Heart

I held a beating heart in my hands today.  It wasn't beating when I first saw it.  The heart belonged to a 20-year-old kid, though I didn't know that at the time.  I didn't even know his name.  

What I did know, however, was that he was dead.  And it was my job to reverse that.

The ambulance called in the late afternoon with a 3-minute ETA on a multiple gunshot wound victim with CPR in progress.  They managed to place an intra-osseous line and give him some IV fluid on the way, but salt water can't restart a heart. 

After a flurry of activity, our team was ready when he arrived 4 minutes later.  He looked like any other kid when they rolled through the doors - thin, muscular, a young face with a close-cropped scruffy goatee, a tattoo of some initials and a date on his left upper arm.  What made him different was the absent look in his eyes and the medic sitting on him, pushing rhythmically on his chest.  They yelled out some information as they transferred him from their stretcher to ours:

Twenty years old.  Found barely breathing about 8 minutes ago, stopped breathing 7 minutes ago.  Gunshot wounds to the chest, right arm, left groin.  Asystolic.  

Dead.

A cursory glance at him revealed a gunshot wound to the left chest just above and medial to the nipple.  Directly over where the heart is.  The mortality rate for such an injury is very high, and when the patient comes in dead it approaches 100%.

This kid had only one possible chance, though I knew that chance was fleetingly small at best.  I grabbed a scalpel - the big one.  A splash of iodine on his chest seemed more for show rather than any possible actual antisepsis.  I incised from his sternum all the way down the side of his chest to the bed.  I inserted a Finochietto retractor and opened his chest wall as widely as it would go, cracking a few ribs as I went.  The chest was full of blood, as was the pericardium (the tough membrane that surrounds the heart).  The heart was twitching, barely moving.  I grabbed the scissors and opened the pericardium widely.  The heart was struggling, trying, but there was nothing to pump - it was empty.  Nearly his entire blood volume was now on the bed, on the floor, on my shoes.  I started squeezing the heart, trying to circulate what little volume he had left.

By this time others had placed multiple IVs, including a large-bore central line in his femoral vein.  Blood was running into him as fast as the rapid transfuser would go.  Epinephrine was injected.

The reason why the heart was empty was immediately evident - there was a hole in the left ventricle, the main chamber that pumps blood to the body.  Everything we were giving him had drained right out.  I plugged the hole temporarily with my finger, but when a bullet goes in, it must also come out.  I found the exit wound on the back side of the left ventricle, and plugged it with another finger.  Now the heart began filling.

And still I continued squeezing.

I shouted for some pre-loaded pledgetted sutures and repaired the anterior hole first, taking care to avoid the anterior interventricular vessels.  This is a very difficult prospect as the heart continued to 1) move (weakly), trying to restart itself, and 2) bleed.  Stitch, plug, squeeze.  Stitch, plug, squeeze.  I turned the heart over and repaired the posterior wound in the same way.

Stitch, squeeze.

And then it started beating again.  Hard.  Rhythmically.  

Above the din I loudly asked someone at his head to check for a carotid pulse.  "I GOT A PULSE!  I GOT A PULSE!" someone shouted back at me.  I don't even remember who it was.

I checked my repairs - a tiny bit of oozing, but they were solid.  As his heart started pumping away stronger and stronger I put my fingers on his neck and confirmed a carotid pulse.  Ba-dum.  Ba-DUM.  For one ephemeral moment I thought he had a chance.  Then my eyes went up to his - his pupils were blown.  Fixed and dilated. 

God. Damn. It.

My mind immediately started going over the possibilities - maybe we had been fast enough.  Maybe the pupillary reaction would return.  Maybe.  More blood.

I went back to look at my repair, and the heart wasn't pumping nearly as hard.  The epinephrine was wearing off.  I looked at the monitor and his blood pressure was dropping.  And then his heart stopped again.

Squeeze.  Squeeze.  Squeeze.

More blood, more epinephrine.

Squeeze.  Squeeze.

Nothing.

The transient moment had passed.  I took one last look at the motionless heart, looked at the clock, and found myself pronouncing another young kid dead.  It was about 6 PM.  I had no idea where the previous 70 minutes had gone.

This young man is not the first death I've had, and he won't be the last.  Death is something we deal with regularly, and every single one hurts.  But for some reason this one really hit me.  Hard.  

I can't say exactly why this loss struck me so much harder than most others.  Perhaps it is because my best wasn't enough to overcome what I intellectually knew to be a fatal injury.  Perhaps it was because of that brief moment when I thought he could be the 1% who survives.  Perhaps it is because no one ever came for him.

I still don't know his name.

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.

General

general
/'jen(ə)rəl/
adjective
1. affecting or concerning all or most people, places, or things; widespread.
2. considering or including the main features or elements of something, and disregarding exceptions; overall.

General Electric makes all kinds of electrical things.  General Motors makes all kinds of cars and trucks.  General Mills makes all kinds of breakfast cereals.  General stores sell, well, everything.  General . . .

Uh oh, it looks like Doc had a stroke.  Why the hell is he talking about light bulbs, Cadillacs, and Cheerios?

You know, as usual I had a point before you interrupted.  Now if I might finish, I could perhaps get to that damned point.  "General" is a wastebasket term, and just about anything can fall under the umbrella of "general", just as with general surgery.

Ooooh . . . gotcha.

Yeah, maybe next time you won't be so hasty to jump to conclusions about my mental health, which is, as usual, stellar.

Anyway, the best thing about general surgery, the thing that keeps it interesting, the thing that makes me continue despite the 2 AM appendectomies (it's always 2 AM), is the sheer variety of patients for whom I get consulted.  On any given day I could get a call for a pancreatic mass, a perianal abscess (though I would prefer not), an enlarged lymph node, appendicitis (it's always appendicitis), and anything in between.  And when I'm on trauma call, you can add splenic rupture, compartment syndrome, subarachnoid haemorrhage, and anything in between.

It's that "anything in between" that has the capacity to throw me . . . sometimes.  I'm not a cavalier surgeon.  I know what my limitations are, and when a patient tests (or surpasses) those limits, I call for help.  Arrogant surgeons (the prototypical ones on "Gray's Anatomy" with the god complex) think they can do anything to anyone and get away with it.  When they do that, the patients are the ones who suffer, receiving substandard care from doctors who have no business treating them.  Sometimes these calls can be one of those zebras we hear about, something I'm not equipped to handle on my own and really tests my limits.

Recently Dr. Lee (not his real name™) did test my limits, though not in the way I just described.  Make sense?  No?  Don't worry, just like with the Buicks and Count Chocula, it will.

Dr. Lee is an emergency doc that woke me from a deep slumber just after 1 AM, and the call didn't surprise me one bit.  My phone had been ringing off the hook all day up until midnight when it finally shut the hell up for all of 60 minutes or so.  I figured it would be another appendicitis patient who urgently needed me to save his life but decided to wait until the middle of the night to do so just like all the rest.  Grumble grumble fucking grumble.

"So I have this guy here . . ." Dr. Lee started.

Yeah, you always have a guy.  It's 1 AM, so just get the hell on with it.

"He was in a car accident and has a laceration on his forehead . . ."

Well isn't that dandy, at least it isn't appendicitis.  I can suture a forehead.  But wait, so can Dr. Lee.  So why the hell is he calling me?  What else more serious is going on that I can treat?  Is the laceration deep enough to require a multi-layered repair under anaesthesia?  Does he also have a fractured skull?  A lacerated liver?  A haemothorax?  Bladder laceration?  These are all the thoughts that screamed through my head in approximately 0.192 seconds as I awakened fully and listened intently.

". . . The accident was a week ago . . ."

I started listening somewhat less intently and began grinding my teeth slowly, waiting for the punchline.

". . . and he had stitches put in his forehead, and he needs to have them removed."

He stopped.  I anxiously waited for him to tell me why he was really calling me, because if this was really why he was calling me at 1 o'clock in the goddamned morning, the patient isn't the one who would need a trauma surgeon right about now.  I figured it was obviously just a joke, though I noted to myself that I didn't really know Dr. Lee well enough for him to be trolling me like this in the middle of the night.  All those thoughts had lumbered through my skull in the next 0.294 seconds, until he said,

"So, uh, I was wondering if you could take them out."

I was glad I had the mental fortitude and forethought to mute my phone before letting loose the string of expletives that would have made Quentin Tarantino and Samuel L. Jackson blush.  I finished cursing, composed myself, unmuted my phone, and asked him slowly and carefully if I had seen the patient a week prior and stitched him up.

"No, it was done at another hospital."

Mute.  Expletives.  Unmute.

"Is the wound infected?" I asked him, hoping at least there was something to justify this.  Anything.

"No, it's healed just fine.  The stitches just need to come out."

Mute.  Expletives.  Unmute.

I don't think my voice was nearly as composed as I intended it to be just then as I said in a quavering voice, "Then why are you calling me at 1 AM instead of either A) telling him to see, at a reasonable hour, whoever put them in, or B) taking...the...sutures...out...yourself?"

There was a slight pause before he said (with a baffling amount of confidence that what he was saying made perfect sense), "Because you're listed as being on call for surgery."

At this point I made no effort to conceal my true emotions as I explained to Dr. Lee in no uncertain terms that he, as a fully trained emergency physician, was fully capable of 1) evaluating a wound and 2) removing sutures, especially sutures that were not mine.  I also explained that he was fully capable (maybe) of using his brain to determine if calling me at 1 AM to remove someone else's sutures made any logical sense whatsoever.  I was not entirely convinced that Dr. Lee believed me as he told me he would just send the patient home to follow up with the surgeon he saw initially.

I grumbled (probably . . . I don't remember my exact response), hung up, cursed some more, wondered at what carnival Dr. Lee won his medical degree playing fucking Skee Ball or something, and went back to sleep, visions of giant teddy bears and MD degrees hanging from the ring toss game dancing through my head.  General surgeons are trained and expected to do pretty much anything at any time (within reason, of course), but that conversation strained even my admittedly ample limits.

The patient that actually needed me and was actively dying came in about 3 hours later, but that's a story for another post.

Dead bowel

Well, you asked for it.  I mentioned dead bowel (well, the smell of dead bowel, to be precise) in a previous post, and several commenters asked for the stinky story behind the stench.  I haven't yet told that story here for . . . well, the reason is . . . ok, if I'm mentioning the smell of a case, don't you think I'm trying to save you people here?  And you lunatics still want to know about it?  REALLY?

Seriously, you people are messed up in the head.  I'd seek professional help.  No, not from me, dammit.  I don't do crazy.  Fine, if that's the way you feel, then you're about to get what you deserve.  If you really must know then I have no choice but to preface this story with the following completely 100%  totally entirely invented probably illegal legal disclaimer:

I hereby disavow any and all responsibility for keyboards, monitors, iPhones, Galaxy S6s, iPads, Kindles, laptops, iMacs, netbooks, Chromebooks, and/or any and all other media readers that may be temporarily or permanently stained, made inoperable, and/or otherwise ruined by your vomit.

YOU HAVE NOW BEEN WARNED.  THERE WILL REAL PICTURES OF DEAD BOWEL.  Turn back now etc etc.

Good grief, you people are still here?  Ok, but remember - you asked for it.  

I'm sure everyone has heard the phrase that bad things come in threes.  The logical people will naturally and logically argue, "That it isn't true, it's just that human brains seem to enjoy fitting things into patterns, so when bad things happen, we like to lump them in with other bad things that happened in close temporal proximity."  To those logical people, I'd simply like to say "Fuck you!  You obviously have NO idea how the Call Gods work." 

A few years back Intensive Care Doctor (not her real name™) called me in a panic (N.b. when the people who devote their lives to caring for the sickest people are frantic, it's never a good sign).  She had an elderly, frail patient who had been battling a severe Clostridium difficile infection and was circling the drain despite treatment with several different antibiotics and immunoglobulin over the previous few days (these were the days before faecal transplants existed).  Nothing was working, she was about to die, and they wanted me to take out her colon as a measure of last resort.  She was so sick by that point that my two choices at this point were 1) do nothing and let her die, or 2) open her up, remove her entire colon, and then let her die.

Unfortunately her family wanted to give it the old college try, so as I opened her abdomen less than an hour later, the stench of death slapped me in the face like a drunk moron at a bar getting his due from that nice lady he won't stop bothering.  I removed her entire colon and performed an end ileostomy, but the damage to her system was done, and she was dead before I even got to the hospital the next morning.  I don't have a picture of her colon, so you'll just have to trust me that it wasn't just mostly dead, it was all dead.

That was number 1. 

WAIT JUST ONE DAMNED MINUTE!  YOU PROMISED PICTURES OF DEAD THINGS!  THERE ARE NO PICTURES YET, JUST A CARTOON OF AN OPERATION, ASSHOLE!

Oh just you wait, I'm getting there.

Number two came about a week later.  I got a call from Emergency Doctor (not his real name™) who had a patient who was actively dying.  He was in his 50s and came in complaining of severe abdominal pain associated with nausea and intractable vomiting for the past day.  When he described his abdomen as "rigid", my ears pricked up.  "Rigid" is a term used only for the worst-looking abdomens, ones that look as if they could burst a la Alien, and it makes general surgeons extraordinarily nervous.  It usually indicates that something catastrophic has happened in the abdomen, and that bad something will evolve into a fatal something if not addressed immediately.

I got the patient into the operating theatre about 45 minutes later, and upon opening his abdomen I found his entire small intestine dead.

All that black-looking stuff is supposed to be pink-looking stuff.  The man had suffered from chronic mesenteric ischaemia, a condition where the blood supply to the intestine is compromised and results in severe, chronic abdominal pain after eating.  To treat this he had a stent placed into his superior mesenteric artery (which supplies blood to the small intestine), and as I was transecting that artery to remove the specimen I found (and removed) a large clot that had clogged the stent and the artery, killing his intestine:

Since my necromancy skills are still poor, my only options were A) close up and let him die, or B) remove the entire small bowel, leaving him with short bowel syndrome (where you do not have enough surface area to absorb nutrients so you must depend on IV nutrition to live).  Since you've seen the specimen, obviously I went for option B.  Miraculously he survived, and about a year later I sent him to consult with a transplant surgeon about a bowel transplant (yes, those exist).

I thought I had had enough of dead bowels for some time, but the Call Gods (of course) had other plans: number 3.

Barely two weeks after I discharged the previous patient I got a call from a different Emergency Physician (still not his real name™) about a young man with an acute abdomen.  He was 35 and healthy, but his abdomen was rigid and his CT scan "looks funny".  I assumed he didn't mean "funny ha ha" but rather "funny oh shit please help".  But even I have to admit he was right - his scan did look funny - his small bowel looked thickened and sick.  All of it.

Again to the operating theatre, and again I found dead stuff . . . lots of it.  I once again had the choice of letting this young man die or attempting a huge and heroic surgery.  Based on the picture, you can safely assume you know which avenue I chose:

Perhaps it doesn't look as bad as the last one, but it was - there were patches of deadness along his entire small bowel up through and including his ascending colon (which you can see in the top portion of the picture).  But unlike the previous patient, the clot was in his superior mesenteric vein, not the artery.  This had caused progressive congestion of the intestine followed days later by organ death.  I again removed the entire small intestine, leaving the guy with an end jejunostomy and short bowel syndrome.  And again he miraculously survived.  Because the mesenteric vein is an extremely rare site for a blood clot I asked my haematology colleagues to investigate.  After he woke up and had his breathing tube removed several days later, he admitted that he had also had multiple clots in his leg veins in the past but never took his blood thinner.  After an exhaustive search we finally got a hit - Prothrombin 20210 mutation.  After I sent him home (on blood thinners) he was unfortunately lost to follow up, so I have no idea if he took his meds or if he is even alive.

So there you have it - my favourite dead bowel cases.  That isn't by any means all the dead bowel cases I have seen, but I still find it interesting that I had three so closely lumped together.  But with all that dramatic drama, I strongly suspect that the overwhelming response from the readers will be, "That's it, Doc??  SERIOUSLY?  THAT'S IT??  That wasn't so bad!  I want a refund!"  Maybe you're right.  Maybe I blew it way out of proportion.  Maybe it isn't quite as bad as I described it.

But just remember one thing: you couldn't smell it.

Withholding information

I don't like asking questions.  I really, really don't.  I wish I could scan a barcode on your wrist and get every detail about your health both past and present.  Unfortunately that technology doesn't exist yet (BUT HOVERBOARDS DO?  COME ON, SCIENTISTS!), so instead every patient I see gets the same exact series of questions.

• What are your medical problems?
• What surgeries have you had?
• What medications do you take (including over-the-counter and herbal)?
• What medication allergies do you have?
• What medical problems run in your family?
• Do you smoke/drink/use illicit drugs?

There are other general questions about current health status (Any headaches?  Recent illnesses?  Are your vaccinations up to date?) followed by a detailed physical examination.  All this takes time, and I'd really prefer to skip it, because generally people suck and I don't like talking to them.  But sadly I can't avoid it, because every question I ask has a specific purpose, and none of them deserves to be skipped.  

In other words, when I ask you a question, you'd damn well better answer, because I need to know the answer.  Unlike my daughter (who seems to enjoy talking just for the joy of hearing herself speak), when I speak it is for a reason, and my questions are purposeful and meaningful.

I guess Gary (not his real name™) never got that message.

The emergency physician called me for a patient with a perirectal abscess.  It seemed that everyone in the entire {redacted} metropolitan area had a perirectal abscess that night, and Gary was yet another guy with pus in his ass.  At least it wasn't midnight, when most other people decide that they've finally had enough of the exquisite pain in their ass and decide to seek care.

When I first arrived, I saw the usual suspect - a relatively young, healthy-appearing gentleman who couldn't sit still.  He reminded me of a kindergartener who just can't keep his butt in his seat, but unlike the little tots, this guy had a very good reason for his restlessness.

I went through my usual thorough evaluation, asking the questions I always do.  His answers were all very straightforward - No medical problems, no medications, no allergies, no prior surgeries.  Simple, right?

If it were simple, I probably wouldn't be writing about it.

I was expecting to see a swollen painful area surrounded by redness.  Ha!  Not even close.  On examination, the area around his anus looked like a bomb had gone off.  Everything I touched hurt, and it was far too painful to allow me to perform a full exam, but from what I could see his posterior was a total mess, probably the worst I had ever seen.

"No medical problems at all?" I probed, my suspicions rising.

"Nope, healthy as a horse, Doc", he replied quite confidently.

Unfortunately his process was way too complex to deal with under local anaesthesia, so I booked him immediately for the operating theatre.  Once he was asleep I was able to assess the situation better.  There were at least a dozen areas draining pus, several old scars, and what looked like an anal fistula (a connection between the anal canal and the skin).  I had a feeling I knew exactly what I was looking at, but what I definitely did know was that I was most assuredely not the first surgeon to have been here.

I drained two large abscesses and placed a seton through the fistula.  During the procedure I was explaining the purpose of the seton to the medical student (it allows the fistula to heal without damaging the external anal sphincter, if you were wondering), and at one point I said, "If I didn't know any better, I would swear this guy had Crohn's disease.  But he insists he doesn't."

I admitted him for wound care and antibiotics, and the next day Gary felt much better.  His fever had resolved, his white blood cell count was improving, and he was able to sit still for the first time in weeks.  I told him that he could probably go home the following day.

The next morning the student called me with some surprising (not really) news.  "Doc, I was rounding on Gary and he told me that he does have Crohn's disease.  He was diagnosed about 5 years ago."

Stunned (not really) silence ensued.

I went to discharge Gary a bit later that day, but before he left I felt obligated to ask him why he omitted that rather important bit of pertinent information.  Hopefully his response will make more sense to you than it did to me, but I'll let Gary tell you the reason in his own words:

"Well Doc, you asked me if I had any medical problems that I took medicine for, and I don't.  Because I stopped taking my Crohn's medicine a few months ago."

It was then that I realised I had tried to simplify (and thereby shorten) my questions, and I had combined "Do you have any medical problems" with "Do you take any medications," and the result had been "Do you have any medical problems for which you take medicine?"  And Gary had taken it literally . . . to the word.

At his follow up appointment, Gary and his ass were both looking and feeling much better.  I advised him quite firmly to go back to his Crohn's disease specialist to get back on his medication.  And to tell any future doctors that he does, and always will have, Crohn's, even if he decides to stop taking his medication.  Oh and by the way, if you're wondering why he stopped (as I was), he apparently had spent all his money on beer, cigarettes, and video games (seriously) and didn't have enough left over.  For his medicine. (Yes I realise that paragraph had two sentence fragments.  I'm not proud of myself).

Withholding information is generally stupid, with one notable exceptions: not telling young kids the truth about Santa Claus and the Easter Bunny is reasonable (I hope mine aren't reading this right now).  However, if you really feel the need (and you really enjoy delayed pain), go ahead and keep secrets from your spouse.  Withhold information from the police (if you're really that stupid).  And if you are truly masochistic, don't tell your accountant and lawyer everything.

But for fuck's sake, don't withhold information from the one person trying to take care your your body, especially if you aren't.