Saturday, 31 December 2016

New Year's Resolution

I'm not perfect.  That should surprise none of you, least of all Mrs. Bastard. I do strive to improve myself in various ways, but change is difficult.  I fear change.  I try to avoid change.  So how can I resolve this incongruent conflict between stagnation and improvement?

A new year's resolution, of course!  Right?

Ha.  No.

I've never made a new year's resolution for one simple reason: they're all bullshit.  Studies show that nearly 80% of people break their resolution before January 15th, and 90% by January 30th.  Studies also show that a certain anonymous blogger made up 100% of the statistics in that last sentence.  But seriously, how many people actually keep their resolution long term?  Have you?  Of course not.  And why?

Because new year's resolutions are bullshit.

The common resolutions are obvious: lose weight, exercise more, get in shape, drink less, quit smoking, save more money, eat better.  I can't do any of those resolutions, because I'm already in great shape, eat well and exercise regularly.  Ok, none of that is true, but in all honesty exercising sucks.  I hate it, and it sucks.  Studies show that people who exercise regularly live 6 years longer than those who don't, but they spend those 6 years exercising (see statistic on statistics above).  So fuck exercise.

But as 2016 comes to a close, I decided that this will be the first time in my {redacted} years on this planet that I will make a new year's resolution.  Because why not.  These things are all meant for us to better ourselves, and who can argue with that?  So what have I chosen as my resolution?  Well it certainly isn't exercise more (really, fuck exercise).  My diet sucks, but there is no chance whatsoever at changing that significantly.  Despite my horrid eating habits, I do not need to lose weight.  And I don't smoke (obviously).

Here it is:

Yell at my children less.

I unfortunately have a very short fuse when it comes to my beautiful children.  I love them more than life itself, and sadly that fact gets pushed to the back of my mind way too often as I find myself losing my temper at them, usually for petty things.  My daughter procrastinates, my son talks too much, and these habits (among others), while bad, are not bad enough to have earned the wrath that has come down on them.

Sure I'm chronically sleep deprived and of course I'm chronically faced with stress from my job, but those are no excuse whatsoever for some of the tantrums I've thrown at them.  They don't deserve to have me take out my ire on them.  Not only that, but Mrs. Bastard gets scared whenever I yell, and that isn't remotely fair to her.  I've never cursed at them, and I've never hit them.  NEVER.  But there has been too much yelling, very little of it actually warranted.

So there it is, my new year's resolution, one I may actually keep.  All resolutions are supposed to be important, but this one especially is.  My children deserve better of me.

I had thought about "Eat fewer doughnuts" as my resolution, but I just ate two.

Mmmmm . . . doughnuts.

Monday, 19 December 2016

Lessons learned

The conversation I was having with my patient's boyfriend and father was going quite well, I thought.  I was reassuring them that Annabel (not her real name™) would be just fine.  It might take some time, I explained, but I expected her to walk out of the hospital within a week or so.  As I am a realist rather than an optimist (though some would say I'm actually a pessimist), giving such reassurance is a rare occurrence for me.  Annabel's boyfriend was therefore understandably smiling when he said, "That's great news, Doc!  So the first lesson to be learned here is wear your seat belt.  And the second is not to crash!" he laughed.  I didn't.

His smile evaporated after the next thing I said.

But I'm getting ahead of myself.  Let's go back to a more appropriate portion of the story: the beginning.

Annabel (still not her real name™) was brought to me just before 1 AM on a Saturday morning, having been ejected from the car she had been driving.  The first lesson Annabel apparently never learned was to wear your damned seatbelt, because if she had been wearing it she would not have been ejected.  The second lesson she very clearly never learned (which both MomBastard and Mrs. Bastard drilled and continue to drill into my head) was to wear a coat in winter, because Annabel was not wearing one when she was found in a pile of ice and snow.

"Hey Doc, this here is Annabel.  She drove her car through a farm."

A farm?  Just when I'd thought I'd heard it all.  My look of utter bewilderment apparently prompted the medic to continue.

"Yeah, she crashed through a whole bunch of stuff including a fence.  We found her outside the car on the ground in the ice.  She's real cold and she's been unresponsive the whole time.  Blood pressure has been fine though."

On my initial evaluation she was ice cold and indeed unresponsive.  She was moving all of her extremities (good) in an uncontrolled fashion (bad), so while I considered the possibility of a brain injury, my concern for a serious neck injury was rather low.  But my concern for an Everything Else injury remained high.  Because she was both unresponsive and uncooperative (a rather difficult combination), we intubated and sedated her to protect her airway and allow us to complete our examination.  As the anaesthesiologist was inserting the breathing tube, I performed her abdominal ultrasound.

As Annabel was a rather, ah, big girl, the sonogram was technically difficult to perform.  However, when I put the probe over her spleen I saw what appeared to be fluid between it and her left kidney.

Oh shit.

I moved the probe over to her right side and placed it over her liver, and this time there was no doubt: fluid.  Blood.  A lot of blood.

Damn.

The next several minutes were spent drawing labs and getting X-rays.  Other than a fractured left humerus, nothing jumped off the screen at me.  Even her initial lab work was normal, except for one number: her blood alcohol level was over three times the legal limit.

Sigh.  God damn it, Annabel.

The questions in my mind immediately became 1) Where was that blood coming from, 2) Was it still bleeding, and 3) What do I have to do about it?  Based on the mechanism of injury, the most likely culprits were the liver and/or the spleen (obviously), but there are several other potential sources (mesentery, omentum, bowel, diaphragm, pelvis, major vessels, etc).

Once I was sure her blood pressure was stable, we brought her over to the CT scanner.  The pictures flashed through very quickly, but even a blind parking meter maid would have been able to see the large laceration on the right lobe of her liver.  Her brain was fine, and her other scans showed no other injuries.

Fortunately the vast majority of liver lacerations stop bleeding spontaneously and require no intervention whatsoever.  Over the next 36 hours, Annabel's bleeding stopped, and her boyfriend and father showed up to claim her.  And this is where we pick up our story.

"So the first lesson to be learned here," Annabel's boyfriend started as he tapped her foot with a relieved smile, "is wear your seat belt.  And the second is not to crash!", he laughed.  I didn't. 

"Actually," I began, "the first lesson is don't drink and drive."

His smile disappeared quicker than free bagels at a breakfast conference.  He looked at Annabel, then back at me, then back at her again.  "She was . . . Was anyone else . . .?"

No, I told him, she had been alone, and it was a single vehicle accident.  He looked partially relieved, but only for a moment.  "What about the police?  Are they . . .?"

I informed him that the police never came, so because she wasn't under arrest yet, she probably had gotten away with it.  Again there was a brief moment of relief before I launched back in to it.  Annabel was still intubated, but she was awake and could hear every word I said.  Though I was speaking to her boyfriend, I made sure she understood that my somewhat gentle tirade was directed firmly at her. 

"She is damned lucky that she (you) didn't kill herself (yourself), and even luckier that she (you) didn't kill anyone else.  My wife drives my children around on these same roads, and if she (you) had injured or killed any of them, we would have a Very Large Problem."

I'm not sure how much of that conversation Annabel heard that day, but it makes little difference because she heard the exact same conversation in progressively firmer tones every day until she went home a week or so later.  

If Annabel had been wearing her seat belt, she wouldn't have been ejected and probably would have walked away from the accident.  But if she hadn't been driving drunk, the first point would be moot. 

Did she learn her lesson?  I'd like to think so.  I made sure to drive the point home with her boyfriend and father several times, and I almost demanded that they both continue drilling it into her once they took her home.  

I will humbly request that anyone reading this do the same thing. 

Thursday, 15 December 2016

DocBastard's Translation Guide

There are innumerable great things about being a doctor, and specifically about being a trauma surgeon.  I get to save lives, work with great people, work with my hands, and share stupendously stupid stories with you fine people.  But sadly it isn't all rainbows and butterflies.  Unfortunately there are downsides.  There are several downsides to trauma, including being away from my family and babysitting drunk idiots, but by far the worst aspect is talking to people.

I may not have mentioned it here (or not lately), but generally speaking, people suck.  A lot.  People lie, do stupid things, drive recklessly, are irresponsible, and don't know how to communicate so they resort to poking other people with sharp stabby things.  I realise full well that I have a job that requires me to take care of these people who suck, but they suck nevertheless.

What irritates me the most is how everyone lies.  Ok, perhaps not everyone, just . . . most everyone.  And it usually isn't just one lie, but rather a string of lies that progressively builds on itself.  Fortunately I've heard pretty much every lie out there, so I can not only detect it, but also translate it into the truth.

This post is mainly intended for others in the medical field, but perhaps non-medical-types may still find it instructive.

Without further ado, here is DocBastard's Complete Trauma Translation Guide.

Lie: I've only had two drinks.
Truth: I can't remember how many drinks I had because I lost count back when I was vomiting on my shoes.

Lie: No, I don't do drugs.
Truth: I smoked weed 5 minutes ago, 2 hours ago, 6 hours ago, and if you hand me my pants, I'll fire one up right now.

Lie: I don't know who stabbed me.
Truth: I know exactly who stabbed me, but if I tell you, he'll be arrested and I won't be able to exact my revenge when I get the hell out of here.

Lie: I'm allergic to ibuprofen, acetaminophen, and aspirin.
Truth: I ran out of heroin, and saying "Ow" is the easiest way to score some narcotics.

Lie: I haven't used heroin in 6 months.
Truth: I used heroin 6 minutes ago.

Lie: Those aren't track marks on my arm.
Truth: Those are track marks on my arm.

Lie: I have fibromyalgia.
Truth: I'm addicted to Percocet.  Please give me some.  {Note: No disrespect intended to people who actually have fibro, but plenty of disrespect to all the fakers.}

Lie: I ran out of my blood pressure medicine a week ago.
Truth: I have no idea what blood pressure medicine I take and I don't give a fuck, so I haven't taken it in a year.

Lie: I don't know why I jumped out of the car.
Truth: I don't remember why I jumped out of the car because I'm soooooo high.

Lie: I wasn't wearing a helmet because they can cause more harm in an accident.
Truth: I wasn't paying attention in science class, so I don't understand the spread and absorption of kinetic energy.

Lie: That packet of white powder that you just found in my ass isn't mine.  I'm just holding it for a friend.
Truth: I can't think of a better lie right this second.

Lie: So there I was cleaning my bedroom in the nude, and I slipped and fell on the dildo, and that's how it got stuck in my ass. One-in-a-million shot!
Truth: You know exactly what happened.

Lie: This is the first time I've ever driven drunk.
Truth: I don't remember all the other times I've driven drunk.

Lie: This is the last time I'll ever drive drunk.
Truth: Until next time. 

Lie: This was my first time trying PCP.
Truth: Name a drug, any drug.  Yeah, I've tried it.  That one too.  Aaaand that one. 

Lie: There's no way I could be pregnant.
Truth: I have unprotected sex all the time. {Thanks to ndenunz for the reminder.}

Lie: I don't know why he shot me.
Truth: I created and/or put myself into a dangerous situation where I might get shot.

Lie: I ran out of Percocet and I can't get to my pain doctor for another week.  I just need a few to get me by.
Truth: This is the truth, and I know you aren't supposed to give me more, but I'm hoping you'll take pity on me. 

Lie: Yes I was wearing my seatbelt, so I have no idea how my face hit the windscreen.
Truth: I didn't even know my car had a seatbelt.

{EDIT: Thanks to Janel for these next three:}
Lie: I am NOT drunk!
Truth: Sure I'm drunk, just not as drunk as I usually get on Saturday nights. 

Lie: I just ran out of my blood pressure medication! I'll die without it! 
Truth: I haven't been compliant in months, and I just realized I'm out. 

Lie: I'm going on vacation, so I need my oxycodone filled early
Truth: I took them all already and my doc's pushover and gave me another prescription, so fill it. 

Lie: I just need a 10-pack of insulin syringes. They're for my grandma. 
Truth: I'll be shooting up in the parking lot.

There you have it.  I know there are more lies I'm forgetting, so I hope you folks can help fill in the gaps. 

And that's the truth. 

Monday, 12 December 2016

You never know

I've said several times before that surprises in my line of work are bad.  I can think of only a handful of cases where I've been in the middle of an operation and said, "Hot damn!  That sure looks good!"  I had a case exactly like that just recently (which I will be writing about in a week or two), but cases like those are few and far between.

But surprises, even bad ones, can still be fun.  One of the fun things about trauma surgery is that I often don't know what I'm getting into as I'm getting into it.  A bullet that enters the abdomen, for example, can hit literally any organ (knife wounds are not typically as severe), so I may be repairing the stomach, resecting a portion of intestine, removing the spleen, and suturing the liver all at the same time (sort of).  Before I begin each Trauma Mystery Case I always try to guess what the injuries will be, but I am usually woefully incorrect and tend to under- or overestimate dramatically.

But I'm also a general surgeon, and general surgery is more predictable.  Even in difficult cases, like perforated diverticulitis or a perforated gastric ulcer, I usually have a pretty good indication about what I'm going to have to do.  It is rare that I have no idea what's going on before I make my incision, so general surgery surprises, both intra-operative or post-operative, are much rarer.

That said, Isadore (not her real name™) surprised the hell out of me recently.  Not once, not twice, but thrice.

When the emergency physician called me and asked me to see Isadore urgently, I must have let out an audible groan, because I heard a soft chuckle on the other end of the line.  "I know, I'm sorry," she said.  "But hey, at least she's pretty healthy!"

With all due respect to all the nonagenarians out there, there is no such thing as a healthy 93-year-old woman.

Ninety three-year-old Isadore had come in due to exquisite pain in her right groin for the past day or so, and it was associated with multiple episodes of nausea and vomiting.  The emergency doc described her symptoms and medical history over the phone and told me that she had already ordered a CT scan of Isadore's abdomen, but I didn't even need to see it or hear the results to have a really strong suspicion what was going on.  That pattern is most consistent with an incarcerated femoral hernia with obstruction.
Essentially a loop of intestine gets caught in the femoral canal, a very small space in the groin where the femoral artery, vein, and nerve penetrate from the pelvis into the thigh.  Femoral hernias are much more common in women, especially older women, and they can be surgical emergencies if the blood supply to the entrapped intestine gets cut off, causing that loop of intestine to die.

"So the CT scan shows small bowel obstruction due to a right groin hernia, but no sign of dead bowel" the emergency doc concluded.  I didn't tell her that I already knew that, because believe it or not I don't enjoy acting like a know-it-all fuckwit that often.

No, really.  It's true, damn it!

I arrived a few minutes later and looked at Isadore's CT scan and blood work before going to see her.  Fortunately the scan did not show any indication that her intestine had been compromised.  Her lab work was all stone cold normal, and while there was definitely a loop of small intestine in her right groin where it did not belong that was causing an obstruction, that loop did not appear thickened (which indicates inflammation), and there was no fluid around it (which can indicate vascular compromise).  Hopefully I could simply push the intestine back where it belonged, relieve the obstruction, and send her home the next day.

Now before I go on, I should say that there are young old people and there are old old people.  I see people in their 70s who could easily pass for 60, and I conversely see people in their 50s who look 80.  But never in my life have I met anyone in their 90s who didn't look like they belonged firmly in their 90s.

And as I walked into Isadore's room, she looked exactly as I expected a 93-year-old woman to look: like a 93-year-old woman.  Her sparse white hair was sticking out of her wrinkled head at angles I didn't even know existed, her skin was hanging from her hands like tinsel on a department store Christmas tree, and I think her entire facial complexion was one huge age spot.

Sigh.  This was clearly not someone I wanted in my operating theatre tonight.  Or ever, for that matter.  Surgeons do not relish the idea of operating on someone that would even make Methuselah think "Wow, she's freaking OLD".

On my initial evaluation, her abdomen was not tender at all, but there was a distinct bulge in her right groin that was quite painful.  I tried pushing on it gently to get it to reduce back into the abdomen, but it wouldn't budge.  Even after I gave her some IV sedation, the damned bowel just would not reduce.

Damn it.  DAAAAAAAMMMMMMNNNNNN IT.  I do not want to operate on her.  I do not want to operate on her.

My Inner Pessimist tried thinking of some excuse for me not to take her to surgery immediately, but I was able to beat him back.  I reluctantly told her and her son (who was himself an old old person) that she needed immediate surgery, and I even more reluctantly called the operating theatre to ask them to ready a room for me.  About an hour later I made my incision just above her groin crease, dissected down to the hernia sac, and cleared it of overlying tissue.  As I suspected it was indeed an incarcerated femoral hernia.  But when I opened it, I got my first shock from Isadore:
Not Isadore's bowel
The neck of the hernia was so small and so tight, it had completely cut off the blood supply to this very small (perhaps 3 cm-long) segment of small intestine.  Her incarcerated femoral hernia was actually a strangulated femoral hernia.

What the fuck?  Dead bowel?  How the hell was that even possible?  Her blood work showed no indication of that, nor did her scan!  But whatever the case, thank god I hadn't been able to reduce the hernia.

DAMN DAMN DAMN

My hernia repair had just gotten about 10x more difficult, and 100x riskier.  Instead of just pushing her bowel back into her abdomen and repairing the hernia, I now had to remove the dead portion of intestine and then repair the hernia.  After opening up the hernia defect just a bit, I was able to get a bit of normal intestine through the hole.  I transected the bowel on either side of the dead portion and put the two ends back together.
Not a real photograph™
I then repaired the hernia using only her 93-year-old tissue.  Small bowel resections like these are fairly routine, but nothing can be considered routine in a patient this old, especially with dead bowel.  As soon as I was done I informed her son that my part of the procedure was done, and the rest was up to her.  I never can predict how extremely elderly people will react to surgery and anaesthesia.  Some folks just never seem to recover, and they dwindle, usually rather quickly.

My next shock from Isadore came the next morning when I was doing my morning rounds.  I checked Isadore's vital signs and found them completely normal.  I then went to check on her, and found her to look just as completely normal.  She had no pain whatsoever, she was hungry, and she had walked overnight several times to the restroom.  In short she looked better than the vast majority of my patients one fifth her age.

Uh . . . Hm.  Well ok then.

The following day Isadore continued her recovery, and on the morning of the 3rd postoperative day she was passing bowel movements and eating regular food, and I sent her home without her having taken a single pain pill during her entire hospitalisation.

My third and final shock from Isadore was two weeks later in my office for her follow-up appointment: she still looked like a peach.  After her lightning-quick hospitalisation I suppose I shouldn't have been surprised at all.  I could barely see my incision (if I do say so myself), she was still pain-free, bulge-free, and complaint free.  It was like the entire event had never even happened.  I think I was more scarred by the experience than she was.

Though the course of this case went essentially as perfectly as I could have possibly hoped, one thing it will not do is make me any less nervous the next time I have to operate on someone who is nearly old enough to remember World War I.  Staying nervous helps keep my honest, keeps me on my toes, and keeps me humble.  Complacency leads directly to mistakes.

But it just goes to show that in my line of work, not all surprises are necessarily bad ones.

Monday, 5 December 2016

A day in the life

Woke up, fell out of bed, dragged a comb across my head. 

Don't worry, this isn't a post about music, though that would admittedly be a pretty freaking awesome thing to write about.  Ever since my recent push into politics I've thought about expanding the scope of this blog beyond just medicine, but whenever that stupid thought stupidly flits across my stupid brain, I realise that I don't have much else to say.  And that's rather sad.  Regardless, this post is not about the Beatle's song "A Day in the Life", it's about a day in my life. 

Several people have asked me what a typical day is like in the life of a trauma surgeon.  What I go through, the kinds of patients I see, what I actually do from minute to minute, etc etc etc.  So here, ladies and gentlemen, is my well-thought-out, eloquent, and completely unexpected answer:

There is no such thing as a typical day.  

THE END




Ha!  That sure was easy!  Time for a beer.

What?  What do you mean that isn't good enough?  You mean you want more?  You want actual details?   You do realise that when I typically go into details many people run the opposite way screaming.  You're sure?

FINE.  You're awfully demanding, did you know that?

Let's see, where to begin.  Well, I'll omit the part where I wake up, usher my little monsters out of bed, try to corral them into the kitchen to get them to eat something that resembles a healthy breakfast, help Mrs. Bastard prepare their lunches, and try to find time for my morning cappuccino.  Mmmmmmmm . . . cappuccino . . .

That reminds me, I've only had one coffee today, and today is most definitely a two coffee morning.  I won't bore you with those details either.

Wait, where was I?  Oh, right.  I was trying not to bore you with details of my morning and failing miserably.  Alright then, back to business.  I'll do my best to describe a call day I had recently, which was typically typical for a typical call day.  These are the actual approximate times in my day, starting with . . . 
  • 7:58 AM Arrival at hospital.  Fuck you traffic, I'm two minutes early!  Ha!  Plenty of time for another coffee.
  • 7:59 AM (yes seriously) My pager alerts me to my first car accident of the day, fortunately not my own as I hadn't even gotten out of my car yet and nearly spilled my first coffee of the day which Mrs. Bastard had very kindly put in a to-go cup for me.
  • 9:00 AM My second car accident of the day.  Still working on reading Car Accident #1's CT scans.
  • 10:05 AM Discharge Car Accident #1, working on fixing lacerations on Car Accident #2.
  • 10:30 AM Discharge Car Accident #2.  Breathe.
  • 12:05 PM Lunch. Chicken, rice, broccoli. Hate myself for eating healthfully and look for a doughnut.  Fail.  Eat more broccoli instead.  Damn it.
  • 1:38 PM Car Accident #3.  So far. 
  • 2:10 PM Car Accident #4.  Car Accident #3 is still getting X-rays done.
  • 3:00 PM Wait for radiologist to read films, catch up on dictations.
  • 3:55 PM Level 1 car accident (#5).  She is morbidly obese, approximately 200 kg, sustains massive internal injuries.
  • 4:45 PM Pronounce Car Accident #5 dead.  Discharge Car Accident #3, admit Car Accident #4 for his fractured femur.
  • 5:04 PM Car Accident #6.  
  • 5:04:05 PM Curse Call Gods for making this a Shitty Car Accident Day.
  • 6:30 PM Stuff dinner into my mouth, if you consider cold leftover chicken and more fucking broccoli to be dinner.
  • 7:05 PM Admit Car Accident #6 for multiple rib fractures
  • 8:11 PM Car Accident #7.  Goddammit.
  • 9:05 PM Catch up on dictations.
  • 11:15 PM Lie down to try to sleep.  Fail.
  • 12:54 AM Level 1 fall.  Turns out to be an extremely drunk asshole who fell while trying and failing to fight gravity.
  • 3:05 AM Level 1 stabbing victim, stabbed in the head.  Active bleeding from the scalp.  Place suture to stop bleeding, order CT scan.
  • 3:21 AM Level 1 stabbing victim #2, stabbed in the abdomen.  Examine his abdomen (which is benign) while the first stabbing victim gets his brain scanned (no brain injury, just a scalp haematoma).
  • 3:25 AM Level 1 stabbing victim #3, stabbed in the chest.  Put in a chest tube, drain 500 ml of blood from his left chest.  Order chest X-ray.
  • 3:26 AM Level 1 stabbing victim #4 (yes, really).  Stabbed in the chest, arm, and leg.  Doesn't seem to be dying.  Order chest X-ray.
  • 3:50 AM Check on first three stabbing victims.  None of them appears to be dying.  Look at X-rays.
  • 4:35 AM Finish viewing X-rays and CT scans on all 4 stabbing victims, find no other serious injuries.
  • 4:39 AM Admit Stabbing Victim #3.
  • 4:50 AM Begin repairing Stabbing Victim #1, 2, and 4's lacerations.
  • 5:55 AM Finish discharge Stabbing Victim #1, #2, and #4 home.
  • 5:56 AM Breathe
  • 5:57 AM Run (slooooooooooooooooooowly) to call room
  • 5:58 AM Lie down
  • 5:59 AM Realise I still have a shitload to do
  • 6:00 AM Get up
  • 6:02 AM Walk down to lounge to get a coffee
  • 6:04 AM Coffee #1
  • 6:10 AM Catch up on dictations
  • 7:00 AM Coffee #2
  • 7:15 AM Make rounds
  • 8:00 AM Fuck this place.
So there you have it.  There have been no exaggerations here, and believe it or not this doesn't remotely approach the busiest call day I've ever had.  The number of patients this day (14) was just slightly above average, though the acuity (6/14 were level 1) was higher than normal.

So now you can stop asking.  And if you've never thought to ask, now you never have to.  You're welcome, I think.

Monday, 28 November 2016

Absolutely positively pretty sure

I'm in a fairly comfortable position in trauma surgery, in that I don't always have to be 1) certain or 2) correct.  That might not make a whole lot of sense on the surface, so let me explain.
  • Orthopaedic surgeons have to be 100% positive they are replacing the right, er, I mean the correct hip
  • Urologists have to be 100% positive they are removing the correct (ahem) testicle
  • Surgical oncologists have to be 100% positive they are removing the mass from the correct breast 
I, on the other hand, only need to be pretty sure that there is something catastrophically wrong with someone's chest or abdomen before I slash him open.  If I wait until I'm 100% positive, I could risk serious consequences, like people dying and stuff.  Not only do I not require conclusive evidence, I could even be wrong and the patient may not need an operation at all.  But a trauma surgeon will never be criticised for performing an unnecessary laparotomy or thoracotomy.

Ok, that's not entirely true and I'm exaggerating slightly.  But only slightly.  I should clarify that as long as the surgery is indicated, the surgeon will never be considered wrong, even if there's nothing actually wrong.  After all I can't justify cutting open someone's abdomen if he's been shot in the foot, for example.  However, a patient who arrives in my trauma bay in profound shock and actively dying without an obvious source (ie blood pouring out of his neck) may be justifiably taken for immediate chest and/or abdominal surgery if there is a strong enough suspicion that there is something in one of those cavities that is causing imminent death.

Of course I need to do everything I can to ensure that the surgery is actually indicated, but sometimes there isn't time to verify.  And even if I'm wrong and the problem was elsewhere (sepsis unrelated to the car accident, for example), that is a risk I have to take in order to potentially save his life.  I don't have be completely 100% sure, I don't have to be right, I just have to be pretty damned sure.

I hope that makes sense now.

That being said, I love being sure, I hate being wrong, and I love being right.  And that was most definitely 100% the case with Trent (not his real name™).

I was in the middle of reading a scintillating article on the treatment of pancreatic cancer (ZZZZZZzzzzzzzzzzzzzzzzzzzZZZZZZZZ) when my pager alerted me to a level 1 stabbing victim arriving in 10 minutes.  I looked at my watch and nearly gasped - it was just after 2 PM.  Getting a stabbing victim in the middle of the day is a bit of a luxury.  Operating in the middle of the day rather than the dead of night?  It's almost like a vacation!  I casually tossed (read: aggressively threw) the fascinating (boring as hell) journal aside and ran down to the trauma bay, excited to get a serious trauma while the sun was shining.  Five minutes later I met Trent, though I can't really say that Trent met me, because he was nearly unconscious.  He was moaning and could barely open his eyes.

"Hey Doc, this is Trent.  He's young, maybe 25 or so, single stab wound to the chest."

They had already disrobed him, and despite the cool weather, Trent was sweating profusely.  UH OH, my Inner Pessimist groaned.  A quick survey of both his front and back (never forget to look at the back!) informed me that the medics hit the nail right on the head - one solitary stab wound just to the right of the sternum (breast bone).  I whipped out my handy dandy, um, heart-listening doohicky thingy . . . you know, that thing that goes in your ears that surgeons rarely use . . . whatever.  Anyway, his heart was beating, but for such a young guy it didn't sound very loud.  His breath sounds were normal and equal on both sides, so I doubted he had a serious lung injury.  His heart, on the other hand . . .

A stab wound to this location can go pretty much anywhere and hit pretty much anything - right chest, left chest, abdomen, mediastinum (which contains the heart) - but I strongly suspected my Inner Pessimist (who was screaming "IT GOT HIS HEART, DUMBASS!  IT GOT HIS HEART!!" repeatedly) was right.  I just wanted to be sure before I slashed open his chest.  Or at least pretty damned sure.

While the radiology techs shot a chest X-ray (which was normal, no sign of a pneumothorax), I ran over to get my ultrasound machine.  A sonogram in trauma takes less than a minute and is designed to do one thing: detect fluid where it does not belong, either in the chest or in the abdomen.  I listened to my Inner Pessimist (who was still screaming something about the heart directly in my ear) and put the probe on his epigastrium just under his breastbone first, aiming up at his heart.  Despite doing trauma for {redacted} years, I have still seen very few positive trans-thoracic echocardiagrams, because these folks usually die before reaching me.  This study looked . . . hm, weirdly positive, I thought.  It looked like there was fluid within the pericardium, the sac that surrounds the heart.  In an elderly person with congestive heart failure this could be considered normal, but in a normal healthy young guy with a stab wound to the chest, it always means a hole in the heart.  Well, almost always.  Pretty much.  But having seen so few positive studies, I still wasn't 100% sure.

Knowing I didn't have to be 100% sure (but still wanting to be), I completed the sonogram of his abdomen (which took about 45 seconds) and saw no fluid around his liver, kidneys, spleen, or pelvis.  ("THE HEART!  THE HEART!").  Just to be the tiniest bit surer I went back up to his chest, and again there was that thin line of black (fluid) around his heart where only white (tissue) should be.

I was now absolutely positively at least 95% pretty sure that the knife had pierced at least the pericardium, if not the heart itself.  That was more than enough for me and Trent.

About 15 minutes later we were in the operating theatre, and on the way I explained to him that I was going to open his chest and repair his heart.  I am unsure if he heard most of what I said, and I'm even less sure that he understood any of it.  As he was put under anaesthesia, I did the one thing I had been wanting to do since he arrived: I put my finger into the stab wound.  Gently.  For me this is the most accurate method of demonstrating that a knife (or gunshot) wound penetrates into some cavity where it should not have been.  I felt my finger slide between two of his ribs (one of which had been fractured by the knife), and the tip of my finger nestled right onto something that was beating, moving rhythmically at exactly the same pace as the monitor was beeping.

My "95% sure" was now 100%.

Five minutes later his sternum was split in half.  I opened his pericardium, and there to greet me was a 2 cm laceration in his right ventricle.

In case you hadn't guessed, that's considered a Very Bad Thing.

The key in this situation is to stop the bleeding.  Initially, this is very easy to do - I stuck my finger over the wound to plug it.  This allowed the anaesthesiologist time to catch up with resuscitating him, and it allowed the nurses time to get the supplies I needed to fix it definitively.  It only took about 15 minutes to suture the laceration, 5 minutes to look around the rest of the chest to confirm that there weren't any other injuries (there weren't), and about 30 minutes to close.  In all, it took about 75 minutes from the time he hit the trauma bay door until he was in the recovery room.

And only four days for him to walk out of the hospital.

Over those four days, unlike most of my patients Trent was extremely appreciative of our work to save his life.  He made every effort to say "Thank you", or "I really appreciate you", at every opportunity.  Trent even made it clear that he needed to shake my hand whenever I left the room.  I always make a conscious effort to treat all my patients equally no matter what, so while his appreciation did make taking care of him that much easier, I am absolutely positive that I did not treat him any differently than anyone else.

Well, pretty sure.

Monday, 21 November 2016

Doctors make the worst patients

We apologise for the recent foray into politics and now return you to your regularly scheduled stupid stories.

Yeah, yeah, yeah, everyone knows the stereotype that doctors make the worst patients.  What's funny is that I thoroughly enjoy perpetuating the stereotype because it's absolutely goddamned true.  We do make the worst patients, and I freely admit it.  I don't know if it's because we think we're indestructible or if we just enjoy living in denial that anything could actually be wrong with us.  But whatever the reason, we suck.

I will also freely admit that I personally am a terrible patient.  Fortunately I do not have any chronic medical conditions, so I don't have any prescription medication to accidentally ignore and forget to take on purpose.  But I do tend to ignore my own health, instead focusing on the health and wellbeing of others.

But getting back to people who aren't me, DadBastard is a perfect example of a doctor not taking care of himself.  He willfully ignored MomBastard's advice (badgering) to get a screening colonoscopy at age 50 like his GP recommended ("I'm too busy" was his usual excuse).  He ignored my advice (annoying constant nagging) to do it at 55.  Finally at 60 he did it . . . and it was stone cold normal.  His colon was squeaky clean.  Fortunately he resisted rubbing that fact that in our faces.  Much.

Dr. Natalie (not her real name™)  is another perfect example.

Dr. Natalie is an ophthalmologist friend of mine whom I have known for nearly a decade.  She is very friendly, very smart, and very good at her job.  I hadn't seen her in quite some time when I ran into her recently.  As I gave her a hug I noticed the cast on her right wrist.  The trauma surgeon in me was immediately curious about what happened.

Apparently she had been running early one morning before the sun was up, and it wasn't bright enough for her to see the branch on the path.  She stumbled over it, landing on her outstretched right hand.  Completely plussed (what the hell is the opposite of "nonplussed" anyway?), she finished her 5 km run, and when she got home she noticed her hand turning purple and swelling impressively.  While she suspected it was fractured, she went to work anyway, where she had a full schedule of patients to see.  As the day went on, the swelling and pain got worse, so she suspected it was broken.  Unfortunately she had a flight to catch the next morning, so she thought, "Meh, I'll just wait until I get home in 3 days to get it X-rayed".

Since she had a cast on her right hand, you can obviously guess the outcome.

What I haven't yet mentioned is the fact that I "ran into" Dr. Natalie in her office on a Saturday morning, because I had called her and asked her to see me emergently.  Because my right eye was fucking killing me. 

For, uh, the past week. 

Yes indeed, the doctor in this story who is the worst patient is not DadBastard, not Dr. Natalie, but I.  Ha!  Gotcha!  Now that is a Usual Suspects-level plot twist!

Not really. 

My eye had been hurting for about 7 days.  It had started the morning after I had done some major sanding on a project I'm currently building, and it hadn't gotten any better.  It felt like something was in there, and flushing it and rubbing my eye hadn't helped either.  It wasn't hurting to the point of preventing me from working or sleeping, but it was definitely very irritating, nearly as irritating as antivaxxers (I had to squeeze that in here somehow).

What finally made me seek care was when I woke up Friday morning and the vision in my right eye was blurry.  SHITSHITSHITSHIT.  I don't know much about the eye, but I do know that is bad.

I finally broke down and consulted someone.  No, not Dr. Natalie, at least not at first.  Against my better judgment, I saw an emergency physician.  Now before you go and start accusing me of various things, I didn't want to, I had to.  It was also rather convenient, since I was on trauma call and in the emergency department/A&E anyway.  I found a doc I know and trust (relatively speaking) and told him of the foreign body sensation I was having in that eye, and he very nicely agreed to take a look.  He put some fluorescein dye in my eye, looked with his special scope, and saw . . . absolutely nothing.  No corneal abrasion, no foreign bodies, nothing.

I breathed a sigh of relief and then immediately realised how stupid that relief was.  If it wasn't a foreign body or corneal abrasion, what the fuck was it?  Retinal detachment?  Macular degeneration?  Some disgusting parasite?  Cancer of the eyeball?  Dry eye?

Ok, I admit didn't actually think of dry eye, because my Inner Pessimist was only allowing me to think of either life- or career-threatening maladies at that point.

The next morning my vision was just slightly worse in that eye, and the foreign body sensation was also a bit worse.  E-FUCKING-NOUGH.  I had had it.  I did the last thing I wanted to do - I called a colleague for a favour on a Saturday morning.  After I told Dr. Natalie of my symptoms (including the blurry vision), she very graciously and without any hesitation whatsoever told me to meet her at her office in an hour.

After she took a detailed history, she put the fluorescein dye in my eye again.  It took her exactly 1.272 seconds (I timed it) to do a rather impressive double take.

"Oh my god, how long has it been hurting?" she gasped.

A week, I told her.

"Doc (not your real name™), you have, let's see, one, two, three . . . SIX foreign bodies in there!  How the hell have you been working like this, and why the hell didn't you call me sooner?  Most people are crying and calling for emergency appointments with ONE foreign body, and you've been living with SIX of them for a WEEK??"

I let out a small, sheepish sigh of relief combined with a slight pang of guilt and a rather large pang of stupidity.

She very carefully removed all six shards of sawdust (yes, sawdust), and after completing a full eye exam she told me that my cup-to-disc ratio was perfect (HUZZAH!) and that there was no sign of infection (HUZZAH!).  She expected the pain to last for another day and my vision to return to normal a few days after that.

And there was the real sigh of relief.

It took one glorious night of 8 glorious hours of sleep for the pain to improve dramatically.  Four days after that my vision returned to normal, or rather whatever I had previously considered normal. 

I often say that any day you learn something is not a wasted day, and I definitely learned something that day.  Yes sir, this little episode taught me a very valuable lesson: wear goggles while sanding

What, you thought I was going to say "Be a good patient and see a doctor"?  Ha ha!  No way!

I'm indestructible. 

Sunday, 13 November 2016

Real name

FAIR WARNING: THIS POST MAY ANGER A LOT OF PEOPLE.  I UNDERSTAND THIS FACT AND DECIDED TO WRITE AND PUBLISH IT ANYWAY.  MAY GOD HAVE MERCY ON MY SOUL ETC ETC.

I'm going to do something a bit different on this post.  Actually, two somethings different.  First, I'm going to use a patient's real name, and without her consent.  Before anyone asks, yes I know what I'm doing, and no I've not gone crazy.  The second different thing will be that I'll be veering away from medicine, something I've been loathe to do here.

The very keen reader will notice that the previous paragraph doesn't make sense.  But like everything I write, it will all (I hope) make sense by the end.

The patient I will discuss is sick.  Very sick.  Very VERY VERY VERY sick.  She's been sick for a long time, and recently she's gotten even sicker.  I have been following her for quite some time, though I am not smart enough to fix her.  I'm not sure anyone is.

Her name is the United States of America (her real name™).

I'm sure most of you saw that coming the proverbial mile away.

That's right people, I'm going to talk politics on this blog for only the second time (I think).  Though I follow international politics (looking at you, Brexit), I tend to avoid talking about it like naturopaths avoid evidence.  If you really want to lose a friend, bring up politics.  Pick any topic you like.  Chances are you'll be A) disagreed with, B) quickly, and C) vehemently.  No one can seem to agree on anything.

Except Donald Trump.

Everyone seems to agree that he is a misogynistic, xenophobic, homophobic, racist asshole.  Yet over 60,000,000 people voted for him.  Let that sink in for a moment - over sixty million people voted for the Apprentice guy, a man who has never held public office, whose biggest claim to fame is being a "successful" businessman (whose success is measured by not paying taxes because he lost nearly a billion dollars) and reality television star, and who seems to anger every ethnic minority (and many ethnic majorities) by spewing bile and bilge at every turn.

And he was just voted president of the United States of America.

Keep in mind that I have no dog in this fight.  This is not my circus, and these are not my monkeys.  I am an outsider looking in, but I can faithfully and without reservation say that if this were my circus and if they were my monkeys, I would not have voted for Donald Trump.  Not in a million years.  It has little to do with the fact that Trump inexplicably still believes that vaccines cause autism (I'm sure you knew that was coming) or that vice president-elect Mike Pence denies evolution and believes god created the universe in exactly six days, but more with the fact that Donald Trump is a misogynistic, xenophobic, homophobic, racist asshole (where have we heard that before).

But he won anyway.  His win without a doubt reveals one thing with incredible clarity: the United States is dreadfully ill.  The fact that such a man could be elected its leader stunned me, but it didn't surprise me (I'll explain).  Anyone who didn't see this coming doesn't follow American politics or its international effects.

Racism and hate in the United States was supposed to be solved by its first black president.  Barack Obama was supposed to fix it with hope and change.  Racism was to be relegated to history books.  Not only has that not happened, but the racial divide has actually deepened (from my perspective).  This has been highlighted by the numerous protests, change.org petitions, "NOT MY PRESIDENT" chants, tweets, blog posts, and newspaper articles about how horrible Trump is, how horrible his presidency will be, how he will be impeached, how they wish he will be a terrible president, and how Hillary Clinton should still be elected despite losing.  THAT IS NOT HELPING.

Over three million people have signed this petition (EDIT: now nearly 4 million) calling on the Electoral College to elect Clinton rather than Trump because Clinton received more popular votes.  While it may seem like that should seem to be a win, the American electoral process is not designed that way, and it has not been set up since its inception.  Just like George W. Bush in 2000 and 3 other US elections, Trump received more electoral votes, and he is therefore the winner.

Any argument about the Electoral College being obsolete and needing to be overhauled or abolished is irrelevant at this point after the fact.  That would be akin to demanding at the end of a football match that the game be extended by 10 extra minutes because your team hasn't scored yet.  You may not change the rules after the fact.  THAT IS NOT HELPING.

This election is and always was about a broken country.  The people wanted a change, and they got it, most probably more than they bargained for.  But the chanting, marching, complaining, whining, and backlash is not helping.  The anti-Trumpers who are protesting are feeding into exactly the same division that allowed Trump to be elected in the first place.  They are driving a wedge between them and the pro-Trump crowd, widening the rift, and IT IS NOT HELPING.

And this isn't just about black versus white.  It isn't just about men versus women.  It isn't just about poor versus rich.  It is fully half the country versus the other half.  Believe it or not, Trump had black, female, young, gay, Hispanic and wealthy supporters, and Clinton had white, male, old, straight, and poor supporters.  Looking at the numbers broken down it is clear that there were certain dividing lines along which folks tended to vote, but there was no group that voted 100% for either candidate.  Somehow despite what Trump has said about women, he still had the support of 42% of them, and despite what he said about Mexicans, 29% of Hispanics voted for Trump.  To me, that speaks volumes.  If it does not speak volumes to you, then you do not understand the problem and ARE NOT HELPING.

Lumping in all Trump supporters as racist, misogynistic, half-breed idiots is exactly the thing that you were fighting against when Trump claimed that Mexican immigrants were criminals and rapists.  It's the exact same thing you were fighting against when Trump endorsed closing the US borders to Muslim immigrants.  You are generalising while fighting generalisations.  THAT IS NOT HELPING.

Worse still, a New York Times book review on Hitler: Ascent, 1889-1939 published about 6 weeks ago made absolutely no effort to conceal a thinly veiled comparison of Donald Trump to Adolf Hitler.  A teacher was suspended this past week for comparing Trump to Hitler.  There are other articles all over the internet making the same comparison.  As much as I disagree with Trump's philosophy, I find the comparison to one of the planet's most reviled humans in history absolutely revolting.  Again, I do not agree with Trump, but the comparison is disgusting and IS NOT HELPING.

This is the same situation that Obama has been in for the past 8 years as I have heard claim after claim that he is the next Fidel Castro and would destroy the United States by leading it into communism.  This has obviously not happened as the United States is just fine and is still (last I checked) a democracy.

I am not saying that capitulation is the right move.  I am not saying that you should give in or give up.  If you want to change the system, then fight to change the system.  If you want your candidate in office, fight for it.  But fight for it NEXT TIME.  Fight for a candidate you believe in, whose policies you endorse, and get that person elected.  NEXT TIME.  But fighting it after the fact because you don't like the result is denying the democratic wish of half the country and IS NOT HELPING.

If you want to wait for Trump to screw something up so royally that he gets impeached or is forced to resign, fine.  Do I think that will happen?  No I do not.  Wishing that it would happen is only wishing ill on the entire country, and THAT IS NOT HELPING.

I will take a moment here to repeat that I support neither Donald Trump nor the vast majority of what he has said and done throughout his campaign.  That said, I also would not have supported Hillary Clinton, Gary Johnson, or Jill Stein for various (and altogether different) reasons.  Hell, I would have voted "DocBastard 2016" if given the opportunity, and I guaran-damn-tee you I would have made a better president than ANY of these goddamned clowns.

*deep breath*

Regardless, the people of the United States need to take a good look in the mirror, take a deep breath, and figure out how exactly they want to proceed, and how they want the next 4 years of their lives to shape up.  Fighting and whining and complaining and protesting will not solve anything, it will only make things worse and guarantee a 2020 win for Trump.

As usual, I don't have all the answers.  Hell, I don't even know if I have any answer.  Except perhaps this one:

Monday, 7 November 2016

Pure idiocy

In case you haven't noticed, recently I've tried getting away from calling my patients "idiots".  I've been trying my damndest to keep in mind that everyone makes mistakes and some people even have reasonable reasons for those mistakes.  People don't deserve to be crucified for doing stupid things, right?  Right, they simply need to be educated.  Jumping to calling people names is childish and silly (not to mention very judgmental), and I think of myself as better than that.  Call it the New And Improved Insult-Free DocBastard!

Having said that, Erin (not her real name™) is a fucking idiot.

I have never done illegal drugs in my life.  I've never felt the urge and I've never given into peer pressure, though I've been around many people who have.  I've never really understood why anyone would want to allow himself to be out of control of one's senses and/or body parts.  It just doesn't look like a good time.  Erin, on the other hand, got herself into heroin at a very young age.  At just 23, she had been in rehab twice already and was taking buprenorphine, an oral medication similar to methadone, to try to stay off heroin.

It wasn't working.  At all. 

One gloriously stupid evening 25-ish year old Erin stupidly decided that, in addition to taking her buprenorphine, she would also stupidly inject herself with heroin.  To add to the steaming, stinking stack of stupid, she then got in her car and drove . . . somewhere.  She apparently had no idea where she was going, because several minutes later she found herself in the middle of nowhere with her car wrapped around a tree.

Well, I shouldn't really say "she found herself", because she was completely unconscious and in no position to find much of anything except the inside of a morgue.  When the medics found her she was slumped over in the passenger seat next to a half-empty liquor bottle (and no, of course she wasn't wearing her seat belt).  They recognised the telltale track marks on her arm and rightly gave her a dose of naloxone to counteract the heroin they (correctly) suspected she had taken.  Normally patients who have overdosed on narcotics wake up immediately after being administered naloxone and are very angry that someone killed their high.  But not Erin.  She woke up only minimally because in addition to being high as a fucking kite, she was also drunk as a Tyrion Lannister (I greatly prefer him to skunks).

Fortunately for Erin (and unfortunately for me), she woke up a bit more on the ambulance ride to me, because when the medics oozed her into my trauma bay, she was fully awake.  And screaming.  Screaming at everyone and everything.  I've never been so angry that I've yelled at a complete stranger who was trying to take care of me, but that was exactly what Erin did, in addition to yelling at the floor, oxygen mask, and cervical collar.

"GET ME THE FUCK OUT OF HERE!  AAAAAH!  GET OFF OF ME!  AAAAAAAH!"

Sigh.  Just another Tuesday night.

My initial survey revealed a few abrasions here and there and a chronic-appearing ulcer on her leg, which looked suspiciously (read: obviously) like a former (or current) heroin injection site.  Of course I never found out because she refused to tell me anything.  When I got to her abdomen, she seemed to wince a bit when I pushed on her left side.

In the trauma world, that's an injured spleen until proven otherwise.

Unfortunately she wouldn't allow me to perform an ultrasound to see if she had blood around her spleen.  Her refrain of "GET THE HELL AWAY FROM ME!" kept ringing out, loud and clear.  After about 30 minutes she finally calmed down (i.e. sobered up) to the point where, instead of screaming at us, she was simply saying "Get away from me" in a calm (though rude) voice.

After much begging and cajoling, we finally convinced her to allow us to perform a CT scan of her abdomen, which continued to hurt rather significantly (though she wouldn't allow anyone to re-examine her).  If you've been reading this blog for any period of time, you can probably predict the outcome of the scan:

Actually, no you probably can't, because I enjoy fiddling with people.  You see, unlike most of the patients I write about, this one WASN'T uninjured.  She had a very nice laceration of her spleen (SURPRISE!) with a significant amount of blood around it.  An injury that severe doesn't usually require surgery, since the bleeding typically stops on its own).  But it does require close monitoring in hospital, preferably intensive care, with frequent blood draws to make sure that the bleeding actually stops (which it does about 90% of the time).

As I walked back to the trauma bay to give her the wonderful news, I thought about just how lovely and fun the next week or so of rounding would be, knowing that she would be a model patient: polite, cooperative, and pleasant to care for.  I probably had a visible scowl on my face when I walked in, but that scowl quickly changed to a gape. 

Erin was getting dressed.

The nurses were trying to calm her and get her to sit back down on the bed, but Erin was having none of it.  "I'm getting the hell OUT of here!"  I calmly and rationally (read: quickly and loudly) explained that she had a very serious injury and she had to stay here.  With me.  Oh, the joy.

"The hell I do!  I need to go home so I can smoke.  BYE!"

I again explained about her injury, why she should stay, and would could happen if she left.  If her spleen continued to bleed, she could easily bleed to death.  She listened, paused, and then demanded to see the papers she had to sign to leave against medical advice.  She also insisted that we not tell anything about her injury (or her drug use) to her father, who had apparently just arrived to see her.  Obviously she had been in this situation before, because she knew all the things to say that prevented us from caring for her in any way.  When her father walked in, she simply told him "I'm fine, dad.  Let's go."

And two minutes later, she was gone like Keyser Söze.

I have no doubt that Erin has pulled this shit before, and I have even less doubt that she will do it again, assuming her splenic laceration didn't kill her.  With her luck, she probably healed up just fine and went back to doing heroin the next day. 

Since as you know I'm a hopeless optimist and always try to see the good side of every story, here is the silver lining of this story: Erin lives well over 2 hours away from me, so the chance of her driving high and drunk again and encountering my wife driving my children around town is very close to zero.

But it is not zero.  And that scares the shit out of me.

Monday, 31 October 2016

Alternatives

For the 2 or 3 of you who noticed the "Idiot" story I mistakenly posted when it was approximately 15.327% (approximately) completed, this is not that story.  For the rest of you, this is still not that story.  Unfortunately the "Save" button is right next to the "Publish" button, and Mrs. Bastard was pressuring me to hurry up so we could leave, so . . . yeah, I guess I'm blaming Mrs. Bastard for that.  It seemed to make more sense in my head than on the screen.  Hmm.

Anyway, this is still not that story.  In case the first few paragraphs piqued your interest, I'm sorry but you'll just have to wait.  After we returned home (from whatever uninteresting thing we had attended . . . possibly shoe shopping), I finished the Idiot story and was all ready for some final editing (BigBrotherBastard always seems to find a typo no matter how careful I am), but before I had the chance I saw a real, actual patient in my office who prompted me to write this.

I know I know, anecdotes are worthless because anyone can make up anything.  But that's all this blog is - anecdotes.  None of you has any idea if any of these stories are real or fabricated (except you, Mrs. Bastard).  Perhaps I'm just a 26-year-old guy sitting at his computer typing fiction. 

But no, I assure you they're all true.  Well, all except one.  Regardless, this really did happen:

Trudy (not her real name™) mentioned Dr. Mercola.  And Dr. Oz.  IN MY OFFICE.  TO MY FACE.

I almost passed out from the rage, and when I almost woke up I almost threw her out.

Trudy was in her early 70s and reasonably healthy for her age, but she had developed acute cholecystitis, an infection of her gallbladder due to gallstones, several weeks prior.  I had removed her gallbladder laparoscopically and had sent her home the same day.  Everything had seemingly been going quite well when she came to see me for her followup visit one fateful day exactly two weeks after her surgery.  But when I walked in I saw something unmistakable sitting on her purse:

A notebook.

I hate notebooks.  I really hate notebooks.  It seems like a rather innocuous item, one that shouldn't inspire such awesome dread and ire.  But these notebooks that are brought to my office all have one thing in common: they are filled with questions.  

Oh, the fucking joy.

I tried to ignore the notebook and instead asked how she was doing, and she reported some minor digestive difficulties (mainly gas and mild bloating), which isn't terribly uncommon after gallbladder surgery.  She wasn't having any pain or nausea, and her appetite was ok, but she was having a lot of gas and cramping after eating.

Her incisions looked perfect (if I do say so myself), and her abdominal exam was completely benign.  But the look on her face quite clearly told me that she felt uneasy about . . . something.  I always finish my followup visits by asking if my patients have any unanswered questions, and this time was no exception, but I did it with obvious trepidation.

"Oh, oh yes I do," Trudy said confidently as she reached for her notebook.

Sigh.  Ok, let's just get this the hell over with.

"Well," she started, turning to page 1, "I was wondering why I've been having so much gas discomfort after eating.  It's really very strange, because I've never had this problem before.  Is this normal after surgery?"

While gas and diarrhea can certainly happen after gallbladder surgery, my Inner Pessimist told me that something else was going on.  I asked if she was eating and drinking normally.  Her face went into a slight scowl.

"No, I've been eating mostly vegetables.  I stopped eating chicken and fish and bread and eggs and milk and sugar and all the other things I usually eat."

My Inner Pessimist started laughing.  He seemed to know something I hadn't quite caught onto yet.

"Why?" I asked her.  My Inner Pessimist started laughing even louder.

"Well, because I was reading online that you just can't eat that other stuff after having gallbladder surgery, and you need to just eat vegetables.  I was also wondering if I actually needed the surgery and if I should have just gone home and done a gallstone flush."

A flush?  Oh for fuck's sake.  Really?  She couldn't possibly have read the bullshit in Mercola.com, could she?  My Inner Pessimist was nearly peeing himself laughing now.

I very slowly and carefully explained that there's no such thing as a gallbladder flush, as I remembered an article I had discussed on Twitter recently about that exact thing.  Something about drinking a mixture of olive oil and something else I couldn't quite remember.  My mind was on that and trying to figure out the next thing to say when I heard her say,

"Oh my god, REALLY?  Because I read that olive oil and lemon juice can flush the stones out naturally without surgery!  Maybe I should have just done that."

Fuuuuuuuuuuuuuuck!  Shut the hell up, Inner Pessimist.

Lemon and olive oil.  While these two things are vital for cooking a piccata, they are not so useful for removing gallstones.  And by "not so useful", I mean completely and utterly useless.  

To explain I drew her a little picture of a 2 mm duct leading out of a gallbladder next to a 2 cm gallstone, and I tried to explain why it would be absolutely impossible to get that stone through that duct.  She kept shaking her head in disbelief.  I didn't know exactly where she had gotten her information, so I told her that most of the stuff she saw on sites like Natural News and Mercola.com was bullshit (though I think I used the term 'bunk') just as an example.  And I reminded myself to Tweet "Fuck you, Mercola" when I got home for good measure.

"NO, NOT DOCTOR MERCOLA!  I LOVE DOCTOR MERCOLA!" Trudy nearly screamed.

Fuck you, Mercola.

Yes, Trudy had actually gotten her medical information from noted quack and bullshit artist Dr. Joe Mercola.  My resultant myth busting with her went on for a full 10 minutes as I obliterated every question she had in her notebook in order.  "So I can really eat whatever I want?" Trudy asked finally.

"Yes," I said.  "You don't have to be careful with what you eat, you just have to be careful where you get your medical information.  Try Medscape and webmd.  And for god's sake avoid Mercola.  Oh, and Dr. Oz too."

Her eyes nearly bugged out of her head.

"OH MY GOD!  NOT DOCTOR OZ TOO!"

My Inner Pessimist shit himself.

It took another 10 minutes, but I eventually convinced her that while Dr. Oz was a brilliant cardiothoracic surgeon, his general medical advice was like homeopathy or a palm reading or a diaper pail: full of shit.  She seemed shaken but relieved at the same time that she could go back to eating normally.  She left about 10 minutes later with a smile on her face, probably looking forward to stopping at a fast food joint on her way home for her first opportunity in two weeks to eat some actual food.

She emailed me a few days later to inform me that her digestive issues had resolved pretty much immediately.  Shocking.

If you follow me on Twitter you know that I rail against "alternative medicine" regularly.  If you don't follow me on Twitter, why the hell not?  It's just like this but only 140 characters at a time.  Actually, Twitter is stupid and you probably shouldn't do it.  Just forget it.

Oh, and one more thing;

Fuck you, Mercola.

Tuesday, 25 October 2016

Annual physical

It's that time of year again - time for my annual physical.  Or I should say, time for me to be a hypocrite and ignore slash skip my annual physical.  I had one about 6 or 7 years ago, and my health was essentially perfect other than a touch of chronic back pain (I love you, ibuprofen).  I don't have a family history of serious diseases, I don't smoke, I drink alcohol occasionally, and I eat balanced meals (thank you, Mrs. Bastard).  Since that time I have advised countless people, including family, friends, and patients, to get their annual physical because it was the right thing to do, despite knowing that I wasn't following my own advice.

Recently the health insurance company Cigna teamed up with a bunch of actors from several medical TV shows (including M*A*S*H, House, Grey's Anatomy, and Scrubs) to create a rather brilliantly funny advertisement reminding people to get their annual checkups.  In case you haven't seen it, here is one of them:



Ha ha!  Classic.  I love self-deprecation from actors.  And this is a great cause with solid advice.  After all, what could be wrong with reminding people to get a checkup if is going to save lives?

Well, here is the problem: there is no evidence that annual physicals actually save lives.  Yes, you heard me right.  Seriously.  A Cochrane review of 14 randomised trials involving over 180,000 subjects showed that people who had general health exams were more likely to have new diagnoses and they were more likely to start on medication for high blood pressure or high cholesterol.  While that may sound good, there was unfortunately no improvement in deaths or overall health in patients who had annual physicals versus those who did not.  Cochrane's conclusion was,

Ouch.

So have I been wrong this whole time?  How can this be?  Sure I've been wrong before, but about this?  Are McDreamy and Turk and Dr. Hawkeye Pierce wrong?  Are annual physicals really unnecessary and potentially harmful?  Well, yes.  And no.  Sort of.  In a way.  Don't worry, by the end this will all be as clear as mud.

I'll explain.

It may seem on the surface that getting people treated for untreated diseases would help.  After all, you can't regulate your blood pressure if you don't know know you even have high blood pressure, right?  And you can't get a biopsy on that enlarged prostate which could possibly be prostate cancer if you don't know it's enlarged.

That was exactly the point of the studies that Cochrane compiled, and the data are fairly clear (if counterintuitive) - it doesn't make a difference if you know you have high blood pressure or high cholesterol or not.  It doesn't make a difference if you don't know you have an enlarged prostate or a breast mass or not.  Getting them treated will not make you live longer.

Make sense?  Yeah, not to me either at first.

The bottom line is this: too many diseases are being over-diagnosed, and thus they are being over-treated.  Many people don't need to have their high cholesterol treated because it won't kill them.  Think of it this way - if you have diabetes, you're going to know it one way or another, so it will be appropriately treated.  You'll go into a diabetic coma or ketoacidosis eventually if you don't, so it shouldn't take an annual physical to find it.  And if your prostate is large enough to cause symptoms of urinary retention, you'll seek care for it, so an annual physical should not be necessary.  The large prostate and breast cancers are the cancers that can kill.

But if you have a relatively small prostate or breast cancer that is found on a routine annual physical examination, this may well lead to the cancer being removed, and while that sounds like a good thing, cancers like this tend to be relatively slow-growing.  So chances are very high that you'd die of something else before the cancer kills you (unless you're very young).  That makes these cancers over-diagnoses and over-treatments.

Make sense yet?  Sort of?

Keep in mind the Cochrane review only looked at cancer and cardiovascular health because they are two of the biggest killers worldwide.  It did not look at diabetes or autoimmune disorders, for example.  

The bigger question here is will this make any difference to how I practice?  I espouse evidence-based medicine whenever possible, so the intellectual answer should be an immediate "Yes".  Unfortunately the real answer is a rather tepid "Probably", at least for my elderly patients.  I try to limit my hypocrisy to a bare minimum, so I can't extol the virtues of evidence-based medicine one second and then cherry pick which parts of EBM I plan to follow the next.  So while I will certainly curtail advising my elderly patients to get their annual checkups, I will most assuredly not actively advise them not to.  I think that still counts.  Right?

Now a breast cancer in a 30-year old is very different than a breast cancer in an 80-year old, so I still believe that annual checkups are important for children and young people because chronic diseases caught early can be managed, and damage can be limited.  My practice there will not change one iota.

EDIT: Thanks to an anonymous reader (is that you, Dr. Franklin?), we now have more information about the Cochrane review, and it sort of affirms what I was saying, and sort of doesn't.  Clear as mud, right?

Occasional SftTB commenter Dr. Cory Franklin coincidentally wrote an editorial at the beginning of 2015 about exactly this subject, and he cited this same Cochrane review and its series of limitations.  Several of the studies in the review are from the 1960s, none of them looked at the elderly or children, and some of them didn't look at women.  One of the main problems he (correctly) saw is that medicine has advanced significantly since many of these studies were performed - statins, better blood pressure medications, advances in minimally invasive interventional cardiology, etc.  Treating high blood pressure and high cholesterol is vastly different in 2016 than it was in 1975, so one would expect morbidity and mortality to vary accordingly.  Does it?  We don't know.

So does this additional information change my view?  Not really.  I still think it's a good idea for children to have an annual checkup, and I still don't think the elderly do.  As for all the cranky curmudgeonly middle-aged people in between (like yours truly), it remains a big muddy grey area with no good answer.  The good thing about grey areas in medicine is that there is no wrong answer.  Huzzah!  We can't be wrong!  But that's also the bad news - it's just as difficult to be right.  We just don't know enough to give fully informed advice.

But despite the distinct muddy lack-of-clarity of the issue, I still have to admit - those are some damned funny advertisements.

Monday, 17 October 2016

Correct vs lucky

I can't tell you how many times I've said "Better lucky than good".  Well, I could tell you ("You can tell me, I'm a doctor"), but it would be nothing more than a wild guess.  And while some people may like making wild guesses (I call them "gamblers"), doing that in my line of work can occasionally (read: nearly always) be dangerous and/or reckless.  Fortunately I very rarely have to make wild guesses, since most of the guesswork is eliminated with the assistance of blood work, X-rays, and CT scans.  Oh, and also with the assistance of physical examinations and talking to patients.

Obviously stupidity aside, sometimes all the lab work and studies and tests in the world won't answer a question, and that's when I have to make the very uncomfortable decision of guessing.  At that point it is clearly an educated guess, but it's a guess all the same.

Such was the case with Raul (not his real name™) recently.

Raul was around 70, very healthy for his age, and came to the hospital complaining of abdominal pain.  This is an incredibly common complaint, and there are entire textbooks devoted to delineating the cause and treatment of abdominal pain (no seriously, look it up).  The problem with Raul wasn't necessarily his pain, but where it was located - in the left upper abdomen.  This is a very unusual site for pain, because in all the other parts of the belly we usually at least have some idea about what's going on:
  • Right lower quadrant: appendicitis, right kidney, Girl Part Problems
  • Right upper quadrant: Gall bladder, liver
  • Epigastrium: foregut stuff (stomach, duodenum, esophagus), heart
  • Mid-abdomen: midgut stuff (small bowel)
  • Left lower quadrant: diverticulitis, left kidney, Girl Part Problems
There really isn't much that can cause pain in the left upper abdomen other than the spleen, and that's such a rare problem outside of trauma that we tend to ignore it.  But Raul kept pointing to his left upper abdomen, saying that it felt like a sharp pain, but mainly when he sat up.  He had no other complaints, no fevers, no nausea, and he was moving his bowels normally.  

In case you are wondering why I mentioned that last bit, pooping is very important to general surgeons, almost as important as that big beaty pumpy thing in the chest whose name I forget.  Honestly, I'm halfway convinced that cardiologists have murmurs and extra heart sounds built into their stethoscopes because no one else can seem to hear them.

Anyway, I kept mashing on Raul's left upper abdomen and was rewarded with . . . absolutely nothing.  Not a grunt, not a wince, and no masses that I could feel.  Nothing.  Zip.  His ribs didn't seem to hurt either, nor did his back.  All the while he kept saying his left upper abdomen hurt, though not when I examined it.

Hm.  What the hell.

With a confusing exam in hand, Raul went off to the CT scanner.  As the pictures initially flew by, something strange caught my eye.  I went back over it carefully slide by slide, and there was definitely something wrong with his bowel.  There seemed to be a twist in the mesentery (the blood supply) of the small intestine known as a "whirl sign".  There were also a few loops of intestine in the left upper abdomen (of course) that were very slightly dilated, but they did not appear obstructed.  He had gas and stool throughout his colon, so whatever he was eating and drinking (and all the various fluids his body was making) was making its way through to the end.

Hmmmm.  What the hell.

I went back to talk to Raul and his wife, and I gave them the news.  I wasn't exactly sure what the news was, and I made sure to express that quite clearly to them.  I was not impressed with his exam at all, and while the whirl sign can be indicative of a small bowel volvulus (twist), most of the time it is not.  And since Raul had no nausea and was passing gas from below (yes, farting is also very important to general surgeons), his bowels were not clinically obstructed.  Armed with that very strange information, I explained that we had two options - 1) do something, and 2) do nothing.  I could immediately take Raul to the operating theatre to take a look inside and see if something was twisted, or we could watch him and see what happens.

I was unclear of the cause for his pain, because any gut pathology should refer pain to the  mid-abdomen, not the left upper abdomen.  But something was definitely off here.  I just didn't know what.  I didn't have a clear diagnosis, and I didn't want to guess.  He was having little pain at that point, so he and his wife sagely decided to wait.

I hate waiting.  I HATE WAITING.  I suck at waiting.  God damn it, I did not go into surgery not to operate.  I chose this field so I could FIX stuff, dammit!  Unfortunately sometimes not operating is the right thing to do.

Grrrr.

I went to see Raul first thing the next morning, and he was feeling somewhat better.  He had been drinking fluids overnight still with no nausea, and he was still passing gas.  His pain, however, was not gone, though it was mildly improved.  I mashed on his belly again and he still felt no pain whatsoever.  I again presented him his two options: something or nothing.  I didn't feel that he needed an operation, though that was mainly a guess because something in his presentation gnawed at me.  Something about this whole situation Just Wasn't Right, but I still hesitated to guess what that meant.  We opted to wait another day.

The next day, Raul still had no nausea, he was drinking, and his pain had improved a bit more.  At that point I decided to send him home, with the understanding that if whatever he had returned, he would most assuredly need an operation.

I heard nothing from him or his wife the next day.  Success!  Huzzah!  No news is supposed to be good news.  Right?

HA!  No.

The next morning I woke up to an email from his wife saying that he had woken up at 2 AM (WHY THE HELL IS IT ALWAYS 2 AM??) with the same exact left-sided pain.  He still had no nausea, he was still drinking, and he still was pooping.  She also mentioned that their regular doctor had asked why the stupid consulting surgeon, who clearly was an idiot, didn't order a follow-up X-ray to see if the twist had untwisted, and he told them to head back to the hospital immediately.

Damn damn DAMN.  I was the stupid consulting surgeon!  What the hell had I missed?  Am I a terrible doctor?  Am I a shit surgeon?  I hadn't thought he needed an operation, but should I have just bitten the bullet and taken him for a potentially massive surgery?  SHITSHITSHITSHIT

I drove to the hospital trying to figure out A) what I was going to say to them when I saw them, B) when I was going to do his surgery, and C) how I was going to rearrange my schedule since I had patients to see in the morning and a lecture to give to medical students in the afternoon.  By the time I got there, he was already prepping for his repeat CT scan, and I nearly called the operating theatre to schedule him before seeing him.  But now something about him seemed . . . different.  He still looked quite comfortable, he had still been eating normally and passing gas, and his abdominal exam was still completely normal.  But his pain was significantly worse and now localised mainly in his left back.  

Wait, what??  Why in the world was his back hurting now?  What the hell is going on with this guy?  I must have missed the "Intestine bone connected to the back bone" day in medical school.  But it still didn't sound like any kind of bowel issue.  Did he have a kidney stone?  Some kind of weird lumbar hernia that I hadn't seen the first time?  Did he have a short in his internal wiring?  Or was it something else entirely?

I wheeled him over to the CT scanner personally to avoid any kind of delay.  The radiology techs seemed a bit startled to see a surgeon pushing a gurney, but I ignored their strange leers.  And just like last time, I watched the pictures as they flashed on the screen.  I scrolled through his scan picture-by-picture, and unlike last time his bowel looked completely and utterly normal.  The twist that had been there before was gone, and the oral contrast he had just drunk had traversed all the way to his colon.  There was no dilation, no obstruction, no inflammation, nothing.  But then I went back up to his chest and saw something completely unexpected: 

Pneumonia.

Raul's left lower lung was completely collapsed and filled with infection, he had a pleural effusion, and just to tie it all up with a nice little bow, he had a pulmonary embolus too. 

So I hadn't made a huge blunder after all.  The sigh of relief that I heaved was probably rivaled by the one when Mrs. Bastard said "yes", and I must admit I mentally pumped my fist several times as I walked back to Raul's room.  I also must admit I felt pretty shitty for doing so knowing that Raul was still very sick.,  He just wasn't surgically sick.

"I have good news, and I have bad news," I started with a bit of a smile.  "Which would you like first?"

"Uh, the good news," Raul's wife said.  She had a tendency to talk for him, as I've noticed many wives do.  No offence, ladies.

"Well, the good news is that you don't need surgery.  Your bowel is completely normal.  {dramatic pause}  The bad news is that you have pneumonia."

"Pneumonia??"

"Yes, pneumonia.  And a pulmonary embolus."

They were probably more surprised than I was at the diagnoses, but they were also both visibly relieved that surgery was not in their immediate future.  Though some people seem to enjoy undergoing painful and risky procedures, most people don't.  But just as I was about to leave, Raul's wife gave me an even bigger surprise.

"That's actually not the bad news," she said.  "The real bad news is that we won't need to see you anymore."

I'm sure I blubbered and gibbered nonsensically as she asked if I was absolutely sure that I didn't want to be Raul's and her GP.  I am fairly certain I blushed, and I haven't blushed in years.  Decades, even.

Raul stayed in hospital for a few days getting antibiotics, and he felt like a new man (not really) when he went home again.  But before they left they both made sure to ask one more time if I would be willing to be their GP.  I wanted to say that no one in his right mind would want to be a GP, but that would be an insult to GPs everywhere.  Instead I just politely smiled and declined.

But seriously, why would anyone want to go into internal medicine?

I could probably answer, but it would just be a guess.

COVID-19 Mythbusting (clean)

Due to popular demand (well, two polite requests, actually), I have decided to create a clean version of my post about COVID-19 myths . If...