Wednesday, 1 October 2014

Participation

WARNING #1: I MAY SOUND LIKE A CALLOUS ASSHOLE IN THIS POST
WARNING #2: I'M NOT TRYING TO SOUND LIKE A CALLOUS ASSHOLE
WARNING #3: I DON'T GIVE A FUCK IF I SOUND LIKE A CALLOUS ASSHOLE

I wear two hats on a daily basis.  Under the first hat is a general surgeon who is trying to save the world from appendiceal disease one goddamned appendix at a time at 2 AM (always at 2 AM).  I'm also trying to cure the world of breast cancer, gall bladder disease, colon cancer, chronic wounds, skin cancer, hernias, and a host of other problems, some big and some small.  But under the trauma surgeon hat, I'm mainly dealing with stupidity.  And as comedian Ron White said, "You can't fix stupid".

As a trauma surgeon, all I deal with are injured people.  After practicing trauma surgery for {redacted} years, I have a very good sense for how long people should be in pain, how long people should be in hospital, and who should be able to go straight home to finish recovering versus going to a rehabilitation facility.  Most people are anxious to get out of the hospital and get back to their normal lives.  Some tragically misinformed people think spending extra time in hospital will make them better.  A few people try and take advantage of my good will by trying to wheedle extra time off work.

And then there are people like Stuart (not his real name©).

Superficially, Stuart was little different than many of the other motorcycle victims I've seen over the years.  He was a large fellow in his mid-20s, covered with tattoos, and he fell off his bike when he took a turn too fast and hit a patch of gravel.  He tumbled over and over, narrowly avoiding getting run over by the car behind him.  When he arrived at my trauma bay, he was clearly in discomfort, mainly in his lower back, left chest, and right thigh.  A quick look at his right thigh told me something bad was going on - it was swollen and deformed, a sure sign that his femur was broken.  When I touched his chest he yelped, so I immediately thought of rib fractures.  An X-ray confirmed a simple fracture of his femur, and a CT of his torso showed a pneumothorax (collapsed lung) on the left but no broken ribs.  He did have three minor fractures in his lower back, but they were clinically insignificant, the type of fracture that is annoying but doesn't cause any disability.

About 18 hours, one chest tube insertion, and one femur repair later, I entered his room on my morning rounds, and Stuart barely opened his eyes to greet me.  "How are you?" I asked in my cheeriest voice (as cheery as I can be at 7 AM before my first cup of coffee).

"Terrible," he droned.  I didn't expect him to be nearly as cheerful as I was less than 24 hours after his accident, but I would have at least appreciated him making an attempt to open his eyes and acknowledge my presence.  Typically pain starts to improve dramatically the day after surgery, so the next morning I figured he would be a bit peppier.

Day 3: "Terrible," he moaned, again without even bothering to look at me.  After discovering that he hadn't even tried to work with the physical therapist the day before, I nicely explained that today was the day for him to get out of bed and start working on his recovery.  I also gave him some good news - I would be removing his chest tube that morning, so hopefully that would help alleviate his pain and encourage him to get out of bed.  I expected to be able to send him home later that day, or the next morning at the latest.

Day 4: "Terrible," he groaned.  He barely opened his eyes before telling me that he didn't bother trying to get up the day before.  Again.  "Ok, I know you're in pain, but let's work on getting that under control and getting you up and walking today so I can get you home," is what came out of my mouth while GET UP is what was going through my mind.

Day 5: "Terrible," he whined.  He still hadn't even made an attempt to get out of bed despite my encouragement.  His nurse the day before had also tried encouraging him, giving him a bit of tough love that he obviously needed.  She tried to get him to be an active participant in his recovery.  His response was to demand a different nurse, a request that I flatly refused.  GET UP!!

Day 6: "Terrible," he whimpered.  Somehow he had still avoided getting up out of bed.  I tried explaining how bedrest doesn't make you better.  Quite the opposite - the longer you stay in bed, the weaker you get.  He just turned over in bed.  GET YOUR ASS UP!

Day 7: "Terrible," he cried.  The therapists, with the assistance of 4 nurses and aides, had finally managed to get him up into a chair.  It had also been the first day he had even allowed the nurses to change his bedsheets since his admission.  Despite our encouragement, he continued to actively prevent his own recovery.  GET YOUR LAZY ASS OUT OF THIS FUCKING BED, YOU GODDAMNED SLUG!

I won't bore you with days 8-10, because they were eerily similar to 1-7.  His array of injuries should have resulted in a 3-4 day hospital stay and him walking out of the hospital.  Instead, he stayed for well over a week and ended up going to a rehabilitation facility to finish recovering, all because he refused to participate in his own care.

If you're ever unfortunate enough to be a patient of mine or one of my colleagues, keep one very important thing in mind: the biggest advocate you have for your own health is you.

37 comments:

  1. I am possibly going to have a csection in the next month or so due to complications a breech minion growing inside me. The thought of the csection doesn't scare me. The idea of moving around afterwards is terrifying! I am terrified of being that guy even tho I know it's not good for me.

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    1. Just have your pillow up against your belly when you get out of bed the first time so all the stuff falls back into place. Get up when they tell you and it won't be bad. My first was sunny side up, my second was early. I knew what to expect with the second. My only problem is that I come out of anesthesia swearing like a sailor. That was so many years ago.....

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    2. If it's any consolation my mother who had two c-secs was up and moving around pretty comfortably the next day after both of hers. I had a baby naturally and things still had to fall back and readjust to the new breathing room.

      The scariest part is standing up for the first time. But once you realize your guts aren't going to spill out all over the floor it gets 10x better from there. :)

      Congrats on the little minion btw!

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  2. the guys who look the toughest are usually the biggest wimps. my field triage guide is if they ask about the bike, I know they are going to be okay.

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  3. I recently had my appendix removed. two hours after I woke up I was out of bed and shuffling myself to the toilet. all the gas from the laparoscopy apparently decided to go
    out the back door, so to speak, so my guts were roaring like a jet engine. instead of moaning to the nurse about my terrible gas pain and lying in bed like a pathetic lump, I
    got myself up and out bed and walked until the pain passed. the nurses were impressed with how much walking I did.
    this guy is pathetic! what a dweeb!

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    Replies
    1. When I was 7 I had my appendix removed via open surgery (is that the word? I have no idea what 'not-keyhole' is called). I refused the strong pain medication as I didn't need it and I didnt't like the oxygen mask they told me I had to wear if i used the medication, and was up moving as soon as they'd let me. The doctors got confused the morning after, cause they expected me to still be in bed, and I'd got up and gone to the hospital 'school'. I ended up being discharged the same day and went back to school the next week.

      I don't know if pain feels worse as an adult, having not suffered anything as bad since, but I agree with you. He was acting like a big baby.

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  4. Hahaha same thing happened to my hospital neighbour while I was in for appendicitis recently. She needed 5 nurses to haul her out of bed onto a chair. Too bad my docs kept nagging me to get out of bed. Nurses also rejected my request for a wheelchair for toilet the moment I woke up. Had to raise myself out to walk or risk pee-ing in bed thx to the litres of water, gas and who knows what else they pumped into me over the last 12 hours

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  5. remember: Jesus couldn't heal the lame man until he was willing to get up and walk.

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  6. Couldn't you just remove the catheter so he was forced to get up?

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    1. 10-1 the guy would have insisted on a bedpan.

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    2. You're complicating a very simple problem. Observe:

      "I want a bedpan"
      "No"

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    3. then he pees the bed.

      remember: never argue with an idiot, they will drag you down to their level and beat you with experience.

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    4. I have a hard time imagining even the biggest idiot stubbornly insisting on lying in his own pee to stay in bed.

      You're probably right though, if someone would rather pee in their own bed it's not worth the headache to keep trying with them.

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    5. you have much more faith in humanity than I do.

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    6. @Shark:

      You'd be surprised at the number of hospital patients who would rather piss themselves in the bed than get up and go to the toilet.

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  7. Wow the advancement in medical science is amazing - walking on a fractured femur in less than a week.

    When my brother had his femur broken as a child (35 years ago) he had to spend 6 weeks in traction, then 6 more weeks in a plaster cast (ankle to hip), plus months of physical therapy after the cast came off.

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  8. Just discovered your blog...I think I'm in love.

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  9. Hi Doc. I know you've been following the Jahi McMath story for some time, and just recently, a video has surfaced of Jahi moving her arm twice in response to her mother's commands. Could you write an entry on this and what it may mean for her?

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    1. I'd be interested in hearing Doc's more professional opinion, as well, and I am sure he would love to have the medical profession learn something new - but at the same time, everything I was able to find that came from reputable news sources rather than blogs (not that I don't consider Doc reputable - but I don't have proof the other blogs are not biased) basically implied that the only evidence of recovery comes from sources under the complete control of the family and their legal team.

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    2. I read the same thing. I was anxious to see if Doc posted his thoughts on this.

      Sounds like junk science to me. My only question is, if indeed we are to believe these reports, why wouldn't her brain be liquidating as was expected?

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    3. I suspect because she has been the first dead person who has been artificially kept physically functioning for so long. - so the medical world finds that some of their conjectures have been somewhat in error. keep the tissue oxygenated, and keep supplying nutrition, and the tissue remains viable - but that doesn't necessarily mean it regains full function.
      my speculation - don't know if it is valid. my training extends to keeping the blood moving until the professionals get there.

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    4. Assuming this isn't a hoax, then logically speaking, she was probably twitching before her parents asked her to. Figuring out her pattern and then asking her to move, doesn't mean she's responding, it means her mother knows when she's going to spasm.

      Remember dead bodies at the morgue can move or twitch too. They also moan.

      Most likely though, it's a hoax. It could be electric pulses, it could be someone out of view moving her hand.

      The only certainty is that their lawyer is the lowest level of scum for exploiting this family like he is. He's making money off a dead girl, and continuing to use her to make a mockery out of the medical community.

      I will be happy to be proven wrong, but wishes and prayers don't bring people back to life.

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    5. I question whether exploiting is the correct term for the lawyer's relationship with the family, but then, I am more cynical than some; and I know the family is doing pretty well off the donations as well.

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    6. @Ken Brown
      She's not the first person to be brain dead that long and kept alive

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    7. that's why I said it was what I suspected. my training does not include history of the condition known as brain death. just how to delay it with CPR.

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    8. As expected as soon as Jahi popped back into the news, I started getting questions (both here and via email). Unfortunately it looks like I'll have to do another post to sum things up so far. The bottom line (for now) is that we have to wait for independent confirmation from a non-biased source.

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  10. He felt terrible. That was his truth. The bike accident was another layer to a life he would describe as "terrible." Now, his bike was toast, and he had injuries that, despite medical intervention, would, in all likelihood, cause him at least intermittent pain. You took the time with the non-German woman and it worked. Why not this guy who had also given up.

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    Replies
    1. because he assumed the problem with the not-german woman was a language barrier - so he took the time to address the presumed language barrier. are you suggesting that if he had asked the guy "wo bist du?" on the first day, the guy would have responded better?
      this is why the title of this entry is "participation" he can take all of the time in the world, and I rather suspect the hospital and rehab staff did spend rather a lot of time, but if the patient refuses to do anything other than lay in bed and moan - it is just wasted time. It also pretty much guarantees that the patient WILL be crippled for life.

      about a year ago I lost a firefighter who got killed in an ATV accident. I didn't lose her because she got killed, in fact, she had been killed in the accident a couple years before she ever joined the department. - she joined because she wanted to repay the emergency services community for bringing her back to life and giving her another chance. I lost her because she moved out of town.

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    2. I *did* take the time with this guy. I sat with him, explained why it was so important for him to get up and explained to his family why it was so important to get up. Every day. He barely looked at me.

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    3. Could this have been a case of depression, and did a hospital psych see him at any point? I don't think you're an insensitive asshole, but his extended lack of cooperation makes me wonder if there was something else going on.

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    4. I don't call psych for lazy people. Was he depressed (i.e. sad) at crashing and injuring himself? Yes. Was he clinically depressed? No. He was just lazy.

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  11. This story reminds me why I don't miss working as an RN. It's rewarding working with patients who want to partner with you to get them well. It's another whole thing to "care" for a sloth who won't move but who uses the PCA as often as possible and demands their pain pills on the hour (clock-watchers).

    Heck, when I had my hip replaced (dysplasia) I was out of bed the next morning, 14 hours after surgery. The only reason I wasn't up the day of surgery was PT went home at 6 p.m. Surgery Wednesday afternoon, out the door Friday after lunch.

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  12. As a patient rehabbing from a major injury I am very glad you left nursing Cali.

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  13. What a wimp! My hubby and then 14-yo daughter got hit by an 18-wheeler while out riding. The injuries were such that, despite full-face helmet and head-to-toe protective gear, they had to be airlifted and hubby was not expected to survive. My daughter had broken tooth, cheekbone, L tib fib and femur, R ulna and radius, and a pneumothorax. By day 3 in ICU, she was asking to start moving. By day 7, she was discharged. Many surgeries and months of therapy later, she got her first job as a rollerblading carhop and has started jiujitsu. Not a single "I can't". She just gritted her teeth and carried on. That "grown" man should've been ashamed.

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    Replies
    1. Here's some of the story, if you're interested.
      Www.primoworks-on2wheels.com

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  14. We had a guy last year in our ER that degloved two of his toes from dropping a crate on his steel toe boots. He only came in because his buddies made him. AND he seriously suggested we could duct tape the exposed area so he could go back to work.

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    1. lest people perpetuate the myth about steels being worse than nothing, could you describe what would have happened if he had dropped that same crate without the steels? (and seriously, how was he lifting a crate heavy enough to crush a set of steels, unless they were compromised to begin with?)

      Delete

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