Monday 28 December 2015

Least favourite diagnoses

I have a little internal list in my head that I update from time to time whenever it strikes me.  The official title of this list is "My Least Favourite Diagnoses", but my pet name for it is "If I Ever Get This, Please Kill Me".  For your reading displeasure, I've decided to share that list with you fine folks:
  1. Penile cancer - duh
  2. Fournier gangrene - a necrotising infection of the scrotum, penis, and perineal area which I've warned you not to Google in the past.  No, I'm dead serious - DO NOT GOOGLE THIS.
  3. Fibrodysplasia ossificans progressiva - All the muscles and connective tissue in the body are progressively converted to bone, causing the appropriately-named Stone Man Syndrome
  4. Whatever the hell Joseph Merrick (the Elephant Man) had
For god's sake, please do NOT search for pictures of any of those things.  If you do, I hereby declare and avow that I will NOT be held responsible for any damage done to your computer, phone, tablet, etc from being coated with your own vomit.  And you probably shouldn't click any of those links that I accidentally provided on purpose.

There's one diagnosis that is currently not on the list that has been on there a few times, but it falls off and gets replaced from time to time (at one time it was replaced by Ebola).  I waver back and forth on whether or not this diagnosis qualifies, since it is technically treatable though not curable.  Regardless, even if it doesn't officially qualify for my list at this particular moment, it still qualifies as my least favourite surgical diagnosis for my patients:


There is precious little that can strike fear into the heart of a general surgeon (the good ones, at least).  But hearing the words "bowel obstruction" (or any other surgical catastrophe) in conjunction with "Crohn's disease" and "multiple prior surgeries" can make even the most war-hardened general surgeon soil his scrubs (or at least get really, really nervous).  In case you've never heard of the scourge which is Crohn's disease, it is an autoimmune disorder in which the body attacks its own digestive tract - any portion of it, from the mouth to the anus and anything in between.  This causes severe inflammation, resulting in chronic (often debilitating) abdominal pain, malnutrition, diarrhoea, and ano-rectal abscesses and fistulae (if you don't know what those are, I assure you they are exactly as unpleasant as they sound.  Another link you probably shouldn't click).  It can also cause life-threatening complications including bleeding, obstructions, and bowel perforations.

Sounds like tremendous fun, right?


An experience with my bank teller (I warned you) got me thinking a few days ago.  I was trying to make a simple transaction, no talking necessary, but Mr. Chattypants was having none of that antisocial nonsense.  Somehow he managed to get me to divulge that I'm a surgeon, and he immediately asked the second question that pops into nearly everyone's head.  The first question, of course, is "What's this thing on my leg/face/arm/ass?"  I guess he decided to skip that one out of some sense of dignity and/or social grace, so he went directly to the second question which, regardless of the social situation, is always "What was your most difficult case?"  I've had several readers ask me the same question, so . . .

If you've put 2 and 2 together, you can see where this is going.

While knee-deep in my surgical training, I had the opportunity to treat Xavier (not his real name), a 50-ish year old gentleman who had been diagnosed with Crohn's disease about 30 years prior.  Since that day (which he eloquently described as "the worst fucking day of my miserable life"), he had been on every medication that researchers much smarter than I had been clever enough to invent, though none had provided any real (or long-lasting) improvement.  His chronic abdominal pain and rectal bleeding finally came to a head about 10 years before when he finally underwent an ileocæcectomy (a surgical procedure to remove the end of the small intestine and beginning of the colon and reconnect the two ends), which looks something like this:
Surgeons know to avoid operating on Crohn's patients unless it is an absolute necessity, and in Xavier's case, it was.  His disease was isolated (at least back then) to the terminal ileum and caecum (the end of the small intestine and beginning of the large intestine), but this area had become so inflamed that it had ruptured.  

That was only the beginning of Xavier's problems.

Unfortunately there is no cure for Crohn's disease, and performing this life-saving surgery to remove a perforated segment of intestine did nothing to improve his overall process.  In Xavier's case it saved his life (for the time being) but opened him up to a whole spectrum of new problems.  Literally.  Over the course of the next several years, he was treated with multiple medicines to modulate his immune system, but despite the attempts to prevent further complications, he had further complications.

He had increasingly bad flares increasingly more often, and he eventually wound up with an entero-cutaneous fistula, an abnormal connection between the bowel and the skin, and bowel contents leak out.  In an attempt to prevent even more problems (read: death), the fistula was initially treated without surgery.  Unfortunately with each flare it seemed a new fistula popped up.  This non-operative approach predictably failed, and several years and several surgeries later, he was left with an abdomen that looked something like this:
Not Xavier's abdomen
By the time I met him he had an end jejunostomy, several entero-cutaneous fistulae contained within a blind-ended segment of ileum, and a mucus fistula at the proximal end of his remaining descending colon.  If that makes no sense to you, it made only slightly more to me.  Basically his intestine was a jigsaw puzzle with several missing pieces, several misshapen pieces from multiple other puzzles, and three Monopoly tokens, and the three of hearts.  Fortunately it made complete sense to Dr. Anderson (not his real name™), the surgeon responsible for putting Humpty Dumpty back together again.  The goal, he told Xavier, was to take everything apart and put everything back together again.  This was an extraordinarily risky surgery, fraught with potential dangers - leaks, more fistulae, and death.  Despite the risks, Xavier wanted all of his fistulae gone, and he pleaded with us not to create any new ostomies if at all possible.

"Risky" didn't even begin to describe it.

At precisely 7:45 AM, Xavier was put under anesthesia.  Dr. Anderson went over the game plan with me, took a deep breath, and we began.  It took us nearly an hour just to incise the skin from around the intestine.  As the case proceeded, we had to separate the bowel not only from the abdominal wall, but also from itself.  Years of chronic inflammation had caused everything to mat together into a giant clump of solid collagen.  We meticulously dissected his tissue, trying to cause as little trauma as possible, and failing often.  By noon we had finally gotten past the abdominal wall and into the abdominal cavity, and by 5PM we had delineated most of his internal anatomy.

That was the easy part.

The segment of small intestine containing the multiple fistulae had to be removed and the two ends reconnected, leaving a blind-ended segment.  One end of that segment then had to be connected to the small intestine, the other end to the large intestine.  In all we made three new anastomoses (connections between the bowel), any of which had the potential to leak or create new fistulae.  Dr. Anderson and I finished the case just before 10 PM, having taken one restroom break each, and no breaks to eat.

And we still hadn't cured his Crohn's disease.

We had told Xavier prior to surgery that, if he survived, he would have an extremely long recovery in the hospital, and an even longer one at home.  Unfortunately to make a long story short (too late), Xavier did not survive his surgery.  It's difficult to say what actually killed him, but the simplest explanation is that his chronically weakened system wasn't strong enough to endure a 14-hour surgery.  Xavier went into the procedure a broken and defeated man, unable and unwilling to endure his debilitating disease any further.  In his mind, death was preferable to continuing on as he was.  On the night he died, the last thing he told me before I went home for the evening was, "No regrets, Doc."

Which brings me back to my list.  After writing this story and thinking of what Xavier went through, Crohn's disease just made it back on.

NOTE: For more information on Crohn's disease, go to the Crohn's And Colitis Foundation of America website or the Mayo Clinic website.

Monday 21 December 2015

Interview with Mrs. Bastard

Ok folks, I asked, you responded, and now you're getting what you deserve.  I compiled the list of questions that you asked Mrs. Bastard, and after a lot of prodding, begging, and pleading she grudgingly answered almost all of them.  A few were duplicates, a few were a bit too personal, and one or two were just too bizarre, so they were unceremoniously dumped faster than a Kardashian marriage. 

So without further ado, in no particular order, here is your interview with Mrs. Bastard.  I tried to keep my own comments out of it, but this is my damned blog and I'm totally an attention whore, so I just couldn't keep my stupid mouth shut the whole time.  So any pithy comments by me will be placed {in brackets}.

Now you fine people are about to learn part of why I married this woman.  Don't say I didn't warn you.

Dear Mrs. Bastard,
What is the hardest part about being married to a doctor, and what is the best part?
I don't think there is a best part about being married to a doctor.  The best part is just being married to Doc (not his real name™) {awwww} - it has nothing to do with his profession.  The worst part is that he isn't here a lot of the time.  We miss parties and dinners because I don't want to go by myself.
What are some of the things both you or Doc did which lead to a successful and lasting relationship despite the difficulties?
Me not giving a shit anymore.  Not having as many expectations about Doc being present for stuff. {Love you too, dear.}
What is your favorite "trauma story" ever?
The Coke bottle up the ass.
Has being married to a doctor ever caused tensions in your marriage?  If so, how were you able to overcome those tensions?
I think there is always tension, because I can't plan vacations without knowing his schedule, never knowing if when I have to go on a business trip I can coordinate it with his schedule, never knowing if he'll miss the next school play or other big thing in our kids' lives.  I don't think we ever overcome those tensions, we just learn to deal with them and work through them methodically and logically. {See why I married her?}
How did you two meet?  When did you know he was "the one"?  I want to know the mushy side!
{TOO PERSONAL!  DON'T ANSWER THAT!}  It was a mutual stalking and love at first sight on both sides.  {Damn it.}  Our courtship involved lots of movie rentals (when that still existed) and pub trivia nights.  {And if you want to know our top-secret pet name for each other, FORGET IT.}
Are you a doc as well?  Which of you decided he should be known as "DocBastard" and why?
I'm not a doctor.  The "DocBastard" was all his idea.
What do you work as?  It's mentioned that you work, but I don't believe it's ever been indicated outright.
I'm Wonder Woman. {Seriously, she is}
How did the name "DocBastard" come about?
I have no fucking idea.  {Yes she does!  For the real answer, see this.}
If one of your children decided that they were going to become a doctor, what advice would you give them?
We would not allow this travesty to happen.  My kids are smarter than that.
I think DocBastard has mentioned in a previous post that you work too - do you ever find it difficult to judge your own work commitments alongside raising a family, given that your husband has a really demanding job with unpredictable hours?
Of course.  That's why I have a mobile full of "to do" lists.  Speaking of lists, did you change the light bulb above the piano yet?  {No dear, I haven't.  Damn it.}  And you should all know that Doc does NOT keep "to do" lists, so I have to keep HIS lists too. {Because, fuck lists.}
What is the most inconvenient time the Call Gods decided to borrow the doctor?
Nothing naughty!  But there have been more than our fair share of dinner parties, birthdays, and middle-of-the-night interruptions which everyone is used to, including the neighbours.
Does he put his freezing cold feet on you when he finally crawls into bed?  If so, do you swat him with a pillow?
HA!  Good one!  No, it is quite the opposite, which is why Doc now wears socks and sweatpants to bed so I can't achieve my goal of foot warmth.  {Damn right!  I have no idea why her feet are always so cold, even in summer.}
What is your favorite book?
George's Marvelous Medicine by Roald Dahl.
Do you read all of Doc's blog posts?
Most of them.  I usually catch up on them when I have bouts of insomnia and want something to put me to sleep.  {Gee thanks, dear.}
Do you typically talk about work (either his or yours) at home?
We talk about his work all the time, because I want to know if there were any blog-worthy traumas.  We talk about my work occasionally.  My work, though far less interesting than his, has its fair share of blog-worthy idiots.
What are the TV shows that you watch together?
Game of Thrones.  I can't believe we have to wait until April for next season, damn it. {I know!  Damn it.}
What about Doc drives you crazy?
Staying up until all hours of the morning writing this fucking blog.
Would you ever go back to school, and if so, for what?
Asking if I want to go back to school is like asking me if I want to be pregnant again.  HELL NO.
What is your biggest regret?
Eating that sushi when I knew I shouldn't have.
Is Doc really a bastard?  I doubt it, but the question begs to be asked.
I've never seen him at work, so I have no idea if he really is a bastard there.  But if he were a bastard at home, he'd be a homeless bastard.  So, no.
What is Doc's most irritating habit?  And what do you think he would say is yours?
Pen flipping!  His fingers are always moving.  As for me, he would say that my most annoying habit is asking him to do something and then doing it myself if he doesn't do it in what I consider a timely manner {which, for her, is about 0.482 seconds}.  I also squeeze the toothpaste tube from the middle. {Come on!  The tube even tells you to squeeze from the bottom!  Grrrr...}
Do his stories ever gross you out?
No, I can't remember him ever showing me anything that really bothered me.  Everything is fair game, and I think our kids are even used to it by now.
How often does Doc tell you stories from his work that you'd have preferred not to hear?
Almost never.
When you and Doc get a chance to plan a "date night", what activity do you prefer?  Quiet evening at home, dinner and a movie, dancing and drinks at the club, evening at a play or opera, comedy club, or . . .?
As we both are actually spies, it's really hard to accommodate our day jobs and our parallel lives as spies.  But if we actually did have time, we would choose dinner and a movie. {Or would we?  Dun dun DUN!}
If a movie of Doc's life were to be made, what actor would you choose to play him?  Who would/should play you?
Oh, that's easy.  Doc would have to be played by Denzel Washington, and I would be played by Salma Hayek.
Mrs. Bastard - you really don't mind him calling you "Mrs. Bastard" on the internet in front of everybody?
He calls me WHAT?  Oh my god, you're right!  Stop the press!  Let's go back and change every blog post ever!  What was I thinking?  I should have a little more self respect!  Actually no, "Doc Asshole" and "Mrs. Asshole" just don't have the same ring to them.  I think DocBastard and Mrs. Bastard hold.
If Doc wasn't a doctor, what career do you think he would have chosen or been good at?
He would be a plumber.  Not a good one. {I'm pretty sure that isn't true.  And I resent that.}
Mrs. B. - I find it fun to ask for the impossible and watch people work really hard to give it to me.  Your hubby seems up to a challenge so hopefully you are as well.  Here goes - please describe) as best as possible because I am quite sure there is no such thing) a typical day in the life of the Bastard family.
Boring and routine, just like pretty much every other family in the world.  Go to the gym, wake up, shower, get kids to school, go to work, worry about all my lists, make more lists, do some shit on the lists, come home, get kids home from school, look at dinner list, take something out of the freezer and check it off the list, nourish the Little Bastards (Doc too, if present), bathe the Little Bastards, put Little Bastards to bed, do more work, go to bed.  Rinse, lather, repeat.
Does Doc ever bring his work home with him?
He is always working because he has patients in hospital all year round.  There is little work-associated mess that comes home, and he were to make a mess, you better believe he would clean it up. {I believe in always cleaning up my own mess.} 
So there you have it, folks.  Hopefully after reading that you can understand why I snatched up this woman before some other guy grabbed her.  A sincere thanks to everyone who submitted a question.  If you have any others, you'll just have to wait until next year's interview (assuming she hasn't had me assassinated by then).

Oh, and if you're wondering - yes, Salma Hayek.

Saturday 19 December 2015

2015: The Year The Food Industry Gave In To Anti-GMO Fear Mongering

I've had several requests to write about GMOs on this blog, but so far I have not taken up the mantle.  It's a huge topic that is very poorly understood by the general public, and I've been loathe to tackle the subject.

Until now.

My editor at The Daily Beast asked me to write an "End of the Year" wrap-up-type article, and I asked (read: begged and pleaded) if I could write a satirical 2015 summary a la Dave Barry, the fabulously hilarious columnist who has done just such an article every year for as long as I've been reading the newspaper.  If you've never read any of them, click on that link.  Seriously, do it now.

Anyway, the answer I got from her was a resounding "no".  She was asking for a real article, one that was thought-provoking, interesting, and sciency with real actual science and stuff.


So here is what I came up with.
Since it was published earlier today I've already gotten a few vitriolic tweets directed at me:

Tweets like these tend to make me very happy, because they offer no actual response to the content of the article, just worthless, childish name calling.  I would welcome some actual dialog about GMOs, because that might offer me a chance to educate some misinformed folks.  But just like antivaxxers and creationists, the anti-GMO crowd seems to have already made up their collective minds, despite the lack of evidence that GMOs are in any way unhealthful.

But they're genetically modified!  That's über-scary!  Frankenfood!  Frankenfish!  AAAH!!!

Nope, not scary.  Just an unfortunate name.  If they had been called "healthy fuzzyfoods" none of this uproar would have happened.  Ok, that's probably not entirely true, but I think you get the point.

I welcome (relevant) comments, concerns and research regarding GMOs below.  However, any and all so-called "articles" from Natural News, Mercola, Greenmedinfo, and their ilk will be deleted with extreme prejudice.

And don't worry - this won't replace my usual weekly post.  Coming this week - the interview with Mrs. Bastard.  Stay tuned.

[UPDATE 10 July 2020]
I have been informed by a very intrepid (and thorough) reader that there are several broken links in the Daily Beast article above. Unfortunately I have no ability to update the dead links on their website. However, the most important article, "An overview of the last 10 years of genetically engineered crop safety research", can be found by clicking here. Thanks very much to the alert reader for catching it and notifying me.

Monday 14 December 2015

Better than I

Yes, the title is "Better than I", because I'm an obnoxiously pedantic stickler for grammar, and "better than me" is grammatically incorrect.  So there.  And yes, "So there" is a sentence fragment, because I also have artistic licence.  Huzzah!

Anyway . . .

I've never really considered myself much of a wordsmith (though MomBastard and DadBastard might disagree with me), especially when it comes to speaking aloud.  When I write words on the page, however, I somehow (usually) manage to get relatively coherent thoughts from the deepest bowels of my brain onto the paper (virtually speaking), and it occasionally even comes out with some modicum of eloquence (though not in this post, apparently).  But sometimes, believe it or not, I find myself at a loss for words.  It doesn't happen often, and it always involves something surprising, shocking, or wholly unexpected.  When I find myself in this situation, I find it difficult (and sometimes impossible) to express myself.  The words which do tumble effortlessly out of my mouth in times like these resemble something a bridge troll might say.

Fortunately Glen (not his real name™) had no such tongue-tying problem.

Most of my patients bring themselves to me.  Not literally, of course.  What I mean is that most of them have done something that have caused their injury, either directly or indirectly.  A select few, however, are actually innocent victims, and through no fault of their own find themselves with a hole in something that needs fixing.  Glen fell squarely into that category.  He was on his way to his car after finishing his night shift at a store when he was carjacked.  He had undergone training at work and was taught to comply with the bad guy, so Glen did everything the bad guy screamed at him to do - get out of the car, hands in the air, give me the keys.  But as the bad guy got into his car, he turned around and shot him anyway.

This makes me believe that "mankind" is one of the English language's great oxymorons.

Glen was brought to me shortly after midnight as a "Level 1 gunshot wound to the chest".   These patients are usually either A) dead, B) alive but actively dying, or C) completing the act of dying when they roll through my door, but not Glen.  Unlike the usual pale, sweaty, and/or unconscious gunshot wound victim, Glen was sitting up on the stretcher, making jokes with the medics.  With a blood stain on his shirt. 

Um . . . what?

"Hey there Doc, this is Glen," the medic started.  "He was carjacked and shot this evening.  He has two gunshot wounds, one to the left shoulder, and one to the right chest.  No active bleeding.  He's been stable the whole time, blood pressure is 125/60, heart rate is 65, oxygen saturation is 100% on room air."  

A quick glance at Glen's wounds revealed that the medics had described him exactly right.  It appeared as though the bullet had gone into the back of his left shoulder, through both sides of his thorax, and out through his right chest.  I immediately started ticking off all the vitally important structures between those two holes:
Approximate location of Glen's wounds
  • Heart
  • Lungs
I initially stopped there, because just those two organs (ok three, technically) are enough to make any trauma surgeon incredibly nervous.  But unfortunately there is much more: aorta, pulmonary arteries, pulmonary veins, superior vena cava, left innominate/subclavian artery...

You get the idea. 

As I was looking at him quizzically, wondering how he was still alive let alone looking healthier and in a better mood than I (other than the several holes he had in his body that I did not), he flashed me a huge smile and said, "Hey Doc, how long do you think this will this take?  I have to be at work at 10."

Wait, wait, wait.  You just got carjacked and shot, and the thing you're most worried about is being on time for work?  The same work where you just got shot?  What kind of person does that?

I liked him instantly. 

I explained to him that he may have serious, life-threatening injuries, and he may need a huge life-saving operation depending on what those injuries were.  Since he was so stable, I sent him for a CT scan to see where this magic bullet had gone and what it had hit (or not).  As the pictures flashed on the screen, the look on my face must have gone from incredulity to amazement and back again.  The bullet had gone into the back of his left shoulder (missing his scapula), through his left trapezius muscle, between two ribs (fracturing neither of them), grazed the left lung (which was not collapsed), into the left pectoralis muscle (missing the subclavian artery and vein), through his sternum, through his right pectoralis muscle, and back out into the outside world.  Of all the major structures between the two holes, the bullet had hit exactly ZERO of them.  All he had was a fractured sternum.

As soon as I finished looking at the scans (and picking my jaw up off the floor), I went to give Glen the news.

"Well Glen, I have some good news and bad news.  The good news is that the bullet did no major damage to anything."
"That's great!  What's the bad news, Doc?" he said.
"The bad news is that I need to keep you here in the hospital overnight, and you're going to be late for work."   I tried to tell him how lucky he was, but my brain locked up.  I couldn't think of anything witty or even remotely interesting to say.

Glen had no such issues.  He flashed me another huge smile, gave me a high five, and summarised the situation better than I ever could:

"Well ain't that some shit."

Yes, Glen.  Yes it is some shit.  Those probably aren't exactly the words I would have used, but hell, who needs eloquence anyway.

Tuesday 8 December 2015

The Hospital

The hospital is not a safe place to be.  That may sound counterintuitive to some, but those of you in the medical field know exactly what I mean.  Whenever I have a patient who is hesitant to leave even though they meet discharge criteria, I always tell them the same thing: the hospital is not where they want to be.  

"Remember, this place is a big building filled with lots of sick, infected people.  If you are not one of them, you should not be here."

That usually gets the message through. 

Having said that, not every patient even needs to be admitted in the first place.  Far from it.  In fact, most patients who are seen as emergencies and/or traumas do not needed admission, and I make every effort to prevent people who don't need to be here from being here a second longer than they have to be. 

Margaret demonstrated this point quite elegantly recently.

Transfers from outside hospital always must be taken with a grain of salt.  A very large grain of salt, approximately the size of the iceberg that sank the Titanic.  Whenever I get a call for a consultation from Outside Hospital, the rationale is always the same: they want the patient out of their hospital and in mine.  Perhaps we offer services or specialists they don't, perhaps their hospital is full, perhaps the emergency physician has a brain the size of a newt's and can't make a damned decision.  Regardless, they usually say anything they can to make that transfer happen, even when that transfer isn't at all necessary.  The emergency physician at Outside Hospital (not its real name) called me about Margaret, an elderly woman in her 70s who had fallen.

Her: Hi, Doc.  So I have this very nice 70ish year-old woman who fell and has multiple left-sided rib fractures on CT. 
Me (impressed and surprised it isn't total bullshit): Oh? That sounds bad. Tell me a little bit more about her.
Her: Well, she is 75.
Me: ...Yeah, you said that.  And?
Her: Uh, well she has a history of COPD.  She's been having increasing difficulty with pain control and has been having problems breathing since the fall because of pain.

It sounded like a reasonable request for a transfer, but something about the tone of her voice made me suspicious.

Me (suspicious): Any other pertinent history?
Her: Just hypertension, which is well-controlled.  Her vital signs are all normal and her oxygen saturation is 95% on room air {which is normal, especially for someone with COPD}
Me (more suspicious): Any other injuries?
Her: No. The CT scan shows no pneumothorax or hemothorax.
Me: (even more suspicious): Wait, when did you say her fall was?
Her: (pause)… Six days ago.
Me: …
Her: Hello?

Yes, Margaret had fallen nearly a week ago but had not sought medical care.  She had been treating her pain at home with ibuprofen and aspirin, which was (obviously) not sufficient.  Ordinarily a patient like this with isolated rib fractures would be admitted to the hospital for pain control with narcotics only for a day or two.  Once the pain is controlled, I would have sent her home with oral narcotics to allow the ribs to heal themselves, which takes 6-8 weeks.  I explained this carefully (read: slowly and repeatedly) to the emergency physician (who should have known all of this already), but she felt that I should be the one to give her narcotics.

Me: Wait, what have you given her for pain so far?  Morphine?  Hydrocodone?  Oxycodone?  Hydromorphone?  Fentanyl?
Her (whispering): Uh, nothing.
Her: ...
Me: Weeeeell, instead of the added expense of transferring her to another hospital, why don't you try, I don't know, giving her some goddamned pain medicine? You can give her the exact same medicine I would give her!

There is a very large possibility that may not be exactly what I said, and there is a slight possibility that I withheld all of the other colourful language that immediately sprang to my brain.  I tried to explain to the emergency "doctor" that all Margaret needed was some pain medicine to get on top of her pain, and then a prescription for something to go home with.  If she could prevent a woman like that with COPD from staying a moment longer in the hospital than necessary, that would be ideal.

She seemed completely shocked by the idea of actually treating a patient.  Nevertheless, she grudgingly agreed to try and only call me back if she were unsuccessful. 

Perhaps surprisingly, I didn't hear back from her.  Margaret got her pain medicine and went home where she belonged.

This is not meant to be a commentary on emergency physicians (ok, maybe a bit), but rather on the importance of using your brain.  Much like a delicious dark chocolate bar (fuck you, white 'chocolate') sitting uneaten on the shelf, an unused brain is worthless.  

Wednesday 2 December 2015

The REAL truth about that coffee mug

I'm talking about "that" coffee mug.  The only way you wouldn't know what the hell I'm talking about is if you don't follow me on Twitter, and if you're reading this, I find that hard to believe.  Seriously, there's a little "Follow me" button right over there ----->

Go click it.

Regardless, for those few of you who still have no idea what I mean, here is the coffee mug in question:
It's a hilarious, if not sadly accurate commentary on the state of medicine in 2015 that has been making its way around the Internetosphere over the past few days.  I've written about exactly this issue in The Daily Beast (it was the first article I wrote, in fact), and I've continued talking about it to whomever is unlucky enough to listen to me.  So it was with great amusement that I came across and tweeted this picture yesterday, and it was with the same great amusement that I showed it gleefully to Mrs. Bastard, who was just as amused as I.

Not everyone is amused, however.

Some people are taking it way too seriously, like Dave deBronkart, also known as "e-patient Dave", a blogger at  This morning my wife forwarded me a piece that Dave wrote this week titled "The truth about that 'your Googling and my medical degree' mug" in which he says that Googling is not a sign of patients thinking they are doctors, it is a sign of people making themselves "engaged, empowered, e-patient(s)".

Dave quite correctly says that a well-informed patient is a good patient - one that partners with his doctor to come to a decision that is best for the patient.  He also quite correctly says that doctors who insist they are right are terrible practitioners, because no one knows everything about everything.  I can not and would not disagree with anything Mr. deBronkart said.  That is not "the truth" about the mug, however.

What I would disagree with is Dave's main point - that patients who use google to learn about their condition are necessarily well informed, and therefore better patients.  They may be, but it all depends on where they get their information.

As an experiment, I googled "colon cancer".  It took google exactly 0.27 seconds to come back with 14.5 million hits.
Scrolling down through the results, the information is generally excellent - the Mayo Clinic, medicinenet, and the National Cancer Institute, the American Cancer Society, the National Library of Medicine, webMD, and MD Anderson are the first 7 hits (Wikipedia is the 8th).  If anyone were to read any of those sites, the information would most likely be highly accurate, and that patient would end up better informed for reading it.

But not everyone reads those articles.  Googling "colon cancer cure" gave me 1.75 million hits, and there it was on page 2: "Lindsey: Cures Colon Cancer With Cannabis in 48 days".  Of course this is a much sexier title than "Treating bowel cancer", and of course the headline is designed to encourage clicks. And what the article does is chronicle a woman's story of conventional colon cancer treatment with surgery and evil toxic Big Pharma chemo, followed by a supposed cure with cannabis oil.

Unfortunately not everyone is going to look up conventional (read: effective) treatment of colon cancer, because conventional is the alternative to the evil toxic Big Pharma chemo that people are looking for these days.  Going one more step down the rabbit hole, I googled "colon cancer alternative", which yielded nearly 7 million hits.  And that's where the real BS starts:
You can see where I'm going with this.  And that is just for colon cancer.  I wisely decided not to delve into some of the more controversial medical diagnoses, like fibromyalgia, chronic Lyme disease, and adrenal fatigue.

The internet is truly a wonderful cache of medical knowledge, full of useful information.  But it is also a vast wasteland of pseudoscience, questionable practices, and outright bullshit.  What makes it so dangerous is that many people can not tell the difference.

Do I discourage my patients from researching their conditions?  Absolutely not.  Well-informed patients are almost always easier to talk to (and by extension easier to care for).  But I always refer patients to reputable websites, and advise them to avoid questionable sites.

And Natural News should be avoided like the plague.

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...