Sometimes you just get a lucky shot. Sometimes you swear that you will never be successful in your endeavour but somehow, BAM! you get it. The other day I had a your typical demented, stroked out, bedridden, contracted, DNR nursing home patient come in with a fever. A blasting fever of 105+. The problem was that the urine was clean and CXR clear - as was the rapid influenza swab, abdomen benign and labs OK except WBC count of 19K. We all DREAD this because we know what may be coming - a lumbar puncture to rule out meningitis. Now, an LP is a pain in the ass enough in a cooperative, thin person, but in the aforementioned patient, it has potential to be beyond nightmarish. My hope was that the family would not want an invasive procedure like this since her overall prognosis was so poor but alas, they wanted the dang LP. I figured I would make a token attempt and then refer it to the inpatient team to have it done under fluoroscopy. After all, she was obese, had kyphosis, and like all 86 year olds, certainly had narrowed disc spaces. Couple this with combativeness and her pretzel-like shape (making the access to the lumbar cistern all but impossible) and you have about a 1% success rate. But would you know it, I got it on the second stick! Clear fluid - almost like ambrosia to me!!!! Man, the neurologist and the residents thought I was the God of LP’s. Little did they know that had this been a more routine case, I am sure I would have missed! Murphy’s law is like that!

The Bovie(tm) is a cautery device that all in the medical field know about. It typically is used in the OR by surgeons for the stopping of bleeding and is usually powered by a powerful generator that creates a strong electric current. It makes a cool “bzzzzzp!” sound. We don’t have the luxury of such a device in the ER but there is a less powerful but extremely useful portable version. It is powered by AA batteries and is basically a hot iron (but very small in size) that burns small bleeders quite effectively. Yesterday I had to use one on an elderly patient, bedridden, stroked out, demented, DNR with horribly rotting teeth, who had badly bitten her tongue. Blood was pumping out from a small artery and she was aspirating on it. Since the family refused intubation I had to try to the stop the bleeding with her awake. Well, she was essentially a vegetable - at baseline only responded to painful stimuli so “awake” is taken with a grain of salt. Given the severity of the bleeding and her contracted and combative state, I did not have the luxury of sedating her or properly anaesthetising her. I had to have FOUR staff members help me. Two had to retract her clenched mouth, one had to try to retract the tongue up so I could see the bleeder, and one had to suction the blood. After about 10 tense minutes the portable Bovie did it’s thing and the bleeding stopped (burning flesh does not smell good by the way). Haemoglobin was decent so I was able to discharge her! The family was very happy. Win! Win!

I love you so much that I am going to give you a big ole’ hug. I am going to hug you so much to show you how wonderful you are. I am going to squeeeeeze you really hard. I am going to squeeze you so much that you think your ribs are crushed and you are going to call EMS to come into the ER.

I love you even though you dragged our whole family in at 3am to have an xray that was normal and were discharged on Motrin.

I love you so much I am not going to hug you again.

Does it just annoy me or everyone else when people come into the ER (most often from the inpatient floors) with the most minor of “workplace injuries”?  The typical case is like I had last night. A tech on the floors stated she was grabbed  by an elderly patient and had her wrist and shoulder twisted.  No visible signs of trauma.  Full range of motion. Why the hell would you feel the need to come to the ER to get evaluated (which was basically me just telling her to take some Motrin and ice it)? Because it happened at work and now you want to leave work and have the weekend off.  Please, unless you have an injury like above - just suck it up!!!!  ”Oh doctor, make sure the person you are referring me to accepts workman’s comp!!!”  Grrrr….

This past week between Christmas and New Years, I worked a lot of shifts - they were memorable for the fact that they were all insanely busy. Also, many patients were insanely sick (see my last few posts for example) but this one was really out of left field. A man in his early 50’s came in in the morning complaining of abdominal pain - that started in his left lower quadrant in the middle of the night when he rolled over in bed. He was fairly healthy and active although he had two cardiac stents. No abdominal surgery in the past. He came in and was to me halfway overanxious and dramatic and halfway sick. It was sort of hard to tell at first. He had a pretty tender abdomen diffusely but when he sat upright, the pain (and tenderness) was much reduced. He dropped his BP when we started an IV and began hyperventilating. However, after 2mg of morphine, I was able to get a better exam (as he had calmed down a bit) and was still pretty tender. His labs were normal and he had no fever. A CT was ordered and although he remained fairly comfortable appearing while he was drinking his contrast, his heart rate continued to rise. As he went for CT, I was figuring he might have perforated diverticulitis at the worse or mesenteric ischaemia at the worst. When I looked at his CT (I like to look at all my CT’s where I have a suspicion of something bad instead of waiting 30 minutes for the radiologist to read them), I was shocked. It looked like he had been in a major blunt trauma. His belly was full of blood! Not air, but blood! I called a radiologist and discussed it with him - what had happened was that somehow his spleen had spontaneously burst! Most likely, he had a cyst in it that ruptured and just bled and bled and bled - mimicking a trauma CT where a person suffered a ruptured spleen from something like a baseball bat to the flank. Luckily his repeat CBC did not show too much of a drop in Hgb. He went to the OR for a probable splenectomy - although the surgeon told me he would try to repair it.

The scary thing is that he was due to go skiing the next day to a relatively remote area! That would have been the end of him…….

Remember to get your annual screening exam!

Sorry for the downer theme two days in a row but lately, most of my memorable cases have been sad and or really sick. It always saddens me when an elderly person neglects themselves and does not let their family help. It is even worse when they refuse to divulge any symptoms to them. The other day I had an elderly woman come in by EMS for altered mental status - which turned out to be caused by hypoxia, hypotension, and fever. She lived alone and had been deteriorating for several days as per her family. Every day they visited her she minimized her obviously poor condition. Each day in fact the family called EMS but she shooed them away. Finally after 4 days of this she was nearly obtunded and could not refuse anything. When she arrived she was a mess. Conveniently covered with stool, severely dehydrated, febrile, tachycardic to 150 and with a BP of 80/50. Her Pulse Ox was not reading. As we undressed her and I was preparing to intubate her and flood her with fluid, we noticed her left breast. She had a huge fungating invasive cancer on it. All around it was the worse fungal dermatitis I have seen in years. The stench was horrible. When I went out to talk to the family to tell them she was very sick and needed to be intubated and resuscitated, I asked them if they knew about the breast. No, they said. They noticed that she seemed to be protective of the area for several months and shot down their enquiries about what was going on. After a fortunately uneventful intubation, the chest x-ray showed a huge left lung mass with pleural effusion and probable superimposed infiltrate. Of course she had no good IV sites so I had to throw a left internal jugular line in. Luckily again, I got it on the second stick - no pansy-assed ultrasound guidance for me - and started a Levophed drip along with broad spectrum antibiotics and IV fluids. It was pretty clear to me that this woman wanted to be left to die - and did not want to burden her family. So, when I went back out and told them of her prognosis, they had a good sense to make her DNR - and in fact planned on withdrawing care once a definitive diagnosis of something terminal was made. I am sure in several days, that will come to pass.

Maybe if she had just told them her wishes earlier when she was more lucid - and had been up front about her condition, we would all not have had to go through all this.