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.

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.)

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.

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.

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.

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

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.

I have made knock-off Samoas before but this is the closest to the real Girl Scout Cookies that I have tried. Not easy to make so you really have to not want to pay the Girl Scouts to do the work for you.

Recipe By:

“Siriously Delicious” by Siri Daly

Yield:

30

Ingredients:

Cookies:
1 cup unsalted butter, at room temperature
½ cup powdered sugar
½ teaspoon vanilla extract
⅛ teaspoon almond extract
2 cups all-purpose flour
½ teaspoon table salt
Coconut-caramel topping:
2 1⁄2 cups sweetened shredded coconut
12 ounces store-bought caramel candies
2 tablespoons whole milk
Pinch of table salt
Chocolate coating:
6 ounces milk chocolate baking bar, chopped
6 ounces semisweet or dark chocolate baking bar, chopped
1 teaspoon vegetable oil

Directions:

1. Heat the oven to 300 degrees.

2. Make the cookies: Beat the butter and powdered sugar with an electric mixer on medium speed until smooth. Add the vanilla and almond extracts and beat until combined.

3. Sift together the flour and salt in a separate bowl. Slowly add the sifted ingredients to the butter mixture, beating on low speed until combined. Shape the dough into a disk; wrap in plastic wrap, and chill 30 minutes.

4. Meanwhile, make the topping: Spread the coconut on a baking sheet. Bake until lightly toasted, about 10 minutes, stirring frequently.

5. (Be careful, as coconut burns easily.) Set aside. Increase the oven temperature to 350 degrees.

6. Unwrap the chilled dough disk and roll it out on a lightly floured surface to a 1⁄4-inch thickness. Cut the dough, using a floured 2-inch round cutter. Using the tip of a sharp knife, cut out a 3⁄4-inch circle in the center of each cookie, reserving the cutouts for scraps. (I used the small plastic lid off a medicine spray bottle to cut out the inner circle. Next time, I would just skip cutting out the holes at all unless I really wanted them to look authentic.) Reroll the scraps as necessary. I had to rechill the dough between rollings as it is very soft. Place the cookies, 1 inch apart, on parchment paper-lined baking sheets.

7. Bake until the edges begin to slightly brown, 10 to 14 minutes. Cool the cookies on the pans for 5 minutes, then transfer to wire racks and let cool completely, about 20 minutes.

8. For the coconut-caramel topping, place the caramels, milk and salt in a saucepan over low, and cook, stirring occasionally, until melted and smooth. Stir in the toasted coconut and remove from the heat.

9. Spread the topping over the top of each cooled cookie. (After doing removing the coconut mixture from the centers of a few, I decided to be less than authentic and just leave the centers filled with caramel/coconut. In fact, next time I would just skip cutting out the centers at all. Less authentic but taste just the same and ever so much easier.) Let stand until the topping is set, about 20 minutes.

10. Meanwhile, make the chocolate coating: Pour water to a depth of 1inch into the bottom of a double boiler over medium heat; bring to a boil.

11. Reduce the heat to a simmer; place the chocolate in the top of the double boiler (or place a heatproof bowl over simmering water, making sure the water does not touch the bowl), and stir until melted. Add the vegetable oil and stir until you have a glossy chocolate sauce.

12. Remove from the heat.

13. Dip the bottoms of the caramel-covered cookies into the chocolate coating by holding each cookie between your thumb and pointer finger.

14. Place on parchment paper-lined baking sheets. Place the remaining chocolate coating in a piping bag, a zip-lock plastic bag with the corner snipped off, or a plastic condiment squeeze bottle. Drizzle the chocolate over the top of each cookie. Chill the cookies until firm and set, about 15 minutes.

Notes:

If you just want to eat them and are not too hung up on recreating the originals, skip the hole in the center. Saves a lot of headache and, obviously, has no effect on the taste.

These are not too different from Tad’s Oatmeal Chocolate Chip Cookies but more spices and the pudding gives a different texture.

chocolate chip oatmeal

Recipe By:

Gourmet Magazine, March 1992

Yield:

60

Ingredients:

1 cup solid vegetable shortening
1 unsalted butter, room temperature
1½ cups sugar
1½ cups firmly packed dark brown sugar
4 eggs
7 ounces vanilla instant pudding mix
1 tablespoon vanilla extract
2 teaspoons baking soda
2 teaspoons ground cinnamon
1 teaspoon ground nutmeg
1 teaspoon salt
2 cups old-fashioned oats
4½ cups all-purpose flour
24 ounces semisweet chocolate chips
3 cups chopped walnuts (I almost never put nuts in my cookies.)

Directions:

1. Heat oven to 375 degrees. Grease heavy, large cookie sheets. (I always use baking parchment.)

2. In a large bowl, beat together shortening and butter until light. Gradually add white and brown sugars and beat mixture until fluffy.

3. Add eggs one at a time, beating well after each addition. Add pudding mix, vanilla extract, baking soda, spiced and salt, and mix until well-blended.

4. Mix in oats, then flour. Stir in chocolate chips and walnuts.

5. Drop cookie dough by 2 tablespoon balls onto prepared cookie sheets, spacing 2 inches apart.

6. Bake until just starting to brown on the edges, about 12 minutes. (Do not overbake.)

7. Cool cookies 5 minutes on cookie sheets. Transfer cookies to wire racks and cool.

I have not made a bag, specifically for myself, for a long time. I recently had my Timbuk2 bag stolen. I had been taking my junk to work in that bag for over 20 years. What a bummer! To make myself feel better, I made a great new bag, just to my specifications.

Classic orange and black.

Big enough to hold everything I need during a shift in the emergency department.

Cool zippered pocket built into the side.