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.

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.

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.

Believing evidence

I made the quote box above extra large because it is extra true.  I will quite literally believe anything no matter how ludicrous it may seem if there is actual, real, true, and verifiable evidence to support it.   I don't care how crazy it seems as long as there is not just evidence, but solid evidence.

There is now a video purportedly showing that Jahi McMath is breathing on her own.  Evidence?  Yes.

Solid evidence?  Not so much.

On his blog, Professor Thaddeus Pope reposted a video that had been posted to the "Keep Jahi McMath On Life Support" page on Facebook.  I feel I must quibble with Professor Pope just a bit, as he states she "breathes on her own" and puts the word "death" in quotation marks, much like the anti-brain death faction.  Regardless, the majority of the 5+ minute video focuses on the lights on the ventilator that is breathing for Jahi.  For a good portion of it, Jahi appears to be breathing faster than the 12 breaths-per-minute to which the machine is set, and the Patient Effort light occasionally blinks, indicating that Jahi is breathing on her own.

Or does it?

The "Jahi is alive" crowd seemed to think that Jahi starting menstruating indicated that her brain was alive, but there have been other documented cases of brain dead patients starting puberty.  Similarly there are also documented cases of brain dead patients showing supposed respiratory effort.  Unfortunately for Jahi (and even more so for her her mother), it does not indicate that Jahi is not brain dead or will ever "go to the mall" as Nailah says in the video.

In this case report from Poland, a patient who had failed two brain death examinations was noted to have multiple triggered assisted breaths.  The clinicians were baffled, so more brain death confirmation studies were ordered.  There was no blood flow to the brain on ultrasound, and a cerebral angiogram confirmed no cerebral blood flow.  They concluded that "Cardiogenic oscillations associated with incorrect low ventilator trigger settings may falsely suggest persistence of breathing efforts in a brain-dead patient".  In other words, the airway pressures changed during heart beats, and this falsely indicated to the ventilator that the patient was trying to take a breath.

Another case report documents a very similar phenomenon, where a brainstem dead patient was shown to have triggered breaths on the ventilator.  The authors' conclusion sound eerily similar: "'Triggering' was probably caused by a decrease in airway pressure in time with cardiac contraction. The trigger flow rate is crucial as factors other than the patient's inspiratory effort can initiate flow from the ventilator with very sensitive settings."

And a very well-described case series from China tells of two more patients with similar presentations, both documented brain dead using a combination of clinical examination, apnoea testing, and EEG silence, and both with triggered breaths on the ventilator.  In both cases, brain death testing was repeated, and it remained consistent with brain death.  At the risk of sounding like a broken record, they concluded, "Minimal changes in circuit flow unrelated to the respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing BD."

In other words, it very well may not be Jahi breathing at all, but rather other factors making it seem like Jahi is breathing.

The saddest part of this latest episode in the saga is at the end of the video, the camera pans over to Jahi, flaccid and motionless, eyes still closed, exactly as she was when she died 3 years ago.  In her continued deluded state, Nailah thinks of this as an improvement.

It would be painfully easy for anyone to verify the veracity of this video.  It would take a pulmonologist less than five seconds to say either Yes or No.  If an intensive care doctor examined her and said "She's breathing.  Nope, not brain dead", I would have no choice but to believe it no matter how ludicrous.

Imagine the media frenzy surrounding the first documented case in human history of even partial recovery from brain death, whether miracle or marvel of modern science.  We all know that Jahi's parents enjoy a show.  They revel in publicity.  They enjoy the attention.  I have no doubt whatsoever that they absolutely know how easy proving this video would be.

But that hasn't happened.  Ask yourself why.  I think we all know the reason.

So until it does happen, I cannot believe it, and I remain utterly and completely sceptical.

Becoming a trauma surgeon

I swear I wrote this same damned post a few months or years ago, but my chronically aging brain couldn't seem to find it despite hours (read: 75 seconds) of exhaustive (read: cursory) searching.  Unfortunately because I couldn't initially find it that means either A) I'm losing my mind, B) I've lost my mind, C) I'm losing my mind, or D) I never wrote it AND I'm losing my mind.  Therefore I am forced to write it again.  Grumble grumble etc etc.

The fact that I did find it means that it's probably A.  Or B.  Or possibly C.

Write what again, you may ask?  This.  No, not the word "this", I mean this blog post.  The one I'm about to write.  I mean the one I wrote.  No, not the other one, I mean the one I've just written and and that you're currently reading.  That is, in your temporal point of view, the one you're about to read or are currently reading . . .

GOD DAMN IT I have got to learn not to drink 2 coffees and a latte before sitting down to write.  I usually limit myself to one damned coffee a day, so clearly that is a good policy, one that I need to adhere to more strictly.

[intermission for caffeine washout]

Ok now that my mind is no longer buzzing and is instead running along at a somewhat normal pace, I'll continue.

I've had numerous people tell me over email during the past few years that they wish to pursue a career in trauma surgery, and they invariably ask the same thing: advice on how to get to where I am, if trauma surgery can mesh with their desired lifestyle, how to cope with long hours, losing patients, etc.  I touched on the subject a bit here and here, but not in enough detail.  Trauma surgery is a noble profession (if I do say so myself), so I feel it is my duty and privilege to guide people along that path if that is their particular flavour of torture that they've chosen.  However, instead of emailing people the same advice over and over, I am writing this so I can lazily point them to this post in the future rather than writing everything out again.

My first advice is always "RUN AWAY!  GO BE AN ACCOUNTANT OR A BANKER OR A ARCHITECT OR ANYTHING ELSE YOU FOOL!"  This may sound like I am actively trying to veer people away from medicine, but the only reason it sounds like that is because I AM trying to steer you away, because going into medicine is hard, going into surgery is even harder, and going into trauma surgery is a fucking bitch.  My apologies to all the actual fucking bitches out there for comparing you to trauma surgery, because in all honesty it isn't a fair comparison.  Trauma surgery is much worse than you, you fucking bitches.

I say that with my tongue firmly implanted in my cheek, because as difficult as trauma surgery is, it is also the most rewarding profession I know (other than toll booth collector).  However, before you embark on the journey that begins in college and concludes with you cutting open someone's chest and squeezing his heart in a desperate attempt to keep him out of the morgue, you need to know exactly what enemies stand in your way and will try to defeat you at every turn along the way.

I will preface any and all (real) advice by saying that I am not and have never been on an admissions committee.  It has been many moons since I applied to medical school, and requirements and expectations may have changed.  They also vary from country to country.  Medical school training is also in flux, so take everything I say with a very large grain of salt.

With that nonsense out of the way, there are many obstacles to surmount, and I covered some of them in that prior post that I mentioned previously.  As I said, medical school requirements are different from country to country.  For example, in all American and most Canadian medical schools you must first complete a 4-year undergraduate degree prior to starting your 4-5 year journey through medical school.  In most European countries and Australia you go directly from high school to a 6-8 year medical school.  In India medical school is 6 years.  If you happen not to live in one of those areas, I'm not your mother - go look it up, damn it.

The major roadblocks in undergraduate university are the dreaded science prerequisites - some combination of biology, chemistry, organic chemistry, and physics.  These also will vary from country to country and school to school (for example, some medical schools also require biochemistry).  Regarding courses to take (and/or avoid), I cover that topic in great detail here.  The bottom line is this: kill the prerequisites, and then (and only then) take courses that interest you and make you a well-rounded individual.  Are you interested in advanced maths?  Study that.  Do you like ancient Chinese literature?  Study that.  Art history, music, philosophy . . . the choices are nearly endless.  It's college, for chrissakes, and you only get this opportunity once.  But don't be that guy who takes all science courses and loses out on studying subjects that interest you because you think medical schools want that.  THEY DON'T.  Quite the opposite - they want people who aren't science robots.  I think.  Maybe.  Probably.

Assuming you do well in college (especially on those core science courses), depending on where you live (again) you then need to destroy the Medical College Admission Test (which is used in the US, and Canada) or GAMSAT (used in Australia and UK).  Other countries have their own tests, which all have the same purpose - to defeat you and destroy your dreams and beat you into submission and force you to do something else with your life.  It is incredibly easy to fail these tests and choose another profession, and that is exactly what they are designed to do.  They weed out the weak links.

Medical school is similar everywhere - learn, learn, learn, learn, and then just when you think your brain can't possibly accept any new facts without jettisoning some actual useful information, you have to learn some more.  I can't give you any advice here except to learn stuff.  Lots of stuff.  If you say you aren't good at rote memorisation, then med school is not for you.  You can try to have "a life" during medical school, but don't count on it.

You'll have to get through all the other rotations (paediatrics, internal medicine, obstetrics, etc).  If you're truly a surgeon at heart, these will bore the life out of you.  I felt like I'd rather stick hot pokers in my eye than sit through another 6-hour rounding marathon where we stand and talk and talk and stand. 

When you finally get to your surgery clerkship, learn as much as you can.  Try to suck up to the surgeons without it being obvious that you're sucking up (trust me, we can tell).  Be interested, be enthusiastic, but don't fake it.  We can detect false enthusiasm a mile away.  Get there early and be the last to leave.  Read your books the night before, and know the operation better than I do.  Know the anatomy and be prepared to be quizzed mercilessly (aka "pimped").  If you don't know your shit, it will be obvious  Make it clear that you want to learn surgery, not because you're faking it, but because you do.

When it comes to becoming a surgeon, in the UK it takes about 10 years (2 years of foundation training, 2 years of core surgery training, and 6 years of specialty training).  In the US you go through The Match where you apply for residencies, which last for 5-7 years.  In Australia surgery training is 5-6 years after medical school.  After all that, training in trauma is an additional 1-2 years.  If that seems like an interminable torturous lifetime of training, just wait until you're in the middle of it.  It seems even worse. 

Until you finish.

The biggest hurdle to get over, at least in my opinion, is meeting someone.  I got damned lucky and met Mrs. Bastard before I started medical school, and I was even luckier that she stayed with me during the entire ordeal and afterwards.  

Seriously, what the hell was she thinking?

If you're wondering if it's possible to have and/or start a family during surgery training, I am living proof that it is.  I got married a few weeks before starting mine, and my daughter was born towards the end.  My wife says that all that means is that we managed to see each other for five minutes nine months earlier, but I'm pretty sure she's exaggerating.  I don't really remember though.  My brain has mercifully blocked out that entire section of my life.

I think I'll stop there.  I could go into much more detail, but I think this has been boring enough for everyone NOT interested in becoming a trauma surgeon (which is approximately 99.99582% of you, according to my calculations).  Perhaps the remaining 0.00418% of you gained a little insight into how I became the curmudgeonly pessimist you've all come to love to despise. 

Perhaps not.