The Go-Go's Said It Best

Vacation
All I ever wanted
Vacation
Have to get away

That's right, vacation. No updates for a couple of weeks. Stay tuned.

Sugar Walls, Week 2

I wrapped up my second and final week of ob/gyn -- it was difficult, if for no other reason than it was two weeks of nights ONLY. I wanted to flush that gyn pager down the toilet. I was responsible for rounding on all the gyn service patients all night long, and every fifteen minutes I'd get the same page:

Nurse: "Doctor, the patient in room x is having vaginal pain."

Me: "She just had surgery."

Nurse: "And it's hurting her."

Me: "Give her four milligrams of morphine."

Nurse: "Not until you write the order."

Me: "Fine, I'll be up in a minute."

I'm going to turn these women into morphine addicts just so I can get some sleep.

But I do have one order I love to write: "discharge vag packing, discharge to home."

Back to the obstetrics part (warning, it's not for the faint of heart):

I find it interesting that after two weeks of ob/gyn, I, as an ER doc, am supposed to know how to deliver a baby if they come into the ER in labor. I suppose, however, that nature took care of it for hundreds of thousands of years before doctors came along and co-opted that duty, but regardless, babies seem to pop out. On the other hand, before the advent of modern medicine, childbirth was the number one cause of female mortality. The truth is, if someone comes to the ER in labor, then a) that baby had better deliver itself as mother nature intended, or b) there'd better be a separate ob/gyn service in the hospital on call. Sure, I can do the basics, but if the shoulder gets stuck, I don't have a lot of knowledge or resources of my own.

And what a messy procedure birthing is. Push push push push push. Ladies, before you go to the doctor in labor, it makes sense to give yourself an enema if you have time. Because with all that pushing, most women will also -- if it's in there -- take a dump. Then baby comes out facefirst in mommy's poo, and then mommy inadvertenly urinates all over the back of baby's head -- welcome to the world! No wonder they always come out crying.

I'm really not that insensitive -- I do still marvel at the process of giving birth. It's unreal to me how much work you women go through to have one. There's so many potential complications, not the least of which is that most of you end up tearing at least part of your vagina as the baby comes out. I even saw one woman tear straight through to her rectum.

THEN the placenta comes out about ten minutes later. The baby is beautiful, fine, but the placenta is just nasty. It's an alien-looking blob of tissue, replete with vascular tentacles enrapturing it in spirals and swirls. It's half enclosed by a gray membranous sac, and it spills out into your hands or a hospital bucket. It's hot and steamy, and it looks quite like an oven-fresh pizza. I am absolutely dumbfounded and viscerally sickened when I think about how some human cultures used to eat it -- I can't even eat my real lunch after a placental expulsion.

Being pregnant, I've realized, is no joke. Hrmph, you women say, I could have told you that eons ago. Fine, I get it, I'm a man (somewhat), so I don't have to deal with that aspect. Recently, there was one very interesting patient on the ob service.

She was thirty years old, and it was her second pregnancy. She was 37 weeks into it, technically full term, but still a few days to weeks short of where we wanted her to be exactly. She was brought in by ambulance because her husband said she was just "acting funny." Actually, it was more like she was on crack -- running around, manic, obsessively cleaning, talking with pressured speech. This was nothing necessarily too new -- apparently she had had this type of behavior in the past intermittently. Her five year-old son had a strange but calm look on his face as his eyes rolled around with a sigh; he seemed to be thinking, mom's on crack again.

Not quite.

As it turned out, she was hyperthyroid. One's thyroid hormone is responsible for the general state of metabolism and mental functioning, similar to how your car has an engine that just kind of makes it run at its baseline at all times -- you either have a good engine, a slow one, or sometimes one that's just a bit too fast. And if your thyroid level is too high, it can be toxic, a condition called thyroid storm (sounds like a superhero, doesn't it?).

So this woman is squirming around and can't sit still. It is actually very dangerous to be in thyroid storm, so it requires immediate action -- especially if she's pregnant. But there's a somewhat comical side to this -- this poor patient is out of her head, is unaware of what she's doing, running around with doctors and nurses trying to keep up with and catch this pregnant lady running all around the floor. She won't stay in bed, she keeps vomiting up her anti-thyroid medication, and she won't shutup. We threw a nasogastric tube in her to give her her medicine, but she ripped it out. Now picture a bunch of doctors and nurses holding her down, squirting an oil enema in her butt filled with medicine, and then trying to keep her buttcheeks clenched together for five minutes for the medicine to absorb.

Finally she calms down -- a little. Enough to have a baby, anyway. So baby comes out, and the little tyke, slippery though he may be, is cute in that nascent-but-ugly kind of way that newborns are.

Now it's 5am. I get to go home at 6am, and actually, that's the beginning of a two-week vacation period for me, woohoo!

So of course guess what happens at 5:45am? MY FUCKING PAGER GOES OFF FOR ANOTHER CONSULT. MOTHERFUCKER!

"Fine," I say to myself. "You know what? I'll just bang this consult out real quick -- she's 25 years old, barely pregnant, a little vaginal spotting. Check her pregnancy hormone, ultrasound her, have her come back in two days for a re-check, just like all the others. I'll be fifteen minutes late, I can deal with that."

Now you know what comes next: the consult becomes complicated.

First, she's 250 pounds. Fat is the enemy of all doctors at all levels of training -- gross anatomy in med school is exceedingly difficult when you have to dissect through layers and layers of fat, and when you're attempting to find a vein to catheterize an IV line, you're also in a similar quandary. And I had a fair amount of difficulty actually finding her vagina. There's only one place it could be, but just believe me when I say that it isn't always quite so easy.

In goes the vaginal ultrasound probe and there goes my only-fifteen-minutes-late mantra. I had no idea what I was looking at -- funky uterus, funky ovaries, even funky bowel with pre-formed shit swirling around in it. Sigh. Call the chief.

"What the fuck is that?" says the chief under her breath to me.

"Shut-up! *I* said the SAME thing!" I told her.

"No way!"

"Way!"

Now the patient chimes in: "What's going on down there with you two?" We felt like schoolgirls being hushed.

Two hours later, my angry ass is wrapping up her admission to the service -- more blood, more tests, more this, more that. That's two hours of my vacation time GONE -- two hours of a bloody mary or a ketel tonic I could be drinking. Yes, at 6am. I deserve it.

Turns out, she had a ruptured hemorrhagic ovarian cyst, but her baby was fine.

The cap on this 11th-hour admission was that the med student wheeled this 250-lb woman in her stretcher over my big toe. Throb throb throb.

Nothing a bloody mary won't fix.

I finish rounding on the gyn-oncology patients. It's a sad sight, really. On our service, there's a 19 year-old girl with advanced, invasive, metastatic cervical cancer. There's another woman with spinal mets from her uterine cancer that was just picked up incidentally. And another woman my age who did the right thing: got her pap smears once a year, every year, didn't drink, didn't smoke, took her vitamins, no family history of cancer, no risk factors. Despite this, however, she developed an aggressive cervical cancer that has eaten away most of her belly and now is leeching at her liver. She has about six or nine months more to live, and she has a two-year old son at home. And finally, another woman on our service has advanced ovarian cancer; she's cachectic and pale, yet her belly is so big and round with cancer and fluid that it's impeding her ability to breathe properly.

I wrap up the morning, put on my coat and scarf, sign out to the morning team, and I'm on my way out the door. In the lobby, I pass by one of the ER nurses I know well -- her name is RoseAngelie, and well, to put it bluntly, she's fresh-off-the-boat from the Philippines. Lovely woman, really, but a mouth like a sailor (she tells me she has "known" many sailors in her homeland; I guess they give their own type of English lessons). I swear, the other nurses call her "Flip," and though she has no idea why, she loves that nickname.

"Hey bitch!" she says to me in a stuttered accent.

I keep walking. "Hey RoseAnglie."

I'm about ten feet away from her, and despite the heavy foot traffic in the lobby of the hospital, she shouts, "Are you still a pussy doctor this week?"

I turn red FOR her, yet I don't stop my beeline for the front door escape hatch from the belly of the beast.

"Yes!" I shout back.

I'm twenty feet away so she's even louder now. "MAKE SURE YOU SHOWER! YOU DON'T WANT TO STINK LIKE PUSSY ALL DAY!"

Mortified though I may be, I know that she does have a point.

Off to bed. After a long shower.

The Baby in the Sugar Walls

It's about 4 a.m., I'm on my fifth latte, and I STILL have yet to plume through the myriad of post-operative hysterectomy charts and round on the gyn patients upstairs and pull out their post-op vaginal packings (a/k/a "vag packs," kind of like fanny packs). My pager (again) goes off, and it's the pediatric ER.

(Note to pre-meds: you better be SURE you want to do this before you invest 175K into it.)

Sigh. Add another consult on my list of things to do before 6 a.m.

I pick up the phone and dial the number.

"Peds ER," says an unnamed voice.

"G-Y-N returning a page," I say.

"Hold please." The Girl From Impanema muzak is playing along lightly while I'm on hold. After thirty seconds of it, I'm humming along, suprisingly in a somewhat better mood because of it.

"Hello gyne?" says someone on the other end.

"Yes."

"I have a consult for you."

"I know." (rowr, kind of bitchy of me.)

"She's a 17 year old girl, pregnant, vag bleeder." (Nice of the resident on the other line just to ignore my 4 a.m. bitchiness and let it go.)

"How many weeks along is she?" I ask.

"About six weeks according to the date of her last menstrual period."

"How was her exam?"

"Non-focal. Abdomen is benign, no blood in her vaginal vault, cervical os is closed."

"Thanks," I said. "I'll be down in a minute."

I grab my coffee and take the elevator down to the peds ER. Unshaven, sweaty and gross, I drag my feet as I walk in.

"Good God," said one of the nurses, "you look awful."

"Gee, thanks," I said.

"Seriously, you look sick. You're so pale and skinny!"

"At least you think I'm thin," I said.

"Really, are you sick? The bags and circles under your eyes are HUGE."

"OKAY," I retorted, "I get it. No, I'm not sick. Actually, yes I am. I'm sick of these 30-hour shifts. I haven't eaten anything but coffee in the last 12 hours. Now where is that patient I'm here to consult on?"

"Room 10. Now here's a bagel."

"Thanks but no thanks. I just want to get this over with."

So I walk into room 10, and I saw this giggly seventeen year old, seemingly without a care in the world on her face. Already I'm upset that she appears so well and healthy, yet for SOME reason decided that 4 a.m. would be the best time FOR HER to waltz into the ER. She's chatting away on her cell phone while her cousin is sitting with her doing the same thing.

"Excuse me," I interrupted, "I'm the doc from ob/gyn."

"Hi doc!" she's grinning ear-to-ear. For some inexplicable reason, I just want to slap that smile off of her face. First do no harm, first do no harm, first do no harm.....

"What brings you in at 4 a.m.?"

"I'm pregnant."

"For how long?"

"About six weeks. And I've been bleeding 'down there' for two days now."

She proceeds to tell me that she's been having vaginal spotting -- not frank bleeding, per se -- for two days, but no other associated symptoms. I scan her chart and see that her vital signs are completely fine, so there's no issue of hypovolemia or bleeding too much. We go through her medical and obstetrical history, and she tells me that this is her fourth pregnancy. At seventeen years of age. Her first pregnancy was at fourteen, and every year since then she's been pregnant. And every year she has aborted each one.

I became very angry with her. I'm pro-choice, but as with all liberties, there are abuses. And this girl -- hardly a woman -- fit every stereotype: young, obnoxious, pregnant, drinks alcohol while pregnant, never tested for STDs, and was using abortion as a form of birth control. And her mother was in the waiting room. Whether her mother was involved in her life or not was essentially irrelevant from a legal standpoint -- a minor becomes emancipated from a medical standpoint as soon as she becomes pregnant.

So I explained to her what would happen: a speculum exam, bimanual exam, then an intra-vaginal ultrasound probe to do a sonogram of the uterus and ovaries and look for the pregnancy to make sure it's intrauterine and not ectopic.

I move to put in the speculum very gently.

"OWWWW!!!" she screamed, holding her friend's hand. "It HURTS."

"Sorry," I said, "I'm being as gentle as possible."

After three more tries, and three more times of her tensing up, protesting, squirming, I got fed up. I'm human, especially at 4 a.m. This girl was SUCH a drama queen.

"LOOK," I told her, "This is your FOURTH pregnancy, and from what we've already talked about, you've had plenty of sex over the last few years. This speculum is quite smaller than the average penis, so don't tell me you can't do this."

I know how many of you readers are gasping right now. Maybe your technique is wrong, you're thinking. Keep your thoughts coming, I know they are one of the following criticisms of me:

You're such a paternalistic asshole to this poor little girl.
You don't know her home situation, maybe she's being abused and/or raped, and THAT'S why she's pregnant.
You're so insensitive.
You've never had a speculum exam, how would you know what hurts and what doesn't?
You're so inappropriate to say that to her.
You're a male in a male-dominated society, you should show her more respect.
Maybe she wasn't having sex per se to get pregnant, the man could have ejaculated around her vagina without actually going inside of her, that's why it hurts.
Maybe she has an STD and this exam really hurts her.
She really needs you to LISTEN to her and be more humanistic towards her right now, this is very tough for her.

Now, here's what you should do: take all of those overly-p.c. thoughts, write them on a piece of paper, them crumple it up, reach around to your backside, and push it deep inside your own asshole.

I don't think I should have to defend myself, but SOMEBODY apparently needs to be more authoritative to this girl and teach her how to respect herself and her own body more than that. Someone needs to help her take control of her life. I'm not that somebody per se, but I think that she probably needed and still needs more discipline, self-imposed or otherwise before she callously throws her own life away to HIV/AIDS or God knows what else.

But yes, I get it, that isn't exactly the most appropriate thing to say. It was 4 a.m., I was overly stressed, overly worked, overly annoyed. But really, isn't what I blurted out essentially true?

Regardless, after I scolded her, she shut up, we did the exam, and she didn't complain that it hurt at all anymore. In fact, she indicated (verbally and otherwise) that she was quite comfortable the whole time.

I did the ultrasound exam and showed her and her friend a picture of this tiny bubble inside her uterus.

"That's your baby," I said.

"Awwww....." she cooed.

We finished up, and I told her that she had a viable pregnancy in her uterus, not a tubal one that would have to be terminated.

"Here's the clinic number for follow-up," I said.

"Thanks. Is this the number where I can get an abortion? I think I want to get rid of it."

My face turned red. "This is a general number," I told her. "From here, you can either make an appointment for prenatal care and testing, or you can get an abortion. It's your choice and I support your right to choose, but to be honest with you, I think you're being irresponsible."

Gasp. In this day and age, can a doctor talk to a patient like that?

I think yes. Very often, the medical establishment is levelled with criticism that we're too paternalistic, that we tell people what to do, that we think we know what's best for someone.

Isn't that why we go to medical school? Isn't that why we become doctors?

I argue that we DO know what's better for you and it's our job to explain those choices to you and what they mean. It IS paternalistic, but it's designed to be that way. I never tell anyone what to do, but I have my advice. No, you shouldn't eat so much red meat, but is it paternalistic to instruct a patient not to do that? In this era of choice, should I not tell people what those choices mean and help them make a decision? I understand that I'm human too and that I may make mistakes or that I may not know everything and that I too have unhealthy habits (like staying up for thirty hours in a row), but I posit that I certainly know more about medicine and healthcare than 99% of my patients and I should tell them what their choices are and what those choices mean for them.

"What do you mean, irresponsible?" she said.

"I mean this: you're seventeen, this is your fourth pregnancy, and you're using abortion as a form of birth control. You can do what you want, but you need to remember that your actions have consequences. When I say you're being irresponsible, I mean that you're sexually active at a young age, you've never been tested for STDs, you have no idea if you have HIV or not, and you're letting men take advantage of you sexually. I think you should respect yourself more than that and take better care of yourself and take more control of your life. I sound like your father, but I'm not and I don't want to be. These are your choices to make, and I think you should be making smarter choices."

"I see," she said, eyes downcast. "No one's ever said anything like that to me before."

"Well I think it needs to be said," I told her. "Now, do you have anymore questions before you're discharged?"

"Yes," she said. "Can I make another appointment with you? I'd like you to be my doctor."

Something clicked inside me and I wasn't mad anymore. Instead of seeing her as an irresponsible brat, I now thought of her more as a misguided teenager who was unaware of the opportunities that she had. Perhaps her parents had never taught her the value of a good education, perhaps men sent her the message that she was only worth something through sex, or both. And I'll admit -- yeah, I felt a little flattered by the encounter, that she felt like she could trust me with so much information and care after only fifteen minutes.

I explained that I didn't have clinic hours, but she should make an appointment soon to see someone about getting proper testing and care for herself. She agreed to get testing for HIV and other diseases, and to start seeing a physician regularly and getting pap smears.

I recently checked her medical record number in the computer, and as it turns out, she had in fact gotten all necessary tests and had a appointment for a pap smear. As for the baby, however, I really have no idea if she had an abortion or not. If I'm not her primary doctor, then I think that that is not my business. It is, after all, as I explained to her, her choice to make.

Sugar Walls, week 1

Kudos to anyone who recognizes that title from Sheena Easton (love her).

Yup, you guessed it. I'm on ob/gyn for two weeks right now. Nights only -- that part sucks.

I realized upon re-reading this blog that it sounds like book chapters. I intended a stream of consciousness, so I'll try to keep it as such.

I was really afraid to start. Most med students can tell you that 95% of them will look in horror at the prospect of starting their ob/gyn rotations (I was). The residents in ob/gyn have a reputation for being hardheaded complete bitches. Yes, that's sexist.

I think, however, that's unfounded. I love my current team -- my chief resident is a rockin' supersmart woman (who often lets me go home early); there's a fabulous intern on the team with great hair; and there's this awesome power-lesbian with huge arms that I wish I had. She's a fantastic teacher and is really showing me how to do gyn exams and ultrasounds very well. If anyone knows snatch, she does.

There's also this cute, mousy Asian med student on who is so eager. Ah, I remember those days, when I had a passion for this before residency beat it out of me in a meager six months. She did what I did on my first day on ob/gyn as a student -- after she delivered her first baby (a truly wonderful experience -- ONCE), she forgot to clamp the umbilical cord and cut it first.

Blood everywhere. Squirting like a stuck pig. This little slippery umbilical cord is flipping about like a firehose with no fireman attached to it. By the time we got the cord clamped, the room looked like it was right out of a murder scene. Poor med student, she was soaked in blood and amniotic fluid (always wear a faceshield!).

I carry the gyn consult pager all night long, and I'm supposed to see every gyn patient on the floor. Kudos to you women -- I don't know how you put up with that organ. Every time I look at it, it's a bloody (literally) mess and it seems so painful. (Granted, I see the sick ones, that's what they're doing in the hospital.)

I just saw two consults. The first one was a heavyset Hispanic woman in her late 30s who was not pregnant and came to the ER with fairly heavy vaginal bleeding two weeks before she was supposed to get her period. Nice lady, a little worried, but her hematocrit was stable as was her vital signs, so I didn't get too worked up over this one. Her transvaginal ultrasound was neat -- it showed a ruptured hemorrhagic ovarian cyst (another thing we men don't have to put up with). And I know this sounds terrible, but all I could think was how HAIRY she was "down there." I mean, I sat in front of her and could not see any labial skin. Just hair. I've never seen anything like it. Regardless, she was fine.

The next one was completely, wholly bizarre. This really highlighted to me the level of denial some people can be in in relation to their illness.

Apparently there was a woman who came to the ER for an asthma exacerbation. She had a recent cold and was feeling worsening shortness of breath. Something triggered her asthma, so she was huffing and puffing and trying to get air. The ER did the appropriate thing and gave her some steroids and an inhaled nebulizer treatment. She had felt much better.

So how is this a gynecology story?

I got a page from the ER about her. (In case you're not following: I'm an ER resident, so I spend most of my time in the ER. However, some months I rotate on other services to learn from subspecialists in that area so I'll know what to do with these patients when they come to the ER. Currently I'm rotating in ob/gyn so I get calls from the ER requesting me to consult on patients there for gynecologic complaints.)

So the ER called and told me her pulmonary story.

"Okay," I said, "what's the gyn issue?"

My ER compatriot on the line said, "we were discharging her and she made a mention of how she had a little 'extra bleeding down there.'"

"How much is 'extra'?" I asked.

"Well, I did a pelvic exam on her. You have to see this."

"See what?"

"Just come down."

So I headed downstairs to the ER gyne room. I introduced myself to the patient, told her that I would be evaluating her gynecologic complaint. She proceeded to tell me how she had some extra vaginal bleeding apart from her normal period.

"Mmmhmm. About how much extra would you say?" I asked.

"Hard to say. I just sit on the toilet and bleed," she replied.

"How often?"

"Everyday."

"For how long?"

"Oh, a few years now."

A few years? Odd. So I told her I would do a pelvic exam now, and I instructed her to lay back and put her feet in the stirrups and push her knees out towards her side.

I sat in front of her, pulled back the sheet, and I was left momentarily speechless: there in front me, was a huge mass coming out from her vagina. It was about the size of a large man's fist, and it looked like -- honest to God -- a pinecone, with triangles overlapping one another in a spiral fashion. And it was porous and glistening with mucous and slowly dripping with blood.

This was a giant vaginal tumor, and it was hanging out of her introitus, attached to the inside of her vagina by a thick biologic stalk. I hope you're not eating while reading this.

"Ma'am," I said with a forced expression of calmness that belied my suprise and disbelief. "How long has this been here?"

Her eyes became downcast, as though she was just busted for a crime.

Sigh. "About three years," she replied.

"Three years?" I echoed. "Have you seen anyone about this?"

"Nope."

"Why not?"

"I don't want to know what it is. I figured it would go away."

Three years later, it hadn't. Apparently it had only gotten bigger.

How's that for denial? This woman had a giant, fungating cancer spilling out of her vagina, and I could see the chaff marks on her inner thighs where this lecherous thing was rubbing against them as she walked.

We had a pretty long talk about this. I did what I thought was appropriate -- I didn't tell her right then and there that it was a giant tumor. I told her that there were several possibilities of what it could be (which is true), but honestly, there's not a lot on the differential diagnosis of a fungating mass extruding from the vagina that was growing over the last three years. She just didn't want to know she had cancer. I told her that she needed to be admitted and worked up appropriately, that we needed a sample to send off to pathology to get a handle on what this was.

Despite her denial, however, it seemed like she was almost relieved to hear someone tell her the truth: that it might in fact be cancer and she might (okay, probably) need surgery, chemo, radiation or all the above.

I thought about taking a picture of it for submission to a journal, but thought better about it for now. I get the feeling she doesn't want to be a medical curiosity on display.

Anyways, it's 2am. That means it's time to get some coffee.

Add A Splash of (Brown) Color

Sometimes I forget that I work in the Bellevue ER; that I'm in the middle of New York City; that I'm at the crossroads of the world. Sometimes I think that all ER's are the same, and you see the same things and the same patients no matter where you go, from bucolic Iowa to the knife-and-gun club of Cook County.

And then every once in awhile some random event in the ER will grasp my head and wrench me back into reality, followed closely by the conclusion: "yep, I'm in New York, and I'm in Bellevue. And this place is a theater of the absurd."

Such was the case just recently.

One not-so-lonely night in the ER, there was a slow but steady stream of patients with the usual nighttime myriad of complaints: cough, cold, fever, asthma attack, even a broken limb or two. I was sitting behind the central ER desk (eye of the hurricane), gossiping with the nurses and filling out some charts in the small amount of downtime that I had. The only commotion swirling about the ER at that time was the prisoner who was just brought in from Riker's Island who had yet to be seen by a doctor. He was visibly upset about something, and every few minutes he would mutter an obscene phrase or two in the general direction of the staff or police.

"How was your date with that set-up, Sarah?" I asked the nurse as I was furiously charting the last patient I just discharged.

"It was alright," she said. "He scored points by paying for a nice dinner, but the dude was just not quite my type."

"What's your type?" I asked.

"Not ugly."

"Are you going to call him?"

"He already called me. Twice."

"When was your date?"

"Yesterday."

"That's a little suffocating."

"To say the least. I think he thinks that --"

"Sorry to interrupt, Sarah," I said as I abruptly cut her off. "But do you smell that?"

"Smell what?" she asked.

"I think...I think I smell a code brown," I said.

Sara turned her nose up into the air and looked around in no specific direction. Whiff whiff. "I definitely do. Did someone shit in their stretcher?"

This (a "code brown," as we call it) actually is not an uncommon occurrence, especially when one deals with the very ill. Having gone through four years of medical school, gross anatomy, gross pathology, and 1.5 years of residency so far, I've been exposed to the gamut of both intracorporeal and extracorporeal fluids. Like most people, I used to recoil in disgust. After enough repeated experiences, however, one is desensitized, no matter how much one thinks he or she will not be. Each resident, however, is entitled to usually one exception to that rule. My exception happens to be fresh, food-filled, chunky vomit. No matter how many times I see it, and no matter in what quantity, it evokes a visceral response in me that brings up my own vomitus to near-expulsion. But otherwise, I'm pretty much okay with whatever is around. Blood? Not a problem anymore in the least, even if it's pumping out of an artery across the room. Pee? It's normally a sterile liquid, I could care less. Poo? Hardly a second thought, just natural waste material. Mucous? It's just a natural secretion. Even bile -- though it's green and warm, is still -- to me -- a natural excretory substance designed to help us digest our meals.

So when Sarah (or anyone) asks me if someone shit their bed, it just takes a blithe, non-chalant form with an air of insouciance to all the staff. It's like asking if the patient in bed X had their EKG already done: you just chalk it up to daily ER business and simply say yes or no.

Or in this case, I don't know. I did smell poo, that's for sure. And in this business, if you smell poo, then there is poo. I thought Sarah and I were going to have to go looking for the culprit, but that's when I heard it:

SPLAT.

And again:

SPLAT.

I looked up from my chart and swiveled around in the chair. And there, on the wall in front of me, was a flattened turd stuck to the wall, about six feet off the ground. Radiating out in all directions from it were satellite turds that had broken off upon impact. About three feet away on the same wall was a similar exploded asteroid with its own orbiting remnants.

"YOU MOTHERFUCKERS!" screamed the guilty party. Sarah and I turned around more and saw our culprit -- the prisoner from Riker's Island.

"IS HE THROWING SHIT AT US???" asked Sarah in disbelief.

"Yeah and you'd better duck fast!" I replied.

SPLAT. The wall was starting to look like a Jackson Pollock, albeit monochromatic.

"WHO THE FUCK YOU THINK YOU GUYS ARE?!" screamed the prisoner at no one in particular. "YOU THINK YOU CAN JUST ARREST ME FOR NO GODDAMN REASON AND LOCK ME UP? I GOT RIGHTS YOU KNOW! MOTHERFUCKERS!!!"

In a regressive display of behavior, this evolutionary speedbump had actually shit into his orange "NEW YORK D.O.C." jumpsuit (it was just missing that ubiquitous 'I heart' in front of it), and he was reaching around with his free, uncuffed hand (the other being cuffed to his stretcher) into his pants, pulling out semi-solid feces, and hurling it in no particular direction in a display of general rage at his predicament.

"YOU THINK YOU CAN LOCK ME UP? DON'T YOU KNOW WHO I AM, MOTHERFUCKERS??"

The arresting officer who brought him had already scrambled to the other side of the ER, way out of projectile arc-of-the-turd reach.

"Officer!" I pleaded, "can you do something about your guy? He's in your custody!"

"Yeah but he's in your ER," replied New York's Finest. "All I do is watch and make sure he doesn't escape. And he's not runnin' nowhere."

You piece of shit, I thought. Apropos.

Thinking more quickly than the rest of us, like a soldier bolting out of a foxhole, Sarah ran over and curtained off the bed, effectively shielding the rest of us. We could now see the outlines of turds being pelted into the curtain. Surely he would run out of ammunition soon.

We waited.

And waited.

More screams: "I'M GONNA FUCKING KILL ALL OF YOU AND SUE THE PANTS OFF ALL YOU FUCKERS!" (In that order? I wondered.)

And though he continued to scream, the flinging of the poo finally did stop. The ER was already being sprayed down with that orange-scented industrial-strength shit-stomping scentspray. But all that stuff does is mix with shit and make it smell like orange shit.

Even though I had no clue why he was brought to the ER in the first place, I -- nor did anyone else -- go near him until he stopped his turd-hurling. ("Protect yourself FIRST," we were told on day one of internship.) And although he kept yelling in some ambiguous protest of some violation of his self-celebrity, he eventually, well, ran out of ammo.

I had our own 5-and-2 cocktail ready to ambush him. That's five milligrams of haldol, a powerful antipsychotic, and two milligrams of ativan, a powerful sedative. This tried-and-true combination -- also known as Vitamin H and Vitamin A -- could bring down a baby elephant. So with faceshield on, I led a group of gowned-and-gloved hospital police officers into the curtained area. I was actually pretty impressed with our group effort -- in less than ten seconds, despite his howling, he was held down and I injected our cocktail into his shoulder. Just as quickly, we retreated and waited.

Ten minutes later, he was out. Head back, drooling, snoring and sitting in his own dooky. And all anyone in the ER could smell was orange shit.

After hooking him up to a monitor, I again approached his arresting officer.

"What was he sent here for?" Bellevue is the Manhattan County hospital -- anyone in custody in New York City -- specifically, Manhattan -- with a medical problem gets processed, treated and cleared at Bellevue (a source of many other stories).

"He said he had high blood pressure."

High blood pressure? His systolic blood pressure was 145; that's probably lower than mine.

"I don't believe this. All this commotion for a systolic of 145??"

"I'm not a doctor," said the officer, "I just bring 'em here."

"What was he arrested for?" Important to know if it was narcotic-related.

"Petty theft. He stole some beer."

Great. In a massive waste of resources, we were now compelled to give this guy the full monty work-up. He was sedated, so he couldn't answer any questions. The nurses and patient care techs cleaned him up (God bless 'em), blood was taken, labs were drawn. And in my own form of passive/aggressive-but-medically-justifiable revenge, I stuck a large foley catheter in his penis, and put a rubber catheter in his nose to keep him from snoring and obstructing his airway while he was sedated.

He slept peacefully (and sanitarily) for the next six hours. All labs were negative, as were his portable chest x-ray and EKG. All toxicology tests were negative (I lost five bucks to Sarah -- I had my money on PCP, and she bet that he was "just a grade-A jumbo asshole," though they're not mutually exclusive). And except for a blood pressure that never jumped over 150, his vital signs were normal.

He was significantly calmer when he awoke.

"Sir," I said. "Why are you here?"

"I got arrested and told 'em I had high blood pressure."

"Do you take anything for it?"

"No."

"Do you have any other medical problems?"

"No."

"Are you on any medications?"

"No."

"Drugs?"

"No."

"Are you having any problems or pain anywhere at all?"

"No."

I wanted to kick his ass. True, he was 250 pounds and I'm 150 when wet, but still, it's the thought that counts.

I didn't say another word to him. I'm certain he remembered pelting the ER with turds, but in case he didn't, I didn't want to remind him of any future offensive weaponry he could unleash again.

"Officer," I said to his arresting agent, "he's medically cleared. Get him out of here."

A few minutes later, the a.m. shift of residents came to relieve the war-torn and weary, ragged bunch that we were.

Bright-eyed and full of a good night's sleep, one co-resident said, "How was it? Regular night in the ER?"

"A regular New York City night I guess," I replied. And then I gathered my coat and bag and left in a New York minute.

Where To Hide Your Drugs

It was close to 2 a.m., and the ER was in full swing: a wild woman shouting madly in Russian in one corner, a broken arm in another, and a naked drunk guy desperately resisting our attempts to clothe him in another corner.

It's the graveyard shift in the ER, but it's never dead. These are the hours where the oddities of New York City nightlife and medical drama collide. And if there's also a full moon outside, all bets are off. It is a well-known but inexplicable fact to all ER doctors, police officers and firemen that a full moon not only influences the ocean's tides to advance, but it also similarly pulls psychotic tendencies to the frontal lobe of the brain where they can be expressed without inhibition. In fact, the police bring in so many of these disturbed persons -- found yelling, screaming, and flailing about for no reason -- that we have a separate triage category for them: EDPs, for Emotionally Disturbed Persons. They usually require physical restraint and they also respond quite nicely to chemical restraint until we can figure out what's going on with them.

At any rate, around 2 a.m. one particular night, I took a large gulp of coffee (nectar of the Gods for residents) and picked up the next chart (it's like playing Russian Roulette when you go to pick up the next chart -- you're not quite sure if at best you'll be relieved at what's there or at worst you're dead -- or wish you were). The complaint on this chart: penis pain.

Before I go see any patient, I look at the vital signs recorded on the triage sheet when they arrived. If they're fine, I can relax a bit. Otherwise, I usually depend on the nurses to pull me aside and tell me someone is really sick and I need to see them stat. Penis Pain's vitals were normal, and I asked the nurse Kim to tell me what she knew about him.

"I don't know anything about him," she said. "He won't tell me anything."

"Why not?" I replied.

"I dunno. Maybe it's because I'm a woman and he's not comfortable?"

"Did you see his dick?"

"I don't go fishing if I don't want to eat what I catch."

Interesting way of putting it.

Fine. So when I see any complaint, after looking at the vital signs, I run through a preliminary list in my head of the differential diagnoses -- what could it be? Occam's Razor for diagnostic parsimony is usually best heeded: the simplest and most likely explanation is usually the correct one. In emergency medicine, however, that's to be taken with a grain of salt. It is important to stress that anything could be going on.

Penis pain. Hmmm. Start with the most serious possible cause: priapism. That's a condition in which a man gets an erection that doesn't go away. I know -- great problem to have, right? Wrong. It hurts. A lot. After four hours, it's acutely painful and it's one of the true few urologic emergencies -- at that point, the blood in the penile structures (the corpora cavernosa) begins to sludge and rot; with compromised blood flow, the rest of the penis isn't getting perfused, and you get irreversible damage. In short, Lorena Bobbitt could make a legal career of cutting off dicks that are past the tipping point, so to speak.

If it's truly his penis that hurts and not his balls, then the list is otherwise kind of short: a cut, an ulcer, a sore, a bruise, or -- God forbid -- he broke it during sex. Yes, it happens.

So I pull back the curtain. Nice man. Upper 30's, maybe. Nothing seemingly acute. Just sitting on the stretcher, dangling his legs.

"Hey sir," I said. "How're you doing?"

"Could be better. Otherwise I wouldn't be here, heh heh." True.

"Tell me what's going on."

"My dick hurts."

"Did you injure it?"

"Kind of."

"Can I see it?"

He takes off his pants and I assumed that I might see priapism's painful erection. I should have already learned by this point not to assume anything. But it was soft and just hanging there.

"May I examine it?"

"Sure." So -- with gloves, of course -- I give that thing a good exam. No sores, no cuts, no bruises, nothing that seemed out of the ordinary, and he wasn't really wincing or flinching as I was moving his penis during the exam.

"Can you tell me exactly what about it hurts?"

"Well doc, I was running from the police."

That's very common among our patient population.

"Okay," I said, "continue."

"Doc, I had some crack. And they was runnin' after me."

"Are you currently on drugs right now?"

"No I'm not."

"Okay, continue."

"The police were runnin' after me, and I ran behind my building and hid my crack so they couldn't arrest me. Well, they did arrest me but they had to let me go because they didn't find anything on me. I hid my drugs and now I can't get them out."

The wheels in my head started to turn faster. Let's see: he was arrested, but they couldn't find anything. That means he didn't stick them up his ass since the police are legally able to do a body cavity search. But he has penis pain. And hidden drugs. And he can't get them out.

No.

No way.

He didn't.

He couldn't have.

"Sir," I began, "are you telling me that you hid your crack inside your penis?"

"Yeah doc. I did. And it worked."

Touche.

"How did you do this?"

"I rolled up the little baggy and stuffed it in there," he said matter-of-factly.

The average bag of crack looks like this:



It's about one-by-one inch. Impressive that he did that.

"Sir," I said, eyes slightly wider, "When did you do this?"

"Three days ago."

"Three days ago?? How have you been peeing?" Medically, it was important for me to know so that I could discover if there was any urinary retention, but honestly, I just wanted to know.

"It kind of leaks around it all day. I figured I'd pee it out, but that ain't happened."

A self-stenting urinary catheter -- made out of crack. Genius! I should market this thing.

"Well," I factually stated, "I guess we gotta get that out, huh?"

"That's what I'm here for," he calmly stated.

I love honest patients. All doctors really appreciate it -- it makes our job easier. Really, we've seen it all -- there's no need to be embarrassed. We know you didn't slip in the shower and fall rectum-first on that flashlight. We know those track marks on your arm aren't from repeated bee stings. Just be honest -- it makes things go more smoothly and it helps us help YOU. It's better all around just to be upfront.

I've seen a lot, but I haven't seen this before. And in med school, there was no book chapter called "Removing Crack From A Penis." That's one reason why I love emergency medicine -- it requires MacGuyver-esque innovation. You work with the materials you have at hand. And to start with, that's all I had: my hands.

So picture this sight, if you will: I've got a gloved hand wrapped around this man's penis, slowly milking it back and forth, essentially giving him a handjob where my reward is a bag of crack. Surely this makes my mother proud. And despite several minutes of this, I got nuthin'.

"You don't think I tried that doc?"

"Well," I said, "I wanted to try the least invasive method first."

"What's next?" he nervously asked.

"Well, do you know how far it's in?"

"No. But it should just barely be in there. I mean, I had about 30 seconds to put it in there before the po-po caught up with me."

So now picture this: I'm prying open the tip of his urethra with one hand, and I've got a penlight in the other while my eye is about one centimeter away from the opening of his penis. So help me God, if you decide to leak urine right now.....

And there it was. Just out of reach. In the back of my head I was wondering if he was really a psychiatric patient making up the whole thing, but the evidence was staring at me square in the eye, so to speak.

"Alright sir," I said, "I think we can do this quickly."

"Please do," he said.

I grabbed a small pair of forceps from a suturing kit, cleaned off the head of his penis with antiseptic, reached in, blindly but gently fished for a bit, grabbed onto the bag and slowly pulled it out.

There it was, the corner entrapped in forceps -- a bag of crack. It slowly rolled out into full form, three nice little rocks.

"WHEW!" I heard him say. "THANK YOU DOC. I FEEL SO MUCH BETTER NOW."

"You're quite welcome," I said. "Do me a couple of favors. One, stop buying crack. Two, stop putting it in your penis."

"I can at least do number two."

Like I said, I love honest patients.

"Although I don't see any blood," I told him, "I'm sure you caused a little internal urethral damage by doing this. So I'm writing you a prescription for some antibiotics to prevent an infection and a follow-up appointment in urology clinic. Come back to the ER for any reason whatsoever -- more pain, you still have trouble urinating, bleeding, fever, pus, anything that concerns you. Any questions?"

"Just one."

"Shoot."

"Can I have that bag back?"

I raised my eyebrows. I actually thought about it for a second. He'd been through a lot already, and I have no business holding onto this bag. But then if I gave it to him, not only would it be ethically dubious at best, I think I'd also be guilty of distribution of a controlled substance. Nah, better not.

"I think not."

"Alrighty then," he said. "Have a nice day and thanks again doc!" And out he traipsed, walking quite comfortably.

With Kim the nurse as my witness ("What are you doing with that bag of crack?" she asked. "Long story," I replied), I dumped it into the needles-and-sharpies bin.

"Kim," I said, "now don't go fishing for this if you're not going to eat what you catch."