Meagan is a paramedic who asked me for a Tad Bag. She shared this picture of her cat sitting in the bag. She shared this picture with me and I share with you.

I don’t always make whole bags. A friend came over and asked me to put a strap on her computer bag. This is what I came up with. Though it was a pain to sew down inside the bag, it turned out very well.

Tahini is like peanut butter made out of sesame seeds. I think that distinctive flavor of sesame goes great with the chocolate chips, added in with generosity in this fun recipe.

Recipe By:

cooking.nytimes. come

Ingredients:

4 ounces unsalted butter, at room temperature
½ cup tahini, well stirred
1 cup granulated sugar
1 large egg
1 egg yolk
1 teaspoon vanilla extract
1 cup all-purpose flour, plus 2 tablespoons
½ teaspoon baking soda
½ teaspoon baking powder
1 teaspoon kosher salt
1¾ cups chocolate chips
Flaky salt, like fleur de sel

Directions:

1. In the bowl of an electric mixer fitted with the paddle attachment, cream butter, tahini and sugar at medium speed until light and fluffy, about 5 minutes. Add egg, egg yolk and vanilla and continue mixing at medium speed for another 5 minutes.

2. Sift flour, baking soda, baking powder and kosher salt into a large bowl and mix with a fork. Combine flour mixture to butter mixture at low speed until just combined. Use a rubber spatula to fold in chocolate chips. Dough will be soft, not stiff. Refrigerate at least 12 hours.

3. When ready to bake, heat oven to 325 degrees and line a baking sheet with parchment paper or nonstick baking mat. Use a large ice cream scoop or spoon to form dough into 12 to 18 balls.

4. Place the cookies on the baking sheet at least 3 inches apart to allow them to spread. Bake 13 to 16 minutes until just golden brown around the edges but still pale in the middle to make thick, soft cookies. As cookies come out of the oven, sprinkle sparsely with salt. Let cool at least 20 minutes on a rack.

Notes:

I skipped refrigeration and they were fine.

Cooking at this lower temperature, they really didn’t brown well for me.

Frequently people with complicated past medical histories come into the emergency department for care. If they have an organized list of their problems, it is really helpful. We want to keep their past history in mind as we evaluate the new problem that brought them to the emergency department today.

At other times, people are hypochondriacs or just weirdos and their list is really not helpful. It can be fascinating reading, however. Here is one such list. I reproduced it as exactly as I could.

Currenty told I have the following wrong

1. Prostate Cancer
2. Broken back and I spent 2 days in VA hospital and told nothing they could do due to many breaks
3. Diabetes type 1 was on 12 units of insulin and now at 25 units. Started type 2 in 2003 and became type 1 in 2009. one injection in am and one in pm.
4. Degenerative disc disease
5. Peripheral neuropathy
6. nerve neuropathy
7. Osteoporosis vertebroplasty
8. Both eyes operated on for cataracks
9. Fatigue
10. Feet go numb and once turned blue due diabetes.
11. Multiple age indeterminate compression deformities diagnostic code abnormality
12. Several calcification within pelvis which likely represent phleboliths.
13. Ureteral calculi cannot be excluded sub acute end plate deformity at L1, L2, L4, L5 with associated enhancement
14. Enlargement of prostalic.
15. L3 and L4 bilateral neroforaminal stenosis.
16. Degenerative changes causing central canal and bilater neuroforamind stenosis at L4 and L5
17. post operative changes of left laminotomy at L5 and Sl.ss
18. Mild compression deformities at L5, L2, LI.
19. cant walk too for before getting tired
20. Right hand drops things. Left does it too but not as much as the right
21. Very bad time going to sleep and sometimes have nightmares and wake up sweating around the neck.
22. Side effects of meds I took caused me to loose my wife and son. Now separated.
23. Anger sometimes very bad when I take the meds.
24. Urinate a lot due diabeties and have to wear depends. Have to eat 5 to 6 meals a day due hunger pangs and get weak if I don’t eat to point I feel like I may faint.
25. Diabetes started 5/13/03 type 2 and 2009 turned to type 1.
26. Wife MS started 4/20/09 and had to spend a week in hospital
27. ED since I got diabetes.
28. new meds don’t work.
29. Use cane to walk straight.
30. Handwriting iffy to bad at times.
31. Spondylolysis
32. compression at SI nerve root
33. Somatoform disorders
34. Lumbar spasms
35. peroneal neuropathy
36. Partial thromboplastin
37. Spurs at C4, C5, C6
38. disk ogenic end plate marrow signal changes at C5, C6and alio for a minal narrowing
39. always feel tired and fatigued
40. Incurable lymphedema
41. Cellulitis
42. PTSD
43. Congenitial interbody fusion
44. Bright flair signal in left frontal sub cortical whit matter in brain.
45. Bulging at L4, L5 level of the ventral surface of the thecal sac.
46. lumbosacrale spine
47. 3 nodules in lungs
48. Diffuse asteopenia.
49. When I lose sleep for two or more days I become very weak and may take another day or two to get better. One week I got 7 hours of sleep for the whole week. Almost dropped dead from that series of lost sleep.
50. Hit many times with hyperglycemia and hypoglycemia. Last 3 yrs none occurred.
51. blood glucose once hit over 500 now average 90 to 200 no matter what I do Meds make the numbers all over the place.
52. once slept for 24 hours another day 23 hours felt very weak and out of it.
53. PTSD

The other morning, I had to take care of three penises before lunch. That was an unusual concentration of penis problems so I decided to share them with you.

The first was a thirty-year-old man with a “drip” or discharge from his penis. Of the three penis complaints, his was the most common for us to deal with in the emergency department and, as a result, the easiest. For about a day he had been having a thick, green discharge from the end of his penis with some burning when he urinated. He admitted to having unprotected intercourse with someone he was sure had passed this little present on to him. This sort of discharge is usually caused by gonorrhea so I treated him for that as well as chlamydia, because they so often travel around together. He was advised to notify all of his sexual contacts and a report was sent to public health.

Penis number two was a twenty-year-old who came in saying he caught the end of his penis in his zipper. This had caused a little cut that would not stop bleeding. Sure enough, he had a little cut and it was still oozing but it was clear he was lying about how he got it. An uncircumcised man who catches the end of his penis in his zipper will almost always catch the end of the foreskin. Most of the time, this just causes a painful pinch but it can cause a small laceration. The end of the foreskin can also get caught in the zipper so deeply that the patient is unable to get it out. I have seen more than one man come in with the zipper, cut free from the old pants, caught on the end of his penis and tucked down into the pants he was then wearing. We have little tricks to get the foreskin out of the zipper without doing any more damage and such a patient is always quite appreciative once he is extricated.

It was immediately clear that this man had not caught his penis in his zipper at all. His laceration was in the frenulum of his penis. This is a thin connection between the bottom of the glans (head) and shaft. It is down underneath the foreskin and very protected from any errant zipper. The frenulum is frequently damaged from too exuberant sex, which is most certainly what happened to this man, though he persistently denied it.

There are several tricks for getting a pesky little cut like this to stop bleeding. Most will stop with just some good pressure. When this doesn’t work, the next thing I try is a little injection of local anesthesia with epinephrine (adrenaline.) This causes constriction of the blood vessels, which helps stop the bleeding. If that doesn’t work, I put one or two little stitches into the cut. That always fixes the problem. This guy didn’t need the stitches and went off happy that his penis was no longer bleeding. Makes me wonder if he thought we still believed his zipper story or not.

Penis number three is saved for the last because his was the most unusual and difficult to care for of the three. He was a seventy-year-old who was unable to pee. His doctor recently told him he was passing a kidney stone. In the past, he had a kidney stone stuck in the end of his penis and he had to go to the emergency department to have it pulled out. He said he could now feel a stone half way down the shaft of his penis and that that was probably the reason he couldn’t pass urine.

Evaluating his penis was difficult because he had a small penis and was quite obese. The shaft of his penis was almost covered by the fat of his mons pubis (hair-covered skin above the penis.)

The most straight-forward way to fix a penis plugged by a stone is to pass a Foley catheter through the penis and into the bladder. The catheter pushes the stone back into the bladder so the patient can pee. Then, the patient can then follow up with his urologist to have the stone removed.

A while after I asked the nurse to pass the catheter, she came back saying she was unable to do so. The patient had phimosis, which is a scarring of the foreskin so it cannot be retracted off the glans. With a combination of the patient’s obesity, small penis and phimosis, there was no way the nurse could get to the opening of the urethra to pass the catheter into it.

This kind of situation is a urological emergency. The patient is unable to void and he needs to empty his bladder. However, because I was working in a small-town emergency department with no urologist on call, I had to do something. One option I had was to poke a needle through the patient’s lower abdominal wall and pass a catheter straight into his bladder from there. The other option I had was to do a dorsal slit of the patient’s foreskin. This was more aggressive effort to gain access to the opening into the urethra, and it was the approach I decided to take.

First, I used a local anesthetic to numb up his entire penis. I then cut back through the foreskin, trying to expose the glans and find the opening to the urethra.  This ended up being much more difficult than I expected it to be. It had been so long since his glans had seen the light of day that the foreskin was scarred down completely to the underlying glans. I had to insert a forceps a little way, make a small slit in the foreskin, then repeat, all the time controlling the bleeding and making sure not to cut anything but the foreskin. Eventually, I was able to identify the urethra and, with quite a bit of difficulty, get a little catheter passed up into the patient’s bladder. His relief was immediate.

By this time, I was convinced that his scarred down foreskin was the real cause of his inability to void. However, to be sure, I sent him for an ultrasound of his penis and bladder. No stone was detected which confirmed my diagnosis.

The patient went home with the catheter in place and a referral to a urologist. He will need to have a circumcision to fix his problem for good.

In honor of Halloween, I wanted to share a case that came into Charity Hospital when I was resident there. It is one of the most bizarre cases I ever came across and impossible for me to explain.

A woman in her twenties was brought in by ambulance. She was almost comatose because of a combination of drugs and alcohol. She had been found by her roommate naked in bed with “something wrong with her eye.” What we saw was that someone had taken a scalpel and dissected her eye. The lids had both been cut off in a circle around the boney edge of her eye socket. The fatty tissue, eye muscles and everything else around her eyeball had been carefully removed without damaging the eyeball itself. It was clean and the bleeding had been controlled just as it might have been in the operating room. All that was left was her eyeball, still hooked on by the nerve running back into her skull. Her pupil reacted normally, so the assumption was that when she woke up she would have normal vision. However, she would not be able to move her eye or keep it moist by blinking. The specialists said that nothing could be done to save the eye. She would have to have a perfectly good eye removed and some sort of a skin graft placed over the open tissue.

I never heard if they ever found any suspects or more clarification of why or how this happened. Another item to add to your list of reasons to not get smashed on drugs and alcohol.

Shari found this in a magazine while waiting to get her hair cut.

Recipe By:

Martha Stewart

Ingredients:

3 cups unbleached all-purpose flour
1½  cups packed light-brown sugar
½ cup granulated sugar
1 teaspoon baking powder
¾ teaspoon baking soda
1 teaspoon kosher salt
1 cup cold unsalted butter, cut into 1/2-inch pieces
12 ounces semisweet chocolate chips
2 large eggs, room temperature
1 teaspoon pure vanilla extract
24 caramels, such as Kraft, halved *SEE NOTE

Directions:

1. Heat oven to 375 degrees, with racks in top and middle.

2. In the bowl of a mixer fitted with the paddle attachment, beat together flour, both sugars, baking powder, baking soda, and salt.

3. Add butter. Beat on medium speed until combined but some pea-size butter chunks remain.

4. Add chocolate chips. Beat until combined.

5. Beat in eggs, one at a time, and vanilla.

6. Line 2 baking sheets with parchment. Scoop dough into 4-ounce balls (each about 1/3 cup.) Bake a deep, wide hollow in each center. Enclose 3 pieces of caramel in each. Roll back into a ball. Place 6 balls on each sheet. Freeze 15 minutes.

7. Bake, with one sheet on each rack, 10 minutes. Reduce heat to 350 degrees. Swap sheet positions and rotate each sheet 180 degrees. Bake until centers are almost but not completely set (press gently on tops with your fingers to check), about 7 minutes more. Remove from oven. Bang sheets on a counter a few times to create cracks in tops of cookies. Place sheets on a wire rack. Let cool completely.

Notes:

I don’t like Kraft caramels so replaced them with 15 grams of Peter’s caramel in each cookie.

My daughter and son-in-law gave me some teal-colored straps. I decided to make a Sharks bag. I looked at hundreds of Sharks images on the internet, trying to get inspired. I was not happy with how it first turned out so I also bought some white straps and figured out how to make teeth. I am quite pleased, actually, with how it turned out.

I put the obligatory buckle down the side.

Shari made a coconut cream pie for Thanksgiving. Great recipe. Ask if you want it. Anyway, I went looking for cookie recipes that would use up the 7 egg whites left over from the pie. This is what I came up with and, I think their efforts to reproduce that crunch and chew of the brownie edges came pretty close. They are easy to make and very satisfying to eat.

Recipe By:

King Arthur Flour

Ingredients:

½ cup all-purpose flour
¼ teaspoon salt
¼ teaspoon baking soda
2 large egg whites
1 cup sugar
2 tablespoons cocoa powder
½ teaspoon espresso powder
¼ cup vegetable oil
½ teaspoon vanilla extract
1 tablespoon nonfat dry milk powder
1 cup chocolate chips

Directions:

1. Heat oven to 325 degrees Fahrenheit. Prepare a baking sheet by covering it with a greased sheet of baking parchment.

2. Whisk together flour, salt, and baking soda. Set aside.

3. In medium-sized bowl, whisk egg whites until frothy.

4. Add sugar, cocoa powder, espresso powder, oil, and vanilla. Beat until smooth.

5. Whisk in milk powder, then flour mixture.

6. Stir in chocolate chips.

7. Scoop 2 tablespoon blobs of the dough onto the prepared baking sheet, leaving plenty of room for them to spread.

8. Bake  for 25 minutes.

Jacob loves to use his Tad Bad for his gear when he hits the waves in Brookings, Oregon.