Good will

Most of the patients I see aren't injured severely enough to warrant time off from work and are able to go immediately back.  Some I estimate will need a few days off, some need a week or two, and a few likely even need several months to recuperate.  I don't mind writing excuse letters for those with severe injuries, and I'm typically rather lenient with granting time off to recover, partially because I feel bad for them, but mainly because I don't feel like arguing with people (I realise that may come as a surprise to you).

Unfortunately some people decide to take advantage of my good will. 

Kevin (not his real name©) was brought to me a short while back in excruciating agony.  The medics wheeled him in to my trauma bay quickly, in a bit of a panic, because of the "large" amount of blood loss at the scene.  He had some blood on his pant leg and more on his hand, and both his left thigh and left hand were heavily bandaged.  He was writhing around on the gurney like a snake on acid. 

"AHHH!  My leg!  Oh my god, am I going to lose my leg??  Oh god I'm dying!"

As usual, step 1 is to inspect the wounds.  I quickly unwrapped his hand and thigh and then paused, staring agape at what confronted me. 

"How bad is it, Doc?  Tell me straight.  Am I going to live?"

The 2 cm laceration on his outer thigh and the 1 cm laceration on his ring finger, neither of which was bleeding, did not make me fear for his life. 

"Yes, sir," I said flatly, doing my best not to slap the shit out of him for his histrionics.  "I suspect you're going to be just fine.  May I ask what happened here?

It turns out that Kevin carried a pocket knife but had forgotten to close the blade before putting it back in his pocket.  He then sat on the blade, lacerating his thigh, and when he reached into his pocket to retrieve the knife, he cut his finger.  

Twenty minutes and 5 stitches later, we were writing up his discharge papers.  And that's when he hit me with this:

"So how much time off work am I gonna get for this?  I think I'll probably need a week.  Maybe two.  Yeah, I think two."

I explained in no uncertain terms that he could go back to work the next day.  

My good will only goes so far before running out.  

Most injured

I may glamorise my job from time to time (read: all the time) to make myself and what I do seem more interesting.  The sad reality (from my own skewed point of view) is that the majority of my patients are only mildly injured (and sometimes not injured at all).  Most patients get worked up in A&E/ER/ED/casualty department and sent home the same day with stitches, staples, splints, bandages, and/or a stern lecture from me about how to prevent this sort of thing, whatever it may be, from happening again.  For me repeat customers, though good for the bottom line, are bad for business.  If that makes any sense at all.

But who the hell wants to read about someone who was in a minor car accident but was brought to me just as a precaution?  Who wants to know about the old lady who loses her balance and bonks her head on an end table and ends up with nothing but a bump on the head and a mild concussion?  Who cares about yet another drunk guy who falls off his bar stool, spends a couple of hours with me sobering up, and then endures a real sobering drive home with his wife appropriately yelling at him from the driver's seat?  Is anyone even remotely interested in any of that?

I'm certainly not, but I have no choice in the matter.  But I spare you good people the details about the mundane and boring people who come in with minor injuries, mainly because if I didn't you would all run away faster than teens from a Wiggles concert.  No?  Ok, faster than men from a Taylor Swift concert.  Still no?  Ok, faster than sane people from a Miley Cyrus concert.  

Yes.  Perfect.

Anyway, this next guy is not one of those boring people.

I mentioned Orville (not his real name©) briefly in a prior post (he was Victim #2) and promised I would get back to him, so now I'm keeping my damned promise.  Orville is in his mid-20s, and like many young men his age he hasn't outgrown the immature belief that he's immortal and/or indestructible.  Seat belts are too good for him, apparently, because he wasn't wearing his when the car in which he was a passenger went off the road at around 160 kph (100 mph) and struck a tree.  As usual, the tree won.  The tree always wins.  Orville was thrown from the car and landed somewhere near the orbit of Venus, I believe.

When Orville got to me, he wasn't moving at all and was obviously close to death: his heart was beating around 160 times per minute because it was trying to compensate for his dangerously low blood pressure.  About 60 seconds later, his heart gave up and stopped. 

With CPR, several units of blood, and some medications, we restarted his heart a few minutes later, and we continued transfusing even more blood as we were finally able to start our evaluation.  The first and most obvious thing I noticed is that his head looked completely uninjured, unusual for someone in such a severe accident. 

"He is a complete mess," I mentioned to one of the assistants.  "But at least his head looks ok.  But that's about the only thing that looks ok."

Unfortunately looks can be deceiving.

Ultimately his workup revealed the following injuries:

• 5th cervical vertebra fracture
• 5th thoracic vertebra fracture
• 5th lumbar vertebra fracture
• cervical spinal cord injury
• Sacrum fracture
• Open-book pelvic fracture
• Three rib fractures on the left
• Left hemopneumothorax (bleeding, punctured lung)
• Cardiac contusion
• Bilateral (both sides) severe lung contusion 
• Bilateral scapula (shoulder blade) fractures
• Bilateral acetabulum (hip socket) fractures (left side shattered)
• Bilateral Grade IV (that's bad) kidney lacerations
• Urethra laceration
• Bladder laceration
• Mesentery (blood supply of small bowel) laceration
• Multiple small bowel and colon contusions
• Multiple deep left arm lacerations and abrasions
• Subdural haematoma (bleeding under the dura mater, the tough covering over the brain)

His liver (and all the other internal organs) suffered contusions and/or ischaemic injuries from his initial haemorrhagic shock.  There are only a few things on his entire body that weren't injured.  I would say that his arms and legs were uninjured (other than innumerable lacerations and deep abrasions on his left arm), but since he ended up quadriplegic (unable to move his arms and legs due to his spinal cord injury), that doesn't seem to matter quite so much.

It always amazes me when I hear idiots claim that getting thrown from a car is safer than staying in it.  Would you rather get thrown out of a car and deal with all the kinetic energy of hitting the ground, or would you rather stay in the car where all the seat belts, airbags, roll cages, and crumple zones surrounding you and keeping you safe are?

Exactly.

Call Gods Redux

At the risk of sound redundantly repetitive, superfluously repetitious, and recurrently mundane, I believe very firmly in the Call Gods.  I know I bring them up a lot, but despite the fact that Mrs. Bastard and I take the Call Gods very seriously, I get the feeling that a lot of my readers don't.

That is a seriously bad move.

I remain deathly afraid of the Call Gods (even more afraid than I am of huntsman spiders), but only because they continue to demonstrate that they are real.  Really real.  And really evil.

A colleague of mine presented our monthly trauma conference recently.  He spoke of a young man who had been involved in a high-speed rollover motor vehicle accident and was obviously in shock when he arrived at our hospital.  My colleague's workup demonstrated a large laceration of the right diaphragm (the muscle that controls breathing, separates the chest from the abdomen, and keeps all the guts in the belly).  The laceration was so large that his entire liver was up in his chest, compressing his lung and preventing him from breathing properly.  My colleague took him to surgery, pulled his liver back down into the abdomen where it belonged, and repaired the diaphragm.  It was an excellent presentation with a great outcome for the patient, and I listened with a mixture of curiosity and fascination.

Now I've seen innumerable knives and bullets poke holes in the diaphragm that I've subsequently repaired, but those are always relatively small injuries (either knife- or bullet-sized) that are fairly easily fixed with a stitch or two.  But blunt diaphragmatic injuries like the one my colleague presented are typically much larger (and rarer) and can be very difficult to diagnose and repair.  All during the presentation I kept thinking to myself, "With all the blunt trauma I see, I can't believe I've never seen a blunt traumatic diaphragm injury."

See where this is going yet?  Talking about the Call Gods . . . Yeah, I didn't at the time.

I happened to be on call that same day, and it turned out to be a very light day with only two low-level, minimally-injured fall victims coming in.  So after finishing up writing a blog post, I thought I might tempt the Call Gods and lie down to try to get some sleep that night.

HA!  No.  The Call Gods were watching me carefully, and they obviously decided they would not be allowing anything like that.  Not during their watch.

Just before midnight my lovely pager (which I adore and never want to throw across the room) informed me that a level 1 (high level) motor vehicle crash victim would be arriving in 5 minutes.  Two minutes later as I rushed towards the trauma bay, my lovely pager nearly did get thrown against the wall when it told me a second high-level car accident victim would be coming in another five minutes.

Triage mode: activate.

Victim #1, a young man in his 20's who had been driving way too fast (without his seatbelt on, naturally) and had struck a tree, arrived moaning about 4 minutes later, his heart pounding away at 140 beats per minute.  His blood pressure was ok, but his oxygen level was low.  A quick push on his chest revealed air in the soft tissues and a distinctively sickening crunchy feeling, a sure sign that he had rib fractures which had punctured his lung.  We had just enough time to insert a chest tube to re-expand his lung before victim #2 (who happened to be victim #1's passenger) arrived.  He was also in his mid-20's, but he looked much closer to death than his friend.  His heart rate was around 160, but his blood pressure was so low it was nearly undetectable.  His pelvis was obviously severely fractured and was likely bleeding profusely internally, so we put on a pelvic binder and started transfusing him rapidly with blood.  As his blood pressure improved, victim #1 went over to the CT scanner, and as it scanned through his chest the first thing I noticed was his stomach and spleen in his chest.

Very funny, Call Gods.  Very fucking funny.  Assholes.

In case you don't remember your basic human anatomy, the stomach and spleen belong in the abdomen, not in the chest.  This guy obviously had a ruptured diaphragm, a diagnosis I confirmed in the operating theatre a few minutes later.  As expected I found his entire stomach, his lacerated spleen, and portions of his colon and small intestine protruding through a gaping hole in his diaphragm.  I pulled all that stuff out of his chest, fixed the 14cm hole in his diaphragm (yes, that's big), removed his bleeding spleen, and fixed two lacerations in his colon.

I'd like to say that he walked out of the hospital a few days later, but his shattered hip somehow prevented that.  He also had several other potentially-lethal injuries, including a transection of his aorta, which as you can imagine is bad.  Not just bad, but VERY BAD.  It's a particularly nasty injury where the aorta ruptures just past the point where it turns south towards the feet.  Nearly 90% of patients with this injury die before reaching the hospital, and overall 95% don't make it.  Yet he did.

His friend survived too, even though his list of injuries was far longer.  I'll address him in a future post when I fulminate again about seatbelts.

If I ever had any doubt about the Call Gods' existence (not that I ever really did, mind you), this eliminated any shred of uncertainty.  {Redacted} years of practice with not-a-single blunt diaphragm injury until the day I happened to see a presentation on the subject and mention that I had not yet had one . . . it isn't just a coincidence.  It can't be.

Hey Call Gods, I've just noticed that I've never won the lottery.  Not even once!  Call Gods?  Hello?

Idiot

It's that time again, folks!  That's right, time for another story about my favourite idiot -

ME!

Everyone knows the unwritten rule about pregnant women.  I don't mean "Don't touch the pregnant belly" because it seems everyone breaks that rule (as odd as that is).  Seriously, why do random strangers feel it is their right to approach a pregnant woman they don't know and pat her abdomen?  How did that ever become socially acceptable??  

No, the rule I'm talking about is "Unless you are 100000% positive she is pregnant, don't ask a woman about her pregnancy.  Ever.  EVER.  EVER EVER EVER."

I hear the gears in your collective brains turning, and you're already putting 2 and 2 together.  A story about an idiot . . . Doc is the idiot . . . asking a woman about pregnancy . . .

Hahaha, no I did not break that rule!  Please, I'm not that stupid.

No, I'm far stupider.

One of our trauma nurses was pregnant recently with her first child.  She only works part time, so I don't see her that often.  After an absense she returned, her belly still somewhat large.  I couldn't remember when she was due, so I thought I would ask.

"So Tina (not your real name), when are you due?"

As I listened helplessly to the words tumbling out of my mouth, it dawned on me that the last time I saw her had been about 4 months ago, and that she had been about 6 months along in her pregnancy.

Hopefully you're not really bad at arithmetic or somehow missed that health class where you learn that human gestation is only 9 months (well, 40 weeks actually).  In case you don't see the problem, Tina spelled it out for me. 

"Uh, I had my daughter a month ago.  Today is my first day back."

A dead, awkward silence then ensued for what seemed like an hour.  During that 2 seconds of real time (but what seemed like an hour of Stupid Time) of excruciation, she looked directly in my eyes, and I swear I could actually hear her silently screaming at me, "I JUST HAVEN'T BEEN ABLE TO TAKE OFF THE BABY WEIGHT, ASSHOLE.  BUT THANKS SO MUCH FOR FUCKING POINTING IT OUT ON MY FIRST DAY BACK, YOU GIANT SHITHEAD!!"

I realised immediately that there's just no recovery from that gaffe, and I may as well have slapped her in the face and called her a whore, because that would have been somehow less insulting.  So I said the only thing I could have done - 

"Haha!  I know that. I'm just kidding.  Have any pictures?"

I'm 99.99953% sure that she didn't buy it, but only because you'd have to have the brain power as low as a homeopath (sorry, I had to throw that in) to believe such a ridiculous excuse.  But pull out the baby pictures she did, and after we cooed together over her 25th or so photo, all seemed forgotten. 

It was another close call.  I'm not sure how many more of those I'm going to get before my brain goes too far and gets me into real trouble. 

DocBastard's Fantastical Homeopathy Journey, Part 1

Update: I edited this today to add some links, and Blogspot decided to repost it as a new post. Sorry for any confusion. 

After my recent post about the common cold and homeopathy, I decided to research a bit further and delve deeper into the so-called science of homeopathy.  What I found made me want to cry, and I'm pretty sure that if my science-loving brain had legs it would have jumped out of my skull.  What I thought was simply water memory and a ridiculous degree of dilution had only barely scratched the surface of pseudoscience and magical thinking.  It turns out that believers in homeopathy have an entire series of hypotheses of how homeopathy supposedly cures people of everything from the common cold to cancer to anthrax and ebola, and each theory is more ridiculous than the last:

• vital forces
• quantum physics
• nanoparticles
• vibrational remedies
• energy medicine (remedy) to cure an energetic health problem that has a similar vibration
• coherent domains
• alignment of water molecules
• miasms (the weaknesses in our bodies that come from the diseases of our ancestors)

Articles written by homeopaths truly read like fantasy novels.  The fact that anyone believes in this stuff enough to practice it is ridiculous enough.  But the fact that there are others who buy into it (and then actually buy it) is downright flabbergasting.  I can't decide if these people A) don't understand what homeopathy really is, B) don't trust modern medicine, C) feel some overwhelming need to believe in something unearthly and magical, or D) don't understand physiology, anatomy, biology, chemistry, and physics.

My best guess is it's some combination of all four.

Regardless, having engaged in several conversations regarding homeopathy, and having been blocked by Twitter's three most vocal and vociferous (that's right, vociferous . . . look it up) homeopathy champions (whose names I won't reveal), I kept noticing the same stupid (and fallacious) arguments in favour of homeopathy popping up -

• Celebrity (or British royalty member) X believes in homeopathy
• Millions of people use it
• Homeopaths don't believe in (or care about) science or the cult of scientism.  We just know it works.
• Evidence?  We ain't got no evidence!  We don't need no evidence!  We don't have to show you any stinkin' evidence!
• You've never tried it, so your opinion is invalid.  

As ridiculously puerile as that last one is, I still tried to counter with logic: I've never tried crystal meth, yet I somehow still know it's bad.  When the homeopathy zealots countered that perfectly reasonable rationale with the same stupid refrain over and over again, I decided to say "To hell with it!" and go with the old standby - If you can't beat 'em, join 'em.

That's right - I decided to try homeopathy, just to prove a point.

I've been dealing with low back pain for at least 5 years.  I've seen several doctors of various specialties (internist, othopaedic surgeon, physical medicine doctor), and I had an MRI of my lumbar spine which was, of course, completely 100% normal.  There is nothing anatomically wrong with my back, but it still feels like a family of fire ants is battling a clan of scorpions down there all day, every day.  I have tried several classes of medicines with varying levels of success (though I have stringently avoided narcotics), and I've found that ibuprofen far and away works best.

According to homeopathy "experts" their remedies are more efficacious than these supposedly  toxic chemicals with all their fancy names and scary side effects, so I'm giving homeopathy a fair shot, and I'm documenting my entire homeopathy experience right here for the world (ie the few people who read this stupid blog) to see.  

Before I started my fantastical journey I set out a few ground rules: 1) I will visit a fully-trained homeopath, not some fly-by-night charlatan (though who could really tell the difference? . . . I kid, I kid.  Not really.), 2) I will NOT inform my homeopath that I am a sceptic, 3) I will otherwise be entirely truthful with the homeopath, 4) I will take my remedy exactly as prescribed, 5) I will not taint the experiment by using actual medicine.  Oops . . . that sure sounded like bias.  Well tough shit.  It is bias.

I chose not to reveal my scepticism because I didn't want my underlying disbelief in the entirety of homeopathy to cause any bias for my new practitioner.  So without further ado, here is my trek through the wild, wacky, and wonderful world of homeopathy.

Day 1
I arrived 20 minutes early (as requested) for my scheduled appointment with Dr. Homeopath (not her real name).  As I walked in the door I was greeted with soft music that I'm quite sure was meant to be soothing but which I found gratingly repetitive and made me want to jab my ears with a pen within 15 seconds.  The receptionist smiled warmly as she gave me a sheaf of paperwork to fill out.  There was absolutely nothing unusual at first: the top page could have been found at any doctor's office, asking my demographics, my entire medical history, etc.  I got through this page quickly since I'm a fairly healthy guy and I don't take any prescription medicine.  No allergies to medicines, only one prior surgery (appendectomy).  No serious family history.  I'm up-to-date on all my vaccinations (including rabies and heart worms, I think).  The reason for my visit and any prior treatments.  All the usual stuff.

And then it started to get a bit . . . strange.  The first question on page 2 asked if I could trace my symptoms back to any incident, including accidents, injuries, griefs, or "mental upset".  Mental upset?  It then asked about any serious shock, disappointments, or frights.  Well, the movie "Poltergeist" scared the shit out of me when I was a kid.  Should I include that?  And I was really sad when I lost the grade 4 science fair.  Does that count?  It then asked which weather pattern I am more troubled by - cloudy or clear.  Um . . . cloudy I guess?  I was then asked if I sleep with blankets, partially covered, with a fan on, with the window open, with arms/legs outside the blankets, or nude.  Nude, of course.  I wondered how this impacted any kind of patient care in the slightest, but I diligently (and honestly) pressed on.

Then just after asking how often I weep (not cry, weep) and how often I experience clairvoyance (wh . . . what??), it traversed the astral plane directly from "a bit strange" to "WHAT THE FUCK ARE YOU ASKING ME??".  The paper listed about 100 adjectives and asked me to circle each and every one that described me:   

PLAYFUL, TENACIOUS, CUTE, LOYAL, INOFFENSIVE, CONSIDERATE, FUNNY, LOUD, BOUNCY, RESOURCEFUL, BOSSY, PESSIMISTIC, HEADSTRONG, SCEPTICAL, SARCASTIC, BLANK, PERSUASIVE . . .

I wondered why the hell the fact that I consider myself headstrong and considerate should have anything to do with why my back hurts, but I dutifully circled about a dozen of them (no, I did NOT circle "cute" or "bouncy").  I then signed "DocBastard (not his real name)" at the end and wondered what the fuck I had gotten myself into.  I didn't have long to wonder, because only a few minutes later I was called back.  

That is the end of part one.  If I make this any longer, no one will be able to focus long enough to get through all this crap.  Part two will be coming soon.  Stay tuned, folks.  You think the shit is deep now?  Just you wait.

It doesn't fucking work

Update: Part II can be found here, and Part III can be found here.

Angel on his shoulder

Mrs. Bastard likes to say that everything happens for a reason.  Good or bad, she seems to think everything is part of a master plan.  According to her apparently the universe's plan includes our shower breaking for the 295th time, my burrito exploding in the microwave (again), and me getting stuck in traffic so long that I feel like the road and I are becoming close friends.  I don't always agree with her beliefs, especially when she tells me that she believes asparagus is good for me.  Regardless I don't really believe in fate or destiny, and to me everything feels more like random chance.

But sometimes the universe smacks me in the face and reminds me to listen to my wife.  VERY CAREFULLY.

'The witching hour' in popular culture usually refers to midnight, but it can also mean any arbitrary time that something bad happens (or so Wikipedia tells me, and the internet has never lied to me before).  For me, the witching hour for trauma is right around 5 AM, because by the time I'm done working up the patient, it's too early to do anything else but too late to go back to sleep.  So when my pager woke me at 5:06 AM, I groaned, grumbled, said a few colourful curse words, and went down to see what was going on.  When George (not his real name) was wheeled in a few minutes later, I groaned even more.  He didn't look injured at all, and the medics admitted that they could barely find any outward signs of trauma.

"This is George (not his real name).  He was the rear-seat passenger in a rollover motor vehicle crash.  Looks like they hit a tree and flipped.  Pretty severe damage to the car.  George says he never lost consciousness and has a bit of a headache and some pain in his neck."

My first thoughts whenever I get a rear-seat passenger are 1) Where's the driver? and 2) Where's the front-seat passenger?  Are they injured?  Uninjured?  Taken to a different hospital?

A detailed examination showed that George only had minor abrasions on his forehead and knee, and CT scans confirmed no serious injuries.  Once the dust settled I had a chance to chat with George and get a bit more information.  It turns out he was texting with his head down when the accident occurred.  When the car flipped, the roof caved in, entrapping his head between the roof and his seat's head rest in that awkward downward position.  Even the severe impact of the accident wasn't enough to jar his mobile phone loose from his hand, however (I'm convinced some young people glue their mobiles to their hands), so he was able to call emergency services.  As you may have already surmised by his good outcome, he was wearing his seatbelt.

His two friends in the front seats were not.

As I was preparing the discharge paperwork, a police officer approached me to ask if I had heard The News.  I didn't know what "The News" was, but in my line of work "The News" is never good.  But I had a feeling that I was at least about to get an explanation about the driver and the other passenger.

George's two friends were both dead.

I still find it astounding that in a crash where two people in the car die, a third passenger can literally walk away with barely a scratch.  It speaks volumes to the safety features that modern cars have and how well they work when used properly.  I don't know if George believes in fate or destiny, but whatever the case may be he certainly seemed to have an angel on his shoulder that morning.

I'm seriously considering starting to listen to my wife more often.