Monday, 28 December 2015

Least favourite diagnoses

I have a little internal list in my head that I update from time to time whenever it strikes me.  The official title of this list is "My Least Favourite Diagnoses", but my pet name for it is "If I Ever Get This, Please Kill Me".  For your reading displeasure, I've decided to share that list with you fine folks:
  1. Penile cancer - duh
  2. Fournier gangrene - a necrotising infection of the scrotum, penis, and perineal area which I've warned you not to Google in the past.  No, I'm dead serious - DO NOT GOOGLE THIS.
  3. Fibrodysplasia ossificans progressiva - All the muscles and connective tissue in the body are progressively converted to bone, causing the appropriately-named Stone Man Syndrome
  4. Whatever the hell Joseph Merrick (the Elephant Man) had
For god's sake, please do NOT search for pictures of any of those things.  If you do, I hereby declare and avow that I will NOT be held responsible for any damage done to your computer, phone, tablet, etc from being coated with your own vomit.  And you probably shouldn't click any of those links that I accidentally provided on purpose.

There's one diagnosis that is currently not on the list that has been on there a few times, but it falls off and gets replaced from time to time (at one time it was replaced by Ebola).  I waver back and forth on whether or not this diagnosis qualifies, since it is technically treatable though not curable.  Regardless, even if it doesn't officially qualify for my list at this particular moment, it still qualifies as my least favourite surgical diagnosis for my patients:

CROHN'S DISEASE

There is precious little that can strike fear into the heart of a general surgeon (the good ones, at least).  But hearing the words "bowel obstruction" (or any other surgical catastrophe) in conjunction with "Crohn's disease" and "multiple prior surgeries" can make even the most war-hardened general surgeon soil his scrubs (or at least get really, really nervous).  In case you've never heard of the scourge which is Crohn's disease, it is an autoimmune disorder in which the body attacks its own digestive tract - any portion of it, from the mouth to the anus and anything in between.  This causes severe inflammation, resulting in chronic (often debilitating) abdominal pain, malnutrition, diarrhoea, and ano-rectal abscesses and fistulae (if you don't know what those are, I assure you they are exactly as unpleasant as they sound.  Another link you probably shouldn't click).  It can also cause life-threatening complications including bleeding, obstructions, and bowel perforations.

Sounds like tremendous fun, right?

WARNING: TERRIBLE SEGUE AHEAD

An experience with my bank teller (I warned you) got me thinking a few days ago.  I was trying to make a simple transaction, no talking necessary, but Mr. Chattypants was having none of that antisocial nonsense.  Somehow he managed to get me to divulge that I'm a surgeon, and he immediately asked the second question that pops into nearly everyone's head.  The first question, of course, is "What's this thing on my leg/face/arm/ass?"  I guess he decided to skip that one out of some sense of dignity and/or social grace, so he went directly to the second question which, regardless of the social situation, is always "What was your most difficult case?"  I've had several readers ask me the same question, so . . .

If you've put 2 and 2 together, you can see where this is going.

While knee-deep in my surgical training, I had the opportunity to treat Xavier (not his real name), a 50-ish year old gentleman who had been diagnosed with Crohn's disease about 30 years prior.  Since that day (which he eloquently described as "the worst fucking day of my miserable life"), he had been on every medication that researchers much smarter than I had been clever enough to invent, though none had provided any real (or long-lasting) improvement.  His chronic abdominal pain and rectal bleeding finally came to a head about 10 years before when he finally underwent an ileocæcectomy (a surgical procedure to remove the end of the small intestine and beginning of the colon and reconnect the two ends), which looks something like this:
Surgeons know to avoid operating on Crohn's patients unless it is an absolute necessity, and in Xavier's case, it was.  His disease was isolated (at least back then) to the terminal ileum and caecum (the end of the small intestine and beginning of the large intestine), but this area had become so inflamed that it had ruptured.  

That was only the beginning of Xavier's problems.

Unfortunately there is no cure for Crohn's disease, and performing this life-saving surgery to remove a perforated segment of intestine did nothing to improve his overall process.  In Xavier's case it saved his life (for the time being) but opened him up to a whole spectrum of new problems.  Literally.  Over the course of the next several years, he was treated with multiple medicines to modulate his immune system, but despite the attempts to prevent further complications, he had further complications.

He had increasingly bad flares increasingly more often, and he eventually wound up with an entero-cutaneous fistula, an abnormal connection between the bowel and the skin, and bowel contents leak out.  In an attempt to prevent even more problems (read: death), the fistula was initially treated without surgery.  Unfortunately with each flare it seemed a new fistula popped up.  This non-operative approach predictably failed, and several years and several surgeries later, he was left with an abdomen that looked something like this:
Not Xavier's abdomen
By the time I met him he had an end jejunostomy, several entero-cutaneous fistulae contained within a blind-ended segment of ileum, and a mucus fistula at the proximal end of his remaining descending colon.  If that makes no sense to you, it made only slightly more to me.  Basically his intestine was a jigsaw puzzle with several missing pieces, several misshapen pieces from multiple other puzzles, and three Monopoly tokens, and the three of hearts.  Fortunately it made complete sense to Dr. Anderson (not his real name™), the surgeon responsible for putting Humpty Dumpty back together again.  The goal, he told Xavier, was to take everything apart and put everything back together again.  This was an extraordinarily risky surgery, fraught with potential dangers - leaks, more fistulae, and death.  Despite the risks, Xavier wanted all of his fistulae gone, and he pleaded with us not to create any new ostomies if at all possible.

"Risky" didn't even begin to describe it.

At precisely 7:45 AM, Xavier was put under anesthesia.  Dr. Anderson went over the game plan with me, took a deep breath, and we began.  It took us nearly an hour just to incise the skin from around the intestine.  As the case proceeded, we had to separate the bowel not only from the abdominal wall, but also from itself.  Years of chronic inflammation had caused everything to mat together into a giant clump of solid collagen.  We meticulously dissected his tissue, trying to cause as little trauma as possible, and failing often.  By noon we had finally gotten past the abdominal wall and into the abdominal cavity, and by 5PM we had delineated most of his internal anatomy.

That was the easy part.

The segment of small intestine containing the multiple fistulae had to be removed and the two ends reconnected, leaving a blind-ended segment.  One end of that segment then had to be connected to the small intestine, the other end to the large intestine.  In all we made three new anastomoses (connections between the bowel), any of which had the potential to leak or create new fistulae.  Dr. Anderson and I finished the case just before 10 PM, having taken one restroom break each, and no breaks to eat.

And we still hadn't cured his Crohn's disease.

We had told Xavier prior to surgery that, if he survived, he would have an extremely long recovery in the hospital, and an even longer one at home.  Unfortunately to make a long story short (too late), Xavier did not survive his surgery.  It's difficult to say what actually killed him, but the simplest explanation is that his chronically weakened system wasn't strong enough to endure a 14-hour surgery.  Xavier went into the procedure a broken and defeated man, unable and unwilling to endure his debilitating disease any further.  In his mind, death was preferable to continuing on as he was.  On the night he died, the last thing he told me before I went home for the evening was, "No regrets, Doc."

Which brings me back to my list.  After writing this story and thinking of what Xavier went through, Crohn's disease just made it back on.

NOTE: For more information on Crohn's disease, go to the Crohn's And Colitis Foundation of America website or the Mayo Clinic website.

Monday, 21 December 2015

Interview with Mrs. Bastard

Ok folks, I asked, you responded, and now you're getting what you deserve.  I compiled the list of questions that you asked Mrs. Bastard, and after a lot of prodding, begging, and pleading she grudgingly answered almost all of them.  A few were duplicates, a few were a bit too personal, and one or two were just too bizarre, so they were unceremoniously dumped faster than a Kardashian marriage. 

So without further ado, in no particular order, here is your interview with Mrs. Bastard.  I tried to keep my own comments out of it, but this is my damned blog and I'm totally an attention whore, so I just couldn't keep my stupid mouth shut the whole time.  So any pithy comments by me will be placed {in brackets}.

Now you fine people are about to learn part of why I married this woman.  Don't say I didn't warn you.

Dear Mrs. Bastard,
What is the hardest part about being married to a doctor, and what is the best part?
I don't think there is a best part about being married to a doctor.  The best part is just being married to Doc (not his real name™) {awwww} - it has nothing to do with his profession.  The worst part is that he isn't here a lot of the time.  We miss parties and dinners because I don't want to go by myself.
What are some of the things both you or Doc did which lead to a successful and lasting relationship despite the difficulties?
Me not giving a shit anymore.  Not having as many expectations about Doc being present for stuff. {Love you too, dear.}
What is your favorite "trauma story" ever?
The Coke bottle up the ass.
Has being married to a doctor ever caused tensions in your marriage?  If so, how were you able to overcome those tensions?
I think there is always tension, because I can't plan vacations without knowing his schedule, never knowing if when I have to go on a business trip I can coordinate it with his schedule, never knowing if he'll miss the next school play or other big thing in our kids' lives.  I don't think we ever overcome those tensions, we just learn to deal with them and work through them methodically and logically. {See why I married her?}
How did you two meet?  When did you know he was "the one"?  I want to know the mushy side!
{TOO PERSONAL!  DON'T ANSWER THAT!}  It was a mutual stalking and love at first sight on both sides.  {Damn it.}  Our courtship involved lots of movie rentals (when that still existed) and pub trivia nights.  {And if you want to know our top-secret pet name for each other, FORGET IT.}
Are you a doc as well?  Which of you decided he should be known as "DocBastard" and why?
I'm not a doctor.  The "DocBastard" was all his idea.
What do you work as?  It's mentioned that you work, but I don't believe it's ever been indicated outright.
I'm Wonder Woman. {Seriously, she is}
How did the name "DocBastard" come about?
I have no fucking idea.  {Yes she does!  For the real answer, see this.}
If one of your children decided that they were going to become a doctor, what advice would you give them?
We would not allow this travesty to happen.  My kids are smarter than that.
I think DocBastard has mentioned in a previous post that you work too - do you ever find it difficult to judge your own work commitments alongside raising a family, given that your husband has a really demanding job with unpredictable hours?
Of course.  That's why I have a mobile full of "to do" lists.  Speaking of lists, did you change the light bulb above the piano yet?  {No dear, I haven't.  Damn it.}  And you should all know that Doc does NOT keep "to do" lists, so I have to keep HIS lists too. {Because, fuck lists.}
What is the most inconvenient time the Call Gods decided to borrow the doctor?
Nothing naughty!  But there have been more than our fair share of dinner parties, birthdays, and middle-of-the-night interruptions which everyone is used to, including the neighbours.
Does he put his freezing cold feet on you when he finally crawls into bed?  If so, do you swat him with a pillow?
HA!  Good one!  No, it is quite the opposite, which is why Doc now wears socks and sweatpants to bed so I can't achieve my goal of foot warmth.  {Damn right!  I have no idea why her feet are always so cold, even in summer.}
What is your favorite book?
George's Marvelous Medicine by Roald Dahl.
Do you read all of Doc's blog posts?
Most of them.  I usually catch up on them when I have bouts of insomnia and want something to put me to sleep.  {Gee thanks, dear.}
Do you typically talk about work (either his or yours) at home?
We talk about his work all the time, because I want to know if there were any blog-worthy traumas.  We talk about my work occasionally.  My work, though far less interesting than his, has its fair share of blog-worthy idiots.
What are the TV shows that you watch together?
Game of Thrones.  I can't believe we have to wait until April for next season, damn it. {I know!  Damn it.}
What about Doc drives you crazy?
Staying up until all hours of the morning writing this fucking blog.
Would you ever go back to school, and if so, for what?
Asking if I want to go back to school is like asking me if I want to be pregnant again.  HELL NO.
What is your biggest regret?
Eating that sushi when I knew I shouldn't have.
Is Doc really a bastard?  I doubt it, but the question begs to be asked.
I've never seen him at work, so I have no idea if he really is a bastard there.  But if he were a bastard at home, he'd be a homeless bastard.  So, no.
What is Doc's most irritating habit?  And what do you think he would say is yours?
Pen flipping!  His fingers are always moving.  As for me, he would say that my most annoying habit is asking him to do something and then doing it myself if he doesn't do it in what I consider a timely manner {which, for her, is about 0.482 seconds}.  I also squeeze the toothpaste tube from the middle. {Come on!  The tube even tells you to squeeze from the bottom!  Grrrr...}
Do his stories ever gross you out?
No, I can't remember him ever showing me anything that really bothered me.  Everything is fair game, and I think our kids are even used to it by now.
How often does Doc tell you stories from his work that you'd have preferred not to hear?
Almost never.
When you and Doc get a chance to plan a "date night", what activity do you prefer?  Quiet evening at home, dinner and a movie, dancing and drinks at the club, evening at a play or opera, comedy club, or . . .?
As we both are actually spies, it's really hard to accommodate our day jobs and our parallel lives as spies.  But if we actually did have time, we would choose dinner and a movie. {Or would we?  Dun dun DUN!}
If a movie of Doc's life were to be made, what actor would you choose to play him?  Who would/should play you?
Oh, that's easy.  Doc would have to be played by Denzel Washington, and I would be played by Salma Hayek.
Mrs. Bastard - you really don't mind him calling you "Mrs. Bastard" on the internet in front of everybody?
He calls me WHAT?  Oh my god, you're right!  Stop the press!  Let's go back and change every blog post ever!  What was I thinking?  I should have a little more self respect!  Actually no, "Doc Asshole" and "Mrs. Asshole" just don't have the same ring to them.  I think DocBastard and Mrs. Bastard hold.
If Doc wasn't a doctor, what career do you think he would have chosen or been good at?
He would be a plumber.  Not a good one. {I'm pretty sure that isn't true.  And I resent that.}
Mrs. B. - I find it fun to ask for the impossible and watch people work really hard to give it to me.  Your hubby seems up to a challenge so hopefully you are as well.  Here goes - please describe) as best as possible because I am quite sure there is no such thing) a typical day in the life of the Bastard family.
Boring and routine, just like pretty much every other family in the world.  Go to the gym, wake up, shower, get kids to school, go to work, worry about all my lists, make more lists, do some shit on the lists, come home, get kids home from school, look at dinner list, take something out of the freezer and check it off the list, nourish the Little Bastards (Doc too, if present), bathe the Little Bastards, put Little Bastards to bed, do more work, go to bed.  Rinse, lather, repeat.
Does Doc ever bring his work home with him?
He is always working because he has patients in hospital all year round.  There is little work-associated mess that comes home, and he were to make a mess, you better believe he would clean it up. {I believe in always cleaning up my own mess.} 
So there you have it, folks.  Hopefully after reading that you can understand why I snatched up this woman before some other guy grabbed her.  A sincere thanks to everyone who submitted a question.  If you have any others, you'll just have to wait until next year's interview (assuming she hasn't had me assassinated by then).

Oh, and if you're wondering - yes, Salma Hayek.

Saturday, 19 December 2015

2015: The Year The Food Industry Gave In To Anti-GMO Fear Mongering

I've had several requests to write about GMOs on this blog, but so far I have not taken up the mantle.  It's a huge topic that is very poorly understood by the general public, and I've been loathe to tackle the subject.

Until now.

My editor at The Daily Beast asked me to write an "End of the Year" wrap-up-type article, and I asked (read: begged and pleaded) if I could write a satirical 2015 summary a la Dave Barry, the fabulously hilarious columnist who has done just such an article every year for as long as I've been reading the newspaper.  If you've never read any of them, click on that link.  Seriously, do it now.

Anyway, the answer I got from her was a resounding "no".  She was asking for a real article, one that was thought-provoking, interesting, and sciency with real actual science and stuff.

Damn.

So here is what I came up with.
Since it was published earlier today I've already gotten a few vitriolic tweets directed at me:

Tweets like these tend to make me very happy, because they offer no actual response to the content of the article, just worthless, childish name calling.  I would welcome some actual dialog about GMOs, because that might offer me a chance to educate some misinformed folks.  But just like antivaxxers and creationists, the anti-GMO crowd seems to have already made up their collective minds, despite the lack of evidence that GMOs are in any way unhealthful.

But they're genetically modified!  That's über-scary!  Frankenfood!  Frankenfish!  AAAH!!!

Nope, not scary.  Just an unfortunate name.  If they had been called "healthy fuzzyfoods" none of this uproar would have happened.  Ok, that's probably not entirely true, but I think you get the point.

I welcome (relevant) comments, concerns and research regarding GMOs below.  However, any and all so-called "articles" from Natural News, Mercola, Greenmedinfo, and their ilk will be deleted with extreme prejudice.

And don't worry - this won't replace my usual weekly post.  Coming this week - the interview with Mrs. Bastard.  Stay tuned.

Monday, 14 December 2015

Better than I

Yes, the title is "Better than I", because I'm an obnoxiously pedantic stickler for grammar, and "better than me" is grammatically incorrect.  So there.  And yes, "So there" is a sentence fragment, because I also have artistic licence.  Huzzah!

Anyway . . .

I've never really considered myself much of a wordsmith (though MomBastard and DadBastard might disagree with me), especially when it comes to speaking aloud.  When I write words on the page, however, I somehow (usually) manage to get relatively coherent thoughts from the deepest bowels of my brain onto the paper (virtually speaking), and it occasionally even comes out with some modicum of eloquence (though not in this post, apparently).  But sometimes, believe it or not, I find myself at a loss for words.  It doesn't happen often, and it always involves something surprising, shocking, or wholly unexpected.  When I find myself in this situation, I find it difficult (and sometimes impossible) to express myself.  The words which do tumble effortlessly out of my mouth in times like these resemble something a bridge troll might say.

Fortunately Glen (not his real name™) had no such tongue-tying problem.

Most of my patients bring themselves to me.  Not literally, of course.  What I mean is that most of them have done something that have caused their injury, either directly or indirectly.  A select few, however, are actually innocent victims, and through no fault of their own find themselves with a hole in something that needs fixing.  Glen fell squarely into that category.  He was on his way to his car after finishing his night shift at a store when he was carjacked.  He had undergone training at work and was taught to comply with the bad guy, so Glen did everything the bad guy screamed at him to do - get out of the car, hands in the air, give me the keys.  But as the bad guy got into his car, he turned around and shot him anyway.

This makes me believe that "mankind" is one of the English language's great oxymorons.

Glen was brought to me shortly after midnight as a "Level 1 gunshot wound to the chest".   These patients are usually either A) dead, B) alive but actively dying, or C) completing the act of dying when they roll through my door, but not Glen.  Unlike the usual pale, sweaty, and/or unconscious gunshot wound victim, Glen was sitting up on the stretcher, making jokes with the medics.  With a blood stain on his shirt. 

Um . . . what?

"Hey there Doc, this is Glen," the medic started.  "He was carjacked and shot this evening.  He has two gunshot wounds, one to the left shoulder, and one to the right chest.  No active bleeding.  He's been stable the whole time, blood pressure is 125/60, heart rate is 65, oxygen saturation is 100% on room air."  

A quick glance at Glen's wounds revealed that the medics had described him exactly right.  It appeared as though the bullet had gone into the back of his left shoulder, through both sides of his thorax, and out through his right chest.  I immediately started ticking off all the vitally important structures between those two holes:
Approximate location of Glen's wounds
  • Heart
  • Lungs
I initially stopped there, because just those two organs (ok three, technically) are enough to make any trauma surgeon incredibly nervous.  But unfortunately there is much more: aorta, pulmonary arteries, pulmonary veins, superior vena cava, left innominate/subclavian artery...

You get the idea. 

As I was looking at him quizzically, wondering how he was still alive let alone looking healthier and in a better mood than I (other than the several holes he had in his body that I did not), he flashed me a huge smile and said, "Hey Doc, how long do you think this will this take?  I have to be at work at 10."

Wait, wait, wait.  You just got carjacked and shot, and the thing you're most worried about is being on time for work?  The same work where you just got shot?  What kind of person does that?

I liked him instantly. 

I explained to him that he may have serious, life-threatening injuries, and he may need a huge life-saving operation depending on what those injuries were.  Since he was so stable, I sent him for a CT scan to see where this magic bullet had gone and what it had hit (or not).  As the pictures flashed on the screen, the look on my face must have gone from incredulity to amazement and back again.  The bullet had gone into the back of his left shoulder (missing his scapula), through his left trapezius muscle, between two ribs (fracturing neither of them), grazed the left lung (which was not collapsed), into the left pectoralis muscle (missing the subclavian artery and vein), through his sternum, through his right pectoralis muscle, and back out into the outside world.  Of all the major structures between the two holes, the bullet had hit exactly ZERO of them.  All he had was a fractured sternum.

As soon as I finished looking at the scans (and picking my jaw up off the floor), I went to give Glen the news.

"Well Glen, I have some good news and bad news.  The good news is that the bullet did no major damage to anything."
"That's great!  What's the bad news, Doc?" he said.
"The bad news is that I need to keep you here in the hospital overnight, and you're going to be late for work."   I tried to tell him how lucky he was, but my brain locked up.  I couldn't think of anything witty or even remotely interesting to say.

Glen had no such issues.  He flashed me another huge smile, gave me a high five, and summarised the situation better than I ever could:

"Well ain't that some shit."

Yes, Glen.  Yes it is some shit.  Those probably aren't exactly the words I would have used, but hell, who needs eloquence anyway.

Tuesday, 8 December 2015

The Hospital

The hospital is not a safe place to be.  That may sound counterintuitive to some, but those of you in the medical field know exactly what I mean.  Whenever I have a patient who is hesitant to leave even though they meet discharge criteria, I always tell them the same thing: the hospital is not where they want to be.  

"Remember, this place is a big building filled with lots of sick, infected people.  If you are not one of them, you should not be here."

That usually gets the message through. 

Having said that, not every patient even needs to be admitted in the first place.  Far from it.  In fact, most patients who are seen as emergencies and/or traumas do not needed admission, and I make every effort to prevent people who don't need to be here from being here a second longer than they have to be. 

Margaret demonstrated this point quite elegantly recently.

Transfers from outside hospital always must be taken with a grain of salt.  A very large grain of salt, approximately the size of the iceberg that sank the Titanic.  Whenever I get a call for a consultation from Outside Hospital, the rationale is always the same: they want the patient out of their hospital and in mine.  Perhaps we offer services or specialists they don't, perhaps their hospital is full, perhaps the emergency physician has a brain the size of a newt's and can't make a damned decision.  Regardless, they usually say anything they can to make that transfer happen, even when that transfer isn't at all necessary.  The emergency physician at Outside Hospital (not its real name) called me about Margaret, an elderly woman in her 70s who had fallen.

Her: Hi, Doc.  So I have this very nice 70ish year-old woman who fell and has multiple left-sided rib fractures on CT. 
Me (impressed and surprised it isn't total bullshit): Oh? That sounds bad. Tell me a little bit more about her.
Her: Well, she is 75.
Me: ...Yeah, you said that.  And?
Her: Uh, well she has a history of COPD.  She's been having increasing difficulty with pain control and has been having problems breathing since the fall because of pain.

It sounded like a reasonable request for a transfer, but something about the tone of her voice made me suspicious.

Me (suspicious): Any other pertinent history?
Her: Just hypertension, which is well-controlled.  Her vital signs are all normal and her oxygen saturation is 95% on room air {which is normal, especially for someone with COPD}
Me (more suspicious): Any other injuries?
Her: No. The CT scan shows no pneumothorax or hemothorax.
Me: (even more suspicious): Wait, when did you say her fall was?
Her: (pause)… Six days ago.
Me: …
Her: Hello?

Yes, Margaret had fallen nearly a week ago but had not sought medical care.  She had been treating her pain at home with ibuprofen and aspirin, which was (obviously) not sufficient.  Ordinarily a patient like this with isolated rib fractures would be admitted to the hospital for pain control with narcotics only for a day or two.  Once the pain is controlled, I would have sent her home with oral narcotics to allow the ribs to heal themselves, which takes 6-8 weeks.  I explained this carefully (read: slowly and repeatedly) to the emergency physician (who should have known all of this already), but she felt that I should be the one to give her narcotics.

Me: Wait, what have you given her for pain so far?  Morphine?  Hydrocodone?  Oxycodone?  Hydromorphone?  Fentanyl?
Her (whispering): Uh, nothing.
Me: NOTHING??  
Her: ...
Me: Weeeeell, instead of the added expense of transferring her to another hospital, why don't you try, I don't know, giving her some goddamned pain medicine? You can give her the exact same medicine I would give her!

There is a very large possibility that may not be exactly what I said, and there is a slight possibility that I withheld all of the other colourful language that immediately sprang to my brain.  I tried to explain to the emergency "doctor" that all Margaret needed was some pain medicine to get on top of her pain, and then a prescription for something to go home with.  If she could prevent a woman like that with COPD from staying a moment longer in the hospital than necessary, that would be ideal.

She seemed completely shocked by the idea of actually treating a patient.  Nevertheless, she grudgingly agreed to try and only call me back if she were unsuccessful. 

Perhaps surprisingly, I didn't hear back from her.  Margaret got her pain medicine and went home where she belonged.

This is not meant to be a commentary on emergency physicians (ok, maybe a bit), but rather on the importance of using your brain.  Much like a delicious dark chocolate bar (fuck you, white 'chocolate') sitting uneaten on the shelf, an unused brain is worthless.  

Wednesday, 2 December 2015

The REAL truth about that coffee mug

I'm talking about "that" coffee mug.  The only way you wouldn't know what the hell I'm talking about is if you don't follow me on Twitter, and if you're reading this, I find that hard to believe.  Seriously, there's a little "Follow me" button right over there ----->

Go click it.

Regardless, for those few of you who still have no idea what I mean, here is the coffee mug in question:
It's a hilarious, if not sadly accurate commentary on the state of medicine in 2015 that has been making its way around the Internetosphere over the past few days.  I've written about exactly this issue in The Daily Beast (it was the first article I wrote, in fact), and I've continued talking about it to whomever is unlucky enough to listen to me.  So it was with great amusement that I came across and tweeted this picture yesterday, and it was with the same great amusement that I showed it gleefully to Mrs. Bastard, who was just as amused as I.

Not everyone is amused, however.

Some people are taking it way too seriously, like Dave deBronkart, also known as "e-patient Dave", a blogger at e-patient.com.  This morning my wife forwarded me a piece that Dave wrote this week titled "The truth about that 'your Googling and my medical degree' mug" in which he says that Googling is not a sign of patients thinking they are doctors, it is a sign of people making themselves "engaged, empowered, e-patient(s)".

Dave quite correctly says that a well-informed patient is a good patient - one that partners with his doctor to come to a decision that is best for the patient.  He also quite correctly says that doctors who insist they are right are terrible practitioners, because no one knows everything about everything.  I can not and would not disagree with anything Mr. deBronkart said.  That is not "the truth" about the mug, however.

What I would disagree with is Dave's main point - that patients who use google to learn about their condition are necessarily well informed, and therefore better patients.  They may be, but it all depends on where they get their information.

As an experiment, I googled "colon cancer".  It took google exactly 0.27 seconds to come back with 14.5 million hits.
Scrolling down through the results, the information is generally excellent - the Mayo Clinic, medicinenet, and the National Cancer Institute, the American Cancer Society, the National Library of Medicine, webMD, and MD Anderson are the first 7 hits (Wikipedia is the 8th).  If anyone were to read any of those sites, the information would most likely be highly accurate, and that patient would end up better informed for reading it.

But not everyone reads those articles.  Googling "colon cancer cure" gave me 1.75 million hits, and there it was on page 2: "Lindsey: Cures Colon Cancer With Cannabis in 48 days".  Of course this is a much sexier title than "Treating bowel cancer", and of course the headline is designed to encourage clicks. And what the article does is chronicle a woman's story of conventional colon cancer treatment with surgery and evil toxic Big Pharma chemo, followed by a supposed cure with cannabis oil.

Unfortunately not everyone is going to look up conventional (read: effective) treatment of colon cancer, because conventional is the alternative to the evil toxic Big Pharma chemo that people are looking for these days.  Going one more step down the rabbit hole, I googled "colon cancer alternative", which yielded nearly 7 million hits.  And that's where the real BS starts:
You can see where I'm going with this.  And that is just for colon cancer.  I wisely decided not to delve into some of the more controversial medical diagnoses, like fibromyalgia, chronic Lyme disease, and adrenal fatigue.

The internet is truly a wonderful cache of medical knowledge, full of useful information.  But it is also a vast wasteland of pseudoscience, questionable practices, and outright bullshit.  What makes it so dangerous is that many people can not tell the difference.

Do I discourage my patients from researching their conditions?  Absolutely not.  Well-informed patients are almost always easier to talk to (and by extension easier to care for).  But I always refer patients to reputable websites, and advise them to avoid questionable sites.

And Natural News should be avoided like the plague.

Monday, 30 November 2015

Holiday request

I'm venturing a bit outside my comfort zone on this post, but it's for a very good reason: to honour a request by Mrs. Bastard.  Now I'm by no means a "Yes, dear" kind of husband, but I do everything I can to make her happy, especially when her request makes my life just a bit easier in the process. 

Last night Mrs. Bastard had an interesting proposal for me.  Unfortunately it did not involve any adult fun-time activities, but it piqued my curiosity nonetheless:

"As a holiday present for your readers, why don't you ask them to ask me questions.  Sort of an 'Ask Mrs. Bastard' kind of interview."

Hmm . . .

I had to admit I was intrigued by the idea.  I seem to recall someone emailing me just such an idea some time ago, but I never mentioned it to her since I didn't think she would ever agree in a million years.  But, as it seems to happen so often with her, I was wrong.  Again. 

Sigh

Anyway, she's obviously up for it, so this is your chance, folks.  Put your questions for Mrs. Bastard in the comment section before she changes her mind.  They can be any question you like - questions about her, questions about me, how the hell she puts up with me, what makes her tick, what she sees in me, why she hasn't traded me in yet for a better model, etc.  I solemnly swear (really) I will ask her each and every one.  I do not guarantee, however, that I will post every response, and I can definitely guarantee that any questions she (or I) deems too personal will be ignored and/or deleted with alacrity and extreme prejudice.

Ready?

Go.

Monday, 23 November 2015

Perspective

I have a pretty damned good life, and I'm not a bit ashamed to admit it.  I am healthy, I managed to find the most wonderful woman in the world before anyone else nabbed her, I have two beautiful, healthy children, and I happen to be in a profession that allows me to live a very comfortable lifestyle.  I seem to have no reason or right to complain about anything.  Ever.

But, I still do.  Yes sometimes events around me stack up so that it seems the world is conspiring against me, and at times like these I begin to feel sorry for myself like a big baby.  I whine and complain and moan and groan with no legitimate reason to do so.  Fortunately these times are rare, so my family and colleagues don't have to suffer my maudlin, melancholy, moody self very often (huzzah for synonymous alliteration!).  Plus, it seems that every time I find myself in such a mood, something eventually happens that metaphorically grabs me by the ears and screams in my face, "SNAP THE HELL OUT OF IT, YOU FUCKING IDIOT!"

Just such a thing happened again a few days ago.

As I was on call for general surgery, I went through my entire day seeing patients without a single call from the emergency department/A&E.  Not a gall bladder, not a bowel obstruction, not even a perirectal abscess.  Nothing.  But the Call Gods evidently wanted to have some nasty fun with me, because just as I was about to sit down to read my son a bedtime story, the call came.  

Appendicitis.  Of course.  Goddammit, why?  Why couldn't they call me at noon?  Why must I miss ANOTHER bedtime?  My blood was boiling, my blood pressure was rising, and I started bitching to myself, thinking of an alternative career I could pick up.  I could be a car salesman or a window washer or a chef or anything else god damn it!

Then I took a deep breath.  Calm down, stupid.  It could be worse.  Much worse. 

I went to the hospital to see the patient, who had a relatively simple and early case of appendicitis.  Her operation should take me no more than 15 minutes, so I immediately called the operating theatre.  I was perfunctorily told that there were several scheduled cases from the daytime still pending, and that one of the orthopaedic surgeons had an emergency open fracture to do.  I would have to wait until he was done, which meant waiting another 5 to 6 hours.  At least. 

SHIT.  Moan, moan, moan.  Well, at least I would get to read that story to my son.

I went home, read my son his story (Charlotte's Web, if you were curious) put him and my daughter to bed, and waited.  And whined.  And waited.  And then I whined and waited some more.  Four hours later I was still waiting, so Mrs. Bastard decided to go to bed while I waited and whined to myself.  

Finally just before midnight the operating theatre called me to let me know that they had called in a second team, and my patient was ready.  She was fortunately much more patient and understanding than I.  Regardless, I brought her into the room, helped the anaesthesiologist put her to sleep, and walked back out of the room to scrub.

While I was scrubbing I looked down the hall and saw the aforementioned orthopaedic surgery also scrubbing.  I waved to him and went into my room.  As I was putting on my gown and gloves, I asked the nurse what the orthopaedic surgeon was doing, since he should have been done with the open fracture by then.

"Oh, he's doing a total hip replacement.  On a 94-year old."

He's doing what?  To a what?  At midnight?!

"Yup, he had to bump himself to do the open fracture, so he is just starting it now."

Wooooooow.

As expected, the appendectomy was very simple (it actually only took me about 14 minutes).  I finished my surgery, scrubbed out, spoke to the patient's son, changed, and went home, all before the orthopaedic surgeon had really gotten into the meat of his case.  

And just like that, I realised I could be that guy.  Even worse, I could be that guy's patient.  Suddenly I didn't feel sorry for myself anymore.  My minimal misery was severely put in its place.  

I got home around 1AM, snuck into my children's bedrooms, gave them both a kiss, tucked them in, crawled into bed, kissed my wife, and promptly fell asleep. 

Life was good again. 

Monday, 16 November 2015

Ha freaking ha

It's time for another post about the Call Gods.  Yes indeed, yet another goddamned post about the goddamned Call Gods.  I can hear several of you groaning, "Not another Call Gods post!  We're sick of hearing Doc's paranoia about them, especially since they don't exist."

And that's where you're wrong, nonbeliever.  They exist.  Oh, do they ever exist. 

What, you don't believe me?  Still?  How is that even possible?  Are you even listening??  After everything I've told you, you still don't believe me? 

Juuuuuust wait.  You will.  And by the end of this post if you still haven't converted to my weird little religion, then you obviously haven't been paying attention this whole time, and you should probably head off to YouTube to search for some fail videos or something.  Or maybe go check out fmylife.com.  Either one will make you feel just that much better about your own life.

Where was I?  Oh right, I was talking about myself as usual.  Anyway, in addition to the fucking Call Gods (Ha ha!  Just kidding, Call Gods!  Please have mercy!) I also talk about appendicitis a lot, because I see it a lot.  It seems to me sometimes that I'm curing the world of appendiceal disease one person at a time.  But lately I've been in a bit of an appendix lull.  I haven't taken out an appendix in about a month, whereas I usually do at least one or two a week, if not more.

Hear that foreboding music yet?

This morning as I showered (stop picturing me nude, you perverts) I was thinking "Wow, I haven't done an appy in a while.  How long has it been?"  It had been at least three weeks, and I couldn't remember ever going so long between appys.  So I tried to remember the last one I did. 


The call from the emergency doc predictably and inevitably came at 4 PM (at least it wasn't midnight, right): a healthy 62-year old guy with, you guessed it, acute appendicitis.  I went to the hospital to do the surgery, which turned out to be uncomplicated and relatively easy.  But just as I was finishing up, my mobile in my pocket rang.  "There is my next appendix," I joked with the staff.  I finished up and took the man to recovery.

Much to my relief, the call had been from a friend, not from the emergency doc again.  WHEW.  I changed clothes and got in my car, happy I would be home in time for dinner and my kids' bedtime.  


I hadn't even pulled out of my parking space when my mobile rang again.  I recognised the caller ID immediately - the ER/A&E.  And as you've probably surmised by now, it was indeed yet another appendicitis patient.  As I write this, I'm sitting in the operating theatre waiting for him to come up from emergency.  I've now missed dinner, and my kids will be fast asleep by the time I get home.  Mrs. Bastard too, most likely.

Fuck you for ruining yet another evening with my family, Call Gods.  Fuck you.

Monday, 9 November 2015

Jahi McMath update

In lieu of a stupid patient story this week, I have an update on the Jahi McMath saga.  That's right, the story that just won't go away still hasn't gone away - Jahi McMath's family has filed an amended complaint (thank you Professor Thaddeus Pope for uploading it) stating that they have evidence that she is, in fact, alive.

A board-certified pediatric neurologist claims to have examined her and has determined that she does not meet brain death criteria.  As Prof. Pope explains, the focus will be on paragraphs 30-36.  I'll present some excerpts from the complaint followed immediately by my thoughts on each.
30.  Since the Certificate of Death was issued, Jahi has been examined by a physician duly licensed to practice in the State of California who is an experienced pediatric neurologist with triple Board Certifications in Pediatrics,  Neurology (with special competence in Child Neurology), and Electroencephalography. The physician has a sub-specialty in brain death and has published and lectured extensively on the topic, both nationally and internationally.  This physician has personally examined Jahi and has reviewed a number of her medical records and studies performed, including an MRI/MRA done at Rutgers University Medical Center on September 26, 2014. This doctor has also examined 22 videotapes of Jahi responding to specific requests to respond and move.
This is specifically different than their prior claims in that this time a board-certified physician, a pediatric neurologist, in fact, has actually personally examined her.  According to the complaint he has also watched 22 videos of Jahi responding to verbal stimuli.  This paragraph gives me great pause for two reasons.  First, why is the physician not named?  There is much speculation that the doctor is Alan Shewmon, who is a vocal opponent of brain death, but why not reveal his name?  Second, why should he have to watch videos of Jahi supposedly responding to voice commands if he has personally examined her?  Did she not respond to commands when he was with her?  And are these the same lousy quality videos that have been posted and scrutinised already?  This strikes me as very odd.
31.  The MRI scan of September 26, 2014, is not consistent with chronic brain death MRI scans. Instead, Jahi's MRI demonstrates vast areas of structurally and relatively preserved brain, particularly in the cerebral cortex, basal ganglia and cerebellum.
32.  The MRA or MR angiogram performed on September 26, 2014, nearly 10 months after Jahi's anoxic-ischemic event, demonstrates intracranial blood flow, which is consistent with the integrity of the MRI and inconsistent with brain death.
Cerebral blood flow and MRI scans do not factor into clinical brain death.  And why are they referencing an MRI/MRA from over a year ago?  Don't they have a more recent study?  If not, why not?  If so, why don't they present it?
33.  Jahi's medical records also document that approximately eight months after the anoxic-ischemic event, Jahi underwent menarche (her first ovulation cycle) with her first menstrual period beginning August 6, 2014. Jahi also began breast development after the diagnosis of brain death. There is no report in Jahi's medical records from CHO that Jahi had began pubertal development.  Over the course of the subsequent year since her anoxic-ischemic event at CHO, Jahi has gradually developed breasts and as of early December 2014, the physician found her to have a Tanner Stage 3 breast development.
34.  The female menstrual cycle involves hormonal interaction between the hypothalamus (part of the brain), the pituitary gland, and the ovaries. Other aspects of pubertal development also require hypothalamic function. Corpses do not menstruate. Neither do corpses undergo sexual maturation. There is no precedent in the medical literature of a brain dead body developing the onset of menarche and thelarche.
I find it very hard to believe that Jahi, who was 13 at the time of her operation, had not started menstruating already.  According to a recent study of American girls, the average age of thelarche (breast development) is 9.7 years and menarche (onset of menses) is 12.8 years (12.2 for black girls).  It is highly probable that she had started menstruating already, and besides she would also not be the first brain dead child to undergo puberty, so these paragraphs are essentially irrelevant.  What bothers me most about this paragraph is that she had already started to develop breasts before her surgery as this picture proves:
This is a blatant lie in the complaint - she had undergone thelarche without question, likely years before (statistically speaking).  If they are so willing to make such an obvious lie in a legal document, what else are they willing to lie about?
35.  Based upon the pediatric neurologist's evaluation of Jahi, Jahi no longer fulfills standard brain death criteria on account of her ability to specifically respond to stimuli. The distinction between random cord-originating movements and true responses to command is extremely important for the diagnosis of brain death. Jahi is capable of intermittently responding intentionally to a verbal command.
This is the key paragraph.  The anonymous neurologist claims that she responds to stimuli . . . intermittently.  If this is actually true, then she is not brain dead.  However, that is a very big "IF", and it hearkens back to the question of whether or not she was able to respond when examined by the neurologist or only on video.  If she was only responding to voice on the videos, that is worthless as evidence in my opinion.  If I were the presiding judge, not in a million years would I accept those vague and unreliable videos as evidence of anything.  What this paragraph does not say is that the doctor performed (and that Jahi passed) a bedside brain death exam.  Perhaps I'm reading too much into it, but perhaps not.
36. In the opinion of the pediatric neurologist who has examined Jahi, having spent hours with her and reviewed numerous videotapes of her, that time has proven that Jahi has not followed the trajectory of imminent total body deterioration and collapsed that was predicted back in December of 2013, based on the diagnosis of brain death. Her brain is alive in the neuropathological sense and it is not necrotic. At this time, Jahi does not fulfill California's statutory definition of death, which requires the irreversible absence of all brain function, because she exhibits hypothalamic function and intermittent responsiveness to verbal commands. 
There are numerous reports of brain dead patients being kept on somatic support for years without their bodies deteriorating, so the fact that this has not happened to Jahi is also irrelevant.

In all, the evidence supplied by Jahi McMath's lawyer is suspect at best, worthless at worst.  I am incredibly curious why the neurologist was not named - this seems a very strange way to run a high-profile legal case.  Perhaps the anonymity was maintained because it is so high profile, but perhaps one of the lawyers here could shed some light on whether or not this is typical.  Regardless, I will wager these claims will be enough for the judge to allow the case to continue.

My one takeaway from this update is that if paragraph 35 is true, if she is truly able to respond to verbal stimuli, even intermittently, then she IS NOT DEAD.  Full stop.  Keep in mind that any claims of responsiveness made by the family will need to be verified by an outside neurologist.

And with that, I will open the comments to whatever wild speculation your brains can come up with, except for one particular individual who remains banned and whose comments will be deleted immediately (you know who you are).

Monday, 2 November 2015

Trauma drama

There's a very good reason "trauma" and "drama" rhyme.  I'm convinced that whoever was responsible for those two words' etymology could see the future and just knew that trauma patients would cause the second-most drama in the hospital.  The most is caused by psychiatric patients of course, unless you watch Grey's Anatomy, in which case you believe the drama is a result of the nurses and doctors all sleeping with each other in every bathroom, janitor's closet, and stairwell in the hospital.

As usual, I digress. 

Since I don't deal with psychiatric patients (much) (thank god) (there's a reason for that), I have to be satisfied with the Trauma Drama.  Fortunately, I'm seldom disappointed. 

Maurice (not his real name™) was brought to me one gloriously dramatic day having been shot in the back.  That doesn't usually happen if you're the victim of an attempted robbery (most armed robbers give up when their victims run away), nor does it happen often by accident.  Ordinarily you'd have to do something pretty awful to deserve being shot in the back.  

Maurice certainly fit the bill.

The trajectory of the bullet was admittedly strange to me - it entered his flank on one side and exited the mid-back on the other side.  That's an awfully odd track, so I instantly suspected something weird.  Maurice, like most every gunshot victim, wasn't offering up any details about what happened.  It's quite amazing how people instantly clam up the moment you ask how and why they got shot.

Regardless, Maurice's vital signs were surprisingly stable, though I strongly suspected something awful was going on inside his abdomen.  I pushed lightly on his belly, and he made a noise somewhere between a grunt and a squeal.  No need for a CT scan here - Maurice had peritonitis, and I called the operating theatre immediately.

I rushed downstairs and managed to beat him by several minutes.  I was waiting there with the police officers (who apparently had a few questions to ask Maurice), and they seemed to be chuckling to themselves.  When they saw me, they asked if I expected Maurice to live.  I told them I had no idea, and that it depended on what kind of catastrophe I found. 

"Did you hear what happened, Doc?" one of them asked me.

Oh, do tell.

"Maurice here was sleeping with his best friend's girl.  His friend found out about them, but he didn't say anything to Maurice, and they just got in his car together.  I guess he was planning on driving him to some remote location and then shooting him, but they didn't get that far, so the guy just turned and shot him while they were still in the car."

During surgery I found a series of holes in his small intestine and two in his colon.  It took me a bit less than two hours to remove two segments of his small intestine, put the ends back together, and repair his colon.  I left the operating theatre and told the officers that I expected him to live.

But the drama didn't end there - Maurice's wife showed up to the hospital later that evening.  I spoke to her briefly to tell her what I found and what I did to her husband, and she barely responded at all.  Based on the look on her face (which strangely reminded me of the look on MomBastard's face when I was a child and she knew I had done something wrong, I just didn't know which evil deed of mine she had discovered), someone had already told her why Maurice had been shot.  I (wisely) decided to leave it alone and not poke that particular snake.  I decided simply to be satisfied that Maurice didn't die from his wounds. 

Somehow his wife didn't kill him either.  

Monday, 26 October 2015

Even sicker

Very few words strike fear into the heart of a trauma surgeon.  Keep in mind that we see some of the worst of the worst, the most gruesome of images - open fractures, gunshot wounds to the heart, amputations, tabloid stories about Kim Kardashian - things that would make many people lose their lunch.  Since I'm writing this, you've likely (correctly) assumed that there is at least one thing that fazes us, one thing that bothers trauma surgeons enough that any of us would experience palpitations at the sheer mention of it . . .

CIRRHOSIS

Most people have probably at least heard of cirrhosis, but I suspect very few actually understand its gravity.  In short, it's a chronic and incurable disease where the liver is scarred beyond any ability to heal, typically from either long-term alcohol abuse or hepatitis C.  After the liver has endured more than it can handle, it eventually loses its ability to perform its many functions, including producing clotting factors and other proteins, and filtering the blood.  The only treatment for cirrhosis is treating the symptoms, and the only cure is liver transplantation.  To put it mildly, I think of cirrhotics as walking Jenga games, and if at any time one even not-so-critical piece is pulled out, the whole thing will fall down into a bleeding, jaundiced, encephalopathic mess.

Graphic enough for you?  Good, then I'll move on.

Cirrhosis patients are some of the most brittle any doctor will ever come across.  Their overall health needs to be closely monitored and their medication just as closely adjusted to account for any disturbance.  Bleeding is a huge potential risk because of the lack of clotting factors, so risky behaviour (skydiving, martial arts, cutting bagels) should be avoided.  Alcohol should also be strictly avoided to prevent the situation from acutely worsening.  Obviously.  Acetaminophen (Paracetamol/Tylenol) should also be avoided the way I avoid painting.  I hate painting.

Gary (not his real name™) had absolutely no idea how bad a disease cirrhosis is, because despite the risks he continued making it worse.  And worse.  And worse.

To demonstrate how stupid Gary was, allow me to introduce a fantastical hypothetically analogous situation.  To start, this may require a bit of a stretch of your imagination, but pretend for a moment that smoking cigarettes is stupid and dangerous.  I know, I know, it's a big stretch, but bear with me.  Now let's also pretend that degreasing your shop equipment with gasoline is also a touch on the dangerous side.  So it stands to reason that, in our completely absurd and wildly hypothetical situation, smoking while using petrol as a solvent is stupendously stupid.  Now imagine doing all this in a 100% oxygen environment. 

While it's only an analogy, that was Gary.

I can't really say that Gary was a smart guy, because he wasn't.  I can't even say Gary was of average intelligence or even slowly below average, because anyone with more than 8 working synapses would know that being diagnosed with chronic Hepatitis C is a very bad thing.  Gary, on the other hand, took it as an opportunity to start drinking heavily.  He also used it as an excuse to do other really stupid things, like buying a motorcycle.  Completing the decathlon of stupidity was, of course, the combination of all these activities.

On this particularly fateful day, Gary decided that he wasn't content with just throwing gasoline onto his Personal Risk Fire, so he threw some dynamite on there as well.  He got slobberingly drunk, got onto his motorcycle, and then barreled down the motorway at twice the posted limit.  It doesn't take a genius to predict how this ended.

Cirrhosis + alcohol + motorcycle + speed + stupidity = an painfully obvious dénouement

Surprisingly when Gary rear-ended a car that had stopped for a traffic light (neither of which Gary saw), he didn't die immediately.  When he arrived in my trauma bay he smelled like the men's restroom in a rather seedy pub (ladies, if you've never had the pleasure of experiencing that aroma, just use your imagination.  And it's just a bit worse than that).  He was too drunk to even tell me where it hurt, so I ended up scanning him from head to toe.  What I found was not a huge surprise:

  • nearly every rib on the left side was fractured
  • left lung was collapsed
  • left acetabulum (hip socket) was shattered
  • sternum (breast bone) was broken
  • left scapula fracture
It came as no surprise, however, that his blood alcohol level was four times the legal limit.  What did shock me was that his liver looked fine . , , ok, perhaps not fine, but it was at least uninjured.  It had the typical appearance of someone with advanced cirrhosis, and he had numerous other dilated veins (varices) in his esophagus, spleen, and abdominal wall also typical of cirrhosis.  Other than a severe concussion, his brain was also uninjured (though I must admit I was surprised to find one in his skull).  I had to remind myself that a CT scan is a test for the presence of an organ, not necessarily for function.

Gary got a chest tube to re-inflate his left lung, and I admitted him to the intensive care unit.  I spoke with his family, and they informed me that Gary had been diagnosed with cirrhosis several years prior, and instead of taking meticulous care of himself, he had stopped taking his blood pressure medicine and let himself decline into a state of constant inebriation.  I commented immediately to the intensive care doctor that I had a Very Bad Feeling about my new friend Gary, and that he was at an extremely high risk of deteriorating extremely quickly.

My prediction turned out to be even truer than I could have imagined.  A few days later Gary started circling the drain (god damn you Katy Perry for stealing that medical idiom), and a day after that he was dead.  I can't really put my finger on what exactly killed him, but cirrhosis has a way of sneaking up on you the way every killer in every movie has ever done: 1) jump, 2) scream, 3) dead.

Gary's death was tragic, but it was also predictable and preventable.  For those who are unlucky enough to be saddled with the diagnosis of cirrhosis, it will eventually get you.  The only 2 questions are 1) when and 2) what can you do to delay it.  

Unless you're someone like Gary who did everything he possibly could to accelerate his meeting with eternity.