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THE WOMAN WHO SWALLOWED A TOOTHBRUSH
and Other Bizarre Medical Cases
By Rob Myers, Tracey Millen
ECW PRESSCopyright © 2003 Rob Myers
All rights reserved.
Emergency room doctors and nurses are in a constant state of languid preparedness. Periods of boredom are quickly replaced by life-threatening heart attacks, traumas, and other terrible conditions. Shards of broken bones poking through bloodied skin, slippery intestines protruding through bullet holes, severe head injuries — anything that can go wrong with the human body may result in an emergency room visit at any time, day or night.
On a quiet Wednesday evening approaching midnight, sirens wailed and lights flashed as a 56-year-old man arrived at the emergency department via ambulance. He had awoken from a restless sleep 30 minutes earlier with sudden severe abdominal pain. He quickly called 911. Though he lived close by, it took the two slender paramedics longer than expected to load his obese 5'6" 450-pound frame into the ambulance.
His folds spilled over the sides of a narrow hospital gurney in the triage room, as the skeletonized version of his story was elicited by the triage nurse. A quick check of his vital signs indicated that beyond his girth, there was a serious problem afoot.
He was tachycardic (had a rapid heart rate) with a pulse of 120 beats per minute. His blood pressure was low at 90/60, he was feverish and breathing rapidly. Oxygen, an intravenous line, and a cardiac monitor — all the basics — were in place as the emergency room physician appeared. The curtain rattled as he entered the tiny cubicle.
"What brings you to hospital Mr. Canderas?" he inquired.
"I don't feel so good" was the unhelpful reply.
"Could you be more specific?" the doctor continued.
"Well, I couldn't get to sleep so I got out of bed around 10 p.m. and fixed myself a snack and watched some TV." It seemed to take a huge effort to speak.
The doctor couldn't imagine that the large man before him could walk or fix a snack. "Must sleep in the kitchen," he thought.
"I must have dozed off in the chair," the patient continued. "I carried myself over to bed and lay down but I didn't feel right, sort of like I ate too much."
"Go on, go on," said the doctor.
"I suddenly got this horrible stomach pain. I puked all over the bed and called an ambulance."
The doctor moved over to the middle of the bed and worked on Mr. Canderas's abdomen. His hands were lost, enveloped by moist pockets and crevasses, surrounded by smooth waves of rubbery tissue. He watched Mr. Canderas's face as he poked and prodded his abdomen. Then it came. Not a subtle grimace of displeasure, but a yelp so painful and piteous that were he 300 pounds lighter, parts of him surely would have jumped off the bed.
Diving through fat, the doctor's hands had landed on a rigid board-like abdomen. Irritation within the peritoneal cavity, as with appendicitis or liver injury, causes severe pain with rigidity of the abdominal muscles. This man had an acute abdomen. With the associated fever, fast heart rate (tachycardia), and relatively low blood pressure (hypotension), an emergency surgical exploration (laparotomy) was necessary.
The wheeled gurney squeaked and strained under the weight as Mr. Canderas was transported to the operating room, where the centerpiece is the surgical table (although surgeons may disagree). Surgical tables are standard issue and, consequently, narrow. This presented a problem for Mr. Canderas, as the table could accommodate perhaps one of his fleshy limbs. A fleet of four tables and half a dozen of the O.R. night staff was required to finally secure nearly a quarter ton of limp tissue and ready it for the knife.
He was anesthetized and intubated. The surgeon sliced and sliced and sliced. Yellow flecks of fat melted and dripped into the surgical field, lit by a blazing overhead light. Pools of blood formed and were quickly drained by a suction catheter. The peritoneal lining appeared like a thick piece of Saran wrap, embedded with a criss-cross of minute blood vessels. The scalpel rose and fell, and there was silence, punctuated by the staccato beep of the heart rate monitor.
Doritos. It was not initially clear whether they were cheese flavored or spicy, but they were definitely Doritos, caked in what looked like cake. A corner of a Pop-tart, the size of a quarter, slipped out, fighting with the Doritos for release from the confines of the abdominal cavity. What in the world were undigested, and in many respects unchewed, food particles doing swimming about Mr. Canderas's abdominal cavity? How did they get out of the stomach and gastrointestinal tract?
A visual inspection of the stomach secured the diagnosis: a linear tear along the lesser curvature of the stomach, like a crevasse in a mountain. His stomach had quite simply burst. Excessive ingestion of food and drink was more than his stomach could handle. Fill up the tank and the gas will spill out. Fill up the stomach and vomit, or it will rupture.
Mr. Canderas spent two weeks in the ICU, ventilated on a respirator. Antibiotics were poured into his bloodstream around the clock, carried off to fight the infection in his abdomen. He finally turned the corner and gradually improved. After a month-long hospital stay he was ready for discharge, 93 pounds lighter. The advice from his physicians was simple: don't eat when you're full.CHAPTER 2
An Iranian man was admitted to the orthopedic ward for elective back surgery. Orthopedic surgeons are renowned for their impressive surgical skills. They are excellent with a hammer and nail, but many are less adept at histories and physical examination.
Notwithstanding, the orthopedic resident mustered all of his exam skills and placed his stethoscope in the "tripod" position. The tripod position is just below the sternum. This placement allows a surgeon to listen to the heart, lungs, and abdomen at the same time.
"What's this?" he thought. "I hear something." A sound whooshed through the stethoscope tubing to the young trainee's ears. It was loud and it was obvious. You didn't need a medical degree to know that this was an abnormal sound.
The orthopod thought the murmur was too loud to be a normal variant, though had no idea what the origin could be, so he postponed surgery and sent the man for an echocardiogram. Echos utilize ultrasound waves to image the heart, akin to ultrasound technology that examines the fetus of a pregnant woman. Abnormal heart sounds, like murmurs, may be benign, or reflect serious cardiac disease.
The patient spoke no English, and a Farsee interpreter was unavailable. Through a mixture of hand signals and cajoling, the man was directed to lie on his left side as the technologist took the microphone-shaped probe and placed it on the man's chest.
As the cardiac anatomy was uncovered, the technologist saw an uncommon though not unusual abnormality. The young Iranian had a small hole in his heart known as a ventricular septal defect (VSD). VSDS are a type of shunt, an abnormal communication between two parts of the heart. The abnormality may cause excess blood flow into the wrong chamber of the heart.
As the probe glided across the gel-smeared chest, another oddity appeared. "What was sitting in the apex of the left ventricle?" thought the technologist. The left ventricle is the heart's largest and strongest chamber, while the apex is the lowermost portion. Embedded in the patient's heart was a bright oblong object. Clearly this was neither a tumor nor a blood clot. She was at a loss. Despite 20 years of experience and thousands of echocardiograms, she had never seen anything like this. And what did it have to do with the VSD, if anything? She called the cardiologist.
He too was baffled. Other than a tumor or blood clot, he could think of no other possibility, and yet it looked like neither. "Let's get a chest x-ray," he said. "Maybe that will help."
An hour later he had the chest x-ray in his hands, and secured it on the x-ray viewer, an illuminating light source. "The object is shaped like a bullet," he said. He went back to the patient and examined his chest. A small two-inch scar was present just below his breastbone (sternum). With the aid of an interpreter, he was able to piece together the story.
While patrolling the Iran-Iraq border during the war of the 1980s, the patient encountered a platoon of Iraqi soldiers attempting a cross-border infiltration. Shots were exchanged, and the young Iranian fell to the dust, blood pouring from his chest. A makeshift stretcher was fashioned and after an agonizing wait on the battlefield, he was rushed to a military hospital. He remained for three weeks of observation, and was discharged with little information about his condition, save for a warning that his heart wasdamaged. He felt well, with no cardiac and respiratory symptoms. The murmur had gone undetected on his immigration physical exam.
A CAT scan of his chest confirmed the story. A bullet pierced his chest, ricocheted off a rib, crossed the ventricles of his heart (causing a VSD), and, slowed by its journey, embedded itself into the apex of his left ventricle. This was the first reported case of a bullet causing a VSD, staying in the heart, and causing no symptoms. As there appeared to be no hemodynamic compromise, no symptoms, and no other adverse affects on the heart, no surgery was advised, and he was subsequently lost to follow-up.CHAPTER 3
BEWARE OF MINERAL OIL
A young woman of 25 presented to the hospital after collapsing on an airplane. She was traveling from Ecuador to her home in New York City. In the middle of the flight she suddenly stood up, clumsily bolted forward, and tripped over other passengers onto the carpeted aisle. She cried out in anguish as she keeled over. A physician (a pathologist unfortunately) was on the same flight, but could offer little help except for an autopsy were it necessary. He recalled enough medical training to turn her on her side to prevent her from aspirating her lunch, a portion of which she had just emptied from her stomach.
She was taken to the back of the plane and laid across three seats. She was screaming and kicking and required restraints. The pilot decided to divert the airplane to Dallas.
Over the following 15 minutes her abdominal pain became progressively intense. Her behavior was increasingly bizarre and erratic. "I must get to the washroom!" she yelled.
A kind elderly woman, certain this was simply a case of psychotic constipation, offered the woman her mineral oil. "A laxative will help dear, just take this," she said.
The woman was in and out of consciousness. By the time the plane landed and taxied toward the gate, her condition had deteriorated. She was lifted into the ambulance and driven to hospital.
In the emergency room, restraints secured her to the stretcher. Her main complaint was severe abdominal pain. Yelling in a mixture of English and Spanish, she was hallucinating and perspiring heavily. She screamed at the unseen spiders under her skin, and prayed to a hovering angel. On exam, her heart rate was racing at 160 beats per minute, and her blood pressure was dangerously elevated at 250/130. Her pupils were dilated, her skin gray. She resembled Linda Blair from the movie The Exorcist. Her abdomen was exquisitely tender and board-like. This was a surgical emergency. A ruptured appendix? A tubal pregnancy? A bad meal the night before?
The surgeon was called. He was new to the hospital, in his first year after a decade of training and sleeplessness. Miss Ecuador was sped to the operating room, kicking and screaming against the binds on her wrists and ankles, spewing a stream of incomprehensible insults, spinning her vomit-riddled hair wildly.
A 500-watt beam of light shone on the surgical field from an overhead lamp. The patient's smooth skin was cut from navel to sternum. A shallow river of blood formed and fell down the sides of her abdomen. The surgeon stared inside the cave he had cut.
"Nothing wrong on a surface inspection of the intra-abdominal contents," the doctor noted.
His size 7½ gloved hands entered the abdomen and explored, desperately searching for the problem. Suddenly they grabbed it like a football. It was her stomach, overgrown and distended to twice its normal size. Through the translucent mucosa of her intestinal walls he caught a terrifying sight. Long cylindrical tubes, like enormous fly larvae, were infesting her intestines and presumably her stomach. He let out a gasp, shocked at what he was witnessing. With trembling hands he cut into her stomach, prepared to leap backwards and save himself. Sweat stained his back and chest. What ghoulish form would fly forward when released from the confines of the stomach?
Condoms spilled out. Dozens and dozens of condoms, each filled with a fortune in cocaine. The lass from Quito was a body-packer. Surgical buckets, often used for entrails, a transplanted organ, or other body parts were filled one after the other with condom packages of cocaine. Five buckets overflowed with 178 condoms, 45 of which were ruptured.
As the surgeon was transferring the horde, the patient suffered a sudden cardiac arrest. Despite massive and prolonged resuscitation efforts, she died on the operating room table. The diagnosis, confirmed with post-mortem blood analysis, was acute cocaine intoxication.
Each of the 178 condoms contained approximately 4.5 grams of cocaine, for a total of 800 grams (nearly a kilo). Depending upon the frequency of recreational use, and thus tolerance to its effects, a lethal dosage of cocaine is approximately two grams. This young woman had ingested 400 times that amount.
The burden of so many packages had distended her stomach and intestines, causing severe abdominal pain. Perhaps one had ruptured, releasing a stream of cocaine into her body. Unfortunately, the mineral oil acted upon the latex of the condoms, and dissolved them. By mistakenly offering a mineral oil cocktail, the elderly woman inadvertently contributed to the demise of the patient. The mineral oil caused the release of toxic amounts of cocaine, resulting in cardiovascular collapse and death.CHAPTER 4
A seven-year-old boy was taken to the pediatrician complaining of leg pain and swollen, bleeding gums. His height and weight were average. He had been developing normally and had never been hospitalized. He was a healthy and energetic boy until his symptoms began two months previously.
His appetite was poor and he was peevish and irritable. He had developed mild diarrhea. His leg pain had become suddenly unbearable that day, but he soldiered on and walked into the examining room with a grimace. On exam, both weight and height had slipped considerably over the year. There was a mild fever. His gums were swollen and blue, bleeding easily when touched. Little red spots had erupted all over his skin, as if he had been pricked by thousands of tiny needles. Miniature droplets of blood oozed from his hair follicles.
Fearing a severe illness, the pediatrician immediately admitted the boy to hospital. He underwent numerous investigations over the following week. Blood tests showed a low red blood cell count, consistent with mild anemia. X-rays showed abnormally thin bones. Leukemia was considered, but an examination of his bone marrow showed no abnormal cells. He was poked everywhere. Blood was sent to biochemistry, hematology, microbiology, and pathology, but still there was no clear diagnosis for his puzzling condition.
Excerpted from THE WOMAN WHO SWALLOWED A TOOTHBRUSH by Rob Myers, Tracey Millen. Copyright © 2003 Rob Myers. Excerpted by permission of ECW PRESS.
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