Sandy Brown, MD

Disclosures

November 02, 2007

"I'm sorry," Dalia said over the intercom, "but I have an urgent call from one of your patients. Michael McMillan's wife is on the phone. He's been urinating blood for 4 days."

Usually, Dalia only interrupts me when I'm with a patient for calls from other doctors, but she makes exceptions for emergencies. Before she even brought me Michael's chart, I recalled that he had suffered a similar episode of gross hematuria 2 years earlier. Then, he had had enough bleeding to cause clots, which blocked his urethra and required a catheter to enable him to void. An abdominal CT was negative for bad characters. Michael recovered but refused referral to a urologist. I thought that odd. Then, only 3 months ago, he alleged to have accidentally sat on a pin, which he thought had broken off inside of him. A far-fetched story but, sure enough, a KUB film showed the pin lodged near his prostate. A trip to the OR was needed to extract it. Now this. It just didn't make sense.

Michael's wife Wendy told me that he could hardly stand up and looked wan. "What should we do?" she asked apprehensively. "Put Michael on the phone," I instructed her. She brought him the phone. "Michael," I asked, "What's going on?" "Doc," he said, "I should have 'fessed up to you a long time ago. I needle myself. I've been sticking needles into my body ever since I was a teenager. Four days ago, I stuck a long needle through my abdomen into my bladder. It bled for a day and then stopped. But yesterday it started up again in earnest. I think I've lost a lot of blood." I was astounded. There was nothing about Michael that even hinted that he might be self-destructive. "Stay put, Michael," I told him. "I'll call you right back."

Being without a local urologist, I immediately called Fred, a urology colleague in a nearby town. "He's seeing a patient right now," said Julie, his receptionist. "Is he doing a procedure?" I asked. "No." "Then interrupt him."

I apologized to Fred for intruding, and then told him this incredible story. "I would have had him go to our ER, but outside of trying to place a catheter and transfusing him, there's not much more we could have done if he continued to bleed. He needs a urologist." Fred agreed and told me he'd give his ER doc and the urologist on call a heads-up. "Send him over," Fred said. "That's a new one for me." "Me too," I said.

After giving Michael's wife directions to the neighboring medical center and instructions for transporting him, I paused to reflect. Why hadn't I picked up on his psychiatric illness sooner? True, it wasn't your run-of-the-mill kind of self-mutilation. I had never seen a case such as this and neither had Fred nor the ER doc who had gotten the heads-up. (My psychiatrist friend to whom I referred Michael told me that needle sticking is a form of repetitive self-mutilation -- a failure to resist impulses to harm oneself without suicidal intent.) That's what fascinates me about this business: Just when you think you've seen it all, you're blindsided by something you never could have imagined.

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