We had a 16 year old kid last night who decided to go to a church party. Sounds fairly benign right?  Wrong. This party was surrepticiously fueled by shots of Jack Daniels and Ecstasy.  What better a way to see God?

Actually he did not see God.  He saw the back of an ambulance. He saw the ER. He saw his irate parents.  He saw me.  He saw Haldol.

He started vomiting his socks off and getting paranoid.  He was convinced the world was ending - to which I told him yes, it is- but hopefully not in our lifetime! 

This last shift we had a morbidly obese middle aged lady come in for swelling of the legs, knee pain, and rash. When the PA went into see her she lifted her skirt to show the legs (which had mild edema and arthritic knees).  Before he could say anything else, she suddenly lifted her dress above her head to show him her massive fungal infection under her breasts and in her fat folds.

Not a good image to have in your mind right before lunch….

By the way, the woman was not Japanese but we had a sumo wrestler in mind!

I bet many of you don’t know this - but once someone is declared disabled and eligible for social security disability payments (usually a paltry sum by the way), they are eligible for medicare. Makes sense since once you are disabled, you probably can’t work and thus can’t get insurance except out of your pocket (or if you are married to someone who gets the benefits through their job). However, there is TWO YEAR waiting period til they kick in! Now, in 1972 when the law was created (that is the law that makes medicare cover people who are eligible for SS disability benefits), they had the two year waiting period in there to save money (and perhaps to curtail perceived abuse). As of now, many many people who are permanently disabled (by diseases like MS, traumatic injuries, strokes, etc) are caught in this health care gap with no coverage. There are two exceptions - End Stage Renal Disease and ALS (Lou Gehrig’s Disease). What do these people do? They go without care and end up in the ER when things get really bad. They run themselves into bankruptcy and spend down to be eligible for medicaid. Of course we know that when you let something go, the costs of fixing a bigger mess are more than the cost of prevention! We all know there is abuse of disability benefits but that does not mean that people who deserve it should suffer as a result of these scammers (who should really be better weeded out during the application phase anyway!).

I was just down in Washington DC for a health care lobbying group and this issue really struck home. There is a bill on the table to phase this waiting period out over 10 years to slowly absorb the costs (probably about 8 billion which is no chump change). As a civilised society, this is something we need to do. I doubt it will happen until this president of ours leaves office - but hopefully whomever is elected in November will support the measure. Our wonderful W would likely veto it even if it got through congress.

Here is another old one while I am out of town….

So, people come in with bizarre stories but this one was really out there. A 40ish year old guy came in last summer with a cut in the roof of his mouth. It was fairly large so I was curious as to what could have caused it. He said that while he works on his car (which is parked out in is backyard), he likes to periodically do some archery. He has a target set up near the car and takes a few shots to break up the monotony of changing the oil or whatever he was doing with the car. The really weird part was that he said he likes to keep an ARROW IN HIS MOUTH while he works on the car (much like someone who keeps a pen in their mouth while sitting at the computer). Of course you can see where this is going….. He trips and falls and of course the sharp point of the arrow pierces the roof of his mouth. Luckily he had only superficial damage to his palate. His discharge instructions included something I have never written before: “Do not place the tip of an arrow in your mouth”.

So here is a case for all you clinicians out there (or anyone else with any medical knowledge who wants to chime in). We had a 36 year old man from India (although has been in the US for a dozen years and has not gone back in several) who presented with severe unilateral flank pain for several days - becoming unbearable. His vitals were basically normal except for tachycardia. His exam was remarkable for mild obesity and severe left CVA tenderness to percussion. He appeared older than stated age. The rest of his exam was normal - no abdominal tenderness, normal genital exam, lungs clear. His labs were also basically normal except that he had a small amount of blood in his urine. Normal CBC, Chem panel, liver and renal function. A CT of the abdomen/pelvis without contrast was obtained to look for a presumed ureteral stone and subsequent hydro.

The scan did show significant left sided hydro but no calculi were seen. Additionally the retroperitoneum was full of “fibrosis” to the point of which it appeared to be obstructing his left mid ureter, causing the aforementioned hydro. No lymphadenopathy, masses or vascular abnormalities noted, just fibrosis everywhere. There also was a lesser amount of fibrotic chances in his peritoneal space as well.

He went for cysto yesterday to relieve the obstruction but the diagnosis has not been made yet - we should know in a few days. Give me your thoughts? I have mine and will post it in the comments after I hear some from you.

Many children ingest or put foreign bodies into places they should not go. For example - beads in the ear, jelly beans in the nose, eating button batteries.  Now, by the time you are 13, you should be past that stage.  However, this 13 year old that came in recently had some issues.

Well, for whatever reason, he figured it was a good idea to stick a plastic bobby pin into his urethra!  Yeowwwwch!  In fact, he stuck it in so far it got lost up his penis!  Not being very comfortable probing deep into a child’s urethra, my colleague called in peds urology. We thought he might have to use a cystoscope - although the thing was palpable halfway up his penile shaft.  He anaesthetised the urethra with some viscous lidocaine and then was able to milk the pin far enough out and reach inside with a long nosed haemostat to grab the end. 

Out it came with minimal trauma.  All I can think of is the extreme discomfort most men exhibit when you have to a urethra swab for Gonorrhoea/Chlamydia.  And then you only go in about a half a centimeter! 

Yeowwwch!  Man, that kid has some issues he has to work out with a psychiatrist!

Why is it that people always seem to blame particular things for the cause of their distress? No matter what, 90% of people who come in for gastroenteritis (vomiting and diarrhoea), they always blame either A). Chinese food or B). Mexican food. Never mind that most cases are due to random viruses that people just get from the environment. People are absolutely convinced to the contrary.

The other day one patient was so sure that their lower GI distress was because of a Chinese food meal they had about 2 hours before the symptoms began. So much so that they were already planning on suing the restaurant (because after all, SOMEONE has to compensate you for your pain and suffering!!!) It takes me a good chunk of time to explain to them that if it were from “food poisoning”, it would most likely be from a meal they had 24 hours ago! (like Salmonella or Shigella)

The other stereotype was a few years ago during the SARS outbreak. People came in with gastroenteritis and thought they had SARS from the Chinese restaurant! Other people came in with upper respiratory symptoms, convinced they had SARS. Why? They had just been on an Airplane from New York to DC that contained, horror of horrors. Asian people!

Where do people get these ideas? Probably from the same people that say that the way to treat a seizure is to stick a spoon in the person’s mouth to stop them from “choking on their tongue”!