Archive for November, 2015
Low back pain is very common. It is the most common medical reason for people in America to miss work. It is so common that when people ask me why they have back pain I feel like answering, “Because you are a human.”
Being such a common condition, back pain is also a common reason for people to come to the emergency department. We see everything from people with strains caused by lifting something heavy to people who have low back pain every waking minute of their miserable lives.
There is not much we can do in the emergency department for most people who have low back pain: Provide temporary relief of the pain. Give reassurance. Write prescriptions. Give advice for further care at home.
Mixed in with all of this regular back pain, there are people who have something really bad happening. This is a great example of what makes my job so challenging and interesting: I have to recognize the rare “bad” back pain among all those “regular” back pains.
To identify low back pain that might be caused by something serious, we look for what we call the Red Flags of Low Back Pain. Basically, the red flags are clues there is some pathology in the spinal column that puts the spinal cord at risk of injury. For example, decreased blood supply can cause a “stroke” of the spinal cord. Other injuries are caused by pressure against the spinal cord from things like cancer, an abscess or a herniated disc.
Patients with these red flags need further investigation that is not warranted in the vast majority of patients with low back pain. What raises a red flag for me? Cancer patients with new back pain, old age, fever, loss of tone in or numbness around the anus, problems emptying the bladder, among others.
One night, a 47 year-old lady came in with a four-day history of low back pain with pain and numbness down her left leg. She said she had never had anything like this and had never before seen a doctor for back pain. She was miserable. She leaned to the left when she walked and was unable to walk at all without holding onto something. She said she had no control of her urine and stool. As part of my exam, I stuck my finger in her anus. She had no tone and was unable to pinch down on my finger.
I hope I did a good enough job of explaining the red flags to help you see why I was seriously concerned this patient had something bad causing injury to her spinal cord. I needed to make arrangements for her to be admitted to the hospital, be seen by a neurosurgeon and have an MRI done to identify the badness causing her problems.
I paged the neurosurgeon on call and told him my patient’s story. He surprised me by calling her by name. He said he had recently admitted her to another local hospital. All the tests done there were normal and, after being in the hospital for a couple of days, the patient miraculously got better and walked out.
I went back to the patient and told her of my conversation with the neurosurgeon. I explained we would give her no more opiates for pain and that there was no reason for her to be admitted to our hospital that night. On hearing this, she leapt out bed, flipped me off and briskly walked out, swearing at me as she went.
There is no way for me to know how this lady ended up with red flag symptoms. How did she know all the bad things to lie about? How did she learn to fake having no anal tone? Was she faking to get opiate pain medications? Did she have Munchausen Syndrome?* I really don’t know and your guess is as good as mine.
While we traveled around, getting my medical training, we lived in the south for several years. Being born and raised in the west, I was not used to the colorful adjustments many people in the south have made to English, or at least, the ways they speak that are so different from the way I grew up speaking. That caused me to be aware of things people said that I thought were interesting. Now, years later, as I look back at what I thought was interesting, it is as much a comment about my naïveté as how people, many of them poor and uneducated, spoke.
Here are a few interesting examples of things people said that I found worth keeping a note of:
An 84 year-old man came in with a severe nose bleed. He was very upset and told the nurse, “I’m bleeding to death! Get a doctor in here that will give me a shot of coagulant.” (There is no such thing as a “shot of coagulant.)
A young woman came in complaining of a “bad infection in my grinder.” (vagina)
A lady with seizures told me she was on “Die-lay’-tuns” and “Tri’-ger-talls” (Dilantin and Tegretol)
A patient walking along the side of the road told me he “div” into the ditch to avoid being hit by a car. (dived or dove)
“I had rech up for a pair of shoes and my chest started to hurt.” (reached)
A man, complaining about his girl friend not being able to have an orgasm said, “She’s cum hung.”
“I droove over to my cousin’s house.” (drove)
An 88 year-old lady who didn’t want her sweater turned inside out got upset with my efforts to help her with her clothes and said, “Don’t put it inerds, outerds.”
One of the things I really enjoy about baking is being organized and in control. I move through the kitchen smoothly and efficiently, timing my activities for best results. It fits my personality and pleases me. This is best done alone or with a capable assistant.
Our youngest daughter, McKenzie, took a very early interest in my baking. Whenever she realized I was getting things out to bake, she would come straight into the kitchen and ask, “Can I help?”
I am embarrassed to say that, at first, this set me back a bit. Inside, I would groan at the challenge this would be to my baking efficiency. I am not embarrassed to say, however, that my priorities always put her and our relationship above those selfish feelings that drove me to groan inside at having a little, inexperienced assistant in my pursuit of baking efficiency.
Every time I baked with McKenzie, I really enjoyed it and the result was that she was not only a great baking companion but became a very capable baker in her own rights.
The other day, we discovered a paper she wrote for a middle school English writing assignment. It warmed a father’s heart to see how well she wrote and how much she had taken baking into her own heart. With her permission, I share it with you today.
By way of explanation, she said, “I would have been in 7th or 8th grade (2002 or 2003.) It’s funny, when I read this I thought, ‘This must have been for Mr. Hanes’ English class.’ His writing style and lessons stick out the most in my memory. He was huge on how you structure your essays, with intros, transition sentences, main points 1, 2 and 3… It’s funny to read and see me trying and follow those principles precisely.” This explains the nature of this essay so well.
How to Make the Best Chocolate Chip Cookies
The sweet chocolate chips mixed with the tangy vanilla… This is how you make one of the best chocolate chip cookies in the world. The first step is to get all of the ingredients together. Next, you have to mix them, and last is a few secrets to make them better. The first step is all of the ingredients.
You have some dry, and some wet ingredients in these cookies. It calls for 3 cups of flour, 1½ teaspoons of cinnamon, 2 teaspoons of baking soda, 3 cups of oats, 3 cups of chocolate chips, and 1½ cups of white sugar and the same for brown. The wet ingredients are, 1 cup of real butter, 1 cup of shortening, 2 eggs, and 1 tablespoon of vanilla. The next thing you have to do is mix them together.
All of these ingredients must go in a special order. First, is the butter, shortening, and sugars. You let them mix up really well. Then, you add your eggs and vanilla and mix well. Next, you put in all of the dry ingredients. The last two steps are the chocolate chips and then the oats. There are a few more details to make perfect cookies.
I have a few secrets to my success. The first one is I do not cook them for a set time. I cook them until they are slightly brown on the edges. The second one is to soften the butter so that it mixes in easily. The last and most important is not to use Quick Oats! All of these useful tips will help make great cookies.
There are many ways to make cookies but there is only one real way. Three steps to make these wonderful cookies are last, my secrets, next, the order you mix them up and first, the ingredients that you use. This is how you make the best chocolate chip cookies in the world.
About three in the morning, two patients came in complaining of headaches. They were placed in different rooms. Their situations were amazingly similar. They both: 1) had a long history of severe headaches but had not had such a bad one in several years
2) were visiting siblings from out of state
3) had severe cardiovascular side effects to Imitrex, a non-narcotic headache medicine
4) had headaches triggered by food allergies and admitted to dietary indiscretion leading to this current event
5) were asking for a shot of the narcotic Demerol and a prescription for Vicodin.
They were told that they would only get a shot if they had someone to give them a ride home. The man said his sister was in the waiting room. He walked to the waiting room, saying he was going to find her. He was seen walking out alone and getting into an empty car.
The female patient also walked out, saying her brother was waiting for her outside in a white Volvo. She soon returned saying he was not there. She assured the nurse that he would be right back and it would she please administer the shot. When the nurse declined, she went to make a phone call but said there was no answer. Next, she asked if there were any vending machines. When she was directed to them, she walked out and was seen jumping into the car where the man was waiting. They drove off together, unsuccessful in what was clearly a ruse to get narcotics for feigned headaches.
I don’t know why in the world they would both use exactly the same story at the same time to try to get opiates in the emergency department. This exemplifies the complexity of the lies someone will fabricate to try to get a fix.
I got this recipe from my daughter-in-law, Elizabeth. My favorite ginger cookie, without a doubt, is the Taku Ginger Cookie. Takus are chewy whereas these are very dense and firm. I twisted this recipe, as I so often do, by adding chocolate chips. That causes a complication in that the dough is already stiff and doesn’t flatten out very well. Filling it full of chocolate chips only makes them less likely to flatten out. They are really good! (But not at good as Taku Ginger Cookies.)
½ cup coarsely chopped fresh ginger
1½ cups canola oil, divided
4 cups granulated sugar, divided
¾ cups molasses
1½ teaspoons salt
1 tablespoon cinnamon
5¼ teaspoons baking soda
¾ teaspoon ground cloves
7 cups flour
3 cups semi-sweet chocolate chips
1. Heat oven to 350°.
2. Mix fresh ginger with ½ cup of the oil in a food processor until well-minced. Strain out the fiber and throw it away. Set aside the ginger-infused oil.
3. In a large mixing bowl blend 3 cups of sugar, molasses and eggs.
4. Add ginger oil plus the remaining 1 cup of oil to the egg mixture and blend until smooth.
5. In a separate bowl, mix together the salt, cinnamon, baking soda, cloves and flour.
6. Add the dry mix to the wet mix and blend well.
7. Stir in chocolate chips.
7. Line cookie sheets with parchment paper.
8. Scoop the cookie dough into 2 tablespoon balls and roll in the reserved 1 cup of granulated sugar.
9. Place on prepared cookie sheets and bake for about 8-12 minutes. About half way through, remove them quickly from the oven and flatten each ball with the buttered bottom of a drinking glass, dipping it into sugar between each flattening, the return quickly to the oven to finish baking. Bake just until the tops crack and the cookies are flat. They will look raw even after 10 minutes even though they are golden brown. They will stiffen up. The original recipe calls for you to drop the baking sheet onto the counter three times as you take them out of the oven, so they flatten even more.
10. Cool completely on wire racks.
You better like lemon poppy seed if you are going to make these. And be ready with your ingredients. I made a quadruple batch for the emergency department and it took THREE bottles of lemon extract! As is usually the case with good sandwich cookies, the filling really makes them.
Recipe Adapted From:
For the cookies:
½ cup butter, at room temperature
¾ cup sugar
1 egg, at room temperature
1 tablespoon lemon extract
2 teaspoons vanilla extract
½ teaspoon baking powder
½ teaspoon salt
1 tablespoon poppy seeds
1¼ cups flour
½ cup cornmeal
For the lemon butter cream frosting:
½ cup butter, at room temperature
½ teaspoon salt
1 tablespoon lemon juice
zest of 1 lemon
1 teaspoon lemon extract
Yellow food coloring, optional
1½ cups powdered sugar, * SEE NOTE
1. Heat oven to 350°F. Line 2 large cookie sheets with parchment paper or silicon baking mats. Set aside.
2. In a standing mixer, cream the butter and sugar until light and fluffy, about 2 minutes.
3. Add egg and extracts. Beat on medium speed until combined.
4. Combine baking powder, salt, poppy seeds flour and cornmeal.
5. Stir into butter mixture, just until combined.
6. Scoop tablespoons of dough into balls and place on cookie sheets at least 1.5″ apart. Flatted with the bottom of a drinking glass that has been buttered and dipped into sugar, redipping the glass bottom back into the sugar before flattening the next ball.
7. Bake for 8 to 10 minutes. Transfer to a rack to cool completely.
8. While the cookies are cooling, make the frosting.
9. Beat the butter until light and fluffy.
10. Add salt, lemon juice, lemon zest, lemon extract and food coloring. Beat until combined.
11. Slowly mix in the powdered sugar.
12. Frost the bottoms of half of the cookies. Cover the frosting by pressing with the bottoms of the other cookies, forming sandwiches.
I like to sift the powdered sugar when I make frosting.
About six o’clock in the morning, we got a call from an ambulance that they were bringing in a pediatric gunshot victim. I asked myself, “A little kid shot this early in the morning? What the heck?”
In our trauma system, “pediatric” means up to age 18, so I immediately started picturing a seventeen-year-old gang banger shot in the line of duty. This thought was disturbed by a clarification from the nurse: a nine-year-old shot in both legs. That is really strange and left me wondering what the story would be behind this one.
As the trauma team began to assemble in the trauma room in preparation for the arrival of the little gunshot victim, an overhead announcement was heard: “Minor trauma in the department now.” That is said when a trauma patient comes in by private car, rather then by ambulance, and presents to the triage desk in the front of the emergency department.
This patient was also a gunshot victim and the coincidence made me think, immediately, that these two events had to be somehow associated with each other. I assumed we had two victims from the same firefight.
I met the man just as they were going to move him from the wheelchair onto the hospital bed. There was a hole in the top of his athletic shoe with a bit of blood oozing out. He was middle-aged and of slight build. He was in a lot of pain and was very upset. He told me he was getting ready to go to work when his gun accidentally went off. I was unable to get him to explain why he had the gun while getting ready to go to work or why there was a bullet in the chamber. “It was an accident, I swear!” he hollered over and over again.
I tried to reassure him as we started in on all of the treatment he needed: get him undressed and get his shoes off; start an IV for fluids, pain medicine and antibiotics; get an x-ray of the foot; get some more information about just what happened; find if he had any medical history and if he needed a tetanus shot.
As all of this was getting started, the boy came in. He had been shot with a single bullet as he lay on his side in his bed. The bullet entered one of his legs just below the knee, tore off a huge hunk of flesh, shattered the shinbone and passed into the other leg, breaking that shinbone, as well, and lodging just under the skin. We entered into the same plan of care for this gunshot victim.
When I went back to the bedside of the man, I learned that he shot himself through the foot with a high-powered rifle. There was a nasty hole through the middle of his foot leaving one of his toes almost detached. I also learned from the police that, after going through his shoe and foot, the bullet had also gone through his floor and come out of the ceiling in the apartment below, striking the nine-year-old boy as he slept in his bed.
To clarify, I went back to the bedside of the little boy and greeted the mother who was just arriving in the room. She spoke only Spanish so I served as her greeter, translator and explainer. She corroborated the story that a bullet had come down out of the ceiling, striking the boy as he slept in bed.
Both patients were admitted to the hospital. They both needed to go to the operating room to have their injuries surgically repaired. Both would probably end up with some sort of disability because of the accident. Both may well be emotionally scarred as well.
As I was finishing things up, word came back through the police that the wife of the man who was shot in the foot reported he had written a suicide note and had his rifle out with intentions of killing himself when it accidentally went off into his foot. If he was depressed before, how much more depressed will he be now?