A woman from Utah was visiting a friend in New Orleans when they had some sort of a falling out. For reasons unknown to me, this falling out resulted in her being committed to the Crisis Intervention Unit (CIU) at Charity Hospital, where I was spending a month to learn more about psychiatric emergencies. I was told that her three-year-old son was taken into protective custody when she was committed to the psychiatric unit.

As I talked to her, it was impossible to really understand what had happened to her. Nothing she told me made any sense and she contradicted herself as well as the reports I received from the ambulance personnel and nurses. She had Borderline Personality Disorder. “Borderline” doesn’t mean “almost a problem” but means more like “almost completely nuts.” There was no effective treatment for personality disorders so it was not clear to me what the psychiatrists were going to do for her. She was still in the CIU when I finished my shift and went home.

When the patient’s mother in Utah found out the patient had been committed to the psychiatric ward, she called the local leader of her church and asked him to intervene to win her daughter’s release. A friend of mine, Doug, was an ophthalmology resident at Charity Hospital and a member of the same church. He was asked by the local church leader to go see if he could get the patient out of the psych ward. When someone was willing to take responsibility for the patient, the people in the CIU were only too happy to let her go. Doug took her to a mid-range hotel not far from the hospital. He used church funds to pay for a room and gave her additional money for food and incidentals. Once the mother knew the patient was free, she bought a ticket for her daughter to fly back to Utah. The patient was told that someone would come and take her to the airport the next morning.

Later that night, while at a dinner at the church with his family, Doug got a call from the manager of the hotel. He was told the woman had taken the money she was given and had purchased booze with it, which she was using to try to seduce any man who passed by as she swam naked in the hotel swimming pool. The manager told Doug the woman was no longer welcome at the hotel and he needed to come pick her up.

When Doug got to the hotel, the police were there but refused to take the patient into custody because the hotel manager was not interested in pressing charges. The only thing that Doug could think to do was to try to get her back to the CIU. When it was clear that the police were not going to hold her, she told Doug to “F— off” and set out down the street, with clothes on, I believe.

I have no idea what happened after that. It certainly made me appreciate that Doug was willing to do so much to try to help her. It also made me very empathetic for the mother and left me to only imagine what kind of grief this crazy woman had caused her family because of her mental illness. As I have said so many times over the years, “Mental illness is just the worst.”

The recipe for Monster Cookies came into our family from Jessie, college buddy and BFF of our daughter, Hilary. She didn’t use a specific recipe, just grabbed one off the Internet, so that’s I what I did. Here it is, adjusted a bit for my taste. I don’t really care for peanut butter cookies but these are good.

Recipe By:

Adapted from Paula Deen

Yield:

44

Ingredients:

3 eggs
1¼ cups packed light brown sugar
1 cup granulated sugar
½ teaspoon salt
2 teaspoons baking soda
1 teaspoon vanilla extract
12 ounces creamy peanut butter
½ cup butter, softened
½ cup M&Ms
½ cup chocolate chips
¼ cup raisins, optional
4½ cups oatmeal

Directions:

1. Heat oven to 350 degrees F. Line cookie sheets with parchment paper or nonstick baking mats.

2. In bowl of a stand mixer, combine eggs and sugars. Mix well.

3. Add salt, baking soda, vanilla, peanut butter, and butter. Mix well.

4. Stir in M&Ms, chocolate chips, raisins and oatmeal.

5. Drop 2-tablespoon balls of dough onto prepared cookie sheets. Flatten them a little with your fingers.

6. Bake 14-16 minutes. Let stand about 3 minutes before transferring to wire racks to cool. *See notes.

Notes:

Original recipe called for 8-10 minutes. I found them to have a much better chew and hold together better when cooked long enough that the bottoms started to brown. This is one of those rare cookies that doesn’t seem to suffer much if they are cooked longer.

My son’s mother-in-law asked if I could make a bag for her yoga mat. I wondered if something other than a bag might work better. What I came up with was a wrap. The wrap rolls around the rolled-up pad. It closes with Velcro and can be thrown over her shoulder. I think it came out pretty nice

And so does Hunter.

A.L. was a 65-year-old man who came in complaining of having been assaulted. This was not any ordinary assault. It took place while sitting in our waiting room. But, wait. Let me start at the beginning.

For the last three years, A.L. had been assaulted many times by “private investigators.” They used a gas to render him unconscious, then inflicted trauma to his legs. Most of the time, the trauma was localized to his calves but, lately, they had moved above the knees. They didn’t actually land blows on him but would grind their palms into his flesh, causing localized pain and swelling. He said they did this to avoid leaving any bruises as evidence. When he woke, he always found new areas of swelling and tenderness, which he could identify by carefully feeling the flesh of his legs.

These assaults happened almost daily and sometimes up to four times per day. They could happen anywhere, including in the parking lot walking into the hospital. Often, he was alone, as when he was working in empty offices at night where he was trying to run his janitorial service. They could also happen when others were around, as in the ED waiting room. He was even assaulted while in bed with his girlfriend. When I asked him how it could be possible that someone could gas and assault him while he was sitting in our crowded waiting room, he said, “They are very sneaky. They have their methods.” The fact that no one else had ever seen this happen did nothing to cause him to doubt it took place.

He provided excruciating details about the techniques used to assault him. He meticulously described how they did all of this without leaving any evidence. He said they had, within the last month, changed to a different type of gas as they were afraid he might be getting immune to the effects of the gas previously used.

Since he was always unconscious when these attacks happened, I asked how he knew who was doing it and why they were doing so. He said he knew because he once “came to” just as they were leaving and he saw the bushes outside move as they rushed away.

When asked why someone would be doing this to him, he was evasive. It was clear he believed someone felt wronged by him and that these attacks were retribution for that wrong. He refused to elaborate on what that wrong might have been or who was having the private investigators assault him.

He said he had been to the police many times and they refused to take him seriously, which upset him. He also admitted he had been to our emergency department many times for the same thing and, again, had not felt supported in his struggles.

After talking to him for about twenty minutes, fascinated by the details and long course of his delusions, I asked him what he thought I could do for him in the emergency department. I had to ask this question several times before I got a specific answer because, rather than answer the question, he would just go back and repeat details of the assaults.

Finally, he said he wanted me to put casts on his legs so “they” couldn’t inflict any more injuries. He wanted help getting a single medical care provider who could see him each time he presented so that person could document, over time, the various injuries he suffered at the hands of his assailants.

He seemed to understand when I told him I would not be able to cast him. However, I could respond to his second requests by referring him to get a primary care provider.

Up until this time, our conversation was very calm and agreeable. That all changed when I finally told him he had paranoid delusions. That really set him off. He started to holler and swear at me, saying he was not delusional. He had evidence of everything he was telling me if someone would take him seriously and not just blow him off as everyone, up to that point, had done.

I finally had to pull out the line I use at times like this. “You know these things are true and I can’t convince you otherwise. But I also know they are not true and you can’t convince me they are. So, we will just have to leave it at that and it’s time for you to go.”

I told him his discharge papers would include directions for contacting a mental health provider and I encouraged him to do that. He left very unhappy. I had no hope he would follow my recommendation.

A few weeks later, I saw this same gentleman, again. He came in with exactly the same story and, of course, had made no effort to get any mental health assistance. I felt so sorry for him but there was, literally, nothing I could do to help him. Even listening to him didn’t help when he saw that he was not believed.

Check out this article to better understand fixed delusions. This describes my patient very well.

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

I have mentioned Alex before. He was the head cook at our church girls’ camp, where I was the baker and slave. Here is a recipe I only got from him a couple of weeks ago. They really get in your mouth with coconut, oats and Wheaties.

Recipe By:

Alex M.

Ingredients:

1 cup butter, melted
1 cup sugar
1 cup brown sugar
2 eggs
1 tablespoon vanilla
2 teaspoons baking soda
2 teaspoons baking powder
2 cups flour
1 cup coconut
2 cups oatmeal
2 cups semi-sweet chocolate chips
2 cups Wheaties

Directions:

1. Mix together in order shown above. Stir the Wheaties in by hand and gently, mixing only enough to coat them.

2. Roll or scoop into 2 tablespoon balls. Place on baking sheets covered with baking parchment.

3. Bake at 350 degrees for about 13 minutes. DO NOT OVER-BAKE! They will be soft on top and just browned on the bottoms and edges.

4. Cool on baking sheet for two minutes before placing onto cooling rack.

Black straps only rarely come in and, since they are so cool, are much in demand. Many people have asked for a black bag and I have to say, “Sorry.”

One of our nurses, Jessica, wouldn’t take “No” for an answer. She went onto Amazon and bought a roll of black strapping. Here is the bag I made out if it. The only bag I have even made with new materials.

The other night, a woman rushed in asking for help getting her injured boyfriend out of the car. She said he had been drinking with friends when they called to say he had been stabbed and needed her help. When she got there, he was covered with blood, nearly unconscious and unable to stand. The friends helped her load him into her car and she rushed him to the hospital.

A nurse and a tech went with the woman to her car. There, they found a man slumped in the front seat. He had dried blood all over his face and soaked into his clothes. He moaned as they moved him into a wheelchair and pushed him into the emergency department.

When I entered the trauma room, I saw a tall, big-boned, muscular man covered in blood. His head was thrown back in the wheelchair and he was moaning. Though conscious, he did not respond to staff’s questions or instructions. His size and passive posture led to a quick conversation about how to best get him out of the wheelchair and onto the gurney. I bent over and, talking closely into his ear, firmly encouraged him to help us get him onto the bed. That was enough to get him to stand and move over to the gurney, where he fell back, moaning, his eyes closed the whole time.

I then stepped back against the wall at the foot of the bed while the nurses and techs got him undressed, placed him on a cardiac monitor, recorded some vital signs and started IVs.

Just then, the trauma surgeon walked in and asked me what was going on. I told her he had been stabbed, he seemed to be very drunk and we were in the process of evaluating him for possible serious injuries.

Suddenly, the man, who had hardly been able to hold his head up, leapt from the gurney, hollering loudly. He pulled the IVs out of his arms, yanked the monitor leads from his chest and tore off his gown. Throwing everything on the floor, he stood, naked, in the middle of the room, blood running down his muscular arms from where he had pulled out the IVs. Everyone was amazed at his miraculous transformation. He had suddenly gone from being a nearly unconscious rag doll to an erect, angry man who was hollering, swearing and waving his arms threateningly. Staff immediately stepped back away from him and pressed against the walls of the room, wondering what might happen next.

At first, his profanity-laden tirade was directed at no one in particular. Soon, he focused on me. Though his eyes had been closed and he had been acting incoherently, it became obvious he heard what I told the trauma surgeon and was very upset that I assumed him to be drunk.

He walked forward and got right up in front of me. Waving his arms wildly and pointing at his bloodied face, he screamed at me for saying he was drunk and not paying any attention to his stab wound.

I can’t say I was not afraid but I just stood, statue-still. I stared him straight in the eyes and did everything I could to not respond to him at all. Not getting a reaction from me, he turned and walked around the room, hollering at others who stood, lined against the walls. He picked out a nurse in the farthest corner, called her a “bitch” and gestured threateningly at her.

Recovering their wits somewhat, some of the staff tried to calmly talk him down. He paid no attention to them. He continued to pace the room, completely naked, with dried blood all over his face and fresh blood dripping down his arms. At times his ranting seemed incoherent. Then, he would say something like, “Look at me! Standing here buck-naked in fronta y’all. What the
f—?” All the time this was going on, his poor girlfriend was sobbing in the hallway outside the trauma room.

Eventually, he seemed to tire of it all and started looking for his clothes. Several of us encouraged him to let us evaluate him to make sure he was not seriously injured. This, he refused, demanding to be given his bloody clothes so he could leave.

This presented a difficult ethical question. When he came in, it seemed he was impaired. A person in that condition could not wisely refuse medical care. If he had tried to leave, it would have been appropriate to restrain him until we were sure he was either okay or competent to assume the risks of leaving against medical advice.

Now, I had a very different patient. He was alert, talking clearly in full sentences, and able to pick me out as the one who insinuated he was intoxicated. What was my responsibility? Did we need to tackle and restrain him to protect him from making a bad decision and leaving? Should staff be put at risk in order to make sure he didn’t leave until it was clear he was alright?

By then, security officers had arrived, waiting for my instructions on to how to deal with this man. I had to decide. He was big, strong, upset and covered with blood. I knew it would be a nightmare to try to take him down. Rather than put staff at higher risk, I told everyone to let him leave if he wanted to. It took him quite a while to get dressed as he kept getting distracted and continued hollering at people. Eventually, however, he walked out.

The next day, I got the following email from one of our physician assistants, referring to this same patient:

Hello Dr. Tad,

A patient presented to the ED today to apologize for his behavior during his most recent ER visit. He was very sincere, and wanted to apologize for his horrific behavior. He is very sorry and appalled at himself, stated he is not normally like that, and continued to profusely apologize, asking to please have me pass on how remorseful he was.

Sincerely,
C.M. PA-C

A 15-year-old boy got in trouble at football practice. As punishment, his coach sentenced him to do 150 pushups over the weekend. His mother was assigned to monitor him and make sure he was compliant.

On Monday, he was unable to move his arms, which were in severe pain, and he noted that his urine was darker than normal. All of this concerned his mother, who brought him to the emergency department. This story of over-exercising, followed by excessive muscle pain and dark urine was worrisome to me. Quick blood and urine tests confirmed my suspicion. He had rhabdomyolysis.*

The excessive use of the muscles of his arms and shoulders caused enough muscle damage that a protein, myoglobin, was released from the muscles in such large amounts that it turned his urine dark. If not treated, that same protein could be toxic to the kidneys. This patient had to be admitted to the hospital to get pain medicine and IV fluids until his muscles healed and the myoglobin was cleared from his blood and urine.

Over-exercising is one of the more common causes of this condition. As far as I know, I have never seen it just from over-use of the upper extremities. Since your legs have so much more muscle mass than your arms, it is a lot more likely for this to develop after over-use of the legs. For example, we often see prisoners who do squats over and over until they develop rhabdomyolysis. They come in from jail with leg pain and dark urine and have to get admitted to the hospital.

I wonder if my patient’s coach will assign 150 pushups as behavior modification again.

*I posted a case previously about rhabdomyolysis. Please see Dancing with the Stars in a previous post.

Also, for more information, check out this Wikipedia article: https://en.wikipedia.org/wiki/Rhabdomyolysis

This is one of those recipes that is all over the Internet. It seems weird to call them “peanut butter” when there is no peanut butter in them at all.

For some reason, I have always referred to the chunky ingredients added at the end of the cookie recipe as “floaties.” Don’t ask me where that came from. Maybe it is because I just can’t think of a better word. Anyway, this recipe has more floaties than any other recipe I have ever made. Seriously, packed with nuts and chips.

Recipe By:

All over Internet

Yield:

36

Ingredients:

6 tablespoons unsalted butter
12 ounces semisweet chocolate chips, divided
2 ounces unsweetened chocolate
2 large eggs
1 tablespoon instant espresso or coffee powder
2 teaspoons pure vanilla extract
¾ cup sugar
⅓ cup all-purpose flour, plus 1 tablespoon
1 teaspoon baking powder
¼ teaspoon kosher salt
1 cup walnut halves, not chopped
1 cup pecan halves, not chopped
⅔ cup peanut butter chips

Directions:

1. Heat oven to 325 degrees. Line baking sheets with parchment paper.

2. In a bowl set over simmering water, melt butter, 6 ounces of chocolate chips, and unsweetened chocolate, stirring occasionally, until just melted. Remove from heat and cool for 15 minutes.

3. In bowl of electric mixer fitted with paddle, beat eggs, espresso powder and vanilla until combined.

4. Add sugar. Raise speed to medium-high and beat for 2 minutes, until the batter is thick and falls back on itself in a ribbon.

5. With  mixer on low, slowly stir in  chocolate mixture.

6. Combine ⅓ cup of flour, baking powder, and salt in a small bowl. Stir into chocolate mixture with a rubber spatula.

7. In another bowl, combine walnuts, pecans, peanut butter chips, remaining 6 ounces of chocolate chips and 1 tablespoon of flour. Fold into chocolate mixture.

8. Scoop 2 tablespoon balls of dough, 1 inch apart, onto prepared baking sheets. Bake for 15 minutes exactly. Cool on baking sheets.

I have not had a lot of success with three colors in one bag. Here is the latest try. I kind of like it.