Archive for October, 2012
An eighty-six-year-old lady came in by ambulance with a report of having passed out at home.
When I walked in the room, her two sons were at the bedside. I recognized both of them. Rafael had been a tech in our emergency department years ago. His brother, Cesar, called me by name as I approached them. He had also worked at our hospital in the past. The two were very attentive and gave me their mother’s history.
The patient’s initial evaluation was pretty straightforward. She denied any pain or losing any blood. She had been pretty healthy her whole life. She was pale and her blood pressure was low.
I got busy trying to figure out what was wrong with her. As anticipated from her appearance, she was very anemic. I needed to figure out why her blood count was low and do something about it. When we put a tube down into her stomach, it brought back blood so I figured her anemia was caused by a bleeding ulcer. I ordered a blood transfusion and continued looking for other problems.
As test results and vital signs showed she was getting worse and worse, I shared the information with the patient’s sons along with my increasing pessimism she was going to survive. All the time, I was doing everything I could to save her. At one point, we had fluids, blood and medications running in six IV catheters.
As we approached the end of my shift, the patient took a turn for the worse. The nurse noted her abdomen was distended. I checked her and, sure enough, her belly was blown up like a balloon and very firm. A quick peak with an ultrasound confirmed it was full of blood.
This changed things. Bleeding ulcers are a medical condition, cared for in the hospital by internal medicine specialists. A belly full of blood is a surgical condition. But the patient was not stable enough to even think about operating on her. She was going to die.
Even though I knew no one would operate on her, I asked a surgeon to come and see her to make sure we’d done everything we could do to save this woman’s life. The surgeon came, saw the patient briefly and told the sons there was nothing that could be done.
With the picture of futility now clear, the sons had to decide whether to have us keep making heroic efforts to save their mother or to just make her comfortable as she died. They were clearly troubled by this and still undecided when the patient was ready for transfer to a bed in intensive care. As the sons stood to leave the emergency department, I walked up to Cesar, shook his hand and gave him an abraso: the kind of hug Mexican men give each other. When I turned to Rafael, he fell on my shoulder, wrapped his arms around me and sobbed. Then, rather than release me like Cesar had done, he held me and cried. So did I.
When they walked out, I returned to my writing area, trying to get myself under control to finish up my charting. A co-worker asked how I was doing. I was surprised when I used the word “fun” to describe the experience. What I meant was that it was an emotional, human interaction made even more intense because it was with people I knew. It really was a “fun” experience.
Another weird ingredient and a bit of a pain to order online or go to a weird store but well worth it. They are beautiful! I think they are delicious but Shari said they tasted like canned creamed corn. Not a very positive comment.
1 cup butter, at room temperature
1 ½ cups sugar
1 large egg
1 1/3 cups flour, 5.85 ounces
¼ cup corn flour, 1.5 ounces
2/3 cup freeze-dried corn powder, 2.25 ounces
¾ teaspoon baking powder
¼ teaspoon baking soda
1 ½ teaspoons kosher salt
1. Combine butter and sugar in the bowl of a stand mixer fitted with the paddle attachment and cream together on medium-high for 2 to 3 minutes. Scrape down sides of bowl, add egg, and beat for 7 to 8 minutes.
2. Reduce mixer speed to low. Add flour, corn flour, corn powder, baking powder, baking soda, and salt. Mix just until the dough comes together, no longer than 1 minute. Scrape down the sides of the bowl. Briefly stir again.
3. Using a 2 ¾ ounce ice cream scoop (or a 1/3-cup measure), portion out the dough onto a parchment-lined sheet pan. Pat the tops of the cookie dough domes flat. Wrap the sheet pan tightly in plastic wrap and refrigerate for at least 1 hour, or up to 1 week. Do not bake your cookies from room temperature. They will not bake properly.
4. Heat oven to 350°F.
5. Arrange chilled dough balls a minimum of 4 inches apart on parchment-lined sheet pans. Bake for 18 minutes. The cookies will puff, crackle, and spread. After 18 minutes, they should be faintly browned on the edges yet still bright yellow in the center; give them an extra minute if not.
6. Cool the cookies completely on the sheet pans before transferring to a plate or to an airtight container for storage.
Make freeze-dried corn powder by grinding freeze-dried corn in a blender. You can find freeze-dried corn at Whole Foods. I bought mine at honeyvillegrain.com. Store the leftover powder in an airtight container so it won’t absorb moisture.
Huge cookies like they recommend are not practical for me. I use a 2-tablespoon scoop. I cooked them for 14 minutes and they had just a touch of brown around the edges.
I heard an overhead announcement for assistance to the ambulance bay and went out to see if I could help. The police were there. They had a suspect they could not get out of the patrol car.
As I peered into the back seat, I could see part of the patient. He was hogtied which means he had handcuffs on wrists and ankles and all four were fastened together behind his back. He was thrashing and screaming incoherently. Somehow, he had thrown himself onto the floor of the patrol car and wedged his head under the back of the front seat. Because he was naked, all I could see through the window was his bare buttocks and his balls sticking up between them.
It was pretty tricky to get a naked, sweaty, fighting, crazy person dislodged and out of the car. After we got him onto the gurney, I noticed he was not moving. We quickly moved him into a room for assessment and treatment. He had a low pulse, no blood pressure and was not breathing. We were quickly able to get him through this situation and he was fairly stable when he went up to intensive care. With all his thrashing, he had dislocated his elbow. A toxicology screen showed only cocaine in his blood. All of this from taking drugs.
I told you that story so I could tell you another one:
The ambulance arrived with a thirty-year-old man in police custody. While being arrested, he crammed little packets of white powder into his mouth and started to chew and swallow them. I don’t know if he was acting crazy before he downed the drugs but by the time he arrived in the emergency department, he was out of control.
He filled the paramedics’ gurney, being a tall, large-boned and very obese man weighing close to 500 pounds. He was thrashing, confused, and sweaty. His heart was pounding. He was naked from the waist up and his hands were cuffed behind his back.
Everything we needed to do for him was made difficult because of his size, sweatiness and fighting. First, we rolled him from the ambulance gurney face down onto one of ours. After we put four point leather restraints on him, we removed the handcuffs. It took two people on each extremity plus several more on his trunk to control him at this stage. We were then able to roll him onto a different gurney so he was now face up. His legs were secured to the bottom of the gurney and his arms to the top above his head.
The next step was to get an IV started. Even in leather restraints, the patient was still flailing so, I ordered intramuscular sedatives to begin the sedation process while the nurses tried to start an IV. Then, I turned my attention to other patients, leaving the nurses, techs, security officers and police to care for this guy.
A few minutes later, the nurse came and told me she had not given the patient the sedatives because he was “playing opossum.” Since it was my impression that he was in a drug-induced, incoherent state, I didn’t understand how he could be faking it, so I went right to the bedside. Sure enough, my fears were justified. The patient was in arrest. His pulse was 30, he had no blood pressure and he was not breathing.
He needed a tube passed down into his windpipe to protect his airway and allow us to breathe for him. Huge people like this can be nearly impossible to intubate so I faced this with some trepidation. Fortunately, we were able to get this done without too much trouble. Once he was intubated and we were blowing oxygen into his lungs, his blood pressure and pulse came up and we were able to prepare him for transfer to intensive care.
I don’t want to get weighed down with the medical issues here, but let me say there were plenty of things suggesting this patient was going to die.
So both of my patients were under arrest for taking drugs. Their legal problems, however, were the least of their worries as their drug use might have lead to their deaths.
A few weeks ago, the newspaper had three recipes billed as their favorite chocolate chip cookies. Of course, I took a close look at them. Two were very close to the basic Toll House version which don’t really do too much for me but this one was different. The pudding mix caught my attention so I tried them. If you like basic chocolate chip cookies, this is the recipe for you. It is easy to make but the cookies are more interesting than Toll House, not as flat and greasy. As is my way, I left out the pecans though I am sure they would be great with nuts. Give them a try!
1 ½ cups chopped pecans
1 cup unsalted butter, at room temperature
1 ½ cups light brown sugar, packed
2 large eggs
1 teaspoon water (why?)
1 tablespoon vanilla extract
3.4 ounce package vanilla instant pudding mix
1 teaspoon baking soda
½ teaspoon salt
1 cup old-fashioned oats
2 ¼ cups all-purpose flour
12 ounces semisweet chocolate chips
1. Heat oven to 375 degrees. Toast pecans in the hot oven for about 3 to 4 minutes. Let cool. Set aside.
2. Line cookie sheets with parchment paper.
3. Using an electric mixer, beat butter until light. Gradually add brown sugar and beat until fluffy. Add eggs one at a time, beating well after each addition.
4. Add water, vanilla extract, vanilla pudding mix, baking soda and salt. Beat until well blended.
5. By hand, mix in oats, then flour, then chocolate chips and pecans.
6. Drop cookies by 2 tablespoons balls onto prepared cookie sheets, spacing 1 inch apart.
7. Bake until cookies appear dry and tops are lightly cracked and soft when pressed, about 8 to 9 minutes. Do not over bake. Cool cookies for 5 minutes on cookie sheets, then finish cooling on racks.
This is a story of a patient I took care of in the intensive care unit (ICU) during my training. As luck would have it, this young man was hit by lightening right outside the hospital. Medics arrived at the scene almost immediately and found him in ventricular fibrillation, an erratic heart rhythm that can result from a large electrical shock. This rhythm is ineffective in pumping blood. The resultant lack of circulating oxygen rapidly leads to brain damage and, eventually, to death.
Just like in the television dramas, the medics gave the patient a quick cardioversion shock, which caused his heart to return to a normal pumping rhythm. They then bundled him up and brought him into the hospital.
In the emergency department, the patient’s heart was beating fine. Though still unconscious, he was coming around enough to thrash about and he vomited a very large amount of undigested food all over himself, the gurney and the floor.
Now, I have a lot of experience with vomit. I have vomited many times. I have been with family members many times when they have vomited. In the emergency department, having patients vomit is just a way of life. So, to be noteworthy to me, a particular episode of vomiting must be pretty amazing. This one was.
The patient’s vomitus was filled with discs of pressed meat about the size of a mouth. It was clear he had recently eaten a deli sandwich by biting and swallowing big hunks without chewing any of it. This left the round pieces of meat intact when swallowed. They came back up the same way. I had never seen anything like that before.
Now back to the lightening strike victim. We sedated him to keep him from thrashing around and admitted him to the ICU. Since his heart rhythm was now stable, the big question was whether he had suffered brain damage during the time his heart was not beating. We would only know that when he woke up, if he woke up.
The next day, we took him off of sedation so we could start to assess his mental state. Our initial reaction was of disappointment. Though the medics had saved his life by rapidly getting his heart beating again, it was obvious he had suffered brain damage. The patient gave us his first name and asked for food, but he was clearly not normal. Since the patient came in the hospital with no identification, we asked him about his family. He could only come up with the first name of his sister. Another indication of his brain injury was that he seemed completely unconcerned about his situation, content sitting in a hospital bed getting all the food he wanted.
The following day a young woman came to the hospital. She read in the newspaper about our unidentified lightning strike victim and wondered if it were her brother.
After talking with her for a minute, I felt comfortable taking her in to see our patient. I was filled with some trepidation, wondering how she was going to handle it when she realized he was brain-damaged.
It was immediately obvious they were siblings. As she walked into the room, she rushed to give him a hug and he called out her name. It was a touching scene, but my emotions were complicated. I wondered how I was going to help her recognize his loss of mental faculties. How would she handle the realization that her brother was not what he used to be?
As soon as things calmed down a little, I gently shared with the sister our observations about her brother, describing what we believed to be brain damage caused by his time with no oxygen flowing to his brain.
As I talked, she got a puzzled look on her face. When she finally got the big picture, she kind of laughed. “Oh, no,” she said. “This is the way he always is.” He then got dressed, she took him home and they all lived happily every after.
This shows how his metal necklace burned his skin when it was heated up by the lightening. He also had a burn where his bicycle was leaning against his hip.
Hilary came up with the idea of the flower. Of course, I stole it. Now, lots of people who already have bags have been asking for a flower bag. When I got to work the other night, two PM shift clerks were talking about flower bags and asking for one. Another person who asked for one was my mother-in-law. How could I say “no”?
Momofuku Milk Bar as printed in September 2010 issue of Bon Appetit
¾ cup nonfat dry milk powder
½ cup all-purpose flour
3 tablespoons sugar
2 tablespoons cornstarch
¾ teaspoon coarse kosher salt
6 tablespoons unsalted butter, melted
1. Heat oven to 275°F.
2. Line large rimmed baking sheet with parchment.
3. Combine milk powder, flour, sugar, cornstarch, and coarse salt in medium bowl.
4. Add butter. Stir with fork until clusters form.
5. Spread mixture evenly on prepared sheet. Bake until crumbs are dry and crumbly but still pale, about 10 minutes.
6. Cool Milk Crumbs completely on sheet.
Can be made 1 week ahead.
2 cups unsalted butter, at room temperature
1 ½ cup sugar
1 ½ cup plus 2 tablespoons packed brown sugar
½ cup plus 2 tablespoons light corn syrup
2 large eggs
5 ¼ cups all-purpose flour
2 teaspoons baking powder
1 teaspoon baking soda
1 teaspoons coarse kosher salt
2 cups (full recipe) Milk Crumbs
1 ½ cups dried blueberries
1. Combine butter, both sugars, and corn syrup in large bowl of stand mixer fitted with paddle attachment.
2. Beat on medium-high speed until fluffy and pale, occasionally scraping down sides of bowl, about 3 minutes.
3. Add eggs. Beat on medium-high speed until mixture is very pale and sugar is completely dissolved, about 10 minutes.
4. Add flour, baking powder, baking soda, and salt. Beat on low speed just until blended, occasionally scraping down sides of bowl.
5. Add Milk Crumbs. Mix on low speed just until incorporated.
6. Remove bowl from mixer. Stir in blueberries just until evenly distributed.
7. Using 1/4-cup ice cream scoop for each cookie, drop dough onto 2 large rimmed baking sheets (make sure they will fit in your refrigerator.) Cover with plastic wrap and refrigerate at least 24 hours. Can be made 2 days ahead. Keep chilled until baking time.
8. Position 1 rack in top third and 1 rack in bottom third of oven and heat to 375°F. Line 2 large (18×12-inch) rimmed baking sheets with parchment. Transfer chilled dough scoops onto each sheet.
9. Bake, 2 sheets at a time, until golden, reversing sheets halfway through baking, about 12 minutes total. Repeat with remaining chilled dough, cooling and relining sheets between batches. Transfer cookies to racks; cool completely.
Original recipe calls for them to be baked 20 to 22 minutes. I thought that sounded like too much but the pictures showed a brown cookie so I tried it and they were just over-done. I have never let them go over 12 minutes.