I recently went mountain biking in Moab, Utah. Unfortunately, I fell just as our ride was starting. It was soon apparent to me that I had broken some ribs on the left side of my chest. I painfully rode back to the trailhead and found a ride back into town, rather than trying to ride the rest of the 26 miles we had planned for that morning.
Since there is really no treatment for broken ribs, I knew there was no reason for me to seek medical care. I just set myself up on the couch of our rented condo and tried not to move around too much until I could head back home.
A week later, I was back at work, feeling better and was taking only ibuprofen for pain. “This has not been that bad,” I thought to myself. Little did I suspect that a surprise setback lay ahead.
I woke up on Saturday morning, eight days after my fall. As I got out of bed, I was surprised that I had more pain in my chest than I had been experiencing the previous few days.
While I was in the shower, the pain got a lot worse and any movement was now causing severe pain. Getting dressed was really tough but I pressed on, feeling sure it would soon pass.
As I started down the stairs into the living room, I was seized with a muscle spasm along my left spine that left me completely incapacitated. I hollered, stiffened and became unable to breath or move until the muscle spasm relaxed and the broken ends of my ribs were not being driven against each other.
The spectacle I presented on the stairs caused everyone in the house to come running. My wife, son and daughter-in-law rushed to my side, trying at the same time to understand what was wrong and wondering how they could help.
Several things went through my head as this was going on. I know enough about this sort of thing to understand, basically, what was going on. The pain from my broken rib was causing my back muscles to go into spasm. That was causing severe pain which was making the muscle spasms worse. Whenever I moved, I was caught in this terrible cycle and the only thing that helped was to not move, at all. Understanding this, I was not worried that I might have some terrible, life-threatening condition. I recognized that this understanding helped me a lot, compared to people without my training and experience who might be freaking out, wondering if they were dying or something.
I next thought that I always have to ask my patients to rate their pain on a scale from 0 to 10. In doing so, I sometimes wonder what pain I would rate at a level of 10, the most pain anyone could experience. “Now I know,” I thought.
After I was through with my clinical and analytic thoughts, my attention turned to how to get off the stairs. If I moved my trunk at all, like to take a step, the pain would come back and I couldn’t move. There was nothing I could do about it. With help from my wife and son, I forced myself down the stairs and collapsed on the couch, trying not to scream the whole time.
There I stayed the rest of the day, unable to move without triggering the same terrible pain. When it came time to try to take a nap, I needed help from my wife and son who moved me as if I were a piece of fragile furniture, trying to keep my spine from moving.
At bedtime, they helped me in the same way back up to my bed. The next day I still had pain and had to be careful but was some better. By the following day, I still had the rib pain but all of the spasms were gone. Today, I am almost pain free. I am back to riding my bike with no problems.
Now, I told you that story to tell you this one:
The next week at work, I introduced myself to my next patient. She was a lady about my age who told me a sad story about being attacked three days earlier by her mother, who suffered from Alzheimer’s Disease. She had been knocked to the ground and injured her chest. She told me she was pretty sure she had broken a rib and, knowing there was nothing to do for it, had just been taking ibuprofen and putting up with the pain.
What brought her in was that she had woken that morning with severe muscle spasms on the same side as her broken rib. The pain was so severe she was incapacitated by it and was worried about a complication of her chest injury.
As I listened to her, I had a hard time not smiling, which I knew would not be perceived well. As soon as she had a chance to tell me of her concerns, I briefly told her of my experience the weekend before. I explained what I thought had happened to both of us. I reassured her that what she was going through was completely understandable and she had nothing to fear. I also assured her that we would get her feeling better in a short time.
After some intravenous morphine and valium, she was feeling much better. She went home relieved to know she was going to be fine, happy to be out of pain and appreciative of a doctor who was able to empathize so distinctly with her suffering.
There is some irony in recognizing that she went to the emergency department and got some help while I just stayed at home and suffered.
My friend, Lisa, sent me a recipe for Hard Boiled Egg Chocolate Chip Cookies. “What the…?” I asked. A quick Google search showed that something that sounded bizarre to me was, actually, all over the place. I tried some different recipes and this is the one I liked the best. They are very moist but are not nearly as good the next day so make small batches or eat them up!
This is a very interesting way to make cookies. I’ve never seen a cookie recipe that asked you to blend the butter into the flour as if making pastry. This is a small batch but even at that, it was pretty tricky to get the food processor to mix it up. The processor was just too full. When it was done, however, the dough was fabulous and it was really fun to mix the chocolate chips in with my hands. Had to repeat it thee times to make enough for the emergency department.
2¾ cups flour
1 cup cold butter, cut into small chunks
1 teaspoon salt
½ teaspoon baking soda
¾ cup white sugar
½ cup brown sugar
1 teaspoon vanilla extract
2 hard boiled eggs, peeled and diced finely
2 cups semi-sweet chocolate chips
1. Heat oven to 350°F.
2. Mix flour, salt and soda in a food processor.
3. Add butter and process until mixture is the texture of small crumbs.
4. Add sugars, vanilla, and boiled eggs. Pulse again until mixture comes together.
5. Remove dough to a large bowl. Add chocolate chips and combine by hand, using a wooden spoon or clean hands.
6. Scoop 2-tablespoon balls of cookie dough onto parchment-lined baking sheets. Flatten slightly with your hand.
7. Bake 13-15 minutes or until the edges of the cookies are lightly browned.
8. Remove cookies from oven and let them sit on the cookie sheet for 3-5 minutes before transferring them to a cooling rack. Eat them today.
Here is Hunter enjoying one:
Here is a picture of my hens. No wonder I am always looking for egg recipes:
One night this week, one of my physician assistants came to me frustrated that the patient he had gone to see had run him off, saying he wanted another doctor. Matt had addressed two complaints the patient had: difficulty urinating and a nagging cough. When the patient went on to more complaints, including shoulder pain he had been suffering with for over a year, Matt recommended he take up these more chronic problems with his primary care physician. That is when the patient ran Matt off.
It was now my turn. I found an elderly man asleep on a gurney wearing sunglasses and a beret pulled down over his face. I introduced myself and went over his first two problems. When I asked him if he had any other concerns, he told me about his shoulder pain, for which his primary care doctor usually gave him Vicodin. He then said all he wanted was to be treated with sympathy.
I asked him if he had come for sympathy or for Vicodin. He calmly answered, “Vicodin would be fine, thank you very much.”
This all took place in the hall right in the busiest part of the emergency department and as soon as he answered my question, I was surrounded by suppressed laughs. I had not intended my question to be comical. I’m sure he didn’t intend his answer to be funny either, but, together, they made everyone laugh. This was especially funny to staff surrounded every day by people looking for opioids for their chronic aches and pains.
Semolina is made from hard durham wheat. It is cooked, dried then ground. It looks and feels kind of like corn meal. It gives these cookies an interesting texture. They are soft and very lemony.
Hunter enjoys one after a spaghetti lunch.
Adapted from Food.com
3 large lemons
½ pound unsalted butter
½ teaspoon vanilla extract
2 cups sugar
1 teaspoon salt
3 cups semolina
1 cup all-purpose flour
To dust the cookies
½ cup sugar
1. Using a grater, grate lemon peels, removing only the yellow part. Set aside. *See notes.
2. Squeeze juice from the lemons. Set aside.
3. Combine butter, vanilla, sugar and salt in an electric mixer fitted with a paddle. Beat until creamy.
4. Add egg, ½ cup lemon juice and grated rind. Beat until incorporated.
5. Reserve any extra lemon juice for another use.
6. Decrease speed to slow. Add semolina and flour, beating until just incorporated.
7. Cover with plastic wrap and chill in the refrigerator for 1 hour.
8. Heat oven to 325°F.
9. Scoop dough into 2 tablespoon balls. Roll each ball in sugar then place on greased baking sheets.** See notes.
10. Flatten each ball to about ½ inch thick. *** See notes.
11. Bake cookies on the middle rack of an oven for about 14 minutes, or until the surface starts to crack. They will not start to brown.
12. Remove from the oven and let cool before removing from baking sheet.
*This finely grated citrus peel is called zest. I have a zester, specifically made for this job. It works ever so much better than a regular grater.
**I almost always use parchment baking papers but these didn’t come off the papers well at all.
*** My preferred method to do this: Butter the bottom of a drinking glass. Dip it into sugar. Gently flatten a dough ball to desired thickness. Re-dip in sugar before flattening the next ball.
When Shari and I went to Sydney in 2016, we hung out with our Australian friends, Rachel and Richard, who recommended several classic Australian treats for us to try. This is the one that I came home and made. They are shortbread cookies and the icing makes them. Dr. Al’ai, one of our emergency physicians, went crazy over them, saying they were just like a cookie he remembers from his childhood in the Philippines.
For the biscuits:
1 cup unsalted butter, 250gm, at room temperature
1/2 cup, powdered sugar, 80 gm
2 cups all-purpose flour, 250 gm
1/2 cup custard powder, 80 gm. *see notes
For the buttercream:
1/4 cup unsalted butter, at room temperature
1 cup powdered sugar, 160 gm ** see notes
1 teaspoon vanilla extract
1. Heat oven to 350°F. Line two baking trays with parchment.
2. To make the biscuit dough:
3. Using an electric mixer with paddle attachment, beat butter and sugar until combined.
4. Sift flour and custard powder into the butter mixture. Mix gently until the dry ingredients are fully absorbed into the butter mixture to form a dough.
5. Wrap dough in plastic wrap and allow it to rest at room temperature for about 15 mins. If the dough is too soft to roll, place it in the fridge instead and allow it to rest for 15-30 mins or until the dough is slightly firm (but not too firm.) (I found refrigeration to be unnecessary.)
6. Scoop mixture into 1 tablespoon balls.
Place on prepared trays and press down with the back of a fork.
Bake for about 15 mins or until their edges are light golden. Remove from the oven and allow to cool on the baking tray for about 10 mins. Transfer onto a wire rack and allow the biscuits to cool completely.
7. While the biscuits are cooling, make the buttercream. Using an electric mixer with paddle attachment, beat butter, sugar and vanilla until light and fluffy.
8. When biscuits are cooled completely, sandwich two biscuits (back to back) with a dollop of buttercream in the middle.
Originally from the book, Country Women’s Association of Australia (CWA): Biscuits and Slices, contributed by Alisa Bond from Riverside Branch Tasmania.
* I bought Bird’s Custard Powder online from Amazon Prime but Rachel told me she saw it at Whole Foods. Also note that Corine, our daughter’s mother-in-law, from Canada, says this is the key to perfect Nanaimo Bars!
** I alway sift my powdered sugar when making icing. It is just easier to get it smooth.
A sixty-year-old woman came in by ambulance. The nurse entered “abdominal pain, flank pain” as the chief complaint. The nurse advised me that the patient was deaf and only spoke Spanish, so I grabbed some paper and a clipboard before going in the room.
I introduced myself and showed her my name badge so she would know my name. She motioned that she was deaf. I smiled, nodded, and pointed to my “Hablo Español” button as well. I then wrote on the paper, “Que pasa?” (What’s going on?)
She took the clipboard and started writing. “This isn’t going to be too bad,” I thought to myself.
When she returned the clipboard, I saw she had written, “Susana,” which was her name. That was about the best we did. With her reading my lips and using her sketchy Spanish, I was finally able to learn that she was, indeed, deaf. She only spoke Spanish and didn’t know any sign language. She also had never gone to school and didn’t read or write. On top of that, no family member had come in with her; someone who, I hoped, would be better able to communicate with her than I was.
Usually in medicine, we rely a lot on the history to start figuring out what is the matter with someone. In this case, through lip reading and pantomime, I was able to understand that she was having pain in her lower abdomen and flank. That was about the best we could do. I examined her and ordered tests, doing more tests than I might normally have to do since I didn’t want to miss something.
The tests all came back normal, her pain was controlled with the medicine I gave her and we were finally able to get hold of a family member who came in and helped get her discharged.
When it comes to communication challenges, it is hard to beat a non-English speaking patient who is deaf and doesn’t sign, read or write.
Some people really want their doctor to know the exact details of their symptoms. This often leads to extended written accounts of details patients believe will help with their diagnosis. Here is a reproduction of a written note a patient brought in to help outline his symptoms. If you have a hard time following it, I do to. In the end, we found nothing wrong and the patient left without a diagnosis. As I sent him off to follow up with his primary care doctor, feeling sure he had no emergency, I wondered if someone, someday, will find a strange medical condition to explain the symptoms or if it was all just mental. This is not an unusual thought as I discharge people. It seems mental to me but I don’t know everything.
Diabetic Type II
Off meds long time
#’s run in 200’s
-woke up dizzy
-sat on edge of bed
-got online and video chat so people could watch me, make sure I was OK
-eyesight got strange
-couldn’t see part of right side of vision. close one eye can see OK. close other eye see OK. both eyes – missing right side view
-right side of lips (top + bottom) went numb for a little while. right arm and leg got weak and shaky
-only lasted a little while then lips ok again + arm/leg ok too (no shaky)
-nauseas – didn’t throw up – just wretched
-headache left front behind eye
-took Naprosyn Sodium (just one)
-went to sleep
-eyesight still messed up
-woke up feeling better
-eyesight ok (but bright spots)
-bright spot/line in right eye fading but still there
afternoon -small headache
-took Naprosyn – headache faded away
1 periods of dizziness