Author Archive

Coffee Malteds

Written by Tad. Posted in Cookies

 

Recipe By:

All over the Internet

Ingredients:

3 cups all-purpose flour
½ cup unflavored malted milk powder
1 teaspoon baking powder
1 cup butter, at room temperature
1 cup sugar
½ cup packed light brown sugar
2 tablespoons ground coffee, preferably from espresso beans (or use instant or powdered coffee or espresso*)
1 teaspoon fine sea salt
2 large eggs, at room temperature
2 large egg yolks, at room temperature
1 tablespoon pure vanilla extract

Directions:

1. Position the racks to divide the oven into thirds and preheat it to 350°F. Line two baking sheets with parchment paper or silicone baking mats.

2. Whisk the flour, malt powder, and baking powder together. Set aside.

3. Working with a stand mixer fitted with the paddle attachment, or in a bowl with a hand mixer, beat the butter, both sugars, espresso, and salt together on medium speed until well blended, about 3 minutes.

4. Scrape down the bowl, return to medium speed and, one by one, beat in the eggs, yolks, and vanilla, beating for 1 minute after each goes in.

5. Turn off the mixer, add the dry ingredients all at once and pulse, just to begin incorporating the flour and malt powder. Stir until combined. Using a cookie scoop, scoop out level portions of dough and place them two inches apart on the lined baking sheets.

6. Bake for about 14 minutes, rotating the baking sheets top to bottom and front to back after 8 minutes. The cookies will be soft and golden only around the edges. They won’t look done. They’ll firm as they cool. Transfer the sheets to racks and then, after about 10 minutes, carefully lift the cookies onto the racks to cool completely.

Notes:

*I tried them with coffee extract, half as much as called for. People thought they were butterscotch, rather than coffee. Use full coffee if you want the full coffee flavor.

Try adding mini chocolate chips. I liked them better this way – more interesting.

Taking a Dump at McDonalds

Written by Tad. Posted in Kooks

A middle-aged man with a black eye and scrape over his cheek sat on the gurney, obviously upset. He said he went into the local McDonalds to take a dump. Just as he was settling in to do his duty, a “crazy guy” he had never seen before broke into the stall hollering at him and accusing him of some insult.

The crazy guy got even more upset when my patient denied what he was being accused of and hit him across the face.

It was clear my patient’s face was not seriously harmed, so I asked if he had been injured anywhere else. In response, he pulled the sheet off his lap and showed me a large gash in his leg and a big blood clot on the end of his penis.

My mind started to spin. Something didn’t make sense. The man’s pants were clearly not cut, but he had serious injury to his genitals. I actually opened my mouth to ask him to explain. Then, I remembered an important detail and shut my mouth again. The patient had told me right at the beginning that he was attacked while taking a dump at McDonalds. In that situation, his pants might have been removed from danger but he would have been even more vulnerable.

I have never seen a penis injury like this before. The knife cut the foreskin in two and nipped off the very tip of his penis. It was still bleeding quite a bit.

We cleaned him up. I stitched the laceration on his leg. I put some stuff called Surgicel on the bleeding part of his penis. It helps promote clotting. And I had him hold pressure on it. Then, I made arrangements for him to be taken to a larger hospital for evaluation by a urologist. I really have no idea what sort of treatment they might recommend for this injury. If you cut the tip of your finger off like that, you just need to keep a dressing on it and it will heal up fine. But a nipped penis? I have no idea.

So, lesson learned: keep your pants up when you are taking a dump at McDonalds.

My “Cookie Bag”

Written by Tad. Posted in Trauma Strap Bags

For years, I have been taking cookies to the emergency department. Usually, they are stacked in gallon-sized Zip-Lock bags, carried in my Cookie Bag. The other day, when I came home from the hospital, I noticed that some of the seams were coming apart. I took it to my sewing room to mend it, like I have done with other bags a few times in the past.

As I started to sew up the splitting seams, I was surprised at what happened. The nylon straps just crumbled rather than sew together. The bag was literally falling apart. That lead me to do two things: 1. sew a new bag. 2. look to find out how old the Cookie Bag was.

Looking back, I was able to find a picture of my newly created Cookie bag: 20 August 2012. Almost seven years ago. That bag took a lot of cookies to the ED in its time. Now, it has been replaced. We will see how long this one lasts.

Dead Cookie Bag

Same bag when new in 2012

Replacement Cookie Bag 2019

My Husband Needs Me

Written by Tad. Posted in Kooks

My patient was a 60-year-old woman with lower abdominal pain. Her evaluation led to a CT scan which showed a very large pelvic mass, thought by the radiologist to be worrisome for ovarian cancer.

I frequently tell people we don’t diagnose cancer in the emergency department, which is technically true. But in a case like this, where it is very likely to be cancer, I have to be honest with the patient about what I have found. I pulled up a stool at the bedside and calmly told her what the scan showed. I clarified that it was most likely cancer and that I had made some phone calls to arrange to send her to see a gynecology/oncology specialist to get a definitive diagnosis and start her on the treatment she might need.

As the gravity of my news set in, she started to quietly weep. She was a nurse and understood, better than most of my patients, just what she might be facing. She quickly got hold of her emotions and then said she would not be taking me up on my offer to transfer her to see the cancer specialist. Her husband had cancer, she said. He was due to start his next round of chemotherapy the following day and she needed to be there to care for him. She had no time to care for herself. She would just go home and deal with her own problems when she could.

As I sat at her bedside, I was really moved emotionally. I saw a person who understood that delaying her treatment could lead to her death. But she cared more about her husband’s welfare than her own and felt she really had no choice in the matter.

I discharged her with the information about the specialist, with hopes she would find a way to go and get the consultation she so badly needed. I was unusually sobered and emotional when she left. As I recognized the effect this was having on me, I tried to understand why this affected me so much more than I would have expected.

One part of it, I am sure, was just the beautiful selflessness. All she cared about was taking care of her husband. Also, I could really relate. I am about her age and am married to someone I care about much more than I care about myself. I think her situation really hit close to home, leaving me very empathetic, with all the associated emotions.

Fortunately, this story has a happy ending. She came back a few days later. She had gotten her husband all set with his chemo and rounded up some social support as well. She went on to have surgery and was told it was not cancer, after all. So, fortunately, this story doesn’t have a tragic Shakespearean ending like I originally feared it would.

Tad’s Chocolate Fountain Cookies

Written by Tad. Posted in Cookies

For Fathers’ Day, my wife did a chocolate fountain for our fathers. I wondered what to do with the left over chocolate/oil mixture. I schemed a bit then came up with this recipe.  The cookies are dense and have a very pleasing chew.  The oats add an interesting texture and the cinnamon richness in taste. They made me proud enough to put my own name on them.

Recipe By:

Tad

Serving Size:

60

Ingredients:

3½ cups  flour, 15.75 oz
1 teaspoon baking powder
1 teaspoon soda
½ teaspoon salt
2 teaspoons cinnamon
1 cup  butter, softened
2 cups  brown sugar
⅔ cup  sugar
2 large eggs
12 ounces milk chocolate, melted over double boiler
2 tablespoons vegetable oil
1 tablespoon vanilla
3½ cups  oats, 10.5 oz
3 cups  chocolate chips

Directions:

1. Heat oven to 350 degrees.

2. Combine flour, baking powder, soda, salt, cinnamon. Set aside.

3. Whip butter and sugars.

4. Stir vegetable oil into melted chocolate.

5. Mix eggs, chocolate mixture and vanilla into sugar mixture.

6. Blend in flour mixture until just combined.

7. Stir in oats.

8. Stir in chocolate chips.

9. Scoop into 2-tablespoon balls. Place on baking sheets lined with parchment.

10. Partially flatten each ball with the bottom of a drinking glass that has been buttered then dipped in sugar. Dip the glass bottom again in sugar before flattening each subsequent ball.

11. Bake about 13 minutes. Don’t bake them until they look done or they will be over-done (as is true with almost all cookies.)

WrestleMania

Written by Tad. Posted in Kooks

A thirty-five-year-old man with a history of drug and alcohol abuse as well as mental illness, eloped from a long-term residential rehab facility in Georgia. He flew to our fair, California city to watch WrestleMania. I don’t know if he enjoyed the show or not but while here, he relapsed and fell into drinking excessively and taking methamphetamines.

This landed him in our emergency department, from which he was sent to psychiatry. There, he was evaluated and discharged. The psychiatrist said he could not be held against his will because he was not a danger to himself, a danger to others or gravely disabled. She noted he was sorry for what he had done. He promised to go to the airport, fly back to Georgia, return to his rehab and resume care with his psychiatrist.

If he really did make that promise to the psychiatrist, he didn’t follow through. In the subsequent week, he was kicked out of three different hotels because of problems caused by his excessive drug and alcohol abuse.

He was readmitted to our emergency department during my shift. In addition to being addled from methamphetamines, he also had severe conjunctivitis or eye infection. Both of his eyes were so swollen, red and yucky with dried discharge he was unable to open them. Usually, conjunctivitis is an annoyance. This man’s eye infection was particularly bad because his methamphetamine use caused him to dig and pick at his eyes constantly. He was aware enough to feel the irritation in his eyes but not aware enough to stop digging at them.

When we met, he was sleeping on a gurney in the hallway. I prodded him and called his name. He moaned and shifted a bit but was unable to talk. He was also unable to open his eyes because they were, literally, glued together with crusty yellow discharge. I had to pinch his upper and lower eyelids and pull them apart in order to see his red, swollen eyes underneath.

My plan was to observe him until his drugs wore off and then discharge him with antibiotics.

Over the next several hours, his mental status gradually improved and he was finally able to converse. He told me about coming to California because he loved WrestleMania. He admitted he had been drinking and doing drugs and, though he said he was sorry, he also admitted he had no plans to change any of his present behaviors when he left the emergency department. He also had no plans to return to Georgia any time soon. He denied having suicidal ideas, though he acknowledged that what he was doing was bad for his health. Though he was better, he was still not able to open his eyes or walk.

During this time, his mother called from Georgia. She demanded to talk with every staff person who would talk to her. Finally, it was my turn.

The mother made several demands. First, she wanted her son admitted to our hospital. To that, I explained he didn’t have any medical condition that would justify a medical admission. No one would admit him just because he was doing stupid things that were not good for him. As soon as he could walk, he would be ready for discharge.

She then demanded he be sent to psychiatry. She knew about his previous admission to that unit in our hospital. She told me the psychiatrist who discharged him said if he didn’t follow through on his promise to fly back to Georgia it would be proof he was a danger to himself and he would need to be committed.

I told her taking someone’s rights away is not something to be done lightly. We don’t do that just because someone is making very bad decisions, as in the case of her son. He would not be going back psychiatry.

She next insisted we call the police, have them take him to the airport and force him to get on the airplane home. I was amazed when I couldn’t get her to see there was no way the police would do that.

The mother consistently refused to accept any of my responses to her demands. She kept saying things like, “You just don’t understand. His life is in danger if you don’t do this.”

Things with the mother went from bad to worse when her son refused to get on the phone with her. “I don’t want to talk to her,” he said.

“Tell him I won’t scold him,” she assured me. That was not enough to get him on the phone with her.

I was unable to discharge the man before my shift came to an end. Though he had been in the emergency department for fifteen hours, he was unable to walk unassisted to the bathroom and he still could not keep his eyes open. I had to admit him.

After a day in the hospital, he was well enough to leave. The admitting doctor spoke to the patient’s mother on the telephone before discharging him. During that conversation, the mother threatened to sue the doctor and the hospital if they released her son. In part because of that threat, the doctor agreed to keep the patient one more day until the mother could fly out from Georgia to get him, which is exactly what happened. He was sent home the next day with his mother.

Salty Black Licorice Brownie Cookies

Written by Tad. Posted in Cookies

 

My wife doesn’t like black licorice but she really liked these. They are sophisticated and rich. Use less or more ground anise, according to your taste.

Recipe By:

Food52.com

Ingredients:

7 ounces 60% dark chocolate chips
2 tablespoons water
2 teaspoons vanilla extract
1/2 cup unsalted butter
2 large eggs, room temperature
3/4 cup granulated sugar
1/2 cup dark brown sugar, packed
1 cup all-purpose flour
3 tablespoons black cocoa powder (or Dutch-processed cocoa powder)
1 teaspoon baking powder
2 tablespoons licorice root powder (available in specialty spice stores)
1-2 teaspoons ground anise
1/4 teaspoon kosher salt (plus flaky salt for sprinkling on top)

Directions:

1. Preheat oven to 375° F. Line 2 large baking sheets with parchment paper or silicone baking mats.

2. Place chocolate, water, and vanilla extract in a medium heat-proof bowl. Set aside.

3. Place butter in a small pot over medium heat and begin melting. Cook for about 4 minutes, stirring frequently, until butter begins to brown and smell nutty. Immediately pour over chocolate mixture and stir until completely melted. Set aside.

4. Place eggs and both sugars in the bowl of a stand mixer fitted with a whisk attachment. Whip on high speed for 7 minutes until eggs are pale and ribbony. Meanwhile, sift together flour, cocoa powder, baking powder, licorice root power, anise, and salt. Set aside.

5. Reduce mixer speed to low and slowly add melted chocolate mixture. Once combined, add dry ingredients and mix until just incorporated.

6. Using a large #20 cookie scoop (or 3 rounded tablespoons), portion batter onto prepared trays leaving two inches between each. Sprinkle tops with flaky salt and bake until puffed and crackly, about 11 minutes. Remove from oven, give the tray a good smack against the counter, and let cool for at least 20 minutes.

A Bag for Chile

Written by Tad. Posted in Trauma Strap Bags

My friend, Teresa, is heading to Chile, home of her birth, for a visit. She asked me for a BIG Tad Bag to help her carry her stuff around on her visit.

She Won’t Go Home

Written by Tad. Posted in Kooks

As I come up with stories to share with you, I often pick them to exemplify different challenges we face as emergency physicians. Here is an example of something we face not too infrequently: a patient we couldn’t get rid of.

The evening shift doctor had seen her initially when she complained of vaginal bleeding and anemia. He found she was not bleeding and her blood tests showed no anemia. She was discharged just as we were changing shifts. I was warned that she didn’t want to leave and might give me trouble.

Sure enough, about an hour after I took over, the nurse came to me and told me the patient was still nauseous and was not up to leaving. I ordered some nausea medicine.

An hour later, I asked the nurse why the patient had not left the department. I was told she was unable to get a hold of anyone to give her a ride home. I asked that she be put out in the waiting room to await a ride. This is standard procedure when we are busy. The bed is needed for another patient and there is nothing wrong with someone waiting for their ride in the waiting room.

About three hours after I came on duty, she was finally out in the waiting room. But not for long. I soon was advised that she had feigned passing out and had to be brought back into an examination room. When I saw her, she was clearly pretending to be unconscious. I was too busy to deal with her at that time. I left her with the nurses to recheck her vital signs while I hurried off to take care of other, more pressing patient concerns.

Soon, I was able to spend some time reviewing her situation so I could decide what to do next. She was a relatively young, healthy lady. Her vital signs and laboratory tests were normal. She had already been in the ED for almost seventeen hours and nothing wrong had been found. She needed to leave. Still, always haunting the back portions of an emergency physician’s mind is the question: What might I be missing?

At this point, I had only two choices: force her to leave or admit her to the hospital. I mentally ran through both of those options in my head. We admit people to the hospital to receive medical care not available as an outpatient. This patient was in no need of such care. I couldn’t ask the admitting doctor to see her if it was clear there was nothing wrong with her. I had no choice but to accept a certain liability and send her out, even if she didn’t want to leave.

First, I had to wake her up. I was sure she was faking her unconsciousness. I proved this with an ammonia capsule. This is the modern equivalent of smelling salts.* A concentrated liquid ammonia compound is held in a small, thin-walled glass vial surrounded by an absorbent material. The vial is broken by being compressed between two fingers, releasing a strong ammonia smell. It is placed under the nose of the “unconscious” patient. No conscious person could continue to pretend to be unconscious when one of these is placed under his/her nose.

As I expected, her first reaction to the ammonia was to hold her breath. Tears then started forming in her eyes. When she was not able to hold her breath any longer, she turned her head to get her nose away from the capsule. I followed her, keeping the annoying, irritating stimulant under her nose until she was forced to talk to me.

“Why don’t you want to go home?” I asked.

“I don’t feel good,” was all she could come up with.

“I am sorry, but you are going to have to leave. Do you have anything you want to ask me?” She had no reply so I instructed the nurse to discharge her.

She had occupied a bed in our emergency department for almost eighteen hours by the time she walked out. How sad that someone’s life would be so messed up that lying around an emergency department pretending to be ill was better than anything else she had going on.

*https://en.wikipedia.org/wiki/Smelling_salts

Tad Bags Sewn in a Hotel Room

Written by Tad. Posted in Trauma Strap Bags

I have been working out of town. This gives me time looking for entertainment in my hotel-room home. This last week, I decided to take my sewing machine and try to make up some bags for people who have been asking for them. Here is what I came up with.

  

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