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Patient Encounters

Time To Join The Debate Team?

I’m getting to dread Friday evenings in the emergency department. This past Friday, I saw six patients who had assorted injuries from football games. Six. Two of them had concussions, which goes along with a recent study published by the CDC showing that concussions are on the rise. See articles here, here, and here. CDC report is here. There is a lot of debate on how to manage sports-related concussions. The American Academy of Neurology essentially recommends discontinuing participation in the sport until symptoms resolve and appropriate evaluation … by a neurologist (or other physician with “proper training”) … prior to being cleared for participation. The Consensus statement on concussion in sport (2008) recommends physical and cognitive rest until symptoms resolve and then a graded return to activity prior to medical clearance. There is also an excellent but dated (1999) article in American Family Physician containing a summary of the then-current treatment recommendations for concussion. Several recommendations included discontinuing participation in the sport if several concussions occurred. Anyone symptomatic when I see them gets taken out of sports and gym until cleared by their physician. I also had another “oops” from Dragon Naturally Speaking related to the football injuries which was almost finalized in the medical record … I dictated “… followed by hitting head on another player’s football helmet.” Dragon spat out ” … swallowed getting hand in another player’s foot vomit.” Haven’t seen foot vomit in a while, but I know I wouldn’t want to be getting my hand in it.

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No Deal

There are a few times in emergency medicine when you know that a patient is either very sick or very injured. When you see a car screech to a halt in the ambulance bay and then see people get out of the car and start running about haphazardly, it is generally a good bet that the person still in the car is in need of immediate medical assistance. When a car drives by the emergency department entrance and pushes someone out of the passenger door, and takes off, leaving the person laying on the asphalt, it is generally a good bet that the patient needs urgent medical assistance and that the person providing the transport was either involved in some criminal malfeasance and has a warrant or, alternatively, the driver just no longer wanted to deal with the patient. Yep, driveway dump patients are usually quite challenging. Many times, there is no ID. Most times they are either unconscious or near unconsciousness. Those face plants on the concrete welcome mat don’t help matters. So there she sat in Room 7. The latest driveway dump. Ahhhh lucky Room 7. The room closest to the ambulance entrance. The room that housekeepers knew to keep stocked with extra towels and gowns and masks. Personal protective gear we used to protect ourselves from the blood, vomitus, and even the occasional excrement that would sometimes fly our way as we cared for our patients. Walking in the room, there was a different smell, though. Not the typical “sanitizer residue” odor you get every time the room is cleaned. More of a stagnant “chili con queso” aroma. Quite pervasive, too. In any event, the patient was quite inebriated, quite loud, and quite uncooperative. We removed her baggy jacket and wanted to get her undressed so we could put a gown on her. We couldn’t understand much of what she was saying in slurred Spanish, but from the tone of her voice, she didn’t want anything to do with taking off her t-shirt and army fatigues. So I sat down to start an IV line on her. Naturally, I got it on the first stick, because I am just that good. Then the patient looked at me and said “Morphine?” I looked at her with a surprised look. “Morphine?” she repeated, pointing at her IV. “Por que?” I asked. Yes, I know a few words in Spanish. Not sure why I asked her “why”, though. I knew that I wouldn’t understand what she described as her excuse. I was right. I did pick out the word “dolor” a couple of times from the next few minutes of her description why she needed morphine. “Espera el doctor” I told her. Hopefully she understood that I meant she needed to wait for the doctor to examine her. She reached into the pocket of her army fatigues and pulled out three objects wrapped in tin foil. Then she held them out to me. An odor of refried beans and salsa just kicked up a couple of notches. I looked at the objects. They were flattened tacos. Refried beans were squeezing out of the sides of a couple of them and crumbs of hot sauce-covered taco shells were dropping all over the floor. She raised her eyebrows and nodded her head as she extended her arm even further. “You,” she said, pointing at the tin foil objects. “Me, morphine?” No, ma’am, sorry. I don’t accept bribes of makeshift taco salad in exchange for controlled substances. It’s against my ethos. However … I could probably get you some Tylenol … Number Three. And ...

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Hot Blooded

“I’ve had a fever,” said the 50-something year old lady who wasn’t feeling well. “My muscles ache and I don’t feel well.” OK, not much to go on. “Well, how high was your fever?” I asked. “Just under 207 degrees.” “You mean 102.7?” “No, 207.” “As in 2-0-7?” “Yes, as in ‘2-0-7.'” She was starting to get annoyed. “Do you think I don’t know how to take my temperature?” Ummmm. Well, her temperature was 99.7 in triage. Then the backoom banter began. How are we supposed to take her temperature … with one of those oven roaster thermometers? Talk about hot-blooded … wow. Hey, 5 more degrees and she’ll evaporate “I’m Mrs. Heat Miser, I’m Mrs. Sun. I’m Mrs. Green Christmas … I’m Mrs 201. Her air conditioning bills must be hell in the summer. A little later, one of the nurses brought the fun to an end. Doc, her temperature is 101.8. She wants to know what you’re going to do about it. “Hey, we’ve already dropped her temperature by 105 degrees. What more does she want?” Don’t some things just make your blood boil? This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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True Love

A nice 89 year old man was brought to the emergency department by ambulance complaining of chest pain. While I was talking to him, he mentioned that he and his wife would be celebrating their 65th wedding anniversary in a few days. So I asked him “What’s the key to your long marriage” He rubbed his chin and I sat back, expecting some profound words. He came up with this: “We don’t communicate much. When I complain, she doesn’t listen. When she complains, I don’t listen. It works out well that way.” A little while later, Harvey’s wife Marge came to see how he was doing. She was petite, well-dressed, and sharp as a tack. I wished her a happy 65th wedding anniversary. She gave me a funny look. “It’s our 64th anniversary and it’s not for six months, but thank you.” I looked at Harvey. Marge looked at me and then looked at Harvey. He frowned and waved his hand at her as if to tell her to go away. “Did he tell you it was our 65th anniversary?” she asked. “Well, kind of.” “You can’t pay attention to him. You know how he got here?” “By ambulance?” “Yeah. He was pacing back and forth in the kitchen and finally said ‘I wonder what’s taking the ambulance so long.” I asked him why he called the ambulance. He said that he had been having chest pain all week. Then I told him I didn’t hear him talking on the phone. He told me he used the phone in the living room … that’s sitting in a drawer … that hasn’t been plugged in for years. So I called 911 and they were at our door in 10 minutes.” Then Harvey gets mad. “Marge will you shut up already? I’m the one having chest pain here. Now button your lip.” Ahhhhh. True love.   This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Emergency Department Complaints

Recent patient complaints requiring emergency department evaluation: 1. “Belly button problem”. White and blue stuff keeps growing in belly button and thinks that there may be fungal infection there. Brought some in a plastic bag for analysis. Diagnosis: Umbilical Lint 2. Ambulance transport for rectal itching. The patient was having difficulty reaching his bottom to wipe himself due to his size. Diagnosis: Buttock Dermatitis Another reader looked at patients’ presenting complaints during a shift. 12 patients had cramps/back pain 5 were well-appearing febrile children About 10 other patients had issues the equivalent of a stubbed toe 6 patients had conditions needing emergency treatment. Because of the crowding, these patients had to wait. Out of all those patients, guess who complained … one of the women with back pain. This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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Who Was That Guy?

An elderly patient with Alzheimer’s Disease was brought by concerned family members after reportedly having blood in his stool. I introduced myself to everyone in the room and to the patient. When I tried to obtain a history from the patient, it was clear that he didn’t recall what happened. So I began obtaining the history from the family members. Midway through the history, the patient interrupts and says “HEY! Who IS that guy?” “That’s the doctor, dad,” his daughter gently said. We finished discussing the history and then I asked the patient if it was alright that I examined him. “Sure.” I got through most of the exam and then explained that I needed to do a rectal examination to look for blood in his stool. The patient’s daughter stood up and told him that he needed to pull down his pants and roll over on his side. I stepped away from the cart to get a pair of gloves and a Hemoccult card. I heard the patient asked again “Hey. Who was that guy?” “That’s the doctor, dad, he’s just examining you.” “Oh, OK.” I went back over to the bed and explained to the patient “You’re going to feel a little pressure, now.” He tolerated the exam well. After I was finished, I washed my hands and excused myself from the room to go send the Hemoccult card to the lab. As I was walking out the door, the patient says “HEY! Who was that guy and why the HELL was he sticking his FINGER in my BUTT!?!?” His daughter calmly said “That was the doctor, dad, he was just checking to see if you have blood in your stool.” “Yeah? Well he has fingers like a gorilla!” This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

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