Even more things I don't understand

Despite the fact that I've written a handful of complimentary posts about myself, I'm not one to toot my own horn very often.  That said, though I rarely claim to be smarter than anyone, I have to admit that I'm a fairly intelligent guy.  Despite this, I've written about things I don't understand in the past, and it's been quite a while since I have, so I feel it's high time I embiggen the list of things I just can't seem to wrap my mind around.

• women (yes, I still don't understand them)
• the appeal of mushrooms
• how anything got done before the Internet
• Twilight
• smoking

Of the myriad things I just can't fathom, I think I understand smoking the least.  With all of the health problems that cigarettes cause, I simply can't understand how anyone these days could possibly begin (or continue) smoking.  Now before anyone starts yelling and screaming that nicotine is addictive, I ALREADY KNOW.  I know how easy it is to become addicted to cigarettes, and I know how difficult it is to quit once you're hooked.  But it's a rare soul who doesn't know at least one person who was affected adversely by cigarettes - lung cancer, emphysema, chronic bronchitis, oral cancer, cataracts, heart disease, stroke . . .

And yet, people still smoke.

"GET TO THE POINT, DOC!" I can hear you screaming.

I will.  I promise.

I got a call from an emergency physician some time back for Samuel (not his real name©), a gentleman in his 50s who had a history of severe peripheral arterial disease.  If you've never heard of PAD, it's very similar to coronary artery disease, except that instead of the arteries of the heart getting blocked by gunk and causing a heart attack, it's the arteries in the rest of the body (including the legs, intestine, etc) that become blocked, causing all the tissue downstream to die.  The most common causative agents are smoking, diabetes, hypertension, and high cholesterol, all of which Samuel had or did.

About a month prior to coming to my hospital, Samuel's aorta, that rather-important artery that comes off the heart and supplies blood to the entire body, had become completely blocked at the point where it splits to supply blood to the legs, so a bypass surgery was done at an outside hospital.

Today Samuel was having severe abdominal pain, so the emergency physician correctly presumed that he was having a complication from that surgery.  He promptly ordered a CT scan of his abdomen which fortunately ruled out any complication of his bypass (such as a leak or infection or blockage of an artery), but it surprisingly showed a small bowel obstruction.  His small intestine was dilated to about 8-times its normal diameter, but more even more ominous was that it looked like the blood supply to a segment of the bowel had twisted on itself, an entity called intestinal volvulus.  Any tissue whose blood supply is twisted will eventually die, so this is a dire surgical emergency.

Thirty minutes later he was in the operating theatre, and 30 minutes after that I had successfully untwisted his intestine, which was perhaps an hour or so from dying.  As you can probably imagine, that's not a good thing.  I watched it for a few minutes, waiting for the colour to normalise (it did), and then I closed him up.  Another life saved!

Maybe.  (Cue the dramatic music.)

I went out to the waiting room to find his wife and let her know that everything went well.  As I was chatting with her and letting her know how I expected his recovery to go, a familiar odour reached my nostrils - cigarette smoke.  After I was done, I asked her if she had any questions.  When she said "no", I told her that I had one:

"When are you going to quit smoking?"

Her smile immediately faded, and she looked at her feet.  "We're trying to quit," she almost whispered.

Wait . . . we?  Are you telling me this man who nearly lost his legs a month ago because of his smoking is STILL SMOKING?

With a stern look and not even a hint of mirth, I told her that she and Samuel had to quit.  NOW.  "I don't care if you go cold turkey, use nicotine gum, a nicotine patch, prescription medicine, chewing gum, e-cigarettes, meditation, yoga, hypnosis, acupuncture, or voodoo," I said, trying not to yell.  "Your smoking was making him smoke, and his smoking is killing him, slowly but surely."

I sent Samuel home a week later, repeatedly beating my point into his skull daily.  Unfortunately (though perhaps not surprisingly) he never showed up for his follow-up appointment.

I don't expect perfection, except from myself (though I rarely attain such heights).  But I do expect people to help me help them get better.  Why can't (or won't) so many people do that?

Yet another thing I don't understand. 

Spirit of the season

In the interest of peace, love, and goodwill toward idiots, I've decided to forgo a formal update this week and leave everyone with a few thoughts:

1) We're approaching 3 million page views here.  That's just unfathomable.

2) I'll probably do a post soon about personal confessions.  I have plenty from which to choose. 

3) I've been contemplating dropping the anonymity.  

With that said, Merry Christmas, Happy Chanukah, Joyous Festivus, and Happy Holidays.  

I would like to sincerely wish everyone who reads this a happy, healthy, and safe 2015. 

Best,

Doc

Compliments

WARNING: I WILL BE SHAMELESSLY RISKING SPRAINING MY SHOULDER BY PATTING MYSELF ON THE BACK IN THIS POST.  

Admittedly this blog is dedicated to idiots and stupidity, and as I've said numerous times my favourite idiot remains me.  So having told several stories where I am the goat, I think I've disparaged myself enough to have earned myself a complimentary update.

If you want more idiot stories, you'll have to wait.  Probably not very long.

Since finishing my training I have spent very little time around other doctors in clinical situations, so I therefore have no idea how my colleagues speak to patients.  I don't know what kind of terminology they use, if they have prepared speeches for certain situations, or how they treat patients in general.  I have a fairly well-established bedside manner, and it seems to serve me very well in the vast majority of situations.  Though my demeanor rarely changes much, every now and then I have to tailor it for certain types of patient (those who are very difficult, very drunk, very upset, very young, very old, etc).  Some people need a bit more care, some need a stern talking-to, others need massive doses of sedatives to shut them up.

Kidding, kidding.  Sort of.

Generally speaking, my philosophy is this: If you're nice to me, I'll be nice to you.  Because of this ideology, every so often patients tell me (compliment warning) that I make them feel better just by sitting with them for a few minutes, talking with them, and explaining everything in excruciating detail, probably more detail than they want or need.

Apparently this is not the norm for surgeons.

Nathaniel (not his real name©) was the unfortunate driver of a petrol (gasoline) tanker truck.  In the wee hours of the morning Nathaniel swerved to avoid another driver, and his truck lost control and flipped on its side.  Incidentally, I hate the term "wee hours".  "Small hours" is no better.  I don't know why it bothers me so much.  Non sequitur over.  Anyway, sparks began to fly from the now-exposed underside of the truck, and despite debilitating pain in his chest, Nathaniel wisely decided not to be anywhere near his truck when those sparks interacted with the several thousand gallons of highly-explosive fuel he had been hauling, and he ran.

When he was brought to me about 30 minutes later, he was clearly agitated, clutching his chest and having trouble breathing.  When I pushed lightly on his chest, he grunted and looked at me as if I were Satan.  His chest felt unstable to me, and an X-ray confirmed that he had 4 fractured ribs.  Fortunately his lung had not collapsed, he had no bleeding in his chest, and he had no other serious injuries.  I explained that his injuries were painful but not life-threatening and that the only treatment was pain medicine and time.  That seemed to calm him somewhat.

Over the next several days, I quickly assessed that he would be a patient who required a bit more TLC than my typical patients.  My daily rounds with him, which should have taken no more than 3 minutes to press on and listen to his chest, assess his pain, and go over his X-ray, took at least 15 minutes while I sat with him, listened to him describe his pain, and reassured him that he would heal, but it would simply take time.

A few days later his pain had improved to the point where he could walk without difficulty, and he no longer needed IV narcotics.  I discharged him, telling him he could continue his recovery at home, though it would be several more weeks until he felt completely better.

As I was sitting in my office about a week later, I got a call from Nathaniel, asking if he could transfer his care to me.  Confused, I told him I was already his doctor, so I asked him what he meant.  "Well, I really liked the way you cared for me in the hospital.  You were so patient with me and you really listened to me, so I want you to be my primary doctor."

I told him that while I don't do primary care, I was truly honoured by the request, and that simple question was one of the best compliments a surgeon could get.  I gave him the phone number for an internist whose philosophy is very similar to mine - be direct and honest, and above all else listen to the patient.

To the medical students reading this, I hope you take this vignette to heart and learn a valuable lesson that DadBastard and GrandpaBastard taught me a long time ago.  Ultimately all patients want the same thing: to be treated like a human being.  What I did isn't difficult, it isn't special, and it isn't unique.

All I did was treat Nathaniel like I treat everyone - with respect.

Just when you think...

Ok, NOW I've seen everything.

That's a phrase that enters my brain almost every time I am on call.  After seeing children shot in the head, grown men crying like babies over minor abrasions, a woman kicked in the head by a deer, a man impaled in the boy-parts by a piece of his broken motorcycle, fingers cut off by power saws, and every conceivable traumatic injury in between, it seems like the Call Gods can't possibly find something I've never seen.  I think that everything that could possibly happen has happened, and I've seen it.  But then the Call Gods throw me a curve ball, something that even my wildest imagination couldn't envisage.
Yes, it happened again.

My second patient of the day was another fall victim.  The first one had been an elderly lady who fell down the stairs and broke her back.  This one, however, had fallen from a standing position.  When I heard that mechanism of injury, I groaned.  Audibly.  LOUDLY.  For patients like these, I think of it this way: if you fall from a standing position badly enough to pass out, you probably are A) drunk, B) drunk, C) drunk, or D) otherwise unhealthy enough to have passed out merely from falling down.  They are usually not the worst injured patients, and I rarely get too excited at the prospect of seeing another elderly ground-level fall "victim" with bumps and bruises and little else.

A few minutes later Arthur (not his real name©) arrived moaning and groaning, yelling that his hands hurt, his head hurt, his neck hurt, his legs hurt . . . pretty much everything from the tips of his hair to his toenails hurt.  He was a rather burly guy, about 120kg, but he was acting like a 15kg toddler.  His only outward signs of trauma were some abrasions on the bridge of his nose and his forehead, but whenever I touched his hands or legs, he screamed.

His workup was essentially negative - bumps and bruises, a cervical strain (whiplash), and a concussion.  So if he sounds like most of the other ground-level falls, why the hell am I writing about him?

Because he wasn't drunk.  He didn't trip and fall.  No, Arthur was wrestling with his wife who got the better of him, jumped on his back, and put him in a choke hold until he passed out and fell flat on his face.  Five minutes later when he still hadn't awakened, his wife freaked out and called emergency services.

As he explained what had happened, his wife walked in.  She couldn't possibly have been as tall as Arthur's chest, and she might have weighed 1/3 what he did.  I listened to Arthur intently, my eyes flitting from him to her, trying to look him in the eye while all the time doing my best not to break out in a fit of raucous laughter.

Did he let her win, or is she some kind of human honey badger?  I have no idea, but fortunately the little Tasmanian devil didn't do any major damage.  As I walked out, only one thought crossed my mind:

NOW I've seen everything.

Sign from above

Based on the title you may be worried this post will be some theistic diatribe.  Nay, never fear, intrepid readers.  I would never subject you to such nonsense which I would never want to read and which, I'm fairly certain, violates several portions of the Geneva Conventions.  However, Mrs. Bastard has often told me that everything happens for a reason and that things may be signs from above, so while I don't have any idea what those reasons may be, I sometimes wonder if she's right.

What happened recently with Claudette (not her real name©) made me rethink things and wonder if Mrs. Bastard could be right.

Claudette was the passenger in a car accident early one morning.  Incidentally, why is it always 1 AM?  Doesn't anyone want to get into an accident and let me take care of them at 2 o'clock in the afternoon?  I'm fully awake, I'm done with lunch, I have nothing better to do, so get into your accidents then!  Come on!  Wait, where was I?  Oh right, 1 AM.  Apparently her boyfriend (who was driving) fell asleep at the wheel and went off the road, hitting a tree.  The tree, which was not moving at the time of the accident, didn't give one flying fuck that a car just hit it at 120 kph and remained exactly where it had been before the car hit it.  Trees are kind of funny that way.  Anyway, I have no idea what happened to her boyfriend, but Claudette was brought to me in a bit of a daze.  She didn't have a scratch on her, but she clearly had a concussion.  A CT of her brain showed a small subarachnoid haemorrhage.  Fortunately she had no other injuries, and three days later she went home, sore as hell, but otherwise ok.

She followed up with me in my office about a week later.  When I walked into the examination room, the first thing I noticed was the sheaf of papers from the hospital sitting on the exam table, along with her mobile phone and a cigarette lighter.

Bad move, Claudette.

If you know anything about me, you know that I look for any reason to get on people's cases for smoking, but I knew my "WHY THE FUCK DO YOU SMOKE?!" tirade would have to wait until I finished my exam and explanation about what she should expect as she recovers from her brain injury.

Wait wait wait, aren't you going way off topic here, Doc?  Quitting smoking is great and all, but since when is this post about that?

Oh pipe down, you.  I'm getting to it.  Stop being so damned impatient.

As I was saying, after a thorough physical examination, I explained how her symptoms may last for several more weeks, but that I expected a full recovery.  She told me how she couldn't bring herself to drive yet, and that she still freaked out whenever she tried to get in a car or saw headlights.  She went through her long list of questions for me, and when she was finally done, I took a deep breath and gave her my best "STOP SMOKING, DUMMY!" speech.  She looked rather embarrassed the entire time, but she nodded along compliantly.  When I was done, she looked up with a sad little smile and said,

"You know, it's funny . . . when we got in the accident, we were on our way to the store to buy cigarettes."

. . . Aaaaaaaaaaaaaaand there it is.  If that isn't a clear sign that she is supposed to stop smoking, I don't know what is.