I heard an overhead announcement for assistance to the ambulance bay and went out to see if I could help. The police were there. They had a suspect they could not get out of the patrol car.

As I peered into the back seat, I could see part of the patient. He was hogtied which means he had handcuffs on wrists and ankles and all four were fastened together behind his back. He was thrashing and screaming incoherently. Somehow, he had thrown himself onto the floor of the patrol car and wedged his head under the back of the front seat. Because he was naked, all I could see through the window was his bare buttocks and his balls sticking up between them.

It was pretty tricky to get a naked, sweaty, fighting, crazy person dislodged and out of the car. After we got him onto the gurney, I noticed he was not moving. We quickly moved him into a room for assessment and treatment. He had a low pulse, no blood pressure and was not breathing. We were quickly able to get him through this situation and he was fairly stable when he went up to intensive care. With all his thrashing, he had dislocated his elbow. A toxicology screen showed only cocaine in his blood. All of this from taking drugs.

I told you that story so I could tell you another one:

The ambulance arrived with a thirty-year-old man in police custody. While being arrested, he crammed little packets of white powder into his mouth and started to chew and swallow them. I don’t know if he was acting crazy before he downed the drugs but by the time he arrived in the emergency department, he was out of control.

He filled the paramedics’ gurney, being a tall, large-boned and very obese man weighing close to 500 pounds. He was thrashing, confused, and sweaty. His heart was pounding. He was naked from the waist up and his hands were cuffed behind his back.

Everything we needed to do for him was made difficult because of his size, sweatiness and fighting. First, we rolled him from the ambulance gurney face down onto one of ours. After we put four point leather restraints on him, we removed the handcuffs. It took two people on each extremity plus several more on his trunk to control him at this stage. We were then able to roll him onto a different gurney so he was now face up. His legs were secured to the bottom of the gurney and his arms to the top above his head.

The next step was to get an IV started. Even in leather restraints, the patient was still flailing so, I ordered intramuscular sedatives to begin the sedation process while the nurses tried to start an IV. Then, I turned my attention to other patients, leaving the nurses, techs, security officers and police to care for this guy.

A few minutes later, the nurse came and told me she had not given the patient the sedatives because he was “playing opossum.” Since it was my impression that he was in a drug-induced, incoherent state, I didn’t understand how he could be faking it, so I went right to the bedside. Sure enough, my fears were justified. The patient was in arrest. His pulse was 30, he had no blood pressure and he was not breathing.

He needed a tube passed down into his windpipe to protect his airway and allow us to breathe for him. Huge people like this can be nearly impossible to intubate so I faced this with some trepidation. Fortunately, we were able to get this done without too much trouble. Once he was intubated and we were blowing oxygen into his lungs, his blood pressure and pulse came up and we were able to prepare him for transfer to intensive care.

I don’t want to get weighed down with the medical issues here, but let me say there were plenty of things suggesting this patient was going to die.

So both of my patients were under arrest for taking drugs. Their legal problems, however, were the least of their worries as their drug use might have lead to their deaths.

A few weeks ago, the newspaper had three recipes billed as their favorite chocolate chip cookies. Of course, I took a close look at them. Two were very close to the basic Toll House version which don’t really do too much for me but this one was different. The pudding mix caught my attention so I tried them. If you like basic chocolate chip cookies, this is the recipe for you. It is easy to make but the cookies are more interesting than Toll House, not as flat and greasy. As is my way, I left out the pecans though I am sure they would be great with nuts. Give them a try!

Recipe By:

Emily Meacham

Yield:

40

Ingredients:

1 ½ cups chopped pecans

1 cup unsalted butter, at room temperature

1 ½ cups light brown sugar, packed

2 large eggs

1 teaspoon water (why?)

1 tablespoon vanilla extract

3.4 ounce package vanilla instant pudding mix

1 teaspoon baking soda

½ teaspoon salt

1 cup old-fashioned oats

2 ¼ cups all-purpose flour

12 ounces semisweet chocolate chips

Directions:

1. Heat oven to 375 degrees. Toast pecans in the hot oven for about 3 to 4 minutes. Let cool. Set aside.

2. Line cookie sheets with parchment paper.

3. Using an electric mixer, beat butter until light. Gradually add brown sugar and beat until fluffy. Add eggs one at a time, beating well after each addition.

4. Add water, vanilla extract, vanilla pudding mix, baking soda and salt. Beat until well blended.

5. By hand, mix in oats, then flour, then chocolate chips and pecans.

6. Drop cookies by 2 tablespoons balls onto prepared cookie sheets, spacing 1 inch apart.

7. Bake until cookies appear dry and tops are lightly cracked and soft when pressed, about 8 to 9 minutes. Do not over bake. Cool cookies for 5 minutes on cookie sheets, then finish cooling on racks.

Becca, one of my blog’s closest followers, asked for a black and blue bag. I was not sure how it would turn out but take a look:

Not Bad!

This is a story of a patient I took care of in the intensive care unit (ICU) during my training. As luck would have it, this young man was hit by lightening right outside the hospital. Medics arrived at the scene almost immediately and found him in ventricular fibrillation, an erratic heart rhythm that can result from a large electrical shock. This rhythm is ineffective in pumping blood. The resultant lack of circulating oxygen rapidly leads to brain damage and, eventually, to death.

Just like in the television dramas, the medics gave the patient a quick cardioversion shock, which caused his heart to return to a normal pumping rhythm. They then bundled him up and brought him into the hospital.

In the emergency department, the patient’s heart was beating fine. Though still unconscious, he was coming around enough to thrash about and he vomited a very large amount of undigested food all over himself, the gurney and the floor.

Now, I have a lot of experience with vomit. I have vomited many times. I have been with family members many times when they have vomited. In the emergency department, having patients vomit is just a way of life.  So, to be noteworthy to me, a particular episode of vomiting must be pretty amazing. This one was.

The patient’s vomitus was filled with discs of pressed meat about the size of a mouth. It was clear he had recently eaten a deli sandwich by biting and swallowing big hunks without chewing any of it. This left the round pieces of meat intact when swallowed. They came back up the same way. I had never seen anything like that before.

Now back to the lightening strike victim. We sedated him to keep him from thrashing around and admitted him to the ICU. Since his heart rhythm was now stable, the big question was whether he had suffered brain damage during the time his heart was not beating. We would only know that when he woke up, if he woke up.

The next day, we took him off of sedation so we could start to assess his mental state.  Our initial reaction was of disappointment. Though the medics had saved his life by rapidly getting his heart beating again, it was obvious he had suffered brain damage. The patient gave us his first name and asked for food, but he was clearly not normal. Since the patient came in the hospital with no identification, we asked him about his family.  He could only come up with the first name of his sister. Another indication of his brain injury was that he seemed completely unconcerned about his situation, content sitting in a hospital bed getting all the food he wanted.

The following day a young woman came to the hospital. She read in the newspaper about our unidentified lightning strike victim and wondered if it were her brother.

After talking with her for a minute, I felt comfortable taking her in to see our patient. I was filled with some trepidation, wondering how she was going to handle it when she realized he was brain-damaged.

It was immediately obvious they were siblings. As she walked into the room, she rushed to give him a hug and he called out her name. It was a touching scene, but my emotions were complicated. I wondered how I was going to help her recognize his loss of mental faculties. How would she handle the realization that her brother was not what he used to be?

As soon as things calmed down a little, I gently shared with the sister our observations about her brother, describing what we believed to be brain damage caused by his time with no oxygen flowing to his brain.

As I talked, she got a puzzled look on her face. When she finally got the big picture, she kind of laughed. “Oh, no,” she said. “This is the way he always is.” He then got dressed, she took him home and they all lived happily every after.

This shows how his metal necklace burned his skin when it was heated up by the lightening. He also had a burn where his bicycle was leaning against his hip.

Hilary came up with the idea of the flower. Of course, I stole it. Now, lots of people who already have bags have been asking for a flower bag. When I got to work the other night, two PM shift clerks were talking about flower bags and asking for one. Another person who asked for one was my mother-in-law. How could I say “no”?

Source:

Momofuku Milk Bar as printed in September 2010 issue of Bon Appetit

 Milk Crumbs:

Ingredients:

¾ cup nonfat dry milk powder
½ cup all-purpose flour
3 tablespoons sugar
2 tablespoons cornstarch
¾ teaspoon coarse kosher salt
6 tablespoons unsalted butter, melted

Preparation:

1. Heat oven to 275°F.

2. Line large rimmed baking sheet with parchment.

3. Combine milk powder, flour, sugar, cornstarch, and coarse salt in medium bowl.

4. Add butter. Stir with fork until clusters form.

5. Spread mixture evenly on prepared sheet. Bake until crumbs are dry and crumbly but still pale, about 10 minutes.

6. Cool Milk Crumbs completely on sheet.

 Notes:

Can be made 1 week ahead.

 Cookies:

Ingredients:

2 cups unsalted butter, at room temperature
1 ½ cup sugar
1 ½ cup plus 2 tablespoons packed brown sugar
½ cup plus 2 tablespoons light corn syrup
2 large eggs
5 ¼ cups all-purpose flour
2 teaspoons baking powder
1 teaspoon baking soda
1 teaspoons coarse kosher salt
2 cups (full recipe) Milk Crumbs
1 ½ cups dried blueberries

 Instructions:

1. Combine butter, both sugars, and corn syrup in large bowl of stand mixer fitted with paddle attachment.

2. Beat on medium-high speed until fluffy and pale, occasionally scraping down sides of bowl, about 3 minutes.

3. Add eggs. Beat on medium-high speed until mixture is very pale and sugar is completely dissolved, about 10 minutes.

4. Add flour, baking powder, baking soda, and salt. Beat on low speed just until blended, occasionally scraping down sides of bowl.

5. Add Milk Crumbs. Mix on low speed just until incorporated.

6. Remove bowl from mixer. Stir in blueberries just until evenly distributed.

7. Using 1/4-cup ice cream scoop for each cookie, drop dough onto 2 large rimmed baking sheets (make sure they will fit in your refrigerator.) Cover with plastic wrap and refrigerate at least 24 hours. Can be made 2 days ahead. Keep chilled until baking time.

8. Position 1 rack in top third and 1 rack in bottom third of oven and heat to 375°F. Line 2 large (18×12-inch) rimmed baking sheets with parchment. Transfer chilled dough scoops onto each sheet.

9. Bake, 2 sheets at a time, until golden, reversing sheets halfway through baking, about 12 minutes total. Repeat with remaining chilled dough, cooling and relining sheets between batches. Transfer cookies to racks; cool completely.

Notes:

Original recipe calls for them to be baked 20 to 22 minutes. I thought that sounded like too much but the pictures showed a brown cookie so I tried it and they were just over-done. I have never let them go over 12 minutes.

The psychiatric emergency department at our hospital notified us they were sending a patient with chest pain. Everyone who recognized her name knew we were in for a challenge.

This middle-aged woman had been to our emergency department many times and was always difficult to deal with. She has serious medical problems but also serious psychiatric problems. This makes treating her especially challenging.

When she arrived, I went into the room and politely introduced myself, as is my habit. I asked her about her chest pain, the pains in her legs and her recent falls. She had a pleasant demeanor and looked comfortable as she described pain in her legs that made her unable to walk. Her physical examination showed no indication of serious injury.

I explained the tests I recommended to make sure she was not having a heart attack or blood clots in her lungs: electrocardiogram, chest x-ray and blood tests. She agreed. I then told her I was not going to be giving her any narcotics.

“That’s fine. I’m not here for drugs. I’m not a drug addict,” she said in a sweet voice.

I was glad she agreed with me and told her the nurse would be right in to get the tests started. I began to walk out of the room.

“Just a minute, doctor. What are you going to do for my pain?” she asked.

I reassured her we would give her all the medications we usually give someone who might be having a heart attack or blood clots but we would not be giving her any narcotics. I turned again and walked out of the room.

Then she went off. She started to scream at me at the top of her voice using every foul word you could think of.  At the same time, she grabbed anything she could get a hold of and yanked on it. First, she ripped the phone cord out of the wall and threw the phone on the floor. She jerked the monitor cables out of the monitor and threw them on the floor.

We responded to the noise of her screams and the sound of the phone hitting the floor and prevented her from pulling the courtesy curtains out of the ceiling. After we moved things out of her reach, she pulled off all of her clothes and threw them on the floor. Eventually, unable to get a hold of anything else, she started throwing her immense weight back and forth in the gurney, trying to tip it over. Since she was so extremely obese and was rocking so violently, she almost went over but was prevented from doing so by staff.

So there she was, an extremely large woman, butt naked, rocking violently, trying to tip her gurney over and screaming obscenities at the top of her lungs.

Her insults were mostly directed at me. She accused me of being a bigot and not giving her pain medicine because she was black. She yelled she was being treated like a slave on the plantation. She shouted if she were white or Hispanic or Asian, we would be giving her pain medicine. Her screams included the foulest swearing she could come up with and filled the whole emergency department, upsetting other patients and visitors. Staff had a hard time taking care of other patients and doing necessary duties like talking on the phone because her obscenity-laced screams were so distracting.

Extreme conditions require extreme responses. When people are violent and put themselves and staff at risk of physical injury, something has to be done to prevent this. In such unusual circumstances, we may need to put heavy leather straps around both ankles and both wrists then tie the patient down to the gurney. This was such an occasion. It took four security officers and several other staff members to get her into four point leather restraints. She refused all medical care and, even tied down, was able to keep staff from covering her naked body. I wanted to sedate her, but she said she was allergic to each sedative I proposed. All we could do was keep her in the middle of the room so she couldn’t grab anything. She screamed non-stop for the half hour it took us to make arrangements for her to go back to emergency psychiatry.

Once arrangements were made, she rolled out the door. I had assumed security would have at least tied a sheet over her but their efforts to do so had been unsuccessful. Her enormous thighs and gut covered her private parts, but her pendulous breasts were fully exposed. She left, still screaming at the top her lungs, “No pain meds for fuckin’ niggers,” over and over again.

Recipe By:

My daughter-in-law, Elizabeth, sent this to me. It can be found all over the Internet

Ingredients:

2 cups all purpose flour
½ teaspoon baking soda
½ teaspoon salt
½ cup butter
¾ cup cocoa powder
2 cups sugar
1 teaspoon vanilla extract
2/3 cup buttermilk
2 cups chocolate chips

Directions:

1. Heat the oven to 350F.
2. Line a baking sheet with parchment paper.
3. In a medium bowl, whisk together flour, baking soda and salt. Set aside.
4. Melt the butter in a small, microwave safe bowl.
5. In a large bowl, combine the melted butter (still warm) with cocoa powder and whisk until very smooth.
6. Whisk in sugar, vanilla extract and buttermilk.
7. Gradually stir in the flour mixture until no streaks of flour remain.
8. Stir in the chocolate chips.
9. Drop dough in 2 tablespoon balls onto prepared baking sheet, leaving about two inches between cookies to allow for spread.
10. Bake for 10-12 minutes, until cookies are set around the edges.
11. Cool for 2-3 minutes on a baking sheet, then transfer to a wire rack with a spatula to cool completely.

Notes:

Very chocolaty and rich. Don’t over cook them!

One of the most important things I do as an emergency physician is reassure people. True, I occasionally do something that might save someone’s live. I frequently provide treatment to help people feel better and assist in a more rapid recovery from injury or illness. But most of the people I take care of don’t have a serious condition and can go home with little or no treatment. All they need is to understand they will be fine. They need reassurance.

Most people in this situation are glad to have an explanation and happy to be reassured. They are relieved to know their chest pain is not coming from a heart attack. They are thankful to know they don’t have a broken bone or appendicitis.

I get frustrated when I determine that someone has nothing worrisome but he or she refuses to accept my explanation and reassurances. I have found it nearly impossible to satisfy such a patient.

Here are two stories of people who were completely unsatisfied with my explanations and reassurances:

Fainted

A sixteen-year-old boy fainted after spraining his thumb. The most common reason for someone to faint after a sudden, painful event is what we call a simple faint. There are some bad things that can cause fainting but all of them are very rare in an otherwise healthy youngster. After asking this patient some questions and looking at him carefully, it was clear to me he had just fainted and would be perfectly fine.

I spent quite a bit of time with the patient, his mother and siblings. I explained how I came to a conclusion that he had only fainted and why I felt comfortable sending him home.

As I finished my explanation, the mother put her head down and shook it, apparently displaying some dissatisfaction with what I had said. I asked if there were some problem. She said, “No,” and resignedly added she would take him to be checked by his own doctor.

At this point, the sister got upset and angrily said if the patient left and became “comatose or died,” she was “going to come and get” me.

The brother then became irate and hollered that this was a “charity hospital and no one is going to do anything for you here.”

I tried to discuss the situation with these family members but they were not interested in any more discussion. They all stormed out without waiting for their discharge papers.

Nausea, Vomiting and Diarrhea

A fifteen-year-old boy came in by ambulance with nausea, vomiting and diarrhea. The paramedics had started an IV so I ordered some intravenous fluids and medicine for the nausea. I then continued seeing other patients who had been waiting longer and were more likely to be ill.

When I finally got to the room, the patient told me he started vomiting and having diarrhea after eating nachos for dinner. He had looked weak and his mother thought he was going to pass out, so she called the ambulance. However, after the IV fluids and medicine I had given him, he was now feeling fine and had no more symptoms. His examination and vital signs were normal.

I explained to the mother what I found and why I thought her son had food poisoning or stomach flu. I reassured her he would most likely be fine in a day. I promised to prescribe medicine for vomiting and diarrhea in case he needed it at home, and again reassured her that he was going to be fine.

This is my basic speech to reassure people when they have gastroenteritis. Most people are glad to have such an explanation. Not this mother!

As I spoke, she filled with angry indignation. He had almost passed out! How could I just look at him, not do anything and know he was going to be fine? I had not even done any blood or urine tests on him!

I started my explanation over again and reviewed my thinking with her. He was a young, healthy boy who was very unlikely to have anything serious the matter with him. He had symptoms that are really only consistent with one of two minor, self-limited illnesses. He had a normal examination and vital signs. He had responded to the treatment he got and was feeling and looking fine.

The more I explained, the madder she got. She was just not going to believe that her son, who almost passed out, could be sent home without any tests being run. I asked her what tests she would recommend running. Of course, she had no idea about what tests one might run and the fact that I asked her just seemed to make her even madder. If I had done some sort of tests and told her they were normal, she would have been happy. The irony completely evaded her that she would have had no idea if the tests were really able to find any problems in a patient like this.

At this point, she refused to talk to me. I asked if she had any other questions or if there was anything else we could do for them. She didn’t reply and fixed her steely gaze on the wall behind my back.

The patient did have a question but when he tried to ask me, she told him to just shut up. He tried again and again she told him to shut up and not say anything as they were going home.

I told her the nurse would bring the prescriptions. She said she didn’t want any prescriptions. I told her they were coming anyway and she could do with them what she wished. They left without the prescriptions or discharge papers.