Archive for April, 2020

Covid-19

Written by Tad. Posted in Cookies

The other night, the charge nurse came in with cookies her daughter had made to celebrate our crazy times. I think she did a great job!

Tamarind-Jaggery Gingersnaps

Written by Tad. Posted in Cookies

I am always looking for some cookie that sounds like something I have never tried before. I am familiar with tamarind from my years living in Mexico, though I admit I never developed a taste for the candy Mexicans make with tamarind, sugar and chile. I like Indian food but admit, as well, that I am not too familiar with many of the ingredients used in Indian cooking. I had the garam masala but had to go online to buy tamarind paste and jaggery. This was a fun cookie-baking adventure.

Recipe By:

thetakeout.com

Yield:

40

Ingredients:

2 5/8 cups all-purpose flour, (12 ounces)
1 teaspoon baking soda
1 teaspoon kosher salt
2 teaspoon ground ginger
1 teaspoon garam masala
¾ cup butter
  cups powdered jaggery, sifted (see note 1)
1 egg
1 teaspoon vanilla extract
¼ cup molasses
2 heaping tablespoons tamarind paste (see note 2)
½ cup granulated sugar, for rolling (see note 3)

Directions:

1. In medium bowl, combine flour, baking soda, salt, ginger, and garam masala. Whisk to combine. Set aside.

2. Using a stand mixer fitted with the paddle attachment, cream butter and jaggery until light and fluffy.

3. Add egg and vanilla to butter mixture. Mix to combine.

4. In small bowl, combine molasses and tamarind paste. Add to butter mixture. Mix to combine.

5. Set mixer speed to low. Add dry ingredients in 3 installments, scraping down sides of bowl between additions, until combined.

6. Transfer dough to a resealable glass or plastic container. Chill thoroughly, at least 2 hours and up to 3 days.

7. Heat oven to 350 degrees. Line baking sheets with parchment paper. Put granulated sugar in a small bowl.

8. Portion and shape dough into 20-gram (1 tablespoon) balls (*see note 4) Drop each into the bowl of sugar and roll to coat. Transfer cookies to the prepared baking sheets, leaving at least 2 inches between each.

9. Bake until the cookies are golden underneath but still quite tender, 13-15 minutes. Let cool 2-3 minutes on baking sheets. Transfer to wire racks to cool completely. The cookies will crisp as they cool.

Notes:

1. Jaggery is unrefined palm sugar. It is like Mexican piloncillo, which is made of cane sugar.

2. Make sure to use tamarind paste, not concentrate.

3. I prefer Sprinkle King Con AA White Coarse Sugar.  I get it from supplyvillage.com.

4. I always use a cookie dough scooper. Well worth the investment.

Assaulted in the Emergency Department

Written by Tad. Posted in Kooks

Working in the emergency department can be dangerous. It is a stressful place for everyone. Many patients are impaired from drugs and alcohol. Mentally ill patients frequently end up in the emergency department. Gun shots have even been fired while I was working in my emergency department.

I have been an emergency physician for over thirty years. During that time, I have been yelled at and threatened. I have been spit at several times, once right in the face. But I have never been physically assaulted – until recently, when I was actually knocked down by a patient. I was not injured but I was surprised at how much this bothered me. I realize the older I get, the more at risk am to being assaulted. Also, to do well in a high-risk environment, one has to kind of fall back on the “it can’t happen to me” defense. Once it has happened to you, it is harder to effectively use that. I was really shaken by this. Enough that it contributed to my decision to retire, a bit earlier that I had planned to. It was important enough that I want to tell you about it.

Staff alerted me that a patient having a seizure had just arrived. He was being wheeled into the room the same time I entered. I saw a healthy-looking young man, about twenty years old, sitting up in the wheel chair. He was clearly faking having a seizure.

For some reason, faking seizures is a pretty common way for people to try to gain attention. Some of them are pretty good fakes but an experienced emergency physician can often tell, at a glance, the patient is not really having a seizure. I shared my impression with my staff. That allowed them to relax and move ahead with stuff like getting vital signs and attaching the patient to the monitor. I went to take care of another patient while all of that was being done.

When I went back into the room, the patient was behaving normally. His brother-in-law was with him and helped give me the following history. The patient had just come from another hospital where he was admitted to intensive care, a breathing tube was passed down his throat and he was treated with multiple medications to get him to stop seizing. The patient and his family were unhappy with his care so they signed him out and brought him to our hospital in the neighboring city. The patient complained, “All they did was just knock me out.” He admitted he had not been taking his seizure medicine before he had the seizure that took him to the other hospital.

I started with his vital signs and a physical examination, which were normal. To evaluate someone who is having seizures, I might have ordered blood tests, a urine drug screen and a CT scan of the brain. However, since he had just come from another hospital, I thought testing might have already been done. I asked the patient for permission to request records from his previous visit, thereby avoiding unnecessarily repeating tests.

Before too long, the report was faxed over from the other hospital. It was pretty amazing. He had arrived having seizures and had been given several medications to stop them. None worked. As a last resort, the patient was paralyzed and put under general anesthesia. A breathing tube was passed into his windpipe and he was placed on a ventilator. All laboratory testing was normal, as was the CT scan of his brain. Up in intensive care, they let him slowly wake up then pulled the breathing tube out. He promptly refused further treatment, signed out against medical advice and left the hospital.

Within a couple of hours, he was back in their emergency department, seizing again. Once more, he was given medications to stop his seizures. They repeated all of the labs and the CT scan. When no medications stopped his seizures, they decided to paralyze and intubate him again. Before they did, he stopped seizing, refused further care, and signed out against medical advice a second time. That’s when he came to our hospital. So, in the last twenty-four hours, the patient received two complete seizure work-ups. All was negative.

Seizures are hard on the brain. Someone who has been seizing a long time usually does not wake up right away. It could take hours before returning to normal mentation. For him to stop seizing, wake up and immediately walk out of intensive care made me wonder if he had been faking all along. Regardless, he was not having seizures in my department. All he needed to do was go home, take his medicine and follow up with his doctor.

As is my habit when discharging someone, I went into the room and sat on a stool at the foot of the gurney. I calmly explained what I learned and why there would be no reason for us to do any additional testing or provide him with any treatment. As what I was saying began to sink in, he started hollering and swearing at me. He stood up, called me several nasty names, pulled off his monitoring pads and yanked the IV out of his arm.

He announced he was leaving and I could see he was in no frame of mind to listen to me anymore. So, I stood, moved to the door and pulled it open for him to go. As he walked by me, he took a big swing at my head. Reflexively, I pushed the door into him to protect myself. The door knocked him back and kept his roundabout swing from landing a blow. He quickly recovered and came back swinging, knocking me down onto the gurney. Fortunately, his brother-in-law jumped between us and pushed him back against the wall, giving me a chance to roll off the gurney onto the floor. I then scrambled out the door on the other side of the room.

I was not injured but I was shaken. I am sure he would have hit me if I had not been able to use the door to protect myself and if his brother-in-law had not been there to hold him back.

I can’t help but think he was a troubled person. I assume everything that happened at the other hospital as well as his assaulting me as I tried to give him discharge instructions were as a result of underlying mental problems. It makes me wonder how long it will be until he attacks someone else and whether that person will be as lucky as I was to escape serious injury.

Cocoa Nib Chocolate Cookies with White Chocolate and Fleur De Sel

Written by Tad. Posted in Cookies

If you have not baked with cocoa nibs, you should really give it a try. They are roasted, cracked cocoa beans. They have a great, nutty flavor and add a fun crunch to your cookies.

Recipe By:

The Grand Central Baking Book by Piper Davis and Ellen Jackson

Yield:

48

Ingredients:

1¼ cups all-pose flour
½ cup unsweetened cocoa powder
½ teaspoon salt
½ teaspoon baking soda
12 tablespoons unsalted butter, at room temperature
¼ cup granulated sugar
¾ cup packed light brown sugar
1 teaspoon vanilla
½ cup cocoa nibs
½ cup white chocolate (such as Lindt) chopped fine*, 3.5  ounces

Directions:

1. *  Chop the chocolate  into small chunks just smaller than the size of a chocolate chip.

2. In a medium bowl, sift together the flour, cocoa, salt, and baking soda.  Set aside.

3. Using a stand mixer and the paddle attachment, beat the butter, granulated sugar, and brown sugar on medium speed until light and fluffy, about 3 minutes.  Add the vanilla and beat to combine.

4. Reduce the mixer speed to low and add the dry ingredients.  Mix just until combined.  Using a wooden spoon or rubber spatula, fold in the cocoa nibs and white chocolate.

5. Divide the dough in half.  Place each half on 14-inch length of parchment or wax paper.  Smooth and pat the dough into two 2-inch by 10-inch logs.  Twist ends securely and refrigerate the logs for at least two hours and up to 3 days.

6. Preheat the oven to 325˚F.  Line two baking sheets with parchment paper.

7. Slice the cookies 3/8-inch thick and place them about 1 inch apart on the prepared baking sheets.  Bake for 15 to 20 minutes or until the cookies are just firm to the touch.

Last of the Blue Straps

Written by Tad. Posted in Trauma Strap Bags

I have always been limited in my bag making by what straps have been discarded in my emergency department. I recently made these bags, using the very last of the blue straps I have. So, no more blue bags.

Chocolate Peppermint Surprises

Written by Tad. Posted in Cookies

 

These cookies were billed as “Fudgy and rich, like brownies.” That is certainly true. They are very chocolatey and decadent. You can adjust the amount of dough incorporated into each cookie. The more the dough, the more fudgy they are and the subtler the mint flavor. I am excited to make them with other stuff in the center like peanut butter cups, Werther’s candies or marshmallows.

Recipe By:

Sunset

Ingredients:

¾ cup all-purpose flour
1 teaspoon baking powder
½ teaspoon kosher salt
16 ounces bittersweet chocolate (60% cacao), chopped
¼ cup unsalted butter
4 large eggs, at room temperature
1½ cups Demerara or turbinado sugar, *see notes
1 tablespoon vanilla extract
30 small peppermint patties, such as York, 1 package, about 20 ounces, unwrapped and chilled

Directions:

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

2. Put chocolate and butter in a medium-sized metal bowl and set over a saucepan of 1-inch simmering water. Bowl should not touch water. Heat, stirring occasionally, until chocolate melts and is completely smooth. Remove bowl from pan and let cool. **see notes

3. Using a stand mixer with whisk attachment, beat eggs on medium-high speed until foamy.

4. With motor running, gradually add sugar. Continue beating until mixture is light and tripled in volume, about 7 minutes.

5. Blend in cooled chocolate and vanilla, scraping bowl as needed.

6. Reduce speed to low and mix in dry ingredients until smooth. The dough will be thin, like cake batter. Chill, covered, until dough is firm enough to scoop. The original recipe said, “at least 4 hours or overnight.” When I chilled it overnight, it was so hard it was unshapable. So, it needs to be chilled to be able to work with it but watch that it not get too hard.

7. Heat oven to 350°. Line 2 baking sheets with parchment paper. Using 1-tablespoon scoop, portion a half-dozen balls of dough onto a work surface. Roll them in granulated sugar. Lightly butter the bottom of a drinking glass. Press each dough ball, with the bottom of the glass, into a disk about 2 inches wide. Repeat to make a second disk. Set a peppermint patty on one disk. Top with a second and press edges to seal. Repeat to make more cookies, spacing them about 1½ inches apart on lined baking sheets.

8. Bake 1 sheet of cookies at a time until set at edges and crackled in center, about 12-14 minutes. Let cool on baking sheets for a few minutes, then loosen from parchment with a wide spatula and transfer to wire racks to cool completely.

Notes:

*I just used granulated sugar. The original recipe says. “Light brown, partially refined Demerara and turbinado sugars have a more complex flavor than regular brown sugar. You can find them with the baking supplies at well-stocked grocery stores.” I guess my local Nob Hill is not well-stocked.

**I carefully melted them in the microwave like my dad, a master candy maker, always did.

Human Experimentation and Medical Malpractice on Mexican Children

Written by Tad. Posted in Kooks

This is a complaint that a patient submitted to Customer Service at the hospital. Customer Service sent it to me as Medical Director of our emergency department. When I would get such a complaint, it was my responsibility to look at the medical record, talk with any staff involved and reply to Customer Service.

Just for background: a spinal tap is a common procedure performed on children and adults in the emergency department. It is done to make sure they don’t have spinal meningitis, which is a serious brain infection which can kill or seriously injure the infected person if not treated repidly. To preform a lumbar puncture, a kid has to be held tightly while a little area on the lower back is numbed up. A small needle is passed between two bones in the spine to take out a sample of fluid that is then sent to the laboratory to look for signs of infection. It is not fun for the baby, the parents or the doctor. It is also not an operation nor experimentation.

This is one of many similar complaints this man made to Customer Service. Most were about Hispanics not being treated appropriately in the hospital. His complaint was so wacko, it was hard to even take it seriously as I formed a response.

Here it is. Other than removing names, it is copied word for word from his Customer Service complaint form.

 

Subject: Human Experimentation and Medical Malpractice on Mexican Children

Attn: Chief Administrator, The Medical Center

RE: Spinal tap surgery performed on 2-3-year-old Mexican Child by M.D. (non-surgeon) & assistant.

  1. Location: Emergency Room A (close to entry/exit)
  2. Time: 2-3 a.m. (morning), 2 September
  3. Condition: Non-surgical, non-hygiene; inhumane – young child screaming throughout experiment.
  4. Physician: Dr. M. and other emergency room associate (at least one.)
  5. Please note: Child and Parents spoke no English.
  6. Please note: After this inhumane butchery, Dr. M. and company celebrated for an hour between 3 and 4 a.m. in the morning. (This is the second experiment/celebration we are aware of by Dr. M. & et. al.)
  7. Immediate suspension w/o pay, arrest, imprisonment, prosecution and revocation of medical license are mandated for public safety.

I have additional notes from my conversation with the patient, however they are covered here.

 

Drunken Mormon

Written by Tad. Posted in Kooks

Maybe you are tired of hearing stories about drunks, but I am afraid any blog about emergency patients is going to be full of stories about drunks. We see so many drunks it takes a pretty amazing drunk to be remembered many years later. Here is a sad one I will never forget.

An elderly woman was found in her home, intoxicated, with a half-empty vodka bottle at her bedside. It was not clear who had called the paramedics. She had no complaints and said she was in no need of medical care. She had been verbally and physically abusive to the paramedics before she arrived. She had to be restrained in the emergency department to keep her from striking our staff.

She was very thin, half naked, intoxicated, disheveled and wet with urine. She was very uncooperative and refused examination and treatment. She demanded to be let out of the restraints.  When I pointed out that she was too drunk to be trusted out of restraints, she adamantly denied being intoxicated, saying she was a Mormon and didn’t drink alcohol.

This was an interesting defense to use on me. Though she obviously had no way of knowing it, I am a practicing Mormon. This makes me very aware that most Mormons live by health standards that forbid the use of alcohol. Using Mormonism as a defense for her present situation might have worked on someone else but was clearly not going to work on me. Also, as an emergency physician, I am very familiar with signs of alcoholism and am very good at telling who is drunk. It was obvious to me that she was both an alcoholic and acutely intoxicated.

I then did what I usually do with such people: wait. I checked on her frequently, expecting that, with time, she would sober up, allowing me to be assured she had just been drunk and not in need of medical care for some other problem.

As she sobered, she admitted she had been drinking but she denied being drunk. Every time I tried to talk with her, she got upset and threatened to “cut (my) balls off.” She refused to call for anyone to come take her home.

It took all night for her to sober up.  When she was ready to leave in the morning, she continued to refuse to call for a ride. She was provided with dry clothes and allowed to leave. As she was walking out, I couldn’t resist the temptation to say to her, “Have fun reading your Book of Mormon.”

She stopped, angrily spun around and flipped me off before turning on her heels and walking out.

Jam Cookies

Written by Tad. Posted in Cookies

I made this with LeBonMagot White Pumpkin and Almond Murabba with Cardamom and Vanilla. (Murabba means Jam.)  It was a gift to me from my daughter, who went into a specialty store in Manhattan, where she lives, and asked the clerk for the most interesting ingredient they had that could be use in cookies. Quite a challenge to come up with a distinctive cookie recipe using jam!

Recipe By:

Mazar Cuisine

Ingredients:

1 egg
6 tablespoons sugar
1/2 cup oil
6 tablespoons butter
1 teaspoon baking powder
1 teaspoon vanilla
3 ½  cups flour
½ teaspoon salt
1/2 cup pecans, finally chopped
8 ounces jam

Directions:

1. Heat oven to 350 degrees.

2. Beat egg and sugar.

3. Beat in oil, butter, baking powder, vanilla and salt.

4. Stir in flour, in intervals.

5. Spray 9×13 inch baking pan with cooking spray.

6. Press dough flat into baking pan.

7. Spread evenly with jam.

8. Spread nuts evenly over jam.

9. Bake 35 minutes.

Copyright © 2014 Bad Tad, MD