Sunday 27 September 2015

Safety mechanisms

Seat belts.  Helmets.  Gun safeties.  Shoulder harnesses.  Shut-off valves.  Dead-man switches.  Fire extinguishers.

What do all of these things have in common?  1) They were all designed to save your life in an emergency, 2) They were all added to the safety arsenal as an afterthought when someone realised they were necessary, 3) They work when used properly.

I understand that last one may seem obvious, but stay with me here.  I'm going somewhere with this.

Pneumatic nail guns are wonderful inventions that make construction jobs infinitely easier (not to mention a hell of a lot of fun).

Wait wait wait, nail guns?  What the hell are you on about, Doc?

Yeah, you didn't see that coming, did you?  You thought this was going to be another seat belt or motorcycle story, didn't you?  Listen, I told you to stay with me.  Just think for a second - trauma, nail guns, safety . . . you better believe a good picture is coming.  So be patient.  Or just skip to the end if you want to act like an impatient child.

As I was saying, banging nails with a regular hammer all day runs the risk of repetitive stress injuries, not to mention smashing your thumb (we've all been there) and cursing in front of children who just want to "help" you build them a bird house.  Nail guns eliminate those risks, but they introduce new, even riskier risks, namely firing a sharp weapon somewhere into your body.

To counter that risk, every nail gun (except the ones that fire tiny nearly-harmless pin nails) has a safety mechanism built in to the nose so that the gun must be pressed against a hard surface with relatively significant force for it to fire.  If you're wondering how I know this, I own five of them, including a framing nailer, an angled finish nailer, a straight finish nailer, a stapler, and a pin nailer.  I love my tools.

But I digress.

Joe (not his real name™) was one of those people who didn't seem to think the safety mechanism on his nail gun mattered.  He was completing a frame on a house using a large framing nailer when there was an . . . incident.  An accident.  Well, something happened.  I can't say exactly what that "something" was, because Joe wouldn't tell me.  I'm not sure if it was because he was too embarrassed or because he was screaming in pain.

When he was rolled in, he was fully dressed and clearly in agony.  Most patients who come my way are at least partially disrobed so the medics can assess the extent of their injuries.  Not Joe.  The medics mentioned that because of an "apparent leg injury" they tried to remove his pants, but they wouldn't come off.  And every time they pulled, Joe yelped even louder.

As he was lying there on the stretcher, his leg looked fine.  No blood, no weird angulation from a bad fracture.  But when he rolled to the side so we could see the back of his leg, the problem suddenly became glaringly obvious.

If you're wondering why he was screaming, maybe this X-ray of his knee will satisfy your curiosity:
If you can't tell, that's a 9cm (3.5 inch) clipped-head framing nail that went into the back of his knee, through his femur, and into his patella (kneecap).  It was embedded so deeply and so thoroughly into the bone that the head of the nail had dragged the fabric of his pants at least 1 cm under the surface of his skin, pinning his pants to his leg quite effectively.  

Yes indeed, he had used one of these:

to fire one of these:

into the back of his knee.  Just to give you an idea of how big these framing nailers are, well, a picture is worth a thousand words:

They are HUGE.  And notice the nose of the gun being pressed into the wood?  That's the safety mechanism that all these guns have.  Well, almost all of them.  That nose didn't exist on Joe's gun, because he had removed it.

No, I did not ask him why. 

I still have no idea how he shot himself in the back of the knee, and he repeatedly insisted that there was no one around him and that he did this to himself by accident.  Regardless, the orthopaedic surgeon took him to the operating theatre and had to use various metallic instruments of death and destruction to remove the nail from his femur and patella.  A few days later, Joe walked out of the hospital, still insisting that he did this himself.  Somehow.

So now think back to all the safety mechanisms I mentioned at the beginning.  What else do those things have in common?  They only work IF YOU USE THEM.

Monday 21 September 2015

Call Gods Madness

The Call Gods have many different ways of torturing me.  Sometimes they send me nasty surgical cases, sometimes they send me nasty patients, and sometimes they send me nasty patients with nasty cases.  And then there are those exceedingly rare occasions they send what seems like the entire city's population to my trauma bay all at the same time.  But whatever they do, they always seem to do it with an evil sneer.  I can almost see them laughing in pure murderous glee as my third gunshot wound to the head and/or abdomen of the day is dropped on my doorstep.  I swear I can hear them snickering as they drop off yet another drunk spitting asshole who fell and bonked his head on the street while leaving the pub.

I definitely heard them loud and clear when Mr. Screamer (not his real name™) came in.

It was a typical warm Saturday during the summer.  My kids were outside playing, enjoying lemonade and a run through the sprinkler, while I was trapped under the warm glow of the fluorescent lights in the trauma bay.

Oh, the joy.

The patient load was typical: a motorcyclist had lost control and crashed into the ground (the ground won, as usual); several car accident victims were brought in; a middle-aged couple had been brought in, both of them having been stabbed multiple times by their PCP-using son.  In the midst of all the barely-controlled chaos, I heard a blood-curdling scream followed by a string of expletives that would have made even Tyrion Lannister blush.  It was coming from elsewhere in the department, and I realised with a smile that all of my patients were (surprisingly) behaving themselves, so this bad character was apparently not one of mine.

The emergency docs must be having a fun time trying to corral that mess, I chuckled to myself, reveling in the fact that it wasn't my problem (this time).  Better them than me.

If you aren't hearing the dramatic "dun dun DUN" foreshadowing music yet, then you haven't been paying attention.

A few hours later when the next fall victim was brought in, Mr. Screamer was still at it, flinging obscenity at anyone who came near his room.  At this particular moment he was cursing at the security guards who were tasked with making sure he didn't harm himself or anyone else.  However, their presence seemed only to aggravate him further.  One of the nurses came in to the trauma bay laughing and told me the guy was one of their alcoholic frequent fliers who was back for the second time that week.


I silently laughed once again, apparently still oblivious to the Call Gods' warning signs.

When my phone rang at 3 AM, it didn't seem any different than the 395 other calls I had gotten that day.  (dun dun DUN)  The ring tone was the same and the voice on the other end seemed the same, but it turned out that this was the Call Gods calling.

"Hey Doc, so you know that guy who's been screaming bloody murder all night?  Dr. Dumbass (not his real name, though it should be™) just called me to say that he had apparently been beaten up, and he has a subarachnoid haemmorhage on his brain CT.  He wants us to consult on him and admit him."

The profanity that came to mind would have been perfectly suitable coming out of Mr. Screamer.

The guy spent the next 10 days in hospital with me.  You may expect that he calmed down once he sobered up, but HAHAHAHAHA no.  For his entire stay his demeanor vacillated between "Fuck you, Doc" and "I'm going to shit on your floor" before I was finally able to discharge him.

I should have seen it coming, but I obviously was trying my best to ignore them.

Fuck you, Call Gods.  Fuck you.

Monday 14 September 2015


It's been nearly 4 years since I started this blog, and with every new post I find it harder and harder to find material that isn't boring, repetitive, or both.  I'd like to write about homeopathy, seatbelts, antivaccinationists, or smoking every week, but I suspect I would lose and/or bore everyone to tears by doing so.  Instead, I wait for the truly good stories, ones that I find inspiring or unusual. Barring that, I sometimes take more mundane subjects and try to spin them in an interesting way.

And sometimes the stories just write themselves.

I ordinarily hate phone calls from emergency physicians at midnight.  Rarely do I answer the phone and hang up with a smile.  By now you've probably guessed that's exactly what happened recently.  You'll find out why I was smiling momentarily, I promise. And I guarantee you'll end up smiling too.  And maybe even laughing your ass off.  Or maybe scowling.  Possibly vomiting.  Whatever.

No promises. 

Dr. Elise (not her real name™), a lovely and strangely competent emergency physician, had a rather strange lilt to her voice when I picked up the phone.  I immediately suspected by the tone of her voice what was coming, and boy was I ever right.  I like being right.

Dr. Elise: Hi, Doc.  So I have this really nice guy with his really nice wife. They were, uh, having some, uh, fun.  And then it got, eh, lost. 
Me: It?
Dr. Elise: Yeah, it
Me (smiling): What exactly is it?
Dr. Elise: ...
Me (smiling bigger): Elise?
Dr. Elise: ...
Me (chuckling audibly): Eliiiiiiise?
Dr. Elise: A . . . a vibrator. 

Smiling yet?  Because you know damned well a picture is coming.  I hadn't had a rectal foreign object in quite some time.  If you're wondering why I was so excited, you're not alone, because Dr. Elise and two of her colleagues asked me the exact same question.  Why do I get so damned giddy at rectal foreign objects?  Do I have some strange fetish?  Do I enjoy the schadenfreude?  Am I just a sick, perverted bastard?  No, I told her, the answer is much  more mundane than that: removing RFOs is very, very satisfying.  

For me, that is. 

Anyway, I got to the hospital a few minutes later, and I did my best to suppress my giddiness as I walked in.  I have no idea what most people would think of a surgeon with a stupid grin on his face as he walks into the hospital, but I suspect it would be nothing good.  Probably some serial chainsaw killer shit.  I went straight to the radiology computer and pulled up his X-ray:
Yep, that's a vibrator all right, I thought.  A BIG one.  Now to get it out.  

On the X-ray it looked awfully high in his rectum (yes his), so I went to get a pair of ring forceps that I suspected I would need.  I then went in to his room to introduce myself.  He looked terribly uncomfortable sitting there next to his wife.  Obviously.

Me: Hello, I'm Doctor {Redacted}.  You're Mr. Patterson (not your real name™)?
Mr. Patterson: Ugh.  Yes.
Me: Nice to meet you.  And you're Mrs. Patterson?

They both glanced at each other, looked at the floor, and whispered, in unison, "No."

See?  This stuff just writes itself sometimes.

As expected, I could barely feel the base of the vibrator with the tip of my finger.  And also as expected, it was caught under the sacrum.  Fortunately I was just able to nudge the base of it over the sacrum with my fingertip.  I slid the forceps along the length of my finger, grabbed it, and told him "Push."

He pushed.  I pulled.  


It was a very satisfying *plop*, which reinforced why I like these cases so much.  I then held up their lost toy and asked them both if they wanted it back.  They both wordlessly shook their heads vigorously, so I threw it straight in the bin, accepted their heartfelt thanks, said goodbye, and walked out. 

No embellishment needed this time.  None at all.

Tuesday 8 September 2015


If you've never heard of Amy Winehouse, take a moment to look her up (or just click on her name).  Go ahead - I'll wait here.  I promise not to leave without you.

Ok, she's gone!  Quick, let's ditch her!

Kidding, kidding.  But seriously, Ms. Winehouse was a ridiculously talented young lady (with a ridiculously ironic name) who, like many other musicians before her, ended herself way too young due to the effects of drugs and alcohol.  Arguably (and again ironically) her best-known song was "Rehab", an autobiographical song (which won numerous awards) protesting her father's wishes for her to undergo drug and alcohol rehabilitation.

That's a very garrulous and needlessly-stupid way for me to introduce rehab, especially considering that's not even the type of rehab I'm talking about in this story.  I'm talking about physical rehab here.  Hm, I guess I've never been very good at segues, so maybe I shouldn't even bother to try.  Though now that I think about it, I think Natalia (not her real name ™) could have used Amy Winehouse's type of rehab too.

There you go, a segue.

Natalia came in as a high-level trauma, having been shot in the left axilla (armpit).  That's always a tricky area, because I never know which way the bullet went - up into the axillary vessels, sideways into the chest, down into the abdomen, etc).  On her initial exam she had no breath sounds on the left side (uh oh), her abdomen was markedly tender (UH OH), and we found the exit wound on her right flank (UH FUCKING OH).  It's almost never good when a bullet goes in one side of the body and out the other.

Oh, and one other thing we found on her were track marks on her right arm.


Though some shootings appear on first glance to be drug-related, I usually don't like to assume they are, because I tend to be wrong.  Sometimes, however, it is exactly what it looks like.  According to the police officer who came with her, this was a drug deal gone bad, and Natalia ended up on the wrong end of the gun.

When I placed a chest tube in her left thorax, about 600ml of blood came out.  Fearing something very bad going on in her abdomen, I took her directly to the operating theatre where I found that the bullet had ripped two holes in her stomach, tore through her liver, and then went through her right kidney before exiting into the outside world.  After repairing everything (except the kidney, which I left alone), I admitted her to intensive care where she spent the next several days detoxing from heroin.  I guess if you really have to go through heroin withdrawal, doing it intubated and heavily sedated in the ICU is the way to go.

It took her nearly three weeks to get off the ventilator, and by the time her lungs were functioning well enough to get her off the ventilator, she was so debilitated and weak that she couldn't stand without three people helping her.  She clearly needed rehab (finally, the point!), the physical rehab type, not the drug rehab type.  But unfortunately Natalia wasn't having anything of it.  Even though she couldn't walk and barely had the strength to stand, feed herself, or wipe her own ass, she just wanted to go home.  And she kept threatening to leave against medical advice.

I had a sneaking suspicion there was a sizable bag of heroin back at home that was calling her name.

It took several more days (and several people) to convince Natalia that rehab was where she belonged.  I think that nearly falling and cracking her skull open while trying (and failing) to walk to the restroom finally convinced her.

Finally after two months in hospital, the transfer arrangements were completed, and Natalia finally left.  The following day I saw that her name was off my patient list, and I was thrilled for two reasons: 1) for getting her out alive, and 2) for preventing her from leaving against medical advice.  Success, right?


Around 10AM that morning my phone rang.  I recognised the caller as the social worker who had arranged everything for Natalia.

Well this can't be good.

Social worker: Hi Doc, good morning.  Did you hear about Natalia?
Me: Uh, oh.  Uh, no.
SW: Well she got to the rehab facility just fine, and she just . . . well, she just left!
Me: Wait, she did what?
SW: Yeah, I made all the arrangements, the ambulance took her there, they checked her in, and then she just . . . left!  She went home!
Me: . . .
SW: Can you believe it?

And I said no, no. no.