Monday, 26 October 2015

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.

34 comments:

  1. "throwing gasoline onto his Personal Risk Fire"

    love this

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  2. I can see why he might have wanted to "live life to the full" for the time he had left, so to some extent, if he had taken up skydiving I might have understood that. But really, taking up drinking heavily as a way to cope with liver disease has to be worse than putting all your money on "red 7" as a way to pay the rent - at least you stand some chance of succeeding with that!

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  3. @Ugi - I can kind of understand the suicide by booze aspect of this. If his options for living life to the fullest were limited, either by money or lack of imagination, then staying drunk enough to numb his fear until the booze could finally kill him might have seemed like an acceptable way to go. I don't happen to agree, but that's me.

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    1. Fair point - he might simply have given up and decided to blot out his remaining life with booze. It's very difficult to know how one would feel until one has been in that situation, so I wouldn't like to say that it's a stupid reaction. Even thou' it seems like a stupid reaction.

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  4. so far I have only encountered one customer who has managed to achieve drunk times 4. this means either my home state is much more lenient on alcohol saturation, or Gary was unusually dedicated to his efforts.

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    1. of course, we frequently don't hear the person's score. we just pour them onto a backboard and aim them at the trauma bay. our drunk X4 actually managed to autoextricate despite being in a car with his seatbelt properly fastened. I'm guessing the fact the car was torn apart across the passenger compartment had something to do with that.

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  5. I wonder if this was a form of slow 'not officially suicide' suicide, as in someone receives a long term diagnosis that's serious but manageable with lifestyle changes, but instead of making those changes, just...gives up.

    For example, a friend's husband was diagnosed with diabetes -- not the kind that you have to inject insulin (I think; he's kinda vague on this) but simply eat right, exercise, and keep tabs on your blood sugar. But instead of doing that, he just refuses to take care of himself and takes a really nihilistic view of it all. So now he's losing his vision, he's in and out of hospital, his overall health is crap, and you can tell he's just waiting to die. It drives all of us crazy, but how do you deal with someone who just gave up?

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    1. I know a guy in the same boat. He's suppose to be watching his diet, but then eats burger king and drink sugary shit. Or he will until he's not feeling well then whatever the doctor does before he plummets down like a lead balloon (as he would without the doctor) is the cause of him feeling sick. He kept blaming an assisted living home for putting salt in his food, I went and talked to them about his special diet and I find out he's throwing pizza parties for everyone and driving out to burger king. But... the nurses are the ones trying to kill him. -sigh-

      Sometimes you have to detach and leave people to their own devices.

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  6. I'm confused about the two links on "Katy Perry" and "stealing that medical idiom". How are those related? No idea what you're referring to.

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    1. Doc was in a Rush for you to understand the suicidal, headbanging tendencies Gary must have been suffering:
      Taste me you will see
      More is all you need
      You're dedicated to
      How I'm killing you

      You're welcome (:

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    2. I don't like Katy Perry's music (though she's awfully nice to look at), so I changed her link to a band I thoroughly enjoy. And I had no idea that "Circle the Drain" was a song of hers until I googled the term, searching for a medical definition, and the first several thousand hits were her goddamned song (which sucks, by the way). So I changed that link to the first song that popped into my head.

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  7. This particular story hit *really* close to home for me. The end of this week marks the first anniversary of my extended family's own "Gary" making his transition. Our guy, to whom I will refer as "Edward" in deference to Doc's tradition of "not his real name," was much more fortunate than "Gary," and perhaps even luckier than "Rufus" in the previous story.

    When the cirrhosis induced by years of over-drinking finally brought him to what we thought was the end of the road about 10 years ago, medical staff was not only able to pull him through one more time, but get him on the waiting list for a liver transplant. Less than a month later, the transplant came through!

    Edward's amazing recovery from the process (no issues with rejection, or any other kind of complication, and a release from the hospital in record time) merited his case being written up in the medical journals, and for several years he was regaled as the most prominent "transplant success story" by the staff of the world-reknowned university teaching and research hospital at which he'd received the care. Within two months of the transplant surgery, Edward was not only in better health than he'd been for the previous 20 years, but back to work part-time, and enjoying all the outdoor activities (camping, hunting, and fishing) for which he hadn't had the energy for the previous 5 years.

    Problem was...Edward never accepted the reality that the great gift of a second chance at life required some serious changes to his lifestyle if he wanted to *maintain* that good health. He believed that because he had a "brand new" liver, he could literally start all over again, figuring that it would be at least another 20 years or so before he felt any ill effects. He was pretty conscientious for the first two years after the surgery, but soon began to backslide....by the 5-year mark, he was pretty much drinking and smoking as much as he'd been before the transplant, and so neglecting his his diet and exercise routines too. He'd end up in the hospital now and then when he was feeling really bad, or when family members pressured him to go in, but of course never heeded the recommendations for follow-up once the immediate crisis was handled, and even left the hospital against medical advice a few times, determined to do things his own way. By the time lung cancer was finally diagnosed, the "new" liver was significantly damaged too. As Doc has already stated, cirrhosis affects *many* body functions that are controlled by the liver, so of course the conventional cancer treatments (surgical removal of a significant tumor, chemotherapy and/or radiation to knock out any remaining bad stuff) were not as successful as they may have been in a person with a healthier liver.

    During the afternoon and evening of Halloween 2014, he made a few phone calls to family and friends from his hospital bed. Though he was in pretty good spirits, he told us that he was tired and ready to "get out of here and go home." We got the phone call from his daughter around 1 AM to let us know that he had, in his own way as always, accomplished that.

    Edward was, IMHO, never really trying to *end* his own life. He simply couldn't deal with his share of the responsibility for *saving* it.

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    1. "Problem was...Edward never accepted the reality that the great gift of a second chance at life required some serious changes to his lifestyle if he wanted to *maintain* that good health."

      "Edward was, IMHO, never really trying to *end* his own life. He simply couldn't deal with his share of the responsibility for *saving* it."

      I thought that was beautifully written and very well-stated.

      I'm sorry for your family's loss of "Edward", who I bet wasn't a bad person but wasn't prepared to recognize that he was still far more fragile than he liked.

      As I'm in the midst of chemotherapy and feeling altogether too healthy (which worries me), I'm reminded by many NOT to push my luck. Which is why I'm not at work today, because my WBC count was a bit low yesterday, predicted to drop still further today unless the Neulasta kicks in first. The dogs and cat are very happy to have me here.

      Wednesday

      P.S. And thank you again to the person who posted the words "fungating tumour". I'm not looking forward to another 15 rounds of chemotherapy, a mastectomy, radiation, physical therapy and far too frequent get-togethers with my oncologist, but it sure beats those images. As it happens, the genetic results indicate that I'm at increased risk for several types of cancer and now the rest of the family is also aware.

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    2. just remember: you are paying your oncologist to worry on your behalf. you live your life.

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    3. Eventually I'll live my life. Right now I have to find the money to keep it going. Even with insurance this is not inexpensive and the catastrophic limits are very high for our family. Doesn't help that my husband is talking about quitting his job and never working again (he's far too young to retire). Fortunately, I carry the health insurance but I still resent his bringing it up as a topic of discussion. There's a time and a place and this is neither.

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    4. Chemotherapy is a money maker for doctors and pharmaceutical companies. Big business for hospitals too.

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    5. you're right - it is very childish of your husband to be bringing that up at this time.

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    6. @anon: slandering medical treatment is big business for alternative "medicine" bloggers and quacks. and much of alternative "medicine" is a big money maker for morticians and undertakers.

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    7. Anon - Is chemotherapy perfect? Of course not - it's poison, designed to kill cells. But countless people have been cured of their leukemia due to chemotherapy. And countless others' lives have been either extended or improved due to chemotherapy. I'm sure all those people would gleefully disagree with you and your ignorance.

      So kindly take your ignorant comments and fuck off.

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    8. Everyone knows chemo makes you feel like shit. Oncologists do not lie to their patients and tell them chemo will A) cure their terminal cancer or B) make them feel wonderful. If one does, he's a quack and deserves to be flogged and have his medical licence burned in front of him.

      Chemo for end-stage cancer is designed to give people with a death sentence a little more time with their families, time to check things off their bucket lists. It's called "palliation". Look it up, then fuck back off.

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    9. @Anonymous - As a current cancer patient, please fuck off. You have no idea what you're talking about. I'm not stage 4, so going through this is best for my long-term survival. It still stinks on a bunch of levels but I'm lucky that I DO have decent insurance even as I grouse about the never-ending nickel and dime bills.

      Yes, I do wish my husband would stifle it at this time but we all have our less than charming moments. He'll pull himself together.

      I can hardly wait to hear what John Benton, errr, "anonymous" has to say about killing cancer stem cells without killing the patient outright.

      DocBastard - would you like a bag of chips with your can of Coca Cola or Pepsi? I have apple cider and popcorn, so I'm ready for a chuckle. I'd offer you honey mead + Sprite but it's hard to obtain.

      Wednesday

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    10. For sure!

      @ Wednesday - Wishing you great success on the rest of your journey to good health. Anyone can have an opinion, but you and your doctors will always be the most qualified "experts" to make the right choices in your situation.

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    11. and so far, cornboy has a slightly worse track record than a broken clock.

      I'm not quite sure whether this anon is cornboy, or some other fool trying to flog the latest grade of reptile lubricant.

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    12. Thank you! I hope to be around to be annoying to and annoyed by my husband and many others for a long long time.

      W

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  8. I once saw a guy in the ER with cirrhosis. He also had tachy-bradycardia, with his heart going in and out of v-fib. He coded three times during my four-hour shift, one time in front of his family who had come in to talk to the doctors. He probably needed a pacemaker, but he would have to stabilize before anyone could operate. I don't know what ultimately became of him, but he's probably dead. He was 60 years old.

    Don't be an alcoholic.

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    1. Don't be an alcoholic. Hhmmmm..... what a novel idea! Wish I'd have thought of that years ago.

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    2. You couldn't have thought of it unless you came across it on Wiki and saved it as a "copy/paste" item for your future trolling endeavors. You don't appear to have coherent, original thoughts.

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  9. Great post as usual, Doc! Though I must say, this post didn't serve as a nice, brief study break (as it usually does for me). Rather, it caused me to freak out that my physiology midterm is tomorrow and you were the one who reminded me where fibrinogen is made ><' Seriously, this blog is so funny and sarcastic that sometimes I forget it's a legitimate medical blog.

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  10. This comment has been removed by a blog administrator.

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    1. John - Banned means banned. Fuck off.

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  11. Am so happy, i never believe i will be this happy again in life, I was working as an air-hoster ( cabby crew ) for 5 years but last year i loose my job because of this deadly disease called Hepatitis B (HbsAg), I never felt sick or have any symptom, till all workers were ask to bring their doctor report, that was how i got tested and i found out that am HbsAg positive that make me loose my job, because it was consider as an STD and is incurable disease, i was so depress was thinking of committing suicide, till i explain to a friend of mine, who always said to me a problem share is a problem solved, that was how she directed me to this clinic called HEALTH MED LAB CLINIC, that was how i contacted them and i get medication from them and i got cured for real, I just went back to my work and they also carry out the test to be real sure and i was negative. Please contact this clinic if you are hepatitis B positive their email is ( healthmedlab@gmail.com ) they are life saver.

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  12. My step dad had a triple bypass in 1981. From the blood that was transfused he got hep C. I guess they didnt test donated blood for that years ago. He didnt know till he had severe cirrosis. He took care of himself and still got a tumor and died from Liver cancer.

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  13. I tried to donate blood for the first time in my life about 4 years ago, and the local county health department telephoned me that afternoon and said I needed to go to see a doctor immediately because I had hepatitis B. I had absolutely no symptoms. I had several blood tests over the course of a year or so, and my doctor said I was a chronic carrier. My sister had Down's syndrome, and my doctor said I probably got it from her as she lived in an institution for a period of time. As the disease progressed all medication stopped working, i was introduced to Health herbal clinic in Johannesburg who have successful herbal treatment to hepatitis B. I spoke to few people who used the treatment here in USA and they all gave a positive response, so i immediately purchased the hepatitis B herbal formula and commenced usage, i used the herbal supplement for only 7 weeks, all symptoms gradually faded away, herbs are truly gift from God. contact this herbal clinic via their email healthherbalclinic @ gmail. com or visit www. healthherbalclinic. weebly. com

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