Tuesday, 25 October 2016

Annual physical

It's that time of year again - time for my annual physical.  Or I should say, time for me to be a hypocrite and ignore slash skip my annual physical.  I had one about 6 or 7 years ago, and my health was essentially perfect other than a touch of chronic back pain (I love you, ibuprofen).  I don't have a family history of serious diseases, I don't smoke, I drink alcohol occasionally, and I eat balanced meals (thank you, Mrs. Bastard).  Since that time I have advised countless people, including family, friends, and patients, to get their annual physical because it was the right thing to do, despite knowing that I wasn't following my own advice.

Recently the health insurance company Cigna teamed up with a bunch of actors from several medical TV shows (including M*A*S*H, House, Grey's Anatomy, and Scrubs) to create a rather brilliantly funny advertisement reminding people to get their annual checkups.  In case you haven't seen it, here is one of them:

Ha ha!  Classic.  I love self-deprecation from actors.  And this is a great cause with solid advice.  After all, what could be wrong with reminding people to get a checkup if is going to save lives?

Well, here is the problem: there is no evidence that annual physicals actually save lives.  Yes, you heard me right.  Seriously.  A Cochrane review of 14 randomised trials involving over 180,000 subjects showed that people who had general health exams were more likely to have new diagnoses and they were more likely to start on medication for high blood pressure or high cholesterol.  While that may sound good, there was unfortunately no improvement in deaths or overall health in patients who had annual physicals versus those who did not.  Cochrane's conclusion was,


So have I been wrong this whole time?  How can this be?  Sure I've been wrong before, but about this?  Are McDreamy and Turk and Dr. Hawkeye Pierce wrong?  Are annual physicals really unnecessary and potentially harmful?  Well, yes.  And no.  Sort of.  In a way.  Don't worry, by the end this will all be as clear as mud.

I'll explain.

It may seem on the surface that getting people treated for untreated diseases would help.  After all, you can't regulate your blood pressure if you don't know know you even have high blood pressure, right?  And you can't get a biopsy on that enlarged prostate which could possibly be prostate cancer if you don't know it's enlarged.

That was exactly the point of the studies that Cochrane compiled, and the data are fairly clear (if counterintuitive) - it doesn't make a difference if you know you have high blood pressure or high cholesterol or not.  It doesn't make a difference if you don't know you have an enlarged prostate or a breast mass or not.  Getting them treated will not make you live longer.

Make sense?  Yeah, not to me either at first.

The bottom line is this: too many diseases are being over-diagnosed, and thus they are being over-treated.  Many people don't need to have their high cholesterol treated because it won't kill them.  Think of it this way - if you have diabetes, you're going to know it one way or another, so it will be appropriately treated.  You'll go into a diabetic coma or ketoacidosis eventually if you don't, so it shouldn't take an annual physical to find it.  And if your prostate is large enough to cause symptoms of urinary retention, you'll seek care for it, so an annual physical should not be necessary.  The large prostate and breast cancers are the cancers that can kill.

But if you have a relatively small prostate or breast cancer that is found on a routine annual physical examination, this may well lead to the cancer being removed, and while that sounds like a good thing, cancers like this tend to be relatively slow-growing.  So chances are very high that you'd die of something else before the cancer kills you (unless you're very young).  That makes these cancers over-diagnoses and over-treatments.

Make sense yet?  Sort of?

Keep in mind the Cochrane review only looked at cancer and cardiovascular health because they are two of the biggest killers worldwide.  It did not look at diabetes or autoimmune disorders, for example.  

The bigger question here is will this make any difference to how I practice?  I espouse evidence-based medicine whenever possible, so the intellectual answer should be an immediate "Yes".  Unfortunately the real answer is a rather tepid "Probably", at least for my elderly patients.  I try to limit my hypocrisy to a bare minimum, so I can't extol the virtues of evidence-based medicine one second and then cherry pick which parts of EBM I plan to follow the next.  So while I will certainly curtail advising my elderly patients to get their annual checkups, I will most assuredly not actively advise them not to.  I think that still counts.  Right?

Now a breast cancer in a 30-year old is very different than a breast cancer in an 80-year old, so I still believe that annual checkups are important for children and young people because chronic diseases caught early can be managed, and damage can be limited.  My practice there will not change one iota.

EDIT: Thanks to an anonymous reader (is that you, Dr. Franklin?), we now have more information about the Cochrane review, and it sort of affirms what I was saying, and sort of doesn't.  Clear as mud, right?

Occasional SftTB commenter Dr. Cory Franklin coincidentally wrote an editorial at the beginning of 2015 about exactly this subject, and he cited this same Cochrane review and its series of limitations.  Several of the studies in the review are from the 1960s, none of them looked at the elderly or children, and some of them didn't look at women.  One of the main problems he (correctly) saw is that medicine has advanced significantly since many of these studies were performed - statins, better blood pressure medications, advances in minimally invasive interventional cardiology, etc.  Treating high blood pressure and high cholesterol is vastly different in 2016 than it was in 1975, so one would expect morbidity and mortality to vary accordingly.  Does it?  We don't know.

So does this additional information change my view?  Not really.  I still think it's a good idea for children to have an annual checkup, and I still don't think the elderly do.  As for all the cranky curmudgeonly middle-aged people in between (like yours truly), it remains a big muddy grey area with no good answer.  The good thing about grey areas in medicine is that there is no wrong answer.  Huzzah!  We can't be wrong!  But that's also the bad news - it's just as difficult to be right.  We just don't know enough to give fully informed advice.

But despite the distinct muddy lack-of-clarity of the issue, I still have to admit - those are some damned funny advertisements.

Monday, 17 October 2016

Correct vs lucky

I can't tell you how many times I've said "Better lucky than good".  Well, I could tell you ("You can tell me, I'm a doctor"), but it would be nothing more than a wild guess.  And while some people may like making wild guesses (I call them "gamblers"), doing that in my line of work can occasionally (read: nearly always) be dangerous and/or reckless.  Fortunately I very rarely have to make wild guesses, since most of the guesswork is eliminated with the assistance of blood work, X-rays, and CT scans.  Oh, and also with the assistance of physical examinations and talking to patients.

Obviously stupidity aside, sometimes all the lab work and studies and tests in the world won't answer a question, and that's when I have to make the very uncomfortable decision of guessing.  At that point it is clearly an educated guess, but it's a guess all the same.

Such was the case with Raul (not his real name™) recently.

Raul was around 70, very healthy for his age, and came to the hospital complaining of abdominal pain.  This is an incredibly common complaint, and there are entire textbooks devoted to delineating the cause and treatment of abdominal pain (no seriously, look it up).  The problem with Raul wasn't necessarily his pain, but where it was located - in the left upper abdomen.  This is a very unusual site for pain, because in all the other parts of the belly we usually at least have some idea about what's going on:
  • Right lower quadrant: appendicitis, right kidney, Girl Part Problems
  • Right upper quadrant: Gall bladder, liver
  • Epigastrium: foregut stuff (stomach, duodenum, esophagus), heart
  • Mid-abdomen: midgut stuff (small bowel)
  • Left lower quadrant: diverticulitis, left kidney, Girl Part Problems
There really isn't much that can cause pain in the left upper abdomen other than the spleen, and that's such a rare problem outside of trauma that we tend to ignore it.  But Raul kept pointing to his left upper abdomen, saying that it felt like a sharp pain, but mainly when he sat up.  He had no other complaints, no fevers, no nausea, and he was moving his bowels normally.  

In case you are wondering why I mentioned that last bit, pooping is very important to general surgeons, almost as important as that big beaty pumpy thing in the chest whose name I forget.  Honestly, I'm halfway convinced that cardiologists have murmurs and extra heart sounds built into their stethoscopes because no one else can seem to hear them.

Anyway, I kept mashing on Raul's left upper abdomen and was rewarded with . . . absolutely nothing.  Not a grunt, not a wince, and no masses that I could feel.  Nothing.  Zip.  His ribs didn't seem to hurt either, nor did his back.  All the while he kept saying his left upper abdomen hurt, though not when I examined it.

Hm.  What the hell.

With a confusing exam in hand, Raul went off to the CT scanner.  As the pictures initially flew by, something strange caught my eye.  I went back over it carefully slide by slide, and there was definitely something wrong with his bowel.  There seemed to be a twist in the mesentery (the blood supply) of the small intestine known as a "whirl sign".  There were also a few loops of intestine in the left upper abdomen (of course) that were very slightly dilated, but they did not appear obstructed.  He had gas and stool throughout his colon, so whatever he was eating and drinking (and all the various fluids his body was making) was making its way through to the end.

Hmmmm.  What the hell.

I went back to talk to Raul and his wife, and I gave them the news.  I wasn't exactly sure what the news was, and I made sure to express that quite clearly to them.  I was not impressed with his exam at all, and while the whirl sign can be indicative of a small bowel volvulus (twist), most of the time it is not.  And since Raul had no nausea and was passing gas from below (yes, farting is also very important to general surgeons), his bowels were not clinically obstructed.  Armed with that very strange information, I explained that we had two options - 1) do something, and 2) do nothing.  I could immediately take Raul to the operating theatre to take a look inside and see if something was twisted, or we could watch him and see what happens.

I was unclear of the cause for his pain, because any gut pathology should refer pain to the  mid-abdomen, not the left upper abdomen.  But something was definitely off here.  I just didn't know what.  I didn't have a clear diagnosis, and I didn't want to guess.  He was having little pain at that point, so he and his wife sagely decided to wait.

I hate waiting.  I HATE WAITING.  I suck at waiting.  God damn it, I did not go into surgery not to operate.  I chose this field so I could FIX stuff, dammit!  Unfortunately sometimes not operating is the right thing to do.


I went to see Raul first thing the next morning, and he was feeling somewhat better.  He had been drinking fluids overnight still with no nausea, and he was still passing gas.  His pain, however, was not gone, though it was mildly improved.  I mashed on his belly again and he still felt no pain whatsoever.  I again presented him his two options: something or nothing.  I didn't feel that he needed an operation, though that was mainly a guess because something in his presentation gnawed at me.  Something about this whole situation Just Wasn't Right, but I still hesitated to guess what that meant.  We opted to wait another day.

The next day, Raul still had no nausea, he was drinking, and his pain had improved a bit more.  At that point I decided to send him home, with the understanding that if whatever he had returned, he would most assuredly need an operation.

I heard nothing from him or his wife the next day.  Success!  Huzzah!  No news is supposed to be good news.  Right?

HA!  No.

The next morning I woke up to an email from his wife saying that he had woken up at 2 AM (WHY THE HELL IS IT ALWAYS 2 AM??) with the same exact left-sided pain.  He still had no nausea, he was still drinking, and he still was pooping.  She also mentioned that their regular doctor had asked why the stupid consulting surgeon, who clearly was an idiot, didn't order a follow-up X-ray to see if the twist had untwisted, and he told them to head back to the hospital immediately.

Damn damn DAMN.  I was the stupid consulting surgeon!  What the hell had I missed?  Am I a terrible doctor?  Am I a shit surgeon?  I hadn't thought he needed an operation, but should I have just bitten the bullet and taken him for a potentially massive surgery?  SHITSHITSHITSHIT

I drove to the hospital trying to figure out A) what I was going to say to them when I saw them, B) when I was going to do his surgery, and C) how I was going to rearrange my schedule since I had patients to see in the morning and a lecture to give to medical students in the afternoon.  By the time I got there, he was already prepping for his repeat CT scan, and I nearly called the operating theatre to schedule him before seeing him.  But now something about him seemed . . . different.  He still looked quite comfortable, he had still been eating normally and passing gas, and his abdominal exam was still completely normal.  But his pain was significantly worse and now localised mainly in his left back.  

Wait, what??  Why in the world was his back hurting now?  What the hell is going on with this guy?  I must have missed the "Intestine bone connected to the back bone" day in medical school.  But it still didn't sound like any kind of bowel issue.  Did he have a kidney stone?  Some kind of weird lumbar hernia that I hadn't seen the first time?  Did he have a short in his internal wiring?  Or was it something else entirely?

I wheeled him over to the CT scanner personally to avoid any kind of delay.  The radiology techs seemed a bit startled to see a surgeon pushing a gurney, but I ignored their strange leers.  And just like last time, I watched the pictures as they flashed on the screen.  I scrolled through his scan picture-by-picture, and unlike last time his bowel looked completely and utterly normal.  The twist that had been there before was gone, and the oral contrast he had just drunk had traversed all the way to his colon.  There was no dilation, no obstruction, no inflammation, nothing.  But then I went back up to his chest and saw something completely unexpected: 


Raul's left lower lung was completely collapsed and filled with infection, he had a pleural effusion, and just to tie it all up with a nice little bow, he had a pulmonary embolus too. 

So I hadn't made a huge blunder after all.  The sigh of relief that I heaved was probably rivaled by the one when Mrs. Bastard said "yes", and I must admit I mentally pumped my fist several times as I walked back to Raul's room.  I also must admit I felt pretty shitty for doing so knowing that Raul was still very sick.,  He just wasn't surgically sick.

"I have good news, and I have bad news," I started with a bit of a smile.  "Which would you like first?"

"Uh, the good news," Raul's wife said.  She had a tendency to talk for him, as I've noticed many wives do.  No offence, ladies.

"Well, the good news is that you don't need surgery.  Your bowel is completely normal.  {dramatic pause}  The bad news is that you have pneumonia."


"Yes, pneumonia.  And a pulmonary embolus."

They were probably more surprised than I was at the diagnoses, but they were also both visibly relieved that surgery was not in their immediate future.  Though some people seem to enjoy undergoing painful and risky procedures, most people don't.  But just as I was about to leave, Raul's wife gave me an even bigger surprise.

"That's actually not the bad news," she said.  "The real bad news is that we won't need to see you anymore."

I'm sure I blubbered and gibbered nonsensically as she asked if I was absolutely sure that I didn't want to be Raul's and her GP.  I am fairly certain I blushed, and I haven't blushed in years.  Decades, even.

Raul stayed in hospital for a few days getting antibiotics, and he felt like a new man (not really) when he went home again.  But before they left they both made sure to ask one more time if I would be willing to be their GP.  I wanted to say that no one in his right mind would want to be a GP, but that would be an insult to GPs everywhere.  Instead I just politely smiled and declined.

But seriously, why would anyone want to go into internal medicine?

I could probably answer, but it would just be a guess.

Friday, 7 October 2016

Believing evidence

I made the quote box above extra large because it is extra true.  I will quite literally believe anything no matter how ludicrous it may seem if there is actual, real, true, and verifiable evidence to support it.   I don't care how crazy it seems as long as there is not just evidence, but solid evidence.

There is now a video purportedly showing that Jahi McMath is breathing on her own.  Evidence?  Yes.

Solid evidence?  Not so much.

On his blog, Professor Thaddeus Pope reposted a video that had been posted to the "Keep Jahi McMath On Life Support" page on Facebook.  I feel I must quibble with Professor Pope just a bit, as he states she "breathes on her own" and puts the word "death" in quotation marks, much like the anti-brain death faction.  Regardless, the majority of the 5+ minute video focuses on the lights on the ventilator that is breathing for Jahi.  For a good portion of it, Jahi appears to be breathing faster than the 12 breaths-per-minute to which the machine is set, and the Patient Effort light occasionally blinks, indicating that Jahi is breathing on her own.

Or does it?

The "Jahi is alive" crowd seemed to think that Jahi starting menstruating indicated that her brain was alive, but there have been other documented cases of brain dead patients starting puberty.  Similarly there are also documented cases of brain dead patients showing supposed respiratory effort.  Unfortunately for Jahi (and even more so for her her mother), it does not indicate that Jahi is not brain dead or will ever "go to the mall" as Nailah says in the video.

In this case report from Poland, a patient who had failed two brain death examinations was noted to have multiple triggered assisted breaths.  The clinicians were baffled, so more brain death confirmation studies were ordered.  There was no blood flow to the brain on ultrasound, and a cerebral angiogram confirmed no cerebral blood flow.  They concluded that "Cardiogenic oscillations associated with incorrect low ventilator trigger settings may falsely suggest persistence of breathing efforts in a brain-dead patient".  In other words, the airway pressures changed during heart beats, and this falsely indicated to the ventilator that the patient was trying to take a breath.

Another case report documents a very similar phenomenon, where a brainstem dead patient was shown to have triggered breaths on the ventilator.  The authors' conclusion sound eerily similar: "'Triggering' was probably caused by a decrease in airway pressure in time with cardiac contraction. The trigger flow rate is crucial as factors other than the patient's inspiratory effort can initiate flow from the ventilator with very sensitive settings."

And a very well-described case series from China tells of two more patients with similar presentations, both documented brain dead using a combination of clinical examination, apnoea testing, and EEG silence, and both with triggered breaths on the ventilator.  In both cases, brain death testing was repeated, and it remained consistent with brain death.  At the risk of sounding like a broken record, they concluded, "Minimal changes in circuit flow unrelated to the respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing BD."

In other words, it very well may not be Jahi breathing at all, but rather other factors making it seem like Jahi is breathing.

The saddest part of this latest episode in the saga is at the end of the video, the camera pans over to Jahi, flaccid and motionless, eyes still closed, exactly as she was when she died 3 years ago.  In her continued deluded state, Nailah thinks of this as an improvement.

It would be painfully easy for anyone to verify the veracity of this video.  It would take a pulmonologist less than five seconds to say either Yes or No.  If an intensive care doctor examined her and said "She's breathing.  Nope, not brain dead", I would have no choice but to believe it no matter how ludicrous.

Imagine the media frenzy surrounding the first documented case in human history of even partial recovery from brain death, whether miracle or marvel of modern science.  We all know that Jahi's parents enjoy a show.  They revel in publicity.  They enjoy the attention.  I have no doubt whatsoever that they absolutely know how easy proving this video would be.

But that hasn't happened.  Ask yourself why.  I think we all know the reason.

So until it does happen, I cannot believe it, and I remain utterly and completely sceptical.

Tuesday, 4 October 2016

Becoming a trauma surgeon

I swear I wrote this same damned post a few months or years ago, but my chronically aging brain couldn't seem to find it despite hours (read: 75 seconds) of exhaustive (read: cursory) searching.  Unfortunately because I couldn't initially find it that means either A) I'm losing my mind, B) I've lost my mind, C) I'm losing my mind, or D) I never wrote it AND I'm losing my mind.  Therefore I am forced to write it again.  Grumble grumble etc etc.

The fact that I did find it means that it's probably A.  Or B.  Or possibly C.

Write what again, you may ask?  This.  No, not the word "this", I mean this blog post.  The one I'm about to write.  I mean the one I wrote.  No, not the other one, I mean the one I've just written and and that you're currently reading.  That is, in your temporal point of view, the one you're about to read or are currently reading . . .

GOD DAMN IT I have got to learn not to drink 2 coffees and a latte before sitting down to write.  I usually limit myself to one damned coffee a day, so clearly that is a good policy, one that I need to adhere to more strictly.

[intermission for caffeine washout]

Ok now that my mind is no longer buzzing and is instead running along at a somewhat normal pace, I'll continue.

I've had numerous people tell me over email during the past few years that they wish to pursue a career in trauma surgery, and they invariably ask the same thing: advice on how to get to where I am, if trauma surgery can mesh with their desired lifestyle, how to cope with long hours, losing patients, etc.  I touched on the subject a bit here and here, but not in enough detail.  Trauma surgery is a noble profession (if I do say so myself), so I feel it is my duty and privilege to guide people along that path if that is their particular flavour of torture that they've chosen.  However, instead of emailing people the same advice over and over, I am writing this so I can lazily point them to this post in the future rather than writing everything out again.

My first advice is always "RUN AWAY!  GO BE AN ACCOUNTANT OR A BANKER OR A ARCHITECT OR ANYTHING ELSE YOU FOOL!"  This may sound like I am actively trying to veer people away from medicine, but the only reason it sounds like that is because I AM trying to steer you away, because going into medicine is hard, going into surgery is even harder, and going into trauma surgery is a fucking bitch.  My apologies to all the actual fucking bitches out there for comparing you to trauma surgery, because in all honesty it isn't a fair comparison.  Trauma surgery is much worse than you, you fucking bitches.

I say that with my tongue firmly implanted in my cheek, because as difficult as trauma surgery is, it is also the most rewarding profession I know (other than toll booth collector).  However, before you embark on the journey that begins in college and concludes with you cutting open someone's chest and squeezing his heart in a desperate attempt to keep him out of the morgue, you need to know exactly what enemies stand in your way and will try to defeat you at every turn along the way.

I will preface any and all (real) advice by saying that I am not and have never been on an admissions committee.  It has been many moons since I applied to medical school, and requirements and expectations may have changed.  They also vary from country to country.  Medical school training is also in flux, so take everything I say with a very large grain of salt.

With that nonsense out of the way, there are many obstacles to surmount, and I covered some of them in that prior post that I mentioned previously.  As I said, medical school requirements are different from country to country.  For example, in all American and most Canadian medical schools you must first complete a 4-year undergraduate degree prior to starting your 4-5 year journey through medical school.  In most European countries and Australia you go directly from high school to a 6-8 year medical school.  In India medical school is 6 years.  If you happen not to live in one of those areas, I'm not your mother - go look it up, damn it.

The major roadblocks in undergraduate university are the dreaded science prerequisites - some combination of biology, chemistry, organic chemistry, and physics.  These also will vary from country to country and school to school (for example, some medical schools also require biochemistry).  Regarding courses to take (and/or avoid), I cover that topic in great detail here.  The bottom line is this: kill the prerequisites, and then (and only then) take courses that interest you and make you a well-rounded individual.  Are you interested in advanced maths?  Study that.  Do you like ancient Chinese literature?  Study that.  Art history, music, philosophy . . . the choices are nearly endless.  It's college, for chrissakes, and you only get this opportunity once.  But don't be that guy who takes all science courses and loses out on studying subjects that interest you because you think medical schools want that.  THEY DON'T.  Quite the opposite - they want people who aren't science robots.  I think.  Maybe.  Probably.

Assuming you do well in college (especially on those core science courses), depending on where you live (again) you then need to destroy the Medical College Admission Test (which is used in the US, and Canada) or GAMSAT (used in Australia and UK).  Other countries have their own tests, which all have the same purpose - to defeat you and destroy your dreams and beat you into submission and force you to do something else with your life.  It is incredibly easy to fail these tests and choose another profession, and that is exactly what they are designed to do.  They weed out the weak links.

Medical school is similar everywhere - learn, learn, learn, learn, and then just when you think your brain can't possibly accept any new facts without jettisoning some actual useful information, you have to learn some more.  I can't give you any advice here except to learn stuff.  Lots of stuff.  If you say you aren't good at rote memorisation, then med school is not for you.  You can try to have "a life" during medical school, but don't count on it.

You'll have to get through all the other rotations (paediatrics, internal medicine, obstetrics, etc).  If you're truly a surgeon at heart, these will bore the life out of you.  I felt like I'd rather stick hot pokers in my eye than sit through another 6-hour rounding marathon where we stand and talk and talk and stand. 

When you finally get to your surgery clerkship, learn as much as you can.  Try to suck up to the surgeons without it being obvious that you're sucking up (trust me, we can tell).  Be interested, be enthusiastic, but don't fake it.  We can detect false enthusiasm a mile away.  Get there early and be the last to leave.  Read your books the night before, and know the operation better than I do.  Know the anatomy and be prepared to be quizzed mercilessly (aka "pimped").  If you don't know your shit, it will be obvious  Make it clear that you want to learn surgery, not because you're faking it, but because you do.

When it comes to becoming a surgeon, in the UK it takes about 10 years (2 years of foundation training, 2 years of core surgery training, and 6 years of specialty training).  In the US you go through The Match where you apply for residencies, which last for 5-7 years.  In Australia surgery training is 5-6 years after medical school.  After all that, training in trauma is an additional 1-2 years.  If that seems like an interminable torturous lifetime of training, just wait until you're in the middle of it.  It seems even worse. 

Until you finish.

The biggest hurdle to get over, at least in my opinion, is meeting someone.  I got damned lucky and met Mrs. Bastard before I started medical school, and I was even luckier that she stayed with me during the entire ordeal and afterwards.  

Seriously, what the hell was she thinking?

If you're wondering if it's possible to have and/or start a family during surgery training, I am living proof that it is.  I got married a few weeks before starting mine, and my daughter was born towards the end.  My wife says that all that means is that we managed to see each other for five minutes nine months earlier, but I'm pretty sure she's exaggerating.  I don't really remember though.  My brain has mercifully blocked out that entire section of my life.

I think I'll stop there.  I could go into much more detail, but I think this has been boring enough for everyone NOT interested in becoming a trauma surgeon (which is approximately 99.99582% of you, according to my calculations).  Perhaps the remaining 0.00418% of you gained a little insight into how I became the curmudgeonly pessimist you've all come to love to despise. 

Perhaps not. 

Friday, 23 September 2016

DocBastard's Translation Guide

There are innumerable great things about being a doctor, and specifically about being a trauma surgeon.  I get to save lives, work with great people, work with my hands, and share stupendously stupid stories with you fine people.  But sadly it isn't all rainbows and butterflies.  Unfortunately there are downsides.  There are several downsides to trauma, including being away from my family and babysitting drunk idiots, but by far the worst aspect is talking to people.

I may not have mentioned it here (or not lately), but generally speaking, people suck.  A lot.  People lie, do stupid things, drive recklessly, are irresponsible, and don't know how to communicate so they resort to poking other people with sharp stabby things.  I realise full well that I have a job that requires me to take care of these people who suck, but they suck nevertheless.

What irritates me the most is how everyone lies.  Ok, perhaps not everyone, just . . . most everyone.  And it usually isn't just one lie, but rather a string of lies that progressively builds on itself.  Fortunately I've heard pretty much every lie out there, so I can not only detect it, but also translate it into the truth.

This post is mainly intended for others in the medical field, but perhaps non-medical-types may still find it instructive.

Without further ado, here is DocBastard's Complete Trauma Translation Guide.

Lie: I've only had two drinks.
Truth: I can't remember how many drinks I had because I lost count back when I was vomiting on my shoes.

Lie: No, I don't do drugs.
Truth: I smoked weed 5 minutes ago, 2 hours ago, 6 hours ago, and if you hand me my pants, I'll fire one up right now.

Lie: I don't know who stabbed me.
Truth: I know exactly who stabbed me, but if I tell you, he'll be arrested and I won't be able to exact my revenge when I get the hell out of here.

Lie: I'm allergic to ibuprofen, acetaminophen, and aspirin.
Truth: I ran out of heroin, and saying "Ow" is the easiest way to score some narcotics.

Lie: I haven't used heroin in 6 months.
Truth: I used heroin 6 minutes ago.

Lie: Those aren't track marks on my arm.
Truth: Those are track marks on my arm.

Lie: I have fibromyalgia.
Truth: I'm addicted to Percocet.  Please give me some.  {Note: No disrespect intended to people who actually have fibro, but plenty of disrespect to all the fakers.}

Lie: I ran out of my blood pressure medicine a week ago.
Truth: I have no idea what blood pressure medicine I take and I don't give a fuck, so I haven't taken it in a year.

Lie: I don't know why I jumped out of the car.
Truth: I don't remember why I jumped out of the car because I'm soooooo high.

Lie: I wasn't wearing a helmet because they can cause more harm in an accident.
Truth: I wasn't paying attention in science class, so I don't understand the spread and absorption of kinetic energy. 

Lie: That packet of white powder that you just found in my ass isn't mine.  I'm just holding it for a friend.
Truth: I can't think of a better lie right this second.

Lie: So there I was cleaning my bedroom in the nude, and I slipped and fell on the dildo, and that's how it got stuck in my ass. One-in-a-million shot!
Truth: You know exactly what happened.

Lie: This is the first time I've ever driven drunk.
Truth: I don't remember all the other times I've driven drunk. 

Lie: This is the last time I'll ever drive drunk.
Truth: Until next time. 

Lie: This was my first time trying PCP.
Truth: Name a drug, any drug.  Yeah, I've tried it.  That one too.  Aaaand that one. 

Lie: There's no way I could be pregnant.
Truth: I have unprotected sex all the time. {Thanks to ndenunz for the reminder.}

Lie: I don't know why he shot me.
Truth: I created and/or put myself into a dangerous situation where I might get shot.

Lie: I ran out of Percocet and I can't get to my pain doctor for another week.  I just need a few to get me by.
Truth: This is the truth, and I know you aren't supposed to give me more, but I'm hoping you'll take pity on me. 

Lie: Yes I was wearing my seatbelt, so I have no idea how my face hit the windscreen.
Truth: I didn't even know my car had a seatbelt.

Lie: I am NOT drunk!
Truth: Sure I'm drunk, just not as drunk as I usually get on Saturday nights. 

There you have it.  I know there are more lies I'm forgetting, so I hope you folks can help fill in the gaps. 

And that's the truth. 

Monday, 19 September 2016


I'm a goddamned good father, and I'm not too proud to admit it.  Of course as I write that my 9-year-old daughter is sitting right next to me, but it's ok - I made her go to the other room before she saw it.  I don't know exactly how it happened, but Mrs. Bastard and I seem to have stumbled into an series of good parenting decisions and techniques (not that we are perfect), such that we have the best kids in the world.  I don't mean to demean any other parents out there, but it's a simple fact that someone on the planet must have the best kids in the world, and I just so happen to be that guy.  No, they aren't perfect either, but as Albert Einstein once said, no one is perfect.

It may not actually have been Einstein that said that.  Maybe it was Nikola Tesla.

Anyway, our parenting equation is rather simple - 1) Mrs. Bastard and I are always there for our kids, or if we can't be, we make damned sure to have a responsible backup, 2) every decision we make is for the benefit of our children, 3) we do everything we can to keep our children safe.  Very very simple.  Take those three things and add them up and you get two very strict (and very effective) parents with two very sweet, very well-behaved, and very well-adjusted children.  They're both also totally freaking adorable, but I can't really take credit for that - that's good luck more than anything else.  Plus, they obviously get their looks from their mother.

We didn't read any parenting books and we essentially ignored much of the advice that we got from our parents (sorry MomBastard, DadBastard, and Bastards-in-law), and yet we are somehow doing a damned good job.  I know this may seem like another Extol Doc's Virtues post, but it really isn't.  Well, I guess up until now it is.  But from now on it isn't.  I swear.  We aren't perfect parents - I yell a bit too much, Mrs. Bastard yells a bit too little - but we're good.

If only Aiden (not his real name™) had been so lucky.

I've said it many times before, but nothing good happens at 2 AM.  This is true for adults, but even truer for teenagers.  (As an aside, how can something be truer?  If it is true, can something else be more true?)  The only reason a 16-year old should be out at 2 AM is if he is working to support himself and/or his family.  Otherwise they should all be in bed asleep, which is exactly where I was when my pager woke me to tell me I would be getting a Level 1 gunshot victim in 5 minutes.


When Aiden rolled through the door, my first impression was "Why the fuck isn't this kid in bed asleep on a school night?  What the hell was he doing?  Why the hell was he shot?  Who did he piss off?"  Fortunately my ever-so-slight drowsy haze had worn off, so I had the self-restraint to ask him none of those questions.

"Hey Doc," the medics began.  "This is Aiden.  He's 16, through-and-through gee ess double-you to the right thigh."

Indeed Aiden had two small holes in his leg - one just above the knee and one on the back of his mid thigh.  But unlike in movies, it doesn't take a big hole to cause major problems.  My first priority in cases like this is to see what was hit.  There are lots of Very Important Things in the thigh (including 1) artery, 2) bone, 3) nerve, and 4) vein), so my job was to rule in (or out) injuries to all of them.  Sure there's plenty of muscle in there too, but who the hell cares about that.

I was able to lift his leg without him screaming in pain, so I tentatively scratched bone off the list of Potentially Injured Things.  I then placed my finger on the top of his foot to feel his pulse.

Wait, wait . . . his pulse?  On his foot?  Isn't the pulse on the wrist?

Yes, his pulse on his foot.  I didn't know this before medical school either, but on the top of your foot there's a little bone protruding slightly (the first cuneiform, if you were wondering), and just towards the outside of this is the dorsalis pedis artery, which is one of two arteries that supplies blood to the foot.  I put my finger there and felt . . . nothing.  I then went to his posterior tibialis artery (the other aforementioned blood supply to the foot) which is just behind the bone on the inside of the ankle.

Also nothing.

The pulses were strong in his other leg, so I knew we had a Big Problem.  How big a problem was still up in the air since I hadn't yet addressed question 3, the nerve (much like the muscles, the vein isn't really a big issue).  I touched his foot and asked him if he could feel it.


I asked him to move his toes.


SHIT.  This had just gone from a Big Problem to a Really Big Problem.

Aiden was rushed down to the operating room where the vascular surgeon found exactly what we were all expecting to find - a lacerated superficial femoral artery and femoral nerve.  My colleague was able to re-establish blood flow by doing a bypass graft, and we tried to piece the nerve back together as best we could.

While you may be thinking "Hey, at least you got blood flow back!", a well-perfused leg with no sensation and no movement is not a leg at all, and an amputation and prosthesis is usually more functional.  Think of it as a bank with a top-of-the-line safe, a beautiful atrium, plenty of safety deposit boxes, and a vault full of money to lend . . . but no customers and no staff.  It may look like a bank, but it is not a bank, just an empty, useless building.  That is probably a terrible analogy, but it seems to have legs, so I'm running with it.

Har dee fucking har.

Horrible analogy and worse joke aside, Aiden's leg seemed like it would end up a useless appendage.  Maybe.  Time would tell if the nerve would heal.

When I went to see him the next morning and re-examine him, several female party goers were there.  At least, that was my first impression.  The two reeked of alcohol, marijuana and god-knows-what else, had on ridiculously long fake eyelashes and enough makeup to cover a clown car full of clowns, and were wearing mini-skirts that, if they were any shorter, would qualify as belts.

I figured they were Aiden's friends, though if I ever caught my daughter dressing like that I would immediately tell her to GO GET DRESSED.  Neither of them had shown up overnight when, you know, their loved one was shot, because they were too busy "at the club", they told me.

I was somewhat stunned to find out that one of the girls was Aiden's teenage sister.

I was even more stunned to discover that the other one was his mother.

Aiden had been shot while he was out partying on a school night.  His mother did not know this (and I had to inform her of it) because she had been out partying (at a different party, of course) with his sister.  Now do not misunderstand me - I am not saying that that 16-year-olds should be confined to their bedrooms and not allowed to go out.  What I am saying is that Aiden's mother had no fucking clue where he was, what he was doing, and who he was doing it with, and the reason for that was because she was too busy dressing up like a prostitute and getting drunk.

Actually I take that back - I've seen prostitutes better dressed than these two.

Am I being overly judgmental here?  Perhaps.  But keep in mind I'm not judging his mother based on how she was dressed, but rather on her actions: 1) not knowing what her young son was doing, and 2) getting high and drunk while not knowing what her young son was doing.  And to be fair, Aiden was the one who put himself in the situation that got him shot.  That was his doing, not his mother's.  But overall it was a glaring circumstance of irresponsibility at its very worst by everyone involved, and Aiden almost lost his leg because of it.

Yes, almost.  Fortunately Aiden's nerve decided to start healing, and by the time he left the hospital he was starting to move his toes and had some sensation back.

Perhaps my perspective will change when my children get older, but my actions will not.  I will continue to be there for them, and whether they like it or not I will know where they are and who they are with at all times.  I have friends and neighbours who have older children, so I know this is not only possible, but eminently doable.  There will be times when they screw up, I know that.  There will continue to be times when I am too strict and yell too much.  But there will not be times when I screw up and ignore being a parent.

They are far too important for that.

Monday, 12 September 2016

Fool me once

I don't know if Albert Einstein actually said that or not, but goddammit it's a good fucking quote.  And because Einstein is one of the most universally praised people in the history of mankind, I'm going to run with it, because maybe that will make me look better and smarter by association.

Probably not.

Just in case that first quote isn't clich├ęd enough, here's another:
That one is attributed to Anthony Weldon in The Court and Character of King James all the way back in 1650, though some people seem to think it was coined by anti-abortion activist Randall Terry (who was only born in 1959).  Really, people?  The adage is centuries old!

Anyway, I can't really decide which one is more pertinent for this story, so I'll go with both of them.  

I'm a cat guy.  Yes, I love cats.  I like dogs too, but I don't own one and never have.  I don't have a cat either because . . .

"Whoa whoa, wait just one goddamned second.  What the fuck are you smoking?  You're going from Einstein to Anthony Weldon to your preference of pets?  Do you not understand segues??"

SIT DOWN AND SHUT UP.  It will make sense in a moment if you'd give me a chance, for fuck's sake.

As I was saying, I would have at least one cat (probably two) if Mrs. Bastard weren't horribly allergic.  And while I do like cats, I like Mrs. Bastard a hell of a lot more.  After all, unlike Mrs. Bastard, cats can't make lasagna (much to Garfield's dismay).

Lasagna aside, as much as I like cats I understand that they bite sometimes.  When they get scared or startled or just decide to act like an asshole, they can release their inner lion and pounce.  I wouldn't get rid of a cat just because it bit me once, but if it was a constant problem, the cat would go.  Fool me twice, etc etc.  Sorry Hypothetical Cat, but I like my intact epidermis more than any tiny adorable feline.

House cats are quite small, and while their bites hurt, I've never heard of anyone getting seriously mauled by a cat.  Dogs are another story altogether.  Dogs can do real damage with their teeth, as several of my patients (and their various savaged body parts) can attest.  If a pet dog bit me unprovoked, the dog would be evicted.  End of story.

Terrence's Wife (not her real name™) obviously had no such policy.

Terrence was in his late 60s and had suffered a series of strokes over the past decade, leaving him paralysed with no sensation on the right side of his body and essentially bed-bound.  He lived with his wife (who took care of him and cooked for him), and his Jack Russell terrier, who ate him.

Before I go on, read that last sentence back.  No, that was not a typo.

I'll explain.

A few weeks back Terrence was brought to our hospital after his dog ate his toe.  Once again, in case you missed that little nugget, I'm going to say it again: The dog ate his toe.  When he was brought in, the great toe on his right foot was missing.  It was gone.  Just . . . gone.  The podiatrist tried his best to piece what remained back together, but dogs' mouths aren't known for being clean, and as expected the wound got infected.  After a lengthy stay in hospital, he was sent home on antibiotics.

And that's where we pick up Terrence's saga.

His wife woke up on this fateful morning and noticed something . . . odd.  She saw . . . wait wait wait, I can't say it any better than she did.  She said, and this is a direct quote without any paraphrasing whatsoever, "Well, he had toes when we went to bed last night!"

We looked at his foot, and the toes were gone.  All of them.  Gone.  GONE.  In case you don't believe me, here are Terrence's X-rays:

Notice anything missing?  On the off chance you aren't a radiologist, here is a normal foot. 
See those little toe-shaped things on the end where toes should be that look just like toes?  Those are toes.  

Terrence didn't have any.

When the medics first arrived on the scene, they had no idea what had happened to Terrence, nor did Terrence or his wife.  Somehow.  They were throwing around the idea that he had been attacked by an intruder.  Why they would believe that an intruder would break in, not steal anything, and then gnaw off his toes, I have no idea.  I wish I could have heard the conversation, but in my mind it went something like this:

Wife: Where are his toes?
Medic 1: Oh em gee your right! {yes, in my mind he misused "your"}  Where are his toes?
Medic 2: Maybe someone broke in and cut them off?
Medic 1: If they did, they used an old dull butter knife.
Wife: But they didn't steal anything!
Medic 2: Oh wait, there are his toes.

That was the point in the conversation when the dog bounded into the room and vomited up the toes onto the floor.  Lest you think my creativity is getting the better of me, unlike the fabricated conversation above, I am not making this part up: the dog actually truly and veritably vomited Terrence's toes.

The same dog that had eaten his toe a few weeks before . . . spent the night eating the rest of them.  And then vomited them onto the floor.

I can only imagine the stunned silence in the room.

I called the same podiatrist back, and he once again tried to piece what was left of Terrence's foot back together.  All the king's horses and all the king's men, you know.  

I'm sure the burning question in everyone's mind is: How quickly did they kill the cursed man-eating dog and get rid of its body?  Well, as of the last time I spoke to Terrence's wife, the dog was still alive and well and living at Terrence's house.  And eagerly awaiting his return, no doubt.  I mean, the poor dog must be hungry.  Am I right?  Hello?  Is this on?

So that leaves me with one final lingering question: What the hell do people say about "Fool me thrice"?