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.

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


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 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, 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.