Monday, 18 September 2017

Listen to me

There is a nearly 100% chance that I know more about trauma and trauma surgery than you.  I fully realize how arrogant that sounds, but if you think about it for one second hopefully you'll understand why I say it.  Having studied for several years in university, several more years of medical school, over half a decade of surgical training, followed by {redacted} years of surgical/trauma practice, hopefully I know a hell of a lot about surgery.  Actually now that I think about it, if I don't know more than you about trauma surgery, then my patients have a real problem.

Unless of course you also happen to be a trauma surgeon, in which case hi!  Welcome!

Because most people see the white coat as a symbol of an authority figure, I rarely get questioned on my orders and recommendations.  Most of the time people nod and say something to the effect of "Yes, doctor."  Don't get me wrong, I don't expect people to take everything I say at 100% face value, because as this blog has demonstrated I am most assuredly not always right.  Though I don't expect blind adherence, what I do expect is for my patients to listen to me.

Since I don't do kids, all of my patients are adults with adult brains (relatively speaking), so they are (unfortunately) free to listen to what I have to say and then make up their own mind.  Tragically, some of those minds are just plain stupid.

The Thursday in question was just like any other typical Thursday, in that everybody seemed to be getting assaulted.  I don't know if there was a knife show in town or if the government was spraying everybody with DocBastard's Super Aggression Chemtrails® again, but it seemed that everyone was getting stabbed, punched, or shot, Oliver included.

Oliver (not his real name™) was my second penetrating trauma victim of the day (the first will be found in a future post as well).  He had reportedly been stabbed by Some Dude for Some Reason with Some Weapon at Some Point in the past hour.  The medics were not terribly forthcoming with details, because Oliver would not tell them anything.

"Hey Doc, this is Oliver.  20 years old.  Single stab wound to the left lower chest.  Breath sounds have been equal, and he has been calm and cooperative although not talking much.  Vital signs are all stable."  By the time the medics finished their story, Oliver had already been hooked up to the monitors.  His heart rate was 61, his blood pressure was 118/68, and his oxygen saturation was 100% on room air.  Hm, I thought, he can't be too seriously injured, because vitals can't get much better than that.

As the medics correctly reported, Oliver had a single 5 cm stab wound to the left lateral chest just where it meets the abdomen.  These thoracoabdominal injuries can be a diagnostic and therapeutic nightmare, as the knife could potentially have penetrated anything in his left chest (including lung, heart, and/or great vessels) or anything in the abdomen (including colon, small intestine, stomach, spleen, and diaphragm).

Shit.

So I did what I always do in this situation – I put my finger in the hole.  Oliver was clearly unhappy with this manoeuvre, but the laceration was quite deep, extending towards his midsection underneath his 12th rib. I could not feel any obvious penetration into his chest or abdomen, but unfortunately knife blades tend to be thinner than my finger, so this is not a perfect test in any way.  Since all of his vital signs remained rock stable, his next stop (after a normal chest x-ray) was the CT scanner.  Much to my surprise and chagrin, though the scan did not show any injury in the chest, it did show a small amount of fluid (read: blood) in the left upper abdomen along with a few dots of air where they did not belong.

Shit!

While the air could have come from the outside world, it was more likely to be leaking out from a hollow organ (ie stomach, small intestine, or colon).  However, not wanting to base my decision solely on a picture on a computer screen, I went back to examine Oliver, whose vital signs were still completely normal (and probably better than mine at that moment).  His abdomen was still soft, flat, and completely nontender (except at the stab wound).  At this point my options were:
  1. Patch him up and sent him home, which was a terrible idea.
  2. Observe him for the next 12 hours to see if any signs of peritonitis develop from a perforation that I conveniently decided to ignore for half a day.  This is only a slightly less bad option, because by the time peritonitis develops, Oliver would already be (by definition) sick as hell. 
  3. Take Oliver to the operating room, insert a laparoscope into his abdomen, and take a look around. 
I went with option 3.

Ninety minutes later I had a laparoscope in his abdomen, where I was able to see a small amount of blood in the left upper abdomen as well as a small laceration to his diaphragm. 

Wait wait wait Doc, 90 minutes?  Why the hell did it take you 90 minutes to get him to theatre?  That's malpractice!  I'm going to report you etc etc.

Hold on there, bucko.  Remember how I said Oliver was my second penetrating trauma of the day?  Well the first one came in exactly two minutes before Oliver did.  He was much sicker than Oliver was, so I had to take him to theatre first.  Remember also when I said he would be addressed in a future post?  He will.  I just haven't gotten to it yet.  So hold onto your stupid report and stick it somewhere dark.

Anyway, the diaphragm laceration certainly needed to be repaired, but I also need to make sure nothing else had a hole in it that needed repair.  I remove the laparoscope and opened him up the old fashioned way, but after an exhaustive search the only other injury I found was a very small laceration to his omentum.  The air on the CT scan had indeed come from the outside world, but assuming that without doing surgery is a potentially lethal mistake.  Fortunately for Oliver this was the best possible outcome – his postoperative course should be short, about two to three days, and hopefully uneventful.  

Hopefully.  (Foreshadowing . . .)

I heaved a big sigh and repaired his diaphragm, everybody gave each other a high-five for a job well done (not really), and I closed.  I went to see Oliver the next morning at 7 AM, and he was putting his clothes on, getting ready to leave.  You know, 12 hours after major surgery.

Uh . . . 

"Oh hey Doc.  Listen, I got to go.  I have things I need to do at home," he told me with a small wince of pain as he buttoned his shirt.  I looked at him sternly and then very slowly and carefully and using very small words explained to him that he just had major surgery 12 hours earlier, and he should expect to be in the hospital for 2 to 3 more days.  But Oliver would have nothing of it. 

"Nope, sorry I got things I gotta do at home.  I've been walking, I feel fine, I need to go."  I heaved a very heavy sigh, looked at him even sternlier (yes, that should totally be a word), and explained everything that I had just explained, this time a bit more slowly, a bit more forcefully, and using even smaller words so that he would be sure to understand.  

Nope.  The nurse called me an hour later to alert me that he had indeed left the hospital against medical advice.  

And then one of the emergency physicians called me seven hours after that to tell me that he was back. 

Of course. 

When I went in to see him the following morning, he looked only mildly abashed, like he had barely done anything wrong.  "Welcome back," I told him with a scowl.  "Yeah, I probably shouldn't have left, right?" he said, finally looking up from his mobile.

"Right," I told him in that same stern voice I had used before.  "That was a stupid thing to do.  Really stupid.  I expect you to stay here in hospital this time until I discharge you.  Clear?"  He simply nodded and went back to playing a game on his mobile.

As expected, Oliver had normal post-laparotomy pain which is best treated, you know, in a hospital.  He stayed in hospital for 3 more days until his bowels woke back up (which is normal after major abdominal surgery), and he then went home again.

But not until I discharged him.

Saturday, 9 September 2017

No, Jahi McMath is still not alive

I'm stunned.

I'm simply stunned.

As you can probably imagine, considering everything I see in my trauma bay, it takes a lot to stun me.  The most recent judge in the Jahi McMath case managed to do it.

If you aren't familiar with Jahi, you can read more about her sad case here (there are links to other updates in that post).  In short, at age 13 she underwent a complicated nasopharyngeal surgery back in December of 2013.  The surgery reportedly went well, but postoperatively she bled to the point of cardiac arrest and eventual brain death (which was verified by 6 separate physicians).  Her mother fought the diagnosis, and she moved Jahi to New Jersey where she still resides, on a ventilator and unresponsive.

Or is she?

The family has released several videos showing Jahi supposedly moving to verbal cues and another showing her overbreathing her ventilator (if you aren't familiar with that term, just google it).  They claim this proves she is not brain dead, and they found a well-known brain death critic named Alan Shewmon, a paediatric neurologist, to supposedly corroborate their hypothesis.

In response to this, judge Stephen Pulido this past week declared that there is a possibility that Jahi is not in fact brain dead, so he has decided to send the case to a jury to decide if Jahi is still dead or if she no longer satisfies the requirement for brain death.

There are several glaring problems, all of which have combined to flabbergast me.

The first and biggest problem I have here is that Alan Shewmon HAS NOT EXAMINED HER.  He solely relied on the 49 unsubstantiated videos supplied by Jahi's family to formulate his opinion that Jahi does not meet the criteria for brain death.  I've seen several of the videos, and I can definitively tell you that they mean exactly jack shit.  For example, one of them shows only Jahi's foot moving in response to her mother's voice.  That's it, just her foot.  There is no indication how long they were taking video, if she was moving her foot prior to the commands being given, etc.  It's absolutely meaningless.

Let me reiterate this in no uncertain terms: Alan Shewmon has averred in a sworn statement given to the court that Jahi no longer meets criteria for brain death based solely on these videos.  The only instance when he examined her was in December of 2014, at which time he stated that she was not in any way responsive (see paragraph 9).  He has NOT re-examined her since.  Not to mention the fact that nothing in the videos is acceptable in either diagnosing or ruling out brain death.

And Judge Pulido not only accepted Shewmon's ridiculous statement, he has kicked this to a jury to decide in response to it.

Since when does a jury get to decide who is living or dead?  I thought that was the job of doctors.  Has medicine advanced to the point where a group of twelve people can make medical diagnoses?  And who the fuck decided it was a good idea to do that based on the testimony of a doctor who hasn't even examined the damned patient?

Consider this - if I were to make a diagnosis on a patient I had not examined, what would you call me?  At best, you should call me unethical.  At worst, a quack.  And even worse, consider this: Judge Pulido is asking a jury, presumably without any medical training whatsoever, to synthesise and assess information that even experts would have difficulty with?  Are you fucking kidding me?

This case has officially become a farce.  It was sad and risible before, but this latest development is absolutely ludicrously preposterous.  I don't know how else to put it.

As I have said many times before, if new evidence comes to light showing that Jahi is in fact not brain dead, I will recant everything I have said and state without question that I was wrong.  Until then, this is fucking ridiculous.

Friday, 1 September 2017

Diversity

This probably goes without saying, but the world of trauma is pretty damned diverse. I don't mean to say that trauma is different from other medical specialties in that way, because I'm sure every doctor feels the same way about his or her chosen field. However, all those other doctors are wrong. Trauma is clearly the best.

I kid, I kid. Sort of. Not really.

Think about it though - GPs see mostly elderly people with chronic diseases like hypertension and diabetes and high cholesterol, but also the odd patient with back pain, a sniffle, various other aches and pains, or a vague sense of unease. Not so diverse. Specialists only see patients in their particular chosen area. Trauma, on the other hand, is so varied is because we see every and any manner of traumatic injury, intentional, accidental, and otherwise: car accidents, motorcycle crashes, falls (from standing, off ladders, out of windows, from bed, from pub stools), stabbings, assaults, gunshot victims, bicycle crashes, animal attacks (these stories are usually the best), industrial accidents, sports accidents, and other. Diversity.

I can't really categorise Mauricio (not his real name™) in any other way, so he must therefore be an other.

If there is one thing I've learned from watching crime shows, it is don't run from the police. Don't run on foot, don't flee in a car, don't speed off on a motorcycle, just don't fucking run. No matter how fast you think you are, even if the officers themselves are not terribly swift, the police dogs and helicopters are faster than you. Mauricio apparently either never watched these shows or isn't smart enough to pick up the message.

My bet is the latter.

The walk-in clinic is an off-shoot of A&E/ED in which I have very little involvement. If you think I avoid the emergency department and their "I just, I don't know, I just don't feel right" patients, you better believe I avoid this part of it. This area is reserved for the non-emergent emergencies (ie the patients who can usually wait to see their GP the following day or week or year), but unfortunately I still get the occasional call from docs there about patients with facial fractures they can't deal with or lacerations they don't want to deal with. The stories are rarely good, which is why I never tell them.

Until Mauricio.

Mauricio had been brought to the walk-in clinic by police after what they called a "fall".  They are not medics, so I can't really fault them for not giving an appropriate consultation, but I will anyway because Mauricio was not a fall, as we all found out later. Regardless, the emergency physician's workup on Mauricio included a CT of his brain which found two surprising results: 1) he actually had a brain, and 2) a subdural haematoma, which was why I was called. He was complaining of a headache (obviously) though he was neurologically intact. Despite the rather ugly looking scan, he had no weakness, numbness, or any other complaint. He ultimately would not need surgery, but he still needed to be closely watched in intensive care to make sure that his brain didn't swell and the bleeding didn't worsen.

Despite the two surprises we already had, the diagnosis wasn't the real surprise. It was the mechanism of injury that was.

Mauricio had been caught trying to steal a car. I say trying because he apparently is a shit car thief and could not even get in the door. A bystander apparently saw him using a clothes hanger to try to unlock the door (yes, really) and called the police. When they arrived about 15 minutes later, he still hadn't figured out that 1) the hanger would never work on that particular model car, and 2) a rock would have broken the window and gotten him into the car much more easily. Anyway, when the police told him to freeze (or whatever the hell they actually yell in 2017), he did not freeze. No, he ran.

And ran.

And ran.

Right into a brick wall.

Now last time I checked, brick walls are neither small nor particularly mobile, so surely Mauricio was just so drunk that he stumbled into it, right? Nope. His blood alcohol was negative, as was his urine tox screen. He actually literally just ran into a brick wall.

I can add this to the pile of "Well, I doubt I'll ever see that shit again."

Tuesday, 22 August 2017

Prison

I don't typically think of my job as dangerous.  Quite the opposite, actually - the trauma bay is supposed to be a safe place where people who have done something particularly dangerous and/or stupid come to get something fixed.  Whenever we get a rowdy patient (who is usually either A) drunk, B) high on PCP, C) an asshole, or D) some combination of the above), everyone in the trauma bay knows that, with one quick phone call, several very burly men who could easily pass for moderately large bears will descend upon the asshole and defuse the situation in approximately 4.72 seconds. 

Sometimes, however, even that isn't enough. 

Unlike the trauma bay, prisons are violent places, and violent things tend to happen there.  Granted my information regarding the violence inherent in the penal system is mostly limited to what I learned in The Shawshank Redemption and O Brother Where Art Thou, but that knowledge base expanded significantly recently when I met Ervin (not his real name™). 

I don't usually get too worked up when my trauma pager alerts me to an impending "assault".  That may sound callous, but it's for several good (I think) reasons: 1) When people are assaulted, it is most commonly limited to the face, 2) if these people suffer any injuries (past lacerations and contusions), it is most often a broken nose or other facial bone, 3) those fractures rarely require surgical intervention, and 4) if they do, I call the maxillofacial surgeon to do it.  So when my pager alerted me to an assault arriving in 8 minutes, I sighed and put away the blog post I had been trying diligently (yet failing miserably) to make sound less stupid. 

But then something caught my eye - the patient was arriving by air, not ground.  Hm.  That could mean it was more serious than I was imagining.  Or it could mean the patient was injured further away than an ambulance could drive in a reasonable amount of time.  Or it could mean something else.  Yes, the dreaded "other".  

And of course it was "other". 

When Ervin was wheeled in, the first thing I noticed was the prison jumpsuit.  The second, third, fourth, and fifth things I noticed were the various handcuffs and shackles pinning him to the stretcher.  The next thing I noticed was the mask over his face (think Hannibal Lecter).  Finally came the bevy of police officers accompanying him.  This bodes poorly, I thought. 

And I didn't even know the half of it yet. 

"Hi there, Doc. This is Ervin.  Ervin has been (god damn it Ervin, stop fighting!), uh he's been tussling with the prison guards for the last (damn it, Ervin! Stop fucking spitting!), um for the last two days.  He's being transferred, and (fucking hell guys, he's trying to claw my arm again!), he's being transferred to another facility and doesn't want to go I guess." 

Imagine trying to wrangle a cat into a pet carrier.  Now imagine the cat is extremely angry.  Now also imagine that cat is 2 meters tall, weighs 110 kg, and can curse constantly.  Yeah, that's Ervin. 

He was covered head to toe in abrasions and contusions, and he had obviously earned every single one of them.  Ervin continued fighting as we moved him to our stretcher, and I've rarely seen such a relieved medic crew get the hell out of my trauma bay so quickly.  The officers, on the other hand, thankfully stayed. 

"You want us to uncuff him, Doc?" one of the officers asked me. 

"Hey wait," one of the nurses said.  "I know this guy!  Yeah, Ervin!  He was here as an 'assault' two days ago after he fought with the prison guards!  He injured two techs and a nurse, and he tried to kick me in the face!" 

The police officer looked at me askance. 

Uncuff him? Seriously? 

"Hell. Fucking. No.  Under no circumstances.  NO."  Yes, those were my exact words. 

The tech moved towards him to place an IV, and I immediately stopped her.  I made it clear to everyone in the room that no one was to come near this guy with anything sharp, and all we were going to do was get a quick 5-second CT scan of his brain, see that it was normal, and then send him right back from whence he came.  Fortunately when we brought Ervin to the scanner, he decided the CT doughnut wasn't as threatening as a roomful of cops, so he stayed still long enough for me to see a normal brain. 

Thank you for this one small thing, Call Gods

As I was chatting with a few of the guards a short while later, one of the nurses beckoned to me.  "The radiologist is on the line for you.  He has a critical finding he needs to tell you about." 

Oh come on, no. No. NO. 

It turns out I had missed a tiny subdural haematoma and an even tinier cerebral contusion.  I looked at the scan again and still couldn't see it, so I had another radiologist look at it.  He confirmed that I was indeed not a radiologist and the other radiologist is.  The finding was, in fact, real.  

God. Damn. It. Fuck You, Call Gods. Fuck you. 

So now I was obligated to admit this asshole, put an army of security guards and police officers on him, start an IV, try to do neuro checks on him every hour, repeat the CT scan in a few hours . . . 

Fuck. Just, fuck. 

I did exactly that, apologising to everyone involved in the process.  No one wanted to take care of Ervin, though we all did dutifully and respectfully.  Ervin, however, was not nearly as accommodating.  There were two very large police guards inside his room at all times, and fortunately his outbursts were mostly limited to hurling verbal abuse at anyone he could see.  

The following day his repeat CT scan was stable, his neuro exam was stable (read: he was still a violent asshole), and I kicked him the fuck out of my hospital before he could injure anyone else. 

I have no doubt I will see him again. Soon.

Friday, 11 August 2017

Surreal

Those of you who are regulars here or follow me on Twitter know my feelings on pseudoscience (otherwise known as "bullshit").  Depending on the day, my opinion wavers somewhere between "Pseudoscience is potentially dangerous nonsense" and "What the fuck are you idiots thinking".  Fortunately I've had very few interactions with pseudoscientific nonsense in my professional career, though several years ago I did have one woman ask me about Dr. Oz and an "olive oil flush" for gallstones.  Since I've been ranting and raving about various bullshit modalities like chiropractic, homeopathy, and acupuncture, I've often wondered how long it would be until my next encounter.

Wonder no more.

I was asked to see Barbara (not her real name™) late one evening for what sounded like typical acute cholecystitis - several days of right upper quadrant abdominal pain, fever, nausea, and vomiting.  Before going in to examine her I looked at her abdominal ultrasound, which showed multiple large stones in her gall bladder along with thickening of her gall bladder wall and inflammation surrounding the gall bladder itself.  Checking her bloodwork, her liver function tests were all normal (so no sign of a biliary tract obstruction - good), and her white blood cell count was mildly elevated as would be expected.  It seemed like a slam dunk, and it was.

Mostly.

When I entered Barbara's room, she had a friend with her, which is certainly not unusual.  I examined her carefully, and the only abnormality was fairly severe tenderness in her right upper abdomen, typical of someone with a gall bladder infection.  I explained the treatment protocol, which would be giving her IV antibiotics overnight followed by a laparoscopic surgery the following morning to remove her infected gall bladder.  I went through my prepared speech which I've given hundreds of times, including the risks, benefits, and alternatives.  And as usual I ended with my normal conclusion: "Do you have any questions?"

It was one of the few times I've regretted it.

Barbara whipped out a little notepad with myriad hand-written notes, and I was immediately bombarded with approximately 1,058 questions, everything from the mundane ("How long will I be out of work?") to the somewhat-strange-but-still-almost-normal ("What anaesthetic agent will I be given?") to the completely bizarre ("What are your instruments made of?").

Then she hit me with one that was so far out in left field it may as well have come from a different country:

"Can I keep my gall bladder?"

Um.  Uhhh.

I had to explain to her that I was obligated to give the gall bladder to the pathologist, who would cut it into thin slices and make sure she didn't have something wacky like gall bladder cancer, so, um, no, you can't keep your disgusting infected gall bladder.  I offered her the option to keep one of her stones instead, which she readily accepted.

And then her friend started asking questions.  Approximately 792 more.

Sigh.

After what seemed like two hours (but was probably closer to 8 minutes), I finally made my way out of her room, where her nurse caught my eye.  She rolled her eyes and smirked in a plainly obvious "Oh, she got you too?" look.  I merely smiled back weakly, feeling lucky to have escaped.

The following morning I went to see Barbara, and she still looked uncomfortable.  Regardless, she told me she was ready for surgery, which was scheduled for later that afternoon.  I went back to my office to see patients for a few hours, returning to the hospital about 30 minutes before her operation was due to begin.  I figured she would be in the pre-op area, which she was.  What I didn't figure was who would be with her.

The only way I could properly describe Barbara's visitor would be to say that she looked like she stepped directly out of 1967 into a time machine, landing in my hospital in 2017.  She could have easily passed as someone who went to a costume party dressed as a hippie and then forgot to remove the costume, so she simply continued living as a hippie.  She had one hand on Barbara's right shoulder and another on her back, and it looked like she was giving her some kind of weird massage.

"Oh, hi Dr. Bastard," Barbara smiled.  "This is Rena (not her real name™), my reiki master."

Your . . . your what?

I had no idea how to reply, and the anaesthesiologist could sense the palpable awkwardness growing by the second.  He gave me a knowing look, rolled his eyes, and clearly trying to break the tension said, "Yeah, I missed my last two reiki appointments."

Heh, good one.

"I KNOW, ISN'T IT AMAZING?" Rena replied with a broad smile, obviously missing the obvious sarcasm, which was obviously obvious.  Barbara smiled too, missing the fact that now both the anaesthesiologist and I were staring at each other, our mouths agape.

It's difficult to render me speechless.

In case you aren't aware of what reiki is, it's bullshit.  It's pure, unadulterated bullshit.  Here, I'll give you the rundown: take prayer, add running your hands over someone to transfer energy to them, and you have bullshit.  I mean reiki.  No, I was right the first time.  Bullshit.

I had never seen reiki actually practiced in real life, so I watched agog as Rena ran her hands over Barbara's right shoulder, muttering encouraging words (I guess) and supposedly transferring some universal life force into her.  This was happening as her very modern IV antibiotic was running through a very modern plastic tube into her very physical vein.

I couldn't think of anything else to say, so I quickly signed my paperwork, muttered something about changing into scrubs, and walked out.  The anaesthesiologist looked jealous.

Barbara's surgery was moderately difficult though uncomplicated.  Her gall bladder was quite inflamed, but it was no different than most any other case of acute cholecystitis I've handled through the years.  She went home the following day feeling somewhat better, but still in some pain.  My typical gall bladder patients go home the same day as surgery and are back to their usual activities within a day or two, relying on ibuprofen (if anything) for pain.  Barbara, on the other hand, emailed me several times a day over the next few days to describe the progression of her pain, nausea, appetite, temperature, and anything else she managed to quantify.  She finally started feeling better just over a week later, to her (and my inbox's) great relief.  She came for her follow-up visit two weeks after surgery, Rena tagging along.  Of course.

With that goddamned notepad.  Of course.

After conducting my exam (everything looked absolutely fine), I dutifully answered all of her remaining questions, including "When can I start juicing again?".  Barbara and Rena both profusely thanked me for my patience and warm bedside manner, and they left looking quite satisfied.  If they only knew what I had really been thinking.

Now I realise that this is only an N of 1 and anecdotes are not data, but it sure seems to me that Rena's energy transfer didn't fucking work.  Of course it's possible Barbara's surgery would have been even more difficult, and her recovery much more protracted, if she hadn't had the reiki treatment done.  Right?

Ha!  No.

Monday, 31 July 2017

Expect the unexpected


Apparently Heraclitus of Ephesus was the first to say something to the effect of "Expect the unexpected", though his exact words were more like "He who does not expect will not find out the unexpected, for it is trackless and unexplored" which sounds much more "Greek philosopher"-ish and less "David Avocado Wolfe meme"-ish.  Regardless, I've always thought this phrase stupid and meaningless, because how can you expect the unexpected?  If you expect it, then it isn't actually unexpected, is it.  What a stupid adage, almost as stupid as "YOLO", am I right?

When I was younger I used to think that was just me being even more pedantic than usual.  But then I became a trauma surgeon and learned what "unexpected" really means.  It was then that "Expect the unexpected" took on a whole new meaning.

A "typical" trauma day for me will involve somewhere between 5 and 20 patients, most of them lightly-to-moderately injured (abrasions, lacerations, contusions, perhaps a broken bone here and there).  These are folks who need X-rays more than a trauma surgeon, at least initially.  Perhaps 10% are severely injured, and 1-2% have truly life-threatening injuries.  So on any given call day I can usually expect one or two "Level 1" traumas who need my immediate attention.  So you can imagine my surprise when the first 4 trauma patients who rolled into my trauma bay one recent Saturday were all Level 1s.

Fuck you, Call Gods.

The first patient was a middle-aged drunk man who was stabbed in the chest multiple times (at 9 o'clock in the morning?  Really?) but only had superficial injuries.  This story is not about him.

The second was a young man who was stabbed in the abdomen and left arm (at 10 AM?  Fucking really, Call Gods??) and had multiple lacerations to his small and large intestine as well as the left brachial artery and required a laparotomy, resection of the small intestine, repair of the colon, and repair of the brachial artery.  This story is not about him either.

The third was a teenager who was shot in the thigh (at noon?  Seriously, what the fuck, Call Gods??) and had a broken femur which required surgical fixation.  Nope, this is not about him.

The fourth guy, on the other hand . . . yeah the fourth guy threw everyone off.  I bet at this point even the Call Gods were tired of playing the same goddamned joke on me.

I was already exhausted and ready to go home by the time Quinton (not his real name™) was brought in at 1 PM (only 19 more hours to go!).  "Hi everyone, this is Quinton.  We found him on the side of the road.  Looks like he was hit by a car.  Got an abrasion on his left shoulder, looks like his face landed on a stick.  His left eye is, well, it's just missing.  He's unresponsive, not moving anything for us."

The road they found him near is a high-speed road, so everyone immediately jumped into action knowing that he had been suffered a high-velocity, high-energy strike.  The potential injuries were vast - literally anything could be injured.  Since the anaesthesiologist was intubating him, I started at his feet and made my way up.  His feet and legs were fine.  Pelvis, stable.  Abdomen was soft, flat, no obvious injuries, ultrasound negative for blood in the belly.  Chest was stable, no obvious rib fractures, breath sounds were equal.  His heart was beating a bit fast, but the sounds weren't muffled, so I doubted a blunt cardiac rupture.  Arms and hands were normal.  His neck looked normal.

And then I got to his head.  His left eye wasn't missing, but it wasn't normal either.  The globe (eyeball) was ruptured, presumably from the stick he had landed on.  I didn't so much care about the eyeball - while that injury looks seriously bad, you can live without an eye.  His scalp had some matted dried blood in it which made evaluation of his scalp impossible.

With his airway secure and his vital signs stable, we got a quick X-ray of his chest (normal) and pelvis (normal) and went immediately to the CT scanner.  When a scan is done, the tech first shoots a "scout" film, which is essentially a plain X-ray of the body part to be scanned.  The tech shot the scout intending to set up for the scan then said something entirely unexpected:

Tech: Um . . . there's a bullet in there.
Me: Wait, there's a what??
Tech: No wait, I was wrong.
Me: Whew.
Tech: There are two.

I looked at the screen, and sure enough there was a bullet sitting right in the middle of his head and another one in his face.  Uh . . . what?  I had assumed he had suffered a high-velocity, high-energy strike, but this wasn't exactly what I had in mind.

The CT images came through a few seconds later, and to say I was surprised would be a drastic understatement.  That matted blood on his scalp was hiding a gunshot wound and underlying skull fracture with a large haematoma in his brain, with the bullet coming to rest in the soft tissue of his cheek.  The second bullet had apparently gone through his eyeball and lodged in the middle of his brain.  There was severe swelling of his brain and transtentorial herniation.  If that sounds bad, it's probably even worse than it sounds.

It takes a lot to surprise me, but that SURPRISED THE HELL out of me.

About an hour later Quinton was in the operating theatre with one of my neurosurgery colleagues, despite the fact that we both knew any aggressive treatment would likely be futile.  Unfortunately we were both right - it took him two more days to finish dying.  No one ever came to identify him, so organ donation was impossible.

I like to joke that I'm a pessimist and that pessimists get more happy surprises, but in reality surprises in the world of trauma are nearly universally bad.  And expecting the unexpected sure sounds like a great way to avoid surprises.  Sometimes, however, the unexpected is just, well, unexpected.

Thursday, 27 July 2017

Education

To me (and hopefully to you), education does not necessarily mean what one learns in a classroom.  Sure, there are plenty of things to learn while sitting and listening to someone with the charisma of an oak tree droning on and on about what some army general 300 years ago did to win some plot of land that doesn't even belong to that country that no longer even exists.  However, practical knowledge is more important than anything else.  Except maths - for fuck's sake, learn your maths.  How else are you going to know how much that sale is saving you?

Anyway, the most educational experience of my life has undoubtedly been in the trauma bay.  There are so many lessons I have learned there through the years, and though I'm not saying you can't learn this stuff elsewhere, I personally would likely never have learned them anywhere else for any reason.  These are pearls of wisdom that I will teach my children and take with me everywhere until the day I take my last breath.

And I'd like to share a few of them now.

Ahem . . .

Donkeys are singularly nasty creatures.

A donkey bite looks shockingly like a human bite. 

Helmets work well, but only when applied to the head.  Corollary: helmets are shit at protecting the face.

Gravel is hard to remove from skin.  

Asphalt is much harder than bone.

Many people underestimate gravity.

Trucks have the capacity to move out of the way.  Trees don't. 

Untreated schizophrenia is fucking terrifying.

PCP intoxication can look surprisingly (and terrifyingly) like untreated schizophrenia.

People will deny anything, even something glaringly obvious, for any reason.

Your dog will eat your foot if it gets hungry enough.

A bag of drugs can be hidden in literally any bodily orifice.  If one is not available, a new one can and will be created. 

Power tools can explode. 

People will lie, cheat, steal, beg, plead, wheedle, cajole, bargain, debate, and negotiate for a prescription for narcotics that they don't need. 

Children who have parents that don't give a damn will do stupid things at 2 AM.

Percocet can be a gateway to heroin. 

Holding your baby in your arms will not necessarily stop a pissed off ex from shooting or stabbing you. 

Jealousy is apparently a good enough reason to stab someone in the heart. 

A hammer can be just as lethal as a gun.  So can a deer.

There truly is no limit to the depth of human stupidity.

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Now I fully realise that last lesson can be learned by anyone in nearly any field.  Everyone has stupid stories to tell, many of them hilarious in their absurdity.  But the difference is that only in very few occupations can your stupidity kill you.  Or others.