Even sicker

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

CIRRHOSIS

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

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

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

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

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

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

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

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

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

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

• nearly every rib on the left side was fractured
• left lung was collapsed
• left acetabulum (hip socket) was shattered
• sternum (breast bone) was broken
• left scapula fracture

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

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

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

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

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

Lucky day

Lightning never strikes the same place twice.  This phrase is patently untrue, as anyone with access to Google can discover in about 0.298 seconds.  However, the general meaning usually holds true - uncommon things happen uncommonly, and for them to happen twice to the same person is highly improbable.  But it happens - just ask Roy Sullivan (if you're too lazy to click the link, Roy got struck by lightning a record 7 times).

Speaking of uncommon things with improbable odds, the lottery is stupid.  I've heard it said often that the lottery is a tax on people who don't understand statistics.  Before anyone complains and yells "Hey Doc you idiot, I won a few dollars/euros/rupees/rubles/whatevers in the lotto!"  Yes, I know people win.  A few people.  A very few.  Sure it's great if you win, but what are the odds?  Astronomically ridiculously low.  In many lotteries around the world, you are many times more likely to be hit by lightning than to win.  Literally.  Makes me wonder if Roy Sullivan ever played the lottery.  Maybe he should have.  Hm.

Moving on.

So yes, the lottery is stupid.  It's no wonder that I've never bought a lottery ticket.  In fact, a friend of mine has his own lottery - whenever he feels the urge to be stupid and buy a ticket, he puts the money in a jar, and at the end of the year, he empties the jar and BAM!  there are his lottery winnings.

As stupid as the lottery is, I still told Rufus (not his real name™) to buy a ticket.

"Wait, what?  GODDAMMIT Doc, you just told us the lottery is stupid, and you still told a patient to play?  And how the hell did that even come up in conversation?"

I'll explain.  Obviously.

Rufus came to me as a high-level trauma with a huge gauze bandage around his neck.  The medics explained that he had been walking to his car when someone came up behind him and randomly stabbed him in the neck.  You know, because that's what normal people do at noon on a Wednesday.

The wound wasn't actively bleeding, but stabs to the neck can be critical.  There are a lot of very important structures in that area that connects the head bone to the chest bone - spinal cord, carotid arteries, jugular veins, oesophagus, trachea, etc.  When a knife goes in, I never know which direction it went - up, down, left, right, backwards, forwards.  So I am forced to do a detailed physical exam (is the patient coughing or vomiting up blood?  Are all his pulses intact?  Can he move and feel his limbs?  Is there blood squirting up to the ceiling?) followed by various studies to confirm and/or rule out any serious injuries.

On my initial exam, there was a rather large and deep laceration to the posterior (back) portion of the right side of the neck with some mild blood oozing out.  But there was no blood on the ceiling and no other obvious signs of serious injury.  His vital signs were all stable, and he was able to move his arms and legs.

Good, no spinal injury.

His carotid pulses were normal (and besides, the carotid and jugular are towards the front of the neck anyway).  The knife wound seemed to go towards the back of the neck, so I was not immediately concerned about the major vascular structures.  What remained were the trachea and oesophagus, though it seemed equally unlikely they could be injured.  After packing the wound to prevent further bleeding, I got several studies (including both tracheoscopy and oesophagoscopy) which miraculously showed no major injury.

For folks like this who should have died but didn't, my usual joke before they leave the trauma bay is to buy a lottery ticket on their way home, since this was definitely their lucky day.  Unfortunately I forgot to tell this to Rufus.  He got a few stitches for his trouble, and the next morning he went home.

I saw him back in my office about a week later to check his wound.  Everything was going well and his wound had healed nicely.  As I was removing the stitches, he and I were marveling about how serious his injury could have been but wasn't.  It was then that I finally remembered to tell him to buy a lottery ticket, though I suspected his luck had run out.

Rufus: Oh I did buy one, Doc.
Me: You did?  What, this past week?
Rufus: Oh no no.  You see I was actually walking back to my car just after buying some tickets and hadn't gotten a chance to scratch them off yet.  That's when that guy stabbed me.  I thought he was going to rob me, but he didn't even steal them or anything.  He just stabbed me and ran away.
Me: Well that's . . . good, though utterly ridiculous.  So did you win?
Rufus: Well I scratched them off as soon as I got home from the hospital.  And you know what, I won enough to pay my rent this month.  That really was my lucky day!

See?  Lightning does strike the same place twice.  So to speak.

Levels

SPOILER ALERT: IF YOU HAVEN'T READ OR WATCHED "GAME OF THRONES", WHAT THE HELL IS WRONG WITH YOU?  IT'S ONLY THE BEST TV SERIES EVER!  GET THE HELL ON WITH IT!  OH, AND DON'T READ THE LAST PARAGRAPH.

Jumbo eggs.  (Yes, I went straight from "Game of Thrones" to jumbo eggs.  It's just how I roll.)  Extra large sweatpants.  First-class airfare.  Prime beef.  All these things have something in common other than having nothing whatsoever to do with trauma.  Yes, the common thread is that they are the highest level, the biggest.  The top of their class.  Elite.  I could put "BMW-level douchebag driver" on that list too, but I can't decide if they're actually at the bottom of my list of asshole drivers or the top.  I should probably google that, but I have a point to make.

I think. 

Right, the point I was desperately trying to make is that trauma patients have levels too.  Different hospitals have different code names for their various trauma levels, but just to simplify things I'll refer to them very non-creatively as 1 and 2.  The vast majority of patients who come in are level 2, the lower level.  These are folks who have fallen from a height of less than 10 feet, were in a car accident but are awake and alert with stable vital signs, were assaulted, shot in the arm or leg, etc.  Mechanisms of injury that shouldn't necessarily kill you in 5 minutes.

Level 1 trauma patients are those who may be actively dying either based on their presenting exam or how they were injured.  Falls from 60 feet.  Gunshot wounds to the torso or head.  Stab wounds with actively pulsatile bleeding.   Brains leaking out of ears.  I could go on, but I fear I'd lose some readers.

The medics in the field decide what level patients are prior to calling them in, but as I've said before I only believe about 10% of what I hear on The Box before they arrive.  Quite often, more often than I'd care to discuss, patients who should be a Level 2 are brought in as a Level 1 or vice versa.  Now of course I understand it is often very difficult for medics, who usually have no formal medical education, to determine who should be a high-level trauma.  Is this guy who fell off his barstool unconscious because he passed out or because he conked his head on the floor hard enough to bleed into his brain?  Is the heart rate 160 because he's bleeding to death or because he just mainlined cocaine and methamphetamine?  Is that blood on the patient's abdomen or intestine (yes, I've actually seen that confused)?  More often than not caution ("Better safe than sorry") takes the front seat over logic.

But sometimes the guys in the field just plain blow it.

The Noon Gunshot Wound is a rarity in my world, since these patients seem to enjoy getting shot closer to 1 AM for some reason.  If it were me, I'd much rather get shot during the day, since I would expect my trauma surgeon to be more alert at that time of day.  But maybe that's just my personal bias creeping in.  I digress.  Anyway, my pager alerted me just before lunch time that a Level 2 gunshot victim would be arriving in 5 minutes.  These are almost exclusively gunshot wounds to the arm, leg, foot, or hand; nothing that would be immediately life- or limb-threatening.  So I skipped (not really) down to the trauma bay expecting to greet a stable patient who could talk to me.

Ha!  No.

Instead, when Lawrence (not his real name™) rolled in, he was paler than the gurney sheet, sweating more than a marathoner in Dubai, with a blood pressure around 90/40 and a heart rate hovering around 140.  Even a blind man would be able to see that this man was actively dying in front of his unseeing eyes, but somehow the medics didn't.  It didn't help their case that Lawrence kept moaning "Please don't let me die!  Please don't let me die!"

That's invariably a very bad sign.

The medics seemed to have no sense of urgency as they rather sluggishly transferred him to our gurney.  "Multiple gunshot wounds, one to the abdomen, one to the left arm.  He's been like this since we found him."

LIKE THIS?  WHAT, YOU MEAN DYING!?  AND NOTHING ABOUT HIM SCREAMED "LEVEL 1" TO YOU IDIOTS?

A quick survey found one gunshot wound in the right lower part of his abdomen, a corresponding exit wound in his left flank, and another entrance wound in his left forearm as the bullet passed through him.

As you can imagine, there are A LOT of very important structures between those holes.  

An even quicker poke on his belly elicited a very deep, almost primal growl, and 3.26 seconds later (I timed it) I was on the phone with the operating theatre staff telling them Lawrence and I would be there in 4 minutes.  I didn't bother getting an X-ray on his almost-certainly fractured arm, because that wouldn't kill him in the next hour.  Whatever was going on in his abdomen, on the other hand, would.

During surgery I evacuated about 2 liters of blood from his abdomen, found multiple active arterial haemorrhages in his mesentery (the blood supply to the intestine), along with 6 holes in his small intestine and 2 in his colon.  Ninety minutes, several units of blood, two small bowel resections, and two colon repairs later, Lawrence was admitted to intensive care where he stayed for a couple of days.  An X-ray that evening confirmed a left radius fracture, but fortunately he would not require surgery to repair it, just a cast.  

In spite of, and certainly not because of, the medics' relative inaction, he walked out of the hospital 9 days later.

In full defence of my emergency medical personnel colleagues (who often do wonderful and heroic things), I completely understand that evaluating and labeling these people in the field can be difficult.  Determining who is severely injured can be next-to-impossible in certain situations.  But this one should have been easy.  As easy as pie.  A piece of cake.  Mmmm...cake.

It does make me wonder though, what injury would be necessary for this crew to call a level 1?  A Ned Stark-style decapitation?

I told you there would be a spoiler.  Anything I can do to get a Game of Thrones reference in. 

Sense. This story makes none.

If you've been here for a while, you know by now that some of my stories make little sense until the big reveal at the end (at least that's how it seems in my ego-inflated head).  You know, something like an M. Night Shyamalan movie . . . before they started to suck.  Now don't misunderstand me, I don't mean to say I think my stories are as good as the Sixth Sense in any way.  I'd never be that arrogant.  Maybe as good as Unbreakable, though.  Yeah.  But not The Happening.  God no.  And definitely not The Village or Lady in the Water.  Those two steaming piles of horse shit represent several hours of my life I'll never get back.  Those 4 hours would have been better spent waxing my back or learning to juggle chain saws. 

Anyway, this isn't one of those stories.  Like all of M. Night's recent movies, this one makes no sense at the beginning, fails to improve by the middle, and by the end there is just no good resolution at all.

Make sense?  No?  Good.  Kind of makes you want to stick around to read it, just to watch the impending train wreck, right?  Hello?  Are you still there?

Damn it.

For the two or three die-hard masochists who still remain (likely just my parents . . . they'll read anything I write no matter how bad it is), I'll do my best not to bore you.  Much.

Just as I was sitting down to eat my very appealing-looking Frozen Vending Machine Hamburger© (I swear I saw something similarly appetising in Shaun Of The Dead), my pager alerted me that an assault had just arrived in the trauma bay.  Wait no, not an assault, but two assaults.  

My "meal" would have to wait.

Walk-ins are not terribly uncommon, but two arriving simultaneously is, and it usually indicates a pub brawl.  The patients are usually two of the lesser entrants who couldn't hold their own against their larger (and drunker) opponents.  Occasionally it's domestic violence or something similar where the two patients beat each other up.

Nope.  Not this time.  Not exactly.

When I got to the trauma bay a minute or so later, the first victim was obvious - a young woman sitting on a stretcher with a black eye, holding a toddler in her arms.  Since she looked reasonably ok, I immediately started searching for the second victim who I thought might need closer attention.  But the trauma nurse saw me looking around, smiled that "I-know-something-you-don't-know-but-will-definitely-upset-you" smile, and pointed to . . . the baby.  The same baby who was sitting happily in mum's arms, smiling, drinking a bottle.

Really?  Really?  The baby was the second trauma victim?  What the . . .

I went back to Lisa (not her real name™) to assess the damage.  No instability in her face, no bleeding, normal eyesight.  Her 6-month old baby was happy as can be with no ill-effects whatsoever.  After speaking with Lisa for a few minutes, I got her story.  Apparently she had been arguing with the baby's father when he had punched her in the face (because that's apparently what people do when they argue).  Unfortunately the argument was taking place on the top of the stairs (because apparently that's where people argue), and Lisa had been holding the baby at the time (because apparently screaming at your mate while holding your child is normal behaviour).  She tumbled backwards down the stairs, baby and all.  She lost consciousness, but the baby was shielded by Lisa and wasn't even scratched.

I evaluated the baby, and he seemed completely fine, bright-eyed, not crying, uninjured.  I did a quick head-to-toe examination, and finding not a single mark on him or anything remotely resembling a traumatic injury, I sent him to the main department to be evaluated by the emergency physician. 

Other than the black eye Lisa was also uninjured.  A CT scan confirmed no brain injury and no facial fractures.  As I was looking at her scan, a nurse brought in the baby.  To be scanned.

Yes, the emergency physician had bewilderingly ordered CT scans of the brain, spine, and face for the baby.  FOR THE BABY.  They were all negative.  Please try to contain your surprise.

What did not come back negative was Lisa's urine drug screen, which was positive for cocaine.

After the baby was cleared by the emergency doc, I sent them both home, still shaking my head in bafflement at the sheer absurdity of it all.

Did any of that make sense to any of you brave souls who stuck around?  Because none of it did to me.  Still doesn't.  I've read this back half a dozen times, and it's all completely ridiculous.

The only thing that makes less sense is that after it was all over, I went back and still ate that damned hamburger. 

EDIT:

Several people have already pointed out the obvious that the emergency doc was just covering his ass by over-ordering tests.  While I understand that perspective, there was absolutely no indication to expose this child to any amount of radiation, let alone 3 CT scans' worth.