Delusional Parasitosis

Written by Tad. Posted in Kooks

Two people came in an ambulance together. He was twenty-eight, she was twenty-six. They were put in the same room and had been instructed to undress and put on gowns. They both told the intake nurse they had things crawling out of their bodies. He focused mostly on his skin but she also had “things” coming out of her eyes, ears, nose, mouth and vagina.

 

When I entered the room, he was sitting quietly on the gurney while she was agitated and walking around the room. Usually, I start by talking to patients to find out what their symptoms and history are. Then I do an examination. It was not possible to do that in this situation because, as soon as I walked in the door, the young woman started to talk and, boy, did I get an earful! She came to me and started showing “them” to me. She had an LED flashlight and a magnifying mirror. She held the mirror up to her face, shined the flashlight onto her eyelid and said something like, “See that!”

 

When I asked her what I was supposed to be seeing, she gave me an exasperated look, turned the light and mirror to her lip and asked me, again, to look with her at what was crawling out. When I told her I didn’t see anything, she loudly voiced her indignation, pointed to her skin and said, “See! There it is right there! Are you telling me you don’t see anything?”

 

Patients with mental problems causing them to believe their skin is infested often have sores where they have been digging at themselves. They point to these sores as evidence of their disease. In this woman’s case, there was not a scratch or sore anywhere she pointed, just normal skin.

 

As soon as she detected that I didn’t believe she was infested, she got really upset. She started referring to others who had seen “them” and asked me what I thought the others had seen, if there was really nothing there. The most specific I could get her to be when referring to other witnesses was “the doctor at the shelter,” but she was too agitated to tell me if she had been previously seen by another doctor and what, if anything, had been done for her.

 

When I continued to be unconvinced she had something coming out of her various body parts, she suddenly turned her attention to her partner. She pointed to his skin, which was marked by multiple sores which looked like he had been picking at himself. He was not nearly as animated as she was but he sat there, patiently trying to help her identify things crawling out of him. He was no more successful in showing me what they were looking for than she was.

 

When I tried to get specifics about how long this had been going on, what these things looked like, how big they were, what color they were and where they went after they crawled out, it only made them more indignant, unhappy and agitated.

 

At this point, I turned to an approach I developed years ago to deal with patients who are convinced they have a problem when I am sure they don’t.

 

I told them I recognized that they knew they were infested with something and I acknowledged how upsetting this must be. I told them I also knew they were not infested. I told them they had a mental disorder and named it: delusional parasitosis. I said I understood that they didn’t believe me. I also told them I was firm in my opinion and they were not going to convince me otherwise. In concluding, I said something like, “So, it is time for you to leave. I will give you the telephone number for our Mental Health Urgent Care clinic as well as a number to get a Primary Care Physician in a clinic.”

 

I have found that this sort of firmness is necessary because truly delusional people can’t be convinced. The more you try to get them to see logic, the more they get upset that they are not convincing you. I just have to tell them I am sorry, recommend they get psychiatric follow up and send them out, almost always upset and unhappy with me.

 

In this case, things just went from bad to worse when I followed this time-tested approach. The woman got even more agitated. She paced around the room, hollering about the lack of care they were being provided. She demanded to see my boss and the head of the hospital so something could be done. She was so agitated that the nurses called security and soon there were three uniformed officers outside the room. It got so bad that a Sherriff’s officer, there with a prisoner from the county jail, came to the room to see what was going on.

 

My two patients refused to get dressed. Refused to leave. Refused to take their discharge papers. They said they were not going anywhere until something was done for them. Finally, after the Sherriff threatened to arrest them, they got dressed and stomped out, the woman hollering and cursing.

 

Over the years, I have seen many cases of delusional parasitosis and its companion condition called Morgellon’s Disease, where people think they have fibers coming out of their skin. Each case has been a little different. Some patients are calm and, in every other way, reasonable. They talk logically of their complaints. They are pleasant in taking recommendations to follow up with their doctor but they remain convinced they are infested. On the other end of the spectrum, some patients act truly crazy, as with the woman described above.

 

Sometimes people connect their infestation to their environment. I once saw a man who was certain something was crawling out of a mat he had to stand on at work. No matter how many times the mat was changed and the area cleaned, as soon as he went back to work, he got them again.

 

I had a patient who was sure she was infested with bedbugs. No matter how I tried to help her understand that bedbugs just crawl out of your bedding at night, suck your blood and then crawl back to the bedding to wait for another night, she was sure she had bedbugs under her skin. She could not be convinced otherwise.

 

Another time, I saw a twenty-five-year-old woman who was convinced she had lice in her hair. The fact that no lice or nits could be produced had no effect on her beliefs. She had been treated multiple times for lice and, yet, she was sure they persisted. She constantly dug at her hair with a pencil until she had a huge ball of tangled hair on the back of her head. Even as she talked with me, she dug and dug in her hair, trying to get a bug out to show me.

 

Once, I had a couple come in wanting papers they could use to force their landlord to do something about the bug infestations they had from their apartment. Their place had been fumigated multiple times and the landlord and pest people told them there were no bugs. My patients were unable to provide a bug as evidence. Yet, they wanted a doctor’s note saying they were, indeed, infested so they could force the landlord to do something about it. When two people are equally involved in a delusion, it is called folie a deux.

 

I have seen many patients with delusions over the years. This case was amazing for two reasons. It was a fascinating case of folie a deux. Also the woman had absolutely the worst case of delusional parasitosis I have ever seen. She had things coming out of every part of her body. She was agitated and aggressive. She was threatening and refused to put her clothes on and leave when she was dismissed. It is an amazing example of how your brain can play really nasty tricks on you.

 

If you are interested, read more at my favorite medical reference: https://en.wikipedia.org/wiki/Delusional_parasitosis

Ambrosia Cookies

Written by Tad. Posted in Cookies

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Alex was the head cook when I was the baker at our church’s girls’ summer camp. This recipe came from him. Easy to make and a good way to dispose of left over M&Ms from Halloween!
Recipe By:

 

Alex
Yield:

 

36

Ingredients:
2 1/2 cups flour
1 teaspoon baking soda
1/2 teaspoon salt
1 cup butter
1/2 cup sugar
3/4 cup brown sugar
2 teaspoons vanilla
1 egg
2 cups M&Ms or chocolate chips
Directions:
1. Heat oven to 375 degrees.

2. Mix flour, baking soda and salt. Set aside.

3. Cream butter and sugars together until light and fluffy.

4. Add vanilla and egg. Beat well.

5. Add dry ingredients to creamed mixture. Mix well. Stir in M&Ms.

6. Bake 10-12 minutes until edges and bottoms just browning. Don’t over-bake!

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To Room 11, Stat!

Written by Tad. Posted in Kooks

The other night, an overhead announcement in the emergency department caught my attention: “Dr. Tad to Room 11, STAT! Dr. Tad to Room 11, STAT!” Since I know my staff would not call me like this unless there was a real reason, I dropped everything and hustled to Room 11.

I got there just as the patient was being moved from a wheelchair onto the bed. I made my way through the crowd of staff filling the room, everyone hurrying to take her clothes off, get vital signs, put her on a heart monitor and start an IV.

When I got to the bedside, I saw a young woman who looked dead. She was pale as a sheet. She was unconscious and not breathing or moving. I could not feel a pulse.

I barked orders to make sure someone was doing each of the many things that needed to be done at once. In situations like this, we use the pneumonic “ABC” to prioritize our actions. “A” is for Airway. Before figuring out what her underlying medical problem was, we first took steps to protect and keep her airway open. I told the respiratory therapist to prepare to intubate her, pass a tube into her windpipe.

After Airway comes “B” for Breathing. Once the airway was open and protected, we would check to see if the patient was breathing well. If not, we would need to breathe for her by putting her on a ventilator.

“C” is for Circulation. Does she have a pulse? What is her blood pressure? Is she bleeding? What needs to be done so that blood is getting to her vital organs?

In Room 11 that night, I soon was able to stop worrying about “A” and “B” because, once she was out of the wheelchair and flat on the gurney, enough blood got to her head that she woke up. She started to complain of pain and asked for water. Airway and Breathing were good.

It was now obvious that Circulation was her problem. Along with the pallor I already described, her blood pressure was low and her pulse was fast. These are all signs of hemorrhagic shock. Since she was not bleeding on the outside, my assumption was that she was bleeding internally. I took a quick listen to her heart and lungs. I felt her abdomen, which was tender and distended. More orders were given in response to this new information.

As the rest of the team pressed to get IVs started and get blood work for the laboratory, I turned to find out who had brought her in. I went into the hall and found her concerned husband, a young Vietnamese man. His English was weak, but there was no time for a translator. I was able to learn that she had been complaining of abdominal pain and might be pregnant.

As soon as I heard that, I instructed a clerk to call the obstetricians and tell them to come to Room 11 immediately. I then ran an ultrasound probe over the patient’s belly and found just what I was expecting. Her abdomen was full of blood.

I called for Type O-negative blood to be rushed up from the blood bank so a transfusion could be started. This blood can be safely given to anyone if there is not time to check the patient’s blood type. The blood bank keeps some available for just this kind of situation.

About this time, the obstetricians came rushing into the room. I quickly told them what I had found and what we were doing. One stayed to help with the resuscitation and to try to get more information from the husband. The other called the operating room to say they were bringing the patient straight up.

The pregnancy test came back positive just as they pulled her gurney out of the room, headed for the operating room. There, they found her abdomen full of blood from a ruptured ectopic pregnancy.* She had a rough go of it but they were able to stabilize her by stopping the bleeding and giving her more fluids and blood. She left the hospital a few days later. She had a scar on her abdomen and was missing the fallopian tube in which the pregnancy had established itself. Otherwise, she was no worse for wear.

Reviewing this case fills me with gratitude. This lady was dying. It makes me glad I knew what was needed to keep that from happening. It also makes me glad we have the facilities to provide the care she needed. In times gone by and in many places in the world today, if this happened to a woman, she would be dead. I am really appreciative of my team. They did just what was needed when a life was on the line. I am also grateful for good luck. If the patient and her husband had delayed in coming to the hospital or gotten stuck in traffic or lost, we might not have had the chance to give her the services we trained hard to provide.

 

*If you are interested in reading more about ectopic pregnancy, here is a reference frpm my favorite medical resource: https://en.wikipedia.org/wiki/Ectopic_pregnancy

 

FabMo Donation

Written by Tad. Posted in Trauma Strap Bags

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1255 straps donated to FabMo this week. I didn’t realize how long it had been since I dropped off the last load and they were glad to have them!

http://www.fabmo.org

Pumpkin Cheesecake Snickerdoodles

Written by Tad. Posted in Cookies

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This recipe was forwarded to me by Eli, a nurse in our emergency department. Even though I chilled the dough all day, it was too soft to be able to seal it around the filling and roll into a ball. I had to scoop balls of dough onto a plate covered in plastic wrap. I then covered the balls with another sheet of plastic wrap, flattened them, then put them in the freezer until they were stiff enough to handle. It complicated the process a lot but people really liked them in the emergency department.

Recipe By:

Bakeaholic Mama

Ingredients:

3¾ cups all-purpose flour
1½ teaspoon baking powder
½ teaspoon salt
½ teaspoon ground cinnamon
¼ teaspoon freshly-ground ground nutmeg
1 cup unsalted butter, at room temperature
1 cup granulated sugar
½ cup light brown sugar
¾ cup pumpkin puree
1 large egg
2 teaspoon vanilla extract
Filling Ingredients:
8 ounces cream cheese, softened
¼ cup sugar
2 teaspoons vanilla extract
Cinnamon-sugar coating:
½ cup granulated sugar
1 teaspoon ground cinnamon
½ teaspoon ground ginger
Dash of allspice

Directions:

1.  In a medium bowl, whisk together flour, baking powder, salt, cinnamon, and nutmeg. Set aside.

2. In a stand mixer with a paddle attachment, beat together  butter and sugars on medium high speed until fluffy.

3. Blend in pumpkin puree, egg and vanilla.

4. Slowly add dry ingredients on low speed just until combined. Cover and chill dough for an hour.

5. To make the cream cheese filling, blend cream cheese, sugar and vanilla together. Chill for an hour.

6. Heat oven to 350 and line your baking sheets with parchment paper.

7. In a small bowl, combine the sugar and spices for the coating and set aside.

8. To make the cookies, take a tablespoon of the cookie dough. Flatten it like a pancake and place a teaspoon of the cream cheese in center.

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9. Form another tablespoon of the cookie batter into a flat pancake shape and place on top of the cream cheese. Pinch the edges together sealing in the cream cheese and roll into a ball. Roll in the cinnamon sugar coating and place on the prepared baking sheet 2 inches apart.

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10. Repeat until the dough is gone and flatten the cookie dough balls with a heavy bottomed glass or measuring cup.

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8. Bake the cookies for 10-15 minutes or until the tops start to crack. Let cool on the baking sheet for 5 minutes and transfer to a wire rack.

Two Patients with Broken Ribs

Written by Tad. Posted in Kooks

I recently went mountain biking in Moab, Utah. Unfortunately, I fell just as our ride was starting. It was soon apparent to me that I had broken some ribs on the left side of my chest. I painfully rode back to the trailhead and found a ride back into town, rather than trying to ride the rest of the 26 miles we had planned for that morning.

Since there is really no treatment for broken ribs, I knew there was no reason for me to seek medical care. I just set myself up on the couch of our rented condo and tried not to move around too much until I could head back home.

A week later, I was back at work, feeling better and was taking only ibuprofen for pain. “This has not been that bad,” I thought to myself. Little did I suspect that a surprise setback lay ahead.

I woke up on Saturday morning, eight days after my fall. As I got out of bed, I was surprised that I had more pain in my chest than I had been experiencing the previous few days.

While I was in the shower, the pain got a lot worse and any movement was now causing severe pain. Getting dressed was really tough but I pressed on, feeling sure it would soon pass.

As I started down the stairs into the living room, I was seized with a muscle spasm along my left spine that left me completely incapacitated. I hollered, stiffened and became unable to breath or move until the muscle spasm relaxed and the broken ends of my ribs were not being driven against each other.

The spectacle I presented on the stairs caused everyone in the house to come running. My wife, son and daughter-in-law rushed to my side, trying at the same time to understand what was wrong and wondering how they could help.

Several things went through my head as this was going on. I know enough about this sort of thing to understand, basically, what was going on. The pain from my broken rib was causing my back muscles to go into spasm. That was causing severe pain which was making the muscle spasms worse. Whenever I moved, I was caught in this terrible cycle and the only thing that helped was to not move, at all. Understanding this, I was not worried that I might have some terrible, life-threatening condition. I recognized that this understanding helped me a lot, compared to people without my training and experience who might be freaking out, wondering if they were dying or something.

I next thought that I always have to ask my patients to rate their pain on a scale from 0 to 10. In doing so, I sometimes wonder what pain I would rate at a level of 10, the most pain anyone could experience. “Now I know,” I thought.

After I was through with my clinical and analytic thoughts, my attention turned to how to get off the stairs. If I moved my trunk at all, like to take a step, the pain would come back and I couldn’t move. There was nothing I could do about it. With help from my wife and son, I forced myself down the stairs and collapsed on the couch, trying not to scream the whole time.

There I stayed the rest of the day, unable to move without triggering the same terrible pain. When it came time to try to take a nap, I needed help from my wife and son who moved me as if I were a piece of fragile furniture, trying to keep my spine from moving.

At bedtime, they helped me in the same way back up to my bed. The next day I still had pain and had to be careful but was some better. By the following day, I still had the rib pain but all of the spasms were gone. Today, I am almost pain free. I am back to riding my bike with no problems.

Now, I told you that story to tell you this one:

The next week at work, I introduced myself to my next patient. She was a lady about my age who told me a sad story about being attacked three days earlier by her mother, who suffered from Alzheimer’s Disease. She had been knocked to the ground and injured her chest. She told me she was pretty sure she had broken a rib and, knowing there was nothing to do for it, had just been taking ibuprofen and putting up with the pain.

What brought her in was that she had woken that morning with severe muscle spasms on the same side as her broken rib. The pain was so severe she was incapacitated by it and was worried about a complication of her chest injury.

As I listened to her, I had a hard time not smiling, which I knew would not be perceived well. As soon as she had a chance to tell me of her concerns, I briefly told her of my experience the weekend before. I explained what I thought had happened to both of us. I reassured her that what she was going through was completely understandable and she had nothing to fear. I also assured her that we would get her feeling better in a short time.

After some intravenous morphine and valium, she was feeling much better. She went home relieved to know she was going to be fine, happy to be out of pain and appreciative of a doctor who was able to empathize so distinctly with her suffering.

There is some irony in recognizing that she went to the emergency department and got some help while I just stayed at home and suffered.

Hard Boiled Egg Chocolate Chip Cookies

Written by Tad. Posted in Cookies

My friend, Lisa, sent me a recipe for Hard Boiled Egg Chocolate Chip Cookies. “What the…?” I asked. A quick Google search showed that something that sounded bizarre to me was, actually, all over the place. I tried some different recipes and this is the one I liked the best. They are very moist but are not nearly as good the next day so make small batches or eat them up!

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This is a very interesting way to make cookies. I’ve never seen a cookie recipe that asked you to blend the butter into the flour as if making pastry. This is a small batch but even at that, it was pretty tricky to get the food processor to mix it up. The processor was just too full. When it was done, however, the dough was fabulous and it was really fun to mix the chocolate chips in with my hands. Had to repeat it thee times to make enough for the emergency department.

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Recipe By:

the-girl-who-ate-everything.com

Yield:

24

Ingredients:

2¾ cups flour
1 cup cold butter, cut into small chunks
1 teaspoon salt
½  teaspoon baking soda
¾ cup white sugar
½ cup brown sugar
1 teaspoon vanilla extract
2 hard boiled eggs, peeled and diced finely
2 cups semi-sweet chocolate chips

Directions:

1. Heat oven to 350°F.

2. Mix flour, salt and soda in a food processor.

3. Add butter and process until mixture is the texture of small crumbs.

4. Add sugars, vanilla, and boiled eggs. Pulse again until mixture comes together.

5. Remove dough to a large bowl. Add chocolate chips and combine by hand, using a wooden spoon or clean hands.

6. Scoop 2-tablespoon balls of cookie dough onto parchment-lined baking sheets. Flatten slightly with your hand.

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7. Bake  13-15 minutes or until the edges of the cookies are lightly browned.

8. Remove cookies from oven and let them sit on the cookie sheet for 3-5 minutes before transferring them to a cooling rack. Eat them today.

Here is Hunter enjoying one:

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Here is a picture of my hens. No wonder I am always looking for egg recipes:

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Vicodin, Thank You Very Much

Written by Tad. Posted in Kooks

One night this week, one of my physician assistants came to me frustrated that the patient he had gone to see had run him off, saying he wanted another doctor. Matt had addressed two complaints the patient had: difficulty urinating and a nagging cough. When the patient went on to more complaints, including shoulder pain he had been suffering with for over a year, Matt recommended he take up these more chronic problems with his primary care physician. That is when the patient ran Matt off.

It was now my turn. I found an elderly man asleep on a gurney wearing sunglasses and a beret pulled down over his face. I introduced myself and went over his first two problems. When I asked him if he had any other concerns, he told me about his shoulder pain, for which his primary care doctor usually gave him Vicodin. He then said all he wanted was to be treated with sympathy.

I asked him if he had come for sympathy or for Vicodin. He calmly answered, “Vicodin would be fine, thank you very much.”

This all took place in the hall right in the busiest part of the emergency department and as soon as he answered my question, I was surrounded by suppressed laughs. I had not intended my question to be comical. I’m sure he didn’t intend his answer to be funny either, but, together, they made everyone laugh. This was especially funny to staff surrounded every day by people looking for opioids for their chronic aches and pains.

 

Lemon Semolina Cookies

Written by Tad. Posted in Cookies

Semolina is made from hard durham wheat. It is cooked, dried then ground. It looks and feels kind of like corn meal. It gives these cookies an interesting texture. They are soft and very lemony.

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Hunter enjoys one after a spaghetti lunch.

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Recipe By:

Adapted from Food.com

Yield:

24

Ingredients:

3 large lemons
½ pound unsalted butter
½ teaspoon vanilla extract
2 cups sugar
1 teaspoon salt
1 egg
3 cups semolina
1 cup all-purpose flour
To dust the cookies
½ cup sugar

Directions:

1. Using a grater, grate lemon peels, removing only the yellow part. Set aside. *See notes.

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2. Squeeze juice from the lemons. Set aside.

3. Combine butter, vanilla, sugar and salt in an electric mixer fitted with a paddle. Beat until creamy.

4. Add egg, ½ cup lemon juice and grated rind. Beat until incorporated.

5. Reserve any extra lemon juice for another use.

6. Decrease speed to slow. Add semolina and flour, beating until just incorporated.

7. Cover with plastic wrap and chill in the refrigerator for 1 hour.

8. Heat oven to 325°F.

9. Scoop dough into 2 tablespoon balls. Roll each ball in sugar then place on greased baking sheets.** See notes.

10. Flatten each ball to about ½ inch thick. *** See notes.

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11. Bake cookies on the middle rack of an oven for about 14 minutes, or until the surface starts to crack. They will not start to brown.

12.  Remove from the oven and let cool before removing from baking sheet.

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Notes:

*This finely grated citrus peel is called zest. I have a zester, specifically made for this job. It works ever so much better than a regular grater.

**I almost always use parchment baking papers but these didn’t come off the papers well at all.

*** My preferred method to do this: Butter the bottom of a drinking glass. Dip it into sugar. Gently flatten a dough ball to desired thickness. Re-dip in sugar before flattening the next ball.

Copyright © 2014 Bad Tad, MD