I have been thinking tonight, for some reason, about vomit. Not just vomit but also vomiting. I think I will give an overview of my life’s experience with vomit and vomiting and some highlights, if you will, of my medical experience with the same.

Our daughter-in-law, Elizabeth, claims to have never barfed in her life. I have vomited so many times that it just seems to me like a normal thing to happen to all humans. Usually vomiting is caused by eating something bad (“food poisoning”) or an intestinal virus (“stomach flu”) that you catch from another person.

It is so common that I am amazed when people come into the emergency department and think they are dying because they are vomiting. Or they want to know exactly why they are vomiting and are amazed when I am unable to tell them.

I remember the first time our son, Philip, vomited. He was about a year old. We were sitting in church and out it came, all over. I grabbed him up, put my hand over his mouth and ran out, vomit dripping behind us. I remember looking at him later in the day and feeling so sorry for him. I knew he would be fine but still felt bad for him, especially being so little and unable to understand what was happening.

When our daughter, McKenzie, was about the same age, she vomited grape juice on the dining room floor, which left a purple stain that was with us until we got new carpet.

Our daughter, Hilary, always seemed to vomit when we were traveling. She spent the night vomiting into a stinky pit toilet on a night ferry in Thailand when she was about eight. We never even knew she had done so until morning, when she gave told us about it. She did the same on Christmas Day in a yucky airport bathroom in Peru.

The first truly memorable vomit I remember as a medical student came when I was working at the Veterans’ Hospital. I was caring for an elderly patient who had a blockage in his rectum. Nothing could go out down below so he was vomiting stool. I would have been totally grossed out by the idea of vomiting poop but watching someone actually do it was pretty hard for a new medical student to take. I remember really feeling sorry for him as we tried to provide him some relief.

Blood causes the most exciting vomit. People with ulcers can vomit some blood, which can sometimes be dangerous, but liver patients are the ones with really scary bloody vomit. They develop esophageal varices which are swollen, engorged veins running around the lower esophagus. The blood in them is under an unusually high amount of pressure and, if they bleed, they really bleed. I am talking about huge volumes of pure blood, gushing out, uncontrollably. When this happens, it is about as scary as anything I have to deal with as an emergency physician. Someone like this can die, and die fast, so a huge effort is launched to control the bleeding and replace what is being lost. It is not unusual in this situation to end up with blood all over the patient, the bed and bedding, the curtains and walls and the healthcare providers. This is exciting vomiting.

I recently posted on this blog about the boy who had pancreatitis and we only discovered the cause when he vomited a huge pile of wriggling, waxy-looking round worms. He admitted he had vomited worms at home but had flushed them. He didn’t tell anyone because he was embarrassed. Everyone there was truly grossed out by vomiting worms.

Another noteworthy episode of vomiting came from the only patient I have ever taken care of who was struck by lightening. He was in his twenties and had apparently just finished eating a luncheon-meat sandwich before being struck by lightening while seeking shelter from a big thunderstorm.

He was lucky enough to quickly have his heart returned to a normal rhythm. As he was coming to, he vomited, which is not unusual in such a situation. What was unusual was that the sandwich meat all came out in rounds, the size of his mouth, with jagged edges from where his teeth had bitten off the meat. The fact that the meat was still in these rounds proved he had swallowed the meat without having chewed it. When he recovered, we discovered he was developmentally disabled, perhaps explaining why he would wolf down a sandwich without chewing it.

All little babies urp up their milk. This bothers some new parents who bring the baby in to the emergency department worried it might be something serious. Most of the time, it is not serious but sometimes it is. One vomiting condition that can develop in little babies is pyloric stenosis. The muscle around the opening from the stomach to the first part of the small intestine is too thick and keeps the baby’s food from passing out of the stomach. These kids get real vomiting, not just urping up. In is often described as “projectile vomiting,” to differentiate it from normal baby barfing. My parents say that when my little brother had this, he vomited so badly and lost so much weight that they were afraid he would die. Once the diagnosis is made, this is easily treated with a minor surgery and the baby is back to milk and normal baby barfing again.

I see and hear people vomit every day at work. Still, as you can see above, not all vomiting is created equal.

A friend of mine, Janine, brought me a bag of curry-flavored granola. She bought it but the curry flavor was a bit too much for her. I used it, rather than the oatmeal I usually put in my trademark chocolate chip oatmeal recipe. It was subtle but a couple of people in the emergency department immediately recognized the unusual flavor. I think I will try it again with some other kind of granola. Thanks, Janine!

Directions:

1. Heat oven to 350 degrees.

2. Cream 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 granola.

7. Form into balls on cookie sheets.

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

I got this recipe from my sister-in-law, Kim. I have shared other recipes on this blog that I got from her and here is another good one. They are VERY rich and chocolatey. The marshmallow and piece of chocolate on top make them look really cool and they have a great texture. Fun cookies! Thanks, Kim!

Recipe By:

Adapted from Averie Cooks

Ingredients:

½ cup unsalted butter
12 ounces semi-sweet chocolate chips
1¼ cups light brown sugar, packed
3 large eggs
2 teaspoons vanilla extract
¼ cup unsweetened cocoa powder
1¼ cups all-purpose flour
1½  teaspoons baking powder
¼ teaspoon salt
8 ounces dark chocolate, diced into ½ -inch pieces
12 large marshmallows, cut in half

Directions:

1. Heat oven to 325F. Line a baking sheet with a Silpat or parchment or spray with cooking spray.

2. To a medium, microwave-safe bowl add butter and chocolate chips. Heat on high to melt for 1 minute. Stop to check and stir. Heat in 15-second bursts, stopping to stir after each burst, until chocolate has melted and can be stirred smooth. Allow melted chocolate mixture to stand for 5 minutes to cool slightly.

3. To a separate large bowl add brown sugar, eggs, and vanilla. Beat with a handheld electric mixer on medium speed just until blended, about 1 minute.

4. Add cooled chocolate mixture and beat on medium speed until just until combined, about 1 minute. Stop and scrape down the sides of the bowl.

5. Add cocoa powder, flour, baking powder, and salt. Beat on low speed just until combined, about 1 minute. Stop and scrape down the sides of the bowl.

6. Using a 2-tablespoon cookie scoop, form dough balls and place them on the baking sheet, spaced at least 2 inches apart. Bake for 10 minutes, or until edges and tops have just set, even if slightly undercooked and glossy in the center.

7. Remove baking sheet from oven, add 1 piece of dark chocolate to the center of each cookie, pushing down very slightly just so it breaks the surface and sinks down.

8. Place one marshmallow half on the top of each piece of chocolate on all the cookies, pushing down very slightly so the marshmallow adheres.

9. Return baking sheet to oven and bake for about 5 minutes, or just until marshmallows have puffed; don’t let them brown and don’t over-bake. Allow cookies to cool on baking sheet for about 10 minutes before serving.

Notes:

Chocolatey? I made a triple batch for the ED so that was 36 ounces of chocolate chips as well as the ¾ cup cocoa and the chocolate on the top.

A forty-year-old man was sleeping on the living room couch. Around 3:00 in the morning, his family tried to wake him to send him to bed. They called 911 when they were unable to arouse him. When the paramedics arrived, they found him unresponsive, not breathing and with very small pupils. They diagnosed opiate overdose and administered a shot of naloxone, which blocks the effects of opiates. He immediately woke up. That confirmed their diagnosis and removed the immediate risk to the patient.

In the emergency department, he admitted he had taken too many of his opiate pain pills (Percocet,) which his primary care doctor prescribed him for chronic foot pain.

At that time, he was fine because the naloxone was blocking the effects of the opiates. My main concern then was that the naloxone usually wears off before the opiates. If that happens it is possible for such a patient to lapse, again, into life-threatening unconsciousness. To prevent this possibly happening after discharge, we observed him for a couple of hours to make sure he would not go unconscious again and stop breathing at home. He had no further problems and was discharged about 8:30 when his father came to pick him up.

I later learned that he spent the day with his family then, that night, again fell asleep on the couch. This time, for some reason, the family decided to let him sleep. In the morning, they found him dead, presumably from another overdose.

Unfortunately, addiction to prescription opiates is common and on the rise in our society. This young man nicely fit the demographics of the epidemic: men between 25 and 54 years old. Not only are more people dying from prescription opiate overdose. Heroin use, which had been falling for years, is also on the rise. Addicted people turn to heroin when they are unable to get prescription medications or they become too expensive. Hence, deaths from heroin overdoses are also on the rise.

If you are interested in reading more, here is a reference to my favorite medical reference, Wikipedia, and another from the Centers for Disease Control and Prevention.

https://en.wikipedia.org/wiki/Opioid_overdose

http://www.cdc.gov/drugoverdose/data/overdose.html