Tuesday, 27 June 2017

Rare

If you are a regular reader here (or even an irregular reader) or if you follow me on Twitter (and if you don't, WHY THE HELL DON'T YOU), it probably seems like I get angry on rare occasions.  Ok, sometimes.  Alright, often.  OK ALL THE GODDAMNED TIME.  The truth is that anger is just a facade, a face that I put on to make my words seem more compelling.  I'm actually a very level-headed person and I manage to keep my composure in nearly any situation no matter how infuriating it gets.  Yes, I rarely yell at my children when they do something particularly egregious (though I have kept my 2017 New Year's Resolution for the most part), and yes my wife and I have the very infrequent argument which never escalates past what I would consider a minor tiff (and we never go to bed angry - excellent advice for anyone not yet married).

So no, in reality I'm not angry all the time.  In fact, I very rarely am.  It takes a lot to get me angry.

Roscoe (not his real name™) got me angry.  VERY fucking angry.

Some people don't talk much as they enter the trauma bay, and the reason for this is varied:
  1. Brain injury
  2. Intoxicated
  3. Asshole
  4. Scared of the police
  5. Deaf
Severely brain-injured patients typically do not open their eyes, and I can only recall one deaf patient in the past decade or so, so when Roscoe was brought to me with his eyes wide open yet refusing to say a word, I strongly suspected some combination of 2, 3, and 4.

"Hi there Doc, here we have Roscoe.  He's 19, we think.  That's the only thing he'd say to us, and he had no ID on him.  He wrapped his car around a pole at around 100 kph (62 mph), we think.  He isn't saying much, so we don't know if he has anything on board {"on board" is medic speak for "drugs/alcohol"}, and we also don't know if anything hurts.  We haven't found much in the way of outward trauma.  Have fun, Doc!"

I hated that medic just then, but I wasn't angry.  Yet.

Roscoe looked like a healthy young man, he didn't smell of alcohol, and he barely had a scratch on him, just an abrasion or two on his left knee and elbow.  All his limbs seemed to be intact, he didn't groan as I pushed on his chest or abdomen, and his back and neck appeared normal.  The biggest problem I had to assess was his brain: was his lack of speech a product of a drug other than alcohol or did he have a brain injury?  A CT scan should tell me quite quickly.

And it did - his brain appeared as normal as the rest of his exam.

However, this didn't answer my question fully.  A CT scan will show a subdural haematoma, subarachnoid haemorrhage, or haemorrhagic cerebral contusion very nicely, but a concussion doesn't show up on any scan as it is purely a clinical diagnosis.  I walked back to the trauma bay from radiology with my mind working frantically, trying to figure out what was going on from the information I had.  And as I walked back into the trauma bay, the amount of information I had suddenly jumped up several notches: Roscoe was talking.

I overheard him tell the nurse in a very hushed voice that he had taken something that a friend of his had given him after they had smoked several joints.  He wasn't sure what the pill was, all he knew was that it was round and white and made him sleepy . . . which explains why he fell asleep at the wheel.

I was annoyed, but still I wasn't quite angry.

Roscoe's mother showed up (with a little boy in tow) a short while later after his lab work had come back.  It was all normal except for his urine tox screen, which was positive for marijuana and diazepam (Valium).  Roscoe's mother was cooing over her son, obviously (and rightly) thankful he was uninjured.  Her cooing quickly stopped when I told them about his tox screen.

"WHAT?  YOU TOOK WHAT?  WHERE THE HELL DID YOU GET THAT!  YOU'RE ONLY 17 YEARS OLD!  YOU COULD HAVE KILLED YOUR BROTHER!  WHAT THE HELL WERE YOU THINKING, ROSCOE!"

Wait, kill your younger brother?  What?  

It turns out Roscoe (who was only 17, not 19, not that that made a damned bit of difference) was on his way to pick up his 7-year-old brother from a birthday party but decided it would be a great idea to stop at a friend's house, smoke a few joints, and take a random pill just before getting back in the car.

NOW I was angry, and I was sure glad I wasn't the only one as Roscoe's mother continued her well-deserved tirade.

I get angry when innocent people are put in jeopardy because of the stupid decisions of others.  Sure, Roscoe had put his own life on the line, but he had also endangered the life of his little brother as well as all the other people on the road around him.

Normally I try to calm family members down so they don't yell and disturb the other patients in the trauma bay and the rest of the department, but not this time.  Nope, not a chance.  I let Roscoe's mother give him the business as long as she wanted, and boy did she.  I have no doubt whatsoever that this wasn't the last Roscoe would hear of it from her.  She continued berating him as they left the trauma bay, the little boy still walking silently behind them.

Having proofread this post several times, I feel myself getting angry again.  Does anybody know a homeopathic remedy I could use to calm me down?

Oh, never mind.  I found one.

Tuesday, 20 June 2017

Too old

I'm sure everyone reading this has heard the adage "Age is just a number".  To most, this aphorism means that you're never too old to have fun.  To a trauma surgeon, however, it sounds like an excuse for older people to do stupid shit that should be left to younger idiots.

Now before anyone accuses me of being "ageist" or something, just stop a minute and think.  Is it "ageist" to expect a 20-year-old kid to understand how the world works?  No, of course not.  Young kids just aren't old enough and therefore don't have the necessary experience.  That's why we (generally) don't elect 20-somethings to elected office; they just don't know any better.  On the other hand, it also is not ageist to expect a middle-aged person to have accumulated enough firsthand knowledge of things to avoid doing seriously stupid shit.  Older people should just know better.

Quincy (not his real name™) should just know better.

I should start by saying that Quincy is not a stupid man, or so I found out later.  That was not the initial impression I got, however.

It was early afternoon on a beautiful bright warm Saturday afternoon when Quincy was brought to my trauma bay in a rather sorry state.  I rarely get the full story from the medics, relying only on rough bits of information.  This case was no different.

"Hi everyone, this is Quincy.  54 years old.  Helmeted rider of a motorcycle, crashed at around 70 kph (about 45 mph).  Brief ell oh see (LOC: loss of consciousness), awake and alert now.  Complaining of severe abdominal pain, right hand pain, left hip pain."

Quincy was mostly awake and mostly alert, and he groaned audibly as he was moved from the gurney to our stretcher.  My Inner Optimist started whispering at me as Quincy was hooked up to the monitors, revealing a heart rate of 120 but a normal blood pressure.  "It's probably nothing.  He's probably just very amped up from the accident is all."

My Inner Optimist is annoying as hell.  And often wrong.

My initial exam showed an open fracture of his right hand and significant tenderness in his left hip.  But what really struck me was his abdominal exam.  He kept pushing my hand away whenever I pushed on his belly, something he didn't even do when I was examining his obviously badly fractured hand.  And when I did push, his rather rotund abdomen felt like a board, and it hurt a lot more when I released pressure compared to when I pushed.

1) Voluntary guarding.  2) Board-like rigidity.  3) Rebound tenderness.  All signs of peritonitis.  Quincy had something seriously wrong inside his abdomen that was killing him, and he needed surgery.  Now. 

I rather gleefully pointed out to my Inner Optimist that he was wrong again. 

Quincy's blood pressure held steady in the normal range for the next ten minutes as he was packaged up and brought down to the operating theatre.  Expecting the worst I made a large vertical laparotomy incision, and I was not disappointed.  What struck me first as I entered his abdomen was the smell of vomit, clear as day.  What struck me second was the lack of BIT (Blood In There).  Something, most likely his stomach, was clearly perforated, but somehow that something wasn't bleeding.  Perforations are bad, bleeding is bad, and the two together are worse.  Perforations without bleeding are still bad, but only slightly less bad.

Starting in the upper abdomen I began literally scooping out handfuls of onions, chicken, and corn (WHY THE FUCK IS IT ALWAYS CORN), reinforcing my assumption that his stomach had a large hole in it.  And when I finally got my hands on it, my suspicion was confirmed - a 7 cm laceration across the fundus and antrum (the lowest portion near where the stomach empties into the small intestine).  I initially controlled it with atraumatic clamps to stop any more stuff from leaking out, and I then fired a stapler across the injury to repair it.  His descending colon also had a partial-thickness laceration which did not penetrate the entire wall (fortunately) which I also repaired.  Nothing else was injured, which explained the lack of BIT.

Normally at this point in a trauma operation I would close and everyone would high-five and congratulate each other for another life saved (not really), but not today.  No, now came the really fun part: cleaning up.  

You would be surprised how large and deep the peritoneal cavity is, so now knowing that you would probably not be surprised how easily and in how many places corn (GOD DAMN IT, WHY ALWAYS CORN) can hide.  Several litres of irrigation later, I was still pulling out bits of . . . stuff ("What is that, carrot?").  This left me feeling wholly unsatisfied that he was clean enough to close, so I didn't.  I created a temporary vacuum closure and brought him to intensive care with plans to bring him back in a day or two, clean him out again, and possibly close.  IF he was clean.

Two days later his peritoneal cavity was surprisingly nearly spotless.  There were only a few partially digested bits of food left, and after irrigating with more litres of saline irrigation, I closed him.

A couple of days later after Quincy was extubated and off the ventilator, I finally got to ask him what I had wanted to know since he arrived: why had he crashed.  His answer was something I would expect from a teenager.

"Well you see Doc, I was showing off to the guys in my motorcycle club, doing a wheelie, and . . ."

"Wait," I interrupted, "you were doing a wheelie?  At 70 kph?  Are you aware you're 54 years old?"

He smiled weakly and laughed even more weakly.  "Yeah, it was probably stupid."

"Probably??"

He laughed again.

I had a very long chat with Quincy and his wife about his recklessness and how he was too old
for this shit.  I could almost excuse this kind of nonsense behaviour with a 20-year old kid (almost) because that's what 20-year old kids do - stupid shit.  But not Quincy.  It turns out he was a highly intelligent, articulate, competent middle aged man who just had a momentary lapse of judgement that nearly ended his life.  Quincy's wife looked me dead in the eye and assured me that his motorcycle was already up for sale at a bargain price.  I suspect it will be sold to a reckless kid who will probably do something equally stupid with it.

But that's probably just my Inner Pessimist talking.

Tuesday, 13 June 2017

Stupid update

This is the update you've all been anxiously awaiting - the update on last week's near-catastrophic near-career-ending story.  Or maybe you don't really give a fuck and I'm just being overly dramatic again.  In any case, if you missed it I did a Very Stupid Thing and tried to grab a chunk of Japanese maple that was spinning on my lathe at 750 RPM.  Ok, I didn't really try to grab it - it wasn't intentional, I was just trying to prevent the machine from jumping off the table because the log was unbalanced.  Regardless, my hand contacted the spinning log resulting in a deep gouge in my left hand that required three sutures.  Here is the offending log:

And here is the part of the log that actually hit my hand:


The irregular portion in the middle of the picture is where a rather large chunk of wood tore off and lodged in my hand.  And before you sick bastards say anything, no, there's no goddamned blood on it.  I withdrew my hand fast enough that the blood went on my floor, not the wood.  Fortunately.  I guess.

If you aren't saying "OW OW OW OW" right now, then you haven't been paying attention.

Of course in hindsight I should have bolted the lathe to the table when I first bought the lathe and built the table, but I hadn't intended on turning big rough logs at the time.  And then I changed my mind but didn't change the setup.  This rather (completely) silly (idiotic) manoeuvre led to the nearly-career ending injury about a week and a half ago.  Fortunately it did not actually derail my career.

Or my hobby.

What, you didn't think I'd let a goddamned log beat me, did you?  As soon as I got home from the hospital I disassembled the lathe table, installed some bolts, and then bolted the damned machine to the damned table like I should have done in the first damned place.  And as I was finishing, the lidocaine wore off.

Ow.  Ow.  OW.

I stayed out of the shop for a few days after that, not so much to protect my hand but more so Mrs. Bastard wouldn't have to remind me to be careful.  If that makes it sound like she was nagging me, I assure you she wasn't.  I was just being restless and stupid and anxious to return to creating stuff.  But then yesterday I decided that enough was enough - it was time I got back into it.  And when I did, the maple log was staring at me, daring me to work with it again.  So I did.  I put on the appropriate safety gear, grabbed my bowl gouge, and got to work.  And here's what came out of it:


That's right, log.  I beat you.  I WIN.

Fuck you, log.

Monday, 5 June 2017

Stupid, stupid, stupid

I think I make it clear that I see a lot of people who do stupid things.  Some of these people doing stupid things are actually stupid so can hardly be blamed for acting stupid, while some have simply made a stupid choice.  These choices may endanger their own lives or the lives of those around them, depending on A) what particular flavour of stupidity they've decided to commit, and B) how stupid that stupidity is.  But of all the stupid patients I have ever treated, few have come close to matching the stupidity of my least favourite patient:

Me.

Yes, the trauma surgeon became the patient a few days ago.  Fortunately I didn't put my life in danger, but I did stupidly threaten my career.

If you don't already know, I'm an avid do-it-yourselfer.  I paint, fix, create, mend, build, really anything that involves anything around the house.  If there is a tool that doesn't involve metallurgy or automobiles, there is a very high probability that I have it.  For example, when our automatic coffee machine went bad about two years ago, Mrs. Bastard bought a new one, but I wouldn't let her take it out of the box.  Instead, I bought a new solenoid and installed it (I didn't even know what a solenoid was at the time, but it's amazing what you can learn on YouTube).  And when the water pump on that same machine started making funny noises two weeks ago, I installed a new one.  Yeah, the new coffee machine is still in the box.  Boom.

Anyway, in addition to fixing most anything (people included, apparently), I also am an amateur woodworker.  Name a woodworking tool, I have one (or three).  I've built most of the new furniture in my house over the past 10 years, but my newest wood hobby is turning.  Last fall I bought a lathe and made myself some turning tools, and I've been getting to know the machine and its capabilities, making several little bowls and cups in the process.

You can probably see where this is going, even if I couldn't.

Four days ago I upped the ante and decided to try a bigger bowl.  I installed the maple blank on my lathe, knowing it would be unbalanced and that I had to balance it by turning it round while it was spinning at relatively low speed (around 600 rpm).  What I didn't realise was exactly how unbalanced it would be, because the lathe started bouncing all over the place.  My split-second reaction was to try to grab the machine to stop it from falling over, but in that instant my left hand came in contact with the spinning wood, not the machine.

Oops.

I felt the wood hit my hand near the thumb, but I didn't immediately feel any pain.  My second reaction (which should have been my first reaction) was "TURN IT OFF, STUPID!".  The wood came to a stop, and I then assessed the situation.  These were the thoughts that came into my brain in order:
  1. Whew, the lathe is ok.  Good.
  2. Hm, I didn't get that balanced very well.
  3. Why the hell does my left hand hurt?
  4. What's that red stuff on the floor? 
I looked down at my hand, and there was a lovely jagged laceration on the thenar eminence (the fleshy part of the palm at the base of the thumb).  As I should have done from the start, I went into Trauma Mode.  I was able to move my thumb - good.  I could feel the tip of it - good.  The laceration was deep, and I could see some subcutaneous tissue.  Not so good.  It was bleeding - not so good.  Um, was that exposed bone?  Shit . . . let me explore the wound to see if there are any foreign bodies in there -

OW OW OW OW OW OW OW OW OW FUCK OW OW

As I grabbed a paper towel to stanch the bleeding, I started to catalogue the supplies I have at home to suture it up.  Lidocaine - check.  Needles and syringes - check.  Gauze - check.  Suture material - check.  Needle driver, forceps, and scissors - check, check, and check.

Sweet, it's my left hand and I'm right handed, so I can suture this myself.  

Wait wait wait . . . how am I supposed to tie a knot in the suture with one hand.  God damn it.  Just go to the hospital, idiot.

Mrs. Bastard has a rather eerie ability to sense when things are going awry.  More than once she has called me when something is amiss, not actually knowing 1) that something is wrong, or 2) what that something is.  If I believed in psychic abilities (no, I do not), I would believe Mrs. Bastard has them.

My mobile literally rang as I was getting out of my car at the hospital (100% true).  I didn't even have to look at it to know that it was my wife.  Somehow.  My exact first words to Mrs. Bastard before I even said "Hello" were:

Me: Ok, well on the bright side, I decided not to put in my own sutures.
Mrs. Bastard: . . .
Me: . . .
Mrs. Bastard: . . .
Me: Hello?
MB: WHAT. DID. YOU. DO.

It wasn't so much a question as a statement.  I told her I was fine, I still had all my fingers, but that my lathe had sort of bit me.  She sighed.  It wasn't an "Oh well, I love you, dear" sort of sigh, but more of a "You're an idiot and we'll talk about this when I get home" sort of sigh.

An hour later I had a numb thumb, a large chunk of maple (that I had initially mistaken for bone) in my pocket as a souvenir (ok, "large chunk" may be a slight exaggeration, but 7 x 6 x 3 mm is HUGE for a splinter), a tetanus (Tdap) booster, and several polypropylene sutures in my hand.  It wasn't until I was driving home that it dawned on me just how close I came to ending my career in that moment.  I've seen some horrific life-altering woodworking accidents in my trauma bay, and I just as well could have lost my thumb (or even several of my fingers).

I got lucky.  That was it.  Nothing but dumb luck saved my hand (and my career).  But as I've said innumerable times in my life, I'd much rather be lucky than good.  My hand will heal up in a few more days, I'll take out my own sutures (at least that I can do myself), and I'll get back to turning that bowl, having relearned an extremely valuable lesson.  Every now and then one of my tools teaches me to treat them all with utmost respect and never let my guard down, even for a split second.

And if anyone is wondering about the tetanus vaccine, no, I'm still not autistic.

Tuesday, 30 May 2017

Changing my mind

I think of myself as a very decisive fellow.  After I've gather sufficient information and I make up my mind about something, according to my calculations there is a 98.047% chance (approximately) that the decision is final.  In rare circumstances (like when I was a ChildBastard and decided that I didn't like seafood) I may gather yet more new information and decide that my initial decision was wrong (mmmm . . . lobster).  But those instances are few and far between.  Even rarer are the times when I go from A to B then back to A.

And then you have times like with Clancy (not his real name™) when I go from A to B to C to Q.  

My mind was made up when I heard the Box announce Clancy's injuries about 15 minutes before he arrived - this guy was going to be fine I decided before even meeting him.  He was stabbed in the thigh, which is typically not a severe injury.  The blood supply to the leg is in the groin, and the thigh is a surprisingly large place, so getting stabbed in it anywhere other than the groin is very rarely a huge problem.  However, having done this for {redacted} years, I know that I can only trust about 10% of what I hear over the Box, so a penetrating injury to the thigh is always treated as a high level trauma.

And then Clancy arrived and proved it.  It turns out that "side" sounds a lot like "thigh" over the Box.

"Hi everyone, this is Clancy, 23 years old.  He was stabbed once in the left side with a steak knife.  He isn't sure how deep it went."

Clancy was a rather large chap, in the same way Jaws was a rather large fish.  He weighed in at just under 150 kg (330 pounds), and was indeed stabbed once in the left flank right where his spleen, kidney, and colon should be living.  God damn it.  And unfortunately none of those organs particularly enjoys having holes poked in it. 

My first step in any case like this is to determine how deep the wound goes and in what direction.  So my initial move is to stick my finger in the hole (mind out of the gutter, people).  This is by no means a perfect tool, because my finger may not be able to find the knife tract, and a thin blade can penetrate deeper than my fingertip will allow.  However, I've found exactly nothing that can be as quickly diagnostic as a Finger In A Hole.  And before I say anything else, I know exactly what that sounds like, and I absolutely stand by that statement 100%.  Anyway, just by looking at a stab wound I can't tell what direction or how deep the knife went.  A Finger In A Hole can quickly answer both questions.

He groaned slightly as my finger went in (STOP SNICKERING, DAMN IT!).  And in.  And in.  As I said, Clancy was a large fellow.  Fortunately (or unfortunately, depending on how you look at it), the knife tract was rather wide so it was easy to follow downwards towards his abdomen (not upwards towards his chest), and anteriorly towards his innards (not posteriorly towards, well, nothing vital).  I could feel my finger going through fat and more fat and then . . . space.  My fingertip slipped into his peritoneal cavity, and my mood sank.

Sigh.  Straight to the operating theatre.

The general teaching is that anyone with a penetrating injury to the abdomen with clear violation of the peritoneum (the lining that contains all of the intra-abdominal organs) needs immediate exploratory surgery.  No other tests are necessary, because if the knife went through that final layer, it most probably poked a hole in something in there.  I immediately called out to the waiting operating staff standing by the door that we would be coming down in 5 minutes.

I explained all of this to Clancy, including the fact that something, everything, or nothing may be injured.  He looked shocked but surprisingly understanding.  I looked up at the monitor to see how fast his heart was beating. 

65.

Uh, hm.  As my son would say, well that was unexpected.  People with major intra-abdominal injuries usually have significantly elevated heart rates, and their blood pressure can be low depending on how sick they are.  I pushed on his belly and got nothing.  No pain whatsoever.  But since he was so obese, maybe I just wasn't pushing hard enough. I tried again, this time mashing on his belly.  Nope, still nothing. 

Hmmm.  My mind seemed to be changing.  

After contemplating for a moment, I decided to change my operative plan to a diagnostic laparoscopy - putting a camera in through a very tiny incision in his umbilicus and looking at all of the organs to assess for damage.  If blood, bile, stool, or gastric contents are found, the procedure is quickly converted to a major laparotomy, and any damage is repaired.  However, if there is no blood, no food leaking out of the stomach, and no poop leaking out of the intestine, then no major exploratory surgery needs to be done and the patient is saved a huge (and unnecessary) operation.

I went back and explained this to Clancy, and he seemed slightly relieved and still understanding despite the drastic change of plan.  I called the theatre staff and told them of the change, and as I did so I looked at Clancy's monitor again.  His heart rate was now 62, his blood pressure was 127/65 (probably better than mine at the time), and he looked completely comfortable.

Mind.  Changing.  Again.

Because he was so rock stable, I then decided to do a CT scan of his abdomen on the way to the operating theatre.  It could at least guide me as to where I needed to place the camera first.  Five minutes later I was looking at his scans as they flashed on the computer screen, and I was shocked - I could see exactly where the knife had penetrated into his abdomen, but it only went in about 2 mm.  There was a very nice (and very clear) 1 cm layer of fat between the furthest extent of the stab wound and the closest organ (the descending colon).  No blood, no air, no fluid, nothing.  The radiologist actually read the scan as normal and missed the stab wound.

And my mind changed yet again.  A to B to C to Q.

I somewhat abashedly approached Clancy yet again and told him the good news, that he probably did not need any surgery at all.  Considering how many times I had changed my mind in the past 20 minutes, he took the news quite well.  Just in case the CT was wrong, I decided to keep him in the hospital overnight and re-examine his belly every hour or so to make sure nothing was brewing.  And 10 hours (and 10 re-examinations) later, I sent Clancy home with no new scars (except perhaps mental ones).

We often say in surgery that the enemy of good is better.  Trying to get something from good to perfect often leads to complications, so we usually leave well enough alone.  Being decisive is usually good, but additional information can actually be better.  Sometimes.

After I wrote this post and read it back, I realised that it could potentially make me seem wishy-washy or irresolute, so I decided to delete it rather than publish it.  

But then I figured "Ah, fuck it", and I changed my mind.

Monday, 22 May 2017

Instant dislike

There are some patients who come into my trauma bay whom I can instantly tell I will like, both as a person and as a patient.  These people are generally calm, respectful, and cooperative, saying things like "Please" and "Thank you".  Taking care of patients like this, no matter how severely injured they are, is typically easy, bordering on a pleasure.  However, there are others whom, the instant they hit the door, I can tell I won't like one bit.  The patient might be screaming bloody murder for no apparent reason, or hurling invective repeatedly at anyone and everyone, or he may just have a lousy attitude that instantly puts everyone in a bad mood.  But no matter what I think about them as a human being, I still take care of these people exactly the same as anyone else; I don't have to like you to treat you.  But sometimes, rarely (fortunately), I start to dislike someone before I even meet them.

How is that even possible?

Ask Charlene (not her real name™).  She'll fucking tell you.

The day I came across Charlene was a typical busy Friday, in that nearly everyone was drunk, obnoxious, or both.  Right around the time when my stomach started growling for dinner and reminding me that I hadn't eaten anything all day except one vending machine sandwich which contained something that was almost, but not quite, entirely unlike chicken, the head nurse called me to ask how many patients I would accept.

Ugh.  That can't be a good sign.  My Inner Optimist was strangely silent.

Whenever I get that phone call, my mind instantly jumps into mass casualty mode, and I become fearful that my city has finally become the site of a mass attack.  But then my mind starts wandering into regions it probably doesn't belong.  Perhaps a bus from the Haemophiliacs Convention collided with a razor blade delivery van?  Or did the International Space Station land on a church?

Fortunately it was none of those things, but something much more mundane.  My Inner Optimist started singing quietly (and annoyingly) as I discovered it was simply a multi-car accident with numerous victims, none of whom seemed critically injured (according to the medics on the scene).  However, there were lots of them, and all of them needed evaluation.  Unfortunately our department was already relatively full, so we could only accommodate three more patients.

Well, my Inner Optimist said happily, at least it's only three!

About 15 minutes later the first victim arrived.  He was in his 50s and screaming in pain, but despite the din, I did not dislike him - the bone sticking out of his ankle gave him every right to scream as loudly as he wanted.

Ouch.

"Hey Doc, this is Len (not his real name™)", the medic started.  "His car broke down on the side of the road and he was working under the hood trying to fix it.  His son had stopped his car behind his, and some idiot who overdosed on heroin fell asleep at the wheel and plowed into all of them, along with several other cars.  No Ell Oh See {Loss Of Consciousness}.  He's got an open ankle fracture, also complaining of severe pain in the opposite leg and shoulder.  His wife is also on the way.  And so is the OD."

Len's disposition was pleasant despite his pain, but though I didn't know the overdose guy yet, I already didn't like that fucking guy.  At all.  Because fuck that guy.

Len's wife showed up a couple of minutes later looking far less injured, perhaps only a sprained knee and a few abrasions here and there.

As I was working up Len's wife, Charlene arrived.  I heard Charlene before I saw her, which is never a good sign and made me like her even less (if that was even possible).

"Hi Doc, this is Charlene.  She rear-ended a bunch of cars on the side of the road after she fell asleep at the wheel.  She said she used heroin and alcohol just before getting into the car.  She was unresponsive when we got there, so we gave her some Narcan and she immediately woke up and started screaming."  He glanced at her and scowled.  So did I.  Charlene screamed.  A lot.

"OW!  Oh god, I'm hurting everywhere!  I need some pain medicine!  Oh god please help me!"

Of course you're hurting, I thought.  That's what Narcan does - it blocks the effects of opioids.  In addition to waking up narcotic overdose victims, it also makes them very unhappy because they start hurting everywhere.

Other than an abrasion across her chest and abdomen (at least she had the sense to put on her damned seatbelt), she had no obvious injuries.  However, she continued to scream in pain and demand pain medicine.  I asked the nurse to give her a small dose of ketorolac, a non-steroidal (and non-narcotic) anti-inflammatory analgesic, and I made it very clear to everyone listening, including Charlene, that she was not to get any narcotics.

"Ow!  My teeth hurt!"

I did not like Charlene.  No, unless I found some serious injury, Charlene would not be getting any narcotics from me.  At all.  For anything.

A few hours later after her heroin, alcohol, and Narcan all wore off, Charlene was strolling comfortably around the department while her two victims were still on their gurneys in pain.  In addition to his open ankle fracture, Len had a fractured femur on the opposite leg and a broken arm,  He would need multiple surgeries to repair all the damage.  His wife had a broken vertebra in her lumbar spine, but it was a stable fracture so no surgery would be necessary.  I fumed silently as I got Charlene's discharge paperwork together, all the while gritting my teeth and betting she would ask for narcotics.  She did not disappoint.

"Doctor," she started in a all-too-obviously-sweet voice, "would you please give me some oxycodone?  You know, just to tide me over?"   I looked over slowly and silently, and she must have seen the look of fury in my eyes because she quickly added, "I don't usually do heroin, really!  I just ran out of my pain medicine and my friend offered me some heroin, so I did it just this once.  Please?"

Sure, you just did it this once.  While you were drunk.  I did not like Charlene.  "No," I said as steely as possible.  "You may take ibuprofen or aspirin or acetaminophen or naproxen."

She looked disappointed but not the least bit surprised.  However, she wasn't done.  "How about some Xanax?  Please?  Just a few."

No, I thought.  I will absolutely not provide you with drugs that will sedate you and alter your level of consciousness!  You just severely injured multiple people with your car after you overdosed!  What the fuck kind of idiot do you think I am?

"No, you may not," I said as simply as I could.

Again she looked unsurprised.  I was shocked she hadn't claimed an allergy to all the over-the-counter medicines as most addicts do, and I could easily interpret the "Well, it was worth a shot!" look on her face.

Without skipping a beat, she said without a hint of irony, "Well, it was worth a shot!"  Then she smiled.  SHE SMILED.

No, I did not like Charlene.

Twenty minutes later after Charlene had left, the nurse approached me to tell me that after she gave Charlene her discharge paperwork, she overheard her asking three different emergency physicians to write her prescriptions for oxycodone, hydrocodone, Valium, Xanax, and codeine.  The nurse reported that all of them looked at her like she had two heads and denied her repeated requests.

No, I did not like Charlene one bit, but I guaran-goddamn-tee you that I, or one of my colleagues, will see her again.  And probably soon.

Friday, 12 May 2017

Names

According to my research (aka a 0.385 second Google search), the most common surname in the world is Lee.  The next most common family names include Zhang, Wang, Nguyen, Garcia, Hernandez, and Smith.  Unfortunately not everyone is lucky enough to be born into such an instantly recognisable name and must instead suffer through their lives with less common names.  Others are unlucky enough to be given names like Preserved Fish, Hans Ohff, or Dick Passwater.  Yes, those people actually exist.  Really.

I, however, am named none of those things.  While my name isn't particularly difficult to pronounce for anyone with an IQ higher than a brine shrimp, that doesn't stop 90% of people from mispronouncing it.  I therefore shorten it from {redacted} to {rdctd}, but while that may be somewhat easier to pronounce, it somehow doesn't make it any easier to remember.  Most of my patients just end up calling me "Doc", as all of you fine people do (and for the record, I'm perfectly fine with that).

Mikel (not his real name™), however, had no such problem with my name.

My standard greeting when a new patient rolls into my trauma bay is "Hi, I'm Doctor Bastard, and I'll be saving your life today."  Ha! not really, but what a great introduction that would be, right?  Unfortunately I would have to be about 386 times more arrogant than I actually am to use such a line, but that doesn't stop me from fantasising about it.  Aaaah.

Anyway, in reality I introduce myself as "Doctor Bastard (not my real name™)", and 99.9452% of the time (approximately) when they repeat it, that is the last time it will ever escape their lips.  I gave Mikel that same standard salutation as he was wheeled in and the medics were giving their report. 

"Hi Doc, this is Mikel.  25 years old, no medical history.  Gunshot wound to the left abdomen, and there is, um, something sticking out of the right side of his abdomen."

Shit.  In general having something unidentifiable sticking through your abdominal wall is considered a Very Bad Thing. 

I pulled the sheet back to find that the something was a loop of his small intestine with several holes through it.  SHIT.  Yes, that definitely falls under the Very Bad Thing umbrella. 

His vital signs were ok, which meant he wasn't actively dying.  Yet.  But a trans-abdominal gunshot wound meant he needed surgery.  Now.  I knew he had at least two holes in his small intestine (that I could see) that needed fixing, but I figured that was just the proverbial tip of the proverbial iceberg.  The question was, how many more holes were there, and what organs would I be attempting to fix.

I explained all of this to Mikel, and he immediately responded "I understand, Doctor Bastard.  Thank you.  Please do everything you can, Doctor Bastard.  I really appreciate your help, Doctor Bastard."

Um.  What?  Hearing my name repeated was shocking enough. Hearing it pronounced correctly twice was astounding.  But hearing it thrice was almost enough to make me faint.  

Not really.

A quick (but thorough) examination of the remainder of Mikel's body revealed no evidence of any other injuries (not that he needed anything else to potentially kill him).  We rushed him straight to the operating theatre without delay, Mikel chattering all the while.

"You're going to save my life, Doctor Bastard.  I know you are.  I'm in your hands, Doctor Bastard.  You aren't going to let anything bad happen to me.  Isn't that right Doctor Bastard?"

It was more than just a bit unnerving.

Image result for torn jeansWhen I opened up his belly I found it full of blood, as expected.  I poked the intestine that had been protruding back inside and then examined everything.  I addition to about 2 liters of blood and the two holes in the small intestine I already knew about, I found a separate 25-cm portion of small intestine that had been essentially shredded.  Think 1990's torn jeans.  Yeah, kind of like that.

Unbelievably none of the other organs had been injured.  The stomach, gall bladder, liver, colon, spleen, pancreas, and kidneys were all completely fine.  I repaired several holes that were amenable to being fixed and removed several that were not.  After re-establishing gut continuity, I sort of felt like all the king's horses and all the king's men.

Humpty Dumpty was back together again.

The following morning before I left the hospital, I went to see Mikel first.  I was expecting to find him fast asleep, or at least lethargic as hell, considering the trauma his physiology had endured over the previous 8 hours.  Nope.  This is one instance where I was not sorry to be wrong.

"Good morning, Doctor Bastard!" he greeted me with a wan smile and a slight wince as he sat up in bed.  "You look tired.  How was the rest of your night?  How are you feeling today?"

Hey, wait.  That was supposed to be my question!  That was the second time in a row Mikel had surprised me.  I smiled and told him it didn't matter how I felt, because I wasn't the one who just had a major surgery 8 hours ago.

"I feel pretty good, Doctor Bastard.  Sore, but ok.  You saved my life!  I can't thank you enough, Doctor Bastard.  Thank you so much!"

Mikel's hospital course was amazingly fast and shockingly free of complications.  Despite the number of repairs I did and anastomoses I created, none of them leaked.  And every day when I went in to see him, Mikel greeted me with the same big smile and the same "Good morning, Doctor Bastard!  How are you today?"  Four days after his surgery, he walked out of the hospital.

And two weeks later he walked into my office with the same big smile and the same "Good morning, Doctor Bastard!" once again.  He was doing well, his incision had healed perfectly (if I do say so myself), and his intestines were all working just fine despite their recent slight reworking.  He gave me a hearty, firm handshake and several more "Thank you"s on his way out.

After he left my office, I had a few minutes to contemplate.  Perhaps my other patients would remember my name too and perhaps appreciate what I had done for them.  Maybe Mikel was a sign that things were going to change.  Huzzah!  My mood was bright as I walked in to see my next patient, a guy who had been stabbed in the leg multiple times and on whom I had spent nearly an hour sewing up.

"Good morning," I said brightly.  "How is your leg feeling?"

My hopes were dashed and my mood sent crashing back to earth by his response:

"Uh, ok I guess . . . have we met?"

GOD. DAMN. IT.