Never Get Sick on the First of July

By Larry Miller MD

Never Get Sick on the First of July includes more than 100 of the most human, outrageous, memorable, and, yes, weirdest and funniest incidents of Doctor Miller's medical training at Chicago's Cook County Hospital, where he earned the Intern of the Year Award. While each is a story unto itself, the episodes trace his development as a physician and are woven together by his underlying philosophy emphasizing a personalized, and empathetic approach to patient care.

The stories are enriched by illustrating his thought processes and reveal tightly held secrets that until now only medical "insiders" knew. Readers will not only be entertained by the situation, but will also gain a rare understanding of the dynamics that give emergency medicine such powerful appeal.

Readers will learn how a mysterious headache was caused by a nail some "friends" had pounded into the victim's head, and find out how a patient got "lost" for three months on a surgical ward. Every story is a grabber; every one is true.

With the tremendous popularity of the television series "ER" (which took place at Cook County Hospital), you will be surprised to know what it was really like inside the nation's favorite emergency room. Doctor Miller's book illustrates what everyone should know before going to any ER, especially on the first of July.

• Language: English
• Publisher: BookBaby
• Release date: Aug 8, 2020
• ISBN: 9781098320348

Book preview

COPYRIGHT©

All stories contained herein are the exclusive property of Larry J. Miller MD and have been copyrighted© by Larry J. Miller MD in 1992, 1996, 1997 and 2020.

All rights reserved.

No part of this book may be reproduced in any form without written permission from the publisher and author.

Edited by: Charles Neighbors

Add Cover by: Mark Miller

ISBN: 978-1-09832-033-1 (Print)

ISBN: 978-1-09832-034-8 (eBook)

Contents

INTERNSHIP AT COOK COUNTY HOSPITAL

EMERGENCY ROOM

Patient Nailed for Cheating at Cards

You Better Know What to Do

Nurse McKernan - The Original ‘Hot Lips’

Them Parties Where ‘Friends’ Put Things Up Your Ass

Sarah Miller’s ‘Coma’ Cured by Threat of Brain Surgery

PID Shuffle Confirmed by Positive Chandelier Sign

Victim’s 26th Rape - ‘Every Time I Visit Sam’s Bar’

Don’t Listen to Patients Who Scream

Pelvic Exam Interrupted by Dislocated Jaw

The 24-Hour ‘Athlete’s Foot’

Mass Production Sutures - But Never Suture a Stab Wound

Cop Aims Pistol at My Privates, While I Suture

New Coma Treatment Successful but Breaks Man’s Legs

Baby Born Under Taxi Cab at Night

Leg Ulcer Treated by Maggots Ruins Rice Soup

Searching for a Fractured Skull in the Ghetto

Squadrols - Precursor to Paramedics, But Hold on to Your Wallet

‘Just Sign the Death Certificate’

Murder Victims Disappeared from the Official Count

Dennis the Cop Makes Busts to Sell Pot

Speck Found in ER After Police Ignored Him

Entrance Wound but No Exit Wound and No Bullet

‘She’s Not a Bad Woman — She Just Has a Bad Temper,’

Abused Husband

Friends and Relatives are The Most Dangerous

(Warriors Need Zippers)

The Hose-Down Room - Sheepskin Mitt and a Towel

‘Jesus Told Me to Do It’

Mysterious Deaths Traced to Clustering of Independent Ice Picks

(the Cross of Death)

Man Attempts Suicide Because of Multiple Failures; And Fails Again

Woman in Labor Screams, ‘I Am Not Pregnant!’

GOMERs – Their Q Sign is Worse Than Their O Sign

My Compulsive Quotations Sent Me to the Black Panther Grand Jury

BLOOD BANK

Woman Loses 93 Pints of Blood

Blood Bank Checking and Savings Accounts

Cash Deposits Required for Hernias

Your Blood for a Visit

Embezzlement Ends Career of Prominent Surgeon

Suture Removal Delayed Six Weeks

THE HOSPITAL

I Was Astonished

The Best Care and The Best Training

Automatic Elevator Operators Make More Money than the

Chief Surgeons

Physicians

Rotations

MEDICAL WARD (Depressing But Not Hopeless)

Filipino Nurse Wakes Me at 4:00 A.M. for an ‘Itch’

Gypsy King’s Family Sleeps in the Hall

Tunnels and the Abandoned Patient

The Yellow Indian

Luke’s Pickled Brain

Diabetic Coma Cured in 8 Hours — Infuriates Chief Resident

The Intravenous Cast

Always Operate if a Patient Vomits 8 Pints of Blood

GOMERs Dumped - Families Chased

Doctor Bernstein Urinates on Patient to Facilitate Transfer

Stroke Cured by Reducing Dislocated Jaw

Heroin Addict Gets His Fix While Undergoing ‘Cold Turkey’

(Every Junkie’s Dream)

45-Year-Old ‘Crock’ Suddenly Dies in My Hands

THE LABOR LINE

I Was Blind Doing Pelvic Exams

Fight for Twins Cleverly Staged

Doctor Happy Claims ‘All Americans Look Just Alike!’

Doctor Smith Tries to Induce Labor on Me,

While I Sleep in the Pit Room

12-Year-Old Takes Teddy Bear to Delivery

Baby Named ‘Placenta Previa’ Paging ‘Doctor Frank Breech’

Tires Stolen During Delivery but Returned On Demand

ORTHOPEDICS

Read the Book, Apply the Cast; We’ll Fix it in the Morning

Interns Required to Solve ‘Prosthetic’ Shortage

The Penis Always Points to the Fracture (Throckmorton’s Sign)

Patient Wanders Naked Down Eisenhower

Expressway at 10 Below Zero

‘My Next Girlfriend Will Have to Live on the 1st Floor!’

UROLOGY

Why ‘Mad Merin’ Solicits All the Nurses, All the Time

Circumcision Ruined by a ‘Kiss’

Superintendent of Schools Gets Caught by a Wrench

CONTAGIOUS HOSPITAL

Orion, Green Spots and Decorating

The Hill Fine Arts Center and the Family

PSYCHIATRIC WARD

Patient Claims, ‘I Lost Millions Because Everyone Was Against Me’

Saved from 4th Floor Ledge

PEDIATRICS

Kids Hide Behind Mothers or Risk Mean Old Doctor’s Needle

Teathers and the Magical Black Light

Eating Plaster - Must Taste Good

Puerto Rican Baby Dies In My Arms - Parents Devastated;

(Too Little, Too Late)

OUTPATIENT

The Man Who Lost His Nature

English-to-English Dictionary Even for U.S. Natives

The Man Who Kept Breaking His Cast

Neurosurgeon Hypnotizes Nurses and Medical Students

SECURITY

‘Breaking and Entering Not My Responsibility’

Doctors’ Parking Lot - Not a Safe Place for Your Car

OUTSIDE THE HOSPITAL

Al Clements Falls Through ‘El’ Tracks

Bargain Argyle Socks and The Suit that Could Not Be Dry Cleaned

Five Felonies Witnessed in One Hour

Two Minutes to Escape

I Almost Missed Dinner in My Honor (Intern of the Year)

PUERTO RICO

PUERTO RICO - A DOCTOR’S CAMELOT

SURGERY RESIDENCY AT COOK COUNTY HOSPITAL

Never Get Sick on the 1st of July

The Lost Chicago Bear

Doctor Meyer Lives on the Sixth Floor

Swarms of Green Bugs in the O.R. – Wounds Look Like Christmas

Crash Corley Breaks Records But Loses Fingertip

Anesthesiologist ‘Decides’ to Bend Rules for Locked Bowels

They Slip In, but They Don’t Slip Out

The Great Breast Bust

Belly Dancer Risks Death Rather than Ruin Her Belly -

Doctors Demand Free Tickets

I Turn Down Diamonds, but Say Yes to a Shirt

Poison Arrow Revenge

‘You Can’t Fool Me, I Have Pid!’

Decubiti and the Circular Bed

RETURN TO THE EMERGENCY ROOM

Mac Outsmarts the Intern

You Want Your 13 Hemostats Returned Where?

Nurses ‘Attacked’ Me, but I Found My Beeper

‘KNIFE AND GUN CLUB’ AT WORLD’S FIRST TRAUMA CENTER

Eight Chest Tubes Inserted In Two Hours

Twenty-Six Critically Injured Patients Await Emergency Surgery

I Invent a New ‘Needle’

Transvestites Abused

Stab Wound Returns

BURN UNIT

Forty-Two Victims from Fire-bombed Bar

The Two-Hour Bandage Change

Patient Has 24 Hours to Settle His Affairs

The Late Terrifying Commute Home

Medical Students Attacked Despite Claiming,

‘We’re Not White, We’re British’

‘Alonzo - Do NOT Land on the Dan Ryan Expressway!’

My Infant Son Abandoned on the Beach

I Left Cook County Hospital in Shambles

SAYINGS, RULES, LAWS

ABOUT LARRY J MILLER MD

DEDICATION

Over the years I have worked with hundreds of nurses, most of whom were friends as well as mentors. They have been my eyes, ears, hands, and feet, and my confidantes. Many times they saved me from an error in medication, pointed out an oversight of an obvious diagnosis or alerted me to problems I was unaware of. Although performing a different role than theirs, I have always viewed nurses as equals in the professional care of emergency patients. Their years of experience and sensitivity to patients have given nurses a sixth sense that is far more valuable than any laboratory analysis.

Most emergency nurses are highly motivated, dedicated, competent, and caring. They reinforce my instructions, prepare patients for treatments I have to render, and assist with procedures I could not accomplish alone. Without them, I could not possibly provide the level of medical care patients have come to expect.

These nurses often work under adverse conditions. On swing shifts, they switch from days to nights with little time to readjust their biological clocks. Theirs is one of the highest-stress occupations, where their decisions and accuracy often mean the difference between life and death. They deal constantly with patients who are agitated, frightened, and often on their worst behavior. Nurses competently handle throngs of demanding patients, all wanting to be seen first. Not only do nurses triage patients, identifying the most acutely ill, but they must also prioritize their work. Keeping one’s sanity in such a chaotic environment is a monumental task.

Compounding their problems, nurses must deal with doctors, many of whom have ego problems (the God complex), are rude and tend to treat nurses like subhuman servants; not exactly what you’d expect from the individuals who should most appreciate their competence and indispensable function. Besides the disrespect shown by some doctors, nurses are treated like fast food employees by hospital administrators who have historically underpaid and undervalued their essential services. The immense gap between nurses’ and doctors’ incomes is a national disgrace.

The ultimate insult too many times originates from nursing supervisors, who seem to ignore their own experiences as staff nurses. Instead of making their subordinates’ jobs easier and more productive, these nurse managers often burden their staffs with irrelevant, inflexible policy requirements and bureaucratic charting nightmares. No wonder we have a crisis caused by a shortage of experienced nurses.

Nurses who have survived such difficult working conditions have earned my utmost respect and admiration. For those who have shared with me many of life’s most precious and rewarding moments, as well as some of the most devastating and shattering experiences, I feel a tremendous debt of gratitude and deep affection.

To these valiant women and men, I dedicate this book.

I.

INTERNSHIP AT COOK

COUNTY HOSPITAL

EMERGENCY ROOM

Patient Nailed for Cheating at Cards

The young man stumbled into the ER holding his head, moaning and complaining of a horrible headache. He looked sick. (Over the years, I have learned to trust this look: dull eyes with droopy eyelids, an inanimate expression, gray skin tone, cold sweat, listless movements of the head and extremities, and an almost monotone voice. You can’t really document medical problems based on appearance, but over all, this look always spelled trouble to me.) After searching my memory for diagnoses of headaches, I proceeded to work up this patient (complete a medical history, conduct a physical exam, and initiate a battery of lab and diagnostic tests to determine what caused his problem). I asked him what happened.

It all began about three days ago when I was playing cards with my friends at a party. I had some extra cards up my sleeve so I’d be sure to win. When they caught me cheating, they were really mad. They said I’d never cheat again and they started beating me up and pounding me on my head. The next thing I remember was waking up in the alley the next day and I had this horrible headache and it’s getting worse. Doc, everything looks blurry, it’s hard to walk. I’ve been throwing up.

Good grief, I thought, these are all signs of a skull fracture or a subdural hematoma (bleeding into the brain). Something serious is going on with this fellow. I examined him very carefully like the eager intern I was. When I checked his pupils they reacted normally, so I performed a neurological exam, checking his balance and coordination, examined his scalp for bruises, looked in his ear for possible bleeding and found nothing. His physical exam checked out fine except he felt awful, was vomiting, and he had a terrible headache.

Still baffled, I sent him to radiology for skull x-rays. X-ray orders had to be handled cleverly at Cook County. If you wanted a patient processed quickly, you tied a red tag to the patient’s toe (or somewhere). Red-tag x-ray patients would probably be back in a few hours. That was considered fast. No red-tag and they might be gone for 12 hours or more just waiting their turn because there were so many patients. Several times I sent a patient for a routine x-ray just before getting off my shift, only to find the patient had not returned yet the following day when I started my next shift. I knew my headache patient needed a skull series fast, so I tied a red tag to his toe.

An hour or so later, Head ER Nurse McKernan called me, alarmed. Miller, come here quick. I ran to the view box. A 3-inch nail was clearly visible, driven straight into the top of my patient’s head. On the AP (anterior/posterior or front-to-back) view, you could see where this guy’s friends had struck him dead center and the nail penetrated right between the two sides of his brain.

I raced back to the patient, totally amazed he was still alive, and examined his scalp more carefully. I gingerly picked through his thick Afro hair and, sure enough, spotted a tiny scab. When I scraped it off, I saw the shiny head of the nail! I explained what had happened to my patient, but he could not believe his friends would pound a nail into his head. To convince him, I had to show him the x-rays.

No wonder I have such a bad headache, Doc, he groaned.

I called a skeptical neurosurgery resident who, after taking one glance at the x-ray, rushed the man into surgery, opened his skull, pulled out the nail, and placed him on antibiotics. To everyone’s amazement, the fellow survived and went home 10 days later. Of the thousands of headaches I have treated over the years, this one was the most bizarre, caused by cheating at cards.

You Better Know What to Do

From day one, my University of Michigan Medical School professors repeated this imprecation: Remember this lecture because on the first day of your internship you might be assigned to the emergency room and you might be faced with this situation and you’d better know what to do. That always got my attention. I took that advice to heart.

When I checked in at Cook County Hospital for my internship on The 1st of July, 1965, I could have been assigned to any one of twelve different departments. Sure enough, just as my professors had predicted, my first assignment was the emergency room, and not just any emergency room. This was one of the largest and busiest trauma centers in the world, treating more than 1,000 patients every day.

The emergency room at Cook County was a huge, sprawling facility encompassing an entire city block. It was divided down the center into female and male sections, necessary because of the total lack of privacy in this high-volume ER. When I walked into the first floor of the hospital, following arrows pointing to the emergency room, I saw throngs of people colliding with each other, stampeding through the doors and swarming the information desk. It was like Christmas Eve at Marshall Fields, except these people were not in a holiday mood. Many were bleeding or crying and they all seemed desperate. Nurses, doctors, orderlies, and aides worked their way through the crowd, running in every direction, ignoring pleas for help. Police were dragging in thugs in handcuffs. Stretchers transporting the critically injured were being pushed to treatment areas, knocking people out of the way. Blood was everywhere. People were screaming and dying. It was a war zone. Seeing my crisp white uniform, patients tugged on my shirt to ask for help. I was no help. I couldn’t even find my way to where I was supposed to report.

Finally, I saw a nurse who looked as if she knew where she was going. I followed her through a door that said NO ADMITTANCE. Whenever you’re trying to gain access to something, these warning signs usually lead the way. For example, if you need to get inside a TV cabinet, just open the panel that says do not remove these screws. When she reached her desk and picked up some charts, I caught up with her. Excuse me Nurse. Do you know where the new interns are supposed to report?

Yep, right here, she said, handing me the stack of charts in her hand. Go see these patients.

What have I gotten myself into? I thought. Who are these patients? What am I supposed to do with them? What if they need medication or surgery? Is there anyone here to help me? What do I write on the chart? My heart was racing. I was excited about starting my internship, but now I was terrified at being thrust into bedlam without a clue. Shouldn’t I get some kind of orientation? I had no time to worry about such details because the nurse opened the door and patients streamed in.

Nurse McKernan - The Original ‘Hot Lips’

The 1st of July, my first day of internship at Cook County Hospital, proved I had come to the right place for the best hands-on medical experience. From the beginning I was in the midst of all the drama and the action in one of the busiest emergency rooms in the country. Fresh out of medical school, I was up-to-date on the latest technology, treatments, and diagnostic procedures, well aware that my major shortcoming was patient experience. In the span of one day I was transformed from a medical student into a real doctor with real patients. Never before had I been totally in charge of any patient’s care from diagnosis to treatment. Cook County patients were totally unlike those I had seen in medical school, who had all been worked up by residents and attending physicians before they ever got to me. Besides, at the University of Michigan Hospital I was only examining them for training purposes.

At Cook County I was confronted by real life or death emergencies where the patients were depending on me alone. With pressure to keep up with the relentless patient flow, I could spend only so much time with each person or I would have to neglect 10 others. I had to evaluate each patient quickly, make a medical decision, order treatment, and get that person moving.

Man, I was excited about treating these people, eager but terrified, knowing that I would soon get in over my head. Junior and senior residents were available to consult with if we beginners ran into problems. Once in a while, a resident would stop by to see what we were doing, to make suggestions or criticize, and sometimes to give us a pearl (a little gem of knowledge we could store for later use). I cherish the thousands of pearls tucked away in my treasure chest that have saved me from time to time and been of great benefit to my patients, too.

As I worked through that first chaotic day in the ER, I began to study how the other interns were handling difficult situations. I watched how the nurses dealt with problems and observed the interaction between other interns and the nurses. Many of the interns were arrogant — barking orders to the nurses, fighting with them over procedures, and in general establishing rules about who was the doctor and who was the nurse. Their attitude: I’m not going to be shoved around by some nurse. After all, I’m the doctor.

Despite these arrogant neophytes, the nurses seemed unfazed by all the frantic activity. They had been around for a while and seen many crops of new interns pass through the ER on the 1st of July each year. If things got too sticky, the nurses complained either to the chief resident or to Karen McKernan, the chief nurse. Of all the people I worked with in the men’s emergency room (interns, residents, attending staff, orderlies, staff nurses), it was clear that the real boss was Nurse McKernan, known to everyone as Mac. Whatever Mac said was law. When Mac spoke, everyone listened — everyone, except some of the cockier interns.

Nurse McKernan had been in charge of the Cook County emergency room for more than five years. Street smart, she had seen thousands of gunshot and stab wounds and knew what to expect and precisely what to do. Mac was an attractive 27-year-old with blond hair and a loud mouth, who — some years later when the TV show MASH was popular — would forever be associated in my mind with the character of Hot Lips Houlihan. But it was Mac’s medical knowledge I was interested in, not her hot lips. Unlike some of my colleagues who were trying to prove a point by establishing their primacy over the nurses, I wanted Mac on my side. I figured she could save me from disaster. If she’d pass on her secrets, I’d be a better doctor.

Later that first day, I went up to Mac. After work tonight I’d like to talk to you about the emergency room.

Sure, she said. Meet me at The Greek’s around seven.

The Greek’s was a restaurant/bar right across the street from the main entrance of Cook County, and was the doctors’ and nurses’ favorite place to unwind. Affectionately, we called it The Recovery Room. It was a huge 50s-style diner with a long u-shaped counter in the center. Tattered booths lined the walls. TVs mounted near the ceiling gave out as much light as the colorful neon beer signs on the walls which seemed to be the only source of lighting. The chatter of the patrons competed with the blare of the Cubs latest defeat.

I was so high after my first day in the ER I literally bounced across the street into The Greek’s. Mac was in a booth with a long-haired blonde nurse named Judy and Judy’s boyfriend, Roland Link, a first-year surgical resident. As they made room for me to squeeze into the booth, I said, Mac, I’ve seen more today than I saw in four years of medical school.

We had a lot to talk about, beginning with the man who was nailed for cheating at cards. Was this an unusual day? I asked.

Mac said, Hardly a day goes by that something spectacular doesn’t happen. She began to tell story after story: shootings, stabbings, cardiac arrests, asthmatics who died in the waiting room, and heroin overdoses.

I was so spellbound I was startled to realize it was past 11 p.m. and I had to leave if I wanted any sleep at all before my next shift. I got to the point. Mac, I wanted to see you tonight to ask for your help.

Somewhat taken aback she was nearly incredulous. You want me to help you?

I spelled it out. Yes. I have no clue what I am doing. I have a good medical education, but my experience doesn’t hold a candle to yours. You’ve seen it all. I want you to teach me your tricks of the trade. I want you to point out my mistakes and show me interesting patients and unusual x-rays. I want to learn everything you know. I want to leave Cook County being the best-trained doctor who’s ever gone through this place.

She grinned and without hesitation, replied. Sure, Streaker, I’ll help you. I like your attitude. We’ll make a great team.

She called me Streaker because I had brought a copy of the Chicago Tribune to work. On the front page was a photo of four tourists streaking through a small Mexican town stark naked. A popular craze of the sixties was for a group of Americans to visit a small Mexican village, take off all their clothes, hold them in their hands and streak through the village as startled bystanders stared with amazement. After streaking through the village, the tourists would dress and move on to the next little town. I thought that was hilarious and Mac and I had some good laughs over the article.

Let’s streak through Michael Reese’s emergency room some time, she suggested. (Michael Reese was the high class hospital a few blocks up the street from Cook County.)

Sure. Why not? I only agreed because I didn’t think she was serious. However, after getting to know her better, I learned she was dead serious about streaking. During the four years I knew her, Mac always called me Streaker.

My apprenticeship arrangement with Mac paid off handsomely. Whenever an interesting patient came in, she would come by, quietly tug on my sleeve and say, Come here, Streaker, I’ve got something to show you. She’d say I’ve got a bad asthmatic you have to see right away. You need to give him some epinephrine.

How much?

0.5 ccs of 1/1000.

Or she’d say, I’ve got a stab wound that’s going downhill. You need to see him right now! Or I’ve got a patient with appendicitis. She was always right. I would walk to the patient and say, Sir, you have appendicitis. They would be amazed at my clairvoyant ability because I had not even examined them yet.

Mac, how do you always know when a person has appendicitis?

I watch how they walk in, lie down and hold their side and, when I poke the right side of their belly, they harden up like a rock.

Besides being a walking medical encyclopedia, Mac was a lot of fun. She was always laughing and telling jokes, a necessity for keeping your sanity in such a mad house. She liked working with me because I let her do things the other doctors wouldn’t. She might say, I’ve got a guy over here with pain in his belly. Is it all right if I get some x-rays, lab work, start an IV, and give him some Phenergan for nausea?

I had so much confidence in Mac’s ability I usually said, Go ahead.

Mac was a practical joker, too. One evening she called my beeper and said, Streaker, meet me at The Greek’s for a drink.

I declined. Mac, I’ve been working extra hours on this rotation and I need some sleep. I’m going to my room.

I was in a deep sleep when Mac and a couple of her friends began pounding on my door. What do you guys want? I asked as she barged into my room with an IV bottle of 5% alcohol, some long IV tubing and needles. The other nurses had drinks in their hands. (We used the intravenous alcohol to stop premature labor. At that time, it was the treatment of choice for stopping labor so small babies got a few extra days to mature before delivery. Since then we have found better drugs that don’t cause alcohol’s side effects.)

Mac said, If you’re too tired to come drinking with us, then we’re going to come drinking with you. We’re going to start an IV of alcohol so you can ‘drink’ while you sleep. She slapped a tourniquet on my arm and began rubbing my forearm with an alcohol swab.

Oh no you don’t, Mac! You’re not starting any IV alcohol on me. I don’t care how tired I am, but you’re not giving me intravenous alcohol! I’ll go to The Greek’s with you.

Amazing how little sleep you need when you’re having fun.

Them Parties Where ‘Friends’ Put Things Up Your Ass

I never knew what bizarre twists I’d encounter when I came to work. Each patient had a unique story, but I could seldom guess what it was until I began my examination. James’s chart simply noted lower abdominal pain. I asked him what was wrong and how I could help.

Well, Doc, I went to one of them parties last night. You know — you’ve been to them parties, Doc.

What kind of party are you talking about?

You know, them parties - where your friends stick things up your asshole.

As a new Chicagoan having just arrived from Ann Arbor, I could truthfully say, I’ve never been to one of those parties, James. I’m not sure I’ve even heard of them.

Well, yeah, Doc. They put something up my asshole and now I can’t get it out.

Do you know what your friends put up your rectum?

What’s a rectum? Maybe that’s what they put up my asshole!

Well, I thought, this guy is a real weirdo, but he does need help. So, I put on a glove to perform a rectal exam to see if I could find the mysterious object. I remembered my anatomy professor’s words, The anal sphincter (circular muscle that closes the rectum) is the smartest muscle in the human body, even smarter than the thumb. It can distinguish between solid, liquid and gas. However, the sphincter does some strange things when approached by an examining finger. It tries to hide. It is usually difficult to get the sphincter open to admit the lubricated glove and once inside, the sphincter clamps on your finger like a vise. Doctors often exacerbate the problem by being rough and in a hurry. To make a difficult exam a little easier, I always try and get my patients to relax by talking them through the procedure and by being gentle. After all, the exam shouldn’t hurt because an examining finger is narrower than the average stool. But the psychology of a rectal exam turns the smartest muscle in the world into a cowering spasm.

Unlike most rectal exams, when I approached this guy, his sphincter opened easily and almost sucked my finger inside. He seemed to be enjoying the exam. His prostate was normal and he had no hemorrhoids or tumors lining the rectal wall. James, I can’t find anything in your rectum.

He insisted. Doc, I know something is up there! Keep looking.

We’ll have to take an x-ray to look farther than I can reach with my finger. I sent him off to radiology.

Several hours later, Nurse McKernan shouted, Hey, Streaker, get over here quick. Mac was lucky, she got to see all the x-rays before anyone else. James’s x-rays were hanging on her view box. Just beyond the reach of my examining finger in his lower colon loomed a huge screwdriver. Fortunately for his colon, the handle went in first. Unfortunately, that was why it did not want to come out.

I called the surgeon and told him I was referring a patient whose friends had literally screwed him. The surgery was uneventful, but I decided right then never to go to one of them parties.

Sarah Miller’s ‘Coma’ Cured by Threat of Brain Surgery

Sara Miller was brought to the emergency room by ambulance on September 1st, my birthday, and the first day of my rotation in the female emergency room. I’ll never forget Sarah because we shared the same last name. She was totally unresponsive. One of the most baffling medical emergencies is the person in a coma who has no available medical history. There are many possible causes of coma, ranging from head trauma with bleeding into the brain to metabolic abnormalities like diabetes and drug overdoses. To help us unravel such mysteries, we have a series of decision points (algorithms) and actions to be taken based upon examination findings.

I shook her and yelled right into her ears and she never even flinched. There are various levels of coma, which doctors rate on a scale of 3 to 15 (the Glasgow Coma Scale), the lightest level responds to a loud voice or other noise stimulation. Deeper comas respond only to sharp pain and the deepest grade responds to no physical stimulation. You could do open heart surgery on those people and they wouldn’t stir.

The first step emergency physicians are taught to take with coma patients is to make sure their airway is clear and their breathing is adequate. Sarah was breathing normally, so I proceeded with the next level of evaluation. I pricked her feet on both sides with a needle. She didn’t flinch. I made a fist and rubbed my knuckles up and down on her breastbone (a procedure called the sternal rub) and I placed my thumbs in the grooves of her upper orbit (that particularly painful stimulation forever immortalized in my medical-school memory as the Arab Eye rub). Not a twitch. Sarah was in a deep coma. Sarah’s pupils were equal and reacted to light, her reflexes were normal, and she did not demonstrate the dreaded Babinski reflex (the big toe raising toward the head when the bottom of the foot is roughly stroked — a sign of brain damage). Her vital signs were good — her blood pressure normal, her pulse strong and regular, her respirations satisfactory. I continued a general medical exam and found her heart was normal, the lungs clear, and her abdomen soft with no masses or fluid present. Upon further examination, nothing abnormal surfaced.

At that point in Sarah’s evaluation, I ordered laboratory tests to determine her blood count, blood sugar, and asked for skull x-rays. I had just given the charge nurse orders to begin the tests when Robert Boswell, MD, the chief resident, walked in. Oh, look. It’s Sarah Miller, he said. He obviously knew this patient well. "Doctor Miller, quick, hand me a