A 31-year-old woman came in with right eye pain, decreased vision and light sensitivity for eleven days. She had been pounding a screw driver with a hammer to try to open a lock. As she did so, a piece of metal broke off and hit her in the eye. She experienced a lot of pain and could see blood inside her eye. It was not clear why she had not sought care earlier or why she finally came in.
Her vision was decreased in the right eye and I could see a hole through the iris (colored part). An x-ray showed a large piece of metal (foreign body, in doctor talk) in the middle of her eye. I called an ophthalmologist and admitted her to the hospital so they could operate on her, take the metal out and deal with the developing infection.
A case like this brings up some interesting questions about human behavior. I would think that pretty much everyone would look at their eyesight as being very important and something to be protected. It seems clear to me that someone pounding metal who gets a pain in the eye and can see blood inside the eye would immediately assume the eye had been injured by a hunk of flying metal. Putting this all together, I would also assume that most people would immediately seek medical care. Indeed, we see people all the time who have an injury of some kind and head immediately to the emergency department even if it is something minor like a sprained ankle.
So, why did this woman with pain and blood in her eye wait eleven days to come in for care? Most of the time, I don’t ask why an individual would make what seems like an unwise decision. Such questions might be perceived as being judgmental and would not change what I need to do for the patient.
On occasions, when I have asked or the patient volunteered their reasons for a delay in coming in, they give reasons like this: fear of doctors, worry about the cost, having no ride, thinking it is going to get better or didn’t really think it was that bad. Such reasoning doesn’t always lead to bad decisions. If you have a cold or a minor sprained ankle, it is very unlikely there will be a bad outcome without medical care. But people use these same reasons to delay seeking care for serious illnesses like heart attacks, strokes, or a serious injury to the eye.
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 the eye 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.
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.
All over the Internet
1 cup butter, at room temperature
1¼ cups granulated sugar
⅔ cup packed brown sugar
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
5 cups corn flake cereal
½ cup milk powder
3 tablespoons sugar
1 teaspoon salt
9 tablespoons butter, melted
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.
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.)
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.
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
½ cup butter at room temperature
¼ cup Coca-Cola at room temperature
4 cups powdered sugar
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.
Eating Out Loud
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
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.
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:
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!
New York Times Cooking
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
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.
* 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?