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Patient Encounters

Old School Cough Management

“I can’t stop coughing,” said the hacking patient. “I’ve tried Robitussin and Triaminic [hack hack]. They don’t help.” “I also saw my doctor [hack hack] and got a prescription for Tessalon. That didn’t help either [hack].” “I went back to my doctor and got a prescription for Cheratussin with codeine. That [hack] helped a little, but I’m out [hack hack]. I’m coughing so hard that I can’t sleep. Is there something [hack] stronger you can give me?” You’re in luck. Several studies have shown that nebulized lidocaine helps to control intractable coughing. Let’s get you started on a treatment. Three mls of a 1% solution of lidocaine via nebulizer usually works well. Sometimes I’ll even add 1 ml of 0.5% bupivicaine to the solution to extend the duration of its effect. After about 10 minutes, the symptoms were gone. Success! “Well, aren’t you going to give me something for home?” “We can give you a little more Cheratussin with codeine, although I don’t prescribe that too often.” “I don’t want that. I already told you it didn’t help.” “I’m assuming you don’t want Tessalon, either.” “That doesn’t work on me.” “Honey is shown to improve coughs in kids. You can try that.” Then he pounds his fist on the counter. “Jesus! Don’t you people give Dilaudid for coughs any more?” Nope. No we don’t. Ricola drops. Those help, too.

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Time to Retire?

I’m getting the impression that one of the docs from a nearby hospital needs to retire. A couple of patients have come in with statements he’s made that … well you decide. Patient family member 1 (happens to be a CNA at our hospital) “Question for you: Are there bones inside the brain?” “Umm. No. The brain sits inside the skull which is a bone, but there is no bone inside the brain. Why do you ask?” “Well, my great aunt fell and hit her head. They took her to Metro General Hospital. Dr. Smith over there showed us her CT scan and said “let’s just hope that’s bone in there.” For the non-medical people reading along, both bone and blood appear as white on CT scans. Bone doesn’t grow inside brains. The term “bonehead” is a misnomer. Patient family member 2 Patient comes in with severe edema from the feet to the waist in pretty severe CHF. He had other medical problems and was rather cachectic in his upper body. We discussed plans to admit the patient and said he’d probably be in the hospital for a couple of days. “You’re going to give him some fluids, right?” “Noooo. When someone is in heart failure, we usually give them medicine to get the fluid out of the body, not put more in.” “Well, when we were over at Metro General Hospital with the same problem last month, Dr. Smith gave him fluids and told us that Roger was ‘dehydrated from the waist up.'”

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The Drowning

By Birdstrike MD   “You want them to see you, like they see any other girl” -Against Me!   I head to work at my new locums job on the California coast. Summer 2015 is going to be a great one, I think to myself. I make the turn into the hospital parking lot and a rusty old Trans Am cuts me off. I slam on the brakes to the soundtrack of screeching tires. Geez, I think to myself. It’s my first day at this job and they’re already trying to kill me. I drive on, and I pull into my parking space. My headache is starting a little too early for this shift, I think to myself. The sun is out, the sand is hot, and it seems like everyone must be at the beach but me.  The humid heat is as thick and soothing as suntan oil.  I leave it and walk into the cold and clinical hospital. Out of the EMS radio and through the air crackles, “ELDERLY FEMALE CARDIAC ARREST…DROWNING…INTUBATED…NO PULSE…45 MINUTE DOWN TIME…ETA 5 MINUTES.” Jane the nurse looks at me.  “This one’s yours,” she says with a wink. “You got it,” I answer. Way to start off with tragic one, I think to myself and take a deep breathe, shaking my head. “Boom” goes the grinding, mechanical sound of the automatic doors as EMS rolls the stretcher into my ER. In they wheel my patient, while feverishly sweating and performing CPR and bagging air in and out of the patient, one breath at a time. With my back against the wall, they wheel the head of the bed up to me. I see a large, elderly female, dressed in a bright orange one-piece women’s bathing suit. I grab my laryngoscope and look to make sure the ET tube is in the airway. Her face is bloated and purplish-pale except for the mess of pink lipstick smeared around her mouth, likely from EMS attempts at placing the tube. I check the tube and it’s okay. “45 minutes with no pulse at any time? Drowning?” I ask EMS. “Yes sir,” responds one of the burly EMS guys. “We got the tube in right away, started CPR, gave epi per protocol, and…..nothing.” “Did you see any of her family?” I ask. “No family. She was with a big church group at the beach for a picnic, with a bunch of kids. Youth group, or something,” says the EMT. “What?! Doc. Look!….” says Nurse Jane who had just cut off the patient’s bathing suit, pointing at the patient’s groin. There, no longer covered by the woman’s bathing suit, is a penis and testicles. I look at Jane, I look at the two EMTs, and they look at me. “I’m just as confused as you doc,” says the EMT, looking at me wide eyed as he raises his hands. “What’s the patient’s name again?” I ask. “Let’s make sure we have the correct patient and correct name.” “We’ve got a driver’s license and the picture matches. Pat ——, female, is what’s on the ID,” says the EMT. “So, the friends that are here, know, or don’t know? Help me out here.” “I have no idea, doc. Her friend, who looked like a little old church lady, referred to her as ‘she.’ That all I know,” answers the EMT. “Okay, thanks. Regardless, we have no pulse, over 45 minutes of downtime and zero chance of survival with a warm water drowning. Time for me to call the code and notify the family. Time of death 17:01.” CPR stops. I’ve declared the ...

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Body Blow

A patient came in semi-conscious with low blood pressure. She was known to paramedics for her history of opiate abuse. In the past, the patient had been treated several times for adverse effects from excessive doses of prescription pain medications. The nurses were having trouble trying to start an IV and there were no good veins visible, so I grabbed an IV, put a tourniquet around the patient’s arm, and slapped the back of the patient’s hand several times to get the veins to stand out. It worked. I was able to get an IV in on the first stick and the patient received some Narcan which immediately woke her up and brought her blood pressure back to normal. Then she demanded to see a hospital administrator. “That doctor hit me.” “Wait. Whoa. What??” “He hit me in my arm, then he hit me in the side of my head.” “Ma’am, I slapped the back of your hand so I could start an IV, but no one was near the head of your bed.” “No … You. HIT. Me.” Another patient was in the room next to hers waiting to have a laceration sutured. The curtain had been pulled back so that everyone could access the patient’s bed and the patient had watched the entire event. “You’re lying. He didn’t touch you.” The patient said. “You mind your business,” said the resuscitated patient. “I WANT to talk to an administrator.” So the administrator came to the emergency department and took statements from everyone. He promised the patient that he would follow up on the matter and he left the room without even talking to me. A little while later, I went and sewed up the laceration on the other patient’s face. “You’ll be able to resume your modeling career in no time,” I said with a smile. “Sorry you had to wait.” “Hey. At least you didn’t hit me,” he said with a wink. “Yeah, well you haven’t been discharged yet,” I joked back. Shortly after we had discharged the patient, the overdose patient rang her call light and demanded to see an administrator again. The administrator came back to the emergency department and spoke to the patient. A nurse overheard him promising to follow up on both matters. But what happened? No one had been in her room between then and the first complaint. Turns out that the patient told the administrator that I had also threatened to hit another patient. I’m wondering if the administrator can investigate someone being run over by a truck after they leave hospital property …

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This Is All YOUR Fault

When a patient comes to the emergency department at 3:30 in the morning with an injury that was sustained while moving furniture just prior to arrival, it raises my eyebrows a little. When the first two sentences out of the patient’s mouth to the triage nurse are “I need something for pain – it’s 10 out of 10” and “Also, I’m allergic to Toradol, tramadol, codeine, morphine, and I can’t take NSAIDs because I have an ulcer” then it raises my eyebrows even more. The injury wasn’t a 10 out of 10 injury. The patient was reportedly moving a couch while wearing flip flops. She caught her foot and hit the outer part of her great toe on the edge of the couch. In the process, she ripped the callus off the side of her great toe, leaving a raw area about an inch in diameter and a scrape to her instep. This injury caused her to have 10 of 10 pain. As the nurse started to clean her wound, the patient howled. Literally. “Aren’t you going to give me anything for this pain?” “How about we start with some Tylenol.” “Tylenol?!?!” “You’re allergic to all of these other medications and your wound certainly doesn’t look bad enough for something like Norco. So I think we’ll start with some Tylenol.” She looked at her boyfriend who had accompanied her to the emergency department. “You know, it’s FAKERS like you who make it so that people in legitimate pain like me don’t get proper pain medicine.” He had a shocked look on his face. I didn’t know the boyfriend, but I kind of agreed with the patient’s sentiments. Drug seeking patients do tend to ruin things for patients who really are in pain. This woman appeared to be overacting from the pain she was having from her injury, but who knows? It wasn’t too busy in the ED at the time, so I went and looked the patient up on the state controlled substances database. Surprisingly, the patient only had 88 prescriptions for controlled substances from 18 different prescribers in the past 12 months. Only four prescriptions for Norco in the past 10 days. I went back in the room and handed her the printout from the state database. She scowled at her boyfriend. “This is all YOUR fault.” Then she got up and stomped out of the emergency department before the nurse had a chance to bandage her wound or to provide her with Tylenol for her 10 out of 10 pain. Funny how information can have such a dramatic effect on relieving pain.  

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A False Alarm

There aren’t too many times that the staff gets the giggles when a patient’s monitor shows ventricular tachycardia. Normally, there is a flurry of activity while everyone wheels a code cart into a patient’s room ready to deliver lifesaving shocks. So when the new nurse was halfway through her second day working in the ED, she couldn’t believe how calm the staff was when the cardiac monitor began alarming in Room 8. Room 8 was Clarence. He had dementia and was a transfer from the nursing home for mental status change. When Clarence arrived by ambulance, he seemed just like the same old Clarence they’d seen dozens of times in the ED before. Toothless smile. Southern drawl to his speech. Always wanted coffee – cream no sugar. A lot of times staff would try to avoid putting Clarence on a cardiac monitor because the monitor would often give false alarms when they were attached to him. But the paramedics stated that Clarence had some PVCs on the way to the emergency department, so the triage nurse dutifully attached EKG leads to Clarence’s chest. About 20 minutes later, Clarence’s monitor showed ventricular tachycardia. “BLEEP BLEEP BLEEP BLEEP BLEEEP” went the alarms. One nurse and the secretary looked at each other, smiled, and shook their heads. The new nurse looked quizically about the department, obviously wondering why no one was running to bring the crash cart into Clarence’s room. The charge nurse started to get up from her chair, then sat back down and continued charting. “Mary, can you go and check on Room 8 for me?” “Um … sure,” said the new nurse as she walked briskly into Clarence’s room. Thirty seconds later, Mary came back to the nursing station with a stunned look and a red face. “Everything OK in there?” asked the charge nurse. “Well … yes,” she said as she regained her composure. “It seems that the only thing going fast in that room was Clarence’s hand under the sheets.” “Welcome to the team. You’ll get to know these patients as well as we do in no time. As for Clarence, I’ll take care of him. A nice cup of coffee — cream, no sugar — usually breaks his ‘ventricular tachycardia’ fairly quickly.” “But did he have a pulse?” asked one of the doctors. Mary smirked. “I’m kind of a … new … nurse. Maybe you could help me check that?” The doc smirked. “See, you’re going to fit in here just fine.” ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

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