Tuesday, 4 September 2018

A tale of two patients

It's been over two months since I wrote anything, which is by far the longest interregnum I've ever taken.  And by "interregnum" I mean "I've been too goddamned lazy and/or distracted to sit down at my computer and get some writing done".  Sure, I've seen many blog-worthy patients in the past 8 weeks, but I've just had some trouble framing them into what I thought would be an interesting story.

Until now.

I'd like to present a pair of patients whom I admitted on the same date just a few hours apart.  Both were seriously injured and both spent considerable time with me recovering.  But I found the differences between the two rather startling.  So for this post I've decided to do something a little bit different and see who can spot the differences.

Ready?

Let's begin.

Patient 1: Ivan (not his real name™) was the victim of a hit-and-run pedestrian accident.  He was walking home from work when a car struck him at high velocity.  He suffered a complex fracture of his left tibial plateau, a right humerus fracture, an open right ankle fracture, several broken ribs, and a ruptured urinary bladder.  I performed an exploratory laparotomy and repair of his bladder laceration, and an orthopædic surgeon performed a surgery for his humerus, two surgeries for his right ankle, and 3 surgeries for his left knee (so far).  He had an external fixator on his left knee for several weeks while his œdema improved before his final two surgeries, he had an uncomfortable urinary catheter in his penis for several weeks while his bladder healed, and he was unable to bear any weight on his right (dominant) arm and both legs for 2 months.  In short: he was broken.

Patient 2: Tera (not her real name™) was driving her car down a dark road at night with a blood alcohol level over twice the legal limit when she went off the road and struck a tree.  In the process she fractured her left acetabulum (the socket of the hip) and a bone in her right hand.  She required one surgery on her left hip and was unable to bear weight on her left leg for 6 weeks (no surgery was required for the right hand).  In short: she was mostly fine.

Every day that I went to see Ivan, he was kind, respectful, and polite despite his multiple injuries and significant pain.  "Thank you, doctor" was his closing statement each morning as I walked out of his room.  Even though I had cut him open and inserted a large, uncomfortable tube into his penis, he thanked me.

On the other hand, every day that I went to see Tera, she had nothing but complaints.  The nurse took too long to get my medicine (20 minutes), the nurse took too long cleaning me up (15 minutes), it's too hot (it wasn't), my leg is swollen (it's broken, of course it is), my splint on my hand is too tight (it wasn't), it took too long getting back from getting X-rays (30 minutes), no one is telling me what's going on (yes I was), I want to be transferred to another hospital.

Anyone see the difference yet?

I sure did.  As I walked from one room to the other day after day, the difference in their attitudes astounded me.

Tera (who you will remember caused her own injuries by driving drunk) did nothing but complain.  She even refused physical therapy on multiple successive days because of pain despite the fact that it was the only thing keeping her in hospital.  I wanted to suggest to her nicely (read: scream in her face) that she had a team of people whose entire job was to take care of her so she could try showing some basic gratitude, but I didn't.  No, I just listened.  Standing there and listening to her many grievances was a far, far better thing that I did than I had ever done.  And yet she never once said "Thank you".  She showed no appreciation or gratitude at any time before I finally was able to send her to rehab.

Ivan, on the other hand, who was much more severely injured through no fault of his own, who was completely unable to walk, who had a catheter hanging out of his penis, who had three broken limbs, and who had a huge incision on his abdomen, was still able to smile and cooperate and participate with his own care.  No matter what was asked of him, no matter how much pain he was in, Ivan simply gave a weak smile, said "Ok", and then did it (or at least tried).

Look, I understand that no one wants to be in the hospital.  My patients are in pain and I'm asking them to get out of bed and walk.  I get that.  But all I ask for is a little civility and a little gratitude.  Trust me, I don't want to be seeing your obnoxious drunk ass in the trauma bay at 2 AM either or repairing your bladder at midnight, but here we both are.  So let's try our damnedest to make the worst of times into the best of times.

Friday, 29 June 2018

Finally over

It's over.  After nearly 5 years, the Jahi McMath saga is finally over.

Almost.

If you aren't aware of the Jahi McMath story, then you obviously have not been reading this blog very carefully, because I have written about her rather extensively, first here, then here, here, here, here, here, here, and most recently here.  The short version is that Jahi was a 13-year-old girl who underwent a series of upper airway procedures for sleep apnoea in December 2013 which was complicated by bleeding, cardiac arrest, anoxic brain injury, and brain death.  Jahi's family refused to accept the diagnosis, and thus began a battle between Jahi's mother, Nailah Winkfield, and Children's Hospital Oakland over whether Jahi was really brain dead (she was) and what should have been done with her (nothing).

Eventually Nailah and CHO came to an agreement that Jahi would be released from the hospital to her mother's care, and after moving from California to New Jersey (one of only two states where brain death can be refused on religious grounds), Jahi has remained on a ventilator, completely unresponsive, still brain dead, at a private apartment.

Over the ensuing years there was a report that she had started menstruating, despite evidence to the contrary that she had already had her first period prior to surgery.  There was a video supposedly showing her breathing over her ventilator, despite the fact that in April while she was in hospital she never did.  There were videos released by the family purportedly showing Jahi moving her finger or a foot to voice commands despite radiologic evidence that her cerebral audio pathways were completely destroyed and she had no anatomic mechanism by which that could be possible.  A neurologist rather ludicrously claimed, based solely on these videos, that Jahi was not brain dead, but rather severely disabled.  Despite these claims, Jahi never woke up, never opened her eyes, never showed any sign of life other than a beating heart.

Ever since this adventure began, I've been rather adamantly averring that Jahi was dead and that delaying her burial was unethical and nothing short of cruel to her and her siblings.  There have been a multitude of deniers, people full of hope and wishes and thoughts and prayers, that claimed Jahi would wake up.  Through it all I have continued to maintain that brain dead is dead, that Jahi would never wake up, that no one in human history who was properly diagnosed as brain dead had ever recovered from it, even a little bit.  While that may on the surface seem callous and uncaring, it is in fact quite the opposite.

And though sometimes I don't want to be right, I was right.

On June 22, 2018, over 4 1/2 years after she lost her life, Jahi finished passing on.  For the sake of simplicity, I will refer to this event as her death, even though she actually died on December 9, 2013 and was declared dead on December 12, 2013.  I have known about her final death since it happened, but I decided not to write about it until it was reported in the news out of respect for her family and what they are going through. 

Jahi had been hospitalised several times for various issues, including January and April of this year for some kind of undisclosed "intestinal issue".  I suspect it was intestinal ischaemia (decreased blood flow to the gut), though I cannot confirm this.  She was treated with antibiotics both of those times, and the surgeons seemed unwilling to operate on her.  Finally in early June she was taken to surgery, where they apparently found nothing grossly wrong.  Nailah and her supporters of course declared this as some kind of miracle.  I, on the other hand, knew that it was simply the beginning of the end. 

Jahi started a slow but steady decline since then, including renal failure and lactic acidosis, culminating in disseminated intravascular coagulation, multi-system organ failure, and fulminant liver failure causing uncontrollable bleeding.  She was apparently brought back to the operating theatre for "one last look" on June 22, got back to the intensive care unit, promptly coded, and died.  Again.

It's finally over.

I suspect Nialah will continue her legal battle against CHO, though I would be shocked if CHO doesn't immediately settle the wrongful death lawsuit out of court just to get it over and done.  But Nailah plans to pursue a federal civil rights lawsuit to get the date of death on the death certificate changed from December 12, 2013 to June 22, 2018.  I haven't a clue what she thinks that would accomplish nor how much time and effort this would take away from her caring for her three other children.

I don't know details of Jahi's various illnesses or operations, nor can I divulge how I know this information, nor is that in any way important.  What is important is that Jahi can finally be laid to rest after being abused for so many years.  And her siblings can finally move on with their lives.  And I can finally stop writing about this case. 

Until the next one comes along.

NOTE: I realise it has been over a month since I have written anything here, and for that I apologise.  It isn't that I haven't had any interesting cases, because I have.  However, it has become increasingly difficult to frame my stories in a way that I have not before, and I don't want to risk becoming boring and/or repetitive.

Wednesday, 23 May 2018

Likely story

I read a little story on the internet some time back (and because it was on the internet, it simply must be true) about a young man who was brought to the trauma bay (not mine) after being shot, and though he definitely looked like he was up to no good, he claimed he was shot while waiting for his grandmother to pick him up to take him to church.  No one in the trauma bay believes his ludicrous story, of course, until Grandma shows up a short while later in her Sunday Best, looking for her grandson to take him to church.

We often joke about what nefarious deeds our trauma patients have been perpetrating immediately preceding their injuries, and I have no idea if that vignette is true, but whether you believe it or not, it makes for a great fucking story.  This story is kind of like that.

Not really.

Mondays are supposed to be slow, easy trauma days.  After all, the Call Gods should be exhausted after harassing the unlucky weekend trauma surgeons for 72 straight hours (Friday counts as a weekday in the Call God Calendar for some damned reason), but this Monday was most definitely not easy.  The chaos started exactly 2 minutes after I walked through the door (fall), and it continued with a new fall or car accident or motorcycle crash every 30 minutes or so for the next 10 hours.  For a while it appeared that I would break my personal record for trauma patients in one shift, but finally right around dinner time it slowed down, giving me just enough time to shovel a cold hamburger (leftover from lunch) into my face before my pager started screaming again:

level 1 GSW 5 minutes

God damn it.

Exactly 12 minutes later (damned rush hour) Ryan (not his real name™) rolled through the door.  Screaming.

Sigh.

"Hi Doc, this is Ryan.  19 years old.  We've found 3 gunshot wounds - one to the right upper chest, looks like an exit wound in the right upper back, and one in the right hand.  Vitals stable, decreased breath sounds on the right.  Got two large bore IV's in his AC's."

"AH GOD DAMN MY HAND DAMN GOD DAMN"

I knew at once Ryan and I would get along swimmingly.

On my initial assessment, his breath sounds sounded clear and equal to me (I don't know how the hell the medics hear anything in those ambulances with the sirens wailing), so I doubted he had a pneumothorax (collapsed lung).  He indeed had a gunshot wound to the anterior right shoulder and a corresponding wound (entry? exit?) in the back of the shoulder.  Fortunately he was moving his shoulder and arm perfectly and had a bounding radial pulse, so I seriously doubted the bullet hit his humeral head or the neurovascular supply to the arm (which is much closer to the armpit).  His hand, on the other hand (har har har) was Seriously Fucked Up.

X-rays confirmed that he had no injury to the bones of the shoulder and no pneumothorax, but what he did have were several broken bones and lacerated tendons in his hand.  As I was consulting the hand specialist, I overheard Ryan giving his story to the police:

"I was sitting in my kitchen eating dinner when I heard a bunch of shots outside, and I guess a couple of them hit me."

Yeah, sure you were, Ryan.  I wonder if they actually expect anyone to believe this bullshit story.

After I patched Ryan up temporarily until the hand specialist could come in, I went back to reassess the last 172 traumas (or so it seemed) who had come in that day, suture up some lacerations, and discharge a few who had managed to sober up.  About 3 hours later I was finally nearly caught up when my pager went off again:

level 1 GSW 7 minutes

GOD DAMN IT.  IT IS FUCKING MONDAY, CALL GODS!

We cleared the trauma bay and readied ourselves for the next young man who was about to arrive.  Or at least we thought we did.

The 67-year-old woman who rolled through the door was not what we were expecting.  Nor did she really look like she had been shot.

"Hey Doc, this is Doris (not her real name™).  She was sitting in her kitchen eating dinner with her grandson a few hours ago when a bunch of bullets came through the window.  I think her grandson was brought here earlier, wasn't he?  Anyway, she has one gunshot wound to the left buttock.  No exit wound.  Bleeding is controlled."

Uh . . .

Ahem.  Hm.

I assessed Doris while eating some serious crow, and all I found was a single wound with the bullet retained in her rather voluminous left buttock.  A CT scan confirmed no serious injuries, and a short while later she was walking upstairs to visit her grandson.  I, on the other hand, had several days of making rounds on Ryan and Doris (who was always there visiting) to remind me just how stupid and wrong my stupid and wrong preconceived notions usually are.

If you're wondering about the three hour delay, Doris initially decided to forgo medical treatment when the medics arrived to pick up Ryan because, as she explained it, her wound wasn't really bleeding, she was walking normally, and she thought a few paper towels would do the trick.  And she was probably right.

Anyway, I guess this story proves once again what happens when you make an assumption: it makes an ass out of you and umption.  Or something.  Whatever, I just need to get some goddamned sleep.  Fuck you, Call Gods.

Tuesday, 8 May 2018

The Resident, part 2

I can't remember if I promised I would never watch an episode of The Resident ever again, but if I did, I am officially rescinding that promise.  Don't worry, it's for a very good reason.

If you have no idea what "The Resident" is, I urge you to click here and read this.  In short, it is a very terrible TV show written by a very terrible writer about very terrible doctors doing very terrible things.  I got into a bit of a feud with the show's creator and writer, Amy Holden Jones (which is detailed in the post linked above), regarding the blatant and rampant anti-doctor rhetoric that suffuses the entire first episode.  As bad as the pilot was, I told myself I would never watch another episode.

Until now.

Amy seemed to take great offence at my twitter profile picture (if you're not familiar with it, it's right over there).  She seemed to think it was an example of patient shaming and that its use would somehow prevent people who inserted a foreign object into their rectums from seeking medical care.  I have no idea if Ms. Holden has ever had any foreign objects impacted in her rectum, but in my experience with many patients who have, they do not tend to wait long, nor do they allow profile pictures from anonymous trauma surgeons on the internet from finding someone to remove the offending object as quickly as fucking possible.

But I digress.

During my little tiff with Amy a few months ago, she threatened to write an episode of her soap opera that related to shaming of rectal foreign object patients and/or an incompetent trauma surgeon (unfortunately I believe that was in a series of tweets which have since been deleted or which I otherwise cannot find).  I laughed it off at the time.

And I'm still laughing it off, because she did.

Dr. Mark Hoofnagle is a general surgeon in Philadelphia, and he has taken it upon himself to fall on his sword and watch The Resident each week, live tweeting as he does.  It is a very amusing take on the show, and it has also gotten him blocked on Twitter by Ms. Holden.  According to Dr. Hoofnagle's assessment, his past week's episode appears to feature, well, me.  Or at least a very poorly done spoof of someone like me:
Of course I had to check this out.

Literally 14 seconds into the "Previously, on The Resident" recap, someone says "York, what did you shove up your rectum this time, and this flashes on the screen:
Hmmmmmmm.  Does this look familiar?  No, I can't possibly be seeing what I think I'm seeing.  I'm sure this is just an unfortunate coincidence, right?  Let's move on.

On second thought, let's temper my torture (and yours) and move way on.  In fact, let's skip all the regular soap opera bullshit and just get to the scenes in question.

A woman is struck by an ambulance and brought to the trauma bay, and the trauma surgeon, Dr. Nolan, somehow diagnoses a ruptured diaphragm from a pelvis X-ray.  I'm trying my best to ignore the pseudo-medical bullshit, so I'll simply say that while this is a major injury, we see this regularly and repair them routinely.  Dr. Nolan, however, appears confused by the diaphragm rupture, so instead of, you know, fixing it like a trauma surgeon, he calls in Dr. Austin, a cardiothoracic surgeon, to do it.  "He'll probably . . . save her life", he says.

Wait, what??

During the surgery, the trauma surgeon stands on the opposite side of the room looking at the monitor while Drs. Austin and Bell (the dangerous surgeon from the pilot) perform the trauma surgery.  Sigh.  Austin finds a lacerated spleen.  "Do you need a trauma surgeon, or . . . ?" the trauma surgeon meekly asks.  "NO", Austin replies while Nolan pathetically holds his hands in front of him, turns around, and wanders away like a chastised child.  He then stands idly by as Austin and Bell do . . . something to stop the spleen from bleeding.

I had to skip about 30 minutes of routine soap opera bullshit to get to the part I was seeking.

Dr. Austin is doing an aortic valve replacement on a nice old lady (who happens to be the mother of York, the rectal-foreign-object patient from earlier) and who, of course, codes on the table and appears to be in imminent danger of dying.  Austin coolly stands in the corner with his arms folded during the code and calls for . . . Nolan, the trauma surgeon.  When asked why he's calling for a trauma surgeon when there is no trauma, he replies gruffly, "I have my reason".  Nolan comes in a few seconds later, hands scrubbed, ready for surgery.  "I'm here.  What's going on?  What do we got?" he asks as he bursts through the doors.  He looks around confused.

"Am I needed for this surgery?" he asks hesitantly.

"No you are not needed for this surgery, Dr. Nolan", Austin chides.  He doesn't need a trauma surgeon, he merely makes him look like an idiot and uses him as an example of "someone who listens, who learns, and who understands", whatever the hell that means.  Understands what?  I have no idea, even after watching the scene five times.  Nolan then starts to quote Nietzsche before Austin cuts him off with, "You've served your purpose.  Now get out."  Nolan again turns pitifully and leaves.

Cut to advertisement.  That's the end of our trauma surgeon experience on The Resident.

I  have no idea what this scene was supposed to represent or what the message here was other than "HAHA, look at this idiot!  Trauma surgeons are totally lame!"  The scenes seem to have been poorly cobbled together for the sole purpose of making the trauma surgeon look bad, and by extension to make me look bad.  It is yet another glaring example of Amy Holden's utter contempt for doctors.

I find it amusing and rather pathetic that Amy Holden would go to these lengths to prove a point.  What that point is, I'm still trying to figure out, but I strongly suspect she watched the episode back and said, "There!  I sure showed him!"

Perhaps I'm over-reading this.  Maybe I completely misread the message being delivered.  Maybe I'm just really egotistical and this has absolutely nothing to do with me whatsoever, and the bottle-in-the-rectum X-ray and the feeble trauma surgeon appearing in the same episode just a few months after our spat are nothing but a huge coincidence.  Maybe Ms. Holden had this episode written years ago and has just been biding her time, waiting for the opportunity to present it.

But I somehow doubt it.

Friday, 20 April 2018

Colleague

As everyone should know based on my tagline, I usually write stories about stupid things a patient of mine has done.  I will occasionally write a story about myself, mainly stupid things I've done or said, and every now and then I will write about something stupid another doctor has done.  But I recently realised that of all the posts I've written, there is one thing woefully and glaringly absent: stories of my very smart colleagues doing very stupid things.  The reason for this is probably obvious - I don't care to write about other surgeons' blunders, preferring to focus on my own.  Sure, I talk about emergency physicians and the stupid things they've done, but they're emergency physicians and likely deserve the abuse.  (A note to all my emergency associates out there: shush, you know I secretly respect you.  And that you deserve the abuse.)

The main reason I don't write about my colleagues is that I rarely get detailed enough stories from them.  I have no reason to believe my patients and their antics are special or unique in any way, and I'm sure the other trauma surgeons have just as many stories as I do.

Except Dr. John (not his real name™).  Not because he doesn't have as many, but because he has more.

Way more.

Dr. John always seems to have bad stuff happen around him and has been described as having a bit of a black cloud over him.  I think this is quite understated: He is a certified, bona fide, 100% undisputed shit magnet.  Wherever there is a shitstorm, you can rest assured that Dr. John is at the center of it.  It obviously isn't his fault - he isn't the one out there crashing cars into trees, toppling motorcycles over ravines, or stabbing people in the face.  No, he's just the trauma surgeon taking care of the people who have all decided to have these terrible things happen to them all at the same time.

Lest you think I'm exaggerating, I'm not.  At all.  He will often still be in the operating theatre four or five hours after his shift is over, still fixing the mess from the previous day.  Fortunately he is a very good surgeon, but the patients that he acquires always seem sicker, more badly injured, and more bizarre than mine.  This was almost exactly the case recently, except instead of finishing surgery four hours after his shift was over, it was twelve hours.

And I finally discovered why.

I was on call one recent Sunday after John had been on call the previous day.  I instantly knew it had been another Dr. John Shitstorm because his stuff was still littering the call room when I got there and the bed looked not-at-all-slept-in.  So I got out my computer and started reading (Ready Player One, if you're curious), waiting for him to come and gather his stuff.

And I waited.  (Good book)

Aaand I waited more.  (Very good book)

Aaaaand I waited more (Wow, that was a fun book)

About ten hours, zero traumas, and no John later, my pager finally went off with my first patient of the day: a fall.  Sigh.  I walked down to the trauma bay where I was greeted with an elderly person who fell out of a chair the previous day and had no injuries.  While I was working her up, another trauma came in, this one a very lightly injured car accident victim.  Two patients, two discharges.  It was shaping up to be a very light day . . . until Trauma Nurse Martha (not her real name™) decided to pipe up.

"Doctor Bastard," she said with a grin, "we're going to have a good night.  I can feel it.  You're going to get some sleep tonight!"  There was dead silence as everyone stared at her, mouths agape.

WHAT THE FUCK DID YOU JUST SAY TO ME?

Martha has been a trauma nurse for about 20 years, so she obviously knows about the Call Gods.  She also knows that what she just said is never to be even thought about, let alone uttered aloud. 

After finishing discharging the two traumas, I went back to my call room, muttering something about Martha fucking knowing better the entire way.  It was now just past 8 PM, just over halfway through my shift.  Still, it had been very quiet for a Sunday as I had had only had two patients so far.  I could feel the sense of foreboding rising inside me when I got a text from John.

Hey is my stuff in the call room?

It seemed John was finally done with whatever the hell he was doing.  He came to the call room a few minutes later, and with a huge grin on his face he recounted the two car accident victims he had gotten 15 minutes before his shift was up, both of whom had suffered lacerations to their mesentery (the blood supply to the intestine), both of whom had segments of bowel which were dead and required resection, and both of whom were now barely clinging to life.  I listened, rapt, as he detailed the procedures he had done, amazed at his bad luck.  

"Wow, rough shift," I told him when he finally took a breath.

"I love this stuff!" he replied with a laugh.  

What?  Despite having been awake for at least 38 hours and looking completely exhausted, he was as giddy as a schoolboy.  We chatted for a few more minutes as he collected his things.  On his way out the door, he said something that made me understand the Dr. John Shitstorm:

"I hope your night is quiet.  Have a great night!"

WHAT THE FUCK DID YOU JUST SAY TO ME?

The rest of my night went exactly as you expect after both Martha and John decided to give a big "FUCK YOU" to the Call Gods.  Keeping in mind that I only had two traumas over the previous 14 hours, I then got a drunk man who fell down the stairs at 11 PM, a drunk driver who crashed into a tree just before midnight, a stabbing at 1 AM, a drunk man who fell off a bicycle at 2 AM and an elderly woman who fell out of bed at 4 AM. 

The end of my shift finally rolled around, ending my misery.  I may have said a few not-so-subtle curses under my breath, but they were directed not at the Call Gods, but rather at John and Martha.  After what Martha and John said, I couldn't even blame the Call Gods for what they did to me.

But at least now I got it.  I finally understood why John is a shit magnet.  Because John doesn't give a fuck about the Call Gods.  He challenges them.  He taunts them.  He uses them to fuel his desire to operate on fucking everyone.

John is a shit magnet because he wants to be.

Monday, 9 April 2018

Compartment syndrome

NOTE: I realise I have not published any new posts in 4 weeks.  That is highly unusual for me, and I do not expect it to become a trend.  This was a combination of a dearth of interesting stories and a well-deserved holiday.  It turns out {redacted} is quite nice this time of year.

There are several absolute surgical emergencies in trauma.  These are operations which need to be done right now (or ideally 30 minutes ago) in order to save a life or limb.  Some are rather obvious:
  • active arterial bleeding
  • open skull fracture
  • intestines outside body
  • hole in heart
Some are decidedly less obvious:
  • bowel ischaemia (loss of blood supply to the intestine)
  • compartment syndrome
That last one is probably one you've never heard of, but it certainly belongs on the "Get To Theatre Now" list.  In short, the pressure inside a compartment (leg, arm, abdomen) rises higher than the systolic blood pressure, which then essentially chokes off the blood supply to the things in (and beyond) that body part.  Massive bleeding or swelling in the abdomen, for example, causes blood supply to the intestines and kidneys (among other things) to be cut off, leading to acute renal failure, bowel necrosis, and rapid death.  Injuries to the lower leg can cause swelling of the muscles in any of its four compartments, leading to muscle death, eventual limb death, and even more eventualler (that's a technical term), death.

Diagnosing lower extremity compartment syndrome is fairly straightforward despite its relative rarity.  As the swelling worsens and blood supply is gradually cut off, it presents with the 5 P's: Pain, Paraesthesia (decreased sensation), Pallor (paleness), Paralysis, Poikilothermia (inability to regulate temperature), and finally Pulselessness.  Anyone with a cold, insensate, paralysed, pulseless leg needs emergent surgery.  Now.  NOW.

NOW!

Unfortunately there is no medical treatment for compartment syndrome.  The only available recourse is to open the affected compartment to allow the contents room to swell and expand, thus re-establishing blood supply to the dying tissue.  Without it, the limb will die within a few hours, as will the patient not too long afterwards.

And Erik (not his real name™) had compartment syndrome (not his real diagnosis™).

I'll explain.

It was a rather slow day, though I made damned sure not to remind the Call Gods of this fact.  One of the nurses seemed not to give much of a fuck about the Call Gods, because out of nowhere I heard "Gee, it's been rather quiet today."

WHAT THE FUCK DID YOU JUST SAY?

Not five minutes later, the phone rang.  Of fucking course.  It was Outside Hospital (not its real name™) with a trauma consult.  Sigh.  These are rarely interesting, usually rib fractures after a car accident or facial fractures after an assault.  My ears seldom perk up when taking these consults.

"Hell Doctor Bastard, I'm calling from Outside Hospital.  I have a guy here with compartment syndrome I need to send over right away."

My ears perked up.  Something real?  On a slow day?  I waited for the story with bated breath.

"His name is Erik.  He is 29 years old, was struck by a car and was seen here earlier, but he looked ok so we sent him home.  He came back because of persistent pain in his left leg.  The leg is swollen and tight, and he needs to be decompressed."

Well now, this is some real trauma!  Huzzah!  But before the fanfare and sending troops to get him, I needed some additional information.

Me: Ok, does he still have a pulse {the pulse is usually the last thing to go}?
Her: Oh yes, it's normal.
Me: Well that's good.  How is his sensation and motor function?
Her: Normal.  He's been walking just fine.  Actually he said his pain is a little better today.
Me: ...
Her: Hello?
Me: Um, is the leg cold?
Her: No, it's warm.
Me: ...
Her: Hello?
Me: ...
Her: So can we send him over?
Me: ...
Her: Hello?
Me: This doesn't sound like compartment syndrome. At all.  He has a warm, sensate, normally functioning leg with a pulse?  And you said he was hit earlier today?
Her: Oh no, not today.  The accident was 16 days ago.
Me: It was . . . wait, WHAT?
Her: He said the swelling got worse, but it's been better the past two days. 
Me: ...
Her: So can I send him over?

WHAT. THE. FUCK.

The major problem was that I could not afford to say no.  If I told her to send this ridiculous-sounding bullshit consult home and he actually did have compartment syndrome, he would lose his leg and I would deserve to lose my licence.  So I grudgingly accepted the transfer (but not before thoroughly educating the emergency doc on what compartment syndrome actually is), knowing full well I would most likely be discharging him from my trauma bay 20 minutes after he arrived.

But I was wrong.  It was 15 minutes.

He walked into my trauma bay (yes, really) 5 hours later.  His leg was not cold, it was not tight, it had normal sensation, and it had a normal pulse.  In fact it was barely swollen at all.  And all his bruises were in their final stages of healing.

The good news was that the Call Gods must have taken pity on me, because they sent me nothing the entire rest of the evening.  Don't you worry though, they got their revenge next time.  But that's a story for another time.

Monday, 12 March 2018

Jahi

I tried my best, I really did.  I've seen the article, I read it, and I tried to ignore it.  I had fully intended to leave it alone until I had some more actual information, and just like anything else, my resolve was firm until it wasn't.

Many of you know exactly what I mean, but for those of you shaking your head and wondering exactly what the hell I'm talking about, you obviously missed the title.  Yes, I'm talking about the article about Jahi McMath in The New Yorker magazine titled "What Does it Mean to Die".  In case you haven't read it, click the link, read it, and then come back.

No seriously, go read it.  Yeah yeah yeah, I know it's long!  JUST READ IT.

Done?  Good.

If you're anything like me, the first thing you noticed was the pictures.  There aren't many, but there is one very-obviously-posed picture of Jahi looking quite bloated though peaceful in her bed covered by an "I believe in Miracles" blanket, her mother leaning in talking to her, her step-father looking on and smiling, and her little sister peering in through the doorway.

Give me a break.

Much more striking than how Jahi looks is the overriding racial overtones that are pervasive throughout.  The article starts with this little tidbit from Jahi's mother Nailah in the fourth paragraph:
Just two paragraphs later we get this quote from Nailah's mother Sandra:
Is any of this true?  I wasn't there, so I can neither prove nor disprove these allegations.  However, the procedure was performed at a world-class children's hospital (in a city that has a larger black population than white), not a run-of-the-mill facility or some rural clinic.  I obviously can't disprove it, but I find it all but impossible to believe.  And of course the doctors and hospital in question cannot defend themselves due to privacy laws.

The article goes on to explain how Nailah failed to understand how Jahi could be pronounced dead even though "her skin was still warm and soft and she occasionally moved her arms, ankles, and hips".  This was doubtless explained to the family dozens of times both in the immediate aftermath and in the ensuing four years.  I've written about it here multiple times, though I have a strong suspicion they haven't read it.  Maybe they should.

Anyway, the article then delves back into thinly veiled racism with this passage:
And then:
Probably not surprisingly, Dr. Williams remembers the conversation differently (though her contradiction is not further explained in the article).  Unfortunately it gets even worse in the very next paragraph:
Sigh.  I nearly put the article down and stopped reading at this point, because the slant was plainly obvious.  However, Jahi's story was not about race, it was about a little girl who suffered a horrible post-operative complication and died.  It was never about race until they made it about race.

The next portion of the article is a retelling of the legal struggles Nailah went through and how she eventually got Jahi out of California to New Jersey, where she remains to this day.  It isn't until over 3000 words later that we finally get into the heart of the issue - what it means to die (you know, the title of the damned article).  The author goes into the history of how brain death criteria came into being, and she unfortunately delves into the seemingly true (yet demonstrably false) assumption that brain death was somehow invented in order to facilitate organ transplantation.

It would have taken the author 0.211 seconds (I timed it) to find an article from the Journal of Medical Ethics written by Dr. Calixto Machado (a name that should sound strikingly familiar to anyone who knows Jahi's case and who is mentioned later in the article) in 2007 that directly refutes this point.  The title is rather unambiguous: "The concept of brain death did not evolve to benefit organ transplants", and the main point is summarised quite concisely in the introduction:
It is commonly believed that the concept of brain death (BD) evolved to benefit organ transplantation.  Nonetheless, a historical approach to this issue will demonstrate that both had an entirely separate origin.  Organ transplantation was developed thanks to technical advances in surgery and immunosuppressive treatment. Meanwhile, the BD concept was developed thanks to the development of intensive care techniques.
Later the article explains how Jahi has supposedly developed the ability to move her hand and foot in response to verbal commands.  This claim is based on a series of videos that have been corroborated by exactly no one, yet they somehow have convinced neurologist Alan Shewmon to declare that she no longer meets brain death criteria.  What the article fails to mention is that Jahi had brainstem auditory evoked potentials performed back in September of 2014, which revealed that there was no auditory pathway, making it therefore an anatomic impossibility for her to hear anything.  She simply has no neural pathways that can allow her to hear the commands to which she is supposedly responding.  This hearkens back to the Terry Shiavo case, where her parents insisted that she could see them and respond to them, but an autopsy later revealed that her visual cortex had been destroyed, rendering her completely blind.

Just like with Jahi, Terri's parents had "video evidence".  Just like with Jahi, Terri's parents believed that Terri was interacting with them.  And just like with Jahi, Terri's parents were wrong.  What you can't see in Jahi's video clips (but can with Terri's) is the presumably hours and hours of footage it took for Nailah to get these cherry-picked video clips.  I have no doubt that Nailah saw Jahi twitching her hand and foot and recorded as much footage as she needed to get exactly what she wanted.  There is an excellent explanation here about why we have no reason to believe these videos.

However, the part of the article that caused me to groan the most was this:
Really?  REALLY?  She just so happened to have that conversation with her kids the previous year?  And Jahi just so happened to say "Keep me on one of those"?  Apparently we, the readers of this article, are expected to be too stupid to see right through this.  We're supposed to believe that Jahi asked for what her family is doing to her.  That she wanted this existence. 

No.

Of all the things that have never ever happened, this never happened the most.