As I come up with stories to share with you, I often pick them to exemplify different challenges we face as emergency physicians. Here is an example of something we face not too infrequently: a patient we couldn’t get rid of.

The evening shift doctor had seen her initially when she complained of vaginal bleeding and anemia. He found she was not bleeding and her blood tests showed no anemia. She was discharged just as we were changing shifts. I was warned that she didn’t want to leave and might give me trouble.

Sure enough, about an hour after I took over, the nurse came to me and told me the patient was still nauseous and was not up to leaving. I ordered some nausea medicine.

An hour later, I asked the nurse why the patient had not left the department. I was told she was unable to get a hold of anyone to give her a ride home. I asked that she be put out in the waiting room to await a ride. This is standard procedure when we are busy. The bed is needed for another patient and there is nothing wrong with someone waiting for their ride in the waiting room.

About three hours after I came on duty, she was finally out in the waiting room. But not for long. I soon was advised that she had feigned passing out and had to be brought back into an examination room. When I saw her, she was clearly pretending to be unconscious. I was too busy to deal with her at that time. I left her with the nurses to recheck her vital signs while I hurried off to take care of other, more pressing patient concerns.

Soon, I was able to spend some time reviewing her situation so I could decide what to do next. She was a relatively young, healthy lady. Her vital signs and laboratory tests were normal. She had already been in the ED for almost seventeen hours and nothing wrong had been found. She needed to leave. Still, always haunting the back portions of an emergency physician’s mind is the question: What might I be missing?

At this point, I had only two choices: force her to leave or admit her to the hospital. I mentally ran through both of those options in my head. We admit people to the hospital to receive medical care not available as an outpatient. This patient was in no need of such care. I couldn’t ask the admitting doctor to see her if it was clear there was nothing wrong with her. I had no choice but to accept a certain liability and send her out, even if she didn’t want to leave.

First, I had to wake her up. I was sure she was faking her unconsciousness. I proved this with an ammonia capsule. This is the modern equivalent of smelling salts.* A concentrated liquid ammonia compound is held in a small, thin-walled glass vial surrounded by an absorbent material. The vial is broken by being compressed between two fingers, releasing a strong ammonia smell. It is placed under the nose of the “unconscious” patient. No conscious person could continue to pretend to be unconscious when one of these is placed under his/her nose.

As I expected, her first reaction to the ammonia was to hold her breath. Tears then started forming in her eyes. When she was not able to hold her breath any longer, she turned her head to get her nose away from the capsule. I followed her, keeping the annoying, irritating stimulant under her nose until she was forced to talk to me.

“Why don’t you want to go home?” I asked.

“I don’t feel good,” was all she could come up with.

“I am sorry, but you are going to have to leave. Do you have anything you want to ask me?” She had no reply so I instructed the nurse to discharge her.

She had occupied a bed in our emergency department for almost eighteen hours by the time she walked out. How sad that someone’s life would be so messed up that lying around an emergency department pretending to be ill was better than anything else she had going on.

*https://en.wikipedia.org/wiki/Smelling_salts

I have been working out of town. This gives me time looking for entertainment in my hotel-room home. This last week, I decided to take my sewing machine and try to make up some bags for people who have been asking for them. Here is what I came up with.

I have made knock-off Samoas before but this is the closest to the real Girl Scout Cookies that I have tried. Not easy to make so you really have to not want to pay the Girl Scouts to do the work for you.

Recipe By:

“Siriously Delicious” by Siri Daly

Yield:

30

Ingredients:

Cookies:
1 cup unsalted butter, at room temperature
½ cup powdered sugar
½ teaspoon vanilla extract
⅛ teaspoon almond extract
2 cups all-purpose flour
½ teaspoon table salt
Coconut-caramel topping:
2 1⁄2 cups sweetened shredded coconut
12 ounces store-bought caramel candies
2 tablespoons whole milk
Pinch of table salt
Chocolate coating:
6 ounces milk chocolate baking bar, chopped
6 ounces semisweet or dark chocolate baking bar, chopped
1 teaspoon vegetable oil

Directions:

1. Heat the oven to 300 degrees.

2. Make the cookies: Beat the butter and powdered sugar with an electric mixer on medium speed until smooth. Add the vanilla and almond extracts and beat until combined.

3. Sift together the flour and salt in a separate bowl. Slowly add the sifted ingredients to the butter mixture, beating on low speed until combined. Shape the dough into a disk; wrap in plastic wrap, and chill 30 minutes.

4. Meanwhile, make the topping: Spread the coconut on a baking sheet. Bake until lightly toasted, about 10 minutes, stirring frequently.

5. (Be careful, as coconut burns easily.) Set aside. Increase the oven temperature to 350 degrees.

6. Unwrap the chilled dough disk and roll it out on a lightly floured surface to a 1⁄4-inch thickness. Cut the dough, using a floured 2-inch round cutter. Using the tip of a sharp knife, cut out a 3⁄4-inch circle in the center of each cookie, reserving the cutouts for scraps. (I used the small plastic lid off a medicine spray bottle to cut out the inner circle. Next time, I would just skip cutting out the holes at all unless I really wanted them to look authentic.) Reroll the scraps as necessary. I had to rechill the dough between rollings as it is very soft. Place the cookies, 1 inch apart, on parchment paper-lined baking sheets.

7. Bake until the edges begin to slightly brown, 10 to 14 minutes. Cool the cookies on the pans for 5 minutes, then transfer to wire racks and let cool completely, about 20 minutes.

8. For the coconut-caramel topping, place the caramels, milk and salt in a saucepan over low, and cook, stirring occasionally, until melted and smooth. Stir in the toasted coconut and remove from the heat.

9. Spread the topping over the top of each cooled cookie. (After doing removing the coconut mixture from the centers of a few, I decided to be less than authentic and just leave the centers filled with caramel/coconut. In fact, next time I would just skip cutting out the centers at all. Less authentic but taste just the same and ever so much easier.) Let stand until the topping is set, about 20 minutes.

10. Meanwhile, make the chocolate coating: Pour water to a depth of 1inch into the bottom of a double boiler over medium heat; bring to a boil.

11. Reduce the heat to a simmer; place the chocolate in the top of the double boiler (or place a heatproof bowl over simmering water, making sure the water does not touch the bowl), and stir until melted. Add the vegetable oil and stir until you have a glossy chocolate sauce.

12. Remove from the heat.

13. Dip the bottoms of the caramel-covered cookies into the chocolate coating by holding each cookie between your thumb and pointer finger.

14. Place on parchment paper-lined baking sheets. Place the remaining chocolate coating in a piping bag, a zip-lock plastic bag with the corner snipped off, or a plastic condiment squeeze bottle. Drizzle the chocolate over the top of each cookie. Chill the cookies until firm and set, about 15 minutes.

Notes:

If you just want to eat them and are not too hung up on recreating the originals, skip the hole in the center. Saves a lot of headache and, obviously, has no effect on the taste.

These are not too different from Tad’s Oatmeal Chocolate Chip Cookies but more spices and the pudding gives a different texture.

chocolate chip oatmeal

Recipe By:

Gourmet Magazine, March 1992

Yield:

60

Ingredients:

1 cup solid vegetable shortening
1 unsalted butter, room temperature
1½ cups sugar
1½ cups firmly packed dark brown sugar
4 eggs
7 ounces vanilla instant pudding mix
1 tablespoon vanilla extract
2 teaspoons baking soda
2 teaspoons ground cinnamon
1 teaspoon ground nutmeg
1 teaspoon salt
2 cups old-fashioned oats
4½ cups all-purpose flour
24 ounces semisweet chocolate chips
3 cups chopped walnuts (I almost never put nuts in my cookies.)

Directions:

1. Heat oven to 375 degrees. Grease heavy, large cookie sheets. (I always use baking parchment.)

2. In a large bowl, beat together shortening and butter until light. Gradually add white and brown sugars and beat mixture until fluffy.

3. Add eggs one at a time, beating well after each addition. Add pudding mix, vanilla extract, baking soda, spiced and salt, and mix until well-blended.

4. Mix in oats, then flour. Stir in chocolate chips and walnuts.

5. Drop cookie dough by 2 tablespoon balls onto prepared cookie sheets, spacing 2 inches apart.

6. Bake until just starting to brown on the edges, about 12 minutes. (Do not overbake.)

7. Cool cookies 5 minutes on cookie sheets. Transfer cookies to wire racks and cool.

I have not made a bag, specifically for myself, for a long time. I recently had my Timbuk2 bag stolen. I had been taking my junk to work in that bag for over 20 years. What a bummer! To make myself feel better, I made a great new bag, just to my specifications.

Classic orange and black.

Big enough to hold everything I need during a shift in the emergency department.

Cool zippered pocket built into the side.

After 27 years of working in a big, urban hospital, I switched to a small, community hospital. The biggest adjustment for me is the difference in access to resources. In the big city, we had access to all the equipment and specialists that might be needed. We rarely had to transfer patients out to other facilities for additional care. Now, I do not have all those supports and it can be stressful.

For example, a young Hispanic couple brought their 1-year-old daughter to our small, community hospital at three o’clock on a Sunday morning. They were concerned about bruising and swelling around her right eye. She had been born with a clouding of the cornea – the clear part on the front of the eye. However, the parents had been told their daughter’s eye was otherwise normal.

The parents said the bruising and swelling started the day before and had gotten worse. She had not been injured and appeared to be in no distress. The father even pointed out that it didn’t seem to hurt her when he pressed on it. She was behaving completely normally.

Looking at her eye, I could see that the cornea was, indeed, cloudy. The conjunctiva, the white part, was also a bit red. There seemed to be no pain or tenderness although there was bruising, as the parents had noticed. Bruising and swelling often indicate trauma. However, I did not detect swelling and there was no reason to suspect child abuse based on the way the parents and big sister behaved.

All that aside, there was clearly something wrong. She had proptosis. Her right eye was bulging out farther than the left one. Neither did it seem to move normally, though that was a bit hard to test in a one-year-old.

Acute proptosis may be caused by infection. If you get infection around your eyeball, the swelling causes the eye to push forward abnormally. In this situation there was no history of fever or other signs of infection. And, again, the kid was acting perfectly fine. It seemed impossible she had an infection severe enough to cause proptosis and still feel well enough to play normally with her sister.

My dilemma was: “Does this kid have something acute going on that needs me to transfer her to another hospital for care tonight? Or, is this something that can wait until Monday morning when she can see her primary care doctor and be referred to a specialist?”

I decided the only way to know was to scan her. This presented another challenge. A CAT scan would probably give me the information I needed, but we try to avoid CAT scans in kids because of the ionizing radiation it exposes them to. The earlier in life you get radiation, the more likely it will end up causing cancer many years down the road. An MRI scan would be a safer test since it would not cause exposure to radiation, but there was no MRI in our small hospital at night or on weekends. In order to get that test, I would need to transfer her to a bigger hospital where they had MRI available. However, the whole purpose of getting the scan in the first place was to help me decide if she needed to be transferred!

I finally decided it was important enough to justify getting the CAT scan done at our hospital. It showed a mass behind the eye that the radiologist said could be either a hemangioma or a sarcoma. A hemangioma is an abnormal and benign wad of blood vessels that you are born with. A sarcoma is a tumor that is usually malignant. Either of of the two would cause the baby’s eye to be pressed forward.

My impression was that if the baby was born with a hemangioma, the doctors would probably have picked up on it when they evaluated her cornea. I think the mass was a tumor that had been developing slowly. As it gradually pushed the eye forward, a little vein ruptured causing the non-tender bruising the parents noticed.

Though the situation was serious, there was no reason to transfer her to a higher level of care in the middle of the night.

The poor parents. Though I did my best to explain the situation, I don’t think they really understood what they were up against. They took off to put the baby back to bed.