Psychiatric patients can be either frustrating or enjoyable, depending on their demeanor. With six of the first ten patients I saw having psychiatric issues, I got to see both sides of the spectrum today.

First was a woman who was having dizziness. She also made it clear that she was “bipolar and a little schizo.” I wasn’t sure what the threshold was between “a little schizo” and “a lot schizo,” but trying to find an answer to that question wouldn’t have been very productive.  She apparently wanted to be admitted to the hospital. When we told her that she could be discharged after receiving some IV fluid and some medication for her dizziness, she was upset. Then she said she felt suicidal. The psychiatrist knew her well, evaluated her, and cleared her for discharge. Then she said she was having chest pain and forgot to tell us. We added a set of cardiac enzymes and performed a normal EKG. The old records showed that she had a clean cardiac catheterization four months ago. We dutifully ran the case by the cardiologist who also cleared the patient for discharge. As the nurse was walking out of the room after giving the patient her discharge instructions, she yelled out the door “I had brain cancer once, too, you know.”
I looked at the nurse. She looked at me. We both stood there for a few seconds wondering about the significance of the statement. Then simultaneously we shook our heads, threw our hands up in the air, and went back to our business.

Then, there’s the lady who came in for a disappearing lump in her armpit – for the past 8 months. The lump only appeared when she rolled on her deodorant. We couldn’t find any lump on exam – even after having the patient pretend to roll on deodorant. I told the patient that she would need to see her family physician and could bring her deodorant with her to the appointment. Then I left the room to start the discharge papers. The patient yelled “hey doc, come here” to the resident, so he went back in the room. About 30 seconds later, he came out beet red in the face.
“What happened?”
“She said ‘watch this!’ then she pulled up her shirt, whipped her boob out of her bra, and squeezed it. Milk squirted across the room. Then she laughed.”
Then we laughed.
Then came the comments.
“Clean up in aisle 8!”
“It does a body good. Pass it on.”
“Somewhere in this world there is someone that would pay money to see that.”

All this entertainment and a paycheck too …

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Interesting but sad case that bypassed the ED but about which we later heard.

An elderly female with previous coronary artery disease, diabetes, and hypertension called EMS for chest pain. Then she has a syncopal event in front of her husband.

Medics arrived and found the patient in ventricular tachycardia.  They cardioverted her back to sinus rhythm, but she was still hypotensive. EMS transports her as a sudden cardiac arrest to a STEMI facility.

The patient is taken directly to cath lab which had already been activated due to the EMS report of a “code STEMI.”
During the angiogram, the patient remained unstable, went in and out of ventricular tachycardia, and remained markedly hypotensive, requiring fluid resuscitation and pressors. The angiogram showed severe three vessel disease.

Cardiologists couldn’t get the patient stable despite pressors, IV fluids, multiple defibrillations, and ACLS drugs.

Then the cardiology fellow notes that the patient’s abdomen seemed to be distended – moreso since the case started. They directed the cardiac catheter down the aorta and injected dye while doing cineangiography.  It showed contrast material going into the patient’s peritoneal cavity.

Shortly afterwards, while making arrangements for the patient to be taken to surgery, she died on the table.

The rest of the history came out when the husband was informed of his wife’s death. The night before, the patient had been seen at a different hospital for evaluation of abdominal pain.  They diagnosed her with “obstipation” and sent her home.

Some of you are probably wondering how cardiologists missed the ruptured abdominal aneurysm when they inserted the catheter into the groin and advanced it up the aorta into her heart. Radial access is all the rage these days, so initial access was through the arm and not through the leg. Therefore, the catheter didn’t pass through the lower aorta.

So why was the patient in ventricular tachycardia? The cardiologists surmised that the hypotension led to low cardiac perfusion, which, in the setting of severe CAD, caused chest pain, cardiac ischemia, and the arrhythmias.

The patient probably wouldn’t have survived surgical repair of her aneurysm, but one of the down sides to that holy grail of a short door to balloon time is that it is more difficult to obtain a complete history.

Ironic that sometimes hospital boards and/or administrators care more about their numbers than they do about the actual patients. When hospital boards or administrators pressure medical staff to meet unreasonably high standards for “door to balloon times,” perhaps lawyers need to start looking at the administrators and board members for reckless decisions that result in adverse patient outcomes.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Two different patients came in with strange “bug” complaints.

The frustrating thing for doctors is that the patients with “bug bite” complaints are absolutely convinced that the bugs are present and are causing all kind of physical maladies. Many times they are not.
The frustrating thing for the patient is that the doctors are sometimes … well … skeptical of the complaints.

The first patient had small scabs on her arms and lower legs – typical of neurotic excoriations. There were scars in these same areas where previous “bug bites” had occurred and healed. No scars on the back or other hard to reach areas.
According to the patient, the bugs were hiding under her skin, crawling out from under her skin, biting her, then crawling back under her skin again and hiding when she tried to kill them.
I used a magnifying glass to look at the areas to show her that there were no bugs.
She corrected me. She had done research on the internet and the bugs were too small to be seen – even with a magnifying lens. Besides, the bugs that had infested her integumentary system liked the dark, so they only came out when it is dark in her bedroom.
“I can feel one crawling up under the skin on my leg now. Can you see that lump moving?”
She pointed to an area on her skin. We both stared at her leg for about 30 seconds.
Um, no. No movement.
I suggested that she leave the light on at night if the bugs were afraid of the light. That didn’t work. Apparently they bugs know when she is sleeping and pick that opportunity to bite her.
She had been to multiple dermatologists, family practitioners, and emergency departments. She had been told that things were “all in her head” in the past, but didn’t believe it. No it wasn’t scabies. No it wasn’t bed bugs.
Knowing that I wouldn’t win this battle, I thought for a few moments while thoroughly washing my hands and came up with the cure.

(more…)

There are a few times in emergency medicine when you know that a patient is either very sick or very injured.

When you see a car screech to a halt in the ambulance bay and then see people get out of the car and start running about haphazardly, it is generally a good bet that the person still in the car is in need of immediate medical assistance.

When a car drives by the emergency department entrance and pushes someone out of the passenger door, and takes off, leaving the person laying on the asphalt, it is generally a good bet that the patient needs urgent medical assistance and that the person providing the transport was either involved in some criminal malfeasance and has a warrant or, alternatively, the driver just no longer wanted to deal with the patient.

Yep, driveway dump patients are usually quite challenging. Many times, there is no ID. Most times they are either unconscious or near unconsciousness. Those face plants on the concrete welcome mat don’t help matters.

So there she sat in Room 7. The latest driveway dump. Ahhhh lucky Room 7. The room closest to the ambulance entrance. The room that housekeepers knew to keep stocked with extra towels and gowns and masks. Personal protective gear we used to protect ourselves from the blood, vomitus, and even the occasional excrement that would sometimes fly our way as we cared for our patients.

Walking in the room, there was a different smell, though. Not the typical “sanitizer residue” odor you get every time the room is cleaned. More of a stagnant “chili con queso” aroma. Quite pervasive, too.

In any event, the patient was quite inebriated, quite loud, and quite uncooperative. We removed her baggy jacket and wanted to get her undressed so we could put a gown on her. We couldn’t understand much of what she was saying in slurred Spanish, but from the tone of her voice, she didn’t want anything to do with taking off her t-shirt and army fatigues.

So I sat down to start an IV line on her. Naturally, I got it on the first stick, because I am just that good.

Then the patient looked at me and said “Morphine?”
I looked at her with a surprised look. “Morphine?” she repeated, pointing at her IV.
“Por que?” I asked. Yes, I know a few words in Spanish. Not sure why I asked her “why”, though. I knew that I wouldn’t understand what she described as her excuse.
I was right. I did pick out the word “dolor” a couple of times from the next few minutes of her description why she needed morphine.
“Espera el doctor” I told her. Hopefully she understood that I meant she needed to wait for the doctor to examine her.

She reached into the pocket of her army fatigues and pulled out three objects wrapped in tin foil. Then she held them out to me. An odor of refried beans and salsa just kicked up a couple of notches. I looked at the objects. They were flattened tacos. Refried beans were squeezing out of the sides of a couple of them and crumbs of hot sauce-covered taco shells were dropping all over the floor.

She raised her eyebrows and nodded her head as she extended her arm even further.

“You,” she said, pointing at the tin foil objects. “Me, morphine?”

No, ma’am, sorry. I don’t accept bribes of makeshift taco salad in exchange for controlled substances. It’s against my ethos. However … I could probably get you some Tylenol … Number Three.

And you can even keep the tacos.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

“I’ve had a fever,” said the 50-something year old lady who wasn’t feeling well.
“My muscles ache and I don’t feel well.”
OK, not much to go on.
“Well, how high was your fever?” I asked.
“Just under 207 degrees.”
“You mean 102.7?”
“No, 207.”
“As in 2-0-7?”
“Yes, as in ’2-0-7.’” She was starting to get annoyed. “Do you think I don’t know how to take my temperature?”

Ummmm. Well, her temperature was 99.7 in triage.

Then the backoom banter began.

How are we supposed to take her temperature … with one of those oven roaster thermometers?
Talk about hot-blooded … wow.
Hey, 5 more degrees and she’ll evaporate
“I’m Mrs. Heat Miser, I’m Mrs. Sun. I’m Mrs. Green Christmas … I’m Mrs 201.
Her air conditioning bills must be hell in the summer.

A little later, one of the nurses brought the fun to an end.
Doc, her temperature is 101.8. She wants to know what you’re going to do about it.
“Hey, we’ve already dropped her temperature by 105 degrees. What more does she want?”

Don’t some things just make your blood boil?

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

A nice 89 year old man was brought to the emergency department by ambulance complaining of chest pain.

While I was talking to him, he mentioned that he and his wife would be celebrating their 65th wedding anniversary in a few days.

So I asked him “What’s the key to your long marriage”
He rubbed his chin and I sat back, expecting some profound words. He came up with this:

“We don’t communicate much. When I complain, she doesn’t listen. When she complains, I don’t listen. It works out well that way.”

A little while later, Harvey’s wife Marge came to see how he was doing. She was petite, well-dressed, and sharp as a tack.

I wished her a happy 65th wedding anniversary.

She gave me a funny look. “It’s our 64th anniversary and it’s not for six months, but thank you.”
I looked at Harvey. Marge looked at me and then looked at Harvey. He frowned and waved his hand at her as if to tell her to go away.

“Did he tell you it was our 65th anniversary?” she asked.
“Well, kind of.”
“You can’t pay attention to him. You know how he got here?”
“By ambulance?”
“Yeah. He was pacing back and forth in the kitchen and finally said ‘I wonder what’s taking the ambulance so long.” I asked him why he called the ambulance. He said that he had been having chest pain all week. Then I told him I didn’t hear him talking on the phone. He told me he used the phone in the living room … that’s sitting in a drawer … that hasn’t been plugged in for years. So I called 911 and they were at our door in 10 minutes.”
Then Harvey gets mad. “Marge will you shut up already? I’m the one having chest pain here. Now button your lip.”

Ahhhhh. True love.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Recent patient complaints requiring emergency department evaluation:

1. “Belly button problem”. White and blue stuff keeps growing in belly button and thinks that there may be fungal infection there. Brought some in a plastic bag for analysis. Diagnosis: Umbilical Lint

2. Ambulance transport for rectal itching. The patient was having difficulty reaching his bottom to wipe himself due to his size. Diagnosis: Buttock Dermatitis

Another reader looked at patients’ presenting complaints during a shift.
12 patients had cramps/back pain
5 were well-appearing febrile children
About 10 other patients had issues the equivalent of a stubbed toe
6 patients had conditions needing emergency treatment. Because of the crowding, these patients had to wait.
Out of all those patients, guess who complained … one of the women with back pain.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

An elderly patient with Alzheimer’s Disease was brought by concerned family members after reportedly having blood in his stool.

I introduced myself to everyone in the room and to the patient. When I tried to obtain a history from the patient, it was clear that he didn’t recall what happened. So I began obtaining the history from the family members.

Midway through the history, the patient interrupts and says “HEY! Who IS that guy?”
“That’s the doctor, dad,” his daughter gently said.

We finished discussing the history and then I asked the patient if it was alright that I examined him.
“Sure.”
I got through most of the exam and then explained that I needed to do a rectal examination to look for blood in his stool.
The patient’s daughter stood up and told him that he needed to pull down his pants and roll over on his side. I stepped away from the cart to get a pair of gloves and a Hemoccult card.
I heard the patient asked again “Hey. Who was that guy?”
“That’s the doctor, dad, he’s just examining you.”
“Oh, OK.”

I went back over to the bed and explained to the patient “You’re going to feel a little pressure, now.”
He tolerated the exam well.
After I was finished, I washed my hands and excused myself from the room to go send the Hemoccult card to the lab.
As I was walking out the door, the patient says “HEY! Who was that guy and why the HELL was he sticking his FINGER in my BUTT!?!?”
His daughter calmly said “That was the doctor, dad, he was just checking to see if you have blood in your stool.”
“Yeah? Well he has fingers like a gorilla!”

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

A patient comes into the emergency department holding his jaw.

He has had a chronic toothache for the past two weeks. We looked up his old records and he had been coming to the emergency department with toothaches and back pain for the past four years.

He has a dentist appointment scheduled at an out of town clinic for a week from Monday. He just needs enough pain medicine to hold him over until that time. After all, he’s been “popping Tylenols like candy” and they haven’t helped him one bit.
“Exactly how much Tylenol are you taking?”
“I’ve gone through 3 or 4 hundred in the past week. I’ve probably taken 50 or so in the past day or so.”
“You mean ‘fifteen’, as in 1-5?”
“No, fifty … like 5-0.”
“OK, well, we’re going to need to check your liver enzymes and get a Tylenol level on you to make sure that you don’t need a liver transplant. Taking that much Tylenol can be potentially deadly.”
“OK, whatever. Can I at least get some medicine for my pain?”
“Sure.”

I then took out a needle, drew up some Marcaine, and performed a mandibular block on him.
The pain was gone, but he didn’t seem happy.

About 45 minutes later, his Tylenol level and liver enzymes came back.
Anyone want to guess what they were?

Zero?!?!! I was shocked. Normal!?!?! Thank goodness.

“Well, your Tylenol level is zero, so there’s no Tylenol in your body.”
“Yeah, well they were generic.”
“Generic Tylenol still has Tylenol in it.”
“Yeah, not as much as the real stuff, though. Can I get something stronger for the pain?”
“Since you have already stated that you were overdosing on medications, I am hesitant to give you anything stronger for your pain. I can make a call and try to get you into the County Dental Clinic in a couple of days, though.”
“This is bull****. I’m going to sue you and this damn hospital for not treating my pain.”
“You already told me that the pain was gone after the shot I gave you.”
“You’re NOT giving me anything to TAKE HOME!”
“I’m sorry, I’m just not comfortable prescribing you additional medication, especially when all these doctors are being charged with crimes when their patients overdose.”

He stormed out of the emergency department cursing at all of us.

The nurse came up to me afterwards and said “You could have at least written him a prescription for some Tylenol.”

Funny.

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.