Glow-In-The-Dark Pee

R the nurse was walking down the hall with an open urine cup, looking at it and smelling it. That doesn't happen too often. It looked like it was glowing; Mountain Dew straight out.

"You should put that under a Woods lamp (a black light)", I said. So we did, and gosh darn if it didn't glow like a kid's glowstick at Disneyland.

So what's the guy's story? He was an ingestion, unclear history, suicide attempt for two days...perhaps he decided to add antifreeze to his list. Antifreeze has a compound called fluorescein added for this exact reason, because antifreeze kills kidneys, tastes sweet, and tends to get ingested by kids and dogs. And alcoholics.
His blood alcohol level came back at an impressive 0.390, which is a personal best for me; this, actually, was really good news. Antifreeze is fun for two reasons--one for the fluorescent pee, two because the old school antidote is a lot of alcohol. The two are metabolized by the same pathway, but alcohol is a better substrate, so if you drink enough, you can prevent the antifreeze from being changed into it's toxic metabolite.

As with anything that's 'interesting', the guy's antifreeze level came back very low. Possible we just missed it and he had peed it all out. But, a Google search also turned up a wide variety of things that turn your pee fluorescent. In fact, there was an article in a pediatric journal that discussed a random sample of 30 pediatric urine tests, 21 of which were fluorescent underneath a Woods lamp. None of those patients had antifreeze poisoning.

Turns out niacin and other B vitamins turn your pee fluorescent, among other things, including certain other medications. I also wonder about food coloring, especially in children (perhaps why 21 of 30 randomly selected had fluorescent pee--have you seen what they eat?)

So the next time your friend drinks a pint of antifreeze, take him or her under a black light and hand them a fifth of tequila. And, again I'm reminded, even the classic cases, aren't.

Jaded

The slow progress from naive to bitter I expected, but the first patient who burned me I didn't see coming.

26-yo female came in with lower pelvic pain and bleeding that she truthfully attributed to endometritis, and had a long history of work-up for the same. I don't know about the literature, but I've seen a couple patients have significant pain from this condition, where implants of uterine lining in the pelvic cavity cause pain secondary to bleeding; though outside the uterus, they are hormonally responsive. It's not fun, partially because the pain and scarring isn't life threatening, so patients tend to feel their complaint is minimized.

The nurse, Robert, recognized her immediately and warned me that she was a 'frequent flier', and had been to the ED numerous times in the past six months. Her first request for pain medication was for Dilaudid, which I've seen used multiple times in my first ED but not at my second. It's considered overly strong. Too fast acting, too likely to cause respiratory depression. I'm sure the high is killer. I'm also sure that the pain relief is both quick and dramatic.

Most patients who are opiate-naive don't have a favorite yet; they may remember what they had last time, but they often mangle the name or just don't remember. The nurse was suspicious from the beginning that she was exaggerating her complaint to get more substantial pain relief.

The work-up, as expected, was negative for any of the more dangerous causes of bleeding and lower pelvic pain like an ectopic pregnancy or a ruptured ovarian cyst. I went to check on her, and sat down at the bedside. She was shaking, sitting curled up. She said she was frustrated by the pain she was still having and didn't feel like she was under control; we had offered a Percocet script to take with her and a dose of Toradol (similar to ibuprofen) before leaving, but that wasn't sufficient. She said she'd call for a ride if we could help her control her pain.

I walked back to the attending doc, who said he'd be willing to do that after she called for a ride. So I went back and told her and she said she'd call and picked up her phone. I went back and told the doc.

"Did she call?" he said.
"She was going to", I said.
"She can't have anything until she calls and her ride is on the way", he said. Then he looked at me. "Here's what's going to happen. She'll say she's getting a ride, get the shot, and take off. Then she'll drive herself into an abutment with narcotics in her system".

I didn't believe it. I thought she was genuine. Then I went back and talked to her again, and she said, 'Oh, did you want me to call? I wasn't clear'. The context made it suspicious. Maybe she was just gaming me into getting her high. The tricky part was that she did have genuine pathology; no one was arguing that. The argument was that she was way too into a shot of Dilaudid. By the time she finished her plea, called, and then 'couldn't get a ride', she would've had good relief from her oral pain meds.

So that plea, where she was shaking and frustrated and talked about how her pain had gotten worse after the pelvic exam, all calculated? Who knows? Perhaps all genuine but just accentuated. These are the drug seekers I have to get used to, the ones who are really sick. The most egregious are sickle cell patients, classically. They get so zonked out that they'll be close to respiratory arrest and still requesting meds. No one, however, will argue that a sickle cell crisis is faked. You try having your hemoglobin precipitate out in your peripheral arterial system.

The IV component can't be underestimated, either. Benadryl would never be considered a drug of abuse, but in the form of an IV push (given in one dose) it produces a high just because of the route.

I guess I'm a bit more cranky and jaded than before my shift started. I still believe pain must be treated, but, just as with every other complaint, the world is grey--or, in the case of the ED, a bit green.

What do this shack and a little girl have to do with an EKG?

So there's a foundation, Hearts for Kids, that helps kids in Africa get heart transplants. That's awesome. This picture, from their website, is where their patients live.

I don't know anything about them, I just found them with Google while I was searching for rheumatic fever. If you do a Google image search for the same, you'll see a lot of black and white pictures from the pre-antibiotic era of people who died from RF, including Mozart. Then I saw this picture. Not black and white. Full color. Hmmm.

RF is still on our diagnosis list of kids with fever and migratory rash; it can attack the heart most famously, or cause people to have similar symptoms to Huntington's disease, also known as Syddenham's chorea. During a grand rounds last week, a distinguished class of residents at a top program didn't recognize a video of it. That video was taken in Africa. To learn about it, I've had to use the Internet, textbooks, and slides, because I've never seen a case, and likely never will until I travel overseas.

According to an NEJM article, rheumatic fever in the US has decreased precipitously. From being a more common topic than stroke in the era from 1967 to 1976, it is now rare, and a search of all medical journals in the US yields only eight articles between 1997 and 2006. But in places like that in the picture above--that is, the 80% of the world without access to prompt antibiosis for strep throat--there are 470,000 new cases of ARF each year.

What got me on this topic? EKGs, actually. Wolff-Parkinson-White syndrome is a sub-set of supraventricular tachycardias, or fast heart rhythms. It is a characteristic, classic finding on an EKG; there is a bit of an early rise in the QRS complex called the delta wave, and it represents a track of heart muscle that goes around the normal pathway of conduction. It typically does not cause problems (story to the patient) but can proceed to ventricular fibrillation (story to students) if you block the normal pathway.



Our hearts have a built in delay to allow for filling of the ventricles. Because the WPW pathway bypasses that system, if it becomes ascendant, it conducts directly from the atria to the ventricles at a rate of anywhere from 150-300 beats per minute. That is sometimes called 'badness'. If the patient is unstable, the best treatment is to shock them (electrical cardioversion). If they are stable but fast, a variety of drugs can be used; I learned that adenosine, which is usually used even in the field by paramedics for narrow-complex tachycardias should not be used for WPW, but some texts seem to suggest it is acceptable. I'll have to read more to figure out the differences.

WPW was first described by a few physicians, as often happens, but Paul Dudley White, who worked at Harvard at the turn of the century, described it in 1908. It is interesting to note why he became a physician, and to wonder why he decided to focus on the heart. He, like countless others at the turn of the century, before the advent of penicillin, lost a sister to acute rheumatic fever at the age of 12.

Tired

My speech doesn't slur so much as pause, catch. I'm still processing the last thought as I ask for the next.

Slow, and careful. Musn't miss.

Light is a soft glow at the edge of vision. Sounds encroach. Monitors pace thought, insistent, racing.

Moments magnify. As if the previous one isn't gone yet, new one already here.

My stray thoughts are of sheets, and food. Heavy, sweet food.

Standing in the middle of this river, current stronger than it appears. How tempting to float rather than wade.

To be the responsible one at 4 am.

And, finally, the morning air.

Genius Parade, part 1

At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.

Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.

Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.

Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.

Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?

Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.

After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.

So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?

His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.

And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.

Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.

During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.

Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.

Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.

I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?

In the meantime, I'll try to be less of an idiot, if only for the sake of others.