The woman was middle aged. Her presenting complaint was “Eye Problem.” She was ill-kept, making me think she might be homeless. She said she had been having “parasites” coming out of her eyes for a long time. At first, they were right inside her eyes and now, they were in the eyelids. Sometimes they were black and other times they were white, shaped like a string, probably when they were laying eggs. She had seen many doctors before but no one had ever been able to help her. It was unclear why she had decided to try again that night.

I talked to her for quite a while, looked at her eyes and skin, and then gave my honest impression. Her complaints didn’t fit any sort of parasite infection I was familiar with and I was not going to be able to help her. I told her it was probably all in her head, though I could be wrong and maybe some day somebody would discover with what she was infested.

I shared with her information on finding a doctor in a clinic, reassured her and sent her on her way.

The very next patient I went to see was listed as “Rash.” In the room was a man who was about the same age and apparent social status as the lady with the eye parasites though I made no connection between the two. He launched into a prolonged story about being infested with mites. He told me how they migrated around his body, showing up in different places at different times and looking different as they moved around and came out of his skin.

When I had heard enough and looked at his “rash,” I started into my “you may have something but it is probably all in your head” explanation when I was interrupted by someone in the hallway outside the room.

“He don’t believe us! He ain’t gonna do nothin’ for us!” It was the lady! They were living together on the streets and had developed a shared delusion about being infected with parasites.

I went over things with them, again, and they left, complaining that nobody ever believed them.

Here is a link to our old friend, Wikipedia, to explain that this sort of shared delusion is a well-described condition: http://en.wikipedia.org/wiki/Folie_à_deux

This reference has a couple of case studies that provide insight into how this can present itself: http://www.minddisorders.com/Py-Z/Shared-psychotic-disorder.html#b

A twenty-nine-year-old woman came to the emergency department complaining of numbness and inability to move her legs when she woke from a nap earlier in the day. She had pain in her neck and back, and was unable to feel anything from her waist down. She also had numbness of her hands.

She had been in a car crash four days earlier. After the crash, she was seen and evaluated at another hospital. She had no numbness or weakness at that time.

Though this story made no sense to me, I was still worried and launched into an aggressive evaluation that included x-rays and consultations with a neurologist and a neurosurgeon. Every thing came back normal.

I gave her a shot for pain and soon she was completely normal. She walked out of the emergency department in no distress.

The second crash victim was a forty-seven-year-old man who complained of having chest pain for years. He blamed the symptoms on a car crash he had ten years previously. He had been seen in the emergency department many times for the same problem. He had also been seen many times by his primary care physician, a gastroenterologist, a pulmonologist and an orthopedist. He had x-rays, CT scans and MRIs, none of which showed any pathology. He had seen many different doctors for this same problem and was sick of it. He came to the emergency department that night for us to get to the bottom of his problem. He didn’t want any pain medication. He wanted to be diagnosed and fixed.

He described the pain as being in his lower ribs bilaterally but worse on the right. He said it felt like his ribs were broken apart and were tearing into his intestines and diaphragm.

Examining the patient and getting his story were all I needed. There was nothing I could do in the ED that night to find the cause of symptoms he had suffered for years and for which he had already had many negative tests. However, I was unsuccessful using this logic to reassure him he had no physical problem.

In order to show me he really had a problem, he stood, raised his shirt and pulled in his abdominal muscles. Being a thin man, this caused his lower rib margins to stand out. They were a little asymmetrical. This, to him, was evidence of pathology he knew was there.

I finally had to resort to the line I use in situations like this. I said something like: “I am sorry. I don’t believe you have a physical problem and you cannot convince me you do. I am also not going to be able to get you to agree with me. So, we are just going to have to agree to disagree.”

Off he went, miserable and sad, and completely unwilling to entertain the idea that all of his suffering might be coming from his mind.

Dr. Debbie’s twins enjoying the twin bags I made for them.

Another cookie recipe that caught my attention because the word “chewy” was in the title and made with all coconut oil. They were sweet, chewy and delicious but a bit boring so I added macadamia nuts and white chocolate chips to make them more elegant and interesting.

Source:

Adapted from: twopeasandtheirpod.com

Yield:

36 cookies

Ingredients:

2 ¾ cups all-purpose flour

1 teaspoon baking soda

1 teaspoon baking powder

½ teaspoon salt

1 cup granulated sugar

1 cup brown sugar

2 large eggs

1 cup coconut oil melted but not hot

2 teaspoons vanilla extract

1 cup shredded, sweetened coconut

1 cup oats

1 cup macadamia nuts, coarsely chopped

1 cup white chocolate chips

Directions:

1. Heat oven to 350 degrees. Line baking sheets with parchment paper and set aside.

2. In a large bowl, whisk together flour, baking soda, baking powder, and salt. Set aside.

3. In a large bowl cream together sugar, eggs, coconut oil and vanilla extract until light and fluffy.

4. Slowly add dry ingredients and mix until combined.

5. Stir in oats, coconut, macadamia nuts and white chips.

6. Form into 2 tablespoon balls with a cookies scoop. Place on prepared baking sheets. Bake for 10 to 12 minutes or until cookies are set and slightly browned. Let cookies cool on baking sheets for 2 minutes. Transfer to a wire cooling rack and cool completely.

Last week, I told about falling off my mountain bike and making it to the hospital with obviously injured left shoulder and leg. I had just arrived at the emergency department at the end of my last posting.

I swooned as soon as they pushed me into the treatment room. That passed pretty fast once I was flat on the bed. An IV was quickly started in my hand and I was injected with morphine. I didn’t like the way it made me feel but I was very glad to have the pain controlled.

Getting my x-rays was the worst part of my ED adventure. Even after morphine, it was torture to get my arm in the correct position to diagnose my posterior shoulder dislocation. Most shoulders dislocate forward or anterior. Mine had dislocated backwards. I had read about posterior shoulder dislocations, but it is so unusual that none of my emergency medicine colleagues I talked with could actually remember having seen one before. It also explains why my efforts to reduce it on the mountain were unsuccessful.

It was nice being taken care of by my friends. The emergency physician and nurses took special care of me. The trauma surgeon heard I was there and poked his head in on me.

Once the diagnosis was made, they put me out and the orthopedist pulled on my arm. He thought it was back in and ordered more x-rays but, as I came to, I could tell very clearly it was not. I told him so and, even though I am a doctor, he still sent me for x-rays to check. That led to more of the same painful positioning for more x-rays.

When I got back to the room, the orthopedist came and told me it was still dislocated. I resisted saying, “I told you so.” He then said he was pretty sure he could put it back in without more medicine because I had already been given so much. As soon as he started to pull, my hollering convinced him he was not correct. The next time they put me under, they were more successful and I woke up with my correctly positioned shoulder held in place with a sling.

The x-rays of my knee didn’t show an obvious fracture so I was discharged with my leg in an immobilizer. My wife took me home and I got into the house and bed without too much trouble since I was able to limp on the bad leg as I walked with only one crutch.

Then next day, I had an MRI. It showed good news for the shoulder: no specific injury. But the news for the leg was bad: non-displaced tibial plateau fracture. The tibia is the shin bone and its plateau is the large part that forms the knee joint. So, I went to non-weight bearing for six weeks! That would be bad enough if I could have walked on crutches but, for the first couple of weeks, I had to use only one crutch. That meant that, to get around, I have to crawl (using just one arm and one leg,) use a wheel chair, or hop. Since we have a tri-level house, I was basically stuck in my bedroom where all I could do was hop from the bed to the toilet and back again.

It was interesting how being laid up worked on my head. All I could do was lie in bed and worry. I worried about being constipated from taking narcotics and lying in bed. I worried about getting addicted to the pain medicine. I worried about a blood clot forming in my swollen, immobile leg. I worried that my leg would never be the same again and I my active life as I knew it had come to an end. I pictured my self an addicted, constipated cripple on blood thinners. To make all of this worrying worse, I had trouble sleeping because of the pain and discomfort of the sling and immobilizer so I had plenty of long nights to contemplate my bleak future.

Fortunately, all worked out well for me. I missed nine weeks of work but, no constipation, no blood clots, no addiction. Back hiking and riding my bike. Just a setback that has helped me be more empathetic towards others in similar situations.

I made another one of these shoulder bags for my sister-in-law, Kim. It was a bit hard to take a picture in the mirror of myself wearing it but you get the idea. Maybe she can send me a picture of her wearing it. She is a lot better looking than I am.

We bought sour cream for something we were going to make for dinner but didn’t end up using it. In such cases, I head for Google to see what “sour cream cookies” will produce. Here is the recipe I chose. When I took them to the emergency department, they were rapidly consumed. Pat, a clerk, said they were the best I ever made. They were not my favorite. I am more into chewy than soft and cakey. These are really soft and cakey. Oh, and I don’t care much for the nuts, even when finely chopped.

Source:

Cooks.com

Yield:

36

Ingredients:

½ cup butter, at room temperature

1 cup brown sugar, packed

2 large eggs, beaten

2/3 cup sour cream

1 teaspoon vanilla extract

2 cup all-purpose flour

½ tsp. salt

¼ tsp. baking soda

½ tsp. nutmeg

1 cup chopped dates

1 cup chopped walnuts (I used pecans and did them very fine in the food processor.)

Directions:

1. Heat oven to 375 degrees.

2. Cream butter and sugar until light and fluffy.

3. Blend in eggs, sour cream and vanilla.

4. Combine flour, salt, baking soda and nutmeg, mixing well. Stir into creamed mixture.

5. Gently stir in dates and nuts.

6. Scoop into 2 tablespoon-sized balls onto ungreased cookie sheets or sheets lined with parchment.

7. Bake for 10 to 12 minutes or until golden brown.

5. Cool about 5 minutes on cookie sheet and then remove with a spatula. They will be soft.

My parents bought a huge jug of coconut oil at Costco. Though they use some coconut oil, they recognized they didn’t need that much so they gave it to me. I came home committed to using it, since it was a gift from my parents.

I Googled “coconut oil cookies” and came up with several options to try. I liked these the best because the author said they were chewy (very good for my taste,) they used only coconut oil rather than a combo of oils, and they used coconut flavoring, which I have liked since my Aunt Mabel June shared her Cowboy Cookies recipe with me. These cookies are rich and very coconuty. They were just as good the second day, which is unusual.

Source:

howsweeteats.com

Yield:

30 cookies

Ingredients:

¾ cup coconut oil, melted but not hot

1 cup brown sugar, packed

1/3 cup granulated sugar

1 large egg

1 large egg yolk

2 teaspoons vanilla extract

¼ teaspoon coconut flavoring

2 cups all-purpose flour

½ teaspoon baking soda

¼ teaspoon salt

1 cup shredded coconut

1 cup mini chocolate chips (I used regular sized and they were fine)

1. Heat oven to 325 degrees F.
2. In a large bowl, whisk together melted coconut oil and sugars. Let sit for 15 minutes.
3. Whisk in egg, egg yolk and flavorings. Mix until completely smooth.
4. Add baking soda, salt and ½ cup flour. Stir to combine.
5. Add remaining flour, ½ cup at a time, stirring after each addition.
6. Fold in coconut and chocolate chips.
7. Scoop dough into 2 tablespoon balls. Place balls on parchment-lined baking sheet about 2 inches apart.
8. Bake 12-14 minutes, or until just set and edges turn a little brown. Let cool completely before removing to racks.

Note:

The original recipe called for less coconut and chocolate chips. It also called for them to be baked for only 7-8 minutes which, at this temperature, is hardly long enough to get them to sag.

Judy was the high bidder for the bag. Any money from such sales will be donated to the Foundation at my hospital. Thanks to all who participated!

A few years ago, I went for a mountain bike ride in the Soquel Demonstration Forest in the Santa Cruz Mountains. I was several miles up into the ride when I hit a tree and ended up on the ground. As my head cleared, I was in severe pain. I had a lot of pain in the left shoulder and couldn’t move it but there was nothing that felt like a fracture. I diagnosed a dislocation. The left knee hurt like heck, too, but was also not obviously fractured. I managed to get up and I could walk, although with a bad, painful limp.

Once assessing my physical condition, I assessed my assets and liabilities, as I had to decide what to do next. It was early on a Friday afternoon in February but was one of those perfect California winter’s days. Though it was not at all cold at the time, it would not be fun spending the night up there.

I decided that sitting and waiting for help was not an option. In retrospect, that was a good choice since I didn’t see a single person as I hiked out and there were no cars in the parking lot when I finely got there. If I had waited for help, I would have been up there all night. It was early in the afternoon in February but was one of those perfect California winter’s days. Though it was not at all cold at the time, it would not be fun spending the night up there.

Next, I had to decide whether I was better of with or without my bike. Though I couldn’t peddle it and could only use one arm, I decided to use it as a crutch and see how I did.

As I started hobbling up the hill, leaning on my bike, I realized I would be a lot more comfortable if I could relocate my dislocated shoulder. I have relocated many shoulders, including one on my friend on the ski slopes, so I was sure I could do my own. I put the bike down, grabbed my arm, bit down hard and tried to twist my shoulder back into place. This resulted only in a huge scream of pain. I gave up and, as soon as I could see straight again, continued on. As I went, I talked myself into believing I really could reduce my shoulder if I were just tough enough. I put the bike down again. I really focused all my attention on overcoming the pain and getting that shoulder back in joint. This time, I really pushed and twisted but with the same disappointing result.

After that, all I could do was just keep on going. When it was uphill, I walked, pushing the bike with my good arm and using it as a crutch. When it was downhill, I got on and coasted. Though this makes sense, the getting on and off was the worst part of it all. I couldn’t bend my left knee and any leaning over killed both the knee and shoulder. I was worried about loosing my balance and going down again as I struggled to get on and off the bike. I got so tired I was really tempted to lie down and take a break but my shoulder and knee had gotten so stiff and painful I was really afraid I would not be able to get up again once I was flat on the ground. So, when I had to, I rested by sitting on the bar of the bike but mostly I just forced myself to keep going.

It took me about two hours to get back to the parking lot, then I had to get the bike on the rack and drive about an hour from there to get to my hospital.

As soon as I could get a signal on my phone, I called my wife, told her I had hurt my shoulder and asked her to meet me at the hospital. She arrived first and was waiting for me at the loading zone in front of the emergency department. She was surprised when I told her I needed a wheel chair as she was just thinking of a shoulder injury.

They were waiting for us when she wheeled me into Room 2B. As soon as they pulled me up next to the gurney, I swooned. I think my adrenalin kept me going up until that time. When I was finally in a safe place, my autonomic nervous system let down and I almost passed out.

Next week, I will tell you about what happened next. I have told you about so many of my patients, I guess it is only fair to tell of my experience as a patient in the emergency department.