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Tag Archives: Patient Encounters

The Church of Holy Syncope

If this post ends suddenly, it means that a lightning bolt has shot through the roof of my house and knocked me off my chair. A 79 year old lady with an intertrochanteric fracture and a left wrist fracture. An 81 year old guy with a bleeding goose egg on the back of his head. The 88 year old grandma who busted her hip and her walker in the same fall. The 87 year old lady who passed out in the pew but who was caught before she injured herself. What do each of these octogenarians have in common? They were brought to the ED via ambulance straight from the Church of Holy Syncope. After our fourth ambulance run in two hours from the local church, I discussed this phenomenon I have witnessed with one of the paramedics. Think about it. Many elderly people don’t make it out of the house much. Maybe grandma will make it out one day a week to have her hair done. Maybe grandpa goes out to the Elks Lodge one night a week to play cards. But where do a lot of elderly people seem to congregate every week? You got it. The Church of Holy Syncope. If you have trouble getting around with a walker, maybe someone helps you up the stairs and into the pew. Then you’re on your own. And no matter how old you are, you have to follow the rules: Don’t eat anything before communion. That way, all the diabetics take their medications when they wake up and then go to ground during mass. Kneel. Sit. Stand. Kneel. Stand. Sit. Kneel. Kneel more. Stand up and walk to the front to get communion so you can finally eat something when you’re done. Go back and kneel again. That’s more exercise than most octogenarians get all week. If they don’t pass out from overexertion, you know darn well that one of these kneel-sit-stand cycles is going to get them dizzy and make them DFO (“dun fall out” – as in “Doc, I dun fell out”). What are the steps made from at the Church of Holy Syncope? Marble or concrete. Nice soft substances so that when people fall going up or down, they have a nice soft landing. Oh, and if there happens to be an ice storm on a Sunday morning, not only do the poor old folks go to ground, but then they grab clothing and take the younger healthy ones with them. If we’re having a really unlucky day, we’ll get a “twofer” from one DFO. I didn’t know churches had the ability to franchise, but our EMT Scott enlightened me. If you look at the business filings of churches, most are subsidiaries of the Church of Holy Syncope. You might think you’re going to St. Peter’s, but really you’re a member of one big corporate church conglomerate. Call me crazy, but I bet that the American Academy of Orthopedic Surgeons has some kind of “in” with the Church of Holy Syncope and Sunday masses. I just know it. Now pardon me – I have to go hide in the basement. I just heard a crack of thunder.

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Drug Seekers Suck

This morning as I was leaving my shift, one of the local cops mentioned that they are having a real problem with Vicodin sales and use … in the high school. Kids strung out during classes. Must be a great learning experience. Where do you think these teenagers are getting their stash? Then there’s this article about a doctor who was sued for giving pain medications to a patient and not sufficiently warning the patient about its possible effects upon driving. (Hat Tip to Kevin, MD) Oral arguments and the opinion of the court are at this link. Keep the above in mind as you read the following which happened a few days ago. A lady with a previous history of chronic neck and back pain now comes in with frontal headaches for the past month. Of course, her pain is a 10 on a 1-10 scale. She gets dizzy at times when she stands. Sometimes she gets nauseous. She says that she has vomited twice in the past 3 days. She used to take Vicodin for her back and neck pain, but she’s out of them now. I look through her old charts. She seems to like Dilaudid and Vicodin. It’s a busy shift, so she had to wait for a couple of hours. When I walk in the room, she’s laying on the bed with her arms folded. She seems upset with the wait, but she’s playing the “nice” card, I can just tell. She’s sizing me up from in between those fingers over her eyes. Very polite. Says “thank you.” Compliments me on being so nice even though we’re so busy. I engage in some small talk with her and she actually is a nice lady. The little voice in back of my head is literally kicking me in the mastoid right now. “Hey! WhiteCoat! Don’t be a sucker. She may be nice, but remember her history! Being overly “nice” is page 2 of the drug seeker’s handbook!” Since her headaches are a “new” complaint, I examine her from head to toe. No fever. No sinus pressure. No temporal arteritis. Fundi normal. No photophobia. No meningeal signs. No abdominal problems. No focal neurologic deficits. Oh, by the way, she still has that chronic pain in her back. Can’t find anything abnormal on her exam other than her “10 out of 10” pain. I don’t care how nice she is, she isn’t getting Dilaudid. We give her some Phenergan for her nausea and some Imitrex for her headache. Her headache improves to a 5 out of 10. “By the way, doctor, my head still hurts. Could you please give me something else for pain?” “Absolutely,” I tell her. “But it isn’t going to start with the letter ‘D,'” I think to myself. We give her some Toradol. Her pain is down to a 2 of 10. “See, lady?” I think to myself, “you don’t need narcotics to get rid of your pain.” When we tell her that we’re going to discharge her, she is actually grateful. She thanks everyone for being so nice. “Kill ’em with kindness.” That’s page 3 in the drug seeker’s handbook. Well it worked. I sent her home with some Imitrex, Phenergan, and a couple of days worth of narcotics. The little voice in my head pulled the otoscope off of the holder and whacked me in the back of the neck with it. What a sucker I am. That’s not the end of the story, though. Two days later she’s back. Of course there’s another doc working that day. Divide and conquer — ...

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You Never Know What's Coming Next

I smiled a little bit when the nurse handed me the next patient’s chart. An 18 year old had come in at 2 AM complaining of blood in his stool. Other docs may have yelled at him for waiting until 2AM to be seen in the ED for this “problem.” I just figured he’d need a little reassurance about some hemorrhoids or an explanation on how to manage a fissure. No big deal. A quick in and out. I walked in and he was sitting on the bed smiling. “How’s it goin’, doc?” “Good, so tell me about the blood in your stool.” “Well, the past few times that I went, there was blood there.” “Do you mean stool with blood in it or do you mean that you’re passing blood instead of stool?” “There’s a lot of blood there. I went in the toilet and left it there so you could look at it.” That’s one of those things that is sometimes helpful but that down deep very few doctors want to hear. Right up there with “I brought my stool in a baggie for you to look at,” “the poopy diaper is sitting on the counter over there” and the one woman who was attempting to disimpact herself who held up her finger and said “its about that color” – referring to the stool still stuck underneath her fingernail. “OK, I’ll check it after I get done looking at you.” The tech was just finishing up her vital signs (which were all normal) and I asked her to get orthostatic blood pressures while she still had the blood pressure cuff in place. Then a funny thing happened. As the patient stood up, he started wobbling a bit. I thought he was kidding at first. Then he started to fall forward towards the tech. I reached over the bed, grabbed his shirt, and pulled him back onto the bed. He was out cold. His face was white and his lips were pale – never a good sign. His pulse shot up to 150 and his blood pressure dropped to 70 systolic. I ran over to the toilet and it was filled with blood. Definitely not a hemorrhoid. Got two IVs in and called for blood. We tipped the head of the bed back and soon he was back in the land of the conscious again. “Did I just pass out?” “Yes … yes you did.” Got him a commode in the room and he ended up having a couple more bloody bowel movements. His hemoglobin was 9, which was low, but it was probably a lot lower than that after losing all the extra blood. Called in the cavalry who admitted him to the ICU. Ended up having an AV malformation. The next time I went to the bathroom, I passed something a little strange looking, also. It looked like this (credit): Gotta love the ED. Even when you think you’ve got a handle on things, you never know what’s coming through the door.

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A Physical Impossibility

Last night was interesting. These types of patient interactions are why I love medicine so much. A young lady was brought in by intoxicated family members after being unable to tolerate quite as high of a blood alcohol content as her present company. She had vomit all over her and was in need of a good night’s sleep. We gave her some medication for her vomiting and watched her for several hours. She finally sobered up enough to go home. I was discussing the discharge instructions with a sober family member who had come to get her. One of the less than sober family members apparently wanted us to watch the patient longer. “What if she goes home and drinks more?” “I’m sending her home with someone responsible so she won’t do that.” “What if she doesn’t listen?” “I can’t force her not to drink even if I send her home with no alcohol in her system.” Getting visibly irritated, she snapped back “Well what’s going to happen if she wakes up DEAD?!?” Several comebacks to that one were running through my mind at that moment. I chose the most politically correct one and told her “Ma’am, I can assure you … that won’t happen.”

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