callous cheif complaints

[WilcoWorld]

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OK, so I'm barely over a month into my EM career & I've alredy started to develop the macabre sense of humor that almost seems required in EM. Well, I sorta always had it, but now it's slipping into my presentations. I still treat my unresponsive patients (even the "gomers") like their grandchildren are in the room watching me, btw, so please don't get on some high horse about humanism. Here's a chief complaint I came up with for a nursing home patient the other day:

"More unresponsive than usual."

any others?

 

[Sessamoid]

OK, so I'm barely over a month into my EM career & I've alredy started to develop the macabre sense of humor that almost seems required in EM. Well, I sorta always had it, but now it's slipping into my presentations. I still treat my unresponsive patients (even the "gomers") like their grandchildren are in the room watching me, btw, so please don't get on some high horse about humanism. Here's a chief complaint I came up with for a nursing home patient the other day:

"More unresponsive than usual."

any others?

I've heard that before and wondered what it meant. Maybe normally they don't respond to loud noises, but now they don't respond when you yank out the foley by accident without deflating the balloon?

 

[f_w]

Referral from psychiatry for altered mental status:

Patient is now paranoid delusional. Please evaluate for organic cause (patient is otherwise only delusional).

 

[GCS:3]

any others?

From last month...

"Pain in sternum when moves arms. Also has a vein on his penis that he wants doctor to look at. Mostly there post-masturbation"

Definitely a senior case...

 

[docB]

I had a pt who the police put on a psych hold for a traffic violation. Under reason for hold on the form the officer wrote "failure to maintain proper lane spacing and failure to yeild to an ambulance."

 

[anonymousEM]

my intern had one that was "more responsive than usual" yesterday from the NH. So they checked her sugar since she seemed to care what was going on around her...it was 47

 

[ISU_Steve]

We were called to a nursing home once for a patient that would be best described (by me on the run report) as "2nd degree penile abrasions and tearing due to excessive onanism"

Basically the guy was gorked and spent all day wanking off. Ended up with friction burns (complete with blisters- I made the EMT student check) and small tears that were bleeding profusely. That had to be the strangest chief complaint I've ever seen.

Another good one:
"Chest pain on the left side; patient concerned because the pain is normally on the right side."

 

[Daiphon]

how about "anxiety in the vagina"...

(without missing a beat, the attending says "get some ativan up in there and get her out of here")

-t

 

[ISU_Steve]

What? "Anxiety in the vagina"? Come again? (no pun intended)

 

[GeneralVeers]

We were called to a nursing home once for a patient that would be best described (by me on the run report) as "2nd degree penile abrasions and tearing due to excessive onanism"
QUOTE]

Saw a patient the other day who had developed phimosis from too much wanking. I thought that the pain receptors were there to tell you to stop doing it when it hurts....

 

[ISU_Steve]

Daaaaaaaammmmmmmn.
*squirms uncomfortably in chair*
Owwwwwwwwwwwwwww.

Yeah, you would think that there would be pain and your brain would go "Hey we should probably stop now," but you never know how depraved of an individual you are dealing with- maybe he liked pain....who knows.

 

[Daiphon]

What? "Anxiety in the vagina"? Come again? (no pun intended)

heh heh... i wish i was kidding. wait, no i don't... that was the highlight of my night!

 

[GeneralVeers]

On my second call night of hell (no sleep, this time because the call room was full), I sent a patient home AMA. I got called to the floor because this crack-addicted lady (rule-out MI of course) was complaining of constipation. She insisted that we get her own brand of laxative which is not on forumulary. After explaining this to her, she proceeds to tell me that she wants some codeine for her back pain. I explained to her that I was called to the floor to treat her constipation, and I was not about to give her a constipating opioid. She got angry, and signed out AMA. That was good because it freed up a bed for a crack-addict with a real medical problem (like SOB after doing crack).

 

[anonymousEM]

ah crack chest pain/sob, what would an EM intern on IM do all night if it weren't for them....we have this debate on rounds all the time....the only ones who infarct are the ones who use again...but which of our pts will never use again......or in one attending's eyes, it's their own *($&)(# fault if they infarct after we warn them.....

 

[Febrifuge]

I've wondered about this, because I've heard the gentle version of the warning... but since this thread is about callousness, has anyone tried to gague the effectiveness of being utterly blunt with that conversation? I'm sure the addiction is still more powerful than the logic of it, but I'm an optimist, and maybe it help somehow to say to a person, "oh, cool. I know exactly how you're going to die. And maybe when. Wanna hear how an infarction works?"

 

[a_ditchdoc]

In defense of the crack addicts, I gotta say that in my many years as a medic I am not sure that I have ever seen a crack addict in the middle of a MI. I once saw a hypertensive lady pop a vessel in her brain from smoking crack, and a few lethal overdoses from swallowing crack as the police swarmed in, more than a few shot over crack, but not an actual MI that I can recall.

Considering all the drug abusers I have transported, it certainly makes me think that the risks of death from crack are overblown. What are some of your experiences...


(Oh yeah, almost forgot. Favorite complaint: "I have to spit too much." When I asked why spitting was a problem so severe that she had to call an ambulance, she advised me that "I have never had to spit too much before.")

 

[Sessamoid]

Hmm....

Considering all the drug abusers I have transported, it certainly makes me think that the risks of death from crack are overblown.

I once saw a hypertensive lady pop a vessel in her brain from smoking crack, and a few lethal overdoses from swallowing crack as the police swarmed in, more than a few shot over crack, but not an actual MI that I can recall.

Sounds like the risks of death from crack are pretty high, as compared to say... basket weaving.
🙂

 

[a_ditchdoc]

Hmm....
Sounds like the risks of death from crack are pretty high, as compared to say... basket weaving.
🙂

Agreed, but the risks seem much lower than say "Sittin' on the corner mindin' my own business" 😎

 

[ISU_Steve]

That's only dangerous if you don't avoid the two dudes. You know, "some guy" and "that one fella".

As for being blunt, we did this with one of our frequent flier drug seekers on the ambulance- we'd be paged for a report of "back pain, patient is en route to the ambulance station". "C" would come up riding a few minutes later on HIS BICYCLE. He'd park his bike, come walking over and start saying that his back hurt so bad that he needs something for it. *bacly fake limp* Don't get me wrong, he's a very nice man- he just happens to be a very nice man with a very extensive drug habit.

My boss (the head paramedic) was exceedingly stupid and would give "C" pain meds, which in classical Pavlovian conditioning, only reinforced the behavior. Finally after the second or third time I had to deal with this ass, I'd had enough. I flat out told "C" that he could not be getting anything from me except the shot of Narcan that I was giving him at that moment, while lecturing him on how he was wasting my time and endangering others and how he was going to die, describing all the nasty diseases I've seen junkies succumb to. Needless to say he went into withdrawl and spent the rest of the trip cursing me. You know what? He started checking the parking lot of the ambulance building to see who was working before he would call 911 to avoid having me do that again.

 

[docB]

I've wondered about this, because I've heard the gentle version of the warning... but since this thread is about callousness, has anyone tried to gague the effectiveness of being utterly blunt with that conversation? I'm sure the addiction is still more powerful than the logic of it, but I'm an optimist, and maybe it help somehow to say to a person, "oh, cool. I know exactly how you're going to die. And maybe when. Wanna hear how an infarction works?"

I usually tell anyone that is skinpopping that they'll be dead in less than 5 years if they don't stop. Once you're skin popping you're screwed.

I tell the 20ish crowd who use sympathomimetics that they are middle aged because they'll be lucky to see 55 if they keep using.

I explain to the suburban headache housewives and back pain dudes that while Demerol may be the thing that they like best it is highly addictive and is very popular with "the gutter class street junkies." That always gets their attention. "Are you calling me a junky?" they ask indignantly. "No." I say, "I'm just pointing out that you like the same drugs." They leave pissed off but often they don't come back and I'll guarantee they think it over.

 

[ISU_Steve]

LMAO....I'll have to remember that about the Demerol.....

 

[ERMudPhud]

I've wondered about this, because I've heard the gentle version of the warning... but since this thread is about callousness, has anyone tried to gague the effectiveness of being utterly blunt with that conversation? I'm sure the addiction is still more powerful than the logic of it, but I'm an optimist, and maybe it help somehow to say to a person, "oh, cool. I know exactly how you're going to die. And maybe when. Wanna hear how an infarction works?"

I usually try to find out if they have kids, a surprising and depressing number do. I then explain that they will almost certainly be dead before their kids graduate from high school, get married, have kids, etc... I've made quite a few cry doing this but I'm not sure if any of them actually quit.

 

[anonymousEM]

In defense of the crack addicts, I gotta say that in my many years as a medic I am not sure that I have ever seen a crack addict in the middle of a MI.

One, as a med student at the hosptial where they never have people with crack chest pain...there I saw one with an acute STEMI crack CP...now, in the hospital where i work now, we see a ton of pain, but i've never seen it be an MI...

 

[ditch doctor]

Back in my previous life as a paramedic (now starting MS3) I had a "More unresponsive than normal". We show up and were told "she's just not acting right". We walk into the room and find a ~70s female with a line of lividity and rigor. I would guess that's a little more unresponsive than normal. The nurse on duty states that she doesn't know much because it's shift change and she just got there (at 4:00am!?) but she had checked the patient about 15-20 minutes ago and "she was fine"!!

Ok, so I helped my wife study for the NCLEX and it's no STEP 1 but it's not *that* easy of an exam. How do these people get licensed????

PS A ditchdoc, nice nic!

 

[ditch doctor]

Agreed, but the risks seem much lower than say "Sittin' on the corner mindin' my own business" 😎

That's only dangerous if you don't avoid the two dudes. You know, "some guy" and "that one fella".

His relatives, "Some Dude" was terrorizing our city as well... Where I used to work, we actually had a lethal trio: "Some white dude, some black dude and some mexican dude."

If we could only catch this "Dude" crime family, we could effectively wipe out crime.


***EDIT: Sorry... My name is Ditch Doctor and, I... I... I'm.... I'm a... Newbie on this board. I tooled around and have seen that there has been some variation of this exact post for about 2 years now...

Of course, if it weren't for Noobs, there would only be like half of the flaming that goes on.... Also, what were the avg. Step 1 scores for EM again? 😳

 

[GeneralVeers]

Why do the crack users keep coming to the ED for CP/SOB? If they know they get these symptoms after smoking crack, why spend 2 days in the hospital (and 2 days away from the crack)?

Certainly if they come into the ED and have known or suspected drug history they are not getting any narcs until I confirm that something is indeed medically wrong. Toradol is my favourite medicine in the world.

 

[spyderdoc]

If they know they get these symptoms after smoking crack, why spend 2 days in the hospital (and 2 days away from the crack)?

Uh, like what makes you think they won't be doing crack for the 2 days they are in house?
I've known of many a pt injecting various substances (brought in by visitors) into their peripheral AND central lines....esp when doing my county rotations as a student....

 

[doctor7]

...and here's a classic fibromyalagia from good ole' SoCal

"doctor, doctor....dalor everywhere"

 

[Jeff698]

Mom comes in with 2 month old Gerber baby. This has got to be the most healthy child I've ever seen.

Me: How can I help you?
Her: Look at my child's huge rash.
Me: What rash?
Her: This big one, right here.
Me: Oh, this tiny, tiny, tiny freckle?

Gotta love urgent care.

Of course, it could be worse. She could have brought Jr. to the ED at 3am.

Take care,
Jeff

 

[EMApplicant]

...and here's a classic fibromyalagia from good ole' SoCal

"doctor, doctor....dalor everywhere"

was she short and fat? i think i've had that patient before...

 

[GeneralVeers]

was she short and fat? i think i've had that patient before...

Not to be racially insensitive, but it seems like hispanic women have massive pain all over their bodies all the time. I've learned enough Spanish to get through a basic physical, and if I ask "Tiene dolor aqi..." and point to any body part they always say yes.

 

[f_w]

I've known of many a pt injecting various substances (brought in by visitors) into their peripheral AND central lines....esp when doing my county rotations as a student....

Actually, in the meantime I have met 3 patients who managed to talk some community surgeon into placing chest-ports on them, mainly to feed their injection habit (official diagonis: acute intermittent porphyria and fibromyalgia. Both conditions impossible to disproove but necessitating continuous pain treatment). Mysteriously, these ports get infected q3months, often with polymicrobial cultures. I have seen one of these ports explanted, including the membrane which had multiple cored holes.......

 

[ISU_Steve]

Speaking of people with drug habits and venous access....there used to be an OB/GYN here who about 7 years ago lost his medical license because he was brought into the ER unconscious with the narcotic trifecta. Dose of naloxone brought him around and further examination revealed a saline lock on a vein running along the side of his calf muscle.

 

[Jeff698]

There was a resident who was brought in to the ED after driving his car off of the Galveston seawall with a saline lock hanging from his arm. Seems fentanyl decreased his ability to apply the breaks. Either that, or it made him miss the tiny obstacle in front of him...the Gulf of Mexico.

BTW, there is an article in this month's Annals about resident addiction. It mentions this case. Good article. Nice point about the same characteristics that drove him to succeed in medical school drove him to addiction.

Take care,
Jeff

 

[GeneralVeers]

There was a resident who was brought in to the ED after driving his car off of the Galveston seawall with a saline lock hanging from his arm. Seems fentanyl decreased his ability to apply the breaks. Either that, or it made him miss the tiny obstacle in front of him...the Gulf of Mexico.

BTW, there is an article in this month's Annals about resident addiction. It mentions this case. Good article. Nice point about the same characteristics that drove him to succeed in medical school drove him to addiction.

Take care,
Jeff

Supposedly anesthesiology has a high rate of drug abuse due to easy access to drugs (not to mention the boredom during long cases).

 

[Annette]

I've had many frank discussions with patients on crack. Had a discussion with one guy when his EF was 40% and had developed diabetes. Had another one post MI #6 when his EF was 20%. Had the talk yet again, with his wife present, flat out saying "YOU ARE GOING TO DIE AN ABSOLUTE MISERABLE DEATH SOON" when his EF was 10%. Was fired for my trouble. His next doctor tried to hire him when his EF was 2% for non-compliance. Guy wanted a heart transplant when his EF drifted down to 1%.

Oh, and I love the fact that another crack patient got put into a private room when his room mate complained that he was making drug deals on the phone.

 

[bikerboy]

While at the local county ED:

"I drank 18 beers and felt pretty bad, so I drank 6 more and still felt bad"

Huge alcoholic who says he normally drank a case/day.

-Only people who go to meetings are alcoholics, everyone else is just a drunk...

 

[The White Coat Investor]

Not to be racially insensitive, but it seems like hispanic women have massive pain all over their bodies all the time. I've learned enough Spanish to get through a basic physical, and if I ask "Tiene dolor aqi..." and point to any body part they always say yes.

We call this status hispanicus. It is especially bad in middle age hispanic female trauma patients and results in A LOT OF UNNECESSARY RADIATION. But, what do you do?

 

[Jeff698]

We call this status hispanicus.

A similar condition is acute tachy-lordia with intermittent ohelpmejesus-itis.

The nice thing is this condition is typically diagnosed from down the hall.

Take care,
Jeff

 

[SuitsYou]

Toradol is my favourite medicine in the world.

Amazing how many narc seekers state they are allergic to it.

Funny one, 28yr old female comes in with low back pain
"I mismanaged my endometriosis"
Indeed

 

[GeneralVeers]

We call this status hispanicus. It is especially bad in middle age hispanic female trauma patients and results in A LOT OF UNNECESSARY RADIATION. But, what do you do?

LMAO...status hispanicus is one of the funniest things I've heard in weeks! One of the senior residents who's from Cuba calls it "Hispanic Panic".

 

[WilcoWorld]

Now, I'm in no way advocating intravenous drug abuse, nor do I advocate working high/drunk/otherwise compromised, but if the OB/GYN or the resident formerly mentioned who were fired for narc abuse had their abuse discovered during an ED visit, then isn't it aviolation of privacy to fire them for it? Their medical records shouldn't have been available to the employers, legally speaking, so I don't see how it was legal to fire them for something discovered during an ED visit. If anyone has the authority to do so, please clarify.

 

[ISU_Steve]

LMAO...status hispanicus is one of the funniest things I've heard in weeks! One of the senior residents who's from Cuba calls it "Hispanic Panic".

We had a Cuban pulmonologist who used to describe panic attacks among his fellow Cubanos as "Cuban conniptions". But I like "status hispanicus" better.....

 

[a_ditchdoc]

I have responded to many auto accidents, the majority of which resulted in dents that I could have left with a swift kick, where every occupant in the vehicle complained of multiiple injuries that resulted in the inability to walk. We lovingly referred to them as "Colonel Sanders Specials..."

"Ohhhhh I hurt.....!"
Does your Neck hurt?
"Yesss...my neck huirts...(moan)...!
Does you back hurt?
"Ohhhhh...yes...my back hurts...(bigger moan for emphasis)!"
Do your wings hurt?
"Ohhhh...yes...my win...I hurt all over...(moan...).

Colonel Sanders Special = Neck, Back, and Wings....

And just like the original KFC specials, the longer you let them sit, the better they bocome...

(It is also a deeply held suspicion that the impact of the crash, if there was an actual impact, sounds much like a cash register opening...CHA-CHING!)

 

[margaritaboy]

CC: "Ass fell out."

 

[Jeff698]

Do your wings hurt?
"Ohhhh...yes...my win...I hurt all over...(moan...).

My favorite question in those patients is "do your teeth itch?".

Take care,
Jeff

 

[unk_fxn]

Now, I'm in no way advocating intravenous drug abuse, nor do I advocate working high/drunk/otherwise compromised, but if the OB/GYN or the resident formerly mentioned who were fired for narc abuse had their abuse discovered during an ED visit, then isn't it aviolation of privacy to fire them for it? Their medical records shouldn't have been available to the employers, legally speaking, so I don't see how it was legal to fire them for something discovered during an ED visit. If anyone has the authority to do so, please clarify.

The papers from the medical board when I got my RTL said that I was required by law to report any physician who may be impaired for any reason to the board immediately.

 

[bulgethetwine]

CC: "Ass fell out."

Was working Peds ED last week and the triage had cleverly entered "blowing bubbles" as a chief complaint.

Turned out the the toddler had been fed soap by her little brother. By the way, if a certain joke is springing to mind, remember this was a Peds ED...

 

[ISU_Steve]

Ah, that brings back the memory of the kid with "radioactive drool", a description used by the 15 y/o babysitter, and a very panicked 15 y/o babysitter at that, who had called 911 when she noticed the toddler had bright yellow drool. Turned out he had eaten the color tube (that spongy thing) inside a highlighter, dying his mouth the color of a neon banana.