Cat Feces

A 51-year-old man came in by ambulance. When I walked in the room, I immediately noted a foul smell. An Emergency Medical Technician student working with me that day took the patient’s vital signs and then started undressing him so he could be fully evaluated. 

When the student took the patient’s socks off, he noticed there was cat feces on the patient’s foot. So, it was clear where the foul smell was coming from. What wasn’t so clear is how the patient could have stepped in cat poop at home, smearing it on his foot and between his toes, and then put his socks on before calling the ambulance to come to the hospital. 

Hit Twice on the Freeway

This 34-year-old man was stopped in his car on the side of the freeway when he was struck from the rear by another car at unknown speed. He didn’t seem to have been injured in the crash so he got out of his car to see what was going on. While standing by his car,  he was knocked to the ground by another passing car. He was treated in the emergency department for abrasions, lacerations and a severely fractured ankle. 

Shot to Remove Your Memory

I told a lady I was giving her a “strong medicine to get rid of your inflammation.” She objected, thinking it would take away her memory because she confused “inflammation” with “information.”

While I was serving as the Chair of our emergency department, one of my duties was to keep the medical staff advised of certain patients who presented with particularly challenging situations. Here is a memo I wrote to our staff about a man who, after recovering from injuries to his left leg, kept it immobilized in a cast or splint even though his doctors told him it was not in his interest to do so. He continued doing this so long his leg started to suffer from muscle wasting (atrophy) and joint stiffness, which could become irreversible. 

This patient may have had some sort of Munchhausen Syndrome, a condition where people misrepresent their illness or even hurt themselves to continue to get medical attention. He also might have been trying to damage himself so he could blame it on his work injury and get permanent disability. Who knows what his motivation was but here is his story, retold in my memo, which I have revised for confidentiality.

Date:               30 October

To:                   Emergency Physicians and Physician Assistants

From:              Dr. Tad

Subject:           Mr. Williams

This is a 45-year-old man who, in May, had an operation to repair a left heal fracture. He subsequently suffered a left knee injury at work. 

He has been followed by a podiatrist (foot doctor) and an orthopedic surgeon. He has come to our emergency department ten times in the last six weeks saying that, unless his left ankle and left knee are put in a cast, he has too much pain and can’t use his crutches. His knee and heel are apparently completely healed from his previous injuries. Still, he has insisted on having his leg immobilized in a cast or splint for so long that his muscles are wasting away because of atrophy.

One of our doctors took the time to call his doctors. This is what she found: The orthopedic surgeon said that, as the patient became more mobile with rehab and showed significant improvement in his knee injury, he began a pattern of going to the emergency department of another hospital in town and insisting he needed a long leg splint, which he usually got. When the orthopedic surgeon would see him, the splint would be removed, but the patient would be back in the emergency department a few days later. It got to the point that the other emergency department would refuse to put on a splint and send him on his way. That is when he started coming to our emergency department. 

His insistence on immobilizing his leg has led to atrophy and joint stiffness. The orthopedic surgeon eventually dismissed him from his care, as the patient would not cooperate with the treatment plan. His podiatrist agreed that immobilization was not in the patient’s best interest and also no longer sees him.

Please keep this in mind as you have occasion to provide medical care to this patient.

In our society today, people go to the emergency department for about anything they might need. If you look back through my blog postings, you will see stories of many ridiculous reasons people have come to see me. 

One service we provide in the emergency department that most people wouldn’t think of is finding someone a place to stay. Sometimes, this is just a shelter for the night. Sometimes, people can’t be sent home. Because of social, physical or mental problems they really can’t return to wherever they came from. In such cases, we look for a reason to admit them to the hospital for medical care. If they are not in need of such care, we have to find them some place to go. We call this “placing” a patient. 

Here is a revised memo sent from one of our social workers to the Medical Director of our hospital about a young man who was driving everyone crazy trying to “get placed.”

Hi Dr. T,

I wanted to update you on the patient I came to talk with you about 2 weeks ago. He is a 23-year-old man who is a paraplegic (paralyzed from the waist down) and absolutely functions independently. I have placed him in two boarding houses in the last few weeks, but he has been kicked out of each one. He refuses to stay in a shelter. He was asked to leave the Helpful Home Board and Care last week. He was supposed to pay his rent within 3 days of admission. He failed to do so, saying his social worker (me) told him Medicaid or our hospital would cover this expense. 

This patient continues to lie about everything and has contacted Adult Protective Services (APS), the police department, and the fire department several times a day over the last week. He tells them I specifically told him he should call 911 and be taken to our emergency room. This is very frustrating for me, as I have received multiple phone calls from these agencies all day, every day about this patient, who continues to try to manipulate our system. The bottom line is that this patient was living independently for three years and then started going from skilled nursing faculty to skilled nursing facility, staying for 90 days, so his Social Security benefits would not be in jeopardy. He knows the system! He then presents to emergency rooms, wanting to be placed. I have placed him twice. He is non-compliant with independent living and is rude to staff. He is more independent than he appears to be and is severely lazy. It is his decision to be lazy.

He has a very dependent personality and believes this is our problem, not his. Several social workers from two hospitals in town have spoken with him about how he needs to take some responsibility for himself. We have given him resources for shelters, board and care homes and skilled nursing facilities. He has income from Social Security. The problem now is that he is not going to go away. He will continue to present himself to our emergency room, call APS, the police department and the fire department daily until he gets what he wants, which is to be placed. As mentioned above, I have placed him twice, but he has burned his bridges and I do not want to continue burning my bridges with the facilities I work with. The emergency room is informed that they should not admit him for placement reasons, but of course they will continue to see him for alleged medical complaints. My supervisor is well aware of this case and the problems the patient has been causing our staff, other hospitals and law enforcement agencies.

You may get a call as well from APS. Everyone who has assessed him here and at the other hospital agrees he functions independently, but he is very lazy, entitled and doesn’t want to take responsibility for himself.

Sincerely,

M.D., MSW

Years ago, I started making cookies from recipes by Momofuku Milk Bar in New York City. I was eventually able to actually go to their store in Manhattan. I was not all that impressed with that experience but I continue to enjoy their cookie recipes. These are really fun cookies to make and eat. And they look great, too.

Recipe By:

All over the Internet

Ingredients:

1 cup butter, at room temperature
1¼ cups granulated sugar
⅔ cup packed brown sugar
1 egg
1 teaspoon vanilla extract
1 ½ cups flour
½ teaspoon baking powder
¼ teaspoon baking soda
1½ teaspoons salt
3 cups cornflake crunch (see below)
1 cup mini chocolate chips
1 cup mini marshmallows

Cornflake Crunch
5 cups corn flake cereal
½ cup milk powder
3 tablespoons sugar
1 teaspoon salt
9 tablespoons butter, melted

Directions:

1. Cream butter and sugars in bowl of stand mixer fitted with paddle attachment. Scrape down sides of bowl. Stir in egg and vanilla. Beat for 7 to 8 minutes.

2. Reduce mixer speed to low. Stir in flour, baking powder, baking soda, and salt. Mix just until the dough comes together.

3. On low speed, paddle in corn flake crunch, mini chocolate chips and marshmallows until they’re incorporated.

4. Divide dough into ¼-cup balls. Line balls on a parchment-lined sheet pan. Refrigerate for at least 1 hour, or place in freezer for 30-45 minutes. (If they are not chilled, they will flatten out too much, especially if you mix the marshmallows in rather than use the stuff method.)

5. Heat oven to 375°F.

6. Re-arrange the chilled dough a minimum of 4 inches apart on parchment. Bake for 11-16 minutes. The cookies will puff, crackle, and spread. They should be a little brown around the edges and on the bottoms.

7. Cool the cookies completely on the sheet pans before transferring to a plate or airtight container for storage.

Cornflake Crunch:

1. Pour cornflakes into medium bowl and crush them with your hands or bottom of a cup.

2. Stir in milk powder, sugar, and salt. Stir in butter.

3. Spread on a parchment. Bake for 20 minutes.

4.  Cool completely before storing or using in a recipe. (I keep left-overs frozen.)

I recently came into possession of an old leather coat that fit no one in our family. I decided to try to mix leather and trauma straps into a bag. Not bad for a first try.

I saved the pocket and just included it in the design.

A young man came in as a trauma patient after having been stabbed multiple times. At first glance, the worst injury was a large slash across the front of his chest. However, it only involved the skin and didn’t penetrate into the chest. So, it was really just “a mere flesh wound.”

A small laceration on his face was much more worrisome. The cut was on his cheek just below his left eye. His eye was bulging forward, what we call proptosis. Though he could see well, he was unable to move it normally.

Further evaluation of his facial injury showed the knife had penetrated his check and broken through the bone just blow the eye. It passed through the orbit, which is the space in the skull the eyeball sits in. Then, the knife entered into his brain. The proptosis was caused by bleeding in the orbit, filling the space between the skull and the eye with a blood clot. The eye and nerves which allow for vision had been missed by the knife, so his vision was unaffected.

His chest wound was cleaned and stitched in the emergency department. He was then admitted to the hospital for further evaluation and care by the ophthalmologist and neurosurgeon.