Black Widow

Written by Tad. Posted in Kooks

I had an interesting patient this last week: a lady I believe was bitten by a black widow spider.

There are lots of black widows around. There were many empty lots around the house where I grew up in Sparks, Nevada. I used to go through those lots turning over rocks, boards and other junk. Almost anything I turned over would have a big black widow spider under it.

There are plenty of black widows around here, too. We don’t see people bitten by them because they are very shy and only bite when forced to.

My patient was a lady about forty-years-old who came in with pain where she was bitten on her lower back. She also had the other symptoms of black widow spider envenomation: abdominal pain, chest pain and aches in all her muscles. She was really miserable. She was trembling and her heart was racing.

There is no specific treatment for black widow spider bites. My patient was given pain medicine and intravenous fluids. Laboratory tests were done to make sure there was not something else going on. When she was feeling better and her vital signs were normal, she was sent home.

The diagnosis of black widow envenomation is made when a patient has the right signs and symptoms and the offending spider is correctly identified. In this case, when they killed the spider, they destroyed the abdomen, which is where the hourglass-shaped red spot is found. The rest of it sure looked like a black widow to me and she had the signs and symptoms. As far as I know, this is only the second one I have seen in my thirty years of practicing emergency medicine.

 

Abdominal Pain

Written by Tad. Posted in Kooks

In medical school, they teach you about diseases. They teach you who is most likely to get a certain illness. You have to learn what kind of symptoms a person with that condition might have and what is found when examining such a patient. You learn how to put all of that together to make a diagnosis.

When evaluating a patient, the first thing we do is take a history. In appendicitis, we look for a classic story of vague discomfort around the belly button that, over the next few hours, settles into the right lower abdomen. Classic other symptoms are nausea, vomiting and fever. Most people with appendicitis don’t have diarrhea.

Next comes the physical exam. In this case, how does the patient look generally? Does he look sick? Is he tender in just the right place? Is there nothing else that would lead you to think this was something other than appendicitis?

Next come lab tests. The urinalysis should be normal and the white blood count should be elevated.

If there is any question, the last step is a CT scan of the abdomen, which is the test now used to establish the diagnosis. Why not just scan everyone? It is time-consuming, expensive and exposes the patient to a lot of radiation. So, the history, physical examination and laboratory results help us decide who is most likely to benefit from a scan.

I recently had a young man come in who hadn’t gotten the memo on appendicitis. He had left abdominal pain that started in his flank and went up to his upper abdomen. He had abdominal tenderness but not where his appendix is expected to be. His blood count was normal. His pain was gone after some medicine. He was smiling and happy as he thanked me on his way out the door.

The next night, he came back in, sicker. His white blood cell count was very high and he was really tender all over his abdomen. His CAT scan showed appendicitis. I called a surgeon to admit him to get his appendix taken out.

By the time one has been doing this for as long as I have, it is expected that common diseases will present weirdly. Still, this is an unbelievably atypical presentation of a common disease. It is a good example of how challenging and frustrating my job can be.

An Uncomfortable Feeling Down There

Written by Tad. Posted in Kooks

Rectal Foriegn Body

A patient has been visiting our emergency department a lot lately. He is a permanent resident of a psychiatric care facility and he likes to stick thinks in his rectum. The staff at the facility have to keep everything away from him or he will spirit it away and insert it. Fortunately, most of the things he gets ahold of are small and don’t need to be removed, like a glue stick or a cap to a pen. When this happens and the staff of the care facility find out about it, they send him to us. We just send him back home to poo.

In this case, he was able to get a hold of a can of shaving cream. He had to be taken to the operating room where the surgeons were able to remove it once he was asleep and relaxed. Sometimes, it is not possible to take the object out via the way it was inserted and it is necessary to cut into the abdomen to remove it. The patient ends up with a colostomy for a while, then a second operation in a few months to take down the colostomy.

Don’t Smoke Old Joints You Find Lying Around Your Apartment

Written by Tad. Posted in Kooks

As in so many areas of the country, we have a lot of trouble with methamphetamine abuse. It was not always so. Years ago, the drug of choice in our fair city was phencyclidine or PCP. It is what we refer to as a dissociative drug, meaning that it chemically disconnects the brain from the rest of the body. People who took too much PCP were especially difficult to take care of because they could act crazy, sometimes with apparently superhuman strength.

One night the medics and police brought in one such patient. It took several fire fighters, medics and police to get him tied to the gurney with leather restraints.

After heavy sedation to control his thrashing, he slept for hours. When he woke up, he denied any psychiatric or drug abuse history. He said everything started that night after he finished off a partially smoked joint he found sitting around the apartment. He denied knowing there might have been PCP in the joint though that was a common way to ingest it.

As I was discharging him, he asked me if using a Vick’s nasal inhaler would help clear the PCP from his system. I had never heard of that before. The fact that he would ask such a thing called into question his insistence that his PCP ingestion was completely accidental.

Richard’s Thank You Bag

Written by Tad. Posted in Trauma Strap Bags

I have told you about RAFT, Resource Area for Teachers. One day, we were there looking around and talked with a man who was there looking for material to sew into bags. At the time, he was sewing bags for homeless people. I gave him straps to use for his project.

I have lately been in contact with Richard again. He is sewing bags for poor Navajos in Ship Rock New Mexico. When he came for pick up several bags of straps, he left a sample of his work as a thank you to me. Here is a picture of the bag he left. I like the way it folds in on itself when you hold it by the handles.

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Hot Cocoa & Marshmallow Sandwich Cookies

Written by Tad. Posted in Cookies

DSC03570 DSC03581

The blogger, who posted this on The Cackling Cookie, said she would try to make them thumbprint rather than sandwich cookies. I tried them both ways. For the sandwiches, I made each cookie from only a tablespoon of dough. For the thumbprints, I made each cookie from two tablespoons of dough. Even though I pressed a nice indentation in them prior to baking, I had to press the center again as soon as they came out of the oven.* Since the marshmallow cream runs, the sandwich cookies were a mess unless eaten immediately whereas the thumbprints were a lot neater.**

Recipe By:

https://cacklingcookie.wordpress.com

Yield:

34 sandwiches

Ingredients:

2¼ cups flour
1 teaspoon baking soda
1 cup unsalted butter, softened
¾ cup brown sugar
¼ cup sugar
3 ounces instant chocolate pudding mix
2 eggs
1 teaspoon vanilla
12 ounces milk chocolate chips***
7 ounces marshmallow cream

Directions:

1. Heat oven to 350°.

2. Line baking sheets with parchment.

3. Combine the flour and baking soda. Set aside.

4. In a large bowl, cream together butter and sugars.

5. Beat in instant pudding mix until blended.

6. Stir in eggs and vanilla.

7. Stir in flour mixture.

8. Stir in chocolate chips.

9. Place one tablespoon balls of dough onto prepared baking sheets.

10. Bake 10-12 minutes until edges are golden brown. They may still look a little under-done. Once they are comfortable to touch, transfer to a cooling rack.

11. Sandwich a heaping tablespoon of marshmallow cream between two cookies. Continue with the remaining cookies until done.

Notes:

*
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**

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*** I made them with mini-chocolate chips because little cookies don’t tolerate the big chips as well and because the base of these cookies is not very chocolaty, having only the pudding to  contribute chocolate flavor, so they do really well with semi-sweet chocolate rather than milk chocolate.

Nurse Liz and Mom Liz

Written by Tad. Posted in Trauma Strap Bags

Nurse Liz

Last week, I posted a picture of the doctor that delivered our new grandson. Here is a picture of the nurse, Liz, who helped our daughter-in-law, Elizabeth labor. She seems happy with her Tad Bag.

Seizure from Hell

Written by Tad. Posted in Kooks

Quite a few people suffer from seizures because they have epilepsy. Other medical conditions can also cause seizures. For example, we frequently see alcohol withdrawal seizures since we see so many people with alcohol addiction.

We recently had a patient with bad alcohol withdrawal symptoms. He was doing pretty well with the treatment we had given him and was waiting to be admitted to a bed upstairs. Suddenly, I heard a nurse call, “Dr. Tad, we need you in Room 17, STAT!” I knew I would find the patient seizing, but I was not prepared with the how horrible his seizure was. Though I may have seen hundreds of seizures in my professional career, this was, without a doubt, the worst I have ever seen.

The patient was a large, though not overly obese man. He was on his back on the hospital gurney in his boxers and was jerking so violently he almost lifted himself off the bed with each jerk. His face was purple and blood oozed out of his mouth from where he bit his tongue. As the seizure continued, he became incontinent. Stool and urine seeped out of his underwear directly onto the thin black mattress, the bed sheet having been pulled off by his violent shaking.

As the seizure subsided, he started to breath with short, cough-like exhalations. With each breath, he spattered blood and spit all over the room and everyone there. By the time a nurse arrived with an injection to stop the seizure, it had already stopped, as they usually do.

Pretty soon he was awake, his tongue quit bleeding, we had him cleaned up and he was on his way upstairs.

Copyright © 2014 Bad Tad, MD