The psychiatric emergency department at our hospital notified us they were sending a patient with chest pain. Everyone who recognized her name knew we were in for a challenge.

This middle-aged woman had been to our emergency department many times and was always difficult to deal with. She has serious medical problems but also serious psychiatric problems. This makes treating her especially challenging.

When she arrived, I went into the room and politely introduced myself, as is my habit. I asked her about her chest pain, the pains in her legs and her recent falls. She had a pleasant demeanor and looked comfortable as she described pain in her legs that made her unable to walk. Her physical examination showed no indication of serious injury.

I explained the tests I recommended to make sure she was not having a heart attack or blood clots in her lungs: electrocardiogram, chest x-ray and blood tests. She agreed. I then told her I was not going to be giving her any narcotics.

“That’s fine. I’m not here for drugs. I’m not a drug addict,” she said in a sweet voice.

I was glad she agreed with me and told her the nurse would be right in to get the tests started. I began to walk out of the room.

“Just a minute, doctor. What are you going to do for my pain?” she asked.

I reassured her we would give her all the medications we usually give someone who might be having a heart attack or blood clots but we would not be giving her any narcotics. I turned again and walked out of the room.

Then she went off. She started to scream at me at the top of her voice using every foul word you could think of.  At the same time, she grabbed anything she could get a hold of and yanked on it. First, she ripped the phone cord out of the wall and threw the phone on the floor. She jerked the monitor cables out of the monitor and threw them on the floor.

We responded to the noise of her screams and the sound of the phone hitting the floor and prevented her from pulling the courtesy curtains out of the ceiling. After we moved things out of her reach, she pulled off all of her clothes and threw them on the floor. Eventually, unable to get a hold of anything else, she started throwing her immense weight back and forth in the gurney, trying to tip it over. Since she was so extremely obese and was rocking so violently, she almost went over but was prevented from doing so by staff.

So there she was, an extremely large woman, butt naked, rocking violently, trying to tip her gurney over and screaming obscenities at the top of her lungs.

Her insults were mostly directed at me. She accused me of being a bigot and not giving her pain medicine because she was black. She yelled she was being treated like a slave on the plantation. She shouted if she were white or Hispanic or Asian, we would be giving her pain medicine. Her screams included the foulest swearing she could come up with and filled the whole emergency department, upsetting other patients and visitors. Staff had a hard time taking care of other patients and doing necessary duties like talking on the phone because her obscenity-laced screams were so distracting.

Extreme conditions require extreme responses. When people are violent and put themselves and staff at risk of physical injury, something has to be done to prevent this. In such unusual circumstances, we may need to put heavy leather straps around both ankles and both wrists then tie the patient down to the gurney. This was such an occasion. It took four security officers and several other staff members to get her into four point leather restraints. She refused all medical care and, even tied down, was able to keep staff from covering her naked body. I wanted to sedate her, but she said she was allergic to each sedative I proposed. All we could do was keep her in the middle of the room so she couldn’t grab anything. She screamed non-stop for the half hour it took us to make arrangements for her to go back to emergency psychiatry.

Once arrangements were made, she rolled out the door. I had assumed security would have at least tied a sheet over her but their efforts to do so had been unsuccessful. Her enormous thighs and gut covered her private parts, but her pendulous breasts were fully exposed. She left, still screaming at the top her lungs, “No pain meds for fuckin’ niggers,” over and over again.

Recipe By:

My daughter-in-law, Elizabeth, sent this to me. It can be found all over the Internet

Ingredients:

2 cups all purpose flour
½ teaspoon baking soda
½ teaspoon salt
½ cup butter
¾ cup cocoa powder
2 cups sugar
1 teaspoon vanilla extract
2/3 cup buttermilk
2 cups chocolate chips

Directions:

1. Heat the oven to 350F.
2. Line a baking sheet with parchment paper.
3. In a medium bowl, whisk together flour, baking soda and salt. Set aside.
4. Melt the butter in a small, microwave safe bowl.
5. In a large bowl, combine the melted butter (still warm) with cocoa powder and whisk until very smooth.
6. Whisk in sugar, vanilla extract and buttermilk.
7. Gradually stir in the flour mixture until no streaks of flour remain.
8. Stir in the chocolate chips.
9. Drop dough in 2 tablespoon balls onto prepared baking sheet, leaving about two inches between cookies to allow for spread.
10. Bake for 10-12 minutes, until cookies are set around the edges.
11. Cool for 2-3 minutes on a baking sheet, then transfer to a wire rack with a spatula to cool completely.

Notes:

Very chocolaty and rich. Don’t over cook them!

One of the most important things I do as an emergency physician is reassure people. True, I occasionally do something that might save someone’s live. I frequently provide treatment to help people feel better and assist in a more rapid recovery from injury or illness. But most of the people I take care of don’t have a serious condition and can go home with little or no treatment. All they need is to understand they will be fine. They need reassurance.

Most people in this situation are glad to have an explanation and happy to be reassured. They are relieved to know their chest pain is not coming from a heart attack. They are thankful to know they don’t have a broken bone or appendicitis.

I get frustrated when I determine that someone has nothing worrisome but he or she refuses to accept my explanation and reassurances. I have found it nearly impossible to satisfy such a patient.

Here are two stories of people who were completely unsatisfied with my explanations and reassurances:

Fainted

A sixteen-year-old boy fainted after spraining his thumb. The most common reason for someone to faint after a sudden, painful event is what we call a simple faint. There are some bad things that can cause fainting but all of them are very rare in an otherwise healthy youngster. After asking this patient some questions and looking at him carefully, it was clear to me he had just fainted and would be perfectly fine.

I spent quite a bit of time with the patient, his mother and siblings. I explained how I came to a conclusion that he had only fainted and why I felt comfortable sending him home.

As I finished my explanation, the mother put her head down and shook it, apparently displaying some dissatisfaction with what I had said. I asked if there were some problem. She said, “No,” and resignedly added she would take him to be checked by his own doctor.

At this point, the sister got upset and angrily said if the patient left and became “comatose or died,” she was “going to come and get” me.

The brother then became irate and hollered that this was a “charity hospital and no one is going to do anything for you here.”

I tried to discuss the situation with these family members but they were not interested in any more discussion. They all stormed out without waiting for their discharge papers.

Nausea, Vomiting and Diarrhea

A fifteen-year-old boy came in by ambulance with nausea, vomiting and diarrhea. The paramedics had started an IV so I ordered some intravenous fluids and medicine for the nausea. I then continued seeing other patients who had been waiting longer and were more likely to be ill.

When I finally got to the room, the patient told me he started vomiting and having diarrhea after eating nachos for dinner. He had looked weak and his mother thought he was going to pass out, so she called the ambulance. However, after the IV fluids and medicine I had given him, he was now feeling fine and had no more symptoms. His examination and vital signs were normal.

I explained to the mother what I found and why I thought her son had food poisoning or stomach flu. I reassured her he would most likely be fine in a day. I promised to prescribe medicine for vomiting and diarrhea in case he needed it at home, and again reassured her that he was going to be fine.

This is my basic speech to reassure people when they have gastroenteritis. Most people are glad to have such an explanation. Not this mother!

As I spoke, she filled with angry indignation. He had almost passed out! How could I just look at him, not do anything and know he was going to be fine? I had not even done any blood or urine tests on him!

I started my explanation over again and reviewed my thinking with her. He was a young, healthy boy who was very unlikely to have anything serious the matter with him. He had symptoms that are really only consistent with one of two minor, self-limited illnesses. He had a normal examination and vital signs. He had responded to the treatment he got and was feeling and looking fine.

The more I explained, the madder she got. She was just not going to believe that her son, who almost passed out, could be sent home without any tests being run. I asked her what tests she would recommend running. Of course, she had no idea about what tests one might run and the fact that I asked her just seemed to make her even madder. If I had done some sort of tests and told her they were normal, she would have been happy. The irony completely evaded her that she would have had no idea if the tests were really able to find any problems in a patient like this.

At this point, she refused to talk to me. I asked if she had any other questions or if there was anything else we could do for them. She didn’t reply and fixed her steely gaze on the wall behind my back.

The patient did have a question but when he tried to ask me, she told him to just shut up. He tried again and again she told him to shut up and not say anything as they were going home.

I told her the nurse would bring the prescriptions. She said she didn’t want any prescriptions. I told her they were coming anyway and she could do with them what she wished. They left without the prescriptions or discharge papers.

Source:

hersheys.com

Yield:

About 40 cookies

Ingredients:

1 cup butter, softened
2 cups packed brown sugar
2 eggs
2 teaspoons vanilla extract
1 ¾ cups all-purpose flour
1 teaspoon baking soda
1 teaspoon ground cinnamon
½ teaspoon salt
3 cups oats
1 1/3 cups (8 oz. pkg.) HEATH BITS ‘O BRICKLE Toffee Bits
1 cup MOUNDS Sweetened Coconut Flakes (optional)

Directions:

1. Heat oven to 375°F.

2. Lightly grease cookie sheet or line with parchment paper.

3. Combine flour, baking soda, cinnamon and salt. Set aside.

4. Beat butter, brown sugar, eggs and vanilla until well blended.

5. Stir in oats, toffee bits and coconut, if desired.

6. Drop 2-tablespoon balls of dough about 2 inches apart onto prepared sheet.

7. Bake 8 to 10 minutes or until edges are lightly browned.

8. Cool 1 minute. Remove to wire rack.

Sue, a nurse in our ED, asked me for a black bag with an orange flower. I told her, “No way,” as there are no more black straps coming in. Well, I got some black together and made if for her. Turned out pretty nice, don’t you think?

Not G-Rated
My patient was a 39-year-old man who presented in police custody. He wouldn’t talk to me but the police said he they had been called to the home of a twenty-year-old woman who said someone tried to rape her. The woman was drinking at her home with the man. She told police he put his hands around her throat to force her to engage in oral sex but she fought back and bit him. When police arrived at her place, they found her roughed up and upset. A testicle was sitting on her living room floor.

She told them who the body part belonged to and where he lived. Medics, who had been called to the scene, put the testicle in a plastic bag, placed it on ice and brought it to the emergency department in case it could be reimplanted.

When police got to the man’s house, they found him lying on the couch in pain. They brought him into our emergency department for care before he went into custody.

The man’s injury was very interesting in that none of the scrotum was missing. She had pinched the testicle so strongly that it literally popped through the skin, leaving a linear laceration on the front of the scrotum through which the testicle had been pushed out.

We numbed up his scrotum, irrigated the wound and stitched him up. He went off to jail with fifty percent fewer testicles than he had when he got up in the morning.

The woman was also brought in for evaluation. As the word circulated through the emergency department that a woman had bitten off a man’s testicle in order to keep from getting raped, the staff was impressed. Our immediate response was to be moved with compassion for her and pride that she had stood up for herself. She was kind of a hero.

Everyone there was on her side and wanted to be with her emotionally. However, she was just the nastiest person to interact with. She was drunk, dirty and smelly. She was so foul in body and personality that it was impossible, after interacting with her, to continue to have any fond feelings towards her at all.

Her evaluation showed she suffered bruises and scratches but was in no need of medical treatment. The police took her home.

We later found out the woman was a prostitute and the man was on parole after serving seven years on a prior conviction for forced oral copulation.

Here is a redacted copy of the article in the local paper about this event:

Man loses testicle, held in assault.
By XX, Paper Staff Writer
A 20 year-old Sunnyvale woman told police she reacted in self-defense when she bit off the testicle of the man who sexually assaulted her.

A  Municipal court judge on Tuesday ruled XXX, 39, must now stand trial on one count of forcible oral copulation.

The woman, who was drinking at her home with XXX on September 29, told police they may have kissed, but when XXX put his hands around her throat to coerce her to engage in oral sex, she fought back and bit him.

“She thought she was going to die,” said The Department of Safety Detective.

She suffered major bruises around her neck and on her shoulders, scratches and minor bruises on her back and arms, and abrasions on her knee, police reported.

After the woman called police, officers found XXX at his home and rushed him to The Medical Center.

XXX was paroled from prison in February after serving seven years on a conviction for forced oral copulation, according to state Department of Corrections. He remains in jail in lieu of $250,000 bail.

These are a bit tricky and it takes some work to keep the caramel inside the dough. I don’t know what difference the Nutella makes as they didn’t taste too much like hazelnut to me.

Recipe By:

My sister-in-law sent this to me. She got it at http://barbarabakes.com

Ingredients:

2 ½ cups flour all-purpose flour
½ cup unsweetened cocoa
1 teaspoon baking soda
½ teaspoon salt
1 cup sugar
¾ cup firmly packed brown sugar
1 cup unsalted butter, softened
½ cup Nutella
2 eggs
2 teaspoons vanilla
36 caramels, unwrapped and frozen
1/3 cup granulated sugar for rolling, optional

Directions:

1. In medium bowl, sift together flour, cocoa and baking soda.

2. In large mixing bowl, beat sugar, brown sugar and butter until light and fluffy.

3. Beat in Nutella, eggs and vanilla until well combined.

4. Add dry ingredients and mix just until combined.

5. Cover bowl with plastic wrap and chill for 1 hour  or more so the dough is easier to handle.

6. Heat oven to 375º.

7. Shape a tablespoon of dough into a ball. Press a caramel into the center of each ball and reshape into a ball. Roll in granulated sugar and place on parchment-lined cookie sheets, then place the cookie sheet in the freezer for 15 minutes before baking.

8. Bake 10 to 12 minutes or until set and slightly cracked.

9. Remove from oven and cool on the baking sheet for 5 minutes before transferring to a wire rack to cool completely.

 Notes:

Don’t over bake.

Again, inspiration from Montreal. When we were poking around in shops there, we were looking at various bags. One inspired me this week to come up with this one.