At Nob Hill on the day after Easter, we bought some bags of Palmer’s caramel-filled chocolate eggs for half price. We should have tried one first because they were not very good and we determined not to eat them. Their presence inspired me to use them for my Emergency Department cookies on Thursday.

I used the recipe for Chocolate Whopper Malted Cookies from my blog but left out the Whoppers and chocolate chips.

I put a tablespoon of dough on the parchment.

I perched an egg on the dough.

I covered it with another tablespoon of dough.

When baked, the egg melted and filled the cookie with chocolate and caramel

Where Did that Tampon Go?

A 34-year-old lady came in after attending her hypnosis session earlier in the day. She said she was on her period so, before going to hypnotherapy, she remembered changing her tampon, placing a fresh one.

When she got home, however, she was surprised to discover there was no tampon. She was unable to remember everything that happened while she was under hypnosis so she was worried. Where might her tampon might have gone? Was she molested while under hypnosis?

Using a vaginal speculum, I looked and could clearly tell there was no tampon. Every thing was normal. I was unable to tell her where the tampon may have gone or under what circumstances.

This put me in a position of having to make a decision. If there is reason to think someone may have been sexually assaulted, we call the police. They come, take a report from the patient and decide whether to call in the Sexual Assault Response Team to do a forensics examination. Since the only reason to think this patient may have been assaulted was that there was no tampon in her vagina when she thought there should have been, I chose not to call the police. In this sort of situation, I often wonder if I made the correct decision or not.

Another Fall?

A 43-year-old man was seen for shakiness, which was determined to be a side effect of his psychiatric medicines. He was discharged and, while walking out of the emergency department, tripped and fell. He was reexamined and found to have no injury. As he was trying to leave the second time, he was walking backwards, smiling, waving good-bye and thanking our staff when he tripped, fell backwards and hit his head. This required a third evaluation before he was finally discharged without problems. It was tempting to write on his discharge instructions: “Don’t walk backwards while smiling, and waving good-bye.”

I Just Want to Kill Someone

A young man tried to stab someone and was apprehended by the police. Rather than arrest him, they put him on a psychiatric hold, called an ambulance and sent him to the emergency department. He told me, “I just have to kill someone.” He needed no medical care so he was sent to the emergency psychiatry.

The police later called the emergency department. Apparently, after sending him to us, they came up with more information about him. They asked that we keep him until they could come and take him into custody. We immediately called emergency psychiatry to let them know the police wanted him. We were told he had been discharged less than an hour after arriving there.

This spring, we went to Patagonia to celebrate our thirty-fifth anniversary. While we were there, we discovered alfajores* (all-fah-HOR-es.) This week I tried for the first time to make them and they turned out really fun. The cookies are very easy to make and, if you buy the dulce de leche rather than make it, as I did, and you skip dipping them in milk chocolate, as I did, they are really easy to make and very tasty.

Recipe By:

All over the Internet

Ingredients:

1 cup cornstarch
¾ cup all-purpose flour
1 teaspoon baking powder
½ teaspoon baking soda
¼ teaspoon salt
½ cup unsalted butter, at room temperature
⅓ cup granulated sugar
2 large egg yolks
1 tablespoon pisco or brandy** SEE NOTES
½ teaspoon vanilla extract
1 cup dulce de leche, at room temperature
Powdered sugar, for dusting

Directions:

1. Place cornstarch, flour, baking powder, baking soda, and salt in a medium bowl. Whisk briefly to combine. Set aside.

2. Place butter and sugar in the bowl of a stand mixer fitted with a paddle attachment. Mix on medium speed, stopping the mixer to scrape down the sides of the bowl once with a rubber spatula, until the mixture is light in color and fluffy, about 3 minutes. Add egg yolks, pisco or brandy, and vanilla. Mix until incorporated, about 30 seconds. Stop the mixer and scrape down the sides of the bowl. On low speed, gradually add the reserved flour mixture and mix until just incorporated with no visible white pockets, about 30 seconds.

3. Turn dough out onto a piece of plastic wrap. Shape it into a smooth disk. Wrap it tightly. Place in  refrigerator until firm, at least 1 hour.

4. Meanwhile, heat the oven to 350°F and arrange a rack in the middle. Line 2 baking sheets with parchment paper and set aside.

5. Remove  dough from the refrigerator. Unwrap it. Place it on a lightly floured work surface. Lightly flour the top of the dough. Roll to 1/4-inch thickness (the dough will crack but can be easily patched back together). Stamp out 24 rounds using a plain or fluted 2-inch round cutter, rerolling the dough as necessary until all of it is gone.

6. Place  cookies on  prepared baking sheets, at least ½ inch apart. Bake 1 sheet at a time until the cookies are firm and pale golden on the bottom, about 12 to 14 minutes. (The cookies will remain pale on top.) Transfer to a wire rack to cool completely.

This is where I dipped them in tempered milk chocolate. Some I dipped the bottom cookie and sprinkled the top with powdered sugar, others I dipped both cookies.

7. Flip half of the cookies upside down and gently spread about 2 teaspoons of the dulce de leche on each. Place a second cookie on top and gently press to create a sandwich. Dust generously with powdered sugar before serving.

Notes:

* Alfajores are cookies we ate in Chile. I understand they are common in other South American countries as well. The cookies are basically short bread cookies made softer and crumblier by adding corn starch. They are usually sandwiches filled with dulce de leche, which is sweetened, condensed milk cooked until it thickens and turns a rich, dark brown color. You can buy it or, if you want to make your own, you can find recipes on line. In fact, I saw one posting entitled, “8 Ways to Make Dulce de Leche.”

** I had no pisco or brandy so I just left this out. When in Chile, we ate one type of alfajor that tasted like booze and we didn’t enjoy it as much as we did the others, so I don’t think we missed anything by leaving it out.

A couple of weeks ago, I shared bags made, for the first time, with red straps. Since then, I came across short straps of red. One was seat belt materiel, the other just regular straps. I think I am going to adopt the seat belt one for my personal use.

Last week, I talked about “Chief Complaint” and gave an example of a list of complaints from a Vietnamese woman. As it so happens, I had a patient this week from Guatemala who presented me with a similar list of complaints.

After introducing myself, I asked her why she was there. She then talked for at least ten minutes without mentioning a single medical symptom. Instead, she went on and on about her husband losing his job, how they lost their apartment because the landlord raised the rent, how her son was in trouble with the law and how worried she was about her daughter who was now also homeless.

To help you understand how difficult it is for me to listen to long stories like this, I have to take you back to what was going on just before I walked into her room. For hours, I have been constantly going over my dominion, scheming on what I need to do next in order to keep things moving along. Check this lab, go see how that patient is feeling, look at an x-ray that has just been taken, check to see if an ultrasound or CT scan has been done, go see if a patient in pain has gotten his pain medicine and if it worked to relieve his pain. Constant hustle. Constant search for efficiency. Constant effort to get patients feeling better and either admitted or sent home.

As I look at the computer and review what is going on with the patients in my fourteen beds, I judge that the next most appropriate thing to do is to rush into Room 5 and check on a fifty-four-year-old woman listed as having “abdominal pain.” I check the results of lab tests that were done when she arrived, look at her vital signs, and check the computer for her past history. I hustle into the room and introduce myself.

So, here I am, listening to that patient go on and on about the problems of her life. She told a very sad story that had nothing directly to do with her medical condition or her visit to the emergency department. The need I see to show empathy in my body language and speech is exactly at odds with the feeling I have inside: an emergency physician zooming to provide everyone with the best care possible and get everyone either discharged home or admitted as quickly as possible. My adrenalin is up. I’m on “Go!” mode inside. But, right away, I recognize that I need to keep all of that completely hidden as I listen to this poor lady. I sit down. I cross my legs. I fold my arms in my lap. I take a deep breath and look at her.

As I said, about ten minutes went by with me wondering when she was going to get around to her medical complaint. I finally couldn’t stand it any more and took the opportunity to repeat my initial question. “I am so sorry. So, why did you come to the emergency department tonight?”

At this point, she pulls out a paper, listing her complaints. I reproduce it here:

I am stress.

I am nerves.

Anxiety

Pain back of my head

No eating well

Pain in my stomack

Short breath

Dise (dizzy)

I can’t sleep.

I got bone cancer.

I got crams.

I can’t walk.

My mouth dry I can’t talk.

I am homeless.

The list didn’t have everything on it as she came up with several other complaints as we talked. For example, for the last year, the middle toe on her left foot has felt like the bones were crunching, causing severe pain.

I carefully examined her then I reviewed the results of the x-rays and blood tests that had been done and were all normal. I empathized with her then explained that I would give her some medicines for pain and anxiety and refer her to medical and psychiatric clinics. Hopefully, someone would be able to address all of her problems that we were not going to be able to fix in the emergency department that night.

I ask her if she has any questions and then I rush off to see my next patient.

When evaluating patients in the emergency department, we start with what is called “The Chief Compliant.” This is what the patient says is wrong, usually a symptom. Sometimes, that is very straightforward: “I fell and twisted my ankle” or “I have chest pain.”

Based on the chief complaint, we ask more questions, do a physical exam and maybe some testing.

Sometimes, the chief compliant is so bizarre it is hard to even get passed it. Once, a lady came in and said, “Every time I have sex, I bark like a dog.”

When I hear a complaint like that, it is hard to even think of a question to ask in clarification and there is certainly nothing you can image would be helpful in a physical examination or any lab tests. It all just kind of stops with the chief complaint.

Another case like that happened recently when a man in his twenties came in and said, “I’ve been tasting saltiness in my throat, like seawater for the last two days.” He had Googled it and been unable to find a cause so he came in because he was sure it was something serious. I asked some more questions to make sure I was not missing something then did a thoughtful examination before sending the patient home with reassurance. My usual line for this sort of complaint goes something like this: “I have never experienced this symptom in my life nor have I ever heard of anyone else having this symptom.” I then explain why I think there is no reason to be concerned and send the patient home.

Another way the chief complaint can tell the whole story is when it is so long, bizarre and covers too many different symptoms. This is especially true if the symptoms have been going on for a long time. Basically, the more complaints, the stranger they are, the more they involve different body parts and the longer they have been going on, the less likely it is to be an issue in the emergency department.

Sometimes, people have so many different complaints that they actually have them written out, in list form. These are often amazingly long, detailed and even bizarre.

Here is a list I was given by a 38-year-old Vietnamese patient who had been having trouble for many years. She had come from Vietnam two months previously and came to my emergency department so I could figure out what was wrong with her.

Since childish:

-easy having fatigue

-tired when working

-excited easily

-often passed out when I was in VN (not use any medication)

-insomnia

-forgettable hard study

-starting

-grinding of the teeth

In this case, some follow-up questions, a good examination and some basic lab tests showed nothing to worry about. She was referred to find a primary care doctor.

A couple of week ago, I made a bag out of seat belts that was olive green and bright yellow. I came across some more yellow and green and made this bag. It is not seat belt material and the green is a lot brighter. By the time I made the bag, there was not an inch of green left over to fix the buckle on so I used black.

Anyone following the cookie recipes in my blog will know that an unusual ingredient is the most likely thing to get me to try a new recipe. The other night, LA, one of our emergency doctors, challenged me to come up with ube cookies. At first blush, this seemed crazy but when I went to the Internet, I was able to find several possible recipes to try.

One of the biggest challenges I had was coming up with the ingredients. Most of us have never even heard of ube. It is a yam that is amazingly purple, colored like a beet. It is very popular in the Philippines. The first time I heard of it, was when I ate ice cream made out of it. Naturally purple and very tasty.

This is the kind of recipe that you will only be able to try if you live somewhere with lots of Filipinos or you are willing to go online and have ube jam and ube flavoring sent to you.

I have made chocolate crinkle cookies many times so the idea of a bright purple crinkle cookie really grabbed me. This is fun cookie baking and eating!

Recipe By:

bakehappy.net

Yield:

30 cookies

Directions:

3 cups all purpose flour
2 teaspoons baking powder
½ teaspoon salt
1 cup unsalted butter
½ cup brown sugar
1 cup sugar
2 eggs
1 cups ube jam / halaya,  *SEE NOTES
2 teaspoons ube flavoring,  **SEE NOTES
2 cups powdered sugar ***SEE NOTES

Directions:

1. Combine flour, baking powder and salt. Set aside.

2. Cream butter and sugars until light and fluffy.

3. Beat in eggs.

4. Beat in ube jam and ube flavoring.

5. Gradually stir in dry ingredients.

6. Cover bowl with cling wrap and chill for 4 hours or overnight.**** SEE NOTES

7. Heat oven to 350 degrees.

8. Scoop 2 tablespoon balls of dough with an ice cream scoop. Roll dough balls in powdered sugar. Arrange baking sheets covered with parchment.

9. Bake about 14 minutes until just set. Of course, as in all cookies, don’t over-bake.

Notes:

* Original recipe called for Ube Jam from Mountain Maid Training Center. It is made with ube and sugar but also milk. If you Google “ube jam,” you come up with recipes that mostly contain milk and butter and are more like pudding than jam, like we would put on toast. The jam I bought at Seafood City, my local Filipino market, has just ube and sugar. That is what I used for these cookies.

** When I first saw “ube flavoring” in this recipe, I thought, “Oh, sure.” But, sure enough, at Seafood City, they had McCormick Ube Flavoring. Amazing from my white American perspective.

*** I alway sift my powdered sugar. I just like it better without lumps.

A new angle on a blue and yellow bag:

I have been called a lot of names while caring for patients in the emergency department. Many of them are too rude to repeat here and have been hurled at me by people who were chemically impaired. I always ignore these insults.

Even in 2015, I am still sometimes called a hippie. I am never sure if that is because of my ponytail, my turquoise necklace or my general, California demeanor. I usually ignore this as well, since it also feels like an insult.

I have also been called a couple of other names I would like to share with you. They were both uttered by psychotic patients, and I presume nothing offensive was meant by either.

One night, a patient suffering from mania was put on the gurney in the hallway right across from where I sit at the computer. As is typical of manic patients, she was hyper and talked constantly. I ordered something to calm her down while she waited to go to psychiatry.

Waiting on the gurney, she was unable to sit still or stay quiet. She talked constantly and addressed herself to anyone who passed by. After all of her concerns had been addressed, everyone just kind of had to ignore her, in order to get anything else done.

The first several times she called, “Hey, Doctor…!” I stopped what I was doing and addressed her concerns. Eventually, I also had to ignore her.

When I stopped responding to her, she just escalated. Soon, she was hollering, at the top of her voice, “Hey, Doctor! Hey Doctor! Hey Doctor!” over and over again.

When I still didn’t respond, she started hollering, “Hey, Doctor Yeast Infection! Doctor Yeast Infection! Doctor Yeast Infection…!” You can imagine the effect that had on the department as she hollered my title over and over again at the top of her voice. This continued until she finally got tired of yelling or the medication had some effect on her, though she was still hollering out once in a while when she was escorted to psychiatry.

The other notable name was also uttered by a mentally ill person. I was, again, sitting at the computer. I recognized that a bit of a ruckus was developing nearby as a patient approached a resident (doctor in training) and was talking in an aggressive and agitated manner.

The nurse told me the patient had already been seen by another doctor and was discharged. She was being escorted out to the waiting room, when she saw the resident and approached her, wanting to file a complaint. As the nurse and the resident tried unsuccessfully to get her to settle down, I felt a need to intervene as I am, essentially, the captain of the ship.

I had some trouble getting the lady to stop talking to my resident and recognize that I was the one she needed to talk to. Eventually, she turned to me and, rather than look at my face, looked at my name badge. Then, she said, “Shut up, Doctor Diaper Pants,” and walked out, talking only to herself.

I have addressed in this blog several times the conflict I face when mentally ill people do things that are funny. Sometimes, they are really funny. It is very hard to not laugh when someone calls you “Doctor Yeast Infection” or “Doctor Diaper Pants.” But, recognizing the patient is talking that way because of her illness, I immediately feely a conflict that prevents me from really laughing and enjoying the mirth. It is so funny and yet so sad at the same time.