Suicide, Tantrum or Just Stupid?

Beep, Beep, fuss, beep....... "Hi this is Doctor   ___, what do you have?" "Hey Doc, we have a 22 year old male who od'ed on xanax and drank some liquid dishwasher detergent." "What are his vital signs? Is he alert and protecting his airway?" I ask. "Yes he is stable and protecting his airway. His vitals are HR 98, RR 24 and BP is 134/92, he is alert and oriented x 3." they scream back over the radio. "Great, what is your eta? If he starts to crash let us know." I said. "Thanks Doc, we are 10 minutes out."


It was 2 in the morning and we had 4 sets of paramedics on their way in with a variety of sick and not so sick patients. I continued taking care of the patients I already had and waited for this toxic ingestion to arrive. About 10 minutes later I heard a bunch of yelling and screaming coming from the paramedic bay as my toxic patient arrived, yelling and screaming at everyone. One profanity after another came flying out as he made sure to insult everyone his eyes came in contact with. As the paramedics rolled him by I looked up to see how sick my new patient was and I yelled, "take him to room 3, in case I have to intubate him." They obliged and looked like all they wanted to do was drop off this maniac and get out of the ER as fast as possible.

I made my way over to room 3 and started examining the patient as they hooked him up to all the monitors in room 3 and he started told us the story be he was just yelling and obviously agitated. He told me to F+&*& off and attempted to spit on me. This was not the first nor the last time a patient who I was trying to care for tried to spit on me, so I was prepared and dodged the spit like a champion bull fighter. I quickly assessed the situation and fortunately his much calmer girlfriend was there and could tell us what happened and what she saw.

As it turned out he had been on a bender and had "eaten" (her words) all the xanax in the house, which was not enough to kill him. He was only looking to get high but when he found out they were out of xanax he became irate and decided to drink some Cascade, about 2 cups in her estimation. He immediately started throwing up at home and she thought most of it had come back up. I quickly completed my exam and noted that his throat was irritated and also that his teeth were particularly shiny and had no streaks.

I had one of the medical students call poison control to get any further recommendations for treatment and I started a some treatments and stabilized the patient. I saw a few other patients when I was called back by the nurse because "Mr. Clean" (her words) had started to cough up / vomit blood. I made my way to room 3 prepared to intubate  our patient but he look ok and was ventilating nicely. He looked like he was withdrawing from xanax / other benzos. I gave some medication too help prevent a full fledged withdrawal with seizures and other horrible symptoms.

Finally poison control called back and I was paged to take the call. I explained what I had done so far; which tests I had orders, and the interventions / treatments I had started. The doctor on the other end of the line, said "perfect, you did not even need to call us, great job!" I told him thanks and explained I needed to document his recommendations for liability reasons and he chuckled and replied with "smart, very smart, cover all your bases." He also let me know what to watch for and what to expect.

Fortunately my patient had not consumed enough of Casacade to cause major problems that would be permanent. He did however burn his throat, mouth and esophagus. He also had aspirated some into his lungs. I explained to him and his family and  girlfriend that he would be admitted into the hospital. At this point the patient was calmed down and ready to talk. It sounded like this whole event was a tantrum and not a suicide attempt. I called for a 24 hour sitter anyway just incase. I was able to make some phone calls for social work to see him the next day and talk to him about getting into rehab.

This was 1 patient of the 24 I saw that night. While I was caring for him I had 6 other patients in rooms that I was responsible for as well. What I night. I love what I do, it never gets old and when you think you have seen it all, the doors come flying open and a new adventure begins. You can't make this stuff up, real life better than fiction.

The thing about emergency medicine is that you get to do a little bit of everything. You do some minor surgeries / procedures, OB/GYN, psychiatry, orthopedics, dentistry, urology, neurology, GI, cardiology, ophthalmology, dermatology, pediatrics, toxicology, radiology, anesthesiology, primary care and so much more.  Often you do all of these within the same shift. Perfect for ADD / ADHD.

Good times.

Tough Cases in the ER

I am on emergency medicine in a urban trauma one center and I'm working 12 hour shifts. I work 7 PM to 7 AM for 7 AM to 7 PM. It feels good to be back in my element, my home. This is a scratch that this is a busy emergency department and receive lots of very sick patients tonight

I had an interesting patient the other night. This was a 34 -year-old African-American male with HIV-positive, ESRD (End Stage Renal Disease, and  a rip roaring case of pneumonia with a recent pulmonary embolism (PE). He  was recently in our ICU unit for pneumonia he was discharged  last week and this morning woke up with worsening shortness of breath. He decided to come into the emergency department because of his worsening symptoms when I enter the room I immediately knew this was a sick patient. He was talking just fine but his blood pressure was low and he was having a difficult time getting his oxygen. So I decided to work this individual up for  sepsis. I ordered the appropriate labs and films and imaging and I looked at some of his old records.

He had a low CD4 count which is bad for someone’s immune system. He had moved from HIV+ to  full-blown AIDS. His low blood pressure continued to plummet. I started him on IV fluid, bolus to bolster his blood pressure. His blood pressure started to come up but it was not high enough, so I decided I was going to put a central line in for better access. I started a medication that helps maintain blood pressure.   This medication, seemed to help him and he remained stable  in the emergency department.

We got his chest x-ray back and it showed a worsening left-sided lower lobe pneumonia. He was discharged last week with pneumonia and  today it was worsening which probably explained his worsening shortness of breath and symptoms. His discharge x-rays were much improved  from today’s x-ray. I was fairly certain he was improving and after he was discharged  he continued to improve but then started to get worse. He was a very sick individual and needed to be placed back in the ICU.

So I called the ICU doctor to let them know about this patient. This patient  needed  a  central venous  line. This is a catheter that is placed  into a major vessel like the internal jugular carotid to give better access  for medications and fluids. Placement of a central line is bread and butter of emergency medicine. We place them all the time.  The ICU senior resident came down because she wanted to learn how to do a central line. She asked me if I would show / teach her. I said yes. We started  to do a central line. We had to avoid  doing  a central line on the right internal jugular which is where we normally like to do it, because this patient had dialysis catheter  on the right. This meant we had to place the central line on the left. I begin to show the senior resident how to do the central line.  We were both in our sterile gowns and she was having difficulty getting in the vessel.  After several attempts I asked if I could show her personally and do central line. I proceeded to show her how to get a central line in the femoral. I was able to get the vessel. However when I advanced the wire it became difficult to advance, so I stopped. This could have been due to a clot in the vessel, my attending tried a couple of times but was unsuccessful.

The patient’s blood pressure had significantly improved and he was maintaining his vitals. We decided to get him up to the unit and place the line later if he needed that level of access. The patient was talking and he said he felt fine  and thanked us as he was transferred  up to the ICU. He was checked into the unit and was stable.

A little while later I heard a code RRT (Rapid Response Team) called to the ICU and I had a feeling it was for this patient. It turned out that he was talking on the phone when he just suddenly slumped over. He was found to be in a-systole (essentially dead). He was revived 3 times before finally died. He most likely had a big pulmonary embolism. He most like would have died from his worsening pneumonia given his near zero CD4 count. 

Ultimately I was able to follow up on this patient and it turns out the he had a large saddle pulmonary embolism in his pulmonary arteries that came from a DVT (deep venous thrombosis) in his lower extremities.

These cases rock your world every time.