Our six-year-old grandson, Hunter, got a Swiss Army knife for his birthday. After misplacing it several times, I recommended he never just put it down. To reinforce this idea, I made him a tray to put at his bedside. I recommended he keep the knife only in two places: his pocket and the tray. I showed him that his tray was just like the one I use for such things in my bedroom. Since I made one for him, I also made one for his sister, Pippa, who said she was going to put her necklace and headband in it.

Hunter’s                                                               Pippa’s                                                           Tad’s

A 47-year-old woman came into the emergency department one evening. The “Chief Complaint,” as recorded by the nurse, was “Pain in the neck for 3-4 years. Wants x-ray done.”

She told me this all started about three-and-a-half years ago when she woke up in the morning with a “slit” in her left neck. She said she didn’t really think anything about it at the time. Since then, however, she has been having several troubling symptoms, making her think a chip had been implanted in her neck that night. She had been seeing strange flashes of light. Other than that, her symptoms were vague. She said she had “weird things happening all the time.” She had some vague discomfort in the neck but not really any pain. This was the first time she had sought medical attention for this problem. She couldn’t give me a reason why she decided to get checked out that day. She would not offer any idea of who might have implanted a chip in her neck or why. She had no medical history other than hypothyroidism. She denied any history of mental illness or substance abuse.

Her physical exam was unremarkable. Her neck was normal. I noted a lack of any scar. She behaved completely normally with no evidence of obvious psychiatric disorder.

There are many reasons for me to not believe what she was saying was true. I didn’t believe in a “chip” that could alter her behavior. I saw no reason someone would sneak into her bedroom one night and implant a chip in her neck. I don’t know how someone would do so without her waking up. I don’t know why she would not have freaked out if she woke with a slit in her neck that appeared while she slept. I don’t know how having a chip under her skin would cause her to see flashing lights and have all kinds of weird things happen to her. Though I didn’t believe she had an implanted chip I did believe she thought it was true.

So, my diagnosis was “delusion.” Here is one definition for a delusion: an idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder.

This fits her perfectly. Her belief certainly was idiosyncratic. She firmly held it to be true. Most people would generally agree her belief was not in keeping with reality. She was not open to any rational argument used to try to convince her otherwise.

What kind of delusional patients might an emergency physician deal with? I had an elderly man who believed all our laws were invalid since they were not based on English Common Law. I have seen several people who believed they had chips implanted in them by the CIA. I have seen patients who have delusions of religious persecutions. Toxic vapors and molds pervade the delusions of many patients. People irrationally believe their neighbors are pestering them. Delusional parasitosis, where people believe they are infested, inside and/or out, by vermin is rather common. I had one patient who was convinced our doctors were using “Mexican children” as “guinea pigs,” performing unnecessary tests on them. People sometimes feel persecuted or, the opposite, have delusions of grandeur where they think they are very important and due more respect than they are provided by society. They sometimes believe they have an illness causing their symptoms, even an illness not known to medical science. They sometimes have body image issues. Sometimes these delusions are wide-ranging and associated with paranoias. In other cases, they are limited and specific. Delusions can range from offering mild amusement to the outside observer, to severe, socially incapacitating conditions.

As with any medical abnormality, a doctor caring for such a patient wants to provide treatment. Many treatments have been shown to help with delusional disorder, though with various degrees of effectiveness. Treatments include medications and various types of behavioral therapies. One big problem in getting them help is they don’t want psychiatric help. They know what they are suffering from is not a psychiatric problem and they resent any insinuation they are crazy. So, they are often resistant to any recommendations for psychiatric intervention.

With that background, how should I deal with this patient? Within a short time of talking with her, I was sure she was delusional and I was not going to be able to “fix” her problem. I focused on listening, making sure she knew I was on her side. I recognized that one of the reasons she had come in was to get “an x-ray.” I was sure no imaging would show a chip in her neck but, in order to show I was interested in helping her, I ordered an ultrasound, explaining to her why I thought that would be better than a regular x-ray in identifying something that might be implanted in her neck.

When the ultrasound report came back negative, it was time for her to leave. I went over things, explaining that any chip in her neck would have shown up on the ultrasound. The problem with this disorder is that, by definition, it is resistant to logical evidence. I knew she would leave with her delusion intact, even with my reassurances about her ultrasound. I told her she needed to make an appointment with her primary care physician for further evaluation and treatment.

Some might say that punting to the primary care doctor is a lame way for me to escape a difficult situation but this patient needed a lot more help than what she might get from one visit to the emergency department. In reality, I had no treatment to offer her.

How the patient reacts to all of this helps determine how honest I would be with her. If she says, “Thank you very much” and leaves, I am done. But sometimes these people will not do that. Often, they have been to many doctors, including their primary care doctor and no one has done anything. Sometimes they say something like, “I know I have a chip in my neck but you just think I’m crazy!”

When I am pushed into this situation, I usually resort to is something like: “I can tell you are upset and I understand why. You know you have a chip in your neck and I know you don’t. There is nothing I can do to get you to believe there is no chip and there is nothing you can do to get me to believe there is. So, we are just going to have to agree to disagree and you will need to look elsewhere for further care.”

Even after that, often the patient will just start over again with their arguments trying to convince me. Sometimes, they will get angry and storm out, threatening to sue me or report me to the Medical Board. I never know when I enter into this last part of the visit whether the patient will walk out quietly with my sympathy or angrily with shouted threats.

Being an emergency physician, I never know what happens to delusional patients I have seen. How many of them work things out and get back to normal? How may carry on with their delusion giving them some trouble for a long, long time? How many degrade and become diagnosed with severe mental illness? I never know.

In anticipation of retirement, we bought a Sprinter van, fixed by Roadtrek into an RV. One of the things we learned right away is the importance of being organized, living in such a small space. We decided it would be good to have everything we need for the laundromat in a single bag. It is lined with a plastic box, in case of spills. Now, when it is laundry time, we just have to grab it and the clothes and head off.

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 19-year-old came in with discomfort in her vagina. She said she had used her mother-in-law’s “old douche bag.” She said she was afraid her nephew, who had been playing with the bag earlier, put marbles in it. She was afraid she might have marbles in her vagina. Her husband checked her, feeling for a marble earlier today. He said, “There is something up there that doesn’t belong there.” I removed a cat-eye marble from her vagina.

A 50-year-old man came in after a three-foot-long board was dropped onto him. The board had a nail sticking out of it, which was stuck into the scalp on the top his head. He had walked to a neighborhood fire station where the medics were called. They transported him with the board carefully secured in place. I just pulled it out.

A 37-year-old man stepped on a screwdriver that went clear up through, poking out the top of his foot.

A 15-year-old was brought in by ambulance after being hit by her 10-year-old sister with a can of Pringles.

A 26-year-old female presented at 6:00 in the morning complaining of being weak and tired after being up all night drinking whiskey at a party.

I was in the mood for something chocolatey to get my mind off of Covid-19 so I had Hunter and Pippa come over and help me make them. Given the need to ice them with lots of chocolate icing, they didn’t really make too much of a mess and we had a great time.

Recipe By:

King Arthur Flour

Yield:

24

Ingredients:

Cookies
1/3 cup unsalted butter
1/2 teaspoon salt
1 teaspoon vanilla extract
1 teaspoon baking powder
1/2 cup granulated sugar
1 large egg
1 1/2 cups flour
1/3 cup milk

Icing
2 cups semisweet chocolate chips
1 1/2 tablespoons light corn syrup
1 teaspoon vanilla extract
3/4 cup heavy cream
1 1/2 cups confectioners’ sugar, sifted
1/8 teaspoon salt

Directions:

1. Preheat the oven to 400°F. Line with parchment paper two baking sheets.

2. In a large mixing bowl, beat together the butter, salt, vanilla, and baking powder.

3. Beat in the sugar, then the egg.

4. Add the flour to the wet ingredients alternately with the milk, beginning and ending with the flour. Do this gently; there’s no need to beat the batter.

5. Using a spoon or a tablespoon cookie scoop, drop the dough onto the prepared cookie sheets. The balls of dough should be about 1 1/4″ in diameter. Flatten each mound of dough to a circle about 1 1/2″ across; wet your fingers or a knife, or grease the buttered bottom of a drinking glass or measuring cup to do this. Leave 2″ to 2 1/2″ between each cookie, for expansion.

6. Bake the cookies for about 10 to 11 minutes, or until they’re a mottled brown on the bottom (carefully tilt one up to look), but not colored on top. You may see the barest hint of browning around the edges, but these cookies are supposed to be soft and cake-like, so don’t over-bake them. Remove the cookies from the oven, and let them cool right on the pan as you make the frosting.

7. To make the icing: Place the chocolate chips, corn syrup, vanilla, and cream into a large microwave-safe bowl, or into a large saucepan.

8. Heat the mixture until it’s very hot; the cream will start to form bubbles. Remove from the heat, and stir until smooth.

9. Beat in the confectioners’ sugar and salt. Let cool to warm room temperature while you make the cookies. Dip the top of each cookie into the warm icing; swirl the cookie around to really give it a good coating. Set the cookies back on the baking sheet.

10. Spread the remaining icing evenly atop the cookies. If it’s too soft and flows off the cookies, let it set a bit, until it’s firmer. It’ll feel like you’re piling on a lot of icing; that’s precisely the point!

11. Allow the icing to set completely, then store the cookies airtight in a single layer.

Baltimore Berger

Sourdough Chocolate Chip Cookies

I made these during Covid-19 lock down.  I usually translate all the measurements in recipes from Great Britain into American but I found the recipe to be enjoyable as it is so I am just saving it pretty much like he wrote it.

Recipe By:

The Boy Who Bakes

Yield:

24

Ingredients:

225 g unsalted butter, diced
380 g plain flour
1 teaspoon baking powder
1 teaspoon baking soda
1 teaspoon flaked sea salt
220 g caster sugar
220 g light brown sugar
3 large egg yolks
240 g sourdough starter discard (100% hydration)
1 teaspoon vanilla extract
500 g dark chocolate, roughly chopped

Directions:

To make the cookies we first need to brown the butter. Don’t be tempted to skip this because this isn’t just done for flavour it also removes the water content from the butter which is being replaced by the starter, if you skip this step the resulting recipe will have a very different texture. Place the butter into a saucepan and over medium/high heat cook until the butter melts, bubbles and then foams. Keep a close eye on it as it can burn quickly, when the milk solids have browned the water will have been evaporated off so remove from the heat and set aside for 30 minutes or so, to cool slightly. Once browned you should have 185g unsalted butter left (that’s if using butter with an 82% fat content).

Whilst the butter is browning, place the flour, baking powder, baking soda and salt into a large bowl and whisk together to combine. When ready to make the cookies place the butter and sugars into a large bowl and using an electric mixer, fitted with the whisk attachment, whisk for a couple minutes to combine and to break up any lumps.

Add the egg yolks and whisk for 2-3 minutes on medium/high. Don’t worry if this looks separated or greasy at the moment, it will come together once we’ve added the starter.

Place the bowl on your scale and measure in the required sourdough discard, adding the vanilla as well.

Mix in for a few minutes or until the mixture becomes smooth and fully combined, it should look a little like a thick cake batter.

Add in the flour mixture and mix in on low speed, just until everything comes together as a dough.

Finally, switch to the paddle attachment and add the chocolate, mixing briefly until evenly distributed. Press a sheet of clingfilm onto the surface of the cookie dough and refrigerate for at least 4 hours before baking (my preferred time frame to bake these is between 4-24 hours). When ready to bake preheat the oven to 180C (160C Fan) and line a couple baking trays with parchment paper. Roll the cookies into balls roughly 70g in size, placing 6 per baking tray, with plenty of space between each one as these will spread. Sprinkle the cookies with a little flaked sea salt.

Bake in the preheated oven for about 16-18 minutes or until the cookies are lightly browned around the outside. If the cookies come out a little puffy looking give the baking tray and firm tap on the counter to help them flatten a little. Allow to cool on the baking tray for 10 minutes before transferring to a wire rack to cool completely. Stored in a sealed container these will keep for 4-5 days. You can also freeze these balls of cookie dough for up to a month, baking straight from frozen with just a minute or two of extra bake time.

Notes:

Note: With my regular cookie recipes I will leave the dough in the fridge for up to three days but with these remember that even though the discard may be less active than your usual starter you are adding sourdough to fresh flour so overtime the dough will ferment a little more, so the longer you leave the dough the stronger the finished flavour.

Once the dough is chilled and you’ve rolled them into balls you can freeze these for up to a month. To freeze place the balls onto a parchment lined baking tray that will fit in the freezer. Freeze the cookies until frozen solid, at this point the cookies won’t stick together so you can add them to a freezer bag or Tupperware to save on space.

For the chocolate I normally like a high-quality dark chocolate but you can really use whatever you have, be that a milk or dark, bars, chips or wafers. Each one will make a slightly different cookie with different textures and tastes but they’ll all be great.

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 46-year-old man working to make a wall of rebar which gave way and fell over, pinning him underneath it. He had a one-inch diameter piece of rebar running through his right biceps. He was soaking wet from the water that was used to cool the metal as it was cut on each side of his arm to free him from the structure.

A 24-year-old lady was driving in reverse in her driveway when she looked in the rear-view mirror and saw her children playing behind the car. She freaked out, jumped out of the car without putting it in park, and was promptly knocked down by the open door. The car also continued and knocked over both of the children, running them over all of them. Fortunately, none was seriously injured.

A group of teens rolled their car while driving in reverse in a parking lot of a shopping mall.

The daughter of my elderly patient with diabetes said, “I woke up and found her on the floor unresponsible.”

A 54-year-old woman was sitting in church when she developed “power in my vagina” which moved up into her heart and caused chest pains.

More Bad Tad Meanwhile next time!

Steven Colbert does a segment on his “A Late Show” that he calls “Meanwhile.” It is a collection of little news items, too small to stand alone as a story on his show. Here is another little “Bad Tad Meanwhile.” A little fact about a patient where there is no more information available or it doesn’t matter. Just weird encounters in the emergency department.

A 74-year-old man claimed he came in to be seen “sooner rather than later” because he didn’t want to be a “bad looking corpse.”

A young man fell on an arrow, which stabbed him up under the chin. It passed through his tongue, the roof of his mouth and into his nasal cavity.

A young woman came in complaining of a “bad infection in my grinder.” I had never heard a woman refer to her vagina as a “grinder” before and have not been able to find such a definition anywhere, even in the likes of Urban Dictionary. Maybe I am just not street wise.

I asked the son of an elderly man if his father had any medical problems. He said, “He has something wrong with his arm.” I pulled up the patient’s sleeve to reveal a dialysis shunt. So, chronic renal failure on dialysis turned into “something wrong with his arm.”

More Bad Tad Meanwhile next time!

Here is a departure from my usual bags. I started making bags to find a use for trauma straps that were otherwise ending up in the trash. Years later, we were eating lunch in a little South Asian grocery store with a little restaurant in it. They had big rolls of nylon straps for sale. I was unable to learn what Indians might use them for but I bought a roll to see what I could come up with.

Here is a picture of the bag I made. I modeled it after a shopping bag we bought when we were on vacation in Mexico in 1992. It has been such a great bag for us for all those years that I decided to recreate it. I have now made two of them and they are great for larger volumes like going the beach. No trauma straps but a fun bag.