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.

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. 

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. 

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.

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.