Archive for February, 2021
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?
These are more complicated to make than a lot of cookies but they came out striking looking and are delicious.
1 cup flour
½ cup unsweetened cocoa powder
1/4 teaspoon salt
1/2 cup unsalted butter, at room temperature
2/3 cup granulated sugar
1 large egg yolk
1 tablespoon heavy whipping cream
1 teaspoon vanilla extract
1/2 cup sparkling sugar or powdered sugar for rolling, or just leave plain
CARAMEL* see notes
1 cup granulated sugar
6 tablespoons unsalted butter, cut into tbsp.-size chunks
1/2 cup heavy cream
1/4 teaspoon fine sea salt, plus about 1/2 tsp. for sprinkling
1. Make cookies: Heat oven to 350°.
2. Sift flour, cocoa powder, and salt into a bowl. Set aside.
3. In another bowl with a mixer on medium speed, beat butter and granulated sugar until pale and fluffy.
4. Reduce speed to low and add egg yolk, cream, and vanilla.
5. Gradually beat in flour mixture.
6. Scoop dough into rounded 2-tablespoon portions and roll into balls. Roll balls in sparkling or powdered sugar to coat. Place 2 inches apart on parchment paper-lined baking sheets.
7. With end of a thick-handled wooden spoon, gently press an indentation into center of each cookie. (I use a cork that we have had in our kitchen for years. I don’t think it has any other reason than to make thumbprint cookies.)
8. Bake until cookies are just set, about 10 minutes. (The depressions tend to fill in a bit as they bake, so as soon as they’re out of the oven, give them another press with the spoon if necessary.) Slide parchment with cookies onto cooling racks and let cool. If you’ve used powdered sugar, sift a little more onto the cookies.
9. Make caramel: Put granulated sugar in a large nonstick frying pan; spread evenly. Heat over medium-high heat, stirring constantly with a wooden spoon. Sugar will form clumps but eventually will melt and turn into a dark, amber-colored liquid, about 6 minutes.
10. As soon as it’s liquefied, reduce heat to medium-low. Stir in butter until incorporated.
11. Stirring constantly, drizzle in cream. Boil 1 minute, stirring. Remove from heat and stir in 1/4 teaspoon sea salt. Scrape into a bowl and let cool completely.
12. Assemble cookies: Spoon about a teaspoon of caramel into each cookie. Sprinkle with a few grains of sea salt.
You’ll have more caramel than you need, but that’s never a bad thing–it’s great on ice cream. Don’t be tempted to cook a half-batch of caramel, as it won’t cook right and will seize up.
I used the Peter’s Caramel block I had in the cupboard. Shari shaped a 12-gram discs of caramel for each cookie. Three minutes before they were to be cooked, I took the baking sheet out of the oven, placed a caramel disc on each cookie then returned them to the oven to finish cooking. I sprinkled the sea salt on when they came out.
My mother-in-law says, “Things always come in threes.” I don’t believe that but I can’t help notice coincidences in my practice. Usually, it involves looking for different patients with similar illnesses or injuries. In this first case, it was infant twins who shared three identical abnormalities.
Mom brought in her fraternal (not identical) twin daughters for fevers. They had been sick about the same period of time. I diagnosed both with urinary tract infections. It was kind of a surprise that the two of them would come down with an infection like that at the same time. I also noticed they both had umbilical hernias and were tongue-tied. Umbilical hernias are hernias at the belly button. They are not at all unusual in kids this age but it was certainly an interesting coincidence that they both had them. To be tongue-tied means that the frenulum (the small fold of skin beneath the tongue) is too short or tight. This keeps a person from being able to stick his or her tongue out normally. It is usually treated with a minor procedure where the doctor numbs and snips the frenulum, releasing the tongue to stick out normally.
It seemed to me quite a coincidence that both of these sisters had the same three abnormalities.
Speaking of coincidences…
One night, a young man was dancing. While doing so, he thrust his arm into the air, causing a dislocation of his shoulder with the arm stuck straight up in the air. Shoulder dislocation is a pretty common injury we see in the emergency department. That it happened when he was dancing was really unusual as the shoulder usually dislocates because of a fall or other injury that involves more energy. Also, a shoulder dislocation usually results in the patient’s arm hanging down at his or her side. Having it dislocate so it is locked with the arm pointing straight up in the air is also very unusual. I gave him pain medicine and sedatives. I was then able to easily get his arm back in the socket again.
Two nights later, another young man came in with his shoulder dislocated and stuck up over his head. Rather than dancing, this happened when he rolled over in his sleep. It sounds crazy but there are people whose shoulders can just pop out of joint, even from rolling over in bed. Usually this joint instability arises from previous dislocations which damage the supporting structures of the joint leaving it subject to easily popping out. This often needs to be corrected with surgery. Again, they usually present with the patient’s arm down to his or her side. That he also had his shoulder locked with his arm pointing up only two nights after the other guy is quite a coincidence.
You can imagine my mother-in-law would have had me keeping my eyes out for that third shoulder dislocation with the arm pointing up in the air, but it never happened.