The ER: One Hundred

By Rade B Vukmir

We try to learn from every patient, to help them get better and to facilitate understanding of their health and the progression of the disease process impacting both body and spirit. This book allows one to understand the human interface with the diagnostic process.

Summary

The Emergency Department(ED), or Emergency Room(ER) as i

• Language: English
• Publisher: Dichotomy Press
• Release date: Jan 14, 2016
• ISBN: 9781944351175

Rade B Vukmir

Rade B Vukmir MD, JD is an American Physician, who has contributed extensively to emergency medicine and critical care medicine practice in clinical, academic and innovation arenas. Likewise, a dual professional degree involving both medicine and law has allowed impact in medical professional liability, risk management and patient safety initiatives.

Book preview

Chapter 1

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Gland Trouble

She was pleasant and cheerful. Her mom said that she had right-sided abdominal pain. They looked almost alike; the young child and her mom. She was 13 with a pleasant, smiling face and dark hair. She and her mom looked just alike at this age; it’s a little bit too early for that.

Testing performed by her physician suggested that she had mesenteric adenitis, or swelling of the lymph nodes around the bowel, which can sometimes be seen in young children. She was a robust, ample girl: an adult frame with a child-like thinking process.

At first she wanted me to find the problem but then she changed her mind and wanted to go home. At times tearful and at times happy. It just did not look right.

I asked Mom if she had had any other health problems or if these changes were late.

Mom said, You know, she put on all this weight on in the last few years. Society’s observation was that she was obese because of overeating, I’m sure.

I asked her, Did your primary care physician evaluate her for the infamous ‘gland trouble’ that people often invoke when they are overweight?

Mom said, You know, I asked my doctor about that, but he didn’t seem to have anything to add there. As I evaluated her large frame and coarse features, I noticed her facial hair was inappropriate for someone of her age and of the fair gender. I told Mom that I was almost certain that she had an endocrine, or glandular, cause for this difficulty.

I called it a difficulty—a sterile, scientific version of her life that I was sure would be perhaps difficult now, but almost certainly difficult later. Mom knew I was sure. I sent off laboratory testing, including a ratio of luteinizing hormone (LH) to follicle stimulating hormone (FSH), and sure enough, these two hormones were out of whack, giving her an almost certain diagnosis. I asked the primary care cross-cover physician if I could refer the patient to the endocrine service and she offered that the primary care physician could take care of it.

I said, "Well, unfortunately, it sounds like Mom planted the seed here, and I am not certain there was recognition. I would really want to make sure that the proper diagnosis was made.

The physician said, You know, you are right; to hell with it. Go ahead and make the referral.

Don’t worry, she said jokingly, in the ER. Nothing you can do is right; don’t you know that by now? she added with a twinkle in her eye as she laughed and moved around the corner quickly.

I said, That is a good observation, from the other side as everyone left happily.

The patient—well, she seemed almost gleeful now; there was a reason things were not right in her life and, perhaps more importantly, now there was a solution. Mom sat quietly confident that her suspicions were substantiated as well, and again, a hope for her daughter to be better. I hope things worked out for her.

Polycystic Ovary Syndrome (PCOS)

Those of you with a background in medical training have probably guessed it by now: she indeed had Polycystic Ovary Syndrome (PCOS), an abnormality in the ratios of luteinizing and follicle stimulating hormones. These are the female hormones that regulate the ovulation or egg generating cycle. The patient is sometimes left with an excess of male hormone testosterone, resulting in masculinizing features such as facial hair, increased weight abnormalities, and problems with the processing of glucose, resulting in a diabetic predisposition.

Obviously, this configuration of symptoms is problematic in an adolescent or teen, requiring hormonal assessment and rebalancing if possible.

Chapter 2

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A Tired Heart

This patient’s case did not strike me as a particularly joyful one, but later as the day wore on, I learned to appreciate its subtlety and its tenderness.

The call crackled over the radio: cardiac arrest patient, elderly female, PEA; standing for pulseless electrical activity. This is commonly known as a dying heart rhythm and very few patients actually survive this event. They typically get a few rounds of cardiac resuscitative medicine and maybe a chance of electrical cardioversion, but the result is usually the same—very few survive.

In this particular case, I found a thin wisp of an elderly female. She had the endotracheal or breathing tube placed by the paramedics. It was wedged into a plastic restraint-like device that looks almost medieval in nature. There was a second-year resident there, young and smart, a confident hard charger. I surveyed the situation, asked him to check the placement of the endotracheal tube, and to assist in managing the remainder of the code event. It went on for another few minutes, but the result was as we expected—she had certainly ceased to breathe long ago.

The paramedics now began to weave the tale. The son was home with her; he had just gotten her up to watch the football game. The local team was playing for the AFC championship, and even this patient with debilitating heart disease and dementia would have one more rally to watch the championship football game. When she began to head south, the son called her doctor for advice, but by then it was too late.

As we milled around the desk, I noticed a youthful-looking elder gentleman with a black baseball cap and a thin nylon jacket that one wears to avoid the warmer bulky coat of winter. I was uncertain if this was by choice or from an inability to afford a heavy winter coat; I couldn’t tell which. I remembered my own mom—she never seemed to have a warm coat of her own. I was never really sure of that reason either. When I put one hand on his shoulder to usher him back to the family care area, he looked up and looked away from me, and seemed to know already.

I said, Sir, you know she’s gone, don’t you?

As a tear came to his eye, he said, I knew that she was.

I said, Come back with me and let me get you a phone so you can make some calls. I sat him in the back.

He said proudly, I cared for her, you know.

I said, I know that, sir. I recognize that.

She was getting ready to watch the football game. We were going to watch the football game together.

I said, I know; I believe you sir; that was kind. Sir, there wasn’t much we could do. I think her old heart just got tired. The important thing is that she was at home with you, in her own house, in her own bed, with her family, and not off in some nursing home or with strangers. He seemed to nod approvingly. I guess he never thought about it that way.

I said, Sir, let me take a second; I want to make sure it is ok for you to stay with her.

As I went back to talk to the nurses, she had been prepared, but as I looked into the room the endotracheal tube was still protruding from her mouth. This is routinely done in death until it is decided if the patient is a coroner’s case or not.

I said, Oh, for the love of God, this elder female’s cause of death is as natural as it comes, as I called the coroner and quickly removed the breathing tube. At the end she really looked content and peaceful. Her son would appreciate that; that’s all you can take from this world at the exit from this veil of tears. I congratulated him on the great job he did caring for her at home, surrounded by family in her own house when she left this world.

He nodded approvingly, I guess we did ok, he said.

You did indeed, Sir; I’m sorry for your loss, as I’m sure he felt vindicated in this endeavor.

Pulseless Electrical Activity (PEA)

This patient presented with Pulseless Electrical Activity (PEA), a description used when the heart’s electrical activity continues generating a heart rhythm as it would appear on the tracing over the bed, but with no mechanical activity or pumping of blood. Often it is a sign of a tired heart and there is very little we can do to aid recovery for this end-of-life rhythm. It is funny that even when the heart weakens it still desires to go on as the electrical circuits continue to fire, even if the old pump doesn’t work any longer, as the fire goes out.

Chapter 3

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The Dance

As I entered the room, it was a tough audience; the nurse had already prepped me, suggesting Mom was a nurse wanting to know who I was, what my qualifications were, and if I was good enough to care for her daughter. The nurses reassured them that I was probably ok.

As I went in to see her, she was pleasant, blond hair cut short, parted in the middle with precision. She had been presented to me by the nurse practitioner, who had suggested that she had a rash due to a virus or some drug effect and wanted to put her on an anti-inch medicine, but didn’t opt for any diagnostic testing to be done.

The nurse practitioner said, I’m really not sure what it is, but I think I’ll just send her home on this medicine. Do you want to take a look?

As I went in to see her, she smiled—a pleasant, peaceful countenance. I asked her what had been going on as she then jerked her lower extremities in a way that was dysphoric to her. No, it was not feigned like some patients do; she just intermittently jerked.

She said, You know, it’s even waking me up at night. It’s only in my legs; I don’t understand it. As I gazed at her and thought about this, I said, God, I haven’t seen this in 20 years.

Seen what? her mother asked.

I asked some further questions. Had she had a recent cough or cold?

No.

A sore throat?

She said, No, although this would have been the usual association.

I asked, Do you work with kids?

She said, I am an elementary school teacher and a lot of my kids have been sick. Now it starts to crystallize—the fever along with the potential strep exposure.

The condition afflicting her here was Sydenham’s chorea, an abnormal muscle contraction condition that is based on the streptococcal toxin that can be produced in patients with a recent streptococcal bacterial infection.

What can we do? she asked.

Well, we will get a couple of tests and make sure things are ok, but antibiotics will probably help, and some other medicines can stop the spasm condition. You probably won’t like any of them; one might make you a little loopy, I said as we joked.

No, I don’t want that one.

I gave her benzodiazepine, a muscle relaxant medicine, to help her sleep at night, as mom nodded approvingly.

What did you call that thing again? she said.

Sydenham’s Chorea—St. Vitus Dance

Sydenham’s chorea, often called St. Vitus dance, is typified by rapid jerking movements of the feet and hands. It was a common condition long ago when less antibiotic treatment occurred, and therefore more streptococcal disease was present in the population; it was an accompaniment to rheumatic fever. We just don’t see it that much anymore with so much antibiotic treatment in the environment for most sore throats and upper respiratory complaints.

Typically a disease of children, it can occasionally occur in adults as well. Treatment includes administration of antibiotics to eliminate Group A beta hemolytic streptococcus, antispasmodics to decrease uncomfortable movement, and immune therapy with steroids to decrease inflammation.

Chapter 4

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Stroke

She seemed tired and weak. Her daughter stated that she wasn’t eating or drinking for the last few days. The patient made a feeble attempt at a smile. She had obvious left-sided dysfunction and neglect, probably from an old stroke.

Another person turned up quickly. It was an OR nurse and she thrust her hand out. Oh, you must be new, she said.

I said, In some ways, yes, and in some ways, no.

Well, I haven’t met you, she said.

I said jokingly, Well, I haven’t met you either, so I guess we are pretty much even.

She still had her operating room cap on with a characteristic look of a seasoned OR scrub nurse. Hair is often pulled up tightly, a mask often on, and a tendency towards well-delineated eye makeup, rather than softer tones. This is the last remnant of aesthetic appeal trying to break out while wrapped under a sterile mask and gown. I’m me, she said figuratively.

As I went back to getting the rest of the medical history I asked the daughter if the symptoms had changed.

No, she replied. She had a stroke last July. It’s been about the same—no better and no worse.

I said, Well, she does indeed look dehydrated. We’ll get some laboratories, start some fluids, and hopefully get her nutritional state improved.

As I reviewed her CT scan, however, I got an excited call from the radiologist. He stated that the entire right side of her brain, which controlled the left side of her body, was involved in an abnormal presentation. It looked most likely like a glioblastoma, an aggressive brain cancer.

How would I present this to the family? I worried about being the new doctor and having her primary care physician and other specialists monitoring her health conditions.

It then popped into my head.

Ma’am, I suggested, I’ve got some news, unfortunately. We have noticed on the head CT that there is something a little abnormal—a mass, perhaps.

Is it brain cancer, do you think?

Yes, unfortunately, that is one of the possibilities.

How long has it been there? she said.

I said, Well, it’s hard to tell, but think about it this way: if she had been told last July that she had brain cancer and had 9 months to live, that would not have been a good situation either. She continued to enjoy her family, meals, the Thanksgiving and Christmas holidays, and was able to do all of that without the worry of a cancer.

The daughter thought about it and said, You know, you are right, I think it is better this way; I’m going to take her home. Can we get hospice set-up?

I said, We will be glad to do that. Then I consulted neurosurgery, gave her some steroids for the inflammation, and then everyone wholeheartedly agreed that it was the best choice for this independent lady with a stroke.

Cerebral Tumor—Glioblastoma Multiforme

A stroke can be a great masquerader, often confused with a host of other medical conditions and maladies. In this particular case, the patient had a cancer present with inflammatory change that can sometimes be seen in the post-stroke phase due to fluid edema and inflammation as well. In her case, the changes were subtle and easily confused.

Glioblastoma Multiforme (GBM) is the most common and, unfortunately, the most aggressive primary brain tumor. Patients often present with headache, vomiting, and hemiparesis—the inability to move one side of the body—as was found here. Prognosis is poor with survival ranging from months to a year or two.

At the time of presentation, therapy would have probably not made a difference in long-term survival. I firmly believe that the path that most of us would choose would involve being at home and living independently with our families without the worry of a disease that just can’t be beaten. It’s better to just get a little sleepy and not feel like eating or drinking than to worry about the cancer process itself.

Chapter 5

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I Work for the Government

He was a solid fellow, wearing a black t-shirt with a silkscreen pattern on the front and cut-off sleeves. Not appropriate for January, I thought.

How are you doing? I asked.

Oh, I’m sick, I’m sick, he said.

His mother chimed in as well. He works for the government; he was in Mississippi in the middle of the flu season.

I started to ask, Well what’s bothering you?

Oh, I got a cough . . . oh, I’m aching . . . oh, I can’t drink . . . I’m weak, he said as he sat forward so I could listen to his back.

He was in Mississippi, you know.

Yeah, I know; I remember that you told me. We will get to that part. Do you have any other health problems?

No, but Doc, let me tell you—I’m 400 lbs, he said, as his mother added, He works for the government; he was in Mississippi.

As I completed my exam and found that his chest was clear, I asked him to open his mouth. I was then confronted with a horrendous looking soft palate—the roof of his mouth was fiery red with white exudate and almost had a coating or membrane on top of it.

I said, What were you doing in Mississippi? Were you in any standing water?

No, we were just ripping down houses—drywall mainly.

Ok, have you had your immunizations? I asked.

Yes.

Did you get punctured by a nail or step on a sharp object?

No, I didn’t, he said.

I asked, Does your throat hurt?

He said, My throat is fine, Doc. I’m coughing, I’m weak; oh, I’m sick.

I said, Well, I don’t know, and I haven’t seen a case in a while, probably not for 15 years or so, but I’m wondering if you might have diphtheria.

As it turned out, he didn’t actually work for the government, but for a contractor doing recovery work in the area.

I now began to treat the patient for this antiquated condition; it had pretty much gone away with the advent of the proper immunizations. Then again, people are not getting immunized for various reasons these days, and we are starting to see diseases such as diphtheria, pertussis, and tetanus return. (How’s that for the human psyche? Get a disease nearly conquered and then opt out of the treatment so it can then come back to haunt you.)

I then consulted the infectious disease specialist and told him my theory. It’s possible, not probable. Only a slight possibility. I haven’t seen diphtheria in awhile, but it could be.

He said, Diphtheria. I can’t believe that.

I said, Well, it’s not a classic pseudo-membrane [a dense adherent coating] but it can be seen with this sort of condition as well.

He shook his head and said, I can’t believe it.

I then asked him, Have you ever seen diphtheria?

No, not really, he stammered. I’ve seen it on the internet.

Well, then, you might better come down and take a look, I said. Then I also suggested that the Center for Disease Control (CDC) website may help.

He came down and examined the patient for a good long while, fretted about antitoxins, and then said, You know, this could be diphtheria; it is certainly a possibility.

As we were getting him admitted, the patient said, Thanks doc, I feel a little bit better.

Fluids and Tylenol do wonders.

Diphtherial Pharyngitis

Diphtheria is a condition that is caused by a bacterial organism called corynebacterium diptheriae. It has significantly decreased since the ad" vent of immunizations, but every once in a while it rears its head, typically in unimmunized populations of some geographically isolated groups in developing countries. Domestically it appears in some individuals with religious- or cultural based objections to vaccinations.

The disease often presents with sore throat, swollen lymph nodes, and fever. There is a characteristic thick grey coating known as a pseudomembrane. The bacterium elaborates a toxin that can affect the heart, kidneys, and lungs. Cases that are untreated can have a significant mortality rate.

The treatment involves the administration of good old-fashioned penicillin and a horse serum antitoxin that can make the patient sick in his own right, so one needs to make sure of the diagnosis. The classic case is often associated with a pseudomembrane that lies on the roof of the mouth, as this patient had.

Because certain diseases become more rare in the population, many healthcare professionals have never seen or treated them first-hand, so there is a greater chance of delayed diagnosis.

Chapter 6

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Things are Not Always What They Seem

As I was processing other patients and paperwork, she began pacing more noticeably within the space of her exam room. Actually, it was two room spaces; she was crossing back and forth, pacing, sitting down, getting up, appearing frustrated, and then sitting back down. One of the medical students went in to try to talk to her again, but returned after about five minutes, sheepishly reporting that the patient had not wanted to tell her much.

I said, "Well what did she actually tell you?"

The student said, Well she had been here about four days ago and was diagnosed with a corneal abrasion.

The patient was a contact lens wearer, and this often predisposes patients to such pathology. She was given antibiotic drops and was instructed to follow-up with the eye doctor or ophthalmology consultants, which she did.

I asked the student if the patient had followed up with anyone and she said that she hadn’t.

I said, Well, those two things are incongruent.

I guess she did follow-up, but she didn’t make a call today, she said.

I said, Well, that is sometimes less important, but at least she clearly made her follow-up visit and was motivated to do that. Then I asked about the progress of her complaint—whether it got better at first and then got worse, or if it steadily worsened. Those sorts of subtleties are important.

She said, Well, it got better for the first couple of days but then seems to have worsened again.

Ok. That is a helpful clue that is indeed important, I said.

The student said, I told her that I had had a contact abrasion myself, and it often seems to get better initially because of the numbing drops or topical anesthetic but then it often worsens.

Well, I’m not so sure that is the right analogy, I said. That event usually takes place in the first 30 to 45 minutes after the event, but is not likely three days later; this is clearly something different. We need to look at this again. Why don’t we go see her together.

As we entered the room, she continued to pace, appearing thin, wearing a frayed, faded black handkerchief tightly around her head. There was a clear fluid streaming out of both eyes in rivulets down her cheeks. I asked how she was doing.

She snapped back pretty quickly. Well, not so damn good.

I said, I can see that; looks like that’s uncomfortable.

It hurts like hell.

We then reviewed the history and found out that there was conformation of the information that was previously discussed as well as follow- up with ophthalmology. She had gotten eye ointment followed by soothing contact lense patches for the eyes.

She said, They both fell out.

I said, Well before we talk any further, let’s put some numbing drops in your eye and see if that helps.

Gotta do something, she said.

Only about two minutes after I put in the tetracaine drops she was able to open her eyes and see again. She seemed much less agitated now.

She said, Those contact lenses were probably pretty dirty.

Well, there’s not much we can do about it now, I said, as I conducted another eye exam. I put the fluroscein stain in and it glowed a bright yellow under the black light.

I then told her, Dear, you still have a contact in your right eye.

Well, I guess I do, she said.

I said, This one may be done; infection has probably leeched from the organism as well.

We plucked it from her eye and saved it for culture; this would allow us to identify the unusual organism that was possibly affecting her other eye. As I continued with the rest of the exam, a huge corneal ulcer was present on the contralateral—or opposite—eye. This is an especially painful condition that was causing her an inordinate amount of pain—so much, in fact, that she was almost belligerent during the initial part of the exam. Fortunately as time wore on she was pleased with our interest in her current medical situation. I ended up referring her to a corneal specialist, a person who deals with the thin, clear part at the front of the eye that is so crucial when it comes to day-to-day vision. She thanked us as she left for a cab ride to the specialist to further refine her care.

Corneal Ulcer

A corneal ulcer is an especially painful condition in which the transparent corneal stromal layer of the seeing part of the eye is eroded. It is often associated with great pain and is usually found in those with other chronic health conditions such as diabetes. The typical patient is a contact lense wearer. This patient’s unruliness toward the staff was due to the extreme pain she was experiencing due to this condition. It was alleviated by clear physician–patient communication, making it easier for us to carefully and effectively treat her.

Chapter 7

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My Arms are Tingling

Inoticed that he was a stout fellow as he grasped my hand; his forearms were thick with muscle and sinew. They were resilient and strong. His hands were rough and chapped—not like mine from too much hand washing, but thickened and calloused from a lifetime of hard manual labor.

What’s wrong? I asked.

He said, You know, I have had a cold for three weeks, Doc, and my arms are tingling.

Your arms? I asked. One or both?

Both.

I asked, Anything with your legs at all?

No, nothing there, he said.

He felt damp, moist with perspiration. He was diaphoretic—the doctor term for that wetness of the skin that usually indicates some real pathology or presence of significant disease. I worked him up for pneumonia