Cramp Champ

After 33 years of being an ER doc, I had a first time chief complaint. A 60+ year old patient came to the ER around 0400 complaining of painful leg cramps. The patient reeked of Ben-Gay and it took a great deal of control, to not start laughing at the less than urgent nature of the patient's problem. As an example of Karma, I spent my first not at home (after my usual three 10 hour nights from hell) walking around the house trying to relieve my own painful calf and foot cramps. I especially hated the fact that my left big toe was painfully sticking up like a flag pole.

Leg cramps, aka Charley horse, are not restless leg syndrome. RLS is a movement disorder that is treated with meds for Parkinson's disease. Although RLS is uncomfortable and may be associated with some muscle cramping, it is not nocturnal leg cramps. Cramps are painful contractions of the thigh, calf and/or foot muscles.

Any athlete will recognize the painful muscle cramping that occurs during or immediately after heavy exercise, especially in hot weather. Dehydration, electrolyte loss through sweating, and the build up of lactic acid in the muscles from anaerobic metabolism can lead to these painful muscle contractions, sometimes referred to as heat cramps. When the diaphragm is involved the dolorous spasm may be called a "stitch".

Nocturnal leg cramps have been linked to sitting for long periods of time, dehydration, overuse of the muscles, standing or working on concrete floors and a number of medications. The list of prescriptions medication includes diuretics, statins, lithium, and morphine. The incidence of nocturnal leg cramps increases with age and is occasionally associated with diabetes and peripheral vascular disease and infrequently with endocrine disorders such as hypothyroidism and hypoglycemia.

There is no well established treatment for nocturnal leg cramps. Good hydration, stretching of the calf muscles before bed, having loose bed clothes and linen, even riding an exercise bike have been proposed as preventatives. Eating potassium rich foods, such as bananas and oranges is recommended. Drinking water before bed may be helpful but, will lead to another night problem for men in my age demographic.

Quinine is a medication that was (and sometimes still is) used to treat malaria. As a doctor back in the 70's, many of the elderly patients that I treated were taking quinine nightly to prevent leg cramps. There is no double blind study that definitely shows improvement in the frequency or intensity of leg cramps by taking quinine. Anecdotal reports have perpetrated the continued use of quinine for this condition. My patient had taken quinine sulfate when he was awakened by his painful cramps. The down side of quinine is significant. Side effects include headache and tinnitus (ringing in the ears), thrombocytopenia (low platelet count), cardiac rhythm disturbances, and fatal hypersenitivity reactions.

Diltiazem, a calcium channel blocker used to treat hypertension and rapid heart rates, has been tried with some success to treat nocturnal leg cramps. Vitamin B6 30 mg daily has also been proffered as a treatment option. Neither has been subjected to a well controlled study.

So it is 3 AM and you are awakened by painful cramps in your lower extremities; what do you do? First, get out of bed and begin to walk around. Drink some water. Gently massage the involved muscles. Take a warm shower or bath. Do some stretching of your calves.

If you are plagued with frequent nocturnal leg cramps, talk to your primary care doctor. A check of your electrolyte levels, thyroid function and possibly even EMG (electromyelography) may be helpful in finding a treatable cause.

Update on my status: I have 12 shifts left at the General Hospital. Working another Sunday- Tuesday for the Memorial Day Weekend, will reinforce the need to find greener (less stressful) pastures. The new night shift at The General will commence in June. The hours will be 10PM to 6AM. I have nine of these truncated shifts before my final night on June 25. I will begin my new job around July 18th. My schedule will be 11PM to 7 AM working 12 shifts per month. The night shift census is 4-6 patients. I have been averaging 25 patients per 10 hour night at The General.

APAP

APAP is short for acetaminophen, the active ingredient in Tylenol and Feveral. APAP is used to treat fever and pain. It is found as a single drug and in combination with other medications in cold and flu treatments. I touched on APAP in a prior post titled OD. A recent patient and a memory from the past led to today's blog.

APAP toxicity is primary from injury and death of hepatocytes, liver cells. NAPQI is a metabolite, an altered form of APAP as is metabolized by the liver. NAPQI depletes the liver's store of glutathione, an antioxidant. Once the supply of glutathione is exhausted, the hepatocytes are unable to repair the damage caused by NAPQI. Alcohol and medications that use the same pathway for liver metabolism, will exacerbate the toxic effects of APAP. Isoniazid, which is used to treat tuberculosis, and phenobarbital and carbamazipine, both anticonvulsants, are in this group of medications.

In an acute overdose of APAP, either as a suicide attempt or inadvertent excessive dose given by a parent, well established toxic levels are predictable. 200 mg per Kg of body weight is enough to cause liver damage. The level of APAP at 4 hours after a single ingestion can be plotted on the Rumack-Matthew nomogram to help the ER doc decide if the patient requires treatment. Many times we see patients who have been taking excessive amounts of APAP over days. The nomogram is not helpful in these patients.

The early signs of hepatic injury from APAP are not very specific. The patient may have some right upper abdominal discomfort and complain of nausea and vomiting. As the liver is crucial for the maintenance of glucose levels, low blood sugar may be found. Easy bruising is also a sign of liver injury, as the liver manufactures proteins involved in the clotting of blood. As the levels of nitrogen containing toxins, such as ammonia, build up in the blood, the patient may show signs of hepatic encephalopathy. Confusion, problems walking, and lethargy are all signs of effects of these toxins on the brain. A healthy liver normally clears these products of protein metabolism and absorbed toxins from the gastrointestinal track.

Lab tests will reveal elevated liver enzymes, transaminases. Bilirubin may be above normal and later in the course of the disease, abnormal kidney function will be noted. The prothrombin time, a measure of the clotting cascade will begin to rise. The key to a successful outcome is to initiate treatment as soon as possible, preferably before the patient is in significant liver failure.

N-acetylcysteine or NAC is the antidote for APAP damage to the liver. There is an intravenous form of NAC that is sold as Acetadote in the US. Prior to its introduction, NAC had to be given orally. This was a problem because the patients often had vomiting from liver injury and the oral form of NAC smells like rotten eggs. If liver failure has progressed too far, only a liver transplant will save the patient.

Early in my long career, I examined a toddler who looked gravely ill. The child was jaundiced, dehydrated, unresponsive and bled excessively from attempts to establish an IV and draw blood. The lab tests showed all the signs of liver failure. I began NAC by a nasogastric tube as the IV form was not available at that time. The child was transferred to a major pediatric hospital but died from liver failure. The child had been treated for a viral infection with APAP by the parents. The pediatrician had told the parents to give one teaspoon of children's APAP, which contains 160 mg of the drug, every four hours as needed for fever. The problem arose because the parents mistakenly gave one teaspoon of infant APAP, which contains 500 mg, every four hours.

More recently a patient was seen in the ER who was taking more than the maximally recommended dose of APAP for chronic pain. The doses taken were 25-33% above the maximal dose but over many days the liver began to be effected. This patient was started on Acetadote and made a full recovery.

Update:

My mother-in-law is, in the words of the hospice nurse, actively dying. She is unresponsive and hasn't had any oral intake in several days. We are amazed that she is still alive. My wife and I are with mother as I write this post.

The next phase of my career will begin in July. I will be leaving the ER I have called home for the past 28 years. My departure was forced by the hospital administration's displeasure with my relationship with the nursing staff. The outpouring of support from current and former ER nurses, my colleagues in the ER and on the medical staff, EMS personnel, local police officers and firefighters, and my patients has been heartening.

I have decided to remain a B.O.N.E.R. doc. I will stay on nights but in a much less busy ER. The privilege of providing care to those most in need, is my motivation. Stay tuned.

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.

E

With Mother. She is sleeping more. Her intake and output is diminishing. She is not in pain or anxious. The aides and nurses from hospice have been wonderful.

I received a call today from E. E worked with me on nights for many years. She retired and enjoys her life. She has had some health concerns and we had a good conversation. She advised me that I should follow my heart and head in deciding how to adapt to the rest of my career.

In the day, there was E and L, an aide and me. Our friend S was our night x-ray tech and our friend D was in the lab. E had trained at the world's best pediatric hospital and her partner L was an experienced critical care nurse. E reminded me that even in those quieter times I could be a PITA. She reminisced how she or L would give me a verbal or physical smack upside my head when necessary.

Two years ago E called to tell me of some disturbing symptoms. She correctly diagnosed her own disease and I arranged for one of my partners to treat her in the ER. An recent alarming visit to an ER where she lives during the winter, was precipitated by chest pains and severe hypertension. She was treated and is doing well.

Last week I cared for two patients with intracerebral hemorrhages (ICH). The first patient was 61 years old. The family found the patient on the floor with evidence of having vomited and unresponsive to voice or touch. The paramedics did a great job of entubating and stabilizing the patient. A CT scan revealed a large ICH that was distorting the normal brain anatomy. I stabilized the patient's blood pressure and transferred her to a tertiary care hospital. The family told us that the patient had been complaining of a headache for a couple of days. The patient had no medical history, but had seen a doctor regularly for check ups. The prognosis is not good.

The second patient was an octagenarian who walked in with symptoms of an episode of confusion and possibly some slurred speech. The patient complained of a worsening headache for a few days. The patient was on coumadin for an irregular heart beat. CT scanning and labs were ordered. The INR was above the therapeutic level and the CT showed a small ICH. There was no evidence of a shift of the normal brain structures. Arrangements were made to transfer the patient to a tertiary care hospital and I started medication to control her blood pressure and gave fresh frozen plasma to reverse her clotting abnormality. The prognosis is good.

My brother-in-law has arrived and we have the golf tournament on the TV. Mother was an avid golfer. Her father and husband were also devoted to the game. She told me that they were disappointed, when I began dating their daughter, because I had no interest in golf. The sounds of the tournament brought a smile to her face.

In the near future I will be enbarking on the next stage of my career. The world's oldest ER doc will become a part timer. Shorter hours, a less busy ER, and fewer or maybe no nights are my goals. I think that with this change I can make it to 40 years in emergency medicine. For now I will enjoy spending time with the extraordinary woman who I am fortunate to have as my mother-in-law.

C'est La Vie

It's Life! The founder of the Brotherhood Of Nocturnal Emergency Room doctors has made a decision. It is time to get off nights. I am at peace with the decision. The lack of sleep, the volume of patients, the constant stress has effected me mentally, physically and emotionally. The nursing staff has rightly complained about by surly and disruptive behavior. Patients who wait hours before seeing a physician or PA do not care about an old and tired ER doc's problems.

As I write this posting, I am waiting to find out my fate. Will I be allowed to stay at the hospital where I have worked for 29 years, or will my unprofessional actions send me on a job search? Retirement is not an option. A less stressful work situation is in order. Another physician in my group has been advocating for 8 hour night shifts for years. My fellow B.O.N.E.R. doc, Zorba and I have stubbornly clung to our 10 hour nights. Pride, arrogance, and hubris all contributed to my insistence on maintaining my schedule even as my health and interpersonal relationships suffered.

My problems are trivial compared to the fate of my mother and mother-in-law. Nearing 92 years of age, my mother has settled into her life in a nursing home. The facility is clean, well staffed and maintained, and Ma is safe and secure. That doesn't totally free me of the guilt of only seeing her once a week. My schedule and the distance between my home and the nursing home makes once a week visits all I can give. Ma is pleasantly confused. Her short term memory is impaired but she knows her family and friends and enjoys visitors, phone calls, and activities.

The exotic woman of indeterminate age, who is my wife, has a equally extraordinary mother. I met my mother-in-law some 40 years ago. She was intelligent, attractive and strong willed. My Dad advised to check out the mother of the women I dated. His words of wisdom proved fateful. Mother has lived a life of honor. She loved and cared for her husband as he became disabled from a progressive neurological disease. She loved her children and grandchildren. She and my wife travelled together, saw shows and had a wonderful mother-daughter relationship. Mother gave love and support to her sister, niece and nephew, friends and coworkers. She was still working in retail 32 hours a week when she was diagnosed with pancreatic cancer.

Mother has survived breast and uterine cancer with attendent surgeries. She had one hip replaced twice and the other hip once. Osteoarthritis became another challenge to overcome. She kept in touch with old friends and made new friends as she moved and worked in different locations. Impeccably dressed and coifed, she exemplified class.

Since the last paragraph, I have left Starbucks and my meeting with the director of my group. I am sitting a few feet from Mother. She is resting comfortably. She smiled when I arrived and gave her a kiss. She wishes to die with dignity. She left the hospital for the last time and is home with hospice care. She is surrounded by her familiar belongings including furniture, pictures and her beloved collection of elephants. Her family will be with her until the end and honor her wishes.

Our family will continue our lives. We will be bereft but inspired by Mother's life.


The world's oldest ER doc will eventually get off the night shift. I will remain a B.O.N.E.R. doc in my heart. B.O.N.E.R. doc emeritus.

Clusters

The world's oldest ER doc has survived another winter. Too much snow, leaking roofs, freezing temperatures and no Caribbean vacation made this a particularly onerous winter. The continuously rising ER census added to my SAD.

My beloved wife booked us for a three night escape in VERMONT. It snowed 12 inches the day after our arrival and I had extreme flop sweat driving home in an ice storm. We returned to the hacienda to find 6 inches of wet heavy snow. We did discover the joy of snowshoeing but a beach in Puerto Rico would have been oh so therapeutic.

What does this have to do with clusters? Nothing, I just needed to vent. Before getting to clusters, she, who is an exotic woman of indeterminate age, made a scheduling conflict. This deprived me of my one excuse to take the tuxedo out of mothballs. We missed the black tie charity ball. The upside was that our grandniece, along with her mother, grandmother and grand aunt, got to enjoy a sophisticated night of dinner and "Mary Poppins".

Epidemiology is the study of the spread and control of diseases. A cluster is a "pocket" of a disease or condition that is statistically aberrant. A person of my acquaintance recently pointed out that her neighborhood had a large number of young people with learning disabilities and or mental illness. The cause was not evident to her but she suspected that neurological Lyme disease might play a role.

The incident of a disease in a population can be easily enumerated. One in a hundred or one in 10,000 are derived from the number of cases of an illness in a given population. The geographic distribution of these cases may not be even, i.e., clusters. Clusters of cases may represent a local factor that contributes to the disease or be totally random.

Bacterial meningitis has a definable incidence in the US. The clustering of cases in military installations and college communities is real and represents the grouping of large numbers of potentially susceptible people in a small area.

When an an unusually rare disease suddenly appears in a narrow population, there is often a specific cause. Clear cell carcinoma of the vagina began to appear in young women back in the sixties and seventies. An epidemiological examination revealed that all the young woman had been exposed to DES in utero. Diethylstilbesterol was given to women at risk for miscarriage in the fifties and sixties. It did not prevent miscarriage but did induce abnormalities in the genitourinary tracts of the exposed children.

The virus that caused HIV was found after the disease AIDS was recognized. Unusual pneumonias, rare cancers, and early deaths sparked the epidemiologists to uncover the roots of the AIDS epidemic and led to the successful isolating of the HIV and the treatments that have prolonged the lives of these patients. Our blood supply is constantly being screened for transmissible diseases, thanks to the work of medical sleuths in epidemiology and medical research labs.

A disturbing trend among well intentioned parents, is to not vaccinate their children. The rationale for this dangerous decision is the belief that vaccines may cause autism. The facts are that the incident of children diagnosed with autism is climbing. There are any number of reasons for this rise in cases of autism. Better knowledge of the variety of conditions in the autism spectrum by physician and the general public accounts for some of the increase. The miasma of chemicals in our environment from PCB's, phthalates, hormones fed to animals, and industrial and agricultural run off, may all cause damage to developing nervous systems. There is no evidence that the MMR or other vaccination causes autism.

The human brain looks for patterns. Seeing the image of Abe Lincoln in a potato chip illustrates this phenomenon. The danger lies in not remaining scientifically skeptical in the pursuit of seemingly significant clusters of disease. Don't believe everything you read on the internet. This blogger tries to be accurate. I use information from peer reviewed scientific literature, not Wikipedia.

Stay informed, be skeptical.

I saw my first robin yesterday, and I heard the congaree of the redwing blackbird last weekend. Spring is here. Rejoice!

Chronic

A young woman came to the ER this past week with a number of vague complaints. She had lightheadedness when she stood up, occasional nausea and had done several home pregnancy tests which were all negative. She had had these complaints for weeks. She had state based health insurance. Unlike those of us with commercial insurance, she didn't have to make a copayment for using the ER as a walk-in clinic. In her defense, she had been unable to find a primary-care physician willing to accept her insurance.

The issue of why she was triaged as a priority 3, which put her on the physician side of the ER instead of the "fast track" for the PA's to evaluate, is a subject for another blog. Her vital signs were normal. She was fit, healthy looking and a cursory exam revealed no evidence of any disease process. A review of symptoms was unhelpful. This pleasant woman asked if I would do some blood tests. I was tempted to decline any testing as unnecessary and more appropriate for a primary care setting. The problem of a dearth of available options for this patient led me to acquiesce to her request. Her EKG, chem panel, thyroid screen and complete blood count were all normal. I referred her to the local health clinic knowing that they would accept her insurance but that she would be given an appointment several months in the future.

This is not an isolated occurrence in the ER. Every shift, I see many patients who could easily be assessed and treated in a physician's office or clinic. The ER staff tries to cope with these less than urgent cases along with the truly sick and injured patients that require emergent treatment.

Chronic pains, persistent skin conditions, medication refills, and management of long-term illnesses such as hypertension and diabetes make up some of the non-urgent problems arriving in the ER. Patients with a physician inexplicably show up in the ER within 24 hours of a scheduled appointment to deal with their problem. This pattern will be familiar to anyone who works in an ER.

Over scheduled primary care offices send patients to the ER as a convenient source of labs, x-rays and treatment. Call a pediatrician at 2:00 AM and tell him or her that little Johnny or Susie has a fever and more likely than not the concerned parent will be told to go to the ER. The reasoning is understandable. The doctor may have a full office the next day or it is the weekend and the office is closed. Fear of a malpractice suit based on advising the parent by phone and the child does poorly or dies, is also a valid reason to direct the parents and child to the ER.

Patients arrive in the ER by ambulance and through the front door. The ambulance patients are usually more seriously ill or injured. A significant percentage of ambulance patients simply use the ambulance as a free taxi ride. One's insurance determines who ultimately pays for inappropriate ambulance use. The non urgent patient who arrives by ambulance often expects the hospital to pay for a taxi to return them home. This cost is not recouped. The federally mandated requirement to provide translation services to all patients is also not compensated. The financial viability of community hospitals is tenuous. Free care, expensive "language lines", feeding and warehousing psychiatric patients for days, and taxi vouchers all adversely effect a hospital's bottom line.

Like all my readers, I am a tax paying citizen of this wonderful country. I vote in all elections. I make use of written and electronic sources of information to keep current. Local and national politician make laws that effect my own health care insurance and the way I practice my profession. No editorial comments will be offered by this writer. I am simply reporting the truths of the ER as I perceive them.