Sunday, 30 December 2012


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:


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


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."


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
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." 


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:


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


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.


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. 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 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


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 it isn't me, I swear!  Anyway, this friend of mine has had a problem 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 Miss A tell me that this blog puts her to sleep?  I suppose she can stop asking her doctor for sleeping pills now.