The medics told us he was about sixty years old and lived in his car. He had gotten out of the car and collapsed, unable to get back up. He was apparently on the ground for several hours before passersby discovered him.

The medics said they had tried to get all his clothes off but had been unable to do so because, they felt, his flesh was rotting underneath and some of the overlying clothes were sticking to him. They said the horrible smell coming from him was rotting flesh, not feces (a more common cause of stinky people coming to the hospital.)

As we finished undressing him, it was clear the medics were only partially correct about the source of his bad smell because his pants were full of feces. In addition, his clothes were so dirty they were shiny, slick and just tore apart rather than needing to be cut off. It was obvious something was going on under the sleeve of his left arm, which the medics had not been able to uncover. When I got to that area, I held my breath, cut the sleeve of his shirt at the wrist then tore it to the elbow and pulled the cloth away from his forearm. As I did so, a huge pile of maggots fell down off a large mass on the back of his forearm and onto the floor. Everyone gasped and the emergency technician standing by me screamed. The combination of the putrid smell and the sight of the maggots crawling on his raw flesh and the floor was absolutely disgusting.

I looked around for the intern I had brought in the exam room with me and he was nowhere to be found. When I later asked him why he left, he said he was sorry but he had to leave because he was about to lose it. I laughed at him but totally understood since I actually felt nauseous myself.

As soon as we could tell the patient was medically stable, we sent him to the shower where two unfortunate technicians had to shower him to get rid of his excrement and wiggly guests. We then made arrangements for him to be admitted to the hospital.

I had a forty-year-old man come in with perfuse rectal bleeding. He had a polyp removed from his colon two days before. He said there was no problem during the procedure but he had spent the next night in the hospital for some reason and just gone home twelve hours before he rolled into Room 15.

His pulse was fast and his blood pressure was low, signs of hemorrhagic shock. He had piles of clotted blood between his legs and it was starting to drip on the floor and was tracking up the bed under him and on the sides of his back. To complicate things, he was as fat as a whale. In fact, he was so fat, he had a tracheotomy in the front of his neck so he could breath.

Now, all of this was bad enough but he informed me he was also a Jehovah’s Witness and would accept no blood products. Usually, someone who is in hemorrhagic shock and gets no blood transfusion dies.

I took a quick peek at him and it became rapidly clear that, because of his morbid obesity and his shocky state, it was going to be nearly impossible to get an IV in him. This was urgently needed to give him fluids, even if he would not take any blood.

This is why I went into emergency medicine and I went to work. I started calmly barking orders and telling my support staff what I needed them to do to help me. I tried unsuccessfully to get a large intravenous (IV) line under his collarbone into his subclavian vein. He was just too fat to be able to get the needle at the proper angle and deep enough to hit the vein. I tried to use the ultrasound to look for his internal jugular vein but was unable to find it because his neck was too fat. He also was too fat to use any landmarks on his neck to direct my needle so I couldn’t use that approach. In the mean time, I had called the gastroenterologist, telling him to come in and scope the guy to get the bleeding stopped. I felt this was our only hope. I called the intensive care unit physician to get him an ICU bed and I called the trauma surgeon to come help me with the IV. Basically, I was pretty sure he was going to die so I called everyone so no one would wonder why I had just sat there and let him die.

Fortunately, for the patient, two good things happened. First, just as the trauma surgeon got there, I was able to get a huge IV into his right femoral vein so we could get some fluids in him. I was only able to do this after the nurse pulled his belly towards his head so I could get into his groin and get access to the vein. The second stroke of good fortune was the bleeding seemed to have slowed, if not stopped. So, by the time he went up to the ICU, his blood pressure and pulse were stable. If he was going to die, at least it wouldn’t be in the emergency department. I did everything I could and it worked out well. Good story.

I will never win a customer service award for this one, though. The guy, along with presenting a HUGE challenge to caring for him because of his religious beliefs and his morbid obesity, he was a huge whiner, too. I finally got so sick of him asking me if what I was going to do would hurt that I told him to shut up. I said something like, “Sir, you are about to die. Everything I am doing is to try to keep you alive. You have to assume it is going to hurt. Just shut up and let me try to save your life.” I felt bad about it and he continued to whine so I don’t know if it did any good. When he wasn’t whining, he was talking on the phone telling his mother goodbye or mumbling praises and prayers to God. Very interesting.

As it turns out, he didn’t die. In fact, he came back one night the next week to see me again. He told me he got his bleeding fixed by the gastroenterologists and was discharged a couple of days later. He came back in to see me again when he had some pain that freaked him out. Fortunately, he was fine and went home. Still, it gave me a chance to apologize to him for being short with him but also to explain my fears he was going to die and the effect it had on me. He accepted my apology and thanked me as we shook hands before he left for home. It was a nice kind of interaction we don’t get too much of in emergency medicine.

My daughter made the bag with the yellow flower and the braided strap. I copied her idea and made the one with the orange flower.

This recipe came originally from Bev, a clerk in our department for many years. The glaze is a bit of a pain and covers up the interesting texture but the tangy zing really makes these cookies.

Ingredients:

1 cup butter, at room temperature

½ cup shortening

2 cups sugar

3 large eggs

2 teaspoons vanilla

1 teaspoon lemon extract

zest from one lemon

4 cups flour, 18 ounces

1 ½ teaspoons soda

1 ½ teaspoons baking powder

1 teaspoon salt

9 ounces lemon drops, cracked*

juice of 3 large lemons, about ¾ cup

3 cups powdered sugar, sifted

 Directions:

1. Heat oven to 350 degrees.

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

3. Beat butter and shortening until fluffy.

4. Beat in sugar until fluffy.

5. Beat in eggs, vanilla, lemon extract and zest.

6. Slowly add flour mixture. Stir until combined.

7. Stir in lemon drops.

8. Form into balls on prepared baking sheet. Bake about 10 minutes until edges just starting to brown.

9. Cool completely.

10. Prepare glaze: Combine lemon juice and powdered sugar. You may need to adjust the amount of juice or sugar depending on how big the lemons are.

11. Dip tops of cookies in glaze and let them dry on wire racks.

 Note:

To crack candy I put the lemon drops in a quart-sized Ziploc bag. I place the bag on a hard surface and hit each candy with a single hit, just hard enough for it to crack. This allows for relatively large pieces.

A fourteen-year-old girl was the driver of a car that was involved in a motor vehicle accident. She was driving the car at a high rate of speed on the freeway. When the highway patrol went to pull her over, she tried to outrun them and ended up running into the concrete divider of the freeway. She and her passengers were brought in as trauma patients.

The driver was severely injured as were the two severely intoxicated adult male passengers. The patient was admitted to the hospital with her jaw broken in two places, a severe ankle sprain and lacerations on her face. Her blood alcohol level was negative so she had not been drinking but she seemed to be a poor choice for a designated driver.

Most of my bags are simple with non-closing, oblong openings. I bought some zippers and messed around making bags that would accommodate them. As us usually the case with such endeavors, the first bag was OK and each subsequent was better.

I am always looking out for a new cookie recipe to try. One thing that will catch my attention is a weird ingredient. That is what caught my attention in this recipe.

Adapted from: Raley’s/Nob Hill Magazine

Serving Size: 24

 Ingredients:

1 cup brown sugar

1/2 cup peanut butter

1/2 cup butter, softened

1 teaspoon vanilla

1 large egg

1  1/4 cups flour

1 teaspoon soda

2 cups Cocoa Puffs Cereal

2 cups chocolate chips

2 teaspoons shortening

Directions:

1. Heat oven to 350°F.

2. Line two baking sheets with parchment paper.

3. With a mixer on high, whip peanut butter and butter. Stir in sugar. Stir in vanilla and egg. Mix until creamy.

4. Combine flour and baking soda. Stir into sugar mixture.

5. Stir in cereal just until combined.

6. Shape into balls and place on prepared cookie sheets about 2 inches apart.

7. Bake for 10 to 12 minutes or until light golden brown.

8. Remove to racks to cool completely.

9. Place chocolate chips and shortening in double boiler over boiling water.

10. Stir while heating until melted and smooth.

11. Remove from heat and continue to stir while it cools some more.

12. Dip half of cooled cookie in chocolate, scrape the excess off the bottom and place on wax paper to dry.

 Notes:

Original recipe called for microwaving the chocolate and shortening which does work. I just like the control of the double boiler better.

I have made these buy just throwing in the unmelted chocolate chips with the cereal and omitting the shortening. They were good but the were much richer and more impressive to look at and eat when dipped in the melted chocolate.

People in ED went crazy over them though no one could guess they had Cocoa Puffs in them. I tripled the batch for ED.

This is, word for word, the note I wrote on this patient’s chart:

Family members called the ambulance when they found the patient chewing on her fingers today. The patient is demented, bedridden and completely dependent for all of her care. She was reportedly more agitated lately including spitting and chewing on things like her blankets. She had no history of self-mutilation but today the patient’s temporary caretaker found her chewing on her hands. The daughter, who normally cares for the patient, is ill herself and hospitalized elsewhere.

On the left hand, fingers 2 to 5 (index, long, ring and pinky) have extensive soft tissue damage. The fifth finger is essentially chewed off with just a strip of tissue left attaching it to the hand. Bones are visible in the other fingers with considerable amount of soft tissue damage present.

The patient went to the operating room for amputation of the fingers.

I don’t remember where I got this recipe but it is one of our favorites. The chocolate is rich but not too dark. They are nice and sweet but the tartness of the cherries contrasts the sweetness very nicely. They have a great texture. I buy several bags of the dried cherries at Costco when they have them. They don’t spread out too much and are firm enough to survive the trip to the emergency department.

Serving Size: 60 cookies

 Ingredients:

3 cups flour, 13 1/2 ounces

1 cup cocoa, 2 3/4 ounces

1 1/2 teaspoons baking powder

3/4 teaspoon baking soda

3/4 teaspoon salt

3 cups sugar

1 cup butter, softened

1 tablespoon vanilla

3 large eggs

2 cups dried cherries, 14 ounces

2 cups chocolate chips, 14 ounces

 Directions:

1. Heat oven to 350 degrees

2. Combine flour, cocoa, baking powder, baking soda, and salt. Set aside. (I like to do this with my fingers. It just feels good.)

3. Place sugar and butter in a large bowl. Beat with a mixer at high speed until well blended.

4. Add vanilla and eggs. Beat well.

5. With mixer on low speed, gradually add flour mixture. Beat just until combined.

6. Stir in cherries and chocolate chips until just combined.

7. Place scoops of cookie dough 2 inches apart onto prepared baking sheets.

8. Bake for 12 minutes or just until set. Remove from oven. Cool on pans until set.

I am most proud of a couple of these I made. Part of the reason is they turned out really nice. In addition, it was really a pain to make them. Getting the diagonal straps to line up evenly was difficult. Then I had to get the tube that forms the sides be the right size for the bottom. Pat, one of our dayshift nurses, got the best one and every time I see her carrying it, I am quite pleased and tell her she has the best bag I ever made.