Saturday 27 June 2015

Idiot anaesthesiologist

Several people emailed this story to me shortly after it broke, and someone posted a link to it as a comment on a previous post, so I feel like you overbearing people have harassed me into writing about it.  Ok, that's not exactly accurate - the truth is that as soon as I read this story, I knew I had to write about it.  Fortunately my editor at The Daily Beast agreed that it's an insane story and gave me the green light immediately.  I don't think I have anything additional to say that I didn't say in the article, so feel free to read all about it here.

So now you all can make your comments here and STOP OFF-TOPIC COMMENTING ON OTHER POSTS, DAMN IT.

Monday 22 June 2015



I've mentioned my much larger older brother before, but I've never written about my also-much larger younger brother.  Until now.  He and I didn't always get along when we were kids.  In fact, we fought like, well, like brothers.  Well, more like Tasmanian devils, only louder and more vicious.

Ah damn it, a story about Doc when he was a child?  Who the hell cares?  Where's the stupid patient story, Doc?

Hey hey hey, pipe down!  There's a stupid patient story later, so just be patient and indulge me for one goddamned second while I reminisce wistfully over here.  Now can it.

As I was saying, when I was about 13 years old, I witnessed LittleBroBastard getting picked on by a bully three years older and a full head taller than he.  The older boy was teasing him, shoving him, and taunting him mercilessly.  Now wait just one damned minute, that is not ok, asshole, I thought as I watched it happen.  He's my little brother!  Only I am allowed to pick on him!  Though I wasn't the fighting or confrontational type, but I walked right up to the boy anyway and slugged him in the gut.  Down he went in a heap of unbridled testosterone and over-aggressive obnoxiousness.

And I promptly got called to the principle/headmaster's office.  Of course.

I trudged slowly to the office, expecting to get suspended or beaten or defenestrated or something.  Rather than punishing me, however, the headmaster leaned in close with a wry smile and almost whispered, "I would have done the same exact thing if that had been my little brother.  Go back to class."

My point (finally!) is that while some actions may have good intentions and the act itself remains wrong, it is still somehow defensible.  Some actions, on the other hand, may not have bad intentions but are completely indefensible.

Still following me?  No?  Well then skip the rest and go check out some cat videos on YouTube.  For the three of you who are still interested in how this will all play out, please do stay with me.  Because Evan (not his real name©) illustrated my point beautifully recently.

The only good thing I can say about Evan as he was wheeled in to my trauma bay was that at least it wasn't 3 AM.  His style of screaming is almost tolerable at 5 o'clock in the evening when he rolled in.  Almost.  Evan, a healthy 24-year old guy, had been riding his motorcycle without a helmet (naturally) when he lost control and crashed into a car.  The medics reported that he flipped over the car and landed awkwardly (is there any other way to land after hitting a car?) on his left side.  There was a large pad covering his left thigh, and the medics told me that he had an open femur fracture (though this is only accurate about 25% of the time).  Well, if he has an open fracture at least he has a good reason to be screaming, I thought somewhat grimly.  I removed the pad carefully, and what I saw can best be described as a velociraptor attack wound:
Evan's left thigh
His thigh seemed stable, however, so I would have been surprised to have found an underlying femur fracture (an X-ray would later confirm that my lack of suspicion was completely warranted).  A thorough head-to-toe examination failed to identify any other major injuries, though I was completely unsurprised that his breath reeked of alcohol. 

Alcohol + motorcycle + no helmet + nighttime + idiot = ?

That's a bad mathematical equation right there.  Anyway, over the next 45 minutes, all the king's horses and all the king's men (read: I) managed to put Humpty Dumpty back together again.  I placed about 80 sutures in his leg and had to remind him at least that many times to stop fucking squirming goddammit and shut the fuck up.

There's a very slight chance that what I actually said was "Please lie quietly so I don't injure one or both of us, sir".  But what I was thinking was much more colourful and contained words and phrases more suitable for a Westerosi tavern.

After I was finished, I looked over his labs and was still unsurprised to find his urine drug screen positive for both marijuana and cocaine.  Surprisingly, he had no serious injuries other than the dinosaur mauling.  By that time his mother had arrived to pick him up, so I took her aside to tell her what I found, as well as that her son had been drunk and high on multiple drugs and was lucky that the only person he injured was himself.

She was shaking her head and frowning while I was telling her the bad news, so I assumed she was on my side.  That's when I rediscovered (yet again) how stupid it is to assume.

"But it wasn't his fault," she said.  "The car hit him!"

I guess she saw my look of sheer incredulity and was uncomfortable with the silence that ensued, because she filled that awkward silence with even more stupidity.

"He was just in a car accident a few months ago and he broke his elbow and five ribs.  He was high then too."

As I stared at her in awed silence she then continued defending his behaviour for some inexplicable reason, explaining that he was just going to the store to pick up a few things, it wasn't a long trip, he wasn't that drunk.  You know, all the usual bullshit.  I'm sure my eyes conveyed quite clearly what was going through my head, most notably "What the fuck are you talking about, you lunatic?"  I finally got tired of listening to her defending his indefensible behaviour, so I told her the same thing I tell the family of every drunk driver - "My wife drives my children on these same roads, and if he had injured or killed one or all of them, I would NOT be ok with that.  AND NEITHER SHOULD YOU."

I can't say that either of them understood the gravity of the situation, but neither of them looked particularly abashed as they left a few minutes later.  I felt like slapping the shit out of both of them as they walked out just to try to make sure they got the message.

I think that would have been completely defensible.

Monday 15 June 2015

Jahi McMath lawsuit

Even though there have been no real updates since my last post on Jahi, the fact that I have 270 comments (at the time of this writing) tells me one thing: that people are still interested in this story.  Many of those comments here have come from a certain gentleman (that term is used rather loosely) who is well-known to the Jahi McMath community for trolling any story regarding Jahi.  Regardless, there is clearly still interest in the story, so I thought I would try to add whatever I can.

One of my readers (thanks to Tamie for sending the link to the Trials & Tribulations blog) sent me a link to the lawsuit brought by Nailah Winkfield (Jahi McMath's mother) against Children's Hospital Oakland and Dr. Frederick Rosen, Jahi's otolaryngologist.  There are some rather interesting things in the complaint, so I thought I'd explore them a bit here.

Before I start, however, I'd like to remind everyone (including the unnamed troll) that the events and timelines in the complaint do not necessarily reflect reality.  This is merely the family's version of the truth.  It is a well-known fact that eyewitness testimony is often highly inaccurate, so while reading through the complaint this must be kept in mind.

Starting off is the title page with the name of the complainants and defendants, including Frederick Rosen MD, CHO, and Doe 1-100 (which allows them to sue up to 100 people/entities to be named later as more information is gathered).  While this seems completely insane, it seems fairly standard.  Page two just continues with the cast of characters, so I'll skip it.

Page three is where it starts to get interesting.

The end of page 2 states "In 2013, defendant ROSEN diagnosed JAHI McMATH with sleep apnea.  ROSEN recommended a complex and risky surgery for sleep apnea which included the removal of her tonsils and adenoids (an adenoidtonsillectomy); the removal of the soft pallet and uvula or a uvulopalatopharyngoplasty (UPPP) and a submucous resection of her bilateral turbinates."

Immediately evident should be the fact that this was not a simple procedure as was often portrayed by the media.  It wasn't even one procedure - it was three.  Also evident should be the misspelling of "soft pallet" on line 2.  A pallet is a platform or a crude bed.  The palate is the roof of the mouth.  While it may seem like I'm being awfully pedantic, this complaint is a legal document not a stupid blog post, so for fuck's sake make sure it's grammatically correct.

The complaint then explains how it is "usually recommended" to try CPAP before surgery for sleep apnoea, and if surgery is to be done, that it is "usually recommended" to remove the tonsils and adenoids first prior to the more extensive procedures.  It then uses as a source.  I'm not sure if this is typical for legal complaints, but there it is.  Maybe a lawyer can shed some light on this, but it seems rather amateurishly phrased.

Moving on to the meat of the document: the complaint.

Paragraph 11 of the complaint states that Jahi was taken to surgery at 3:04PM, and that despite Dr. Rosen noticing a "suspicion of medialized carotid on right", he failed to mention this to anyone, including the recovery room (PACU) nurses and paediatric intensive care (PICU) nurses.  A medialised carotid artery is a congenital anomaly where the carotid artery doesn't run in a normal course.  It is a known risk factor for catastrophic bleeding in patients undergoing tonsillectomy:
However, Dr. Rosen was under no obligation to mention his suspicion to anyone.  I've run across aberrant vasculature from time to time, but I've never felt the need to tell anyone about it after surgery.  If there is no bleeding when I'm done, there's no bleeding.  However, if there is bleeding later, it has to be stopped.  The difference between this surgery and my procedures is that Jahi's haemorrhage was visible.  If one of my patients were to bleed postoperatively, the nurses would not be able to see it directly.  They would rely on other things (like an elevated heart rate, decreased blood pressure, increasing abdominal pain, nausea, etc) to tell them that the patient is bleeding.  These nurses had no such need for any clinical suspicion whatsoever: Jahi was bleeding in front of them.  While it may have been useful for Rosen to tell one of the nurses that Jahi had a higher risk of postoperative bleeding because of his suspicion, not doing so was not negligent.

In paragraph 12, the complaint says that Jahi's parents were denied permission to visit Jahi, and after 30 minutes they "decided to enter the PICU to visit JAHI".
And here is where I encounter big problem #1.  When I'm done with surgery and my patient goes to the recovery room, family members are not allowed to visit immediately while the surgeon and anaesthesiologist are giving report to the nurses.  This process typically takes at least 30-45 minutes.  The same exact thing happens in the intensive care unit.  When Mrs. Bastard had surgery a few years ago, I waited in the waiting room just like everyone else.  I had my ID badge and easily could have gone into the recovery room whenever I wanted.  But I knew that the doctors and nurses had a job to do, and I didn't want to interfere.  When family members are there, they get in the way.  I don't care who you are or what you think you deserve, you do not march into the ICU just because you want to visit your loved one.

In paragraphs 13-15, the document details how Jahi's mother was first instructed to suction the blood from her mouth, then admonished for doing so, then admonished for not doing so after she stopped.  While it's true that different nurses may do things slightly differently, I'll wait to read the nurses' notes before commenting further on this.

Paragraph 16 starts to get absurd.  The complaint states that "the nursing staff at CHO did not appear to be contacting a physician since none was coming to her daughter's assistance".  I can say with near certainty that a physician (either Dr. Rosen or one of the paediatric intensivists) was called at some point during this prolonged episode of bleeding.  I can't imagine a series of nurses strolling by a bleeding 13-year old girl, handing her some paper towels and a Yankauer suction, and not calling either the surgeon or the intensive care doctor.  Again, I'd have to see the nurses' notes to see who was called and when, but I don't believe this for one moment.

Paragraphs 17-19 detail Jahi's continued bleeding and ultimate code.
Then paragraph 20 contains a rather curious claim - it states that "During the resuscitation efforts in the morning of December 10, 2013, approximately two liters of blood was pumped out of JAHI's lungs."  I've never seen any amount of fluid, let alone blood, pumped out of a patient's lungs.  While it's certainly possible that Jahi aspirated some blood during her ordeal, I would find it very hard to believe that 2 liters of it made it into her airway.  I would find it much easier to believe that two liters of blood was drained from her stomach.  After a patient is intubated, a nasogastric tube is inserted and the stomach is "pumped".  No such tube is placed into the lungs.  This seems a specious and spurious claim.

The next few paragraphs explain what happened over the next few days after Jahi was declared brain dead.

And then paragraph 24 contains the almost laughable claim that was plastered all over the news.  Supposedly when Jahi's mother met with Dr. David Duran, CHO's Chief of Paediatrics, he "began slamming his fist on the table and said, 'What is it you don't understand?  She is dead, dead, dead, dead!'"  I find it very difficult to believe that anything remotely resembling this farce happened.  At all.  I've met some pretty damned callous doctors in my day, but not a single one would ever treat a family like this, especially a family that just lost their 13-year old child.

The last thing I'd like to mention is that the complaint says she is dead, but also that she isn't.  No, really:
In paragraph 35, it states that Jahi "has been injured and has sustained a profound impact to the quality of her life."  Well yes, she was injured, but she's dead.  There is no quality of life.  The complaint then goes on to admit that:
There it is in the third cause of action: "for wrongful death".  Again, I'm not a lawyer (thank god), so I don't know if it is considered normal to sue someone for injury or death or both.  Or something.

There is more to the complaint, but nothing that I really feel needs to be shared or discussed.

The complaint is dated March 2, 2015, and the next phase of the suit (gathering of information) can take months or more.  Regardless, I have a strong suspicion that the hospital and Dr. Rosen will both settle out of court, because I doubt anyone (except possibly the family and Chris Dolan) wants to see this dragged out in public again.

One last note: I am in no way saying that the actions of Dr. Rosen, the nurses, any of the other doctors, Nailah Winkfield, or Sandra Chatman, was right or wrong.  I am not condoning or condemning anyone or anything.  Whether anyone was actually at fault is still unknown.  But what people tend to lose sight of in situations like these is actually the most obvious thing of all: the loss of Jahi was a tragedy, and something clearly went drastically wrong.

Tuesday 9 June 2015


I hate the Call Gods, and they know it.  They only rarely ignore me, so usually they have their sick little fun by torturing me either by being evilly funny or funnily evil.

And sometimes they completely forgo humour and are just plain cruel, though not necessarily to me.

I don't typically keep statistics on my call days, but this particular day was so sad and so bizarre that I just couldn't help myself: I had a total of 8 patients, with 7 survivors and 2 deaths.

Wait doc, you said it was only 8 patients!

Yes I did.  Now before you think I'm the worst mathematician in the history of the world, I'll explain.  But then, you already knew I would.  So shush and read on.

My day started off so slowly, just an early morning bicyclist who lost control but managed to break his fall with his face.  The pavement was significantly harder than his face (as it always is), so he suffered several facial fractures, abrasions, and lacerations.  His brain fortunately was fine, so he would live.  I wish I could say the same of all my patients that day.  Yes, that's foreshadowing.

Eight hours then went by with nary a call, but then the Call Gods sent me a page that included a single word that instantly puts fear into any trauma surgeon's heart:


Pregnant patients are generally treated the same way initially as any other patient, though with one major proviso: take care of the mother first.  If you think that sounds either callous or uncaring towards foetuses, think of it this way - when you're flying, they tell you to put your own oxygen mask on before helping others.  Why?  Because if you pass out while trying to help others (since you didn't put your own mask on first), you will then be unconscious, and therefore unable to help anyone.  The same goes with pregnant women - if the mother dies, the foetus dies with it, so help mum first.  Though the basics are the same, the finer details of the workup do get tweaked a bit around the uterus, however.  Ultimately we do everything in our power to save both patients, but if a choice has to be made, we save mother first.

When Jacqueline (not her real name©) arrived in my trauma bay about five minutes later, she was clearly in a great deal of discomfort.  She was 8 months pregnant with her first child and had been riding in the rear-left seat of her car (with her seatbelt on, fortunately) when her door was struck by another car at high velocity.  Unfortunately she lived a good distance from my hospital, so she had to be flown by air ambulance, which took about an hour including the time it took to extricate her from the car.  She was mainly complaining of left chest pain and lower abdominal pain.  And there was bruising around her lower abdomen.

OH . . . SHIT.

Her vital signs were all reasonable and her ABCs all checked out, so I made the quick assumption that she was not actively dying.  While others rushed to attach monitors, check her vital signs, and start the head-to-toe evaluation, I grabbed my ultrasound machine (which I normally use to assess for any signs of internal bleeding from the spleen or liver), squirted the gel on her belly, and looked for the foetus.  It obviously wasn't difficult to find, but it wasn't moving at all.  Hoping it was just asleep, I found the foetus' chest to look for the heartbeat.  There it was . . . and nothing.

Shit shit shit shit shit shit shit shit shit

The obstetrics team had just arrived, so as they gathered all the necessary equipment for an emergency Cesarean section, I finished my ultrasound examination, looking for any signs of internal bleeding.  The only abnormality I saw was a big air pocket in the left chest, which is usually indicative of a pneumothorax (a collapsed lung).  Usually.  Foreshadowing abounds.

The obstetrician laid her hands on her belly and somehow immediately diagnosed the problem: placental abruption.  The accident had caused the placenta to separate from the uterine wall, and the foetus had been deprived for oxygen for over an hour.  As I stood there with my mouth agape, a detailed (though quick) ultrasound confirmed the intrauterine foetal demise.  The baby was dead.

Not Jacqueline's actual X-ray
All the noise in the trauma bay suddenly turned into absolute silence.  I stood back in stunned disbelief as the obstetrician gave Jacqueline the bad news.  As Jacqueline began sobbing, and as heartbreaking a moment as it was, I realised I still had a very sick patient to treat.  I couldn't afford to let her (or me) get sidetracked by the tragedy.  After allowing a few moments of grieving, we got a chest X-ray which showed that the air in her chest wasn't a collapsed lung at all.  I personally took her over to the CT scanner, which confirmed the diagnosis - that the air pocket in her chest turned out not to be a collapsed lung, it was her stomach.

The obstetrician then asked me to delay the surgery until the next day after she deliver the foetus vaginally.

No, I told her quite firmly.  She needed immediate surgery for her ruptured diaphragm.  It takes a relatively high-energy impact to rupture a diaphragm, and that sort of impact can injure any other abdominal organ as well.

I took her straight to the operating theatre where I opened her abdomen from top to bottom.  The uterus was taking up the majority of the space in the peritoneal cavity, so the obstetrician and I first delivered a beautiful little girl via Caesarian section.  After we removed the placenta she started suturing up her uterus, and despite my best efforts my eyes kept wandering to the crib that the neonatology team had brought into the room.  All I could see was a pale, immobile foot.

No no no, I still have work to do.  Focus, damn you.

The tear in her diaphragm was rather large, about 14 cm, big enough for her entire stomach to get through.  I pulled her stomach back into her abdomen and repaired the diaphragm.  Fortunately I found no other injuries, so I closed her up.  That was the easy part.  The hard part was next . . .

Telling her husband and her mother.

Many tears and hugs later, I trudged back to the trauma bay, feeling worse than I had in years.  My thoughts kept going to my own children and how I would have reacted had my wife been injured when she was pregnant.  Ok Call Gods, I thought grimly, that's the worst tragedy you assholes are going to throw me today, right?

No.  No it was not.

Just before midnight Carl was brought to me with a gunshot wound to the back of his left shoulder.  And no heartbeat.  He had been awake and breathing when emergency services first got to him, but en route his heart stopped.  As soon as he arrived I opened his left chest widely and saw the the bullet had entered his shoulder, gone into his chest, through his lung, and into his spine.  His entire blood volume was in his chest, and there wasn't a damned thing I could do except to pronounce him dead.

And that's how out of eight patients, I got seven survivors, two losses, and a huge desire to hug my wife and children the second I got home.

Monday 1 June 2015


The Call Gods have been fucking with me.  Well, they always fuck with me, but lately they've been fucking with me even more than usual.  I know that may seem hard to believe now that you know what you do about them . . . actually, maybe they've been more evil than usual because I've told you about them.  I'll need to think about that for a while.

In the meantime, I'll explain what I mean and hope the Call Gods aren't able to read this.  Because if they can, they will rain down a shitstorm of epic proportions that will officially end me.

In addition to serving me ice-cold vengeance (though what I ever did to anger them in the first place is beyond me), they also play games with me.  No, not fun games like Pac Man or Skee-ball, but nasty games like Test Doc's Mental Strength.

I have mentioned Trauma Themes in the past, but I'll review in case you've forgotten.  Lord knows I've tried to forget and failed miserably.  Anyway, some of my days seem to be like the movie Groundhog Day - the same thing happens over and over.  I've sensed this many times in the past, but I've never actually chronicled it.

Until now.

Fuck you, Call Gods.  I'm on to you.

Two weeks ago I had a relatively busy trauma call with a total of 13 patients brought to me.  This may not seem like that big a number over a 24-hour period, but when you consider that it can take upwards of an hour per patient (or even longer for the seriously injured patients), that number doesn't seem quite so reasonable anymore, especially when half of them come in after midnight.  What made this day stick out in my memory was that three of them came in with isolated left shoulder injuries (dislocations and/or fractures).

What, you're not impressed?  That isn't a good enough example for you?  Don't worry then, I'm just getting warmed up.

Two months ago I had eight patients come in all day.  It wasn't that busy, and the night was rather quiet.  Now keep in mind that I get all variety of traumatic injuries, including car and motorcycle accidents, stabbings, shootings, assaults, bicycle accidents, boating accidents, industrial accidents.  That particular day all 8 of my patients were falls.  No car accidents, just falls.  One after another they came - fall, fall, fall, fall, fall, fall, fall, fall.

Still not buying it?  Ok, it gets better.

On a beautiful spring day, one where I was expecting a very busy day, I had only two patients all day.  Just two.  It was a lovely day, I was blissfully not busy, and I actually managed to enjoy the spring weather.  But though the Call Gods saw fit to spare me a lot of nonsense, what they did decide to send me were both sports-related injuries: first a martial artist who was kicked by his sparring partner and broke a rib, and then a football player who got sandwiched between two other players and suffered a concussion.

Still not good enough?  STILL not a believer?  Oh you will be after this.

Towards the end of last year I had a rather busy day, though nothing too out of the ordinary.  But of the 10 patients I had that day, two of them had isolated injuries . . . to the left 4th finger.  Yes indeed, the Call Gods chuckled as they delivered me a young man who had amputated the tip of his left ring finger with a table saw, and I guarantee they were laughing their evil asses off as they dropped off another young man who was shot through his left ring finger.

If you aren't a believer in the Call Gods by now, then you haven't been listening to a thing I've said.  And if you are a believer, I'm sure you realise the risk I'm taking by potentially angering them even more, but you know what?  FUCK THEM.

Ha ha!  Just kidding, Call Gods.  Ha ha!  Good joke, right?  No seriously, I was just kidding. Guys?

Not dead

I'll start this post by answering a few questions that may or may not be burning in your mind: No, I'm not dead.  No, I didn't g...