Impaled on Tree-trimming Equipment

Written by Tad. Posted in Kooks

A young Hispanic man came in telling the nurse he had fallen and been poked in the buttock four days before. He was worried the wound might now be infected.

When I reviewed the story with him, he corroborated the nurse’s note, adding nothing else. Though I speak Spanish fluently, I didn’t have the vocabulary to understand just what it was he landed on. I decided it probably didn’t really matter.

At my instruction, he pulled down his pants and rolled over. He showed me a puncture wound on his left buttock. It was healing nicely and showed no signs of infection.

As I went to reassure him there was no infection, a little something prompted me to wonder if there might be something else going on. I asked him if he thought it possible that a piece of whatever he landed on might have broken off inside him. He answered affirmatively and I sent him off for an x-ray of the area. I had the idea there might be a small chip of metal under his skin causing him some discomfort.

A few minutes later, the x-ray technician called me in to have a look at the x-ray. She was as amazed as I was to see the outline of a metal bar almost an inch in diameter that looked like a round file. One end was right under the skin where he had the wound. The other end disappeared off the film heading towards his pelvis.

We called him back to x-ray where more films showed the metal went clear up into his pelvis. The other end of the file was sitting right in the middle of his bladder!

When I went to show him the x-rays and explain my plan to get it out, I asked him if he had been having any blood in his urine to which he sheepishly admitted.

I called the urologist to our assistance. They took him to the operating room and put him to sleep. They passed a scope into his bladder and took pictures, which he later shared with me. They showed the file coming up out of the floor of his bladder like an empty flagpole. He then cut into the patient’s buttock, grabbed the file with some pliers and, with some effort, pulled it out. The scope was then reinserted to make sure no repair was needed. He was kept in the hospital for a couple of days and left, good as new.

When I see things like this, I frequently ask myself, “What if…?”

He landed on this huge bar with such force it went up through his skin, the muscle of his buttock and the floor of the pelvis before it broke off. It entered the pelvis just off the midline. Had it passed through the center, it could have destroyed many important midline structures. The base of the penis with its blood supply and nerves important for erectile function, the urethra where the urine passes from the bladder to the penis, the prostate, and the rectum were all at great risk in an injury like this. He might have suffered some injury that could have caused him a lot of trouble for the rest of his life. Instead, he was just fine. I wonder how much he appreciates what good luck accompanied the bad luck that caused his injury that day.

Large and Small

Written by Tad. Posted in Trauma Strap Bags

This week, I thought I would show the largest and smallest bags I ever made. The size of the large one was determined by the mesh materiel with a draw string I salvaged from another bag. It ended up so huge, I didn’t know what the heck to do with it. Then one of our registration clerks said she would like a large bag for her kids beach stuff. Viola. An appreciative home for it.

The small bag was made to hold just what we need to take to the gym: car keys, wallet, phones, gym passes, gloves.

Salty-sweet Butter Pecan Cookies

Written by Tad. Posted in Cookies

I don’t really like butterscotch chips or pecans but they are fabulous in these wonderful cookies!

Source:

This recipe was forwarded to me by my daughter, McKenzie. It was originally from King Arthur Flour Company

Yield:

4 dozen 3″ cookies

 Ingredients:

1  1/3 cups pecan halves

2/3 cup light brown sugar, firmly packed

2/3 cup granulated sugar

1/2 cup butter

1/2 cup vegetable shortening

1/2 teaspoon salt

1/2 teaspoon espresso powder

1 teaspoon baking soda

2 teaspoons vanilla extract

3/4 teaspoon butterscotch, vanilla-butternut, or butter-rum flavor

1 teaspoon vinegar, cider or white

1 large egg

2 cups King Arthur Unbleached All-Purpose Flour, 9 ounces

1  1/3 cups butterscotch chips, 11 ounces

2/3 cup granulated sugar

2 teaspoons salt

 

Directions:

1) Heat the oven to 375°. Prepare two baking sheets.

2) Place the pecans in a single layer in a pan and toast until darkened a bit and smelling toasty, about 8 to 9 minutes. Set aside.

3) In a large bowl, combine the brown sugar, 2/3 cup sugar, butter, shortening, salt, espresso powder, baking soda, vanilla, second flavor and vinegar. Beat until smooth and creamy.

4) Beat in the egg, again beating until smooth. Scrape the bottom and sides of the bowl with a spatula to make sure everything is thoroughly combined.

5) Mix in the flour then the chips and nuts.

6) If you’re going to refrigerate the dough, cover with plastic wrap and refrigerate for about 4 to 5 hours or overnight. Cookie dough refrigerated for 3 1/2 to 4 hours will spread moderately; chilled overnight, it will spread much less.

7) Mix the second 2/3 cup sugar and 2 teaspoons salt for the coating in a bowl. Scoop 1 1/2″ balls of dough into the sugar/salt mixture, rolling to coat. Transfer to the prepared baking sheets, leaving 2″ between them on all sides.

8 ) Bake the cookies for 10 to 11 minutes. Their edges will be chestnut brown and their tops a lighter golden brown. (For dough that’s been refrigerated, add 30 seconds to 1 minute to those baking times.) Remove them from the oven and cool on the pan until they’ve set enough to move without breaking.

 Notes:

I used regular, all purpose flour. I used raw sugar for the coating, which made them a bit crunchier. I didn’t refrigerate the dough and they came out great though the balls were a bit dicey to handle while dipping and placing on the baking sheets.

I bought the vanilla-butternut flavoring on line from, who else but King Arthur Flour Company

Abruptio Placentae

Written by Tad. Posted in Kooks

The nurse called me into the room. A thirty-year-old woman had come in by ambulance. She told the nurse she was four months pregnant and had suddenly started to bleed heavily from her vagina. She was not having a lot of pain.

When I walked in the room, she was lying on the gurney in a hospital gown that was rapidly becoming soaked with blood. Playing around the bed were the patient’s two daughters, about three years and eighteen months in age. They seemed to have enjoyed the ambulance ride and were unbothered by the excitement and all of the blood.

A lot of things happen simultaneously when I face this sort of situation. One look helps get a feeling for how sick the person is. Then vital signs come as an IV is being started and blood tests are being ordered. All of this is happening while I am talking to the patient, listening to her and feeling her abdomen.

Once I get the important information I need and get the treatment and testing started, I do a pelvic exam, which is really where the money is in a patient like this. This lady had a very large vagina and it was packed with a ton of blood and blood clots. I used a big pincher called a ring forceps with balls of gauze-wrapped cotton to remove the blood and blood clots. Over and over again I reached in, scooping blood and blood clots out which splatted onto the absorbent pad I had spread on the floor.

Eventually, I was able to get enough of the blood out to see she was still bleeding but the opening up into the uterus (womb) was still closed. That told me that even though she was bleeding heavily, she was not presently aborting. Now I knew what I needed to tell the obstetricians when I called them.

We got her vital signs fixed with IV infusions. We got blood ready for a transfusion. The obstetricians came down and did an ultrasound that showed an eighteen-week-old living fetus. They examined her down below again and found she was still bleeding. All of this pointed to abruptio placentae, which is defined as the premature separation of the placenta from the uterus.

So, the patient had a perfectly healthy baby, which she wanted, but she was going to bleed to death unless it was taken out of her. The way the OB attending physician put it to the patient was something like, “We want you to be here to take care of the two girls you already have rather than dying trying to have a third.”

The poor lady was in tears as she concented to going to the operating room to have her pregnancy aborted to save her life. Her husband was working in San Francisco and couldn’t be reached and she said she had noone else to come and support her or help her with the girls.

By the time she went to the operating room, she was stable. The girls stayed with us until morning when a social worker could come and try to get some help for them. The lady was sad but I am sure she was grateful to get medical treatment that certainly saved her life.

All of this made me think about what Rick Santorum said about why a woman shouldn’t have an abortion even if she were raped. He said something like, “It is her baby and she should accept it and love it.” I wonder if he would have advised my patient to just go ahead and die rather that have an abortion to save her life. It was very sad and very painful for that woman to have to make such a decision but it was really the only justifiable decision to be made, in my opinion.

 

 

Yellow and Blue Bags

Written by Tad. Posted in Trauma Strap Bags

When the helicopters come in, they frequently have short blue straps on their boards. I have been saving them up and finally came up with some bags using them. The yellow-crossed bag looks like a Swedish flag!

 

 

 

 

 

Typical Evening in the Emergency Department

Written by Tad. Posted in Kooks

When I tell people I work in the emergency department, they usually think first of taking care of injuries. Trauma is only a small part of what I do. One night, I printed out the ED census, listing all the patients in our ED at that time. Here is a review of that list which gives you a good idea of what is going on in my life when I am at work. It was about 6:30 PM. Here is a list of the patients and what was going on with them at the time.

62-year-old lady with chest pain. It is very difficult to get her history. Multiple blood tests were sent to the lab. Her potassium came back hemolyzed so it had to be redrawn and resent. We are waiting for that at this time. I am considering whether she needs admission.

22-year-old sent here by clinic doctor with high suspicion of pulmonary embolus (blood clot in the lung.) Multiple blood tests were sent to the lab. She is in CAT scan at this time. She will probably need to be admitted for anticoagulation.

54-year-old lady with chest pain. It is very difficult to get her present and past history. Multiple lab tests, EKG and chest x-ray have been ordered. I am planning on admission.

73-year-old lady from nursing home with possible seizure and cyanosis. She has had no history of either in past. I had to call the nursing home for more information from the nurse there about what happened there. I then interviewed her son when he showed up. Her x-ray shows a pneumonia. I am considering admission for pneumonia with cyanotic episode. Her CAT scan is pending at this time.

34-year-old lady with large abscess on her abdominal wall from shooting drugs. The physician assistant didn’t feel comfortable she could adequately drain it. The patient has been given multiple doses of intravenous narcotics until she could be comfortable enough for me to finish draining and packing it. She will probably be able to go home.

30-year-old lady who was in a car crash. She is very upset and complaining of neck pain among other pains. It took almost an hour to get her registered so neck x-rays could be taken. She is in X-ray now.  Her emotional situation and delays in getting her registered required me to visit the bedside multiple times. She will probably be able to go home, assuming her x-rays are normal.

31-year-old lady who passed out and has chest pains. After chest x-ray, EKG, labs and reevaluation, I considered work up for pulmonary embolus but she is being discharged.

57-year-old man with chest pain and numbness of his legs. He has complicated present and past histories. I had to review his labs, x-rays and old chart. I had to medicate him to get him out of pain. He has been admitted.

14-year-old girl came in as a trauma alert from a car crash. Her x-rays and a reevaluation are pending. She probably will be able to go home.

22-year-old man with infection of operative sight. He has had lab tests and a surgical consult with consideration for readmission.

61-year-old man with chest pain. He got an EKG, x-ray, and blood tests and has been admitted. We are waiting for him to be assigned a bed so he can go upstairs.

74-year-old man with head and neck pain. He is getting a CAT scan and lab tests.

42-year-old lady with pains from car crash. She is the mother of the 14-year-old. She will be discharged when her daughter is ready to go.

33-year-old lady with very complicated present history of headaches, chest pains, vomiting and numbness like what she had with her stroke. It is very difficult to get the history. She had multiple labs, EKG, chest x-ray, CAT scan of her head and extensive review of her old chart. She is admitted.

40-year-old lady with vaginal bleeding and feared pregnancy. She will be discharged if her pregnancy test is negative. Will need a pelvic ultrasound and obstetrics consult if it is positive.

72-year-old man visiting from the Philippines with multiple complaints arising from not getting adequate care for his hypertension and diabetes. He had multiple labs, EKG, chest x-ray and ultrasound of his leg. He is admitted.

53-year-old lady with atrial fibrillation (irregular pulse) with a pulse rate of 180. She has a complicated history. She had multiple labs, EKG and a chest x-ray. She required multiple doses of multiple drugs in an unsuccessful attempt to control her heart rate. I talked with intensive care resident as we considered putting her in Intensive Care. Her pulse is now controlled enough that she will be admitted but not to ICU.

62-year-old lady with chest pains after a car crash. She is getting x-rays and labs. She may need a CAT scan and a trauma consult depending on the results.

43-year-old lady with severe allergic reaction. She is being observed after having been given intravenous drugs.

32-year-old man with abdominal pain. Laboratory tests and surgery consult were obtained. He is admitted to the operating room to have an appendectomy.

52-year-old lady admitted with weakness and shakes from alcohol withdrawal. Multiple lab tests were done and intravenous drugs were given to control her symptoms. Her disposition will depend on lab tests results and how she responds to treatment.

50-year-old man came in by ambulance after injuries from an altercation. He just arrived and has not been seen yet.

24-year-old lady with pelvic and abdominal pain worrisome for pelvic inflammatory disease. Her lab tests are pending. She may need a pelvic ultrasound and a gynecology consult depending on the results of her tests.

75-year-old man with head and neck pain. He just arrived and has not been seen yet.

End Cut Bag

Written by Tad. Posted in Trauma Strap Bags

The end of each strap is folded back and sewn to itself. When I had collected enough ends from black and orange straps, I formed them into a bag made entirely of the ends. Check it out!

Maple Cranberry Oatmeal Cookies

Written by Tad. Posted in Cookies

 

Recipe from: San Jose Mercury News

Serving Size: 60

 

Ingredients:

3  1/2 cups flour, 15.75 oz

1 teaspoon baking powder

1 teaspoon soda

1/2 teaspoon salt

4 teaspoon cinnamon

1 cup butter

2 cups brown sugar

2/3 cup sugar

2 large eggs

1 cup real maple syrup

4 teaspoons vanilla

3  1/2 cup oats, 10.5 oz

3 cup dried cranberries, 14 oz

 

 Directions:

1. Heat oven to 350 degrees.

2. Combine flour, soda, salt, cinnamon and set aside.

3. Whip butter and sugars.

4. Stir in eggs, syrup and vanilla.

5. Blend in flour mixture until just combined.

6. Stir in oats.

7. Stir in cranberries.

8. Bake 13 minutes or until the edges and bottoms are just turning light brown.

 

Notes:

Caramel Sauce Option: Substitute caramel sauce for the maple syrup. Substitute chocolate chips for the cranberries. They taste great but the wonderful texture suffers a bit.

White Chip Option: Decrease the oats to 3 cups, add 1 1/3 cup white chips and decrease cranberries to 2 cups.

Pumpkin Option: Try pumpkin puree in place of maple syrup and increase sugar. (I have not yet done this but doesn’t it sound good?)

Tad’s Oatmeal Chocolate Chip Cookies

Written by Tad. Posted in Cookies

Serving Size: 72

Ingredients:

1 cup shortening
1 cup butter, softened
1  1/2 cups sugar
1  1/2 cups brown sugar
1 tablespoon vanilla
2 eggs
3 cups flour, 14.5 ounces
2 teaspoons soda
1  1/2 tsp cinnamon
3 cups oats, 9.5 ounces
4 cups chocolate chips

Directions:

1. Heat oven to 350 degrees.

2. Cream shortening, butter and sugars until fluffy.

3. Beat in eggs and vanilla.

4. In separate bowl, sift together flour, soda and cinnamon.

5. Stir flour mixture into sugar mixture.

6. Stir in chocolate chips and oats.

7. Form into balls on cookie sheets.

8. Bake 13 minutes or until just turning brown on the bottom and around the edges.

Notes:

Alternative: Add 3/4 teaspoon coconut flavoring with the vanilla and 1  1/2 cups shredded coconut with the chocolate chips.

Another thing to try: replace the shortening with coconut oil. Good flavor and creamy texture. Very good.

Copyright © 2014 Bad Tad, MD