Monday, 13 April 2015

10 Commandments of Trauma

Being a trauma surgeon is hard.  I am constantly dealing with idiots who have usually done something very stupid that put them in my trauma bay.  But I also multitask, performing life-saving surgery, talking to families and telling them their loved one has died, and babysitting drunk idiots, all while trying to keep Mrs. Bastard happy and trying to find time to see my little Mini Bastards (not their real names©) before they're fully grown.  Mrs. Bastard may argue with me that her life is even more difficult, since she also works full time and is the one mainly responsible for trying to tame my little monsters, and to be honest, she has a fair point.  

Before you think I'm just boo-hooing and being all melodramatic about the difficult life that I chose for myself, no this isn't a "Feel Sorry For Doc and Mrs. Bastard" post, so don't even think about dumping any unwarranted and unwanted pity on us.  Besides, this post isn't really about me (or her) anyway. 

After giving it much thought, though being a trauma surgeon and a trauma surgeon's wife may both be difficult, I've decided that being a trauma patient is the hardest job of all.

I understand that my trauma patients have it rough.  They are whisked from their car or home or McDonald's (yes, really) in an ambulance at breakneck speed, sirens blaring, weaving through traffic, often with no recollection of what has transpired.  They may regain consciousness en route without any clue how they got there.  One minute they're enjoying a Big Mac and Coke (mmmm . . . Big Mac and Coke . . .), the next moment they wake up with a hard collar around their necks and a haematoma on their forehead, strapped to a hard backboard which prevents them from moving, and they're screaming down the road towards the hospital.  Then once they get to me, all their clothes are cut off as they are stripped completely naked, IV's are shoved unceremoniously into their arms, and strangers start asking them questions while poking and prodding every square inch of their bodies.

Holy.  Shit.  This is what many people consider to be their ultimate nightmare, and rightfully so.

Yet, despite how difficult a time I know these people are having, I still expect a certain level of consideration and tact from my patients.  However, many (ok, most) of my patients fail to live up to even these admittedly low standards.

So with that in mind, I'd like to propose a list, a 10 Commandments of Trauma if you will, of how you should (and shouldn't) act with your trauma surgeon. 

Thou shalt not lie       
This goes without saying.  Or at least it should.  Don't tell me you weren't driving when you were.  Don't tell me you didn't smoke marijuana when I smell it on you.  Just tell me the damned truth.  I am not the police, I'm just trying to take care of you, so lying to me will avail you nothing.

Thou shalt not omit
If I ask you what medical problems you have, don't leave anything out.  Do you have diabetes?  Tell me.  Are you on blood thinners?  Tell me.  Do you have untreated HIV or hepatitis C?  Then FUCKING TELL ME before I am exposed to your infectious blood. 

Thou shalt admit to alcohol consumption
This ties in to commandment #1, but somehow everyone who is wheeled in smelling like The Pub at 2AM claims to have only had two beers.  I'm going to check your blood alcohol level anyway, so you may as well be honest.

Thou shalt not curse at me
I don't care how drunk you are, you will not swear like a sailor in my trauma bay.  My nurses and assistants and I will speak to you respectfully, but we damn well demand that you do the same, asshole.  I mean sir.

Thou shalt not argue with me about seatbelts and helmets
No, you are not safer by not wearing your seatbelt.  This is a ridiculous argument with absolutely no veracity whatsoever, and the fact that anyone actually believes this horseshit boggles the mind.  And helmets save lives and brains (just in case anyone making this argument actually has one), though if you actually are thinking about arguing this with me, then obviously the very existence of your brain is up for debate.  Not wearing a helmet or seatbelt is stupid and indefensible.  Full fucking stop. 

Thou shalt not say 'no'
Don't misunderstand me - I'm not saying that you should blindly follow anything your trauma surgeons says.  HOWEVER, if you find yourself in the care of a trauma surgeon and he (or she) tells you that you need immediate surgery, there is a very high likelihood that you will be dead soon.  Listen carefully, then say 'yes'.

Thou shalt not say 'I don't know'
What medicines do you take?  What do you mean 'I don't know'?  What's that scar on your abdomen? Oh, it's from the last time you got shot'?  Great, what did they do when they were in there?  What do you mean 'I don't know'?  It's your body - fucking KNOW IT.  If you don't care, don't expect anyone else to.

Thou shalt not whine about needles
Unless you actually are a child, don't act like one.  Yes, you're getting an IV.  Yes, it will hurt for 2.13 seconds.  Yes, I will give you morphine through that IV if you need it.  No, I will not put you to sleep to suture that tiny laceration on your arm.  And if you are covered with tattoos and tell me you're scared of needles, I will fucking slap you.  Not really, but in my head I will fucking slap you.

Thou shalt learn something
Ok, you made a mistake and did something stupid.  Fine, you're human just like the rest of us.  But if this is the third time your horse has kicked you, maybe you need to learn more about horses (or get a new horse that isn't an asshole).  And if this is your fifth time crashing your motorcycle, maybe you shouldn't be riding. 

Thou shalt be appreciative
We work long hours and spend the night in the hospital in a tiny call room away from our spouses and children just so we can be available 24 hours a day, seven days a week, 365 days a year (366 next year) to save you and your drunk ass.  Fucking say 'Thank you', at least once.

***
I plan on printing these out in a very large font and posting them on the door of my trauma bay, though I don't expect them to last long.  I have a feeling the administration wouldn't approve.   To hell with it, I'm going to do it anyway.

45 comments:

  1. I used to do transcription for a living and I remember a very interesting series of interviews with volunteer, public focus groups discussing whether or not they would ever approve a centralized database, available to every health facility in the US, with their medical history on file. I was amazed how many people are dead-set against that idea. The moderator/interviewer even pointed out that if you, say, travel out of state and are in a horrid car accident and are unconscious, the ER people at the hospital have little or nothing to go on as far as any meds you may be taking, allergies, etc.

    Some of the focus group people were just mortified that this group of strangers would find out that they may have had previous drug addictions or STDs or erectile dysfunction or whatever. They were adamant that it was information that was strictly between them and their family doctor.

    I just couldn't believe that these folks really thought that anybody in an ER setting cared, or hadn't seen it all before. And truly, if someone is using any drug, prescribed or otherwise, ER docs really, really, really need that info to avoid interactions.

    Sorry for the long comment (I know, get my own damn blog), but I'm one of those who think it's a dandy idea for all physicians to have immediate access to at least a person's abbreviated medical history, especially any medications or therapies they might currently be on.

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    1. I am the other way around. I was absolutely shocked that the hospital ER staff didn't have immediate access to information in the patient file at THE HOSPITAL GENERAL PRACTITIONER OFFICE.

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    2. If the Internist does not have an affiliation with the hospital then no. This should not change. HIPAA is paramount.

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  2. My niece competes in equestrian eventing. The competitors all have to have their full medical history on file, and carry paperwork in a packet that is strapped to their arm whenever they ride. (I think some of the competitions now have them carry it on a computer chip in a bracelet they wear, that the EMTs can scan.) It's presence is checked before they can enter the ring EVERY TIME.
    I think this is an excellent idea, because when the EMTs need it, they NEED it.

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    1. If I may ask, where is this? I've never seen this and I ride.

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    2. In California, at Woodside.

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    3. I'll ask my instructor about this... They didn't do that at my old barn, but my new one might. It is a good idea though.

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    4. It may not be mandatory for trail riding. I note that Mutzali's niece participates in eventing which will involve dressage, cross country and stadium jumping. It may also only be mandated at USEF events. I think it's a dandy idea though. So is programming ICE into your phone when you're out trail riding. Regardless of signal strength.

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    5. I'm getting into eventing, ha ha.

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  3. I remember when seat belt use was just becoming a thing and mandatory use was being floated about. A lot of people insisted that the only way to survive an accident was being "thrown clear." Ever encountered any of those folks?

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    1. He has, hes made a post about it:

      http://docbastard.blogspot.co.uk/2014/07/more-seatbelt-stupidity_16.html

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    2. Ha, you beat me to it, I was just going through the archives, looking for that exact post!

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    3. yes. we call them "trauma patients you have to look for before you can stuff in the ambulance"
      the we have thrown partially clear, or as we refer to them: "DRT" (Dead, Right There)
      I almost never see an unbelted occupant be the least injured in a crash.

      and then we have the one that went off the road, flipped its convertible end over end, somehow without being thrown out, and then fell out of the seat onto its face. it had only had a couple of drinks.

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    4. I know someone who actually survived a crash because they were thrown clear, but they were also driving drunk. That being said, wearing a seatbelt saved me from at least severe injuries, probably death. I wear one every time I'm in a car.

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    5. I had one of those. the passenger was thrown clear. the driver was thrown partially clear. they both may or may not have survived if they were wearing belts - the cab took most of the damage.

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    6. I've met two exceptions to the seatbelt rule. The first is my ex-wife's grandfather, who escaped death twice by not wearing a belt. The first involved a steel beam sliding off a flatbed in front of him; the beam came through the windshield and punctured the driver's seat just below collarbone-level. "Lucky" he was able to flatten himself across the seat and only be pinned in. His second involved the car spinning (mostly) under a semi-trailer; had he not been flung clear of the car, he would have been sheared along with the top half of it. The other is my sister-in-law, who flipped (more than once) her Miata; it's final position was upside-down. Had she not been flung 20' behind the car, it would have been messy to say the least.

      Mind you, neither of these has changed my mind about wearing my belt religiously; there were some times (when I drove a ragtop with no rollbars) I had to think about what would happen to me if I inverted her while strapped upright. Even reclined fully, the headrest still poked above the doorline. But better to play the odds, rather than backing fluke circumstance. That's just a sucker bet.

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    7. The "flung free" being safer is a myth. Cars have roll cages, crumple zones, and airbags that are designed to protect you, but they only work if you're still in the car. If it's a choice between being thrown from a car against the road or a tree and possibly being crushed by the rolling car vs. staying in the car and being protected by the safety mechanisms, the choice is obvious.

      As for the steel beam, that's an outlier to say the least. One can never predict any kind of accident, but freak accidents should not factor in.

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    8. Convertibles make a stronger argument for driving safely; if you flip one, you are most likely dead. With many models having no rollbar or head-bar on the seats, any overturn is going to put the entire weight of the car on the front windshield. Said structure is usually at a slope, and likely to collapse. The rule isn't "don't wear a belt," it's "don't swerve hard."

      Staying with your vehicle reduces damage even when it's a bicycle. I spent some time in college velodrome cycling, and my coach stressed hard to hold onto the bike if you went down. If you stay on the bike, there is only one obstacle for following traffic to avoid, and all you're going to lose is skin. If you release, you tumble (into fast-moving traffic), vastly increasing the types of injury you're subject too.

      I wasn't using the steel beam as a reason to not wear a belt; I was using it as an example of the logic people use when they are convinced they're safer without.

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  4. Huge difference between tattoo needles and medical needles....just sayin.

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    1. Having had experience in both (I've got a sleeve), I've got to say that by the time the tattooist is making the 3rd or 4th pass over an area that has already been done in a couple of colors, I'll take a medical shot in the arm, butt, or hand any day. To me it's like comparing a brief pinprick to having a cheese grater scraped back and forth over your skin.

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    2. My earliest memory is from when I was 2 and hhospitalized with pneumonia. I remember waking up and the first thing I saw was this seemingly giant IV hanging out of my arm. I am completely and utterly terrified of needles. If I have to have a shot or have blood I go into panic attacks and sometimes even vomit or faint. Tattoo needles, however, don't bother me since the needles don't go internally. I like the way tattoo needles feel and even enjoy watching the needle deposit the ink into my skin. I can't even watch someone else get a shot without throwing up.

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    3. Dude, talk a mental health doctor. They can prescribe you a fast acting beta blocker to take 15 minutes before a stressful event so you don't have panic attacks like that.

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  5. I am phobic about needles. I have to make a point of not watching needle sticks, whether they are in me or in someone else.

    that confessed, I might just print these out and hand them out to the ambulance crews.

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  6. Hi Doc,
    I am one of those who are tattooed but really, really afraid of needles. :D Thing is, I don't like the feeling of how it is in my arm, and I can feel my blood being sucked out or something dribbled in. *blech But I won't complain, unless the nurse takes more than three attempts. Because then it really starts to hurt.

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  7. also, if the trauma doc's crew is sticking needles, it means the paramedics didn't do their job. and if you don't like needles, an IO will give you the screaming heebie jeebies. (hint: O stands for Osteo)

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    1. Heck I get a bit of the heebie jeebies thinking about putting an IO in someone, specifically the screw-type, the pop-in aren't quite as bad.
      ~Anon RN

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    2. our medics use EZIO which is a screw in.

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    3. Um, please tell me that most patients who get one of these types of injections are unconscious. Man, I could have gone the rest of my life in blissful ignorance, not knowing that an IO was something that might happen to me some day.

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    4. unconscious with such low blood pressure that you can't get a needle into a vein.

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    5. An IO is usually only placed in by ER docs, trauma surgeons or EMTs sometimes. I have never seen a nurse do it. NY catagorizes it as a surgical procedure. It last 24 hrs.

      I have seen it go in if the person meets sepsis guidelines. It hurts initially but then it fades. I have administered it and I had it given to me after a car crash. Depends on pain tolerance of individual. Very common now.

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  8. I'm part of the "have tattoos but hate needles" group. I won't whine about getting a needle in me, but I absolutely cannot look at it. Something about seeing my blood get sucked up grosses me out. I also hate the feeling of stuff going into my veins (like the saline solution when you donate plasma). It's just yucky. Tattoos, however, feel like a cat scratch to me, and I get enough of those at home.

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  9. I clot easy, which is great for being injured but terrible for drawing blood. I have to let them know so they can use a wider needle, otherwise they end up repoking me 2-3 times. But shots? No problem.

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  10. Dear DocBastard:

    I know you already addressed the vaccine "debate," but I would dearly love for you to take a look at this corner of the internet here --

    http://whyarethingsthisway.com/

    -- and comment on it in a future blog or DB post (assuming that actually smiting it through cyberspace is out of the question).

    ReplyDelete
    Replies
    1. I hadn't seen that before, but after a quick perusal I can confirm that it's a veritable treasure trove of antivaccine fuckwittery. I wouldn't even know where to begin taking it down, but there is great potential.

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    2. Why don't you try starting by supplying a citation to a paper reporting results comparing patients who got more aluminum injected to less, or empirically measuring the toxicity of injected aluminum in neonates, that doesn't report its highly toxic at the levels found in the vaccine series?

      If you look at my first post, or my latest, you'll find lots of citations to peer reviewed papers of the above types, except that all the ones I've ever found reported the aluminum was highly toxic.

      I would love to see a citation on the other side.

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    3. No, you wouldn't like to see any citation, because hard-core antivaxxers ignore it. It would take me weeks to disassemble your claptrap, and nothing in your mind would change.

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    4. I assert there is no such paper in the peer reviewed literature. The claims that vax are safe and effective are a sham and cargo cult science.

      Prove me wrong. Show a citation.

      If you do, and it actually qualifies, my mind will definitely change on the subject of whether such a citation exists.

      Delete
    5. Let me put it another way.
      I expect you've never thought much before about the toxicity of the aluminum in the vax series. Doc's have been injecting it for 80 years. You assumed there was some published support for this.

      Now I come along and tell you, there isn't. All the studies injecting neo-nate animals, and a direct study on preemies in the NEJM, show this level of aluminum is highly toxic, causing long term damage to bone density and brain development, among other things. And all the epidemiology that actually bears on the subject, at least all I've seen, indicates that the aluminum is causing huge problems. Its highly correlated with autism, for example. And the CDC and the FDA and the IOM don't cite any on the other side on the issue. They cite Mitkus, which is a mathematical model based on dietary experiments in weaned mice.

      So what is your response to this. Do you thank me for telling you new information? Or do you call me names?

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    6. Just for giggles, I looked at that site. The first sentence of the second post asserts that there is no link between the polio vaccine and the eradication of polio. (I am a child of the 50's and I had friends who ended up crippled due to polio. This crap makes me mad.)

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    7. mutzali you misquoted me.

      However I suggest to you that much of what most people believe about vaccines, and not just vaccines but the world much more widely, are just-so stories that have propagated through the crowd because of their surface appeal and/or because some interest is making a profit off them. The red pill is every bit as much a revelation in the real world, if you finally digest it, as it was for Keanu in the movies.

      Delete
    8. Nat Philosopher:

      http://jama.jamanetwork.com/article.aspx?articleid=2275444&resultclick=3

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    9. I am under 80 years old. since I have done things that should have broken a bone, and I have not broken a bone I can assume my bone density is just fine. since I am able to formulate complete sentences and comprehend cause an effect I can assume my brain is as good as or better than those who cannot comprehend how a global vaccination campaign and polio being essentially eradicated might be connected.

      also, I have not contracted polio.

      also, there is very little profit in vaccines at one to three doses per person, but a HUGE profit in treating the illnesses the vaccines prevent.

      not that Nat cares - his mind is mae up and it is useless to try to confuse him with facts.

      Delete
  11. Nat, your first sentence: "There’s no compelling reason to believe the vaccine was relevant to the disappearance of polio, or at least was the major factor."

    So you didn't say "there's no link", but that there's "no reason to believe" there's a link. Semantic games. Same bullshit.

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  12. I would like one of these in vet clinics also. Owners/clients just love to lie. If they just told us straight up that their dog ate their weed stash, it would save them a lot of money and extra testing. We're gonna find out one way or the other, and we are not going to use their stoned dog as evidence and call the cops on them. Seriously. We care not one iota about them. We care about the dog. Just tell us the truth and let us do our job!!!

    I am moderate-heavily modified (tattoos piercings scarification brand subdermal implants and flesh suspensions for fun) person, and I don't enjoy having needles poked into me as much when I don't get a pretty picture on my skin. But I still always watch, and I definitely don't complain. I've always believed the medical professional is doing whatever they're doing to help me, so why would I want to get in the way of that? I know not everyone has believed that though. So maybe I'm lucky to have had great health care. I'm a Vet Nurse of 8 years, now applying for paramedics and may one day think about medicine, for surgery.

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