Travis Stork, MD, cohost of TV’s The Doctors—I was working the overnight shift in a remote hospital in the Rocky Mountains. Late in the evening, a young black teenager was brought into the ER. He lived at sea level and had never been in the mountains. After skiing all day, he felt really ill. Everyone assumed it was altitude sickness.
He was sweating and had abdominal pain and nausea. His heart rate was elevated. We sent off his lab work, and his blood sugar came back at almost 600—normal is less than 100. His platelets, necessary for clotting, came in at 10,000; they should have been over 150,000. He was extremely anemic too. I did an ultrasound of his abdomen, and it looked like his belly was full of blood. This wasn’t altitude sickness. And in the short time I’d been trying to figure out what was wrong, he was getting sicker. The friends he was traveling with were terrified, and rightly so.
The mystery was finally solved with an old-fashioned microscope. When we looked at his blood, we saw some sickled red blood cells. That’s how we were able to diagnose sickle cell trait. If you have sickle cell trait—which means you got the sickle cell gene from just one parent instead of two—you have no symptoms at low altitude, but high altitude can sometimes cause the red blood cells to warp into sickle shapes and deprive vital organs of oxygen. This teenager didn’t know he had it, but the effect of the altitude on his blood cells was so extreme that after just a short time in the mountains, his spleen had ruptured when its blood supply had been compromised.
He needed platelets immediately, but we didn’t have enough at the remote hospital. And there was a blizzard, so the medical helicopters couldn’t fly. It was a scary night. We met an ambulance that drove halfway up from the city with blood products and transferred him to the city hospital for emergency surgery. The story has a happy ending: He recovered fully.
The Curious Case of the Man with a Very Unusual Boil
Ryan A. Stanton, MD, director of emergency medicine, University of Kentucky Health Care Good Samaritan Hospital—A man in his 20s came into the emergency room with a painful boil in his left armpit that had been getting larger for about three weeks. The abscess didn’t have the usual redness, plus it had been growing for much longer than a typical abscess. When we drained the boil, clear fluid came out instead of pus … and then a bullet poked through!
The man said he’d been shot a few years earlier, but the bullet had gone in near his collarbone. Although the bullet had never been removed, it hadn’t bothered him. Over time, with gravity, the bullet had migrated from the top of the shoulder to the bottom of the armpit. Then the natural movement of his arm rubbed that bump until it finally became irritated. I grabbed some forceps and pulled the bullet out. He took it home!
The Curious Case of the Lady with Crazy Blood Sugar
Louis Rubenstein, MD, medical director of Hospitalist Services at South County Hospital, Wakefield, Rhode Island—When I was just out of training, a woman in her 70s was admitted to our hospital with weakness and very low blood sugar. We gave her IV dextrose (a sugar solution), and she improved. We ran a few tests and asked what medications she was taking; she said only a mild tranquilizer called Xanax for occasional anxiety. We chalked her symptoms up to poor appetite and sent her home.
But within a week she was back in the hospital with exactly the same problem: low blood sugar. This time, we called her husband and asked him to read off all the pills in the medicine cabinet. The answer again was “just Xanax.” We checked her for an insulin-producing tumor. Since these results take a while to come back, we sent her home.
When she returned within a week again, we were a bit exasperated and suspicious—something was definitely fishy. This time, one of our interns asked the patient’s husband to bring in all the pills in their medicine cabinet. He brought us a bag of vitamins and aspirin, as well as the bottle of Xanax.
That’s when we discovered her “Xanax” was actually Micronase, which is a medicine used by diabetics to lower blood sugar! The pharmacy had inadvertently pulled it off the shelf and slapped a Xanax label on it. We notified the pharmacy of the error—a completely isolated fluke—and sent the patient home with a clean bill of health.
The Curious Case of the Boy with Strange Abdominal Pain
Kenneth V. Iserson, MD, professor emeritus of emergency medicine at the University of Arizona—A nine-year-old boy was brought into the emergency department with severe abdominal pains. His parents said that for years their son had been suffering from attacks of pain so extreme he’d double up and scream. Doctors, having ruled out several conditions, suspected metabolic abnormalities, and they put him on medications and a special diet, but nothing worked.
After examining the boy, I leaned back against a big, red resuscitation cart and did something that’s not typical emergency physician behavior: I closed my eyes and just thought. I stayed like that for five minutes, going through all the possibilities. Finally, I opened my eyes and said, “I think we need to do a CAT scan—right now.”
Barely 45 minutes later, after I’d bumped the boy ahead of several people to get him in quickly, I got a frantic call from the radiologist. The kid had severe malrotation of his intestines: All the tubing that’s normally held in place by ligaments and tissues was just free-floating, so it could move and twist. This intermittent twisting was obstructing the blood flow to the boy’s intestines, causing his attacks of pain. It’s an emergency situation because if the blood flow is obstructed for too long, part of the intestines could die, and that could be fatal.
We contacted the pediatric surgeon on call, who took him straight to the operating room and tacked it all down—and that’s what finally cured the problem.