We had a family of evacuees from Texas in the peds ER yesterday. They were placed in a homeless shelter temporarily, their medicaid paperwork hadn't gone through yet, parents managed to find temporary work but still haven't received their first paycheck, and all four daughters managed to pick up nasty cases of head lice. Dad spent over $200 of Rid and Nix and managed to treat three of the four girls, but the youngest daughter's lice just kept coming back. He's now out of money, scared to put any more toxic chemicals on his 3 year old's head, and the shelter won't let them back in until she's cured.
So he comes to us broke and at his wit's end. We quickly realize that the best treatment option, malathion, costs $112 per bottle. We called social work and financial advisers and they couldn't figure out a way to get the cost covered by medicaid and our pharmacy doesn't have an adequate dose on hand to treat her here. It was recommended that we give them another dose of Rid and a "good luck."
Instead, the entire medical team sat down and through genius manipulation of every possible billing code loopholes managed to arrange two free treatments here and two free follow up appointments for additional treatment if needed. Amazing.
Friday, October 24, 2008
Tuesday, October 21, 2008
Impossible patient of the month
A simple-sounding case came in. Middle aged woman with advanced ovarian cancer that's metastasized to the abdomen. Underwent a major abdominal surgery (small bowel resection) just about a month ago. Decided two days ago to stop taking her pain medication (because pain medicine just masks the problem and she knows there's something wrong with her and refuses to be on pain medication until her real problem is addressed). So she presents with (surprise!) abdominal pain. We've done a workup. All her labs are essentially normal and an abdominal CT shows nothing other than expected post-surgical changes.
Easy, I think to myself, and walk in to the room prepared to have a conversation about how recovering from surgery takes time and how she has a good reason to have abdominal pain and how very logical it is that she may be dependent on pain medication for a little while.
I'm not even in the door when she starts:
"You all walk in here with your glib remarks and your know-it-all answers. But I know my body and I know when something's wrong with it and telling me that the cancer or the surgery is responsible for my pain is simply unacceptable."
(Which of course is the cause of her pain, and is what I was just about to tell her). She kept going:
"Five years ago, the doctors told me I had three months to live, if I'd listened to doctors (pronounced in the same tone of voice most patients use to describe things like poop or intestinal parasites) I would have been dead four years ago."
(I resist the urge to point out that a prognosis is not exactly a direct order to die immediately when the time is up.)
She continued for a good 20 minutes, calling me glib about three more times (I still hadn't spoken), and informing me that she did research on the internet and he presentation is classic for pancreatitis. I finally timidly interject, pointing out that we looked at her pancreatic enzymes and performed a CT and that she doesn't have any indicators of pancreatitis. She gives me a look that vaguely resembles the way people look at a puppy who keeps running into a glass window. Speaking very slowly: "People are not textbooks, dear. I have never presented typically."
I finally gave up and called her surgeon who agreed to talk to her. Long story short? A terminal cancer patient with abdominal pain following abdominal surgery who refused to take pain medication for her thoroughly expected pain was admitted to the hospital for a thoroughly unnecessary workup of her aforementioned pain.
The kicker. As I walked out I peeked at her chart. She'd been requesting Dilaudid (the strongest pain medicine we have in the ED) every 30 minutes since arriving.
Easy, I think to myself, and walk in to the room prepared to have a conversation about how recovering from surgery takes time and how she has a good reason to have abdominal pain and how very logical it is that she may be dependent on pain medication for a little while.
I'm not even in the door when she starts:
"You all walk in here with your glib remarks and your know-it-all answers. But I know my body and I know when something's wrong with it and telling me that the cancer or the surgery is responsible for my pain is simply unacceptable."
(Which of course is the cause of her pain, and is what I was just about to tell her). She kept going:
"Five years ago, the doctors told me I had three months to live, if I'd listened to doctors (pronounced in the same tone of voice most patients use to describe things like poop or intestinal parasites) I would have been dead four years ago."
(I resist the urge to point out that a prognosis is not exactly a direct order to die immediately when the time is up.)
She continued for a good 20 minutes, calling me glib about three more times (I still hadn't spoken), and informing me that she did research on the internet and he presentation is classic for pancreatitis. I finally timidly interject, pointing out that we looked at her pancreatic enzymes and performed a CT and that she doesn't have any indicators of pancreatitis. She gives me a look that vaguely resembles the way people look at a puppy who keeps running into a glass window. Speaking very slowly: "People are not textbooks, dear. I have never presented typically."
I finally gave up and called her surgeon who agreed to talk to her. Long story short? A terminal cancer patient with abdominal pain following abdominal surgery who refused to take pain medication for her thoroughly expected pain was admitted to the hospital for a thoroughly unnecessary workup of her aforementioned pain.
The kicker. As I walked out I peeked at her chart. She'd been requesting Dilaudid (the strongest pain medicine we have in the ED) every 30 minutes since arriving.
Monday, October 20, 2008
spread your wings
Spent yesterday morning doing weapons of mass destruction decontamination drills with the local urban search and rescue team. I left with an extraordinary increase in my level of trust in our government. The resources committed to saving lives in the event of any kind of disaster- the thought, planning, training, equipment: just unbelievable. We really have a warehouse filled with enough medical and rescue equipment to save thousands of lives. And it can be deployed within hours. It was really awe-inspiring. And it's always fun to dress up in a uniform and play with heavy equipment in the company of local firefighters.
Then last night was my first Lifeflight shift. We ride fixed wing flights and effect hospital transports for patients too sick to be treated out in the community hospitals who wouldn't tolerate an ambulance ride to the capital. Neither of my patients were really sick or exciting but they definitely wouldn't have done well on a three hour car ride. It was absolutely beautiful flying over New Mexico as the sun came up. And again, got to wear a jumpsuit which is always a bonus. The EMS crews have taken to calling us me a "baby doc." (Code for med student) Very cute, although I do worry that some of the patients may have gotten the false impression that I'm a neonatologist.
This week has been a crazy one in the hospital. Insane trauma after insane trauma, the capstone of which came in last night while the trauma bay was already completely filled. A young yard worker came in with a tree branch through his heart. We wandered through the trauma bay on our way back from delivering a patient upstairs and the ED looked like a full on war zone.
Something in the water? Full moon spillover? Well, wish me luck on my shift tonight. . .
Sunday, October 19, 2008
Case of the day
An urban legend comes to life!
A paramedic was at home eating a peanut butter cup when he accidentally inhaled a bit of it. He tried to do the Heimlech maneuver on himself, his wife tried as well, no luck.
So what does he do?
He grabs a kitchen knife and performs a cricotracheotomy on himself. (For the non-medical, he cut a hole into the front of his neck, and then stuck his finger through it and into his trachea below the obstructing peanut butter cup.)
Yeah. Pretty hard-core.
The beeper message when he came in was my favorite part: "Criked himself."
Careful this Halloween!
A paramedic was at home eating a peanut butter cup when he accidentally inhaled a bit of it. He tried to do the Heimlech maneuver on himself, his wife tried as well, no luck.
So what does he do?
He grabs a kitchen knife and performs a cricotracheotomy on himself. (For the non-medical, he cut a hole into the front of his neck, and then stuck his finger through it and into his trachea below the obstructing peanut butter cup.)
Yeah. Pretty hard-core.
The beeper message when he came in was my favorite part: "Criked himself."
Careful this Halloween!
Friday, October 17, 2008
overheard in disaster medicine course lecture
"Bottom line is no one's going to want to go shopping in a supermarket where a bunch of radioactive cesium's been dispersed. I'm pretty sure."
Jerk
Stick with this story, it gets better and better.
1. 30ish year old dood with girlfriend and young son in tow drinks 12 beers, gets in car, crashes car into a parked truck.
2. When Mr. D hears police coming, he gets out of his car and begins running, leaving injured girlfriend and child in car.
3. When caught by police, acts remarkably appropriately, cooperates, expresses concern for his family in the car, states that he had some beers, and that he is not injured.
4. Police mention that he is not a first-offender, is going to be charged with a felony, and will probably do jail time. All of a sudden Mr. D's "entire body hurts" and he falls to the ground "unresponsive."
5. Mr. D is brought to the ER and continues to play possum for. . . 9 hours. We stuck a catheter in him, performed sternum rub after sternum rub, multiple IVs, no response. Yet he miraculously was seen looking around, scratching his head, and readjusting his blankets every time he though he was alone. When caught, right back to playing dead.
Now our ED was absolutely packed this night and there were people literally sitting in the hallway with crushed limbs waiting for a bed. And Mr. D? Lying there taking a nap while his family, who are actual injured patients, are being scanned and sutured and splinted, and while other actually sick patients are out in the waiting room because he's tying up a bed in some incomprehensibly selfish (and short-sighted) bid to avoid a felony charge.
6. Mr. D ends up being scanned and x-rayed to the tune of several thousand dollars, since he's now been persistently "unresponsive" with no discernible cause for six hours.
7. Finally, at 6:30 am, the attending had enough. A rather vigorous finger pinch with a pair of trauma shears miraculously raises our patient from the dead. Hallelujah! He has no idea where he is, no idea what's happened for the past ten hours, he hurts all over, he's so so concerned about his family. He knows he messed up, it's never going to happen again, he's going to get into treatment today, he just wants to know his kid is okay.
8. I halfway fall for it, give the guy the benefit of doubt, sneak him in to see his girlfriend, check the various body parts he claims are injured (essentially his entire body), and arrange for a few more x-rays to be safe.
9. 8am. Mr. D leaves the hospital, abandoning his girlfriend, his injured child, the team that spent the past ten hours treating his uninjured, smelly, drunk, lying self. I spend close to an hour (after my overnight shift) looking for him, thinking maybe, in spite of everything, he was legitimately injured and is hurt or lost. I call security. I walk through all the bathrooms. I call the police in case he's hurt out on the streets. No luck.
10. 9:10am I go in to tell the girlfriend that I can't find Mr. D, ask if she knows where he might be. "That bastard left us in the hospital again!"
Yup, this is not the first time.
1. 30ish year old dood with girlfriend and young son in tow drinks 12 beers, gets in car, crashes car into a parked truck.
2. When Mr. D hears police coming, he gets out of his car and begins running, leaving injured girlfriend and child in car.
3. When caught by police, acts remarkably appropriately, cooperates, expresses concern for his family in the car, states that he had some beers, and that he is not injured.
4. Police mention that he is not a first-offender, is going to be charged with a felony, and will probably do jail time. All of a sudden Mr. D's "entire body hurts" and he falls to the ground "unresponsive."
5. Mr. D is brought to the ER and continues to play possum for. . . 9 hours. We stuck a catheter in him, performed sternum rub after sternum rub, multiple IVs, no response. Yet he miraculously was seen looking around, scratching his head, and readjusting his blankets every time he though he was alone. When caught, right back to playing dead.
Now our ED was absolutely packed this night and there were people literally sitting in the hallway with crushed limbs waiting for a bed. And Mr. D? Lying there taking a nap while his family, who are actual injured patients, are being scanned and sutured and splinted, and while other actually sick patients are out in the waiting room because he's tying up a bed in some incomprehensibly selfish (and short-sighted) bid to avoid a felony charge.
6. Mr. D ends up being scanned and x-rayed to the tune of several thousand dollars, since he's now been persistently "unresponsive" with no discernible cause for six hours.
7. Finally, at 6:30 am, the attending had enough. A rather vigorous finger pinch with a pair of trauma shears miraculously raises our patient from the dead. Hallelujah! He has no idea where he is, no idea what's happened for the past ten hours, he hurts all over, he's so so concerned about his family. He knows he messed up, it's never going to happen again, he's going to get into treatment today, he just wants to know his kid is okay.
8. I halfway fall for it, give the guy the benefit of doubt, sneak him in to see his girlfriend, check the various body parts he claims are injured (essentially his entire body), and arrange for a few more x-rays to be safe.
9. 8am. Mr. D leaves the hospital, abandoning his girlfriend, his injured child, the team that spent the past ten hours treating his uninjured, smelly, drunk, lying self. I spend close to an hour (after my overnight shift) looking for him, thinking maybe, in spite of everything, he was legitimately injured and is hurt or lost. I call security. I walk through all the bathrooms. I call the police in case he's hurt out on the streets. No luck.
10. 9:10am I go in to tell the girlfriend that I can't find Mr. D, ask if she knows where he might be. "That bastard left us in the hospital again!"
Yup, this is not the first time.
Saturday, October 11, 2008
Scary!
Ms. M was a very sweet 23 year old woman who was involved in a minor car accident this morning. She went over to Other Major Emergency Department complaining of some minor neck and abdominal pain. They examined her, took x-rays of her neck and sent her home with some ibuprofen, end of story.
She comes back to our ED about six hours later complaining of continued abdominal cramping and a gush of vaginal bleeding when she went to the bathroom earlier. She states that her last period was about five weeks ago and that it's been pretty much regular every month until then. I order a quick pregnancy test, thinking maybe she's 5-6 weeks pregnant and having a spontaneous abortion, draw some labs, and go back to examine her.
So her exam is essentially normal except for some stretch marks on her stomach and a fullness in her lower abdomen that feel remarkably like uterus full of baby. Strange for someone who's last period was only five weeks ago.
Well, I set up for a pelvic exam, sit down at the foot of the bed, lift the sheet. . . and there is fully formed loop of umbilical cord protruding from her entirely open cervix. . . which has a head pushed up against it. This young lady was not having a spontaneous abortion, she was in full-on labor. The bleeding she felt earlier was apparently her water breaking.
I rushed out, trying my very best to look like a calm and competent professional and not like the scared medical student I was, and called ob-gyn. End of the story, this young woman was more than six months pregnant. She had no idea. The baby, by now, had no heartbeat, and she ended up being rushed to OR to deliver the dead fetus.
It's impossible to say when the pregnancy terminated, but I can't help but wonder if the other hospital had caught the pregnancy this morning if she might have been able to successfully deliver. I don't know.
Moral of the story: Every single woman who could conceivably, remotely be pregnant must must must must have a pregnancy test no matter what they come in complaining of.
(The triage nurse apparently took this lesson to heart, my next patient was a 71 year old woman with abdominal pain. The triage sheet helpfully stated "urine pregnancy test negative.")
She comes back to our ED about six hours later complaining of continued abdominal cramping and a gush of vaginal bleeding when she went to the bathroom earlier. She states that her last period was about five weeks ago and that it's been pretty much regular every month until then. I order a quick pregnancy test, thinking maybe she's 5-6 weeks pregnant and having a spontaneous abortion, draw some labs, and go back to examine her.
So her exam is essentially normal except for some stretch marks on her stomach and a fullness in her lower abdomen that feel remarkably like uterus full of baby. Strange for someone who's last period was only five weeks ago.
Well, I set up for a pelvic exam, sit down at the foot of the bed, lift the sheet. . . and there is fully formed loop of umbilical cord protruding from her entirely open cervix. . . which has a head pushed up against it. This young lady was not having a spontaneous abortion, she was in full-on labor. The bleeding she felt earlier was apparently her water breaking.
I rushed out, trying my very best to look like a calm and competent professional and not like the scared medical student I was, and called ob-gyn. End of the story, this young woman was more than six months pregnant. She had no idea. The baby, by now, had no heartbeat, and she ended up being rushed to OR to deliver the dead fetus.
It's impossible to say when the pregnancy terminated, but I can't help but wonder if the other hospital had caught the pregnancy this morning if she might have been able to successfully deliver. I don't know.
Moral of the story: Every single woman who could conceivably, remotely be pregnant must must must must have a pregnancy test no matter what they come in complaining of.
(The triage nurse apparently took this lesson to heart, my next patient was a 71 year old woman with abdominal pain. The triage sheet helpfully stated "urine pregnancy test negative.")
Overheard on rounds
Resident: "Mr. Z is an 77 year old alcoholic homeless gentleman who was hospitalized for three months. He was released yesterday to a Motel 6, immediately drank a fifth of vodka, and was brought in by ambulance after being seen falling down multiple times."
Attending: "Well there's your problem, he should've stayed at a Holiday Inn."
Attending: "Well there's your problem, he should've stayed at a Holiday Inn."
Friday, October 10, 2008
Balloons!
Pretty right? Unfortunately, last night's shift brought not one but two balloon related patients to my domain. I knew it was just a matter of time, I'd heard this happens every year. The first case was a sad, though not too terribly surprising, case of balloon meets electric wire, catches on fire, and people jump out. I feel somewhat responsible too, I was just thinking to myself as I entered my shift how lucky we were that there hadn't been any balloon accidents this year. Totally jinxed us.
The second event involved this famous balloon:
A young father, PC, brought his son to the fiesta to collect pins (all the balloon owners make small pin representations of their balloons and lots of locals collect them over the years). Now PC was lucky enough to get the last darth vader balloon pin. A group of young men noticed this, and not-so-politely asked that he hand the pin over. PC declined, saying he was starting a collection for his son. The young men were not so satisfied with this response, followed PC to the parking lot, and beat him up. He came in with a tremendously dislocated finger, I mean almost not attached to his hand anymore, and cuts all over his face and neck from where they had kicked him. While he was down. For a balloon fiesta pin.
He was one of the sweetest, most delightful patients I've had, even after I and three orthopedic surgeons literally pulled on his dislocated thumb with all our might for just about twenty minutes.
The happy ending? He still has the darth vader pin. He turned to me as he was leaving for surgery, "It was totally, totally worth it doc."
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