Justifiable trauma

Many of my patients happen to be in the wrong place at the wrong time.  Like the fine young gentleman covered in gang tattoos who was surely walking home from his shift volunteering at a soup kitchen who just happened to find himself in the crossfire of a shootout over drugs, which he has of course never touched in his life but somehow ended up in his tox screen, much to his utter astonishment.  Many others bring trauma on themselves (by driving drunk, getting into a fistfight with a mixed martial artist, etc).  But regardless of how stupid someone has been, I've always found it difficult to say that anyone truly deserved the injuries they got.

Until this guy came in.

At 1AM my pager told me that an assault victim would be coming in five minutes.  I immediately started thinking of the type of person who is liable to get beaten at that time of night.  When you get assaulted in the middle of the night, you're either on the wrong end of a robbery or doing something really stupid.  So I was assuming the victim must be a cashier at a convenience store.

Not this guy.

When he hit the door, it looked as if his face had been used as a punching bag.  Both eyes were black and blue and swollen shut, he had lacerations on his ear and forehead, and blood coming from his nose.  And he had some very nice steel bracelets (read: handcuffs).   Often when I get an assault victim in police custody, it's the police who have done the assaulting.

Not this guy.

As I was examining him, one of the nurses made the mistake of asking exactly what happened.  He explained that some guy beat the hell out of him just because he had caught him naked in bed with his son.  

"So what?  It's 2013!" you're thinking. 

You didn't let me finish. He caught him in bed with his 6-year old son. 

Yeah. 

"But they can't prove anything," he said with a creepy smile. 

I froze, barely able to believe what I had just heard.  My bedside manner instantly vanished, and I may have been a bit more rude and abrupt than my usual.  Fortunately he had no serious injuries (by which I mean "unfortunately, the father hadn't beaten the shit out of the guy enough"), and I gave him right back to the police after stitching him up.  

I can't imagine the guy even making it to the hospital if I had caught him with my son.  Most people don't deserve their injuries, but this guy earned every bit of his.  And more.

A REAL bastard

After reading about how I talk bluntly (and sometimes appropriately harshly) to my patients, you might just think I talk to all of my patients that way and that I'm a right bastard.  But you'd be wrong - my bastardish ways are like Batman - tough, dark, gritty, and exactly when and where (and only where)  it needs to be.  But I can also be extremely kind, even when you might not expect it.  Even when the patient might not expect it. 

I was called to see a 28-year old idiot, er, man, who had an abscess in his antecubital fossa of his left arm. 

WOOOO!  WOOOO!  Red alert! Red alert!  IV drug abuser!  WOOOO!  WOOOO!

In case you didn't catch that (or don't have a damned clue what I'm talking about), an abscess is a pus-pocket and the antecubital fossa is the inside of the elbow where your arm bends and most people have big, fat veins that are perfect for injecting drugs into.  And most people are right handed, so they inject drugs into the big, fat vein in the bend of their left arm.  Make sense?  Yes?  Good.  Moving on then. 

When he first showed up, he told the ER doc that a bee had stung him.  Yeah.  Fortunately he realised quickly that no one bought his cockamamie story, and he copped to injecting cocaine into his arm.  He also claimed it was his first and only time, and that he had used a brand new insulin needle he got from a friend.  It's a classic bullshit story, but strangely enough, they believed him.  I'll get to why in a minute. 

Just as I arrived to his room, the wild-eyes nurse caught me outside and said, "I have never witnessed anything so unprofessional in my entire career!"  Seeing the quizzical look on my face, she explained: the infectious disease specialist (who had just left) had waltzed up to the man, tore his bandage off, and had started squeezing the hell out of his arm trying to see if pus would come out, all the while scolding him and telling him that this was his own stupid fault.  She then walked back out without another word. 

And you thought I was bad!  Sure I might tell someone that their actions were stupid, but doing it while inflicting needless pain is ridiculous.  This woman is the real Doc Bastard. 

When I walked in, I saw a nicely-groomed, polite, obviously well-educated young man in tears.  I instantly felt sorry for him, but there was something about him that made me too believe that this really was the first time he has used IV drugs.  The fact that he had no track marks definitely helped.  After explaining what was going on, I numbed his arm and drained the abscess.  As I was doing it I told him gently, "I'm not going to beat you up about what you did, because I can tell you know it was dumb, and I'm sure you're beating yourself up enough already." 

He looked up at me, tears running down his face.  He smiled and nodded silently, and I knew he'd never do this again. 

Sometimes I have to remind people not to be stupid.  Sometimes other bastards do it for me.  But sometimes a kind, reassuring word is all it takes. 

Honey versus vinegar

I think most people have heard the old adage you can catch more flies with honey than vinegar.  In my line of work, it mostly applies to the patients rather than to the doctors.  Certain patients of mine, who may or may not have been under the influence of illegal substances at the time, have been absolutely flabbergasted that I have dared call their actions stupid.  They simply can't believe that their doctor doesn't have to be nice to them.  One of my many drunk drivers actually called me a bastard (yes, seriously) because I told her to her face that her drinking and driving was incredibly stupid.  Imagine that - calling me a bastard.  Hm.

Anyway, don't misunderstand me - the vast majority of the time, I'm extremely polite and courteous to my patients.  While that is true, the opposite often isn't.  Somehow certain people have this notion that it's ok to be nasty to the people trying to take care of them and/or their loved ones.

A patient of mine a little while back was involved in a motorcycle accident, and he suffered an open fracture of his lower leg.  He required multiple surgeries by my orthopaedic surgery colleagues, but this left him with a large open wound for which I needed to do a skin graft.  I explained this to him in great detail (like I always do), and he acted as he always did with me - calm, polite, and respectful.

His mother, on the other hand...

I got a call the night before surgery, and before his mother even introduced herself she launched into an all-out attack that would make even Attila the Hun proud.

"WHAT ARE YOU DOING TO MY SON?  WHAT SURGERY DO YOU THINK YOU'RE DOING ON HIM?  WHY DOES HE EVEN NEED IT?"

I allowed her to vent at me for a full 5 minutes before calmly explaining what I intended on doing and why he needed the skin graft.  And then...she got personal:

"HOW LONG HAVE YOU EVEN BEEN A DOCTOR?  DO YOU EVEN KNOW WHAT YOU'RE DOING?  MY SON WILL NOT BE YOUR GUINEA PIG!  I WILL NOT LET YOU EXPERIMENT ON HIM!"

No.  NO.  You can ask all the questions you want and you can even yell at me if it makes you feel better, but you may not call my professionalism into question.  Right then I interrupted her, something I almost never do, and I told her that I categorically refuse to have a conversation with her if this was how she chose to speak to me.

Silence.

Before she launched another barrage I told her to think very carefully about how she spoke to the person who was trying to save her son's leg.

More silence.  And then she hung up on me.

What the...?  I actually stared at the phone for a few seconds, incredulous.  After several attempts at trying to call her back, she finally called me back 10 minutes later.  She was profusely apologetic, she just wanted what was best for her son etc etc.  I told her that didn't excuse the way she spoke to me nor hanging up on me.  Incredibly, she agreed with me and apologised again.  It was like I was speaking to a different person.

The skin graft surgery went very well, and he went home a few days later.

It may surprise you that being nice isn't in my job description.  While I usually am nice, my actual job is to fix you up, get you back home in one piece, and possibly educate you so you don't make the same stupid mistake again.  Until this little episode I wasn't aware that part of my job was to give people an education in manners.

College

Where can you learn how to drink like a professional, party your ass off and sleep until 2 PM, figure out how to stuff all your classes from Tuesday through Thursday so you have a 4-day weekend every week, make a ton of new friends, run naked through the streets, eat like a starving wild animal, learn how to be an adult while still acting like a horny, hormone-infused teenager, sleep with anything that moves, and still have summers off?

Didn't you read the title? Why, college of course! 

Oh, and I guess you can get an actual education while you're there, too.  I sort of forgot about that.

I've had several readers ask me to give them suggestions on what to do at university to maximise their chances of getting into medical school.  Classes to take, extracurricular activities to do, what to major in, etc.  Ok, get your #2 pencils ready.  No seriously, write this down.  This is valuable stuff.

1) My best advice to everyone considering medical school is do not, under any circumstances, major in a hard science.  "WHAT???  ALL PRE-MEDS MAJOR IN BIOLOGY!  HOW CAN I NOT MAJOR IN BIOLOGY?" I hear you all screaming now. 

Now pipe down and listen before you start yelling at me.  Face it, you're going to have to take biology, chemistry, organic chemistry, and physics anyway.  So why burden your course load with more useless biology classes just because everyone else does?  Those classes will not help you get into medical school, nor will they help you once you're in.  At all.  I didn't remember a shred of organic chemistry once I was in medical school.

Plus (and thanks for already making this next point for me), almost all pre-meds major in biology, and medical school admissions officers don't want yet another biology major robot.  They want to see a well-rounded individual who didn't just take science courses.  So take psychology.  Take art history, music, archaeology, philosophy, literature, economics, political science...universities offer so many diverse courses in so many diverse subjects, it would be a travesty to go through four years without taking advantage of them.  Hell, I've heard of colleges offering courses on the history of surfing and Harry Potter!  (That's two separate courses, by the way...Harry Potter wasn't much of a surfer, as far as I know.)

2) My next piece of invaluable advice is to study.  DUH.  Seriously, do you really need me to remind you of this?  YES YOU DO. Sure, college is supposed to be fun.  But you're there to learn, and I don't mean learn how to drink beer while standing on your head.  So stop being lazy, wake up before noon, and study your ass off.  You only get one shot at this, so don't blow it.

3) Destroy your core science classes.  Medical schools look at these grades first, and they look at them hardest.  While they may be interested that you took it, they don't really give a flying fuck if you aced Ancient Russian Literature.  They do, however, want to see A's in biology, chemistry, and physics.

4) Do something that sets you apart from the other lemmings. 

"I know, I'll volunteer at a hospital!" 

BOOOORING!!  EVERYONE is going to be volunteering at a hospital, so be unique. Do something different.  I don't mean volunteering at a strip club...don't be that different.  For example, I read textbooks-onto-tape for blind students and I volunteered at a free clinic for the homeless.  Not only was it different, it was a great conversation starter.  Everyone is unique - so be uniquer.  Yes, that's a word.  Ok it isn't, but you get the point. 

5) Be damned sure you want to go into medicine.  This isn't a whim that you can change mid-stream - it's a lifelong endeavor.  A career as a doctor is a commitment to continuing improvement, constant education, repeated sacrifices, and the ultimate in satisfaction.  Even though my hours are long, I get to go home at the end of the day and say, "I saved a life today."  And that's pretty damned cool.

Even if you follow all this advice, I obviously can't guarantee you admittance, but this should definitely increase your chances.  Now for all you who have asked about this, I'm not sure how you think I became your mentor, but in case you need a letter of recommendation, I'd high suggest choosing someone else.  I'm fairly certain that admissions officers will not be impressed with a recommendation from "Doctor Bastard".

Let me do my job

Even though I've been driving for several decades, I will confess that I barely have a clue about how an internal combustion engine works.  I know that there are pistons that move in cylinders due to contained explosions of gasoline caused by a spark plug, and there is a lot of other, uh, stuff in there, and...well, that's about it.  So whenever I have car problems, I take it to a mechanic.  He's an expert and knows how this complicated machine works, while I just don't.  If he tells me that I have a problem with a caliper, pump, gasket, belt, or flux capacitor, I have little choice but to believe him.  I'm not saying I'll trust everything he says implicitly - if I have any doubt, I'll call a second opinion (my brother, who has literally disassembled and reassembled several engines), and if he and I think the mechanic is taking me for a ride (pun intended), I'll find a different guy.  But if it's legitimate (and it invariably is), I keep my mouth shut, whip out my credit card, and wonder how many of the mechanic's mortgage payments I'll be making this time.

"Is this really a post about cars?  I didn't come here to read about your damned car troubles, Doc!"

Fine, I'll get to the point.  It's not my fault you're so impatient.  Anyway, if you think a car engine is complicated, it's a cakewalk compared to the human body.  See, I told you I'd get to the point.  I know how the human body works and what makes things go wrong, and the vast majority of people don't.

So why do so many people question me?

Several months back I took care of a young man who was involved in a serious car accident involving speed, youth, alcohol, and a dash of stupidity.  His only serious injury was a very small bruise in his brain which was immediately diagnosed with a CT scan.  I repeated his brain CT the next day, and it looked completely stable with no signs of worsening.  The treatment for this type of injury is time and physical therapy, and most people recover fully, spending only a few days in the hospital.  Initially he could barely talk, but after a few days he started doing much better; he was talking, eating, and walking, and he looked about ready to go home.

That's when I got the inevitable irate call from Doctor Mom.  She had apparently heard of my plans to send him home in a day or two, and as soon as I said "Hello" (at 10 PM, no less), she launched into her enraged verbal assault.

"HOW CAN YOU BE SENDING MY SON HOME?  YOU HAVEN'T EVEN DONE AN MRI!  HOW DO YOU KNOW HE'S NOT BLEEDING IN HIS BRAIN!"

I very calmly tried to explain that his repeat scan was stable and he was doing much better, and that is how I knew there wasn't any further bleeding.  She immediately calmed down, thanked me, and said...oh, who am I kidding?  My rational thinking did absolutely nothing to calm this irrationally crazed woman, who relentlessly continued her attack.

"WHY HAVEN'T YOU DONE AN MRI?  YOU DON'T KNOW HE ISN'T BLEEDING BECAUSE YOU HAVEN'T LOOKED!  HE NEEDS AN MRI!  HOW LONG HAVE YOU BEEN A DOCTOR??"

My wife unfortunately overheard her enraged ramblings, and I nearly had to restrain her from grabbing my phone and yelling at her and calling her a lunatic.  I again calmly explained that an expensive MRI wasn't necessary, because clinically he was doing fine.  And even if I had suspected anything wrong, which I didn't, a CT scan would be a much better, faster, and less expensive test.  But even if I ordered an MRI and even if it showed a bruise, it wouldn't change my care plan one bit because clinically he was doing so well, so why even order it?

"I CAN'T BELIEVE YOU HAVEN'T ORDERED AN MRI!"

You get the point.  This back and forth continued for over 20 minutes, with me calm and rational, her...not so much.  I continually had to resist the urge to ask her where she went to medical school and did her trauma training.  Finally, unsatisfied, she let me and my wife go to sleep.  Shockingly, her son was doing even better the next day, and I sent him home, right on schedule.  He did NOT get an MRI.

I would never dream of questioning how tight my mechanic is tightening the bolts on my car's engine or what type of wrench he uses, or if he installed my serpentine belt correctly.  At some point I have to realise that this person knows a lot more than I, so I just need to shut the hell up and let the expert to his job.  So if you have questions, please ask.  But then after I explain things satisfactorily, unless you happen to be a trauma surgeon, shut the hell up and let me do my job.

Appendicitis

The most common operation I perform (by far) is an appendectomy.  I make a 1 cm (that's less than 1/2 inch - ok, that's the absolute last metric conversion I'm doing!) incision at the umbilicus (that's the belly button for the 99% of you illiterate in Latin), another tiny 1 cm incision on the left side of the abdomen, and a 0.5 cm incision on the lower abdomen.  A camera goes through the first incision, instruments go through the other two, and the appendix comes out in a nice clean plastic bag about 8-10 minutes later.  Most patients go straight home from the recovery room, and those that don't typically go home the next day.  It's a very satisfying little operation, mainly because patients feel so much better so quickly.   It's a beautiful operation, but one that I hate doing at 2 AM.

I think that most everyone has heard of this disease, since not a single patient of mine has asked me "What's appendicitis?" when I've told them they have it.  But I'm constantly amazed that more people don't ask what the appendix is for.  Come on, people!  I'm removing a piece of you!  Granted it's a little piece (about the size of your little finger), but aren't you the least bit curious to know what the thing does and what's going to happen to you when you don't have it anymore?

If you're really curious...well, tough.  The truth is that no one really knows.  There are several theories out there, and most of them sound like complete and utter rubbish.  Some researchers a few years ago announced that they believe the appendix acts like a "safe haven" for good bacteria which can then recolonise the colon after an infection, essentially "rebooting" the colon.  That sounds like a very nice theory, doesn't it?  That's wonderful!  The human colon has a reset button!  It's great, except for one problem - it doesn't.  The bacterial flora of the appendix is exactly the same as the rest of the colon.  This theory sounds like a bunch of shit to me.  Pun intended.

Other researchers believe that it has some immune function, especially in fetuses.  This theory is at least partially true - there is some immune tissue in the appendix, but when you look at all the other immune tissue you have, it's a tiny fraction, so it certainly doesn't contribute a whole lot.  It's like peeing into a pond.  Sure, you might be adding more water, but it's undetectable.

Most people believe the appendix is a vestigial organ - one that used to serve an important function but doesn't anymore due to evolution (THAT'S RIGHT!  EVOLUTION!  COME AT ME, CREATIONISTS!  Please?  Pretty please?).  It may have contributed to digestion in some manner back when cavemen ate roots and leaves, but it doesn't need to do a whole lot with the burgers and pizza that we stuff into our faces these days.

So the bottom line is that we don't know.  Regardless, that doesn't excuse the fact that most people don't even ask.  For those rare few who do ask me, I have my own theory, one that I think very few general surgeons would refute:

The sole purpose of the appendix is to keep general surgeons busy and awake in the middle of the night.  Fuck you, appendix.  Fuck you.

Nerves

It never ceases to amaze me what patients will allow me to do to them under the influence of anaesthesia.  I have to take you apart, fix you, and put you back together again, Humpty-Dumpty style.  That's nerve-wracking stuff, as I'm sure you can imagine.  There are countless things that can go awry, and one wrong move can literally mean the difference between life and death.

So why aren't more people deathly nervous before surgery?

It's a question I can answer from personal experience.  When I had appendicitis (over 20 years ago), I wasn't nervous at all before going under the knife.  All I knew was that this pain was excruciating, I felt like dying, and I just wanted to get this goddamned thing out of me RIGHT NOW.  It wasn't until years later during my training, assisting with my very first appendectomy, that I actually got scared.  Is the incision in the right place?  Is the skin bleeding?  Did I cut the fascia in the right plane?  Is the muscle bleeding?  Did I poke a hole in the bowel on my way in?  Did I tie off the appendix tightly enough?  Is it too tight?  Did I irrigate enough?  Too much?  Did that suture fall off?  Is there an abscess I missed?  Did I forget something?  Will there be a skin infection? 

You get the idea.  Interestingly, even though most of my patients don't seem particularly nervous, I've had a few of them ask me if I'm nervous before operating on them.  My standard answer:

"Yes."

A look of combined panic, terror, and "GET ME THE HELL OUT OF HERE!" universally ensues.  As the patients are probably locating the nearest exit and simultaneously mentally reviewing their lawyer's phone number, I give them a warm, reassuring smile and explain my response. 

I always get nervous before every operation, no matter how simple or routine it may seem, from a mole removal to an appendectomy to a pancreas excision.  I'm constantly reviewing the steps in my head, even if I've done it 1000 times (which I have), and I'm constantly thinking what could go wrong at every stage of the procedure.  Being nervous keeps me on my toes.  When a surgeon loses that edge, he gets complacent. And complacence is what causes mistakes to happen. 

As I go carefully through my explanation, their look goes quickly from "SHIT I'M GOING TO DIE!" to "I think this guy might know what he's doing" and then finally to "Ok, I'm in good hands".  Only when I see that look do I allow the anesthesiologist to proceed. 

If your surgeon isn't nervous, you should be.