One night, I had an amazing patient. It is hard to do justice in a note like this just how amazingly bizarre he was. He came in by police at about 6:00 in the morning. I sat and listened for maybe half an hour while he told me his story.

He developed complications of gastric banding surgery. He was in a Veterans Administration hospital in city across the state for six months before being transferred to a VA hospital close to us where he had been for a year! He told me about how the police had arrived at his hospital room the day before as the doctors pulled out his IVs and drains. He was taken in hand cuffs to jail where he was booked on warrants for old misdemeanors. He told the most pitiful story of illness, innocence and victimization.

As I read through the papers that came with him, there was quite a different story. He was believed to be a sociopath who was malingering in the hospital in order to not go to jail for his felony warrants. He told them he was unable to eat anything so they were giving him total parenteral nutrition (TPN), which means everything you need for survival intravenously. When he was found to be gaining weight, they searched his room and found hidden food. The report went over other crazy stuff they had been putting up with for a year and half with the guy.

On the way to the jail, he told them he felt ill so they took him to another hospital near us where he got evaluated, cleared and sent on to jail. As soon as he got to the jail, the nurse who evaluated him decided he was too sick for jail and refused him, sending him to us. So, after a year and a half in a hospital, being deemed safe for discharge then going to a second hospital where he was deemed safe for jail he is now in my ED. For an emergency physician, this is a nightmare.

I looked at all of his stuff and sent him back to jail. I am told he refused to walk or to sit up on the bench in the custody van so he was taken back on the floor of the van, handcuffed to the underside of the bench. I am sure that was not the last time we will be seeing this guy.

The other night the paramedics brought in a woman with burns on most of her scalp. The medics said when they got to the residence, the patient was screaming hysterically. They could see a fire had been burning in the fireplace and some partially burned wood was scattered out onto the hearth. The fire appeared to have been recently put out and there was water in and around the fireplace as well as on the carpet, the couch and the patient. When the medics asked the patient what happened, all she would say was, “I have lice!” The best they could guess from looking at the scene was she had put her head inside the fireplace to burn her hair in order to get rid of the lice. Water had then apparently been used to douse her and the fire.

By the time she arrived in the emergency department, she had stopped screaming because the medics had given her morphine. Now she could not keep her eyes open and was unable to answer questions.

She certainly painted a pathetic picture. She was very obese, had no teeth and her tongue kind of stuck out as she snored. Some of her hair had obviously been cut off near the scalp before this event. Most of the scalp and her ears were burned.

I reviewed records from previous visits, which showed she was diagnosed with schizophrenia. Her urine drug screen showed she had taken phencyclidine, also known as PCP or angel dust. That is just the worst combination: a drug that makes you crazy taken by a crazy person.

The burns were not severe enough for her to be admitted to the burn unit so we cleaned her up, dressed her head and sent her to the psychiatric emergency department.

Someone asked for a bumble bee bag and here is a sample of what I came up with.

A real cookie-baking snob wouldn’t even look at a recipe like this, let alone make them and like them. This is as easy as cookie baking gets and they are really fun. I don’t like cake mixes. I don’t like white chips. Yet I really like these. Give them a try!

Recipe By: San Jose Mercury News

Serving Size: 24

 Ingredients:

1 box chocolate cake mix with pudding

2 large eggs

½ cup canola oil

1 tablespoon vanilla

1 cup nuts, chopped (optional)

1 cup coconut

1 1/2 cup white chocolate chips

Directions: 

1. Heat oven to 350 degrees.

2. Mix all ingredients together.

3. Bake for 12-13 minutes.

 Notes:

Watch out because the chips tend to separate out and go to the bottom. I actually have to dump the dough out of the KitchenAid then mix it up and scoop it from the counter to keep the chips evenly distributed in the dough.

They are tender and people frequently comment on them being like brownies.

These are really buttery and sweet with a fabulous flavor that reminds me of my Dad’s panoche or See’s Bourdeaux. I got this recipe from Sandy, my son’s mother-in-law. She found it at americastestkitchen.com

Ingredients:

20 tablespoons butter

8 tablespoons butter

1/2 cup sugar

1/2 cup dark brown sugar

3 1/2 cups dark brown sugar

4 cups flour, 21 ounces

1 teaspoon soda

1/2 teaspoon baking powder

1 teaspoon salt

2 large eggs

2 large egg yolks

2 tablespoons vanilla

Directions:

1. Heat 20 tablespoons butter in light colored skillet, swirling constantly, until dark golden brown and has a nutty aroma. Stir in remaining 8 tablespoons butter. Set aside to cool.

2. Heat oven to 350 degrees.

3. Mix together sugar and 1/2 cup brown sugar. Set aside.

4. Mix together flour, soda, baking powder and salt.  Set aside.

5. Mix together 3 1/2 cups brown sugar and cooled butter just until combined.

6. Stir in eggs, egg yolks and vanilla, just until combined.

7. Stir in flour mixture, just until combined.

8. Form into balls about 2 tablespoons in size. Roll dough balls in sugar/brown sugar mixture.

9. Bake 12 to 14 minutes until edges are just browned and set but centers are still soft.

Notes:

1. I have browned the butter in a skillet, as they recommend, and in a sauce pan and the skillet it better.

2. I never looked for “dark brown sugar” but just used the brown sugar from Costco.

3. Consider dipping them in the same chocolate/shortening mixture used in the Cocoa Puffs recipe.

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.