Mystery Rash of Doom

Yes, it looks like your child might have a rash. Sorry you had to wait so long. I may not be an expert at Dermatology, but one thing I know about rashes is this:

If I have to get up real close and squint to see it, then it probably isn't an emergency.

Hearing Loss

"It's the most common sensory abnormality in the world."

A tone that most adults can't hear but kids can.

I can't hear the secret tone unless I turn the speakers way up, but it drives my kids crazy.

Yeah, it's from last year. I didn't have a blog then.

To Repair or Refer

When a patient says, "as long as you do your best, I will be happy" it makes the doctor happy too. And that's the way things should be.

More on Drug-Seekers

Despite the allegations of some of our detractors, most ER docs are compassionate types who generally give patients the benefit of the doubt. We don't like to see our patients suffer, and honestly we usually don't have the time or the inclination to consistently sort out who is scamming us and who is telling the truth about their medical history, their dramatic pain performance, or their allergies to medications.

It is only the most heinous offenders to whom most of us would deny treatment: those who are the most frequent of flyers, those who are abusive to the staff, those who don't bother trying to follow up for definitive care/management, or those who we actually can prove are lying to us. Suspicion of lying is not sufficient for me to deny analgesia, but once a patient has been caught in a lie and the documentation is on the chart, that individual will not likely receive narcotics from me ever again unless clear evidence of injury is present. A broken arm will suffice; another "migraine" will not.

It's rare that we can ever obtain definitive evidence of lying, however. When a patient tells me that they haven't gotten any Stadol NS in two months, and a prescription is clearly documented on the chart only two weeks ago, that is a slam dunk no-brainer. Yes, I read your old charts. See ya.

When I have time to talk to a pharmacist and learn that a patient has been doctor-shopping for Vicodin, they're out the door empty-handed. When a patient sloppily writes "ES" after the "Vicodin" on their Rx, I guess they think the pharmacist is too stupid to notice. Wrong. I'll tell the pharmacist to tear it up, and I'll make a notation in the chart. When a patient crosses out the "100 mL" and writes "16 ounces" on their cough syrup prescription, then they have given us all the proof we need to cut them off. Good luck EVER getting another narcotic from either our facility or that pharmacy, buddy. Move along.

The best scammer I've seen was a 30 year old guy who was new in town, with a pretty good kidney stone-ish writhing act, and somehow he managed to put some blood in his urine. He was requiring unusually high and frequent doses of narcotics to ease his pain, and my spidey sense was tingling from the start. Still, I medicated him repeatedly, because I'm that kind of guy. I caught him in a misstatement when he claimed that he was a newly-hired golf pro at a famous country club, and he misidentified the head golf pro there. I confronted him with his error, but he stood by his statement. I should have kicked him out then and there, but again, I gave him the benefit of the doubt.

He finally "passed" a small stone, which I sent off to pathology for analysis. His CT scan eventually was normal, and his pain was miraculously improved by that time.

When I got the pathology report in the mail the following week, it read "100% artifact." He had given me a little pebble from his backyard. Hopefully he will actually suffer from a kidney stone some day, then the karmic balance will be restored.

UPDATE: ER Nursey adds some excellent points.

RIP SRV

October 3, 1954 – August 27, 1990

More Than a Filling

You never know what you are going to see next in the ER. That's why I like it. You can be cruising along with some basic chest pain workups, a couple of upper respiratory infections, a few minor traumas, and the usual assortment of abdominal painers. What an easy job this is, you might think to yourself. Then something weird walks in. Something like this (no not the dog, but you can click on the picture to see what happened to him):

The chief complaint was "allergic reaction," and the patient was sent straight from the dentist's office to the ER after having first received a shot of Benadryl. He was having a deep filling placed in a lower molar when suddenly one side of his face began to swell up.

When I entered the room, I noticed that the left side of his face was indeed slightly swollen, but he reported that it had gone down quite a bit after the Benadryl. When I palpated his neck, I immediately noticed the unmistakable crunchy feel of subcutaneous emphysema, or air in the soft tissues, which extended from cheek to collarbone.

An X-ray of the neck confirmed my examination, but the chest X-ray was negative for pneumothorax or pneumomediastinum. So how did this happen? Further history from the Dentist revealed that she had used compressed air to dry the lower molar after retracting the periodontal space adjacent to the tooth. Apparently air was forced into the cheek and neck by the dental equipment. Initially the cheek swelled up, then the trapped air gradually spread out in various soft tissue planes of the neck. So the swelling really had "gone down."

So what about the treatment and disposition of a case like this? It isn't the sort of case that is easily looked up in a standard reference book. Neither the referring Dentist nor her Endodontist partner had ever heard of such a complication, so they weren't much help. The on-call oral surgeon and ENT physicians both agreed that the air would probably be gradually absorbed without any adverse consequences, but both recommended prophylactic antibiotics just in case.

The patient was discharged with an oral antibiotic, and his Dentist later reported that everything turned out well. This complication of Dentistry is not unheard of, but it was to me and to the referring dentist.

Search Audio Codes

My Most Popular Post

I still get several hits a day from newcomers searching for information on this topic and twice as many comments as any other post on my blog. Who knew that lingual nerve injuries were so common? Certainly not me.

Pepper Spray

Otherwise known as OC (Oleoresin Capsicum) spray, it can be an effective nonlethal adjunct to your personal self-defense plan. These ASP Keychain Defenders are easy to carry, very unobtrusive, and really solid. Nobody will know you are carrying pepper spray, unless you have to use it on them.



As far as the funniest pepper spray video I could find, well it's right here. Enjoy:

(LANGUAGE WARNING)



Watch the whole thing or skip to the end....I don't think sticking your head in a bucket of water with a snorkel is really a "defensible position," hehehe.

They do sell the Fox brand pepper spray featured in the video on the website I linked, but the Fox canister isn't as convenient to carry as the ASP keychains. I have purchased from J&L, and I found them to have excellent customer service. I highly recommend them.

The keychains pictured are technically twice as hot as the Fox spray, btw. The keychain has a 10% concentration of 2 million Scoville heat units, while the Fox spray has a 2% concentration of 5.3 million Scoville heat units.

UPDATE: Another funny OC video, with a good ole boy in the backyard learning his lesson.

Finally the legend Johnny Knoxville (of Jackass fame) in a video comparing pepper spray, a stun gun, and a taser. His impression? "The pepper spray is the worst, by far."

Why Administrators Suck, Chapter XLVII

So I need a female chaperone to stand inside the room for 30 seconds while I do a quick breast exam. All the nurses are busy with other patients, and the techs are doing ECGs or transporting patients. My favorite unit secretary is sitting at her desk literally five steps away from the patient's room in question. The phone is not ringing, and she is contentedly surfing the internet.

"Can you help me out with a quick breast exam?" I ask nicely.

"Sorry, I'm not allowed to do that anymore."

Blank stare. "You've chaperoned me hundreds of times over the years. Who said you can't?"

"Mrs. Peaker, the new hospital administrator."

"Wait a minute. You can take a break, can't you? I've seen you get up and eat once already during the shift."

"Yes, I get two 15 minute breaks per shift."

"And they still sometimes make you act as a babysitter for psych patients, right?"

"Yes they do."

"And I bet if you had to go to the bathroom, you'd be allowed to do that, wouldn't you?"

"They couldn't stop me."

"But this person specifically forbids you from getting up to assist me in patient care?"

"Yes."

"She's a nurse, right?"

"Yes."

"Then get her on the phone and see if she'll come chaperone me herself."

"She probably wouldn't know how."

Indeed.

Vacation Pics

The Moody Gardens Aquarium is a cool place to visit, almost like scuba diving without getting wet. Except for all the screaming rug rats running around, that is. These are a few pics from my formerly cutting-edge but not yet obsolete pocket-sized 2mp Sony, mostly without flash to save my fading batteries.

Lionfish


Eel


Shark


King Penguins




Quote of the trip, courtesy of my wife: The kids were fighting and being difficult, as kids occasionally do. As we were headed to the ultra-fake mechanical dinosaur exhibit, we passed a fake high voltage line, presumedly intended to keep the fake dinosaurs inside the exhibit, ala Jurassic park. Nice touch, really.



"Would it kill me if I touched it?" my daughter asked.

"Why don't you touch it and find out?" smirked the wife.

I had to get a picture after that. And then the batteries died.

Quote of the Night

You can't make this stuff up.

A patient who was admitted for vomiting and abdominal pain a couple of hours earlier comes walking back down to the ER, dragging his IV pole, saying that he left a bottle of booze in his room.

Where did you leave it?

"I hid it inside my pillow. Can I go look for it?"

There is already another patient in that room, but the housekeeper didn't find any bottle when she cleaned the room. Was it one of those tiny little airline bottles?

"No, it was almost a whole fifth of vodka."

Sorry, we haven't seen it.

"Well, can I buy another bottle from y'all then?"

Off the Clock

Be back soon.

Another Pain Scale

From an Orthopedic Surgeon.

Paging all fibromyalgia patients......

Love Shouldn't Hurt

A haunting first person account of domestic violence and abuse, bravely and beautifully told.

Bravo for you, SSG.

Old rap, new rap

As interpreted by Napoleon Dynamite.

Golden Age


New Style

Bad Idea

"The doctors said that cocaine had weakened my heart for good. What do I have to lose? Gimme another rock, man."

"I know when they brought me into the ER that I couldn't walk or move my left side. But I'm almost back to normal now. I think I'll go home."

"I know I need to be admitted, but there is nobody at home to feed my dog. Can't I just come back tomorrow?"

"You ain't no REAL cop. You just a rent-a cop.
You can't do nothin' to me."

"The intergalactic space commission has authorized me to complete my assignment to dissect the brains of the children. You can't keep me here against my will! I'm gonna sue your ass!"

"Yeah, my boyfriend gave me another black eye. But he's really a sweet guy, except when he drinks. We can still work it out."

Weak and Dizzy

ERnursey nails it.

Weak and dizzy = 6 hour ER workup.

And after all that, we usually confirm that weak and dizzy = lonely and sad.

But we still have to do the 6 hour workup.

Just in case.

Set Phasers to...Barf!

New flashlight weapon makes targets throw up.

"The handheld device (uses) light-emitting diodes to emit super-bright pulses of light at rapidly changing wavelengths, causing disorientation, nausea and even vomiting in whomever it's pointed at."

Nice. Teleportation is just around the corner.

Quote of the Night

As a burly male nurse and I were examining a demented old lady from a nursing home, she turned to him and asked, "Did you buy that dress you were trying on? It looked so good on you."

We hadn't finished chuckling about that when she turned to me and said "You like to eat, don't you." Not a question, but a statement. She must have got quite a kick out of that one, because she smiled and cackled contentedly to herself "Heeheehee...you sure do like to eat."

Heeheehee. No soup for you.

Self Portrait

As interpreted by the Simpsonizer.

h/t 10/10

The Simpsons Movie was outstanding, btw. I highly recommend it, and so do my kids. The political commentary was hilarious.

Here is a flash game featuring one of the scenes, for those who enjoy such things. If you get past level 12, I'll buy you a dozen donuts.

Blogiversary

My blog is one year old today. Thanks to everyone who has stopped by.

The Magic Touch - Book 2

In this chapter, a young girl is brought in by her concerned parents because she is unable to walk. It seems that she had gotten her foot caught underneath the couch, and when she was pushed down by her brother, she had apparently twisted her knee.

After being carried into the ER and placed on a stretcher in the arms of her mother, her crying had diminished to a whimper.

As is my practice, I palpated the rest of her body first, putting all of her joints through their range of motion and looking for secondary injuries that might have been masked by the distracting knee pain.

Finding none, I gently worked my way up the involved leg; starting at the toes, she remained silent and trusting as I palpated the foot, the ankle, the shin....

WAAAAAAAAHHHHHHHHH!!!!!!!!!

She made it quite clear that the knee was the part that hurt. My tympanic membranes sympathized. I tried to gently bend her knee, but she was crying so hard by that point that I figured it would be better to just get the X-rays first. So I ordered some Motrin for her and moved on to my other patients.

When the X-ray didn't reveal any fracture or dislocation, I asked the nurse to get some ACE wraps, because I was obviously going to have to put her in a splint to immobilize the knee. When I walked back into the room, there she stood, happy and giggling. Then she began to dance. Yes, dance. Then she ran across the room to her mother, singing. She was completely healed.

I felt a little bit like Jesus, but I'm sure it was really just the Motrin.
Oh, to be young again and bounce back from injuries so quickly.

Book 1 here

Scalped!

A fun day at an amusement park ends badly when an 11 year old girl somehow gets her hair caught in a ferris wheel.

Amazing case report and description of the repair, with graphic pictures.

No matter how brave you think you may be, I recommend that you do NOT look at the other case report on that site concerning the industrial accident and the resulting degloved penis. Don't say I didn't warn you.

UPDATE: Technical details from a Plastic Surgeon blogger