Friday, 31 January 2014

Cover your ass

As long as you aren't illiterate or didn't skip the title because you were trying to scroll to the disgusting picture at the end (there isn't one this time...sorry for the disappointment), then you've no doubt noticed that the title of this post is "Cover your ass".  For you with your minds in the gutter, I'm not referring to women blocking the view to their posteriors while lecherous men leer at them from behind.  No, I'm referring to the common medical practice of doing unnecessary tests for the sheer purpose of "just in case".  In case you A) have never had any experience with the healthcare system, B) just woke up from 50 years of cryogenic sleep, or C) are an alien who just landed on Earth, I'll explain what I mean:
  • A patient with multiple broken ribs getting an unnecessary full cardiac workup "just in case" his chest pain is actually from a heart attack, not his multiple broken ribs
  • A patient with a simple chest cold getting an unnecessary CT scan of the chest "just in case" it's actually a pulmonary embolus
  • A child with a simple cold getting a prescription for antibiotics from the pediatrician "just in case" the parent complains about not getting antibiotics, even though antibiotics are worthless against the cold virus
  • An ER doc calling for a ridiculous unnecessary surgical consultation for some bullshit reason just in case the doctor is brain dead and has no fucking clue how to actually work up a patient and make a diagnosis
It's that last bullet point that drives me completely batshit crazy (for obvious reasons), and I wish I were exaggerating.  In my experience, emergency physicians are notorious for calling anyone and everyone for anything and everything.  Some of them have even admitted to me that they "sell" patients to specialists so they will be admitted and out of their department sooner.  Recently it nearly drove me to throw one of them off the roof.

Dr. Halfwit (not her real name) called me to let me know she was seeing a female patient who had pain in the right lower portion of her abdomen, and she was concerned about appendicitis.  It sounded reasonable enough, so I told her to get a CT scan to rule out GPP - Girl Part Problems (that's the technical term), which can often masquerade as appendicitis - and call me with the results.  A few hours later I just happened to be in the CT scanner room as her scan was being performed, and it took me all of 1.38 seconds to see her huge ovarian cyst on her right side - clearly the source of her pain - and her perfectly normal appendix.  I told Dr. Halfwit what the CT showed and to call the gynaecologist for an evaluation, and I logically thought that would be the end.

HAHAHA, logic.  Right.  Emergency physicians seem to use logic like accountants use Erlenmeyer flasks or like lawyers use morals - not at all.

A few hours later (now around 2 AM), another ER doc (this one has perhaps 10% of a usable brain) who had taken over for Dr. Halfwit called me about the same patient whom she had not discharged and had now been in the department for over seven hours.  The gynaecologist had seen the patient, correctly diagnosed her with a large ovarian cyst (hmm, where have we heard that before?), and had cleared her to be discharged home to follow up with her own gynaecologist as an outpatient.  We have a diagnosis and a why the hell was Dr. Brainless (perhaps his real name) calling me?  Just to verify the accuracy of his name?  Maybe, though I'm not sure he even had the brain power to comprehend that he has no brain.  Or something like that.

Anyway, Dr. Brainless explained to me that he wanted me to confirm that the gynaecologist's plan was ok.  I paused as I waited for the punch line, because NOBODY can be that stupid.  Right?

When the punch line didn't come, I realised he was serious.  "Wait a second," I said.  "You actually want me, a surgeon, to tell you if a gynaecologist's plan for a patient with an isolated gynaecological problem and no surgical problem whatsoever is ok?"

"Yes", he said, "I'm just covering my ass."  He stared at me in anticipation, waiting for some sage wisdom.  I stared back at him, dumbfounded, astonished, flabbergasted, and several other synonyms.

With a mighty effort, he mustered enough brain power to explain that he didn't feel that 1) an ultrasound showing an ovarian cyst, 2) a CT scan confirming an ovarian cyst and a normal appendix, 3) a physical examination entirely consistent with an ovarian cyst and entirely inconsistent with appendicitis, and 4) a gynaecologist confirming an ovarian cyst were enough to actually diagnose a simple ovarian cyst.  No, Dr. Brainless needed a surgeon to help him with GPP.  I told him to his face that he should be embarrassed that he can't rule out appendicitis and diagnose an ovarian cyst himself, let alone with multiple doctors and studies doing the work for him.

After I thoroughly lambasted him for his complete ineptitude, he made it very clear that he refused to discharge the patient until I examined her.  I stared back at his dull, empty eyes, turned on my heel, marched into her room, performed my examination (which was shockingly consistent with an ovarian cyst), and reported back to Dr. Brainless that she did, in fact, have an ovarian cyst and that she could, in fact, go home.  Then without another word I left, confident in my own diagnostic skills but entirely doubtful of Dr. Brainless'.

If you aren't sure of a diagnosis, please call me for help.  But if you have 21st century technology available that can make the diagnosis for you, USE IT.  I understand that not every doctor can be a rocket scientist or a brain surgeon (so to speak), but I at least expect them to be smarter than a newt. 

Tuesday, 28 January 2014


I've been called a lot of things during my career - baby doc, nurse, asshole, student, intern - but I've never been called a fraud until just a few weeks ago.  While arguing with a few people on Twitter about the meaning and significance of brain death, I was accused of not being a real doctor.  Of being a fake, a fraud.  

At first I tried to defend myself, to tell these people that I am, in fact, a doctor, that I actually do take care of patients, I actually save lives.  Of course they didn't listen.  They continued their crusade against me.  I have no idea why they felt the need to try to discredit me.  Maybe they just don't like that I disagreed with them.  Regardless, I stopped defending myself.  I started ignoring them because I realised it didn't matter what they think. 

Except that it does matter.  My integrity, honesty, and professionalism have never been called into question like this.  The problem I have is that I have no defence. I have no way of proving myself, short of revealing my identity.  I use a pseudonym because I staunchly refuse to compromise the privacy of my patients and my family.

I seriously doubt any of my "doubters" will read this.  But on the off chance one of you is reading this and got this far, ask yourself one question:


Why would I impersonate a doctor online?  What motive would I have?  What would I possibly have to gain?  Money?  I haven't make a penny off any of this and I don't expect to.  Fame?  Ha, no.  Respect?  I get enough of that from my family, colleagues, and patients, and I would hardly expect to get any real respect from random people online.  So why go to the trouble of such an elaborate hoax for so long?

The truth is that I started this blog for myself, so I wouldn't forget my stories, and so my children (when they get older) would know what Daddy deals with when he goes to work.  But it's evolved into more than that. 

I write now because I enjoy writing, and I continue writing because there seems to be a decent number of people out there who enjoy it.  It doesn't take long to write a blog post, just a few minutes here and there, and I wish I had more time to write a daily update.  But I don't. 

If no one else reads this blog ever again, I'll at least still have my stories for my wife and my children.  And for myself.  I don't do this because I have to.  I do it to inform, amuse, and educate.  

If you'd like to believe I'm not a doctor, you have the right to your opinion.  But I'm sure the scores, possibly hundreds of patients who are still on this Earth because of me and my team would rabidly disagree with you. 

Friday, 24 January 2014

Fuck you, Justin Bieber

I know in my last post I promised a stupid story about me, but this takes precedence.  The post about me is written, but it will have to wait.  I've done stories about stupid patients, stupid doctors, and stupid lawyers, but never about a stupid celebrity.  Yesterday the opportunity presented itself, and I would be an idiot not to pounce on it.  This time the idiot is not me, it is a 19-year old self-absorbed, egotistical, narcissistic little twit named Justin Bieber. 

Let me start by saying I am not jealous of Justin.  No really, I'm not.  Stop laughing and hear me out.  I'm not jealous of his enormous army of fans ("Beliebers"), I'm not jealous of his $160 million that he's earned before age 20, I'm not jealous that he's so damned cute (I'm at least as cute as he, I assure you), and I'm not jealous that he's approximately 431,758,962 times more famous than I (but who wants to be famous anyway?).  So why the acerbic title?  Why the venom then?  If it isn't jealousy, why am I so angry with the adorable little moppet?

It's for one simple reason: because Justin is an idiot who thought it was ok to drink alcohol (apparently his blood alcohol level was below the legal limit, even for a minor), smoke weed, pop some prescription pills, have a few buddies block off a street in Miami, rent a Lamborghini and a Ferrari, and drag race at 4AM going double the speed limit.  Fortunately no one was hurt.  Even more fortunate was that he got caught.

This stupid story is stupid on many levels, like Stupidception.  Sure he drove after drinking alcohol, but that's not the worst part.  And sure he acted like an entitled ass when he got pulled over ("What the fuck did I do?  Why did you stop me?" he moronically said), but that's not even the worst part.  No, the worst part is that Justin has millions of rabid fans thinking that what he did yesterday is forgivable and just a simple mistake.  A quick check of social media finds this minuscule sampling of how his fans see this (these are actual, unedited quotes):

  • Everybody makes mistakes, but it doesn't mean they're bad people.
  • Listening to all my favorite J-Biebs songs in honor of his arrest
  • it's now our time to save our lifesaver
  • he has been depressed just a kid who is depressed who needs help
  • I honestly love him 
  • Justin all your fans are here for you it's not your fault
  • no matter what we won't give up on him he saved us now it's our turn to save him
  • Bieber is a smart young man that just did something dumb
  • he has been under too much pressure, hope people can understand
Maybe Justin should stop listening to his delusional fans for one minute (seriously girls, he is NOT your boyfriend) and talk to Bob. 

I met Bob (not his real name) just after midnight some time ago after what he described as a typical night - getting home from work and getting shitfaced at the bar.  Most nights he had his buddy drive him home, but this night that buddy had stayed home sick.  It was a short drive, so Bob decided to drive himself.  He'd never had any problems getting home from the bar.  Until now. 

The driver of the other car came around a corner only to see Bob's headlights speeding towards her in her lane.  Her 8-year old daughter was asleep in the back seat, and she didn't even wake up as her mother tried to swerve but didn't have time.  Both cars were obliterated.

Wendy (not her real name) and Bob were both brought to me at the same time in separate ambulances.  Bob had been too drunk to put on his seatbelt, and his face went straight into the windscreen.  He was awake and talking, however.  Very intoxicated, but talking.

Wendy was not.  Her head took the brunt of the impact, and she was barely conscious when she arrived, her head injury obvious and massive.  I ran back and forth between the two trauma bays, barking orders, tending to both, trying to determine in the first few seconds who was injured worse.  I got my answer 5 minutes later when Wendy's heart stopped.  We started CPR, but despite exhaustive measures we could not get it restarted.  I pronounced her dead about 30 minutes after she arrived.  I found out later that night that her daughter, who had been taken to the local children's hospital, had died at almost the same time. 

Bob ended up having a LeFort III fracture of his face - the bones of his midface were basically all shattered and dissociated from the rest of his skull- but no other serious injuries.  I went to see him the next morning, and he had no recollection of the night before.  I explained that he would need extensive reconstructive surgery by a highly-specialised plastic surgeon to put his face back together.  When I asked if he had any questions, he had only one:

"Was anyone else hurt?"

I nodded.  His shoulders dropped and his badly-swollen eyes widened. 

"How bad?  Come on Doc, tell me.  Oh god, how bad is it?"

I struggled internally between anger over what he had done (imagining how I'd feel if it had been my wife and daughter he had killed instead of Wendy and hers) and feeling sorry for him for what he was about to hear.  Knowing he had to hear the truth, I gave it to him, honestly and fully.

He sank to the bed and cried openly.  I paused but had nothing else to say that would change anything, so I left without saying another word.  It was clear that Bob would punish himself worse than my words, or any judge and jury, ever could.

Bob left the hospital a few days later, his face still swollen but fully reconstructed.  For the rest of his life Bob will have to look in the mirror and see the scars on his face.  Those scars will be a daily reminder of how just one simple, little mistake can profoundly change your life, and the lives of everyone around you, forever. 

When Mr. Bieber was released from jail after posting bail an hour after he got there, he had a perfect opportunity to change many lives for the better by choosing to do the right thing.  All it would have taken to make a huge difference was to stop outside the jail, apologise for his stupidity, recklessness, and carelessness, speak out vehemently against impaired driving, and show his millions of young, impressionable fans around the world that what he did was wrong.  Instead, he decided to do what any reasonably responsible citizen would do - pause, preen, and pose for pictures while perched atop his handler's Cadillac Escalade (in leather pants, no less).  

He simply waved to his screaming horde of fans for a moment and left.  His window of opportunity is closing fast, but he still has a chance to try to make amends. 

But I strongly suspect he won't.  And that makes me very, very angry.  It is moments like these, moments that should be humbling, that show the world your true character, and he has done that.  Now you know why I have no respect for this kid - because he has no respect for himself, his community, or his fans.

Saturday, 18 January 2014

Jahi McMath Misconceptions and Twitter

Up until a few weeks ago, I thought Twitter was the stupidest idea ever.  Microblogging?  Really??  Think about it, what can you really say in 140 characters or less?  As it is, you can barely get one idea through.  Then if you start responding to multiple people, your ability to communicate is even more limited.  And if you dare use hashtags, your character count dwindles to near zero, and you have resort to things like saying "u" or "ppl".  I'd rather stick hot pokers in my genitals than say "u". 

Regardless, having engaged in several Twitter brawls (a few still ongoing), I can definitively say that Twitter is, in fact, the stupidest idea ever.  Yet I find myself continuing to try to argue with (and educate) several ignorant individuals who, for reasons known only to them, seem hell-bent not only on ignoring facts and ethics but also on denying science.  But arguing on Twitter is next-to-impossible, partly because of the character limit.  But the main reason is that anyone can get a Twitter account, especially people whose sole intent is to malign, abuse, and insult.  And as I've seen firsthand, 140 characters is plenty when your goal is either to foment mischief, spread malinformation, or both. 

Having said that, I'd like to use this opportunity to expound some of what I've said while trying (in 140 characters or less) to battle the nonsense I've come across on Twitter and comment threads on the various Jahi McMath stories I've read.  Which is pretty much all of them. 

1) Brain death is not full-body death. The body is still alive. 
This is a very simple mistake to make, but it is no less a mistake than eating potato salad that's been out for several hours on a hot summer day.  The body sure does look alive, it's warm, and the heart is beating.  But the body is just functioning, not alive.  It may seem a fine distinction, but there is a world of difference between a body that is merely functional and a live person.  You can argue that a bacterium is alive despite not having a brain.  I would counterargue that a tree is also alive despite not having a brain.  The fact is humans are different.  We have personalities, our consciousness, our humanity.  That lives in the brain and nowhere else.  
2) The brain can recover and heal. 
From an injury, yes.  From death, no.  Dead brain cells remain dead forever.  No amount of prayer, hope, or time ever can change that.

3) It is not illegal to have a brain dead patient on a ventilator, so Jahi's family isn't doing anything wrong.  
It isn't illegal to put a doll on a ventilator either.  For that matter it isn't illegal to stand on your head naked and sing "Wrecking Ball" by Miley Cryus.  But why would you?  All of those things lead to the same thing: no benefit whatsoever, and everyone thinking you're insane.

4) Jahi's family isn't hurting anyone, so what they are doing isn't unethical. 
First, they are hurting themselves by refusing to accept and deal with reality.  The lasting memories they will have of Jahi will not be of the beautiful, vibrant 13-year old girl they once knew, but rather of the brain-dead, unresponsive girl lying in a hospital bed with a machine pumping air in and out of her every few seconds.  The memory of her voice and laughter will be drowned out by the sounds of the ventilator.  

The second (and infinitely more damaging) harm is that this gives other families the idea that what Jahi's family is doing is somehow normal or ok.  The consequentialist theory of normative ethics states that an action is moral if the consequences of that action are more favourable than unfavourable.  For those of you still awake after reading that bit of soporific academic drivel, it's entirely obvious that keeping dead people on ventilators serves no reasonable purpose, other than preventing families from ever having to let go, which is the ultimate act of selfishness. 

5) Jahi's family had to fight to have her removed from CHO, which was trying to block them from leaving, which violates their rights. 
Another very common misconception.  Except for psychiatric patients who are involuntarily held because they present a threat to themselves or others, patients cannot be kept in hospital against their will.  Jahi's family could have taken her from the hospital at any time, but there was no facility willing to take her in her current state.  Her family was trying to compel the hospital to place a tracheostomy and feeding tube, because the hospital correctly felt it was unethical to perform surgical procedures on a dead patient and refused.  The court would not force the hospital to perform the procedures, and ultimately the two sides reached an agreement that the hospital would release Jahi's body to her mother's care. There was never an order from the court forcing the hospital to release her.

6) Jahi's doctors tried to force their opinions and will on her family. 
The doctors only had their patient's and her family's best interest in mind.  After she was declared dead, they allowed several days for the family to congregate and for a second opinion to confirm the diagnosis.  Obviously the family, denying logic and reason, disagreed with what was in their best interest.  It seems obvious that if the doctors had forced their will, Jahi would have been taken off the machines and buried weeks ago.

7) Her family does not agree with the legal definition of death, so they have the right to challenge it. 
I've seen this argument several times, and on the surface it may seem to make sense. However, if I say I disagree with the legal definition of stealing, does that allow me to take a Bugatti Veyron?  At least 6 physicians confirmed the diagnosis, and simply disagreeing that Jahi is dead does not bring her back to life.   

8) People who are legally blind have some sight, so legally dead people have some life. 
Before you say anything, yes someone actually said this.  Of all the arguments I've seen, this is by far the most preposterous (and funniest).  There is no such thing as "legally dead".  You are either dead or you are alive.  Death by neurological criteria is the same as death by cardiac criteria.  And Jahi, unfortunately, is dead.

On another note, Paul Byrne wrote another piece on, where he states that Jahi has regained the ability to regulate her core body temperature, a function of the hypothalamus (which is part of the "primitive brain" and controls thermoregulation, hunger, thirst, and the circadian rhythm).  This "fact" has been corroborated by exactly no one, and I can do nothing but question its validity based on the source.  This will firmly remain in the "Unsubstantiated Rumours" category until it is verified. 

One final note: this will probably be my last post pertaining to the tragic story of Miss McMath.  I've taken enough time (both yours and mine) trying to educate, inform, and correct misconceptions.   After this I plan on returning to my stupid stories, stupidly starting with a stupid story about stupid me.  For those of you who found me via Jahi, I hope you'll follow along with me and continue to share my tiny corner of the Internet.  If you choose not to, then FINE!  I DIDN'T WANT YOU TO ANYWAY!

Tuesday, 14 January 2014

Set them free

If you want something very, very badly, let it go free.  If it comes back to you, it’s yours forever.  If it doesn't, it was never yours to begin with. 
- Unknown

Everyone has heard that very famous phrase (or the slightly more compact version) which is often incorrectly attributed to Richard Bach.  After scouring the vast reaches of the universe (ie a 0.392 second Google search), I have been unable to identify the true source of these wise words.  Apparently they were originally written by an anonymous student of Jess Lair, a teacher and author who published it in his book “I Ain’t Much Baby—But I’m All I’ve Got in 1969.  Sting popularised the saying further in his grammatically-incorrect song "If You Love Somebody Set Them Free" in 1985 (subject-verb agreement, Sting).

So on the subject of people who deserve to be set free, the continuing story of Jahi McMath has caught the attention of people around the world.  It has sparked emotions on both sides of the issue ranging from sadness to sheer outrage.  The outpouring of support the family has gotten (both in prayer and in monetary donations) has only been overshadowed by the almost-criminal accusations made against Jahi McMath's doctors and Children's Hospital Oakland, as well as similar wild accusations made against her family.  The vehement conjecture on both sides has done nothing but push the actual tragic loss of a young girl to the side in favour of bitter and worthless squabbling.

But this post is not about Jahi McMath.  Not primarily, anyway.  On the opposite end of the spectrum from Jahi lies Marlise Munoz.  Marlise, just 33 years old and 14 weeks pregnant, collapsed at her home in Texas on November 26, 2013.  Her husband Erick found her lifeless on the floor, and she was rushed to John Peter Smith Hospital in Fort Worth where, despite exhaustive efforts, she was pronounced dead by neurological criteria, possibly due to a fatal pulmonary embolus.  She and her husband had discussed this possibility after she lost her brother in an accident, and she had decided she would not want to stay on machines.  To honour her wishes, Erick asked her doctors to remove her from life support and let her go, to set her free.

Despite his request, her doctors refused to turn them off.

Wait, what?  Why?  Do her doctors believe in miracles?  Are they,  like Jahi's family, trying to defy medicine, science, and logic?

No, they were simply following the law.  Unbelievably, Texas has a law (Section 166.049) stating that "A person may not withdraw or withhold life-sustaining treatment under this subchapter from a pregnant patient".  And because Marlise was pregnant when she died, the hospital and her doctors have adamantly refused to remove her from the machines according to her wishes 7 weeks later.

"Wait, wait, wait", I hear you thinking.  "Something isn't right here.  The law specifically says 'life-sustaining treatment'.  There's no life to sustain!  She's dead!"

Well, yes.  You know that, I know that, and I'm sure her doctors and the hospital know that.  But despite that very logical argument, the hospital's spokesperson said, "In all cases, JPS will follow the law as it applies to health care in the state of Texas. State law says life-sustaining treatment cannot be withheld or withdrawn from a pregnant patient."

But it says . . . life-sustaining . . . and she's . . . but . . .

To try to clear my head from the insanity of that statement, I decided to research pregnancy and brain death, and I was a little surprised by what I found.  The journal BioMed Central published a review article in 2010 where they found 30 documented cases of pregnant women declared brain dead between 1982 and 2010 and kept on machines, essentially as incubators, until their babies were delivered.  These women averaged 22 weeks pregnant at their time of death, and the babies were born an average of 7.5 weeks later (though 2 of them were kept on support for over 100 days).  Only 12 of the 30 delivered a healthy baby who survived more than a few days.

The most interesting thing to come out of this report is that 10 of the 30 deceased women were then able to donate their organs after delivery, weeks after being declared dead.  So with maximal support (including ventilatory, hemodynamic, endocrine, fetal, thermoregulatory, nutritional, and infectious), even brain dead bodies can be sustained for weeks, months, or possibly even years.

We are living in the future, where the science of medicine has advanced to the point where even dead bodies can be sustained on machines.  But the obvious question is


Why do it?  In the case of Jahi McMath, that question has not been answered.  Her brain is gone, never to return.  "Jahi" as a person is gone.  What purpose does it serve keeping her body functioning?  I understand the family not wanting to let go, but at the end of the day they have to understand that death is a part of life.  It is inevitable for all of us.  And keeping a lifeless shell on machines just because you aren't ready to say goodbye is denial and futility at their most basic.

On the other hand, in the case of Marlise Munoz, the answer to "Why?" is clear - to give her foetus a chance.  But that brings up another even better question: Just because we can, should we?  Marlise didn't want this, her husband doesn't want this, and her parents don't want this.  But the state and hospital are forcing this treatment on them, twisting the law to fit a patient for whom it was never intended.  Two of the three people who helped draft the law have even said that brain-dead women would not be covered by the law, because it only specifies "life support" (hmm, where have we heard that before?).

So here we are, two families with similar, though almost opposite, problems.  In one case, Jahi McMath has been reduced to a hollow vessel, forced to stay on machines by a family in denial who can't say goodbye.  In the other, Marlise has been reduced to an incubator, forced to stay on machines against her will and that of her family who want to let go but can't.
If you want something very, very badly, let it go free.  If it comes back to you, it’s yours forever.  If it doesn't, it was never yours to begin with. 
- Unknown
It seems to me that both Jahi's family and the hospital in Texas need to let them go free.

Note: If you are interested in reading the full article from BioMed Central, click here.

Saturday, 11 January 2014

The ethics of compassion

It is unethical not to be compassionate when you are a physician.  Treating people or their families poorly isn't helpful to anyone in a stressful situation.  But a big problem exists there - ethics is not taught in medical school.  Then again, neither is compassion.  So where do you learn them?  Can you learn compassion, or is it something you just have?

Or don't have?

She could have been anyone's grandmother.  White hair, glasses, plenty of wrinkles.  But she was not your typical 91-year old.  She lived by herself, she cooked for herself, and she still had a twinkle in her blue eyes.  She was not doddering and did not need a cane or walker, though she took each step slowly, carefully, deliberately.  She didn't drive, but she still went food shopping with her daughter every week.  And somehow that was where it all fell apart.

She paid for her groceries and walked out of the store.  She either didn't notice the curb or didn't remember it.  It was only a few centimeter difference in height, but as she missed the step, her weight shifted forward.  Her daughter tried catching her but couldn't reach her in time.  She struck the pavement, her face taking the brunt of the impact, and she passed out immediately.

She woke up as she was being transferred from the gurney to my stretcher.  "What's going on?  What happened?" she asked.  I asked her name.  "It's Catherine", she replied, looking around the room, frantically trying to regain her bearings.  "What happened?  Where am I?"

I explained that she fell and was in the hospital.  She was a complete mess - her hair was matted with dried blood, her left eye was swollen shut.  There was a large laceration on her forehead.  Her nose was bleeding and angled to the right.  I suspected facial fractures but feared worse. 

"What's happening? Where am I?"

That's when the perseveration started.  Repeated questions - a sure sign of a brain injury.  But how bad was it?  A concussion at least, to be sure.  But was that it?

"What happened?  Where am I?  Where's my daughter?"

After assessing the rest of her and finding no significant injuries, we took her to the CT scanner.  I looked at the images of her brain quickly as they were taken, and there it was, my fears confirmed - a large subdural haematoma, bleeding in her brain.  Considering the amount of blood I was very surprised she was awake at all.  It was perhaps a survivable injury for a younger patient, but only with a risky and aggressive brain surgery to remove a segment of the skull and drain the blood.  But in someone this age...

I went out to the waiting room where her daughter was anxiously awaiting news on her mother's condition.  She handed me a piece of paper with a list of her medical conditions, medications, and allergies.  I looked through it quickly, and one word immediately jumped off the page: warfarin, a very potent blood thinner. 

Damn it.  

I took a deep breath and carefully explained to her daughter what was happening, how her mother's brain was bleeding, and how the bleeding would be difficult - if not impossible - to stop due to the blood thinner. 

"Is she awake?"

"Yes, but probably not for too much longer."

She looked surprisingly calm despite the devastating news.  

"What's happening?  Where am I?" Catherine repeated as we walked in.  The nurse was answering the question for the 8th or 9th time using a quiet, soothing voice, despite the fact that she was clearly getting annoyed.  I waited for a few minutes and answered a few more questions, then I excused myself to consult with the neurosurgeon.  As I was loading the CT images I told him Catherine's medical history, about the blood thinner.  He took one look at her scan and laughed.  "She's ninety years old?  Ha!  Nope, not survivable.  Need to talk to the family.  She's as good as dead."

I knew that would be his impression.  A person that age with that size bleed on blood thinners is not going to survive no matter what we do.  "I'll talk to them," I said.  I didn't expect his laugh, and I didn't like his attitude.

By the time I got back to Catherine's room a few minutes later, she was already much sleepier, but still talking.  "What's going on?"  As I told her daughter the news, she nodded knowingly, clearly having figured it out already.  When I started to explain that surgery wasn't an option, she stopped me and smiled sadly.

"Thank you, but she wouldn't have wanted that anyway.  We've had many conversations about this with her over the past few years.  You know, just in case.  And she's told us she would want us to let her go.  How much time do you think we have?"

I liked how she said "How much time do WE have".  Most people would have said "does she have", but she was asking how much time they had left together.  I appreciated the subtle nuance.  I told her maybe minutes, maybe hours.  But not long.  She took her mother's hand, and I left them together. 

I went back to see them a few hours later.  The rest of the family had arrived, and they all looked calm and peaceful, Catherine included.  She was unconscious, barely breathing, but comfortable.  Her daughter saw me, smiled, walked over to me, and gave me a wordless hug which said "Thanks" louder than words ever could. 

I don't like watching people die.  It's the opposite of what I do.  But sometimes it's the compassionate thing to do.  Sometimes the right thing, the ethical thing to do is stop fighting.  Sometimes the person we really need to support is the one who is still here, standing at the bedside of the one who is not. 

Thursday, 9 January 2014

Brain death and organ transplantation Mythbusters

Whenever I watch Mythbusters, I think how great I would be as a cast member.  It would be perfect - I love busting myths, I think Adam Savage and Tori Bellici would be great to hang out with, I think Jamie Hyneman and Grant Imahara would be great to have a conversation with, and I think Kari Byron is ridiculously attractive.  Sorry Kari, but it's true.  But just when I'm ready to apply for the job, I realise that I have no idea how to build any of the contraptions they build, I know pitifully little about robotics and physics, and I don't live anywhere close to San Francisco.


So instead I have to settle for being a trauma surgeon and busting medical myths in my free time.  This time I'll be focusing on brain death and organ transplantation and YES I'M STILL STUCK ON JAHI MCMATH, DAMN IT!  Sue me!  And stop interrupting.  Anyway, in my last post I did an informal Q & A session, answering some questions about Jahi specifically.  I'm casting a wider net this time, focusing on some more general issues.  So without further ado...

Myth: Patients' families are the ones who determine when their loved one has died, not doctors.
Reality: No.  No no no no no.  NO.  Have I said that enough?  NO!  According to this report, Jahi's mother's lawyer Christopher Dolan said it is "the right of a parent to make health care decisions relating to whether or not a ventilator gets removed from their child."  With that I fully agree.  However, he went on to say that families should be the ones to determine death, and here is where he is venturing into territories where he does not belong.  Determining death in some situations is quite simple - if the heart is ripped out of the body, the head has been detached from the body, etc.  But it takes a doctor with years of training to diagnose brain death.  Who wants families deciding when someone dies?  What if a family decides gramps is dead while he's still watching reruns of Matlock and Murder, She Wrote because they want his 1965 Aston Martin DB5?  Should they be able to declare him dead?  The fact of the matter is this: the family should have full control over their loved ones' healthcare decisions while they are alive, but that control ends when the patient dies.  Lawyers don't determine when people die.  Families don't determine when people die.  Judges don't determine when people die.  Doctors do.  End of story.

Myth: If you are an organ donor, the hospital will not treat you as aggressively as if you weren't because they want your organs.
Reality: Uh, no.  Some people seem to think that the first thing we do when we see a new patient is look for a donor card.  Of the thousands of patients I have seen (and I see some VERY sick, often actively-dying patients), I have looked for exactly ZERO donor cards.  While I am repairing a liver laceration or opening a chest, I guaran-damn-tee you I am NOT wondering, "Is this person an organ donor?  Maybe I shouldn't suture that liver all the way.  And maybe I should leave a little hole in the heart so this guy bleeds to death.  I know someone who could really use his kidney!"  Accusing doctors of this is not just disheartening, it is sickening and questions our very moral fibre.

Myth: Brain dead organ donors are not actually dead when their organs are removed, and they suffer tremendously during the procedure.  That is why they are paralysed during organ harvesting - so they can't get up and walk out of the operating theatre.  
Reality: Anaesthesiologists administer a neuromuscular blocking agent (a medication that paralyses the body) to prevent the reflex muscle contraction that is initiated in the spinal cord.

Myth: Brain dead organ donors' heart rates and blood pressure go up during organ harvesting, a sure sign they are feeling PAIN.
Reality: No, the increase in blood pressure and heart rate are reflexes from the spinal cord.  The pain centre, which is located in the brain, is dead, so a pain sensation is impossible.  This explains why donors are given anaesthetic agents (sedatives) during the procedure - to prevent this from happening.

Myth: The concept of "brain death" was made up by a bunch of Harvard lunatics who wanted to increase the number of available organs for transplantation and knew that brain-dead people aren't dead.
Reality: This bit of absurdity refers to the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.  Unfortunately for those who believe this nonsense, organ transplantation and brain death, as concepts, were developed entirely separately.  The idea of brain death started evolving as early as 1892, well before any organ transplantation was ever done.  Read this for more information.

Myth: The criteria for determining brain death were established in the 1960's, so they are obsolete.
Reality: Brain death in the 60's is the same as it is now.  Brain's haven't evolved the ability to heal since then, so the clinical criteria are still completely valid.  Regardless, we now have confirmatory tests for brain death which are often done, including EEG (which was available in 1968), cerebral angiography, and radionuclide brain scans.  There is debate about whether or not any of these confirmatory tests are necessary to confirm brain death.

Myth: Catholics don't believe in brain death, so removing even a brain-dead Catholic patient from a ventilator is murder.
Reality: False.  Pope John Paul II himself agreed that the use of neurological criteria for determination of death was legitimate.  If you choose not to believe me, you can read the National Catholic Bioethics Center's FAQ on brain death for confirmation.

Myth: Hospitals profit from organ donation.  If a patient dies and donates their organs, the hospital gets to keep them and profit from doing 10 more operations.  So hospitals are financially encouraged to call people "brain dead", even when they may not be.
Reality: Conspiracy theories don't look good on you.  The vast majority of hospitals do NOT have organ transplantation programs, so if a patient dies and donates their organs, chances are very high that the hospital will not keep the organs.  For example, there are well over 2000 hospitals in Germany, but only 33 of them perform kidney transplants, 16 perform heart transplants, and 18 do liver transplants.  Of the 4000 hospitals in the US, about 5% of them have transplant programs (heart, lung, kidney, pancreas, liver, and intestine).  These are just two examples, but the statistics worldwide are similar.

Myth: Hospitals can sell donated organs to the highest bidder.
Reality: Organs are not bought or sold.  They are donated and then routed to the patient most in need.  Nearly every country that participates in organ transplantation has a national register, so that every organ can be traced from its donor to its recipient.

Myth: There is a large black market dealing in human organs.
Reality: This one is partially true.  It is illegal to sell human organs in all countries worldwide except one (GET YOUR HEAD OUT OF YOUR ASS, IRAN!).  However, there is still an international black market where organs are bought, usually from a poor, desperate victim, and then sold to the highest bidder.  The Declaration of Istanbul was drafted in 2008 and adopted by over 100 countries in an attempt to shut down the illegal organ trade.  No word yet on its effectiveness.

Myth: Organs are harvested from executed prisoners in China.
Reality: This is unfortunately true.  However, the country is banning the practice starting later this year.

Monday, 6 January 2014

Jahi McMath FAQ

Repetition as a concept is bad.  Repeated repetition is worse. Add ignorance, stupidity, blind faith, half-truths, or outright lies to the repetition, and it becomes completely intolerable.  I engaged in my first Twitter argument regarding Jahi McMath a few nights ago, and I kept hearing the same stupid questions and the same ignorant comments.  Perhaps if I had a TARDIS I could find every one of these ignorant people who are undermining the reputation of Children's Hospital Oakland and their staff (and the entire medical community in general) and try to talk (ie slap) some sense into them. Unfortunately, I haven't the time, patience, or TARDIS to do so.

So instead I decided to put some of the more poignant questions here in order to answer them as clearly and concisely (read: using small words so the simple-minded can understand) as possible.  Brace yourselves, folks.  It's about to get deep.

Q: Jahi is in a coma, so she could just wake up!  People like this wake up all the time.  They need to give her more time so she has a chance to get better. 
A: That's clearly not a question, but I'll address it anyway.  This seems to be the main point that people just don't seem to get, so read this very carefully: She is NOT in a coma.  She is not in a persistent vegetative state (PVS).  She is brain-dead.

Q: Ok fine, but there's no difference anyway.  They're all the same!
A: Again, not a question.  You're not even trying, are you?  Anyway, no NO NO!  They are NOT the same thing, not remotely.  A coma is an unconscious or semiconscious state, while a persistent vegetative state is a prolonged coma, often due to permanent brain injury.  There are countless reports of coma patients waking up, and reports of people in a persistent vegetative state getting better to varying degrees.  This is because with comas and PVS, the brain is still alive.  But with brain death, the brain has been deprived of oxygen and has died.  In the entire history of humankind, no person who was actually brain-dead has ever woken up.

Q: But why? All these reports can't be false, can they?  I've read it on the Internet, so it must be true!  The Internet would never lie to me!
A: Of course they can all be false.  The short answer is because the central nervous system has no capacity to heal.  None.  Ever.  The longer answer is when the brain, brainstem, cranial nerves, or spinal cord is injured, it is injured forever.  If these cells die, they are dead forever.  Jahi's brain and brainstem were deprived of oxygen for too long, so they have both completely died.  Therefore there is a 0% chance of those cells ever healing.  Not a 1% chance not a 0.01% chance, not a 0.000001% chance.  Zero.  It is physically impossible for her to ever wake up.

Q: But you haven't examined her!  How could you possibly know this?  Are you making this all up?  
A: No, but I have read the report by Dr. Paul Fisher who DID examine her, and that's good enough.  He did an extremely comprehensive neurological exam.  All of her brainstem reflexes have disappeared, her pupils are fixed and dilated, and she failed an apnea test.  She was taken off the ventilator for nearly 10 minutes, and she had no respiratory effort whatsoever.  If her brainstem were alive, she would have tried to breathe as her carbon dioxide levels rose.  She didn't.  Therefore her brainstem is dead.

Q: Well what if you're wrong?  Aren't doctors wrong all the time?
A: All the time?  No.  Occasionally?  Yes.

Q: Well doesn't that prove that you could be wrong here?
A: No.  At least 6 physicians have done a thorough examination, all of which were conclusive for brain death.

Q: But you just said doctors make mistakes!  What if they all made one?
A: She's also had two electroencephalograms (EEGs) which have shown no electrical activity in the brain.  Live brains have electrical activity.  She also had a radionuclide brain scan which showed no blood flow to her brain.  Brain tissue is extraordinarily sensitive to lack of oxygen, so no blood flow means a dead brain.  A computer could read a flat EEG and a blank brain flow scan.  Then again, so could a 5-year old.

Q: But couldn't you still be wrong?
A: No.

Q: But there are all those stories about brain-dead people waking up!  What about Zach Dunlap and Colleen Burns and Sam Schmid and Suzanne Chin and...?
A: I don't have access to their medical records, but clearly none of them were ever actually brain dead.  Perhaps their families were told they were brain dead by mistake.  Perhaps the families were told they had a "severe brain injury" and their families heard "brain dead" instead.  Perhaps the doctors made a mistake in their examination and subsequent diagnosis.  Regardless, because of all the reasons I stated above, it is 100% impossible for someone who is brain dead to wake up.

Q: But what about miracles?
A: You may believe in miracles all you want, but I will NOT get dragged into a theological debate.  Beliefs are funny things.  Personally I believe that all of you will eventually come to your senses and finally understand the science here, but that doesn't mean you will.

Q: What harm could all this really be doing?  Why are you so opposed to giving her a chance?
A: Quite simply, this is setting a dangerous precedent that will make some people think it's ok to keep a dead body on machines.  I also fear that it will prevent some people from deciding to become organ donors, which is the most noble sacrifice anyone could possibly make.

Q: But her heart is still beating!  Her body is warm!  And her kidneys are making urine!  Are you telling me that dead people have beating hearts?  Should we make caskets waterproof to protect the ground from all the urine the dead people make?
A: Clearly you don't understand basic human anatomy and physiology.  The heart, kidneys, and lungs do not require a brain to function.  If I hooked a human kidney up to an oxygenated blood flow, it would produce urine, no brain (or batteries) required.  Same thing goes for the lungs, heart, and all the other cellular mechanisms.  Because Jahi's body is hooked up to a ventilator, it pumps oxygenated air into her lungs.  Her lungs, also requiring no brain input to exchange gases, continue to exchange oxygen for carbon dioxide, and her cells which are receiving blood flow (remember, her brain is NOT getting blood flow) will continue to function.  So her body will stay warm, her heart will still beat, and her kidneys will still make urine.

Q: So doesn't that mean she's alive?  Isn't brain death not true death?
A: No.  There are two definitions of death - cardiac death (heart stops, all other cells then die) and brain death (brain dies).  Both mean the same thing - the patient is dead.  One is not "more dead" than the other.  Jahi is no less dead just because she has a beating heart.  She has no functional brain.  Just like anyone who thinks brain dead people can wake up.

Q: Well aren't you an arrogant ass.
A: Yes.  Any other questions?

Q: No.
A: Good.

Friday, 3 January 2014

Jahi update

I've written several stories about other subjects over the past week, but I can't bring myself to post them.  Not until this whole Jahi McMath situation is finally sorted out.  Ever since my wife told me about the story, I've been completely obsessed with it.  I stay up much later than I should, reading every news story I can find.  What I find most fascinating are the comments that readers have been posting, not only on the news stories but on the Facebook support page that Jahi's uncle set up.  The comments I see range all over the map:
  • anger towards the family ("LET HER GO ALREADY!!!")
  • sympathy and empathy
  • prayers for the girl and her family
  • personal guarantees that Jahi will wake up
  • unrelated stories of other brain-injury patients recovering
  • links or stories of people they know who have survived brain death
To the people offering support, I think it's a wonderful sentiment.  These unfortunate people need all the support they can get, and knowing that there are people who care will do nothing but help.  To the people who are angry and yelling at the family, your pleas are falling on deaf and blind ears (wait a minute, does that...forget it, I'm going with it), and you're making yourselves look like arrogant, callous, uncaring assholes, so you may as well stop and crawl back under your rock.

Finally, to all the others telling fairy tales about your brain dead aunt who was minutes away from the morgue when she suddenly woke up and is now walking and talking and writing novels, my best advice to you would be to shut the fuck up.  Despite every bit of medical information out there, the family is so deep in denial that they refuse to believe reality, and the clear reason for that is that they are getting fed lies and half-truths from people like her shameless huckster of a lawyer Christopher Dolan, medical "experts" like Paul Byrne and Jonathan Fellus, and YOU.  All of you are doing nothing but sustaining a false sense of hope in a hopeless situation.  I have been calling this nonsense "misinformation", but I don't think that term is accurate.

In an effort to try to illustrate my point, I decided to coin a new word: "malinformation".  Unfortunately, a 0.426 second Google search informed me that someone else got to "malinformation" first, so I can't actually claim it as mine.  DAMN IT.  Anyway, misinformation is bad information that is spread unintentionally.  On the other hand, disinformation is bad information that is spread intentionally in order to mislead.  I'd like malinformation, on the third hand (since there is no other hand), to be defined as "bad information that is spread intentionally in order to mislead and can lead to harm".

I've decided to compile a list of quotes and comments that are representative of the problem.  There are literally thousands of comments just like this.  These are real things that real people really said that I really didn't make up.  Really.  In the spirit of realism, I have kept all typos, spelling mistakes, punctuation errors, and displays of gross stupidity exactly as written.
  • A body needs a spirit to be alive.. Her spirit is still with her body as long as her heart beats..she is not deceased.
  • the poor baby doll could come out if this and create a while new medical era and hope for others
  • Brain death simply means no higher neural activity. It may or may not be reversible.
  • My sis in law was a teenager when the drs said she was brain dead. Told everyone to say their good byes. Shes now 30 with two kids. They pulled the same thing with her step dad. He also came out of it. Drs do not know everything. {this person knows *2* people to survive brain death! Amazing!}
  • Brain death is different from total body death.
  • my aunt was on life support, brain dead, and doctors told us she would not live for five minutes once plug was pulled. She lived for three weeks breathing on her on.
  • hint..a bible verse far override s scientific data
  • Life support gives support to the living. It does not give life to the dead. She is alive.
  • The physicians are going on book knowledge and saying no amount of hope can help. Where do the doctors get their knowledge from if not God.
  • the One who created the natural laws by which this universe runs, can override those natural laws any time He wants to!
  • they said one of my clients was brain dead... they (doctors) said pull the plug.... now he is talking...
  • the hospital knows she's still alive that's why they cant wait to kill her and wheel her out of there
  • if the parents want the tubes they should do it..the parents should be the ones to say yes or no..for the doctors to refuse the feeding tubes is plain bullshit..
  • I've seen my share of dead people. For one, they don't have a heartbeat. Last time I checked that was a brain function. And then there's that pesky rigor mortis.
  • Jahi is NOT a body, she is a warm living child
  • A child is not dead unless her mother say she is
  • Read some of Jahi's favourite books to her, play her favourite music...perhaps those will help wake her up.
  • This is wonderful!!! God is amazing!!! Your daughter is alive, and her moving proves it!
  • Because as long as that little girls heart is beating ( BTW- without help ) Then she is VERY much alive!
  • if her brain stem is dead as they say and the machine is breathing for her , wouldn't her other organs die somewhere her kidneys are working fine she's Not dead
  • Yes, I do believe in my heart that Jahi is still alive. They may have determined that she has no brain activity at this time. But that has happened before. Her heart is still working, her kidneys are too. 
  • That is sad to say a child is dead and she is not she is still breathing with a heart beat my eyes water with tears because doctors are Tryn to be god
  • And it doesn't matter how many of you try to say she is dead. A machine can not make her heart beat.
  • The only reason to take someone off life support is you don't love them enough to keep them on it
  • I have seen a person wake up literally right after they've taken the tubes out so.....Jahi will wake up
It's comments like that last one that are causing the most damage.  Everyone seems to know someone who was declared brain dead but woke up and recovered.  Unfortunately, that's just disinformation.  Those fortunate people were clearly never brain dead, but rather in a coma.  People in crisis situations (like having a critically-ill loved one) don't necessarily hear what is actually said to them, and "coma" or "unresponsive" may be processed and incorrectly interpreted as "brain dead".

Let me reiterate the salient point here as clearly as I can: there is not a single documented case in all of human history of someone who is truly brain dead ever coming back to life.  Once the brain is dead, it stays dead forever.  A brain flow study has confirmed that there is no blood flow to Jahi's brain, and several EEGs have shown no activity whatsoever.  No blood flow to the brain equals brain death, and brain death equals death.

Now you may be thinking, "Wait Doc, you mentioned harm.  What harm could they possibly be doing to a deceased body?"  Well, other than denying Jahi her dignity and final peace, nothing.  No, the real harm of this malinformation is 1) making people believe that dead bodies can somehow be reanimated and 2) setting a terrible, dangerous precedent that may be followed by others in the future.  THAT is the real harm being done here, and it is frightening.  Emotional families making irrational decisions based on beliefs and opinions can NOT be allowed to override actual medical facts and decide when a patient has died.

One final point I'd like to make is that I am NOT trying to stir up a religious debate.  Faith is a wonderful thing, and it can be very comforting and healing, in some respects.  What you believe in is up to you, and what I believe in is up to me.  Your faith, whatever it may be, is yours and yours alone, I respect that, and it is not up for debate.  Full stop.