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


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 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.

Tuesday, 4 September 2012


We all know them no matter what they are called where you're from - rednecks, yokels, bumpkins, chavs, bogans, pikeys, carrot crunchers, worzels, etc.  I just call them idiots.  These people have a very special way of acting completely ridiculous and getting into trouble in very creative ways.

The call on "the box" told me I would be getting a victim of a car accident.  What arrived 5 minutes later was a 175kg (385 lb) redneck (for lack of a better term), screaming at the top of his lungs for his wife.


The medics then told me he had actually been thrown out of a moving car, not in a car accident.  He was clearly drunk, though whenever anyone mentioned alcohol, he violently thrashed around and vehemently denied drinking anything.  It took 8 men to hold him down while we established IV access and sedated him so we could perform our assessment.

The medics then said his wife would be coming in another ambulance in 5 minutes.  She had been stabbed.

Wait...what??  He was thrown out of a car, and she was stabbed?  The story made no sense.

When she arrived, she did have three very small, superficial stab wounds in her shoulder and leg, and she had then been pushed out of the same car.  Because she had bruises all over her body, the medics believed that she had been sexually assaulted, and they believed her husband had been thrown out of the car while trying to protect her.  It was a tragic, sweet, sad story.

If only it were true.  Did you really think I was going to tell a sweet, tragic story?  HA!

I found out the next day what actually happened.  These two are from out of town, and they were visiting some friends here and drinking heavily, despite his claims to the contrary.  One of the friends accused Stella (still not her real name) of sleeping with another man, and her husband, with a blood alcohol level of 0.27, decided to beat the shit out of her (her blood alcohol level was 0.21).  The four "friends" then piled into the car and in true idiot fashion began fighting in the moving car.  In the scuffle Stella got stabbed, and both of them were thrown out of the car.  He was screaming for his wife when he first arrived not because he was concerned for her safety, but because he thought he hadn't given her a sufficient beating.

Fortunately neither of them was seriously injured, and they're both back home now.  She refused to press charges against him for the assault, and he still believes that she cheated on him.  It makes me wonder how Hollywood movie writers seem to be out of ideas for movies - the writers just need to spend one day with me.