Monday, 11 December 2017

Now I've heard everything

Most of the mechanisms of injury I see are rather mundane and pedestrian. Auto accidents, falls, stabbings, shootings, pedestrians struck, bicycle accidents, and assaults are the mainstays of what I see, do, and fix. Sometimes I get the "other", however. These can be anything from ordinary (dog bite) to a bit strange (chainsaw to the face) to how the hell did that happen (foot run over by a lawnmower) to what the actual fuck (bitten by a camel). To be honest, it's difficult to come up with a mechanism of injury that I haven't seen.

Until someone does.

Saturday night seems to go along with alcohol just like peas and carrots, peanut butter and jelly, salt and pepper.  It just doesn't seem to flow linguistically, however.  Hm. Anyway, I'm constantly astounded at what drunk people will do to themselves or others, simply because they are drunk. It doesn't seem to matter what they do or to whom they do it, as long as they can blame alcohol.

"Hi Doc, good evening. This is Dawn (not her real name™). Dawn was assaulted with bug spray tonight, and . . ."

I don't typically interrupt the medics in the middle of a patient presentation, but this time I couldn't help myself.

"Wait wait wait . . . what?"

The medic chuckled a bit and continued. "Heh, yeah. Anyway, she was assaulted with bug spray after her and her boyfriend got into a fight after a night of heavy drinking. She's got a lac on her scalp about 5 cm, positive loss of consciousness. She's 49 years old, history of HIV, not taking any meds, no allergies. Only complaining of a headache."

If you're following along here, you probably have the same question I had.  I could not resist the temptation and just blurted it out:

"So, was she hit with the can or sprayed?"

"Heh. Yeah, Both."

Fortunately the spray didn't get in her eyes, so all she needed was a few staples to close the wound and a heavy dose of IV fluid to get her sober.  Once she was coherent, her boyfriend came to take her home.  All was forgiven, apparently.

I know I've said this several times before, but this time I really really really mean it:

NOW I've seen everything.

Monday, 4 December 2017

DNR

If you're in the States, you can rest assured that I am most assuredly NOT writing about the Department of Natural Resources.  Nor am I writing about Denbury Resources, Inc (whose unfortunate symbol on the New York Stock Exchange is DNR).  No, anyone remotely familiar with the medical field (or who ever watched House MD or Holby City or Grey's Anatomy or ER or St Elsewhere or M*A*S*H or Scrubs or Marcus Welby, MD [godDAMMIT there are a lot of medical dramas!]) knows that "DNR" stands for "Do Not Resuscitate".  It represents the primary right of the patient - to refuse medical treatment, even in the face of impending death.  Most usually it is employed by the elderly, severely infirm, or terminally ill to alert their medical care providers that they do not want any heroic measures in the event of sudden or imminent death.

There are various elements to a DNR, including orders not to intubate, not to do chest compressions, not to employ vasopressors (medication to artificially elevate blood pressure), not to give food and/or fluids, not to use dialysis, or to use comfort measures only.  The exact nature of the DNR order, including any and all therapies that may or may not be used, is explicitly elucidated in a signed document that is supposed to be readily available for medical practitioners to see.  That way there can be no ambiguity if an unconscious yet terminal patient is brought to the hospital.  The papers are supposed to be easy to find, though sometimes they can be difficult to track down.

Sometimes, however, the DNR is, well, let's just say sometimes it is slightly more prominent:


According to a case report from the New England Journal of Medicine, this 70-year old gentleman was brought by paramedics to a hospital in Miami, Florida unconscious and intoxicated.  He had a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, and he arrived without any identification or family members.  When doctors disrobed him to do their examination, they found "DO NOT RESUSCITATE" tattooed quite clearly (with "NOT" even underlined) on his chest with his signature underneath.

Open and shut case, done and done, cut-and-dried, impossible to misinterpret, right?  RIGHT?

If that were an easy question to answer, I wouldn't be writing this right about now, would I.

A few hours later his blood pressure dropped precipitously due to severe sepsis, and he developed a severe metabolic acidosis (his serum pH was 6.81 - I have never seen anyone with a pH less than 6.9 survive).  The intensive care doctors who attended to him had a decision to make: A) honour the tattoo as a legally binding DNR or B) treat him as they would any other anonymous patient.

They chose B.

According to lead author Gregory Holt, MD, the doctors chose to invoke "the principle of not choosing an irreversible path when faced with uncertainty", so they categorically ignored the tattoo, starting him on antibiotics, putting him on BiPAP, and starting vasopressors.  In other words, everything short of intubating him.

My first reaction to this story was "WHAT?  WHAT THE FUCK WERE THEY THINKING?  HIS CHEST SAYS DEE EN ARE!"  My next thought was that if they had done chest compressions, they would have been committing assault on this gentleman.  My next thought was . . . calm the fuck down and get some more information, dumbass.

*deep breath*

It turns out cases like this, while extraordinarily rare, are not entirely isolated.  In fact there is a published case report in the literature of a man with a similar "DNR" tattoo (though it is admittedly not quite as explicit) which did not reflect his actual wishes.  That patient had lost a bet while drunk many years before, the loser being required to get a tattoo of "DNR" on his chest.  

"Heh, sounds like one of your patients, Doc."

Indeed it does.  Regardless, Dr. Holt and his team obtained a consultation from their ethics team, who determined that the tattoo most likely did reflect the patient's wishes.  They advised the doctors to honour it as an ordinary paper DNR.  Out of respect for the patient's (hopefully) wishes, an actual DNR order was written.  Fortunately shortly thereafter the gentleman's real out-of-hospital DNR was obtained, and he passed the following morning without incident.

After contemplating this case for some time, I've come to the realisation that it isn't nearly so clear cut as I had originally thought.  If I got a dying trauma patient who had a prominent and unmistakable DNR tattoo, would I really be able to say "Wait, stop, don't do anything.  Look, it says DEE EN ARE right there on his chest!"?  Would that really be the right thing to do without verifying it first?  The part of me that explicitly respects patients' wishes says an very emphatic "Yes", but the entire rest of me (which is admittedly rather small) says "Not so fast".  

I believe that treating a patient who does not want to be treated is malpractice.  However, I also believe I would be obligated to verify the DNR prior to withdrawing or withholding care while consulting my own ethics team.  I also also believe doing anything short of this would be malpractice.

What do you believe?

Friday, 1 December 2017

Interview part 2

Those of you who have been here a while probably (hopefully) remember the interview with Mrs. Bastard from December 2015. If you don't remember it, well, look it up. I can't do everything for you. Anyway, she just shockingly mentioned that she would like to do another one, and since I had intended that to be an annual thing, I should probably keep my word or something.

So you people are officially on duty. Submit your questions in the comments below for my dear wife, and I will choose the best and/or least revealing ones for Interview 2.0, which should be published some time next month as long as the Call Gods allow it. There are no official rules on what questions you may ask, but you'd better god damn well believe that I will categorically ignore any question I deem inappropriate or too personal. I will not be revealing my name, age, location, childhood nickname, or my most ticklish spot (upper back).

Damn it. 

Everyone ready? And . . . GO.

Monday, 27 November 2017

No story

It's been two weeks since my last update. I had a new post all edited, shined up, and ready to go, but then the patient (who had done something fully deserving to have a story written about him) decided to go and do something even stupider and have himself a postoperative complication.

No, it isn't my complication. It was an orthopaedic surgery with an orthopaedic complication, but regardless he isn't doing well. At all. So out of respect for him, I have decided to postpone his story and possibly even delete it, depending on his outcome.

If you can't tell, I'm not happy about this. Even though it wasn't my surgery and isn't my complication, he's still my patient.

Not happy.

UPDATE:
He died. The story will be deleted. God damn it.

Monday, 13 November 2017

Electricity

There are few things on this oblate spheroid we call Earth of which I am truly terrified.  On the top of my list are nuclear annihilation (which seems more likely with the recent escalation of the Kim-Trump 12-year-old child feud), earthquakes, supervolcano eruptions, and pretty much any reptile, sea life, or insect in Australia (seriously Australia, what the fuck is up with Sydney funnel-web spiders and Irukandji jellyfish?).  But a very close fifth is, as you've probably guessed from the title, electricity.

Despite excellent marks in science classes in school, I still don't fully understand electricity, nor do I really care to.  I zapped the shit out of myself trying to change out a faulty light switch back in college, and since then I try to pretend electricity doesn't really exist (not really).  Even static electricity shooting out of my fingertips every winter has me firmly believing that the world is constantly trying to electrocute me.  My relationship with electricity now solely involves me plugging things carefully into outlets and then turning those things on and off.  And as much as I enjoy fixing things, if those things involve wiring or rewiring or anything involving a fuse box, I leave it to the professionals.  Because fuck electricity.

Fortunately professional electricians exist.  I don't know if these people understand electricity completely, trust it implicitly, or just don't give a shit about the occasional zap that could potentially stop their heart from beating (which, though I am not a cardiologist I understand to be a Very Bad Thing).  Irrespective of how or why they do it, they seem more than happy to fiddle with whatever potentially lethal electrical thing has gone awry.  Unfortunately, however, not all professional electricians know what the hell they are doing.

"Electrocution" is a portmanteau of "electricity" and "execution" originally coined in the late 19th century to describe death by the electric chair.  It has since come to mean any death from electrical shock (as opposed to cardiogenic shock, hypovolemic shock, and "OMG can you believe she's wearing that to a funeral??" shock).  Electrical injuries are particularly difficult to treat because they often combine cutaneous thermal injuries (ie burns), internal thermal injuries (including muscle necrosis), cardiac electrical dysrhythmias, and mechanical trauma from the inevitable fall after the shock.  Thankfully they are also relatively rare, and most are treated at dedicated burn facilities, which mine is not.  Despite this, I still see the occasional electrical injury victim.

Like Lou (not his real name™), who was my patient, and his partner, who was not.  Don't worry, I'll explain.

Lou was driving to a job when he heard over his business radio that his partner had suffered a moderate shock while repairing an air conditioning unit in an attic space.  Wanting to make sure his buddy was ok, Lou diverted to that establishment, where he found his partner somewhat dazed but relatively unscathed.  Apparently his partner hadn't turned off the main power before starting, and at some point he had come into contact with a live wire that was hanging from the ceiling.

Now common sense would dictate either A) your partner turning off the power prior to starting, or B) turning off the power after your partner gets a nasty shock.  As you can easily tell, either way the power gets turned off.  Right?  RIGHT?

Common sense, I am sad to report, is no longer common.

Lou apparently decided to finish the job his partner had started without addressing the live wire hanging from the ceiling that had nearly finished off his partner.  He climbed the ladder to the attic space, reached down to get a tool, and as he stood up he caught the live wire with his forehead.

Hilarity did not ensue.

The shock Lou received was significantly greater than his partner's.  He was predictably thrown backwards down the ladder where various parts of his anatomy bounced off several steps, ultimately striking his head on the floor below and losing consciousness.

And that is where we pick up his story.

Lou had just started regaining consciousness when he arrived in my trauma bay.  He was clearly dazed and confused, a dark electrical burn on his forehead, dried blood matting a good portion of his hair.  Surprisingly his main complaint was his right shoulder.  A thorough workup demonstrated a fractured clavicle, a scalp laceration, a relatively severe concussion, and a small burn on his forehead (obviously).  He had no evidence of a cardiac or skeletal muscle electrical injury, but I watched him overnight just to be sure.  He felt much better, though thoroughly ashamed, the next morning when I sent him home.

I get a bit miffed when doctors in other specialties suggest how I do my job, but I admittedly get a rather severe eye twitch when non-doctors do it.  Despite this, before Lou left the hospital I felt entirely comfortable reminding him to turn off the goddamned electricity before working on it.

I also made sure to note which company he works for and made a mental note never to hire them.  Any professionals working on my power lines need to know what the hell they are doing and, you know, not die in my house.

Monday, 6 November 2017

Texas

I was supposed to be publishing another stupid patient story today.  I didn't think I would be writing about this.  Again.  I thought the death of 58 innocent people in Las Vegas a month ago would be enough to stimulate the United States government to talk about gun control.  To at least get a conversation started.  I thought surely something, anything would happen, something would get done, some conversation would get initiated in Washington DC that would lead to some kind of change.

Then over the next few weeks, the furor over the shooting withered.  Then it died completely.  Instead of reading about potential gun control legislation, I read about a new US tax bill that was introduced.  Whoopdefucking doo.

And now there is yet another mass shooting in the US, this time in Texas.  As of this writing, at least 26 more innocent people are dead after a young man walked into a church and started shooting parishioners.  Among the victims are a 5-year-old, the 14-year-old daughter of the church's pastor, and a pregnant mother and three of her children.  As shocking as that may be, this isn't even the first mass church shooting in recent memory.

I'm going to repeat that in case you didn't get it the first time: THIS IS NOT EVEN THE FIRST MASS CHURCH SHOOTING IN THE PAST TWO YEARS.

How the hell is this possible?  How does the American government allow this to continue, time after time after time? 

Because the American public, and their government, just don't get it.  Within hours, gun nuts immediately piped up, defending their precious guns. 
This seems to be one of their favourites, especially after several people were run over in Edmonton a month ago, in Barcelona back in August, and in New York City a few days ago.  On the surface it seems like a valid argument.  But if you think about it a little deeper, the argument boils down to "Crazy people who want to kill will find a way to kill.  Either ban everything that can kill, or don't ban anything."

Really?  Is that the best you can do?  First of all, you need a licence, registration, and training to operate a car.  You need none of those things to buy a gun.  Of course you can steal a truck and use it for whatever nefarious purpose you choose, but that doesn't change the fact that you don't need a licence, registration, or training to buy a gun in the United States.  That is absolutely unconscionable.

Second of all, cars are essential for everyday life.  Guns are not.

Third of all, this guy didn't use a truck.  He used this:
Can anyone explain to me why an American citizen needs one of these.  Anyone?  Are you protecting your family from home invaders with one of these?  Are you hunting with one of these?  Are you going skeet shooting with one of these?  Oh, perhaps this is the reason:

Really?  REALLY?  Yes, that's how the second amendment reads, because that's what the second amendment was originally about.  But this is 2017, not 1791 when that amendment was written.  In 2017 the United States government has hundreds of thousands of soldiers in their army, navy, air force, and marines with the most high-tech weaponry on the planet.  Oh, and in case you didn't notice, they also have fucking drones.  You really think that rifle is going to protect you from drones?  Apparently he does:
Because according to gun fanatics, the solution isn't just more guns, it's more BIGGER guns.  I can't even muster an appropriate response to that.  I just can't.

Then there was this bit of singular stupidity:

I fed this through my Idiot to English Translation Engine, and this is what came out:
People break laws, so you may as well not even make laws. 
Which is quite possibly one of the stupidest arguments against gun control I have ever seen and much stupider than my imagination could have ever dreamed up.  Anarchy as the solution to crime.  Speechless.

So after two horrific mass shootings barely a month apart, surely US politicians are ready to talk about gun control, right?  Right?
Prayers?  These people were at church.  They already had prayers.  Prayers aren't going to stop mass shootings. 

And President Trump (I still can't believe that phrase is real) said this:
Mental health is your problem here.  This isn't a guns situation, this is a mental health problem at the highest level. It's a very, very sad event.
Mental health is the issue with any murder, because only an immoral waste of carbon and oxygen would murder another human being.  But if you give that waste of carbon and oxygen a gun, you make it much easier to take a life.

Or twenty six.

Or fifty eight.

Monday, 30 October 2017

The Speech

One of my favourite things to do is to lecture people.  By "lecture" I don't mean lecturing medical students, which I am unfortunately contractually obligated to do.  It turns out I'm a terrible teacher; I just have absolutely no patience for people who just don't get it.  Ironically, my backup plan if my medical career fizzled was to be a biology teacher.  Yeah . . . that would not have gone well.

No, what I mean is lecturing patients, most notably drunk drivers.  I love it.  I relish it.  I enjoy every opportunity to tell people that what they just did was stupid, reckless (though not wreckless, har har), irresponsible, and their thoughtless act endangered not only their own lives but the lives of everyone around them.  In case you can't tell, I have a canned speech in my head that I've used several hundred times, and it keeps getting better every time I give it.

Unfortunately I don't always get to give The Speech.  Sometimes the bad guys leave before I get the chance, and rarely there just isn't time.  Even more rarely, however, I don't need to.

Like with Edwin (not his real name™).

Being awakened in the middle of the night is a pain in the ass.  Not only do I have to shake out the mental cobwebs to make sure I am alert enough to deal with whatever is coming in, I also have to rinse my mouth a bit and make sure my hair doesn't look completely insane.  Don't misunderstand, I don't care if I look a bit like Albert Einstein, but trust me when I say you absolutely do not want your trauma surgeon looking like Yahoo Serious.  Anyway, when my pager goes off at 3 AM on a Friday night telling me I have a car accident victim on the way, I can be well assured it's a drunk driver.

Enter Edwin the Drunk Driver.

I like to think that Edwin, who was 22-years-stupid, would have been a Type I Drunk had he not been quite as intoxicated as he was.  However, with the amount of alcohol in his system, he could barely keep his eyes open let alone yell at people coherently.  Everything that did come out of his mouth was mumbled worse than Muttley.  I was absolutely astounded he had even been able to find his car keys let alone drive.  Though he couldn't really speak, what he could do was fight: with the medics, with us, with literally anyone who came within arm's reach.  He had blood on his face which clearly came from somewhere, but he was completely unable to cooperate with any sort of workup.  We were therefore forced to sedate him and intubate him to complete (or start) our evaluation.

Once he was sedated the entire team let out a collective huge sigh of relief as the trauma bay immediately quieted.  What was most obvious was the relatively small laceration on his forehead which had already stopped bleeding.  What hadn't stopped bleeding, however, was his spleen.

His splenic laceration was first diagnosed by a bedside ultrasound and was then confirmed by CT scan.  It wasn't the worst I'd ever seen, but it was certainly there.  He also had a few minor fractures in his pelvis, none of which would be anything more than really annoying for the next few weeks.  But as I was going through his blood work, one number stood out that caused my ire to rise.  It was a foregone conclusion that his blood alcohol would be elevated (it was about 4 times the legal limit), but even though the number didn't really surprise me, for some unknown reason it still made me angry.

Actually, no it isn't an unknown reason.  The reason is very known.  It's because my wife drives my children around on the very roadway Edwin was screaming his way through that night.  Edwin put everyone's lives around him at risk, and he was incredibly lucky that only he was injured, luckier still his injuries did not end up being life-threatening.

The Speech was already being prepared in my mind.  I just needed to let him sober up overnight.  No sense in wasting it on a slurring puddle of whiskey or beer or whatever the hell he had been drinking.

By the following morning, Edwin was sober, awake, and breathing on his own, and the breathing tube had been removed.  I stood outside his room readying The Speech with steely resolve, hoping his mother/wife/girlfriend/anyone would be there to hear my scathing lecture.  I took one final breath, turned around, and walked in.

What greeted me was not at all what I expected: Edwin, the loud, brash, obnoxious, out-of-control drunk from the night before was talking softly, almost meekly, with his mother, who looked mildly anxious though not angry.

Well . . . that was unexpected.

After perfunctorily asking him how he was feeling ("Sore, doctor"), if he was having any new pain ("No, sir"), and if he remembered anything from the previous night ("No, sir"), I was about to launch into The Speech when he cut across me gently.

"Doctor, did I hurt anyone last night?  Is everyone ok?"  Tears started to well in his eyes.

My steely resolve was starting to turn into oatmeal.

It only took a minute or two of talking with Edwin to discover that he was truly and genuinely mortified at what he had done and what could have been.  The last thing he remembered from the previous night was drinking at the pub, and the next thing he remembered was waking up in his hospital bed this morning.  He was terrified he had hurt someone, and he had nothing but regret and remorse behind his eyes. 

Yeah yeah, I can already hear a lot of you cynics screaming "But Doc, come on!  He was faking it!  How could you fall for it?  He just feels bad because he wrecked his car!"  No.  I saw his eyes.  This was no act.  I see a lot of drunk drivers and I've heard the lot of them tell me how they've never done it before, they'll never do it again, blah blah blah blah.  I can see right through the charade, and it doesn't impress me in the least.  But Edwin was different.  Edwin impressed me.  He looked instantly relieved when I told him it no one else was hurt, but he was still visibly shaken.

"That just isn't me, Doc.  I don't know why I did that.  I just have no idea."  The tears continued, real tears of penitence.  "I swear that just isn't me.  I just have to learn from this, learn from this mistake.  Never again.  NEVER.  This is a real turning point for me, Doc.  It has to be.  I just don't know what I would have done if I had hurt someone."

And I absolutely believed him.

Edwin was stealing my opportunity to give The Speech, and I let him.  He went on for several minutes beating himself up much more effectively than I possibly could have.  His mother sat behind him, nodding here and there, wiping a tear away every so often.  When he was done he looked up at me.

"At least I didn't hurt anyone.  Right?"

I saw Edwin in my office about a week later.  He was limping slightly and the swelling around his right eye had almost disappeared, though his black eye had not yet.  His laceration had healed well and I removed his sutures.  Before I could even bring it up, Edwin said, "Doctor, thank you for taking care of me.  I've given up alcohol completely.  This was a real wake-up call for me.  I just, well, I just wanted to say thank you.  Thank you."  True remorse is a rare thing for me.  But learning from a mistake that quickly is even rarer.

Now before any of you  just on my case for being a big softy, don't worry - I got to give The Speech just 2 days later.  And I let it rip with no hesitation.