Tuesday 25 February 2014


As a trauma surgeon, my biggest fear is walking into the trauma bay as my wife or one of my children is rolled in on a gurney.  I've often wondered how I would react in that situation - would I be able to keep my cool?  Could I possibly treat one of the people about whom I care the most?  I've often heard that treating a family member is a "conflict of interest", but is it really?  My interest in that moment would be to make sure my family is taken care of, that they get the best possible treatment.  Whenever this hellish scenario pops into my head, the answer to those questions is invariably and obviously "no".  I would immediately call one of my colleagues and have him come in and take over.  It would be absolutely impossible for me to be a sane, rational, objective doctor while looking down on my injured, bleeding wife or child.

Ok, that was probably a bit more maudlin and dramatic than I was intending, and I think the answers to my questions were probably fairly obvious to anyone with more than the brain capacity of a salamander.  But what if the medical problem were outside my area of expertise?  What if someone in my family had a medical (rather than surgical) emergency?  Would I go into Doctor Mode or would I go into Daddy Mode?

I had the chance to answer that question a few years ago.

On a cold Sunday morning my wife and I were startled awake by my daughter coughing.  This wasn't anything new - she'd had a cold for a few days, just a cough and some congestion.  But this cough sounded different somehow.  We rushed into her room to find her sitting up in bed and hacking so hard I thought a lobe of her lung would come shooting out of her mouth.  It wasn't just a normal cough either, but a loud, raspy, barky cough typical of croup.  The cough sounded terrible, but it wasn't the cough itself that bothered me.  Rather, it was the high-pitched, wheezy noise she made as she was inhaling.


That wasn't a wheeze, it was stridor.  It sounds similar to wheezing, but instead of being on expiration, stridor is on inhalation.  It is a sign of the airway above the vocal cords collapsing, and it is very ominous.

This was clearly no ordinary cold.

Mrs. Bastard, who happens to have asthma, ran and grabbed her nebuliser and some of her asthma medicine, and we held the mist in front of our daughter who sat quietly and breathed it in like a little champion.  This settled her down, she was able to breath normally, and she went back to sleep for a few hours.  I, however, did not, not after hearing that sound.  Over the course of the day, she had several more mild episodes which all went away, but late in the afternoon it got worse.  It was then that I found out the hard way that severe stridor is the most terrifying sound I've ever heard.  She sounded like she was struggling to breathe.

We drove her straight to the nearest hospital (where I happen to work), and after hearing her coughing and breathing the nurse brought her straight back to an exam room.  She checked her vital signs, and her oxygen levels were fine, but she was obviously working a bit to breathe.  The paediatrician told me she needed the nurse to place an IV for some medication, and that Daddy had to hold her down during the IV placement.  I held my daughter tightly, and she screamed as they poked her hand with the needle.  As tears ran down her face, her huge eyes stared directly into mine with a look that I will never forget and unmistakably said, "Daddy, how can you let them do this to me?  You're supposed to protect me!  Why, Daddy?  WHY?"

Fortunately the IV went in quickly and without difficulty, and they gave her a small dose of steroids along with some more nebulised medicine via a facemask to calm down her breathing.  After just a few minutes, her breathing had settled down significantly, nearly to normal.  A rapid lab test confirmed that her croup was due to the Influenza A virus.  She fell asleep on the hospital bed with the facemask still hissing quietly, delivering the fine mist of medicine that would open her airways for good.

Sometime after midnight (which was the latest she had ever stayed awake), we brought her, sleeping soundly, back home and put her to bed.  It was only after she was safely in her own bed that I realised my breathing had also just returned to normal.  I'm absolutely positive that it's impossible to hold one's breath for 6 hours, but it sure felt that way at the time.  Her cough lasted for a few more days, and fortunately she had no more episodes of stridor and quickly reverted to the normal, happy little girl she had always been.

So how would I grade my performance?  Under the circumstances I would say I kept my composure reasonably well.  I never panicked, but I was more nervous that day than on any other day in my professional career, and it reaffirmed my belief that doctors should never treat family.  It also reaffirmed that I will never treat my own children.

Unless I'm treating them to ice cream.

Saturday 22 February 2014

Bad guys and their guns

I think we've all seen the movies where the good guys have a shootout with the bad guys.  What inevitably happens is that bad guys shoot and shoot and shoot but can't hit the broad side of a barn let alone one of the good guys (unless it's a Red Shirt from Star Trek...those guys seem like they are bred to get shot and die).  The good guys, on the the other hand, can somehow evade thousands of bullets while shooting two guns at once, all while spinning, leaping, twirling, diving, and flipping, hitting every bad guy in their path and killing them instantly.


The funny thing about these scenes is not just how preposterous they are (you do NOT die instantly when you are shot in the chest!), but how there is a smidgen (yes, a smidgen) of reality hiding out there.  

"Reality?  In movies?  Ha!"

No, I'm serious.  The skosh of truth about gun battles is that the good guys often don't miss, due to their extensive training with shooting these dangerous and potentially deadly things.  Bad guys?  Not so much. 

There comes a time in most people's lives when that little voice inside our heads looks at what we're doing and says "Wait, what the fuck am I doing?  This is really stupid!  I could hurt myself!"  I say "most" because some folks just don't seem to have that little voice telling them to stop and think.  You know, that little voice that annoyingly (but correctly) stops you from sticking your hand in the sink garbage disposal while its spinning, or stops you from calling your abusive ex-boyfriend just to say hi, or stops you from jumping off the roof into the swimming pool.

In Peter's case, I think it's safe to say that his little voice took the day off.

It was a beautiful sunny day when Pete (not his real name) and his buddy decided it would be a perfect day to steal a car.  Their ride of choice?  A sports car, right?  No.  Well perhaps a luxury sedan then?  Nope.  Um, a mid-size hybrid?  No sir.  They chose a minivan for their joyride, though I'm not sure how much joy there is in driving a minivan.  Anyway, in the midst of their joylessride, these supervillains figured that since they had a getaway car already, it would be the perfect opportunity to fulfill a lifelong dream - robbing a bookstore.

"Haha, you mean a bank, right Doc?  Right?  Doc?  Hello?"

No.  A bookstore.  A small one that doesn't have a cafĂ© attached.  You know, those places that Amazon.com is putting out of business.

After driving home and picking up their illegal handgun, the Band Of Evil Geniuses drove to the bookstore and successfully robbed it, escaping with approximately enough cash to buy an economy pack of toothpaste.  

Thanks to the magic of surveillance cameras and silent alarms (I guess our criminal masterminds didn't case the joint and think of that little detail prior to completing their grand scheme), the police caught up with them less than 10 minutes later.  After a brief chase in their high-powered minivan, they crashed into a pole, ditched the car, and ran.  As they were running, Peter turned and fired his weapon multiple times at the police. 

Bad move, Pete. 

The police fired back, and one of their bullets found their mark - the back of Pete's leg.  He fell, bleeding profusely. 

By the time he got to me about 20 minutes later, he had nearly bled to death from the wound on his left leg.  The tourniquet placed by the police wasn't working well, so we put direct pressure on the wound to stop the bleeding temporarily.  As we were doing our comprehensive exam, I found something most curious - a second gunshot wound on the front of his right hip.  Now I was never that good at physics, but it seemed to me impossible to get shot in the front of the hip from behind.

X-rays confirmed a shattered left femur just above the knee where the police shot him, and a shattered right pelvis with bullet fragments all over the place.

For the next several minutes I stared at his right hip wound, trying to figure out how the police had shot him in the front from behind.  Just as I was about to surrender, Peter divulged this little nugget: 

"Hey Doc, I think I did that one."

I'm very rarely speechless, but I guess Pete recognised the clueless look on my face. 

"Yeah, when I was pulling my gun out of my pants, it went off."

That's right, in his attempt to extract his gun from his pants and shoot at the police, Pete had shot himself in the hip.  Shockingly, none of the police officers were hit by our marksman.

Peter spent about a month under armed guard in hospital before he was mobile enough to go to jail.  

I wouldn't dream of challenging Garry Kasparov to a game of chess.  I would never challenge Rafael Nadal to a tennis match.  And I wouldn't think to challenge a police officer to a shootout.  But then again, unlike Peter (and many of my other patients), I have an IQ higher than a radish.

Friday 14 February 2014

Breast cancer

It hopefully will come as no surprise that in addition to being a trauma surgeon, I'm a general surgeon as well.  While it is true that I repair colons that have been lacerated by bullets, fix stomachs slashed by knives, and remove spleens that have been shattered in car accidents, I also remove gall bladders, infected appendixes (appendices?), and many kinds of cancers.  One of the most difficult cancers to treat is breast cancer - not because it is technically difficult, but rather because it is very common as well as a very sensitive subject in a very sensitive part of the female anatomy.  I've been unlucky enough to be the one to tell innumerable people that they have cancer, and it seems that as soon as the word "cancer" escapes my lips, patients begin planning their own funerals.  But when it's breast cancer, the impact is always that much greater.

To give you an idea of the scope of the problem, there are approximately 1,500,000 new breast cancers diagnosed each year worldwide, and over 500,000 people die annually of breast cancer.  That data should be enough to give anyone pause.  Thankfully, because of aggressive screening (with physical examinations and annual mammograms) and equally aggressive treatment, the 5-year survival for breast cancer approaches 90%.

That makes it sound like we're doing a pretty damned good job at tackling a very difficult problem, and further research into both early detection and improved treatments are making our efforts better.  But an article published this month in the British Medical Journal seems to be trying to derail those attempts at improvement.  They studied breast cancer and death rates in 40-59 year old women over a 25 year period who either A) did or B) did not get annual mammograms.  First, they found that the women who got mammograms were found to have 20% more cancers (this makes sense because the mammogram can find a cancer that was not large enough to be felt on physical examination).  But they also found that the proportion of women who died of breast cancer did not differ between the two groups.

Well this is certainly bad news for radiology centers and radiologists, because it seems that we don't need to do mammograms because they don't save lives.  But that's great news for women, right?  We can stop doing mammograms!  Women of the world, rejoice!  No more squashing your breasts every year!

Now ladies, hold it right there before you start burning your mammogram slips along with your bras.  The authors go on to say that the women who were only diagnosed with cancer by mammogram (but were undetectable by physical exam) were "over-diagnosed".

Uh...what?  How do you over-diagnose cancer??  Indeed, the authors claim that because the death rates are the same, that these women didn't need to be diagnosed with breast cancer . . . yet.  Because you see, if they had just waited until the cancer was large enough to feel on physical exam, their risk of death was the same anyway, so we may as well not even do mammograms for women between 40 and 59. 

I don't know if that makes any sense to you, because it certainly does NOT make sense to me.  Leave an otherwise-detectable cancer alone until it grows bigger?  This flies in the face of everything I know about cancer, which is to get it out as early as possible.  I have a feeling Terri (not her real name) would probably agree with me and tear your lips off for suggesting anything different.

I first saw Terri a few years ago when she was 40, though she looked much younger.  She had no family history of breast cancer or other specific risk factors, but she listened to the advice of her primary doctor and dutifully got her first mammogram.  When the mammogram revealed a very small lump in her left breast, her doctor sent her to see me for a consultation.  Because Terri's breasts were so large, when I examined her I couldn't feel the mass.  But when I looked over her mammogram, there was definitely something there.  It was small, round, and smooth, and the radiologist read it as a probable fibroadenoma, a common benign lump.

Terri wasn't satisfied with that.  I wasn't either.  I don't have breasts, so I can't imagine living with a mass in there that someone thinks is probably not cancer.  Put another way, if I found a lump in my testicle and was told, "Eh, it's probably nothing", I would swim through a pool of broken glass to investigate it further.  So whenever I see a woman with a breast mass, I offer to biopsy it or remove it outright.  She opted for removal.  And it's a damned good thing she did.

The mass turned out to be an invasive ductal carcinoma, the most common type of breast cancer.  We did further genetic testing as well, and it confirmed that she was a carrier of the BRCA-1 gene mutation, which confers not only a 65% risk of breast cancer, but also a 50% risk of developing another breast cancer (even in the opposite breast) and a 40% risk of ovarian cancer.

Terri opted for a bilateral mastectomy, and during that consultation I also spoke to her 3 daughters about getting tested for the BRCA-1 mutation, because they each have a 50/50 chance of inheriting the gene mutation from their mother.Having a bilateral mastectomy increases life expectancy by 3-5 years, which may explain why both Angelina Jolie and Christina Applegate chose to undergo the procedure.
At her postoperative follow-up appointment, I was explaining how I was going to send her to see an oncologist as well as a gynaecologist to discuss removing her ovaries.  While I was talking Terri kept interrupting me to say "Thank you".  I was about to say "You're welcome" when, for the first time since I met her, Terri started crying.  I handed her a box of tissues and told her it was normal to be overcome with emotion at this point.

"No, you don't understand," she said.  "You were the third surgeon I saw for this.  The first two told me the lump was nothing and that I didn't even need a biopsy.  But you actually listened to me.  You saved my life, and probably my daughters' lives too.  Thank you.  Thank you."

You're welcome, Terri.  You're welcome.


  • Miller AB,
  • Wall C,
  • Baines CJ,
  • Sun P,
  • To T, 
  • Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. 
  • BMJ 2014; 348.

    Tuesday 11 February 2014

    Therapy and coffee

    A brief note to my patients (not that I expect any of them to read this): I am NOT a therapist.  Let me repeat that in case you missed it: I AM NOT A THERAPIST, and I am most assuredly not YOUR therapist.  I have no interest in hearing about your personal problems.  I am a trauma surgeon, and if you have a punctured lung, a hole in your colon, or a tear in your liver, I very much care about that.  However, I do not care that your dog died when you were 7 and you never got over it.  I do not care how your brother teased you about your curly hair when you were kids.  I am not interested in how your Daddy was always working and missed your piano recital when you were 10. 

    Despite my disinterest in such matters, many patients feel the overwhelming need to dump all their dirty laundry (along with their blood and/or vomit) all over my lap.  It's almost like they see the white coat and immediately think "I have 33 years of issues to get through, and YOU are going to help me cope with ALL of it.  RIGHT NOW."

    Now don't misunderstand me - I have the utmost sympathy for patients who are injured, and I will do everything I can to help them get through their ordeal.  But I do NOT care that Mr. Smith only gave you a B- on your Wuthering Heights essay when goddammit you KNOW you deserved an A.

    However, despite the many times when patients have felt the need to get things off their chests, I've found very few of them to be either amusing, educational, or both.  It's an even rarer circumstances when I've felt authorised to give them advice on such personal matters.  As you may have surmised, one such situation arose recently.

    After a long 24-hour trauma shift, all I want to do is have a coffee, go home, have a coffee, take a shower, have a coffee, and spend some time with my family.  With a coffee.  I had already managed to take care of 18 trauma patients during one particularly busy shift (including two who had tragically arrived dead and stayed dead), and with only 15 minutes left to go and a large cup of coffee on my mind, I thought I was home free.

    The Call Gods had other ideas. 

    As I was daydreaming about my first coffee at home (the hospital coffee is pure, unadulterated crap) my pager went off, telling me that I would be getting a pedestrian struck in 10 minutes.

    DAMN YOU, CALL GODS!  The coffee would have to wait, unless the medics were late.  Please be late...please be late...please be late...

    Exactly 10 minutes later (DAMN IT!) the medics brought me 20-year old Ellie (not her real name).  "This one is a real piece of work!" one of them chuckled as he dropped her off.  Chuckles the Medic couldn't really tell me what had happened to her since she wouldn't talk to them.  "She says she got beaten up.  She doesn't really seem badly injured, but she's complaining about pain everywhere.  She's a real winner!" Chuckles gleefully continued as he and his cronies laughed themselves out the door.


    I did my initial survey from head to toe and saw just a few scrapes on her knees and hands and a bloody swollen nose.  And then I made my first error - I asked her what happened.

    Much like any argument I've ever had with Mrs. Bastard, as soon as my mouth was open I regretted ever opening it.  She launched into her story that didn't end for at least 30 minutes.  We were able to do our entire workup, X-rays and CT scans included, before she was even close to finished. 

    Ellie told us that she and her boyfriend had gotten into an argument over another girl (I don't care) which had escalated into a fight (I don't care).  Not just a fight - a fistfight (I DON'T CARE).  That might explain the abrasions and contusions on her knuckles.  But Ellie was perhaps 150cm (just under 5 feet) tall and might weigh 45kg (100 lb) soaking wet.  I've met very few men smaller than that, so I'm assuming he won based on her broken nose.  I'm also assuming he wasn't satisfied with just winning, because he apparently decided to run Ellie down with his car.  Fortunately she was just knocked onto her hands and knees (explaining the knee abrasions) with no real damage done.

    But as I was looking over her scans (and finding nothing else broken), she continued telling me about her history with her boyfriend (I DON'T CARE).  He had stabbed her last year, she said.  And he had cheated on her with at least 2 other girls.

    "Oh but Doc," she finally concluded.  "Can you tell me how I can avoid getting another STD from him?  He already gave me something last year, and I think he got something else from one of those other whores, and I don't want to catch anything from him again."

    Wait wait wait, let me get this straight - he cheats on you, stabs you, beats you up, and tries to run you over with his car, and you want to know how not to catch an STD from him because . . . you're . . . staying . . . with . . . him?

    "Yeah Doc, I love him."

    I closed my eyes for a moment and went to my happy place.  When I opened my eyes, she was looking at me expectantly, like I was going to give her some sage wisdom.  I took a deep breath.  "The best way," I said slowly and deliberately, "to avoid catching an STD is to NOT sleep with someone who cheats on you, stabs you, beats you up, and runs you over."  I then splinted her nose and sent her home. 

    My coffee was waiting.

    Thursday 6 February 2014

    Dropped on your head

    I will admit that writing this blog is somewhat cathartic.  I get to educate, get things off my chest, and insult various people all at the same time.  While I like sharing my "good saves", I like telling the stories of the stupid, ignorant, irresponsible idiots the most.  And my favourite stories of all are the ones where I'm the idiot.

    Unfortunately I don't have many such stories, at least not many that I'm willing to A) share and B) admit to.  Mrs. Bastard might disagree with that statement, but what the hell does she know.  

    Um, please don't tell her I said that.

    My older brother may also disagree, however.  "You were dropped on your head as a child!" was the classic insult that my brother used to hurl at me whenever I did something stupid, which was fairly often.  My response was usually to yell some idiotic, meaningless insult at him (ie "WHATEVER, YOU BIG STUPID  STUPIDHEAD!") or to do something just as stupid as whatever temporary moment of insanity prompted his comment in the first place, like attacking him.  He was always much larger than I, so my assaults would inevitably fail. 

    Regardless, that insult stuck with me, because I couldn't possibly imagine my father (DadBastard) or mother (MumBastard) ever being so irresponsible as to drop me.  But one day recently the insult suddenly hit close to home.  Very close.

    It was a perfect day for the pool - warm but not too hot, the sun was shining brightly.  My extended family (parents, siblings, various nieces and nephews, cousins, in-laws) was in town for a little torture session get-together, and we all decided it would be an ideal day to hang out at the pool.  My brother-in-law managed to get all of us guest passes to his neighbourhood pool, so we (read: Mrs. Bastard) packed a huge bag of pool toys (seriously, do we really need 124 sinking toys, 95 floating toys, and 45 water guns?) and a picnic lunch, and we all met there just before noon.

    "Wait, BEFORE lunch?  But don't you have to wait 15 minutes after eating before going in the pool?"

    No, you don't.  I thought I busted that myth months ago, but I must have missed it.  Now stop interrupting.

    The picnic area was at the top of a small hill, and the pool was at the bottom.  After eating (no, I did not wait 15 minutes), it was time to swim.  I slathered my 2-year old son in sunblock (SPF 1500, I believe), picked him up, and started down the hill.

    At this point if you remember the title, I'm sure you see where this story is going, even though I clearly did not.

    At the very bottom of the hill while taking the very last step, my left foot turned inwards.  Badly.  As my ankle turned, I felt a distinct "pop", and suddenly my entire left lower leg felt like it was on fire.  It may sound trite and contrived, but the next 2 seconds actually felt like 2 minutes, everything seemingly going in super-slow motion.  I lost my balance and saw my son tumble sideways out of my arms, his head going downwards directly towards the concrete pool deck.  In an attempt to prevent the inevitable, I planted off my left foot (and distinctly remember thinking, "THAT WAS A VERY BAD IDEA, STUPID"), and lunged towards him, trying in vain to catch him.  My arms flailed and my ankle burned as I failed to grab anything more than air, and he landed squarely on his head with a clear, unmistakable dull thud on the concrete.  

    My son immediately righted himself and paused for a moment, trying to figure out what the hell had just happened.  His eyes darted around, clearly saying "Wait, I was just in Daddy's arms, and now I'm not and ow ow OW OW MY HEAD!  OW OW OW OW!"  The crowd in the pool was suddenly dead silent as all eyes turned to the bumbling idiot and his now-screaming child.  

    Terrified that I had just scrambled my son's brain and thwarted any chances of him becoming the next Elon Musk, I did my best to ignore the sensation that a basilisk had latched onto my ankle.  I scooped him up, cradling his head as best I could, and I started limping back up the hill.  My ankle was hurting more and more with each step, but I didn't care.  All I cared about was making sure my son wasn't seriously injured. 

    I flopped gingerly into a chair and looked at my little boy, who by this time was no longer crying but was still clutching me around my neck.  I took a quick look at his head and saw no blood, no bump, not even a single scratch.  After looking him over carefully, I realised he wasn't at all hurt, and after heaving the heaviest and most relieved sigh of my life, I tried to extricate him from my neck so I could assess the damage to my ankle.  But my son wouldn't let go.  It was as if he was saying, "NO WAY, Daddy!  You already dropped me once.  I am NOT letting go this time!"  Mrs. Bastard couldn't even get him to release his grip on me. 

    For the next several minutes I held him just as tightly as he was holding me until we had both completely calmed down.  By the time it was obvious that he was totally fine, it was even more obvious that I was not.  My ankle and foot were swollen to nearly twice their normal size and starting to turn several very interesting shades of purple, mauve, magenta, and violet.  My brother-in-law brought me a bag of ice, and I tried to keep my foot elevated.
    The worst part was that I was on call the following day, and as I hobbled through the hospital towards my next trauma patient (who turned out to be less injured than I), I had to explain to at least 276 different people why I was limping and how careless and stupid I had been.  I considered telling them that I injured myself while fighting off a band of vengeful ninjas, but I thought maybe the truth would be easier to remember. 

    Considering I admitted two slip-and-fall patients that week who had open fracture-dislocations of their ankles, I have to consider myself very lucky that my ankle was only severely sprained and has since healed.  But I am far luckier that my son wasn't hurt.  If this episode taught me anything, it's that I um...it's that...uh...that...

    Hmm.  Now that I think about it, maybe I actually was dropped on my head as a child. 

    Not dead

    I'll start this post by answering a few questions that may or may not be burning in your mind: No, I'm not dead.  No, I didn't g...