Author Archive

Cardiogenic Shock

Written by Tad. Posted in Kooks

I was called into the room to see a young, healthy woman who had abdominal pain, vomiting and diarrhea for several days. I found her to have abdominal tenderness and low blood pressure. She was clearly ill. Of specific concern was that her finger tips were blue, a clear sign something bad was keeping her blood from flowing well. It was not at all clear just what would be causing her illness. I told her, her mother and her boyfriend I was worried and I reviewed with them what I was going to do to get some answers and start treating her.

My first focus was on the abdominal pain, vomiting and diarrhea. I ordered pain medication, fluids and antibiotics in case she had an infection. I was thinking maybe her low blood pressure and the poor circulation to her fingers were just from being severely dehydrated. But, we are always thinking of more unusual, bad reasons our patients are sick, so I ordered more tests than I would normally have done. I also had the charge nurse move her to the room right next to my work area so I could keep a close eye on her.

Her lab tests confirmed she was sick but didn’t answer any questions as to why. I wanted to get a CT scan of her abdomen but because her blood pressure was so low, it was not safe to send her to the Radiology Department. Second best, we did an ultrasound at the bedside. It didn’t show anything in her abdomen but, very much to my surprise, it showed a huge pericardial effusion. That is a collection of fluid between the heart and the sack the heart sits in. It usually occurs because of inflammation and, if it is large enough or develops too quickly, it can press on the heart, keeping it from filling adequately with blood. This could cause low blood pressure and poor blood flow to the fingertips.

The treatment of a pericardial effusion is to pass a big, long needle through the skin in the upper abdomen. It is directed up under the ribs, into the heart sack. The hope is that sucking that fluid out will give the heart a better chance to fill with blood so it can pump more efficiently, raising the blood pressure and fixing the circulation.

Draining a pericardial effusion is done very rarely but, if done quickly and correctly, it can be life-saving. I spread antiseptic over her chest and abdomen. I passed the needle up under her ribs into her chest and was immediately able to start drawing fluid out with a syringe. With the ultrasound, I could see when I had removed it all. Unfortunately, I could also see that, even after the fluid was out, her heart was beating very weakly. Taking the fluid out didn’t help her at all.

Now, at least, I had my diagnosis. Cardiogenic shock. That means the heart is beating so weakly it is unable to keep blood moving well enough to get oxygen into all of the tissues. I then was able to concentrate on her heart as I continued treating her.

Unfortunately, she continued doing poorly. Her blood pressure got so low she went unconscious. I intubated her and ordered multiple medications to keep her blood pressure up enough to send her for the CT scan of her abdomen. I still didn’t understand what could cause vomiting, diarrhea, abdominal pain and cardiogenic shock.

He blood pressure improved just well enough for me to risk sending her to Radiology. The CT scan showed inflamed intestines. Nothing else. It looked like she was probably very ill with a virus. That would cause her intestines to be inflamed and give her pain, vomiting and diarrhea. A virus can also inflame the outside covering of the heart, causing the pericardial effusion. Worse, it can inflame the heart muscle itself, causing viral myocarditis, which can cause the heart to beat weakly. Though I had not found anything I could easily fix, at least I had a picture of what was going on. I didn’t feel like I was missing anything.

While all of this was going on, I had also been making phone calls to get her admitted to the hospital. I talked to our cardiologist who said the patient should go to the bigger hospital in the large city a few miles from us. When I contacted them, they said she was too sick and should go to a “university hospital.” The closest place like that to us had no beds and would not accept her. The next closest place was so busy, I could never even talk to a doctor. Finally, I got ahold of an intensive care doctor at a big university hospital about two hours’ driving time from us. He was very helpful, giving me recommendations on how to treat her as we got ready to fly her to where he was.

Unfortunately, I soon learned the helicopters were grounded because of weather. I knew if she went by ground she might die en route. I also knew if she stayed here, she was certainly going to die.

All this time, she just got worse and worse, eventually requiring CPR. I stood at the bedside with the ultrasound probe over her heart. When it stopped beating, we would do CPR for a while and give her adrenalin injections. This would keep her heart beating weakly but when the effect of the CPR and adrenalin wore off, her heart would stop and we could do it again.

Her mother was kneeling on the floor next to me, holding her daughter’s hand, and begging her to live. Her upset, but remarkably under control, boyfriend was by her head. At one point, the boyfriend’s mother came in as well. She put one hand on the patient and one on her son and prayed, asking God to intervene in the patient’s behalf. I stood there with them, feeling I had done everything possible but that she was certainly going to die.

For almost two hours we were there like that. The patient was too sick to be admitted to our hospital and too unstable to be transferred. She got everything I could possibly use to pull her through, but her heart just kept getting weaker and weaker. I was standing there, watching the family cry and pray as her heart slowly gave out. There was nothing I could do about it. Eventually, her heart stopped completely and she was pronounced dead.

I felt physically and emotionally spent. After the family had some time alone with her, I went in and talked with them. I explained what I thought had happened. I reviewed with them what I had tried to do for her. I cried and said I was so sorry for them.

By the time this was over, I could hardly do anything else. I had a hard time focusing my attention elsewhere because my mind would immediately circle back to this case. Though I am good at leaving my work at the hospital, I was not able to do so in this case and it took a long time for me to work through my feelings and get back to normal.

A measure of how difficult this case was is how it affected the emergency department staff. For a couple of weeks, people who were involved with her care were talking about how challenging it had been. For about that same time period, every time I would come in for a shift, the other doctor would say something like, “Hey, I heard about that case you had…” Everyone was talking about it.

So, a young lady that may have just had the stomach flu, died from cardiogenic shock. It could happen to anyone. Why did she have such bad luck? Why did I have the opportunity to be the one with her and her family while she died? Just my luck. Good or bad?

 

 

Michelle’s Chocolate Chip Cookies

Written by Tad. Posted in Cookies

My son-in-law’s mother sent me this recipe. For just a “plain” chocolate chip cookie recipe, I found this to be very easy and the cookies very satisfying for those who like soft cookies. After I tried them the first time, I baked them three more times in a row.

 

Recipe By:

Michelle Hyde

Ingredients:

1 cup butter
2 cups brown sugar
⅓ cup sugar
2 eggs
4 teaspoons vanilla
1 teaspoon baking soda
1 teaspoon baking powder
1 teaspoon salt
3 ½  cups flour
1 teaspoon instant coffee
12 ounces chocolate chips

Directions:

1. Heat oven to 375 degrees. Line baking sheets with parchment.

2. Cream together butter and sugars.

3. Mix in eggs and vanilla.

4. Combine all dry ingredients.

5. Stir dry ingredients into butter mixture.

6. Stir in chocolate chips.

7. Scoop 2-tablespoon balls onto prepared sheets. Bake 10 to 12 minutes. (Took longer than this in my oven to get the edges just a bit browned, my preferred level of doneness.)

Yellow Bags with Zippered Tops

Written by Tad. Posted in Trauma Strap Bags

 

 

I have not been able to come up with a method to put a zipper in the top of my bag that has really pleased me. Here are a couple of zippered bags I recently made. A real pain do sew and I’m still not very pleased with how they turned out.

Bad Hair Day

Written by Tad. Posted in Kooks

I have seen some pretty bad hair in my years in the emergency department. I am not talking about a style, cut or color not to my taste. I mean gross hair. I have seen lots of people with lice. I have also seen people with problems caused by their belief they had lice when they did not. One woman dug at her hair so much trying to dig out her nonexistent lice that she turned the back of her hair into a giant dreadlock ball. One man burned his scalp when he lit his hair on fire trying to get rid of his lice.

The other day, my patient was a young man who was in the emergency department for something completely unrelated to his hair. As I examined him, however, I couldn’t help but notice he had an Afro pick so entangled in his hair that it was, at first, difficult to tell what it was. He didn’t offer an explanation for how he ended up in this situation.

I asked him if he wanted me to help him take the pick out. He seemed appreciative of the offer. He also agreed to let me take a picture of it and share it with you. With some work, one of our ED techs was able to work the pick out, leaving a giant dreadlock ball for him to deal with later.

We addressed his other concerns and he left, with his newly liberated pick.

Some clarification about what you are seeing in the picture: This is the back of his head. The pick’s handle is pointing straight up. The tines of the comb are enmeshed in the hair, some of them showing below, pointing to the right. A staff member’s hand is on the patient’s right shoulder.

Here is an image from the internet that shows, basically, what the pick looked like.

 

Covid-19

Written by Tad. Posted in Cookies

The other night, the charge nurse came in with cookies her daughter had made to celebrate our crazy times. I think she did a great job!

Tamarind-Jaggery Gingersnaps

Written by Tad. Posted in Cookies

I am always looking for some cookie that sounds like something I have never tried before. I am familiar with tamarind from my years living in Mexico, though I admit I never developed a taste for the candy Mexicans make with tamarind, sugar and chile. I like Indian food but admit, as well, that I am not too familiar with many of the ingredients used in Indian cooking. I had the garam masala but had to go online to buy tamarind paste and jaggery. This was a fun cookie-baking adventure.

Recipe By:

thetakeout.com

Yield:

40

Ingredients:

2 5/8 cups all-purpose flour, (12 ounces)
1 teaspoon baking soda
1 teaspoon kosher salt
2 teaspoon ground ginger
1 teaspoon garam masala
¾ cup butter
  cups powdered jaggery, sifted (see note 1)
1 egg
1 teaspoon vanilla extract
¼ cup molasses
2 heaping tablespoons tamarind paste (see note 2)
½ cup granulated sugar, for rolling (see note 3)

Directions:

1. In medium bowl, combine flour, baking soda, salt, ginger, and garam masala. Whisk to combine. Set aside.

2. Using a stand mixer fitted with the paddle attachment, cream butter and jaggery until light and fluffy.

3. Add egg and vanilla to butter mixture. Mix to combine.

4. In small bowl, combine molasses and tamarind paste. Add to butter mixture. Mix to combine.

5. Set mixer speed to low. Add dry ingredients in 3 installments, scraping down sides of bowl between additions, until combined.

6. Transfer dough to a resealable glass or plastic container. Chill thoroughly, at least 2 hours and up to 3 days.

7. Heat oven to 350 degrees. Line baking sheets with parchment paper. Put granulated sugar in a small bowl.

8. Portion and shape dough into 20-gram (1 tablespoon) balls (*see note 4) Drop each into the bowl of sugar and roll to coat. Transfer cookies to the prepared baking sheets, leaving at least 2 inches between each.

9. Bake until the cookies are golden underneath but still quite tender, 13-15 minutes. Let cool 2-3 minutes on baking sheets. Transfer to wire racks to cool completely. The cookies will crisp as they cool.

Notes:

1. Jaggery is unrefined palm sugar. It is like Mexican piloncillo, which is made of cane sugar.

2. Make sure to use tamarind paste, not concentrate.

3. I prefer Sprinkle King Con AA White Coarse Sugar.  I get it from supplyvillage.com.

4. I always use a cookie dough scooper. Well worth the investment.

Assaulted in the Emergency Department

Written by Tad. Posted in Kooks

Working in the emergency department can be dangerous. It is a stressful place for everyone. Many patients are impaired from drugs and alcohol. Mentally ill patients frequently end up in the emergency department. Gun shots have even been fired while I was working in my emergency department.

I have been an emergency physician for over thirty years. During that time, I have been yelled at and threatened. I have been spit at several times, once right in the face. But I have never been physically assaulted – until recently, when I was actually knocked down by a patient. I was not injured but I was surprised at how much this bothered me. I realize the older I get, the more at risk am to being assaulted. Also, to do well in a high-risk environment, one has to kind of fall back on the “it can’t happen to me” defense. Once it has happened to you, it is harder to effectively use that. I was really shaken by this. Enough that it contributed to my decision to retire, a bit earlier that I had planned to. It was important enough that I want to tell you about it.

Staff alerted me that a patient having a seizure had just arrived. He was being wheeled into the room the same time I entered. I saw a healthy-looking young man, about twenty years old, sitting up in the wheel chair. He was clearly faking having a seizure.

For some reason, faking seizures is a pretty common way for people to try to gain attention. Some of them are pretty good fakes but an experienced emergency physician can often tell, at a glance, the patient is not really having a seizure. I shared my impression with my staff. That allowed them to relax and move ahead with stuff like getting vital signs and attaching the patient to the monitor. I went to take care of another patient while all of that was being done.

When I went back into the room, the patient was behaving normally. His brother-in-law was with him and helped give me the following history. The patient had just come from another hospital where he was admitted to intensive care, a breathing tube was passed down his throat and he was treated with multiple medications to get him to stop seizing. The patient and his family were unhappy with his care so they signed him out and brought him to our hospital in the neighboring city. The patient complained, “All they did was just knock me out.” He admitted he had not been taking his seizure medicine before he had the seizure that took him to the other hospital.

I started with his vital signs and a physical examination, which were normal. To evaluate someone who is having seizures, I might have ordered blood tests, a urine drug screen and a CT scan of the brain. However, since he had just come from another hospital, I thought testing might have already been done. I asked the patient for permission to request records from his previous visit, thereby avoiding unnecessarily repeating tests.

Before too long, the report was faxed over from the other hospital. It was pretty amazing. He had arrived having seizures and had been given several medications to stop them. None worked. As a last resort, the patient was paralyzed and put under general anesthesia. A breathing tube was passed into his windpipe and he was placed on a ventilator. All laboratory testing was normal, as was the CT scan of his brain. Up in intensive care, they let him slowly wake up then pulled the breathing tube out. He promptly refused further treatment, signed out against medical advice and left the hospital.

Within a couple of hours, he was back in their emergency department, seizing again. Once more, he was given medications to stop his seizures. They repeated all of the labs and the CT scan. When no medications stopped his seizures, they decided to paralyze and intubate him again. Before they did, he stopped seizing, refused further care, and signed out against medical advice a second time. That’s when he came to our hospital. So, in the last twenty-four hours, the patient received two complete seizure work-ups. All was negative.

Seizures are hard on the brain. Someone who has been seizing a long time usually does not wake up right away. It could take hours before returning to normal mentation. For him to stop seizing, wake up and immediately walk out of intensive care made me wonder if he had been faking all along. Regardless, he was not having seizures in my department. All he needed to do was go home, take his medicine and follow up with his doctor.

As is my habit when discharging someone, I went into the room and sat on a stool at the foot of the gurney. I calmly explained what I learned and why there would be no reason for us to do any additional testing or provide him with any treatment. As what I was saying began to sink in, he started hollering and swearing at me. He stood up, called me several nasty names, pulled off his monitoring pads and yanked the IV out of his arm.

He announced he was leaving and I could see he was in no frame of mind to listen to me anymore. So, I stood, moved to the door and pulled it open for him to go. As he walked by me, he took a big swing at my head. Reflexively, I pushed the door into him to protect myself. The door knocked him back and kept his roundabout swing from landing a blow. He quickly recovered and came back swinging, knocking me down onto the gurney. Fortunately, his brother-in-law jumped between us and pushed him back against the wall, giving me a chance to roll off the gurney onto the floor. I then scrambled out the door on the other side of the room.

I was not injured but I was shaken. I am sure he would have hit me if I had not been able to use the door to protect myself and if his brother-in-law had not been there to hold him back.

I can’t help but think he was a troubled person. I assume everything that happened at the other hospital as well as his assaulting me as I tried to give him discharge instructions were as a result of underlying mental problems. It makes me wonder how long it will be until he attacks someone else and whether that person will be as lucky as I was to escape serious injury.

Cocoa Nib Chocolate Cookies with White Chocolate and Fleur De Sel

Written by Tad. Posted in Cookies

If you have not baked with cocoa nibs, you should really give it a try. They are roasted, cracked cocoa beans. They have a great, nutty flavor and add a fun crunch to your cookies.

Recipe By:

The Grand Central Baking Book by Piper Davis and Ellen Jackson

Yield:

48

Ingredients:

1¼ cups all-pose flour
½ cup unsweetened cocoa powder
½ teaspoon salt
½ teaspoon baking soda
12 tablespoons unsalted butter, at room temperature
¼ cup granulated sugar
¾ cup packed light brown sugar
1 teaspoon vanilla
½ cup cocoa nibs
½ cup white chocolate (such as Lindt) chopped fine*, 3.5  ounces

Directions:

1. *  Chop the chocolate  into small chunks just smaller than the size of a chocolate chip.

2. In a medium bowl, sift together the flour, cocoa, salt, and baking soda.  Set aside.

3. Using a stand mixer and the paddle attachment, beat the butter, granulated sugar, and brown sugar on medium speed until light and fluffy, about 3 minutes.  Add the vanilla and beat to combine.

4. Reduce the mixer speed to low and add the dry ingredients.  Mix just until combined.  Using a wooden spoon or rubber spatula, fold in the cocoa nibs and white chocolate.

5. Divide the dough in half.  Place each half on 14-inch length of parchment or wax paper.  Smooth and pat the dough into two 2-inch by 10-inch logs.  Twist ends securely and refrigerate the logs for at least two hours and up to 3 days.

6. Preheat the oven to 325˚F.  Line two baking sheets with parchment paper.

7. Slice the cookies 3/8-inch thick and place them about 1 inch apart on the prepared baking sheets.  Bake for 15 to 20 minutes or until the cookies are just firm to the touch.

Copyright © 2014 Bad Tad, MD