Merry Christmas Eve

I haven't posted in awhile b/c I've been off service for a month. Nothing interesting during that time really. But now I'm back in the ER doing a stretch of nights during the Christmas season. As usual, there's no shortage of craziness. Let's see.....

Last night:

An inmate from Riker's came to the ER with the chief complaint of "penis pain." His only past medical history was schizophrenia. So I gulped some coffee and went to interview him. Or I tried to, rather. He was so floridly psychotic that I couldn't -- no one could -- have a conversation with him. I felt very sorry for him -- schizophrenia is a horrible disease. He honestly could not distinguish between what is real and what is not; he was having constant auditory hallucinations. Basically, he said that he had been impregnated by aliens and that he would soon give birth to exactly 500 male-only babies that would emerge from his penis. However, they were all going to be premature and die. The only way that he could stop that from happening -- according to the aliens that were speaking to him and only him -- was to constantly masturbate so that the babies would stay inside.

And masturbate he did. Over the previous four days, he said he had been masturbating NONSTOP -- and based on what I saw, I believed him. I pulled back his sheet, and he penis was raw, skin was denuded, bleeding, and the area around the head of the penis was so swollen (the size of a small baseball), it was choking off the blood supply to the head of the penis (a condition called paraphimosis), and the head was starting to rot, pus was coming out.

"Don't touch it," he said. "You will make me give birth to my babies and I can't have that happen yet." And with that, he swatted me away and started to jerk off.

I briefly thought about admitting him to the ob/gyn service but thought that it might be frowned upon.

Anyway, I had to have his accompanying officers handcuff both hands to the stretcher to prevent him from masturbating. He cried, begged and pleaded with me to let his babies live. I made one futile attempt at reasoning with him, then admitted him to the urology, started him on antibiotics and he had to go to the OR. It took the staff psychiatrist less than five minutes to declare him legally incompetent and without capacity.

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Next up: a twenty year old kid who was out drinking with friends. They were walking back to Penn Station (ostensibly to go back to Jersey) when they came upon construction scaffolding. Mr. Stupid Drunk decided to grab onto the scaffolding and swing from it. The scaffolding crashed down on his head and down he went, lost consciousness for about five minutes, according to his friends.

He arrived fine, talking, no abnormalities on exam, no cuts, abrasions or lacerations anywhere. He was still drunk, and we CT'd his head. I was quite surprised -- he had a fairly large subarachnoid hemorrhage and was bleeding into his brain. In fact, the neurosurgeon had to come down and see if he needed to go to the OR (he didn't). But his status changed from stable to critical, so we had to make sure this belligerent drunk was calm, stayed in bed and didn't move.

Naturally he did the opposite of that. He was loud, obnoxious, and was trying to leave, saying his mom was going to be SO MAD.

So we strapped him down and then he said he was going to piss in his pants. It's the holidays, so we're understaffed -- there were no nurses aides to help him pee, and I couldn't allow him to get out of bed. So I did what I had to do -- unzipped him and held his wee-wee in place while he peed in a portable urinal. This is what I paid $200K for -- to go to med school and learn how to help someone pee. I'm sure my parents are so proud.

Well, his mother DID show up and she WAS pissed. I explained to her the seriousness of the situation, and she said, "I'm going to beat him silly when he sobers up."

"You can hit him anywhere except the head," I told her.

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Then the trauma phone (a/k/a batphone) rings. Someone hit by a car, but vitals were stable. I felt so terrible for this poor guy -- his car stalled, he was changing a tire, and another came by and swiped him. His right leg was almost 100% sheared off at the knee, and the other leg was crushed. Just in time for the holidays, too. As of this writing, the surgeons are still trying to put his leg back together.

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Another dude made a second trip to the ER in as many days for the same problem: left arm pain. He was here yesterday according to his previous chart, and he was x-rayed. After the films were negative, he was discharged with pain meds and follow up. In the intervening time, however, his arm became markedly more painful and now swollen from shoulder to fingertip. Looking at him, he was very thin, pale, cachetic and sickly-looking. On further history, it turns out that he had been losing massive amounts of weight and felt tired and lethargic all the time.

It's said that if you come back to the ER for the same complaint, you'd better fish some more. So I drew bloodwork on him and sent it off to the lab. There's not much in the differential diagnosis of unilateral upper extremity swelling, and in the absence of trauma, something much more sinister is going on. He was slightly tachycardic, so I gave him some fluids and pain medicine in the IV thinking that his pain was causing his fast heartrate.

The the lab called: his white blood cell count was 52 (normal is up to 12), and his d-dimer, or measure of blood coagulability, was sky high. And then, all of a sudden, his heart rate jumped to the 160s, but his blood pressure was stable. He was now in rapid atrial fibrillation with rapid ventricular response. It was a confusing clinical picture with many different symptoms: arm pain, swelling, high white count, rapid heart rate, now in atrial fibrillation.

Sir William Osler was a famous physician from the 1800s who came up with a general rule: if there are multiple complaints, the overwhelming chance is that there is one unifying diagnosis rather that multiple, discrete ones.

So what could this guy have? I wondered.

Think, think, think:

A *very* high white count

Hypercoagulable state

Thin, cachectic, unusual weight loss

Arm pain and swelling

Sinus tachycardia

Now in atrial fibrillation

One diagnosis.

Cancer.

It could only be cancer causing a blood clot and pulmonary embolism. Blood and bone marrow cancers cause your white cell count to skyrocket to those types of numbers. Cancer causes you to be hypercoagulable and get blood clots in your great vessels. Sinus tachycardia is the most-associated heart rate/rhythm with malignant pulmonary embolism. Atrial fibrillation is the second most common.

And as it turned out, his arm swelling was in fact the initial presenation of his lymphoma, and he had a fairly large blood clot in his arm and one in his lung.

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Back at it tonight.