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.

Another Covid-19 trial. My granddaughter, Pippa, helped me make them and ate quite a bit of dough and icing. They are moist and tasty but no one would guess they had Coke in them, by color or taste.

Yield:

24

Ingredients:

2½ cups all-purpose flour
½ teaspoon salt
½ teaspoon baking soda
½ teaspoon baking powder
½ cup butter at room temperature
¾ cup granulated sugar
½ cup light brown sugar packed
½ cup Coca-Cola at room temperature
1 egg room temperature
2 teaspoons vanilla extract
For frosting
½ cup butter at room temperature
¼ cup Coca-Cola at room temperature
4 cups powdered sugar

Directions:

1. Heat oven to 350 degrees.

2. In a large bowl, combine the flour, salt, baking soda, and baking powder. Set aside.

3. Cream together butter, brown sugar, and granulated sugar, until light and fluffy.

4. Beat in vanilla extract, egg, and Coca-Cola, until just combined.

5. Slowly beat in the flour mixture, about a half of a cup at a time, until just combined.

6. Using a 2 tablespoon cookie scoop, scoop cookie dough onto a parchment paper or silicon mat lined baking sheet. The cookies should be about two inches apart to allow for some spreading.

7. Bake for about 13 minutes, rotating the pan halfway through baking. Remove from the oven, allow to sit on the pan for about two minutes, then remove to a cooling rack to cool completely before.

8. To make frosting, beat butter until it begins to turn creamy.

9. Stir in the first cup of sugar.

10. Once combined, stir in the Coca-Cola.

11. Then stir in the remaining cups of sugar, one at a time.

12. Pipe onto cooled cookies and top with sprinkles.

Our daughter, Hilary, gave us a mid-eastern cook book for Christmas. This recipe was in that book and, with the unusual ingredients of tahini and halvah, we just had to make them. Our grandson, Hunter flattened them out with the bottom of a glass and our granddaughter, Pippa pressed the halvah into the tops of the cookies. They came out very tasty, kind of like peanut butter cookies but different.

Recipe By:

Eating  Out  Loud

Yield:

12

Ingredients:

1⅓  cups all-purpose flour
¾ teaspoon baking soda
¼ teaspoon kosher salt
¼ teaspoon ground cinnamon
½ cup salted butter, at room temperature
⅓  cup tahini paste
¾ cup packed dark brown sugar
¼ cup granulated sugar
1 large egg
1 teaspoon vanilla extract
1½ cups bittersweet chocolate chips
½ cup small chunks of halvah, (see Note)
Flaky sea salt, for sprinkling

Directions:

1. In a medium bowl, whisk together the flour, baking soda, kosher salt, and cinnamon. Set aside.

2. In a stand mixer fitted with the paddle attachment mix together the butter, tahini, brown sugar, and granulated sugar on medium-high speed until light and airy, about 5 minutes.

3. Add the egg and vanilla and mix until well combined.

4. Reduce the mixer speed to medium. Add half the flour mixture, and mix to combine. Add the remaining flour mixture and mix to combine, scraping down the sides with a spatula, if necessary.

5. Use a spoon or spatula to fold in the chocolate chips.

6. Cover the bowl with plastic wrap and refrigerate the dough for at least hour or overnight. (You can actually do this up to a week in advance!)

7. Heat the oven to 325°F. Line two baking sheets with parchment paper.

8. Using a 2-tablespoon cookie scooper, form dough into balls. Place the cough balls about 2 inches apart on the prepared baking sheets. Push down a little on each ball to flatten it slightly. Place a couple little pieces of halvah on top of each cookie and gently press them into the dough. Sprinkle with the sea salt.

9. Bake until the cookies are lightly golden, 12 to 15 minutes. Allow the cookies to cool slightly on the pan before transferring them to a cooling rack to cool completely.

Notes:

The author says that if you can’t find halvah, you can mix together 2 tablespoons of tahini with 2 tablespoons of honey. After you’ve flattened the cookies on the baking sheet, press small dents into each cookie and spread about a teaspoon of the mixture on each cookie. Finish with the sea salt. I can’t say how this would turn out but the melted halvah was the best part of the cookie, in my opinion. It was easy to get both the tahini and halvah on line:

As I have said, I have been going through scraps and making bags out of them. Here, I have bags made of three different kinds of yellow straps. It is a fun challenge to plan the bag so I have enough of one kind of yellow strap to finish the whole bag.

Shari and I went to Carlsbad for a week during Covid-19. McKenzie had this recipe and invited me to help her whip them up. They are lovely cookies to look at. The texture was nice but the flavor a bit nondescript. The chocolate drizzle fixed that!

Recipe by:

New York Times Cooking

Yield:

18

Ingredients:

1¾  cups all-purpose flour, 225 grams
¾ teaspoon baking soda
½  teaspoon baking powder
½  cup unsalted butter, at room temperature
1 cup 1 cup (220 grams) light brown sugar, 220 grams
½  cup granulated sugar, 100 grams
⅓  cup white miso paste
¼  cup chunky peanut butter
1 large egg
1½  teaspoons vanilla extract
½  cup Demerara sugar, *see notes

Directions:

1. In a medium bowl, combine flour, baking soda and baking powder, and whisk until incorporated. Set aside.

2. In the bowl of an electric mixer fitted with the paddle attachment, mix butter, light brown sugar and granulated sugar at medium speed until light and fluffy, about 5 minutes.

3. Add miso and peanut butter to the mixing bowl, and continue to mix at medium speed, about 1 minute. Scrape down sides of the bowl to make sure all of the ingredients are evenly incorporated, and mix a bit more if needed. Add egg and vanilla extract, and mix until just combined.

4. Add 1/3 of the flour mixture to the mixing bowl, and mix on low speed until flour mixture is incorporated. Repeat with remaining flour mixture in two batches until all of it is incorporated.

5. Place 1/2 cup Demerara sugar into a small bowl. Using a 2-tablespoon cookie scoop, scoop out a ball. Drop the piece of dough into the bowl of Demerara sugar and turn to coat. Transfer each ball to a parchment-lined baking sheet, arranging them about 3 inches apart. Repeat with all of the dough.

6. Refrigerate for 2 hours and up to overnight. (Even 15 minutes of refrigerator time will help the dough firm up, and the flavors meld. The longer the dough is refrigerated, the more mellow the flavors will be.)

7. When ready to bake, heat oven to 350 degrees. Bake cookies for about 15 minutes, until crisp at the edges and slightly puffed in the middle. They should still be a bit underdone in the center. Pull out the baking sheet and hit it against a counter. Place back into the oven to finish for about 3 to 4 minutes. When cookies are firm at the edges and slightly puffed in the center, pull them out and again hit the baking sheet against the counter. The cookies should appear flat and crinkly at the center. **see notes

8. Let the cookies cool on a baking sheet for a few minutes, then transfer to a cooling rack.

Notes:

* I use Sprinkle King Con AA White Coarse Sugar from supplyvillage.com.

** I found that, cooked this way, they were overdone. I skipped both the counter banging and the second trip to the oven and they turned out great.

***As McKenzie and I were making these, the idea came up to put some chocolate on them. She melted some semi-sweet chocolate chips, stirred in some coconut oil then drizzled it over them. A great improvement in these interesting cookies!

Usually, kids with abdominal pain and vomiting do not have worrisome medical problems. Most of the time, they have eaten something that didn’t agree with them or have a stomach virus. But, there are some serious conditions that give kids abdominal pain and make them vomit. An emergency physician has to think of the bad things every time, in order to make certain that nothing life-threatening is missed.

An example of such a serious condition is intussusception. This happens when a part of the intestine folds into an adjacent part. This “telescoping” causes strain on the walls of the intestine and its blood supply. The damage to intestinal tissues can cause blood and excess mucous in the stool. The classic stool of patients with intussusception is described as “currant jelly,” meaning dark purple and slimy with mucous. If intussusception is not diagnosed quickly, the bowel can become severely obstructed and the involved section of the intestine can die, leading to the need for emergency surgery or even death. Intussusception is something that, though rare, should not be missed by an emergency physician.

Often the diagnosis and treatment of intussusception are accomplished with a barium enema. Barium is a liquid preparation that shows up on x-rays. When intussusception is suspected, the child is sent to the radiology department and the radiologist gently squirts barium through the anus into the intestine, while taking x-rays. If an intussusception is present, it shows up on the x-rays and the diagnosis is made. Often, the pressure of the barium being injected into the colon causes the intussusception to be “reduced,” meaning the intestine is pushed back into normal position. In such cases, the diagnosis and treatment take place at the same time. When a kid comes in with abdominal pain and vomiting, the emergency physician has to decide if the chances are high enough for intussusception to call in the radiologist from home to do the barium enema.

I have only made the diagnosis of intussusception twice in my long career.

Ryan was a previously healthy, 16-month-old boy who had been having abdominal pain and vomiting for three days. He had been seen twice in that time by pediatricians who treated him for dehydration and sent him home. On arrival in our emergency department, he had a large, black stool covered in slime. Given that history, it was clear to me he needed a barium enema. I called the radiologist, who came in from home and confirmed my diagnosis. Unfortunately for Ryan, the intussusception was not able to be fully reduced. I had to admit him to the hospital to be cared for by a surgeon.

Such a case makes me feel really good. I identified a sick kid. I thought of the right disease. I ordered the correct test. This led to timely and appropriate care. It is just the kind of case that makes emergency medicine so fulfilling and rewarding.

The very next night, I saw another little boy, about the same age, also with vomiting and abdominal pain. He had a distended abdomen and had passed a stool that was dark and covered in mucous. You can imagine how this played with my decision making. In all my years as an emergency physician, I had only diagnosed intussusception one time and it had been the night before. Could this even be possible? Yet, all the signs were there and I called for the barium enema.

The radiologist was pleasant but skeptical. Intussusception is unusual enough that, earlier in the day, the radiologists had all sat around together and looked at the x-rays from my case. So, this radiologist knew I had made that diagnosis the night before. Essentially, he was questioning my need for another barium enema, suspecting my diagnosis the night before had me over-call the need for another one tonight.

I acknowledged his justifiable skepticism but said something like, “Last night, we got lucky. Tonight, this kid read the book.” By this, I meant that he had all the things a textbook would say to watch out for in intussusception. He agreed to come in and, just like the night before, made the diagnosis of intussusception. Again, he was unable to reduce it with the barium enema, so I admitted the patient to a surgeon for further care.

As far as I know, I have only seen two patients in my career with intussusception. And they came in on consecutive nights. What are the chances of that?