1+1+1=20

After reading the title of this post, I'm sure your first thought is, "Wow, Doc sure is bad at maths!"  Well you should know by now that there's a point to my poor arithmetic skills.  So that begs the question - when does 1 + 1 + 1 not equal 3?  When could it possibly equal 20?  When addition isn't commutative, obviously.

When it isn't what??

You obviously weren't paying attention during your elementary arithmetic classes.  Bear with me.  I'll get there eventually.

Trauma at 2AM is never good.  It isn't good for me, because I need to drag my ass out of bed and find out what this latest idiot did to land in my trauma bay, and it isn't good for the patient, because he (or she) should have been in bed, but wasn't.  Of course I understand that some people who work at night need to be awake at that time, but the vast majority of the population should be asleep in bed at 2AM, just like I should be, instead of out and about wreaking havoc.  And when stupid people do stupid things in a stupid way in the middle of the stupid night, bad things happen.  Ok, the night isn't stupid, I just threw that in there for effect.  Sorry.

A woman was brought in at 2 AM smelling like...well, you know those drip trays that run around a bar to catch the alcohol that spills?  She smelled like that.  According to the medics, she had run her car off the road, hit a tree, and then flipped her car several times.  After they showed me pictures of her mangled wreck, the fact that she was still alive seemed miraculous.

An extensive workup revealed only bumps and bruises and a very large, ugly-looking 10 cm  (that's 4 inches - dammit US, will you just adopt the damned metric system already!?) laceration going from her lip halfway across her face from where her face had impacted her cell phone.

Her what??  Surely you mean 'where her face had impacted the steering wheel', right?

No, I would  have said that had it been true.  Unfortunately for her and her face, this rocket scientist had decided that it would be a smart move to get drunk, drive on a deserted pitch-black road, and then text someone.  I only wish she had been using voice-to-text, because I imagine her message looking something like this:

oh my god I'm so drunk right now and it's so dark but I ran out of beer so I have to get OH MY GOD OW OW OW OW

If you ever saw "Inglourious Basterds", you surely remember how Brad Pitt cut a swastika into the foreheads of the Nazis he caught so the world could see the scar for the rest of their lives (and if you haven't seen it, go rent it now).  Well this woman will have a horrible scar on her lip and cheek for the rest of her life to remind her how stupid she acted.

Doing one stupid thing (getting blindingly drunk) is bad.  Add a stupid thing on top of it (driving while blindingly drunk), and it's much worse.  Add a third MIND-BOGGLINGLY stupid thing on top of that (texting while driving while blindingly drunk), and it adds up to much more than 3.

See?  I told you I'd get there eventually.

Medical myths

It's amazing what people will believe just because they've heard it so many times.  This applies even more to medical myths.  If something sounds plausible enough, people will not only believe it, but propagate it.  The worst part about this is that it is "medical" information that is being passed on from person to person, and because no one bothers to verify anything beyond a quick Wikipedia search, the misinformation spreads like a virus.  Pun intended.

So after a suggestion from reader Justyna, I've decided to compile a list of some of the more common medical myths in a stupid and useless attempt to dispell them.

MYTH: A woman's ovaries alternate releasing an egg each month.
FACT: Studies show that it's basically a 50/50 chance, which makes much more sense than the body somehow "remembering" which ovary released the egg last month.

MYTH: Going outside in a cold rain without a coat and/or hat will cause you to catch a cold.
FACT: Even my wife continues to propagate this one.  She knows full well that the reason people catch colds during cold weather season is because they are more common in cold weather season, not because the virus can somehow magically detect that its next victim forgot a hat.

MYTH: You lose most of your body heat through your head.  So put on a hat to stay warm!
FACT: This one sounds right - your head is the highest part of your body, and heat rises, right?  Wrong.  This information came from a misguided study of soldiers which found that they lost their body heat through their heads.  The problem with the study is that the soldiers' heads were the only part of their bodies that weren't covered.   Heat radiates out through every part of your body equally, so the head, which comprises about 9% of the body surface area, loses about 9% of the body heat. 


MYTH: You need to drink 8 glasses of water a day.
FACT: My mother said this so many times she may as well have tattooed it on my forehead.  The fact is if you're thirsty, you need to drink something.  If you aren't, you don't.


MYTH: Chewing gum takes 7 years to pass through your GI system.
COROLLARY: You have 7 pounds of undigested meat sitting in your GI system.
FACT: This one is just as true as "If you swallow a watermelon seed, a watermelon plant will grow in your stomach".  And many vegetarians tout the corollary as a reason not to eat meat.  This one is just pure and utter codswallop.  There is no ball of meat sitting in your intestine and causing cancer, and gum will simply pass through your system undigested, much like a coin.  Full stop.


MYTH: Eating turkey makes you tired because of the tryptophan.
FACT: No, no, and no.  Tryptophan is an amino acid found in all meat, and turkey is no exception.  However, even a supposed extra dose of tryptophan isn't enough to make you tired.  If you eat a huge meal, you'll get tired.  The turkey has nothing to do with it, so leave the poor turkeys alone.  If you don't believe me, the Mythbusters busted this one too.

MYTH: "We just have to get the bullet out and he'll be fine!"
FACT: I saw this one on TV just yesterday, and it drives me absolutely bonkers.  Think about it - if a bullet passes through the body, what do you think is more important: getting an inert slug out or, oh I don't know, fixing the holes that the bullet made as it went through stuff?  Every time I see a doctor on TV reaching in with pliers to pull out a bullet and breathing a huge sigh of relief as he pulls it out, I cringe.  Goddammit, ignore the bullet and fix the holes!!

MYTH: We only use 10% of our brains.
FACT: Well, I'm not exactly sure where this one came from, but if it were true, we'd all act like vegetables.

Of all the myths I've listed, the last one is definitely closest to the truth, at least for a majority of my patients, it seems.

Against Medical Advice

I have never told a single patient "I am smarter than you."  I freely admit to having thought it perhaps once or twice or five thousand times, but I've never said it aloud.  While I'm not the smartest guy in the world, I'm certainly well above average.  Additionally, physicians tend to be among the most educated people in the world.

Yeah yeah yeah, hey look at that, it's another Doc Pats Himself On The Back Event!

Oh, shut up!  I'm trying to make a point here and you're just being rude and interruptive.

Well then get to the damned point!

Fine!!  Where was I?  Oh, right.  The fact is, whether they like it or not, unless they happen to be doctors themselves (which they rarely are), my patients know less about medicine than I.  That may sound obvious, but hear me out.  I'm very thoughtful, conscientious, and careful, so when I give advice and make a plan of care, I fully expect my patients to abide by it.  And the vast majority of the time, they do.

Sometimes, however, people have other more pressing needs than some crackpot doctor trying to do something stupid like, oh I don't know, take care of you and your stupid, unappreciative, know-it-all ass!

Wow...sorry about that.  Anyway, a 50ish year old guy was brought to me after he had the shit beaten out of him, er, I mean after he was assaulted by multiple people.  Probably because he fucking deserved it!  


Ahem, let me take a second to gather myself here.  You can probably tell I'm still a bit miffed by this guy, and you'll see why in a minute.  This previously-healthy gentleman was brought to me having been beaten.  He had bruises all over his body, especially his face and torso, and he complained mostly of rib pain.  What was most obvious was the exquisite tenderness over his ribs and his bloody, crooked nose.  He was worked up fairly quickly with multiple X-rays and CT scans, and in addition to his 2 broken ribs and his broken nose, both his lungs were punctured, he had a broken bone in his back, and there was a small amount of bleeding in his brain.  One of these injuries is bad.  Two is worse.  Add them all up, and he's in REALLY bad shape.  Fortunately for him none of the injuries was bad enough to need surgery, but he at least needed very close observation in the intensive care unit for both the bleeding in the brain and the punctured lungs.  I admitted him and ordered repeat scans for the morning to make sure nothing was getting worse.

After I finished explaining this to him, he looked at me with frantic eyes and asked me how long he would be in the hospital.  At least three days or so, I told him.

"OH NO!  I got shit to do, Doc!  I can't stay that long!  I gotta get out of here!"

I resisted the urge to slap the stupid out of him, and I again explained the severity of his many injuries and how several of them could be potentially fatal if they get worse.  He seemed to understand, but he just kept telling me how he had "more important things" to attend to.

The next morning I headed straight to the ICU to make my rounds as I always do, but when I got to his room there was an old lady in his bed.  Thinking they had moved him elsewhere, I checked the computer census, but the computer had no record of him being in the hospital.  Suspicious of the answer, I asked the nurse where he was.  "Oh, he left last night against medical advice.  He said he had something he needed to take care of and refused to stay."

SOMETHING TO TAKE CARE OF??  ARE YOU ACTUALLY SERIOUS?  WHAT COULD POSSIBLY BE MORE IMPORTANT TO TAKE CARE OF THAN YOUR HEALTH?

Horses vs. zebras

If  you were to hear hoofbeats approaching, what would be the first think you'd think of?  Like the vast majority of people, you'd probably think of horses, right?  Of course you would, because that what all rational, sane people would do.  I think of horses also, but I also think of zebras.  Why zebras?  A zebra looks like a horse, its hoofbeats sound like a horse, hell it may even smell like a horse, but it is definitely NOT a horse.  This is the way surgeons learn to think, because just when we think the diagnosis will be something simple and common (a horse!), it turns out to be something completely unexpected.

The ER doctor called for a young woman in her 20's with abdominal pain.  That's certainly common enough - in young people with abdominal pain, my mind automatically goes straight to the horse - the appendix.  "Her pain is all over," he continued, "but mainly in the upper abdomen."  Ok, the appendix is in the lower right part of the abdomen, so it probably wasn't the appendix.  Fine, upper abdominal pain in a woman - it must be her gall bladder.  Another horse!  I prepared myself to ask about liver function and prior surgeries.

"...and mainly in the left upper abdomen."

Uh...the gall bladder is in the upper right, so that's strike two.  There really aren't too many things which cause pain in the left upper abdomen.  The spleen is up there somewhere, but splenic pain is very uncommon.  Now my mind started thinking about zebras.

The next step was to obtain a CT scan, and as I looked at the images, it became clear that this was definitely NOT a horse.  There was something in her stomach that was causing an obstruction.  Was it a tumour?  Whatever it was, the thing was so big it wasn't allowing the stomach to empty.  She needed urgent surgery, so that's exactly what she got.

In the OR, that thing causing the obstruction was not a tumour.  It was...a big hairball.  Yes, a hairball, one that extended about 30 cm (12 inches) down her GI tract.

After surgery, she was questioned about her, um, eating habits.  It turns out that she spent her free time watching TV and eating her wig.  Yes, you read that right - eating her wig.  And it was also discovered that this wasn't the first time this had happened.  Several years before she had had a big ball of cotton removed from her stomach after she had eaten a towel that she had meticulously shredded.

I'm not sure if there is anything more exotic than a zebra that makes the sound of hoofbeats, but I guarantee you if there is, I'll find it.  Because whatever that strange creature is, that is what this case was.

Being right

What could possibly be better than being right?  You get to look smart, prove someone else wrong, and generally look like a hero.  So what could be better than that?

Being wrong.

"WHAT?" I hear you scream.  I've said before that it's better to be lucky than wrong, and there have been very few times in my career when I have hoped against hope that I'm wrong.  These have been the times when I suspect a diagnosis that is life-altering, and not for the better.  Come on, I'm not diagnosing winning lottery tickets here, people.

A 30-something year old woman came to the emergency room complaining of abdominal pain which had been ongoing for the past several days.  As soon as any young person (or any person, for that matter) complains of abdominal pain, it seems that ER docs immediately think "APPENDICITIS!  CALL SURGERY!".  True to form, I was called.  Fortunately the ER doc had at least done the workup, and I will freely admit it was very concerning.  At first glance, she looked ill.  And when people look ill, it's a pretty damned good sign that they are ill.

The first thing I did (after glancing at her) was to talk to her, something that many doctors these days just don't do, preferring to rely on lab tests and CT scans, and failing to realise how much invaluable information can be gleaned from a simple conversation.  She told me that the pain had started a few days ago in her lower abdomen, and around the same time she started having some yellowish vaginal discharge (red flag).  She had also noticed pain during sexual intercourse (BIG RED FLAG).  I pressed on her abdomen, and she was clearly in excruciating pain.  I then excused myself to look at her CT scan (yes, they're still almost as important as talking to the patient), and she had large abscesses (collections of pus) on both sides of her pelvis.

Well, I've never heard of someone having an appendix on both sides, so my mind immediately went elsewhere - girl parts.  In my mind, this woman did NOT have appendicitis; rather, she had tubo-ovarian abscesses on both sides, and she needed urgent surgery by a gynaecologist to drain them and possibly remove her infected tubes and/or ovaries.  Rarely, infections (usually chlamydia or gonorrhea) can spread up the female reproductive tract and form horrendous infectious complexes in the ovaries and fallopian tubes.  

This was where I desperately hoped I was wrong.  If one (or both) ovaries have to removed, it can be devastating for a young woman's fertility.  Even if the ovaries and tubes are left in, they can scar to the point where they no longer function.  And it gets worse (of course it does!) - she and her husband were trying to get pregnant with their first child, and she had just stopped taking her birth control pills 2 months prior.

PLEASE LET ME BE WRONG!  PLEASE LET ME BE WRONG!


The last thing I wanted was to be right.  A ruptured appendix with an abscess is fairly easy to take care of, but this diagnosis was potentially life-changing.  Unfortunately, according to the ER doctor and the gynaecologist, I was already wrong.  Despite all the evidence to the contrary, they were firmly convinced that it was her appendix that was the problem, not her girl parts.  Another surgeon, one of my most senior colleagues, was brought in as a second opinion, and he agreed with the gynaecologist.

By this point her blood pressure was starting to drop,  her temperature was going up, her heart rate was starting to go up, she was sweating more...she was getting sicker.  There wasn't any more time to argue, so I ended up taking her to the operating theatre at 1 AM.  And much to my surprise, I found...(please let me be wrong, please let me be wrong)...

...tubo-ovarian abscesses.  On both sides.  GOD DAMN IT.  Her left ovary looked ok, but her left fallopian tube was a mess.  Her right tube and ovary were both obliterated by the infection.  The gynaecologist ended up taking out her right tube and ovary, but he kept the left tube and ovary in.

The next morning I told her and her husband what we found and what we did, and naturally she was devastated.  I reassured her that she still had one fairly normal ovary and a perfectly normal uterus, so at worst she would need to have her eggs extracted, fertilised in vitro, and implanted into her uterus.  Her egg, her baby.  It was cold comfort at best.

Sure I had been right, but that had been even colder comfort.  There's just no way to sugar-coat it.  Sorry folks, no happy ending this time.