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: 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

Parents

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.

Sigh.

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.

No.

I asked him to move his toes.

Nothing.

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"?

Monday, 5 September 2016

Prayer

"Keep praying."
"I'll pray for you."
"It's in God's hands now." 
"Have faith."
These words are probably uttered millions of times a day in hospitals all around the world.  I've overheard them countless times from family members, friends, nurses, techs, and my fellow doctors.  On first glance they certainly seem innocuous enough - they appear to be uplifting, caring, and supportive, right?

I, on the other hand, tend not to put much faith in faith, so I don't use such language.  To me prayer accomplishes the exact same thing in medicine as putting a banana in your ear - absolutely nothing.

I'm sure there are some religious folks out there reading this with steam coming out of their ears, and to you I merely say "Have faith".  I'll guarantee I will explain my position in due time.  I will not, however, guarantee that you will agree with me.

Now that I think about it, I've changed my mind.  I'll let Adriana (not her real name™) explain.  After reading one of my recent blog posts, her aggravation at the recent shoddy treatment of doctors in the media was reignited.  Because of recent events in her family, she was keenly aware that sometimes when doctors tell family members that their loved one is dead or dying, we are seen as heartless cretins with no soul, no compassion, no empathy.  We are seen as insensitive and unkind. . . for telling the truth.

This reminded me of a cartoon I've seen several times:
Cartoon by Clay Bennett
People in difficult situations don't want to hear the difficult truth - they want to hear something that makes them feel better, even if it isn't completely true.  So friends and family members tell them things to try to make them feel better - to have faith and pray.

But what does that really mean?  Does it help?  No, I'm not asking if prayer helps the patient get better (it doesn't), I'm asking if it helps the grieving family.

Adriana certainly doesn't seem to think so.
Please forgive the writing format and any spelling errors.  I am on autopilot right now.  My husband's grandmother has been in the hospital for a month now, and her husband has finally reached the point of admitting she is not going to get better.  She is unable to communicate and has a trach {a surgical breathing tube}, breathing machine and all the rest of the equipment that is keeping her alive.  We have learned about palliative and hospice care.  I have watched my almost 12-year-old cry and ask why bad things happen to her great grandparents around her even numbered birthdays.  Our 8-year-old just clams up and screams once in a while how much she hates what is happening and when is her Nanny coming home.  They can't see her anymore because it is too traumatic now.  My husband has just started college and he is trying to focus on his classes in the middle of trying to keep our kids and his mom (she is an only child) together during this hellish time.  It looks like this is the last weekend of being in limbo because her husband has finally decided to let her go peacefully and stop holding on to his unicorns and rainbows about the situation. 
The one thing that I can't seem to act properly about is when people keep telling us to pray for a miracle and that God always listens to His people.  We have faith.  We also understand that it is up to God on if we get that miracle.  I guess we didn't fill out the proper request chit because that miracle isn't going to happen and I really want to throat punch the next well-meaning person who tells us to keep praying and have faith.   
Share this if you want to and feel free to fix this up to make it look like it was written by someone who has their act together with the name removed please.  People need to stop telling us and anyone else to keep praying and having faith for a miracle.  They are just making it worse on all of us.  We keep a straight face, but we really want to slap the ignorant out of you guys when we hear that and have to tell you we are losing her and it seems to be God's plan.  We are not mad at God, but this hurts like hell already and making us feel like we just don't have enough faith to override what is happening dumps more crap on us.
I think that sums it up.  Telling someone to keep praying will never help, for several reasons:
  1. Prayer will not help someone get better.
  2. Telling someone who is not religious to pray will not make them feel better.
  3. Telling someone who is religious to pray will not make them feel better, because they already know that they are supposed to pray, and it implies that they are just not praying hard enough.
Will this change any minds?  I seriously doubt it.  By definition those with faith take everything, well, on faith,  But perhaps you'll at least think twice next time you tell someone to pray.

I have faith that you will.

Friday, 26 August 2016

Bad journalism

I'm not a writer.  I dabble a bit here and there and I've even gotten paid for it a few times (Thanks, Daily Beast!), but I don't really pretend to be a writer.  That said, I'm certainly not a journalist.  I don't pretend to be one of them either, so I can't really say I understand the ethics of journalism per se.  I do understand ethics in general, however, so I believe I can definitively say that journalists should report the truth.

That doesn't always happen.

Take the coverage on little Israel Stinson, for example.  In case you haven't been following this very sad case, Israel was a 2-year old boy in California who had an asthma attack nearly five months ago at the beginning of April.  He was initially taken to a hospital and stabilised, then he was moved to the paediatric intensive care at another hospital where he unfortunately suffered cardiac arrest.  After extensive testing he was pronounced brain dead, but he was still moved to yet another hospital for further evaluation.  Two more doctors at the third hospital performed brain death evaluations and again pronounced him brain dead.  Plans were made to remove him from life support.

Ah ah ah, not so fast.

Israel's parents refused to accept the diagnosis, and after much legal wrangling and online fundraising they were able to airlift him to Guatemala where he had feeding and breathing tubes placed.  According to Israel's parents, a paediatric neurologist in Guatemala saw "some brain activity" on an EEG (I have seen no corroborating evidence from any doctor or any report), which supposedly showed that he was not brain dead.  Then about two weeks ago he was transferred back to California, this time to Children's Hospital Los Angeles, with hopes that his parents, Jonee Fonseca and Nate Stinson, could eventually care for him at home.  They got a restraining order preventing the hospital from doing any more brain death studies, presumably because they were afraid of the results - that he was still brain dead.

And as has always been the case in brain death in the entirety of human history, Israel's brain death was not reversible.  A California judge lifted the restraining order yesterday, and as soon as Israel was taken off somatic support, he stopped breathing.  Exactly as would be expected in a brain dead patient.

As a parent (and as a doctor) it upsets me viscerally me that this little boy was kept in limbo for so long because his parents (like those of Jahi McMath) refused to accept that their son was gone, but what exasperates me even more is the way the press has covered it:


+
You get the idea.  The verbiage is strikingly similar, and it is similarly misleading.  No, Israel did NOT die after being removed from life support.  Israel died nearly five months ago when his heart stopped and his brain was deprived of oxygen for 40 minutes.  But it is much more sensational to report that a toddler died after being removed from life support, because it implies the hospital was doing something wrong.

The headlines are misleading enough, but the articles are infuriating - the implications turn into downright accusations.

The most egregious was from Fox 40, a news station based in Sacramento (where, probably not coincidentally, Israel was first declared brain dead at UC Davis).  I can not even sum up the stupidity here, so I will let their own words damn them as the article opens:
A Vacaville 2-year-old is dead, not because of the severe respiratory illness that stole his vibrancy along with his breath last April, but because of the heartless action by a hospital in the midst of an appeal, according to his loved ones and his lawyers.
I can't even.  I want to even, but I can't.  This is how this ridiculous article starts, but if you can believe it, it gets even worse.

"This is a sad, sad state because this is an execution of an innocent 2-year-old in this country. This child was alive and this child was not brain dead," said Attorney Kevin Snider. 
An execution, Snider says, carried out by Children's Hospital of Los Angeles on his client Baby Israel Stinson. 
"Unfortunately the courts and the medical community wanted to rush in and pull the plug on him to be crass," he said. 
Are these people fucking serious?  Sure some doctors (surgeons, mainly) seem to enjoy being crass, but do they really think that doctors are in the business of killing toddlers?  Even putting aside the ridiculous bullshit from the lawyer, is there any such thing as journalistic integrity with these writers?  If there is, I completely missed it.  How could they possibly include that insane quote?  An execution?  Really??

Despite this, Fox 40 made absolutely no effort to show the other side of the issue - that three different doctors at two separate hospitals had all performed independent brain death studies, and all had found the same thing - that he was brain dead.  There was no mention that the EEG is not a definitive study for brain death and that there had been no confirmation of the supposed "brain activity".  There was no comment whatsoever that Israel had been completely unresponsive and had not opened his eyes since his cardiac arrest.  Nothing.  Zero.  Nil.  And of course because of privacy laws in the United States, the hospital was unable to comment on the entire affair and defend their entirely defensible actions.

KCRA, another news station from Sacramento (surprise, surprise) included the insane "execution" quote from Kevin Snider but took it even further:
"This was an execution of an innocent 2-year-old by the authority of California,” Snider said. “Had this child been a murderer or a terrorist, he would have had far more appellate rights by our courts than he was given.”
Wha . . . what . . . WHAT?  Are you . . . WHAT??  This child was given nearly five months to get better.  He didn't.  He was declared dead by three different doctors, and this clown calls this an execution?  Hyperbole does not even begin to describe this putrid cesspool of flapdoodle.  But KCRA doubles down with more Snider claptrap at the end of the article:
"Though society has produced medical geniuses, it also has not produced with people with a high moral IQ in the medical field sadly," Snider said.
I don't believe any more needs to be said about that.  I nearly screamed when I read it, and I was tempted to throw my computer across the room when I typed it.  It just speaks for itself.

And to put a little cherry on top, Israel's parents are reportedly planning on suing Children's Hospital LA, because of course.

Sigh . . .

My final thoughts on Israel's saga is that he is finally at rest.  Finally.  I hope Jonee Fonseca and Nate Stinson will eventually feel some sense of closure.  Israel had been gone for a long time, and his continued presence in a hospital bed was only causing his family undue grief.

I honestly and truly wish them peace.

Monday, 22 August 2016

Advice

Getting advice seems to be a problem from the moment we are born.  Well, not so much getting advice, but listening to it.  Parents warn their children not to run with scissors, put on a jacket, wash their hands, and STOP HITTING YOUR BROTHER.  As children get older, the advice gets more serious: look both ways crossing the street, drive slower, STOP HITTING YOUR BROTHER (that one never seems to change).  This advice seems pretty self-explanatory, though children always seem to argue about it.  But other things we tell children need to be explained: why it's stupid to smoke, why it's necessary to put on your seat belt, why you should STOP HITTING YOUR BROTHER.  And then there is some advice that just shouldn't need to be given.  It is so easy to understand and so damned obvious that it shouldn't even need to be mentioned.

Like "Don't put things in your butt."

Since I just mentioned it, it clearly needed to be mentioned.  To Jack (not his real name™) in particular.

Now before I continue, yes this is another rectal foreign object story, and yes I just posted one a couple of weeks ago.  But this one is just Too. Damned. Good.  So here it is for your reading pleasure and distinct anal discomfort.

My RFO patients have thus far all been men, and Jack was no exception.  What makes him slightly different is his age.  All of the other men in whose rectums I've spelunked have been in their late 30s or early 40s.  In other words, old enough to know better than stick something (Coke bottle, butt plug, dildo, etc) in their asses.  Jack, on the other hand, was in his late 60s.  So WAAAAAY old enough to know better than to stick something in his ass.

Jack came in around midnight complaining of, you guessed it, a pain in his ass.  Apparently he wasn't satisfied with the variety of toys available at his local sex shop, so he decided to make his own.  Now a quick perusal of Google will reveal a wide variety of do-it-yourself sex toy kits.  Yes, I checked.  For science, really.  These evidently were also not good enough for Jack and his, uh, needs.  No, instead of some commercially available silicone toy kit, he decided wax would be better.

Vanilla-scented wax, to be precise.

I walked into Jack's room to see an elderly-looking man in Standard RFO Position - somewhat on his side with a grimace on his face.  I decided not to beat around the bush.

Me: OK, what did you put in there?
Jack: *grunt* It's a candle.
Me: . . .
Jack: *grunt*
Me: And why did you . . . Ugh, never mind.  How long has it been in there?
Jack: *grunt* Two . . .
Me: Oh, just two hours?
Jack: . . . days.

Yes indeed, Jack had melted down a vanilla-scented candle, molded it into an apparently pleasing shape, and inserted it into his rectum.  Two fucking days ago.  He had been trying in vain (obviously) to remove it manually.  He had tried an enema.  He had tried stool softeners.  But last I checked, none of those things can melt wax.

The object was easily palpable in his rectum, but it felt fucking huge.  There was nothing for me to grasp, no way for me to remove it easily.  So off to the operating theatre we went.

Once he was asleep I could do a more thorough exam.  Unfortunately the exam was exactly the same.  It still would not come out.  Most foreign objects can be grasped with some special graspers and will slide back out the way it went in.  But not this goddamned thing.  There was no lip, no flap, no anything on which to gain any purchase.

So I did the next best thing: I crushed it.  That is not hyperbole or exaggeration - I literally put the grasper in his rectum and closed the jaws around the thing, crushing whatever part of it I could into bits.  I then removed those bits and went at it again.

The next 20 minutes of my life consisted of breaking off another small piece and removing it (along with some of the plastic wrapper which he had not bothered to remove), all the while taking care not to grab any portion of his rectum (that would be considered bad, as you can imagine).  Finally it was small enough to remove the remainder, and everyone in the room breathed a large sigh of relief.  I think I even audibly grunted in Jack's place when it came out.

The next morning Jack felt much better.  I gave him his discharge instructions, as well as what he could expect over the next several days.  And predictably I also gave him a bit of advice that should never actually need to be spoken aloud:

1) Don't EVER stick anything into your rectum ever again.
2) If you decide to ignore #1, don't wait two days to seek help when you can't get it out.

Tuesday, 16 August 2016

Learning

I love to learn.  When I was a child I had to read books or *gasp* listen to my teachers.  But nowadays the entirety of human knowledge is contained on a tiny device I keep in my pocket, and any information I could possibly want is simply a finger tap away (Hmm, why did Nicolas Cage change his name from Nicolas Coppola?).  My mantra in life is "Any day you learn something new is not a wasted day."


Well, that's only partly true.  My real mantra is "Don't be fucking stupid", but that doesn't look quite as nice on a picture:

Actually I take that back.  I think it looks pretty damned spiffy.

Anyway, learning is one of the few true joys in life.  There are so many things to learn about, so many topics, so many funny cat videos on YouTube.  One of the best things about medicine (and surgery in particular) is that there are always new things to learn.  New drugs are discovered, new surgical techniques are perfected, new diseases are described, and new treatments are devised to conquer it.

And people discover new ways to act fucking stupid.

When I was a child I thought Russian Roulette was a "game" played only in movies like The Deer Hunter.  But no, it turns out that there are some people stupid enough to have played (and lost) in real life.  And I found out recently that despite the horrendous stupidity that must by definition be inherent in the game, there are still people fucking stupid enough to play it.

Like Tracy (not her real name™).

This should not be a difficult concept to grasp for anyone with more than two brain cells to rub together, but pulling the trigger of a loaded revolver may result in a projectile coming out of the business end very fast.  Even if the gun only has one bullet in it, there is still at 16.67% chance that dangerous things will happen.  That's a phenomenon that is generally regarded as bad, especially when the gun is being pointed at something important, like, for example, a person's head.  Apparently Tracy and her friends weren't aware of the concept, because they all decided to play while "partying". 

Nevertheless, somehow nobody lost.  Perhaps the gun wasn't actually loaded, or perhaps they all got very lucky.  Regardless, the game ended, and no one ended up with a bullet-sized hole in his or her cranium.  But the luck would run out a short while later when the game changed from Russian Roulette to Russian Poker.

I had never heard of Russian Poker before, but apparently instead of pointing the gun at your own head, you point it at someone else.  In other words, stupid goes to stupider.

If you can't hear that foreboding foreshadowing music, then you aren't paying close enough attention.

Tracy was clearly sick when she rolled through the trauma bay doors just before noon.  Not sick like *cough cough* but sick as in I'm About To Die, Please Help Me.  

"Hey there Doc, this here is Tracy.  She's 16, shot once in the lower abdomen.  I can't see any other wounds.  Her heart rate is around 120, blood pressure is about 90."

My Inner Pessimist started yelling at me, "Move faster, dummy!"  I already was moving fast, goddammit.  My Inner Pessimist can be a bit of a dick sometimes.

She was sweaty and had that glazed Don't let me die look in her eyes.  We stripped her clothes off quickly, and the medics were right - a single gunshot wound to the left lower abdomen near the pelvis.  We turned her on her side to examine her back, which superficially looked normal.  I then parted her buttocks (while the medics gaped) and found the other gunshot wound on the left butt cheek.  (Note to all future trauma surgeons out there - ALWAYS LOOK BETWEEN THE BUTT CHEEKS.)

My Inner Pessimist started yelling louder.

Take two fingers and put one on your left lower abdomen beside and below your hip bone and one on your left butt cheek.  Don't worry, go ahead - no one is watching.  Good.  Now imagine a line between those two fingers.  There are a lot of very important structures there - small intestine, colon, iliac artery, iliac vein, ureter, possibly even the bladder.  A hole in any of them could be bad, but an injury to the iliac artery can easily cause fatal bleeding.

She needed to be in the operating theatre - NOW.

Ten minutes later we had her in the theatre where we first put in a bladder catheter, and her urine was clear yellow - good, the chance of a ureter or bladder injury was fairly low (though still not zero).  Five minutes after that I had my hands inside her abdomen.  There was a fair amount of blood, but no catastrophic bleeding.  Inner Pessimist quieted down somewhat as I breathed a brief sigh of relief and quickly examined her colon and found it to be normal (another happy surprise).  My Inner Pessimist finally stopped yelling as I ran her small bowel and found one small bullet hole, which I stitched closed.  I found the entry and exit wounds in the left lower abdomen/pelvis, and the bullet had missed the iliac vessels by less than 1 cm.  It had also missed the sigmoid colon by 1 cm, the bladder by 2 cm, and the ureter by 1 cm.

Now that is lucky.

A few days later as she was recovering she told me the story of how she got shot, including the game of Russian Poker that she had evidently lost.  "I didn't even know they had guns when I went to the party," she told me.  Yet that apparently didn't stop her from participating.  Any reasonable person would, oh I don't know, LEAVE.  

But fortunately being a surgeon means constantly learning, and if there is one thing this episode taught me, it was to update my mantra: