Penmanship

"Shortcut" is one of my favourite oxymorons.  If you ask my wife, she will (correctly) inform you that most of the shortcuts I've found around our house actually take longer to drive than the main road.  Yet I continue to take the so-called shortcut because somehow in my mind they are better, though not necessarily faster, than the main roads.  Damn it, it just has to be better!

Doctors use lots of little written shortcuts and abbreviations when writing daily progress notes in patients' charts.  These notes are not only to document how the patient is doing, but also to communicate our thoughts with nurses, doctors, and other support personnel, so they are rather critical when it comes to patient care.  Like my back-road alternate routes, our shortcuts are designed to save time too, but unfortunately that isn't always the case.

As vital as they are, there is just one major problem with trying to read a doctor's note - they are indecipherable.  Sure, everyone has heard that old stereotype of doctors and their bad handwriting.  But as it turns out, there's a very good reason that stereotype exists - because it's completely true.  Our handwriting in general is absolutely atrocious.  So why do we do it?  Obviously it's to prevent lawyers from being able to read them.  There are actually courses in medical school to teach people to write so that it looks like we are holding the pen with our feet while standing on our hands with our eyes closed.  Ha ha, I kid.  Sort of.

No, the answer is much more mundane - it's simply to save time.  When I have to see 15 patients in the hospital, race to my office to see 10 more, then race back to the hospital to get to the operating theatre on time, every second counts, so I scribble notes as quickly as possible.

Unlike many of my colleagues, I do my best to make sure my handwriting is legible, and about 99% of the time I'm successful.  But most of my colleagues' notes are basically chicken scratch.  It would take the full capabilities of MI6, the CIA, ASIS, and Mossad to translate some of this indecipherable rubbish.  I sometimes can't figure out if my orthopaedic surgeon's note says he is going to "repair the tibia" or "replace the television".

Jamie (not her real name), who works in a pharmacy, emailed me a few days ago with this complaint:

"Why don't some doctors seem to see the importance of writing prescriptions in legible handwriting?  I've been interpreting them for years, but every once in a while you get one that's really bad.  This particular one had me stumped for a while.  Would love to hear your opinion on your blog!"

I'll admit I had to turn it upside down, mirror-imaged, translated into Greek, turned back upright again, and translated back into English before I had a clue what it said.  My guess was:

"Cephalexin 500 mg tablets, two tablets twice daily, #40 tablets.  Mucinex (alas, no dose!) twice daily, #20 tablets, and Zantac 150 mg tablets, one tablet twice daily, #60 tablets".  Somehow I got it completely right.  But it underscores a major problem - how are pharmacists supposed to fill prescriptions that they just can't read?  If there is a mistake (wrong medication, wrong dosage, etc), it's obviously the doctor's fault first.  But I can't help but hold the pharmacist partially responsible if this kind of bullshit doesn't prompt a nasty phone call to the offending doctor admonishing him for writing worse than a 2-year old holding a crayon with his entire fist.

Fortunately hospitals and pharmacies are cracking down on this more and more.  And as electronic medical records and electronic prescribing become more widespread, this sort of problem will eventually (hopefully) vanish.  Until then, I'll have to continue wondering what the hellis supposed to mean.  I think it means either "the patient is doing well" or "meet me at 2PM for golf", but I may have to ask Jamie to translate it for me.

Hannah's story

Several people have written me and asked if the stories I tell are true.  Well yes, they all are and WHAT THE HELL?!  ARE YOU ACCUSING ME OF LYING?

Ok, I will freely admit to changing certain minor details like ages and names, but all of the stories here are absolutely true.  Seriously, I can't make this shit up.  But some stories simply don't need any alteration, because they seem like they belong here just as they actually happened.  Hannah (yes, her real name!) wrote me a little while back with a story of her own, and she thankfully gave her consent to use it and her first name.

Hi Doc,
I am an avid reader of your blog and the various stories you have to tell of your experiences as a doctor.  I have a story to tell myself.  Unfortunately not all doctors or hospital staff are as competent and caring as you seem to be, something I found out the hard way a few years back.

I can remember vividly one morning, when I was around 11 or 12, waking up with HORRENDOUS pain in my abdomen and lower back.  It was so bad I could barely move.  I was also very nauseated and feverish.  My mum heard me yelling, and after I managed to tell her what was wrong, rushed me to the local hospital.  Once there, I assume the doctor's first thoughts were of appendicitis, and I was promptly sent off for blood tests.  Whilst awaiting the results, I saw a doctor who poked and prodded me a bit and asked me whether it hurt (for the record, yes, very much so).  I remember him having to pause the examination a couple of times so I could throw up.  Finally he concluded that I most likely had appendicitis.  I had a fever of 39.5 degrees Celsius {103 degrees Fahrenheit - come on US!  Join the rest of the world!} and generally felt pretty rotten.  However, my blood tests came back perfectly normal.  Not appendicitis, then.  {Blood tests can be normal with appendicitis, by the way}  I was then diagnosed with a UTI.  They prescribed antibiotics and painkillers and I was sent home within a few hours.  

For the next few days my symptoms did seem to improve, but about a week and a half after my first hospital visit I was again vomiting and in agony.  I was again given blood tests again, and again they came back normal.  {This is generally regarded as bad.}  The doctor then concluded that it was either very severe growing pains or constipation.  {This is generally regarded as very bad - "growing pains"?  Seriously?  Idiot ER docs...}  I was again given painkillers and sent home. This cycle continued for around two months.  I think my parents took me to the local hospital five or six times during those two months, and every time we were told I was either growing, constipated, or suffering from a UTI.  {Doc's note - if a doctor can't figure out what's wrong with you after 1 or 2 attempts, find a smarter one.}  I was never given an ultrasound or CT scan or given any kind of test at all, besides blood tests and physical examinations.  My mother often asked why such tests weren't performed and was told that they 'weren't necessary'. 

Eventually my mother got so fed up that the next time the symptoms appeared she took me to a (much better) hospital an hour away.  After explaining my symptoms and history I was again given a blood test.  We all thought the cycle was going to repeat itself, but when the test again came back normal I was sent to see a paediatric urological surgeon.  He asked whether I had been given a CT or ultrasound and seemed horrified when he was told I hadn't.  I was immediately sent off to have both scans done, which showed a rather large obstruction (my mother was told after the surgery that the blockage was a benign tumour about the size of a tennis ball) in my right ureter. Yeah. It turns out that I probably WAS suffering from UTI's and kidney infections, but they were a symptom, not a cause.  The same urologist performed surgery the next day.  I was in hospital for a week after the surgery, and besides pain from the incision, I was feeling much better. 

I'm now 16 and haven't had any recurrence of symptoms since before the surgery.  My right kidney only functions at around 40% and I am still prone to UTIs, no doubt due to all the infections I suffered, but besides that I am in good health.  I know I am lucky that the tumour was benign. 

Keep up the great work Doc.  I know not all hospital staff are as incompetent as the ones I was unlucky enough to be 'treated' by initially.  I know that the majority of those in the medical profession do care about their patients and do their damnedest to see them get better.  

Regards, 

Hannah 

Well Hannah, that just about sums it up.  I'm glad it turned out ok, and I'm grateful for the story.  I only wish someone would have given you and your condition a little more thought instead of passing you off as a "growing" teenager.

No but seriously, growing pains??  What the fuck does that even mean?

That sinking feeling

"Ok everyone, put your books away.  I am giving you all a pop quiz.  I hope you studied chapter 6 like I told you to yesterday!"

We've all felt it - that dreadful feeling you get in the pit of your stomach.  Your heart races, you start sweating, and your stomach leaps up into your throat so you can't breathe and you feel like you're choking.  It's that sense of foreboding that something really REALLY bad is either happening now or is going to happen really soon.

It's bad enough for anyone to get that feeling at all, but when a surgeon gets it, there's a very good chance that someone is going to die very soon.  You'd better hope you aren't nearby when that happens, because it may be you.

Spooked yet?  Stay with me, intrepid reader.

I got a call from one of my primary care colleagues who had an elderly patient in hospital with a small wound on her ankle.   He thought it looked infected, so he asked me to take a peek.  It sounded routine enough, and since I was already in the building, I told him I would happily swing by and see her.

Are you getting that feeling yet?  NO?  Keep reading.

I checked her vital signs before entering her room, and a few things caught my eye: 1) her blood pressure was a bit low even though she had a history of high blood pressure, and 2) her heart rate was a bit high even though she was taking medication to keep her heart rate low. 

Uh oh, that feeling was definitely starting.  Bah, it's probably nothing.  Right?

I introduced myself and asked to see her ankle.  She politely and pleasantly said that she had scraped it on a desk a few days earlier, and the pain just wouldn't go away.  "I've always been a quick healer, so I'm not sure what's going on."  When I examined her wound, it was only a centimeter or two long (less than an inch), but it didn't look right...it just didn't look right.  It was definitely infected, but instead of pus coming out, there was some grayish, foul-smelling drainage that looked like dirty dishwater.

OH.  SHIT.  SHIT!  SHITSHITSHITSHIT

I put my finger in the wound, and as I gently probed the wound, her skin started to fall apart, basically unzipping up her leg in front of my eyes. This was bad.  Very very bad.  Extremely bad.  This was no ordinary wound - this was necrotising fasciitis, also (inappropriately) called the "flesh-eating" disease.

I quickly (but carefully) told her that she needed emergency surgery, that she may lose her leg, and that she very well may die.  This was no time for beating around the bush or tiptoeing around the issue, it was a life-threatening emergency, so I had to be brutally honest with her.  I told her this is an extremely fast-moving infection, and she looked terrified (I certainly couldn't blame her), but she understood and asked me to do everything I could.

Once I got her in the operating theatre, the extent of the damage became grimly and immediately evident.  I opened up her lower leg, only to find that all the muscles below her knee were already stone dead.  I extended the incision upwards, and the infection had already reached her mid thigh.  I quickly made the only decision I could - I had to amputate her leg just below the hip.  Unfortunately it was the only option I had to save her life.  Without it, the infection would reach her torso within minutes, and when that happens, it's all over.

Despite being in her 80's, she survived the operation, and five days later she was transferred to a rehabilitation hospital where over the next few weeks she would learn how to function with only one leg.  She was saddened at losing a leg, but very grateful that that was all she lost.

I often say that surprises in my line of work are almost always bad.  Fortunately they usually aren't this bad.  But when I get that feeling - THAT feeling - I'd strongly advise you to run the other way.  Fast.

Victory

I recently wrote about a patient with a big problem but no symptoms and how this can be a very difficult diagnostic situation to deal with.  Fortunately, this is a relatively rare occurrence.  Unfortunately, the opposite can also happen, too.  What do you do with patients who have lots of symptoms with no good explanation for them?

Is that even possible?  Well, of course it is, otherwise this would be the shortest post ever.  To be fair, I see lots of people who complain of pain with nothing actually wrong because they just want me to give them narcotics.  And I'm not referring to hypochondria, where people think they have pneumonia just because they sneezed.   I'm talking about people who are actively dying, but we can't figure out why.  What then?

I was called to see a woman in her 50's who had undergone open heart surgery earlier that day to repair a damaged heart valve.  The report that I got was that other than mild thyroid disease, she was a healthy woman, and according to the cardiac surgeon, the surgery was uneventful.  She had been admitted to the intensive care unit just to keep a close eye on her, but about 8 hours later, something happened.  Her blood pressure suddenly plummeted, her heart started racing, and she lost consciousness.  A breathing tube was inserted and she was placed on life support, and several medications were started to keep her blood pressure up in an attempt to maintain oxygen flowing to her heart and brain. 

"IT'S HER HEART!  IT'S HER HEART!!" I hear you screaming.  Of course!  Why didn't the cardiac surgeon and intensive care doctor think of that!  Oh wait, they did.  And tests confirmed her heart was absolutely fine.  Her extensive workup had included a CT scan of her chest and abdomen, and that painted a very different (and very bizarre) picture - her entire colon looked inflamed, almost like it was dying.  And it seemed that it was actively killing her.

Wait, what the hell?  How the hell did that happen?  The cardiac surgeon had operated on her heart, not her abdomen!  He and the intensive care doctor didn't know how it could have happened, so they called me.

YES! I get to save the day!  Doc Bastard to the rescue!  Except for one teeny, tiny, itsy-bitsy problem - 

I didn't have a clue either.

The colon can become inflamed if it loses its blood supply for some reason, including a very low blood pressure.  And her blood pressure was very low, so that could possibly explain it.  Except that her blood pressure hadn't dropped until AFTER she had crashed.  So what had caused her blood pressure to drop in the first place?  I was baffled.  It seemed like a very nasty cycle, but something had definitely gone wrong that had kicked her into a downward spiral, and that something was about to kill her.

As a surgeon, there are certain situations where I don't have time (or a need) to ask why, when I have to leap into action without knowing exactly what's going on.  This was definitely one of those times.  It's a "shoot first, ask questions later" sort of thing.  I spoke briefly to her husband, explaining that her colon looked like it was dying, and that if she didn't have immediate surgery to remove it, she would most assuredly die along with it. 

I got her to the operating theatre about 20 minutes later, made a big incision in her abdomen, opened her up, and saw...

...a perfectly normal abdomen.  Her colon was absolutely fine, as were her small intestine, stomach, liver, spleen, gall bladder, and pancreas.  There wasn't the slightest hint that there was anything remotely wrong with this woman.  I went over everything again, and again I couldn't find a single thing wrong.

DAMN IT!  What the hell do I do now?  I came in here to remove some evil, diseased organ to save this woman!  Come on, throw me a bone here!

Realising there was nothing I could do to save her, I started closing her up, mentally preparing my discussion with her husband about how we did everything we could but weren't able to bring her out of it.  But just as I was silently reviewing my feelings of uselessness, the anaesthesiologist told me that her blood pressure was starting to pick up, and her heart rate was returning to normal.  But...I hadn't done anything!  Had I?

As we were getting her back to the ICU, her vital signs continued to improve, and once we got her there, she immediately started to wake up.  When I came to see her the next day, the breathing tube was out, the medications to keep her blood pressure elevated were off, and she was drinking a ginger ale. 

As much as I love saving lives, I can't claim credit for this one.  At least I don't think I can.  Maybe I released some evil humours or a demon or something.  Who knows.  This case happened some time ago, but to this day no one has been able to give me any reasonable explanation for why she got sick OR why she got better.  But just like I don't need to ask why someone is sick sometimes, here I don't really need to ask why she got better.  Sometimes it's just better to accept a victory and move on. 

Truly remarkable

re·mark·a·ble (r -mär k -b l). adj. 1. Worthy of notice. 2. Attracting notice as being unusual or extraordinary.

Albert Einstein was truly a remarkable person because the way his mind functioned was extraordinary.  Nikola Tesla falls in the same category.  These were people whom most people have no possibility of understanding, simply because their brains worked on a different plane compared to the rest of us.

I had such a patient a short while ago.  She was truly extraordinary, but not in the way you might be thinking.

At 3 AM, my pager is the most vile, heinous object on the planet.  I wish I could throw it against the wall and shut it up permanently.  Unfortunately that night my good sense took over as it wailed incessantly, so I simply pushed the button to shut it the hell up, put on my shoes, and trudged down to the trauma bay.  What greeted me was a 30 year old bottle of whiskey.  At least, that what she smelled like.  The second thing was that she was at least 7 months pregnant.

Many people may not know that a drink every now and then is ok for pregnant women, but even the stupidest people know that getting drunk while pregnant is bad.  I felt my temper rising as I introduced myself and asked her what happened.  She had been in the car with her drunk boyfriend (presumably on a beer run) when he had lost control and the car had flipped several times.  Due to her seatbelt and the car's multiple airbags, she didn't have a scratch on her, but she told me "All I need is a CAT scan, and I can go."

I resisted asking her how she knew that and where she went to medical school.  I did, however, ask her how much she had to drink.  "I didn't drink nothing!  I did some cocaine and pot, but my boyfriend was drinking, not me!"

I suppose she saw the aghast look on my face, and I'm guessing she thought that look was because I didn't believe her.  In fact, I was trying my hardest to process what she had just said because it was almost beyond belief.  I was trying almost as hard not to slap her.  She was vehemently denying drinking even though she smelled like she had bathed in vodka, but she had no problem admitting she had smoked marijuana and done cocaine.  While pregnant.  VERY pregnant. 

"Ma'am, you realise that alcohol is bad for the baby, right?  But the cocaine is worse."  My ire was probably plainly visible, though I did my best to maintain my composure.  She had no such luck.  She leapt off the bed, grabbed her shirt, and yelled, "THAT'S IT!  I DON'T HAVE TO LISTEN TO THIS BULLSHIT!  I HAVEN'T BEEN DRINKING!  I'M OUT OF HERE! "  And to make a point, she held up her shirt to my face to show me that it smelled like alcohol.  It sure did, but so did her breath.

She signed her papers acknowledging her right to leave against medical advice, and she whisked out the door. 

Just like Tesla and Einstein, I have no idea how this woman's brain works.  I'm frankly surprised it works at all.

Coke bottle

If you've read back to some of my older posts (or if you frequent Fmylife.com), you've no doubt seen this picture:

It remains my absolute favourite picture of all time, and it's only made better by the fact that it was my patient and I took it.  It's priceless because it is unmistakable.  Even someone who has never seen a pelvis X-ray can tell exactly what it is.

I guess the picture inspired Noor (also known as NoorFML from Fmylife.com) who apparently is quite the artist.  She drew this for me and just sent it, and I felt I had to share it (with her permission, of course).

This was a very nice surprise, so thanks very much Noor.  If anyone else has any pictures like this to share, I would freely welcome (and share) them.

Measure twice, cut once

"Measure twice.  Cut once." 

This quote is actually a basic tenet of woodworking rather than surgery, but the meaning still translates to surgery (and medicine in general) very well.  When you're cutting a piece of wood, you are supposed to make a measurement, mark the piece of wood, and then recheck the measurement before powering up the tool and doing something irreversible.  If you're about to do something that you absolutely CAN'T take back, you'd better make DAMNED SURE you do it right.  So check your work, then double check it, and only then should you cut.

Though this blog seems to be mostly about my own self-glorification (not really), I'm sure it will come as a great shock to many of you that I, DocBastard, am not perfect.  No, no really, it's true.  Please try to contain your surprise.  Damn it, contain yourself!  I am actually not immune to stupid moments, and I may have erred ever-so-slightly once or twice.

(By that I mean that I have had more than my fair share of moments where I've hit myself in the head, called myself an idiot, and wished there was a big pile of dirty glass shards that I could jump into for whatever my most recent egregious fuckup was.)

So of course since this blog is dedicated to exploiting my greatness (not really), there's no way in hell that I would actually reveal any of these "epic fails" (as the kids say), right?

Wrong.

When I was still in training doing a rotation in pediatric surgery, I was given the distinct honour of informing a 6-year old boy named Thomas (not his real name) and his parents that he did not, in fact, have Crohn's Disease, which is a terrible, incurable disease where the body attacks its own digestive system.  The tests had all been done, and they were definitively normal.  Wonderful news!  I marched happily into the room and gave them the good news, much to the delight of the little boy and his parents.  The three of them cried with joy, and I got to witness the sheer happiness on their faces.

And then Thomas and his parents walked into the room.

Uh...um...oh SHIT.

I had mistakenly given the news to his roommate Isaac (also not his real name).  Sure, I had the right room, but I had not thought to double check the bed number in the room, nor had I made sure that the little boy I was talking to was actually Thomas.  I immediately looked for a pit of sand in which to bury my head, but finding none I simply apologised profusely.  I suppose they saw the look of sheer terror (and idiocy) on my face, because fortunately Isaac's parents were very understanding of my little flub.  Before I got the chance, Isaac happily told Thomas the good news, and both of them started jumping on their beds, giggling like tiny mad scientists.  I think that was a better ending than mine would have been anyway.

Ever since then, I always verify the patient's name when I enter a room.  It certainly wasn't my first mistake, nor was it my last, but it was definitely one of my worst.  I'm sure I've repressed some other momentary lapses in sanity, and as the horrid memories resurface, I'll be sure to expose some of my other sins.

And before you ask, no I've never cut off the wrong leg or removed the wrong kidney.  Shame on you for even thinking it.

EDIT: In case you're wondering, this isn't a repeat of a post from a few weeks ago.  I had written it then but hadn't posted it until a few days ago, but it was posted on the day I wrote it instead of the day I posted it.  I just deleted it and reposted it today.

Symptoms

Look up the typical symptoms of appendicitis and you'll likely see the following: Crampy abdominal pain that usually starts in the mid abdomen and then gradually evolves to become an extremely sharp pain in the right lower part of the abdomen, low-grade fever, nausea, and loss of appetite.  The range of symptoms can vary wildly, but that's the typical progression (and coincidentally is exactly how I felt when I had appendicitis almost exactly 20 years ago).   Doctors rely on such typical patterns when we see common (and even some uncommon) diseases, because that's just how things are supposed to go, and patients are supposed to make our lives easy.

HA!  HAHA!  No, that's actually not how it works at all.  It WOULD make our lives easier, and it WOULD allow us to rely on our confirmatory studies that much more.  If I'm suspecting appendicitis because that's what the history and physical examination suggests and the CT scan confirms it, it's an open and shut case.

But what happens when there are no symptoms to go by, huh?  What happens then, smarty pants?

Shane emailed me with a personal story that got me thinking:

"I am an international business and marketing major.  I have always had a passion for sports, playing American football until I was 16.  Around that time I had a devastating knee injury that required me to have my patellar {kneecap} tendon repaired and a tibial tubercle realignment {the part of the shinbone where the kneecap tendon attaches is detached and then reattached in a better location} which required I get three screws.  Two weeks after surgery my doctor took me off crutches and let me walk small distances with my leg brace.  It was smooth sailing.  I went in for my six month post op check up.  I was getting back into fitness again, running, lifting, etc.  The doctor saw my X-ray and screamed "JESUS KID, ARE YOU IN PAIN?  DON'T LIE!"  I laughed and said of course not.  The doctor told me my tibia was not fused where he re-aligned it, and furthermore my screws were all broken.  Now to this day I am still perplexed.  I work at a physical therapist's office and I see this a fair amount.  Broken screws are painful!  Why did I feel no pain and feel undaunted yet still have this major issue under my skin?"

Why indeed.  Unfortunately for Shane I have no answers, because all too often patients don't read the surgical textbook before seeking medical care, so they just don't know what their disease process is supposed to look like to us, so their presentation usually isn't like it appears in books.  Just like veins aren't actually blue and arteries aren't actually red (they're both white, if you're wondering).

A young man was brought to the emergency department by his mother because he had a mild stomach ache after dinner.  Because he had abdominal pain, the emergency room called me without doing any real workup other than basic blood tests and a chest X-ray (because as every ER doc apparently thinks, abdominal pain is a surgical indication).  By the time I got to see him, he felt fine and was actually getting dressed to leave.  I asked him to wait while I looked at his chest X-ray (which the ER doc had ordered but hadn't bothered to look at before calling me).  What I saw made me literally do a double-take - he had free air in his abdomen!  Air is supposed to be contained within your GI system.  When that gas is outside the GI system, that means there's a hole somewhere which is allowing that air (and potentially other bad stuff like stomach acid or poop) to escape.  And that's a surgical emergency.  How the hell did this kid not look sick?

I went back to examine him, and his examination was still completely normal.  He had no abdominal pain when I mashed on his belly.  None.  But there was clearly something very wrong with him.  He had a hole that needed fixing.  STAT.  After explaining the situation to him and his mother, I booked him for immediate surgery.  After he was asleep, I put a laparoscope through his navel and immediately saw a 1/2 cm  (less than 1/4 inch) hole in his stomach.  I repaired it laparoscopically, and he went home 3 days later, still feeling fine.

The fact that he had absolutely no symptoms despite his life-threatening perforated stomach ulcer was strange.  What was even stranger is that he was only 14 years old with no other medical problems.  So how the hell does a healthy teenager get a hole in his stomach like this?  Should everyone with a tummy ache come to the emergency room to make sure they don't have holes in their stomachs too?

If they swallow a fish bone they should.  That's right, this kid had accidentally swallowed a small fish bone during dinner that night, and the bone had eroded through the wall of his stomach.

I don't know why Shane had no symptoms despite his major knee problem, and I don't know why this kid had no symptoms despite having a life-threatening injury.  I think it's nature's way of keeping us on our toes.  If everyone presented just like the textbook says they should, then we wouldn't have to use our brains and any idiot could be a doctor, I suppose. 

Oh, and for those of you keeping score at home, the fact that this ER doc was right is irrelevant.  Or something.