Monday, 22 February 2016

Shut up and listen

I decided to try a brand spanking new-and-hopefully-improved docbastard.net by migrating the blogging platform from Blogger to Wordpress, because Wordpress seems to have several much more powerful utilities, including the ability not only to see the IP address of commenters, but also to ban certain IPs (ahem) from commenting.  And wouldn't that be a nice change.  It also allows me to preview what a post will look like on a tablet and a smartphone, so I can (hopefully) optimise it for everyone.  Maybe.

However, I tried testing out Wordpress in the past week, and I found it a bit unwieldy and much more difficult to navigate compared to Blogger.  Plus, the address that shows up in your address bar is the blog address instead of "docbastard.net/page", so...

Here we still are.  Sigh etc. 

Now with that administrative bullshit out of the way, let's get right on to the real bullshit.

Though I know I come off sometimes as a bit brusque, I'm actually a very humble and modest person.  No, seriously I am.  Ok, stop laughing.  It's true!  Can you please stop . . . ok, this is . . . god damn it, will you knock it off!  Are you done now?  Good, I'll continue.

As I was saying, I'm actually quite modest.  That being said, I think it should be 100% mandatory that every paramedic, medic, ambulance driver, EMT, and anyone else who ever comes into contact with trauma patients in the field should read my blog during their training.  It isn't so much that I think this stupid blog is such great reading, it's just that I think it could be a great educational tool and they could all quickly learn a very valuable lesson, one which can be summed up in one word:

LISTEN!!

If everyone would just shut their goddamned mouths for one goddamned second and simply listened to what people were trying to tell them, my world would be a much happier place.  And as we all know, my happiness is really the most important thing.  Well, that and not letting people die, I suppose.

Since my hospital is the only trauma hospital in the area, the catchment area is quite large, and I therefore often get patients from far-flung lands brought to me.  Very often those long treks to my neck of the woods are unnecessary, as I re-discovered with Agnes (not her real name™) recently.  She was brought in from a neighbouring district after having fallen and broken her hip . . . or so the medics would have me believe as they rolled in.

"Hey Doc, this is Agnes (still not her real name™).  She's 88 years old and fell in her kitchen onto her left hip.  She's really tender there and that leg is definitely shorter.  I felt the bones move when I palpated it."

It seemed like a perfectly reasonable story and a perfectly reasonable reason to make the long trek to my trauma bay . . . until I looked at Agnes' face.  Normally folks with fractured hips are in quite a bit of pain, but Agnes' face was downright stony.  She not only didn't look to be in pain, but she looked almost angry.  Ok, really angry.  I thought this was strange though not completely out of the realm of possibility.  Ok, I thought, maybe she's just a tough, stoic old lady and has a high pain tolerance.  Still, my Inner Pessimist told me that something seemed off.

As the nurses began attaching the monitors and the medics were packing up their gear, I went straight to her left hip and touched it gently.  No pain.  I touched it a little more aggressively.  Still no pain, and no "moving bones".  Hm.  I lifted her leg up and rotated it from side to side.  Nothing.  Hmmmmm.  When I lifted the blanket from her legs I noticed that they were the exact same length.

My Inner Pessimist was right - something was definitely wrong here.  Very wrong.

"Hello Agnes, how are you today?" I asked her.

"Oh, I'm just fine, doctor," she answered with a smile, followed by a glare at the medics.  Uh oh.  She does look fine, but she doesn't sound happy.

"What happened?  How did you fall today, madam?" I continued.

"That's just it.  I didn't." she harrumphed, her eyes boring holes into the medics who seemed to be refusing to look her in the eye.

I glanced at the medics who seemed to be trying to rush out the door, and I finally managed to make eye contact with one of them and stopped him with a look.  I beckoned him to join me.

"She says she didn't fall.  Care to explain?" I asked him as politely as my Inner Pessimist would allow.

Medic: Well, uh, based on our information at the time, we weren't sure if she fell.

Me: You weren't sure?  What does that mean?  Did you ask?

Medic: Um . . . no.

Me: Well why not?  Was she awake and alert?

Medic: Yes.

Me: Then why not ask?  Why did you say she fell?

Medic: That was the information we had at the time.

I saw the conversation quickly devolving into a circular sinkhole of despair.  But before I let him leave, I turned back to Agnes.

Me: So what happened, Agnes?

Agnes: Well I was in my kitchen cooking, and I suddenly just felt a pain in my hip.  That's it.  I tried to tell them.

The look I gave the medic clearly said "YOU ARE AN IDIOT", and he sheepishly turned away and left.  Not only did he not admit to his mistake or apologise, but I seriously doubt he learned a damned thing.

It gets worse.

I looked at the X-ray of Agnes' pelvis  (please sit down) which was (are you sitting?) completely normal, and then went back to talk to her.  After a little investigation, she informed me that she had in fact been cooking in her kitchen while sitting in her wheelchair when her hip started hurting.  By the time she got to me, the pain (from her arthritis) was better.

I wished the medic could have been there to hear that little nugget of information.  I wonder what he would have said then about the information available at the time.

It would have taken the medics exactly 2.14 seconds to ask Agnes what happened, and that would have saved her a useless trip to the hospital and several hours of her life.  It also would have made my day slightly less aggravated.

And that concludes our lesson for today.  Close your mouth, open your ears, and listen.

55 comments:

  1. Ah, yes, but who called a medic for arthritic pain?

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    1. An excellent point. She did. Because her hip hurt.

      I was frustrated enough that I decided not to press the issue further than it had already been pressed.

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  2. In my experience, sometimes the medic needs to ask a few well constructed questions. I've noticed both on and off duty, that some patients tend to go down rabbit holes, and if you just listen, you will be there for hours and forget why you were summoned in the first place.

    but yes, medics tend to be dispatched to events completely different from what actually happened, and if they come in with preconceptions, they may go very far astray.

    My department ultimately gave the medics' dispatchers a directive that if the ambulance rolled they were to dispatch us as well - because they were terrible at triage. we would get dispatched to a person who slid out of their chair and needed help getting back in - which we had no problem with, and have occasionally mumbled about just sending us (taxpayer funded) and not bothering the medics (who bill for services) for those - but then they would have a guy fall off a roof and decide that since it was just a fall, there was no need for a fire rescue crew.
    it can get even worse, if someone calls someone else and admits to making a mistake and the someone else then calls 911.

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    1. Ken, your point about preconceptions may well be the real problem in this case.

      We do know that "Agnes" is elderly. What we don't know, and perhaps Doc doesn't either, is how the call to the medics actually originated. The fact that Doc reported several references to "information available at the time" caused another thought to cross my mind.

      I'm wondering if Agnes may have had a subscription to one of the emergency call system services that are available to seniors and persons with physical disabilities who live independently in their own homes. My own elderly mom has one. Many readers here have probably seen the TV commercials and magazine ads for these, which typically depict a scenario in which an elderly actor pushes the button on their pendant or wristband, and says something like, "Help! I've fallen and I can't get up!"

      We know that (1) elderly people are often more prone to falls than younger folks, because of impaired coordination and possible limb weakness due to arthritis, and (2) elderly people often have more brittle bones, which makes them more prone to fractures, so they suffer broken hips more often than younger folks. I'm wondering if whoever took the initial call from Agnes, whether it was an emergency alert service dispatcher, or a dispatcher from her city's emergency services department, just heard "senior citizen with pain in hip" and made an *assumption* that she'd fallen and broken her hip. This may have been the information that got passed on to the medics who ended up getting the assignment.

      Obviously, this doesn't excuse the medics not personally evaluating the situation once they arrived, and getting a first-hand account from Agnes herself as to the source of her discomfort. I just wanted to make the point that preconceived notions often preclude truly useful communication.

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    2. good thought, and despite adding another layer of interference in dispatching emergency services, I do still recommend an emergency alert device over no emergency alert device, when a person reaches a condition where they may be unable to get to a phone to summon help. despite the fact we get more calls for accidental button presses, than we get for emergencies; we do occasionally preserve a life that could have been impaired or lost if there had not been an emergency call device.

      and this is one of those fields where one save makes all the false alarms worth it.

      (for those thinking of patronizing your local emergency services group, be aware we don't get follow-up visits like Doc B. does. it makes our day to hear a former patient has stopped by to let the crew know they are still alive.)

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  3. You know, glaring at other members of the health care team can get you labeled as disruptive. All kinds of disciplinary things may happen after that.

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    1. Really? What kind of disciplinary things should I anticipate? Should I fear the medics reporting me, because if they did they would also then have to explain why they bypassed the local hospital and transported a patient to our hospital inappropriately. Should I fear the nurses, who were all glaring at them exactly the same way? How about the patient who thanked me for listening to her and was threatening to report the medics? Or the medical students who were in the back of the room laughing about the whole situation?

      Whom should I start fearing first?

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

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    3. She could have had trouble moving because of her hip, limiting mobility, which is a legit reason to call. Then was whisked away to the hospital to avoid litigation on their end.

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    4. Oh, John - Does Bruce know you're posting using his name? I don't think he would be happy about this. Perhaps we should let him know.

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    5. Doc B: I was being facetious. I hope you took my comment in the spirit it was delivered.

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    6. ndenunz - My sarcasmometer must have been on the blink at the time, so I sincerely apologise for not picking that up.

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    7. It seemed very serious ndenunz. And considering the kind of unsavory people who often comment (cough John Benton cough) it was hard to tell.
      Connor

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    8. a more advanced host would probably also support the sarcasm font.

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    9. Don't laugh, please... What is sarcasm font, or were you being sarcastic?

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    10. actually, I was being surreal. there is no sarcasm font - it is used to refer to the fact we can't tell if a typed comment is sarcastic or not.

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  4. How about when the patient is TELLING the medics what is wrong and they ignore her? Pt' s son called 911 because she was having trouble breathing. Pt tells medics she just took some medicine a few minutes earlier, started having burning in her throat, and was too weak to get her own breathing treatment. Tells them, "I think it's an allergic reaction." They document her low BP, rapid heart rate (several times) and listen to her lungs pronounce them clear and tell her her sats are fine. No meds administered, no call to med control for advice, just roll in. Her BP in the ED was in the 50's systolic. It took seconds at the bedside to see this woman was in anaphylactic shock ( the whole body erythema was also a nice clue). My first comment was to agree with the statement she made to the nurse during triage, "You ARE having an allergic reaction, aren't you?" Medics had been hanging around but disappeared as soon as I asked the nurse to get out the meds.
    I think that medics are just like those in any other profession, some are really, really good, some are really, really bad and most are ok. The difference is, people's lives are at stake.

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  5. Thankfully, Ive never had a doctor, for emergency room or general practice or psychiatrist even dentists etc that didnt listen. Except for emergency room docs (who in those cases once theyve come to see me focus on the issue entirely, and only ask questions specifically pertaining to the issue at hand, which is of course fine) they are always willing to listen and talk, whether about what Im there for(listening to possible issues/how it happened etc) or about just general things. To be fair though, when ever I've gone to see a doctor, I've never had to call up medics to take me there- They seem to hire a lot of deaf and blind medics, after all what else could explain all this broohaha. Unless they suffer from Cranial Rectal Inversion Syndrome of course, which isn't outside the realm of impossibility.
    Connor

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  6. This current layout is really hard to read.

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    1. there was a brief moment last night when the format was slightly different. that might have been the issue.

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    2. Still no idea what you mean.

      Ok full disclosure, I tested a new template which I thought looked quite good. I immediately got 2 comments saying how awful it was, so here we are.

      I do love progress.

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    3. I noticed it was different, and I noticed it stopped being different. for a guy, that's pretty observant. I had the impression the column might be a little narrower, but I'm not THAT observant. I'd wondered if you'd gotten it successfully migrated to the other host.

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    4. Yeah that format was REALLY bad....
      no offense Doc.
      Connor

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    5. To clarify, when you switched to the new format the color of the text did not substantially contrast from the color of the background which was also not solid but had some type of pattern to it. Therefore it was very difficult to quickly make out the various letters.

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    6. I understand. It was a test, and it failed to pass muster. That's not to say I won't try again, because I will. Hopefully I can please you high-maintenance people.

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    7. different = bad.

      [/sarcasm]

      I'm here for the stories. the decor is less important to me.

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    8. That's what I thought, but apparently some people come for the stories and stay for the colour scheme. It turns out that some readers' eyes are more sensitive than others'.

      I shall try to accommodate everyone as best I can, but you can't please everyone all the time.

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    9. Oh i come for the stories as well. Its just if a format for some reason is bad enough that it annoys me to read ALOT, i wont neccessarily find it worth reading anymore.
      That said, I would still push through to read this blog.
      Connor

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    10. my favorite antisocial networking site changes formats very frequently. occasionally one is less legible, it's never a big deal.

      Delete
  7. It's still pretty bad. I read from my phone and have to switch to the web version to see anything or be able to read a full blog post. I dont know what You did, but it was way better before.

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    1. I don't know what the problem is since I reverted to the exact same template I had before. Hm. I'll try playing with it and trying new ones in a bit.

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  8. You know damn well why you changed the format. That's really mean.

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    1. Yes, because I was tired of looking at the same drab colours. But you seem to think I had something more nefarious in mind, so I'm just dying to hear your hypothesis.

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    2. It's called sensory overload. When the body's senses tries to compete with each other in trying to process changes in their environment they experience sensory overload. We call it the 'kryptonite' effect.

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    3. if changing the background image from books to a tangerine tile pattern overloads you, you might need to see an optometrist.

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    4. Thank you Ken Brown. You ultracrepidarian you.

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    5. you're welcome. have some strĂ¼del.

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  9. Devil's advocate (and yeah, I know they acknowledged they didn't ask). But for the benefit of lay readers, medics don't always know if they can trust the patient's history. I've had patients swear blind that they didn't yada yada pick your poison. And yeah, the medico-legal climate sucks. A geriatric sitting in a wheel chair, may not need to fall to fracture a hip - osteoporetic fractures, steroids, pathological fractures, yada. Ranging from displaced fractures to subtle undisplaced fractures on plain imaging, with masked symptoms and signs - geriatrics do not necessarily have the same pain perception as younger people. Somebody ordered a hip X Ray, if not protocolised, I'm assuming this is why someone ordered itm even though she did not seem symptomatic residually. Hell, over the top CYA may even result in a CT to rule out an occult fracture not showing on plain imaging. Yeah, sucks, but that's the reality of CYA medicine - the perfection 100 % no miss rate lawyers demand, not sane or rational medicine.

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    1. Fair point. But this one was over-the-top egregious.

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  10. It isn't just in emergency situations people don't listen, or maybe don't trust patients, not sure which. Several years ago I started feeling so tired I couldn't get out of bed. I lost my enthusiasm for usual activities, but was not what I believe to be depressed. Because I was a woman of a "certain age," with my last child off to college, I was diagnosed as depressed (empty nest syndrome and menopausal)and put on several different antidepressants to find the right one. Never found the right one but did find several wrong ones. I swear one came with a Lizzy Borden poster I hung over my bed. I kept telling several doctors I wasn't depressed. I liked my life, my job, my husband and children. I just didn't have the energy to do anything. There was a very quick check of my thyroid, and then I was given the all-knowing smile, and handed a new antidepressant. Finally, I demanded that my doctor run every test possible - over $2,000 of lab work later, they found I had a very severe case of mono (or for you Brits, glandular fever). I was so relived to finally be taken serious after months of no one listening or believing what I was saying. I think this happens to women more often than men, from the anecdotal stories of many women friends. You know how moody we women get after all (sarcasm).

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    1. I have a friend who would be jealous of your lizzie borden poster.

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  11. Doc is Australian. I think Paul Offit is working on a vaccine to prevent glandular fever. He's done messing around with anti-diarrhea.

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    1. I see cornboy is still flinging random stuff at the wall to see if it sticks.

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    2. I had the same thought. Still trying to figure out where Doc is physically located, so that he can be "reported" to "the authorities," I guess.

      Just for fun, I checked in at his alma mater, Google University, to see if writing a blog was sanctionable evidence of medical malpractice anywhere in the world. Came up empty. So, Doc, wherever you are, you're safe! :)

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  12. A long one spanning 2 comments:

    This is something I wish I could staple to the forehead of all the physicians, specialists, and ER doctors that my boyfriend sees. He has a LOT of health issues and has been slowly declining over the last year. (Disabled at 24) Our most recent visit to the ER last week could have been made a LOT shorter if the doctors would just LISTEN. He is a Type 1 diabetic, got tested a week prior for either what is believed to be his 3rd bout of EB/mono or his Langerhaan's cell histiocytosis, he's Flu/Pneumonia negative, he has a liver biopsy tomorrow for elevated liver enzymes over the last 2 years, and new medicines have been making him have anxiety attacks.

    Wednesday midnight, he panicked, starts vomiting and complaining of severe upper left quadrant pain, whole body aches and pains, and a light fever, we were afraid he may have damaged his spleen or something. Ambulance was called and we were taken to the ER.

    We know his history. Being Type 1 since 19 years old, he's not had many issues with his blood sugar EXCEPT when complications make him vomit. Then it gets bad. The ER tech said he came in with a blood sugar of 1050. Not possible. (He's never been over 800 since he was first diagnosed, and last time complications from the flu sent him into DKA a year ago, it was only at 500 and almost in a coma.) They only gave him 10 units of insulin. In less than 10 minutes, his sugar was only 80. 15 minutes later, 42.

    1st doc says there wasn't even acid in his blood, but admits him to the hospital for DKA. Okay...?

    Second doc comes in and says he's going to bring in his gastroenterologist because he thinks it may be his IBD. We explain he hasn't had issues with that in over 6 months and it's brought on by dietary changes, which he's remedied. How about check to see if it was mono related or check his histiocytes? Maybe even check his liver?? No doc even put their hands on him except to check the scarring of the bilateral varicocele surgery he had a month before.

    No one was listening to us or even giving us answers.

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  13. Techs roll in throughout the day checking his blood sugar, all of his meds are verified through a pharmacist, and he eats twice in the day as he still sits in the ER. (No beds available, not the staff's fault.) No fluids hooked up, nothing. His blood sugar keeps rising after 2 meals and after 14 hours of us trying to get a hold of nurses, he's finally given insulin.. at a sugar level of 350. The doctor apparently never ordered it. Never order it or his Paxil, lithium, antibiotic he was taking after the surgery, or his long acting insulin. None of it was ordered. None of it administered.We kept asking the nurse why. She could not reach the doc over the phone. He was only given 2 more doses of insulin over 2 days and some Ativan when he had a panic attack. Again. Only at 10:00pm did a nurse let us know the results of all the blood work they were doing. Nothing. No issues other than elevated liver enzymes that we already knew about. What was the doctor even checking for? Nurse doesn't know, calls the doc, and the doc won't tell her. Next day he gets an endoscopy. For what? Don't know, but it comes back clear. What a surprise. Doc finally gives him all of his missed meds for the day at once the next night. Then sends him home with a blood sugar of 389. "Doc, WHY was I being kept in the first place? I had no acid in my urine. What was I being tested for?" Doc said, "I just wanted to watch your sugar. Go see your physician when you get out."

    THAT'S NOT EVEN WHY HE CAME IN. Thank goodness the severe pain lessened on its own. It's not like anyone helped it. He's still staying at a temp of about 100, still has whole body pain, stomach pain, flares of nausea but no vomiting, the added beauty of Paxil withdrawal, upper left not-as-bad quadrant pain, and now he has some light bleeding in his urine. THANK FUCKING NON-SPECIFIC-DEITY HE DOESN'T HAVE HIGH BLOOD SUGAR and he has an appointment with his new physician the day after tomorrow.

    Because now he refuses to go to the hospital.

    No one would listen, we still have no answers.

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    Replies
    1. Kennie, I truly hope the new doctor will help you both find some real answers, and a decent treatment plan. I'm not a doctor, but even as a lay person, I'm astounded by (1) the apparent lack of attention to keeping his blood sugar levels *stable*, and (2) not checking his liver, since there was pain in that area and you'd made staff aware of the elevated liver enzymes and planned biopsy.

      Best wishes for improved health for your boyfriend, less stress for both of you, and better attention from medical staff as you continue towards this goal.

      Delete
    2. We wound up having to file 4 negligence reports with the hospital's head of Patient Relations. Somehow I highly doubt anything will come of it. We still have no answers and have to wait until the end of the month to see his new GP. Turns out his Gastroenterologist referred him to the wrong person. Woops. His fever is gone, his withdrawal symptoms are gone, and he's stopped the drops of blood in his urine, but he's still in all-over body pain, inguinal pain (from a failed surgery), and never stops being nauseated. His liver biopsy ruled out a lot, basically saying that whatever he's going through isn't being caused by the liver, the liver is being effected by it. He gets the results of his Epstein-Barr test back next week that he got at a local MedStop, and will find out from his Endocrinologist today if his hyperthyroid is causing a lot of the issues or if it's possibly Grave's disease. If it's none of those, he has to look and see if the Histiocytosis has decided to take up residence elsewhere in the body. Fun. It's like the poor guy can't catch a break for anything. Thank you for your concern!

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  14. Doc - I've been reading your blog for quite a while now. Find it wonderfully informative, and with just the right amount of snark that reminds me of some of my work, and the idiots I (occasionally) get to work with/for. I now have a new appreciation for what you do.

    Back in September, I got into a motorcycle accident. This wasn't one of those, "the only thing bruised is my ego" sorts of accidents. This was a side of bike meets guardrail with leg Oreo-ed in-between. I knew I was screwed the moment I landed on the berm on the other side of the guardrail. Figuring I needed to get somebody to dial 9-1-1, I cradled my leg in my arms and stood up. A guy knocked me down. Being totally rural, I figured it would take time to get somebody's attention. What I wasn't counting on was a utility guy up a pole seeing the whole thing. The utility guy was also an EMT in his spare time. He's the one who knocked me down and applied pressure to the artery in my leg - the one that was severed. His buddy called 9-1-1 and turned pale.

    20 minutes later, and lots of talking along with his buddy holding my hand (gotta give it to the buddy - he didn't hurl on me yet held my hand. gotta give it to the off duty EMT, he apologized for the pain while he continued to talk with me and kept me from bleeding to death), a volunteer ambulance arrived. 45 minutes later, we pulled up to the local hospital. They managed to cut off all of my clothes and then put me back into the ambulance to send me to a trauma hospital. 45 minutes later, we were pulling up to the trauma hospital ER. I finally figured out how serious the whole thing was when the ambulance pulled in front of a chorus line of doctors and nurses. Holy Shit! They were all waiting for me and my screwed up leg. I got a trauma surgeon, a vascular surgeon, an orthopedic surgeon, a plastic surgeon, and a variety of nurses. I forgot everybody's name really quickly as they all asked about loss of consciousness and where my helmet was (it came with me to the trauma center) while not looking me in the eyes - much more concerned about my leg.

    6 days of ICU, 5 weeks of hospital food, rehab, and now, 6 months on, my leg is "saved", my life is saved, and I really have a much better appreciation for what a trauma center is meant for. I never want to end up on your sort of table ever again. It's not that you're not nice, competent folk - it's just that I never want to be that totally f**ked ever again.

    Thank, Doc Bastard. Keep cutting (this includes the writing). Going to read your posts with a mostly new perspective from now on.

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