Monday, 18 July 2016

Obesity

For those of you who follow this stupid blog and understand how it works, you've probably already guessed that the title of this post compared to one of my previous posts is no coincidence.  For those of you who don't follow, well why the hell don't you?  There's a little "Subscribe to SftTB" button over on the right, just under the "Follow me on Twitter, dammit" button.  So go push one of them.  Or both of them.  It takes less than 2 seconds and will make me happy.  Or happier.  A little bit, at least.  Dammit.

Anyway, even though I'm a surgeon, I still believe in promoting healthy habits.  I know, I know, I'm supposed to be a stupid automaton with a scalpel and no brain, and public health is supposed to be the domain of general practitioners and blah blah blah.  Fuck that.  I see obese patients, I treat obese patients, and I operate on obese patients, and they happen to be much harder to take care of.  Their surgeries are much harder than those of thin patients, there is a much thicker layer of fat to get through, it's more difficult to visualise the structures I need to see (read: not accidentally poke a hole in), and there is a much higher risk of wound problems.  So though you may consider this to be a tad self-serving, I'm very interested in keeping people a healthy weight.  When it comes to trauma surgery, being obese just isn't helpful.

Or so I thought.

If you believe TV and movies (*cough* Game of Thrones *cough*), any penetrating knife wound to the torso is immediately fatal, unless you're the hero, in which case you have at least 18 seconds to either A) breathe the name of the attacker so you may be avenged, or B) tell the nearest bystander to tell your wife you love her; only then will you exhale your last breath so that the aforementioned bystander may run his hand down your face and close your eyelids which I'm pretty sure wouldn't really work at all in real life.

In reality, stabbings are bad (obviously), but not usually fatal.  I've written about this subject before, but for a really quick recap, most stabbing victims have entirely treatable injuries.  Though the various injuries may be life threatening, most of these folks not only make it to the hospital alive, but due to the intervention of hard-working trauma surgeons, they leave it alive too.  Like Liam (not his real name™).

Only not for the reason you may think.

I don't know if people keep their knives locked up during the day or what, but stabbings only seem to happen at night, usually around 3 AM.  Sometimes people surprise me and come in at 2:45 or 3:15, but it's pretty consistent.  Liam was no different - he got stabbed just before 3 and came in right after 3.  I was having a dream about bacon when my pager woke me (god damn it), so off to the trauma bay I went.

I got there a few minutes before Liam arrived, and a nurse filled me in on the details she had gotten from the crew en route - youngish male, multiple stab wounds to the chest and flank, tachycardic (fast heart rate), but a normal blood pressure.  In the ensuing 6 minutes before Liam arrived, I continually ran through my mind all the possible injured organs, which included . . . well, all of them.  Literally.

The medics didn't seem too concerned as they moseyed down the hall a few minutes later.  Liam, on the other hand, looked near death.  He was sweaty, his eyes were glazed over, and he was thrashing all over the bed.  In the trauma bay this is almost always a sign of shock - real haemorrhagic shock, not the "Oh my, I just saw a dead animal on the side of the road and now I'm in shock!" bullshit.  So I again ran through my internal list of potential Very Bad Things that could be causing his impending death.

"Hey Doc, this is Liam," the medics started.  "Thirty years old.  Stab wound to the left upper abdomen and left flank.  He's been tachy the whole time, last blood pressure was 155/90.  Diminished breath sounds on the left, but his sats have been fine."

I absorbed this information quickly as they moved Liam from their stretcher to ours.
  • Tachy - fast heart rate, could be bleeding.  If not bleeding, it's probably bleeding.  If it isn't bleeding, it's still probably bleeding.
  • Normal blood pressure - if he's in hypovolemic shock, it's stage 1 or 2.  Good.
  • Diminished breath sounds on the left - he probably has a pneumothorax or haemothorax
  • Oxygen saturation is fine - he's young and has healthy lungs, so he's compensating for his injury.
This internal evaluation took exactly the two seconds that elapsed until Liam was settled on our stretcher.  He was already completely undressed, so I examined his wounds:
  1. A 2-cm wound in the left lower chest (not the upper abdomen . . . maybe)
  2. A 2-cm wound in the left lower flank/back
  3. A 2-cm wound in the left lower abdomen
None of the wounds was bleeding, so my job became to figure out where the knife went and what (if anything) it penetrated. The first could have entered the abdomen, hitting the stomach or intestine; or it could have gone into the chest, hitting the lung (bad) and/or heart (really bad).  The second wound could have hit the kidney and/or colon, and the third could have injured the small intestine, colon, or both.  The easiest (and most painful) method to determine this is also the most obvious: stick a finger in the hole and see where it goes, and if the finger enters a body cavity, you have your answer in 2 seconds.  I must have been in a good mood that night because I injected some local anaesthetic before digitally probing all three wounds.  Fortunately all of them seemed to go nowhere, just into soft tissue.  Other than the fact that Liam was morbidly obese, the remainder of his examination was completely normal, including completely normal lung sounds (not diminished on the left as was reported).

My Inner Pessimist began yelling at me.  "The medics are wrong, stupid!"

I actually agreed with my Inner Pessimist for a change, though Liam still looked near death.  Something didn't add up.

Sadly digital wound probings are notoriously unreliable, and any trauma surgeon that relies solely on that modality is making a grave (and possibly fatal) mistake.  So off to the CT scanner we went.  By this time Liam had calmed down significantly, his vital signs had completely normalised, and he was no longer sweating.

Ten minutes later my Inner Pessimist started laughing his ass off.  The scan showed that the knife had penetrated only Liam's rather copious subcutaneous fat in all three locations.  There were no serious injuries, no injured organs, nothing.  Just a guy freaking out over a few tiny lacerations.  He wasn't in shock he was just shocked.

Liam's wounds were irrigated, anaesthetised, and repaired within the half hour, and he was walking out of the trauma bay with a huge smile on his face a few minutes later.  It must be awfully satisfying to go from thinking you're going to die to walking home in the span of an hour.

Had Liam been thinner, the knife could have easily done some major damage, and he could have been facing a major surgery (or two or three) or even death instead of leaving the trauma bay in an hour.

Don't misunderstand me, I am in no way advocating major weight gain here.  But if you do plan on getting stabbed in the future (which I wouldn't recommend), you may as well stock up on ice cream, Oreos, and Coke and get started now.  After all, you have a life to save - yours.

11 comments:

  1. very fortunate for him. and I'm guessing the diminished breath sounds could have been positional.

    ReplyDelete
  2. Grandma Skeptic19 July 2016 at 03:07

    So this is one time that being fat was a good thing. Too bad it doesn't outweigh all of the reasons it is bad.

    ReplyDelete
  3. One of my cats had much the same experience when a neighborhood kid shot him: the round didn't make it through the fat. It's the only time I've been happy with his weight.

    ReplyDelete
  4. Let's hope that Liam, being a young man, won't use this good fortune as an excuse to *not* address his weight issues before he starts experiencing *other* health problems.

    ReplyDelete
    Replies
    1. Very true. and all of the other health problems can be very bad.

      but it bears mentioning that a person who has a significant weight issue usually cannot just make a few changes and have the issue go away; and "fat shaming" does nothing to help them. most morbidly obese people would love to have real help.

      [/PSA]

      Delete
    2. Thank you Ken! This easily could have turned into a forum for fat shaming, but it's been respectful and your PSA was very appropriate and spot-on.

      Delete
  5. I saw a very, very similar case when I was shadowing a surgeon. In this case, the patient absolutely would have died if she hadn't been obese. She'd been stabbed with a 10cm blade by her ex-boyfriend, and the blade had pierced her abdominal cavity in seven places, but it hadn't been able to reach her intestines. Had she not had that wall of fat, the likelihood that the blade wouldn't have punctured her gut was very, very slim.

    ReplyDelete
  6. There are some extreme and unlikely circumstances where being obese is clearly an advantage. If you are stabbed, if you fall into icy water, or simply if you are cut-off with minimal food for an extended period. Thankfully, in modern societies these things apply fairly rarely.

    You can see why, when our lives were generally short and hard and typically ended suddenly, laying down significant body fat was an advantage. These days, where lives are longer and diabetes or cardiac problems are more likely to feature, the balance has clearly swung the other way.

    I would be interested to know Doc': Have you found that car-crash victims are helped or hindered by visceral fat? I have read that various impacts apply to a crash victim, such as the body "hitting" the limit of the seat-belt etc. One of these "impacts" is that of the organs hitting the inside of the rib-cage and this can be significant in a well-restrained body (the un restrained one already having punctured the windscreen at that point). I wonder whether visceral fat might actually help to reduce the organ damage to a belted victim from a head-on.

    Ugi

    ReplyDelete
    Replies
    1. interesting question. now I'm curious, too.

      Delete
    2. I'm not an expert on medicine or car safety, so take this with an entire bowl of salt.

      Many car seatbelts now have force limiters, which do exactly that - they allow the seatbelt to extend a bit if enough force is placed on it. This allows the organs additional room to decelerate. Toyota made a short video of it at http://m.youtube.com/watch?v=k2twNZc-gGI
      Seatbelts are an engineering challenge with a clear scope and goal, which means that engineers can enjoy working in them. Whether the car companies actually put the resources into it can be a different story.

      For an obese person, the initial pretensioners would not be as effective, and the force limiter will allow more travel than optimal. It's possible that the extra flesh in front of the person is as effective at dampening the impact as these devices would be, but I doubt it.

      Chances are that the optimal passenger in a crash is the same size and weight as a crash test dummy, as the safety features are designed for those standards.

      Delete
  7. Oh, I hope that Liam will be fine. The story as always very interesting and exciting! There are a lot writing tips on proofreading-services.org/. I will be waiting for the next story!

    ReplyDelete

If you post spam or advertisements, I will hunt you down and eliminate you.

Comments may be moderated. Trolls will be deleted, and off-topic comments will not be approved.

Web-hosted images may be included thusly: [im]image url here[/im]. Maybe. I'm testing it.