Jahi McMath update...sort of

NOTE: If you have not heard the story of Jahi McMath, I've posted several updates including her full story here, here, here, and here.

When last we heard of Jahi McMath nearly 8 months ago, the startling revelation was made that she was not, in fact, brain dead, but rather very much alive.  Well, sort of.  Ok, not really at all.  This supposed miracle was merely the opinion of one very biased neurologist who does not actually believe in the concept of brain death, as well as a couple of other doctors who hadn't actually examined her and were basing their opinions on two very strange and vague videos of Jahi which seemed to show her moving.  Neither video was compelling or convincing in any way, and shockingly (not really) no new videos (or any other information, for that matter) have surfaced since then.

Then came the news about 2 months ago (which surprised exactly no one), that Jahi's parents were suing Children's Hospital Oakland and the surgeon who operated on Jahi.

And since then . . . nothing.

After waiting many breathless months for an update, we finally got one a few days ago!  And it's from none other than my favourite fundamentalist doctor quack, someone I've mentioned right here before, Doctor Paul Byrne.  In case you either haven't heard of him or have blissfully forgotten the folly of the good doctor, I'll give you the short version - he doesn't believe in brain death.  Full.  Stop.  That's right, he claims that life continues until the heart stops beating.  Even if the brain is completely and fully dead, he thinks a beating heart somehow equals life.

Regardless of how vehemently I (and the vast majority of the medical world) disagree with him, I still read his article voraciously.  I mean, just look at this titillating title:

Jahi is alive -- praise the Lord and pass the ammunition

If you're wondering, no, I haven't the foggiest notion what "pass the ammunition" is supposed to mean either, even after reading his article several dozen times.  And unlike me, Dr. Byrne unfortunately does not always make sure to clarify things by the end of his stupid articles.

But anyway, WOW!  AMAZING!   Jahi is alive!  Was I really wrong the whole time?  Does medical science need to revise every medical textbook and eliminate the diagnosis of brain death?

Now hold everything.  Before you critics get too excited and start penning your "Doc your so stupid I told you so lolololoooool!!1one" comments, remember that Dr. Byrne had said that exact same thing before without any real evidence.  But wait, this time is different!  He says, "Recently, I visited Jahi and her family in her home in New Jersey".  WOW!  AMAZING!  Surely he'll post some wonderful pictures of Jahi alive with her eyes open, or at least he'll share some evidence of why he claims she's alive, right?  Right??

Er, no.  Not at all.

NOT.  AT.  ALL.

Over the next few paragraphs he rehashes Jahi's tragic story, going so far as to put "brain death" in quotation marks, making no apologies for his his opinion that "these two nouns together are not indication of true death".  I'll at least give him credit for constancy.

And then, without further ado, he delves right into his non-medical garbage, throwing away any medical credibility he ever had and throwing around lies like an old baseball:

Three separate apnea tests were conducted on Jahi. Each time Jahi's life supporting ventilator was taken away for 10 minutes. Each time this caused carbon dioxide and acids to build up in Jahi's brain and body. These tests did nothing to help Jahi and very likely resulted in further swelling and damage to Jahi's brain. Yes. The doctors suffocated Jahi for 30 minutes as part of their declarations of "brain death."

No, Paul.  No, no, no.  An apnea test doesn't work that way at all.  I've described this before, but I'll do it again, and maybe Paul can learn something this time (though I have no doubt he will never see this, and even if he does he still won't get it).  For an apnea test, the patient is pre-oxygenated with 100% oxygen to increase the oxygenation of the blood as much as possible.  Then the ventilator is turned off.  As the carbon dioxide level in the blood rises, this stimulates a healthy functioning brainstem to initiate a breath.  If after 10 minutes the patient does not attempt to breathe, the brainstem is considered nonfunctional and dead, and the patient is declared brain dead.  However, if during the test the patient's oxygen level ever drops below normal at any time, the test is aborted and the ventilator is turned back on.

No one's brain is ever "suffocated" during an apnea test.  That's just ol' Paul using fallacious sensationalism at its very worst.  Moreover, it did not cause any additional swelling and damage to her brain.  Besides, her brain had already swelled to the point where it had lost its blood supply and died, which is why the test was being done in the first place.  For anyone, especially a doctor, to claim otherwise is an outright and deliberate lie.  But he goes on:

Everyone should understand that this dangerous test can only harm or even cause death of a patient. 

It is not a dangerous test.  It can not harm, and it can not cause death.  It is used to determine death.  You know this, Paul.  At least you should.  If you don't, you have no reasonable excuse whatsoever.  But he still goes on:

The apnea test is not beneficial for the patient.

Of course it isn't and no one ever claimed it was.  How could a test that is designed to assess death be beneficial??

I paused, took a deep breath, and plodded on, surprised I had gotten this far without rupturing an aneurysm.  And as soon as I restarted I was instantly rewarded with the same stupid, erroneous argument that Dr. Byrne made before - that the ventilator can only work on a living patient.  I hate using YouTube videos as evidence, but, oh what the hell:

As you can see, these lungs are attached to a leaf blower, and they inflate and deflate without any living body (or any body, for that matter) attached.  Strike two, Dr. Byrne.

Paul's next argument is that Jahi was "starved" for a month between the time she was declared dead until a feeding tube was placed after Jahi was moved to an undisclosed facility.  While technically true, there are several things Paul fails to mention: first, the doctors had no legal or ethical requirement either to place a feeding tube or give her nutrition once she was declared dead, and second, humans can go weeks without food without starving as long as they are adequately hydrated (which Jahi was).  Three strikes you're out, right?

HAHA no, he wasn't quite finished.

Paul then says that her heart has beaten 60 million times since she was declared brain dead, which must mean she's alive.  As I've said here before, hearts don't need bodies (or life) to beat.  Don't believe me?  Watch:

Strike four?  Or is that five or six.  I had completely lost track.

But after all those lies, Paul finally got to the meat of his article.  The update!  Finally!

Recently I visited Jahi in her home. 

YES!  At long last, an update from someone who's actually seen her!  Is she moving?  Responding to her mother's voice?  Opening her eyes?  Tell us, Paul!  Tell us!

Jahi is beautiful.  The day that I visited Jahi she had on lip gloss like many teenagers.  A picture of Jahi's hand joined with my hand is enclosed.  Wristbands on both of us state "Jahi is alive" and "Prayer works."

Wh . . . wh . . . WHAT?  That's it?  THAT is your update?  THAT is your "proof" that Jahi is alive?  That she's wearing lip gloss and someone took a picture of you holding her hand with her contracted fingers?  Are you kidding me?  THAT'S FUCKING IT??!  Where's the convincing evidence, Paul?  God damn it, where's any evidence?  It's been a year and a half since she was declared dead, and this is the second time someone has tried to say she's alive without providing a whit of actual evidence.

If she were actually alive, how easy would it be to take a video of her responding to voice?  How straightforward would it be to show a video of her opening her eyes?  How simple would it be to prove that she followed even a simple command?

I will be the first to admit that absence of evidence is not evidence of absence.  The fact that these videos have not surfaced doesn't mean either A) that they don't exist, or B) that they couldn't exist.  But after the media circus that Jahi's family caused surrounding her untimely and tragic death, I will also be the first to submit that were there any real evidence, her family would get it thrown up on the 6 o'clock news faster than you can say "I BELIEVE".

As for you Dr. Byrne, people expect doctors to tell them the truth, even if it hurts.  It is our job, our obligation, our duty to tell people difficult truths, not comforting lies.  You are an insult to your profession, your community, and most of all to yourself.

Not my story

I am very proud of the fact that the stories I tell here are true (with certain details altered for anonymity's sake, of course).  I've confessed in the past that one of them was wholly plumbed directly from the depths of my imagination, but I've also confessed that that may not, in fact, be true.  I always change names, I usually change ages, and I sometimes change genders, medical history, and certain extraneous diagnoses.

For this story, however, I have changed nothing.  Not only because I don't know any of the details, but because the story isn't mine.

I do apologise, but the story you're about to read (hopefully you've stayed with me so far) and the pictures you're about to see are stolen borrowed directly from the New England Journal of Medicine.  As much as I enjoy using only real pictures of my own patients, this one was just too damned good to pass up, and I felt the need to share it with you fine folks.

I know I discuss the Call Gods regularly, and I'm sure everyone must be sick and fucking tired of hearing about them.  But they keep rearing their ugly heads, so I feel compelled to keep sharing.  But the good news about them is that I'm not their only victim.  There are plenty of other trauma surgeons out there as well, so the Call Gods are free to take out their wrath and bestow their gifts on them too.

Like these two guys, for example.

In the interest of time, I'll dispense with the story (probably because I don't know it), except to say that it was a 33-year old man who was involved a motorcycle accident (of course it was a goddamned motorcycle) in Germany.  On initial examination his scrotum was swollen and blue (and before you ask, no, "blue balls" aren't actually blue), and though he had some other injuries (fractures of his forearm and hand), his pelvis X-ray revealed something a bit . . . surprising:

In case you can't read pelvis X-rays, the title of the article is a dead giveaway:

Femoral-Head Dislocation to the Scrotum

Wait . . . wh wh what?  Is that even remotely possible?

HA HA! laughed the Call Gods.  OF COURSE IT'S POSSIBLE!  JUST LOOK AT THAT X-RAY, MORON!

The blue arrow in the photo is pointing to some other pelvic fractures, but that yellow arrow is pointing to the money shot - that's the head of his femur (the thigh bone) in the patient's scrotum.  How it got there is completely beyond my limited imagination, but a CT scan confirmed the diagnosis:

I'll dispense with the obvious "boner" jokes at this point.

The gentleman was taken to surgery, and the orthopaedic surgeon went where few orthopaedic surgeons have ever dared to go before: the scrotum.  They made a direct incision into the scrotum to retrieve the femoral head . . .

. . . and then, with the assistance of some wires, plates, and screws, they put it back where it belonged:

If the pictures aren't amazing enough, the man made a full recovery and was walking without the assistance of a cane only 14 months later.

I have shown these photos to several of my orthopaedic colleagues, and they all have the same reaction I did, which is somewhere between sheer disbelief and "HOLY FUCK!".  One of them mentioned that he has never, ever made an incision in the scrotum and hopefully would never have to.  Fortunately for the motorcycle-riding population of earth, this is a once-in-a-career type of injury.

But freak injuries like this do confirm one thing: the Call Gods aren't nearly through with me yet.

Crossy road

One of my favourite bumper stickers says “HANG UP AND DRIVE!”  There are very few phone calls that absolutely must be made while driving, and even fewer text messages that simply must be sent.  Even using a hands-free device doesn't help you keep your concentration where it belongs nearly as much as you may believe it does.  Probably 99.99% of mobile phone-related accidents could be avoided if people simply set their phones aside and concentrated on the road like they were taught to do.

But I saw a similar bumper sticker recently that infuriated me, and I'll be goddamned if I'm going to keep my stupid mouth shut about it:

HA HA!  It’s totally hilarious, right?  HA HA!  Oh my, I laughed and laughed.  Har dee fucking har har.  Make a fucking knee-slapping joke about drunk driving, something that kills and maims thousands of people every single year.  I wanted to jump out of my car onto their hood, climb into their car, rip off their steering wheel, and beat them with it.

Fortunately I was parked in a lot and the driver of the offending car was nowhere to be seen.  Even more fortunately, I wouldn't actually ever assault anyone.  I don't think.

Anyway, after screaming and fuming and ranting and raving like a deranged lunatic, I started actually thinking about why I was so incensed.  And after ruminating for a while, I realised that the reason I was so angry is that the bump you just hit that caused you to spill your drink might have been a pedestrian who wasn’t looking where he was going because he was looking down at his phone while crossing the street.

I think everyone would agree that drunk driving is bad, and distracted driving is bad, and drunk walking is bad.  But what everyone on the planet seems to be forgetting these days is that distracted walking can be just as bad.

This leads (yes, finally) to my point:

LOOK. UP.

Unless you live in the Brazilian rainforest, it is impossible to walk around without seeing people looking down at their phones - playing games, texting, tweeting, instagraming, snapchatting, or whatever the hell people do instead of looking up.  I’ve seen people walk into walls, trip over curbs, walk into people, and nearly get hit by cars, all because they weren’t looking where the hell they were going because they just had to update their Instagram with whatever the fuck they just ate.

Do you really think anyone gives a flying fuck how omg totally delish your lunch was?  Does anyone actually want to see a picture of your salad?  And if so, do you really need to upload the picture while crossing 4 lanes of traffic?

The number of pedestrians I’ve seen getting hit by cars has been skyrocketing over the last decade, and most of these traumas are preventable because these folks either 1) are still using their goddamned phones as they are wheeled into my trauma bay or 2) immediately ask where their goddamned phones are.

“just got hit by a car going 2 hospital lol”

Seriously, people?  Is everyone that willfully oblivious?  Is it really more important to take your next turn on whatever stupid game you're playing than to make sure you don’t get run down trying to cross the street?  Even Frogger was paying better attention to traffic than you are, and he was a goddamned 1980s 8-bit frog!

This is you on your goddamned phone

If you want to tune out your family and watch the latest fail video compilation on YouTube while you’re out to dinner, fine.  The only things you'll miss are conversation and real social interaction.

But when the meal is over, put it the fuck down and look the fuck up.

Crazy

There’s a very good reason why I don’t treat children, and I can sum it up in one word: parents.  I don’t mind the kids themselves (remember I have two of my own), but the parents can either be so overwhelmingly crazy in trying to protect their children that the craziness metamorphoses into sheer lunacy, or not show even an iota that they care about their child at all.  I’ll admit to understanding the crazy feeling when my own child had croup as a toddler, but I never let myself (or my wife) go completely down the rabbit hole, staying rational while also remaining right by her side every second she was in hospital.

So on the one hand you have crazy overprotective parents who constantly interject, thereby not allowing me to work effectively or efficiently, and on the other you have parents who obviously don’t care one way or the other, which is even more infuriating.

And then you have parents like Yvonne (not her real name©) who have no reservations whatsoever and allow their emotions to completely override any rational part of their brain and are JUST.  FUCKING.  CRAZY.

A laughing emergency physician is a dangerous emergency physician.  When he chuckles as he starts to tell me about a patient, it means it’s either A) something so completely stupid and irrelevant that even he knows he shouldn’t be consulting me, B) something so bizarre that he doesn’t have the foggiest notion how to handle it, or C) a rectal foreign body.  Sadly for me (and for you, I’d imagine), it was not C, but rather B this time when Dr. Mike (not his real name©) called me:

Dr. Mike: Hey Doc, so I have this very nice young lady who clinically has appendicitis, and I’d like to order a CT scan to confirm it, but her mother isn’t consenting to the scan.
Me: Oh, she must be very young then.  But I don’t do kids, Mike.  How old is the patient?
Dr. Mike: 22.
Me: Months?
Dr. Mike: No, years.
Me: ...
Dr. Mike: Are you there?

Apparently Yvonne (the patient’s mother) was afraid of the radiation because her daughter Lilly (not her real name ©) was, and I quote, “so young”.  Mike politely asked me (with a very nervous chuckle) if I would come assess the young lady and talk with her mother.

I audibly groaned, and Mike laughed again.

Fuck you, Mike, I thought.

When I got to her room a few minutes later, Lilly looked mildly uncomfortable, but her mother looked significantly worse, pacing around the room as nervously as a bank robber in a police convention.  On examination, Lilly was definitely tender in the right lower quadrant of her abdomen (right where the appendix is supposed to live).  Her history was consistent with appendicitis and her pelvis was nontender, all things pointing to a single diagnosis.  However, I explained to both Lilly and Yvonne that in a young lady of childbearing age, the right thing to do is a CT scan to confirm the diagnosis.  It could be a Girl Part Problem (like an ovarian cyst or abscess, ovarian torsion, ectopic pregnancy, pelvic inflammatory disease, endometriosis, etc) and confirming appendicitis with a CT scan would reduce the risk of an unnecessary surgery from 20% to less than 5%.

“No,” Yvonne said adamantly, “I don’t want her getting that much radiation.  She’s too young.”

I very calmly explained that the radiation from CT scans is much lower than most people think, and the amount from a single scan would only be a concern if Lilly were an embryo (yes, I actually said that).

Lilly sat there quietly looking at me while her mother shook her head and not-so-politely continued to refuse adamantly.  Resigned to this overarching stupidity, I explained that because her history and examination and blood work were all consistent with appendicitis, and because Lilly was so uncomfortable, the correct next step would be immediate surgery, even though there was still about a 20% chance I was wrong about the diagnosis.  I also explained again about reducing the risk of unnecessary surgery is as easy as a 10-second CT scan. 

"No, absolutely not.  But," Yvonne continued, "I’ve been reading online about treating appendicitis with antibiotics”.  

Oh, shit.

After describing her research at Google University, she then went on to explain how her own appendix had ruptured when she was 7-years old.  I just stared at her, mouth agape, as she recounted how she had needed multiple operations and nearly died because her parents had waited too long before seeking medical care.

"Wait just one goddamned second, you insufferable twit.  You’re actually asking me to make the same mistake your parents made and wait to operate on your daughter until her appendix ruptures and threatens her life?  Are you that mind-numbingly stupid?"  

Ok, there's a chance that I only said that in my mind.  But I wish I had the balls to say it aloud because that’s exactly what was going through my head as I tried to explain patiently and rationally why waiting to operate was the wrong move without using the words “FUCKING MORON”.  Finally, shockingly, she agreed.  Lilly had remained silent the entire time, merely nodding occasionally.

And if that weren't bad enough, that's when the real craziness started: “Have you had enough to eat today?  Are you well hydrated?” Yvonne asked me.

Wh . . . what?  I’ve never been asked that before in my entire medical career.  And before you think this was real concern over my well-being, it clearly was not.  It was just lunacy.

About 30 minutes later Lilly was brought up to the operating theatre, where the anaesthesiologist witnessed Yvonne again asking me if I had had a bite to eat.  “Yes madam," I forced myself to say, "I had a granola bar and a Coke.”

“Ugh, COKE?  Oh dear!  Oh my!  I’m a nutritional microbiologist, you see.  You drank Coke?  Really?  Ugh!”

The anaesthesiologist glanced quickly at me with a look that clearly said, “What the fuck is this lunatic raving about?”  I laughed politely and said nothing, worried that one of the truly revolting thoughts that had been percolating over the previous half hour would come spilling out of my brain through my mouth.

Finally it was time for surgery.  I inserted my laparoscope through a tiny 1cm incision, hoping to find a nice, plump, juicy, inflamed appendix, and the first thing that I saw was . . .

. . . a normal appendix.  There was perhaps a slightly engorged blood vessel on its surface, but not the nice chunky inflamed organ I was expecting.  DAMN IT.  I guaran-damn-tee that this girl's mother is going to accuse me of doing an unnecessary surgery now.  FUCK ME.  I took out the appendix, hoping that there was inflammation inside that I just couldn’t see (this has happened to me in a handful of appendicitis cases).  While I had the scope in there, I examined the ovaries (normal), uterus (normal), colon (normal), small bowel (normal), liver (normal), and gall bladder (fucking normal).

I heaved a great sigh and finished, bracing myself for the conversation to come with Yvonne.  I went out to the waiting room to talk to Yvonne.

Deep breath, Doc.  Deep breath.

I explained what I had found and that I couldn't be sure it had been appendicitis.  I explained the other possible explanations, including food poisoning (which is due to toxins produced by bacteria), a "stomach flu" (which is actually a viral infection, not the flu), mesenteric adenitis, pelvic inflammatory disease (though I had seen no evidence of that intraoperatively), or possibly appendicitis that I just hadn't appreciated.

"So are you saying this was an unnecessary surgery?"

And there it is.  Of course she would ask that.  Deep breath.  No, I told her, even without the CT scan, it was the right thing to do, and this was exactly why I had explained the possibility that it wasn't appendicitis even though her symptoms all fit.  And why the CT scan would have been useful, idiot.  We would just have to wait until Lilly woke up - if she felt better, it was appendicitis.  If not, then we would have to keep looking for other causes and wait for the pathology report, which would still take a few days.  I thought the insanity was over until she asked her followup quesions:

- Could she have room-temperature water when she woke up?  Yes.

- Should she stop eating corn after surgery?  Uh, what?  I mean, no.

- Could this have been caused by the organic quinoa she ate last week?  Ah, no.

- Could this have anything to do with a pain Lily gets in her chest whenever she's sleep-deprived and which goes away after a good night's sleep?  What the ever-loving fuck are you talking about?  I mean no.

Lilly woke up feeling great, and she went home from the recovery room.  Her pathology report came back two days later:

"MILD ACUTE APPENDICITIS"

I don't think I have had that deep a sigh of relief in years.

Listen

I wish there were remedial medical school courses.  Like detention or summer school, except for doctors.  I wish I could send some idiot docs I’ve encountered back to Medicine 101 so they could learn some things that somehow escaped them.  Some of the more important issues that I see way too often are 1) Examine your patient thoroughly, 2) Abdominal pain is not a surgical indication, and 3) Treat patients with respect.  I’ve said it here before, but probably the most important lesson for any doctor (that should be readily self-evident to anyone with an IQ greater than that of a fruit bat) is to listen to the patient.  If there were such thing as Medicine 101 (and perhaps there should be, as this story would suggest), that lesson would be taught on Day 1, and it would then be repeated EVERY SINGLE GODDAMNED DAY until it finally sank in, even into the most hard-headed idiot doctors.

Perhaps Dr. Hugh (not his real name©) would benefit from such a course.

I get calls from Outside Hospital every so often - these are usually small community hospitals that are not equipped to deal with trauma patients because they don’t have the personnel, the proper resources, or both.  The facility where Dr. Hugh is an emergency physician is not one of these hospitals, but for some reason on this fateful night they had no trauma surgeon available.  So I became their trauma surgeon.

Lucky me.

At 7:45 PM (at least it wasn’t 2AM - thanks, Call Gods), Dr. Hugh called me with an emergency.  He had a 70-year old woman who had fallen down the stairs and landed on her left side, and now she had a dangerously low blood pressure.  Normally putting such an unstable patient in an ambulance and transferring her to another hospital would be considered ill-advised, but he wanted to do exactly that anyway.

“We don’t have anyone willing or able to take the case, so I need to transfer her to you,” he explained.

Lucky me.

Since she had fallen on her left side, Dr. Hugh suspected she had ruptured her spleen, but he went on to explain that their CT scanner was old and would take over an hour to scan her, so he couldn’t even rule out internal bleeding before shoving her into the back of an ambulance.  But because her blood pressure was so low, he was very concerned she was bleeding to death, and he was shipping her to me whether I liked it or not.  

Wait, what?

He hadn’t bothered to consult me to ask if this was a very bad idea (it is), he had simply called one of the emergency physicians at my hospital (instead of me), gotten the ok from him (not from the actual doctor who would be seeing the patient . . . you know, me), and stuck her on an ambulance.  But it should be fine, he told me, because his hospital was only 15 minutes away from mine.

My blood pressure was rising.

I was afraid the patient would bleed to death in the ambulance, but something about this whole thing just felt wrong.  I had the distinct feeling that something just wasn’t right here.  Little did I know just how right I would be, though for entirely the wrong reason.

Exactly 115 minutes later (yes, I timed it and NO, that is NOT a typo - it took almost 2 hours), Bertha (not her real name©) arrived looking in better shape than most patients half her age.  She wasn't pale or sweating and she wasn't in pain, she was just sitting up on the gurney smiling, like she knew some big secret but wasn't about to spill it.

I liked her immediately.  

I wasn't too upset that Dr. Hugh hadn't told me about the bruise on Bertha's left arm, but it sure would have been nice for him to have mentioned the huge 20-cm (8-inch) laceration on her left lower leg.  

In his defence, he probably hadn’t actually examined her.  

Though her blood pressure was still quite low (about 80/55) when she got to me, her heart rate was completely normal, as were the examination of her heart, lung, and abdominal.  No pain, no tenderness, no bruising, nothing.  In fact, her only pertinent findings were the bruise and laceration. 

My Inner Pessimist kept telling me that something was definitely awry, though I immediately suspected the problem was more with Dr. Hugh than with Bertha.

“Bertha, do you have high blood pressure?” I asked, the suspicion building rapidly.

“No doctor, I never have.”

I had suspected as much.  Now the big question:  ”Do you have low blood pressure?” I asked with one eyebrow raised.

Her smile widened.  “Yes, ever since I can remember.”

And there it is.  “How low does it usually run, ma’am?”

“Oh, usually around 75-80 over 50.”  I looked at the monitor, which now read 84/45, exactly where it had probably been for the past 7 decades.  “I tried telling that to that doctor at the other hospital, but he wouldn’t listen to me.  My husband tried to tell him too, but he wouldn’t listen to him either!  He just sent me over here!  Couldn't they just give me stitches over there instead of taking all night sending me here?”

I touched her shoulder and smiled gently.  “Don’t worry, Bertha.  We’ll listen here.  I promise.”

Fifteen minutes later I was looking at her completely normal CT scan of her chest and abdomen, and thirty minutes (and 20 sutures) later I was discharging her home with her husband, still smiling. 

Many people think stethoscopes, CT scanners, ultrasound machines, and X-ray machines are the most important instruments doctors can use to make a diagnosis.  But those people would all be wrong.  So what is the most valuable instrument we have at our disposal?

Ears.