April Fool's Day

As I write this posting, I am looking out at several inches of heavy snow. April Fools indeed. The ER is a place where pranks occur almost daily. The odd, unexpected, quirky and bizarre arrive by foot, wheelchair and ambulance stretcher. The intentional April Fool's day prank are rare and amateurish. Painted on rashes and fake aliens erupting from the body are not going to fool the world's oldest ER doc.

It is the unintentional gag that makes the job fun. Many years ago I was confronted with a mother dragging her 6 year old into the ER screaming that he couldn't breath and was turning blue. A quick glance revealed a smurf like coloration of the hands and face but the child was breathing calmly. I pulled an alcohol wipe from my coat pocket and removed the blue dye that had bled from the child's new sweatshirt. The mother's mouth gaped and she left the ER without saying another word. The rare and unexpected finding keeps me on my toes. When I have completed a history and physical exam and reviewed any records in the hospital's EMR, I form my differential diagnosis. The labs, x-rays, CT's, EKG, and ultrasound should yield findings that I hope I have anticipated. The patient with crushing chest pain and difficulty breathing, who is diaphoretic and whose lungs are congested is probably having an myocardial infarction. The EKG should reveal changes that are consistent with an injury to the heart. The chest x-ray should show evidence of congestive heart failure. The labs tests are likely to show elevation on the CPK I and troponin, markers for myocardial damage. Recently I examined a pleasant octogenarian. She was in obvious distress. She described her abdominal pain and vomiting. Her distended abdomen was very quiet to auscultation. She had diffuse but only mild tenderness. She had an intestinal obstruction by clinical criteria. The possible causes of any presenting complaint are prioritized by likelihood of death or disability. Vascular causes are usually first on the differential diagnosis list. Does this woman have a leaking aneurysm, or a blocked mesenteric artery? The patient was given medications for pain and nausea and labs where sent off. I also ordered a CT of her abdomen without IV or oral contrast. My radiology colleagues would not be happy but I felt that her kidneys would be damaged by the IV dye and she would not be able to tolerate drinking a liter of oral contrast with a bowel obstruction. Her lab tests where abnormal but not specific. As I looked at the CT images, I was stunned. There are diseases that all doctors learn about but rarely encounter. Gall stone ileus is one of those conditions. The gall bladder is a storage tank for bile. When one eats a meal containing fat, the stomach releases a hormone, cholecystokinin. This messenger travels through the veins of the abdomen and stimulates the muscles in the wall of the gall bladder to contract and send bile down the bile duct to the small intestine. The bile will aid in the digestion and absorption of the fat content of a meal. Bile can become like sludge. Stones of bile salts, cholesterol and calcium salts may form in the gall bladder. Long term irritation of the gall bladder wall by gall stones may lead to a connection (fistula) between the gall bladder and the duodenum, the first section of the small intestine. In this patient, that is what had developed. A 2.8 cm gall stone had passed from the gall bladder directly into the small intestine. It meandered down the intestine until it became stuck. The blockage of the intestine by a gall stone is a gall stone ileus. The CT images were identical to ones I had seen in a radiology textbook many years ago. The patient was transferred to a major academic hospital. I am sure that the young doctors will provide excellent care and have a story to tell when they reminisce about their fascinating cases. Unfortunately the unexpected findings may be bad news for the patient. When I was an attending in a teaching hospital, a resident presented a case of a young woman he had evaluated and was ready to send home. The complaint was of vaginal redness and discharge. The evidence of a yeast infection was obvious on physical exam and KOH prep. I introduced myself to the patient and was shocked by her pallor. She denied any sexual experience, or antibiotic use. I told the patient that we were going to do some blood tests. The resident had made the correct diagnosis of the presenting complaint but had ignored the obvious anemic condition of this unfortunate woman. A CBC came back with severe anemia, and a markedly elevated white blood cell count with evidence of leukemic cells. The oncology service was consulted and the patient was admitted. Her impaired immune system from the leukemia had led to the yeast infection. All ER docs have had the experience of treating a child brought in for a "stomach bug". The persistent vomiting and impending dehydration led the parents to seek help. The child shows clear signs of dehydration but the respiratory rate of 40 fills me with dread. A check of the chemistries reveals a diagnosis of diabetes; treatable but a life altering diagnosis. The practice of emergency medicine is controlled chaos. Being rather compulsive and definitely controlling, I may have been better served in another field of medicine. I considered becoming a pathologist when I was a medical student. My advisor told me: internists knew much and do little; surgeons knew little but did much; pathologists knew all, but too late. His opinion of emergency medicine (this was in the mid 1970's), was that it was not a valid career choice. 34 years later I am still an ER doc.