Agraphia Medical Tragicomedy

Young and Plump

An elderly lady getting Botox yesterday was talking to the doc about how "horrible" her face looked (really not that bad, in my opinion). Then she looked over at me with a hungry, wolflike grin, and said "I'm nothing like this young, plump doctor over here. He still looks just wonderful."

It... was awkward.

Three Stories

Back pain is one of the most ubiquitous complaints seen in the ER. The vast majority are back sprains or drug seekers, but occasionally something more sinister lurks underneath. Let us consider three cases I saw today; by the end of the day, one patient will go home on pain medications, one will be admitted to the hospital for a life-threatening blood clot, and one will be diagnosed with cancer for the first time.

The first was a 23 year old male who torqued his back while lifting a heavy crate at the shipping dock. For 2 days he's had severe, wrenching back pain. On examination he has visible spasm of his paraspinous muscles, which are incredibly tender to the touch. His left leg is weak, but that's because it hurts his back to use it. A quick prescription for muscle relaxants and some painkillers with physical therapy, and he'll be good as new.

The next was a 38 year old known narcotics-seeking, chronic back pain patient who hops from ER to ER, shopping for pain pills. He looked frightened when I examined him, as if he realized he cried wolf too many times and this time nobody would listen. Something was off, though; unlike most drug seekers, he didn't jump and howl in exaggerated pain the moment I pressed on his back. In fact, his back wasn't painful at all, no matter how hard I pushed, and the pain was too high up to be "low back pain".

Looking through his records, I found a clotting disorder that was diagnosed years ago. Because of his drug seeking behavior, his original doctor stopped seeing him and he was never treated. A CT scan of his lungs (ordered amidst jeering from nurses who knew him all too well) revealed a pulmonary embolus; a massive clot that dislodged from his legs and blocked off one of the arteries in his lungs, potentially fatal if not caught early. He was admitted to the hospital for observation while being anticoagulated.

The last was an incredibly pleasant, polite 58 year old with no history of back pain. He thought he sprained his back three days ago, because it had been hurting nonstop. In fact, even while lying down at night he couldn't seem to get comfortable. Concerned, I asked a few more pointed questions; he had lost 5 pounds in the past 2 weeks, and was so tired he hadn't even been able to make it to the corner store to support his two-pack-a-day smoking habit.

I ordered a simple series of lab tests on him, and was horrified to find my suspicions confirmed - a serum protein gap, acute renal failure, and anemia - almost pathognomonic for multiple myeloma, a type of bone cancer. We referred him to oncology after having a tearful conversation about his future.

This is the reason for all of the school, all the training. In medicine we deal with the 10% of the time that things are not what they seem. The true art of medicine is learning to distinguish between the mundane and the aberrant.

Quote of the night

...may you go to HELL, and once there, meet one thousand demon spawn! They shall judge you for your sins!

Thanks, dude in bed 8! I've always wanted to be judged for my sins, it sounds like fun. Do you get to relive them? Hope the PCP wears off quick because that whole satanic preacher gig just doesn't suit you.

Also, I have noticed that performing 5 12-hour shifts plus 8 hours of lectures weekly is detrimental to my blogging... which is really unfortunate, because I've got a whole lot of awesome stories to pen.

Staring westward

An elderly vietnamese gentleman was wheeled in to the ED last night with a chief complaint of "seizures". He had a stroke last year, and ever since has had full on tonic-clonic seizures once a month. He seizes for 2 minutes and spends the next 30 minutes recovering, confused and scared.

Last night, however, his confusion didn't resolve. When his family realized he wasn't getting better, they dutifully called the paramedics who carted him, unresponsive, to the ED where he sat in the waiting room for an hour and a half... until he projectile vomited bright green bile with his head spinning to the left like the Exorcist.

He was promptly wheeled back to my section of the ED, where I was faced with a completely unresponsive man whose head was torqued as far left as it would go. His eyes stared at some distant horizon. His arm was bunched up towards his shoulder and he held his leg up to his chest like a jackknife. Any attempt to move his head or limbs into alignment were met with extreme rigidity.

With horror, I realized that this man was still seizing; and probably had been on and off for the past 2 hours since the family first called the ambulance. His decreased consciousness wasn't simply from postictal confusion as the paramedics thought. He was in status epilepticus, lost to the world as the neurons in his brain went haywire, haphazardly directing his muscles to spasm.

15 milligrams of diazepam later, his neck finally loosened up and his body became less tense. Now there were more serious fish to fry; 2 straight hours of seizure activity had caused a massive lactic acid buildup in his bloodstream, the byproduct of overactive muscle metabolism. We frantically worked to establish intravenous access so we could hydrate him and neutralize the acid.

And at the end of all our hard work? He woke up. Confused, disoriented, fatigued - but fixed up and on the fast track to recovery. His family was incredibly appreciative, and once he realized what had happened, he was all smiles.

It's moments like these why I went into doctoring in the first place.

Glad to be of service

Last night at County ER, USA, I had the dubious honor of sewing up a 5cm self-inflicted arm laceration on a young, angry, drunk, suicidal, borderline-personality-disorder guy.

It was a fairly superficial cut, as far as these things go. He had multiple other healed cuts on his arms which implied this was not his first time cutting, and since my exam revealed an isolated skin laceration, the first thing to do was irrigate the wound and stitch it up. Straightforward, yes?

Of course not. At County ER we put most of our drunk patients (and all of our drunk, suicidal patients) in 2-point restraints, simply because as they begin to sober up they often decide it's time to leave... and more than a few have still been very drunk while sneaking out the back door. One patient years ago was run over by an incoming ambulance as he made his escape; ergo, restraints until you can make sober decisions.

As my patient started getting it through his thick skull that he was restrained, he began thrashing around. Violently. While I had all my needles out repairing his skin laceration. Did I mention he was hepatitis C and HIV+? Of course he was. Why wouldn't he be?

A particularly hard kick sent my lidocaine syringe arcing through the air, missing my thigh by inches. My suture slipped through my fingers; it's a miracle the needle didn't impale me as I lost my grip on the thread. He stared directly at me with his beady, spiteful eyes, "It's a good fucking thing I'm restrained, because I'd fucking kill you right now. Right fucking now."

Four nurses rushed over to help me restrain him and lock down his arms and legs, assuring him that it was a felony to assault a healthcare worker. I quickly put some gauze on his cut and bandaged him up.

I assume that the 7 stitches I managed to place will hold his cut together just fine. I'm just glad I could be of service to such a fine, upstanding young gentleman.