Ete was a five-year-old boy. At 2:00 in the morning, he woke up screaming with pain from a headache. Mom gave him Tylenol but he was not able to go back to sleep. By the time I saw him, he had suffered with headache for almost twenty-four hours. His vital signs were normal and he had no other complaints or recent illnesses, but Ete looked miserable, holding the top of his head with tears in his eyes.
In adults, sudden on-set headaches like this may be caused by a subarachnoid hemorrhage. This is a very serious condition caused by the rupture of an abnormal blood vessel, usually an aneurysm, at the base of the brain. If the aneurysm is not discovered and treated, complications can lead to brain damage or death.
The work-up for adult patients with this kind of headache is very straightforward. A CT scan of the head shows brain hemorrhage in about ninety percent of people who have one. If the CT is normal, we recommend a lumbar puncture to make sure there is no blood in the fluid that bathes the brain and spinal cord.
All of that is for adult patients. I had never heard of a child having a subarachnoid hemorrhage. Still, Ete’s story was so unusual and worrisome I had to pursue it as a possible diagnosis.
It’s important for emergency physicians to consider the potential risks involved in the diagnosis and treatment of patients. A CT scan of Ete’s head could show a subarachnoid hemorrhage. However, I was not comfortable doing a CT on a five year old. Radiation has bad effects that accumulate over time. So, in little kids, we use CT only if there is no other option.
I ordered morphine and called our pediatrician who agreed to admit Ete to the hospital. He was feeling better by the time he went upstairs.
The first time nurses in the Pediatric Unit checked his vital signs; he had a temperature of 103. This was a sudden change, as he had not had a fever at home or in the emergency department. The pediatricians did a lumbar puncture right away. The results showed he had meningitis.
Ete is a great example of how patients forget to read the book before they come to the emergency department. Though I thought of meningitis as a possible reason for his headache, I was sure he didn’t have it because he had none of the other typical symptoms. All this made for a very interesting and challenging case. Fortunately, Ete should do fine.
Derek and Megan have been generously sharing their zucchini with us. Seemed like a great chance to try some zucchini cookies. The whole wheat flour and lemon zest caught my attention in this recipe.
I grind my own whole wheat flour. Our friends, the Marshalls, gave us several hundred pounds of wheat when they moved to Utah years ago. Hence, we refer to it as “Marshall Wheat.” Though it is at least thirty years old, it still grinds into great flour.
These cookies are soft and cake-like but are earthy from the whole wheat flour and the oats.
3/4 cup sugar
3/4 cup brown sugar, packed
1 cup butter, softened
1 teaspoon grated lemon peel
1 teaspoon vanilla
2 1/2 cups whole wheat flour
1 teaspoon baking soda
1 teaspoon cinnamon
1/2 teaspoon salt
2 cups rolled oats
2 cups shredded zucchini, drained*
2 cups miniature chocolate chips
1. Heat oven to 350°F.
2. Cover baking sheets with parchment. Set aside.
3. In large bowl, combine sugar, brown sugar and butter. Beat until light and fluffy.
4. Add lemon peel, vanilla and eggs. Blend well.
5. Add flour, baking soda, cinnamon and salt. Mix well.
6. Stir in remaining ingredients.
7. Refrigerate for several hours or overnight to let the whole wheat flour absorb as much moisture as possible.
8. Drop 2-tablespoon balls of dough onto the prepared cookie sheets.
9. Bake 9 to 13 minutes or until browned on edges. Immediately remove from cookie sheets.
* I put the shredded zucchini in a sieve and pressed it as hard as I could, until zucchini juice ran through. Then, I spread it between two towels and pressed them together to try to get as much of the water out as possible.
As Edna was waiting for her bed upstairs, I sat down and talked with her for a minute. First, we talked about her medical condition and what she was to expect once she was admitted to the hospital. We then wandered into a more general conversation. I asked her how long she had been coming to our hospital and she said, “I was born here seventy years ago.”
“So that means I have been taking care of you since I started working here twenty-four years ago,” I responded. She then told me, in some detail, about the first time we met, which I had forgotten. Next, she surprised me by asking me if I sewed bags. I told her that I did and asked how she knew of them. “They are all around. Everybody has one,” was her reply.
I thanked her for noticing them. Then, her tone changed and she said, “You know, I’m dying. I have two sewing machines and I would like to give them to you when I go.”
I was surprised at this and didn’t know what to say. I was touched. I was really impressed with the calm way she was addressing her mortality. I was humbled that she would think to leave me something that was important to her when she died. I shared these feelings with her and we had a nice little opportunity to connect in a way that is unusual for an emergency physician and his patient.
I have no idea when she will die or if I would ever get her sewing machines. That is not the point. I don’t need her machines but I am touched by her thoughtfulness towards me.
Eric is one of our physician assistants. He brought in some blondies the other night and I asked him for the recipe. This is the first time I have taken a bar cookie recipe and made cookies from it. They turned out so well, I am inspired to try more. Feel free to use other dried fruit like craisins or raspberries.
1 cup butter
2 cups dark brown sugar
1/4 teaspoon salt
1 teaspoon vanilla extract
2 cups flour
½ teaspoon soda
1 teaspoon baking powder
1½ cups white chocolate, chopped into small chunks*
1 cup dried cherries
1. Heat oven to 350 degrees. Cover baking sheets with parchment.
2. Melt butter in a saucepan. Whisk in sugar and salt.
3. Add vanilla and whisk again.
4. Remove from the heat.
5. Add eggs to the butter mixture and stir well. Set aside.
6. Sift flour, soda and baking powder into a large bowl.
7. Whisk in the egg and butter mixture a little at a time. (It’s important to do this in stages so that you don’t get any lumps.)
8. Leave the mixture to cool slightly, then fold in the chocolate chunks and the cranberries. (If the mixture is too hot, the chocolate will melt.)
9. Form into 2 tablespoon balls onto prepared baking sheets.
10. Bake for 12 to 14 minutes until the outer edges are firm and the middle still a little soft.
11. Cool on a wire rack.
I used Ghirardelli’s white chocolate chips
Who Was She Trying to Shoot?
A 16-year-old girl was lying in bed with a 32-year-old man. They were cuddled up and she had her leg thrown up over his back. The girl’s mother came in and shot at them. The bullet went through the girl’s thigh and into the man’s back. The girl was three months pregnant. Fortunately, the girl and the man were both found to have minor injuries and were discharged.
Because I focus on taking care of patients’ medical issues, I don’t often get involved in their social issues. It does leave one wondering, was the man the father of the girl’s unborn baby? And just who was the mother trying to shoot?
Arrested for Stealing a Wheelchair
An 18-year-old man came in to be evaluated for a gunshot wound to his foot. He refused to say what happened to him. An x-ray was ordered but he left before it was done.
Police later brought him back to the ED. They found him with friends who were pushing him down the sidewalk in a wheelchair they stole from the emergency department during the first visit.
X-rays showed a bullet in his foot and two bones fractured. He was discharged to custody after arrangements were made for him to get needed orthopedic care in jail.
Lucky or Unlucky?
A 16-year-old girl was flown in after being shot in the chest. The bullet went through her lung, diaphragm, spleen and a rib. It ended up just under the skin of her flank. She needed an operation and faced a difficult recovery. But, when you think of all the vital things the bullet missed, she was pretty lucky, given the bad luck she had being shot in the first place.
A 14-year-old was brought in by ambulance after having given birth at home. She was 35 weeks pregnant and had received no prenatal care. She had given birth to her first child approximately nine months earlier.
On the evening of the delivery she went outside to get some fresh air. She felt the baby kick and it fell out, landing on its head on the ground. The umbilical cord apparently snapped when the baby fell out. The family tied a piece of cloth on the umbilical stump and called the ambulance.
The baby was fine other than being a little dirty and having a bump on its head.