Tuesday, 22 August 2017

Prison

I don't typically think of my job as dangerous.  Quite the opposite, actually - the trauma bay is supposed to be a safe place where people who have done something particularly dangerous and/or stupid come to get something fixed.  Whenever we get a rowdy patient (who is usually either A) drunk, B) high on PCP, C) an asshole, or D) some combination of the above), everyone in the trauma bay knows that, with one quick phone call, several very burly men who could easily pass for moderately large bears will descend upon the asshole and defuse the situation in approximately 4.72 seconds. 

Sometimes, however, even that isn't enough. 

Unlike the trauma bay, prisons are violent places, and violent things tend to happen there.  Granted my information regarding the violence inherent in the penal system is mostly limited to what I learned in The Shawshank Redemption and O Brother Where Art Thou, but that knowledge base expanded significantly recently when I met Ervin (not his real name™). 

I don't usually get too worked up when my trauma pager alerts me to an impeding "assault".  That may sound callous, but it's for several good (I think) reasons: 1) When people are assaulted, it is most commonly limited to the face, 2) if these people suffer any injuries (past lacerations and contusions), it is most often a broken nose or other facial bone, 3) those fractures rarely require surgical intervention, and 4) if they do, I call the maxillofacial surgeon to do it.  So when my pager alerted me to an assault arriving in 8 minutes, I sighed and put away the blog post I had been trying diligently (yet failing miserably) to make sound less stupid. 

But then something caught my eye - the patient was arriving by air, not ground.  Hm.  That could mean it was more serious than I was imagining.  Or it could mean the patient was injured further away than an ambulance could drive in a reasonable amount of time.  Or it could mean something else.  Yes, the dreaded "other".  

And of course it was "other". 

When Ervin was wheeled in, the first thing I noticed was the prison jumpsuit.  The second, third, fourth, and fifth things I noticed were the various handcuffs and shackles pinning him to the stretcher.  The next thing I noticed was the mask over his face (think Hannibal Lecter).  Finally came the bevy of police officers accompanying him.  This bodes poorly, I thought. 

And I didn't even know the half of it yet. 

"Hi there, Doc. This is Ervin.  Ervin has been (god damn it Ervin, stop fighting!), uh he's been tussling with the prison guards for the last (damn it, Ervin! Stop fucking spitting!), um for the last two days.  He's being transferred, and (fucking hell guys, he's trying to claw my arm again!), he's being transferred to another facility and doesn't want to go I guess." 

Imagine trying to wrangle a cat into a pet carrier.  Now imagine the cat is extremely angry.  Now also imagine that cat is 2 meters tall, weighs 110 kg, and can curse constantly.  Yeah, that's Ervin. 

He was covered head to toe in abrasions and contusions, and he had obviously earned every single one of them.  Ervin continued fighting as we moved him to our stretcher, and I've rarely seen such a relieved medic crew get the hell out of my trauma bay so quickly.  The officers, on the other hand, thankfully stayed. 

"You want us to uncuff him, Doc?" one of the officers asked me. 

"Hey wait," one of the nurses said.  "I know this guy!  Yeah, Ervin!  He was here as an 'assault' two days ago after he fought with the prison guards!  He injured two techs and a nurse, and he tried to kick me in the face!" 

The police officer looked at me askance. 

Uncuff him? Seriously? 

"Hell. Fucking. No.  Under no circumstances.  NO."  Yes, those were my exact words. 

The tech moved towards him to place an IV, and I immediately stopped her.  I made it clear to everyone in the room that no one was to come near this guy with anything sharp, and all we were going to do was get a quick 5-second CT scan of his brain, see that it was normal, and then send him right back from whence he came.  Fortunately when we brought Ervin to the scanner, he decided the CT doughnut wasn't as threatening as a roomful of cops, so he stayed still long enough for me to see a normal brain. 

Thank you for this one small thing, Call Gods

As I was chatting with a few of the guards a short while later, one of the nurses beckoned to me.  "The radiologist is on the line for you.  He has a critical finding he needs to tell you about." 

Oh come on, no. No. NO. 

It turns out I had missed a tiny subdural haematoma and an even tinier cerebral contusion.  I looked at the scan again and still couldn't see it, so I had another radiologist look at it.  He confirmed that I was indeed not a radiologist and the other radiologist is.  The finding was, in fact, real.  

God. Damn. It. Fuck You, Call Gods. Fuck you. 

So now I was obligated to admit this asshole, put an army of security guards and police officers on him, start an IV, try to do neuro checks on him every hour, repeat the CT scan in a few hours . . . 

Fuck. Just, fuck. 

I did exactly that, apologising to everyone involved in the process.  No one wanted to take care of Ervin, though we all did dutifully and respectfully.  Ervin, however, was not nearly as accommodating.  There were two very large police guards inside his room at all times, and fortunately his outbursts were mostly limited to hurling verbal abuse at anyone he could see.  

The following day his repeat CT scan was stable, his neuro exam was stable (read: he was still a violent asshole), and I kicked him the fuck out of my hospital before he could injure anyone else. 

I have no doubt I will see him again. Soon.

Friday, 11 August 2017

Surreal

Those of you who are regulars here or follow me on Twitter know my feelings on pseudoscience (otherwise known as "bullshit").  Depending on the day, my opinion wavers somewhere between "Pseudoscience is potentially dangerous nonsense" and "What the fuck are you idiots thinking".  Fortunately I've had very few interactions with pseudoscientific nonsense in my professional career, though several years ago I did have one woman ask me about Dr. Oz and an "olive oil flush" for gallstones.  Since I've been ranting and raving about various bullshit modalities like chiropractic, homeopathy, and acupuncture, I've often wondered how long it would be until my next encounter.

Wonder no more.

I was asked to see Barbara (not her real name™) late one evening for what sounded like typical acute cholecystitis - several days of right upper quadrant abdominal pain, fever, nausea, and vomiting.  Before going in to examine her I looked at her abdominal ultrasound, which showed multiple large stones in her gall bladder along with thickening of her gall bladder wall and inflammation surrounding the gall bladder itself.  Checking her bloodwork, her liver function tests were all normal (so no sign of a biliary tract obstruction - good), and her white blood cell count was mildly elevated as would be expected.  It seemed like a slam dunk, and it was.

Mostly.

When I entered Barbara's room, she had a friend with her, which is certainly not unusual.  I examined her carefully, and the only abnormality was fairly severe tenderness in her right upper abdomen, typical of someone with a gall bladder infection.  I explained the treatment protocol, which would be giving her IV antibiotics overnight followed by a laparoscopic surgery the following morning to remove her infected gall bladder.  I went through my prepared speech which I've given hundreds of times, including the risks, benefits, and alternatives.  And as usual I ended with my normal conclusion: "Do you have any questions?"

It was one of the few times I've regretted it.

Barbara whipped out a little notepad with myriad hand-written notes, and I was immediately bombarded with approximately 1,058 questions, everything from the mundane ("How long will I be out of work?") to the somewhat-strange-but-still-almost-normal ("What anaesthetic agent will I be given?") to the completely bizarre ("What are your instruments made of?").

Then she hit me with one that was so far out in left field it may as well have come from a different country:

"Can I keep my gall bladder?"

Um.  Uhhh.

I had to explain to her that I was obligated to give the gall bladder to the pathologist, who would cut it into thin slices and make sure she didn't have something wacky like gall bladder cancer, so, um, no, you can't keep your disgusting infected gall bladder.  I offered her the option to keep one of her stones instead, which she readily accepted.

And then her friend started asking questions.  Approximately 792 more.

Sigh.

After what seemed like two hours (but was probably closer to 8 minutes), I finally made my way out of her room, where her nurse caught my eye.  She rolled her eyes and smirked in a plainly obvious "Oh, she got you too?" look.  I merely smiled back weakly, feeling lucky to have escaped.

The following morning I went to see Barbara, and she still looked uncomfortable.  Regardless, she told me she was ready for surgery, which was scheduled for later that afternoon.  I went back to my office to see patients for a few hours, returning to the hospital about 30 minutes before her operation was due to begin.  I figured she would be in the pre-op area, which she was.  What I didn't figure was who would be with her.

The only way I could properly describe Barbara's visitor would be to say that she looked like she stepped directly out of 1967 into a time machine, landing in my hospital in 2017.  She could have easily passed as someone who went to a costume party dressed as a hippie and then forgot to remove the costume, so she simply continued living as a hippie.  She had one hand on Barbara's right shoulder and another on her back, and it looked like she was giving her some kind of weird massage.

"Oh, hi Dr. Bastard," Barbara smiled.  "This is Rena (not her real name™), my reiki master."

Your . . . your what?

I had no idea how to reply, and the anaesthesiologist could sense the palpable awkwardness growing by the second.  He gave me a knowing look, rolled his eyes, and clearly trying to break the tension said, "Yeah, I missed my last two reiki appointments."

Heh, good one.

"I KNOW, ISN'T IT AMAZING?" Rena replied with a broad smile, obviously missing the obvious sarcasm, which was obviously obvious.  Barbara smiled too, missing the fact that now both the anaesthesiologist and I were staring at each other, our mouths agape.

It's difficult to render me speechless.

In case you aren't aware of what reiki is, it's bullshit.  It's pure, unadulterated bullshit.  Here, I'll give you the rundown: take prayer, add running your hands over someone to transfer energy to them, and you have bullshit.  I mean reiki.  No, I was right the first time.  Bullshit.

I had never seen reiki actually practiced in real life, so I watched agog as Rena ran her hands over Barbara's right shoulder, muttering encouraging words (I guess) and supposedly transferring some universal life force into her.  This was happening as her very modern IV antibiotic was running through a very modern plastic tube into her very physical vein.

I couldn't think of anything else to say, so I quickly signed my paperwork, muttered something about changing into scrubs, and walked out.  The anaesthesiologist looked jealous.

Barbara's surgery was moderately difficult though uncomplicated.  Her gall bladder was quite inflamed, but it was no different than most any other case of acute cholecystitis I've handled through the years.  She went home the following day feeling somewhat better, but still in some pain.  My typical gall bladder patients go home the same day as surgery and are back to their usual activities within a day or two, relying on ibuprofen (if anything) for pain.  Barbara, on the other hand, emailed me several times a day over the next few days to describe the progression of her pain, nausea, appetite, temperature, and anything else she managed to quantify.  She finally started feeling better just over a week later, to her (and my inbox's) great relief.  She came for her follow-up visit two weeks after surgery, Rena tagging along.  Of course.

With that goddamned notepad.  Of course.

After conducting my exam (everything looked absolutely fine), I dutifully answered all of her remaining questions, including "When can I start juicing again?".  Barbara and Rena both profusely thanked me for my patience and warm bedside manner, and they left looking quite satisfied.  If they only knew what I had really been thinking.

Now I realise that this is only an N of 1 and anecdotes are not data, but it sure seems to me that Rena's energy transfer didn't fucking work.  Of course it's possible Barbara's surgery would have been even more difficult, and her recovery much more protracted, if she hadn't had the reiki treatment done.  Right?

Ha!  No.

Monday, 31 July 2017

Expect the unexpected


Apparently Heraclitus of Ephesus was the first to say something to the effect of "Expect the unexpected", though his exact words were more like "He who does not expect will not find out the unexpected, for it is trackless and unexplored" which sounds much more "Greek philosopher"-ish and less "David Avocado Wolfe meme"-ish.  Regardless, I've always thought this phrase stupid and meaningless, because how can you expect the unexpected?  If you expect it, then it isn't actually unexpected, is it.  What a stupid adage, almost as stupid as "YOLO", am I right?

When I was younger I used to think that was just me being even more pedantic than usual.  But then I became a trauma surgeon and learned what "unexpected" really means.  It was then that "Expect the unexpected" took on a whole new meaning.

A "typical" trauma day for me will involve somewhere between 5 and 20 patients, most of them lightly-to-moderately injured (abrasions, lacerations, contusions, perhaps a broken bone here and there).  These are folks who need X-rays more than a trauma surgeon, at least initially.  Perhaps 10% are severely injured, and 1-2% have truly life-threatening injuries.  So on any given call day I can usually expect one or two "Level 1" traumas who need my immediate attention.  So you can imagine my surprise when the first 4 trauma patients who rolled into my trauma bay one recent Saturday were all Level 1s.

Fuck you, Call Gods.

The first patient was a middle-aged drunk man who was stabbed in the chest multiple times (at 9 o'clock in the morning?  Really?) but only had superficial injuries.  This story is not about him.

The second was a young man who was stabbed in the abdomen and left arm (at 10 AM?  Fucking really, Call Gods??) and had multiple lacerations to his small and large intestine as well as the left brachial artery and required a laparotomy, resection of the small intestine, repair of the colon, and repair of the brachial artery.  This story is not about him either.

The third was a teenager who was shot in the thigh (at noon?  Seriously, what the fuck, Call Gods??) and had a broken femur which required surgical fixation.  Nope, this is not about him.

The fourth guy, on the other hand . . . yeah the fourth guy threw everyone off.  I bet at this point even the Call Gods were tired of playing the same goddamned joke on me.

I was already exhausted and ready to go home by the time Quinton (not his real name™) was brought in at 1 PM (only 19 more hours to go!).  "Hi everyone, this is Quinton.  We found him on the side of the road.  Looks like he was hit by a car.  Got an abrasion on his left shoulder, looks like his face landed on a stick.  His left eye is, well, it's just missing.  He's unresponsive, not moving anything for us."

The road they found him near is a high-speed road, so everyone immediately jumped into action knowing that he had been suffered a high-velocity, high-energy strike.  The potential injuries were vast - literally anything could be injured.  Since the anaesthesiologist was intubating him, I started at his feet and made my way up.  His feet and legs were fine.  Pelvis, stable.  Abdomen was soft, flat, no obvious injuries, ultrasound negative for blood in the belly.  Chest was stable, no obvious rib fractures, breath sounds were equal.  His heart was beating a bit fast, but the sounds weren't muffled, so I doubted a blunt cardiac rupture.  Arms and hands were normal.  His neck looked normal.

And then I got to his head.  His left eye wasn't missing, but it wasn't normal either.  The globe (eyeball) was ruptured, presumably from the stick he had landed on.  I didn't so much care about the eyeball - while that injury looks seriously bad, you can live without an eye.  His scalp had some matted dried blood in it which made evaluation of his scalp impossible.

With his airway secure and his vital signs stable, we got a quick X-ray of his chest (normal) and pelvis (normal) and went immediately to the CT scanner.  When a scan is done, the tech first shoots a "scout" film, which is essentially a plain X-ray of the body part to be scanned.  The tech shot the scout intending to set up for the scan then said something entirely unexpected:

Tech: Um . . . there's a bullet in there.
Me: Wait, there's a what??
Tech: No wait, I was wrong.
Me: Whew.
Tech: There are two.

I looked at the screen, and sure enough there was a bullet sitting right in the middle of his head and another one in his face.  Uh . . . what?  I had assumed he had suffered a high-velocity, high-energy strike, but this wasn't exactly what I had in mind.

The CT images came through a few seconds later, and to say I was surprised would be a drastic understatement.  That matted blood on his scalp was hiding a gunshot wound and underlying skull fracture with a large haematoma in his brain, with the bullet coming to rest in the soft tissue of his cheek.  The second bullet had apparently gone through his eyeball and lodged in the middle of his brain.  There was severe swelling of his brain and transtentorial herniation.  If that sounds bad, it's probably even worse than it sounds.

It takes a lot to surprise me, but that SURPRISED THE HELL out of me.

About an hour later Quinton was in the operating theatre with one of my neurosurgery colleagues, despite the fact that we both knew any aggressive treatment would likely be futile.  Unfortunately we were both right - it took him two more days to finish dying.  No one ever came to identify him, so organ donation was impossible.

I like to joke that I'm a pessimist and that pessimists get more happy surprises, but in reality surprises in the world of trauma are nearly universally bad.  And expecting the unexpected sure sounds like a great way to avoid surprises.  Sometimes, however, the unexpected is just, well, unexpected.

Thursday, 27 July 2017

Education

To me (and hopefully to you), education does not necessarily mean what one learns in a classroom.  Sure, there are plenty of things to learn while sitting and listening to someone with the charisma of an oak tree droning on and on about what some army general 300 years ago did to win some plot of land that doesn't even belong to that country that no longer even exists.  However, practical knowledge is more important than anything else.  Except maths - for fuck's sake, learn your maths.  How else are you going to know how much that sale is saving you?

Anyway, the most educational experience of my life has undoubtedly been in the trauma bay.  There are so many lessons I have learned there through the years, and though I'm not saying you can't learn this stuff elsewhere, I personally would likely never have learned them anywhere else for any reason.  These are pearls of wisdom that I will teach my children and take with me everywhere until the day I take my last breath.

And I'd like to share a few of them now.

Ahem . . .

Donkeys are singularly nasty creatures.

A donkey bite looks shockingly like a human bite. 

Helmets work well, but only when applied to the head.  Corollary: helmets are shit at protecting the face.

Gravel is hard to remove from skin.  

Asphalt is much harder than bone.

Many people underestimate gravity.

Trucks have the capacity to move out of the way.  Trees don't. 

Untreated schizophrenia is fucking terrifying.

PCP intoxication can look surprisingly (and terrifyingly) like untreated schizophrenia.

People will deny anything, even something glaringly obvious, for any reason.

Your dog will eat your foot if it gets hungry enough.

A bag of drugs can be hidden in literally any bodily orifice.  If one is not available, a new one can and will be created. 

Power tools can explode. 

People will lie, cheat, steal, beg, plead, wheedle, cajole, bargain, debate, and negotiate for a prescription for narcotics that they don't need. 

Children who have parents that don't give a damn will do stupid things at 2 AM.

Percocet can be a gateway to heroin. 

Holding your baby in your arms will not necessarily stop a pissed off ex from shooting or stabbing you. 

Jealousy is apparently a good enough reason to stab someone in the heart. 

A hammer can be just as lethal as a gun.  So can a deer.

There truly is no limit to the depth of human stupidity.

---

Now I fully realise that last lesson can be learned by anyone in nearly any field.  Everyone has stupid stories to tell, many of them hilarious in their absurdity.  But the difference is that only in very few occupations can your stupidity kill you.  Or others.

Tuesday, 18 July 2017

Continuity

Studies show that . . .

Wait wait wait, I didn't come here for a "Studies show that" article goddammit, I came here for a stupid patient story, Doc!  What the hell are you on about this time?

Wow, three whole words before I lost you.  I think that's a new record.  Yeah, there's a stupid patient story here, but I need a bit of a setup, ok?  Just shut up and listen.  Or read.  Or whatever.

Studies show that . . . still with me?  Good . . . many errors that occur in hospitals are due to miscommunication, especially between doctors during handoffs and/or signout.  When one doctor (or team of doctors) goes off duty and another comes on, the communication between the two is crucial - it must be clear, concise, and complete.  There have been studies done which show that standardised handoffs reduce these errors, and the gist of the article is as follows: fucking duh.

Even better than standardised handoffs, however, is continuity of care: the same doctor taking care of the same patient no matter what.  In the world of outpatient internal medicine, this is fairly simple - you see your doctor when you have a problem, you don't go to different doctors for the same thing, because that's where problems are born.  In surgery, however, continuity is much, much rarer, and in trauma it is nearly unheard of.  Most people don't suffer severe traumatic injuries more than once, and if they do the likelihood that they will be brought to the same trauma center where the same trauma surgeon just happens to be on call is close to zero.  Close to zero, but decidedly not zero.

I'm sure you see where this is going.

The Call Gods reared their heads recently when I received a bicyclist who crashed, striking his head and losing consciousness.  Fortunately he was wearing a helmet, but as good as helmets are at protecting the brain, they are shit at protecting the face.  Jonah (not his real name™) went face-first over his handlebars into the gravel, and he suffered a fractured nose and several lacerations near his left eye.  As I was suturing him, he happened to mention that he had a similar bicycle accident about a year ago where he broke his clavicle and ultimately required surgery.

Dun dun DUN

I am terrible with names and almost as bad with faces, not to mention the fact that I see several hundred trauma patients a year (and the fact that Jonah at that moment would have been unrecognisable to anyone but his mother), but after I was done suturing, a quick look through my list of patients told me that yes indeed, I saw Jonah last year after his most recent accident.  I didn't feel too bad about not remembering him, because he didn't remember me either.

But the Call Gods weren't done.

A few days later I was evaluating Tomas (not his real name™) who had stolen a motorcycle (but not the helmet) and had crashed into a truck.  Heads are significantly softer than asphalt, and when his head hit the pavement (or maybe the truck, I suppose) he suffered a subdural haematoma.  I was staring at the computer screen scrolling through his images when his family came into the trauma bay to see him.  And that was when I heard a rather familiar voice from Tomas' bedside:

"Hey!  Hey, Doctor Bastard!"

Normally I get critically annoyed when someone yells at me from the trauma bay, but I knew that voice, and I knew the certainty with which he repeated my name.

I looked up with a big smile and saw Mikel (still not his real name™) with an equally huge smile on his face.  Mikel, you may recall from a previous post, was shot in the abdomen and required emergent surgery to repair approximately 194 holes in his small intestine.  His injury had been severe and life-threatening and his recovery had been swift and uneventful, but his attitude had been, and still was, incredibly positive.

And he happened to be Tomas' older brother.

Mikel did nothing but grin (as did his mother) as he vigorously and firmly shook my hand and recounted his hospitalisation and subsequent recovery.  He was back to work with essentially nothing but a big scar on his abdomen to remind him of his near-death experience.  He thanked me profusely (again) before asking him to take similar care of his little brother.

That is a different kind of continuity altogether.

And if you're wondering if Tomas had an attitude as positive and inspirational as his older brother, I hate to be the one to dash your hopes for humanity against the rocks, but fuck it, I'll do it anyway: hell, no.  He walked out of the hospital against medical advice at midnight while no one was watching three days later.

Wednesday, 12 July 2017

Actively dying

I have a confession: most of the patients I see are not actively dying, and I'm not a superhero.  I'm sure that will come as a shock and disappointment for some of you, but I cannot sustain this facade any longer.  But sadly it's true; the vast majority of the victims I see in my trauma bay are lightly injured at most, and some are completely uninjured (other than their pride, perhaps).  Car accidents, falls, assaults, even gunshot wounds and stabbings - most of the people I see are sent home from the trauma bay without even spending a night in hospital.  Those are the people I don't write about, because who the hell wants to read that dreck.

On the other hand, there are some who come in dead and stay dead.  Despite my best efforts and plenty of practice, my resurrection skills remain poor.

And THEN there are the ones at death's door.  These are the ones we feel really good about, the ones we talk about over coffee the next morning, the ones I write about.  They are the patients that give me pause, that make me stop and think, "NOW THIS is why I went into trauma."  They are the ones who make the commitment, the loss of time with my family, and the sleep deprivation totally worth it.  These are the "Great Saves".

Bosley (not his real name™) was a Great Save.  Except that I didn't save him.

"Hey Doc, if you didn't save him, why are you writing someone else's story?  Isn't that even more arrogant than usual for you?"

Didn't your mother ever tell you what happens when you make assumptions?  Something about U and umptions.  I don't remember.

Anyway, the story we got from the ambulance crew as Bosley was en route was strange enough, but it only got stranger after he hit the door.  We were told that Bosley was the driver of a car that ran into a building, which happened to be a chemist/apothecary/pharmacy/drug store.  Coincidence?  Perhaps, but perhaps not.

Hm.  Strange things are afoot.

By the time the ambulance got to us about 10 minutes later (just before midnight), Bosley was awake and talking, though something was definitely off.  I couldn't tell exactly what it was, but he just Didn't Look Right.  The medics were acting rather cavalier, however, clearly playing off the whole "trauma" thing as nonsense.

"Hey there everyone, this is Bosley.  He's 72, healthy, never sees a doctor.  He was on his way to the drug store tonight to pick up some medicine for a stomach ache when he hit the wall of the building, low speed, basically no damage.  But he lost consciousness, so with that and his age, we made him a trauma.  No sign of trauma on him, though.  Probably just fell asleep at the wheel, right Doc?" he concluded with a grin.

No.  A quick glance at Bosley told me that was not right.  Though he was awake he looked awfully pale, and he was a bit sweaty despite it not being very warm.  When he was hooked up to the monitor, however, his vitals were all completely fine - heart rate of 71, blood pressure 121/70, oxygen saturation 98% on room air.

Hmm.

The nurses started disrobing him and asking his medical history.  He had no medical problems, no prior surgeries, took no medicines on a daily basis, no allergies, doesn't drink, smokes 1-2 packs of cigarettes a day since he was 17.  Hasn't seen a doctor in 45 or 50 years.  I started my cursory secondary survey, trying to find any body part that hurt.  His head was fine, neck was fine, chest was fine, arms and legs were fine.  But when I pushed on his abdomen, I got a bit of a grunt in return.

Hmmm.

I asked him how much it hurt when I pushed, and he replied, "Not that much, Doc.  But it's been hurting me all day.  That's why I was going to get some medicine, to try to settle my stomach.  It hurts in my back, too."

Hmmmm.

"And I passed out in the parking lot.  That's why I crashed."

Hmmmmm.

Unfortunately it was right about this time when we got two walk-in stabbing victims.  Well, that's not exactly true.  Only one of them walked in, while the other had CPR in progress.  I didn't get a chance to examine Bosley more carefully like I usually do, but I glanced at his monitor as I rushed out to try to save the dead patient and saw that his blood pressure was steady at 120/75 and his heart rate was 68.

Good, I thought.  He's stable.  His CT scans should be done by the time the dead guy finishes dying.

It took me about 20 minutes to discover that the dead guy was dead because the knife had created a big hole in his left pulmonary artery (which is generally regarded as a Very Bad Thing), and as soon as I pronounced him dead I ambled over to the CT scanner to look at Bosley's scan.  The tech flashed through the pictures quickly, and something caught my eye.

WHAT THE FUCK IS THAT IN THE MIDDLE OF HIS ABDOMEN??

I took control of the computer's mouse and scrolled through at a more human pace, and what greeted me was a huge (and I mean FUCKING HUGE) abdominal aortic aneurysm.
Not actually Bosley's huge fucking AAA
It doesn't take a radiologist to see THAT LOOKS BAD.  That huge white thing in the middle of the abdomen is an abdominal aortic aneurysm.  In layman's terms, the main artery that supplies blood to the entire body was dilated to approximately 5 times its normal diameter, and it was surrounded by blood that had leaked out of a hole.

Let me repeat that in case the gravity hadn't set in: the aorta had a big fucking hole in it and was leaking.

Bosley didn't know it, but he was actually in danger of dying at any second.  He was literally a figurative time bomb that could literally explode at any moment.  Literally.

And just in case you think I'm being hyperbolous (why the hell isn't "hyperbolous" a word?), I grabbed the radiologist and dragged him over to the screen.  This was his exact reaction:
Oh.  OH!  Oh, oh wow.  Oh, uh that's bad.  That's really bad.  That's a ruptured AAA with a huge retroperitoneal haematoma.  He needs to be in theatre.  Wow.  Just make sure you MOVE HIM REALLY CAREFULLY.
The aneurysm had nothing whatsoever to do with the car accident but rather had been slowly growing over several decades and was related to his smoking and untreated high blood pressure and general lack of medical care over 70+ years.

Eighty two seconds later (I counted) I was on the phone with the cardiovascular surgeon on call, and 29 minutes after that (you're damned right I counted), he was standing next to me looking at the scan, and Bosley was waiting for him in front of the operating theatre.

His aortic aneurysm repair was completed about 4 hours later just as I was finishing an exploratory laparotomy and right colon repair for yet another stabbing victim that came in about two hours after Bosley did (of course).  He stayed in hospital for about 2 weeks before going home with several new prescriptions for high blood pressure and diabetes, none of which I suspect he will take.

It was a great save, it just wasn't mine.  Actually now that I think about it, Bosley's car accident saved his life.  If he hadn't crashed and had simply passed out at home, his neighbours would have probably found him dead on his floor several days later.

Well, I must be off as it's time for my resurrection practice.  Now was that wave the left hand twice and then pronate the right while incanting, or . . .

Shit.

Wednesday, 5 July 2017

Charlie

I'm sure many of you know exactly to whom the title of this post refers.  For those of you who don't, I'll give you a hint: Charlie isn't a patient of mine.

Figured it out yet?  No?

Several people have emailed to and/or tweeted at me (I still hate that I tweet "at" people.  It seems violent somehow.), wondering why I haven't blogged about Charlie Gard yet.  Well, I haven't done any request posts in a while, so you people are finally getting your wish.

For those of you who have no idea about whom I'm talking, I'll give you the short short version.  Charlie Gard is a wee British lad who was born with an incredibly rare genetic disorder called mitochondrial DNA depletion syndrome, in which there is a drop in mitochondrial DNA in affected tissues (muscles, brain, and liver).  The affected cells can't produce the ATP they need to survive, and it typically results in death in infancy or early childhood.

As if that weren't bad enough, Charlie was unfortunately diagnosed with an incredibly rare variant of this incredibly rare disease, called RRM2B-related mitochondrial disease.  There are only 16 reported cases of this variant, and all of them have died in infancy.

Like all children with this disease, Charlie seemed like a healthy, normal boy when he was born last August, but he missed some developmental milestones, so his parents took him to the hospital when he was two months old.  Since then he has been on a ventilator, unresponsive and unable to move.  Ever since his parents received the devastating diagnosis, they have been in a legal battle with the hospital over how to treat Charlie - A) continue with aggressive treatment, or B) stop fighting and let nature take its course.

Sigh.  Here we go again.  Another tragic story of a child taken too soon.

Charlie's parents aren't ready to let go, and it seems they have been in and out of the courts every few months.  An American neurologist (who still has not been named) has averred that Charlie is in the terminal stages of his disease, but he has offered an experimental treatment called nucleoside bypass therapy, which has never been used for RRM2B (though it has had some success with a less-severe variant called TK2) and reportedly costs £1.2 million.  His parents set up a GoFundMe account that raised more than the required amount, but Charlie's doctors at Great Ormond Street Hospital argued that the therapy is untested and has risks that would outweigh any potential benefit.  In April 2017 the courts decided that the hospital could turn the ventilator off and let Charlie pass in peace.

Undeterred, Charlie's parents kept fighting.  They took the case to the Court of Appeals, which upheld the initial ruling in favour of the hospital.  The Supreme Court then heard the case, which again upheld the ruling.  They took it all the way up to the European Court of Human Rights, which just a few days ago upheld the ruling yet again.

Since the ruling, a children's hospital in the Vatican has offered to take Charlie in as has an American hospital, but his doctors have refused to allow him to fly.  Prime Minister Theresa May has agreed with the doctors, and Charlie remains at Great Ormond.  Charlie's parents have since asked his doctors to discharge him, so that he can die at home in his crib with his parents.  But he still remains where he has been for nearly his entire life.

If this is all sounding familiar to you, then you're probably aware of the similar case of Jahi McMath.  However, the two stories differ in one major way.  But how?  After all, just like Jahi, Charlie can't move, he can't cry, he can't eat, he can't even breathe on his own.  Right?  So what is this major difference?

Unlike Jahi, Charlie can feel pain.  That makes all the difference in the world (in my mind, at least).  Charlie has the capacity to feel discomfort from the pokes and prods, the uncomfortable feeling of a ventilator pushing air into his lungs every few seconds, endlessly.  And with no capacity to improve.  Ever.

But just in case you thought this was a mundane story, it doesn't stop there.  Oh, no.  Donald Trump, of all people, has thrown his hat into the ring.
I'm not sure what Trump thinks he can do for Charlie, but I don't think a spray tan would help.

So . . .

With that very long-winded summary of the past 10 months of Charlie's life, I address the requests I've gotten, all of which have been essentially the same - "Doc, please weigh in on Charlie Gard!"

Well, you asked for it, so here goes:

I agree with everyone, and I disagree with everyone.

Thanks everyone, goodnight!

. . .

Ok, ok.

But seriously, I can honestly see everyone's point of view, and there is absolutely no good answer.  On the one hand, the doctor in me sees the futility in any attempted heroic effort, coupled with the fact that Charlie can feel pain though has no way to express it.  On the other hand, the father in me wants the parents to fight for every minute they have with their son.  But on the other hand . . .

There is no other hand.

The sad fact is that Charlie has a universally fatal and incurable disease.  The proposed treatment in America is experimental at best, has only been used a few times on a related disorder with modest success, and has never been used on anyone with such an advanced case.  There is no reason to think it will be able to reverse Charlie's terminal case, and every reason to believe it will simply cause him to endure his pain longer.  However, I can see no reason why the hospital would deny Charlie's parents' request to let them take him home.  They should at least grant them that one final wish.

I can't really say what I would do in this situation.  I'd like to think that my rational side would take over and let my child go peacefully, but just like I tell my patients, I can't guarantee it.  How can anyone think they know what they would do with such an impossible quandary?  What I can guarantee, however, is that any bullshit offer from Donald Trump would be unabashedly and vehemently rejected with alacrity and aplomb.

I welcome any respectful comments and suggestions.  Tell me I'm wrong, tell me I'm right.  Just keep it respectful.

Tuesday, 27 June 2017

Rare

If you are a regular reader here (or even an irregular reader) or if you follow me on Twitter (and if you don't, WHY THE HELL DON'T YOU), it probably seems like I get angry on rare occasions.  Ok, sometimes.  Alright, often.  OK ALL THE GODDAMNED TIME.  The truth is that anger is just a facade, a face that I put on to make my words seem more compelling.  I'm actually a very level-headed person and I manage to keep my composure in nearly any situation no matter how infuriating it gets.  Yes, I rarely yell at my children when they do something particularly egregious (though I have kept my 2017 New Year's Resolution for the most part), and yes my wife and I have the very infrequent argument which never escalates past what I would consider a minor tiff (and we never go to bed angry - excellent advice for anyone not yet married).

So no, in reality I'm not angry all the time.  In fact, I very rarely am.  It takes a lot to get me angry.

Roscoe (not his real name™) got me angry.  VERY fucking angry.

Some people don't talk much as they enter the trauma bay, and the reason for this is varied:
  1. Brain injury
  2. Intoxicated
  3. Asshole
  4. Scared of the police
  5. Deaf
Severely brain-injured patients typically do not open their eyes, and I can only recall one deaf patient in the past decade or so, so when Roscoe was brought to me with his eyes wide open yet refusing to say a word, I strongly suspected some combination of 2, 3, and 4.

"Hi there Doc, here we have Roscoe.  He's 19, we think.  That's the only thing he'd say to us, and he had no ID on him.  He wrapped his car around a pole at around 100 kph (62 mph), we think.  He isn't saying much, so we don't know if he has anything on board {"on board" is medic speak for "drugs/alcohol"}, and we also don't know if anything hurts.  We haven't found much in the way of outward trauma.  Have fun, Doc!"

I hated that medic just then, but I wasn't angry.  Yet.

Roscoe looked like a healthy young man, he didn't smell of alcohol, and he barely had a scratch on him, just an abrasion or two on his left knee and elbow.  All his limbs seemed to be intact, he didn't groan as I pushed on his chest or abdomen, and his back and neck appeared normal.  The biggest problem I had to assess was his brain: was his lack of speech a product of a drug other than alcohol or did he have a brain injury?  A CT scan should tell me quite quickly.

And it did - his brain appeared as normal as the rest of his exam.

However, this didn't answer my question fully.  A CT scan will show a subdural haematoma, subarachnoid haemorrhage, or haemorrhagic cerebral contusion very nicely, but a concussion doesn't show up on any scan as it is purely a clinical diagnosis.  I walked back to the trauma bay from radiology with my mind working frantically, trying to figure out what was going on from the information I had.  And as I walked back into the trauma bay, the amount of information I had suddenly jumped up several notches: Roscoe was talking.

I overheard him tell the nurse in a very hushed voice that he had taken something that a friend of his had given him after they had smoked several joints.  He wasn't sure what the pill was, all he knew was that it was round and white and made him sleepy . . . which explains why he fell asleep at the wheel.

I was annoyed, but still I wasn't quite angry.

Roscoe's mother showed up (with a little boy in tow) a short while later after his lab work had come back.  It was all normal except for his urine tox screen, which was positive for marijuana and diazepam (Valium).  Roscoe's mother was cooing over her son, obviously (and rightly) thankful he was uninjured.  Her cooing quickly stopped when I told them about his tox screen.

"WHAT?  YOU TOOK WHAT?  WHERE THE HELL DID YOU GET THAT!  YOU'RE ONLY 17 YEARS OLD!  YOU COULD HAVE KILLED YOUR BROTHER!  WHAT THE HELL WERE YOU THINKING, ROSCOE!"

Wait, kill your younger brother?  What?  

It turns out Roscoe (who was only 17, not 19, not that that made a damned bit of difference) was on his way to pick up his 7-year-old brother from a birthday party but decided it would be a great idea to stop at a friend's house, smoke a few joints, and take a random pill just before getting back in the car.

NOW I was angry, and I was sure glad I wasn't the only one as Roscoe's mother continued her well-deserved tirade.

I get angry when innocent people are put in jeopardy because of the stupid decisions of others.  Sure, Roscoe had put his own life on the line, but he had also endangered the life of his little brother as well as all the other people on the road around him.

Normally I try to calm family members down so they don't yell and disturb the other patients in the trauma bay and the rest of the department, but not this time.  Nope, not a chance.  I let Roscoe's mother give him the business as long as she wanted, and boy did she.  I have no doubt whatsoever that this wasn't the last Roscoe would hear of it from her.  She continued berating him as they left the trauma bay, the little boy still walking silently behind them.

Having proofread this post several times, I feel myself getting angry again.  Does anybody know a homeopathic remedy I could use to calm me down?

Oh, never mind.  I found one.

Tuesday, 20 June 2017

Too old

I'm sure everyone reading this has heard the adage "Age is just a number".  To most, this aphorism means that you're never too old to have fun.  To a trauma surgeon, however, it sounds like an excuse for older people to do stupid shit that should be left to younger idiots.

Now before anyone accuses me of being "ageist" or something, just stop a minute and think.  Is it "ageist" to expect a 20-year-old kid to understand how the world works?  No, of course not.  Young kids just aren't old enough and therefore don't have the necessary experience.  That's why we (generally) don't elect 20-somethings to elected office; they just don't know any better.  On the other hand, it also is not ageist to expect a middle-aged person to have accumulated enough firsthand knowledge of things to avoid doing seriously stupid shit.  Older people should just know better.

Quincy (not his real name™) should just know better.

I should start by saying that Quincy is not a stupid man, or so I found out later.  That was not the initial impression I got, however.

It was early afternoon on a beautiful bright warm Saturday afternoon when Quincy was brought to my trauma bay in a rather sorry state.  I rarely get the full story from the medics, relying only on rough bits of information.  This case was no different.

"Hi everyone, this is Quincy.  54 years old.  Helmeted rider of a motorcycle, crashed at around 70 kph (about 45 mph).  Brief ell oh see (LOC: loss of consciousness), awake and alert now.  Complaining of severe abdominal pain, right hand pain, left hip pain."

Quincy was mostly awake and mostly alert, and he groaned audibly as he was moved from the gurney to our stretcher.  My Inner Optimist started whispering at me as Quincy was hooked up to the monitors, revealing a heart rate of 120 but a normal blood pressure.  "It's probably nothing.  He's probably just very amped up from the accident is all."

My Inner Optimist is annoying as hell.  And often wrong.

My initial exam showed an open fracture of his right hand and significant tenderness in his left hip.  But what really struck me was his abdominal exam.  He kept pushing my hand away whenever I pushed on his belly, something he didn't even do when I was examining his obviously badly fractured hand.  And when I did push, his rather rotund abdomen felt like a board, and it hurt a lot more when I released pressure compared to when I pushed.

1) Voluntary guarding.  2) Board-like rigidity.  3) Rebound tenderness.  All signs of peritonitis.  Quincy had something seriously wrong inside his abdomen that was killing him, and he needed surgery.  Now. 

I rather gleefully pointed out to my Inner Optimist that he was wrong again. 

Quincy's blood pressure held steady in the normal range for the next ten minutes as he was packaged up and brought down to the operating theatre.  Expecting the worst I made a large vertical laparotomy incision, and I was not disappointed.  What struck me first as I entered his abdomen was the smell of vomit, clear as day.  What struck me second was the lack of BIT (Blood In There).  Something, most likely his stomach, was clearly perforated, but somehow that something wasn't bleeding.  Perforations are bad, bleeding is bad, and the two together are worse.  Perforations without bleeding are still bad, but only slightly less bad.

Starting in the upper abdomen I began literally scooping out handfuls of onions, chicken, and corn (WHY THE FUCK IS IT ALWAYS CORN), reinforcing my assumption that his stomach had a large hole in it.  And when I finally got my hands on it, my suspicion was confirmed - a 7 cm laceration across the fundus and antrum (the lowest portion near where the stomach empties into the small intestine).  I initially controlled it with atraumatic clamps to stop any more stuff from leaking out, and I then fired a stapler across the injury to repair it.  His descending colon also had a partial-thickness laceration which did not penetrate the entire wall (fortunately) which I also repaired.  Nothing else was injured, which explained the lack of BIT.

Normally at this point in a trauma operation I would close and everyone would high-five and congratulate each other for another life saved (not really), but not today.  No, now came the really fun part: cleaning up.  

You would be surprised how large and deep the peritoneal cavity is, so now knowing that you would probably not be surprised how easily and in how many places corn (GOD DAMN IT, WHY ALWAYS CORN) can hide.  Several litres of irrigation later, I was still pulling out bits of . . . stuff ("What is that, carrot?").  This left me feeling wholly unsatisfied that he was clean enough to close, so I didn't.  I created a temporary vacuum closure and brought him to intensive care with plans to bring him back in a day or two, clean him out again, and possibly close.  IF he was clean.

Two days later his peritoneal cavity was surprisingly nearly spotless.  There were only a few partially digested bits of food left, and after irrigating with more litres of saline irrigation, I closed him.

A couple of days later after Quincy was extubated and off the ventilator, I finally got to ask him what I had wanted to know since he arrived: why had he crashed.  His answer was something I would expect from a teenager.

"Well you see Doc, I was showing off to the guys in my motorcycle club, doing a wheelie, and . . ."

"Wait," I interrupted, "you were doing a wheelie?  At 70 kph?  Are you aware you're 54 years old?"

He smiled weakly and laughed even more weakly.  "Yeah, it was probably stupid."

"Probably??"

He laughed again.

I had a very long chat with Quincy and his wife about his recklessness and how he was too old
for this shit.  I could almost excuse this kind of nonsense behaviour with a 20-year old kid (almost) because that's what 20-year old kids do - stupid shit.  But not Quincy.  It turns out he was a highly intelligent, articulate, competent middle aged man who just had a momentary lapse of judgement that nearly ended his life.  Quincy's wife looked me dead in the eye and assured me that his motorcycle was already up for sale at a bargain price.  I suspect it will be sold to a reckless kid who will probably do something equally stupid with it.

But that's probably just my Inner Pessimist talking.

Tuesday, 13 June 2017

Stupid update

This is the update you've all been anxiously awaiting - the update on last week's near-catastrophic near-career-ending story.  Or maybe you don't really give a fuck and I'm just being overly dramatic again.  In any case, if you missed it I did a Very Stupid Thing and tried to grab a chunk of Japanese maple that was spinning on my lathe at 750 RPM.  Ok, I didn't really try to grab it - it wasn't intentional, I was just trying to prevent the machine from jumping off the table because the log was unbalanced.  Regardless, my hand contacted the spinning log resulting in a deep gouge in my left hand that required three sutures.  Here is the offending log:

And here is the part of the log that actually hit my hand:


The irregular portion in the middle of the picture is where a rather large chunk of wood tore off and lodged in my hand.  And before you sick bastards say anything, no, there's no goddamned blood on it.  I withdrew my hand fast enough that the blood went on my floor, not the wood.  Fortunately.  I guess.

If you aren't saying "OW OW OW OW" right now, then you haven't been paying attention.

Of course in hindsight I should have bolted the lathe to the table when I first bought the lathe and built the table, but I hadn't intended on turning big rough logs at the time.  And then I changed my mind but didn't change the setup.  This rather (completely) silly (idiotic) manoeuvre led to the nearly-career ending injury about a week and a half ago.  Fortunately it did not actually derail my career.

Or my hobby.

What, you didn't think I'd let a goddamned log beat me, did you?  As soon as I got home from the hospital I disassembled the lathe table, installed some bolts, and then bolted the damned machine to the damned table like I should have done in the first damned place.  And as I was finishing, the lidocaine wore off.

Ow.  Ow.  OW.

I stayed out of the shop for a few days after that, not so much to protect my hand but more so Mrs. Bastard wouldn't have to remind me to be careful.  If that makes it sound like she was nagging me, I assure you she wasn't.  I was just being restless and stupid and anxious to return to creating stuff.  But then yesterday I decided that enough was enough - it was time I got back into it.  And when I did, the maple log was staring at me, daring me to work with it again.  So I did.  I put on the appropriate safety gear, grabbed my bowl gouge, and got to work.  And here's what came out of it:


That's right, log.  I beat you.  I WIN.

Fuck you, log.

Monday, 5 June 2017

Stupid, stupid, stupid

I think I make it clear that I see a lot of people who do stupid things.  Some of these people doing stupid things are actually stupid so can hardly be blamed for acting stupid, while some have simply made a stupid choice.  These choices may endanger their own lives or the lives of those around them, depending on A) what particular flavour of stupidity they've decided to commit, and B) how stupid that stupidity is.  But of all the stupid patients I have ever treated, few have come close to matching the stupidity of my least favourite patient:

Me.

Yes, the trauma surgeon became the patient a few days ago.  Fortunately I didn't put my life in danger, but I did stupidly threaten my career.

If you don't already know, I'm an avid do-it-yourselfer.  I paint, fix, create, mend, build, really anything that involves anything around the house.  If there is a tool that doesn't involve metallurgy or automobiles, there is a very high probability that I have it.  For example, when our automatic coffee machine went bad about two years ago, Mrs. Bastard bought a new one, but I wouldn't let her take it out of the box.  Instead, I bought a new solenoid and installed it (I didn't even know what a solenoid was at the time, but it's amazing what you can learn on YouTube).  And when the water pump on that same machine started making funny noises two weeks ago, I installed a new one.  Yeah, the new coffee machine is still in the box.  Boom.

Anyway, in addition to fixing most anything (people included, apparently), I also am an amateur woodworker.  Name a woodworking tool, I have one (or three).  I've built most of the new furniture in my house over the past 10 years, but my newest wood hobby is turning.  Last fall I bought a lathe and made myself some turning tools, and I've been getting to know the machine and its capabilities, making several little bowls and cups in the process.

You can probably see where this is going, even if I couldn't.

Four days ago I upped the ante and decided to try a bigger bowl.  I installed the maple blank on my lathe, knowing it would be unbalanced and that I had to balance it by turning it round while it was spinning at relatively low speed (around 600 rpm).  What I didn't realise was exactly how unbalanced it would be, because the lathe started bouncing all over the place.  My split-second reaction was to try to grab the machine to stop it from falling over, but in that instant my left hand came in contact with the spinning wood, not the machine.

Oops.

I felt the wood hit my hand near the thumb, but I didn't immediately feel any pain.  My second reaction (which should have been my first reaction) was "TURN IT OFF, STUPID!".  The wood came to a stop, and I then assessed the situation.  These were the thoughts that came into my brain in order:
  1. Whew, the lathe is ok.  Good.
  2. Hm, I didn't get that balanced very well.
  3. Why the hell does my left hand hurt?
  4. What's that red stuff on the floor? 
I looked down at my hand, and there was a lovely jagged laceration on the thenar eminence (the fleshy part of the palm at the base of the thumb).  As I should have done from the start, I went into Trauma Mode.  I was able to move my thumb - good.  I could feel the tip of it - good.  The laceration was deep, and I could see some subcutaneous tissue.  Not so good.  It was bleeding - not so good.  Um, was that exposed bone?  Shit . . . let me explore the wound to see if there are any foreign bodies in there -

OW OW OW OW OW OW OW OW OW FUCK OW OW

As I grabbed a paper towel to stanch the bleeding, I started to catalogue the supplies I have at home to suture it up.  Lidocaine - check.  Needles and syringes - check.  Gauze - check.  Suture material - check.  Needle driver, forceps, and scissors - check, check, and check.

Sweet, it's my left hand and I'm right handed, so I can suture this myself.  

Wait wait wait . . . how am I supposed to tie a knot in the suture with one hand.  God damn it.  Just go to the hospital, idiot.

Mrs. Bastard has a rather eerie ability to sense when things are going awry.  More than once she has called me when something is amiss, not actually knowing 1) that something is wrong, or 2) what that something is.  If I believed in psychic abilities (no, I do not), I would believe Mrs. Bastard has them.

My mobile literally rang as I was getting out of my car at the hospital (100% true).  I didn't even have to look at it to know that it was my wife.  Somehow.  My exact first words to Mrs. Bastard before I even said "Hello" were:

Me: Ok, well on the bright side, I decided not to put in my own sutures.
Mrs. Bastard: . . .
Me: . . .
Mrs. Bastard: . . .
Me: Hello?
MB: WHAT. DID. YOU. DO.

It wasn't so much a question as a statement.  I told her I was fine, I still had all my fingers, but that my lathe had sort of bit me.  She sighed.  It wasn't an "Oh well, I love you, dear" sort of sigh, but more of a "You're an idiot and we'll talk about this when I get home" sort of sigh.

An hour later I had a numb thumb, a large chunk of maple (that I had initially mistaken for bone) in my pocket as a souvenir (ok, "large chunk" may be a slight exaggeration, but 7 x 6 x 3 mm is HUGE for a splinter), a tetanus (Tdap) booster, and several polypropylene sutures in my hand.  It wasn't until I was driving home that it dawned on me just how close I came to ending my career in that moment.  I've seen some horrific life-altering woodworking accidents in my trauma bay, and I just as well could have lost my thumb (or even several of my fingers).

I got lucky.  That was it.  Nothing but dumb luck saved my hand (and my career).  But as I've said innumerable times in my life, I'd much rather be lucky than good.  My hand will heal up in a few more days, I'll take out my own sutures (at least that I can do myself), and I'll get back to turning that bowl, having relearned an extremely valuable lesson.  Every now and then one of my tools teaches me to treat them all with utmost respect and never let my guard down, even for a split second.

And if anyone is wondering about the tetanus vaccine, no, I'm still not autistic.

Tuesday, 30 May 2017

Changing my mind

I think of myself as a very decisive fellow.  After I've gather sufficient information and I make up my mind about something, according to my calculations there is a 98.047% chance (approximately) that the decision is final.  In rare circumstances (like when I was a ChildBastard and decided that I didn't like seafood) I may gather yet more new information and decide that my initial decision was wrong (mmmm . . . lobster).  But those instances are few and far between.  Even rarer are the times when I go from A to B then back to A.

And then you have times like with Clancy (not his real name™) when I go from A to B to C to Q.  

My mind was made up when I heard the Box announce Clancy's injuries about 15 minutes before he arrived - this guy was going to be fine I decided before even meeting him.  He was stabbed in the thigh, which is typically not a severe injury.  The blood supply to the leg is in the groin, and the thigh is a surprisingly large place, so getting stabbed in it anywhere other than the groin is very rarely a huge problem.  However, having done this for {redacted} years, I know that I can only trust about 10% of what I hear over the Box, so a penetrating injury to the thigh is always treated as a high level trauma.

And then Clancy arrived and proved it.  It turns out that "side" sounds a lot like "thigh" over the Box.

"Hi everyone, this is Clancy, 23 years old.  He was stabbed once in the left side with a steak knife.  He isn't sure how deep it went."

Clancy was a rather large chap, in the same way Jaws was a rather large fish.  He weighed in at just under 150 kg (330 pounds), and was indeed stabbed once in the left flank right where his spleen, kidney, and colon should be living.  God damn it.  And unfortunately none of those organs particularly enjoys having holes poked in it. 

My first step in any case like this is to determine how deep the wound goes and in what direction.  So my initial move is to stick my finger in the hole (mind out of the gutter, people).  This is by no means a perfect tool, because my finger may not be able to find the knife tract, and a thin blade can penetrate deeper than my fingertip will allow.  However, I've found exactly nothing that can be as quickly diagnostic as a Finger In A Hole.  And before I say anything else, I know exactly what that sounds like, and I absolutely stand by that statement 100%.  Anyway, just by looking at a stab wound I can't tell what direction or how deep the knife went.  A Finger In A Hole can quickly answer both questions.

He groaned slightly as my finger went in (STOP SNICKERING, DAMN IT!).  And in.  And in.  As I said, Clancy was a large fellow.  Fortunately (or unfortunately, depending on how you look at it), the knife tract was rather wide so it was easy to follow downwards towards his abdomen (not upwards towards his chest), and anteriorly towards his innards (not posteriorly towards, well, nothing vital).  I could feel my finger going through fat and more fat and then . . . space.  My fingertip slipped into his peritoneal cavity, and my mood sank.

Sigh.  Straight to the operating theatre.

The general teaching is that anyone with a penetrating injury to the abdomen with clear violation of the peritoneum (the lining that contains all of the intra-abdominal organs) needs immediate exploratory surgery.  No other tests are necessary, because if the knife went through that final layer, it most probably poked a hole in something in there.  I immediately called out to the waiting operating staff standing by the door that we would be coming down in 5 minutes.

I explained all of this to Clancy, including the fact that something, everything, or nothing may be injured.  He looked shocked but surprisingly understanding.  I looked up at the monitor to see how fast his heart was beating. 

65.

Uh, hm.  As my son would say, well that was unexpected.  People with major intra-abdominal injuries usually have significantly elevated heart rates, and their blood pressure can be low depending on how sick they are.  I pushed on his belly and got nothing.  No pain whatsoever.  But since he was so obese, maybe I just wasn't pushing hard enough. I tried again, this time mashing on his belly.  Nope, still nothing. 

Hmmm.  My mind seemed to be changing.  

After contemplating for a moment, I decided to change my operative plan to a diagnostic laparoscopy - putting a camera in through a very tiny incision in his umbilicus and looking at all of the organs to assess for damage.  If blood, bile, stool, or gastric contents are found, the procedure is quickly converted to a major laparotomy, and any damage is repaired.  However, if there is no blood, no food leaking out of the stomach, and no poop leaking out of the intestine, then no major exploratory surgery needs to be done and the patient is saved a huge (and unnecessary) operation.

I went back and explained this to Clancy, and he seemed slightly relieved and still understanding despite the drastic change of plan.  I called the theatre staff and told them of the change, and as I did so I looked at Clancy's monitor again.  His heart rate was now 62, his blood pressure was 127/65 (probably better than mine at the time), and he looked completely comfortable.

Mind.  Changing.  Again.

Because he was so rock stable, I then decided to do a CT scan of his abdomen on the way to the operating theatre.  It could at least guide me as to where I needed to place the camera first.  Five minutes later I was looking at his scans as they flashed on the computer screen, and I was shocked - I could see exactly where the knife had penetrated into his abdomen, but it only went in about 2 mm.  There was a very nice (and very clear) 1 cm layer of fat between the furthest extent of the stab wound and the closest organ (the descending colon).  No blood, no air, no fluid, nothing.  The radiologist actually read the scan as normal and missed the stab wound.

And my mind changed yet again.  A to B to C to Q.

I somewhat abashedly approached Clancy yet again and told him the good news, that he probably did not need any surgery at all.  Considering how many times I had changed my mind in the past 20 minutes, he took the news quite well.  Just in case the CT was wrong, I decided to keep him in the hospital overnight and re-examine his belly every hour or so to make sure nothing was brewing.  And 10 hours (and 10 re-examinations) later, I sent Clancy home with no new scars (except perhaps mental ones).

We often say in surgery that the enemy of good is better.  Trying to get something from good to perfect often leads to complications, so we usually leave well enough alone.  Being decisive is usually good, but additional information can actually be better.  Sometimes.

After I wrote this post and read it back, I realised that it could potentially make me seem wishy-washy or irresolute, so I decided to delete it rather than publish it.  

But then I figured "Ah, fuck it", and I changed my mind.

Monday, 22 May 2017

Instant dislike

There are some patients who come into my trauma bay whom I can instantly tell I will like, both as a person and as a patient.  These people are generally calm, respectful, and cooperative, saying things like "Please" and "Thank you".  Taking care of patients like this, no matter how severely injured they are, is typically easy, bordering on a pleasure.  However, there are others whom, the instant they hit the door, I can tell I won't like one bit.  The patient might be screaming bloody murder for no apparent reason, or hurling invective repeatedly at anyone and everyone, or he may just have a lousy attitude that instantly puts everyone in a bad mood.  But no matter what I think about them as a human being, I still take care of these people exactly the same as anyone else; I don't have to like you to treat you.  But sometimes, rarely (fortunately), I start to dislike someone before I even meet them.

How is that even possible?

Ask Charlene (not her real name™).  She'll fucking tell you.

The day I came across Charlene was a typical busy Friday, in that nearly everyone was drunk, obnoxious, or both.  Right around the time when my stomach started growling for dinner and reminding me that I hadn't eaten anything all day except one vending machine sandwich which contained something that was almost, but not quite, entirely unlike chicken, the head nurse called me to ask how many patients I would accept.

Ugh.  That can't be a good sign.  My Inner Optimist was strangely silent.

Whenever I get that phone call, my mind instantly jumps into mass casualty mode, and I become fearful that my city has finally become the site of a mass attack.  But then my mind starts wandering into regions it probably doesn't belong.  Perhaps a bus from the Haemophiliacs Convention collided with a razor blade delivery van?  Or did the International Space Station land on a church?

Fortunately it was none of those things, but something much more mundane.  My Inner Optimist started singing quietly (and annoyingly) as I discovered it was simply a multi-car accident with numerous victims, none of whom seemed critically injured (according to the medics on the scene).  However, there were lots of them, and all of them needed evaluation.  Unfortunately our department was already relatively full, so we could only accommodate three more patients.

Well, my Inner Optimist said happily, at least it's only three!

About 15 minutes later the first victim arrived.  He was in his 50s and screaming in pain, but despite the din, I did not dislike him - the bone sticking out of his ankle gave him every right to scream as loudly as he wanted.

Ouch.

"Hey Doc, this is Len (not his real name™)", the medic started.  "His car broke down on the side of the road and he was working under the hood trying to fix it.  His son had stopped his car behind his, and some idiot who overdosed on heroin fell asleep at the wheel and plowed into all of them, along with several other cars.  No Ell Oh See {Loss Of Consciousness}.  He's got an open ankle fracture, also complaining of severe pain in the opposite leg and shoulder.  His wife is also on the way.  And so is the OD."

Len's disposition was pleasant despite his pain, but though I didn't know the overdose guy yet, I already didn't like that fucking guy.  At all.  Because fuck that guy.

Len's wife showed up a couple of minutes later looking far less injured, perhaps only a sprained knee and a few abrasions here and there.

As I was working up Len's wife, Charlene arrived.  I heard Charlene before I saw her, which is never a good sign and made me like her even less (if that was even possible).

"Hi Doc, this is Charlene.  She rear-ended a bunch of cars on the side of the road after she fell asleep at the wheel.  She said she used heroin and alcohol just before getting into the car.  She was unresponsive when we got there, so we gave her some Narcan and she immediately woke up and started screaming."  He glanced at her and scowled.  So did I.  Charlene screamed.  A lot.

"OW!  Oh god, I'm hurting everywhere!  I need some pain medicine!  Oh god please help me!"

Of course you're hurting, I thought.  That's what Narcan does - it blocks the effects of opioids.  In addition to waking up narcotic overdose victims, it also makes them very unhappy because they start hurting everywhere.

Other than an abrasion across her chest and abdomen (at least she had the sense to put on her damned seatbelt), she had no obvious injuries.  However, she continued to scream in pain and demand pain medicine.  I asked the nurse to give her a small dose of ketorolac, a non-steroidal (and non-narcotic) anti-inflammatory analgesic, and I made it very clear to everyone listening, including Charlene, that she was not to get any narcotics.

"Ow!  My teeth hurt!"

I did not like Charlene.  No, unless I found some serious injury, Charlene would not be getting any narcotics from me.  At all.  For anything.

A few hours later after her heroin, alcohol, and Narcan all wore off, Charlene was strolling comfortably around the department while her two victims were still on their gurneys in pain.  In addition to his open ankle fracture, Len had a fractured femur on the opposite leg and a broken arm,  He would need multiple surgeries to repair all the damage.  His wife had a broken vertebra in her lumbar spine, but it was a stable fracture so no surgery would be necessary.  I fumed silently as I got Charlene's discharge paperwork together, all the while gritting my teeth and betting she would ask for narcotics.  She did not disappoint.

"Doctor," she started in a all-too-obviously-sweet voice, "would you please give me some oxycodone?  You know, just to tide me over?"   I looked over slowly and silently, and she must have seen the look of fury in my eyes because she quickly added, "I don't usually do heroin, really!  I just ran out of my pain medicine and my friend offered me some heroin, so I did it just this once.  Please?"

Sure, you just did it this once.  While you were drunk.  I did not like Charlene.  "No," I said as steely as possible.  "You may take ibuprofen or aspirin or acetaminophen or naproxen."

She looked disappointed but not the least bit surprised.  However, she wasn't done.  "How about some Xanax?  Please?  Just a few."

No, I thought.  I will absolutely not provide you with drugs that will sedate you and alter your level of consciousness!  You just severely injured multiple people with your car after you overdosed!  What the fuck kind of idiot do you think I am?

"No, you may not," I said as simply as I could.

Again she looked unsurprised.  I was shocked she hadn't claimed an allergy to all the over-the-counter medicines as most addicts do, and I could easily interpret the "Well, it was worth a shot!" look on her face.

Without skipping a beat, she said without a hint of irony, "Well, it was worth a shot!"  Then she smiled.  SHE SMILED.

No, I did not like Charlene.

Twenty minutes later after Charlene had left, the nurse approached me to tell me that after she gave Charlene her discharge paperwork, she overheard her asking three different emergency physicians to write her prescriptions for oxycodone, hydrocodone, Valium, Xanax, and codeine.  The nurse reported that all of them looked at her like she had two heads and denied her repeated requests.

No, I did not like Charlene one bit, but I guaran-goddamn-tee you that I, or one of my colleagues, will see her again.  And probably soon.

Friday, 12 May 2017

Names

According to my research (aka a 0.385 second Google search), the most common surname in the world is Lee.  The next most common family names include Zhang, Wang, Nguyen, Garcia, Hernandez, and Smith.  Unfortunately not everyone is lucky enough to be born into such an instantly recognisable name and must instead suffer through their lives with less common names.  Others are unlucky enough to be given names like Preserved Fish, Hans Ohff, or Dick Passwater.  Yes, those people actually exist.  Really.

I, however, am named none of those things.  While my name isn't particularly difficult to pronounce for anyone with an IQ higher than a brine shrimp, that doesn't stop 90% of people from mispronouncing it.  I therefore shorten it from {redacted} to {rdctd}, but while that may be somewhat easier to pronounce, it somehow doesn't make it any easier to remember.  Most of my patients just end up calling me "Doc", as all of you fine people do (and for the record, I'm perfectly fine with that).

Mikel (not his real name™), however, had no such problem with my name.

My standard greeting when a new patient rolls into my trauma bay is "Hi, I'm Doctor Bastard, and I'll be saving your life today."  Ha! not really, but what a great introduction that would be, right?  Unfortunately I would have to be about 386 times more arrogant than I actually am to use such a line, but that doesn't stop me from fantasising about it.  Aaaah.

Anyway, in reality I introduce myself as "Doctor Bastard (not my real name™)", and 99.9452% of the time (approximately) when they repeat it, that is the last time it will ever escape their lips.  I gave Mikel that same standard salutation as he was wheeled in and the medics were giving their report. 

"Hi Doc, this is Mikel.  25 years old, no medical history.  Gunshot wound to the left abdomen, and there is, um, something sticking out of the right side of his abdomen."

Shit.  In general having something unidentifiable sticking through your abdominal wall is considered a Very Bad Thing. 

I pulled the sheet back to find that the something was a loop of his small intestine with several holes through it.  SHIT.  Yes, that definitely falls under the Very Bad Thing umbrella. 

His vital signs were ok, which meant he wasn't actively dying.  Yet.  But a trans-abdominal gunshot wound meant he needed surgery.  Now.  I knew he had at least two holes in his small intestine (that I could see) that needed fixing, but I figured that was just the proverbial tip of the proverbial iceberg.  The question was, how many more holes were there, and what organs would I be attempting to fix.

I explained all of this to Mikel, and he immediately responded "I understand, Doctor Bastard.  Thank you.  Please do everything you can, Doctor Bastard.  I really appreciate your help, Doctor Bastard."

Um.  What?  Hearing my name repeated was shocking enough. Hearing it pronounced correctly twice was astounding.  But hearing it thrice was almost enough to make me faint.  

Not really.

A quick (but thorough) examination of the remainder of Mikel's body revealed no evidence of any other injuries (not that he needed anything else to potentially kill him).  We rushed him straight to the operating theatre without delay, Mikel chattering all the while.

"You're going to save my life, Doctor Bastard.  I know you are.  I'm in your hands, Doctor Bastard.  You aren't going to let anything bad happen to me.  Isn't that right Doctor Bastard?"

It was more than just a bit unnerving.

Image result for torn jeansWhen I opened up his belly I found it full of blood, as expected.  I poked the intestine that had been protruding back inside and then examined everything.  I addition to about 2 liters of blood and the two holes in the small intestine I already knew about, I found a separate 25-cm portion of small intestine that had been essentially shredded.  Think 1990's torn jeans.  Yeah, kind of like that.

Unbelievably none of the other organs had been injured.  The stomach, gall bladder, liver, colon, spleen, pancreas, and kidneys were all completely fine.  I repaired several holes that were amenable to being fixed and removed several that were not.  After re-establishing gut continuity, I sort of felt like all the king's horses and all the king's men.

Humpty Dumpty was back together again.

The following morning before I left the hospital, I went to see Mikel first.  I was expecting to find him fast asleep, or at least lethargic as hell, considering the trauma his physiology had endured over the previous 8 hours.  Nope.  This is one instance where I was not sorry to be wrong.

"Good morning, Doctor Bastard!" he greeted me with a wan smile and a slight wince as he sat up in bed.  "You look tired.  How was the rest of your night?  How are you feeling today?"

Hey, wait.  That was supposed to be my question!  That was the second time in a row Mikel had surprised me.  I smiled and told him it didn't matter how I felt, because I wasn't the one who just had a major surgery 8 hours ago.

"I feel pretty good, Doctor Bastard.  Sore, but ok.  You saved my life!  I can't thank you enough, Doctor Bastard.  Thank you so much!"

Mikel's hospital course was amazingly fast and shockingly free of complications.  Despite the number of repairs I did and anastomoses I created, none of them leaked.  And every day when I went in to see him, Mikel greeted me with the same big smile and the same "Good morning, Doctor Bastard!  How are you today?"  Four days after his surgery, he walked out of the hospital.

And two weeks later he walked into my office with the same big smile and the same "Good morning, Doctor Bastard!" once again.  He was doing well, his incision had healed perfectly (if I do say so myself), and his intestines were all working just fine despite their recent slight reworking.  He gave me a hearty, firm handshake and several more "Thank you"s on his way out.

After he left my office, I had a few minutes to contemplate.  Perhaps my other patients would remember my name too and perhaps appreciate what I had done for them.  Maybe Mikel was a sign that things were going to change.  Huzzah!  My mood was bright as I walked in to see my next patient, a guy who had been stabbed in the leg multiple times and on whom I had spent nearly an hour sewing up.

"Good morning," I said brightly.  "How is your leg feeling?"

My hopes were dashed and my mood sent crashing back to earth by his response:

"Uh, ok I guess . . . have we met?"

GOD. DAMN. IT.

Monday, 1 May 2017

Call Gods are weird

I should apologise in advance for yet another Call Gods post.  I can almost hear two distinctly different groans from all the way over here:

1) Yeah, we fucking get it, Doc.  Call Gods.  Get over it!
2) There are no such things as Call Gods!  It's pure coincidence.  Get over it!

You know what, I should apologise, but I won't.  I don't care what you're moaning and groaning about.  I'm writing about the Call Gods again dammit, because they've been acting . . . strange.  Which for them is, well, strange. 

If you are familiar with the Call Gods, feel free to skip this explanatory paragraph and go check out some funny cat videos.  There are approximately 4,845,130,642 from which to choose.  In case you aren't aware of them, the Call Gods control everything (and I mean EVERYTHING) about what happens to me on call.  Whether I get to eat or not, if I get any sleep, how many times over the course of the night my pager will wake me, the type of patients I'll get (including the types of drunks), and the variety of injuries I'll see.  You may think it's sheer coincidence or that I have a selective memory and remember only what I choose to, but ask anyone in medicine (especially surgery).  You'll get the same response:

"THEY. ARE. REAL."

I know this because they prove it, over and over and over. 

What, you want examples?  I thought you'd never ask.
A few months ago I had a relatively slow day, only 8 patients over the whole shift.  It was typical stuff, mostly car accidents, a fall, and one gunshot wound.  However, in that mix of patients I had two patients who had suffered one injury and one injury only; one of the two had fallen down stairs, the other was shot.  But both had just one body part hurt.  Only one.  What body part?

One finger.  The fourth finger.  The left fourth finger. 

What, you still aren't convinced?  Two out of eight patients, fully 25% of my patients for the day, had isolated left 4th finger injuries on the very same day, and that still isn't evidence enough for you?   You still don't believe?  How is that even possible!  I hear the Call Gods mocking you.  They scoff at unbelievers. 

But wait, there's more.  There's always more. 

My most recent call day was much busier.  I had a total of sixteen patients, including 4 assaults, 3 stabbings (one I took to the operating theatre with lacerations to his colon, kidney, and small intestine), one shooting, one drunk fall, 6 car accidents, and a guy hit in the face by a falling wrench (yes, seriously).  If you aren't seeing a pattern yet, I don't blame you.  I didn't see it either until I got a patient with a glass eye.  That may not sound that strange to you (yet), but I haven't seen a patient with a glass eye in several years, and as soon as I saw her, something inside me twitched.  

Sure enough, two hours later one of the assault victims also had a glass eye. 

Both were fine with no serious injuries, and perhaps a glass eye isn't anything to get worked up over.  I simply like to think of it as the Call Gods reminding me they are there.  Always watching.  Waiting.  Preparing. 

Always.