Sunday, 29 September 2013

What the...

There are some things I just can't explain:



And there are some things I don't want to even try to explain.  This definitely falls in the latter category.  Unfortunately I have to admit that this is not my patient, and I am shamelessly stealing this from a hospital in Canberra, Australia.  

You have to understand...

It's just that...

I just want to start by saying...

Oh, fuck it.  Just read it.

Caberra Times:
"Doctors in Australia have removed a 10-centimetre fork from inside an elderly man's penis after a bizarre sexual mishap.
The 70-year-old arrived at the Canberra Hospital emergency department with a bleeding sexual organ.
He told doctors he had inserted the 10cm dining fork into his urethra almost 12 hours earlier in an attempt to achieve sexual gratification.
But the utensil became stuck.
The fork was not visible but doctors were able to feel it from the outside and X-rays showed its position.
Doctors considered several retrieval options before deciding to pull the fork free using forceps and "copious lubrication" while the patient was under a general anaesthetic.
The elderly patient was then sent home.
The medical emergency was so rare the team of three doctors published the case in The International Journal of Surgery last month.
The paper, titled "An Unusual Urethral Foreign Body", said it was rare to see objects lodged in the lower urinary tract.
It went on to list strange objects found inside other parts of the body, including needles, pencils, wire, allen keys, toothbrushes, light bulbs, thermometers, plants and vegetables, leeches, snakes, cocaine and glue.
"It is apparent that the human mind is uninhibited let alone creative," the authors wrote.
The medical team - Krishanth Naidu, Maurice Mulcahy and Amanda Chung - said the fork case was published to create discussion among the medical fraternity "given the great management challenge faced by the oddity and infrequency with which a fork is encountered in the penile urethra".
The doctors said the motives for inserting objects into the sensitive region were difficult to comprehend.
"The practice manifests primarily during states of pathological masturbation, substance abuse and intoxication and as a result of psychological compounders.
"Autoerotic stimulation with the aid of self-inserted urethral foreign bodies has been existent since time immemorial and have presented an unusual but known presentation to urologists."
They said embarrassed patients usually attempted to retrieve the item themselves, risking urethral injury and foreign body migration.
The real danger was infection leading to death, because ashamed patients often delay medical treatment, they said.
Doctors generally try to avoid surgery in such situations, instead choosing an option that would minimise urothelial trauma and preserve erectile function.
The authors said self-inserted male urethral foreign bodies are rare emergencies that urological and general surgeons face on occasion.
While the insertions are unusual, the paper said "any imaginable object is known to be implicated". 

Yeah.  I have nothing further to say, so I'm just going to leave it like that.

Thursday, 26 September 2013

Wisdom

"You'll understand when you're older."

I always hated when my parents said that.  When I was younger I refused to believe that older people could possibly know things that I didn't.  It just didn't make sense.  I was smart!  I knew everything!  I had wisdom beyond my years.  Right?

What I didn't understand is that anyone can open a book and learn facts.  But learning about how the world actually works can only be learned through experience.  And experience can only come with time.  The longer you survive on this wild, wacky planet, the more wisdom you gain. 

There are, unfortunately, exceptions to this rule.

The patient from my surgical training was older, in his early 70's.  He had the look of a university professor: unkempt white hair, 2-day old beard stubble, dark circles under his eyes, the smell of stale cigarettes and gin.  He was in the hospital for atherosclerosis of both his carotid artery and his coronary arteries and was teetering right on the brink of a heart attack, a stroke, or both.  He was scheduled first for a carotid endarterectomy (an operation to remove an atheromatous plaque from the wall of the carotid artery, thereby removing the blockage and reducing the risk of a stroke), and he was to have a coronary bypass surgery a few days later.  The carotid surgery was to be done first to prevent him from having a stroke during (or after) his bypass surgery.

His carotid surgery went very well, and I went to see him the following day to discuss his upcoming heart surgery.  But what greeted me was an empty room.  I continued on my rounds, figuring he was out taking a walk, getting a snack, or perhaps visiting with family in the reception area.

What I did not figure was that he had walked out of the hospital and gotten a taxi home so he could do a few lines of cocaine.  Apparently over his 70 years of life he never bothered to gain enough wisdom to figure out that cocaine is a very potent vasoconstrictor and can cause heart attacks, especially in people who are supposed to have coronary bypass surgery the next day.

Shockingly, he never made it back to the hospital.

No matter what you do, wisdom comes with age.  Everything you encounter and every experience you have adds to it. The problem is that w
isdom is just like money - it doesn't make a difference how much of it you have.  It is only valuable if you use it.

Monday, 23 September 2013

Impact

im·pact
verb
/imĖˆpakt/
1. come into forcible contact with another object.
"the shell impacted twenty yards away" synonyms: crash into, smash into, collide with, hit, strike, ram, smack into, bang into, slam into
2. have a strong effect on someone or something.
"high interest rates have impacted on retail spending" synonyms: affect, influence, have an effect on, make an impression on

For once, the title of this post doesn't refer to a car driven by a drunk idiot impacting a tree.  No, this has to do with the second definition - having a strong effect.  Some studies have shown that at least half of doctors suffer from a feeling of a low sense of accomplishment and emotional exhaustion, otherwise known as burnout.  I am firmly convinced that if more patients were more forthcoming with appreciation for what their doctors do, these feelings would vanish instantly.

Take for example Brittany (not her real name).  She emailed me recently with this story:

Hi Doc, my name is Brittany (not my real name) and I'm writing to tell you how much I enjoy reading your blog and to tell you how great it is that you care about your patients.  I read a recent entry of yours about patients being not so grateful for being saved.  It just made me think about how I wish I could thank my doctor, who didn't save my physical life, but saved my dream. I was born with a rare eye disorder called Ectopia Lentis, which effected both of my eyes.  I was legally blind and was told I would never drive and would need assistance in school.  I adapted and developed a very good verbal memory and never needed help in school, but I still couldn't do a lot of things I wanted to do.  I live in {redacted} and jobs and public transportation are very few and far between, so I was really worried about what I would be able to do.  When I was 18, I was given information about a case study by an ophthalmologist in another part of the country.  I had surgery to replace my lenses as well as the insertion of rings that would hold the new lenses in place.  My vision is incredible compared to what it was.  I'm now 27, have finished college and graduate school and I have the job I was meant to do.  I'm a school psychologist, which requires me to drive all over my area between the 28 schools that I serve.  After my surgeries, I saw a local doctor for follow up care because the surgeon was out of the area.  He has since moved even further away and I haven't been able to contact him to tell him how much he has truly changed my life and how thankful I really am.  I am now trying to start the process of having my young daughter checked for this disorder, as it is genetic.  I just hope that you know how much you change lives and how many people those people have an impact on.

Sincerely,
Brittany {still not her real name}

In case there are any doctors out there reading this (I know there is one, but he's retired and already knows very well how much his patients appreciated and adored him), you should be aware that there are patients like this out there.  And for everyone else, please let your doctor know of your appreciation.  Saying thanks is very nice, but writing your doctor a little thank you note is 10 times better.  But if your really want to say thanks, write a letter to your doctor's hospital administration.  We always get copies of them, and it warms our hearts more than you could possibly imagine.  It reaffirms our faith that we made the right choice going into this profession.

Saturday, 21 September 2013

Motorcycle safety

I pronounced yet another motorcyclist dead.  A young man, healthy, virile...now with a crushed skull, a life that will never happen, and a wife and children who will always wonder (but never know) why Daddy decided not to wear his helmet. 

Pronouncing someone dead always makes me introspective.  The things I think about are varied, and today it got me thinking about motorcycle safety.  Innumerable motorcyclists I've encountered have told me that their bikes are very safe as long as they are ridden safely.  I try to tell them that having 1500kg of steel, aluminum, roll cages, crumple zones, seatbelts, and airbags surrounding me is very comforting, but they are steadfast in their belief that their motorcycles are just as safe.  So I thought I would try to play Mythbuster today and debunk some motorcycle myths.  And for the first time, I'm citing sources so you motorcycle morons, er, riders have some actual data to read.  No, forgive me.  I meant morons.

Myth #1: Wearing a helmet on a motorcycle increases your mass and therefore increases the force of an impact in a crash, so they should NOT be worn.
Reality: HAHAHAHAHAHA!  Whew, that's a good one.  Seriously though, if you actually believe this utter rubbish, I'm surprised you have enough brain cells to figure out how to get your pants on, let alone how to get your bike's engine started.  One review showed that motorcycle helmets reduce the risk of death in a crash by 42% and reduce the risk of brain injury by 69% (1).  Not to mention that taking a big fat beetle to your helmetless face at 120kph might distract you just a tad and make you more likely to crash.


Myth #2: Most motorcycle accidents are caused by drivers of other cars because I KNOW HOW TO RIDE and everyone else around me is an asshole, dammit!
Reality: Half true.  Statistics show that 25% of motorcycle accidents are single-vehicle accidents, and 75% involve a passenger vehicle.  Motorcyclists see this and assume that means that 75% of motorcycle accidents are caused by car drivers.  But if you dig a bit deeper, in only 2/3 of those accidents involving other cars, the the driver of the car violated the motorcyclist's right-of-way, meaning that fully half of motorcycle accidents are the motorcyclists' fault (2).  Sorry, bikers.  The cars around you may be to blame sometimes, but you're not nearly as faultless as you'd like to believe.

Myth #3: When that car in front of me gets out of my way and allows me to overtake on my badass bike, the driver is being super polite to me.  The driver probably likes motorcycles!  Right?
Reality: Wrong.  We car drivers want you to pass us so you and your obnoxious noise pollution can get the fuck off our rear bumpers and fuck off.

Myth #4: My body armour and full-leather clothes will protect me from the pavement if I am ever separated from my machine.  I'm perfectly safe!  Ha!
Reality: No.  Just, no.  NO.  While it may offer some measure of protection compared to no protective clothing at all, when you hit the pavement at 100 kph, it will NOT completely protect your skin, and it won't protect your bones at all.  I've seen countless riders covered in road rash who were wearing full body armour that got shredded by the asphalt.  Not to mention the many broken bones underneath.  You are not safe out there, even with body armour.

Myth #5: Motorcycle helmets limit my peripheral vision, so I can't see, so fuck you, I'm not wearing it.
Reality: This is an outright lie.  Full helmets do NOT obstruct peripheral vision according to so many studies I don't even feel the need to cite them.  There's nothing more to say about that.

Myth #6: Since there are fewer motorcycles on the road compared to cars, the burden of motorcycle accidents is lower.
Reality: Nope, nope, and nope.  Statistics in the US show that while only 2% of vehicles on the road are motorcycles, fully 5% of road fatalities are motorcycle riders.  According to UK statistics, you are 16 times more likely to be seriously injured on a motorcycle compared to a car (3), and in the US statistics show that you are 16 times more likely to die on a motorcycle (4).  And in Australia you are 30 times more likely to die on a motorcycle than in a car (5).  So it seems the bottom line there is do not, under any circumstances, ride a motorcycle in Australia.

Get the idea yet?  I think by now you've realised the full extent of my hatred of motorcycles.  After reading all this, do you still feel safe on that motorcycle?  If you do, then you're an idiot and illiterate.

References:
1) Liu, B.C; Ivers, R.; Norton, R.; Boufous, S.; Blows, S.; and Lo, S.K. 2009. Helmets for preventing injury in motorcycle riders (Review), Cochrane Database of Systematic Reviews 2009, Issue 1. Oxfordshire, England: The Cochrane Collaboration.
2) http://commons.wikimedia.org/wiki/File:MOTORCYCLE_ACCIDENT_CAUSE_FACTORS_AND_IDENTIFICATION_OF_COUNTERMEASURES_VOLUME_I-_TECHNICAL_REPORT.pdf
3) http://www.dft.gov.uk/pgr/roadsafety/research/rsrr/theme5/indepthstudyofmotorcycleacci4784?version=1
4) http://www.nhtsa.gov/people/injury/pedbimot/motorcycle/safebike/myths.html
5) http://www.transport.sa.gov.au/rss/content/safer_people/road_users/motorcyclists_crashes.htm

Saturday, 14 September 2013

A few good men

I usually write about stupid people doing stupid things because that's what I see most often.  I've estimated that (other than Mrs. Bastard) there about 3 good people left in the world.

Coincidentally I met all three of them today.

In the little free time I have (after working, playing with my kids, and, um, romancing Mrs. Bastard) I enjoy building furniture.  For my latest project I needed 8 full sheets of plywood, so I headed to my local lumberyard.  When I found the wood I needed, there were exactly 8 sheets left on the pallet.  Ah ha!  Perfect!  I had just started loading one of the 35kg (77 lb) sheets into my trolley when a man approached and asked very politely if he could have one of the sheets.  I very apologetically told him that I unfortunately needed all of them.  He simply smiled and said, "Ok, I'll just ask if they have more."  Then he turned to walk away, but he hesitated and turned back around.  I was sure he was going to ask again, but instead he offered to help me put the plywood in my trolley.  I told him it wasn't necessary, but I suppose he saw me struggling and insisted on helping. 

Was he looking for money?  Was he trying to get me to change my mind and give him one?  No, he was just a kind soul offering his help to a stranger.

I thanked him profusely, paid for my wood, and huffed and puffed my nearly 300kg (660 lb) load to my car.  As I sweated my way to get the fourth of them in, I heard someone shout "Hey!  HEY!" behind me.  I turned around to see two men running towards me.  I immediately got nervous and wondered what they had planned (was I about to be mugged for plywood??) until the one who had yelled approached me, smiled, and said, "You have to be careful!  You can't do that by yourself!  You'll hurt your back!"

Despite my protests, he and his friend loaded the other 4 sheets into my car about 20 times faster than I could have done it alone.  Oh but wait, I forgot to mention the best part - one of them only had one arm.  Again, there was no request for money or anything else.  The one-armed man even took my trolley back to the front of the store, and they both disappeared inside.

After treating all the idiots that I see every day, it's nice to know that there are still a few people like this out there. 

Sunday, 8 September 2013

Brotherly love

I have a brother.  We get along fine...now.  When we were kids, though, we fought like brothers often do.  We'd wrestle, punch each other in the arms, and then wrestle some more.  Unfortunately for me, he's 2 years older than I.  Even more unfortunate is that he's 8cm taller and outweighs me by at least 20kg.

That fact never stopped me from attacking him.  And it never stopped him from defeating me soundly every time. 

But our squabbles never escalated higher than that - squabbles and tiffs.  Because underneath the childish tension and puerile pugnaciousness (look it up) was a strong brotherly bond.  And though the fights have long since ceased, that bond persists to this day. 

I have a feeling this next guy and his brother won't have such fond memories.

A man in his mid 20's was brought to me after he got into an argument with his brother.  Was the fight over money?  A girl?  What TV show to watch next?  I didn't ask, because frankly after seeing the 11 stab wounds that his brother inflicted upon him, I didn't give two shits about the reason. 

That's right, you read correctly - his older brother stabbed him 11 times.  In the back.  With safety scissors.  If you've never used or seen safety scissors, those are the blunt ones that children use that require even more force than regular scissors to actually break the skin.

"Your brother did this to you? I asked, astonished.  "Really?"

"Yeah," he replied.  "It's pretty cool, right?"

I simply stared at him. I had no words. 

"Aw man, I'm 25 years old.  I guess I'm just excited.  It isn't his fault, though.  He's just been really stressed lately."

I still had no words. I simply cleaned his wounds, repaired them, and sent him home. 

I can fix wounds.  Family relationships?  Not so much.  Stupid?  That's just unfixable. 

Friday, 6 September 2013

Right of refusal

*** WARNING: ACTUAL SURGICAL PHOTO AT THE END.  YOU HAVE BEEN WARNED.  TURN BACK NOW. ***

Patients have several rights when they walk into a hospital - the right to be seen and evaluated, the right to receive care regardless of their demographics, and the right to refuse care.  If that last one confuses you, don't feel bad - it confuses me too.  Why would someone come to a hospital and then refuse to be treated?  Why bother coming?  Those are questions I have failed to answer every time.  Regardless, if they say "No thanks," I respect their wishes and walk away.

Except this time.

A very healthy woman in her 70's was dragged to the emergency room by her friend because she had been having abdominal pain for nearly a week.  She had a long history of "stomach problems" since she was a small child, but she had no major health problems and had never had any surgery.  When I examined her, I immediately noticed that her abdomen was markedly distended, and everywhere I pushed hurt.  A lot.  After the examination I excused myself to look at her CT scan, and what I saw gave me pause.  No, actually it made me quite nervous.

Ok, it scared the shit out of me.

Nothing was where it should have been.  Her appendix, normally in the right lower quadrant of the abdomen, was in the right upper quadrant, and her spleen, normally in the upper left, was also in the upper right.  Worse yet, there was a long segment of small intestine which was dilated and thick with fluid around it - a dire sign of bowel that has either died or is about to.  And as you can probably imagine, dead intestine equals dead patient.

I quickly went back to see her, only to see her getting up to get dressed.  I asked where she was going, and she politely but firmly told me that she was going home.  I explained that I believed she had intestinal malrotation with midgut volvulus (try saying that 5 times fast) and needed immediate surgery:
"No thank you.  I'm going home," she told me.  "Maybe I'll come back tomorrow if I still feel sick."

"If you go home tonight, there won't be a tomorrow," I warned her.

I told her she would not live through the night without surgery, and I had already called the operating room to prepare a room for me.  Her friend tried to convince her.  Her sister called her from across the country.  Her nephew called her.  But none of us could change her mind.  Normally if a patient still refuses surgery after I fully explain the severity of the situation, I say "As you wish," and I leave.  I refuse to operate on someone who doesn't want surgery.  But something this night made me continue.  Something made me stay and fight.

A full hour later, she finally agreed.  I rushed her into the operating theatre and found this:

In case you hadn't guessed, that black, dead-looking thing is the 75 cm (30 in) portion of her small intestine that had died.  I removed that segment, put her back together, and 5 days later she walked out of the hospital.  As I was discharging her, I told her with a smile that she was one of the most stubborn patients I had ever had the pleasure of operating on.  

"Thank you," she said, "for being just as stubborn as I am."

Sunday, 1 September 2013

Stupid things people say

I have said some STUPID shit in my life.  Everyone has.  And anyone who denies ever saying something mind-bogglingly stupid is saying something really mind-bogglingly stupid.  But have you ever said anything so stupid that as soon as it comes out you wish you could turn back time about 2 seconds and then actually use your brain before opening your mouth?

This next ER doc had just such a moment.

He woke me at 2AM to tell me about a woman in her 40s with acute appendicitis.  He went through his whole story about her pain and how it had progressed over the past few days, and then in my drowsy but increasingly-alert state I asked him if she had any other medical problems or surgeries.

"Well yes, she has metastatic Stage 4 breast cancer."  {The 5-year survival of patients with metastatic breast cancer is about 15%}

"Ok," I replied.  "Unfortunately for her, that doesn't change the fact that she also has acute appendicitis and needs her appendix out.  Anything else?"

His exact words were, "No, other than that she's completely healthy."

I actually paused for a moment while I tried to process that statement.  Then  I said, "So other than her terminal cancer, she's healthy?"

I guess he finally realised the absurdity of what he had said, so he gave a nervous chuckle and said, "Um yeah, I guess."

That wasn't just stupid.  That was ER Doc Stupid.