I treated a guy a few days ago for the “worst lower back pain of his life”. This is a surprisingly common occurrence for emergency doctors, and I must admit that I immediately wrote him off. Mohawk, neonazi tattoos, bad teeth, nasty attitude.

I went through the song and dance, pretending to care about his “back pain after twisting it the wrong way”. I’ve heard this story so many times, from so many drug seekers, that is has competely lost its luster. Immediately I informed him that I was not comfortable prescribing narcotic medications.

“But I’m allergic to tylenol, aspirin, and advil!” he decried, “Please, doctor, it hurts so bad. Can’t you give me something else? Nobody can help me but you…”

Even a couple of years into hearing these complaints I still cringe a little on the inside while I put on the hard, callous exterior. “I’m not going to prescribe you any narcotics today, sir.”

But what if I’m wrong? What if he’s truly in pain and I’m just being stubborn? He was barely able to sit up from the bed without wincing in pain when I examined him. Every small touch sent him into paroxysms of agony. I discharged him with an anti-inflammatory I hoped he wouldn’t recognize the name of.

Two days later I was walking back from the cafeteria and saw him strutting down the hall towards the urgent care with a heavy backpack on, no evidence of the “extreme pain” he had 2 days earlier. The doctor covering urgent care called me when he came in 10 minutes later for an inability to walk.

Nobody likes to be made a fool of, which I suspect is part of the reason Emergency Physicians undertreat pain. I follow up many of my patients in the hospital (did my suspected heart attack actually have one?), but I never follow up on suspected drug seekers. Why? Because I don’t want to turn cynical earlier than I have to.

Friday and Saturday nights in the Emergency Department can be difficult for the nurses and docs working them. People come in for all sorts of frivolous complaints – because really, what better to do on your Saturday night than take a trip to the ED?

In the midst of a particularly hellish half-hour a very well-kempt lady kept motioning me over, clearly upset that she wasn’t being seen. This was while my patient with a subarachnoid hemorrhage was trying to die before neurosurgery could help, my 3 drug-seeking back pain patients were diligently refusing my attempts to give them vicodin (Doesn’t touch the pain! Need something stronger!), and my attending was trying desperately to staunch the flow of blood literally hemorrhaging from a girl’s foot.

Young MAN, I have been waiting for 45 minutes to be seen! I demand you come see me RIGHT NOW!

I told her I’d be in as soon as possible, more because I wanted her to GTFO of my Department than because she was tired of waiting.

10 minutes later I was interviewing her. Her story was meandering and long. Since she had been waiting all of an hour at this point, she was going to take up as much of my time as she could. Her answers to my questions were sarcastic and rude (“Ma’am, any weakness or fatigue lately?” Not until you made me WAIT an hour!)

Suddenly I realized I was looking at shingles. Right sided C3 nerve root distribution with 4 clusters of vesicles. It was in all honesty an excellent diagnosis, and one that I easily could have overlooked. Beaming, I told her what she had.

You know, I just don’t think you know what you’re talking about.

She refused to take the antivirals I prescribed, because she thought I was wrong. She started loudly proclaiming how incompetent my nursing staff was. Her time from triage to discharge was an hour and 30 minutes – faster than most patients ever leave. She kept telling me how valuable her time was, and how I was wasting it.

It left a horrible taste in my mouth for the rest of the night.

Later that shift, I got around to sewing up a cut on a homeless man who had taken a bat to the face. He had been waiting for 7 hours, as the resident caring for him had been seeing trauma after trauma and couldn’t find the time to sew him up.

As I started sewing, he and I started chatting.

You know, doc, I really appreciate you doing this for me. It looks like y’all have been really busy around here… I’ve seen ambulances just pouring in all night long. I certainly respect what you do for people and I just want you to know I’m grateful. I may not know you, but you strike me as a good man.

I suppose your faith gets restored by the people you least expect sometimes. Thanks, homeless guy. You made my night worth it.

It is 5:45 AM as I write this, the harsh glare of my laptop an unwelcome affront to my otherwise dark room.

I need to be at the ambulance depot in about 3 hours – tomorrow (today?) is my medic shift, where I ride along with the paramedics for 12 hours of sirens and speeding. Unfortunately, I’ve just finished a string of night shifts and my biological clock is set firmly to wake by night, sleep by day. I napped for an hour at midnight, but that’s it.

I’ve touched on this in other posts. I really don’t like the idea of pharmacologic sleep, but I suspect that tonight I should have popped a couple Benadryl. I just hate that I may end up doing that for the rest of my life.

Tonight in the Pediatric Emergency Department I saw a 3 year old girl for acute onset of headache and fever.

Fever in a kid is one of those roll-your-eyes-what-the-hell-is-wrong-with-them things, but fever plus a headache leads you, scarily, down the path to meningitis. You do not want to miss meningitis, because it moves fast and kills often.

The problem with meningitis is that the test for it is a spinal tap, which carries its own share of complications. Plus… it’s a big fucking needle in your spine. Kids† don’t respond well with big needles in their spines.

So, carefully, I examined her, trying to rule out meningitis as a diagnosis. No neck stiffness, which was a good thing. Brother had the sniffles at home, which was a strike against. I noticed a small red dot on her hand that looked like a bug bite, but nothing else jumped out.

As a resident, you ALWAYS have an attending physician – someone boarded in your specialty who has finished residency – watching over you. So, I told my attending the story, and she nodded, “I agree, from that story we can’t rule out meningitis. I’ll go take a look at her.”

A few minutes later she came back to the doctor charting room, a huge smile on her face.

“You don’t have to ‘tap her,” she grinned, “she’s got a subtle finding you may have missed. Did you get a good look at the back of her throat?”

In fact, I hadn’t. I’m still hesitant to do things patients don’t enjoy: sticking tongue depressors in kids’ mouths, doing pelvic exams on skittish women, performing rectal exams on healthy young trauma victims.

So, with her supervision, I went back in and really pulled the girl’s tongue out of the way. Sure enough, that same little red bump I had overlooked on her hand was in the back of her throat. Pulling off her shoes and socks revealed one of them on each foot.

Hand, foot, and mouth disease. Classic presentation. Common symptoms include fever, headache, and rash. Treatment is simply ibuprofen for her fever and water for dehydration.

Attending physician, you rock.

† (also, adults)

This is a story that happened to the good Dr. O while I was on shift with her tonight. If female genital complaints gross you out, I suggest you stop reading now and go visit another website… although, it’s pretty funny.

The patient’s chief complaint was “vaginal discharge x 2 weeks”, which – at minimum – requires a pelvic exam. Dr. O interviewed the patient, getting some more background information. Whitish discharge. Unprotected sex. New boyfriend. Run of the mill, most likely a sexually transmitted infection. The nurse comes in, they set up for the pelvic, and begin.

By her account, this was the most horrifically awful pelvic examination she has ever performed. Milky white fluid was leaking everywhere. On the sheets, on her scrubs, on the speculum. It was all she could take not to gag.

Impeccable, composed physician that she is, Dr. O obtained her samples, and then calmly told the patient that she was quite concerned about the amount of discharge. “This,” she said, “is honestly the most fluid I have ever seen on a pelvic exam. We will empirically treat you with antibiotics for a suspected STI, and will call you with the results of the tests as soon as we have them.”

The patient looked at her and said “Aw, that ain’t no discharge. Me and my boyfriend just raw-dogged it right before we came to the ER. That’s all cum.”

“Don’t bother spending too much time with him,” my nurse said, “he’s just whacked out on drugs.” She pantomimed taking a hit off a joint and laughed.

He was 17, high, and hard to talk to. Eyes darting around the room as if the cupboard in the corner was out to get him. Sunken back in his oversized shirt, with his crisp new hat pulled low over his face, engrossed in the TV. Mom, clearly concerned, started the conversation before I could even open my mouth.

“Doc, he is acting WIERD lately.”

That will happen, I thought to myself, when your kid starts smoking lots of pot.

But I soldiered on, trying to avoid judging prematurely. It was a perfect case for a mother bringing in her drug-addled child. The interview was difficult, because he had an extremely flat affect – a medical term for not showing any emotion – and simply didn’t seem to trust me. He was, however, incredibly straighforward about his drug use. Marijuana every 3-4 days, because it made him feel safer.

Safer?

There is a lot said in medicine about a sixth sense; that feeling that something simply isn’t right. People smoke weed for a lot of different reasons, but when they do it because it calms something inside of them, you start to wonder.

Rather than simply chalking his behavior up to drug use, I questioned him further. It was futile at first, but as I kept at it in my doctor persona, he slowly opened up. Suddenly he started talking about Michael Jackson’s death… and how it was “really telling him things” and how “nobody seemed to understand it” but him. CNN was was sending him messages through the TV screen.

He continued, painting me a picture of persecution and fear. He had been followed to the corner store the other day, and he knew they were spying on him through the adjacent aisles. He could overhear wisps of their conversations about him. This had been happening for years, but nobody ever listened. The weed made him feel safe, if only temporarily.

The nail in the coffin was that his biological grandmother and mother both had severe schizophrenia – a fact that somehow was missed each of the 3 times in the past month he was admitted to the Emergency Department for “bizarre behavior”. Previous notes documented “substance abuse” and not much more.

After reviewing his records, I went back into the room and discussed my concern that he was manifesting signs of paranoid schizophrenia. I had made an appointment for him with Behavioral Health, and he was to go there straight from the ER.

The mom simply thanked me, a look of deep sadness in her eyes, and went to sit on the bed with him. He snuggled up to her and dropped his head on her shoulder, eyes glazed over as he watched the news coverage about Michael Jackson’s death. She started crying, quietly, as I left the room.

Tomorrow, I start being a doctor. I’ve had my MD for a couple weeks now – the stamped and signed diploma says so – but it’s not until I see my first patient and introduce myself as Dr. Zac that it will feel real for me.

My first shift is an overnight in the Pediatrics Emergency Department, which is anxiety provoking. I rarely saw pediatric ED cases at my medical school, so it’s pretty foreign to me. On top of which: it’s children. People outside the medical field are scared enough of what it means if their child has a fever. Me? I’m terrified. Because now I’m supposed to know.

I think we don’t give ourselves enough credit when the stakes are high. I’m sure I know more than I think I do – didn’t go to 4 years of medical school for nothing – but the thoughts keep intruding.

What if an unstable asthmatic comes in and I don’t know which drugs to order?

What if a kid comes in, confused and lethargic, and I don’t know if he has meningitis?

What if a 6 year old swallowed a nail?

What if?