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.

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.

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

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.

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.

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.

A 35-year-old man came in saying, “I’m losing sperm every day.” He said it was because he was masturbating too much. He said he masturbated so much he was unable to get an erection any more. He masturbated so much he vomited. This was causing him to lose strength and he felt like something was going to burst inside. He said he would wake up in the morning and if he didn’t masturbate, he would vomit and feel sick. He had been having this problem for many years and never talked to anyone about it in the past. He said he didn’t dare talk to his psychiatrist about this because she was female.

There was nothing I could do for him, of course, other than listen and try to help him see that talking to his psychiatrist about this would be a good idea. I also talked positively, saying that she could probably help him, though I was not so sure that was true.