I walked down the hall to see my last inpatient, billed as a young man with psychotic depression pending psychiatric placement. I heard him yelling about burning witches and eating the walls. It sounded pretty psychotic. (I learned that his sister had been arraigned on manslaughter charges.) I entered the room and was struck by the smell of his breath, like cherries. A fruity smell, could he be ketotic? I instantly thought about ethylene glycol toxicity, maybe he had been sipping antifreeze, but there were no oxalate crystals in his urine. Was it delirium? I checked an O2 saturation; 95%, that wasn’t it. His blood pressure was 120/60. How about checking his finger-stick glucose? It read >400. This boy was in DKA! I started an insulin drip and hydration. It was only later I learned he had been on a starvation diet for weeks, then had binged on candy. His story about burning an old woman in a stove was unfortunately true. I called child protective services.
The ED pager went off again. That old lady who had swallowed a bug had ingested another, possibly a spider. I was worried about brown recluse or black widow envenomation, but it seemed to have been a simple barn spider, as she was now feeling OK. Again I discharged her with stern warnings to limit her invertebrate consumption. I stopped by the multiparous patient. She was happy to have the children and that they were all healthy, but what was she going to do? Where would she go? I called a social work consult.
ICU Time: I headed to the ICU. A sad story: a 24-year-old woman was unresponsive. She had a living will and did not want prolonged life support. She had choked on a piece of fruit. I walked into a room crowded with her family; it looked like seven very short uncles—one of whom was a doctor. They watched sadly as I pulled the endotracheal tube and the IVs. I told them I’d give them some time with her alone and would be back in an hour. It was a somber and tearful affair. She was so young and so beautiful. What a tragic end.
Another ED call; this bug-swallowing lady was driving them nuts. Now she was claiming she had swallowed a thrush, or maybe had thrush. Either way, she was gone before I got down there to see her.
I met with the social worker. She was dressed in a fancy gown and said she had just been at a party. She heard the story of the lady who had had so many children. She thought for a moment then said she had a few leads to check and would get back to me later that day.
We had a rush in the ED: a boy I thought might have rhinophyma and stiff-man syndrome, a girl with warts on her lips she attributed to kissing a frog, another with a glass splinter in her foot. There was a Mr. W.W. Winkee with hypothermia, and a young girl named Mary who thought she had contracted anthrax from a sheep. There was a boy named Jackie Horner with a tenosynovitis of the thumb.
The old lady came back in again. Now she was complaining of abdominal distention. When I finally laid eyes on her, I noted she certainly had a large abdomen. I grabbed a quick X-ray. Apparently she had taken my warnings against consuming avian and invertebrate entities, as now she had radiographic evidence of a feline skeleton. I planned to send her to a tertiary-care facility; perhaps they could do an endoscopic cat removal. Whatever they did, I was afraid if she kept this up she was bound to die.