseases, bacteria are now picking up a new gene called NDM-1 that makes the bacteria resistant to almost all antibiotics. Most of the bacterial with this gene were E. coli, but the gene can apparently can be relatively easily transferred to other bacteria. The only antibiotics that bacteria with this gene were sensitive to were tigecycline and colistin. Right now most of the isolates are in India and Pakistan, but it is only a matter of time before the super duper bugs have spread worldwide.
A 2007 JAMA article showed that MRSA infections were abundant (.pdf file). An editorial accompanying the JAMA article noted that “The estimated rate of invasive MRSA is greater than the combined rate in 2005 for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000).” In addition, the editorial noted that if the predicted number of MRSA deaths was accurate, the 18,650 MRSA-related deaths in 2005 “would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States.”
Currently, a study by the CDC is claiming that the incidence of MRSA is declining (I wasn’t able to find the study on the CDC’s web site) by between 17 and 27 percent in the past few years.
Even if MRSA goes away – which it won’t – there are still other resistant bacteria out there that are going to become a greater part of our lives. According to this San Fransisco Chronicle article, there’s “extremely drug-resistant tuberculosis” (XXDR TB). Doctors don’t even know how to treat this disease – or if they even can treat it. Less resistant TB can cost $100,000 per year to cure. Patients with XXDR TB will probably just die.
The San Fransisco Chronicle article also notes that drug-resistant infections killed more than 65,000 people last year – more than prostate and breast cancer combined. In excess of 19,000 of the patients who died from drug-resistant infections had MRSA.
So how do we stop the spread of resistant bacteria? It’s actually pretty simple.
1. Patients need to stop requesting antibiotics for nasal congestion, coughs, bronchitis, and “sinus infections.” Doctors need to stop prescribing antibiotics for these diseases. Norway nearly eradicated MRSA just by restricting antibiotic use. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better.” The slogan on a packet of tissues in Norway says “Penicillin is not a cough medicine.” See another article on Norway’s approach to antibiotic resistance here.
If we can’t change the habits of doctors who prescribe antibiotics in this country, then antibiotics need to become controlled substances and regulated by the DEA. It is that serious of a problem.
2. Wash your hands. Patients, doctors, everybody. Wash … your … hands. One friend wrote me and asked whether or not you’ll be viewed as a “trouble patient” if you request that your doctor wash his or her hands after entering your room. My reply was that if you politely tell the doctor (or nurse, or anyone else touching you) that you’re concerned about infections and politely ask them to wash their hands in front of you, there shouldn’t be any problems. If they take offense, kick them out of the room and call an administrator. If, on the other hand, you tell them “wash your hands you filthy friggin barnyard animal”, you’re asking for a loogie down your back when you’re not looking.
The video below kind of sums up the whole handwashing idea. I don’t watch TV, but apparently the green on the woman’s hands ends up killing her in the next episode.
Thanks to SeaSpray and to GrumpyRN for the ideas for this post.
We receive this transfer from an outlying hospital for a neurology evaluation. The patient is in his 30s and was out at the bars when he was hit in head with beer bottle during an altercation.
