A typical obese woman, named Noreen, with diabetes is brought to the ER because her family noted that her foot was bleeding when they went to visit her one morning. She lived alone with the exception of her small pet dog who I will call Daisy. Upon further examination, the family astutely noted that three of Noreen's toes were missing. They also noted that Daisy had some blood on her muzzle and that she hadn't touched the food in her dog-bowl that morning. Putting two and two together it was determined that Daisy had apparently eaten three of Noreen's toes off sometime during the night as she slept in her Lay-Z-Boy recliner. Because of the neuropathy from her diabetes, Noreen felt not a single bit or nibble. I seemed to be the only person in the room who was shocked by this situation. Her son, Dylon, and other family members in the room seemed not the least bothered by this terrible and gruesome injury.
"They'll just grow back, right?", says Noreen's son Dylon.
I look at Dylon in his dirty overall's and dirty Kenworth trucking hat amazed by his stupidity. Is he serious? So if people lose appendages, they'll just grow right back? This is a special family I'm dealing with here.
"No they won't just grow back. Not unless your Mom is part starfish.", I said.
"What if we were able to fish the toes out of the dogs poop? Could they be sewn back on?", said Dylon.
You have got to be kidding me. This guy cannot be for real. Does he really think these toes would be salvageable after being eaten and traversing a dog's GI tract?
"Sorry, that won't work either. We are going to have to admit your Mom to the hospital so that these wounds can be debrided and allowed to heal, but, unfortunately there is no way to save her toes".
I don't really remember Noreen ever saying a word. Perhaps she was just too overwhelmed by the situation or perhaps she just had nothing to say. She was admitted, had her wounds cared for, and
after a few days in the hospital, Noreen went "weee-weee-weee all the way home" missing a few little piggies.
Friday, April 29, 2011
Wednesday, April 27, 2011
Blue Tubules
Believe it or not weekend mornings are when I have seen some of the strangest patients in the ER. People usually think of the weekend nights as being the time when all the crazies are out, but this isn't always the case.
I was working one Saturday morning when a woman in her late 20's came in for evaluation. She was accompanied by her fiance' who waited in the waiting room. The fiance' waiting in the waiting room is always a sign that something interesting is about to transpire. If it wasn't weird or interesting, the fiance' would be in the exam room with his wife-to-be, not in the waiting room. This rule of the ER would remain in place that day.
"Hello, what brings you to the ER today?", I said.
"Well, every time my fiance' and I have sex, after we're done and I go to wash up ( she pronounced it "woorsh-up"), I notice these little blue tubules coming out of my privates." the patient says.
Maybe it's just been my white-bread conservative up-bringing, but I've never felt the need to wash-up after having sex. Maybe I'm doing something wrong. Maybe I'm not doing it right. Should you need to wash-up after having sex? These were some of the thoughts going through my mind at that moment, not to mention the thought of "What the hell is she talking about?..... blue tubules!?" "Where do these people come from?" "Ok, there's a hidden camera somewhere and someone is filming this for some type of TV show".
Anyway she proceeds to describe the blue tubules. "They are about the size of a pencil lead and about a quarter of an inch long. I usually find a few of them when I clean up. It's always after we have sex. I don't know where they are coming from." "Have you seen anyone about this before today? Do you have a gynecologist you see?" I ask. Of course, she hasn't seen anyone about this. That's what the ER is for. She doesn't enen know what a gynecologist is. The nurse and I go do her pelvic exam, which to no one's surprise is completely normal. "Are you sure you don't see anything?", she says. "Pretty sure. I can see the entire inside of your vagina and I don't see any little blue tubules." "Well I wonder where they could be coming from", she says. "Maybe we could give you a specimen container to take home with you so the next time you see them, you could collect them. I'll give you the name of our gynecologist on-call that you can follow-up with." That was the most important part. Giving her somewhere else to follow-up other than coming back to the ER.
As the nurse and I were walking out of the exam room, it suddenly dawned on me that the patient had said she only found these tubules after she and her fiance' had sex. I had no idea when the last time they had sex was, and frankly I didn't want to know. Maybe the source of the tubules was his semen. I describe this thought to the nurse. "She said she only saw the tubules after they had sex, right? There was nothing that you or I saw during her pelvic exam, right? Maybe the tubules are in his baby batter! Nurse we need to have her fiance' go to the restroom and wack-off so we can check his jizz for the tubules!" "Are you serious?!", said the nurse. "No way! I don't think I want that guy wacking-off in the bathroom. I was just kidding, but do give her the specimen container to take home with her. She seemed to like that idea."
So, the patient left happy with her evaluation and the plan for follow-up. I never heard anything about her again, so the source of the blue tubules remains a mystery.
I was working one Saturday morning when a woman in her late 20's came in for evaluation. She was accompanied by her fiance' who waited in the waiting room. The fiance' waiting in the waiting room is always a sign that something interesting is about to transpire. If it wasn't weird or interesting, the fiance' would be in the exam room with his wife-to-be, not in the waiting room. This rule of the ER would remain in place that day.
"Hello, what brings you to the ER today?", I said.
"Well, every time my fiance' and I have sex, after we're done and I go to wash up ( she pronounced it "woorsh-up"), I notice these little blue tubules coming out of my privates." the patient says.
Maybe it's just been my white-bread conservative up-bringing, but I've never felt the need to wash-up after having sex. Maybe I'm doing something wrong. Maybe I'm not doing it right. Should you need to wash-up after having sex? These were some of the thoughts going through my mind at that moment, not to mention the thought of "What the hell is she talking about?..... blue tubules!?" "Where do these people come from?" "Ok, there's a hidden camera somewhere and someone is filming this for some type of TV show".
Anyway she proceeds to describe the blue tubules. "They are about the size of a pencil lead and about a quarter of an inch long. I usually find a few of them when I clean up. It's always after we have sex. I don't know where they are coming from." "Have you seen anyone about this before today? Do you have a gynecologist you see?" I ask. Of course, she hasn't seen anyone about this. That's what the ER is for. She doesn't enen know what a gynecologist is. The nurse and I go do her pelvic exam, which to no one's surprise is completely normal. "Are you sure you don't see anything?", she says. "Pretty sure. I can see the entire inside of your vagina and I don't see any little blue tubules." "Well I wonder where they could be coming from", she says. "Maybe we could give you a specimen container to take home with you so the next time you see them, you could collect them. I'll give you the name of our gynecologist on-call that you can follow-up with." That was the most important part. Giving her somewhere else to follow-up other than coming back to the ER.
As the nurse and I were walking out of the exam room, it suddenly dawned on me that the patient had said she only found these tubules after she and her fiance' had sex. I had no idea when the last time they had sex was, and frankly I didn't want to know. Maybe the source of the tubules was his semen. I describe this thought to the nurse. "She said she only saw the tubules after they had sex, right? There was nothing that you or I saw during her pelvic exam, right? Maybe the tubules are in his baby batter! Nurse we need to have her fiance' go to the restroom and wack-off so we can check his jizz for the tubules!" "Are you serious?!", said the nurse. "No way! I don't think I want that guy wacking-off in the bathroom. I was just kidding, but do give her the specimen container to take home with her. She seemed to like that idea."
So, the patient left happy with her evaluation and the plan for follow-up. I never heard anything about her again, so the source of the blue tubules remains a mystery.
Wednesday, April 20, 2011
My Grandfather's Patient
The Emergency Rooms of this country provide a large amount of care to the elderly who reside in nursing homes. These patients may have their own doctors or the nursing home may have a doctor on staff, but when someone at the nursing home is sick they get sent to the ER. Frequently the elderly patient is unable to provide any history as to their illness or injury due to dementia or their general frail state. On those occasions, you have to do your best to assess the patient and determine the cause of their illness. In many ways, it is just like a being pediatrician or a veterinarian. You can't always get information from the patient. You must use your clinical skills to evaluate them. It is sometimes a very difficult thing to do with many complicating factors such as family issues, code status, comfort care etc. These patients are not ones you always look forward to taking care of. Much like the screaming 2 year old with a lip laceration; there are just some patients you would just rather not see.
I went in to see an elderly lady from a nursing home who was 102 years old. She was sent to the ER because she had a fever and a cough. When I went in to see her, much to my surprise she was perfectly alert and oriented. Her mind was sharp as a tack. Despite the frailty of her body, her mind was unfazed by her 102 years. She was a living history book of the past century. I thought of all the things that she would have seen in her lifetime. Two World Wars, space flight, TV, telephone, computers, many advance in medicine, CTscans etc.
I was reviewing her paperwork sent with her from the nursing home including her current medications, past medical history etc. Included in her paperwork was a list of biographical information... her birthdate, place of birth, family contacts and so on. I immediately took note of her place of birth. It was the place of birth of my mother. A small town in the Midwest that few people have ever heard about.
My grandfather came to the United States from Germany at the turn of the century. When he came to the US he ended up going to medical school. He set up practice in this small town. He was the only physician for many miles in this rural area. He ended up paying for his two brothers to also attend medical school and his sisters to attend nursing school. The family established a clinic and eventually a small hospital in this small town. My mother was the youngest of 16.... that's right 16 children that my grandfather and grandmother raised. Surely this lady would have heard of my family. My mother passed away when I was 16. Trying to do the math, I figured my mother was about 30 years younger than the patient I was seeing.
"I see you are from Ironwood*."
"Yes. I spent my whole life there and didn't move here until my husband died. I moved hear to live with my daughter, but several years ago became ill and I have been living at Green Farms Home*".
"My mother was born and raised in Ironwood*".
"What was her name?"
I proceeded to tell Alma* my mother's name and about my grandfather. I asked if she knew them. Her eyes lit up. She said "Why of course!". "Your grandfather was my doctor and delivered two of my children. Your mom used to play with my kids".
We spoke for some time about her memories of my mother and grandfather. My grandfather died before I was born, so I obviously never had the chance to meet him. It was wonderful to hear Alma* tell me what a kind and caring doctor he had been.
I lost my mother at the age of 16. That was a terrible thing to go through. I always thought my mom would have been so proud of me for following in her father's foot-steps. It was such a touching gift for Alma to tell me of my mother's childhood. " What a happy, pretty and smart girl she was", Alma said. It made me sad that I could not share this encounter with Mom, but I could not wait to get home and call my family to tell them of this chance encounter. To think my grandfather had been Alma's doctor when she was a young woman having a family and now I was here to provide her comfort and care towards the end of her life.
That was only time I ever saw Alma. She brought me closer to my mother, my grandfather and had profound impact on me personally and as a physician. My Grandfather's Patient.
I went in to see an elderly lady from a nursing home who was 102 years old. She was sent to the ER because she had a fever and a cough. When I went in to see her, much to my surprise she was perfectly alert and oriented. Her mind was sharp as a tack. Despite the frailty of her body, her mind was unfazed by her 102 years. She was a living history book of the past century. I thought of all the things that she would have seen in her lifetime. Two World Wars, space flight, TV, telephone, computers, many advance in medicine, CTscans etc.
I was reviewing her paperwork sent with her from the nursing home including her current medications, past medical history etc. Included in her paperwork was a list of biographical information... her birthdate, place of birth, family contacts and so on. I immediately took note of her place of birth. It was the place of birth of my mother. A small town in the Midwest that few people have ever heard about.
My grandfather came to the United States from Germany at the turn of the century. When he came to the US he ended up going to medical school. He set up practice in this small town. He was the only physician for many miles in this rural area. He ended up paying for his two brothers to also attend medical school and his sisters to attend nursing school. The family established a clinic and eventually a small hospital in this small town. My mother was the youngest of 16.... that's right 16 children that my grandfather and grandmother raised. Surely this lady would have heard of my family. My mother passed away when I was 16. Trying to do the math, I figured my mother was about 30 years younger than the patient I was seeing.
"I see you are from Ironwood*."
"Yes. I spent my whole life there and didn't move here until my husband died. I moved hear to live with my daughter, but several years ago became ill and I have been living at Green Farms Home*".
"My mother was born and raised in Ironwood*".
"What was her name?"
I proceeded to tell Alma* my mother's name and about my grandfather. I asked if she knew them. Her eyes lit up. She said "Why of course!". "Your grandfather was my doctor and delivered two of my children. Your mom used to play with my kids".
We spoke for some time about her memories of my mother and grandfather. My grandfather died before I was born, so I obviously never had the chance to meet him. It was wonderful to hear Alma* tell me what a kind and caring doctor he had been.
I lost my mother at the age of 16. That was a terrible thing to go through. I always thought my mom would have been so proud of me for following in her father's foot-steps. It was such a touching gift for Alma to tell me of my mother's childhood. " What a happy, pretty and smart girl she was", Alma said. It made me sad that I could not share this encounter with Mom, but I could not wait to get home and call my family to tell them of this chance encounter. To think my grandfather had been Alma's doctor when she was a young woman having a family and now I was here to provide her comfort and care towards the end of her life.
That was only time I ever saw Alma. She brought me closer to my mother, my grandfather and had profound impact on me personally and as a physician. My Grandfather's Patient.
The Anus is a One-Way Street
Working one day in the ER, I see an ambulance crew bringing in a patient on a stretcher face down with his back-side up in the air. This is not the usual mode of transport for patients on stretchers. I follow the crew, along with the nurse, into the room to see what is going on with this man. He's a man who appears to be in his late 50's and smells like a dirty laundry basket onto which someone spilled a 40 ounce beer. When I walk into the room I notice he appears to be bleeding fairly heavily from his rectum. I go up to the paramedic to get some history before going to interview the patient.
"What's going? What happened ?"
"He was driving the wrong way down a one-way street and was stopped by the police" the paramedic said.
"Okay. So why is he bleeding from the rectum?"
"He said he has a broken beer glass in his rectum".
Okay this should be interesting I think to myself. Now on to interviewing the patient. I go into the room and begin to hear the patient's version of how his injury occurred. He proceeds to tell me how he was drinking and driving. He tells me he was driving down the road drinking beer from a regular 16 ounce beer glass and apparently going the wrong way down a one-way street. He said when he saw the lights from the police car and realized he was being pulled-over that he didn't want to get caught drinking and driving with an open container of alcohol, so he stuffed the beer glass up his anus.
"So you mean to tell me from the time you saw the police car you had time to pull over, pull your pants down and place the beer glass up your anus?" I'm not buying it, but that was his story and he stuck to it.
Now the real story comes out. It just turns out this is just a guy who drinks a lot and has a fetish for sticking things up his anus. Unfortunately, this time he picked an object that could not withstand the compressive forces of his lower gi tract. When his wife shows up to the ER, she is not surprised by these events at all. Apparently, this was not his first time to the rectal rodeo. She reported he had been to various ERs on several occasions to have rectal foreign bodies removed. This time was different though. This time he would end up leaving the hospital 4 days later with a colostomy because of the injury to his colon from the shards of broken glass. Hope he had fun.
After years in the ER, the list of rectal foreign bodies I've seen is long and varied. Candles, various fruits and vegetables, lightbulbs, curtain rods, hotdogs, peanut butter jars, ice cream scoops, beer bottles, steak sauce bottles and of course, vibrators. Never have seen a gerbil, though. I've heard about it, just never have seen it.
This seem to be more of a problem with men. When a woman comes in, it's usually just the garden variety vibrator.... and half the time she didn't put it there. With men though, it's a different story. You just never know what it will be. It's usually the story of how it got there that is the most exciting. I always wonder what the insurance company thinks when they receive the bill from the hospital. Of course, most of the folks doing this type of thing don't have insurance. Another cost of healthcare pushed off onto the insured.
So remember, the anus is a one-way street!
"What's going? What happened ?"
"He was driving the wrong way down a one-way street and was stopped by the police" the paramedic said.
"Okay. So why is he bleeding from the rectum?"
"He said he has a broken beer glass in his rectum".
Okay this should be interesting I think to myself. Now on to interviewing the patient. I go into the room and begin to hear the patient's version of how his injury occurred. He proceeds to tell me how he was drinking and driving. He tells me he was driving down the road drinking beer from a regular 16 ounce beer glass and apparently going the wrong way down a one-way street. He said when he saw the lights from the police car and realized he was being pulled-over that he didn't want to get caught drinking and driving with an open container of alcohol, so he stuffed the beer glass up his anus.
"So you mean to tell me from the time you saw the police car you had time to pull over, pull your pants down and place the beer glass up your anus?" I'm not buying it, but that was his story and he stuck to it.
Now the real story comes out. It just turns out this is just a guy who drinks a lot and has a fetish for sticking things up his anus. Unfortunately, this time he picked an object that could not withstand the compressive forces of his lower gi tract. When his wife shows up to the ER, she is not surprised by these events at all. Apparently, this was not his first time to the rectal rodeo. She reported he had been to various ERs on several occasions to have rectal foreign bodies removed. This time was different though. This time he would end up leaving the hospital 4 days later with a colostomy because of the injury to his colon from the shards of broken glass. Hope he had fun.
After years in the ER, the list of rectal foreign bodies I've seen is long and varied. Candles, various fruits and vegetables, lightbulbs, curtain rods, hotdogs, peanut butter jars, ice cream scoops, beer bottles, steak sauce bottles and of course, vibrators. Never have seen a gerbil, though. I've heard about it, just never have seen it.
This seem to be more of a problem with men. When a woman comes in, it's usually just the garden variety vibrator.... and half the time she didn't put it there. With men though, it's a different story. You just never know what it will be. It's usually the story of how it got there that is the most exciting. I always wonder what the insurance company thinks when they receive the bill from the hospital. Of course, most of the folks doing this type of thing don't have insurance. Another cost of healthcare pushed off onto the insured.
So remember, the anus is a one-way street!
Monday, April 18, 2011
Long Weekend in the ER
Finished another long weekend in the ER. I think I saw maybe 10 people from Friday through Sunday who actually needed to be in the ER. When did our country decide that our hospital's ERs were great big walk-in clinics. Have you ever tried to call a doctor's office these days? All you hear is "hang up and call 911 or go to the nearest ER". That is what this past weekend was all about.
"I haven't had a bowel movement in 3 days."--- Go the the ER
"I ran out of my Vicodin"--- Go to the ER
"My 18 year old son keeps smoking marijuana and meth."--- Go to the ER
"I have had a toothache for a month"--- Go to the ER
"I have had abdominal pain for 6 months and have been to 4 ERs and to one different ER already today"---Go to the ER
What is wrong with our population? Do they not know the meaning of the word emergency?
I love how many hospitals now advertise average ER wait times. I have a news flash for you... If you have time to check out various ER wait times, you don't have an emergency. Another little tidbit of information, if you really have an emergency, your wait time is ZERO!
People can't figure out why healthcare in the US is so expensive. It's because we have a society of I want it all right now and can't wait. So the system keeps tolerating this behavior and chugging along wasting resources.
"I haven't had a bowel movement in 3 days."--- Go the the ER
"I ran out of my Vicodin"--- Go to the ER
"My 18 year old son keeps smoking marijuana and meth."--- Go to the ER
"I have had a toothache for a month"--- Go to the ER
"I have had abdominal pain for 6 months and have been to 4 ERs and to one different ER already today"---Go to the ER
What is wrong with our population? Do they not know the meaning of the word emergency?
I love how many hospitals now advertise average ER wait times. I have a news flash for you... If you have time to check out various ER wait times, you don't have an emergency. Another little tidbit of information, if you really have an emergency, your wait time is ZERO!
People can't figure out why healthcare in the US is so expensive. It's because we have a society of I want it all right now and can't wait. So the system keeps tolerating this behavior and chugging along wasting resources.
Saturday, April 16, 2011
How $20 and a stripper changed my life.
I always knew I wanted to be a doctor. As a kid, I don't ever remember thinking of doing or being anything else. The problem was, as I was going through medical school, I could never decide what type of doctor I wanted to become. I liked almost every rotation I did. I wanted to be a surgeon, a pediatrician, a gastroenterologist etc. The only thing I had eliminated for sure was OB. There was just something about pregnant women screaming "take this baby from me!" that made me very nervous.
Then it happened. I was a senior medical student on my rotation through the Emergency Department. It was a Friday night. A stripper came in from a local strip bar complaining that a customer had placed his tip in her vagina (no pun intended) and she could not get the money out. So.... off to the ER. The nurse and I go do her pelvic exam and I proceeded to remove a 20 dollar bill from her vagina. I offered it back to her because, after all, it was 20 bucks and I was pretty sure she had earned it. She didn't want it and told me to keep it. Cha-ching! I'm a poor starving medical student and someone just gives me 20 bucks!
It was about 11 o'clock that evening and I was starving. We had been so busy that I had not eaten since breakfast. There was a local pizzeria that would occasionally deliver pizzas to our ER. They would deliver to the patients in the waiting room as well as to the staff. So, I ordered a large pepperoni pizza to be delivered to the ER. I paid the delivery man the $12 dollars and told him "keep the change". He didn't even seem to notice or think it was odd that I was handing him the $20 dollar bill with a gloved hand. My hunger was satisfied and it was at that point that I realized my calling in medicine. I thought to myself that this was perhaps the only job in the world where you could go to work, pull 20 bucks out of a woman's vagina and then buy your dinner with it!
My life career choice had been made! I completed my Emergency Medicine residency four years later. It has been 22 years now with many adventures since.
Now I know why Mom always said never to put money in your mouth because you never know where it has been!
More true stories of my days and a life spent in the ER to come!
Then it happened. I was a senior medical student on my rotation through the Emergency Department. It was a Friday night. A stripper came in from a local strip bar complaining that a customer had placed his tip in her vagina (no pun intended) and she could not get the money out. So.... off to the ER. The nurse and I go do her pelvic exam and I proceeded to remove a 20 dollar bill from her vagina. I offered it back to her because, after all, it was 20 bucks and I was pretty sure she had earned it. She didn't want it and told me to keep it. Cha-ching! I'm a poor starving medical student and someone just gives me 20 bucks!
It was about 11 o'clock that evening and I was starving. We had been so busy that I had not eaten since breakfast. There was a local pizzeria that would occasionally deliver pizzas to our ER. They would deliver to the patients in the waiting room as well as to the staff. So, I ordered a large pepperoni pizza to be delivered to the ER. I paid the delivery man the $12 dollars and told him "keep the change". He didn't even seem to notice or think it was odd that I was handing him the $20 dollar bill with a gloved hand. My hunger was satisfied and it was at that point that I realized my calling in medicine. I thought to myself that this was perhaps the only job in the world where you could go to work, pull 20 bucks out of a woman's vagina and then buy your dinner with it!
My life career choice had been made! I completed my Emergency Medicine residency four years later. It has been 22 years now with many adventures since.
Now I know why Mom always said never to put money in your mouth because you never know where it has been!
More true stories of my days and a life spent in the ER to come!
Thursday, April 14, 2011
America in the ER
So this is my first attempt at blogging. I am a practicing Emergency Medicine Physician with 22 years of experience. I practice at a large volume urban/suburban hospital somewhere in the Midwest. I decided to start my blog because it amazes me how little people know about what is really going on in the ER's across our country. Every day I am constantly amazed myself. I have been witness to some wonderful things... compassion, caring, healing etc. However, what has become more frequent is the unravelling of our society. The ER is no longer a place to seek life-saving care, although this does happen from time-to-time. It is now the place to try and get narcotics, the place to go when you call your doctor for an appointment and all you get is "go to the ER"and of coarse the place to go for the uninsured or if your fibromyalgia is "flaring up".
I hope to try and share a little slice of the typical day in a typical ER in the heart of America so those who follow this blog will be able to become educated and motivated to bring about some change. I'm talking about change in many areas. Healthcare reform, malpractice reform, realizing this country has a huge drug problem, medicare/medicaid waste and abuse just to name a few.
I will never make things up or embellish the stories of the day. I will only post the events of the day as they happen; good or bad.
So a little preview from today. I learned something today that just dawned on me today after years of practicing. I learned that all these fertility clinics are a waste of time and money. I learned the easiest way to get pregnant is to get a Medicaid card! You will be pregnant within a month of receiving your card guaranteed ( and with many more pregnancies to follow).
Hope you enjoy.
I hope to try and share a little slice of the typical day in a typical ER in the heart of America so those who follow this blog will be able to become educated and motivated to bring about some change. I'm talking about change in many areas. Healthcare reform, malpractice reform, realizing this country has a huge drug problem, medicare/medicaid waste and abuse just to name a few.
I will never make things up or embellish the stories of the day. I will only post the events of the day as they happen; good or bad.
So a little preview from today. I learned something today that just dawned on me today after years of practicing. I learned that all these fertility clinics are a waste of time and money. I learned the easiest way to get pregnant is to get a Medicaid card! You will be pregnant within a month of receiving your card guaranteed ( and with many more pregnancies to follow).
Hope you enjoy.
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