Psychiatry Day

Here in Beersheba, the department of anesthesiology has a contract with Magen David Adom. We provide them with 24-hour coverage in the mobile intensive care ambulance. It's a win-win situation. We get to work outside of the hospital, which is a nice change of pace, and the public gets doctors who have experience in both trauma and acute coronary care management. There are few specialties that combine both fields. Even ER doctors (in Israel) usually stay within their respective fields, either surgical (trauma) or internal medicine.
Usually we do three shifts straight (24 hours) while the paramedic and the ambulance driver are relieved every shift. In the ambulance, just as in the hospital, the "rule of three" applies. The rule of three is sort of a Murphy's law of medicine, or, to quote Morton's salt motto: "When it rains, it pours." The idea is that you never encounter just one patient with a heart attack, or just one car accident during those 24 hours, you always get at least three.
And so it was this time. A day of psychiatric cases masquerading as something else. The day started with a "jumper." A woman "fell" four stories out the window...naked. Her son was sleeping (at 9 am!) at the time. He offered no other information. We found her fully conscious with several fractured limbs. She was relatively lucky that her fall was broken by the roof providing shade over the patio below. We carefully evacuated her on a backboard, which probably prevented nerve damage. We later learned that she had severe vertebral fractures and 70% narrowing of the spinal canal. When I called my fellow anesthesiologists on call later that day, I was informed that the woman jumped because she heard voices telling her to do so.
The next case: A young Bedouin who had lost consciousness. When we got to the scene different family members offered different versions of what happened. One claimed that he fell off a horse. Another claimed that he just collapsed during a soccer match. None of these people actually witnessed the event. The young man was unconscious when we put him in the ambulance. Eventually, the true story came out: that he had a vociferous argument with his brother and had lost consciousness immediately afterwards. In other words, he had an attack of "desert rage." He came to in the ambulance, broke a shelf by kicking it, threatened the paramedic and myself. What a nice guy. The psych consult found no psychiatric disorder. They never do.
Then came another unconscious Bedouin. This time a 14-year-old adolescent girl who chewed 4 pieces of her father's nicotine gum. She probably had palpitations because of the nicotine and then had an anxiety attack. She came to in the ER.
Then the last case of the day: We were dispatched to an elderly lady with chest pain which turned out not to be chest pain at all. It was yet another attack of anxiety. The woman had been informed that her dog was very ill. One of the symptoms of her anxiety was a feeling of "pins and needles" in her face and extremities. It happens because of hyperventilation (a fast breathing rate). After the paramedic helped her to calm down she was all smiles and thanked us for all the TLC (tender loving care).

Then she started to analyze her own reaction and thought it was all rather interesting. And then she floored me completely. She said, "Ya know doc? At the same time I had all these weird feelings." Then, dropping down to a whisper, "I felt very warm in my privates." Now, what is the correct response? What I wanted to say was: "OK, ma'am, that was a lot more information than I wanted to hear." But trying to be polite, I mumbled something like, "yeah that happens, I wouldn't worry about it too much."
So much for thinking fast on my feet. These are situations that they never told us about in med school