After 27 years of working in a big, urban hospital, I switched to a small, community hospital. The biggest adjustment for me is the difference in access to resources. In the big city, we had access to all the equipment and specialists that might be needed. We rarely had to transfer patients out to other facilities for additional care. Now, I do not have all those supports and it can be stressful.

For example, a young Hispanic couple brought their 1-year-old daughter to our small, community hospital at three o’clock on a Sunday morning. They were concerned about bruising and swelling around her right eye. She had been born with a clouding of the cornea – the clear part on the front of the eye. However, the parents had been told their daughter’s eye was otherwise normal.

The parents said the bruising and swelling started the day before and had gotten worse. She had not been injured and appeared to be in no distress. The father even pointed out that it didn’t seem to hurt her when he pressed on it. She was behaving completely normally.

Looking at her eye, I could see that the cornea was, indeed, cloudy. The conjunctiva, the white part, was also a bit red. There seemed to be no pain or tenderness although there was bruising, as the parents had noticed. Bruising and swelling often indicate trauma. However, I did not detect swelling and there was no reason to suspect child abuse based on the way the parents and big sister behaved.

All that aside, there was clearly something wrong. She had proptosis. Her right eye was bulging out farther than the left one. Neither did it seem to move normally, though that was a bit hard to test in a one-year-old.

Acute proptosis may be caused by infection. If you get infection around your eyeball, the swelling causes the eye to push forward abnormally. In this situation there was no history of fever or other signs of infection. And, again, the kid was acting perfectly fine. It seemed impossible she had an infection severe enough to cause proptosis and still feel well enough to play normally with her sister.

My dilemma was: “Does this kid have something acute going on that needs me to transfer her to another hospital for care tonight? Or, is this something that can wait until Monday morning when she can see her primary care doctor and be referred to a specialist?”

I decided the only way to know was to scan her. This presented another challenge. A CAT scan would probably give me the information I needed, but we try to avoid CAT scans in kids because of the ionizing radiation it exposes them to. The earlier in life you get radiation, the more likely it will end up causing cancer many years down the road. An MRI scan would be a safer test since it would not cause exposure to radiation, but there was no MRI in our small hospital at night or on weekends. In order to get that test, I would need to transfer her to a bigger hospital where they had MRI available. However, the whole purpose of getting the scan in the first place was to help me decide if she needed to be transferred!

I finally decided it was important enough to justify getting the CAT scan done at our hospital. It showed a mass behind the eye that the radiologist said could be either a hemangioma or a sarcoma. A hemangioma is an abnormal and benign wad of blood vessels that you are born with. A sarcoma is a tumor that is usually malignant. Either of of the two would cause the baby’s eye to be pressed forward.

My impression was that if the baby was born with a hemangioma, the doctors would probably have picked up on it when they evaluated her cornea. I think the mass was a tumor that had been developing slowly. As it gradually pushed the eye forward, a little vein ruptured causing the non-tender bruising the parents noticed.

Though the situation was serious, there was no reason to transfer her to a higher level of care in the middle of the night.

The poor parents. Though I did my best to explain the situation, I don’t think they really understood what they were up against. They took off to put the baby back to bed.

I am always looking for an interesting ingredient for a cookie. I am sure that is what drew my attention to this recipe. Warning: If you don’t already know that you like matcha green tea, I would recommend you not try these. My experience is that this is not a universally appreciated flavor.

Recipe By:

cookpad.com

Ingredients:

3½ ounces unsalted butter
¼ cup granulated sugar
½ cup brown sugar
1 pinch salt
1 egg
5¼ ounces all-purpose flour
1 tablespoon matcha green tea powder
¼ teaspoon baking soda
½ cup coarsely chopped white chocolate or white chocolate chips

Directions:

1. Heat the oven to 330F. Shift flour, green tea, and baking soda together. Set aside.

2. Microwave butter until it’s melted. Combine the sugars and butter together. Add the egg and salt, then mix.

3. Stir in flour mixture with a spatula. Stir in white chocolate.

4. Drop cookie dough in rounded tablespoonfuls onto baking sheets covered with parchment paper.

5. Bake about 12 minutes. Don’t over bake!

A young man and woman were having an argument. She pulled out a switchblade knife with intentions of using it on him. He wisely turned and started to run away. Just like in the movies, she snapped the blade open and threw it at him. It struck him squarely, burying the three-inch blade deep into his back. He collapsed to the ground, moaning in pain. Someone at the scene tried to pull the knife out but, being unable to do so, called 911.

Our evaluation, including x-rays and scans, failed to demonstrate any evidence of serious injury. He was taken to the operating room where the knife was removed by a spine surgeon.

The blade could have stabbed his lung, spinal cord, esophagus, windpipe or a large blood vessel like his aorta. But, it happened to hit him in just the right place so that only skin and muscle were cut and the point of the knife was buried in the bone. All of these tissues would heal nicely. I’m sure the same could not be said about his relationship with the girlfriend.

The Deadest Person

It was the end of my shift and I was just leaving Slidell Memorial Hospital in Louisiana when I was called back. The paramedics had just alerted the Emergency Department that they were on the way with a severely injured trauma victim and my help was needed.

The patient was about thirty-years-old and was not wearing a helmet when he crashed his motorcycle into a car at high speed. He was thrown under another car, which ran over him. A voluntary ambulance crew picked him up and rushed him to our emergency department, performing CPR.

Since the patient was not breathing, I was assigned to intubate him by placing a tube into his windpipe so we could ventilate his lungs with oxygen. As other members of the team quickly performed their assigned duties, I easily passed the tube, secured it in place and then started to blow oxygen down the tube. What happened then caused everyone to stop what they were doing. With each push of oxygen down the tube, he started to puff up. His neck expanded and air bubbled out of a cut near his eye. His abdomen started to expand, then his scrotum. Each time I pumped in air, his scrotum puffed up a bit more until it was the size of a grapefruit. When I pinched the enlarging scrotum, air was forced out of a large cut over his hip. He was pronounced dead.

An autopsy done the next day showed multiple fractures of his extremities and spine. In addition, he had at least four things that would have killed him: His head was completely dislocated from his upper spine. His left lung was completely ripped off with extensive damage to all the other organs in his chest. There was a huge hole in his diaphragm, which separates the chest cavity from the abdomen. His liver was completely demolished. His pelvis was severely crushed. All of this explained why he had puffed up as we blew oxygen into his wind pipe. The oxygen went down the windpipe and into his chest cavity. It then passed through the hole in his diaphragm into his abdomen. The crushed pelvis allowed the air to continue down into the scrotum and out the hole over his hip.

This was the deadest person I have ever taken care of.

I was wanting to try peanut butter cookies made with butter and powdered peanut butter. When I bought the powder, this recipe was on the back of the bottle.

Recipe By:

Back of bottle of Raley’s Organic Powdered Peanut Butter

This is a common brand of powdered peanut butter.

Ingredients:

¾ cup brown sugar
½ cup powdered peanut butter
½ cup butter, softened
1 teaspoon vanilla
1 egg
1 cup flour
⅓  cup oats
½ teaspoon soda
¼ teaspoon salt
½ cup chocolate chips

Directions:

1. Heat oven to 350°. Line baking sheets with parchment.

2. Cream together brown sugar, powdered peanut butter, butter, egg and vanilla.

3. Add flour, oats, soda and salt. Stir to combine.

4. Stir in chocolate chips.

5. Scoop onto prepared baking sheets. Flatten with bottom of a drinking glass, buttered and dipped in sugar.

6. Bake about 12 minutes.

If you Google Doubtree Cookie Recipe, you will find many different, but similar versions of the same. I got this from our son’s mother-in-law, Sandy. Can’t say how it might compare to the many other versions out there. I also have NO IDEA what the heck a tiny bit of lemon juice might do to a good-sized batch of cookies.

Recipe By:

Crazy for Crust via Sandy Obreza

Ingredients:

½ cup old fashioned oats
2¼ cups all-purpose flour
1 teaspoon baking soda
1 teaspoon salt
¼ teaspoon ground cinnamon
1 cup unsalted butter, melted
¾ cup brown sugar, packed
¾ cup granulated sugar
1 tablespoon vanilla extract
½ teaspoon lemon juice
2 large eggs
3 cups chocolate chips
1½  cups walnuts, coarsely chopped (optional)

Directions:

1. Place oats in a small food processor or blender and grind until they turn powdery. Place them in a medium sized bowl and whisk in flour, baking soda, salt, and cinnamon. Set aside.

2. Stir together melted butter, brown sugar, and granulated sugar until smooth. No mixer needed – just use a wooden spoon or spatula.

3. Mix in vanilla, lemon juice and eggs. Stir until smooth.

4.  Stir in flour mixture.

5. Stir in chocolate chips and walnuts.

6. Line a cookie sheet with parchment paper or a silicone baking mat. Scoop ¼  cupsful of the dough into balls and place on the cookie sheet. You do not need to space them. This is just for chilling. Cover well with plastic wrap and chill at least 4 hours or overnight before baking. Heat oven to 350°F. Place cookies well-spaced on cookie sheets lined with parchment paper or silicone baking mats. Slightly depress each ball with the palm of your hand.

7. Bake for 13-17 minutes.

Notes:

I didn’t refrigerate them and scooped them in 2-tablespoon balls. They were very good, baked for a shorter time, of course.

The Insanity of My Addiction

Paramedics were called to a house where a twenty-six-year-old man was having a severe allergic reaction after injecting methamphetamines. He told the medics he didn’t think it mattered what he mixed the meth in before injecting it. So, since he had some handy, he had used grape juice. Soon after injecting the juice-meth mixture, he started to feel terrible and called 911.

The medics found him in severe distress with fast heart, low blood pressure, swollen face and diffusely red skin. They correctly diagnosed a severe allergic reaction resulting in anaphylaxis and appropriately treated him for the same. By the time he got to the emergency department, he was feeling a lot better.

When I talked with him, he confirmed he had injected meth mixed with grape juice and he didn’t seem to think there was anything strange about having done so. He said he had done the same in the past, and he was sure the problem that day was caused by dirt in the cup he used to make up the mixture.

When I asked how often he used meth, he answered, “How often do I not use meth?” I asked him if he wanted to be smart with me or if he wanted to give me serious answers so I could take good care of him. He said he was not being smart. He used all the meth he could get ahold of.

Since a severe allergic reaction like this can be life-threatening, we watched him for several hours. None of his worrisome symptoms came back, so I went to talk to him before he was discharged. I pointed out that most people would not think it was a good idea to inject grape juice into their veins. He reiterated that he thought it was contamination that caused his problem. I pressed him, again, that it was unwise to inject things not designed for that purpose. He thought for a moment and then agreed, saying, “That’s just the insanity of my addiction.”

Fireballs of the Eucharist

Early in my emergency medicine training, a woman came in screaming because of severe abdominal pain. She told the nurse she suffered similar pains in the past because of “fireballs of the Eucharist,” which we interpreted as fibroids in her uterus. She said she had not had a period for three months but was sure she was not pregnant as her periods were always irregular. She was so upset by her pain that we had a hard time getting more information from her. From the way she looked, I thought she was dying from a ruptured ectopic (tubal) pregnancy or something terrible.

She said she needed to move her bowels but was unable to do so after the nurse helped her onto a bedpan. By then, we had an IV in but she was not responding to pain medicine. In fact, she seemed to be getting worse. She screamed, “Somethings coming out down there!” I slipped on gloves and slid my fingers in her vagina. What I felt puzzled me so much that I was startled and pulled my hand back. “What?” I asked myself. I put my fingers back in to reevaluate. Now I was sure. A head!

I hollered for help and, just as I had the baby delivered, the pediatrician and obstetrician arrived to take over care of the mother and the baby. The baby was probably about two months premature. However, it was pink and crying, which is very good news for a newborn. I told the lady that she had a baby and she cried, “Oh, no! I don’t want a baby!”

At the time, my wife was at about the same stage of pregnancy with a baby that we very much wanted. That made me all the sadder for the lady and the baby.

A Wild Night in the Accident Room

I did my emergency medicine residency training at Charity Hospital in New Orleans. It was a big, inner-city teaching hospital that was always very busy with lots of sick people to take care of. Most of the surgical and traumatic problems were taken care of in the part of the emergency department known as the Accident Room.

One night, while I was on duty in the Accident Room, gunshots blasted out followed by screaming. People scattered in all directions. Others froze, too afraid to go anywhere. Soon, there was a swarm of police pressing in with guns drawn. I was kind of freaked out but also very curious about what was going on.

As it turned out, a prisoner who was there for medical care had asked his guard to let him go to the bathroom. When one of his hands was free, he jumped the guard, got his gun, pistol whipped him, fired off two shots and ran away with the gun. One of the bullets wounded an innocent bystander who had only come into the hospital to poop.

After things settled down, I took care of the injured cop who felt really bad about having let the guy get away. I also took care of three people who were trampled in the stampede that followed the gunshots. It took several hours before people were not afraid to leave the hospital as they thought the escapee might still be outside somewhere. That was a wild night.

When I saw how much these Guittard baking wafers cost, I decided to make them with the Ghiradelli chocolate chips I usually use. After refrigeration, the dough came out so stiff I could hardly form it into balls. After baking, they were great. I repeated with the real Guittard and they scooped beautifully and were delicious. So, I guess you are stuck paying almost a dollar a cookie just for the Guittard chocolate. They are amazingly rich and wonderful with a scoop of vanilla ice cream. (Breyer’s All Natural is my favorite.)

Recipe By:

San Jose Mercury News

Yield:

16

Ingredients:

2¼ cups Guittard semisweet chocolate baking wafers, 12 ounces
3 tablespoons unsalted butter
1 cup all-purpose flour
½ teaspoon baking powder
½ teaspoon salt
2 large eggs
½ cup sugar
1 teaspoon vanilla extract

Directions:

1. Heat the oven to 375 degrees. Line two baking sheets with parchment paper.

2. Using a hot water bath or microwave, melt the chocolate wafers and butter together. Stir until completely melted and smooth. Set aside to cool.

3. In a small bowl, combine the flour, baking powder and salt. Set aside.

4. In a large bowl, with a hand mixer, beat together the eggs, sugar and vanilla until pale yellow and slightly thickened, 2 to 3 minutes. Stir in the cooled melted chocolate mixture. Gradually stir in the flour mixture until just incorporated. Cover the dough with plastic wrap and refrigerate for at least 15 minutes or up to overnight. (I would skip this step and just scoop them out.)

5. Scoop 2-inch mounds onto the prepared baking sheets. Mine didn’t spread out at all.

6. Bake for 12 minutes, or until crusty on the outside but soft in the center. Leave the cookies on the baking sheet for 3 to 5 minutes to firm up, then serve immediately. Store in an airtight container at room temperature for up to 1 week. Reheat to achieve the molten chocolate gooeyness by microwaving them for 10 seconds.