Friday, 5 February 2016

Withholding information

I don't like asking questions.  I really, really don't.  I wish I could scan a barcode on your wrist and get every detail about your health both past and present.  Unfortunately that technology doesn't exist yet (BUT HOVERBOARDS DO?  COME ON, SCIENTISTS!), so instead every patient I see gets the same exact series of questions.
  • What are your medical problems?
  • What surgeries have you had?
  • What medications do you take (including over-the-counter and herbal)?
  • What medication allergies do you have?
  • What medical problems run in your family?
  • Do you smoke/drink/use illicit drugs?
There are other general questions about current health status (Any headaches?  Recent illnesses?  Are your vaccinations up to date?) followed by a detailed physical examination.  All this takes time, and I'd really prefer to skip it, because generally people suck and I don't like talking to them.  But sadly I can't avoid it, because every question I ask has a specific purpose, and none of them deserves to be skipped.  

In other words, when I ask you a question, you'd damn well better answer, because I need to know the answer.  Unlike my daughter (who seems to enjoy talking just for the joy of hearing herself speak), when I speak it is for a reason, and my questions are purposeful and meaningful.

I guess Gary (not his real name™) never got that message.

The emergency physician called me for a patient with a perirectal abscess.  It seemed that everyone in the entire {redacted} metropolitan area had a perirectal abscess that night, and Gary was yet another guy with pus in his ass.  At least it wasn't midnight, when most other people decide that they've finally had enough of the exquisite pain in their ass and decide to seek care.

When I first arrived, I saw the usual suspect - a relatively young, healthy-appearing gentleman who couldn't sit still.  He reminded me of a kindergartener who just can't keep his butt in his seat, but unlike the little tots, this guy had a very good reason for his restlessness.

I went through my usual thorough evaluation, asking the questions I always do.  His answers were all very straightforward - No medical problems, no medications, no allergies, no prior surgeries.  Simple, right?

If it were simple, I probably wouldn't be writing about it.

I was expecting to see a swollen painful area surrounded by redness.  Ha!  Not even close.  On examination, the area around his anus looked like a bomb had gone off.  Everything I touched hurt, and it was far too painful to allow me to perform a full exam, but from what I could see his posterior was a total mess, probably the worst I had ever seen.

"No medical problems at all?" I probed, my suspicions rising.

"Nope, healthy as a horse, Doc", he replied quite confidently.

Unfortunately his process was way too complex to deal with under local anaesthesia, so I booked him immediately for the operating theatre.  Once he was asleep I was able to assess the situation better.  There were at least a dozen areas draining pus, several old scars, and what looked like an anal fistula (a connection between the anal canal and the skin).  I had a feeling I knew exactly what I was looking at, but what I definitely did know was that I was most assuredely not the first surgeon to have been here.

I drained two large abscesses and placed a seton through the fistula.  During the procedure I was explaining the purpose of the seton to the medical student (it allows the fistula to heal without damaging the external anal sphincter, if you were wondering), and at one point I said, "If I didn't know any better, I would swear this guy had Crohn's disease.  But he insists he doesn't."

I admitted him for wound care and antibiotics, and the next day Gary felt much better.  His fever had resolved, his white blood cell count was improving, and he was able to sit still for the first time in weeks.  I told him that he could probably go home the following day.

The next morning the student called me with some surprising (not really) news.  "Doc, I was rounding on Gary and he told me that he does have Crohn's disease.  He was diagnosed about 5 years ago."

Stunned (not really) silence ensued.

I went to discharge Gary a bit later that day, but before he left I felt obligated to ask him why he omitted that rather important bit of pertinent information.  Hopefully his response will make more sense to you than it did to me, but I'll let Gary tell you the reason in his own words:
"Well Doc, you asked me if I had any medical problems that I took medicine for, and I don't.  Because I stopped taking my Crohn's medicine a few months ago."
It was then that I realised I had tried to simplify (and thereby shorten) my questions, and I had combined "Do you have any medical problems" with "Do you take any medications," and the result had been "Do you have any medical problems for which you take medicine?"  And Gary had taken it literally . . . to the word.

At his follow up appointment, Gary and his ass were both looking and feeling much better.  I advised him quite firmly to go back to his Crohn's disease specialist to get back on his medication.  And to tell any future doctors that he does, and always will have, Crohn's, even if he decides to stop taking his medication.  Oh and by the way, if you're wondering why he stopped (as I was), he apparently had spent all his money on beer, cigarettes, and video games (seriously) and didn't have enough left over.  For his medicine. (Yes I realise that paragraph had two sentence fragments.  I'm not proud of myself).

Withholding information is generally stupid, with one notable exceptions: not telling young kids the truth about Santa Claus and the Easter Bunny is reasonable (I hope mine aren't reading this right now).  However, if you really feel the need (and you really enjoy delayed pain), go ahead and keep secrets from your spouse.  Withhold information from the police (if you're really that stupid).  And if you are truly masochistic, don't tell your accountant and lawyer everything.

But for fuck's sake, don't withhold information from the one person trying to take care your your body, especially if you aren't.

Friday, 29 January 2016

Offended

WARNING: THIS POST IS EXTREMELY SWEARY AND CONTAINS "FUCK" A LOT.  IF THIS BOTHERS YOU, FUCK OFF NOW.  I MEAN, TURN BACK NOW.  FUCK.  UNFORTUNATELY THIS IS ANOTHER LONG REBUTTAL OF BULLSHIT.  I APOLOGISE IN ADVANCE IF YOU CAN'T GET THROUGH IT ALL.  

If you know anything about me, you know that it takes a lot to offend me and that I don't get angry easily.  If you don't know anything about me, then you also know this because I just told you.  I realised long ago that getting angry at someone or something doesn't help anything, it just makes me do stupid things like bash my hand against a solid wood door (yes, I did this) or throw a glass against the wall so it discharges hundreds of shards of glass around the room including into a pot of simmering soup (yes, I did this too).  In other words, offending and angering me is difficult.

That said, I'm both offended and angry.  Really fucking offended and really fucking angry.

I was perusing the internet yesterday when I came across an article on Aeon.co entitled "There is no place for the surgeon myth in modern medicine."  Based on the title I assumed it was written by a surgeon-in-training who had encountered a prototypical "Asshole Surgeon" and was railing against his bad behaviour in the operating theatre.  Instead, I was chagrined to discover that the author, Alexis Sobel Fitts, is a freelance journalist who writes about science and medicine after studying science journalism for one year at Columbia University (and English at Yale) but seemingly has no actual science or medical training whatsoever (according to her website).

That bothered me a little bit.  How could this woman know anything about surgery? I thought.  Then I started reading the article, and by the second paragraph I wanted to reach through the computer and slap the living shit out of her.

I rarely give the punchline before the joke, but fuck it, here it is anyway: she claims that surgeons are essentially nothing more than thoughtless, crude barbarians with scalpels who descended from butchers and barbers and merely do, rather than think.

After reading that last paragraph back, I feel the anger rising again.

I'm going to take the liberty of quoting liberally from Ms. Fitts' heaping pile of bullshit, er, article.  No, sorry I was right the first time.  Heaping pile of bullshit.

She starts by describing a scene from The Knick, a show on Cinemax (that I've never seen) which focuses on a surgeon at the Knickerbock Hospital in New York in 1900.  Yes, 1900.  Dr. Thackery is about to perform a life-saving surgery in the era before antibiotics and anaesthesia, and he looks like "the perfect hero", according to Ms. Fitts.  But then she descends into the first bit of bullshit when she relates a joke her sister (who is in medical school) told her: "'An internist can figure out what’s wrong with you, but he can’t fix it,’ it goes. ‘A surgeon has no idea what’s wrong with you, but he’s happy to fix it.'"

Fucking hilarious, right?  Because surgeons don't ever think, and we have glorious cold hard steel to do the thinking for us!  Ha fucking ha!  It gets worse.  Much worse.

She then describes a cadre of medical students who appear to have self-selected as future surgeons as "the frat boys of medical school".  According to Alexis' sister these students are "the first to volunteer for dissection, and the last to answer basic science questions during drills," and that there was a difference "between surgeons, whose ability to solve problems was lauded by the public, and the rest of the medical establishment, whose ability to analyse data and diagnose was valued within."

If you aren't detecting Alexis' pattern of the surgeon being an unthinking idiot with a 10 blade, then you aren't paying attention.  First of all, many medical students don't decide on surgery until they are years into medical school.  I was in the middle of my third year (up until that point it had been a tossup between psychiatry and paediatrics), so this whole idea of a pack of surgical frat boys is ridiculous.  Second, the only people I knew in medical school who didn't want to dissect their cadaver intended on going into neurology or psychiatry.  Everyone else was more than eager to dissect.  Third, some of the biggest gunners (those students who raise their hands first and always seem to study most) were future surgeons, because they had to be (since surgical training is very competitive).  Fourth, since fucking when do surgeons not analyse data (more on that later)?

It became clear to me at this point that Ms. Fitts had not spent one goddamned second with an actual surgeon and was basing her entire ludicrous hit piece on fictional early-20th century television surgeons and whatever lies her sister told her.  It became even more obvious that she had done exactly ZERO research (other than a 0.253-second search on YouTube) when she made several glaring errors in her next paragraph about an internal carotid endarterectomy:
On YouTube, anyone can watch a vascular surgeon remove a growth from the carotid artery, the passageway that transports blood to your face and brain. It is stunning: the skull, splayed open, revealing the thrumming sinewy flesh beneath. The procedure is as uncomfortably intimate as it is delicate. Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response, and the hypoglossal nerve, which controls the tongue.
Good fucking grief.  Where do I even begin.
  1. It's not a growth, it's called a plaque.
  2. The internal carotid artery (which is being operated upon) doesn't supply blood to the face, the external carotid does.
  3. The carotid artery is accessed via an incision on the side of the neck, not by "splaying open" the skull.
  4. "Thrumming sinewy flesh"?  Seriously?
  5. The vagus nerve does not innervate the face, that would be the facial nerve.
At least she got the function of the hypoglossal nerve right.  But it would have taken her less than 5 minutes to correct any of these mistakes.  Other than "thrumming sinewy".  That's just farcical.

Anyway, Alexis continues her relentless assault on surgery:
But remove the glamour of labouring beneath the skin, and surgery can seem much duller. After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis. It’s physical work, at its crudest achieved with simple steel tools and at at its most advanced using tiny, specialized cameras and computerized guides.
Later she adds this little gem:
Surgeons are valued for their ability to execute, not analyse.
Remove the glamour of . . . wait, what?!?  Of course it's duller if you remove the surgery from surgery!  Wouldn't cardiology be less glamorous if you remove the heart?  And surgery is never "removed" from diagnosis!  Does she honestly believe that surgeons simply walk into a room and fix something without knowing what they're fixing or why?  When I see a patient with a bowel obstruction, for example, I first must determine if there is an obstruction.  I do this by 1) interviewing the patient, 2) examining the patient, 3) reviewing labwork to see if there is any evidence of systemic illness (elevated white blood cell count, hyperglycemia, hyponatremia/hypochloremia, lactic acidosis, hypotension, etc), and 4) reviewing the X-rays and/or CT scans.  Once I've determined that an obstruction exists, I then have to determine the best course of action - a trial of non-operative management (since many obstructions will resolve on their own) versus surgery, and if the patient needs surgery, when.  If there is systemic sickness (ie sepsis or impending sepsis), the patient needs immediate surgery.  AND THEN I have to operate and actually fix the problem with my simple steel tools or my tiny, specialised camera (ie a laparoscope).

Does that sound like I'm removed from the more intellectually nimble task of diagnosis?  I have to do this for every single patient I see.  Granted with many patients it is easier and simpler.  But at no time am I ever not thinking.

Are we done yet?  Not remotely.
While medicine sprung from the academy, surgery originates with tradesmen. In the Middle Ages, ‘barber-surgeons’, who had knives and razors at the ready, performed bare-bones amputations and tooth extraction alongside haircuts. Becoming a doctor called for university training, but surgery – requiring less skill – was passed down by apprenticeship. Even women, barred from becoming physicians until the 20th century, could train as surgeons. Low rank is implicit even in the title, surgeon, which is derived from the combination of the Greek words for ‘hand’ and ‘work’.  Surgery's place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures.
Wh . . . wha. . . what the fuck was she smoking?  Yes, barbers used to perform surgery, but that was ages ago.  What the fuck does it matter now?  Why even bring that up except to make surgeons look bad?  Surgeons attend the exact same schools, in the exact same classrooms, take the exact same tests . . . god damn it, you get the fucking point.  And "less skill" and "low rank"?  Bottom of the medical hierarchy?  According to whom, YOU?  Don't misunderstand me, I'm not saying that surgeons are at the top of the medical totem pole, because there is no top or bottom.  Every specialty is necessary and important.  But surgeons spend the most time after medical school of any specialty, often 8 years or more, learning their craft.  Less skill?  Are you fucking kidding me?

Next, Ms. Fitts laments the lack of women in surgery, stating that "surgical specialties remain segregated":
An operation is performed within a distinctly macho context: a showdown between disease and individual doctor, leading a team through authoritative decision-making. 
How is that macho?  What does that even mean?  Do women not solve problems in Alexis' universe?  Regardless of that bit of inanity, it took me all of about 13 seconds (admittedly a bit longer than usual) to find out that while the number of women in surgery is still relatively low, the trend is the exact opposite:
Percentage of women in surgical specialties

I thought enough must be enough.  Her attack on surgeons has to be over, right?  HA!  No.  Somehow in her mind there is something wrong with the fact that only 10% of articles in the prestigious New England Journal of Medicine have to do with surgical innovation:
As evidence-based medicine has become increasingly the standard of discovery, surgeons have not risen to the top of scientific enquiry. Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation.
Apparently Alexis didn't get the memo that we surgeons have our own journals.  Hundreds of them.  And guess what percentage of their articles are about surgery and surgical innovation?  ONE HUNDRED FUCKING PERCENT.

But Ms. Fitts still isn't finished with her all-out assault on surgeons, now claiming that we don't know how to play nicely in the sandbox with the other kids:
And the future of medicine is forcing surgeons to adapt. While surgical achievement fixates on the craft of the individual, advances in medicine are forcing physicians to adapt a team-based approach. Increasingly, a surgical procedure is only a part of an overall treatment plan – forcing surgeons to work alongside their peers in internal medicine. This is coupled with a technological revolution that is creating intelligent tools, requiring the contemporary surgeon to guide their actions by data, rather than instinct.
All this does is demonstrate that Ms. Fitts has no fucking clue how medicine works.  As technology has improved, surgeons have had access to more and more data.  Thus we haven't had to act "by instinct" for decades.  Plus, I consult my internal medicine colleagues regularly to assist in management of medical problems.  For those patients of mine with kidney disease, do I do my own dialysis?  Of course not, I call a nephrologist.  I don't read 2-D echocardiograms, I let my cardiology experts do their job.  I'm not "forced" to work alongside these people, rather my colleagues and I know how the cogs in the medical system all turn.  Ms. Fitts obviously does not.

But she wasn't done yet.  I could almost hear the "plop" as Alexis dumped her concluding steaming pile of excrement:
Atul Gawande, a surgeon and staff writer for The New Yorker implored his peers to place increasing emphasis on diagnostics rather than skill, in a lecture delivered to the Association for Surgical Education in 2001. ‘We are doctors, not technicians,’ urged Gawande, even though for the rest of the world, being a technician might be glamorous enough.
Not that it matters much, but Dr. Gawande was still in his residency when this speech was given, which is surprising considering he was asked to talk about how to improve surgical training when he had not finished his own.  Irrespective of that, Ms. Fitts completely misinterpreted the point of Dr. Gawande's excellent speech.  He wasn't talking about surgeons becoming mere thoughtless automatons, but rather about expanding surgeons' training on surgical diseases and improving communication between 1) surgeons and patients, and 2) surgeons and the rest of the surgical team.

And with that last heave of excreta, Alexis was finally finished.  I counted 17 new dents in my desk where I bashed my head while reading her bullshit article bullshit, and 21 more after I wrote this.  The editors and publishers at Aeon should be embarrassed for publishing this toxic heap of manure, and Alexis Fitts owes every surgeon in the world a huge apology for writing this article of pure ignorance.

I would apologise for the number of "fucks" and the ridiculous length of this post, but I don't think I have any more fucks to give.

Sunday, 24 January 2016

Hypocrisy

EDIT: This was supposed to have been published on January 19. Blogspot seems to think it belonged back in 2015, so it got buried several posts back.  After editing it, it is now showing 24 January, 2016.  I have no idea why.  Technology is great . . . until it isn't.

Smoking bothers me.  Bigots bother me.  Liars bother me.  Pop music bothers me (yes, pretty much all of it).  Trolls bother me.  But what bothers me more than most anything else is hypocrisy.
hy·poc·ri·sy  \hi-ˈpä-krə-sē\ (noun): the behaviour of people who do things that they tell other people not to do
I will not claim to be completely innocent of hypocrisy, since I eat doughnuts and drink coffee despite knowing it isn't the best breakfast/lunch/dinner/snack for me, and despite telling my patients not to do exactly what I just did 20 minutes prior.  And 60 minutes prior.  And 4 hours prior.  And seven times the previous day.

However, there are some flavours of hypocrisy which I find just completely intolerable:
These fine upstanding citizens royally fucked up, and there is really no excuse whatsoever for their behaviour.  It is cases like this that really scorch my hide, but believe it or not there are others that I rate as even more egregious, situations that make me want to bash my head against my desk until it doesn't hurt anymore.

Meet Dr. Carter (not his real name™).

There were several-dozen surgeons ultimately responsible for my training, Dr. Carter prominently included (for reasons which will become obvious shortly).  These men and women were tasked with teaching me how to diagnose surgical diseases, how to operate, when to operate, and when not to operate.  In addition to the surgical aspects of medicine, they also taught me the more abstract points of actually being a physician - how to talk to patients, how to break bad news, and (possibly most importantly) how to behave in general.  This portion of my education was not done in a classroom, it was only learned by carefully observing their behaviour and emulating the conduct I considered best and most appropriate.

More important than anything else Dr. Carter ever taught me was one very valuable lesson - how not to act.

As a cardiothoracic and vascular surgeon, Dr. Carter was responsible for curing some of the worst diseases in some of the sickest patients - he performed coronary artery bypass grafts, lung resections and pneumonectomies for lung cancer, and lower extremity bypasses for peripheral arterial disease.  Some of his patients were actively dying, while most of the rest were passively dying.

My first procedure with Dr. Carter was a short one, an arterio-venous fistula procedure for a patient with kidney failure who needed to start on dialysis.  For the entire hour-long procedure I kept smelling the rancid reek of cigarette smoke wafting off the patient, and I distinctly remember thinking that this patient wasn't doing himself any favours by smoking, despite his already-failed kidneys.  That may be a slight under-representation of my actual thought, which was much closer to "This fucking moron is actively killing himself!  Why bother going through dialysis if he's trying to commit suicide by tobacco?"

That experience shook me and affected me deeply.  I worked with Dr. Carter twice more over the next month, and because smoking is a major risk factor for heart disease, and peripheral arterial disease, I was completely unsurprised that both patients had that same familiar odour of cigarette smoke.  Of course I had previously seen numerous other smokers in my then-brief medical career, but for some reason these particular events stuck with me and began to colour my future interaction with smokers.  Over the ensuing days and weeks I began to ask patients not only if they smoked and how much, but why.  Why had they started?  Why had they continued?  Why hadn't they quit?  Weren't they aware of the damage they were doing to literally every single cell in their bodies?  I confess I never really got any answers that satisfied my morbid curiosity, so eventually I capitulated and stopped.

About a month later as I was about to rotate off Dr. Carter's service, I was assigned to assist him on a coronary artery bypass graft (in other words I was going to watch carefully and try to stay the hell out of his way).  This was an operation I had been looking forward to for the entire rotation, one of the most fascinating operations in existence, and I was giddy at the opportunity.  I eagerly scrubbed in and waited for Dr. Carter to arrive.  I was somewhat surprised when his patient did not smell of tobacco. 

If you can already see the punch line coming, then you're several steps ahead of where I was at that point.  M. Night Shyamalan ("Sixth Sense" MNS, not "The Village" MNS) I am not.

When Dr. Carter finally entered, that familiar scent of cigarette smoke entered with him and smacked me across the face.  It dawned on me (as it no doubt did on all of you several paragraphs ago) that it hadn't been the patients who had smelled of tobacco smoke, it was Dr. Carter.  My mind started racing.  How was this possible?  This man was responsible for treating lung cancer, coronary artery disease, and peripheral arterial disease - the very diseases directly caused by cigarettes.  How could he possibly be a smoker himself?  How could he look a patient in the face and tell him he had lung cancer, and yet still smoke?

As if he hadn't surprised me enough at that point, Dr. Carter floored about an hour later.  In the middle of the procedure, Dr. Carter paused, looked up, and said (I swear I am not making this up), "I'm going to go get a breath of fresh air".  He then broke scrub and walked out of the room.

I looked in bewilderment at the scrub tech, who obviously worked frequently with Dr. Carter, because she simply sighed and rolled her eyes.  She clearly saw the look of utter confusion in my eyes, so she explained to me quite simply, "He's going outside for a cigarette".  Under my mask she couldn't see my jaw open wide in disbelief.  I stood there completely baffled, wondering if that could possibly be true.  And about eight minutes later he strolled back in (reeking even worse of cigarette smoke, of course) and completed the operation without mentioning his little break any further.

This event took place very early in my training, so I did not have the guts to confront him about his smoking.  By the time I finished my surgical training several years later, he was still smoking, and still taking his "fresh air" breaks.

I happened to run into Dr. Carter at a surgical meeting a few years after this, and I was hopeful that he had broken his habit.  As I shook his hand, however, those same acrid fumes greeted me.  I saw him get up to leave in the middle of a presentation and return a few minutes later, his air no doubt somewhat fresher.

Maybe I'm wrong.  Maybe I'm making a mountain out of a molehill here.  Maybe I'm being overly judgmental and a big asshole.  Maybe he simply started smoking long ago and has been unable to quit despite numerous attempts.

But maybe not.  Maybe he needs to quit no matter what it takes and set a better goddamned example for his patients.  Which means I probably shouldn't have a doughnut or three tomorrow for breakfast. 

Fortunately for me, doughnuts don't stink.  Or cause cancer. 

Friday, 15 January 2016

Careers

I would like to warn you ahead of time, oh kind reader, that this is a very selfish post.  I am writing this simply because I'm feeling lazy at the moment.  There will be no stupid patient stories here, no self-deprecation (ok, maybe a little), and no idiotic antivaccine lunatics to make fun of.  Instead I'm writing this as a response to one of my readers who emailed me with a question that I've been asked numerous times.  So rather than a simple return email, I'm writing this in case I ever get asked again.  That way I can just point the reader to this blog post and not have to write the same crap all over again.  So if you have no interest in a career in healthcare (hence the title), go ahead and click here for some stupid "fail" videos.  God damn it, I hate using "fail" as a noun.  It makes me feel dirty.  Ick.  "Fail" is a verb, people!

Ellie (yes, her actual real name™) is a sophomore in high school and emailed me a few days ago with a series of questions.  She is considering medical school but doesn't want to endure the years of education.  So she reconsidered with . . . you know, she can tell her story better than I can.  Take it away, Ellie!
Hi Doc! My name is Ellie (The same one that commented on your blog about vaccines :p).  I’m a sophomore in high school and since about 6th grade I’ve been considering a job in healthcare.  However, I’m really afraid I don’t have what it takes to be in healthcare.  I’ve thought about being a surgeon, but I couldn’t do 12+ years of school.  I’ve thought about being an EMT, but their pay is less than many other in a healthcare field.  I’ve thought about being a nurse, but I’m afraid I’m not compassionate enough.

You’ve written lots on your blog about how you’ve always wanted to be a doctor, but how did you know that you would be right for the job?  What kind of people should go into the healthcare field and what kind of traits do healthcare workers need?

Part of why I’m interested in healthcare is I want to help people.  I’m definitely not the most selfless person, but when I have the skills, I love to help people.  I always get this warm and fuzzy feeling when I help other students who don’t understand the lesson and I’m sure that would translate to healthcare.

Lastly, what kind of jobs would you suggest for teenagers looking to join the medical field (if you can think of any).

Thank you so much,
Ellie
And before anyone asks, yes she gave me permission to use her real name.  No really, she did, and that's her real name.  I didn't change it or anything.  Honest!

Anyway, those are excellent questions, Ellie (still her real name™).  Let me see if I can answer them with some semblance of a logical order.

Whatever job you select, it should be something you love, and if you truly love it, you should pursue it however necessary.  Do you love the idea of being a surgeon?  Does the thought of being anything else make you feel as sad as everyone in the theatre felt towards the end of Inside Out (seriously, if you haven't seen that movie, go see it)?  If the answers to these questions are "yes", then nothing should stop you, even 12+ years of school/medical training.  If you settle for anything less, you will never forgive yourself.  Just like you should never settle on a partner, you should never settle on a career.

Nursing is an excellent option, and though you may not think you are terribly compassionate now, you would probably surprise yourself.  You obviously enjoy helping people, and there is really no career out there like nursing when it comes to helping.  Sure, doctors get most of the credit.  But it's the nurses who are always there, always checking on people, changing bed linens, cleaning bedpans, helping people sit up, fetching water, going for pain pills.  Ok, perhaps that doesn't sound very glamorous, but trust me, when you need help in the hospital, who are you going to ask?  A doctor?  Ha!  The best response you're likely to get from a doctor is, "Let me find your nurse".  Nurses are by and large extraordinary people doing extraordinary things, and I consider myself lucky that people choose that career.

How did I know medicine would be right for me?  I didn't.  It was a gamble, a calculated risk.  There was always a possibility that I would graduate from medical school, start my surgical training, and realise, God damn it, I hate this shit.  There were people in my medical school class who dropped out for various reasons, and I knew several people that quit in the middle of surgical training.  Medicine probably is not for everyone, surgery certainly so.  So who is right for it?  What attributes should people have to go into medicine?
  1. Ethics - You'll sometimes have to make difficult decisions, even life-and-death decisions.  If your moral fibre is not strong, you should not be here,
  2. Judgment - See #1
  3. Intelligence - You don't need to be the smartest person in the world, but there's a lot to learn.  Dummies need not apply and should probably stick to law.  Just kidding, lawyer friends.
  4. Endurance - Long hours, overtime, and little sleep is the norm.  If you need a solid 8 hours of sleep per night, you should probably look elsewhere.
As for jobs that a young person seeking a career in medicine should pursue, the tendency is to volunteer at a hospital.  If I were interviewing candidates for medical school, my response to that would be, "YAAAAAAAAAWN".  Not that volunteering at a hospital isn't useful or educational for everyone involved, it's just BORING.  Every prospective medical student has seemingly done their time as a hospital volunteer.  So if that's what you'd like to do, it's probably fine.  It'll most likely get you by.  But if you really want to stand out from the herd (and trust me, you do) then do something different.  I volunteered reading books onto tape for blind students and at a free park clinic for the homeless.  Both jobs were extremely rewarding, and they stimulated many conversations with interviewers.

There are tons of options out there for teenagers looking to do something.  Volunteer at a soup kitchen or homeless shelter.  Pitch in at a shelter for battered spouses.  Clean up the roadway.  Read books to the elderly at a senior center.  You'll probably be surprised just how satisfying those jobs can be.

I hope that answers your questions sufficiently.  Now if you'll excuse me, I'd like to get back to writing my next Daily Beast article.  Hmm, now that I think about it, it doesn't seem like I'm actually that lazy after all.  Good.

Monday, 11 January 2016

Types of drunk drivers

A sad fact about my job is that I see more than my fair share of drunk drivers.  I am constantly stunned that so many people have the audacity to drive impaired, putting themselves and everyone around them at risk.  In the United States alone (drunk driving statistics are easiest to find there), over 10,000 people died in 2013 due to drunk driving accidents.  Yet people continue to drink heavily and then get into their cars despite the fact that they can barely keep their eyes open, and they continue to provide endless work (and frustration) for me and my colleagues around the world.

Most of the time my reaction to a drunk driver is either 1) anger that this idiot put my wife and children and everybody else in the community at risk by his overriding stupidity, carelessness, and thoughtlessness or 2) well actually, there is no #2.  It's just pure, unadulterated, undiluted anger.  However, one of my 2016 New Years resolutions is to try thinking rather than seething, and in doing so I have already noticed something interesting - drunk people are not all created equally.  This may not come as a surprise to anyone else who actually uses his brain (unlike me sometimes), but I've discovered that drunk drivers come in five very different, and very distinct flavours.

1. The belligerent asshole
This is the guy who comes in angry, stays angry, and leaves angry.  Even though he came in smelling like a pub floor covered in stale whiskey and vomit, if anyone dares insinuate that he's been drinking, he will fling obscenities with reckless abandon.

"WHO THE FUCK SAID THAT?  COME HERE AND SAY THAT TO MY FUCKING FACE!  I AM NOT DRUNK, YOU FUCKING FUCK!  I'LL KICK YOUR ASS!  COME HERE AND I'LL KICK YOUR ASS!  FUCK YOU, ASSHOLE!"

THESE PATIENTS ARE ALWA . . . ahem, excuse me.  Sorry.  These patients are always an absolute pleasure to care for and I look forward to making sure they are happy and healthy before they leave me.  The joy I get at ducking to avoid another wad of spittle that has been flung my way is rather indescribable.

Approximately 15% fall into this insufferable category.

2. The crier
These people come in acting relatively normal, but as the minutes tick by, reality comes crashing down on them, especially if they are unlucky enough to have actually hurt anyone else in their own car or someone else's (or the grandmother crossing the street).  At that point they begin sobbing uncontrollably and are usually completely inconsolable.  They often moan and sob about the tickets they are sure to get, losing their licence to drive, or ending up in jail.  Unfortunately they generally aren't upset that they screwed up, but instead they just feel sorry for themselves.  In short they generally make everyone in the trauma bay just as despondent as they.

Approximately 35% fall into this miserable category.

3. The silent type
I must admit that this is my favourite type of drunk driver, because they are quiet.  Whether it is concussion-related or otherwise, they sit quietly on the stretcher, allowing us to complete our workup, rarely making a sound.  They answer questions, often simply nodding 'yes' or shaking their head 'no', and the trauma bay remains a serene environment.  Ah, serenity now.

Approximately (and sadly) only 10% fall into this lovely category.

4. The obnoxious flirt
These are mostly men, but I've seen many women who fall into this category as well.  They don't seem to care how much they are slurring their speech or how much drool and/or vomit they have on their chin and/or shirt.  They also seem oblivious to the fact that while they obviously think they look like Brad Pitt, in reality they look more like William Pitt.  These distasteful people will mercilessly hit on nurses, doctors, techs, maintenance staff, or random pieces of medical equipment if it strikes their fancy.  You have no idea how sexy an IV pole can look at 2 AM if looked at just the right way, and neither did I until a rather soused patient told me so.

Approximately 15% fall into this arrogant category.

5. The happy, clueless twit
These poor idiots apparently believe that alcohol magically transmogrifies them into Eddie Murphy (that's the 1980's "Beverly Hills Cop" Eddie Murphy, not the 2000's "Pluto Nash" Eddie Murphy, of course).  They fail to understand that being laughed at is not necessarily a good thing.  In reality, their jokes are rarely funny to anyone but them, and this results in the entire department looking like this:







Approximately 20% fall into this occasionally-amusing, though often derisive category.

Those of you doing the math may have noticed that these five categories only add up to 95%.  I've reserved that remaining 5% for the "other" category:
  • sober drunks, those who behave so well you can't really tell they are drunk
  • "I'm not drunk" drunks, idiots who flatly refuse to admit to having had anything to drink at all, even when confronted with a blood alcohol level ("YOUR LAB MUST HAVE MIXED UP THE BLOOD SAMPLES!").  These can sometimes turn into the belligerent asshole.
  • non drunks, people who act drunk but somehow have no alcohol or any other substance in their system
So there you have it.  Regardless of the type, I derive a certain grim satisfaction whenever I see the police give these people the stack of tickets they earned.  There may be other types out there, but I can't think of them at the moment.  Perhaps some readers can chime in with other types I may have inadvertently left out.  It's time for me to keep one of my other 2016 New Years resolutions: yoga.

Just kidding.

Friday, 8 January 2016

Another antivaxxer

WARNING: THIS POST IS LONG BECAUSE IT DEALS WITH THE ZENITH OF IGNORANCE

It happened again.

I had planned on posting a second update this week, something about a stupid patient or something.  I had the update all proofread, edited, and ready to go, but I unfortunately ran into someone on Twitter who inspired* me to change my mind.  This person** is so utterly deluded, so hopelessly brainwashed that I felt the need to sit right down at my computer*** and type a brand-spanking new post and leave the other one for later.
*"Inspire" in this case means she was so violently wrong that I couldn't help myself
** "Person" in this case means a spectacularly and fiendishly ignorant antivaxxer
*** Who the hell uses a computer these days?  It's 2016 for god's sake!  I wrote this on my iPhone with some assistance from my computer.  Thanks, Apple!
The person in question is Charisse Burchett, otherwise known as @Charbrevolution on Twitter.  She is a self-described "bitchcakes" and "fuckzilla", though I can't really say too much about those monikers considering I call myself a bastard.

It's never a good sign when someone's Twitter header is a picture that says "Wake up People // Vaccines = Death Adhd Autism Sids (sic)".  But after Charisse engaged me on a tweet I made on January 4th, I felt obliged to engage her.  My original tweet was a list of things I still can't believe people believe in 2016:
Astronomer Phil Plait tweeted a similar list a day before I did, which must have unconsciously inspired my own list.  There were several dozen things I could have added to my list if Twitter allowed a few thousand more characters, but I felt that list summed it up fairly well.  Charisse out of the blue replied with this:
I wasn't completely sure what she meant, though I did appreciate being called a toad (her insults would get far more hilariously ludicrous in the following days).  A click on her profile told me three very scary things: 1) She was a home vaccine researcher (aka a googler), not a doctor, 2) she was rabidly antivaccine, and 3) she has three children.  This woman needed educating, and quickly.

I clearly had work to do.

After Charisse declared that vaccines cause autism, I corrected her by showing her the study of over 1.2 million children showing no link between vaccines/mercury/thimerosal and autism.  She of course rejected that very compelling data because it failed to support her pre-determined conclusion, so she immediately threw out the Simpsonwood meeting.  This was held by the CDC in 2000 to discuss any potential link between the mercury in thiomersal (aka thimerosal) and autism (none was found, of course).  Bringing up this conspiracy theory is a classic manoeuver by antivaxxers whenever they need one to cover up supposed evidence of a link between vaccines and autism (which doesn't exist).  The issue has been extensively studied both before and since that meeting, and no link has been found.  She then threw out the infamous "list of 122 papers showing a link".  I've seen that list numerous times when antivaxxers perform that particularly predictable Gish Gallop, and it was soundly debunked several years ago (see this paper-by-paper refutation compiled by Liz Ditz).

Evidence, right?  Data, right?  Oh no, Charisse would not be deterred.  She then decided to switch tactics by moving the goalposts, claiming that there are no studies comparing vaccinated versus unvaccinated people.  Wrong again:

Look at that, evidence!  Glorious evidence!  Not just one paper, but 5, including a meta-analysis!  Surely she'll learn something, right?  Her response was classic head-in-the-sand denialism:
What?  I know it?  Was she really denying that those studies actually exist?  Not satisfied with denying, she decided to move the goalposts again:
I have no idea why she would think Americans' immune systems would be any different than any other human's on Earth.  Her response was curious:
Wait, wait, wait, I just showed you that the studies have been done, and they do not show that at all.  Is she illiterate or just ignoring me?  She then asked me to post a link to each study, which I did, expecting her to read exactly -0- of them.  Her response was to move the goalposts YET AGAIN:
That has nothing to do with anything I had said, but I let it go because she seemed to stop replying.  I thought, Maybe I've gotten through to her!  Maybe she's learned something!  Maybe she's taking all this time to read all those wonderfully educational links I've sent her!  Then I remembered that I'm a realist, not an idiot.  Her answer was to move the goalposts again:
Good grief.  I explained that polysorbate 80 has been known to be perfectly safe since the 1950s, which is why it is used in so many products.  The dose of polysorbate 80 in a vaccine is about 25 micrograms (that's 0.000025g), and rats fed a diet high in polysorbate 80 (the equivalent of a human eating 140g daily, the same as getting 5,600,000 flu shots) showed no ill effects (though if this was increased to an equivalent of a ludicrous 1.2kg (48,000,000 flu shots) daily, it decreased birth weight of offspring).  Regarding animal DNA, anyone who eats meat has animal DNA floating around in their serum.  So what.

She then moved the goalpost yet again, claiming that the flu vaccine causes narcolepsy.  This is where I stepped into it, because I hadn't heard of that and asked her to prove it, which I then did myself with a Pubmed search.  Indeed I learned that the Pandemrix vaccine used against the H1N1 strain of influenza in 2009 was found to cause around 1300 cases of narcolepsy around Europe, possibly due to a cross-reaction to an adjuvant used.  That particular vaccine was only used that one year, and no other flu vaccine has been associated with narcolepsy.

I admitted my mistake to Charisse, but apparently my acknowledgement that I don't know everything shattered any credibility (not that I had any with her to begin with).  Apparently Charisse thought that mistake reversed my opinion on everything else I had said:
Ah, no.  I had said none of those things.  But she seemed to think narcolepsy was a death sentence even though it is quite treatable, and that statement apparently made me evil and inspired one of the most fascinating insults I've ever received:
All I can say in response to that is YES.  Because what else can you say to "hulking banana turd"?  Her next tactic was to move the goalposts yet again and claim that Gulf War Syndrome is caused by vaccines.  She claimed she was going to show me up by proving it and I was too easy and fun (that may be true, I am a lot of fun) but I preemptively showed her evidence to the contrary:
Shockingly (not really) she hasn't brought it back up since.  I then decided to change tack and find out if she thinks vaccines are just bad or if they are bad and don't work as advertised.  I mentioned the fact that vaccines eradicated smallpox, which killed half a billion people in the 20th century, and that vaccines have prevented about 17 million deaths from measles alone since 2000.  Her response was entirely predictable:
And she revealed her stunning ignorance on anything having to do with biology, immunology, or science in general:
Yes, despite the fact that we know exactly how vaccines work, why they work, and that they work, she believes this is not causation.  Continuing her spectacular ignorance, she then started with the "Vaccines didn't save us" bit, which Dr. David Gorski (aka Orac) has firmly debunked.  I then showed her this graphic, which very nicely demonstrates how the measles infection rate, shown since 1912, plummeted to near zero after the vaccine was released:
Antivaxxers like the green line because it shows that mortality was already dropping precipitously when the vaccine came out, which is completely 100% true.  But medicine was advancing dramatically in the early 20th century - antisepsis, supportive care, ventilators, antibiotics . . . of course people would survive diseases better since doctors actually knew how to treat them.  But the red line simply can not be dismissed, as seasonal variations are seen until the very time the vaccine was introduced and measles all but vanished.  I then asked her about this one:
For those antivaxxers who think clean water and improved sanitation eliminated these diseases, isn't it funny how that clean water started eliminating polio in 1952 (right when the vaccine was introduced)?  But that same sly clean water waited to start improving measles rates until 1963 (when the vaccine was introduced).  And that sneaky clean water waited to drop mumps rates until a few years later in 1967 (when the vaccine was introduced).  And that water was still so wily that it waited 2 more years until 1969 to start dropping rubella rates (when the vaccine was introduced).

After all this education over a period of several days, I was beginning to think she was a lost cause, when finally Charisse showed her hand:
BINGO.  And there you have it.  Charisse openly admitted that no matter what evidence I showed her, no matter how strong the data, she would never change her mind.  Most believers in pseudoscience and conspiracy theories don't admit this outright, so I confess I was a bit shocked (even more so than after the "hulking banana turd" line).  Despite decades of tireless research by thousands of dedicated scientists and doctors, she (and many others like her) believe her "research" is somehow valid.

So there it is, my latest "conversation" with an antivaxxer.  I think it went pretty well, all things considered (not really).  Did I change any minds?  Not Charisse's, to be sure.  But perhaps someone else reading this (either here or on Twitter) will be swayed, though I seriously doubt anyone will actually read this entire stupid article.  I barely could, and I wrote the damned thing.

But what I do know is that I will not stop educating (read: fighting with) these people, because ultimately the people who lose are children like Charisse's who are left unprotected and susceptible to several painful, debilitating, and potentially-fatal diseases because their parents are either woefully misinformed or willfully ignorant.

Tuesday, 5 January 2016

Brain power

In my line of work, I see a lot of people with varying amounts of brain power.  Many of the people with whom I work have plenty to spare, ER docs excluded.  Just kidding.  Mostly.  Anyway, in contrast most of the patients I see have barely enough brain power to survive, it seems.  I have often thought that it is incredibly lucky that certain patients have a respiratory center in their medulla oblongata and pons which breathes for them, because otherwise they would forget.  I'm shocked that some of these people manage to remember to clothe and feed themselves each day.

That said, I'm even more surprised that people like this try to multitask.  I like to think that I'm of above-average intelligence, so walking and reading at the same time doesn't use all the brain power that I have at my disposal.  For others, however, doing those two activities simultaneously will tax their system, overworking the hamster wheel spinning out of control in their heads.  Chances are if these people are doing something while doing something else, something bad is going to happen.  And if they dare try to do something while doing something while doing something else, the shit is really going to hit the fan.

So you can imagine how the hamster living in the head of poor Riley (not his real name™) felt overworked.

LGFD is a common acronym I use as a new trauma patient rolls through my trauma bay doors.  "Looks Good From Door" usually denotes someone who doesn't look like there are any life threatening injuries - a stabbing to the shoulder, a pedestrian struck at very low velocity, a fall from standing position, a low-speed car accident with seat belts and 472 air bags.  Riley certainly fit the bill - he was smiling and laughing as he rolled in, making inappropriate jokes with the rather attractive medic who was trying not to roll her eyes completely into the back of her head at his lame attempts to pick her up.

"Hey Doc, this is Riley.  He's 20 and fell down about 10-15 stairs.  No loss of consciousness, just complaining of bilateral wrist pain."

"I also have chest pain, Doc!" Riley piped up, putting on a fake frown.  "I think I have a broken heart because this pretty girl won't give me her number!"

The poor medic glanced at me plaintively with a look that clearly said "Please kill me now . . . or him", and I gave her a feeble smile in return.

Riley's vital signs were all normal, and his head, neck, back, chest, and abdomen all seemed fine.  But both of his wrists had obvious deformities.  "I think your wrists are both fractured, sir", I told him.  "We are going to get some X-rays."

I quickly learned from Riley's redoubled attempts to pick up the nurses that he was a student at the local university.  He didn't seem very bright to me, since he was completely unable to absorb the fact that none of the women were interested in him.  I saw more eye rolls in the next 45 minutes than I had in the previous year combined.  It could have been the fact that he smelled like a pub restroom, or it could have been the fact that he wasn't nearly as funny, handsome, or charming as he thought he was.

After looking at his X-rays (which confirmed that both his wrists were fractured), I gave him the bad news.  He looked at me and started laughing.  Something obviously amused him, but he wouldn't let us in on the joke.  No one else was laughing, so I was glad that he was able to entertain someone.  Finally his hysterics calmed enough to the point where he was able to share the joy:

"I always knew it was dangerous to drink and drive, but I never knew it was dangerous to drink and walk!  Ha ha ha ha!"

It turns out he had been checking out Facebook on his mobile phone while walking through the train station, and because he had not been watching where he was going he tumbled down an escalator.  And he now had two broken wrists (and no date) to show for it.

Riley had it mostly right - drinking and walking is dangerous, and drinking and walking while not paying attention is even worse.  But drinking and walking while not paying attention and being an idiot is a life-threatening proposition.