Aspiration of a Scalp Abscess

Written by Tad. Posted in Kooks

I went to see a 31-year-old man who was complaining of headaches and a bump on his scalp just above the forehead. The bump on his scalp was unusual. It was red and tender. It looked and felt kind of like an abscess though it is unusual for someone to develop an abscess on that part of the scalp.

A good way to find out if a bump in the skin is an abscess is to poke a needle into it and aspirate with a syringe to see if any pus comes out. I recommended this to the patient and he agreed.

I got a needle and syringe then wiped the bump with an alcohol swab. I poked the needle into the skin over the bump and pulled back on the plunger. I then slowly advanced the needle, watching for pus. I knew if the needle hit the skull and no pus came back in the syringe it was not an abscess.

But, the needle never hit the skull. Just as I realized this, the syringe started to fill up with liquid. It was not the yucky, thick pus I was expecting from an abscess, but clear, colorless liquid. Cerebral spinal fluid. The fluid that bathes and supports the brain inside the skull. I had poked a needle through his skull!

Shaken, I told the patient what happened. I then ordered x-rays, which clearly showed there was no skull under the lump.

I made arrangements for the patient to be watched in the hospital since I had potentially contaminated his cerebral spinal fluid. This put him at risk of an infection around the brain.

As it turned out, he got no infection and was later diagnosed as having an eosinophilic granuloma or Langerhans cell histiocytosis. This rare condition caused the replacement of normal skull tissue with a tumor that caused the bump on his head.

http://en.wikipedia.org/wiki/Langerhans_cell_histiocytosis

 

 

Where’s the rest of it?

Written by Tad. Posted in Kooks

I pick up the chart of a man in his early forties. “Rectal pain” is the chief complaint.

When I enter the room, the patient is standing in the corner, dressed in a hospital gown and looking rather glum. I introduce myself and ask how I can help him. He mumbles enough of a non-specific answer for me to understand he has something stuck in his rectum that he can’t get out.

I invite him to bend over the exam table as I turn to get some gloves.

Turning back to him, gloves on hands, I pull the gown away from his backside. Sticking out of his anus is the end of a broomstick about a foot long. This surprises me somewhat. I touch it and the patient moans in pain.

“How long has this been in there?” I ask.

“Mmmmm. Four days,” is the reply.

I explain to the patient that we clearly need to give him pain medicine and also something to help him relax before trying to get the stick out. I then excuse myself and pass orders on to the nurse to get this started.

Once the patient is medicated, I return to the room and, again, don gloves. This time, the patient is comfortable enough that he only moans as I pull the stick out. Interesting. The other end of the stick is wrapped in twine. I’m trying to figure this out when the patient looks up at the stick and groggily asks, “Where’s the rest of it?”

An x-ray reveals the outline of a large, penis-shaped dildo stuck in the patient’s rectum. Now, I think I understand what happened. The patient wanted to get the dildo farther into his rectum, so he put it on the end of a broomstick. However, the broomstick was smaller than the inside of the hollow dildo so he wrapped the stick with twine until it fit snuggly inside the dildo and would not come off.

What he failed to consider was what would happen when the dildo was all the way up inside his rectum. Once his anus closed down over the dildo onto the broomstick, it was stuck and couldn’t be pulled back out again.

The poor guy, too embarrassed to seek help, had been sitting – or not sitting – around the house for four days, in miserable discomfort, with that thing stuck in there.

I will blog more in the future on rectal foreign bodies as it is a recurrent and interesting subject in the emergency department. Sometimes, we are able to get them out in the ED. Other times, as in this case, we are unable to do so. In those situations, we call the surgeons. With the patient asleep, and with access to tools they have in the operating room, the surgeons are often able to pull the object out. But, not always. Sometimes, as in this case, the surgeon actually has to cut the abdomen open for removal.

Please don’t ask me why people do this. I never ask. You will just have to use your imagination or go online for more specific information.

Pistachio Ice Cream Cookies

Written by Tad. Posted in Cookies

Recipe Adapted from:

Home-Tested Cookie Recipes

Ingredients:

2½ cup flour
1 teaspoon salt
1 tablespoon baking soda
1 cup butter, at room temperature
1½ cups pistachio ice cream
1 tablespoon vanilla
½ cup sugar
¾ cup brown sugar, packed
1 small box instant pistachio pudding
1 large egg
12 ounces chocolate chips
4 ounces pistachios, coarsely chopped

 Directions:

1. Heat oven to 375 degrees.

2. Combine flour, salt and soda. Set aside.

3. Beat butter, ice cream, vanilla, sugars and pudding mix. It may look kind of curdled at this point. Don’t worry. Stir in eggs.

4. With mixer on low, stir in flour mixture until just combined.

5. Stir in chocolate chips and nuts.

6. Drop in 2 tablespoon balls in prepared baking sheets.

7. Bake about 10 minutes until brown. This is one of those recipes where they look over-done when they are not. Even when brown, they are still soft.

8. Cool on wire racks.

Notes:

Original recipe called for vanilla pudding and had no nuts. They really were not very pistachioy. I changed the pudding and added the nuts which helped a lot. I was thinking of adding some green food coloring. Maybe next time.

 

Orange Slice Cookies

Written by Tad. Posted in Cookies

Again, another cookie with a signature weird ingredient. When baked for 12 minutes, they were cooked but not browned. In fact, look at the pictures and it is hard to tell the raw from the cooked!  They have a dense texture.

 

Recipe By:

Capitol Cookies, Munch Your Way Across the U.S.A. Shari came across this little book while we were shopping at RAFT (Resource Area for Teachers.)

Ingredients:

1 ½ cups brown sugar
½ cup shortening
2  large eggs
2 cups flour, 9 ounces
1 teaspoon soda
½ teaspoon salt
1 pound orange slice candy, diced
½ cup flour
½ cup flaked coconut
½ cup oats
½ cup nuts, chopped, optional

Directions:

1. Heat oven to 325 degrees.

2. Cream sugar, shortening and eggs.

3. Sift 2 cups flour, soda and salt. Blend into sugar mixture.

4. Mix orange candy and ½ cup flour. Stir into sugar mixture.

5. Stir in coconut, oats and nuts.

6. Form into 2-tablespoon balls. Place balls on parchment-lined baking sheets. Flatten with fork.

7. Bake for 10 to 12 minutes.

Notes:

Consider adding some orange and/or coconut flavoring.

Vertical Strips with Pocket on Back

Written by Tad. Posted in Trauma Strap Bags

Sandy asked for a vertical bag with a pocket on the back. I made it like the bag I take cookies to work in every Thursday but bigger. After hers turned out so well, I was inspired to make another.

Here is the cookie bag.

 

 

How Many Times Can You Fall Off a Ladder?

Written by Tad. Posted in Kooks

While Chair of our department, I had occasion to review the medical records of one of our patients. This review prompted me to write the following memo to our doctors:

This patient has been seen many times in our ED for various complaints. She usually reports an injury, as you will see below. In spite of these visits here, she always checks in with a Reno, Nevada address. She is frequently prescribed narcotics. Please keep this in mind as you have occasion to deal with this lady in the future.

Here is a list the dates and chief complaints she gave when registering:

2/92            dental pain

9/91            car crash

1/95            twisted ankle yesterday

3/95            car crash

3/95            fell last night while taking the trash out

7/95             slipped on newly waxed floor yesterday

11/95            car crash

3/96            fell onto shoulder

4/96            fell from ladder

7/96            dental pain

8/96            fell getting out of the tub

11/96            garage door hit head and neck

1/97            fell off snowmobile yesterday

4/97            fell off ladder 2 days ago

5/97            hit with a 2 by 4

6/97            fell attempting to put bolt in an engine

7/97            hit ribs on truck hood when fell off a plastic chair

8/97            fell off ladder yesterday

9/97            fell off ladder yesterday

10/97            struck in ribs by car door opened by granddaughter

10/97            fell off ladder today (17th)

10/97            fell off ladder two days ago (30th)

11/97            slipped and fell yesterday

1/98            fell off ladder two weeks ago

2/98            fell on U-Haul ramp this morning

4/98            slipped on linoleum floor two days ago

5/98            slipped on stairs last night

7/98            fell from chair

7/98            fell onto rocks yesterday

9/98            fell onto buttocks yesterday

11/98            slipped yesterday and hit chest on counter

2/99            bumped chest wall on edge of chair two days ago

4/99            fell against a corner of a refrigerator at 4:00

5/99            slipped and fell at Laundromat

7/99            slipped and fell in kitchen two days ago

8/99            fell down steps yesterday

9/99             fell from ladder yesterday

10/99            fell down stairs yesterday

12/99            fell in bathtub yesterday

2/00            fell off ladder yesterday

3/00            dropped box of books on wrist yesterday

10/00            fell from ladder

Oatmeal Double Chocolate Cookies

Written by Tad. Posted in Cookies

Recipe By:

Nob Hill Magazine

Serving Size:

60 cookies

Ingredients:

1 pound butter, softened
1½  cups  brown sugar
2 large eggs
2 teaspoons vanilla
2 cups  chocolate chips, melted and cooled
2½  cups  flour, 11¼ ounces
4 teaspoons baking powder
½ teaspoon baking soda
½ teaspoon salt
4 cup  oats
2 cup  chocolate chips

Directions:

1. Heat oven to 350 degrees.

2. Combine butter, sugar, eggs and vanilla.

3. Stir in melted and cooled chocolate.

4. Set aside.

5. Combine flour, baking powder, soda and salt.

6. Gradually stir flour mixture into butter mixture.

7. Stir in oats and chocolate chips.

8. Bake for 12-14 minutes.

Notes:

These came out very moist but are more oaty than others I have tried. They also have a good chocolate balance for those of us who are not really crazy about really deep, dark chocolate. Don’t over-bake them. Keep them soft and moist.

How Many Strap?

Written by Tad. Posted in Trauma Strap Bags

I took a couple of nights off last week. I went mountain biking in the Sierras with my friend, Rick. In the five nights I was not there to take care of the straps, this is how many came in:

After I rolled and separated them, this is how many I had to return to the medics to reuse:

This is how many were cut and unable to be reused. I use these for my bags:

These are the buckles cut from the pile seen above:

This gives you an idea of how many of these dumb things I am keeping out of the landfill.

 

I’m Going to Die

Written by Tad. Posted in Kooks

“Doctor? I’m going to die.”

I don’t know if she feels it from within herself or if she reads it on my face.

“Yes.” I mumble, dropping my head, unable to continue to look into her eyes.

“No!” bawls her mother, falling forward and pulling my patient up against her.

She is in her mid-forties, round-faced and hump-backed from the steroids she uses to control the symptoms of her lupus erythematosus. She woke up in the middle of the night with severe chest pain radiating to her back, unable to feel or move her legs. Within seconds from the time the medics unload her onto our stretcher, I know she is dissecting her thoracic aorta, the large artery carrying blood from the heart to the rest of her body. In like manner, I also know there is nothing I can do to keep her from dying. In order to combat the feeling of futility brought on by this realization, I launch into a frantic effort to save her.

I order two large IV’s, blood tests and x-rays. I place urgent calls to the surgeon and radiologist. The results of this effort lead only to frustration. The surgeon says he can’t do anything until I get a CT scan that demonstrates the problem. The radiologist can’t do the scan until the patient is more stable. She is dying.

More frantic calls are placed looking for a thoracic surgeon willing to come in and do something heroic. Again, no one will come until I have a scan showing a dissection. But her blood pressure is too low to send her for the scan.

I order lab tests looking for something I can do to help her. The results only reinforce my feelings of powerlessness. Anemia, acidosis. She is not responding to the fluids and medication I am giving her to try to keep her blood pressure up.

As her blood pressure drops further and her acidosis worsens, she slips into unconsciousness. All of my efforts frustrated, I give in to the inevitable and shrink back into acceptance. I pull the curtain closed behind me, leaving her with her family. They hold her and weep as she quietly slips away.

I weep too. I weep and it hurts. I have failed! No wonder I try so hard to avoid facing death. No wonder I choose to resuscitate rather than let life go quietly away. If she had only lived to get to the operating room or intensive care unit, I would have done my part successfully, even if she died later on. As I face her death, premature and unfair, I am forced to face my inadequacies and the cruelty of life.

I have to go be alone for a while as I deal with my emotions. Soon, I am able to shake off the feelings. I wipe away the tears, pick up the next chart and charge off to see my next patient.

Copyright © 2014 Bad Tad, MD