Statuesque

The patient's mother brought her in to "rule out seizures". The patient was a 5 year old girl, singing, smiling, interactive. When asked why she was worried the girl was seizing, mom said, "She keeps telling me she feels like a statue." "Is she shaking? Staring into space?" "No," mom replied. "She says she feels like a statue." I asked her if the child was still talking and moving when she was feeling like a statue. Indeed, she was. "Do you feel like a statue right now?" I asked. She answered in the affirmative with a nod of the head and a big smile. After a full neurological exam, which included watching her walk and skip around the Emergency Department, I told mom that I didn't think she was having seizures. "Then why does she say she feels like a statue?!" asked mom. "I think she's just being 5. She has an active imagination." Silence from mom. She clearly didn't believe me. I explained that a seizure workup is beyond the purview of the ED and offered to give her the name of a pediatric neurologist. She took the neurologist's name and when she gets to that office, I'm sure he'll wonder what kind of idiot ER doctor sent her.

If it ain't broke...

OK, so this lady came into the department with a cough and shortness of breath. According to her, she just needed antibiotics and a sleeping pill. According to me, she was wheezing. She had no history of asthma, so I decided to give her some nebulizer treatments and get a chest x-ray. When the nurse went to get her for an x-ray, the patient told the nurse that she didn't need one, because she knew her chest wasn't broken. Honest and true.

Ranting

There was a story in the Palm Beach Post the other day about senior citizens buying a quick-access card for emergency medical care as part of their condo dues. http://www.palmbeachpost.com/localnews/content/local_news/epaper/2007/05/12/s1a_ER_CONDOS_0512.html

The article states that by showing the card on arrival to the emergency department, a patient will have his or her care expedited. This is the kind of idea that makes Emergency Physicians cringe. In the Emergency Department, no one is supposed to get special treatment. As patients come in, they are seen by a triage nurse and assigned a severity score. The sickest people go first. As they should. People who aren't having an emergency should go to their doctors' offices. But they don't. I have been chewed out by someone with an ankle sprain for a delay in care that was due to another patient's life-threatening condition. I asked him if he would want his grandmother to wait if she were dying and he said, "She should, if I was here first!" Poor grandma.

The underlying problem seems to be the misuse of the Emergency Department for problems other than emergencies. Here are a few advertising slogans I have come up with for the ED:

The VIP Lounge- Are you too important to make an appointment? Come down to the hospital and throw your considerable weight around.

The My-Doctor-Won't-Refill-My-Percocet-Room- Is your doctor blaming YOU for your addiction to narcotics? Go to a doctor who doesn't know you! Then threaten a lawsuit!

Chez Chronic Condition- Are you sick of your chronic abdominal pain? Is a life of bad decisions catching up with you? Come to the ED and kvetch!

The Sick-to-death Room- Have you seen every specialist there is for your numb toe and everyone says you're fine? Do you KNOW you need an MRI but no one will order it? Come to the Emergency Department and use the secret passwords: "I just can't take it any more".

All's well that ends well...

When people hear that I'm an emergency physician, they inevitably ask, "What's the grossest thing you've seen in the ER?" It's a fair question, but what grosses out the average person doesn't bother me at all. I love to open abscesses because of the feeling of satisfaction that comes with each milliliter of pus that pours out. The awful smell just enhances my joy. But now, I have the greatest gross story ever!

Last week, the local police did a raid on a known drug house. Three of the inhabitants thereof surrendered immediately, but the fourth, who later became my patient, barricaded himself into a bedroom. The SWAT team was called in (a little overkill if you ask me) and they broke down the door. Upon entering the room, the police observed future-patient swallowing several packets of cocaine. They brought him to me for "medical clearance" for incarceration.

Let me clarify "medical clearance". A few years ago a local police district had a man die in custody. It was discovered that he had been highly intoxicated and likely choked to death on his own vomit without anyone noticing. Since then, all suspects who are apprehended are brought to the ED for medical clearance. This supposedly takes any responsibility for the patient's welfare off of the police and shifts it squarely on to my shoulders. I even have to see people with no complaints! What am I clearing? I haven't the foggiest.

However, this was a legitimate clearance issue. If the cocaine packets burst inside future-patient-now-current-patient's intestines, he would die very quickly. The patient was also completely crazed on cocaine. He was brought in with his hands cuffed behind his back, screaming obscenities, fighting with everyone, wearing a layer of cocaine powder around his lips (think Dave Chapelle's drug addict sketch). He freely admitted to using "crack, percocet, xanax, and cough syrup with codeine". When I asked about heroin, he got very defensive and told me, "Hell no! I'm a man of god!" We all have our criteria. In any case, it was obvious to me that this man was not going to cooperate with the flushing out of the cocaine packets and wasn't in a mental state to make coherent decisions. His heart rate was 160 and his blood pressure was through the roof. His veins bulged out of his forehead. We gave him some powerful sedatives and he soon conked out. A tube was inserted through his nose into his stomach. We administed what is called "go-lytely", which is an agent that cleans out your intestines really fast. People take it the night before a colonoscopy to give the doctor a squeaky-clean view.

Two hours later, he still hadn't pooped. I listened to his abdomen, which sounded like a volcano getting ready to erupt. The nurse kept checking to see if he had gone. About an hour later, the nurse checked the patient's bottom and saw something sticking out of his rectum. This brave nurse pulled out the object and found himself holding a little baggie with a bunch of money rolled up in it. What a good place to hide your cash! I have always used a wallet but am reconsidering. The nurse had little time to celebrate, though, because he had taken the proverbial finger out of the dyke, and poop flew everywhere! It was all over everything and everyone. And THAT is the grossest thing I've ever seen.

Physician, heal thyself

It's been a while, I'm aware. Sometimes, doctors are patients, which is what happened to me. And being a patient really sucks. I've always known that I prefer to be wearing the white coat rather than the blue gown, but until I spent a few years in the gown, I didn't really know how it felt.
Delivering bad news is something I do nearly every day. Hearing bad news is relatively new to me, but I've become an expert. And what I've learned is that it isn't really what you say, it's how you say it. The tone of voice is so important. I wanted to know that my doctors were really sorry things weren't turning out well. They seemed as surprised and as sad as I was. And while that didn't give me the outcome I was seeking, it made me feel so much better.
I'm an emotions-on-my-sleeve kind of gal, but have often felt like I have to hold it in when interacting with patients and their families. Now, I don't hold back as much. I let them know how sad I am for them. And even though I can't change the situation, they feel just a little bit better.

Some weird stories

First of all, I was hit by a patient on my last shift. I'd never been hit before. Spit on- yes. Groped- yes. Cursed at- daily. But no patient has ever intentionally raised a hand to me. This woman was bipolar and out of control. We try our best not to sedate or restrain patients in the Emergency Department if we can redirect them verbally. This woman tried to escape, but did not have the capacity to make decisions for herself. I stopped her and put a hand on her shoulder to try to guide her back to her stretcher. She raised her hand a smacked me. It was only on the arm and it only stung for a few minutes, but I was shaken. For her safety and the safety of the staff (me included!), we gave her some powerful sedative medication. I went to check on her later and she looked at me and said, "I'm sorry." I don't think she knew what she was apologizing for, but she did know that she had done something inappropriate. The mind does amazing things.

Next, the goofiest statement of the week. From a woman who had complaints from her head to her toes. When I asked which thing specifically brought her to the Emergency Department, she of course replied, "all of them". In any case, I was asking my usual list of questions, which includes an allergy history. "Well, I used to be allergic to ketchup, but since they took out my fibroids, I can eat it." What?!?! Is this one of those scientology things?

Last is my "I can't believe the lives that people lead" moment of the week. I attended to a young man, about 25 years old, who was brought by the police to be examined before going to jail. He was in handcuffs and had some dried blood in his mouth. He said that the police had beaten his head against the ground nine times and that he had lost consciousness. He seemed a little out of it, so I decided that he needed a CT scan of his head. During my questioning, he revealed that although he is on a powerful heroin-antagonist, he still used IV heroin, his last use being that morning. "Doc, while I'm here, can you look at my arms? I think I have some infections." He sure did. "Do you skin pop?" I asked. "No, I just have bad aim." He asked for a drink of water and I told him that I didn't want him to drink anything until he had his head scan. He was furious. "You could have blood in your brain, which could kill you," I said. He looked at me and said, "Maam, I use heroin every day. I could die at any minute. A little bit of blood in my head doesn't scare me. If I die, I die." There was no answer to that. Before I could get him some water, he agreed to have the scan. It looked fine.

It's not a tumor

Unfortunately, it was. Today I had to tell two patients and their families that they had brain tumors. It is so uncommon to even have one patient with a brain tumor that two kind of overwhelmed me. Both patients were stoic, but their spouses started to cry. It's not necessarily a death sentence, but there is just no good way to tell someone that he/she has cancer in the brain. One patient presented with 2 weeks of worsening memory loss and difficulty word-finding. The other had a change in her mental status. We thought she was on drugs. She wasn't. She had two tumors in her head that were pushing against the other side of her brain. It had been going on for a few weeks and her family doctor told her she had a "complicated migraine". I don't have the benefit of knowing these people. This is the first time I'm meeting them and I have to give them life-changing news. I used to cry with them, but have developed some coping skills in order to keep my sanity. But coping skills aren't enough for these two patients.

0 for 6

It was one of those weeks- I couldn't figure out what was wrong with anybody, it seemed! In one shift, I had four different patients with abdominal pain and none of them had any objective signs of disease. Normal blood tests, CT scans, urinalysis. Even their exams and stories were inconsistent. One of the things I like most about medicine is the search for the right answer. The clues are often hidden, poorly expressed or both. I get such a sense of satisfaction when I figure something out. But not figuring it out is so annoying. One young man had right lower quadrant pain, which made me suspicious for appendicitis. His pain had been there for four days. He had told the triage nurse that his pain was in his left upper quadrant, diagonal from where he told me it was. I treated his pain and ordered some tests. They were all normal and his pain kept coming back. I sent him home. I still don't know what was wrong with him. A teenaged girl came in with right sided chest pain that brought her to tears. Her mother insisted that her right neck was swollen. Her exam was essentially normal. She had no risk factors for a pulmonary embolus (blood clot in the lungs), but I did a CT scan of her neck and chest to make sure. Needless to say, they were negative. When I went back to tell her, the pain had completely resolved and her breathing was unlabored. What was it? I have no idea.