Posts Tagged ‘ERP’

Do they Have Gastroenteritis or Antimony Poisoning?!

Friday, January 7th, 2011

Hey all, it’s ERP from erstories.net. Haven’t done a guest post in a while but here ya go.

Recently there has been a huge uptick of visitors to my ER violently ill with vomiting and diarrhoea.  They (the CDC) thinks it is Norovirus, but that got me thinking.   We see episodes of this sort of thing so often that we almost turn off our brains as clinicians.  We say “you have a virus” before the patient has finished telling us the full story.  We blindly order Zofran, IV fluids and check some electrolytes.  If they feel better after a bolus of fluids and they tolerate some liquids, they go home.  Quick and easy.  Anyway, I got to thinking, what if something else is going on?  Something weird or random (I know I am a geek like that). Something sinister?   During such outbreaks, it would be easier to avoid detection if you were poisoning someone.  This thought got me back to one of my favourite murder-mystery/science books, the Elements of Murder by John Emsley.  You may remember when I blogged here a while back about the cause of death of Napoleon.  My interest in this subject was piqued by reading this book.

Anyway, if you want to poison someone (not that I would advocate such a thing), the way to do it is to do it SLOWLY.  Don’t give a huge lethal dose since that will trigger suspicion that one was poisoned. Also, don’t use things that have very distinctive toxidromes, such as alopaecia.   This includes radioactive stuff like Thallium and Polonium – 210.   If  you give small doses of things that give more common, run of the mill symptoms (such as vomiting and diarrhoea) that are easily mistaken for things like GI viruses, most MD’s won’t be the wiser.  If you are offing  your great-great grandmother to collect her inheritance or life insurance, no one will bat an eye when she kicks it.  The idea is not to trigger an autopsy or official medical examiner evaluation.   Of course, in this day and age, it is much harder since random deaths of young healthy people will almost invariably trigger an investigation even if it occurs over time. Still, I was thinking about this when I saw a 70 year old lady with N/V/D with dehydration, abdominal cramps, low grade fever, mixed in with  about 5 others I had seen with the same thing during a shift.   Perhaps she was rich and some evil nephew could not wait for her to bite the bullet naturally.  Maybe the poisoner was some evil genius with access to all sorts of nasty stuff?

That got me back to my Elements of Murder book and I read about Antimony, the element with the symbol Sb and an atomic number of 51.  It’s  not something that’s usually lying around these days like it was from the 1500’s to the early 20th century, but it is still around in industrial applications and still can be used in a some forms therapeutically to treat some parasitic infections.   There are some problems with using Antimony to poison someone, mostly that unless the body is cremated, it stays detectable in the corpse nearly forever. Thus the key is to avoid an autopsy.  The advantages of it however are that it causes vomiting, headaches, cramps, and sweating – hence it used to be used to treat fevers.  This lady that I saw pretty much had all this – as did many others that I saw last week.  Just giving her small recurrent doses which would be perceived as a relapse over time, and eventually levels would build up to lethal levels where it blocks anticholinesterase enzymes and causes cardiac arrest.   Now, if I were to suspect this poisoning, I could administer chelating agents like Dimercaprol and the patient would likely survive, so the key is to get the patient poisoned during a big Norovirus outbreak when I have the blinders on.

There were some famous murderers that used Antimony, usually in the form of James’ Powder or Tartar Emetic.  One victim’s case that I found pretty interesting was that of Wolfgang Amadeus Mozart. His death at age 35 in 1791, at the height of his creative genius was officially attributed to “Military Fever”, an archaic term no longer used that could represent many real conditions – infectious or otherwise but may in fact really be Antimony poisoning.    There are many other theories about his death that you can read about (head trauma, Trichinosis, complications of Rheumatic fever), however there seems a real possibility that he was poisoned.  Antimony seems to make the most sense (over Arsenic which would be much more common) due to his symptoms of raging fever, vomiting,depression, and severe edema of the extremities and abdomen from renal failure.   He also exhibited a rash (which my lady fortunately did not have) that has been observed in known cases of poisoning.  The theory is that the composer was treated with Antimony for “melancholia” or severe depression (saddled with stress and debt, this would not be surprising) by his doctor  (ironically Antimony was used to treat this but often CAUSES more depression!) and apparently he was pretty sensitive to it.   When he got more ill and appeared to be febrile (“Military Fever” again) he got more Antimony (and some Mercury which is also nasty stuff) until he succumbed 15 days later, leaving his final composition, the Requiem Mass, unfinished.

Some consorts reportedly came forward much later stating that they had poisoned him on purpose, but the evidence seems to point strongly to yet another case of historical medical malpractise!  Back then, you could do what you and most of medical establishment thought was right, and kill someone unintentionally.  If I could go back to virtually any time before the US Civil War, I would tell people to avoid doctors like the plague!  Meanwhile, my lady felt better after her treatment and I discharged her with an Rx for Zofran – which I subsequently realised might contribute to her death if she were being slowly poisoned with Antimony (since expelling the compound from one’s body is critical in avoiding absorption of acutely deadly doses).  Well, lets just hope she had that virus and get back to work clearing the board.

Late Night Entertainment

Saturday, July 10th, 2010

Hey All, it’s ERP from ER stories doing a quick guest post.

The myriad of ways that the staff entertains themselves late at night when there is a lull in the action is boundless. In fact, White Coat has blogged about this.

There is the “Obituary Game” made famous on Nurse Jackie but widely known to have been stolen from Nurse K.  (reading the Obits and taking bets on who the deceased was and what the cause of death was based on their name)

There was “Cane Ball” which we used to play in the ambulance bay in residency (basically stick ball using a cane and a ball of tape).

Saline battles with pre-filled non-sterile flush syringes. (They squirt pretty damn far!)

Recently, we had a sort of “What would it take” game between some docs and PA’s.  Of course it rapidly degenerated into a sexual theme.  Sort of “how much would it take for you to sleep with so and so?” or “Would you sleep with so and so, if….?”   Basically we found quite a variation in tolerances between us.

It mostly revolved around a fairly revolting surgeon at our hospital who is both unattractive physically, lecherous and creepy, and grossly unethical. What we discovered was that the amount required by the women was a minimum of 500,000 dollars providing he wore a paper bag over  his head!

A variation of this was “Would you Rather?” where you have to make a choice between two very unpleasant options – basically the lesser of two evils.  Some choices we were given:

Would you rather fracture your penis or your femur? (I chose the femur)

Would you rather get pancreatic cancer or glioblastoma? (I chose GBM)

Would you rather get a chest tube or a DPL with no Lidocaine? (I chose the DPL)

And of course the old classic, Would you rather be beautiful and stupid or brilliant and hideous?  Man, that’s a tough one!

Anyone else have any good late night time-killing games?

Murphy’s Law of the ER

Tuesday, June 8th, 2010

Hey, it’s ERP from ERstories.net doing a guest post.

The other day during a shift I said to myself “Dang it, it’s Murphy’s Law again” when something went all FUBAR. That made me decide to compile a little list of how that law applies to my job.

1. The GYN cart will only be stocked with the extra large and “virgin” sized speculums when you have a normal-sized patient to examine.

2. The GYN speculum light will not work and you will need to have your chaperon use the odoscope.

3. You will have three or four pages out to various doctors for an hour and no one calls back. The moment one finally does, so do all the others. They get annoyed being on hold and hang up.

4. There is guaranteed to be an issue whenever a patient needs transcutaneous pacing. Of course everything worked fine on the practise, model patients, but the moment you need to use it, the thing does not sense or the wires are not compatible with the pads.

5. The IV is going to blow the moment you have to push Epi – even though it was working fine for an hour before hand.

6. The nurse you need for a patient is always on break.

7. The nurse tells you that the patient in room 15 is getting annoyed waiting for an hour with pelvic pain. When you finally go into the room, the patient is either in the bathroom, waiting room, or fully dressed in a wheelchair.

8 There is never a nursing home’s number on their transfer paperwork, making history taking on a demented, bedridden patient a true joy.

9.The SMA-7 on a critically ill patient is always haemolysed.

10. The rate of RN, tech, and unit secretary “sick” call-ins is directly related to the niceness of the weather outside.

I am sure there are many more. Feel free to submit your own!

Double Entendre

Wednesday, March 17th, 2010

ERP here from Erstories.  A little quick post while I am out skiing.

Yes, I admit I get a little juvenile on occasion during a shift.  Other staff members do as well and I think this is a good thing.  It lighten things up.  A little silly laugh because someone said something that conjures Beavis and Butt-head – style snickering helps our blood pressures come down.  Of course there is a fine line between jokes and harassment but if everyone laughs when someone says something that is unintentionally of sexual connotation, who would complain?

Some of the things I have heard or had said to me:

“Hey ERP, do you have a measuring tool”?

“Who was that new doctor? He pissed me off by getting all up in me.”

“Holy Moly, it is busy. I have never seen such a patient load.”

“Yes, Doctor Newbie, I can help you get that DVD into the slot.”

“Hey ERP, the new patient in room 5 has priapism, go help him take care of it.”

People need to lighten up in the work place.  Sometimes things are just funny!

When Will We Learn?

Friday, February 5th, 2010

Hey, its ERP from ER stories doing a guest rant post.

OK, I have blogged about this before, but nearly every shift, I have cases which emphasize the need to repeat myself.

When the hell with doctors learn to stop obsessing about hypertension?  I don’t mean to say that we should not treat it – of course we should. I am talking about blaming every symptom a patient is having on it.  I am talking about aggressive lowering of the BP in the acute setting.  It is just stupid.

If I had a nickle for every time a patient’s headache or dizziness is attributed to hypertension I would be a millionaire.  The sad truth is that it almost never is!  The BP is a REACTION to the symptoms not the cause.  This is obviously true in people who are chronically hypertensive – it took years for them to develop it so why do we think we need it lowered in 5 minutes?  Of course their pressure will go up to 200 when they have pain.  And guess what, lowering it fast will probably make new problems – like syncope and rebound hypertension caused by crappy old drugs like Clonidine.

This is different than when a young person has hypertensive encephalopathy or when someone has a big head bleed (where you want to lower the pressure only a small amount) or an aortic dissection.  They people do need IV treatment but almost no one else does!

I just had a patient who was admitted to three days in England (where he was visiting I assume)  for “hypertensive emergency” because he was having a room spinning sensation and a systolic pressure of over 200.  Guess what, they lowered his pressure and gave him new drugs to go home with but he still had dizziness! Why? He had obvious benign positional vertigo!  I gave him antivert (an antihistamine that works well for it) and it went away!   And as a bonus, his pressure came down on its own!

So, patients do not check your BP when you feel pain or dizziness (unless you are on the verge of passing out – in which case you are looking to see if your BP is LOW), check it when you feel normal and have been chilling out for 10-15 minutes.  Do that over several weeks and show the numbers to your doctors and let him or her decide treatment.

Doctors, do not attribute every headache, vertiginous episode, or other discomfort referable to the head to hypertension.  Do not agressively lower it in the ER or your office and then discharge the patient.  Do not give someone labatelol because the have a nose bleed.  Do not fail to examine someone and miss benign positional vertigo.  Don’t just treat the number to make yourself feel better!  Treat hypertension for the long term!

How to Get Rid of a Customer

Friday, January 15th, 2010

customer service

Hello, ERP here from ER stories.

The other day we had a woman come in the the ER with complaints of vague chest and back pain for many months.  We noticed she had never been there before and was from out of state.  When asked why she suddenly decided to come in for this problem, she stated that she a seen an ad for our hospital’s new ER on a bus in her neighbourhood and thought, “Hey, that hospital looks great! I think I will go over there right now!”.

Some of the docs joked about how our hospital’s marketing dept was doing too good of a job – in attracting the wrong type of customer!  This hospital wants insured patients to come and schedule elective surgeries and have expensive out patient studies done.  Instead, they got someone with out of state Medicaid come to the ER for a completely non-urgent problem.  (I was personally more annoyed about the fact that she came in for a chronic condition than her insurance status).  Anyway,  due to her Medicaid being out of state, she would not be able to follow up with any of our doctors or our clinic so she would wind up being referred back to her state.

Which is why I was more than suspicious when the lab mysteriously lost not one, but TWO sets of bloods that were drawn on the patient.  Thus she experienced a delay of more than two hours in getting a disposition.  She expressed her frustration by saying “Your hospital is not great at all!  I am not coming back!”.    Hmmmmmmmm.

I’ll Take That as a Compliment

Friday, December 11th, 2009

The image “http://www.davidlnelson.md/images/DistalRadiusFx_fx_lat.jpg” cannot be displayed, because it contains errors.

Fractured Distal Radius (see Arrows)


Complete Posterior Elbow Dislocation

Hello, guest poster ERP here.

If you read my blog, recently I posted about the first “Ice” day of the year. The day that always seems to surprise people, haplessly stepping out onto the stuff in their driveway, front steps, or sidewalk. We always get a big bolus of patients with falls – often with nasty injuries.

Anyway, one of the poor guys I saw that day was the unfortunate owner of the above x-rays (well, ones that were nearly identical to them). He slipped backwards and fell while trying to get into his car. He was in a world of pain (and yes, before everyone goes crayzee, he got PLENTY of IV narcotics!). Realising that I had to reduce that dislocated elbow, and since he had not eaten or drunk anything since the night before, he was a perfect candidate for Dr Conrad Murray’s favourite drug, Propofol (administered by an anaesthesiologist since myself and my PA were doing the reduction – it can be hard to monitor the airway and do a procedure at the same time). Since I had to reduce the elbow (you really should not wait very long to do this), I figured why not try to reduce the distal radius fracture as well? (Not being an orthopaedist, I have only reduced a few of them, usually with the assistance of one). I figured that worse case scenario, he would need another reduction when he followed up with ortho in a few days.

We put the guy out and the elbow reduced easily – return to full range of motion was achieved in short order. Then I bent and yanked on that smashed wrist. The crunching sounds always sort of make me queasy but that is the way it is. I splinted the whole arm from shoulder down to the fingers and ordered the post-reduction X-rays. I thought they looked OK but what do I know? I could tell the elbow was in but I don’t know all those myriad of angles that orthopaedists have to memorise. (for most fractures, there is an angle between the fracture segment and the rest of the bone that you shoot for – and that is what determines if the reduction is successful and not requiring another attempt). About an hour later, the orthopod came in – he had a slew of patients as you can imagine that day – and looked at my handiwork. He deemed the reduction “acceptable” and appeared to be thankful that I had made his day a little easier. I felt like a med student who did his or her first suturing job that did not have to be redone by the attending who came to supervise! Now, I hope he will come in a little faster when I REALLY need him for that drunk guy with an open tib-fib fracture who will inevitably come in at 3am on a Friday night!


Sunday, November 22nd, 2009

Elmhurst Hospital sign reads I'm Hurt

ERP here from Erstories.

Blanked out Letters are sometime appropriate. According to the NY times, people were greeted with the above sign when they went to the Elmhurst Emergency Room in Queens, NY.

Quarterback Offense

Wednesday, October 7th, 2009



Hello all, ERP here.

What is the Quarterback offense?  No, it is not some weird audible in football or a Quarterback sneak. It is a tactic used by plaintiff lawyers (and expert witnesses) to sack ER doctors in court.    How does it work?  Let me give  you an example.

A guy I know who is an excellent ER doctor (and probably more cautious and careful than most) who was sued along with a neurologist for not giving TPA to a patient who presented with stroke symptoms to the ER within the three hour window for its use.

Now, there are MANY, MANY reasons to not give TPA to a stroke patient other than that they presented too late.  The symptoms could be too mild to warrant its risks, there could be a contraindication such as having a coagulopathy, etc.   Regardless, this guy presented to the ER with some RESOLVING symptoms (I can’t remember exactly but I think he had some slurred speech) that was virtually gone by the time he got put into a room in the busy ED.  The ER doc assessed him quickly, and even though he thought himself that it was not appropriate to give the drug, he called the neurologist on call to run the case by him for confirmation. The neurologist agreed and the TPA was not given. The guy was admitted and, and the time of leaving the ED, he had zero symptoms.  Perfect! Right?

Wrong.  A few hours later up on the floor he suddenly stroked out big time and after a long deterioration, died.   The ER doc and neurologist were sued for not giving TPA.

Now, this is related to the title of the post as such.  The plaintiff-sponsored “expert” witness (an ER doctor whose smiling mug is frequently plastered across the pages of many Emergency Medicine magazine/journals as the “face” of a large contract management company.  (Makes me nauseated)) claimed that my friend was not being a good “Quarterback” by FORCING the neurologist to come in and examine and thus administer the drug.

Now, we are supposed to send out a hit man squad to twist the arms of consultants I guess.   Never mind that the guy would not have been given the drug by any prudent ER doc or Neurologist.

Well, the good news is that the jury thought this was silly as well and found in favour of the defense and my friend and the neurologist were exonerated.

What’s next?  The Blitz?  The Double Reverse? The Hail Mary??!??!

I Think you are in the Doghouse

Sunday, September 27th, 2009


OK Ladies, how would you feel in this scenario? Suppose you were standing in an examining room with your husband, fully clothed, waiting for the ER doctor to come in and examine you for a slightly embarrassing problem. Suddenly, your husband, who is getting frustrated with waiting, opens the door and grabs the nearest doctor who is walking by. Leading him into the room, without any chance for an introduction or for you to change into a gown, your husband takes hold of your pants, and apparently not caring that you are not wearing any underwear, yanks them down to your ankles while asking the startled doctor “What do you think this rash is?!?!?!”

I bet he is sleeping on the sofa for at least a few days.

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