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What’s the craziest thing…?

… you’ve ever seen?

This is the usual question I get asked when I tell someone that I practice Emergency Medicine.  It’s not the most practical question to ask, but that doesn’t make the slightest difference.  Although the goal of this site is to educate and help others prevent and properly treat emergency medical conditions, I guess there isn’t any harm in entertaining those who wish to be entertained.  If you are here for that, please also try to gain at least a little education as well.  My most interesting medical cases can be accessed on the main menu area on the left side of the screen, but my craziest cases from a non-medical point of view, can be viewed by scrolling down.

 

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PATIENT’S PHOTOS

With cell phone now so handy people take pictures of just about everything.  I now routinely ask my patients if they took a picture after a car accident and now I have expanded that to a bloody BM

Video of anal burp: a mom took a video of her 8-year-old daughter’s anus opening while she was in the knee-to-chest position supine.  This can be normal, but the mother was worried it meant there had been sexual assault or molestation.  The child seemed very reliable and denied this but the mother was not reassured until seeing the doctor, in the ER.

Bloody stool

 

SEX STUFF

What everyone asks about first when they find out I work in the ER

Genital Parephernalia: A 33 year old male was brought in by ambulance because he was afraid he had “gangrene” of his legs.  He actually just had really bad blisters, probably from walking all over town barefoot or in shoes without socks while “tweaking” on methamphetamine.  Because this gentleman was having a hard time communicating we decided to put him in a room and get him undressed.  What a surprise.  It was no surprise that he had on no underwear.  But what was a surprise was the unique combination of genital parephenalia.  A young man with a Foley catheter to drain his bladder and a leg bag to collect the urine was in and of itself a rare site, especially considering the fact that he had not mentioned it to us.  But what really floored us was the combination of the Foley and a cock ring.  Wouldn’t each prevented the proper use of the other?  You can’t really have sex with a long tube coming out of your penis and attached to a large plastic bag downstream, and I would assume, thought I can’t say I know for sure that it isn’t as easy to urinate with a cock ring on.

Anal Foreign Bodies: I always get asked this one and have only seen it once or twice.  The only one I recall is a guy who had a metal for stuck with the tines pointing down so he had to go to the OR to have it removed.  Why he couldn’t have massaged his prostate with the back endo of a spoon I’ll never know.  “I wasn’t thinking” was his response.  Don’t they make toys for this type of play.  Why people use the wrong tool I’ll also never know

Cock Rings: I’ve seen about 3 cases with these huge metal rings that have to be cut off with a Dremel.  It takes hours.  The company that makes these rings should not be able to buy anything metal

Broken Dicks: I’ve seen a penile fracture three times.  Two were from pulling out a little too far before the next, miss-aimed thrust.  One was a doggie style disaster and the other was girl on top.  The one was a guy who was pushing his morning wood downward so that he would be able to use the toilet after a few minutes when he heard a snap.  He said he had done this a hundred times in the past.

 


DELUSIONS GALORE

A delusion is a fixed incorrect belief that is typically very hard to use logic to dispel

The Bloodletter: One gentleman I saw had been to many doctors before a friend finally made him go to the ED.  He had a delusional belief that there were “Infected veins” in his face and over a period of many months he had been puncturing them with a small needle to drain the infected fluid.  He was as white as a sheet and when his hemoglobin level came back at 4 (normal for a man is about 15) I knew he was in serious trouble.  The psychiatrist saw him but said that he did not meet criteria for a 5150 (an involuntary 72 hour emergency psychiatric hospitalization) as he was not suicidal, homicidal or gravely disabled.  Not knowing what to do next and fearing for my patient’s health I asked him if he would show me what exactly he did.  He asked for a mirror and a proceeded to watch him pierce a spot on his face and squeeze out a small amount of blood mixed with normal intracellular fluid.  He must have spent hours a day doing this to keep his blood level so low.  When I told him that the fluid was normal appearing and not infected and that he was slowly killing himself for no reason he responded, “Thank you doctor, you are the only one who ever asked to see what I was squeezing out of my body.”  He said that knowing there was no “infected fluid” he would simply stop.  He refused a blood transfusion and refused hospitalization. Unfortunately he did not, and when I finally got him to return a few weeks later his blood count was even lower.  This time the psychiatrist fortunately changed their minds and hospitalized him against his will.

A lawyer on amphetamines: It is not an uncommon occurrence to have a patient on methamphetamine come to the ER insisting that they are infected by parasites.  Some will come in with a zip-lock bag full of scabs and insist that they are insects and request you have them analyzed.  Trying to reason with them or convince them that they are wrong if often a waste of time and even backfires.  I had one lady who denied drug use and then when I told her that her tox screen showed amphetamines both her and her boyfriend adamantly denied the test could be accurate because she had been clean for over 6 months.

Black mold coming out of my eyes:Rather than a zip-lock bag full of scabs I once had a patient who had his scabs much better organized.  He was a lawyer who was on Ritalin rather than meth and he had a notebook of scabs taped in a methodical fashion to pages with dates and descriptions like an ornithologist collecting insects.  That was a long process and he eventually went home dissatisfied after I wasted much precious time trying to convince him he needed psychiatric help and to stop Ritalin rather than anti-parasitic pills.

Delusions of parasitosis 3:Another Ritalin riddled patient was at least better suited to figure out when he was wasting both his and the doctor’s time.  Right after I introduced myself to him he asked me if what I was seeing scared me.  “What do you mean exactly?” I replied.  “Don’t you see the black mold coming out of my eyes, mouth, ears and nose.”  When I told him I didn’t see anything definite but I would return with an otoscope (the light to look in the ears) to look he said OK.  On my return he was already dressed and walking out.  “Where are you going?” I asked.  “I’m just going to see my doctor at Kaiser for this.”  I tried to convince his to let me stay but I admit it was half-hearted and I was secretly thrilled he had cut both of our losses.


PARENTS & KIDS

Anus Nothing Wrong Here: One lady had a video to show me of her 11 year old daughter’s anus while she was on her knees leaning forward reading.  She had told her mom it felt like her butt was opening up.  This can be normal I told the mom but the mom was worried that someone had molested her daughter even though the daughter insisted that this was not the case.  The mom then insisted I watch the video and I reluctantly agree.  I of course inquired if there was any pain or bleeding and had a social worker also see them.  I will be forever scarred.


REFUSING TESTS

In the US, most patients want more tests and I have to spend time convincing them why they are unnecessary.  Occasionally the opposite is true.

In Russia any doctor just cut: A 70 year old exuberant Russian gentleman with limited English skills was sent in by an orthopedist to have surgery to drain an infected bursa on the outside of his elbow.  Antibiotics and repeat drainage with needle and syringe had not been enough to cure the problem.  The patient eventually grew impatient not only of having to wait for surgery (he was hungry and told that he could not eat until after surgery), but also questioned the necessity of all our “routine” pre-operative tests.  He didn’t want a chest x-ray, after all it was his elbow, not his chest that was causing the problem.  He didn’t want an EKG or blood tests.  He just wanted to get this over with.  Eventually after refusing all these tests he came to me and said, “Doctor, when I get surgery.  I don’t need this, this, this.  In Russia any doctor cut.  No blood, no x-ray.”  We later learned that years ago the patient had been similarly afflicted and had simply downed enough vodka, sterilized a kitchen knife by fire, and done the job himself.  Eventually the patient went off to surgery and I joked with the nurses that we should hire this man to a committee to help control health care spending in the U.S.  Surely he would have a fresh outlook on the necessity of some of what we do.

 

DRUG SEEKERS

Usually it’s opiates, but occasionally benzodiazepines or others.

Drug Seekers:       metalica, twin gypsies, evidence dept,  faked an appy, kidney stone

Amphetamines see delusions

Faking blood in urine: Some people will come up with a variety of schemes to get opiates in the ER.  One guy was faking a kidney stone and even pricked his finger to get blood to add to his urinalysis as kidney stones often cause a microscopic amount of blood ooze into the urine.  Unfortunately this guy left a bloody fingerprint on the outside of the urine specimen container.  Another guy bit the inside of his mouth and spit in the urine.  Unfortunately his urine also had a lot of bacteria in it so we cultured it and the results showed bacteria that only reside in the mouth.

Script to give Demerol:One lady was sent to the ER by a new primary care doctor for suspected migraines with a note that had a few instructions on it.  The patient added, in quite different handwriting, “give Demerol 100mg”.  I confronted her and she denied adding that.  I then called her doctor to confirm that he had not written this last part.  To try to save time and get the patient to just walk out I told her I was going to need to call the police to come investigate the unusual note and told her “if you are still hear when they arrive they may arrest you”.  She didn’t get the hint and stayed.  The cops actually did take her away in cuffs and prosecuted her.

 

DO PEOPLE REALLY COME TO THE ER FOR THAT?

Whimps:                fingernail,

red line on arm

 

ARE PEOPLE REALLY THAT STUPID?

Stupid:                   Injecting milk p heroin OD,

Wife got pregnant because MD gave OCP rx to husband and he was taking it.

DKA bc rubbing insulin onto skin.  Shot self in foot.

Psych:                    FB in thumb

sraeli lady

F.B.                         FB in both ears

Dysphagia and 3 teeth

 

BLEEDING

Hemoptysis or Hematemesis:  In residency I had a patient that was hospitalized for coughing up blood.  They found blood in his stool so the doctors thought the patient was confused.  He had a history of both tuberculosis and cirrhosis.  He had his GI bleed treated and was sent home.  A week later he coughed up massive blood and asphyxiated suffering severe brain damage but not dying.  He was in the ICU for months.

Massive hemoptysis in a heroin addict: Hemoptysis means coughing up blood.  Usually it is small amounts and is nothing serious, but large amounts can be fatal, not from blood loss but from asphyxiation. I had a patient who was recently discharged from the hospital and then came back with massive hemoptysis, a rare situation which I don’t believe many clinicians or nurses have much if any experience treating.  In massive hemoptysis blood transfusion is almost never indicated unless it is to reverse blood thinners; blood offers no benefit and if anything might be expected to increase the rate of bleeding into one or both lungs making the situation even worse.

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