"I don't know why he swallowed that fly... Perhaps he'll die"

"I don't know why he swallowed that fly... Perhaps he'll die"

The other day I was working at the Rideout ER in triage.  My job is to see people as they are being checked in, do a brief assessment and order any labs or studies that need to be started in order to speed the whole system up.  The main idea being is that they aren't likely to be seen by the doctor right away, and we can use the time between now and then to get a few things done so that their overall stay is shorter. 

Anyway this kid comes in with his mom.  I'm calling him a kid mostly because of his baby face, and probably because he was with his mom, but in reality he was 17.  He was dressed in nondescript military style fatigues, and his mom was wearing whatever mom's wear.  They tell me their story about how they were just in a car accident and rear ended someone a few minutes ago and how it was a shame because the kid has been in boot camp for 2 months, and only has 2 hours on leave.  She had only just picked him up 10 minutes earlier and WHAMO she runs into another car.  The nurse I was with started to make pleasant conversation and asked what branch of the military he was in while we looked at mom's shoulder.  The kid explained that he wasn't in the military, he was in a boot camp style "straighten out your life" program for screwed up kids.  He did a poster child job of explaining how much he liked the program and how it was doing him a world of good to be getting on the right path, blah, blah, blah.  Next thing I know, he and the nurse are talking about how much he likes to fight, but how important it is to pick fights with people that you know you can beat because it helps cut down on trips to the Emergency department and all that.  I'm having trouble keeping a straight face because mom barely has 2 brain cells to rub together, and the kid obviously takes after mom and the whole thing is pretty ridiculous.

So now its the kid's turn to be seen and he needs to have his hand xray-ed because he smacked it into the dash and probably broke his hand (again).  Everything would have been fine except that after all that he started telling me this other story.

He told me that about 2 months ago he was fooling around and accidentally swallowed a tack. 

Me- "You shouldn't swallow tacks", "they are bad for you".

Kid- "Yeah, I know, but I did it anyway."  "I tried reaching in my mouth to get it with my hand but I couldn't reach it."

Me- "You tried to reach into your stomach?"

Kid- "Yeah, I could get my whole hand in my mouth, but couldn't reach any further than that"

Me- "You can get your whole hand in your mouth?  Really?"

Nurse- "You didn't come into the ER when you did it?"

Me- "Your whole hand?  Right or left?" 

Kid- "So then I drank like a gallon of water and made myself throw up a bunch of times to try and get it out."

Nurse- (cause I was hiding behind my clipboard trying not to laugh) "It was just a tack, I'm sure you pooped it out the next day."

Mom- "Did you check your poop?"

Kid- "I'm not going to go digging through my crap looking for a tack!" "I'm not f-ckn' sick", I'm not like my father!" "No f-cking way!"

Me- "But you'd try to reach it with your hand?"  "Really, I am sure it's gone by now."

Kid- "I had my friends punch me in the stomach a bunch of times."  "I started to cough up blood, but we couldn't get it out."

Nurse- "You didn't think the blood had anything to do with the punching?"

Me- "First off, don't swallow tacks but I already told you that.  Second, if you do, come into the ER then, not 2 months after that.  Third, don't try to get the tack out yourself with your hand, or by vomiting water, and certainly not by having your friends punch you in the stomach."  "I'm sure you have already passed it a long time ago, but but since you are so stressed out about this, tell you what, I'll go ahead and order a chest X-ray.  If it's between your chin and your stomach we will see it.  If it's not I am sure it's long gone."

Kid- "OK, cool, thanks"

So they took the kid to his bed and I joked back and forth with the nurse about the patient.  My final words to her were, "Watch, after all that, it's going to be there..."

Sure enough, an hour later the other PA came over to me and said, "Man, how in the heck did you know that tack was in his LUNG?  I never would have guessed that based on his story.  It's in his right main-stem bronchus and he even has an aspiration pneumonia with it!  It's a good thing you thought to check a chest x-ray..."

So I took a look, just below the carina in the right main-stem, was a metallic foreign body.  I could see the pneumonia, and yep, son-of-a-gun there is the tack... wait sec, it doesn't look right... where is the other view?  It doesn't look like a tack... it looks like... A NAIL!  He didn't swallow a tack, he swallowed a nail.  And he didn't swallow it, he breathed it into his lung and got pneumonia because of it.  No wonder he couldn't vomit it.  But seriously, who the heck swallows a nail, tries to reach it with his fingers, and then has his friends punch him in the stomach to try and get it out.  Probably the same guy who doesn't know the difference between a tack and an nail.

Update:  The other day at work this story came up again, and the other PA who saw the kid filled me in on part of the story I didn't know from before.  Why was the kid playing with a nail in the first place?  He was trying to pierce his tongue with it.  It slipped and went down the back of his throat.  Yup.  Trying to pierce his tongue with a nail, had it end up in his lung, and then with the reaching, puking, and punching.  Awesome.

Based on Fluidity css adapted by Dan Delcollo