When you're watching a movie, do you ever find yourself saying, "I bet something is going to fall out that window and land on that guy. SEE! I told you!" Can you predict the future? Can you sense what is about to happen? Well I can, apparently. And I predict that you can too.
A young man was admitted after swallowing a pen. No, not a pin. A pen. A Bic ink pen. How did he do that? No seriously, I'm asking you: HOW THE HELL DID HE DO IT? I have no idea, but somehow he did. And then he came to the ER with abdominal pain, much to the surprise of no one.
We did an upper endoscopy and managed to remove the plastic barrel of the pen, but the ink cartridge and the nib (that's the tip) were nowhere to be found. We figured they would eventually pass through his GI tract...wait, are you predicting anything yet?
Right, they didn't pass. After 3 days of observation, his poop was distinctly ink-free.
Shit.
I got an X-ray which showed the nib somewhere in his small intestine. Still, I figured it would make its way out eventually, and his pain was gone. So I figured I'd send him home and let him poop out the nib in the comfort of his own home.
I went into his room to tell him the good news. "You're going home today!"
"That's great news, Doc. Thanks! Oh by the way..." Oh no...do you see it coming?
"...I swallowed another pen."
He did...how could...but why would he...what a fucking idiot!! I hear you saying.
I knew you were going to say that.
Saturday 25 February 2012
Saturday 18 February 2012
Rudeness
We often joke amongst ourselves about some of the nastier trauma patients who come in who were obviously up to no good. We get idiots who steal cars and crash them after fleeing from the police, morons who get into drug shootouts, and various and sundry other imbeciles. But to make ourselves feel better, we like to fantasise that the gang member who was shot in the abdomen was probably on his way back from delivering flowers to the senior home...the drunk driver was driving back from volunteering at the soup kitchen...you get the idea. Some people cross the line and take this joke a little too far. Others stomp on the line, spit on it, pee on it, and then cross so far over it that you can't even see it anymore.
If you've read through my blog, you've no doubt noticed that I can be brutally honest with my patients. This can sometimes come off as rude, though I don't mean it to be. I always do it in the context of education - telling a patient that what he did was stupid and could have injured himself or someone else. However, some doctors must have missed the "Bedside Manner" lecture in medical school. Take, for example, the anesthesiologist I worked with this evening. Please.
A 19-year old kid got into an "altercation" (as he put it) with another young man, so he pulled out a knife. You've heard the phrase "Don't bring a knife to a gunfight"? Well, this was "Don't bring a knife to a meat cleaver fight." That's right, the other guy pulled out a meat cleaver and then threw it at him, ninja-style. The blade struck him in the face and lacerated him down to his mandible. He was bleeding fairly extensively, and I needed to control the bleeding and repair the wound.
We wheeled him quickly down to the OR so I could fix his face, and the anesthesiologist looks at him and says to him, "So let me guess - you were on your way home from church, right? Haha!"
I was mortified. But it gets worse. After filling out some of his paperwork, he looks at the wound and says to the guy,
"So I guess the other guy had a bigger knife, huh?"
Yes, he actually said that to this guy who was bleeding from an 8cm laceration in his face.
If you've read through my blog, you've no doubt noticed that I can be brutally honest with my patients. This can sometimes come off as rude, though I don't mean it to be. I always do it in the context of education - telling a patient that what he did was stupid and could have injured himself or someone else. However, some doctors must have missed the "Bedside Manner" lecture in medical school. Take, for example, the anesthesiologist I worked with this evening. Please.
A 19-year old kid got into an "altercation" (as he put it) with another young man, so he pulled out a knife. You've heard the phrase "Don't bring a knife to a gunfight"? Well, this was "Don't bring a knife to a meat cleaver fight." That's right, the other guy pulled out a meat cleaver and then threw it at him, ninja-style. The blade struck him in the face and lacerated him down to his mandible. He was bleeding fairly extensively, and I needed to control the bleeding and repair the wound.
We wheeled him quickly down to the OR so I could fix his face, and the anesthesiologist looks at him and says to him, "So let me guess - you were on your way home from church, right? Haha!"
I was mortified. But it gets worse. After filling out some of his paperwork, he looks at the wound and says to the guy,
"So I guess the other guy had a bigger knife, huh?"
Yes, he actually said that to this guy who was bleeding from an 8cm laceration in his face.
Thursday 16 February 2012
Discovery
Unpredictability is an inherent part of trauma - you never know someone is going to get shot or stabbed, you never know when someone will crash their car, when someone will get hit by a train, or when someone will fall off a roof. And when someone DOES get injured and I need to take that person to the operating theatre, I usually don't know the extent of their internal injuries until I'm already inside them. Part of the fun of trauma surgery is finding out what's wrong and then fixing it. It's about discovery. It's the same sense of adventure that prompted Erik the Red, Marco Polo, and Vasco da Gama...sort of. Ok, maybe not.
But some discoveries just aren't fun at all. Take for instance a 19 year old woman who was referred to me for abdominal pain. Gallstones? No. Stomach ulcers? Not at all. Appendicitis, perhaps? Not even close. Her favourite pastime was inserting sewing needles into her abdomen. That's right - she took these...
...and pushed them through her abdominal wall until they were completely inside her. How many? Oh, about 14 or 15 at last count. She chuckled a bit as she told me she just lost count.
Amazingly, none of them had done any real damage (other than some hideous scarring on her abdomen). But now she had decided that she wanted them out because they were starting to hurt.
I said no. Flat out, hands down, open and shut, definitive NO.
If you haven't read my post about leaving bullets in, you can read about it here. We don't usually remove foreign bodies in the abdomen, and this is much more dangerous - for me - than removing a bullet. I looked carefully at her abdominal X-ray:
(Unfortunately, that's not her actual X-ray...she had a few more needles than this person.)
I then told her that there are at least 15 needles inside her, and any one of them could injure me (if I stick myself) or her (if I push the needle into something).
"But what can I do?" she asked me.
Go see a psychiatrist and get some ibuprofen. In that order.
But some discoveries just aren't fun at all. Take for instance a 19 year old woman who was referred to me for abdominal pain. Gallstones? No. Stomach ulcers? Not at all. Appendicitis, perhaps? Not even close. Her favourite pastime was inserting sewing needles into her abdomen. That's right - she took these...
Amazingly, none of them had done any real damage (other than some hideous scarring on her abdomen). But now she had decided that she wanted them out because they were starting to hurt.
I said no. Flat out, hands down, open and shut, definitive NO.
"But how can you leave them inside her??" I hear you asking.
If you haven't read my post about leaving bullets in, you can read about it here. We don't usually remove foreign bodies in the abdomen, and this is much more dangerous - for me - than removing a bullet. I looked carefully at her abdominal X-ray:
I then told her that there are at least 15 needles inside her, and any one of them could injure me (if I stick myself) or her (if I push the needle into something).
"But what can I do?" she asked me.
Go see a psychiatrist and get some ibuprofen. In that order.
Monday 13 February 2012
Deviation
I'm going to step away from my usual modus operandi here and post something that has nothing to do with medicine.
This may seem shocking to some readers, but I do actually have a heart, and it is currently in the possession of my wife and my two children. These three people are the reason for my existence, and everything I do is to support them.
Done vomiting yet? Ok, wipe your mouth. Wait, you missed a little there on the corner. No, the other corner. Anyway, anyone who has kids will be able to relate to this story easily. Those who don't, well, maybe you'll get a chuckle nevertheless.
There comes a point in your child's life when this little person understands that you love him and that he loves you back. I remember that moment with my daughter vividly. That moment just happened with my son. Sort of.
I was holding him just before putting him in his crib. The lights were out, and he was half asleep, having just finished his bottle. His face was barely illuminated by the glow of the nightlight as he turned his eyes directly into mine. His huge hazel eyes stared directly into mine, and I saw a strange, perhaps quizzical expression come over his face, like he had just figured something out. He reached his tiny hand up towards my face, and I thought, "He gets it! He knows I'm his Daddy!" His hand reached my face...
And he stuck his finger directly up my nose...and then he laughed.
Damn. Maybe tomorrow night.
This may seem shocking to some readers, but I do actually have a heart, and it is currently in the possession of my wife and my two children. These three people are the reason for my existence, and everything I do is to support them.
Done vomiting yet? Ok, wipe your mouth. Wait, you missed a little there on the corner. No, the other corner. Anyway, anyone who has kids will be able to relate to this story easily. Those who don't, well, maybe you'll get a chuckle nevertheless.
There comes a point in your child's life when this little person understands that you love him and that he loves you back. I remember that moment with my daughter vividly. That moment just happened with my son. Sort of.
I was holding him just before putting him in his crib. The lights were out, and he was half asleep, having just finished his bottle. His face was barely illuminated by the glow of the nightlight as he turned his eyes directly into mine. His huge hazel eyes stared directly into mine, and I saw a strange, perhaps quizzical expression come over his face, like he had just figured something out. He reached his tiny hand up towards my face, and I thought, "He gets it! He knows I'm his Daddy!" His hand reached my face...
And he stuck his finger directly up my nose...and then he laughed.
Damn. Maybe tomorrow night.
Saturday 11 February 2012
Honesty
Whenever I talk with a patient and/or family members, I always start by telling them that I'm completely open and honest. I don't hold back and I don't pull punches. Let's face it - if you need to see a surgeon, something is seriously wrong with you, and this is not the time for me to pat you gently on your knee and tell you that this won't hurt a bit and everything will be fine. You need me to be honest. You want me to tell you every little detail about what could possibly go horribly wrong.
Full disclosure in medicine is a good thing. When I see a drunk driver, I will flat out tell him that what he did was stupid. I won't go so far as to tell him that he is stupid, but I've come close. And there have been innumerable occasions when I've been tempted to tell an obnoxious patient exactly what I think of him (or her). Some doctors don't seem to have my restraint, however.
A recent patient of mine was struck by a car as she was walking across the street, suffering fractures of her arm and both legs. She was a rotten patient from the beginning - rude and surly. She would barely look at me when I entered her room to see her, and her answers were usually one syllable (when she chose to talk at all). Now I understand that she was seriously injured, but she has to understand that I'm here to help her. Her attitude was lousy, but I put up with it due to her difficult circumstances.
I asked a psychiatrist to see her because of her mood. Apparently she was just as rude to the shrink, but this guy decided he wasn't taking her nonsense...I suppose talking with crazy people all day will do this to a guy. After a rather contentious interview where she was nothing but rude, she basically threw him out of her room. As he was walking out, he turned around and announced,
Full disclosure in medicine is a good thing. When I see a drunk driver, I will flat out tell him that what he did was stupid. I won't go so far as to tell him that he is stupid, but I've come close. And there have been innumerable occasions when I've been tempted to tell an obnoxious patient exactly what I think of him (or her). Some doctors don't seem to have my restraint, however.
A recent patient of mine was struck by a car as she was walking across the street, suffering fractures of her arm and both legs. She was a rotten patient from the beginning - rude and surly. She would barely look at me when I entered her room to see her, and her answers were usually one syllable (when she chose to talk at all). Now I understand that she was seriously injured, but she has to understand that I'm here to help her. Her attitude was lousy, but I put up with it due to her difficult circumstances.
I asked a psychiatrist to see her because of her mood. Apparently she was just as rude to the shrink, but this guy decided he wasn't taking her nonsense...I suppose talking with crazy people all day will do this to a guy. After a rather contentious interview where she was nothing but rude, she basically threw him out of her room. As he was walking out, he turned around and announced,
YOU ARE A NASTY BITCH.Maybe I should try that sometime.
Saturday 4 February 2012
Better lucky than good?
We've all heard the phrase "It's better to be lucky than good." I typically believe in that adage quite strongly, but sometimes it's just better to be good.
I was consulted today on a 26-year old healthy woman who was having excruciating acute-onset abdominal pain, mainly on the right. It was so severe that she was requiring 20 milligrams of morphine per hour. In case you aren't a pharmacologist, that's approximately the dose that would put an elephant to sleep instantly. But she was still very much awake and still writhing in pain. But her abdominal exam was relatively benign, and her lab work was normal. Oh, did I mention that she's 28 weeks pregnant?
Pregnant patients are always diagnostic dilemmas. It's very difficult to work these patients up, and even more difficult to treat certain things, especially surgically. But because her pain was mainly on the right, the immediate concern was acute appendicitis, something that can be very dangerous to the fetus. But something just didn't sit right with me. Actually, all of it didn't sit right with me. Her history wasn't consistent with appendicitis, her exam wasn't consistent, her lab work wasn't consistent, and she even had a CT scan read by two different radiologists who didn't see appendicitis.
I agreed. I didn't think the CT showed anything abnormal. I thought she had a kidney stone.
A third radiologist disagreed - she thought it was appendicitis. The OB-GYN thought it was appendicitis. I asked a colleague (who happens to be chair of the department) to see her as a second opinion - he thought it was appendicitis. Here now were three physicians with about 100 years of combined experience all telling me that this woman had appendicitis.
I still disagreed. My mere 5 years of post-training experience was screaming "IT ISN'T APPENDICITIS! THEY ARE WRONG!"
Unfortunately my hand was forced. I was forced to operate on her because of the radiology reading. I took her to the operating theatre, made a small incision, carefully pushed her uterus to the side, and lifted up a PERFECTLY NORMAL appendix. She and the fetus both tolerated surgery just fine, and she felt much better the next day after she passed her kidney stone.
After this little episode today I've created my own new adage - "It's better to be good than wrong."
I was consulted today on a 26-year old healthy woman who was having excruciating acute-onset abdominal pain, mainly on the right. It was so severe that she was requiring 20 milligrams of morphine per hour. In case you aren't a pharmacologist, that's approximately the dose that would put an elephant to sleep instantly. But she was still very much awake and still writhing in pain. But her abdominal exam was relatively benign, and her lab work was normal. Oh, did I mention that she's 28 weeks pregnant?
Pregnant patients are always diagnostic dilemmas. It's very difficult to work these patients up, and even more difficult to treat certain things, especially surgically. But because her pain was mainly on the right, the immediate concern was acute appendicitis, something that can be very dangerous to the fetus. But something just didn't sit right with me. Actually, all of it didn't sit right with me. Her history wasn't consistent with appendicitis, her exam wasn't consistent, her lab work wasn't consistent, and she even had a CT scan read by two different radiologists who didn't see appendicitis.
I agreed. I didn't think the CT showed anything abnormal. I thought she had a kidney stone.
A third radiologist disagreed - she thought it was appendicitis. The OB-GYN thought it was appendicitis. I asked a colleague (who happens to be chair of the department) to see her as a second opinion - he thought it was appendicitis. Here now were three physicians with about 100 years of combined experience all telling me that this woman had appendicitis.
I still disagreed. My mere 5 years of post-training experience was screaming "IT ISN'T APPENDICITIS! THEY ARE WRONG!"
Unfortunately my hand was forced. I was forced to operate on her because of the radiology reading. I took her to the operating theatre, made a small incision, carefully pushed her uterus to the side, and lifted up a PERFECTLY NORMAL appendix. She and the fetus both tolerated surgery just fine, and she felt much better the next day after she passed her kidney stone.
After this little episode today I've created my own new adage - "It's better to be good than wrong."
Friday 3 February 2012
A, B, C
When a patient is injured, it's up to the paramedics to determine if the patient is injured badly enough to call "a trauma" or not. If they believe he is potentially severely injured, he comes to me. Not bad enough, he goes to the ER to see an ER doctor, and if that person finds injuries that need further care, he consults me.
In trauma we follow certain protocols. It helps us avoid mistakes and it bails us out of innumerable problems. The major protocol couldn't be easier to remember: ABCDE.
A: Airway. Secure the airway, #1 priority, always.
B: Breathing. Is the patient doing it? If not, do it for him.
C: Circulation. Is the patient's heart beating? If not, do it for him.
D: Disability. What's the neurological status?
E: Exposure. Completely disrobe the patient and look for hidden injuries.
You always start with A and you do NOT move on until you're satisfied it's ok. If the patient isn't responding to your treatment appropriately, start back at A and figure out what you missed.
Easy, right? Well...not so much for some people, mainly ER doctors in my observations.
A few weeks ago I had a STAT consult from an ER doc on a patient with multiple stab wounds. Though I was already attending to 5 other seriously injured victims, I immediately ran to the main ER to see a very calm-looking man lying quite comfortably on his stretcher with his right arm and left leg nicely bandaged. Turns out he was stabbed in a bar fight, but no one had looked at his wounds yet.
ABCD...E?
I unwrapped his arm and leg and found three tiny 1cm stab wounds, none of them bleeding. At all.
I called the ER doc over and asked her if she had evaluated the wounds yet. "No, I just heard multiple stabbings and I called you."
Right. Like I wasn't busy enough.
Apparently to her, the protocol is:
A: AAAAAAAHHHH!!
B: Bullshit
C: Consult trauma surgeon
In trauma we follow certain protocols. It helps us avoid mistakes and it bails us out of innumerable problems. The major protocol couldn't be easier to remember: ABCDE.
A: Airway. Secure the airway, #1 priority, always.
B: Breathing. Is the patient doing it? If not, do it for him.
C: Circulation. Is the patient's heart beating? If not, do it for him.
D: Disability. What's the neurological status?
E: Exposure. Completely disrobe the patient and look for hidden injuries.
You always start with A and you do NOT move on until you're satisfied it's ok. If the patient isn't responding to your treatment appropriately, start back at A and figure out what you missed.
Easy, right? Well...not so much for some people, mainly ER doctors in my observations.
A few weeks ago I had a STAT consult from an ER doc on a patient with multiple stab wounds. Though I was already attending to 5 other seriously injured victims, I immediately ran to the main ER to see a very calm-looking man lying quite comfortably on his stretcher with his right arm and left leg nicely bandaged. Turns out he was stabbed in a bar fight, but no one had looked at his wounds yet.
ABCD...E?
I unwrapped his arm and leg and found three tiny 1cm stab wounds, none of them bleeding. At all.
I called the ER doc over and asked her if she had evaluated the wounds yet. "No, I just heard multiple stabbings and I called you."
Right. Like I wasn't busy enough.
Apparently to her, the protocol is:
A: AAAAAAAHHHH!!
B: Bullshit
C: Consult trauma surgeon
Thursday 2 February 2012
Blood
People sometimes ask me how I don't get sick at the sight of blood. It's a damned good question, and one for which I don't have a good answer. I've seen (and smelled) some of the worst things the human body can create, including gangrenous intestine, necrotising fasciitis ("flesh-eating bacteria"), Fournier's gangrene (google it if you dare), and horrible cancers. But it seems the most unlikely people are the ones who are the most likely to faint at the slightest drop of blood.
A group of very large marines were observing in my trauma bay. These are the toughest of the tough, men who can kill you 74 different ways with their pinky fingers and Scotch tape. One if them, a particularly burly fellow, kept pacing the room, excitedly asking when a "good one" was going to come in. The way he was jumping around, you'd think Santa was on his way with a shiny new bike.
Finally a good one came - a pedestrian hit by a dump truck at 80 kph (50 mph). Here's what the floor of the trauma bay looked like when we were done (yes, this is a real picture of my trauma bay last night after we finished):
You'll notice a distinct lack of marine on the floor. That's because we had to pick him up and put him on the stretcher in the next bay after he fainted and fell straight back, landing directly on his clean-shaven head.
A group of very large marines were observing in my trauma bay. These are the toughest of the tough, men who can kill you 74 different ways with their pinky fingers and Scotch tape. One if them, a particularly burly fellow, kept pacing the room, excitedly asking when a "good one" was going to come in. The way he was jumping around, you'd think Santa was on his way with a shiny new bike.
Finally a good one came - a pedestrian hit by a dump truck at 80 kph (50 mph). Here's what the floor of the trauma bay looked like when we were done (yes, this is a real picture of my trauma bay last night after we finished):
You'll notice a distinct lack of marine on the floor. That's because we had to pick him up and put him on the stretcher in the next bay after he fainted and fell straight back, landing directly on his clean-shaven head.