From the category archives:

Emergency Room Stories

The weak and dizzy patient is the bane of emergency medicine.
Both common and nebulous, the weak and dizzy haunt me. Often when I am asked what kinds of cases I have been seeing in the ER, I can only remember the ones who were weak and dizzy. Some are more weak than dizzy, others more dizzy than weak.
And of course, these symptoms can represent something absolutely life threatening, or nothing at all. Naturally, the weak and dizzy patient is usually about 90 years old, thereby increasing the probability of a serious cause, and decreasing the patients ability to describe the symptoms. Lots of tests are required to rule out bad stuff, unless it’s a simple urinary tract infection. I’ll admit I have shouted “YES!” and pumped my fist when the urine came back showing infection on a weak and dizzy patient, thereby saving lots of tests, and giving me a decent diagnosis. I might have done this more than once.
When we discuss health care reform, we need to determine what to do with all the weak and dizzy patients. One solution might be qualified social workers which I read about on ER Nursey. Or maybe I will propose a regional center, someplace in the desert, where thousands of patients move efficiently through a series of conveyor belts, and pneumatic tubes. At junctions they may get a urine test, or blood work, or a CT scan. Automatically, they would be shunted towards their ultimate disposition and treatment–perhaps a comfy bed and some antibiotics, or maybe a poolside lounge chair and a Long Island iced tea.
Of course this facility will need a medical director. . .


Sometimes, a patient’s diagnosis is clear right when we walk in the door. This can be due to a distinctive smell as in the case of rectal bleeding, cyanide poisoning or diabetic ketoacidosis. Other times, you can just tell what is going on by looking, and I would like to contribute the following diagnostic sign to help advance the world’s medical knowledge. If the patient is sitting up on top of the exam room counter, eyes darting around wildly, then the diagnosis is methamphetamine intoxication. I can think of no other reason for a patient to choose to sit on the counter, when there are two other good options, namely the chair, or the gurney. Alternatively, the patient could sit on the floor, or even stand, which makes more sense and is clearly more comfortable than perching on a hard, cold counter top. I have only seen this one time, so I don’t exactly have a body of research here. Nevertheless, I feel the diagnostic accuracy of the “countertop sitting sign” approaches 100%.

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Usually when I pick up a patient’s chart, it’s pretty clear what the problem is going to be before I even walk in the exam room. But once in a while, I get something vague, like “I need to talk to the doctor.”



Sometimes this means they are too embarassed to talk to anyone else about what the problem is. Such was the case when I saw a middle aged man who presented with his wife after some trouble with a flashlight.



I introduced myself to the nervous fellow and asked what the problem was.

“I was fooling around with a flashlight,” he sheepishly reported. “Now I can’t get it out.”



“You mean you put it in your bottom?” I asked. He nodded.

His wife was looking at him with such contempt, I really felt sorry for him.

I tried to make him feel better about the situation, and let him know that he was certainly not the first person with a rectal foreign body, but it didn’t seem to help. “When did you put it in there?” I asked.

“A week ago.”

At this point, his wife’s jaw dropped open, evidently this was news to her as well.

An xray confirmed the location of the flashlight, which fortunately had a plastic edge just perfect for grabbing with a clamp. A little sedation, and a couple pulls later, and problem solved. We discussed some strategies for avoiding this in the future, and the dangers of puncturing the colon. He assured me that I wouldn’t see him again in the ER. So far, he has been right.


 wonder where Jim is. . .?

A carpenter came in recently with a chief complaint of a nail puncture to his thumb.
This is certainly not an unusual injury, but I noticed that the time he was hurt was 3 hours prior to arrival. The patient had shot a 16 penny nail all the way through his thumb with a pneumatic nail gun.
“What took you so long to get here?” I asked him.
The carpenter looked a bit sheepish at that question, and then admitted he had nailed himself securely to the house he was building.
No one was on site to pull the nail out, and he couldn’t reach his hammer.
Fortunately, he had his cell phone in his pocket, so he called his wife. She was not at all squeamish about using his hammer to pull the nail out of the 2X4 framing, but she let me take the nail out of her husband.


A colleague recently saw a newborn child brought in with trouble breathing. He seemed to be trying to cry, but no noise was coming out of his mouth. He was very “floppy”- just no muscular tone at all. Because he couldn’t breath well, he needed to be put on a ventilator to keep his oxygen up. All the tests in the ER came back normal, so there was no explanation for the child behaving this way. He didn’t seem to have any serious infection such as pneumonia, or sepsis. The brain scan was normal. It turned out that the child was from out of the country, and the parents had given him some honey that may have been contaminated.
Laboratory tests showed this child had infant botulism, which resulted in paralysis, to the point where he couldn’t breath on his own. He had to be kept on a mechanical ventilator and admitted to intensive care, until the infection could be treated fully, but he did well, and gradually regained his strength.