Monday, 23 November 2015


I have a pretty damned good life, and I'm not a bit ashamed to admit it.  I am healthy, I managed to find the most wonderful woman in the world before anyone else nabbed her, I have two beautiful, healthy children, and I happen to be in a profession that allows me to live a very comfortable lifestyle.  I seem to have no reason or right to complain about anything.  Ever.

But, I still do.  Yes sometimes events around me stack up so that it seems the world is conspiring against me, and at times like these I begin to feel sorry for myself like a big baby.  I whine and complain and moan and groan with no legitimate reason to do so.  Fortunately these times are rare, so my family and colleagues don't have to suffer my maudlin, melancholy, moody self very often (huzzah for synonymous alliteration!).  Plus, it seems that every time I find myself in such a mood, something eventually happens that metaphorically grabs me by the ears and screams in my face, "SNAP THE HELL OUT OF IT, YOU FUCKING IDIOT!"

Just such a thing happened again a few days ago.

As I was on call for general surgery, I went through my entire day seeing patients without a single call from the emergency department/A&E.  Not a gall bladder, not a bowel obstruction, not even a perirectal abscess.  Nothing.  But the Call Gods evidently wanted to have some nasty fun with me, because just as I was about to sit down to read my son a bedtime story, the call came.  

Appendicitis.  Of course.  Goddammit, why?  Why couldn't they call me at noon?  Why must I miss ANOTHER bedtime?  My blood was boiling, my blood pressure was rising, and I started bitching to myself, thinking of an alternative career I could pick up.  I could be a car salesman or a window washer or a chef or anything else god damn it!

Then I took a deep breath.  Calm down, stupid.  It could be worse.  Much worse. 

I went to the hospital to see the patient, who had a relatively simple and early case of appendicitis.  Her operation should take me no more than 15 minutes, so I immediately called the operating theatre.  I was perfunctorily told that there were several scheduled cases from the daytime still pending, and that one of the orthopaedic surgeons had an emergency open fracture to do.  I would have to wait until he was done, which meant waiting another 5 to 6 hours.  At least. 

SHIT.  Moan, moan, moan.  Well, at least I would get to read that story to my son.

I went home, read my son his story (Charlotte's Web, if you were curious) put him and my daughter to bed, and waited.  And whined.  And waited.  And then I whined and waited some more.  Four hours later I was still waiting, so Mrs. Bastard decided to go to bed while I waited and whined to myself.  

Finally just before midnight the operating theatre called me to let me know that they had called in a second team, and my patient was ready.  She was fortunately much more patient and understanding than I.  Regardless, I brought her into the room, helped the anaesthesiologist put her to sleep, and walked back out of the room to scrub.

While I was scrubbing I looked down the hall and saw the aforementioned orthopaedic surgery also scrubbing.  I waved to him and went into my room.  As I was putting on my gown and gloves, I asked the nurse what the orthopaedic surgeon was doing, since he should have been done with the open fracture by then.

"Oh, he's doing a total hip replacement.  On a 94-year old."

He's doing what?  To a what?  At midnight?!

"Yup, he had to bump himself to do the open fracture, so he is just starting it now."


As expected, the appendectomy was very simple (it actually only took me about 14 minutes).  I finished my surgery, scrubbed out, spoke to the patient's son, changed, and went home, all before the orthopaedic surgeon had really gotten into the meat of his case.  

And just like that, I realised I could be that guy.  Even worse, I could be that guy's patient.  Suddenly I didn't feel sorry for myself anymore.  My minimal misery was severely put in its place.  

I got home around 1AM, snuck into my children's bedrooms, gave them both a kiss, tucked them in, crawled into bed, kissed my wife, and promptly fell asleep. 

Life was good again. 

Monday, 16 November 2015

Ha freaking ha

It's time for another post about the Call Gods.  Yes indeed, yet another goddamned post about the goddamned Call Gods.  I can hear several of you groaning, "Not another Call Gods post!  We're sick of hearing Doc's paranoia about them, especially since they don't exist."

And that's where you're wrong, nonbeliever.  They exist.  Oh, do they ever exist. 

What, you don't believe me?  Still?  How is that even possible?  Are you even listening??  After everything I've told you, you still don't believe me? 

Juuuuuust wait.  You will.  And by the end of this post if you still haven't converted to my weird little religion, then you obviously haven't been paying attention this whole time, and you should probably head off to YouTube to search for some fail videos or something.  Or maybe go check out  Either one will make you feel just that much better about your own life.

Where was I?  Oh right, I was talking about myself as usual.  Anyway, in addition to the fucking Call Gods (Ha ha!  Just kidding, Call Gods!  Please have mercy!) I also talk about appendicitis a lot, because I see it a lot.  It seems to me sometimes that I'm curing the world of appendiceal disease one person at a time.  But lately I've been in a bit of an appendix lull.  I haven't taken out an appendix in about a month, whereas I usually do at least one or two a week, if not more.

Hear that foreboding music yet?

This morning as I showered (stop picturing me nude, you perverts) I was thinking "Wow, I haven't done an appy in a while.  How long has it been?"  It had been at least three weeks, and I couldn't remember ever going so long between appys.  So I tried to remember the last one I did. 

The call from the emergency doc predictably and inevitably came at 4 PM (at least it wasn't midnight, right): a healthy 62-year old guy with, you guessed it, acute appendicitis.  I went to the hospital to do the surgery, which turned out to be uncomplicated and relatively easy.  But just as I was finishing up, my mobile in my pocket rang.  "There is my next appendix," I joked with the staff.  I finished up and took the man to recovery.

Much to my relief, the call had been from a friend, not from the emergency doc again.  WHEW.  I changed clothes and got in my car, happy I would be home in time for dinner and my kids' bedtime.  

I hadn't even pulled out of my parking space when my mobile rang again.  I recognised the caller ID immediately - the ER/A&E.  And as you've probably surmised by now, it was indeed yet another appendicitis patient.  As I write this, I'm sitting in the operating theatre waiting for him to come up from emergency.  I've now missed dinner, and my kids will be fast asleep by the time I get home.  Mrs. Bastard too, most likely.

Fuck you for ruining yet another evening with my family, Call Gods.  Fuck you.

Monday, 9 November 2015

Jahi McMath update

In lieu of a stupid patient story this week, I have an update on the Jahi McMath saga.  That's right, the story that just won't go away still hasn't gone away - Jahi McMath's family has filed an amended complaint (thank you Professor Thaddeus Pope for uploading it) stating that they have evidence that she is, in fact, alive.

A board-certified pediatric neurologist claims to have examined her and has determined that she does not meet brain death criteria.  As Prof. Pope explains, the focus will be on paragraphs 30-36.  I'll present some excerpts from the complaint followed immediately by my thoughts on each.
30.  Since the Certificate of Death was issued, Jahi has been examined by a physician duly licensed to practice in the State of California who is an experienced pediatric neurologist with triple Board Certifications in Pediatrics,  Neurology (with special competence in Child Neurology), and Electroencephalography. The physician has a sub-specialty in brain death and has published and lectured extensively on the topic, both nationally and internationally.  This physician has personally examined Jahi and has reviewed a number of her medical records and studies performed, including an MRI/MRA done at Rutgers University Medical Center on September 26, 2014. This doctor has also examined 22 videotapes of Jahi responding to specific requests to respond and move.
This is specifically different than their prior claims in that this time a board-certified physician, a pediatric neurologist, in fact, has actually personally examined her.  According to the complaint he has also watched 22 videos of Jahi responding to verbal stimuli.  This paragraph gives me great pause for two reasons.  First, why is the physician not named?  There is much speculation that the doctor is Alan Shewmon, who is a vocal opponent of brain death, but why not reveal his name?  Second, why should he have to watch videos of Jahi supposedly responding to voice commands if he has personally examined her?  Did she not respond to commands when he was with her?  And are these the same lousy quality videos that have been posted and scrutinised already?  This strikes me as very odd.
31.  The MRI scan of September 26, 2014, is not consistent with chronic brain death MRI scans. Instead, Jahi's MRI demonstrates vast areas of structurally and relatively preserved brain, particularly in the cerebral cortex, basal ganglia and cerebellum.
32.  The MRA or MR angiogram performed on September 26, 2014, nearly 10 months after Jahi's anoxic-ischemic event, demonstrates intracranial blood flow, which is consistent with the integrity of the MRI and inconsistent with brain death.
Cerebral blood flow and MRI scans do not factor into clinical brain death.  And why are they referencing an MRI/MRA from over a year ago?  Don't they have a more recent study?  If not, why not?  If so, why don't they present it?
33.  Jahi's medical records also document that approximately eight months after the anoxic-ischemic event, Jahi underwent menarche (her first ovulation cycle) with her first menstrual period beginning August 6, 2014. Jahi also began breast development after the diagnosis of brain death. There is no report in Jahi's medical records from CHO that Jahi had began pubertal development.  Over the course of the subsequent year since her anoxic-ischemic event at CHO, Jahi has gradually developed breasts and as of early December 2014, the physician found her to have a Tanner Stage 3 breast development.
34.  The female menstrual cycle involves hormonal interaction between the hypothalamus (part of the brain), the pituitary gland, and the ovaries. Other aspects of pubertal development also require hypothalamic function. Corpses do not menstruate. Neither do corpses undergo sexual maturation. There is no precedent in the medical literature of a brain dead body developing the onset of menarche and thelarche.
I find it very hard to believe that Jahi, who was 13 at the time of her operation, had not started menstruating already.  According to a recent study of American girls, the average age of thelarche (breast development) is 9.7 years and menarche (onset of menses) is 12.8 years (12.2 for black girls).  It is highly probable that she had started menstruating already, and besides she would also not be the first brain dead child to undergo puberty, so these paragraphs are essentially irrelevant.  What bothers me most about this paragraph is that she had already started to develop breasts before her surgery as this picture proves:
This is a blatant lie in the complaint - she had undergone thelarche without question, likely years before (statistically speaking).  If they are so willing to make such an obvious lie in a legal document, what else are they willing to lie about?
35.  Based upon the pediatric neurologist's evaluation of Jahi, Jahi no longer fulfills standard brain death criteria on account of her ability to specifically respond to stimuli. The distinction between random cord-originating movements and true responses to command is extremely important for the diagnosis of brain death. Jahi is capable of intermittently responding intentionally to a verbal command.
This is the key paragraph.  The anonymous neurologist claims that she responds to stimuli . . . intermittently.  If this is actually true, then she is not brain dead.  However, that is a very big "IF", and it hearkens back to the question of whether or not she was able to respond when examined by the neurologist or only on video.  If she was only responding to voice on the videos, that is worthless as evidence in my opinion.  If I were the presiding judge, not in a million years would I accept those vague and unreliable videos as evidence of anything.  What this paragraph does not say is that the doctor performed (and that Jahi passed) a bedside brain death exam.  Perhaps I'm reading too much into it, but perhaps not.
36. In the opinion of the pediatric neurologist who has examined Jahi, having spent hours with her and reviewed numerous videotapes of her, that time has proven that Jahi has not followed the trajectory of imminent total body deterioration and collapsed that was predicted back in December of 2013, based on the diagnosis of brain death. Her brain is alive in the neuropathological sense and it is not necrotic. At this time, Jahi does not fulfill California's statutory definition of death, which requires the irreversible absence of all brain function, because she exhibits hypothalamic function and intermittent responsiveness to verbal commands. 
There are numerous reports of brain dead patients being kept on somatic support for years without their bodies deteriorating, so the fact that this has not happened to Jahi is also irrelevant.

In all, the evidence supplied by Jahi McMath's lawyer is suspect at best, worthless at worst.  I am incredibly curious why the neurologist was not named - this seems a very strange way to run a high-profile legal case.  Perhaps the anonymity was maintained because it is so high profile, but perhaps one of the lawyers here could shed some light on whether or not this is typical.  Regardless, I will wager these claims will be enough for the judge to allow the case to continue.

My one takeaway from this update is that if paragraph 35 is true, if she is truly able to respond to verbal stimuli, even intermittently, then she IS NOT DEAD.  Full stop.  Keep in mind that any claims of responsiveness made by the family will need to be verified by an outside neurologist.

And with that, I will open the comments to whatever wild speculation your brains can come up with, except for one particular individual who remains banned and whose comments will be deleted immediately (you know who you are).

Monday, 2 November 2015

Trauma drama

There's a very good reason "trauma" and "drama" rhyme.  I'm convinced that whoever was responsible for those two words' etymology could see the future and just knew that trauma patients would cause the second-most drama in the hospital.  The most is caused by psychiatric patients of course, unless you watch Grey's Anatomy, in which case you believe the drama is a result of the nurses and doctors all sleeping with each other in every bathroom, janitor's closet, and stairwell in the hospital.

As usual, I digress. 

Since I don't deal with psychiatric patients (much) (thank god) (there's a reason for that), I have to be satisfied with the Trauma Drama.  Fortunately, I'm seldom disappointed. 

Maurice (not his real name™) was brought to me one gloriously dramatic day having been shot in the back.  That doesn't usually happen if you're the victim of an attempted robbery (most armed robbers give up when their victims run away), nor does it happen often by accident.  Ordinarily you'd have to do something pretty awful to deserve being shot in the back.  

Maurice certainly fit the bill.

The trajectory of the bullet was admittedly strange to me - it entered his flank on one side and exited the mid-back on the other side.  That's an awfully odd track, so I instantly suspected something weird.  Maurice, like most every gunshot victim, wasn't offering up any details about what happened.  It's quite amazing how people instantly clam up the moment you ask how and why they got shot.

Regardless, Maurice's vital signs were surprisingly stable, though I strongly suspected something awful was going on inside his abdomen.  I pushed lightly on his belly, and he made a noise somewhere between a grunt and a squeal.  No need for a CT scan here - Maurice had peritonitis, and I called the operating theatre immediately.

I rushed downstairs and managed to beat him by several minutes.  I was waiting there with the police officers (who apparently had a few questions to ask Maurice), and they seemed to be chuckling to themselves.  When they saw me, they asked if I expected Maurice to live.  I told them I had no idea, and that it depended on what kind of catastrophe I found. 

"Did you hear what happened, Doc?" one of them asked me.

Oh, do tell.

"Maurice here was sleeping with his best friend's girl.  His friend found out about them, but he didn't say anything to Maurice, and they just got in his car together.  I guess he was planning on driving him to some remote location and then shooting him, but they didn't get that far, so the guy just turned and shot him while they were still in the car."

During surgery I found a series of holes in his small intestine and two in his colon.  It took me a bit less than two hours to remove two segments of his small intestine, put the ends back together, and repair his colon.  I left the operating theatre and told the officers that I expected him to live.

But the drama didn't end there - Maurice's wife showed up to the hospital later that evening.  I spoke to her briefly to tell her what I found and what I did to her husband, and she barely responded at all.  Based on the look on her face (which strangely reminded me of the look on MomBastard's face when I was a child and she knew I had done something wrong, I just didn't know which evil deed of mine she had discovered), someone had already told her why Maurice had been shot.  I (wisely) decided to leave it alone and not poke that particular snake.  I decided simply to be satisfied that Maurice didn't die from his wounds. 

Somehow his wife didn't kill him either.  

Monday, 26 October 2015

Even sicker

Very few words strike fear into the heart of a trauma surgeon.  Keep in mind that we see some of the worst of the worst, the most gruesome of images - open fractures, gunshot wounds to the heart, amputations, tabloid stories about Kim Kardashian - things that would make many people lose their lunch.  Since I'm writing this, you've likely (correctly) assumed that there is at least one thing that fazes us, one thing that bothers trauma surgeons enough that any of us would experience palpitations at the sheer mention of it . . .


Most people have probably at least heard of cirrhosis, but I suspect very few actually understand its gravity.  In short, it's a chronic and incurable disease where the liver is scarred beyond any ability to heal, typically from either long-term alcohol abuse or hepatitis C.  After the liver has endured more than it can handle, it eventually loses its ability to perform its many functions, including producing clotting factors and other proteins, and filtering the blood.  The only treatment for cirrhosis is treating the symptoms, and the only cure is liver transplantation.  To put it mildly, I think of cirrhotics as walking Jenga games, and if at any time one even not-so-critical piece is pulled out, the whole thing will fall down into a bleeding, jaundiced, encephalopathic mess.

Graphic enough for you?  Good, then I'll move on.

Cirrhosis patients are some of the most brittle any doctor will ever come across.  Their overall health needs to be closely monitored and their medication just as closely adjusted to account for any disturbance.  Bleeding is a huge potential risk because of the lack of clotting factors, so risky behaviour (skydiving, martial arts, cutting bagels) should be avoided.  Alcohol should also be strictly avoided to prevent the situation from acutely worsening.  Obviously.  Acetaminophen (Paracetamol/Tylenol) should also be avoided the way I avoid painting.  I hate painting.

Gary (not his real name™) had absolutely no idea how bad a disease cirrhosis is, because despite the risks he continued making it worse.  And worse.  And worse.

To demonstrate how stupid Gary was, allow me to introduce a fantastical hypothetically analogous situation.  To start, this may require a bit of a stretch of your imagination, but pretend for a moment that smoking cigarettes is stupid and dangerous.  I know, I know, it's a big stretch, but bear with me.  Now let's also pretend that degreasing your shop equipment with gasoline is also a touch on the dangerous side.  So it stands to reason that, in our completely absurd and wildly hypothetical situation, smoking while using petrol as a solvent is stupendously stupid.  Now imagine doing all this in a 100% oxygen environment. 

While it's only an analogy, that was Gary.

I can't really say that Gary was a smart guy, because he wasn't.  I can't even say Gary was of average intelligence or even slowly below average, because anyone with more than 8 working synapses would know that being diagnosed with chronic Hepatitis C is a very bad thing.  Gary, on the other hand, took it as an opportunity to start drinking heavily.  He also used it as an excuse to do other really stupid things, like buying a motorcycle.  Completing the decathlon of stupidity was, of course, the combination of all these activities.

On this particularly fateful day, Gary decided that he wasn't content with just throwing gasoline onto his Personal Risk Fire, so he threw some dynamite on there as well.  He got slobberingly drunk, got onto his motorcycle, and then barreled down the motorway at twice the posted limit.  It doesn't take a genius to predict how this ended.

Cirrhosis + alcohol + motorcycle + speed + stupidity = an painfully obvious dénouement

Surprisingly when Gary rear-ended a car that had stopped for a traffic light (neither of which Gary saw), he didn't die immediately.  When he arrived in my trauma bay he smelled like the men's restroom in a rather seedy pub (ladies, if you've never had the pleasure of experiencing that aroma, just use your imagination.  And it's just a bit worse than that).  He was too drunk to even tell me where it hurt, so I ended up scanning him from head to toe.  What I found was not a huge surprise:

  • nearly every rib on the left side was fractured
  • left lung was collapsed
  • left acetabulum (hip socket) was shattered
  • sternum (breast bone) was broken
  • left scapula fracture
It came as no surprise, however, that his blood alcohol level was four times the legal limit.  What did shock me was that his liver looked fine . , , ok, perhaps not fine, but it was at least uninjured.  It had the typical appearance of someone with advanced cirrhosis, and he had numerous other dilated veins (varices) in his esophagus, spleen, and abdominal wall also typical of cirrhosis.  Other than a severe concussion, his brain was also uninjured (though I must admit I was surprised to find one in his skull).  I had to remind myself that a CT scan is a test for the presence of an organ, not necessarily for function.

Gary got a chest tube to re-inflate his left lung, and I admitted him to the intensive care unit.  I spoke with his family, and they informed me that Gary had been diagnosed with cirrhosis several years prior, and instead of taking meticulous care of himself, he had stopped taking his blood pressure medicine and let himself decline into a state of constant inebriation.  I commented immediately to the intensive care doctor that I had a Very Bad Feeling about my new friend Gary, and that he was at an extremely high risk of deteriorating extremely quickly.

My prediction turned out to be even truer than I could have imagined.  A few days later Gary started circling the drain (god damn you Katy Perry for stealing that medical idiom), and a day after that he was dead.  I can't really put my finger on what exactly killed him, but cirrhosis has a way of sneaking up on you the way every killer in every movie has ever done: 1) jump, 2) scream, 3) dead.

Gary's death was tragic, but it was also predictable and preventable.  For those who are unlucky enough to be saddled with the diagnosis of cirrhosis, it will eventually get you.  The only 2 questions are 1) when and 2) what can you do to delay it.  

Unless you're someone like Gary who did everything he possibly could to accelerate his meeting with eternity.

Wednesday, 21 October 2015

Lucky day

Lightning never strikes the same place twice.  This phrase is patently untrue, as anyone with access to Google can discover in about 0.298 seconds.  However, the general meaning usually holds true - uncommon things happen uncommonly, and for them to happen twice to the same person is highly improbable.  But it happens - just ask Roy Sullivan (if you're too lazy to click the link, Roy got struck by lightning a record 7 times).

Speaking of uncommon things with improbable odds, the lottery is stupid.  I've heard it said often that the lottery is a tax on people who don't understand statistics.  Before anyone complains and yells "Hey Doc you idiot, I won a few dollars/euros/rupees/rubles/whatevers in the lotto!"  Yes, I know people win.  A few people.  A very few.  Sure it's great if you win, but what are the odds?  Astronomically ridiculously low.  In many lotteries around the world, you are many times more likely to be hit by lightning than to win.  Literally.  Makes me wonder if Roy Sullivan ever played the lottery.  Maybe he should have.  Hm.

Moving on.

So yes, the lottery is stupid.  It's no wonder that I've never bought a lottery ticket.  In fact, a friend of mine has his own lottery - whenever he feels the urge to be stupid and buy a ticket, he puts the money in a jar, and at the end of the year, he empties the jar and BAM!  there are his lottery winnings.

As stupid as the lottery is, I still told Rufus (not his real name™) to buy a ticket.

"Wait, what?  GODDAMMIT Doc, you just told us the lottery is stupid, and you still told a patient to play?  And how the hell did that even come up in conversation?"

I'll explain.  Obviously.

Rufus came to me as a high-level trauma with a huge gauze bandage around his neck.  The medics explained that he had been walking to his car when someone came up behind him and randomly stabbed him in the neck.  You know, because that's what normal people do at noon on a Wednesday.

The wound wasn't actively bleeding, but stabs to the neck can be critical.  There are a lot of very important structures in that area that connects the head bone to the chest bone - spinal cord, carotid arteries, jugular veins, oesophagus, trachea, etc.  When a knife goes in, I never know which direction it went - up, down, left, right, backwards, forwards.  So I am forced to do a detailed physical exam (is the patient coughing or vomiting up blood?  Are all his pulses intact?  Can he move and feel his limbs?  Is there blood squirting up to the ceiling?) followed by various studies to confirm and/or rule out any serious injuries.

On my initial exam, there was a rather large and deep laceration to the posterior (back) portion of the right side of the neck with some mild blood oozing out.  But there was no blood on the ceiling and no other obvious signs of serious injury.  His vital signs were all stable, and he was able to move his arms and legs.

Good, no spinal injury.

His carotid pulses were normal (and besides, the carotid and jugular are towards the front of the neck anyway).  The knife wound seemed to go towards the back of the neck, so I was not immediately concerned about the major vascular structures.  What remained were the trachea and oesophagus, though it seemed equally unlikely they could be injured.  After packing the wound to prevent further bleeding, I got several studies (including both tracheoscopy and oesophagoscopy) which miraculously showed no major injury.

For folks like this who should have died but didn't, my usual joke before they leave the trauma bay is to buy a lottery ticket on their way home, since this was definitely their lucky day.  Unfortunately I forgot to tell this to Rufus.  He got a few stitches for his trouble, and the next morning he went home.

I saw him back in my office about a week later to check his wound.  Everything was going well and his wound had healed nicely.  As I was removing the stitches, he and I were marveling about how serious his injury could have been but wasn't.  It was then that I finally remembered to tell him to buy a lottery ticket, though I suspected his luck had run out.

Rufus: Oh I did buy one, Doc.
Me: You did?  What, this past week?
Rufus: Oh no no.  You see I was actually walking back to my car just after buying some tickets and hadn't gotten a chance to scratch them off yet.  That's when that guy stabbed me.  I thought he was going to rob me, but he didn't even steal them or anything.  He just stabbed me and ran away.
Me: Well that's . . . good, though utterly ridiculous.  So did you win?
Rufus: Well I scratched them off as soon as I got home from the hospital.  And you know what, I won enough to pay my rent this month.  That really was my lucky day!

See?  Lightning does strike the same place twice.  So to speak.

Sunday, 11 October 2015



Jumbo eggs.  (Yes, I went straight from "Game of Thrones" to jumbo eggs.  It's just how I roll.)  Extra large sweatpants.  First-class airfare.  Prime beef.  All these things have something in common other than having nothing whatsoever to do with trauma.  Yes, the common thread is that they are the highest level, the biggest.  The top of their class.  Elite.  I could put "BMW-level douchebag driver" on that list too, but I can't decide if they're actually at the bottom of my list of asshole drivers or the top.  I should probably google that, but I have a point to make.

I think. 

Right, the point I was desperately trying to make is that trauma patients have levels too.  Different hospitals have different code names for their various trauma levels, but just to simplify things I'll refer to them very non-creatively as 1 and 2.  The vast majority of patients who come in are level 2, the lower level.  These are folks who have fallen from a height of less than 10 feet, were in a car accident but are awake and alert with stable vital signs, were assaulted, shot in the arm or leg, etc.  Mechanisms of injury that shouldn't necessarily kill you in 5 minutes.

Level 1 trauma patients are those who may be actively dying either based on their presenting exam or how they were injured.  Falls from 60 feet.  Gunshot wounds to the torso or head.  Stab wounds with actively pulsatile bleeding.   Brains leaking out of ears.  I could go on, but I fear I'd lose some readers.

The medics in the field decide what level patients are prior to calling them in, but as I've said before I only believe about 10% of what I hear on The Box before they arrive.  Quite often, more often than I'd care to discuss, patients who should be a Level 2 are brought in as a Level 1 or vice versa.  Now of course I understand it is often very difficult for medics, who usually have no formal medical education, to determine who should be a high-level trauma.  Is this guy who fell off his barstool unconscious because he passed out or because he conked his head on the floor hard enough to bleed into his brain?  Is the heart rate 160 because he's bleeding to death or because he just mainlined cocaine and methamphetamine?  Is that blood on the patient's abdomen or intestine (yes, I've actually seen that confused)?  More often than not caution ("Better safe than sorry") takes the front seat over logic.

But sometimes the guys in the field just plain blow it.

The Noon Gunshot Wound is a rarity in my world, since these patients seem to enjoy getting shot closer to 1 AM for some reason.  If it were me, I'd much rather get shot during the day, since I would expect my trauma surgeon to be more alert at that time of day.  But maybe that's just my personal bias creeping in.  I digress.  Anyway, my pager alerted me just before lunch time that a Level 2 gunshot victim would be arriving in 5 minutes.  These are almost exclusively gunshot wounds to the arm, leg, foot, or hand; nothing that would be immediately life- or limb-threatening.  So I skipped (not really) down to the trauma bay expecting to greet a stable patient who could talk to me.

Ha!  No.

Instead, when Lawrence (not his real name™) rolled in, he was paler than the gurney sheet, sweating more than a marathoner in Dubai, with a blood pressure around 90/40 and a heart rate hovering around 140.  Even a blind man would be able to see that this man was actively dying in front of his unseeing eyes, but somehow the medics didn't.  It didn't help their case that Lawrence kept moaning "Please don't let me die!  Please don't let me die!"

That's invariably a very bad sign.

The medics seemed to have no sense of urgency as they rather sluggishly transferred him to our gurney.  "Multiple gunshot wounds, one to the abdomen, one to the left arm.  He's been like this since we found him."


A quick survey found one gunshot wound in the right lower part of his abdomen, a corresponding exit wound in his left flank, and another entrance wound in his left forearm as the bullet passed through him.

As you can imagine, there are A LOT of very important structures between those holes.  

An even quicker poke on his belly elicited a very deep, almost primal growl, and 3.26 seconds later (I timed it) I was on the phone with the operating theatre staff telling them Lawrence and I would be there in 4 minutes.  I didn't bother getting an X-ray on his almost-certainly fractured arm, because that wouldn't kill him in the next hour.  Whatever was going on in his abdomen, on the other hand, would.

During surgery I evacuated about 2 liters of blood from his abdomen, found multiple active arterial haemorrhages in his mesentery (the blood supply to the intestine), along with 6 holes in his small intestine and 2 in his colon.  Ninety minutes, several units of blood, two small bowel resections, and two colon repairs later, Lawrence was admitted to intensive care where he stayed for a couple of days.  An X-ray that evening confirmed a left radius fracture, but fortunately he would not require surgery to repair it, just a cast.  

In spite of, and certainly not because of, the medics' relative inaction, he walked out of the hospital 9 days later.

In full defence of my emergency medical personnel colleagues (who often do wonderful and heroic things), I completely understand that evaluating and labeling these people in the field can be difficult.  Determining who is severely injured can be next-to-impossible in certain situations.  But this one should have been easy.  As easy as pie.  A piece of cake.  Mmmm...cake.

It does make me wonder though, what injury would be necessary for this crew to call a level 1?  A Ned Stark-style decapitation?

I told you there would be a spoiler.  Anything I can do to get a Game of Thrones reference in.