One of our registration clerks asked me to make a bag he could carry on his back and showed me the one he was using as an example. I was able to come up with something similar to what he had but with that Tad Bag difference.

Manu

If medics call our hospital and report they are bringing someone who may need immediate attention, a Medical Alert is called. This gets everyone’s attention and allows the full capacity of the department to be available for whatever the patient needs.

On Thursday night, a Medical Alert was called for Room 1A. As they came in, I saw a shriveled old man with contracted extremities, staring blankly into space. He was accompanied by medics who were not rushed and did not seem to be very worried about what was going on.

When we were all in the room, I learned the patient was demented, bed-ridden and unable to speak. They said his wife was supposed to have signed papers making him a “No Code.” That means he should not be put on a breathing machine or have CPR done in case he were to try to die. However, before the wife could sign the papers, she took ill herself so the patient was a “Full Code.”

They said the patient had not been eating for weeks and was only getting sugar water through an IV. They said his son had been at the nursing home earlier in the evening. The nurses had called the ambulance soon after he left.

I took a quick look at the patient and it was my impression he was dying. In the nursing home, he had a good blood pressure but it was low when measured in the ambulance and very low when he arrived at the hospital. His pulse was below 30 and he was hardly breathing.

The nurses made busy to start resuscitating him. I stopped them, explained that the patient was all but dead and trying to revive him would be futile. I felt our goal should be to make him comfortable rather than try to revive him. I asked them if anyone felt uncomfortable with that approach and they all agreed. I left to quickly get a phone number to call the son.

When I got the son on the phone, I told him who I was and told him his father was dying. I told him it was my impression that trying to revive him would be futile and I wanted to do everything I could to make sure his father was comfortable and not suffering.

He then asked me to just put his father on “the breathing machine” for the night and they would be in tomorrow to see him.

I was astounded. If he saw his father earlier in the evening, he knew how debilitated his father was. I had just told him his father was dying. In my mind, any son with insight and compassion would agree to let him die in peace.

From my perspective, I could see the nightmare it would be to try to intubate such a contracted, debilitated old man. I could see how horrible it would be to do CPR on him, crunching his chest and cracking his ribs with each chest compression. I knew that an old man who is dying is not going to suddenly be cured by CPR and a ventilator. I knew he would not be fine until it was convenient for his son to get his mother and come to the hospital the next day and decide what to do about their dying loved one.

I was so set back by his casual and uninsightful response that I didn’t know just how to respond to him. I gently tried to get him so see that his response didn’t reflect the true urgency of the situation. “Your father is dying right now,” I said.

“Do everything you can and we will see him in the morning,” was his response.

Unable to get the son to appreciate what was going on, I hung up and headed back to the room, torn. On one hand was the obvious futility of the situation and my desire to not cause suffering in someone who I believed should just be allowed to die in peace. On the other hand was a family member who couldn’t share my vision and just wanted to stay in bed and put off a difficult talk with his mother until the next day.

When I got back in the room, my mind was made up for me. The patient was not breathing, his heart was not beating. He was dead and any effort to reverse that would be considered futile care. I pronounced him dead and went and called the son with the bad news.

When the son arrived later, he said his father had not eaten for weeks and the nursing home doctor had refused to have a feeding tube placed. To me, this meant that the doctor considered the feeding tube as futile. So, whether the family had signed the No Code papers or not, I feel I did the right thing for my patient by just allowing him to pass in peace.

There is no reason to believe that cookies have to be hard to make in order to be good. Here is a recipe that came out of the Nob Hill Magazine. Of course, they put in weird ingredients so you have to go to the store and buy something you wouldn’t ordinarily buy. In this case, when I went to buy the Coco Lopez Cream of Coconut, they had none so I just used regular coconut milk and they were great.

Recipe By:

Nob Hill Magazine

Yield:

24

Ingredients:

1 box yellow cake mix
3 cups shredded coconut, divided
1/4 cup Coco Lopez Cream of Coconut*
1/4 cup butter softened
2 eggs

Directions:

1. Heat oven to 350°F.

2. Stir together cake mix, 2 cups of coconut, Coco Lopez Cream of Coconut, butter and eggs.

3. Scoop dough into 2 tablespoon balls then roll balls in additional coconut.

4. Place on a parchment-lined baking sheet. Bake 10 to 12 minutes.

Notes:

*I used regular coconut milk

I don’t remember where I got this recipe but I have made them several times and they are wonderful. As my wife and I were sharing a warm one tonight, I asked, “How could you even eat an Oreo after having a cookie like this?” The warm, soft chocolate chips coating my tongue along with the bite of the ginger. Wonderful!

Yield:

24

Ingredients:

1½ cups plus 1 tablespoon all purpose flour

1½ teaspoons ground ginger

1 teaspoon ground cinnamon

¼ teaspoon ground cloves

¼ teaspoon ground nutmeg

1 tablespoon unsweetened cocoa powder

½ cup unsalted butter, at room temperature

1 tablespoon freshly grated ginger

½ cup brown sugar, packed

½ cup unsulfured molasses

1 teaspoon baking soda

1½ teaspoons boiling water

7 ounces chocolate chips

½ cup granulated sugar*

Directions:

1. Line two baking sheets with parchment.

2. In a medium bowl, sift together flour, ground ginger, cinnamon, cloves, nutmeg and cocoa. Set aside.

3. In the bowl of an electric mixer, fitted with the paddle attachment, beat butter and grated ginger until whitened, about 4 minutes.

4. Add brown sugar. Beat until combined.

5. Add molasses. Beat until combined.

6. In a small bowl, dissolve baking soda in boiling water. Set aside.

7. Beat half of flour mixture into butter mixture.

8. Beat in baking soda mixture.

9. Beat in remaining half of flour mixture.

10. Mix in chocolate chips.

11. Turn out onto a piece of plastic wrap. Pat dough out to about 1 inch thick. Seal with additional wrap. Refrigerate until firm, 2 hours or more.**

12. Heat oven to 325 degrees.

13. Roll or scoop into 2 tablespoon balls. Roll balls in granulated sugar. Place on baking sheets two inches apart. Bake until the surfaces crack slightly, 10 to 12 minutes. Let cool 5 minutes. Transfer to a wire rack to cool completely.

 Notes:

* Instead of regular granulated sugar, I use Sprinkle King, Kingsblingz Diamond Crystals that I buy online from www.supplyvillage.com. They are large, shiny and give the cookies a great crunch. I only put them on the top of the ball, not all over it.

** I skip the chilling. It will help you handle the soft dough better but I just use a cookie scooper and handle the dough ball gently as I move it from the sugar bowl to the cooking sheet.

Chip is my wife’s cousine and my mountain bike riding budy. He and his wife, Debbie, sent me this picture of their bag visiting Independence Hall in Philidelphia.

The mother of one of my patients told me an interesting story this week. She brought her thirteen-month-old daughter in because of fever and respiratory distress. The reason the mother was so worried was that about three weeks earlier, her daughter came into the emergency department very ill with an acute respiratory illness. After being admitted to the hospital, she worsened and had to have a breathing tube put into her windpipe, be placed on a ventilator and be cared for in the intensive care unit.

Tests showed that her illness was caused by an infection of Bordetella pertussis. She had whooping cough. Fortunately, with antibiotics and aggressive medical attention in the ICU, she recovered and was going to be fine.

The mother told me she was an acupuncturist who had always believed that, in medicine, less was better. She had purposefully avoided any vaccinations, having fallen in with the “antivax” crowd. She felt that vaccinations carried more risk than potential benefit. She had obviously now changed her mind and had the baby scheduled to start on her vaccinations. She could now see that her perspective on illnesses like whooping cough was warped because of the success of vaccinations.

Vaccines are so effective that we have removed the targeted illnesses from our experience so it is easy to be deceived into thinking they are not a threat. At the same time, alarmist, poorly thought-out ideas against immunizations are everywhere and have a big influence on people.

As far as I know, I have only seen two patients, before this girl, who had whooping cough. They were young sisters, also unvaccinated, who were really sick with a miserable cough and were admitted to the hospital. I don’t think I have ever seen anyone with measles or polio.

Diseases like whooping cough, measles and polio caused lots of problems when my father was a boy. Because of vaccinations, most people in America have never seen anyone sick with one of these illnesses so they fall into a false belief that the vaccinations are a problem rather than a way to prevent problems.

With the illness of her daughter, realty set in with this mom and, fortunately, she is very glad to have a second chance.

If you look at my list of cookie recipes, you will see that I messed around quite a bit trying to find a good S’mores cookie. Here is the last one I tried. As with all the others I tried, the cookie part is the hardest to recreate. These look cool. They are clearly chocolatey, marshmallowy and graham crackery but I have just not been able to come up with a cookie that comes close to that crunchy satisfaction you get when making real S’mores around the camp fire.

Recipe By:

Internet

Ingredients:

1 cup all-purpose flour

2/3 cup unsweetened cocoa powder

1 teaspoon baking soda

1/8 teaspoon salt

½ cup unsalted butter, softened to room temperature

½ cup granulated sugar

½ cup brown sugar

1 large egg

1 teaspoon vanilla

2 tablespoons milk

½ cup miniature marshmallows, cut in half

4 full-sheet graham crackers, ground into fine crumbs

 Directions:

1. Whisk the flour, cocoa powder, baking soda, and salt together in a large bowl. Set aside.

2. Using a handheld or stand mixer fitted with a paddle attachment, beat the butter, granulated sugar and brown sugar together in a large bowl on medium speed until creamed, about 2-3 minutes. Beat in the egg and vanilla extract. Scrape down the sides of the bowl as needed.

3.  With the mixer running on low, slowly add the dry ingredients into the wet ingredients until combined. Add the milk. The dough will be heavy and sticky. Cover and chill for at least 2 hours.

4. Take the dough out of the refrigerator and allow to slightly soften at room temperature for 10 minutes. Heat the oven to 350 degrees. Line a large baking sheet with parchment paper or a silicone baking mat. Set aside.

5.  Pour graham cracker crumbs into a bowl. Form a 2 tablespoon balls of dough. Roll each cookie dough ball into the graham cracker crumbs then place on baking sheet.

6. Bake for 10 minutes. Remove from the oven and press 3-4 pieces of marshmallow on top of each cookie. Return to the oven for another 2-3 minutes.

7. Remove from the oven. Cookies will appear undone and very soft. Allow to cool on the cookie sheet for at least 5 minutes before transferring to a wire rack to cool completely.

Sometimes, the people accompanying patients to the emergency department are more interesting than the patients. In this case, the patient was a middle-aged, mentally handicapped man who was brought in by his “friend” for a refill on his blood pressure meds. He was pretty much clueless and it was clear that her life was wrapped up in taking care of him, a job more made difficult by their homelessness.

She was probably about forty-five years old. In contrast to the diminutive patient, she was a large woman, tall, with big bones and heavy, coarse features. She wore slightly dirty, over-sized pants and a tee shirt. She wore no bra over her large breasts.

What made her worthy of my specific attention and a post in this blog was her hair. It was dark brown with a few streaks of gray. It was pulled back at the base of her neck where it turned into a huge single dreadlock that was flattened so it lay against the upper part of her back. She had it covered with a multi-colored cloth sack, sewn specifically for the purpose. It sheathed the hair from the upper back all the way down to the ends. When she stood, it hung well below her waist in the back. When she sat, she pulled it around to the front, coiling it in her lap. I have never seen hair like that in my life, nor have I ever seen hair cared for by sheathing it, like a sword in a scabbard.

Two other things that made her  interesting to me:

As she spoke Spanish, I could tell she was not a Mexican. She told me she was from Cuba. We don’t have a lot of Cubans in our emergency department.

She had on an interesting ring, decorated with the initials CTR. When I asked about it, she said it stood for Choose the Right. She got it from a woman she had cared for in the past, who was a Mormon.

Patients or their family members frequently come in with notes to help detail and clarify what has been going on medically with the patient. Here is one that came in this week:

Over the last 7 years:

1. 50 Dots in vision Freezing my eyes making them Feel paralyzed
2. Migraine Headache Pain Scale 10-0, 10
3. Bloody nose
4. Blood stool
5. Tension in my shoulders
6. Swelling in my hands, feet
7. Nausea
8. Irregular heart beat
9. Pain all over my Body on your Pain Scale a 10, Mine over 100
10. Feels like a lit ciggarrette Burning on my Foot
11. Blindness
12. Cold sweats
13. Nightmares
14. No Period 10 years
15. Adrenaline
16. Seziures

I have asked for a CT Scan for my head and I got one at Stanford. When the results came back, it showed an image then they did color contrast, which showed nothing. Then I thought that I had szcizoeffective. Well I don’t. It’s Geist the little thing in my head and I spend 7 years thinking I was crazy, all types of different things have happened and tonight the pain was just severe.

Here is my niece, Natalie, with her new bag.