Archive for December, 2020
An emergency physician, by training (and, for me, by nature) wants things to be simple and straightforward. Often, patients show up with anything but simple and straightforward complaints. Sometimes they even come in with detailed notes laying out the course of their symptoms. I am sure they think that lots of details will help the doctor get to the bottom of whatever is making them ill. In reality, at least for me, the more complicated it is, the more I am sure I will NOT get to the bottom of it.
Here is a reproduction of a note I was given by a woman one night. My reading of this is not, “I need to pay attention to all of these details.” Rather, it is “This patient clearly has more problems to deal with than asthma.” Whether it is stress or some underlying personality or psychiatric problem, I see this note as evidence that I have no chance of fixing her problems in one visit to the emergency department.
Obviously, I have changed the names and details to protect the patient’s identity.
Sally A. Williams
- Current symptoms:
- Chest feels warm
- Some back pain while lying down (also pinched cervical nerve)
- Still tired and hard to get out of bed
- Terrible dreams where I am fighting to wake up
- Hard to get to sleep
- Hard to stay awake during the day even when using CPAP at night
- Use rescue inhaler with limited success
- Started Prednisone 25milligrams on 10/29 at 9:00, with slight improvement
- Prednisone 10mg on 10/30 at 3:00 a.m. with slight improvement
- Prednisone 15mg on 10/30 at 1:00 p.m. with limited improvement
- Saturations run 92 to 99, with pulse high at 100-110 (Normal saturations 98-99)
- Saturations worse the lower I lie in bed
- Pulse rose to 126 beats approximately 7:00p.m. on 10/30/12
- Flow Meter done on 10/29 and 10/30 measured 350-375
- Feet swell if I am upright for even short time, very painful by night (taken off of Aldactone 25 mg by Dr. Jones in July 2012)
- Started Metoprolol 25 milligram ½ tab 2 times on 9/22/12
- Became tired and started sleeping a lot
- Sleep was disturbed
- Advair 500/50 didn’t seem to completely work
- Felt winded
- Couldn’t seem to catch my breath
- High humidity made it worse
- Hoarseness usually became worse about 4:00 p.m. to 7:00 p.m.
- Started to use rescue inhaler every few days
- Last slight flu was August 2012
- Saw Dr. Jones on 10/19 and she changed medicine to Diltiazem 110
- Previous private patient of Dr. Smith – diagnosis was mild asthma but worsened greatly by colds and flu and general anesthesia
- Previous private patient of Dr. Allen – diagnosis of unknown etiology for feet swelling
Zoloft for nighttime to help keep me calm due to stress of not being able to find a job?
Aldactone 25mg. 2x
As I worked to seal these big blobs of cheesecake filling between the cookie dough discs, I thought they would never survive baking. I was sure they would be a huge mess but I was so wrong. They baked perfectly round with a wonderful filling. I also thought the graham cracker crumbs was a great idea. I am going to try them in my regular snickerdoodle.
8 ounces cream cheese, softened
1 cup confectioners’ sugar
Generous pinch salt
1 teaspoon vanilla extract
1½ cups all-purpose flour
½ cup honey graham cracker crumbs
4 ounces softened butter
½ cup white sugar
¼ cup light brown sugar, packed
2 teaspoons vanilla extract
½ teaspoon salt
½ teaspoon baking soda
¼ teaspoon baking powder
¼ teaspoon ground cinnamon
¼ cup white sugar
¼ cup honey-graham cracker crumbs
4 teaspoons ground cinnamon
1. To make the cheesecake filling, using the bowl of your stand mixer, add all of the ingredients and blend on low to combine. Scrape the bowl and beater and mix on medium speed until smooth, about 30 seconds. Portion the cream cheese mixture onto a parchment-lined plate in heaping tablespoon portions, making 12 scoops total. Freeze at least one hour. (I had to keep the balls in the freezer and take them out only one at a time as I stuffed the cookies. They really need to stay frozen.)
2. To make the cookies, using a medium bowl, whisk together the flour and graham cracker crumbs and set aside.
3. In the bowl of your stand mixer fitted with the paddle attachment combine the softened butter, white sugar, brown sugar, vanilla, salt, baking soda, baking powder and cinnamon. Mix on low to combine. Raise the mixer to medium speed and beat until smooth, 1-2 minutes. Scrape the bowl and beat the mixture for another few seconds.
4. Beat the egg into the sugar mixture, mixing on medium speed until combined, about 30 seconds.
5. Add the flour and graham mixture to the mixer bowl and mix on low until combined.
6. Portion the dough onto a parchment-lined sheet in heaping tablespoon portions, making 24 scoops total. Refrigerate at least 1 hour.
7. Make the graham cinnamon sugar by combining all ingredients in a small bowl.
8. Heat your oven to 350 degrees and line two half-sheet pans with parchment.
9. Take one cookie dough portion and flatten it in your hands into a 2-inch disk.
10. Place a frozen portion of cream cheese on top.
11. Top with another portion of cookie dough, pinching the edges of the dough together to encase the cream cheese. Roll the dough in your palms slightly, and then roll the dough in the cinnamon sugar to coat. Repeat with the remaining dough to make 12 filled cookie dough portions. Roll all portions of cookie dough in the cinnamon sugar and then place 6 dough balls on each half-sheet pan. Don’t flatten the dough balls. Bake until puffed and golden around the edges, turning the pans about halfway through baking, about 17-18 minutes. Cool and enjoy! (I usually enjoy cookies best right our of the oven but these really do need to cool before being eaten.)
Made these for Covid-19 indulgence. The recipe didn’t call for the chocolate chips but I would certainly add them. They were rich and tasty.
½ cup butter, softened
¾ cup brown sugar
1 cup sugar
½ teaspoon salt
1½ teaspoons vanilla
2¼ cups all purpose flour
1 teaspoon baking soda
8 ounces toffee bits
12 ounces chocolate chips (optional)
1. Heat oven to 350 degrees. Line cookie sheets with parchment paper.
2. Sift together flour, baking soda and salt, set aside.
3. In your mixer, cream butter until fluffy, about 2 minutes.
4. Mis in sugars and vanilla.
5. Stir in eggs.
6. Gradually mix in flour mixture until incorporated.
7. Fold in toffee bits and chocolate chips.
8. Drop by 2 tablespoon balls onto parchment-lined baking sheets.
9. Bake 9-11 minutes or until slightly brown. Cool on wire racks.
Our six-year-old grandson, Hunter, got a Swiss Army knife for his birthday. After misplacing it several times, I recommended he never just put it down. To reinforce this idea, I made him a tray to put at his bedside. I recommended he keep the knife only in two places: his pocket and the tray. I showed him that his tray was just like the one I use for such things in my bedroom. Since I made one for him, I also made one for his sister, Pippa, who said she was going to put her necklace and headband in it.
Hunter’s Pippa’s Tad’s
A 47-year-old woman came into the emergency department one evening. The “Chief Complaint,” as recorded by the nurse, was “Pain in the neck for 3-4 years. Wants x-ray done.”
She told me this all started about three-and-a-half years ago when she woke up in the morning with a “slit” in her left neck. She said she didn’t really think anything about it at the time. Since then, however, she has been having several troubling symptoms, making her think a chip had been implanted in her neck that night. She had been seeing strange flashes of light. Other than that, her symptoms were vague. She said she had “weird things happening all the time.” She had some vague discomfort in the neck but not really any pain. This was the first time she had sought medical attention for this problem. She couldn’t give me a reason why she decided to get checked out that day. She would not offer any idea of who might have implanted a chip in her neck or why. She had no medical history other than hypothyroidism. She denied any history of mental illness or substance abuse.
Her physical exam was unremarkable. Her neck was normal. I noted a lack of any scar. She behaved completely normally with no evidence of obvious psychiatric disorder.
There are many reasons for me to not believe what she was saying was true. I didn’t believe in a “chip” that could alter her behavior. I saw no reason someone would sneak into her bedroom one night and implant a chip in her neck. I don’t know how someone would do so without her waking up. I don’t know why she would not have freaked out if she woke with a slit in her neck that appeared while she slept. I don’t know how having a chip under her skin would cause her to see flashing lights and have all kinds of weird things happen to her. Though I didn’t believe she had an implanted chip I did believe she thought it was true.
So, my diagnosis was “delusion.” Here is one definition for a delusion: an idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder.
This fits her perfectly. Her belief certainly was idiosyncratic. She firmly held it to be true. Most people would generally agree her belief was not in keeping with reality. She was not open to any rational argument used to try to convince her otherwise.
What kind of delusional patients might an emergency physician deal with? I had an elderly man who believed all our laws were invalid since they were not based on English Common Law. I have seen several people who believed they had chips implanted in them by the CIA. I have seen patients who have delusions of religious persecutions. Toxic vapors and molds pervade the delusions of many patients. People irrationally believe their neighbors are pestering them. Delusional parasitosis, where people believe they are infested, inside and/or out, by vermin is rather common. I had one patient who was convinced our doctors were using “Mexican children” as “guinea pigs,” performing unnecessary tests on them. People sometimes feel persecuted or, the opposite, have delusions of grandeur where they think they are very important and due more respect than they are provided by society. They sometimes believe they have an illness causing their symptoms, even an illness not known to medical science. They sometimes have body image issues. Sometimes these delusions are wide-ranging and associated with paranoias. In other cases, they are limited and specific. Delusions can range from offering mild amusement to the outside observer, to severe, socially incapacitating conditions.
As with any medical abnormality, a doctor caring for such a patient wants to provide treatment. Many treatments have been shown to help with delusional disorder, though with various degrees of effectiveness. Treatments include medications and various types of behavioral therapies. One big problem in getting them help is they don’t want psychiatric help. They know what they are suffering from is not a psychiatric problem and they resent any insinuation they are crazy. So, they are often resistant to any recommendations for psychiatric intervention.
With that background, how should I deal with this patient? Within a short time of talking with her, I was sure she was delusional and I was not going to be able to “fix” her problem. I focused on listening, making sure she knew I was on her side. I recognized that one of the reasons she had come in was to get “an x-ray.” I was sure no imaging would show a chip in her neck but, in order to show I was interested in helping her, I ordered an ultrasound, explaining to her why I thought that would be better than a regular x-ray in identifying something that might be implanted in her neck.
When the ultrasound report came back negative, it was time for her to leave. I went over things, explaining that any chip in her neck would have shown up on the ultrasound. The problem with this disorder is that, by definition, it is resistant to logical evidence. I knew she would leave with her delusion intact, even with my reassurances about her ultrasound. I told her she needed to make an appointment with her primary care physician for further evaluation and treatment.
Some might say that punting to the primary care doctor is a lame way for me to escape a difficult situation but this patient needed a lot more help than what she might get from one visit to the emergency department. In reality, I had no treatment to offer her.
How the patient reacts to all of this helps determine how honest I would be with her. If she says, “Thank you very much” and leaves, I am done. But sometimes these people will not do that. Often, they have been to many doctors, including their primary care doctor and no one has done anything. Sometimes they say something like, “I know I have a chip in my neck but you just think I’m crazy!”
When I am pushed into this situation, I usually resort to is something like: “I can tell you are upset and I understand why. You know you have a chip in your neck and I know you don’t. There is nothing I can do to get you to believe there is no chip and there is nothing you can do to get me to believe there is. So, we are just going to have to agree to disagree and you will need to look elsewhere for further care.”
Even after that, often the patient will just start over again with their arguments trying to convince me. Sometimes, they will get angry and storm out, threatening to sue me or report me to the Medical Board. I never know when I enter into this last part of the visit whether the patient will walk out quietly with my sympathy or angrily with shouted threats.
Being an emergency physician, I never know what happens to delusional patients I have seen. How many of them work things out and get back to normal? How may carry on with their delusion giving them some trouble for a long, long time? How many degrade and become diagnosed with severe mental illness? I never know.