Monday, 25 November 2019

Seat belts

Let's face it, seat belts are a good idea. This statement is in no way controversial, and all who try to argue against it aren't just "expressing an opinion" or "arguing the other side", they are just plain fucking wrong. Seat belts were designed to keep you safely in the car in the event of a crash rather than getting blasted through a window to land on a fence post, over a guardrail down an embankment, or into oncoming traffic. They are a Very Good Idea that have been implemented spectacularly well all over the world (mostly) (fuck you, New Hampshire).

As simple and effective as they are, I can not believe that there are people living and driving today who still don't put them on, but there are. And because these people exist, I get to take care of them.

And then I get to write about them when they are inevitably injured much more severely than they should have been.

Judy (not her real name™) and her husband Mickey (not his real name™) decided to take a break from their door-to-door Xanax business and take a little drive. Now before I continue, please go back and read that last sentence again. I'll wait right here.

*pleasing hold music, but not the boring twaddle you hear while on hold on the phone*

You're back? Excellent hold music, right? Anyway, I assume you read it back at least twice, because I know I sure did, and I wrote the damned thing. Yes, Judy and Mickey had a little neighbourhood benzodiazepine business. They literally went door to door asking their friends and neighbours if they wanted any pills. Where they got these pills is anyone's guess, but I have to assume business was booming because the police officer who came with them described their stash as a "large grocery bag full".

In case you thought that was stupid, what made it even stupider (yes, that's a word) is that they dipped into their own cache and then mixed the pills with alcohol.

And what made it even stupider is that on their break they decided to go for a little drive while drunk and stoned out of their minds.

And what made it even stupider was then choosing to engage in a street race while stoned out of their minds.

And then what made it the stupidest (yes, that's also actually a word) is that they failed to put on their seat belts.

Ironically I can't even fault them for not putting their seat belts on, because they were both too drunk/stoned to keep their eyes open let alone perform a complex task such as inserting tab A into slot B. How Mickey managed to navigate the controls of a motor vehicle is one of life's great mysteries. Regardless, engage in a street race they did, and I believe it is a safe assumption that they lost. Crashing into a bridge abutment at 120 kph (75 mph) in a 50 kph (30 mph) zone will usually lose you any race fairly instantaneously, unless the objective of the race was to see who dies the fastest (or tries, at least).

And because Judy and Mickey were not wearing their seat belts, both were ejected from the car, far, far away from all the various safety mechanisms that had been designed, extensively tested, and installed specifically to protect them. Mickey was thrown through the windscreen, presumably striking his head and/or neck on the bridge or the ground or a tree or it doesn't really fucking matter what. Judy was partially ejected through the passenger window, bending her lower spine at a rather awkward angle.

Both of them were awake when they arrived in the trauma bay. Neither was moving.

"Hey trauma team, this is Mickey and Judy. He's 50, she's 35. They were in a street race, high speed, struck a bridge. He was ejected, not moving anything below the neck. She was partially ejected, moving her arms but not her legs. Doesn't look good, Doc."

No, no it sure didn't.

Mickey had fractured his sixth cervical vertebra, and a portion of the fractured bone had been pushed into his spinal cord, paralysing him from that point down instantly. He also had a few broken ribs, but those would only pose minor problems (relatively speaking). Judy had fractured her first lumbar vertebra, also injuring her spinal cord at that location. Mickey had no motor or sensory function below his neck, and it was a minor miracle that he was still able to breath on his own, since the nerves that control the diaphragm come from just above that level (C3-5). Judy had no motor or sensory function below her waist in addition to a minor laceration of her spleen.

Both required major spine surgery. Both survived.

I had several opportunities to sit and chat with Judy during her two weeks with me. She was actually a reasonably intelligent woman, polite, appreciative, and apologetic (even though she hadn't been the one driving at the time). Mickey, on the other hand, remained recalcitrant despite his quadriplegia. Despite his horrific and life-changing injury, he was adamant that he had only survived because he had been "thrown clear of the wreck". Judy at least understood that remaining in the car with the seat belts and airbags would have been much less harsh on their bodies than, you know, hitting concrete at 1/10 the speed of sound (yes, really).

She too failed to convince him before she went to a spinal rehabilitation facility.

Mickey had some respiratory complications and ended up needing a tracheostomy. He stayed with me for about a six weeks before going to the same spinal rehab facility, arguing the entire time that he still would never ever wear "that damned belt".

I saw Judy about a month later. She had finished her inpatient rehabilitation and was starting to regain some use of her legs. I saw Mickey about two weeks later, and owing only to the quick response of our neurosurgeon had regained near full use of his arms, though he will remain paralysed from the chest down for the rest of his life. But unfortunately that had only strengthened his bewildering belief that not wearing his seat belt had saved his arms. I again tried to explain that, had he stayed in the car and been buffered by the seat belt and airbag, his injuries would have been significantly less, and he may have literally walked away from the accident, but he only cut me off.

"I'll never wear that damned belt. It would have killed me."

I seldom give up, especially when it comes to something as important and life-saving (and simple) as using a seat belt. But after several attempts and an equal number of rude interruptions, I gave up.

And if you're wondering, I have no idea what happened to their Xanax business. I forgot to ask.

Monday, 18 November 2019

Unpredicted

I often look at my pager sitting next to my mobile phone and think, "How the fuck are we still using this 1950's technology in 2019?" But we still unfortunately rely on these outdated, grossly obsolete prehistoric monstrosities. Regardless, if my pager tells me I'm getting a car accident, I can predict that I will be getting some kind of car accident - rollover, car vs tree, car vs car, etc. If it says I'm getting a fall victim, I can predict with at least 90% accuracy that it will be either an elderly person who lost his footing and fell from standing position, a drunk person who fell from standing position, or a construction worker who fell off a ladder or partially completed building. If I see I'm getting a stabbing victim, I can be fairly well assured it will be a young man in his late teens or early 20's. What I do when they get to my trauma bay varies based on the location and severity of the injuries, of course, but the patterns remain the same.

Until they don't.

This particular day's pattern had been falls. Over my previous 42 hours of call (24 from the last shift and 18 from this one . . . wait, carry the 1 . . . yeah, 42), my last fourteen patients had been falls. ALL of them. Elderly falls from standing, elderly fall off a roof (yes, really), elderly fall off a ladder (yes, really), elderly fall off a toilet, elderly fall out of a wheelchair . . . you get the idea. As you may (though probably don't) remember from earlier posts, I don't much care for falls because they are very rarely exciting or fulfilling (though I did have one guy rupture his bladder jumping off a roof while trying to jump into a swimming pool (and missing) several years back, but that's another story). I was beginning to think that everyone over the age of 70 in the entire {redacted} metropolitan area had decided to fall that day, until my pager finally told me my next trauma would be a level 1 stabbing. My Inner Pessimist seemed excited.

YES! FINALLY!

I know, I know.  It's awfully macabre to want someone to get stabbed, but there are only so many nonagenarian falls I can see in one day before going completely insane. Technically I didn't really want anyone to get stabbed, I just wanted to see someone who had been stabbed. Sort of. Technically. Dammit, you know what I mean.

As my team and I prepared for the patient's arrival by donning our personal protection gear (masks, gowns, and gloves, that is, not guns), I was also mentally preparing for said patient to be another 20-something male rolling through the door with various and sundry stab wounds. So you can imagine my surprise when that 20-something male turned out to be a 70-something female. My Inner Pessimist began pestering me:

They made a mistake! This is obviously yet another elderly fall! Will I ever get anything other than a fall? Am I now officially an Elderly Fall Trauma Surgeon?

As these thoughts rolled around my brain and the medics transferred her from their gurney to mine, the blanket fell from around her neck, revealing a large, bloody bandage. My Inner Pessimist refused to back down, trying to convince me "She probably just fell in the shower against something sharp!"

Shut up, Inner Pessimist.

"Hi Doc, this is Bess.  She's 72, stabbed once in the right neck.  No loss of consciousness.  Bleeding is controlled.  It's pretty big though."

Other than my elderly lady several years ago that was nearly decapitated by her seat belt (that's yet another story for yet another time), this was the first elderly female stabbing victim I could remember. Ever.

Bess was stunningly calm for someone with a 10 cm laceration on the side of her neck. She was also completely alert and sharp as a tack, which made her somewhat different than most of my septuagenarian patients. Her laceration was on the posterolateral aspect of her right neck over the posterior cervical triangle. Whew. I breathed a small sigh of relief. If you simply must get stabbed in the neck (which you shouldn't), that's a good place to do it, mainly because the only really important structures in the area are the transverse cervical artery and accessory nerve (and a few sensory nerves), none of which were close to this particular laceration.

There was no active bleeding and the laceration was well above the subclavian artery, and her neurological exam was normal, so I was not worried about any major vascular or nerve injury. I started to tell her that she would just need a whole bunch of stitches when my pager went off again.

Another fall? Nope, another level 1 stabbing, arriving in 2 minutes.

Hey, at least it isn't another fall! That's two in a row! Woo!

Shut up, Inner Pessimist.

Rhys (not his real name ™) arrived exactly 2 minutes later and looked much more like what I had been expecting with Bess - young, male, healthy, thin, and 25 years old. I was back in my comfort zone. Until Rhys started talking. Well, ranting actually:

"I'm Tupac Shakur's son! You hear me? Tupac's son! You can't hurt me! YOU CAN'T HURT MEEEE! Tupac ShaKUUUUR!!!"

Hey, at least it isn't another fall!

SHUT THE FUCK UP, Inner Pessimist. I fucking hate that guy sometimes.

"Ok Doc, Rhys is 25. Healthy, no meds, history, or allergies. Single stab wound to the right upper abdomen, we think self-inflicted. He's been talking like this the whole time. Oh, and he stabbed his grandmother in the neck too."

Yeah. Because that's what you do to, especially to your own grandmother.

Rhys had a single stab wound to his upper right abdomen, directly in The Box.This is a danger zone where nearly anything in the chest and/or abdomen could be hit, depending on 1) where exactly the patient was in the respiratory cycle when the knife went in, 2) the angle of entry, and 3) how deep it went. Heart, great vessels, lung, diaphragm, liver, gall bladder, colon, stomach, and small intestine are all potential targets.

Fortunately (or unfortunately, depending on how you look at it) Rhys had managed to do significantly more damage to himself than to Bess. He managed to lacerate his right lung, right diaphragm, and liver. Liver lacerations (especially penetrating ones) tend to stop bleeding by themselves, and small right diaphragm lacerations rarely need to be repaired. All he needed was a chest tube, a few sutures, and a few days in hospital to make sure his liver and lung stopped bleeding (they did).

Oh, and restraints. And a psychiatrist. And one metric fuckton (that's the technical term) of sedatives.

Rewind to Bess who, on the other hand, merely needed a few sutures and a new grandson. Ok, a lot of sutures. But yeah, definitely a new grandson. Still, she was completely fine, though sporting a new badass neck scar. Though she had no idea why Rhys stabbed her, she nevertheless remained incredibly stoic (though perplexed) as I fixed her up. As I was placing the dressings and giving her her discharge and follow up instructions, she said probably the most grandmother thing any grandmother has ever said in the history of grandmothers:

"I'm still giving him that shirt and tie I bought him for Christmas. It'll look so nice on him."

Thursday, 7 November 2019

Save

I've said it before, but I'll say it again: trauma is usually boring. I know, I make it sound so utterly fascinating here. I mean, if trauma is so devoid of excitement, why do I do it, and even more importantly, why the hell are you people here to share in my banality?

But it is sadly true: the car accidents, elderly falls, and bicycle accidents are just not typically exciting. Sure they may have some serious injuries, but there are only but so many broken ankles and concussions I can see before I feel ready to pack up and go home. Even the penetrating injuries often fail to inspire my intellectual curiosity. Indeed, most stabbings are mere flesh wounds. When I see a stab to the chest in a man who is awake and talking to me, chances are the knife just went into his chest wall, the bleeding is just from the underlying soft tissue, and a few sutures or staples are all that is necessary to staunch the not-really-exsanguination.

Until it isn’t.

Troy (not his real name™) decided that it would be a great idea to take some PCP before engaging in a high stakes poker match. This may not sound like a very bright idea, but that’s only because it isn’t. While I highly doubt Troy’s poker skills were scintillating while sober, they took a noticeable dive after the PCP, probably because he couldn’t tell an ace from a potato. After he lost everything including his shirt (literally (yes really)), the drugs told Troy that the only reasonable thing to do would be to demand his money (and his shirt) back in a language only he could understand. They guy who won both Troy's shirt and money fair and square said no (or something very closely approximating "no"), so Troy and his addled brain said something incomprehensible and then lunged at him. And the other guy predictably whipped out a knife and stabbed him in the chest.

Troy was brought to me in a still-incomprehensible mass of outrage and paranoia, bleeding very mildly from his chest.

“Hey Doc, this is Troy, 26, healthy. Two small stab wounds in the right chest. Vitals have been good, a bit tachycardic, breath sounds are equal. We put some occlusive dressings over the wounds, but they look pretty small and superficial.”

His vital signs were normal other than a slightly high heart rate of 100 which could easily be explained by the PCP, and he indeed had two small stab wounds, about 1 cm each, in his right chest over his pectoralis muscle, neither of which was actively bleeding. I started to assume that this would be just another “staple and go” stabbing victim, but my Inner Pessimist, on the other hand, wouldn’t let me assume anything and began whispering his usual obnoxious sweet nothings in my ear:

He's awfully thin, and you don't know how big the knife was. Maybe it went into his lung. Or his heart. Or his aorta. Maybe he's bleeding to death and YOU JUST DON'T KNOW.

Yeah. Maybe.

But sure enough a few minutes later a chest X-ray showed a haemothorax, a collection of blood in the thoracic cavity.

I hate when my Inner Pessimist is right.

I inserted a chest tube which drained about 800 ml of dark blood, indicating that the bleeding was not from an arterial source, which you can probably imagine would be a Very Bad Thing. The treatment for a simple haemothorax is chest tube drainage for a few days, at which point the tube comes out and the patient goes home. Another patient saved. Huzzah, or something.

But my Inner Pessimist kept pestering me. What about the heart? Maybe it hit his heart! Look at the heart!

What are the odds, I was thinking. But making assumptions in my line of work is both a very bad diagnostic and therapeutic technique. So I did a bedside ultrasound on his heart and found once again that my Inner Pessimist was right - there was fluid in his pericardium, the sac that surrounds the heart.

Have I mentioned that I hate when my Inner Pessimist is right?

Fluid in the pericardium can be benign in someone with congestive heart failure, but fluid in the pericardium in someone who has been stabbed in the chest is unquestionably a Very Bad Thing. That fluid is blood until proven otherwise, because it means there’s a hole in the heart allowing that blood to escape and collect around the heart. Given enough volume, that fluid can compress the heart and not allow it to function properly, causing tamponade and death. And death is a Very Bad Thing.

What it truly means is I need to fix that goddamned hole. Most people with holes in their heart are either dead or actively dying, and Troy was neither.

Yet.

Ten minutes later we were in the operating theatre, and five minutes after that I was using a very fancy saw to cut down Troy’s sternum. As the saw was doing its job, the slightly larger of the two wounds in his right chest started bleeding bright red blood. A lot. Now he was actively dying.

SHIT.

One of my assistants put her finger in the hole to try to slow the bleeding as the anaesthesiologist started pouring blood into Troy from above. I got his chest open and found about half his blood volume, now bright red, in his right chest. I opened his pericardium and found a very small hole, perhaps 3 or 4 mm, in his right atrium which I quickly repaired. It was clear, however, that was not where this bright red blood was coming from, as the blood in the right heart is deoxygenated and much darker, and the blood kept coming even with the heart repaired.

Hmmmmmmmmmmmmm. . .

A cursory evaluation of the right hemithorax showed that there were no injuries to the great vessels or the hilum of the lung. Well that's all fine and dandy, but that bright red blood was coming from somewhere in there. A closer inspection of the underside of the chest wall, however, showed that the knife had completely transected the internal mammary artery, which had clotted off initially but then started bleeding profusely once his blood pressure increased.

It took about 75 seconds to get that under control and then ligate it. We all then paused to take a breath and take notice of the complete lack of any further bleeding from anywhere. After the fact it all seemed rather trivial, though everyone in the room knew it was nothing of the sort. We all high-fived (not really), I cleaned him up, put in a bunch of tubes, and closed.

The next morning Troy was extubated in the intensive care unit, his haematocrit was rock stable, he was awake alert and talking, and he was shockingly unappreciative of our efforts at saving his life. He had two chest tubes draining the minimal residual blood from his right chest and another drainage catheter coming out of the middle of his chest which we had left in the mediastinum over his heart. I was rather stunned to see him looking so stable after everything that had happened, and after explaining his injuries and what we did for him, I asked him how he was feeling. Without missing a beat (and without answering the question), he demanded, “I need to go home today.”

“Um, no. No you don't. You just had open heart surgery less than 12 hours ago. You understand that, right?”

“But I need to get home to pick up a cheque. I have to go.”

No you don’t. I assumed he needed that money to pay off a gambling debt, but regardless I tried to explain that someone else would have to pick up his cheque. Troy was rather insistent that he had to leave. Unfortunately for him I was even more insistent that he stay.

Troy spent four contentious days in hospital with me, every day asking if he could go home irrespective of the number of tubes hanging out of his body (“I can come back to your office so you can remove it.”) and his inability to complete the most basic of self-care tasks, like walking and peeing. Finally the day of his discharge came, and even up until the moment he left he remained completely, utterly, and in all other ways devoid of any appreciation for what my team and I did for him, never once offering even the briefest of thanks for saving his life.

What did not shock me, however, is that he failed to return for any follow up. It’s been months, and Troy is either doing great or he’s dead, quite possibly of another knife wound. I guess I’ll never know.

Thursday, 31 October 2019

Well armed

Violence is unfortunately part of my job. I'm not talking about workplace violence, though several of my trauma nurses have been victims of that. No, I mean just regular violence - stabbings, shootings, slashings, animal bites, human bites, and assaults with deadly weapons. And sometimes also assaults with not-so-deadly weapons.

Based on the title of this post you may think this story is about guns or the second amendment. I can assure you it is not.

I'll explain.

I sometimes get excited when I see "LEVEL 2 ASSAULT" on my pager, but rarely because of the injuries. Don't misunderstand me, serious injuries can happen with blunt assaults, but they are almost universally some combination of facial lacerations, facial fractures (especially the mandible), and brain injuries ranging from mild concussion to severe intracranial bleeding. I don't fix facial bones (facial reconstruction surgeons do that), and I obviously don't fix brains (brain surgeons do that), so all I can do initially is manage any initial life-threatening cerebral oedema until the brain surgeon arrives. Or apply ice to the face. Fucking wheeeeee. That isn't exactly why I spent {redacted} years training as a trauma surgeon.

No, the singular reason I get excited at blunt assaults is the story. Was this a drunken pub brawl? A fan of the opposing team? A fight with a guy over an ex-girlfriend? A fight with an ex-girlfriend? A robbery gone awry?

Or something even better? 

Rufus (not his real name™) was something even better. Don't worry, before you get concerned that I am a bit too excited over someone getting seriously injured, he wasn't. I don't celebrate serious injuries. Much.

Just before midnight on Saturday night is prime time for drunk assault victims to slosh into the trauma bay, usually having pissed off (or pissed on, occasionally) the wrong guy for the wrong reason. But 10 AM on a Tuesday is just slightly less common. However, that is exactly when Rufus decided to get the shit kicked out of him. The trauma bay immediately filled with the aroma of stale whiskey, old cigarettes, and mothballs (for some strange reason) when the medics rolled an extremely drunk Rufus through the doors just past Coffee Part II Time. They looked not-at-all-concerned (though obviously bemused), because while they were trying to give me their report, Rufus was continually, loudly, unashamedly, and slurredly singing:
He mussst have been an admiral a sssultan or a king, and to hisss praisssses we sall alwaysh sssing. . .
"Sigh. Hey Doc, this is Rufus.  He was assaulted about the face with some object, not sure what it was and he won't tell us because we can't get him to stop singing. He's 62, history of hypertension, untreated. Obvious swelling around his left eye, has a laceration there. Bleeding is controlled. No other injuries as far as we can tell."
Look what he hass done for us he'ss filled ussup with cheer. . .
Ugh. This was obviously not going to be one of those "fun" stories, just another drunk asshole who pissed off the wrong guy. A quick but thorough evaluation of a very slovenly Rufus showed no injuries below his neck, only what I could only assume was several years' worth of built up grime beneath his fingernails. Clean that shit up, people. Seriously.

It was becoming painfully obvious that this would be 1) a boring story, 2) a quick run through the CT scanner, 3) a few sutures, 4) a litre or four of saline to sober him up, and 5) a discharge to whatever cave Rufus called home.

Lord blessh Charlie Mopsh, the man who invented beer beer beer . . .

I was only 4/5 correct.

His CT scans showed no brain injury and no facial fractures, as expected.  He continued singing (he may have gotten one note on key, possibly as many as two) as I tried to renovate him to his former glory and place a few sutures in his creased face. Well, my Innter Pessimist reminded me, at least his singing career can continue, though his modeling days are clearly over.

My Inner Pessimist can be a bit of an asshole sometimes.

At 11 o'clocks we'll ssstop for 5 short sheconds, we'll remember Charlie Mopsh . . .

By the time the police arrived to take his statement, I was already filling out his discharge paperwork. I guess Rufus had finally sobered up to the point where he could speak rather than sing, because he told them a story I was not expecting:

"Well you see officer, there I was at the pub minding my own business when this guy comes over talking shit to me. Now I'm a little drunk {HA!}, but he's real drunk, REAL drunk you see, and I'm not the sort of man to take that kind of shit, so I talk shit right back to him. He gets up in my face real close, so naturally I take a swing at him. You know. Well, he takes his arm off and . . . "

He . . . wait, what?  

"Yeah, he takes his fake arm off and starts beating the hell out of me with it."

I'm glad I was on the other side of the room, because I somehow doubt my agape look was terribly becoming. Nor was the ensuing laughter from everyone within earshot of this conversation.

After Rufus was finished with his story, the police confirmed that they already had in custody both the suspect and his weapon of choice: his prosthetic arm. The next 20 minutes were filled with pretty much everyone over the age of 35 asking if Rufus' real name was Richard Kimble.

Alas, it wasn't. I only know that because, unbeknownst to me, I was about the 14th very uncreative and not-quite-as-clever-as-I-thought person who asked.

Wednesday, 23 October 2019

Break

Yeah yeah yeah, I know I've been gone for over four months, and my Inner Egotist has been yelling at me regularly that my loyal readers (the few I may still have) have probably been missing me and wondering what may have happened. I have also taken several months off Twitter (as you may or may not have noticed), and when my brother recently asked me why, I replied simply, "Sanity". I realised that I was taking inordinate amounts of time writing, and that isn't fair to my family, and it isn't right. They deserve better.

Writing this blog isn't difficult, but it can be time consuming. Coming up with a patient to write about is easy, but making a blog post out of it can be cumbersome, because I don't want my stories to be trite, boring, or repetitive. So instead of putting out boring short stories, I consider it better to put out nothing and keep people wondering.

Well wonder no further, because the patient I'm writing about today was easy to come up with.

It is I.

No, I wasn't in a car accident, and I wasn't stabbed or assaulted, and no I didn't cut off my finger with my table saw or have any other kind of traumatic injury. But over the past few months I have seen three different doctors, including a specialist, a sub-specialist, and a sub-sub-specialist, and I now have an official diagnosis.

In the interest of my own privacy, I will not be revealing what the diagnosis is or the type of doctor that I've been visiting. I will, however, divulge that just this past week I was diagnosed with a very rare degenerative disease that is incurable, progressive, and potentially disabling, though it is not in any way deadly. It's not multiple sclerosis, and it's not ALS or any other motor neurone disease.

I'm not dying.

The good news is that this condition was diagnosed very early, and it was only found based on a hunch that the second doctor had. He very easily could have chalked up my symptoms to aging and let it go, but he decided to investigate further. Usually this disease isn't diagnosed until much later in life once significant and irreversible damage has already been done, but mine was found before any of that happened, so my long term prognosis seems to be good.

The bad new is that no one knows the cause of this disease because it is so rare. It was only first described about 30 years ago, but no one took it seriously until about 15 years ago when it was discovered that it was indeed progressive. Because of that, there is no textbook treatment. The disease is thought to be autoimmune, so I will be taking immunosuppression medication for the rest of my life to keep it at bay. Hopefully.

I'm not looking for sympathy. I'm not interested in anyone's thoughts or prayers. Yes this sucks, but I have accepted the diagnosis and am hitting it with everything I can. Ignoring a problem like this won't make it better, and pretending it doesn't exist will only make it worse.

If you're looking for a silver lining like I was, consider this: if you thought I railed against antivaxxers before, just imagine how I'll treat them now that I am one of those immunosuppressed patients they put at risk with their bullshit.

You're on notice, antivaxxers.

Wednesday, 12 June 2019

Magic bullet

Before you start composing an angry comment over this blog post which seems to be about a blender endorsed by infamous charlatan and overall anti-science fuckwit David "Avocado" Wolfe, this is not about the Magic Bullet blender. Nor is it about this Magic Bullet (warning: link very NSFW). Nor is it about the JFK assassination or the Seinfeld parody thereof.

No, it is about an actually really real magic bullet that struck Belle (not her real name™). So delete your nastygram, sit back down, and stay tuned.

Let me first take you back a couple of weeks before I met Belle. My previous call before Belle's I had gotten a stabbing victim at 8 PM who needed a laparotomy. The call before that I got a car accident victim at 7:30 PM who needed a laparotomy. The call before that I had gotten a fall victim at 7:45 PM who had needed a laparotomy. Cases like these are relatively rare, so getting three in a row at essentially the same time of day is extremely uncommon. But as we all know, bad things tend to happen in threes. Or fours.

Yes, that's foreshadowing.

Now fast forward back (forward?) to the present. I was in the midst of getting over a cold, so I started my day by nearly begging the Call Gods to let me off easy. In retrospect this was a Very Bad Idea. About halfway through the shift the Call Gods proved that not only are they evil and vengeful, but they are also cold and heartless and have no goddamned regard for my feelings. Not that I ever suspected they did.

My pager told me I would be getting a level 1 gunshot victim in 5 minutes. I looked at the clock, and when I saw it was 7:50 PM, I actually looked up at the sky (because somehow in that moment I figured that's where the Call Gods were hanging out and laughing their cruel, heartless asses off) and vigorously and repeatedly cursed them with every single bit of foul language my brain could come up with. Then I took a deep breath and realised I had a job to do, and imprecating some nebulous nefarious fantasy creatures would help neither me nor my patient in the slightest.

Sigh . . . yet another call where I'll be in the operating theatre at 9 PM, I thought.  At least it isn't 2 AM, right?

Belle arrived a few minutes later, and while she didn't necessarily look close to death, she was certainly having some difficulty breathing.

"Hi Doc, 29 year old woman, single gee-ess-double-you to the right back. Blood pressure has been stable, oxygen sats in the 90's, but decreased breath sounds on the right."

My initial evaluation lined up perfectly with theirs - she had a single gunshot wound to the right mid-back with no exit wound. This bodes poorly because I have no idea what direction the bullet was traveling when it hit her or what happened to it once it did. On examination her heart sounded fine, but she had no breath sounds on the right, a sign that she had either a pneumothorax (collapsed lung), haemothorax (blood in the thoracic cavity), or both. Fortunately the treatment of both of these problems is the same - a chest tube. But whenever there is an entry wound with no exit, the main two questions I always have to answer are:
  1. Where did the bullet go?
  2. What did that bullet go through?
The good news is a simple chest X-ray should answer both of those questions within a minute or so. As the nurses were getting IV's started and checking vital signs (which were fine), I was finishing the physical exam (which revealed no exit wound and was also otherwise fine) and the radiology techs got the chest X-ray done. Within a minute I was looking at exactly what I did NOT want to see:

The bullet was overlying the left upper abdomen.

GOD DAMN IT. FUCK YOU, CALL GODS. FUCK YOU TO WHATEVER HELL I CHOOSE TO BELIEVE IN RIGHT NOW.

There are a lot of Very Important Structures between the right mid-back and the left upper abdomen, not the least of which are the right lung, heart, aorta and other great vessels, œsophagus, stomach, liver, duodenum, pancreas, spleen, and diaphragm. Holes in any of those things are by definition Very Bad Things, and holes in a few of them can be rapidly fatal, though obviously she shouldn't have any of those.

Maybe. Probably. At least she wasn't dead yet.

The problem is that an X-ray can't tell me if the bullet is in the soft tissue of the back (which would be fine), the soft tissue of the front (which would be much less fine, since it had to go through the entire body to get there), or somewhere in between (which would also be not at all fine), nor can it tell me what the bullet went through to get there. If the bullet was just in the soft tissue of the back, all she would need is a chest tube and no major abdominal or thoracic surgery. But you've already seen me foreshadow, so you know goddamned well that's not what happened.

A chest tube was rapidly inserted, and about 600 ml of blood drained immediately then stopped. While this sounds pretty bad, that's actually not a huge amount, and the fact that it stopped means there was no active bleeding from the chest. Good. Since her blood pressure and heart rate had remained essentially normal, I had time to get a CT scan for further evaluation.

It didn't answer my questions, it only muddied the waters further.

Not Belle's abdomen
Th scan showed the bullet tract through the right back into the right chest, bouncing off a rib and shattering it, then ricocheting (I guess) towards the left side.  And there bullet was, sitting somewhere in the left upper abdomen (not the soft tissue in the back . . . god damn it) apparently in the space right between the spleen and the stomach.  There appeared to be a blush of contrast in the stomach indicating active bleeding within the stomach (which was of course full of food), which as you can imagine is indeed a Very Bad Thing.

Weeeeell, shit. To the theatre we go. Again.

It was 8:30 PM. Because of course it was.

I re-examined her after the scan and just before wheeling her to surgery, and indeed her left upper abdomen was now mildly tender. Certainly no signs of peritonitis (yet), but the exam was decidedly different than it had been just a few minutes before. I told her she needed emergent surgery to find out what damage the bullet had done, and then (hopefully) fix it. As I listed off the potentially injured organs, I gave her no guarantee that she would survive the surgery just like I do with every such patient, because no matter what I suspect and no matter what I find, it is always both a challenge and a surprise. Belle seemed to take the news well: "Just do the best you can, doctor" was all she said.

I promised her nothing more and nothing less than that. And while I did get a surprise, it was just not the one I could have anticipated:

Nothing.

I found absolutely nothing. I was expecting to find a hole in her stomach with spilled gastric contents, a diaphragm laceration, liver laceration, lacerated intestine, perhaps a lacerated spleen.  But there was no blood in her abdomen, no spillage of food, no injury to any organ whatsoever.  NOTHING.

Well, almost nothing.  I did find one thing.

Knowing the bullet was somewhere in her left upper abdomen, I reached up into that area expecting to find a free-floating bullet between her stomach and spleen like I saw on the CT. I found the bullet alright, and it was indeed free-floating. In her stomach.

IN HER STOMACH.

Wait, what?? How the fuck did that get there? There are only three possible mechanisms for a bullet to get into the stomach:
  1. swallow it,
  2. go through the stomach wall, or
  3. go through the œsophagus and drop in.
Hmm.

I made a small incision in her stomach to retrieve the bullet, which was deformed from having passed through soft tissue (and bouncing off a rib), so option 1 was definitely out. I searched for at least an hour trying to find a hole in the stomach, looking at every square millimetre of its surface, both back and front, top and bottom. Nothing. So option 2 was out. That only left option 3 - through the thoracic œsophagus with the bullet simply dropping into her stomach.  But that would mean the bullet would have had to have juuuust enough energy to get in one wall of the œsophagus, stop, and then fall.

I wasn't buying it, but I had absolutely no other ideas. I took one last look at the stomach wall, but I once again came up empty. Since she had a nasogastric tube traversing the supposed area of injury in the œsophagus, I decided to close her abdomen and look for the injury another way.

My first study immediately after surgery was a CT œsophagram. Contrast was instilled into her œsophagus, and as the scan was done I should be able to see the leaked contrast, showing me exactly at what level the injury was. NOPE. That study, just like her surgery, was completely normal. NORMAL! Usually I want normal studies, but in this case I just wanted to find the goddamned hole.

Hmmm.

The next morning Belle was doing fine, awake, talking, minimal abdominal pain from her incision. Still no signs of peritonitis (or pleuritis, for that matter), and no further bleeding from her chest tube. She was very understanding as I explained how I was still trying to find how the hell this bullet got into her stomach, and that the next test would be an upper endoscopy. Later that day the endoscopist looked at every square centimetre of the inside of both her œsophagus and stomach. NOTHING. No blood, no injury, no hole. Nothing. NOTHING!

Hmmmmmm.

There had to be a hole there!  Where the hell is the goddamned hole?

My final study, my last chance, was a swallow study under fluoroscopy. Belle swallowed oral contrast and the radiologist watched it under real-time fluoroscopy. THAT will definitely show me the site of the injury leaing. It will show the injury, right? RIGHT??

Nope.  It was normal. Negative. Nothing. There was no hole anywhere.

FUCKING HMMMMMMMMMMMMMMMMMMMM

Over the next 4 days Belle had what I can only call a completely normal recovery from a completely abnormal surgery (her chest tube was removed on day 3). By her fifth day in hospital, she had essentially no pain, she was eating, she was pooping, she was walking, and she was ready to go home.

I saw her back in my office a week later, and she was continuing her totally normal recovery. I tried (and probably failed) to explain how bizarre a situation this was, and that she was a once-in-a-career type of patient.  Sure I've seen other patients who probably should have sustained some kind of damage based on their mechanism of injury but didn't, but never something like this. And I probably never will again.

Belle just laughed and said "Thank you for saving my life."

I was not and still am not sure I saved anything (except maybe her lung).

I have presented this case to literally every other trauma surgeon at my hospital, a few trauma surgeons from other hospitals, a few trauma surgeons from other countries, and DadBastard (who you may remember was a general surgeon for several decades). Not a single one has been able to offer me any insight as to how the FUCK this actually happened other than "Well, I guess it was a magic bullet".

So I offer it to you folks.  HOW THE HELL DID THIS HAPPEN?

Wednesday, 1 May 2019

True surprise

How many true surprises are there in life? This was the question I asked Mrs. Bastard when she was pregnant with our first child and wanted to find out the baby's gender (and I didn't). Now I've heard the counter argument that the gender of a baby is not a true surprise, because it's either going to be (except in extremely unusual circumstances) an A or a B, so that essentially eliminates the surprise. I wholeheartedly disagree for reasons I find very difficult to elucidate because I'm right and you're wrong and shut up.

Regardless, I suspected my first child would be a girl. Mrs. Bastard "just knew" it was a boy.

The birth turned out to be one surprise after another. To start, after Mrs. Bastard was struggling with labour for about 10 hours, the baby-to-be began showing signs of foetal distress. The "normal" delivery was immediately converted to an emergency C-section.

Surprise #1.

My wife was very calm (and very awake) throughout the surgery, which was so violent that her blood got on her face, the anaesthesiologist's scrubs, and even the ceiling (yes, really).

Surprise #2.

The baby was unceremoniously extracted from my wife, and the first thing I noticed (YES OF COURSE I was in the operating theatre) was the full head of hair followed immediately by decidedly female genitalia. As I leaned down with a grin and said in my wife's ear "I told you it was a girl", the delivery nurse yelled "IT'S A BOY!"

Surprise #3.

It was NOT a boy. MiniBastard Number One was, and still is, a girl, though her actions occasionally make me suspect she is actually a monkey.

Without question the most surprising aspect of that entire experience was that the nurse, whose job is literally taking care of newborn children, could not tell the difference between a girl and a boy. And before anyone comments about ambiguous genitalia, it wasn't. At all. The nurse was just plain wrong.

Now in case you're wondering why the fuck I'm telling this story and how the fuck it relates to trauma, I will now risk giving everyone whiplash and move on to my seemingly-unrelated-but-still-somehow-related gunshot victim story.

Surprise!

It should come as no surprise that the overwhelming majority of my gunshot victims are young males. I get a few women, most of whom have been shot by ex-boyfriends, but the demographic is fairly uniform. So when I was told I would be getting a gunshot to the chest at 3 o'clock in the afternoon, I was 1) surprised it wasn't at 2 AM, and 2) naturally assuming it would be another young man who would be actively dying.

Wrong and wrong.

When the medics wheeled in 78-year-old Bertha (surprise!), she was awake, alert, and, uh, smiling. Every single person in the room immediately turned to each other and quizzically said the exact same thing: "This is supposed to be trauma, so what exactly the fuck is this?"

"Hello everyone, this is Bertha. She was eating lunch when she heard a gunshot and was hit in the arm and chest. No one else in the house could give us any information. The police are on it. Anyway, she's been awake and alert the whole time. Vitals have been stable."

Bertha turned and smiled at me. Surprise!

Any gunshot-wound-to-the-anything immediately gets a full head-to-toe exam, because where there is one hole, there could be two or three or more. Bertha had a through-and-through gunshot wound to her right upper arm, clearly below where the humerus and neurovascular bundle are found. She was also moving her arm just fine, and her radial and ulnar pulses were both normal and equal to the opposite side, so there was obviously no serious injury there. After going through her arm, however, the bullet had entered her right chest around the level of the 6th rib. And there was no exit wound to be found.

Uh oh . . .

No exit wound means just one thing: the bullet it still in there somewhere. Unless I happen to be able to feel the bullet just under the skin somewhere, I have no way of knowing if it went up, down, sideways, diagonally, backwards, or frontwards. Fortunately, however, we have X-rays to help solve the mystery. Two minutes later I was looking at her chest X-ray, which showed . . . nothing. No pneumothorax, no haemothorax, no fractured rib . . .

And no bullet. Nothing. Unfortunately this could mean that the bullet had gone south into her abdomen, though I doubted it since her abdominal exam was normal. An abdominal X-ray a few minutes later confirmed that this had not happened either. There was no bullet.

Surprise!

I re-examined her chest, and there was clearly and undoubtedly a bullet hole there. She had definitely been shot.  I also re-examined her from head to toe in an attempt to find the missing hole, but I again came up empty. So where the hell was the bullet?

Bertha smiled pleasantly at me.

With my Inner Pessimist yelling that the bullet had probably entered her heart and embolised to her leg (no it didn't, shut up), we wheeled her over to the CT scanner where the surprises continued. The scan from head-to-toe also revealed no bullet. It also showed no injury to her thorax. It then became apparent that the magic bullet did indeed hit her in the chest, but it had lost enough kinetic energy while traversing her arm that it had simply struck her 6th rib and bounced out.

The bullet bounced out.

As I explained to Bertha that she had a few holes but no actual injuries and that she was incredibly lucky, she just smiled at me and said "Thank you. I think my lunch is probably cold now."

And then I sent my gunshot-wound-to-the-chest patient home.

I got home the next morning and told this story to Mrs. Bastard, and she just nodded her head and said "Blog post?" because nothing I tell her about what I see in the trauma bay ever surprises her anymore. I told it to my daughter (who has exactly zero interest in going into medicine) later that afternoon when she got home from school. All she could say was "Wow".

As for me, I just thought of the question I asked my wife when she was pregnant: How many true surprises are there in life?

At least one more.