Tales of the unexpected emergencies
Dipping into the melting pot of humanity
Many doctors do a six-month stint in casualty as part of their early medical training. It was my first job post-internship, and one I have fond memories of. The emergency department – to give it its current politically correct moniker – is the quintessential melting pot of humanity. As well as the obvious tragedy of road traffic victims and sudden unexpected death, casualty was the place to see and experience the unexpected.
Among the unexpected was seeing people who had unfortunately ingested foreign bodies or otherwise inserted objects in various orifices. Anyone with children will likely have experienced the toddler who announces with some pride that they have placed an object in their ear or nose. These vary from beads to stones and include insects, food, parts of toys and seeds.
Objects in the ear are typically lodged within the ear canal itself, although if there is perforation of the ear drum, the object may be found in the inner ear. Inanimate objects that have been in the ear for a short time typically present with no abnormal finding. Bleeding or redness may be present if the object has damaged the ear. If the foreign body has been in place for a while, redness, swelling and foul-smelling discharge may be present. Insects may injure the ear canal by scratching or stinging.
What options are there to remove foreign bodies from the ear? Irrigation under low pressure is the simplest method, but is best avoided with food and other organic matter. If the object is visible with an auroscope, then mechanical removal with a forceps may be the first option; however, if it is likely to break if grasped, then suction may be the way to go.
Children also like exploring their noses, which may coincide with stuffing an object up a nostril. The major concern is the risk of the foreign body travelling down the child’s airway. The right nostril is twice as likely to be involved as the left, which is thought to be because right handed children will tend to favour this side.
Discharge from the affected nostril, a nose bleed or snoring may be the first hint of a problem. Objects that have been in place for an extended period may cause an offensive discharge or bad breath. Metallic button batteries are increasingly found in children’s noses; they can release chlorine gas or leach their alkaline content.
Both adults and children ingest foreign bodies. Most pass harmlessly through the gut, although if the object has sharp angles it may have to be removed surgically. X-rays of objects that are radiolucent are amazingly vivid and the progress of the button battery or necklace charm can be seen if serial X-rays are performed
Dr Chevalier Jackson, a laryngologist who worked in the late 19th and early 20th centuries, preserved more than 2,000 objects that people had swallowed or inhaled: nails and bolts, miniature binoculars, a radiator key, and a medallion that said, “Carry Me for Good Luck”. The Jackson collection is owned by the Mütter Museum of the College of Physicians of Philadelphia, which is refurbishing it for an exhibition due to open soon.
Mary Cappello, author of Swallow, a book about Jackson and his bizarre collection, described him as a fetishist. He certainly displayed a certain zeal at a time when surgical equipment was rudimentary and his peers would have shied away from such interventions. But according to Cappello, 95 per cent of Jackson’s patients survived his surgical efforts, an impressive statistic for the times.
Speaking of fetishes, some of the most bizarre foreign objects seen in emergency departments are those inserted into rectums. They are matched only by the embarrassed excuses of the victims as they feel obliged to explain the presence of dildoes, bottles and glasses. Light bulbs are a frequent finding: when featured in the TV medical comedy Scrubs, it led to the classic line to the effect that, “Either this guy has a light bulb up his ass or his colon has just had a bright idea.”
Casualty departments really are the Gubus of the medical world.