Sunday, 30 December 2012

Zzzzzz

Texting and driving is stupid.  But I've already ranted enough about that.  Drunk driving is even more stupid.  Sure, I could end this post here, but everyone knows all of this.  I bet even the idiot drunk drivers are thinking, "My god, what the hell am I doing??" while they're doing it.  So what the hell is my point?  Unless you've been living under a rock (which is probably one of the safer places to be these days), driving under the influence of drugs or alcohol isn't the only stupid thing you can do at the wheel.  You have also heard of drowsy driving.

What?! You haven't? Have you been living under a rock?

Put simply, drowsy driving is driving while you should be sleeping. About one in 6 fatal traffic accidents can be attributed to driver fatigue, which can impair judgment, delay reaction times, and impairs coordination.  Sound like anything else?  Exactly.  It's been shown to be at least as dangerous as drunk driving, if not more so.

Yet another car accident victim was being brought to me at 2 AM on a night when I had already had 15 patients come in.  I was tired, I was cranky, and I was in no mood for another fucking moron who had thoroughly earned a trip to my trauma bay.  Unfortunately that's exactly what rolled through the door.

A very large woman rolled in on the gurney, and the medics were having a very difficult time stifling their laughter as they told me why she was here.  She had just been prescribed a new medicine, one that notoriously causes drowsiness.  She had taken her first dose that evening and had supposedly discovered another side effect - a severe case of the stupids.  So in the middle of the night, already drowsy from sleep deprivation and her new medicine, she thought it would be a fantastic idea to go out for nachos.  And much to the surprise of NO ONE, she fell asleep and ran off the road into a tree.

Fortunately she was not seriously injured, and after a negative workup I sent her on her way.  I have no idea if she stopped for a snack on the way home.

Stupid doctor

It's that time again: time for another post about stupid doctors!  This time, you may be surprised that the stupid doctor is a trauma surgeon.  You may be even more surprised to learn who the stupid trauma surgeon is:

Me.

Ok, granted, I wasn't a trauma surgeon at the time, I was still a doctor-in-training.  So I can at least use that as an excuse.  But it was one of those moments in my professional life when I deserved a well-earned slap to the forehead.

I had only been a doctor for about a year and was rotating through the intensive care unit, trying to learn how to take care of the sickest patients.  Heart transplants, sepsis, strokes, heart attacks, surgical catastrophes, you name it.  These patients are the worst of the worst, the sickest of the sick, and many of them never make it out.  The patients who can't breathe on their own need mechanical ventilation, and this can be very uncomfortable and disorienting for them.  Many of these unfortunate patients can become severely agitated, and sedation often isn't enough.

One such patient was an elderly woman who was having an exacerbation of her emphysema.  She was intubated, on the ventilator, and fighting it furiously.  The nurses had to attend to her constantly in attempts to calm her, but she seemed to be inconsolable, banging on the bed rails, pulling at her IV lines, and generally being a pain in the ass.  All of the nurses had had it with her.  Around 10 PM as I was making my nighttime rounds, she seemed particularly disturbed.  I looked at her chart and noticed that her name looked German.  All of a sudden a light bulb turned on - perhaps the nurses were having trouble calming her because she didn't speak the language.  I studied the German language for four years in school, so perhaps I could talk to her in her own language!  I could be a hero!

I walked timidly into the room, and her fierce blue eyes immediately narrowed and locked onto mine.  I took a deep breath, racked my brain for the right words, and started telling her that she was ok, everything was fine, and she needed to concentrate on her breathing.  She immediately calmed down ever-so slightly, and her eyes opened wide.  She understood!  I continued talking to her in very soothing tones, explaining in very broken German that her lungs were sick, but we were giving her medicine to make her better.  At least I was pretty sure that's what I said...either that or I said that her lamp cow is sad yesterday and need more painted Wednesday.

Anyway, by the time I was done, she was perfectly calm, she was breathing more easily, and she actually had a hint of a smile on her face.  Three of the ICU nurses watched open-mouthed as I strode confidently out of the room.  "WHAT DID YOU SAY TO HER?" one of them asked.  I simply told them that I explained her situation to her in her own language, and I continued on my rounds.

When I came in the next day, she had clearly gotten better because she was no longer on the ventilator.  She was breathing on her own and looked much more comfortable...and still calm.  I walked into her room and re-introduced myself, and after I finished my examination, I asked if she had any recollection of our conversation.  I wasn't surprised to learn that she didn't (the sedatives can often interfere with memory formation), so I filled her in on the details.

"But I'm not German."

What?  What do you mean, I asked her.

"I'm Norwegian.  My husband was German.  I don't speak any German at all."

Um...well then I guess her lamp cow really was sad after all.

Thursday, 27 December 2012

Actions speak louder...

I'm sure you've heard the phrase "Actions speak louder than words."  Truer words have seldom been spoken.

Or have they?  Perhaps words are sometimes all you really need.

I'm going to deviate from my usual posts (obnoxious, angry ranting and raving), shut my big, fat, stupid mouth, and let someone else do most of the talking for this update.  I get emails from readers with some frequency, many of them asking medically-related questions.  Most of them have nothing to do with trauma - they come from people who are simply desperate for help or answers and don't know where else to turn.  I received this email from Kira (not her real name) about three weeks ago:

I've been told by my doc I have bronchitis but lately I've been coughing up blood and hacking my brains out. I've also been very sore in my entire stomach and lung area. I can't hardly breath and my parents won't listen. They just make fun of how I sound or when I'm in pain. Please help me.

Well I think anyone with more than 7 brain cells can tell that this certainly doesn't sound good.  The only thing I told her was that coughing up blood is not normal, and that she needed medical attention.  NOW.  She responded immediately:

I can't get to the hospital they won't take me.
Shit.  Won't take her?  What?!?  At that point I advised her that if she really is having trouble breathing, she needed to either A) call a taxi or emergency services or somehow get to her doctor without her parents, or B) somehow convince her parents that this is actually something serious.  Coughing up blood (aka haemoptysis) can be a sign of bronchitis, lung cancer, or more serious lung infections like tuberculosis, but it is never, ever normal.
I'll try, doc. Thanks. Ill let you know how I'm doing tomorrow.
And then I got nothing for three weeks.  Was I simply blowing it out of proportion?  Was it not as bad as it sounded?  Was she dead?

I sat next to the computer wringing my hands the entire time, wondering, hoping, worrying...ok, that's a complete lie, but I was mildly concerned.  And then three weeks later, I got this:
Hey doc, I just wanted to let you know I'm finally feeling normal again. It turns out I had a severe case of pertussis (whooping cough). If I had not gone in when you sent me that message back that convinced my parents to take me in, I probably would not be writing this. In fact I would probably be in the ICU. But thanks to you I am now well and happy (if a little short of breath occasionally). I just want to share I also found out because of you I have damaged lungs from where I grew up as a child. If you hadn't convinced me to go in I would have never found this out and been able to learn more about it. If you can please tell your readers don't take second hand smoke lightly. I grew up in a place that was constantly filled with smoke and because of that I'm way more susceptible to bronchitis, pneumonia and all other respiratory issues. Anyway I just wanted to thank you for giving me the best gift of all. My life back. 
Thanks doc!

Now don't get me wrong, I'm not taking credit for anything here other than trying to alert some oblivious parents to take their child's complaint seriously.  My daughter makes mountains out of molehills all the time (Daddy, it's bleeding!!  It's just a papercut, dear.  YEAH, BUT IT'S BLEEDING!!!).  But as a parent you have to be able to detect the difference between exaggeration and reality.  That can be very difficult to do sometimes, especially when you have no medical training.  But when it comes to your children and their health, I feel it's better to err on the side of caution.  It's much easier to bring your child to the doctor and be reassured than the alternative.  Fortunately my email caused Kira's parents to reconsider and spurred them to do the right thing.

See what I mean?  Sometimes words really do speak louder than actions.

Thursday, 20 December 2012

Phrases

I'm sure this is true in all languages, but there are lots of phrases in the English language that don't make a whole lot of sense:

It's a dog-eat-dog world.  Ok maybe some dogs are viciously competitive, but have you ever seen a dog actually eat another dog?
I slept like a baby.  No you didn't, you slept all night.  Babies wake up screaming every two hours!
He wants to have his cake and eat it too.  What is the point of having cake if you're not going to eat it?
It's the bee's knees!  It's...wait, what?  What the fuck does that even mean? 

But other phrases make perfect sense:

I'm as happy as a pig in slop.  Yup, pigs look very happy wallowing in mud.
That went like clockwork.  Sure, fine clocks are incredibly intricate.
It's as smooth as silk.  Self-explanatory.

So what the hell am I getting at?  What exactly does this have to do with anything?  Just wait.  I promise it will make sense in a moment.

A very boisterous (my nice way of saying "obnoxiously loud") man was brought to my trauma bay having been allegedly assaulted by five other men.  His main complaint was a headache due to a gash on his forehead.

"Oh, and my fists hurt too."

Your fists hurt?  I hadn't heard that one before.  "Yeah, Doc.  I think I knocked one of them the fuck out."

Lovely.

My main complaint was that he smelled like a dirty diaper that had been dipped in booze. He and his "buddies" that he had been brawling with had drunk at least a dozen bottles of something, so he had done the only logical and gentlemanly thing he could think to do - he emptied his bladder all over himself during the ambulance ride.  Yes, on purpose.  We peeled his pants off his legs and tried to dispose of them (the pants, not the legs...though trust me, the temptation was there), but the stench wouldn't seem to go away.

We continued with our workup desperately trying to ignore the odor.  In this midst of everything, it turned out that his only available form of identification was an armband with his name and date of birth on it...the armband from the prison from which he had been released the day before.  So naturally he had decided to celebrate his release by drinking and fighting.  Fortunately he hadn't done any major damage and had no major injuries, so he received a few stitches in his forehead for his trouble, and I sent him on his merry way.  The police were only too happy to take him right back.

After this experience, I've added "piss drunk" to the second list.

Sunday, 16 December 2012

Gross anatomy

I got the following email request from George (yes, his real name) asking about my years as a medical student:

My name is George. I’m currently in medical school in {redacted}. So I know practically nothing….
I stumbled upon your blog and it’s amazing. My friends and I now start to sit down, laugh (where appropriate) and discuss what you talk about. Plus, your entries are pretty regular for someone as busy as yourself, very impressive.
Ever thought of writing an entry reminiscing on your past life as a Med Student? Would be great to know what you experienced.

Keep up the great work
George
Well George, I would like to reflect on my years as a medical student for a moment and remember them with fondness.  I would like to do that, but I really can't because it was several years of unimaginable torture.  Ok, that's a gross exaggeration - my residency was unimaginable torture.  Medical school, on the other hand, was more...well, like a really annoying itch that you keep scratching but just won't go away. 

My father went to medical school 30 years before I did, and his father did about 30 years before that.   My grandfather liked to tell the story of his first day of medical school: The dean assembled all the students in the auditorium and then told them, "Look at the student to your left.  Now look to the student to your right.  Now remember this: two of the three of you will not be here on graduation day." 

Ouch.

By the time I started medical school, this was no longer the case.  Students were weeded out in college by such evil devices as Organic Chemistry, a full-year form of torture just slightly more painful than The Machine from The Princess Bride.  But before I started, my father told me that medical school isn't necessarily hard.  There are very few difficult concepts to learn - it isn't multivariable calculus, quantum mechanics, or special relativity.  No, what makes medical school difficult is simply the sheer volume of knowledge that medical students are forced to memorise: anatomy, physiology, biochemistry, pathology, microbiology, epidemiology, histology, embryology, pharmacology, immunology.

On my first day, I happily (and nervously) received my course schedule for the year.  And there it was on page one staring at me, taunting me:

GROSS ANATOMY

Of course I knew it would be there, but just seeing the words on the page gave me pause.  I will be dissecting a real person.  I had dissected small animals in school, but never anything like this.  This was...I didn't exactly know what it was.  But all of a sudden, medical school seemed real.

It got even more real later that day when we got our tour of the "Gross Lab".  When I first walked in, the smell of formaldehyde was so strong it may as well have slapped me across the face.  Now I know why it's called "gross" anatomy, I thought.  We split into groups of four, and we found our assigned cadaver, all of which were wrapped in plastic.  I was in charge of opening the plastic bag, and despite my trembling hands, I got it opened.  And there she was: our cadaver, Rose (not her real name).  Very thin, grey hair, arms folded neatly over her chest, eyes just slightly ajar.  Rose was an elderly lady who looked like she could have been anyone's grandmother. 

The class started with no real drama.  No one fainted, no one dropped out.  We started dissecting very timidly, but after the first day, the nervousness was gone.  The anatomy was absolutely fascinating, but over the next several months there were some oddities in the gross lab and questions that arose that simply couldn't be answered.  When we got to the chest, we could instantly tell who had smoked and who didn't.  Rose did.  Is that what killed her?  And Rose's liver was green instead of the usual rust color.  Why?  Was that her cause of death?  The cadaver next to us was hung like a porn star.  Could he have been?  Another cadaver on the other side of the lab had a transplanted kidney in his pelvis, and another was missing a lung.  Who were these people?

As the months progressed, I learned more about anatomy than I could have ever dreamed.  Muscles, nerves, arteries, veins, glands, internal organs, the brain and brainstem, tendons, bones, ligaments...and all real.  Not just pictures in a textbook.  Real.

Gross anatomy is a course unlike any other.  It isn't just memorising facts - it's memorising what structure is what and how it's all connected to everything else.  That's what makes it so difficult, but at the same time so satisfying.

Looking back at my first day of gross anatomy, it was painfully clear that no one knew exactly how to act.  Several people cracked nervous jokes, some people whispered.  But I just stared silently at the person who would eventually become the best teacher I ever had in my life.  To this day I have no idea how Rose died or why she had decided to donate her body to our medical school.  But when I first laid eyes on her, I still vividly remember my first thought was "Thanks".

Wednesday, 12 December 2012

Mistakes

Are you sitting down? I hope so, because this post might surprise you.

I made a mistake.

Yeah, yeah I know, it happens.  Just breathe.  Deep, cleansing breaths.  Are you breathing now?  Good.  No, this is not the first mistake I've ever made (just ask my wife).  Now I don't usually like being wrong, because being wrong usually makes me look bad, and I don't like looking bad.  But sometimes things just work out so that even though I'm wrong, the guy who is right looks bad.  I guess that doesn't make much sense, but I guarantee you it will by the end of this.

A fine gentleman was brought to my trauma bay having been involved in a rollover motor vehicle accident.  And by "fine gentlemen" I mean he was shabbily-dressed, cursing like a sailor, and reeking of alcohol.  The medic informed me that the guy had admitted to drinking, and this set the patient off on a frenzy.

"I never said that!  That guy's a fucking liar!  Where are you, you fucking liar!  Get over here!  FUCKING LIAR!"

I almost had to restrain him from jumping off the gurney and attacking the medic, who understandably left in a hurry.  On my initial assessment, he definitely smelled strongly of alcohol, and he was certainly acting like just another drunk driver.  He continued acting belligerent and obnoxious, so I tried calming him by talking to him the way I talk to my children - soft tones and a calm voice.  I very calmly and politely informed him that we could do this the easy way or the hard way - the easy way was for him to act like a nice boy and cooperate. The hard way what for me to chemically sedate him and do my workup without him interfering.

"JUST YOU FUCKING TRY IT!"

Really?  This is his response to politeness and good manners?  After a few more calming words, he finally relented and started acting almost like a human being, though he continued to threaten the medic who was long gone.  Still, despite how he was acting (and how he smelled), throughout his workup he vehemently insisted he was not drunk.  He had a small laceration on his head and a concussion, so I got a CT scan of his brain.  Fortunately he was ok and it was negative.  But that wasn't the only thing that was negative -

His blood alcohol level was 0.

Astounded, I made sure the lab hadn't mixed up his sample.  Nope...it was 0.  I closed his laceration with a few sutures and sent him on his merry way.  Even though I had been nothing but polite to him, he continued cursing at me and my staff until he was out the door.

After he left, I sat and wondered why he smelled of alcohol.  Maybe someone spilled a drink on him?  Maybe he uses bourbon as aftershave?  Regardless, I couldn't believe he had actually been telling the truth.  Yes, he was right and I was wrong.  But that could mean only one thing - the reason he was acting like an asshole isn't because he was drunk...it was simply because he's an asshole.

Friday, 7 December 2012

Driving hazards

There are a few things that scare the shit out of me when I see them on the road -
  • People who can't see over the dashboard
  • People talking on their cell phones
  • People texting while driving
  • People reading the newspaper while driving
  • A "Student Driver" sign
  • A driver pretending to be Mario Andretti
I always try to get as far away from these people as possible, because you simply can't devote enough attention to your surroundings when you're too busy fixing your makeup while txting your besty that omg dis song sux!!

There are some very impressive recent studies that have shown that driving while distracted is just as dangerous as driving while intoxicated.  If you text while driving, you are 23 times more likely to crash.  Almost 20% of all crashes which are severe enough to cause injuries are caused by distracted drivers.  At highway speeds, in the length of time it takes to read or write a text message, you travel over 100 m (that's the length of a football field), all while not looking at the road

Just one of these distractions is enough to make your 2000kg missile loaded with explosive fuel dangerous enough.  Add more than one of them together, and you get what happened to Miss M (not her real name), a reader from Australia who wrote me an email about her experience in a car crash.  It's enough to make your head spin.
Hi Doc,
My name is Miss M {still not her real name}.  I'm 26 and I'm a nurse from {edited}, Australia and I read your blog constantly!!  Can I say being a nurse we need a lot more doctors like you around!!  I thought I'd share my story with you.  This happened to me last year.  In Australia when you have completed 120 hours of driving under the supervision of a full licence holder, you become eligible to drive without supervision but with speed limit restrictions of 90 kph {55 mph for our American friends}.  I was stopped to turn right when I heard a screeching noise.  I looked in my rear view mirror but didn't see anything.  Next thing I know, BAM!  I was hit from behind with such force that I was pushed into oncoming traffic where I was hit by another car.  All three cars were destroyed, but no one was killed.  I found out later that the driver who caused the accident was a 17 year old boy who was doing 110 kph in a 50 kph zone while texting.  And to add insult to injury, not once did he even say sorry to me or the other driver for what he did.  Teenagers these days think that they are invincible and that texting and driving is ok, but as you can see from these pictures, it's not.  He could have killed someone else if not himself.  He is now paying over $63,000 in fines and damages, he lost his licence for 3 years, and got charged with negligent driving, colliding with a stationary vehicle, and speeding.  The message needs to get out to young ones that it is not worth texting and driving.
Keep up the fantastic work, Doc!
Miss M










Over 200 billion text messages are sent each month, and I guarantee that 99.999% of them can wait until you've arrived at your destination to be sent.  If you're driving and you really really REALLY have to tell someone something, either pull over and send your message, or put down your goddamned phone and JUST WAIT UNTIL LATER.

Saturday, 1 December 2012

Questions

Getting a medical degree comes with certain perks - people somehow treat me a little differently when they find out I'm a doctor.  There's a certain level of respect that comes with being a physician, especially a surgeon.  On the other hand, there are drawbacks as well, the most common (and often annoying) is the curbside consultation. 

"Hey, you're a doctor.  What's this rash on my back?"

"Oh, you're a doctor?  Hey, why does my knee hurt when it rains?"

"So you're a doctor!  Well you see I have this, uh, friend, and he...no it isn't me, I swear!  Anyway, this friend of mine has had a problem with...do you think you could get him some Viagra?"

Get the idea?  Most of the questions I get are completely unrelated to my field of expertise, which mostly has to do with either holes or sick organs inside the abdomen.  Some, however, are relevant, and one I got recently from a reader named Miss A (not her real name) is particularly germane:

Hey Doc, I've been reading your FML posts for a while and graduated to your blog a few nights ago (which by the way is great reading material when your brain refuses to turn off and allow sleep), and I've noticed you have a few posts about drug seeking. My questions are, when is it ok to ask for medication, when is it ok to ask for stronger medication, and how do you approach the topic with your doctor?

Thanks for your time and opinions.  Miss A
Asking for medication is always tricky as some of my patients have found out.  The problem with pain is that it's 100% subjective.  There is no test I can run on you that proves that you are in agony.  There are warnings that most people emit unconsciously that we can easily detect that tell us that you're in bullshit mode.  So having said that, here are some answers that may help.

When is it ok to ask for medication?  It's always ok to ask for pain medicine.  That doesn't mean you'll get any, but if you're in pain, let someone know.

When is it ok to ask for stronger medicine?  This is where you start to get into that grey zone.  There are some lines that we hear over and over, and all of them raise huge red flags.

"I can only take XXXXX.  It's the only one that works for me."  If you start off by demanding a certain narcotic, especially one that has a side effect of euphoria, chances are very good you will NOT get it from me. Morphine, demerol, codeine, hydromorphone, fentanyl, and heroin all work the exact same way by binding to the exact same receptor.  Their chemistries are all a little different, so they work to varying degrees.  But if one of them works, chances are another one will work too.

"I'm allergic to all of the over-the-counter medicines."  Sure you are.  I can say with 99.99% certainty that isn't true, because the chance of actually having an allergy to paracetamol (Tylenol), aspirin, ibuprofen, and naproxen is very near 0.  And the people who are supposedly allergic to them usually aren't quite sure what the allergy is ("Uh, they all make me sick").  Sorry, but nausea isn't an allergy. 

"None of the over-the-counter medicines work for me."  This is probably one of the biggest red flags.  Of course they don't work - you've been abusing narcotics for so long, the only thing  that WILL work is more narcotics

"It all just hurts!  I need pain medicine!"  If you have no identifiable reason for having excruciating pain all over your body, we can rest assured that you aren't having excruciating pain all over your body.  Yes, there are very rare disorders where very unfortunate patients have pain for no detectable reason.  Fortunately for us (and unfortunately for you), these disorders are exceedingly rare.

How do you approach the topic with your doctor?  Be open, honest, and frank.  Don't be whiny, demanding, or aggressive.  Let your doctor handle the details, and don't try to guide him in one direction.  Understand that there are more and more non-narcotic analgesics available now than ever before, and if your doctor prescribes one for you, don't complain that it isn't Vicodin.  Trust me when I tell you that you do NOT want to take narcotics for your chronic low back pain or your severe menstrual cramps.  Once you start, it can be VERY difficult to stop - if you've ever seen a narcotic withdrawal scene in a movie, they are usually startlingly accurate. 

I hope this helps not only the people with real pain who are seeking answers, but also the idiots who still think they are smart enough to con narcotics from me. 

Wait a second...is Miss A tell me that this blog puts her to sleep?  I suppose she can stop asking her doctor for sleeping pills now.

Wednesday, 28 November 2012

Time heals all wounds

I hate waiting.  I simply can't stand waiting for pretty much anything - lines in the airport, test results, advertisements on TV, everything.  I can't even stand waiting for diseases to get better, and that's exactly why I chose surgery.   Do you have high blood pressure?  Well your doctor can give you a pill that may work...but you won't know for several weeks.  If it doesn't work, he can give you more.  Or less.  Or a different drug.  Or another drug.  Will that work?  JUST WAIT A FEW MORE WEEKS.  On the other hand, do you have gallstones in your gall bladder?  I can take that out.  Colon cancer?  I can cure that!  Perforated stomach ulcer?  I can fix it instantly.  So because it's been 11 days since my last post, I figured my next update should be about waiting.

Appendicitis almost never shows up during the day.  I have no idea why, but it seems no one EVER comes to the ER at 10AM with appendicitis.  Everyone likes to wait until the middle of the night before coming in.  I can't understand how or why they do this, because I've had appendicitis.  And let me tell you, it SUCKS.  It feels like you're being stabbed in the gut with a huge, dull, rusty sword.  And the longer you wait, the higher your risk of the appendix rupturing.  When that happens, it becomes an entirely different disease.  People with mild appendicits usually go home within 24 hours.  People with ruptured appendicitis, however, typically are in the hospital for a week, and some even die.  I only waited about 4 hours before I went to the ER, and my appendix had already nearly ruptured by then.  So how the hell can someone wait a day or even longer before seeking medical attention?  God damn it people, listen to your bodies!  Sorry, sorry.  I digress.

The ER called me a few days ago at 1 AM (of course) to tell me about a 34 year old woman who had just flown back from week vacation on a tropical island.  She had been doubled over in abdominal pain for her entire trip, but she had waited until she got home before coming to the hospital.  Naturally, her CT scan showed ruptured appendicitis.  Greeeeaaat.  After explaining the situation in detail, I took her to the operating theatre where I found this:

Ok, it really wasn't that, but that's what it looked like had happened inside her.  Her appendix had indeed ruptured, there was pus everywhere, and everything was inflamed and stuck to everything else.  I cleaned up all the pus and I managed to chisel her appendix out of the intense inflammatory response (all done laparoscopically, much to my satisfaction).  After a very difficult case, I went out to the waiting room to talk to her husband and his father, who were waiting anxiously to find out the results.

After I told them what I found, her husband said, "That's about the same thing that happened to me!  Remember, Dad?" 

Wait...what?

My mouth probably agape, I stared in disbelief as his father recounted how his son, this woman's husband, had also had ruptured appendicitis when he was a kid on a skiing holiday.  He had also waited a week before seeking medical attention because he didn't want to cut the ski trip short. 

So even though she had been complaining of pain all week, and even though he had been through the exact same thing, they never went to the hospital.  Granted, most people can't diagnose appendicitis that easily, but MOST of us would go to the damned hospital if we were doubled over in pain FOR A WEEK like she was.  Just like her husband, she spent a week in the hospital before she finally went home.  I saw her in my office a few days ago, and she's doing much better.


They say "Time heals all wounds."  But that doesn't quite apply when it comes to surgery.

Sunday, 18 November 2012

Experts

The Internet is both the best and the worst thing to happen to medicine ever.  Well, ok maybe penicillin was pretty important.  And I guess anesthesia was also a big break - rather than simply getting people drunk and hoping they didn't wake up during the procedure, it allowed us to do whatever we wanted for however long we wanted.  But I digress.  These days everybody seems to think that they can google something and instantly become a medical expert.  Nevermind the fact that becoming a doctor actually takes around a decade of school and training.  A 5-second internet search apparently allows people to skip years of training and practice.

A short while ago I admitted a young man who had been involved in a fairly serious car accident.  He had bonked his head pretty hard (that's the technical term) and had a small contusion in his brain.  As per our protocol, I had repeated his CT scan several hours after he arrived, and it confirmed that the contusion had not changed at all.  I admitted him to the intensive care unit, and though he was initially very confused, he improved dramatically over the next few days.  The night before I was going to discharge him home, I got a very irate phone call from his very irate mother.

"How the hell can you be thinking about sending my son home?" she asked me.  "You haven't even done an MRI of his brain!"

No of course I hadn't, I told her.  I very calmly explained to her that her son was getting much better and there wasn't any need to do any further imaging.  The only reason to do a test is if you plan on potentially changing the treatment based on the result.  No matter what any test showed, his treatment wouldn't change.  I tried to explain calmly that not every brain injury patient needed an MRI.  It was a very expensive test that wouldn't change anything. 

Oops.

As soon as the words escaped my mouth, I regretted saying them.  Her screaming grew louder.  She accused me of not doing anything and not caring about how her son was doing.  She then accused me of simply trying to save the hospital money.  I held my own, and nearly an hour later, I finally hung up the phone, absolutely satisfied that I had not convinced her one bit.

Not surprisingly, her son continue to do well, and I sent him home.  He did not get an MRI.

All I ask is that you just please let me do my job. I'm not saying you can't ask questions and challenge me, because I'm not perfect.  I actually appreciate questions.  But you have to understand that google doesn't make you an expert, and unless you've been to medical school, I know a hell of a lot more about this than you do.

I wonder if I can use Google to search how to deal with idiots with a smart phone who think they know more than they do.

Sunday, 11 November 2012

Compliments

WARNING: I may word this post slightly in my favour, so there's a small chance I'll end up looking like a braggart. It isn't my intention, I assure you. But I do have a point. Stay tuned.

One of the worst parts of surgery is that patients really have no idea what actually goes on in the operating theatre. I don't mean the shenanigans and hijinx (just kidding...sort of), I mean the actual operation. The only parts of my work that the patient can see are the bandage and the scar. If those looks good, that seems to be all that matters. Your surgeon could be the biggest hack in the world, but if he can close your skin nicely, he's a superhero. But heaven forbid you get a drop of blood on the bandage, because then you're clearly a butcher. So the only real thing on which a patient can judge their surgeon is his personality - his bedside manner, attentiveness, attention to detail, mannerisms, etc. These things are important, but not as important as his skill in the OR. That's not to say it isn't a wonderful compliment when a patient tells me that she was referred by another patient of mine (I took out her friend's gall bladder, so when she needed surgery, her friend told her to come see me). I even had a woman track me down several years after I took out her appendix to do her breast biopsy when she found a lump. But how do they know if I'm actually any good?

One of our local magazines has their annual "Best Doctors" issue, in which they mail surveys to doctors and ask them who they would go to see if they needed medical care. But here's the problem with that question - I almost never see my colleagues operate. I know who's nice and who's an arrogant asshole, but I don't know who's good! I wouldn't have a clue who to see if I needed surgery. In that regard, I'm no better off than my patients! So who the hell can you trust to judge a surgeon's skill?

Anaesthesiologists and OR nurses, that's who. Think about it - all they do is watch surgeons operate, so you know damned well they know who is good and who is much more likely to remove the wrong kidney.

A man came to see me last week about getting his hernia fixed. He had no primary care doctor, so I wondered how it was that he got my name and number. Did he go to the ER? Did I operate on a family member or friend? As I was about to ask him, his wife knocked and stepped in the room - she's one of the anaesthesiologists I've worked with the past few years. And of all the surgeons at the hospital, she had him come to see me.

I've gotten some nice compliments over the years - it's great when someone tells me that my suit is nice or my haircut looks good. But I think this was one of the best compliments I've ever received.

Wait a minute, what was the point I was trying to make? Oh right, now I remember - don't sprain your shoulder when you pat yourself on the back. Make sure you stretch first.

Tuesday, 6 November 2012

Perseverance

per·se·ver·ance

[pur-suh-veer-uhns]
noun
1. steady persistence in a course of action, a purpose, a state, etc., especially in spite of difficulties, obstacles, or discouragement.

When faced with adversity, some people simply throw in the towel.  Others just don't know when to quit.  And it's a damned good thing this next patient didn't know when to quit, because if she did, she would only have one leg. 

Wait...damn, I'm getting way ahead of myself again.   

This next story comes from Miss C (not her real name).  And prepare yourself for some gory pictures...ok, they aren't really gory, but they are a bit graphic.  Now that I've set it up, here goes:
Hi Doc.  From reading your blog you seem like a really great caring doctor. We need more doctors like you. I've had my fair share of being in hospitals...not for me but for my mother.

My mother was in a horrible accident 7 years ago when I was 12. After a family wedding, my mother was walking to our car and a drunk driver pulled out behind her, pinning her between the cars. It was a hit and run - the bastard just left. The muffler of the car gave her a third degree burn and the bumper of the car shattered her fibula and tibia.  The ambulance came for her and took her to a local hospital.  We arrived at 1:00 am, and we waited in the ER for 12 hours to see a doctor!  Can you believe that?  The orthopaedic surgeon's explanation was that he went out that night and had a few drinks and couldn't do surgery or come in at all.  And there were no other doctors.

When the doctor finally saw her, he told us she needed surgery immediately.  When the doctor was finished with the surgery, there was almost nothing left.  He put a titanium rod in her leg, but the tibia and fibula were protruding out of her leg along with muscle.  The next day, the surgeon came in the room without any compassion and said to my mother, "We're going to have to amputate your leg; you're never going to walk again."
My mother was in shock and in disbelief and asked why.  He replied that he didn't think the bone was going to grow around the titanium rod.  My mother asked why he put the rod in if she was diabetic.  He angrily said, "YOU'RE DIABETIC!? No one told me!"  He grabbed the chart and said, "Either way, it's not going to work out, so we're going to have to amputate."
My mother refused to believe that she wasn't going to walk again, so she refused the surgery and we took my mother home while my father was looking for another hospital.  My sister and I cared for her for weeks.  After two months my father finally found a hospital that specialised in bones. 

We were told she needed surgery immediately.  The first surgery was to take out the titanium rod, shave off the broken bone that was infected, clean out the infection, and place an external fixator
{external hardware that holds the fractured bone in place}.  They did many cleaning surgeries before another major surgery.

They then did a muscle flap {taking muscle from her calf muscle and flipping around to the front of the leg to cover the bone} and two skin graphs.  After four months, several surgeries, and more antibiotics than I can count, she finally went home. 
 
A month after that, after learning how to walk with the external fixator, the external fixator was removed.
Six years and 10 surgeries later, my mother walks.  So much for never being able to walk right?

Well Doc, I thank you for being such a great doctor.  I truly appreciate doctors who take their time to get to know their patients and not just try to get rid of them.
 

You'll notice the horrendous scarring on her leg.  You'll also notice HER LEG, which is still firmly attached to her body.

I give absolutely no excuse for the first surgeon, but I give full credit to Miss C's mother (not her real name) for her almost-ridiculous perseverance in the face of a near-catastrophe.  It's people like this who refuse to give up who make my job worthwhile.

Wednesday, 31 October 2012

Knowing better

Everyone knows the saying "Doctors make the worst patients", and it's completely true. Even though we know something's wrong, we tend to neglect ourselves in order to take care of others first. It's selfless and altruistic...and stupid. But some people know exactly what's wrong with themselves and still choose to put not only their own life in harm's way, but others' as well.

A woman was brought to me around 8PM a few nights ago after she lost control and rolled her car over several times. The medics informed us that when they arrived on the scene of the accident, the patient seemed "post-ictal" - like she had just had a seizure. That report always makes me very nervous because a seizure can be a sign of a serious head injury. This time was no different.

Or was it?

We did our workup, and she didn't appear to have any serious injuries. Her X-rays and CT scans all looked completely normal, as did her physical examination. As I was finishing her exam, she told me that she did, in fact, have a seizure disorder. She swore that she took her anti-seizure medicine that morning just like every morning. But she also admitted that what typically brings on a seizure for her was fatigue.

Sound strange? Oh, just you wait.

It turns out this was her first day back to work after having a baby three months ago. Now in case you weren't aware, babies make you really, really tired. No, let me rephrase that - babies make you so tired that you forget what sleep feels like. But not only was it her first day back to work, she decided that a double shift would be a great idea.

BZZZT! Wrong! It was a really stupid idea that made her exhausted. An even worse idea, one that put her and every other person on the roads (including my wife and children) at risk, was to drive home. She could have called her husband for a ride. She could have asked a colleague to drive her home. No, she drove herself.

As I was explaining how lucky she was not to have injured anyone, I glanced over to her bedside stand and noticed an ID badge from another local hospital.

"Oh, you work at a hospital?" I asked her.

Yes, she told me. She's a nurse. I felt my ire rising. "What field of nursing are you in?"

She couldn't even look me in the eye when she told me: neurology.

That's right, she's a damned neurology nurse who takes care of seizure patients on a daily basis, one who has had a seizure disorder herself for several decades, one who knows exactly what triggers her own seizures, and one who deliberately broke nearly every possible seizure rule and is lucky she isn't dead. I made sure that her husband was in the room to hear all this. From now on, I told him, if you can't drive her to work, make sure she takes the bus.

Whenever I see a stupid driver, I want the power to revoke driving licences. Never has that desire been stronger than that night.

Sunday, 28 October 2012

Seatbelt story

In case people still aren't convinced by the stories I've told about seatbelts, I got an email from a reader a few days ago with a story of her own.  (Coincidentally, my last seatbelt post was exactly a year ago today.  Strange.)  Miss X (not her real name) not only gave me permission to post her story, but she asked if I would share it.

To protect her identity, some names and details have been changed.

Doc,
A few days ago I found a tree at 40mph on a back country road and I have always worn my seat belt but I had never been saved by one.

My friend (whose truck it was) had pulled over because she was crying about unrelated marital issues, so I took over driving and was trying to turn around to go home for ice cream and a chick night.  Instead, the Chevy Silverado hit the tree head on.  I had never driven the truck before and it was dark and raining on the curvy back country road.  I broke the metal pedal on impact.  We were three inches from being legless and five inches from being crushed.  My chest broke the steering wheel off and pushed the steering column down three inches.   I broke my 3rd, 4th and 5th metacarpals in my right hand when the impact caused me to punch the radio.  My friend did the same, but she spiral fractured her left middle finger.  So we have matching purple casts on opposite hands.  We joke that we fist bumped mid impact.  My ribs are sore and my back muscles are not happy but because of our seat belts we walked away from what should have been a fatal accident with a collective four broken bones in our hands, sore ribs, minor airbag burns, and deep seat belt bruising.  Without our seat belts we would have been thrown headlong into a tree and possibly died on impact.  With them we both walked away with relatively minor injuries.

In the pictures, the big dent in the side of the truck shows that when we impacted there was enough force to wrench the truck bed back two inches, and it also dropped the spare tire from under the bed.  If you look below the buttons on the steering wheel you can see how I broke it.  The tire in the picture is at an odd angle because the front axle was cut in half by the transmission being forced into the manifold by the engine.  The X-ray is my hand.  It was actually scarier to see the truck afterwards than the actual accident was.

Thank you for being a wonderful person and doctor.  The world needs more people like you.

In addition to the story, she also sent me several pictures.  Here is what remains of the front of the truck:

Here is the broken steering wheel:

And this, of course, is her hand with the three broken bones.

This is the sort of accident where you could say, "It could have been worse."  You could try to argue that she was just lucky.  No - I prefer to think of her as smart for using the very device that was designed to save her life.

Thanks, Miss X, for sharing your story.  I hope others will learn from you.

Wednesday, 17 October 2012

Technology

If you're looking for a stupid patient story, you'll be disappointed by this update, and I apologise in advance.  If you're looking for a really cool picture, you're in the right place.

If you were in a car accident 25 years ago, chances are very good you have a little scar above your belly button where the trauma surgeon performed a DPL - Diagnostic Peritoneal Lavage.  A small incision was made, a catheter was inserted into the abdomen, and a liter saline was instilled.  That saline was then immediately drained out, and if blood, bile, or stool came out with it, you would have gone straight to the operating room for an exploratory laparotomy where the surgeon makes a much larger incision to get into the abdomen to take a look around.  A very large number of these operations turned out to be unnecessary, because if it was the spleen or liver bleeding (which it usually is), that bleeding almost always stops by itself (over 90% of the time). 

The trauma world has been vastly changed in the past 20 years by the advent of CT scans.  "CT" stands for "computerised tomography", and it's essentially a cross-sectional X-ray.  In the 1990's, a CT scan of the head alone used to take about 30 minutes, since the machine was only able to take one picture at a time.  But we were able to see inside the head for the first time.  These days, a full body scan only takes about 20 seconds because the machine takes 64 or 128 pictures at a time.  The best part is that the really fancy (read: expensive) machines automatically reformat the raw data into 3-D pictures.  But CT scans aren't just for looking at the brain or the guts.  They are also great at finding broken bones, and they are much more sensitive than regular X-rays.  Plus, the pictures just look cool.

In case you don't believe me, here's some proof.  This is an actual 3-D rendering of a patient of mine this past week who was jumped by a gang of misfits who punched and kicked him repeatedly in the face:


In case you don't see it immediately, look at the mandible (that's the jaw bone) on the lower left side of the picture just behind the last molar.  There's a second fracture on the right lower side of the picture just next to the midportion of the mandible. 

Getting all these scans may be a bit more expensive (ok, a LOT more expensive), but it has also enabled us to find a lot of injuries that plain X-rays just can't see.  It has also saved patients from a lot of unnecessary operations.  If I see a bleeding liver or spleen, I know that patient will most likely not need surgery.

Hey, wait a second...I'm operating less than before because of these damned CT scans!  But I love doing surgery!  I'm supposed to hate that, right?  But I just can't...they're just too cool.

Sunday, 14 October 2012

Nine lives?

When it isn't your time to go, it just isn't your time.  I'm not sure how much I believe that, but there are only so many patients I can see who should be dead but aren't before I start believing it.

Imagine for a second that you have a beautiful, tall, old tree in your yard that unfortunately needs a branch at the top trimmed.  Now this is a huge tree, probably 35 or 40 meters high (around 100-120 feet), and the branch in question is near the very top.  What would you do?  Here, I'll give you some choices:

A) Call a tree expert to trim the branch
B) Ignore it and hope it doesn't fall on your house
C) Get several 5 meter (15 foot) ladders, strap the first one to the bottom of the tree trunk, and climb up the first 5 meters.  Then strap the next ladder to the tree trunk and climb up the next 5 meters.  Then tie the next ladder to the trunk and climb up the next 5 meters...

You see where I'm going with this, right?  My patient, a 50-ish year old man who had already beaten prostate cancer and lymphoma, decided to go for option C.  He evidently thought he could also beat  gravity.  But gravity isn't just a suggestion - it's the law. 

Now I know what you're thinking - there's no way the tree was actually 40 meters high!  Doc, surely you're exaggerating!  Really?  Am I?


Those ladders you see are numbers 3, 4, and 5.  Ladders 1 and 2 wouldn't fit in the bottom part of the picture.  After he ran out of ladders, he attached spikes to his shoes and climbed another 7 or 8 meters (20-25 feet) above the top of the highest ladder.  As he was trimming the branches, he cut the one on which he was standing (no, of COURSE he wasn't wearing a safety harness!), and down he went...the equivalent of jumping off the roof of a 9 storey building.  Now when you fall only 3 or 4 meters off a ladder, there's no time to think.  It's just "AAAAAAAAAH!" *thud*  But this guy had over 2 seconds to realise that what he had done was stupid before he hit the ground.  I have a feeling it was something like this:

Fortunately for him, he didn't land on his head.  He fractured his left femur, left foot, left wrist, and right ankle, and several bones in his pelvis.  He also broke a bone in the middle of his back, and he'll need surgery to fix all of his various fractures. 

But keep this in mind - 50% of people who fall 4 storeys die.  NINETY PERCENT of people who fall 7 storeys die.  This lucky guy fell from 9 stories and never even lost consciousness.  It just clearly wasn't his time to go.  So now he has beaten prostate cancer, lymphoma, and gravity.  By my count he only has 6 lives left. 

It makes me wonder what he'll try to defeat next.

Tuesday, 9 October 2012

Now what??

There have been very few times in my career when I've been completely stumped, when I've had absolutely no idea how to proceed.  This is extraordinarily frustrating for a trauma surgeon - we're supposed to know exactly what to do, no matter how difficult the circumstances.  But sometimes something presents itself that is so bizarre, so strange, so unpredicted, that my brain just stops.

I had just such an experience recently.

I got a rather frantic call from a doctor at a small community hospital on a Sunday morning.  He sounded panicked, flustered, and at a loss.

"Yeah, I got 'something' here for you.  He...well, I mean, he was admitted last night...you just have to come and look.  I need your help...I think.  Maybe, probably.  No, definitely.  Please?"

What the hell was going on?  Grumbling under my breath, I drove there grudgingly.  Despite my moaning and groaning, I was actually curious about what was so urgent that he needed me on a Sunday morning.  It wasn't an emergency room patient, it wasn't a surgical patient.  So...what was it?

I walked into the man's room while glancing through his chart.  He was in his 40's, very healthy, though perhaps a bit thin.  He had been admitted the night before due to his rapid heart rate of around 140 beats per minute.  He had no chest pain or any other symptoms, there was no reported history of heart disease, and there were no illegal drugs on his urine screen.  I was confused about why I was there - I'm not a cardiologist!  Why am I here?  Then I turned the page...

"Patient admits to foreign object insertion."

Ah hah.  Now the truth comes out.  It turns out he had taken a bunch of pseudoephedrine the night before, which had caused his heart rate to rise, and then he had...no, I have no idea why, stop interrupting!  Anyway, he had then inserted "something" into his rectum.

"What did you insert, sir?" I said after a brief introduction.

"A butt plug."

Of course, a butt...wait, a what? 

I did a rectal examination, and I could feel the edge of something large, smooth, and flexible, but it was just outside the reach of my finger.  After a minute of thinking, I went down to the operating room and grabbed a large clamp that looked like this:
I returned to his room, instructed him to lay on his side, and I reached up there with the clamp.  Entirely by feel, I grabbed the edge of the thing with the clamp...and pulled.  Slowly, slowly, slowly it started to come out, when finally with a groan from the patient and an audible *POP*, out came this:


There I was standing behind him holding this 25cm (10 inch) long thing, and that is when it happened: I had no idea what to do next.  Do I throw it in the garbage?  Did he want it back?  Do I give it back to him?  Do I say something to him, and if so, what?  I was baffled.  WHAT NOW??

After what seemed like 10 minutes (but was probably closer to 2 seconds), I walked over to the sink, grabbed a paper towel, put it on his bedside table, and put the butt plug on the paper towel.  Then I walked out without a word.

Not surprisingly, I never heard from him again.  I have a sneaking suspicion this situation will arise again in the future, and even after thinking about it, I still don't know what I'll do when it does.

Wednesday, 3 October 2012

You're fired!

I got fired.

Yes, it's possible for a doctor, even a trauma surgeon, to get fired. But I never had...until a few days ago. Fortunately there were other trauma surgeons who were available to care for this patient...wait, let me take a step back and explain. Before you get worried, don't. It has a happy ending. Sorry if I just spoiled it.

A 40-something year old guy was brought to me after he rolled his car over several times. He was clearly intoxicated, but also clearly in a lot of pain. After an exhaustive workup, he had a collapsed lung and several broken ribs. I inserted a tube into his chest to re-expand his lung, and I admitted him to intensive care.

The next few days were rough for him - rib fractures hurt like hell, or so I'm told. About three days later his lung remained expanded, so it was finally time to take the tube out. He was sitting in his chair in the ICU when I came to see him, so to avoid bothering the nurse, I helped him back to the bed and removed the tube without any difficulty.

When I went to his room the next day, his wife ushered me back out.

"We want to see Dr. W" (not his real name) "instead of you from now on."

She must not have seen the flabbergasted look on my face, because she didn't explain. I haltingly told her ok, but I had never been fired before. Without a word, she gave me an awkward half smile and went back into his room. I started to walk away...

No. No! I've never been fired before. What the hell did I do wrong?? I had to know.

I steeled myself, turned back around, and went back to his room.

"I understand what you're saying, and I'll ask Dr. W to see you," I told them. "But if I need to know what I did wrong. If I leave here today having not learned anything, then I can't improve myself."

She explained that they were very upset about how I hadn't gotten the nurse's help the day before, and from their viewpoint that had made removing the tube more difficult and more uncomfortable. I explained that I try to be self-sufficient and not bother the already-overworked nurses. I then thanked them and left, feeling very unsettled. But at least I knew why.

Dr. W called me the next day - he went to see the patient, but he and his wife now wanted me BACK as their doctor. Apparently they were so impressed with how professionally I handled the adverse situation that they instantly felt at ease with me, and their trust and faith in me had been completely restored.

I'll never understand the human mind. This is why it's called "the art of medicine." There's so much more to it than just fixing holes and removing dead stuff.

But every day I learn something new is NOT a wasted day.

Thursday, 27 September 2012

When is a trauma...

Q: When is a trauma not a trauma?
A: When it's not a trauma.

Sounds logical enough, right?  Stay with me here...I'm about to prove that it isn't always so easy to figure out when you don't know the story.

In the midst of an otherwise slow morning, yet another "fall" was about to come in.  Would it be another elderly person on blood thinners who lost the unending fight against gravity?  Some idiot working on his roof in the rain?  An unlucky arborist whose harness broke?

None of the above.  It was a young woman found on the ground in a parking garage.  Great...another one "found down".  Whee, what fun.

Though she didn't have a mark on her head at all, she was certainly acting like she had a severe head injury.  She was terribly confused and could barely keep her eyes open. 

Uh oh, I thought.  This was going to be bad.

Our physical examination only noted some scratches on her knees, and the bottoms of her feet were filthy.  We rushed her off to the CT scanner where I expected to find a massive bleed.

I watched the scans of her brain as the pictures flipped by on the computer screen.  But it soon became clear that she had nothing.  NOTHING!  Her brain (and the rest of her body) appeared completely normal.

As I sat there scratching my head (Maybe she just had a severe concussion?  Diffuse axonal injury?), her sister arrived and told us the patient's name.  Wait a second...I know that name!  That's the same name as one of the ER docs at my other hospital!  I looked closely at the patient...she was still fast asleep, but yes indeed, same person!  And that's when I learned what had really happened. 

She had just come off working the night shift in the emergency department.  She got home and took two sleeping pills which happen to have a very well-described side effect of sleep walking.  Her feet were so dirty because she had sleep walked out of her bedroom, out of her house, and all the way to her parking garage, where she had finally lain down to sleep next to her car.  That's also why she couldn't keep her eyes open.

She woke up about an hour later, completely uninjured but embarrassed as hell.  "I'm supposed to be where you're standing, not in the bed," she told me.  I saw her several days later in her ER when she called me about a patient. 

"Any more interesting walks?" I asked her. 

She smiled at me sheepishly.  "Nope," she said with a blush.  "I flushed the rest of the pills down the toilet."

Sunday, 23 September 2012

Internship

in·tern
/ˈintərn/
Noun
A recent medical graduate who is required to work insane hours, never sleeps, and knows nothing about medicine, yet is expected to answer 1000 daily questions from nurses about how much lorazepam the crazy 82-year old woman in room 476 can have.

I walked into the hospital on my first day of being a doctor not really knowing what to expect. It was 6AM, and the senior residents walked in a few minutes later. The new second year residents looked the happiest to see us because THEY weren't the slaves anymore. It's like they were handing over the keys to the shittiest car to the people who didn't even know how to drive. But they didn't care, as long as they were out of the car.

The first day was hell - I had to make rounds on 25 patients I knew nothing about, and I was immediately bombarded with questions from the nurses, questions I couldn't possibly know the answer to.

"Can we take out 24's foley?"
"Can 15 have a clear liquid diet?"
"The guy is 20 has a fever. What should we do?"
"11 is confused again. Should we give Haldol or get a head CT?"
"Can I send 2 home today?"

Medical school doesn't prepare you for this stuff. AT ALL. If the nurses had asked me how morphine works or to draw a diagram of the coagulation cascade, that I could do. But the actually relevant clinical stuff? I was entirely unprepared.

I quickly figured out who the "good" nurses were. My standard answer was to ask them what they would usually do. If their answer was "What do YOU want to do?", I immediately labeled them "BAD". Fortunately it only took a few days to figure out most of this stuff. It's a sink-or-swim environment, and we all swam.

My first real test came the next day. My chief resident told me to assist Dr. F (not his real name) in the OR. My first operation!! I was absolutely ecstatic. No senior resident, no chief. Just me and the attending surgeon, a man I'd never met.

I walked into the OR to see Dr. F straining by himself at the case - a pancreatic debridement for necrotising pancreatitis. If it sounds awful, that's because it is. It's also a very difficult chief resident-level case.

"Who the hell are you?" he yelled.

I introduced myself.

"And why the hell are you here? Where's the chief?"

I told him the chief had asked me to help him.

"WHAT?  Wait, so let me get this straight...two days ago you were a medical student, right?"

Yes, I said quietly.

"So the chief sent a MEDICAL STUDENT to help me debride a pancreas?!"

All I could do was stare at him and hope he didn't throw a scalpel at me.

"Oh for fuck's sake, come on.  Scrub in, medical student."

I scrubbed my hands, put on my gown and gloves, and slowly took my place opposite him. He took a look directly in my eyes, paused for a second, and asked the tech to hand me an instrument, the same one he was holding.

Wait wait wait... hand ME an instrument?

"Yeah, but make it a plastic one like the medical students use."

Oh.  Ouch.

He was kidding, of course. Over the next two hours he instructed me exactly what parts of the organ to remove (and what parts NOT to touch) and how. We worked together for those two hours cleaning the patient's organs. I was not a bystander or an observer - I was operating. I was a surgeon.

Dr. F turned out to be one of my biggest allies over the course of my training and one of my biggest influences. He taught me not only how to be a surgeon, but how to be a doctor.

Thanks, Dr. F. Thanks very much.

Monday, 17 September 2012

Listen to the patient

It seems these days that X-rays, CT scans, and MRIs have rendered the history and physical examination obsolete.  I've had countless situations when an ER doctor calls me to see a patient based on a CT scan result when they have barely spoken to the patient and haven't even examined him.  Despite advances in medical science, nothing can replace taking a full history, and nothing can replace putting your hands on (and in) a patient.  When I first decided to go into medicine, my grandfather (who was a general practitioner back when they existed) gave me one piece of advice - "Listen to your patients, because if you do 80% of the time they will tell you the diagnosis."  This next story is a prime example.

I received an email from Mrs. L (not her real name) telling me about a horrific experience she had a few years ago.  I've received several stories from readers, and I continue to encourage everyone to submit  stories to me.  But I haven't been inspired to publish one until now:

"This happened about 11, almost 12 years ago. On a Friday night I began having abdominal pains. I figured I was just getting cramps, so I took some medicine and went to bed. The next day I felt fine, and I continued without giving much thought of what might be going on.

The following Wednesday, while at a friends watching a movie, I started having the same pain, but much sharper. I tried to tough it out, and after about an hour I told my friends I was going to go home. I got up and instantly doubled over in pain. My friends were trying to convince me to go to the hospital, and I said not to worry about me, I will just go home. How I thought this was possible given I had a 20 minute drive yet could not walk two feet is beyond me. One of my friends said no, and she went to get my car while the other guy carried me down the stairs and got in the back seat with me.

Once we got to the hospital, I was starting to get worse, and I remember lying on a bench in the fetal position for several hours just crying in pain.  I was finally taken back, and I asked to use the restroom. I went, and there was A LOT of blood.  I was just thinking I got my period, and I'm going to be fine.  I opened the bathroom door, took one step out, and fainted. I was taken to a room, where I waited for test results.  A doctor came in and told me that I was pregnant, which of course caused me to burst into tears (I was 19 at the time).  He informed me that they need to do an ultrasound at this point, so off we went.  I was lying there, and the tech began to do the ultrasound.  She suddenly told me "You need surgery."  I  was wheeled out very quickly when a new doctor told me something about performing surgery on me and he has to do it now.  I remember telling him, "Doc, I only have one ovary, it's on my right side."  He gave me a weird look.  
I woke up a few hours later, and the doctor came in to check on me.  I found out then that I had a tubal pregnancy which ruptured [My note: that's a pregnancy in the fallopian tube, a potentially terrible problem], and due to the internal bleeding, I could have died.  He also asked me how I knew I only had one ovary and fallopian tube since I had never had surgery, nor have I had anything done that would have told me that I was like that.  I told him I don't know, I just knew.  Very crazy, who knows why I told him, or how I knew. Still freaks me out to this day.

If it was not for that doctor, I would not be here.  People like you are the reason I am alive today.  I don't know who that doctor was, but I am forever grateful I am still alive.  No kids, maybe never, but I have a husband, a dog, and am pretty damn happy now.  And you just can't put a price on a happy life, right?

I just wanted to say thanks for what you do, and saving people like me.

Mrs. L"

I've gotten a lot of letters from people asking me why I chose to go into surgery.  I think this post answers that question pretty definitively.  This is EXACTLY why.  Mrs. L could have died that day, yet here she is over 10 years later - alive, happy, and healthy.  And she's absolutely right - you can't put a price on that.

Friday, 14 September 2012

Second opinions

"Ok, I hear what you're saying.  But I'd like a second opinion."

As a patient, if you aren't comfortable with what I tell you, getting confirmation from a second doctor is definitely a good idea.  Even still, these are words that no doctor wants to hear.  Whenever patients say this to me, I always say that I'm not offended, and that a second opinion is their right.  I know this is true.  I really do.  But on the inside, I'm fuming.  I'm very good at what I do, but it's as if you're telling me that you don't believe me, don't trust me, or just don't like me.

My patient was a relatively young pediatrician who had severe acute-onset abdominal pain, and her internist thought she may need emergent surgery.  I examined her thoroughly and reviewed her CT scan, but it looked to me like she had an acute flare of Crohn's disease.  This is NOT a diagnosis I like to make, because it's a terrible, incurable, lifelong disease with potentially horrible complications.  After my examination, I excused myself to chat with her internist and gastroenterologist who had been seeing her.  I discussed the case with them, and they both agreed that this was the most likely diagnosis.  Surgery during an acute flare of Crohn's disease is a terrible idea and is almost never necessary.  A course of steroids usually calms the flare.  I went back and sat with the patient to discuss the situation.  She listened intently, thought for a moment, and said that she wanted a second opinion from another surgeon.

This was a particularly difficult case, and I explained that if she wasn't completely comfortable with my plan of care a second opinion is always fine.  Oh no, she said, it wasn't the plan that she wasn't ok with.  She just thought I looked young and wanted someone a bit older.

Really?  REALLY?  She's also a doctor, and she knew that my assessment was correct.  I wanted to yell at her and tell her I've been a doctor for over a decade and I know exactly what the fuck I'm talking about.  But fortunately I kept my composure and told her that was no problem.  I know I have a young face and I get this sort of thing a lot, I told her with an apparently-boyish smile.  A colorectal surgeon was called in as the second opinion.

He's two years younger than I am, but thankfully his hair is starting to grey.

The colorectal consultant completely agreed with my assessment, and the steroids were started.  The next morning she felt 90% better.  Surgery was avoided, and I felt completely vindicated.

I love being right, especially in situations like this.  Maybe I should dye my hair grey so I look more venerable and believable.

EDIT: The patient sent me an email last night with an update:

I just write to thank you for your care. You were the only doctor, in my honest opinion, who truly cared and helped me during my stay. I underwent extensive diagnostics, and the biopsies are still pending. I went home off steroids which were stopped after 48 hrs. 
 
Thank you for your care and excellent bedside manners.
There is something very satisfying about getting a "thank you" from a patient.  It somehow makes the world seem brighter.
 

Monday, 10 September 2012

A woman scorned

"Heaven has no rage like love to hatred turned,
Nor hell a fury like a woman scorned." - William Congreve, The Morning Bride

"We shall find no fiend in hell can match the fury of a disappointed woman." - Colley Cibber, Love's Last Shift

It seems I'm not the only one that knows not to piss off a woman.  Sure, men can get angry and cause mayhem, but when a woman gets mad at you, you'd better run.  Fast.  Unfortunately this next patient never figured that out.

A very drunk man was brought to me this past weekend having been stabbed in the neck.  IN THE NECK.  The wound wasn't bleeding, so it was clear that the jugular vein and carotid artery weren't injured.  On initial examination, the wound was just about 2 cm (less than one inch) long, a bit above the right collar bone.  Because he was so drunk and belligerent, I sedated him and put in a breathing tube so we could do our workup.

Once he was sedated I wanted to assess how deep the wound was, so I put my finger in the wound...my entire finger.  It takes a lot of force to plunge a knife that deep, so this was obviously done by someone thoroughly enraged.  My secondary exam of the rest of him only showed no other injuries and a tattoo of "Mary" on his left chest (not her real name).

After a battery of further tests, it turned out that no major structures were damaged, and I sutured the wound closed.  I was approached by a police officer as I was finishing, and she told me that his girlfriend Betty (not her real name) was in custody for stabbing him.

"But wait, but the tattoo says Mary!" I hear you say.  Well, yes...and that's the problem.

It turns out he's been married to Mary for several years, but he never bothered to tell his girlfriend Betty about her.  He and Betty were getting hot and heavy in her kitchen and she was tearing his clothes off for some mid-day drunken hanky panky.  He was too drunk to remember to keep his shirt on, which he had done every other previous time so she couldn't see the tattoo.  Unfortunately for him she caught sight of his tattoo for the first time.   After a brief interrogation (consisting only of "WHO THE FUCK IS MARY??"), she grabbed the first thing she saw - a steak knife.

Now you never have to wonder why I treat my wife so well.

Friday, 7 September 2012

Surgical training

Imagine for a moment a job where you are treated like a servant, you make less money than fast food workers, you get yelled at constantly for things that aren't your fault, you often work 120 hours a week (there are only 168 total), no one ever says "thank you", and this servitude is guaranteed to last for at least five years.  Oh, and at any given moment the safety of 25 or 30 people's lives rests squarely on your shoulders.  I'm sure you're just jumping out of your seat wondering how you can apply for this wonderful job, right?  Sound like something you'd be interested in?  Great!  Then train to become a surgeon.

Unfortunately, none of that is exaggerated.  Depending on where you train and what field you want to enter (cardiac, plastics, orthopaedics, urology, general, trauma, etc), surgical training takes between 5 and 8 years after 4 years of medical school.  To say it's a pressure cooker is an understatement - here was a typical day during my training.

4:30AM - Arrive at work, start pre-rounding, gathering vital signs
6:00AM - Make rounds with the team
7:00AM - Make rounds with the senior surgeon/consultant/attending
7:30AM - Surgery starts
4:00PM - Make afternoon rounds
10:00PM - Go home

And during all this time, I had to somehow create time to study.  In all specialties across medicine there are two major components to the training - A) Learn how to be a doctor and take care of patients, and B) Learn about all the stuff that can possibly go wrong with every part of the body.  In surgery, however, there is a very unique third component - C) Learn how to fix all that stuff.  The only way to learn how to operate is to see it and then do it.  But we also have to learn why we are doing the surgery, when to operate, and even more importantly when not to operate.  We then have to learn what to do when there is a complication with surgery.  If something goes wrong, it has to be fixed, and there are so many things that can go wrong it will make your head spin.  (Head spinning is not one of the complications I'm talking about.) 

In addition to working during the day, there's also the dreaded CALL.  This means staying in the hospital overnight, responding to phone calls in the middle of the night from frantic nurses about fevers, bleeding, patients falling out of bed, hiccups (seriously), and anything else that pops into their heads.  It also means seeing patients in the emergency room, assisting with surgery, and trying to steal a minute or two of sleep while praying that your pager doesn't go off again

My first year of training was by far the worst, but it only got marginally better after that.  The hours got a tiny bit better, perhaps only 100-110 hours a week, but the responsibility was much greater as the training progressed.  I had gotten married a few weeks before I started my training, and this whole process strained my marriage to its very limit. Statistics show that there is a 33% divorce rate among surgeons, and some training programs boast a 100% divorce rate, something they seem proud of as if they're saying, "Our trainees work so hard, there is NO time left for spouses!"

I somehow managed to get through my five years of training, and best thing to come out of those seemingly-endless years of torture was my beautiful daughter who was born midway through my fourth year.  The best advice I can give anyone going through this process (or even considering it) is to put family first.  A good training is very important, but nothing is more important than family.

Thursday, 6 September 2012

Medical training

Some of the questions I get most often via email are about medical training - not necessarily my medical training, but about medical school in general, surgical training, and what it takes to do what I do.  In the past day I've gotten email requests for blogging about both my training and medical school, so it seems like these might be some good topics to discuss.

Let me start by saying that being a doctor is pretty damned cool.  I can think of very few professions that get as big an "OOOH!" as when someone asks me what I do for a living, especially when I tell them I'm a trauma surgeon and explain what I do.  Yes, I'll admit it's glamorous as hell, and it's a hell of a lot of fun.

I didn't know that when I decided to become a doctor at age 5.  I remember visiting my grandfather's office (he was a general practitioner) and playing with all his cool instruments and thinking, "I want to use these when I get older!"

Getting to medical school was difficult, as expected.  There is a lot of competition, and everyone who applies is just as good as you.  I was near the top of my class in high school, and medical schools select the cream of the crop.  Even though you may have been used to being at the top of everything, once you're there, you're just like everyone else.  EVERYONE is just as smart as you.

Medical school itself is just as difficult as you've heard.  The workload is heavier than anything you've ever experienced, and the sheer amount of material you're expected to learn seems impossible.  However, somehow you manage to learn it.  ALL of it.  A few people drop out every year, but for the most part, everyone passes despite the difficulty.  The running joke in medical school is this:

Q: Do you know what they call the person who graduates last in his class in medical school?
A: Doctor.

I entered medical school expecting to become a pediatrician or a psychiatrist.  I always loved working with kids, and the human mind has always fascinated me.  But having done my third-year clerkships in both pediatrics and psychiatry, neither of them seemed to be a good fit.  Then on my first day of my surgery clerkship, I scrubbed into my first surgery, put on my gown and gloves, and laid my hands on the anesthetised patient.  YES - THIS FEELS RIGHT!  And that was it - a feeling.  A feeling like I belonged right there and nowhere else.

I'll discuss my surgical training in my next post.  I'd hate to bore anyone by making this too long.

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