A middle aged woman walked up to the emergency department registration window and loudly announced that her mother was in the car and needed help.

Several people ran out to the car to assist the woman’s mother. It appeared that her mother was suffering from ATATPA. Unfortunately, she also weighed at least 300 pounds and … she was dressed in a nightgown.

The patient was awake and was looking around at everyone, but she wouldn’t get out of the car. We asked the daughter what was wrong with her and the daughter told us that her mother was moaning at home. Sadie, the patient, had suffered a previous stroke so she couldn’t talk to us, but she would moan and nod her head every once in a while. No matter what we said, Sadie wouldn’t get out of the car.

Sadie’s daughter had come back out to the car and loudly asked “Well? Isn’t someone going to help my mother?”

We couldn’t coax Sadie out of the car, so, after several minutes of trying to do so, one of the techs and one of the security guards grabbed Sadie by the arms, pulled her out of the car, and eased her onto the ground. Then we scooted her onto a backboard, lifted her onto a stretcher, and wheeled her into the emergency department.

Once Sadie was in the bed and her vital signs were taken, she moaned – just like the moan that she had while sitting in the car. Her daughter got up and stood next to her, rubbing her arm. Then she said,
“Can you believe that they dragged you onto the ground like that? How humiliating. Did that security guard hurt your arm? He did, didn’t he? I’ll have to have a talk with his supervisor.”

At that point, Sadie moaned again. This time I think it was from all the other people in the room simultaneously gritting their teeth.

I left a voice message with the security guard’s supervisor giving him a head’s up and letting him know that the security guard did everything right.

Still, the fact that we even have to worry about covering each others backs like this just goes to show you that sometimes you can’t win for losing.

Little ol’ Marge came waddling up to the registration desk asking to see a doctor because she was urinating blood. In tow behind her was her obviously unhappy husband who was making it clear that the reason for his unhappiness was his wife’s trip to the emergency department.

“Great. Now we can sit in the waiting room so people can cough on us,” he said at the triage desk.

Marge and Charlie finally made it back to a room. Marge was having painless hematuria that began around dinner time. Painless hematuria in an elderly person generally isn’t a good sign. Through the whole history and physical exam, Charlie kept shaking his head and nose breathing.

When Marge gave us a urine sample, it was a medium shade of red in color.
“See what I mean?” She asked.

Charlie shook his head again. He’s going to have some serious guilt when this is all over.

While they were waiting for the lab results, Charlie hobbled to the bathroom. After the toilet flushed, he came out with even more of a frown. He walked back in the room and yelled at Marge.

“You HAPPY?!?! Now I’m pissing blood too. I told you before we left that it was the beets we ate for lunch. Now I got tuberculosis from sitting in the waiting room and we’ll get a thousand dollar hospital bill because you … don’t … listen!”

Charlie was right, it did end up being the beets.

This little interaction reinforced two firmly held beliefs of mine.
First, I will never willingly eat beets in my life.
Second, sometimes half the battle in medicine is asking the right questions.

Yup. 7151 W. Main Street, Apartment 1 is not a residence. There’s not even an apartment there. It’s a McDonalds.

A patient came in with a “hard lump” on his stomach which ended up being an abscess with quite a bit of surrounding cellulitis. The doc did an incision and drainage on the abscess and started the patient on Bactrim, suspecting that the infection was MRSA.

We got the report back while I was working and the doc was right. It was MRSA. But the MRSA was resistant to Bactrim and the patient needed to be started on a different antibiotic to treat the cellulitis.

We called the phone number the patient gave us. Disconnected.
We looked up the patient’s address to see if there was an alternate phone. As a matter of fact, there was … Welcome to McDonalds, may I take your order?

Hey, bud. You may have waltzed out without paying for your treatment, but have fun with your McSepsis and your McSkinGraft – or maybe even your McCasket.

What goes around comes around.

When grandma called the ambulance to come take her husband to the emergency department for his chest pains, she was all in a dither. They just got back from eating at the local diner and he wasn’t feeling good at all.

Paramedics swooped through the home, scooped up grandpa, grabbed his brown paper bag full of medications, and brought him to the emergency department.

Some oxygen and a couple sprays of nitroglycerin had the patient feeling better by the time he arrived. The full bag of medications got passed to the nurse so she could spend her time following JCAHO protocols and write out all of the medications, their doses, and their frequency for the umpteenth time of the day — instead of taking care of the patients.

As the nurse opened the bag, she got a strange look on her face. Then she dumped the “medications” on the counter.

Instead of a bunch of pill bottles, there was a pile of sugar, Sweet and Low, and Splenda packets that grandpa and grandma had lifted from the diner that evening. Didn’t think much of it until the patient’s daughter brought in the other brown paper bag with the patient’s medications.

Suddenly, grandma forgot about grandpa’s heart condition and got pretty feisty about us returning her sugar packets.

If I ever see her sneaking around the coffee machine in our break room, I’m calling the cops.

A lady gets brought in by ambulance for suicidal ideation. During the radio report we can hear her screaming at the paramedics in the background. Bad sign.

She started messing around with Jose Cuervo and Jose got her good. Drunk off her rocker. Going to kill herself and everyone around her. And she was an angry drunk, not a happy drunk.

She was cussing at the police. She was cussing at the staff. She would bug her eyes out of her head and scream when someone tried to examine her. She threatened to hit the staff and then cocked her fist at the security guard.

Stick a fork in you, lady, you’re getting matching sets of leather wrist and ankle bracelets.
Police and the patient’s sister helped hold her down while the restraints went on.

“You BITCH! How could you let them do this to me?”
“Chill out, sis,” the sister calmly replied.

She didn’t chill out. She got worse. She started trying to shake the bed back and forth.

OK, you’re getting a “B-52″ – otherwise known as 5 milligrams of Haldol and 2 milligrams of Ativan. Of course, we had to hold her arm down to start the IV. She was spitting and growling like some caged animal. Then she saw one of the medication syringes coming her way. “Don’t you put that stuff in me! DON’T YOU PUT THAT STUFF IN ME!”  Then she started growling and shaking herself up and down when we pushed it.

If there was a full moon out that night we would have needed a silver bullet.

Once the medications were in, she started threatening to kick our asses. Individually and collectively. She looked at me and said “YOU’RE FIRST!”

“Go to sleep. You can’t do much else right now anyway, lady, you’re in restraints.”
“Yeah, well if you come near me I’ll … I’ll … bite your balls off.”

Thanks for the heads up. If I decide to remove my scrub bottoms and walk around the room in a G-string, I’ll make sure to steer clear of the head of the bed.

Ten minutes later …
[snooooore]

If you don’t know what the reference to the movie is, watch this. Pay special attention to the last line in the scene.

The cause for this patient’s chronic nosebleeds became more apparent when the patient wasn’t able to blow her nose and the resident was unable to insert a sponge into the patient’s nostril to stop the bleeding.

A history of chronic headaches and of more recent vision changes prompted the resident to order a head CT.

A large brain mass which had invaded the patient’s nasal passages and had eaten through the patient’s nasal septum, completely occluding the nasal passages.

Sad case.

A guy in his mid-60’s came in thinking that he had a stroke. He “felt funny” but wasn’t having any other symptoms. The initial part of his exam was normal, so I started doing a neuro exam.

I break a cotton swab in half and use it to lightly poke his arms and legs to test his sensation from side to side.
“Ow, Goddammit! Cut that out!”
I thought he was kidding at first, but when I looked up at him, he furled his brow at me.
“I’m just checking your sensory nerves, sir.”
Then I tell him I’m going to use a reflex hammer to test his reflexes. [Tap tap] I hit his patellar tendon.
“Stop hitting me with that damn thing.”
“OK, fine, but it’s going to be hard for me to see whether you’ve had a stroke if I can’t test to see how your nerves are functioning.”
I hesitated for a few seconds, still half expecting him to crack a smile. All I got was a scowl.
“I need to check to see if you have any muscle weakness. Can you pull up with your arm?”
He pulled up with his left arm but it didn’t go anywhere against my resistance. Good strength.
“Good. Now try it with your other arm.”
He began pulling against my resistance again, then he suddenly grabbed my arm with his free hand and said
“Listen, you better quit f**king with me or I’m going to kick your ass, and if I can’t do it, I have two sons who look like King Kong.”

What I was thinking: “OK, whackball. You don’t have a stroke, it’s just that the lone synapse in your skull is being overworked. And if you don’t let go of my arm in the next 10 milliseconds, people are going to read about you twice on my blog – once to hear me tell the story and a second time when I link to the newspaper article about how some crazed emergency physician slapped the snot out of one of his patients.”
What I said: “Well, sir, it doesn’t appear that you have any signs of a stroke. Be sure to follow up with your doctor tomorrow for a re-check. Have a nice day.”

I didn’t have any bananas for him to take home to his sons, so I’m sure this is just going to be another one of those bad Press Ganey days.

And dang it, I only get one post out of the incident, too.

A patient came in for evaluation of head congestion. As the nurse was getting his vital signs in the room, he asked her who the emergency physician was.
“Dr. WhiteCoat,” she replied.
He turned his head to the side and asked his wife over his shoulder “Is that the one?”
His wife answered “Yup.”
The nurse asked him if he had a problem with me in the past.
“Not unless you call some guy shoving his fist up your ass a problem.”
The nurse looked shocked.
“I came in here with abdominal pain and I threw up blood. This guy tells me he needs to ‘check my rectum for blood.’ Then he buries his arm in my ass up to the elbow. I could have told him there wasn’t any blood up there. He ain’t coming nowhere near me with a pair of gloves from now on.”

When the nurse relayed this story to me, I looked his old records up on the computer before going into the room. Four years ago he came in with abdominal pain and complained of pus in his stool. He ended up having a GI bleed, but no pus was ever found. So the rectal examination has scarred him for the past 4 years.

The nurse and I laughed for a minute about whether I should walk into the room with a gown, mask, gloves and a tube of KY Jelly.

Then I started thinking.

Not too long ago, another patient whom I evaluated for abdominal pain complained to our hospital administration that he was having “post traumatic stress” from the rectal examination I performed. He was afraid of interacting with men bigger than he was and could no longer stand in lines because he was afraid of what the people standing in line behind him might do.

It’s not like I have gorilla fingers. My finger is about 3 inches long and about 1.5 inches in circumference at its widest. Most formed stool is much longer and much wider than my finger, but I don’t know any adults who have developed post traumatic stress disorder from taking a dump. Reactions like this are why I routinely bring a chaperone with me when I do these exams – just to make sure that I don’t lose my wristwatch doing the exam, you know.

It’s not like doctors enjoy doing rectal exams. I can’t go home and say “Hey kids! I didn’t save anyone’s life, but guess what I did at work today!”
Oh, and clenching your butt cheeks together then arching your back in a seizure position doesn’t make things any easier. If you don’t want the exam, refuse it.

If you go to the emergency department to be evaluated for abdominal pain, vomiting blood, constipation, diarrhea, or abnormal stools, it’s nothing personal, but you’re going to need a rectal examination. It’s part of the job I do.

Expect it.

If you don’t complain about it, neither will I … well … at least not that much.

Sometimes you wonder why a mom brings her 6 year old daughter with cerebral palsy into the emergency department at 2:00 in the morning for a fever. What were they doing up at 2:00 AM anyway?
Sometimes you wonder whether parents even know how to take a temperature. The kid’s “fever” was 100.6 when she arrived in the emergency department.
Sometimes you wonder what you’re supposed to do when the mother tells the triage nurse that the child “isn’t acting herself.” How exactly are we supposed to test to see who the child is acting like that evening?
Sometimes you wonder why it always seems to take so long to get vital signs on children. How hard can it be?
Sometimes you wonder why the pulse oximeter doesn’t seem to work on kids. Her fingers are cold. We’ll get another reading when she warms up.
Sometimes you wonder if the techs even know how to use the pulse oximeter. What do you mean that the best oxygen saturation reading you can get is 78%?

Then you go into the room and notice that the child is only breathing 6 times per minute. And you notice that the child appears dusky. And you can’t feel a pulse.

Sometimes you wonder why things never seem where they should be on the pediatric code cart. Where is the damn Broselow tape?
Sometimes you wonder whether or not such a small Ambu bag can really deliver proper ventilations to an intubated child. Ventilate faster.
Sometimes you wonder how long it has been since someone checked the batteries on the intraosseous needle drill. Get rid of this thing and give me a Jamshidi needle. What do you mean “Where is it?”
As you do your best to keep the blips going on the cardiac monitor, and you see them come less and less often, sometimes you wonder what you’re going to tell the child’s family.
When you pronounce the child dead, sometimes you wonder whether your own children are safe and whether you told them you loved them before you left for work.
When the patient’s mother comes back into the room and you tell her that her child has died, sometimes you wonder how much sorrow a person can endure.
As you watch the mom sit in a chair holding her dead child and kissing her goodbye, sometimes you wonder what more you could have done.

When the coroner calls you the next day and says that the child died from overwhelming pneumonia in both lungs and that there was nothing anyone could have done to save her, sometimes you wonder whether he was just saying that to make you feel better.
Sometimes you even wonder why you ever wanted to be an emergency physician.

Then you remember all the people that you do save. And you try to remember all smiles that you have gotten from patients whose lives you have made better. And you try to remember that the power to heal that you’ve been given doesn’t work on every patient.

You try to remember that just because a child died at your hands, you’re still human and you did your best.

It still doesn’t keep you from wondering.

Had a recent patient encounter that just underscored the importance of Dr. Edwin Leap’s recent article on patient satisfaction.

A demented patient was brought by ambulance from the nursing home. He was allegedly short of breath, but, when asked, stated that nothing was wrong. He was clinically stable, we diagnosed him with pneumonia, and I told the patient’s family that I planned to admit him.

Even though his primary care physician was on staff, the family wanted him transferred to the university hospital because in the past when the patient was hospitalized for pneumonia, he got worse and had to be put on a ventilator.

I told the family that the patient was stable and that we had the capabilities to manage his pneumonia, so a transfer at this point probably would not be considered medically necessary. I told them that I would be happy to transfer him, but they would have to sign a federal ABN form stating that if Medicare did not pay for the transfer, the family would be responsible for paying out of their own pockets whatever Medicare did not pay.

The family didn’t want to accept the possibility of paying for the transfer, so they agreed to have him admitted to our hospital.

I got a nice little note from the attending that a few hours after the patient’s admit, his respiratory status worsened. Eventually he needed to be put on a ventilator. Even though we have an ICU and intensivists, the family demanded transfer to the university hospital. The attending transferred him to avoid further complaints. And the family made sure to get the proper spelling of that emergency doctor’s name so that they could write a letter of complaint.

When hospitals overemphasize the results of patient satisfaction surveys, it may come back to bite them.

Rather than deal with the hassles and potential complaints involved with doing the right thing, some docs take the path of least resistance and do things solely to please the patients. Then Medicare refuses to pay for tests/procedures/transfers that aren’t medically appropriate and the hospital eats the cost of the care. Guess who those costs get passed on to?

And sometimes the patients still aren’t happy.