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.

Still no criminal charges, I’m going to guess.

It’s sad when you hear about deaths due to texting while driving. Dr. Frank Ryan recently drove off a California cliff while reportedly making a Twitter post about his dog.

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.

ALSO see this article over at GruntDoc’s site. Definitely worth the read.

For a few hours, our emergency department was Octogenarian Central.

It seemed like every patient that registered to be seen was in their 80’s. Weakness. Dizziness. Constipation. Chest pain. More weakness. Hip pain. Eight out of ten patients were octogenarians. Family members accompanied all of the patients and helped us piece together the multiple medical problems. After my second disimpaction of the afternoon, I longed for a kid with an ear infection.

Then we got an ambulance call. Patient down. Full arrest. Family trying to perform CPR. Yup … he was 81.

The story was especially difficult. The patient was sitting in his living room watching TV with his wife. He suddenly had trouble breathing. He told his family to call the ambulance because he felt like he was going to die.
When the ambulance got there, the patient had arrested. Paramedics did a great job getting back a pulse, but it was short-lived. When the patient hit our doors, he had no pulse.

We tried to revive him, but to no avail. Another angel gets some wings.

Informing the family was difficult. I’ve always said that telling families that a patient has died is one of the most difficult things in medicine. Hasn’t changed in all these years.

But there was a bit of a funny twist to the sad situation.

We called the coroner after the patient dies. He has to come to investigate and release the body. The coroner for this town is a great guy. Probably early 70’s himself. Every once in a while, he just randomly stops in with popcorn or ice cream for the emergency department staff.

He came in wearing a baseball cap with his trademark smile. He patted me on the back and asked me what room the deceased patient was in. I was on the phone, so I pointed to the patient’s room and kept talking.

The coroner walked over to the room, pulled open the curtain to the room, looked at the patient, and screamed out loud. Then the patient screamed out loud. He came back out of the room sweating and looking a bit peaked about the gills.

“I thought you said that the patient was in Room 12!”
“No. I pointed to Room 11.”
“Holy crap, you almost gave me a heart attack. I walked into the room expecting to see a dead person and then she rolls over on the bed. My heart’s still palpitating!”
The daughter of the patient in Room 12 then walks out of the room laughing nervously. “How do you think I felt … seeing the coroner walk into my mom’s room when she isn’t even that sick?”

A patient in her early 70’s was brought in by ambulance for difficulty breathing. She had been a smoker all of her life and her lungs were clearly wearing out on her.

After the patient arrived, a daughter teetered up to the registration desk and asked if she could see her mother. The smell of whiskey on her breath was unmistakable. The daughter went back to the room and sat with her mother for a little while as the smell of Jim Beam wafted through the air. We informed her that things with her mother weren’t looking good.

As the respiratory therapist tried to work his magic, the patient’s daughter got up and teetered back out of the room.

The respiratory therapist’s “healing vapors” had no effect. None of our efforts were improving the patient’s condition, so we went out to the waiting room to tell the family that the patient was getting worse and to ask them about the patient’s wishes for being on a ventilator.

No family members were in the waiting room.
The family was paged overhead in the hospital. No answer.
An aide went to the cafeteria. Not there.
We called the daughter’s cell phone number. Disconnected.
Security went outside to see if they were smoking. Ah HA! They weren’t standing across the street smoking like most of the other hospital visitors (and many patients) do. Instead, the daughter, another woman, and two males were sitting in a car – with the daughter in the driver’s seat – passing around a bottle of Seagram’s. The car was filled with smoke like a scene from Fast Times at Ridgemont High.

Well, Ms. Spicoli, when you finish with your bottle, you might want to come be with your mother.

Traditionally, wakes don’t start until after the patient dies.

In case you wanted another reason not to use drugs, here it is: You don’t know where the drugs have been.

A woman got brought into the emergency department in police custody. She was intoxicated and complaining of pain to her ankle and hip. The story we were given was that she jumped out the window of a house that was being raided by police and injured her ankle and hip in the jump. Following the trauma protocol we did the Airway/Breathing/Circulation/Disability/Exposure routine.

As the patient was being undressed, the nurse noted a piece of newspaper sticking out of the crotch of the woman’s underwear. A little more investigation determined that there was a wad of newspaper stuck into a place where I’m guessing that not many police officers frisk.

When the newspaper was removed, multiple little rocks of white material that appeared to be crack cocaine dropped onto the bed.

“What’s that?” The woman asked. “Whatever it is, it isn’t mine. I just stuffed some newspaper up there because I thought I was starting my period.”

Rrrrrright.

Glad I wasn’t working in the police evidence room that day.

Between about 6PM and 9PM on most Sunday evenings, our emergency department seems to become more crowded with kids and their parents. It used to be less because Sundays were school nights, but now that the kids don’t have to be in school the following morning, the numbers seem to be increasing.

I’ve also noted a trend in the presenting complaints.

You see, due to many court orders governing divorced parents with custody rights, said custody of offspring must change hands at some point in the week. In our county, it appears that the courts like the children to be transferred between parents at 5PM on Sunday evenings.

Of course, after being in the custody of that other evil parent all week (or all weekend as the case may be), the parent with the halo then notices a plethora of bite marks, bruises, fevers, scratches, ravages of vermin, and potential sexual assaults that were inflicted upon their children while those children were not under the watchful eye of the good parent. Emergency documentation of such evidence must be obtained immediately – both to prove that the alleged injuries occurred during the care of the transferring parent and to also prove that the alleged injuries did NOT occur during the care of the receiving parent.

The other problem with these visits is that they induce more visits. If mom is trying to prove that dad is not taking care of the kids, then when dad gets the kids back he sure as shootin’ is going to bring them to the hospital and get pictures to show that mom is really the one who is sexually assaulting the kid AND causing those bruises. As possession of the children changes, so does possession of the halo worn by the parents.

Normal exam. Check.
Alleged hyperdefecation. Check. No I will not say that it is because his mom spanked him. No I don’t want to see pictures of your toilet bowl and I’m not putting pictures of someone’s stool into the chart, either. Not once, not nevah. You can save those mementos and hang them on your fridge next to the calendar.
Normal exam. Check.
Alleged sexual assault. Normal physical exam. Check. No I can’t test for DNA to determine whether anyone’s fingers have been down there besides hers.
Skin rash – resolved. Check. No, there is not a rash there now and it does not matter if we shine a light on it. The rash isn’t there, ma’am.
Insect bite. Check. No it is not a rat bite and no he does not need a rabies shot. If you think her house has rats in it, call the health department. I don’t do house calls.
Bruise to shin from bicycle accident. Check. No I’m not commenting on whether you think his father knew he wasn’t wearing a helmet at the time. You weren’t there. No I’m not writing “severe” bruise. It’s not severe. You have to look at it twice to see it once. My kids have worse bruises than those.

Come to think of it …

Honey … how exactly do you discipline the kids while I’m gone?

A man in his mid-30’s gets brought by ambulance with palpitations. His mom arrived right behind the ambulance.
The patient was obviously anxious and was dripping with sweat. We hooked him up to the monitor and he’s in SVT up to the 160’s.
No medical problems. Occasional alcohol. Smokes half a pack a day. No drugs. This same thing happened to him a year or so ago, the doctors did a bunch of tests and didn’t find anything.
Nothing out of the ordinary on his physical examination.
We ordered some labs and gave him an IV calcium channel blocker. His heart rate came down to the low 100s. He still appeared anxious, so I have him a little bit of a benzo to calm him down. Soon he was feeling better.

His labs came back normal – everything except his positive marijuana screen. He’s lying because he had a bad reaction to his marijuana and we just did a ton of medical testing on him. I grabbed the drug screen result off the chart and headed into the room to confront him about the lying and the drug use.

I opened the door and he and mom were watching TV.
“I got your lab tests back.”
“Listen. Um. I figured I may as well tell you since you’re my doctor and all – I was smoking a blunt of hash at my friend’s house about a half hour before this happened. You think that may have caused my heart to go so out of control?”
“Ummm. Yeah, I do. I had the lab results right here. I was going to ask that your mom leave the room before telling you about your positive drug screen.”
“It’s OK, she knows.”
“Well then she can remind you that you need to stop using drugs.” Mom nodded her head up and down.
“Yeah, I’ve had people tell me that before.”
“You can go home now. Just stay away from the dope,” I said as I left to go finish his discharge instructions.

Then the patient yelled “Hey doc!”
I turned around.
“You’re not going to call the police about this are you?”
“You mean about you using the drugs?”
“Yeah.”
“No. We don’t call the police for drug use …” I hesitated for a second, thinking about whether I should say what else was on my mind. Heck with it. I’m not going to beat around the bush with this guy.
“… but I can give your mom some numbers for funeral homes and some cool sayings to put on your tombstone if you do it again.”

The patient just sat quietly on the stretcher and stared at his toes. The rhythmic beeping of the cardiac monitor and the muffled sounds of a child crying in a room down the hall were all that was audible.

I was standing at the desk finishing writing up his chart as they left the room and headed toward the exit. His mom patted me on the back and whispered “Thank You” in my ear as they were leaving.

Hopefully one type of blunt will stop the other type of blunt.

Freddie came in as a drug overdose.

The medics couldn’t get a line on him. He was unresponsive and his skin tone was somewhere between blue and purple.

A sternal rub didn’t do much to awaken him. We artificially ventilated him with an Ambu bag. His pupils were barely visible. Track marks were on his arm. Yup. He’s an overdose.

The nurses worked flawlessly as a team – applying the cervical collar, inserting IVs, checking blood glucose, then injecting Narcan.

“Watch out,” I told the nursing student who was putting on the EKG leads, “things are going to go wild in about 15 seconds.”
Fifteen seconds went by. Nothing happened.
Damn.
Twenty seconds. The nursing student looked at me.
I shrugged my shoulders. Hmmm. Maybe this wasn’t an overdose after all. What the hell else could this guy …

“rrrRRRR AHHHHHHH! GET THE F*** OFF OF ME!” Arms were flailing. EKG leads were ripped off. The cervical collar was gone in less that 10 seconds. Welcome to the Metro General Rodeo Minute. I marveled how everyone stopped what they were doing (including the secretary) and literally flopped on the patient to hold him down. Everyone except me and the nursing student.

“Slow circulation,” I mumbled as I winked at the nursing student and nodded my head.

We drowned in a sea of F-bombs for another minute or so until Freddie calmed down. Then he asked where the “f” he was and what the “f” happened to him. We told him that he overdosed on heroin. He denied using drugs.

I should have known. Must have been the evil girlfriend.

Freddie’s girlfriend then came into the room. She sat there caressing his hand and organizing the EKG leads so they were all in the same direction going across his chest and over to the monitor. That lasted about 15 minutes. Then she came out of the room and loudly announced:

“We need some water in here.”
I said “Not yet. He just got some medication that may make him throw up. How about a few ice chips?”
“He’s f***ing thirsty.”
Ooooh. Aren’t you the dainty little specimen. So eloquent in your choice of words, too. OK, Mrs. Freddie F-Bomb. No problem.
“Fine, he can have a small cup of water.”

Ten minutes later, Mrs. Freddie F-Bomb was back yelling in the hallway.
“If I go to Wendy’s to get him a hamburger will someone let me back in?”
I was sitting at the desk and responded “He can’t eat anything right now. I don’t want him to throw up. We’ll get him a food tray later.”
“He isn’t eating any of this nasty f***ing hospital food, and if he can keep the water down, he can keep food down.”

I had to agree with her on the “nasty” comment, but I wasn’t going to give her the satisfaction.

“Listen ….”
Almost as if on cue, Freddie then proceeded to hurl all over his bed. Franks and beans looking kind of picture. Maybe some chips, too. I looked back at Mrs. F-Bomb.
“Exactly the reason I don’t want him eating anything.”
“Yeah, well if you were so worried about him puking, then why the f*** did you give him water to drink?”

Have a nice wait in the waiting room, ma’am. Be sure to visit us again real soon.
Oh, and you don’t get a patient survey, either.
Nyaaah.

The registration clerk in the emergency department overheard the following statement from one patient waiting to be seen made to another patient in the emergency department waiting room who is on “The List“:

“Just remember – you’re the addict and I’m the dealer. You get what I give you after they prescribe it to me. Understand?”

Hmmmm. Wonder how much you’ll get for that Tylenol prescription the doctor gave you.