Chief Complaint

Written by Tad. Posted in Kooks

When evaluating patients in the emergency department, we start with what is called “The Chief Compliant.” This is what the patient says is wrong, usually a symptom. Sometimes, that is very straightforward: “I fell and twisted my ankle” or “I have chest pain.”

Based on the chief complaint, we ask more questions, do a physical exam and maybe some testing.

Sometimes, the chief compliant is so bizarre it is hard to even get passed it. Once, a lady came in and said, “Every time I have sex, I bark like a dog.”

When I hear a complaint like that, it is hard to even think of a question to ask in clarification and there is certainly nothing you can image would be helpful in a physical examination or any lab tests. It all just kind of stops with the chief complaint.

Another case like that happened recently when a man in his twenties came in and said, “I’ve been tasting saltiness in my throat, like seawater for the last two days.” He had Googled it and been unable to find a cause so he came in because he was sure it was something serious. I asked some more questions to make sure I was not missing something then did a thoughtful examination before sending the patient home with reassurance. My usual line for this sort of complaint goes something like this: “I have never experienced this symptom in my life nor have I ever heard of anyone else having this symptom.” I then explain why I think there is no reason to be concerned and send the patient home.

Another way the chief complaint can tell the whole story is when it is so long, bizarre and covers too many different symptoms. This is especially true if the symptoms have been going on for a long time. Basically, the more complaints, the stranger they are, the more they involve different body parts and the longer they have been going on, the less likely it is to be an issue in the emergency department.

Sometimes, people have so many different complaints that they actually have them written out, in list form. These are often amazingly long, detailed and even bizarre.

Here is a list I was given by a 38-year-old Vietnamese patient who had been having trouble for many years. She had come from Vietnam two months previously and came to my emergency department so I could figure out what was wrong with her.

Since childish:

-easy having fatigue

-tired when working

-excited easily

-often passed out when I was in VN (not use any medication)

-insomnia

-forgettable hard study

-starting

-grinding of the teeth

In this case, some follow-up questions, a good examination and some basic lab tests showed nothing to worry about. She was referred to find a primary care doctor.

 

 

Yellow and Green, Again

Written by Tad. Posted in Trauma Strap Bags

A couple of week ago, I made a bag out of seat belts that was olive green and bright yellow. I came across some more yellow and green and made this bag. It is not seat belt material and the green is a lot brighter. By the time I made the bag, there was not an inch of green left over to fix the buckle on so I used black.

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Ube Crinkles

Written by Tad. Posted in Cookies

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Anyone following the cookie recipes in my blog will know that an unusual ingredient is the most likely thing to get me to try a new recipe. The other night, LA, one of our emergency doctors, challenged me to come up with ube cookies. At first blush, this seemed crazy but when I went to the Internet, I was able to find several possible recipes to try.

One of the biggest challenges I had was coming up with the ingredients. Most of us have never even heard of ube. It is a yam that is amazingly purple, colored like a beet. It is very popular in the Philippines. The first time I heard of it, was when I ate ice cream made out of it. Naturally purple and very tasty.

This is the kind of recipe that you will only be able to try if you live somewhere with lots of Filipinos or you are willing to go online and have ube jam and ube flavoring sent to you.

I have made chocolate crinkle cookies many times so the idea of a bright purple crinkle cookie really grabbed me. This is fun cookie baking and eating!

Recipe By:

bakehappy.net

Yield:

30 cookies

Directions:

3 cups all purpose flour
2 teaspoons baking powder
½ teaspoon salt
1 cup unsalted butter
½ cup brown sugar
1 cup sugar
2 eggs
1 cups ube jam / halaya,  *SEE NOTES
2 teaspoons ube flavoring,  **SEE NOTES
2 cups powdered sugar ***SEE NOTES

Directions:

1. Combine flour, baking powder and salt. Set aside.

2. Cream butter and sugars until light and fluffy.

3. Beat in eggs.

4. Beat in ube jam and ube flavoring.

5. Gradually stir in dry ingredients.

6. Cover bowl with cling wrap and chill for 4 hours or overnight.**** SEE NOTES

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7. Heat oven to 350 degrees.

8. Scoop 2 tablespoon balls of dough with an ice cream scoop. Roll dough balls in powdered sugar. Arrange baking sheets covered with parchment.

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9. Bake about 14 minutes until just set. Of course, as in all cookies, don’t over-bake.

Notes:

* Original recipe called for Ube Jam from Mountain Maid Training Center. It is made with ube and sugar but also milk. If you Google “ube jam,” you come up with recipes that mostly contain milk and butter and are more like pudding than jam, like we would put on toast. The jam I bought at Seafood City, my local Filipino market, has just ube and sugar. That is what I used for these cookies.

** When I first saw “ube flavoring” in this recipe, I thought, “Oh, sure.” But, sure enough, at Seafood City, they had McCormick Ube Flavoring. Amazing from my white American perspective.

*** I alway sift my powdered sugar. I just like it better without lumps.

Dr. Who?

Written by Tad. Posted in Kooks

I have been called a lot of names while caring for patients in the emergency department. Many of them are too rude to repeat here and have been hurled at me by people who were chemically impaired. I always ignore these insults.

Even in 2015, I am still sometimes called a hippie. I am never sure if that is because of my ponytail, my turquoise necklace or my general, California demeanor. I usually ignore this as well, since it also feels like an insult.

I have also been called a couple of other names I would like to share with you. They were both uttered by psychotic patients, and I presume nothing offensive was meant by either.

One night, a patient suffering from mania was put on the gurney in the hallway right across from where I sit at the computer. As is typical of manic patients, she was hyper and talked constantly. I ordered something to calm her down while she waited to go to psychiatry.

Waiting on the gurney, she was unable to sit still or stay quiet. She talked constantly and addressed herself to anyone who passed by. After all of her concerns had been addressed, everyone just kind of had to ignore her, in order to get anything else done.

The first several times she called, “Hey, Doctor…!” I stopped what I was doing and addressed her concerns. Eventually, I also had to ignore her.

When I stopped responding to her, she just escalated. Soon, she was hollering, at the top of her voice, “Hey, Doctor! Hey Doctor! Hey Doctor!” over and over again.

When I still didn’t respond, she started hollering, “Hey, Doctor Yeast Infection! Doctor Yeast Infection! Doctor Yeast Infection…!” You can imagine the effect that had on the department as she hollered my title over and over again at the top of her voice. This continued until she finally got tired of yelling or the medication had some effect on her, though she was still hollering out once in a while when she was escorted to psychiatry.

The other notable name was also uttered by a mentally ill person. I was, again, sitting at the computer. I recognized that a bit of a ruckus was developing nearby as a patient approached a resident (doctor in training) and was talking in an aggressive and agitated manner.

The nurse told me the patient had already been seen by another doctor and was discharged. She was being escorted out to the waiting room, when she saw the resident and approached her, wanting to file a complaint. As the nurse and the resident tried unsuccessfully to get her to settle down, I felt a need to intervene as I am, essentially, the captain of the ship.

I had some trouble getting the lady to stop talking to my resident and recognize that I was the one she needed to talk to. Eventually, she turned to me and, rather than look at my face, looked at my name badge. Then, she said, “Shut up, Doctor Diaper Pants,” and walked out, talking only to herself.

I have addressed in this blog several times the conflict I face when mentally ill people do things that are funny. Sometimes, they are really funny. It is very hard to not laugh when someone calls you “Doctor Yeast Infection” or “Doctor Diaper Pants.” But, recognizing the patient is talking that way because of her illness, I immediately feely a conflict that prevents me from really laughing and enjoying the mirth. It is so funny and yet so sad at the same time.

Semolina and Peanut Butter Chocolate Chip Cookies

Written by Tad. Posted in Cookies

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The original name of this cookie was Chewy Chocolate, Peanut Butter & Oatmeal Cookies with Semolina Flour. That name is too long and they are not at all what I would call a “chewy” cookie. I would call them “crunchy” from the  texture that comes from the semolina. The dough is smooth and fun to work with and the cookies are soft.

Source:

Adapted from myjerusalemkitchen.com

Yield:

21

Ingredients:

1 cup semolina flour
½ teaspoon baking soda
¼ teaspoon salt
½ cup butter
¾ cup peanut butter *see note
¾ cup brown sugar
½ teaspoon vanilla extract
1 egg
½ cup rolled oats
1 cup chocolate chips

Directions:

1.  Heat oven to 350 F.

2. Line large baking sheet with parchment paper. Set aside.

3. Whisk together semolina flour, baking soda and salt. Set aside.

4. Cream together butter, peanut butter, brown sugar and vanilla.

5. Beat in egg.

6. Beat in semolina flour mixture until just combined.

7. Stir in oats and chocolate chips.

8. Scoop 2 tablespoon-sized balls of dough onto the prepared baking sheet. Bake 13-18 minutes until set and edges and bottoms are golden brown. I would usually not cook cookies that long, but it may be needed for this recipe.

Note:

When we got married, 35 years ago, I came from a “smooth” peanut butter family and my wife from a “crunchy” family. I have alway maintained that there would be no trouble in having both but she converted and now we only have smooth so that is what I used, though the original recipe called for crunchy.

 

Man Assaults Woman

Written by Tad. Posted in Cookies

A 40-year-old woman presented saying a man attacked her earlier in the day. He pulled her legs, kicked her back and cut her with a knife on her arms, legs and chest.

Most of the time, when a woman comes in after being assaulted, she is pretty upset. In this case, my patient was upbeat and pleasant. She  didn’t act very worried that she might actually be injured very badly.

When I looked her over carefully to evaluate her for possible injuries, all I saw was multiple superficial abrasions on the insides of both forearms, across her abdominal wall and both breasts. It was clear they were just scratches and not cuts from a knife. It was also clear from their position, shape and symmetry that they were self-inflicted.

I gently confronted her with my impressions but she continued to steadfastly deny she had caused the scratches or that she had any desire to hurt herself. I recommended she go talk to a psychiatrist but she refused. Had I really thought she was a danger to herself, I would have put her on a psychiatric hold and sent he to psychiatry anyway but I felt this was just strange attention-getting behavior, though I could never get her to admit it.

I had the police come and take a report since she continued to state she had been assaulted. I then sent her on her way, leaving me wondering what was really going on.

Waffle Iron Cookies

Written by Tad. Posted in Cookies

I recently shared a recipe I got from a Daughters of the Utah Pioneers cookbook my wife got from our friend, Louise. This is the only other recipe in that book that was unusual enough to interest me. Who every heard of cooking cookies in a waffle iron rather than baking them? Obviously, they look like no other cookie you have ever seen before. We only have a Belgian waffler you heat on the cooktop. I am pretty sure the author (Mary Nordin) used a regular waffle iron, which would probably be a bit easier.

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Recipe By:

Adapted from Daughters of Utah Pioneeer Cookbook

Ingredients:

1¼ cups sugar
6 eggs
1 cup butter, melted and cooled
1 tablespoon vanilla, ** SEE NOTE
½ teaspoon salt
2 tablespoons baking powder
5 cups flour, 22 ounce
½ cup cocoa (optional)
Directions:

1. Heat waffle iron to medium heat. Oil with cooking spray as needed.

2. Sift together dry ingredients. Set aside.

3. Beat together sugar and eggs.

4. Stir in butter and vanilla.

5. Stir in dry ingredients.

6. Place about 2 tablespoons of dough onto hot waffle iron. Close lid. Cook about a minute or until browned and cooked through.

7. Frost or coat in powdered sugar.

Note:

** Substitute ½ teaspoon anise oil

Yellow and Green Bag

Written by Tad. Posted in Trauma Strap Bags

Most of the trauma straps that come into our department are nine feet long and two inches wide. They are made of nylon or some similar material. Occasionally, straps come in from somewhere outside our county that are different. They are made of the same material as seat belts, which are heavier, smoother and finer than our normal straps.

This bag is first for me in two ways. It is the first time I have actually used the seat belt straps to make a bag and, this one has olive green as an accent. I had never had that color before one showed up this last week.

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Sorry the picture doesn’t do the dark green justice. Believe me, though, it is not black and it looks great with the bright yellow.

 

Uncontrollable Eye Movements

Written by Tad. Posted in Kooks

A twenty-two-year-old woman was brought to the emergency department by her mother for “uncontrollable eye movements.” The patient said, “Every time I close my eyes, my eyes will roll back in my head and I can’t stop them from moving.” She also had uncontrollable twitching all over her body. This had been going on for three weeks and was getting worse, causing trouble sleeping.

She had been to see her primary care doctor who prescribed something for sleep and referred her to a neurologist. Since she seemed to be getting worse, her mother didn’t want to wait for the neurology appointment and brought her to see me.

I watched the patient closely while asking detailed questions about her symptoms and medical history. All the while, I was forming and refining mental lists and questions for myself. After practicing emergency medicine for over thirty years, most of this takes place quickly and subconsciously, but it looks like this…

  • What might cause something like this? Stroke, seizure, trauma, toxicity to medications or environmental substances, neurological conditions like multiple sclerosis, etc.
  • Of the items on that list, what might happen to a twenty-two-year-old, healthy woman? What might come on rather slowly and get worse over three weeks?
  • What might cause these symptoms and only these symptoms so there is no fever, headache, problems with equilibrium or vision, etc?
  • Knowing what I know about the nervous system, the muscles that move the eyes and human behavior, can I find something on the list that might be a realistic consideration in the case of this patient?
  • Is there some sort of laboratory test or imaging study that might help refine the list further?

The patient told me nothing that would help me understand what was going on. She had no past medical history. No psychiatric history. No drug or alcohol use. No exposure to toxins. No seizures or loss of consciousness. Nothing else. She already had blood testing and a CT scan of her brain that were normal.

While we were talking, the young woman sat on the side of the gurney. Everything about her presentation seemed normal: her mental status, hearing and speech. She showed none of the twitching her mother had described. She seemed completely comfortable with her eyes hidden behind dark sunglasses.

When I asked her to remove the glasses, her eyes rolled up so far only the whites, or sclerae, showed. Her eyes moved back and forth up under her half-closed lids.

After a minute or so of this eye rolling, she closed her eyes. I could see they quit moving from side to side and returned to a normal position behind her closed lids. After a few seconds of rest, she would again open her eyes, roll them up, and move them back and forth under her lids. This continued for as long as I was examining her face. As soon as she was allowed to do so, she put back on her sunglasses, which hid her eyes from view.

I asked the patient to perform a couple of simple tasks that test brain or neurological function, things like walking a straight line and moving her pointing finger back and forth between her nose and my finger. When doing these tests, the patient’s eyes came out from under her eyelids and she performed the tasks perfectly. Then, when the test was finished, her eyes rolled back up again.

By the time I was through examining this young woman, I was sure she was fine. I had no idea why she was moving here eyes in this strange way and there was no way to know for sure. Maybe she had some psychological issue that was stressing her out and causing symptoms that had no underlying physical disorder. Maybe she liked the attention and just loved having a concerned mother take her places where everyone paid close attention to her. I don’t know.

Before discharging the patient with reassurance and something stronger to help her sleep, I stopped and ask myself, one last time, if I might be fooling myself and missing something. This last consideration has helped me many times over the years as I try to do a very difficult job.

In the end, the patient put back on her sunglasses, the mother had all of her questions answered, they were assured that the patient would be fine until she could get to see the neurologist, and off they went with me wondering how it was all going to end up.

 

 

Copyright © 2014 Bad Tad, MD