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.

Monday, 1 May 2017

Call Gods are weird

I should apologise in advance for yet another Call Gods post.  I can almost hear two distinctly different groans from all the way over here:

1) Yeah, we fucking get it, Doc.  Call Gods.  Get over it!
2) There are no such things as Call Gods!  It's pure coincidence.  Get over it!

You know what, I should apologise, but I won't.  I don't care what you're moaning and groaning about.  I'm writing about the Call Gods again dammit, because they've been acting . . . strange.  Which for them is, well, strange. 

If you are familiar with the Call Gods, feel free to skip this explanatory paragraph and go check out some funny cat videos.  There are approximately 4,845,130,642 from which to choose.  In case you aren't aware of them, the Call Gods control everything (and I mean EVERYTHING) about what happens to me on call.  Whether I get to eat or not, if I get any sleep, how many times over the course of the night my pager will wake me, the type of patients I'll get (including the types of drunks), and the variety of injuries I'll see.  You may think it's sheer coincidence or that I have a selective memory and remember only what I choose to, but ask anyone in medicine (especially surgery).  You'll get the same response:

"THEY. ARE. REAL."

I know this because they prove it, over and over and over. 

What, you want examples?  I thought you'd never ask.
A few months ago I had a relatively slow day, only 8 patients over the whole shift.  It was typical stuff, mostly car accidents, a fall, and one gunshot wound.  However, in that mix of patients I had two patients who had suffered one injury and one injury only; one of the two had fallen down stairs, the other was shot.  But both had just one body part hurt.  Only one.  What body part?

One finger.  The fourth finger.  The left fourth finger. 

What, you still aren't convinced?  Two out of eight patients, fully 25% of my patients for the day, had isolated left 4th finger injuries on the very same day, and that still isn't evidence enough for you?   You still don't believe?  How is that even possible!  I hear the Call Gods mocking you.  They scoff at unbelievers. 

But wait, there's more.  There's always more. 

My most recent call day was much busier.  I had a total of sixteen patients, including 4 assaults, 3 stabbings (one I took to the operating theatre with lacerations to his colon, kidney, and small intestine), one shooting, one drunk fall, 6 car accidents, and a guy hit in the face by a falling wrench (yes, seriously).  If you aren't seeing a pattern yet, I don't blame you.  I didn't see it either until I got a patient with a glass eye.  That may not sound that strange to you (yet), but I haven't seen a patient with a glass eye in several years, and as soon as I saw her, something inside me twitched.  

Sure enough, two hours later one of the assault victims also had a glass eye. 

Both were fine with no serious injuries, and perhaps a glass eye isn't anything to get worked up over.  I simply like to think of it as the Call Gods reminding me they are there.  Always watching.  Waiting.  Preparing. 

Always.

Monday, 24 April 2017

Gift

Take a little ride with me.  Yes, you.  We're going on a trip, you and I.  Close your eyes.  Now imagine a house, a big house.  A beautiful house.  This house has a wide, lush green lawn, quaint blue shutters, and a sparkling pool in the back.  The house sits on a calm, pristine lake and has a private dock where there is a boat tied up.

Unfortunately your own house burned down some time ago, and now you have nowhere to live.  So you look at this house, and you love it.  You want it.  Not only that, you need it.  You see, it's cold outside, and you have no shelter.  Any day now you fear that you will succumb to the elements.  Your desperation is reaching a critical point.

Then one day as you are standing there staring at this dream house, a man approaches you, seemingly out of nowhere.  He has a smile on his face as he confidently walks up to you and hands you an envelope without a word.  He then smiles warmly once again, turns, and walks away.  Confused, you open the envelope, and inside you find a set of keys.  Looking further you pull out a sheaf of papers - a deed.  No, not just a deed, the deed.  The deed to this house.  The deed to this house with your name on it.

What?  What is this?  Has someone really just given you a house??  Is that even possible?  You tremulously try the key in the door, and it works.  The door swings silently open and you walk inside, incredulous at your luck.  The house is fully furnished.  Even the refrigerator is stocked with food, everything you could want.  You start to tear up as you realise that it was just before you got to the point where you thought you might die that some kind benefactor you don't know and will never meet has given you the greatest gift you could imagine, exactly what you need to live.  Someone has given you the gift of another chance at life.

What do you do to repay the kindness of a complete stranger?  What could you possibly do to show your gratitude?  How do you respond?  I'll tell you:

You throw a huge party, you shit all over the house, you tear it apart, and then you burn it to the ground.  On purpose.  THAT is what you fucking do.

Wait, what?  Why would you do such a thing?  What kind of asshole would take such a gift and stomp all over it?

Zachary (not his real name™), that's who.  Why?  Why would he do that?  I have no idea, you'll have to ask Zachary, because he's the only asshole I know with experience with this kind of utter twatfuckery.

It was a typical Saturday night, which is to say that everyone who rolled through the door of my trauma bay, whether he had fallen, gotten into a car crash, was assaulted, or was stabbed in the head, was drunk.  And Zach was no different.  I believe I saw every type of drunk that night, and Zach was a Type 5 Drunk, meaning he thought he was much funnier than he actually was, which was not at all.  Not even a little bit.

After getting the story from the medics (car vs tree, tree wins), we started our examination of Zach from head to toe.  This always involves undressing the patient completely so that we can look at everything.  His shirt was barely halfway over his head when I recognised a tell-tale sign on his abdomen:

A Mercedes Benz scar.

This was no ordinary scar, and I could have recognised it from across the room.  Anyone who knows anything about surgery will know this immediately as a liver transplant scar, and if you didn't know that before, now you do.

I'm going to pause here to let this scenario sink into your brain for a moment before I go on, because I can feel my blood starting to boil just like it was that night.  If yours isn't yet, it should be.

. . .

*deep breath*

. . .

Ok, ready to go on?  I'm going to skip the remainder of Zach's story, because 1) it isn't that interesting, and 2) just thinking about it is enough to make me want to throw my computer out the window (Zachary was fine despite his best efforts to kill himself and everyone around him).  The short short version, the reason I was so angry, is that Zach had killed his original liver with heavy alcohol abuse over many years, he got a new one, and he was now pissing it away by drinking again.

I'm going to pause again.  My apologies.

. . .

*DEEP breath*

. . .

If you haven't figured out why I'm so angry then you haven't been paying attention and WHY THE HELL ARE YOU EVEN HERE.  *DEEEEEEP breath*  I'm sorry, I shouldn't direct my anger at you when it isn't your fault.  That isn't fair. 

Think of the house.  Like in that imaginary scenario, Zachary was given an extraordinary gift - a new liver, and a new chance at life.  There are no two ways about it; without the new liver, he would have died a horrible early death.  But Zachary was saved.  Some poor soul gave his or her own life to give Zachary a second chance, a new life, and Zach thanked his anonymous benefactor by treating his new liver exactly the same way as he treated his first liver: by shitting all over it.

The things I see in my trauma bay often amuse me, sometimes they sadden me, and sometimes they confuse me.  Rarely, however, do they infuriate me.  Zachary infuriated me.

Perhaps I'm out of line.  Maybe I'm just being dramatic and stupid and I'm over-reacting over nothing.

No.  No I'm not. 

Saturday, 22 April 2017

Two problems

I've had a few people ask me over the past day or so if I'm ok.  Apparently if I don't post a story for over a week, some people get worried about my health or something.  Allow me to assure everyone quite clearly:

I'm fine. 

But there have been a few problems lately that have interfered with my usual plans for weekly updates. Well, two problems actually.  Two very large problems. 

1) People haven't really been acting very stupid around me over the past weeks.  I know that may seem hard to believe considering what you've read about my clientele.  Yes, there have been the usual drunk drivers, stabbings, falling off bar stools, etc.  But there are only but so many ways I can make the same scenario seem different and interesting enough to warrant another post. 
1) I've been on vacation.  No, I won't say exactly where I was (and who wants a mental image of me half naked on a beach anyway), but what I will say is that I learned that my middle school teacher was right: it IS hot near the equator. 

If you're paying close attention, you'll notice both problems labeled #1.  That's because I can't decide which is the more important reason for no recent update.  Don't misunderstand, I can always sit on a beach and write blog stories, but only if I have good enough material, and only if I really feel like it, which I didn't. 

The fruity drink with the umbrella sticking out the top may have had something to do with my newly acquired apathy.  Hm. 

Regardless, not to worry, though.  I'm back in town and back in business.  And doubtless my subjects will give me plenty of blog fodder in 3...2...1...


Thursday, 6 April 2017

Jahi McMath update

It's about that time again, folks: time to revisit the tragic story of Jahi McMath.  In case you're new here and don't know Jahi's story, you can read about it here, here, here, here, and here.  I even wrote a stupid FAQ here.  The short short version of the story is that a 13-year-old girl in California underwent a rather extensive three-part surgery for sleep apnoea and suffered cardiac arrest and brain death back in December, 2013.  She was declared brain dead after multiple separate brain death evaluations by multiple different people as well as by Dr. Paul Fisher, the court-appointed second opinion expert, and multiple ancillary tests confirmed the diagnosis.  Her mother, Nailah Winkfield, refused to accept the diagnosis, so she had her transferred to another hospital in New Jersey (St. Peter's University Hospital) where she had a tracheostomy and feeding tube placed.  She stayed at that facility for 8 months until she was discharged to her mother's care, and has been sustained on somatic support in an apartment in New Jersey since August 2014.

Got all that?  Good, let's move on.

In the intervening 2 1/2 years, we've had sporadic "updates" from the family (and anti-brain death quack Dr. Paul Byrne) claiming that Jahi is alive because she no longer meets the criteria for brain death.  The "proof" for her resurrection has been, shall we say, lacking.  One of the pieces of evidence was a video of Jahi supposedly moving her foot to command, and another was a video of her moving her arm to command.

My last update was over a year ago in March 2016, but it was just a couple of vague pictures of Jahi, still with her eyes closed.  More recently than that in October 2016 a video was posted of Jahi supposedly breathing over the ventilator, again in response to verbal commands.

So what are we to take away from all of this?  What does this all mean?

The short answer: Nothing.

As usual, the "evidence" is meaningless.  How do I know this?  Because it is no longer merely implausible, it is quite literally impossible.

Thanks to Professor Thaddeus Mason Pope's Medical Futility Blog, we now have access to some information that has up until now been mere educated guesses.  A case management statement (whatever the hell that is) was submitted by Jahi's surgeon, Dr. Frederick Rosen, which contains the statements of two experts on brain death, Drs. Thomas Nakagawa and Sanford Schneider.  For a bit of background, Dr. Nakagawa is the division chief of critical care medicine and the director of the paediatric intensive care unit at Johns Hopkins All Children's Hospital in St. Petersburg, Florida, and he has over 25 years of clinical experience in paediatric critical care.  Dr. Schneider is a clinical professor of neurology at the College of Medicine, University of California, Irvine and has been in paediatric neurology practice for 48 years.

These two guys know their shit - THEY ARE EXPERTS.  Both doctors reviewed all available records, starting with her original hospitalisation in California, all the way through the end of her hospitalisation in New Jersey and the release to her mother.  In their statements they disclose some very interesting, and very revealing information.

Dr. Nakagawa describes the several EEGs that were done as ancillary brain death tests (note than an EEG is not a definitive test for brain death).  On December 12th there was no brain activity, and the technician noted that her right arm and left leg were both moving during the EEG.  They also tried auditory and painful stimuli during the test as well as shining a light in her eye, but there was no brain activity in response to anything.  Another EEG was performed on December 17th, and again there was no response to painful stimuli, light touch, or sound.  Yet another EEG was done on December 23rd, which was exactly the same.  This is very important information, because it means that her movements are in fact spinal movements, not caused by brain activity.  Also keep in mind there was no response to sound.  This will come into play a little later.

Nakagawa also goes over Jahi's brain flow scan on December 23, 2013 (page 33) which showed a complete absence of blood flow to the brain, which Dr. Fisher calls "beyond definitive".  Brain tissue cannot survive more than a few minutes without blood, and this was 13 days after her anoxic event and cardiac arrest.  Thirteen days is more than enough time for the brain to die.

He also describes Jahi's clinical exam during her 8-month hospitalisation in New Jersey, and at no time was her examination ever not consistent with brain death.  She never had any purposeful movement, she never opened her eyes, she never had any cough, gag, or pupillary reflex, and she never had any spontaneous breathing.

Drs. Nakagawa and Schneider both talk about the other ancillary tests that were done on September 26, 2014, including MRI, brainstem auditory evoked potentials, upper extremity somatosensory evoked potentials, visual evoked potentials, and EEG.  None of these are accepted ancillary tests for brain death, but they still revealed something very interesting: they were still consistent with brain death.  Additionally, on page 46 of the document Schneider states that the somatosensory evoked potentials demonstrated some integrity of the spinal cord up to the level of C5, but there was no function above this.
It is a medical impossibility that J. McMath is moving in response to verbal commands.  The brain stem auditory evoked potentials test performed at University Hospital on September 26, 2014 . . . demonstrates that as a result of J. McMath's brain death she has no auditory pathways; there were no evoked potentials to maximum aural stimulation.  This test result establishes to a reasonable degree of medical certainty that J. McMath cannot respond to verbal commands because she has no cerebral mechanism to hear sound.
In plain English, the videos of Jahi moving in response to her mother's voice are nothing more than spinal reflex movements, because Jahi CAN NOT HEAR and her brain CAN NOT CAUSE MOVEMENTS because it is dead.  It is now plainly obvious that they simply caught Jahi at a time when her hand and foot were twitching, and they took a video of it while Nailah told her to move.  I don't know if this was deliberately deceptive on Nailah's part, but I suspect it was not.  I believe that she honestly believes Jahi can hear her.  However, she can not.  It is 100% impossible.

In summary, Nakagawa and Schneider exhaustively evaluated everything that had been done to and for Jahi from her surgery up until her release to her mother on August 25, 2014 (there was no evidence that Jahi had been re-evaluated for brain death since that day), and all of the brain death evaluations that were done in California were deemed completely valid.  There was no evidence that anything was awry in any way.  They also both stated, quite definitively, that nothing that had been done since her declaration of death -- no subsequent tests, no exams done at St. Peter's University Hospital, no nothing -- could . . . well, I'll let Dr. Nakagawa sum it up:
There is nothing in McMath's medical records from Saint Peter's University Hospital that would cause a reputable expert in pediatric or adult brain death to question or reconsider the accepted brain death assessments of Dr. Robin Shanahan, Dr. Robert Heidersbach, and Dr. Paul Fisher.
He makes the same statement regarding additional tests she had done in September of 2014, none of which are accepted tests for brain death.  Dr. Schneider then says this, which Nakagawa also averred:
There is absolutely no medical possibility that J. McMath has recovered, or will someday recover, from death.
It seems I may have said something very similar many, many times.

So there you have it.  That's about as definitive as it gets.  Comments, as always, are welcome.  But please keep them respectful.

Saturday, 1 April 2017

Look of disappointment

Clara looked at me with sad, red eyes, tears welling up and starting to run down her flushed cheeks.  I've seen that look before, many times.  Many, many times.  Usually the look comes when I've told someone her son was just killed and I couldn't save him, or someone whose wife has a terminal cancer that I just can't cure.  But not this time.  Clara wasn't related to the patient, she was the patient.  Her look was indeed one of deepest disappointment and sorrow, but it wasn't because she was sad, and it wasn't because she was hurt.  It was because she wasn't hurt.

If it doesn't make sense yet, it will soon.  I promise.  

My trauma shift starts at 8 AM, and it ends exactly 24 hours later.  Full-day shifts are torture; they are antiquated things that should have been retired long ago, but they persist in many places because we haven't come up with a better system.  The worst part of the shift is theh 7 AM - 8 AM portion, because it's right at the time when most people are driving to work and car accidents are likely, and it's right at the time when I'm counting the minutes until my shift is over.  So when my pager went off as I was making rounds at 7:35 AM and looking forward to my first cup of coffee, I was unsurprised but thoroughly disheartened.  What did surprise me was the mechanism of injury:

"LVL 1 GUNSHOT WOUND TO CHEST. 5 MINUTES"

Wait, what?  Who the hell gets shot at 7 o'clock in the morning?  I quickly trudged down to the trauma bay, my mind running through all the possibilities.

None of them, it turned out, proved to be correct.

Clara (not her real name™)  rolled in looking even more disheartened than I was.  That was . . . strange.  Most trauma victims look in pain, angry, half dead, or giddy (in the case of Drunk Driver type 5), but not Clara.  She just looked . . . blank.  She was staring straight ahead at nothing and no one in particular, her face slack and emotionless.  Then she slowly turned her head towards me, and while I expected a smile, a frown, a scowl, or something, her expression did not change one bit.  She simply looked at me.

"Hi Doc, this is Clara.  She's stable, oxygen sats 100% during transport.  She tried to kill herself this morning by shooting herself in the chest with a hunting rifle."

Ah.  That explained her look of sheerest despondence.

Clara dropped her head and stared at the gurney, her face still impassive.  I was half expecting her to either complain, deny, or cry, but she did none of those things.  She just sat.  While I felt terrible for her and her obviously hopeless situation, it was also a very troublesome situation for me, because I then had to say something that I knew damned well she did not want to hear.

"Hi Clara, I'm Doctor Bastard (not my real name™).  I understand you were trying to hurt yourself, but I need to make it clear to you that it is my job to make sure that you do not succeed."

She merely glanced at me briefly, nodded once, and returned to staring at her lap.

The entry wound was in the upper outer portion of her left breast, and the exit wound was on the outer portion of her left back.  Based on the trajectory (and the fact that her lung sounds were clear and equal), it didn't look to me like the bullet had entered her chest, but obviously I needed to be sure.

Her chest X-ray was completely clear (except for a few small bullet fragments in the subcutaneous tissue), an ultrasound of her chest was normal, and a CT scan confirmed that no major damage was done.  No fractured ribs, no pneumothorax, no injury to the heart.  As soon as I saw the pictures, I walked into the scanner to tell her the good news, which (I realised as I was saying it) she would take as bad news.

I put my hand on her shoulder and said simply, "Hi Clara.  I just looked at your scan.  I know you don't want to hear this, but the bullet did not enter your chest.  There's no major injury."  Before I could even finish, her emotionless expression started to break down.  "It's ok.  You're going to be ok.  We're going to get you the help you need."

With that, the flood gates opened, and Clara started openly sobbing.  "Oh no!  Oh god, no!  I can't do this anymore.  I'm 53 years old, I've lost my husband and both of my kids, and I just can't do it.  I can't do it any more.  I just can't!"  She continued to sob as I tried to figure out what to say next.  What could I say?  Is there anything that could make this hopeless situation remotely better?

Ultimately I decided that there was nothing I could say to her that would assuage anything.  I simply gave her arm one final friendly squeeze, smiled meekly at her, and walked out, while I looked up the name of the psychiatrist on call.

Yes, today is April Fools' Day, but this is not a joke or a hoax.  This is a 100% true story.  Clara is a real patient, a real person, with real problems that are clearly worse than I could possibly imagine, bad enough that I had a great amount of trouble empathising with her.

I'm posting this purposely on April 1 to give everyone a break from the silliness that reigns on this date, simply to remind everyone that life isn't a joke for everyone.