Someone please start an academic discussion.

[lucid_leprechaun]

Begs the question: do you really need sterile gloves to collect the CSF?
I mean, you're holding a tube, that's not touching anything. Don't touch the drape, don't touch the back...

???

Still interacting with sterile field, I would. If you introduced CSF infection you’d be ducked

---

Members don't see this ad.

 

[RustedFox]

Still interacting with sterile field, I would. If you introduced CSF infection you’d be ducked

Oh, I get it. There's still the sense of "hey: if you're here, your hands are sterile", but ... "don't effing touch it" also seems to carry as much weight in my brain. Not that we'll ever get any data on this.

 

[turkeyjerky]

To address your top sentence: UHH, YEAH BRO. 90% of my patients in total (regardless of whether or not they require a LP) are histrionic and poor historians. You clearly don't work in the ED.

To address your bottom sentence: "Yeah, you're right, taking a careful history is always impor-... BWAHAHAHAHAHAAAAAAA.

Ohh, Christ - thank God you don't do EM. You'd never make it a shift.

@turkeyjerky and I cross swords on occasion on here, but he's dead-nuts-on-point here. What 90% of my patients really need is a good healthy dose of "shut the eff up and quit whining", but you can't say that - because this is America, where everything is a "disability", including failure to act like an adult. Someones, pain - or the threat thereof, is a very effective truth serum.

Guys, guys... the fact that he asked "Does that sound believable to you?".... AHHAAAAHAAAAAAAHAAHAAAAA! ! !

I'm laughing so hard I scared the cat and woke up the wife. Now, she's mad and it's his fault. LOL.

Ironically, I literally laughed out loud too and woke our cat. That guy’s posts….every single one. Can’t figure out whether he follows this forum just looking to get triggered or if it’s high-level trolling.

Me thinks we’ve finally found the neurologist who gives their patients a letter to take to the ER, outlining their acute pain management program of 2 mg hydromorphone IVP q 15 min.

 

[RustedFox]

Ironically, I literally laughed out loud too and woke our cat. That guy’s posts….every single one. Can’t figure out whether he follows this forum just looking to get triggered or if it’s high-level trolling.

Me thinks we’ve finally found the neurologist who gives their patients a letter to take to the ER, outlining their acute pain management program of 2 mg hydromorphone IVP q 15 min.

Neurologists are always such sissy-la-las.
Sure, they do their thing and they do it well - but I've never met one who wasn't a freaking wuss.

 

[turkeyjerky]

Neurologists are always such sissy-la-las.
Sure, they do their thing and they do it well - but I've never met one who wasn't a freaking wuss.

Harsh but true. Stroke alert for obvious malingering, conversion or just non-neurologic nonsense? Hell yeah, that'll be an MRI/MRA/MRV 2 days in the hospital and an easy diagnosis of TIA.

 

[CoolDoc1729]

Instead of inflicting unnecessary pain you could consider taking an extra 5 minutes to take a better history to see if an LP is indicated. But sure, tell yourself it's the patients fault you are doing the unnecessary procedure and it's good that they suffer!

We literally ask simple yes or no questions that my 3 year old could answer, and the answer is like, well back in 1982 … :4 minutes have passed, no relevant information yet,::
Overhead: Dr CoolDoc1729 to Trauma 1 stat!
Granted sometimes this is from a kind nurse and not a real stat page. Lol

 

[Jabbed]

We literally ask simple yes or no questions that my 3 year old could answer, and the answer is like, well back in 1982 … :4 minutes have passed, no relevant information yet,::
Overhead: Dr CoolDoc1729 to Trauma 1 stat!
Granted sometimes this is from a kind nurse and not a real stat page. Lol

Possibly one of my favorite things to do: “Sir, you’re having a heart attack. You need to answer my questions as concisely as possible”. If their next sentence is long enough that there should be a comma, I say: “when I ask you a question the answer will be three words or less”.

No Press Ganey surveys in CCU!

 

[johnny_bananas]

Neurologists are always such sissy-la-las.
Sure, they do their thing and they do it well - but I've never met one who wasn't a freaking wuss.

“bro” “dude” “freaking wuss” “such sissy-la-las”

You sound like a parody of an ED physician!

 

[johnny_bananas]

Harsh but true. Stroke alert for obvious malingering, conversion or just non-neurologic nonsense? Hell yeah, that'll be an MRI/MRA/MRV 2 days in the hospital and an easy diagnosis of TIA.

For someone that doesn’t know how to differentiate a migraine from meningitis/SAH, I don’t think you should be questioning your colleagues diagnostic acumen.

Next time you can’t diagnose a migraine, instead of doing an unnecessary LP, just consult neurology to come and take a history.

 

[RustedFox]

“bro” “dude” “freaking wuss” “such sissy-la-las”
View attachment 362310
You sound like a parody of an ED physician!

How'd you get a picture of me?!
Parodies are funny, because at the core; there is a kernel of truth.
Enjoy your MRI/MRV/MRA/MVC/Mwhatever.

MODS: Don't ban this guy; (1) he's done nothing wrong, and (2) with every post, he demonstrates how the upstairs folk have no idea how it is downstairs.

 

[greatnt249]

For someone that doesn’t know how to differentiate a migraine from meningitis/SAH, I don’t think you should be questioning your colleagues diagnostic acumen.

Next time you can’t diagnose a migraine, instead of doing an unnecessary LP, just consult neurology to come and take a history.

When you get called to do a consult, how long does it take you to do? Do you do outpatient work? If so, how much time is built into your schedule to see a new patient? Bonus points if you have no prior information about the patient prior to you seeing them at their appointment.

 

[turkeyjerky]

For someone that doesn’t know how to differentiate a migraine from meningitis/SAH, I don’t think you should be questioning your colleagues diagnostic acumen.

Next time you can’t diagnose a migraine, instead of doing an unnecessary LP, just consult neurology to come and take a history.

Way ahead of you. I just call a stroke alert and say I'm concerned about the posterior fossa. Quick tele-neuro consult and easy dispo. Sometimes, if they're being dramatic, I tube right off the bat, for, umm, "airway protection". I hear propofol is great for migraines!

 

[Radetzky]

For someone that doesn’t know how to differentiate a migraine from meningitis/SAH, I don’t think you should be questioning your colleagues diagnostic acumen.

Next time you can’t diagnose a migraine, instead of doing an unnecessary LP, just consult neurology to come and take a history.

Lol my man here be acting like he’s some reincarnation of Osler.

 

[johnny_bananas]

When you get called to do a consult, how long does it take you to do? Do you do outpatient work? If so, how much time is built into your schedule to see a new patient? Bonus points if you have no prior information about the patient prior to you seeing them at their appointment.

There is no set time for consults, the duration is based on the complexity and time required to address the patients issues. So if I get consulted at 4:45pm or I get 15 consults throughout the day, I don’t get to say that each consult is now only 15 minutes per patient because I was planning on going home at 5pm or I should rush because I am tired and post-call.

 

[greatnt249]

There is no set time for consults, the duration is based on the complexity and time required to address the patients issues. So if I get consulted at 4:45pm or I get 15 consults throughout the day, I don’t get to say that each consult is now only 15 minutes per patient because I was planning on going home at 5pm or I should rush because I am tired and post-call.

I feel a general rule consultants should adopt is to not look down on others for not possessing the depth of knowledge you possess as a specialist. Are you really criticizing ED physicians for not performing a full H&P by the time they call you? The point I was trying to make was that it's simply unreasonable to expect this from them given what they deal with in the pit. I won't speak for them on exact numbers, but I'm sure it's not an insignificant number of patients that they see with neurological "complaints" on a daily basis that you simply never hear about and will never know about because they've been dispositioned and discharged without your input.

 

[southerndoc]

I feel a general rule consultants should adopt is to not look down on others for not possessing the depth of knowledge you possess as a specialist. Are you really criticizing ED physicians for not performing a full H&P by the time they call you? The point I was trying to make was that it's simply unreasonable to expect this from them given what they deal with in the pit. I won't speak for them on exact numbers, but I'm sure it's not an insignificant number of patients that they see with neurological "complaints" on a daily basis that you simply never hear about and will never know about because they've been dispositioned and discharged without your input.

The same can be true of urgent care or primary care physicians sending stuff to the ED.

 

[johnny_bananas]

I feel a general rule consultants should adopt is to not look down on others for not possessing the depth of knowledge you possess as a specialist. Are you really criticizing ED physicians for not performing a full H&P by the time they call you? The point I was trying to make was that it's simply unreasonable to expect this from them given what they deal with in the pit. I won't speak for them on exact numbers, but I'm sure it's not an insignificant number of patients that they see with neurological "complaints" on a daily basis that you simply never hear about and will never know about because they've been dispositioned and discharged without your input.

I agree 100% with what you wrote!

For the record I have tremendous respect for the ED physicians I work with and EM as a speciality.

My comments were specific to what turkeyjerky wrote that 90% of the LPs they do are on “whiny migraineurs” and they want them to suffer. If 90% of your LPs are on “migraineurs” you are doing something wrong and should consult at that point and avoid an unnecessary procedure. I don't expect a full H&P, but to make a diagnosis sometimes that requires some digging, and if you are not in a position to do that just consult, there is absolutely nothing wrong consulting for a severe headache. That's better for the patient than putting them through an unnecessary procedure and possible complications.

 

[coffeebythelake]

Begs the question: do you really need sterile gloves to collect the CSF?
I mean, you're holding a tube, that's not touching anything. Don't touch the drape, don't touch the back...

???

i guess no mask needed either?

 

[RustedFox]

i guess no mask needed either?

Great question. I mean; what data do we have to base this decision on? We really don't.
The need for sterile gloves for lac.repair has been debunked.

Is a respiratory microbe going to target the needlehub like Luke Skywalker bullseye'd the exhaust port on the first Death Star, then climb thru the column of CSF to reach the meninges? Sounds radical when you put it that way. Even with a mask; is it going to pour around the mask, thru the air currents, and then climb into the CSF?

We have no idea.

We all know aseptic technique is important. Critical, even.
But if you're just sitting there, holding a tube, not touching anything else while CSF drips; then you go away and the sterile doc gets back in there and finishes, pulls the needle - ?

Seems pretty astronomically unlikely that this is a big risk.
I'm not arguing for one side or another - but the question that it poses is a pretty awesome one.

 

[coffeebythelake]

Great question. I mean; what data do we have to base this decision on? We really don't.
The need for sterile gloves for lac.repair has been debunked.

Is a respiratory microbe going to target the needlehub like Luke Skywalker bullseye'd the exhaust port on the first Death Star, then climb thru the column of CSF to reach the meninges? Sounds radical when you put it that way. Even with a mask; is it going to pour around the mask, thru the air currents, and then climb into the CSF?

We have no idea.

We all know aseptic technique is important. Critical, even.
But if you're just sitting there, holding a tube, not touching anything else while CSF drips; then you go away and the sterile doc gets back in there and finishes, pulls the needle - ?

Seems pretty astronomically unlikely that this is a big risk.
I'm not arguing for one side or another - but the question that it poses is a pretty awesome one.

This topic has been debated a lot in the anesthesia world and if you look back not long ago, even into the 2000s a good number of anesthesiologists would perform neuraxial anesthesia without wearing mask. Such practices changed when clusters of serious infectious events occurred where the lack of mask wearing was implicated. Slam dunk implication, no, but when national organizations send advisories about this I think it is hard to go against that guidance.

I think though that seeking evidence for everything we do is a noble but unobtainable goal. In the absence of such good data doing the most conservative thing seems prudent

 

[RustedFox]

This topic has been debated a lot in the anesthesia world and if you look back not long ago, even into the 2000s a good number of anesthesiologists would perform neuraxial anesthesia without wearing mask. Such practices changed when clusters of serious infectious events occurred where the lack of mask wearing was implicated. Slam dunk implication, no, but when national organizations send advisories about this I think it is hard to go against that guidance.

I think though that seeking evidence for everything we do is a noble but unobtainable goal. In the absence of such good data doing the most conservative thing seems prudent

View attachment 362448

1. Hey, good reply - and Happy Thanksgiving.
2. If I were inclined to argue, I'd give the typical "show me your sources" retort, and we could dissect the literature, and academic debate would ensure. I'm not inclined to argue. It's a trifle of a thing to do (wear a mask, and by extension - wear sterile gloves) when doing such a procedure. I'm not looking to stake some odd claim about whatever.
3. My question really was an honest one: "Does it matter?" - and it seems like the answer is "yeah, bro - this time... it does." That's good enough for me. It seems like a microbe can bullseye a Death Star.
4. Cool photo. "Neuraxial" is a great adjective that I had totally forgotten about; that one's gonna make it back into my charts.

 

[Tuloste]

i guess no mask needed either?

Neuro resident from EU chiming in. Always interesting to read about differences in practice culture. I've never stayed behind for the CSF to drip, never used drapes and never withdrew the needle. A nurse collects the samples without sterile gloves without touching the patient nor the needle at this stage. Afterwards he/she tugs the needle out by it's hub. This probably sounds horrific if you are used to donning a spacesuit for LPs, but afaik this doesn't translate to any more cases of iatrogenic meningitis.

And obviously, the above does not apply to neuraxial anesthesia or epidural blood patches. Both cases differ from a diagnostic LP in respect of flow direction, and due to this I haven't the intestinal fortitude of reintroducing the stylet, whether or not it reduces PDPH.

 

[gamerEMdoc]

OK. I'll jump in because I am dying of boredom. You don't need to use the needle that comes in the kit to do an LP. Please do not use that needle. You will just end up consulting me for the blood patch. A 22ga works just fine. I have even done a tap with a 25ga in a young woman. Yeah you have to sit around for a while if you want 4 tubes but it's less time than a rebound the next day.
Feel free to share opposing opinions.

Even better, use an atraumatic (pencil point) needle instead of the standard quinke needle in the kit. Way less reported post LP HA.

 

[xaelia]

Neuro resident from EU chiming in. Always interesting to read about differences in practice culture. I've never stayed behind for the CSF to drip, never used drapes and never withdrew the needle. A nurse collects the samples without sterile gloves without touching the patient nor the needle at this stage. Afterwards he/she tugs the needle out by it's hub. This probably sounds horrific if you are used to donning a spacesuit for LPs, but afaik this doesn't translate to any more cases of iatrogenic meningitis.

And obviously, the above does not apply to neuraxial anesthesia or epidural blood patches. Both cases differ from a diagnostic LP in respect of flow direction, and due to this I haven't the intestinal fortitude of reintroducing the stylet, whether or not it reduces PDPH.

Can confirm, spacesuit culture seems uniquely U.S.

The ED isn't the OR, shouldn't dress like it.

 

[turkeyjerky]

Can confirm, spacesuit culture seems uniquely U.S.

The ED isn't the OR, shouldn't dress like it.

Care to elaborate on any differences w/ regard to hand washing? It's a little bit of pet peeve of mine, how non-evidence based most infection-control policies are. (For instance, having to wash hands immediately prior to putting gloves on for patient encounters. Or having to wash hands even if I'm literally just sticking my head in the room and not getting w/in 5 feet of the patient).

 

[xaelia]

Care to elaborate on any differences w/ regard to hand washing? It's a little bit of pet peeve of mine, how non-evidence based most infection-control policies are. (For instance, having to wash hands immediately prior to putting gloves on for patient encounters. Or having to wash hands even if I'm literally just sticking my head in the room and not getting w/in 5 feet of the patient).

Can't speak for the OR, but it's not an ingrained culture for hand washing here in the ED. I've carried with me a lot of the U.S. standard precautions and I clearly put on gloves and hit the hand sanitizer boxes far more often than most.

But, from a patient- or physician-oriented outcome standpoint ... I think ... if your hands are dirty ... you should clean them. And not every emergency department activity carries a risk of soiling and onward transmission.

FWIW, various "superbugs" and C. diff are basically nonexistent here, which may make our practices less generalizable.

I've not gone hunting for a true evidence-based audit of any sort of infection control consequences around here.

 

[WilcoWorld]

Can't speak for the OR, but it's not an ingrained culture for hand washing here in the ED. I've carried with me a lot of the U.S. standard precautions and I clearly put on gloves and hit the hand sanitizer boxes far more often than most.

But, from a patient- or physician-oriented outcome standpoint ... I think ... if your hands are dirty ... you should clean them. And not every emergency department activity carries a risk of soiling and onward transmission.

FWIW, various "superbugs" and C. diff are basically nonexistent here, which may make our practices less generalizable.

I've not gone hunting for a true evidence-based audit of any sort of infection control consequences around here.

One thing that really bugs me (pun unintended) is that sanitizer doesn't work for C Diff.

My biggest gripe about the "sanitize in, sanitize out" mantra is that it encourages mindless compliance. Once you numb people unnecessarily sanitizing on they're way to and from a no-touch encounter, it's to be expected that they'll be less effective at hand hygiene for a significant encounter.

 

[GassYous]

I used to think that wearing masks and hats was bs especially when you're behind the drapes in the OR. But then I read about some lady who had a back infection after neuraxial and the cultured organisms matched some mouth bacteria from the performing physician.

 

[thegenius]

I used to think that wearing masks and hats was bs especially when you're behind the drapes in the OR. But then I read about some lady who had a back infection after neuraxial and the cultured organisms matched some mouth bacteria from the performing physician.

seems a little dubious unless the performing physician had a unique mouth bacteria
streptococcus uniquess

 

[Apollyon]

seems a little dubious unless the performing physician had a unique mouth bacteria
streptococcus uniquess

Way back about 15 years ago, had a nutty pt. I recall it was Easter. Called Neuro, who happened to be a nice guy, and saw the pt in the dept. It didn't fit any specific area for deficit. He said, "either it's real, or she's really crazy". Ended up admitting her to the uni hospital. There, echo showed vegetations on the aortic valve. She was nutty from septic emboli. CT said, "valve has to come out". ID says, "have to ID the bug". In the interim, pt dies. What grows out of the cx? I'm forgetting specifically, but it was something that you find in the front yard, not a normal human pathogen (lactobacillus, IIRC, but not the one in yogurt). There was no viable theory as to how she got inoculated with it.

 

[thegenius]

Way back about 15 years ago, had a nutty pt. I recall it was Easter. Called Neuro, who happened to be a nice guy, and saw the pt in the dept. It didn't fit any specific area for deficit. He said, "either it's real, or she's really crazy". Ended up admitting her to the uni hospital. There, echo showed vegetations on the aortic valve. She was nutty from septic emboli. CT said, "valve has to come out". ID says, "have to ID the bug". In the interim, pt dies. What grows out of the cx? I'm forgetting specifically, but it was something that you find in the front yard, not a normal human pathogen (lactobacillus, IIRC, but not the one in yogurt). There was no viable theory as to how she got inoculated with it.

I similarly recall a patient who currently frequents our ED several times a year. We have the ability to read other regional hospitals charts. She's been bacteremic with really odd bacteria and she was once caught on a hospital camera (in the past and not at our hospital) spitting into a syringe and injecting her spit into her IV to get bacteremic. She was a nutty patient!

 

[BoardingDoc]

I similarly recall a patient who currently frequents our ED several times a year. We have the ability to read other regional hospitals charts. She's been bacteremic with really odd bacteria and she was once caught on a hospital camera (in the past and not ours) spitting into a syringe and injecting her spit into her IV to get bacteremic. She was a nutty patient!

Yeah, I had a patient I admitted with munchausen's when I was a resident. I followed up on her because I knew I could read it while noming on some popcorn. Long story short, she was found to have
1: A bag full of cough drops that when unwrapped turned out to contain not cough drops, but tabs of dilaudid and tabs of benadryl
2: She had been grinding these up and shooting them into her CVL.
3: She had been mixing her own feces in with the dilaudid and benadryl.

 

[BoardingDoc]

My other fun patient in a similar (though not as disturbing) vein was the psych patient I saw as a resident who kept getting admitted for unexplained tachycardia. Long story short with her: she had been hiding an albuterol inhaler in her vagina and would sneak it out and take a bunch of puffs whenever her HR would go down. Clever. Bats**t insane, but clever.

 

[Apollyon]

My other fun patient in a similar (though not as disturbing) vein was the psych patient I saw as a resident who kept getting admitted for unexplained tachycardia. Long story short with her: she had been hiding an albuterol inhaler in her vagina and would sneak it out and take a bunch of puffs whenever her HR would go down. Clever. Bats**t insane, but clever.

"Just because I'm crazy doesn't mean I'm stupid."

 

[thegenius]

My other fun patient in a similar (though not as disturbing) vein was the psych patient I saw as a resident who kept getting admitted for unexplained tachycardia. Long story short with her: she had been hiding an albuterol inhaler in her vagina and would sneak it out and take a bunch of puffs whenever her HR would go down. Clever. Bats**t insane, but clever.

Oh man it would have been even better if she had stored her MDI in her vagina and somehow could squeeze her pelvic floor muscles to activate the MDI inhaler, enough times, to cause systemic absorption of albuterol and increase her heart rate.

NOW THAT WOULD BE A PARTY TRICK

 

[WilcoWorld]

seems a little dubious unless the performing physician had a unique mouth bacteria
streptococcus uniquess

It's actually been pretty rigorously investigated:

Trautmann and colleagues reported a case of meningitis caused by a Staphylococcus aureus strain that was identical by pulsed-field gel electrophoresis to the S. aureus isolated from the anesthesiologist’s nose. Rubin et al could trace to a single anesthesiologist Streptococcus salivarius as the responsible agent for six cases of meningitis following spinal anesthesia, and the Centers for Disease Control and Prevention (CDC) reported five cases in Ohio and one case in New York between 2008 and 2009 with the same organisms.

 

[GassYous]

It's actually been pretty rigorously investigated:

Trautmann and colleagues reported a case of meningitis caused by a Staphylococcus aureus strain that was identical by pulsed-field gel electrophoresis to the S. aureus isolated from the anesthesiologist’s nose. Rubin et al could trace to a single anesthesiologist Streptococcus salivarius as the responsible agent for six cases of meningitis following spinal anesthesia, and the Centers for Disease Control and Prevention (CDC) reported five cases in Ohio and one case in New York between 2008 and 2009 with the same organisms.

Here's a nice publication with an informative chart:

Post–Dural Puncture Bacterial Meningitis

A fatal case of viridans streptococcus meningitis is reported, which occurred as a complication of epidural anesthesia. One hundred seventy-nine reported cases of post-dural puncture meningitis are reviewed. Evidence suggests that most cases are probably caused by contamination of the puncture...

pubs.asahq.org

 

[thegenius]

Here's a nice publication with an informative chart:

Post–Dural Puncture Bacterial Meningitis

A fatal case of viridans streptococcus meningitis is reported, which occurred as a complication of epidural anesthesia. One hundred seventy-nine reported cases of post-dural puncture meningitis are reviewed. Evidence suggests that most cases are probably caused by contamination of the puncture...

pubs.asahq.org

View attachment 362665

Ya most of those are 20-30 years old in other countries. We probably do quite well as a whole in 'Merica.

 

[Janders]

Yeah, I had a patient I admitted with munchausen's when I was a resident. I followed up on her because I knew I could read it while noming on some popcorn. Long story short, she was found to have
1: A bag full of cough drops that when unwrapped turned out to contain not cough drops, but tabs of dilaudid and tabs of benadryl
2: She had been grinding these up and shooting them into her CVL.
3: She had been mixing her own feces in with the dilaudid and benadryl.

Did I ever tell ya’ll about the guy I had my first month as an intern (medicine floor month). Tons of red flags, aggressive/violent personality, admitted for repeated high volume BRB via his ostomy. Was getting 4mg IVP DILAUDID Q2hr on the floor! How he arranged that, and for what indication, I have no clue but chapeau.

Anyway, he kept having random vigorous bleeds the day prior to discharge x 3. I finally had a minor break down during our interminable rounds and said I really, honestly felt like he was triggering his bleeds and staying just for the IV opiates, for XYZ reasons. I got a talking to about being a typical ER resident, all cynical and seeing the worst in people. Pretty much each of us has spend extended time sitting in the room chatting with this guy, and no one has him figured out, but apparently I was the only one who smelled a rat. I felt bad, because maybe I was a heartless little first month intern. I did some self-reflection.

So we get ready to discharge him again, he’s been super stable for a couple days. LItereally gets his discharge packet. Says he needs to pop in the bathroom. A few minutes pass. He won’t come out. RN grabs me (she sensed drama). We open the bathroom door. He has a pair of scissors which he’s dismantled, and has one of the blades shoved 5” up his ostomy, just sorta grinding it around getting some heavy bleeding going. He then remove said blade and turned it towards us.

Anyway he then got a nice police / security / psych consult and (hopefully) treatment for what was really wrong.

Somehow the medicine team never congratulated me on my instinct

 

[The Knife & Gun Club]

Did I ever tell ya’ll about the guy I had my first month as an intern (medicine floor month). Tons of red flags, aggressive/violent personality, admitted for repeated high volume BRB via his ostomy. Was getting 4mg IVP DILAUDID Q2hr on the floor! How he arranged that, and for what indication, I have no clue but chapeau.

Anyway, he kept having random vigorous bleeds the day prior to discharge x 3. I finally had a minor break down during our interminable rounds and said I really, honestly felt like he was triggering his bleeds and staying just for the IV opiates, for XYZ reasons. I got a talking to about being a typical ER resident, all cynical and seeing the worst in people. Pretty much each of us has spend extended time sitting in the room chatting with this guy, and no one has him figured out, but apparently I was the only one who smelled a rat. I felt bad, because maybe I was a heartless little first month intern. I did some self-reflection.

So we get ready to discharge him again, he’s been super stable for a couple days. LItereally gets his discharge packet. Says he needs to pop in the bathroom. A few minutes pass. He won’t come out. RN grabs me (she sensed drama). We open the bathroom door. He has a pair of scissors which he’s dismantled, and has one of the blades shoved 5” up his ostomy, just sorta grinding it around getting some heavy bleeding going. He then remove said blade and turned it towards us.

Anyway he then got a nice police / security / psych consult and (hopefully) treatment for what was really wrong.

Somehow the medicine team never congratulated me on my instinct

Reminds me of a guy I had who was homeless and would let other dudes penetrate his ostomy for $$$. He called himself an “Ostitute.” This was years ago when I was a student and hadn’t lost faith in humanity. Would come to our med student free clinic for dressing changes and other random “living on the street” type stuff.

Eventually he rolled into the ED with HSV +/- GC of the ostomy site. IIRC we actually admitted him cuz surgery was afraid the inflammation would occlude the ostomy and wanted serial abdominal exams.

I’ve always wondered if maybe they just wanted to gawk at him on rounds or something.

 

[aafisahar]

Reminds me of a guy I had who was homeless and would let other dudes penetrate his ostomy for $$$.

The ol Philly sidecar. Had multiple patients in residency who didn't want to get theirs reversed for this reason.