Tina, a nurse I work with on night shift, told me she met Marianne at Burn Camp, where burned kids go for a week to hang out with each other and do campy things. As it turned out, Marianne’s parents live right around the corner from us and she went all the way through school with our son, Philip. She grew up, became a nurse and works in our burn unit. Tina told her about my blog and I soon received a request for a bag. Now, when we run into her mom in Nob Hill, we can ask her how Marianne likes her bag.

Here is a little recipe I came up with this morning. The marshmallows melt and caramelize as they bake.

Ingredients:

1/3 cup instant coffee granules

2 tablespoons hot water

2 2/3 cups all-purpose flour

¾ teaspoon baking soda

½ teaspoon salt

½ cup butter, softened

1 ¼ cups white sugar

1 teaspoon vanilla extract

2 eggs

2 cups semi-sweet chocolate chips

2 cups miniature marshmallows

 Directions:

1. Heat oven to 350 degrees F.

2. Dissolve coffee in 2 tablespoons hot water. Set aside.

3.  In a separate bowl, combine flour, baking soda and salt. Set aside.

4. Beat butter and sugar in an electric mixer at a medium to high speed until fluffy.

5. Stir coffee, vanilla and eggs into butter mixture. Mix well.

6. Reduce speed to low and slowly pour flour mixture into the butter mixture. Mix just until combined.

7. Fold in chocolate chips and marshmallows.

8. Drop dough by 2 tablespoon cookie scoop onto an ungreased or parchment-lined cookie sheet.

9. Bake about 10 minutes.

A young man was seen at another hospital in our fair city for a nasty jaw fracture. His jaw was broken in multiple pieces and needed to be surgically put back together. Without surgery, his jaw almost certainly would not heal correctly. One possible outcome was that he might heal with an abnormal alignment, preventing his teeth form coming together correctly. Another possible complication of such a fracture is that it might never heal at all. We call that a non-union. In such a case, he would be left with a loose jaw that would cause him pain every time it wiggled. Because this patient had no insurance, the other hospital arranged for him to be seen in the Plastic Surgery clinic at our county hospital to arrange for his needed surgery.

When he arrived for the appointment, the clinic discovered a big problem – he was not a resident of our county. He was here for work but his residence was still in another county. Not only had he no insurance, he was not eligible for any county-sponsored charity program. Before the man could get a much-needed surgery, he would have to come up with $10,000 cash.

Understandably discouraged, he went back to where he was staying and, I think, accidentally, took too many pain pills along with some Valium a friend gave him. When he went unconscious, his friends freaked and called the ambulance. He ended up in our emergency department.

I kept an eye on him all night as he gradually woke up. When I finished my shift in the morning, I asked a Customer Service representative, to come see him. This patient and his situation took up a good part of her day. She tried every possible way to arrange for him to get surgery, either at our hospital or back in his county of residence. She tried to get him qualified for Medicaid. She tried to see if he could somehow qualify as a resident in our county. She explored with him ways he might be able to come up with the $10,000. He finally left with information on how to try to get the care he needed when he got back home.

This is a great example of just why we should quit pretending the government is not already running healthcare and get rid of this ridiculous double standard in our medical care payment system. The man had to have surgery on his jaw. We, as a society, are not comfortable relegating people who can’t pay for needed surgery to a lifetime of permanent disability. If he had been a resident of our county, they would have operated on him and the taxpayers of the county would have paid for it. Out of our county? No way! Go to your own county and have your county’s tax payers pay for it! What kind of a crazy system is that? One way or the other, he will eventually get the care he needs and the taxpayers will pay for it. Why not come up with some system that is fairer in regards to who pays and who gets treated? That is what we need but would Obamacare fix this problem?

Some ambulance came in from somewhere with maroon straps made of the same materiel as seat belts. They have been sitting around here for a long time and I finally had a chance to make a bag out of them. My new “man bag.”

I wish my picture would do this bag justice. It is made of seat belt materiel and the forest green contrasts very nicely with the bright yellow. No matter how I took the picture with any of my cameras, I can’t make the green not look black.

I asked my daughter-in-law, Elizabeth, to pick the cookies to share with her emergency department this week. She selected:

MOMOFUKU-WERTHERS COOKIES

They turned out great and I am posting this to remind you to give them a try.

http://badtadmd.com/momofuku-werthers-cookies/

Emergency departments often attract people who have nowhere else to go. If you think about it, homeless people retain a certain amount of anonymity in large, busy places like hospitals. There, they can be in out of the weather. They have access to restrooms. They can easily charge their cell phones and electric wheelchairs. If they don’t cause trouble, they are often allowed to sit and rest in waiting rooms. This is a regular thing, but huge problems come up when certain homeless people refuse to leave and can’t be thrown out.

Mr. L— was a homeless man who weighed in at over four hundred pounds. He had serious medical problems and had been admitted to the hospital many times for treatment. When it came time to discharge him, social workers usually tried to transfer him to a long-term care facility. In trying to do this, they faced two challenges. First, Mr. L— refused to cooperate because he didn’t want to spend his disability income on nursing home care. He chose to keep his money for other purposes. Once, when he was admitted to the hospital, he had over $10,000 in cash stuffed in various places on his person and in his belongings. Secondly, even if
Mr. L— agreed, many local nursing homes wouldn’t take him based on their past experience with his nasty, unpleasant behavior. So, when it came time for him to be discharged from the hospital, he would usually motor his over-sized electric wheelchair across the street to the bus stop in front of McDonalds and set up housekeeping.

Early one rainy day, we found Mr. L— in the main hallway of the hospital, right behind the emergency department. He had been there all night. The top part of his body was precariously perched on the edge of his huge wheelchair but the lower part of his body was actually on the floor. To keep himself from sliding all the way to the ground, he had hooked his arm around the armrest of the chair. The reason he had trouble staying in the chair was that it was slippery from his urine and feces.

Most of Mr. L—‘s abdomen and groin were exposed as his pants were sagging down and his shirt was pulled up. He had placed one of his dirty shoes on the window ledge next to the wheelchair. It was being used to hold a plastic bottle that was half-full of urine. Urine and feces dripped down the wall from the shoe to the floor and pooled under the wheelchair. It was quite a sight for the day shift staff that passed by him on their way to work… and the smell was horrendous. Patients, visitors and staff complained he made the air smell so bad they felt like they were going to vomit.

Asking Mr. L— to leave was not really an option because he was not capable of doing so. Yet, he was not cooperative with any efforts to help him. He wouldn’t let himself down onto the floor, but couldn’t get back up into the chair. He constantly complained about being in pain. Yet, he threatened anyone who approached, trying to help him. So, there he was.

Someone from hospital administration finally made the decision to force him to move out of the public area. A team of twenty staff members was assembled. It included 5 medical assistants, 6 nurses, 2 doctors, the shift supervisor, 2 emergency department technicians, 2 security officers and 2 physical therapy staff members. Three administrators stood by directing the effort.

A plan was laid out to get Mr. L— down onto the floor, wash him up and get him back into his wheelchair.

A crane was borrowed from an inpatient unit. Partitions were set up around him to provide some privacy. When he was forced to let go of the wheelchair, he slipped entirely onto the floor. The team of staff rolled him from side to side to cut off his clothes. It then took 30 sheets, 20 blankets, 30 towels and 30 disposable pads to clean and dry him. Twenty packets of antibiotic ointment were used to cover his skin, which was raw and irritated from being in constant contact with his excrement. Over-sized hospital clothes were pulled onto him. His wheelchair was also cleaned. Then, the sling from the crane was laboriously worked under him so he could be safely lifted back into his chair. Once back in his chair, it was impossible to remove the sling from under him. So there it stayed– at a cost of $300 to replace.

It took all morning to get Mr. L— cleaned up. Once he was reseated, he was wheeled to a hallway out of the main thoroughfare. He refused recommendations to sign in as patient and receive medical care. The Sherriff’s deputy, who was called in, said it was not an option to arrest him for trespassing, saying that the jail staff would refuse to accept him into jail because of his many problems. No one had any idea what to do with him, so there he sat. I don’t know what happened after that.

On my way to work the next day, I saw him back at the bus stop across the street from the hospital. From time to time over the next few weeks, a Good Samaritan would call 911 to get him help. Paramedics who responded to the situation told me he always refused care. He lived at the bus stop for several weeks, and then he was never seen again.

I checked vital statistics online and found he died soon after that event, though the details of his demise are unknown to me.

I have had so many people asking for a bag that I did some sewing last weekend.

Hilary was here this week and we came up with these, a variation of one of her favorites. Baking them slowly helps preserve that chewy texture you might want in a cookie with caramel sauce in it.

Recipe from:

Hilary, The EQOTW

Serving Size:

40

Ingredients:

3 ½ cups flour, 15.75 oz

1 teaspoon baking powder

1 teaspoon soda

½ teaspoon salt

4 teaspoons cinnamon

1 cup butter, at room temperature

2 cups brown sugar

⅔ cup sugar

2 large eggs

¾ cup caramel sauce

4 teaspoons vanilla

2½ cups oats

3 cups chocolate chips

2 cups unsweetened coconut, toasted * SEE NOTE

 Directions:

1. Heat oven to 325 degrees.

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

3. Whip butter and sugars.

4. Stir in eggs, caramel sauce and vanilla.

5. Blend in flour mixture until just combined.

6. Stir in oats, chocolate chips and coconut.

7. Bake about 18 minutes or until the edges and bottoms are just turning light brown.

Note:

Spread coconut onto baking sheet. Bake at 250 degrees for five minutes. Remove from oven, stir and return to oven. Repeat until coconut is toasted and aromatic. Don’t over-brown.

I Needed to Eat

A thirty-year-old man came into our emergency department saying he had been treated for a broken jaw at an out-of-state hospital. This was done by placing two “arch bars” along his upper and lower teeth then wiring them to each other so his jaw could not move. In the three months since then, he had not had any follow-up care. When he got tired of not being able to eat because his jaws were wired shut, he cut out the wires but the arch bars were still in place. He was now in our emergency department for some unrelated reason and had no plans to have the wires removed. We also discovered a 1 by 2 inch piece of glass that was under the skin of his buttocks and had been there for the same time.

Very Nice Cops

My patient was a twenty-seven-year-old lady who had been stabbed by her pimp in Oakland a few days before. After being treated at a hospital up there and released, she made her way to our fair city where she was staying with her auntie. Three days later, the pimp found her and stabbed her again. She came to our hospital by ambulance.

Fortunately, her injuries were not serious. We sewed her back together but the most interesting thing to me was how the police dealt with her. My impression is that police are usually not all that nice to drunken black hookers who have been stabbed. In this case, however, the guy who stabbed her is a well-known crook in Oakland and the police were extra-nice to her with the hopes she would testify against him so he would go to jail. Their whole demeanor in dealing with her was unusually calm, patient and understanding. They even came back after her treatment was over and took her back to her auntie’s. I have never had police come back to give anyone a ride home so this was clearly out of the ordinary.