Notes from a Doctor's Practice

I've spent a lot of time in the ER, and I'm always asked to describe the most unusual cases I've handled. Over the years, I've compiled an unofficial list in my head, but have never written them down until now.

The cases below involve conditions and symptoms that are seldom discussed in everyday conversation. Some may find them distasteful or too intense. The fact remains that they do occur regularly in real life, and discussing them can remove the stigma or embarrassment that may prevent someone from seeking medical help.

This article is not for the faint of heart. If you are squeamish or easily offended by frank discussion or graphic medical images, please read no further.

Time Doesn't Heal Everything - Get To The Doctor

A morbidly obese man with a large abdominal pannus (image at right) came in exhibiting red, irritated skin around the abdomen. It looked like a routine skin infection. But what was the cause? During the exam, I lifted the pannus and a turkey sandwich fell from between his folds. The man said it was about a month old, which the smell confirmed.

As you might imagine, abdominal pannus is very common given the much-talked-about obesity epidemic. The most common complication is yeast infection (intertrigo). If you have an abdominal pannus, the goal is to keep the skin under the pannus dry and clean.

Three tips: 1) After bath or shower, lift the hanging skin and air dry or blow dry on cool setting. 2) Use an antifungal powder like nystatin (prescription) or a non-talc powder. 3) If area appears red or itchy, try an over-the-counter antifungal cream.

A woman living alone with multiple medical problems came in complaining of odor and itching of her feet. In what was left of both of her feet wet gangrene had taken over, along with hundreds of maggots. In the folded skin in the groin were more maggots.

As you may have heard, maggots do keep skin lesions clean. But they aren’t easy to get rid of, as they scamper deeper into the wound when they see you coming.

An older gentleman man came in with many complications from his diabetes. I went to take off his socks and as I began to examine him, the tip of his second toe broke off into my hand like a piece of turkey bacon. It was dry gangrene.

Most people have a fuzzy understanding of gangrene -- it's unpleasant to look at and mostly affects fingers and toes. But what is it, really? Gangrene is the death of tissue, almost always from a lack of blood flow. Wet gangrene involves a bacterial infection, dry gangrene does not. Diabetes, circulatory issues, and smoking are some common culprits. In fact, gangrene from diabetes is the most common cause of non-traumatic amputation.

All diabetics should examine their feet daily for any signs of redness or skin breakdown. Since sensation is diminished in the feet, a visual check is critical.

Dry gangrene is usually ischemic (i.e. decreased blood flow to the area) and usually occurs in someone with peripheral vascular disease. Dry gangrene should be very painful in the early stages. A red or purple discoloration will progress to black without intervention. Early evaluation and vascular surgery is the only chance of saving the finger, toe or limb.

Private Part Mishaps

Periodically, men have arrived in the ER with the same complaint: "Doctor, my junk is purple." The culprit is always a metal cock ring that got stuck. I've learned that regular ring cutters available in the ER don’t work. The time it takes to get more powerful (and cringe inducing) wire cutters does not help calm the patient’s nerves.

Guys, please consider the alternatives to metal -- latex, rubber, silicone, leather, velcro, etc.

An elderly woman from a nursing home was brought in and complained of a "large ball” between her legs. It was her uterus, which had come out of her vagina. When one gets older everything starts to sag, and in some cases hang out, including the uterus and rectum.

A rectal prolapse is fairly common in both older men and women, and generally comes from weakened ligaments and years of strained bowel movements. So, eat fiber, drink water, and do your Kegel exercises.

Naturally, the sight of a vaginal or rectal prolapse is very distressing to patients. I find that the general silence around the subject only serves to make it that much more alarming. In reality, it is fairly common in older adults and very treatable.

Retained Objects

Doctors actually use the phrase "retained objects" to categorize this next group of cases. They are very common in the ER, but again, seldom discussed.

A man came in complaining of pain and bleeding from down below. He was trying to quit smoking and had replaced cigarettes with sunflower seeds, eating them shell and all whenever he got the urge.

During the rectal exam, we discovered a giant sunflower seed mass crowning like a baby's head. Despite castor oil and trying to “deliver” it, we ended up picking out the pieces with tweezers until it was small enough to pass.

A woman came in complaining of pain in her pelvis, so the doctor put her in the stirrups and performed a pelvic exam. He immediately removed the problem -- a set of car keys. The woman explained she didn’t want her boyfriend taking the car, so she hid the keys in a place where “he never goes”.

A patient came in with a very simple case: a toilet bowl scrubber had become lodged in his rectum. Curiously, he wasn’t sure how it got there.

So please everyone, remember to get to the doctor if something is troubling you. Don't delay, and don't be embarrassed -- we've probably seen worse.

Bonus Stories

Here are some bonus stories, which I had nothing to do with. Truth or urban legend? You decide.

An unconscious man and his girlfriend arrived with a large lump on his head and several deep scratches on his scrotum. When he awoke, he explained that he had been kneeling naked over the side of his bathtub while cleaning.

The cat must have become transfixed with his swaying testes, and it pounced. The patient struck his head as he jumped in pain, and his girlfriend found him unconscious.

Two parents in the ER were yelling and screaming, thinking that their teenage son was going blind because he was seeing spots. In private, the son revealed that his parents had caught him masturbating earlier that week and told him he would go blind if he continued.

Of course he continued, and the next time he hyperventilated and saw spots. In a panic, he told his parents about the spots, but not about his private activity. When the parents found out the whole story, they loudly complained that their son could, in fact, have gone blind from masturbation, and that we were negligent in not taking them seriously.

While making small talk with an older female patient, she mentioned that the "Kentucky Jelly" on her breakfast tray had a very strange taste. When I asked to see the jelly, the woman handed me a foil packet labeled "KY Jelly."

An elderly woman came into the ER complaining she had green vines in her "virginny". A pelvic exam verified that she did have a six-inch vine growing out of her vagina, and x-rays revealed it was growing from a potato in her vaginal vault.

She explained that her uterus was falling out, so she put a potato in there to hold it up and had forgotten. (Another uterine prolapse. Remember to do your Kegel's, ladies.)