So this happened. I have heard of it happening to others, but for me, it was the first time.
Me: Here with abdominal pain and vaginal bleeding?
Her: Yes.
Me: Any chance you could be pregnant?
Her: No
Me: Last period?
Her: Two months ago
Me: And absolutely NO chance you could be pregnant
Her: No
Me: Gotcha. Ok
…Here’s where I do a physical exam on her. She is obese. She has a large mass in her abdomen about the size of a bowling ball…
Me: I’ll be right back
…I go get the bedside ultrasound. I come to her bedside. I get ready to put the ultrasound on her. She immediately gets out of bed…
Her: I have to go to the bathroom.
Me: Now?
Her: NOW!
Me: …?
…so on the way to the bathroom she tells me that not only is she pregnant, but nine months pregnant. However, she didn’t want the new boyfriend to find out. Read that last sentence again. Yeah. Um… About that…
Her: So I’m 9 months pregnant but don’t want him to find out
Me: You have to go to the OB floor NOW!
…Thus I explained how she was not going to slyly have her baby in the ER without her new boyfriend finding out. She could tell him whatever she wanted… but she is going to go upstairs.
Ah the sweet delicious drama. When I was younger I used to think that the people on Maury and Springer and shows like that were fake. No one could be that ridiculous, right. Those were the days of pure, happy naivete, and I miss them a little bit. Oh well, I have to get back to my drunk friend screaming “GLOCK 44! GLOCK 44! GLOCK 44! GLOOOOOOOOCK 44!”
I think I’m still an optimist… but slowly over time, I may also becoming a surrealist.
In Washington the brilliant leaders have come up with an idea to solve all of the Medicaid woes for the state.
It’s simple (says the politicians), All we need to do is have people not go to the Emergency Department for things that are not emergencies. So, if they do go to the ER for something that is not an emergency, then we are not going to reimburse the doctors or hospitals for taking care of them.
Now I will agree wholeheartedly that people come into the ER all the time for non-emergencies. I see people with colds, earaches, toothaches, diaper rash, nausea/vomiting, and everything rotten that you can possibly think of. Much of the time these are not true emergencies. However, sometimes they are. Sometimes a cold is actually a pneumonia requiring treatment. But I have to run tests to figure this out. The politicians would like you to know your diagnosis before you have been tested so that you don’t go to the ER unnecessarily. Yes, you have chest pain. Yes, it could be a heart attack. But just think, it might just be a cold, right?
Hmm…
Here’s the great part. As an ER doctor, I am also required by law to see every single person who comes through the door. I am NOT allowed to refuse service. So, if someone comes in with a complaint that is not emergent, I am still required by law to do a screening exam and check them out. That’s the law. So now if I worked in Washington I would be required to evaluate people that come in, determine if they are sick or not, then if I determine they are not sick I would not be reimbursed for my effort.
Does this sound weird to only me?
Let’s do some fun and exciting role playing.
Let’s say your computer is broken and you take it to the technician to get fixed.
You: “I think it’s a virus in my computer, I’m scared that that’s the problem,”
Techno-dude: “Alrighty I’ll check it out and get it fixed.
You: “Good. Now I want you to fix it, regardless of the problem, however, if it is NOT a virus, then I’m not going to pay you for your time and effort.”
Techno-dude: “Uh, that doesn’t seem fair”
You: “Shut your face-hole! Fix it!”
Yeah, that’s kinda how this works. Still missing it, well, don’t worry, I’m loaded with analogies like the potato skins at TGIF.
You: Hey Mr. Mechanic-man, my cars making a gnaaark’gnaaark’gnaaark noise (note: this noise is also made by Orcs from various video games (WOW)).
Him: Sure, I’ll check it out.
You: Hold up. I’m worried that it’s my brakes and they might go out and something dangerously bad could happen.
Him: Yeah, well, like I said, I’ll check it out.
You: Right, so could you fix it, but if it’s not the brakes, I’m not paying, k?
Him: That sounds like a completely reasonable and fair way to practice business, but I’m afraid I have to punch you now
What if it was with other physicians as well?
Homicide detective: Hey there Mrs. Pathologist… I need you to do and autopsy on this corpse and determine how he died and if it was due to murder.
Doc-O-the-dead: Will do.
Homicide detective: One thing though. If, after you do all that work and determine the cause, it turns out that it was NOT foul play, we’re not paying for your work.
Doc-O-the-dead: …reeeeeally?
I guess getting forced to work for free is not a bad thing. I suppose we should just do the same with the politician. You have 2 years in office. You said that unemployment would be down, the economy would be up, there would be less taxes and more programs for the poor. The opposite of all of that has happened… So now you don’t get paid. Yeah, I know you were trying your best and tried to do what you thought was right, but we’re not paying, sorry.
If only I had a comic with a squid that conveyed my frustration.
So we have had a group of 3-7 deer that have periodically been living in our backyard.
Oh the majesty, oh the beauty, oh my goodness do they poop a lot! I mean, I don’t want to aggressively detract from their natural grace, but I have about 200 small mounds of deer poop all over my yard.
My brother hunts. I don’t hunt. This is not really due to anything I have against hunting, I just don’t think it’s my thing. However, the more I look over my ever increasing mound of stool, I think that maybe I’ll be cheering for the wrong side next time I watch Bambi.
You know when it gets really interesting?
It’s when you get a nice snow cover and you want to build a snowman with your daughter. The white covering turned into an experience in the dangers of non-explosive land mines. It reminds me of a song…
“Frosty the poop-man, was a jolly, goopy ghoul,
with a corn-cob pipe and a button nose and two eyes made out of stool…”
“There must have been some magic in that deer-poop that we used,
for when we rolled it in a ball, he began to melt and ooze…”
I gave a lecture to a group of med students a few days ago.
As predicted, it kicked all sorts of Twilight (get it? Cause instead of a nasty word I wrote… <ahem>)
I learned after the fact that most speakers prepare, have a lecture, and actually present something. But then
I thought to myself and said:
Self1: You know, I’m kinda thinking a little fuzzy since I just got off a night shift and haven’t slept 3 hours in the last long while, perchance I should actually prepare for said presentation.
Self2: Pshhhhhh!
Self1: Aaah, an excellent point, I hadn’t thought about it like that.
Self2: Though you might want to bring some ER stories with you.
Self1: Also a good idea! Man, me, we’re just full of ideas
Self2: Why are you doing a blog without a tasty beverage in your hand?
Self1: Leaves to get beverage (yes, I actually just did)
It’s weird, because it doesn’t really feel that long ago that I was in their shoes… yet I feel the wave of nostalgia pulsing through me like the sore thumb after playing Atari 2600 in the basement with my brothers. I can still here Chris screaming “superman Jackson, superman Jackson!” as his square block that was somehow supposed to be a foot ball play eluded my guys since Atari was idiotic.
But the chat was pretty well received. I kept the more disgusting descriptions to a minimum for me, which is to say I only gave 2 stories involving maggots and/or pin worms. I mean, parasites give me the jibblies, I just can’t shake it. Though they are a great weight loss plan.
It’s often the little things in life that make a difference.
A kind smile to the lady having a bad day. A quick gesture of assurance, kindness, or the little extra time spent with a loved one to really show that you care. The quick note just saying “I love you.”
Yet more often than not the small choices that make a big difference are wrong.
I don’t like telling people that they made wrong choices. Who am I to point my finger at you and say “I’m right, and you’re wrong.” Well, in a few instances, I’m going to keep saying it.
1. Smoking. (I’ll keep beating this dead horse until the carcass is only delicious horse mulch)
Also, the topic I wanted to cover…
2. Seatbelts & motorcycle helmets. (recently a friend took care of someone in a bad car accident. He was found in the backseat of the car. This would normally not be a bad thing, except he was in the back seat of a car after going through the windshield and back window of another car. Needless to say, a seat belt might have improved the outcome.)
So here’s the deal. Here in Michigan people (and by people I mean the slug-like parasites (lawyers (please not not all lawyers are terrible, one of my best friends in college is actually a lawyer (though he was only mediocre at ping-pong (though this really doesn’t make him less off a good person)), and a pretty cool guy)) seen more commonly in Aliens movies) are trying to repeal the mandatory motorcycle helmet law. Their main argument is this:
“I know it’s stupid NOT to wear a helmet, but I want it to be MY choice to be stupid and it only affects me!”
People don’t want to be told to not be stupid. They want to embrace their own stupidity and be comfortable with it. They want to wrap stupidity around them like a warm sweater. They snuggle up to their bad decisions as if the choice was an idiotic constipated St. Bernard, lapping at their stupid faces with the slobber of consequences be damned. The slobber of consequences, however, often hurt more people than yourself.
Let’s make up an example. I’ll just pick a name randomly, by clicking google images and typing in slobbering dog and finding the first name of the dog I pick… Bruno. Perfect.
Also, for effect, Bruno will talk like Captain Caveman from the old Hanna-Barbara cartoons. I suggest you click this right now so you know what the heck I’m talking about. Captain…CAAAAAAAAAVEMAAAAAN! Oh yeah, that feels good.
BRUNO: Unga-Bunga, me no need helmet, if me get hurt, me not care! Me strong!
ME: But Bruno, with less than 10 seconds, you can reduce the chance of serious injury
BRUNO: Me drive good, no me need! Unga! Me no crash before, me no plan to! Why you plan to crash?
ME: No one plans to crash, Bruno, but don’t you realize-
BRUNO (interrupting): If me be dead, no me care! Me make worms strong since they eat strong Bruno!
ME: But what if you’re just seriously injured? Head injuries can cause horrific long-term, preventable consequences that-
BRUNO: -and me have skull, so me have inside helmet from God. You think you better than God? You say you a doc, but you no know skull is in head. Skull strong. Me safe with skull. Go skull go!
ME: But that doesn’t-
BRUNO: -and if me no get hurt bad, how me get disability for many years? Me just get cool race wheelchair! Me go vroom and have modifications to wheelchair so it go 70! Me go vroom and pass you on right in your hippy prius you drive so slow in fast lane.
ME: What!? I don’t even drive a Prius and what does that have to do-
BRUNO: Unga-Bunga! Seatbelts make you hippy. My arms strong. You have puny arms, you can wear belt for wimps if you want. Me get it fights and block punches with face, that be how strong Bruno is!
ME: I’m pretty sure I’m not winning this with you-
BRUNO: Unga, you just now getting it?
Hmm, I planned for me to win that argument, but you can’t win arguments with the Bruno’s of the world. Thus, instead of them facing the consequences of their actions, the rest of us must deal with it.
Like so many things that occur in the ER I find that logic simply doesn’t apply.
Like I always say, and ounce of prevention is worth a pounding in the arse by a constipated St. Bernard, or something like that.
At one time I thought I could never be grossed out.
I think most guys believe this due to our fragile egos. We must stay macho until we die (most likely from our rocked powered Spree colliding into a brick wall at 200 mph because we added a jet pack onto the back).
I don’t mind gore, I don’t mind broken bones or bloody dismemberment. It’s part of the job from time to time. However, I have discovered my Achilles Heel. So what bothers me? Let’s give you a few examples and see if you can figure it out
#1 Heebie-Jeebies
I go to a kids room who is presenting with a rash. Mother stated that it’s probably a diaper rash. I check out the kiddo and take a look at his diaper area. It looks fine, maybe some scratch marks. Then I separate the butt cheeks and look directly into 239478239847 pinworms squiggling everywhere. You know the scene in Indiana Jones’ face melts. Yeah that was me. They squiggled all over this kid, while I excused myself from the room… and then got the heebie-jeebies
#2 Blech
A very nice, but very fat lady had dropped a pumpkin on her toe. It was a big pumpkin, she was a big girl. About a month later, her blacked toe, which had not been hurting, began to hurt again. She thought there was some white pus in it. Her black toenail flopped back and fourth loosely over her toe. Gross? Not yet… I push and prod over the nail, expecting to express some pus. No pus was there, however I did find several maggots crawling under there. Excuse me a minute, I think I heard my name called outside… Blech!!!
#3 Gleerrb
He said a cockroach crawled into his ear and got stuck. As it turns out, a cockroach crawled into his ear and got stuck. Gleeeeerrrrrb!!!!
#4 Itchy
I took care of a patient who had pneumonia. It was later found out that she had lice. I spent the rest of the day itching, and actually went out and bought the shampoo out of hypochondriasis.
So did you figure it out.
Yeah, things that crawl inside of me and live off of eating me, that’s the thing that gets me grossed out.
If you’ve never actually seen one in person, well, it’s very scary. The entire body goes limp and start shaking violently for about 1-2 minutes.
After that she was breathing extremely shallow and turned ashen gray. We were out and my wife called me over right away. It’s hard to describe the feeling when you are holding your completely limp, ashen, 2-year old daughter. She was completely unresponsive. Scary. Very scary.
My wife quickly explained what had happened and how she saw her drop to the ground. I felt a sort of dichotomy, where half of me was dad and the other half was ER doctor. I could feel her heartbeat racing rapidly and she still was breathing slowly. She felt warm to me and I figured she had just had a febrile seizure, yet with my limp daughter still in my arms, I was panicking.
We called 911 and the first responder came. By that time my daughter had regained some level of consciousness and her color had returned. Went to the ER and her temp was 104.6, which, according to all my medical training, is considered above average.
After a slew of tests and some tylenol and motrin she was doing much better, eating/drinking and watching TV.
But…
Scary.
Nerve wracking.
Terrifying.
I have long said that I can handle the 82 year-old that comes into the ER who is dead or receiving resuscitation. It is the sick little kids that have always and will always scare the living crap out of you as an ER doc.
Currently she is racing around the house smiling, giggling, and just got done riding the “daddy horse” over and over and over… so shes back to baseline, much to the parents delight.
I think that was the scariest thing I have ever had happen to me in my life… how about you?
However, when a nice young daughter is brought in by her mother after admitting to “doing a whole lot” of shrooms, I got quite the interesting surprise. For your fun and joy you should know that shrooms don’t normally pop up on the standard ER urine drug screen, so we have to take people at their word. I truly believe this nice young gal did them.
She was 16ish, angry (not really at anything, just angry at everything). She breathed about 40 times per minute, had a racing heart, and was spouting gibberish.
It sort of went-a something-a like-a this…
“Youdidingflaaaaargorbitbooooorgoorbowhen iDIDN’T DO THAT garble-barlaragarg!”
An IV line, some fluid, time and ativan made things much better. She went home later, calm, apologetic, with a good life lesson about not doing drugs (or at least about not doing too many drugs (or doing the right drugs (or maybe just doing them before mom gets home (or possibly when mom might catch you)))).
2. I have never been bit by a possum (nor skunk, or any small woodland mammal).
For a while I lived on the East side of Michigan, and occasionally we would take care of people from the “thumb” of Michigan. I will try not to be judgmental, but sometimes people really make it hard.
This young man, lets call him Cletus (or Dweezle, or any hick-related yokel name). Now lets add some alcohol to Cletus. If you ever read my blog before, there is a time tested proven formula for calculating your IQ and how it relates to alcohol. Quick reminder, its the NADA (not a dumbass) formula, which goes like this.
Your IQ with beer = (normal IQ) – (7 x number of beers drank)
Cletus was not smart to begin with, so lets give him an IQ of 70. Now add 14 beers. A quick calculation will indicate that Cletus has just rendered himself a negative IQ. Many of you might say this is impossible, but you have never worked an overnight shift on a weekend in the ER. We see people with negative IQ’s ALL THE TIME!!
So now Cletus is outside at roughly 3:30 in the morning in distant hick-county in Thumb-where Michigan. Not much to do until, “IS’M THAT’S A POSSUM!” he exclaims!
Logic would dictate that when you see an angry-looking, sharp-toothed giant rodent-like creature at 4am, one might want to just stay away. Cletus (of course) came to a different conclusion.
Cletus embraced his inner Daniel Boon and via some luck and horrible fate, managed to trap said possum in a crate.
Now what would you do?
Right! You have to kill it! Oh it gets better. Did you think for a minute that Cletus didn’t have a gun? Well, I suppose it could have ended much worse if he had used said gun, but you think he’d shoot it in the crate, or drown it, or put it behind the car or something! No, he didn’t use his gun. He didn’t use a knife, or bow and arrow or any type of weapon. He decided to open the crate…
…Open it and try to step on it (barefooted, of course) to hold it down while you jab it with a sharpened stick.
One bloody messed-up foot later, Cletus hobbles into the ER, proud of himself for killing the possum, and desiring a tetanus and rabies vaccines. This is my life.
Though, I did find a youtube video of some random girl getting bit by a possum as well, so stupidity has no gender boundaries (but its almost ALWAYS a dumb guy, you know that right?)
forward to 1:20 for the event, really not quite that big of a deal…
3. I have never been in 4 point restraints
We restrain people with relative frequency in the ER. Again the majority of the time it is alcohol related. For some, the alcohol make them think they are invincible warriors to be reckoned with, thus they must prove their invincibility against 6 VERY STRONG security guards. They always lose. I am yet to see our security not be able to handle a patient. Mad props to all of you security worker world wide, you don’t get the credit due to you for having to deal with all these drunk jerks.
The other reason is the drunk who perpetually thinks he is sober enough to leave. He gets up, pees on the wall (or in the sink (or in his pants (or on the floor (or in the hall (or (rarely) in the actual bathroom))))), and thinks he’s ready to go. Then he takes one to two steps, and falls flat on his face often creating a large laceration that I now have to sew closed. These fine gentlemen (and not too rarely ladies) get restrained to protect them from themselves (until they sober up).
Yes we have restrained the homicidal or suicidal or psychotic from time to time, but this is actually the exception, not the rule.
4. I do drink beer
Yeah, beer caused pretty much all of these problems, but hey, beer is delicious, just drink responsibly.
I recently read on Xanga how someone thought being a waitress is the toughest job in the world…
In any given work week, I’d say I pronounce three people dead.
Many of these come over a phone call from the EMS who go to houses where people find loved ones dead. They need a doctor to pronounce them dead over the phone. This is pretty easy. The 108 year-old person was found dead in the apartment after not being seen for three days. I see no body. I see no face. The hardest part is figuring out what time it currently is so I can pronounce it.
I have also become somewhat stoic towards the deaths that I actually pronounce in the ER. Granted these also are usually pretty easy to detach myself from. They are usually already intubated. They usually already have ongoing CPR. They come in with eyes closed, and thready vital signs. I never have any normal human interaction with these people other than attempting heroic maneuvers to save their lives.
Most ER docs (myself included) sometimes find running a code like this easier than having to tell a patient that they have a new diagnosis of cancer (or any completely life altering diagnosis).
But death is death.
She was old. Early nineties, but spry. She complained of having chest pain for a week, until it started hurting really badly and decided to call the ambulance.
She had a few heart attacks before, but she also had been told that her heart was too weak for any procedures. The EMS said that all of her vital signs actually looked pretty good until about two minutes from the ER. Then she started getting sicker. Her blood pressure took a dip and her heart rate raced and she said her chest really was hurting a lot more.
Not to sound overly dramatic, but I think she might have known she was dying. I took a quick History and Physical and ordered a bunch of tests. Her vitals were still pretty good, so I really didn’t think she was going to die right in front of me. I did manage to ask her if she would want a breathing tube if she needed it. She denied this. I also asked her if she wanted CPR if her heart stopped beating.
She said she didn’t need anyone pounding on her chest. She said “I’m too old for heroics, if it’s my time, it’s my time.”
It was her time.
I left the bedside and was called back by a nurse about 5 minutes later when she really started crashing. Her blood pressure tanked and her heart rhythm became chaotic. She lapsed in and out of consciousness for a bit. But then she remain unconscious. Her eyes stayed open, and for an ER trauma room, it stayed pretty quiet. It felt wrong to do nothing, even though in my heart, I knew it was right.
We all watched her die in awkward silence.
I closed her eyes and pronounced the death.
I try to be the most positive person in the ER I can be, but that really took the wind out of me.
She had spirit and life upon arrival. She knew who she was and even smiled while in the ER.
Then she died.
The EMS did not have a DNR order on her, but she seemed coherent enough that I respected her last wish for no heroic measures.
It still felt off though. As an ER doc, everything I do is just a battle to prolong the time we have. Then I just watched someone die right in front of me, and it was the right thing to do.
Later, I spoke with her children. They (of course) were sad at her passing, but glad she went relatively quickly and peacefully. They commented that actually she did have a DNR (do not resuscitate) order, thus the decision to not act was the correct one.
I guess she taught me that sometimes in life you can make the right decision, feel good about it, but still hurt about the choice as well.
I’ve been saving random things I’ve heard in the ER over the last year or so. I thought I would share a few with you. I swear each and everyone one of these is a direct quote, none of the following were made up. They came from patients, families, nurses, and random drunks. I’m listing just 10, since people love lists of 10, and most of you are people.
Let the madness begin:
10. <about having to do a pelvic exam>
“Time to go to Australia.”
”What?”
“You know, go Down Under”
9. ”Oh, I didn’t recognize you with your clothes on”
8. <drunk> “Real men don’t wear diapers!”
<nurse> “You just peed your pants…”
7. ”You keep shoving patients up my already raped anus”
6. ”One day, when I eat Ethiopian food I’ll come over and fart in your face and make you hungry.”
5. (on arriving to my shift) “Did you sleep today? You look like shit.”
4. ”I just spilled some surgi-lube on my thingy… I mean my tool… I mean… grrrr!”
3. (nurse to patient, referring to STD’s) ”Ma’am, you can get everything but pregnant, in your mouth.”
2. ”Build a man a fire, he’s warm for the night. Light a man on fire, he’s warm for the rest of his life.”
1. <Resident> “We need to bring prohibition back!”
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