Archive for May, 2015
It is fresh cherry season here.
After peaches, this is my favorite fruit. I am not a great fan of cake mix cookies but I have at least one in my list that is one of my family’s favorites.
That helped me have a good attitude towards trying this one. A couple of people who tried them said they reminded them of scones.
½ cup butter, melted
¼ cup flour
1 box lemon cake mix, 16 ounces
¾ cup white chocolate chips
⅔ cup unsweetened fine shredded coconut, toasted *SEE NOTE
1 cup fresh cherries, pitted and quartered
1. Heat oven to 350°F. Line 2 large baking sheets with parchment paper.
2. Stir together butter, flour, eggs and cake mix in a medium bowl.
3. Stir in chocolate chips and coconut.
4. Lightly mix in cherries.
5. Scoop 2 tablespoon balls of dough onto baking sheets.
6. Flatten gently with bottom of a drinking glass, smeared with butter then dipped in sugar. Redip in sugar before flattening each dough ball.
7. Bake 13 to 15 minutes or until cookies are set in the center and just browning around the edges.
8. Let cool on baking sheets, then store in an airtight container.
* Heat oven to 250 degrees. Spread coconut on baking sheet. Bake for five minutes. Stir and return to oven. Repeat every five minutes until lightly browned and fragrent.
I recently came across a letter I wrote to my parents at the start of my first clinical rotation in medical school. It was one of the first times I actually had the chance to provide medical care to a patient. Here’s my unedited account of a patient I helped care for in the emergency department the first night I was on call:
“Last night, a real victim of self-abuse came in. He was a horrible drunk with feces dried down his legs, in between his toes and under his toenails. He had scrapes and cuts all over from falling down his stairs. I cleaned him up with the help of a nurse and stitched his head closed. That was a new one for me. It was a perfect one to start on, too. He was pretty much out of it so I didn’t have to put on any appearance of looking like I know what I am doing. Also, only one cut needed to be stitched and it was on the scalp, was straight, and only needed four stitches. I also had to pass a naso-gastric tube down him to see if he was bleeding into his guts and that was a new one for me. I kept choking him and the tube kept coming out his mouth. Again, a perfect one to learn on because he wasn’t really with it.”
Finding this gave me pause to consider how I have changed…
I cringe now at my use of the words “victim of self-abuse” and “horrible drunk.” Though these words were probably accurate, they reflect a judgmental tone I am not proud of. It is very hard to stay up all night taking care of people like this and keep a good attitude about it, but I hope my writings now might display more patience and understanding than were demonstrated after my first encounter with such a patient.
Doing procedures for the first time on a real human being was exciting for me as a third year medical student. But, I frequently felt like I needed to act like I knew what I was doing, even when I did not. Putting in sutures and passing a tube into someone who was unaware relieved me of that stress. I didn’t have to pretend I knew what I was doing. Now, thirty-two years later, I don’t have to pretend. I know what I am doing and it is nice to have that confidence.
Four stitches in a scalp was a big deal to me back then. Today, it is about as straightforward a patient as I could imagine seeing. I was really buzzed to actually be able to stitch someone up. Now, it would be a simple, hardly noteworthy event.
Passing a tube through someone’s nose into the stomach can actually be kind of tricky. Way back then, both the novelty and the technical challenge of doing this procedure were exciting. Since I had never done it before, the nurse showed me how to do it. Now, our nurses pass naso-gastric tubes most of the time, so I rarely do it anymore. I only get involved if the nurse has trouble and they need my expertise to get the tube down.
Finally, I have taken care of so many drunks that, if a drunk came in tonight with poop down to his toes, I wouldn’t even be fazed.
It’s no wonder I took time to write my parents and tell them about this first patient – and no wonder it wouldn’t even impress me if I were to see that same patient tonight.
Our grandson and his parents are staying with us for the summer. His mother requested I make Hawaiian Turtle Cookies for the emergency department so she could have some. I happily agreed to make them and enlisted Hunter’s help to do so.
Here is a picture of him testing the measuring spoons to make sure they tasted OK.
If you are looking for a good new cookie to try, I recommend this one.
Last week, I told you a story about an intern draining pus. ( http://badtadmd.com/grand-geyser/ ) It makes sense to follow that with another story of an intern draining pus.
First, some medical background… The Bartholin’s gland sits at the opening to the vagina and secretes fluid for lubrication. Like other glands, it has the potential to get plugged so the fluid can’t get out. The gland, which is normally not even identifiable under the skin, keeps making fluid and starts to swell. To make matters worse, the fluid in the gland is great for bacteria to grow in, so a plugged Bartholin’s gland often becomes infected. This causes redness, pain and more swelling.
The treatment for a Bartholin’s gland abscess is to cut it open and drain the pus. To keep the abscess from reforming, the abscess cavity needs to stay open so it can drain until it is fully healed. A guy named Word invented the absolutely coolest thing to help do that.
The Word catheter is a silicon tube about two inches long and about as big around as a pencil. One end can be blown up with water to form a balloon about an inch in diameter. The other end of the tube has a place to insert a needle to fill the balloon with water. This is what it looks like when the balloon is filled:
After numbing the area, a small hole is cut into the Bartholin’s gland to drain the pus. Then, the rounded end of the Word catheter is placed into the abscess space and the balloon is inflated with water. The balloon allows the catheter to stay in place for about a month while the infection drains and the body’s natural defenses allow complete healing.
So, that’s the background. Now the story:
One night, an intern told me she had a young patient with pain and swelling at the opening to her vagina. That was about enough information to make the diagnosis of Bartholin’s gland abscess. One peek down there was enough to confirm it. Hers was a very large one.
The intern had drained abscesses in other parts of the body but never a Bartholin’s gland abscess. She was excited to drain this one. I verbally took her through the procedure, including some caveats to make things go more smoothly. First, I warned her to not make the hole too large. (I did that once and the balloon wouldn’t stay inside the cavity.) I also told her it can be hard to pass the catheter through the incision if you wait until the abscess is empty. So, she should make the cut and then quickly insert the catheter before the pus stops flowing out.
After giving the patient morphine for pain, we put her legs up in stirrups and coaxed her to relax as much as possible. The intern numbed the area. I warned her that the pus would be under a lot of pressure and might squirt out once the cut was made. I positioned a suction device to capture any pus that came out.
When the intern poked the scalpel into the abscess, the pus immediately started squirting out. The sudden gush of pus caused the intern to freak out. She hollered and jumped back. Pus squirted all over. The intern pulled herself together and tried to push the catheter into the hole. Unfortunately, she had not made the hole large enough, so the catheter wouldn’t pass into the cavity.
With pus continuing to squirt out, she tried to make the hole bigger but was still unsuccessful. I quickly took the scalpel and made an appropriately larger hole. Pus continued to spurt out as the intern tried to pass the catheter into the cavity. At that point, she made a bad move. Somehow, she pulled the needle out of the catheter and she poked herself with it. Again, she jumped and hollered. I told her to hurry and put the catheter in. Finally, just as the pus stopped flowing out, we got the catheter in place and blew up the balloon.
The intern pulled off her glove and saw blood on her hand from where she got poked with the needle. That caused her a lot of alarm until she realized she had been poked with a clean needle.
Everything ended just as it should have.
Well, almost everything. I had been prepared to suction the pus as it exited the abscess. But, when the intern freaked and needed my help, I was less than diligent in my suctioning than I could have been. We ended up with pus on the patient, the bed, the floor and the intern.
In the end, the procedure was perfect but it really felt like “The Three Stooges” or “I Love Lucy” while we were doing it.
I had some more of those left-over Easter caramel-filled eggs and some toffee chips. I decided to clean up the cupboards a little by putting them into a cookie. I chose the $250 Cookie, which I made according to the recipe, then threw in my extra candy in place of the Hershey Bar. This is part of the fun of baking cookies, you really can try different things to see what turns out.
Doctors often place catheters in patients who have problems emptying their bladders. The catheters are frequently placed directly through the urethra but, if they are going to be in place for a long time, a suprapubic catheter is often placed. It is called this because it is placed through the skin, just above (supra-) the pubic bone, directly into the bladder. The urine leaves the bladder through the catheter and is stored in a bag, which is emptied as needed.
Patients with suprapubic catheters are at increased risk of urinary tract infections since we were not designed to have a rubber tube going through our skin into our bladders. When such patients come into the emergency department with fever, we send urine to the laboratory to test for infection. We don’t just send urine out of the bag, however, because it has usually been sitting there for a long time and is over-grown with all kinds of bacteria. In order for the test to be accurate, we remove the catheter, replace it with a fresh one and test the urine that collects in the new catheter and bag.
The other night, I had a patient from a nursing home with fever, low blood pressure, a high pulse – and a suprapubic catheter. A urinary tract infection was high on my list of suspected diagnoses.
Helping me care for this patient was an intern, a doctor working in the hospital during the first year after medical school. I asked her if she had ever changed a suprapubic urinary catheter. When she said she had not, I offered to help her do so.
I told her it was a simple thing to do and verbally took her through the ways in which this is different from placing other catheters, which she had done in the past. One thing I warned her about was that, if the catheter had become plugged, the urine in the bladder could be under pressure and squirt out of the hole in the abdominal wall when the old catheter was removed. I told her I always like to have a towel ready in case that happened.
After explaining to the patient what we were going to do, we positioned her flat in bed and gathered our supplies. We put on sterile gloves and the intern carefully swabbed the area around the old catheter with antiseptic. She slowly removed the old catheter from the hole in the patient’s lower abdominal wall and, as soon as the catheter came out of the hole, a torrent of foul-smelling urine gushed out in a geyser over a foot high. The intern jumped back and I jumped forward. I grabbed my well-placed towel, quickly covering the hole and trying to control the flow of urine. In spite of the towel, the urine flowed out all over the sides of the patient’s abdomen and down between her legs, soaking the sheets and pooling underneath her.
Soon, enough urine had escaped to allow me to move the towel out of the way without risk of being squirted. Now, oozing out of the hole was a thick, yellow-green liquid that looked much more like pus than urine. By then, the intern had gathered her wits and was able to push the new catheter into the hole. Once the balloon on the catheter was blown up, the infected urine started flowing into the catheter rather than out of the hole. We collected a sample to be sent to the lab. The nurse cleaned the patient up and changed her bedding while I went to order antibiotics and arrange for hospital admission.
This was the very worst I have seen urine squirt out when a suprapubic catheter was removed and, for the intern, was a memorable learning experience to have a handy towel ready.
Note: Grand Geyser, in Yellowstone National Park, is the tallest and most spectacular of the predicted geysers. It erupts from a pool of water making it a fountain-type geyser as opposed to Old Faithful which is a cone-type geyser. Grand’s eruption is about 150-180 feet high and lasts about 10-12 minutes.
When I was baking at our church girls’ camp, we ran out of white sugar at the end of the week so I made Snickerdoodles with all brown sugar. I thought they were great. This time, I did the same but substituted browned butter for regular butter and shortening in the original recipe. This results in a very interesting and rich flavor like no ordinary Snickerdoodle.
Adapted from recipe by:
Peg, a nurse I worked with in Dothan, Alabama
1 cup butter
1 ½ cups brown sugar
2¾ cups flour
2 teaspoons cream of tartar
1 teaspoon baking soda
¼ teaspoon salt
1. Heat oven to 400 degrees.
2. Heat butter in light colored skillet, swirling constantly, until dark golden brown and has a nutty aroma. Set aside to cool.
3. Cream together: butter, brown sugar and eggs.
2. In a separate bowl, mix together: flour, cream of tartar, baking soda and salt.
3. Blend both mixtures together.
4. Form into balls and roll in cinnamon sugar.* SEE NOTES
5. Bake for 8-9 minutes.
* ¼ cup sugar to 1 tablespoon cinnamon
** Alternative: Added 3 tablespoons lemon zest to cookie dough. Skip the sugar-cinnamon. When cookies are cool, glaze with 1½ cups powdered sugar mixed with ¼ cup lemon juice.
I recently posted blogs about the “Chief Complaint,” which is the patient’s most important symptom. Another type of complaint is what the patients send in when they are unhappy with some element of their emergency department experience. The complaints that relate to the doctor are sent to the Medical Director of the emergency department. Since I was the Medical Director of our department for several years, I got to review quite a few of this type of complaint. Here is the longest one I ever received. I have reproduced it at closely as I could, changing things to protect the patient’s identity, of course. Please don’t feel like you need to read it all but it is a fascinating insight into one unfortunately patient’s situation.
10 June 2004
Re: Billing Account #XXXXXXX, SS# XXX_XX_XXXX Medicare
My aim was to never pay this account balance due and furthermore, the Federal Government Medicare system should be refunded for your charges.
Admitting Diagnosis – Principal Diagnosis 298.9 – psychosis NOS and Secondary Diagnosis 303.91 – alcohol dependence NOS
My aim was to retain an attorney and sue for elder abuse and misdiagnosed services I was given on 20 July 2001 and for the next 72 hours.
I contacted the State Bar of California to use their referral service – all law offices contacted stated the same message – that they do not file lawsuits against the County and State and this must leave you all free and clear to keep on abusing the elderly!
I am going to tell you the Hospital, the County, and the State right up front that one of the psychiatrists in the acute psychiatric ward, stated to me, my husband, and my daughter– “You should not be in here!” He was absolutely correct – his name, Dr N.
I primarily chose to go to the emergency care at the medical center for the following reasons: I was having a very bad allergic reaction to “something” for the past 20 days. I was having muscle contractions with stiffness and soreness. Pain in the stomach. I had an extreme metal taste in my mouth. I had been vomiting. I had diarrhea. I was dehydrated. I had an itchy red rash and hive bumps. My equilibrium was off balance. I was swollen all over my body. I was constantly belching a “mold like” smell and taste. My gums were bleeding and I could not eat properly. I had gone to another hospital for emergency care on 13 July 2001 (7 days prior.) I was given a referral to see an internist/allergist. I made an appointment, showed up – only to be told by the doctor, that she was not an allergist. This upset me. I just don’t understand why I wasn’t informed when I made the appointment! I left this office with the intentions of making an appointment with an allergy doctor I had seen in the past.
I began to feel much worse and I had to make another decision. I chose to go to the medical center to try and find the cause of the allergic reaction. Mold, mildew, gas smells, environmental pollution can and does cause a great deal of problems for me. Yeast infections are also a problem for me.
My son drove me to the medical center. He was not my choice to drive me there or represent me. He was my only ride! He did not know my health problems and why he was asked about my health problems by the doctor on duty, he accumulated some wrong information right up front!
I was never asked who my choice of a family representative was/is! It is/was my daughter. Reason – she never forgets what I tell her about my health! My husband is not my choice for a representative because he will listen to other people before he listens to what I have to say!
When I checked in at the emergency care desk, the desk clerk asked me what my problem was. I stated why I was there – I was having an allergic reaction to “something.” I “feel like” I had been poisoned. This woman asks who “I think poisoned me.” I told her, “Nobody, but that’s the way I feel!” I had been sipping on wine mixed with water earlier, as it relieved the belches and the itching and the bloody taste along with the metal taste in my mouth. I was not asked for any other symptoms – just go prepare to see the doctor on duty. I was actually prepared for a trip through hell! This female Asian doctor comes in to see me. She starts on me – – –
“You’ve been drinking? You’re drunk!” It made me very angry to be accused of being drunk. When I wasn’t. I told her to “get out of here” – that I didn’t want her taking care of me! They sent in another doctor. He did not apologize for the terrible bedside manner. I heard them asking every patient in the area to be examined – “Have you been drinking?” Why didn’t these doctors check my alcohol level before accusing me of being drunk? They would have found I wasn’t drunk!!
If that is your hospital policy about greeting people with – “Have you been drinking?” May I remind you that dinking alcohol is not against the law! You should post a sign that is noticeable in your waiting room that we ask “how much alcohol you have been drinking” even if drinking is not against the law. I won’t buy any explanation as to it helps you diagnose a person’s problems!
I was diagnosed with the two mentioned on page 1. I was put under arrest. I was thrown into your “Looney Bin” and it is a “Looney Bin.” I didn’t know why I had been thrown in? My gun rights were taken away and this police lady that came by and stated I was a danger to myself??? I don’t know who ordered the “drying out” pills that I was made to take. Strange, for someone who has never been drunk a day in my life – yes, I have drinks, but not to get drunk.
Next comes the pills to treat my “mental illness.” I tried to refuse these pills. No, there was no refusals available. I was threatened with a stay of an extra 9 months in some “holding place” and the head psychiatrist has one of his nurses shove a paper at me and ask me to sign it! I asked them (the head psychiatrist and at least four nurses) what the paper was about? It was a paper to give them (same people) the right to take away further rights and declare me unable, unstable, (whatever you want to call it!) of taking care of myself and they would have some county worker check in on me twice a week. I polled all the healthcare people present and they had to admit I didn’t have to sign the paper. I didn’t. But, I still had to deal with the threat of that 9-month “bonus.” I chose that “mental illness pill.”
It turned me into a near zombie. It made me sicker than ever. My pulse rate was extremely high. I couldn’t walk without running into the walls. “It was the wrong medicine” and this statement came from the psychiatrist. I went to see why these doctors at your hospital thought I had a “Mental Illness.” The pills they give me could not be tolerated. No further visits were needed.
It is scaring the living daylights out of me to get old and be treated in this way! That you can allow your doctors that represent your hospital, your county, your state, to use the judgment they declare to be correct – gained many many times by someone from a person’s family that is not the chosen representative. I learned later that your doctor that declared me to be arrested had caused a vengeance between my husband and me by telling my husband that I stated he had poisoned me. There was also written in my medical report that I was hooked on epinephrine, I had been stealing it to inject myself and I had something like 10 shots within the last 3 days. If these people – your doctors and nurses – make such claims, (I have no idea where they got such claims) they should have checked my body for justifiable proof. There was NO needle marks on me!
How in God’s World can anyone be sent to your “Looney Bin” and be cured of anything? When you are called, “You are coo coo head!” In my report: She has a persistent paranoia that she is infested with molds. She is delusional and preoccupied with mold. Her general appearance is loud and snapping. She drinks to get rid of mold. She is pre-occupied with her mother dying young from a “bee sting.” No, it was a flu injection! Where did they get all this crap? Is this the States, Counties and the State/County run hospital’s way of getting more money from the Federal Medicare system? I am reporting this mistreatment and abuse to the Federal Medicare System. We as human beings should be allowed a second opinion before we are abused and mistreated and thrown (arrested) into your Acute Psychiatric Ward. We should be asked who our choice of family representative is! We should be allowed legal advice before we have to sign any & there are many papers – often. We have had our rights taken away and without informing us older people that all the laws are on your side! You don’t need to ask or tell me when your doctors make a poor judgment! This stinks!
The temp help that came to our office to take my work area also came down with an allergic reaction. She was unable to drive herself to the hospital. I drove her. She was treated correctly! She was 22 years old. I am 68 years old! I now know the source for the allergic reactions was coming from the work place. I found it. Our office unit’s furnace room had uncovered water pipes that were leaking a steady drip into two large size plastic containers which was overflowing into wood. The wood was decaying and the plastic containers were full of green mold (I took pictures.) I had a building contractor and air conditioning –furnace contractor give me an opinion – – extensive changes had to be made and were made.
My workspace was first in line to get this poisonous rotten wood (also odor) and green mold spores (moldy odor.)
I called the State of California Environmental Department asking for information about the environmental condition. It is a poisonous situation and advise workers to use masks when cleaning and replacing the area, and the only real way to be rid of it is to remove and replace!
How could your hospital doctors and your staff declare the mold and poisonous situation was a figment of my imagination and diagnose me with the “Mental illness and a danger to myself” and Medicare (Federal system) is billed for this charge? This is wrong and should not happen to senior citizens! I can get a letter from the building contractor stating the situation he observed in the furnace room to our work place. I also learned that he has had to go for emergency treatment to the hospital for becoming overwhelmed by the poisonous spores wet/dry rot conditions.
I am not retired as my report states. I am not full supported by my husband as the report states. I am 50% owner of my husband’s business and I still do 50% of the work. I am of sound mind and body (still have allergies.) I had myself checked out for proof.
I am not an AARP member. I just don’t feel old enough and I do not have enough time to be a “good” member! But, I am for these members and their rights. We deserve to be treated better. The Federal Medicare system has got to quit wasting money for false diagnoses I call fraud! Medicare has got to start calling for second opinions if you people from the County and State of California can’t clean up your act of allowing older people to be abused by your system and doctors.
Every person arrested or declared mentally ill or both should be allowed a second opinion and legal advise for our own protection before being take by force to your “Looney Bin” and then asking our Medicare Federal System to pay this charge!
I want these people dismissed for abusing me – by false statements – getting wrong information through family members by causing vengeance and asking my driver for my health information then putting him (my son) down as a family member to contact. My adopted son had never been given that privilege. It’s apparent my privileges no longer mattered. I want my chosen family representative – everyone should be asked for their chosen family representative.
These persons should be dismissed from the medical center. Some names are not legible in the written report:
- The desk clerk (female) on duty for writing down the wrong information about the poison remark. Why would she misunderstand a statement?
- The first doctor (female) Asian that accused me of being drunk. Without proper testing.
- The other Asian doctor that took over after I didn’t want to be treated by the rude female doctor. I should have the right to refuse accusations when they are not true. This is the one that started the whole arrest process. He talked to my driver about my health (my adopted son.) He did not ask me if my driver had privilege to speak on my health issues. He didn’t and had never been given privileges! This doctor did not check me for injection marks. Yet accused me of having injections given to myself. I had no such marks! These doctors should not be working anywhere. No. I am not prejudiced toward Asians. I work with them and I like them as friends.
- AJ, MD. He had false information written in my medical report. He was using passed-on false information and misdiagnosing with this false information.
- The psychiatrist in charge of acute psychiatric ward. He has to go for sure. I was forced to take his prescribed pills for “drying” me out and “mental illness.” These pills made me very sick. I was forced with an extra long stay as already mentioned. I was detained for 72 hours against my will.
This doctor, his assistants (females) and your hospital handed me preprinted “rights” information and at the same time telling me what he had the power to do to me! Later, this doctor asked me to sign a paper stating I had “Anxiety.” I signed. His pills gave me anxiety. (It was really a very fast pulse rate.) I signed because I did not want that 9-month “bonus” of a hold on me. He wrote information in my health record that did not come from me the way I discussed/answered his questions. Example: What did your mother die from? I stated: flu injection. Which is correct. His report stated, – bee sting. Now, who in this world would want a doctor – especially a psychiatrist – to treat your brain for a “mental illness” that didn’t know a bee sting from a flu injection!
- I want my gun rights restored. I was surprised when a female police person came into my room and stated I had lost my gun rights – because – I was considered a danger to myself! I was so sick from the “pills,” I couldn’t even get my head off the pillow (I think, I had a pillow?) to give my protest! I needed legal advice. I don’t want my mind, body and soul taken over by the State of California!