Jessica’s “New” Bag

Written by Tad. Posted in Trauma Strap Bags

Black straps only rarely come in and, since they are so cool, are much in demand. Many people have asked for a black bag and I have to say, “Sorry.”

One of our nurses, Jessica, wouldn’t take “No” for an answer. She went onto Amazon and bought a roll of black strapping. Here is the bag I made out if it. The only bag I have even made with new materials.

DSC04342

Big Bloody Guy

Written by Tad. Posted in Kooks

The other night, a woman rushed in asking for help getting her injured boyfriend out of the car. She said he had been drinking with friends when they called to say he had been stabbed and needed her help. When she got there, he was covered with blood, nearly unconscious and unable to stand. The friends helped her load him into her car and she rushed him to the hospital.

A nurse and a tech went with the woman to her car. There, they found a man slumped in the front seat. He had dried blood all over his face and soaked into his clothes. He moaned as they moved him into a wheelchair and pushed him into the emergency department.

When I entered the trauma room, I saw a tall, big-boned, muscular man covered in blood. His head was thrown back in the wheelchair and he was moaning. Though conscious, he did not respond to staff’s questions or instructions. His size and passive posture led to a quick conversation about how to best get him out of the wheelchair and onto the gurney. I bent over and, talking closely into his ear, firmly encouraged him to help us get him onto the bed. That was enough to get him to stand and move over to the gurney, where he fell back, moaning, his eyes closed the whole time.

I then stepped back against the wall at the foot of the bed while the nurses and techs got him undressed, placed him on a cardiac monitor, recorded some vital signs and started IVs.

Just then, the trauma surgeon walked in and asked me what was going on. I told her he had been stabbed, he seemed to be very drunk and we were in the process of evaluating him for possible serious injuries.

Suddenly, the man, who had hardly been able to hold his head up, leapt from the gurney, hollering loudly. He pulled the IVs out of his arms, yanked the monitor leads from his chest and tore off his gown. Throwing everything on the floor, he stood, naked, in the middle of the room, blood running down his muscular arms from where he had pulled out the IVs. Everyone was amazed at his miraculous transformation. He had suddenly gone from being a nearly unconscious rag doll to an erect, angry man who was hollering, swearing and waving his arms threateningly. Staff immediately stepped back away from him and pressed against the walls of the room, wondering what might happen next.

At first, his profanity-laden tirade was directed at no one in particular. Soon, he focused on me. Though his eyes had been closed and he had been acting incoherently, it became obvious he heard what I told the trauma surgeon and was very upset that I assumed him to be drunk.

He walked forward and got right up in front of me. Waving his arms wildly and pointing at his bloodied face, he screamed at me for saying he was drunk and not paying any attention to his stab wound.

I can’t say I was not afraid but I just stood, statue-still. I stared him straight in the eyes and did everything I could to not respond to him at all. Not getting a reaction from me, he turned and walked around the room, hollering at others who stood, lined against the walls. He picked out a nurse in the farthest corner, called her a “bitch” and gestured threateningly at her.

Recovering their wits somewhat, some of the staff tried to calmly talk him down. He paid no attention to them. He continued to pace the room, completely naked, with dried blood all over his face and fresh blood dripping down his arms. At times his ranting seemed incoherent. Then, he would say something like, “Look at me! Standing here buck-naked in fronta y’all. What the
f—?” All the time this was going on, his poor girlfriend was sobbing in the hallway outside the trauma room.

Eventually, he seemed to tire of it all and started looking for his clothes. Several of us encouraged him to let us evaluate him to make sure he was not seriously injured. This, he refused, demanding to be given his bloody clothes so he could leave.

This presented a difficult ethical question. When he came in, it seemed he was impaired. A person in that condition could not wisely refuse medical care. If he had tried to leave, it would have been appropriate to restrain him until we were sure he was either okay or competent to assume the risks of leaving against medical advice.

Now, I had a very different patient. He was alert, talking clearly in full sentences, and able to pick me out as the one who insinuated he was intoxicated. What was my responsibility? Did we need to tackle and restrain him to protect him from making a bad decision and leaving? Should staff be put at risk in order to make sure he didn’t leave until it was clear he was alright?

By then, security officers had arrived, waiting for my instructions on to how to deal with this man. I had to decide. He was big, strong, upset and covered with blood. I knew it would be a nightmare to try to take him down. Rather than put staff at higher risk, I told everyone to let him leave if he wanted to. It took him quite a while to get dressed as he kept getting distracted and continued hollering at people. Eventually, however, he walked out.

The next day, I got the following email from one of our physician assistants, referring to this same patient:

Hello Dr. Tad,

A patient presented to the ED today to apologize for his behavior during his most recent ER visit. He was very sincere, and wanted to apologize for his horrific behavior. He is very sorry and appalled at himself, stated he is not normally like that, and continued to profusely apologize, asking to please have me pass on how remorseful he was.

Sincerely,
C.M. PA-C

 

 

 

 

Too Many Pushups

Written by Tad. Posted in Kooks

A 15-year-old boy got in trouble at football practice. As punishment, his coach sentenced him to do 150 pushups over the weekend. His mother was assigned to monitor him and make sure he was compliant.

On Monday, he was unable to move his arms, which were in severe pain, and he noted that his urine was darker than normal. All of this concerned his mother, who brought him to the emergency department. This story of over-exercising, followed by excessive muscle pain and dark urine was worrisome to me. Quick blood and urine tests confirmed my suspicion. He had rhabdomyolysis.*

The excessive use of the muscles of his arms and shoulders caused enough muscle damage that a protein, myoglobin, was released from the muscles in such large amounts that it turned his urine dark. If not treated, that same protein could be toxic to the kidneys. This patient had to be admitted to the hospital to get pain medicine and IV fluids until his muscles healed and the myoglobin was cleared from his blood and urine.

Over-exercising is one of the more common causes of this condition. As far as I know, I have never seen it just from over-use of the upper extremities. Since your legs have so much more muscle mass than your arms, it is a lot more likely for this to develop after over-use of the legs. For example, we often see prisoners who do squats over and over until they develop rhabdomyolysis. They come in from jail with leg pain and dark urine and have to get admitted to the hospital.

I wonder if my patient’s coach will assign 150 pushups as behavior modification again.

 

*I posted a case previously about rhabdomyolysis. Please see Dancing with the Stars in a previous post.

Also, for more information, check out this Wikipedia article: https://en.wikipedia.org/wiki/Rhabdomyolysis

 

Chocolate Peanut Butter Globs

Written by Tad. Posted in Cookies

chocolate peanut butter globs DSC04300

This is one of those recipes that is all over the Internet. It seems weird to call them “peanut butter” when there is no peanut butter in them at all.

For some reason, I have always referred to the chunky ingredients added at the end of the cookie recipe as “floaties.” Don’t ask me where that came from. Maybe it is because I just can’t think of a better word. Anyway, this recipe has more floaties than any other recipe I have ever made. Seriously, packed with nuts and chips.

Recipe By:

All over Internet

Yield:

36

Ingredients:

6 tablespoons unsalted butter
12 ounces semisweet chocolate chips, divided
2 ounces unsweetened chocolate
2 large eggs
1 tablespoon instant espresso or coffee powder
2 teaspoons pure vanilla extract
¾ cup sugar
⅓ cup all-purpose flour, plus 1 tablespoon
1 teaspoon baking powder
¼ teaspoon kosher salt
1 cup walnut halves, not chopped
1 cup pecan halves, not chopped
⅔ cup peanut butter chips

Directions:

1. Heat oven to 325 degrees. Line baking sheets with parchment paper.

2. In a bowl set over simmering water, melt butter, 6 ounces of chocolate chips, and unsweetened chocolate, stirring occasionally, until just melted. Remove from heat and cool for 15 minutes.

3. In bowl of electric mixer fitted with paddle, beat eggs, espresso powder and vanilla until combined.

4. Add sugar. Raise speed to medium-high and beat for 2 minutes, until the batter is thick and falls back on itself in a ribbon.

5. With  mixer on low, slowly stir in  chocolate mixture.

6. Combine ⅓ cup of flour, baking powder, and salt in a small bowl. Stir into chocolate mixture with a rubber spatula.

7. In another bowl, combine walnuts, pecans, peanut butter chips, remaining 6 ounces of chocolate chips and 1 tablespoon of flour. Fold into chocolate mixture.

8. Scoop 2 tablespoon balls of dough, 1 inch apart, onto prepared baking sheets. Bake for 15 minutes exactly. Cool on baking sheets.

Mr P., Again, Again

Written by Tad. Posted in Kooks

I am so sorry. Looks like this was still not working for some people. Here it is again. I am confident it will work this time. Thanks for your patience.

One the doctors I work with forwarded this article to me. It was written by Otis Warren, an emergency physician. It paints a great picture of a specific patient but also of the bigger social problems associated with public alcoholism.

Enjoy!

http://content.healthaffairs.org/content/35/11/2138.full

 

Eye Poke Defense

Written by Tad. Posted in Kooks

I was working in the Accident Room of Charity Hospital in New Orleans. A young man came in complaining of pain in both of his eyes. He said he had been in an argument with another man in a bar. The other guy had stuck out two fingers and poked my patient in the eyes. The pain caused my patient to bend over. When he straightened back up and opened his eyes, the other guy poked him again, the same way.

He was in so much pain that his friends brought him to the emergency department. A quick evaluation showed that his only injury was corneal abrasions or scratches on the front, clear parts of his eyes. Though this is a very painful condition, it rarely results in a complication and usually heals within a day or two. As per the custom then, we medicated and patched both of his eyes and sent him out with a prescription for pain medicine. His concerned friends helped him out of the emergency department and into their car.

Though we didn’t want to laugh at the patient, we did have a good laugh when I reminded everyone that, in The Three Stooges, Mo would poke Curly in the eyes in the same manner. When Mo tried to poke him again, Curly would use the Eye Poke Defense. He would hold his flat hand up, with the fingers extended, in front of his nose so that Mo’s finger tips could not reach Curly’s eyes.* I joked that our patient should have remembered that trick and it would have helped protect his eyes.

A few hours later, I was surprised to see this same patient come back in, patches still on his eyes, complaining of abdominal pain. He was in a lot of distress and clearly had something serious the matter with him. Only then did we get the rest of the story of what had happened at the bar.

When the eyeball-scratching altercation took place, the bouncer jumped right on the situation and, literally, threw both young men out of the bar. My patient was having trouble with his vision because of his eye injury and his balance because of all the booze he had consumed. When he was thrown out of the bar, he fell, striking his lower abdomen on the top of a fire hydrant.

A guy who has been drinking in a bar usually has a full bladder and a blow to the lower abdomen in this situation can lead to a rupture of the bladder and that is just what happened to our guy. Though he was just kind of sore there during his first visit, it wasn’t until he lost some blood and the blood and urine had some time to irritate his abdominal cavity that he started to get sick. He had to go to the operating room to have his bladder repaired.

Though holding his hand up, like Curly, may have prevented some injury to his eyes, I don’t think it would have done anything to protect his bladder.

 

*Here is a picture of Mo trying to poke Curly, who is very effectively using the Eye Poke Defense.

eye poke defense

Natalie’s Easy and Delicious Chocolate Chip Cookies

Written by Tad. Posted in Cookies

Natalie's

Probably no one needs another chocolate chip cookie recipe but Natalie, one of our physician assistants, told me there were the very best. She swears the secret is dropping them, hot out of the oven, onto the counter top. I was not disappointed!

Ingredients:

1 cup butter
1 cup sugar
1 cup brown sugar
1 egg
1 tablespoon vanilla
2½ cups flour
1 tablespoon soda
½  teaspoon salt
2½ cups chocolate chips

Directions:

1. Cream butter and sugars.

2. Stir in egg and vanilla.

3. Stir in flour, soda and salt.

4. Stir in chocolate chips.

5. Scoop 2 tablespoon balls of dough onto baking sheets lined with parchment.

6. Bake at 350 degrees for 12 to 14 minutes until bottoms and edges are just browning.

7. As soon as you take them out of the oven, drop each sheet from about a foot onto counter top.

8. When set, remove to rack to finish cooling.

Copyright © 2014 Bad Tad, MD