Welcome to another installment of the Top 10 Ways to Avoid the ER

Number 4 – Drugs

Drugs like methamphetamines, heroine, and cocaine are the scourge of every emergency department I have worked in. Meth is the biggest problem now. If these drugs did not exist, I have no doubt that health care costs would be much lower, people would be much happier, and my job would be way easier.

One unfortunate occupational hazard of being an ER doctor is learning way more than you want to about the sexual practices of your fellow citizens. This may give us a skewed perspective on what most people enjoy doing in their spare time, but it also keeps the job fascinating. A young man presented to the ER one day with lower abdominal pain and cloudy urine. Urine testing confirmed an infection in the bladder, but he was quite uncomfortable, so an Xray was done as well. This showed very strange, wispy coils of material in the location of the bladder that baffled the radiologist. “Clinical correlation is needed.” said the radiologist, which is what they say when they have no idea what they are looking at, so you better go talk to the patient again.

The ER doctor went right back to the patient and asked him why he might have strange material floating around in his bladder.

“Well, I suppose it could be the snakes I’ve been putting in my penis.” said the patient.

Apparently, there are tiny baby snakes that fit right inside the urethra, and can make it all the way into the bladder. It’s hard to imagine this being a pleasurable sensation, but evidently this patient thought so.

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.

Its very difficult to rank the most bizarre, fascinating or stressful case out there, but a few come to mind.

She replied with a smile, “I cut myself!”

Something about the way she said that started a couple alarm bells ringing in my head. I asked her if it was an accident, and she said “No, I took a knife and cut myself.” At that point, all bets were off. I worried we were dealing with a major penetrating abdominal injury, and perhaps we were about to start a trauma code.

I pulled back the hospital gown, and found she had about a 10 inch laceration to her abdomen. But that wasn’t all. There was a large amount of gelatinous, yellow-gray goo oozing out of the wound. Now I’ve seen plenty of wound infections, but this was something entirely different. I was afraid to ask, but I had to know. “Um, what is all this stuff in here?” I asked in my most professional, not at all shocked at what I am seeing voice.

“Oh, its noodles, and rice, and some yogurt that I put in there yesterday.” She was clearly happy to be giving me this information and even happier to know that I was completely taken off guard by the whole situation. The poor woman had to be taken to the operating room for a thorough wash out, and later, a psychiatric consult.

Sadly, “cutting” or “self mutiliation” is something we see frequently in the ER. Usually it is less severe than this case, often times patients cut their forearms superficially. It is rarely intended to be a suicide attempt, but it is always something that I take seriously.

As you may have heard, today is “Blog Action Day” organized by www.blogactionday.org which

The theme made me recall one of the most troubling cases I have seen. It happened when I was a medical student in Los Angeles.  A homeless man walked into the ER complaining about flies constantly buzzing about his head.  He was brought back into an examination room, and the nurse handed me the chart with a look of shock on her face.  I glanced at his medical history and noted that he was diagnosed with cancer of his sinuses a few months before, but he had not come back for any follow up.

He was about 50 years old, his hair and clothing were completely unkempt.  He had apparently been living underneath an overpass for a long time.  As I approached him, I noted that the right side of his forehead and cheek were hugely swollen, and there were open wounds in these areas.  I leaned in for a closer look and shined my penlight into the wounds.

What I saw nearly made me fall over backwards.  Dozens of wriggling maggots were writhing throughout the depths of these wounds.  I noticed that they were trying to escape the light, diving deeper into the poor man’s face.

He was right about the flies, of course, there were several in the room flying around.  He asked me for some pain medication, and I was more than happy to order all he needed.