Monday, 24 April 2017

Gift

Take a little ride with me.  Yes, you.  We're going on a trip, you and I.  Close your eyes.  Now imagine a house, a big house.  A beautiful house.  This house has a wide, lush green lawn, quaint blue shutters, and a sparkling pool in the back.  The house sits on a calm, pristine lake and has a private dock where there is a boat tied up.

Unfortunately your own house burned down some time ago, and now you have nowhere to live.  So you look at this house, and you love it.  You want it.  Not only that, you need it.  You see, it's cold outside, and you have no shelter.  Any day now you fear that you will succumb to the elements.  Your desperation is reaching a critical point.

Then one day as you are standing there staring at this dream house, a man approaches you, seemingly out of nowhere.  He has a smile on his face as he confidently walks up to you and hands you an envelope without a word.  He then smiles warmly once again, turns, and walks away.  Confused, you open the envelope, and inside you find a set of keys.  Looking further you pull out a sheaf of papers - a deed.  No, not just a deed, the deed.  The deed to this house.  The deed to this house with your name on it.

What?  What is this?  Has someone really just given you a house??  Is that even possible?  You tremulously try the key in the door, and it works.  The door swings silently open and you walk inside, incredulous at your luck.  The house is fully furnished.  Even the refrigerator is stocked with food, everything you could want.  You start to tear up as you realise that it was just before you got to the point where you thought you might die that some kind benefactor you don't know and will never meet has given you the greatest gift you could imagine, exactly what you need to live.  Someone has given you the gift of another chance at life.

What do you do to repay the kindness of a complete stranger?  What could you possibly do to show your gratitude?  How do you respond?  I'll tell you:

You throw a huge party, you shit all over the house, you tear it apart, and then you burn it to the ground.  On purpose.  THAT is what you fucking do.

Wait, what?  Why would you do such a thing?  What kind of asshole would take such a gift and stomp all over it?

Zachary (not his real name™), that's who.  Why?  Why would he do that?  I have no idea, you'll have to ask Zachary, because he's the only asshole I know with experience with this kind of utter twatfuckery.

It was a typical Saturday night, which is to say that everyone who rolled through the door of my trauma bay, whether he had fallen, gotten into a car crash, was assaulted, or was stabbed in the head, was drunk.  And Zach was no different.  I believe I saw every type of drunk that night, and Zach was a Type 5 Drunk, meaning he thought he was much funnier than he actually was, which was not at all.  Not even a little bit.

After getting the story from the medics (car vs tree, tree wins), we started our examination of Zach from head to toe.  This always involves undressing the patient completely so that we can look at everything.  His shirt was barely halfway over his head when I recognised a tell-tale sign on his abdomen:

A Mercedes Benz scar.

This was no ordinary scar, and I could have recognised it from across the room.  Anyone who knows anything about surgery will know this immediately as a liver transplant scar, and if you didn't know that before, now you do.

I'm going to pause here to let this scenario sink into your brain for a moment before I go on, because I can feel my blood starting to boil just like it was that night.  If yours isn't yet, it should be.

. . .

*deep breath*

. . .

Ok, ready to go on?  I'm going to skip the remainder of Zach's story, because 1) it isn't that interesting, and 2) just thinking about it is enough to make me want to throw my computer out the window (Zachary was fine despite his best efforts to kill himself and everyone around him).  The short short version, the reason I was so angry, is that Zach had killed his original liver with heavy alcohol abuse over many years, he got a new one, and he was now pissing it away by drinking again.

I'm going to pause again.  My apologies.

. . .

*DEEP breath*

. . .

If you haven't figured out why I'm so angry then you haven't been paying attention and WHY THE HELL ARE YOU EVEN HERE.  *DEEEEEEP breath*  I'm sorry, I shouldn't direct my anger at you when it isn't your fault.  That isn't fair. 

Think of the house.  Like in that imaginary scenario, Zachary was given an extraordinary gift - a new liver, and a new chance at life.  There are no two ways about it; without the new liver, he would have died a horrible early death.  But Zachary was saved.  Some poor soul gave his or her own life to give Zachary a second chance, a new life, and Zach thanked his anonymous benefactor by treating his new liver exactly the same way as he treated his first liver: by shitting all over it.

The things I see in my trauma bay often amuse me, sometimes they sadden me, and sometimes they confuse me.  Rarely, however, do they infuriate me.  Zachary infuriated me.

Perhaps I'm out of line.  Maybe I'm just being dramatic and stupid and I'm over-reacting over nothing.

No.  No I'm not. 

Saturday, 22 April 2017

Two problems

I've had a few people ask me over the past day or so if I'm ok.  Apparently if I don't post a story for over a week, some people get worried about my health or something.  Allow me to assure everyone quite clearly:

I'm fine. 

But there have been a few problems lately that have interfered with my usual plans for weekly updates. Well, two problems actually.  Two very large problems. 

1) People haven't really been acting very stupid around me over the past weeks.  I know that may seem hard to believe considering what you've read about my clientele.  Yes, there have been the usual drunk drivers, stabbings, falling off bar stools, etc.  But there are only but so many ways I can make the same scenario seem different and interesting enough to warrant another post. 
1) I've been on vacation.  No, I won't say exactly where I was (and who wants a mental image of me half naked on a beach anyway), but what I will say is that I learned that my middle school teacher was right: it IS hot near the equator. 

If you're paying close attention, you'll notice both problems labeled #1.  That's because I can't decide which is the more important reason for no recent update.  Don't misunderstand, I can always sit on a beach and write blog stories, but only if I have good enough material, and only if I really feel like it, which I didn't. 

The fruity drink with the umbrella sticking out the top may have had something to do with my newly acquired apathy.  Hm. 

Regardless, not to worry, though.  I'm back in town and back in business.  And doubtless my subjects will give me plenty of blog fodder in 3...2...1...


Thursday, 6 April 2017

Jahi McMath update

It's about that time again, folks: time to revisit the tragic story of Jahi McMath.  In case you're new here and don't know Jahi's story, you can read about it here, here, here, here, and here.  I even wrote a stupid FAQ here.  The short short version of the story is that a 13-year-old girl in California underwent a rather extensive three-part surgery for sleep apnoea and suffered cardiac arrest and brain death back in December, 2013.  She was declared brain dead after multiple separate brain death evaluations by multiple different people as well as by Dr. Paul Fisher, the court-appointed second opinion expert, and multiple ancillary tests confirmed the diagnosis.  Her mother, Nailah Winkfield, refused to accept the diagnosis, so she had her transferred to another hospital in New Jersey (St. Peter's University Hospital) where she had a tracheostomy and feeding tube placed.  She stayed at that facility for 8 months until she was discharged to her mother's care, and has been sustained on somatic support in an apartment in New Jersey since August 2014.

Got all that?  Good, let's move on.

In the intervening 2 1/2 years, we've had sporadic "updates" from the family (and anti-brain death quack Dr. Paul Byrne) claiming that Jahi is alive because she no longer meets the criteria for brain death.  The "proof" for her resurrection has been, shall we say, lacking.  One of the pieces of evidence was a video of Jahi supposedly moving her foot to command, and another was a video of her moving her arm to command.

My last update was over a year ago in March 2016, but it was just a couple of vague pictures of Jahi, still with her eyes closed.  More recently than that in October 2016 a video was posted of Jahi supposedly breathing over the ventilator, again in response to verbal commands.

So what are we to take away from all of this?  What does this all mean?

The short answer: Nothing.

As usual, the "evidence" is meaningless.  How do I know this?  Because it is no longer merely implausible, it is quite literally impossible.

Thanks to Professor Thaddeus Mason Pope's Medical Futility Blog, we now have access to some information that has up until now been mere educated guesses.  A case management statement (whatever the hell that is) was submitted by Jahi's surgeon, Dr. Frederick Rosen, which contains the statements of two experts on brain death, Drs. Thomas Nakagawa and Sanford Schneider.  For a bit of background, Dr. Nakagawa is the division chief of critical care medicine and the director of the paediatric intensive care unit at Johns Hopkins All Children's Hospital in St. Petersburg, Florida, and he has over 25 years of clinical experience in paediatric critical care.  Dr. Schneider is a clinical professor of neurology at the College of Medicine, University of California, Irvine and has been in paediatric neurology practice for 48 years.

These two guys know their shit - THEY ARE EXPERTS.  Both doctors reviewed all available records, starting with her original hospitalisation in California, all the way through the end of her hospitalisation in New Jersey and the release to her mother.  In their statements they disclose some very interesting, and very revealing information.

Dr. Nakagawa describes the several EEGs that were done as ancillary brain death tests (note than an EEG is not a definitive test for brain death).  On December 12th there was no brain activity, and the technician noted that her right arm and left leg were both moving during the EEG.  They also tried auditory and painful stimuli during the test as well as shining a light in her eye, but there was no brain activity in response to anything.  Another EEG was performed on December 17th, and again there was no response to painful stimuli, light touch, or sound.  Yet another EEG was done on December 23rd, which was exactly the same.  This is very important information, because it means that her movements are in fact spinal movements, not caused by brain activity.  Also keep in mind there was no response to sound.  This will come into play a little later.

Nakagawa also goes over Jahi's brain flow scan on December 23, 2013 (page 33) which showed a complete absence of blood flow to the brain, which Dr. Fisher calls "beyond definitive".  Brain tissue cannot survive more than a few minutes without blood, and this was 13 days after her anoxic event and cardiac arrest.  Thirteen days is more than enough time for the brain to die.

He also describes Jahi's clinical exam during her 8-month hospitalisation in New Jersey, and at no time was her examination ever not consistent with brain death.  She never had any purposeful movement, she never opened her eyes, she never had any cough, gag, or pupillary reflex, and she never had any spontaneous breathing.

Drs. Nakagawa and Schneider both talk about the other ancillary tests that were done on September 26, 2014, including MRI, brainstem auditory evoked potentials, upper extremity somatosensory evoked potentials, visual evoked potentials, and EEG.  None of these are accepted ancillary tests for brain death, but they still revealed something very interesting: they were still consistent with brain death.  Additionally, on page 46 of the document Schneider states that the somatosensory evoked potentials demonstrated some integrity of the spinal cord up to the level of C5, but there was no function above this.
It is a medical impossibility that J. McMath is moving in response to verbal commands.  The brain stem auditory evoked potentials test performed at University Hospital on September 26, 2014 . . . demonstrates that as a result of J. McMath's brain death she has no auditory pathways; there were no evoked potentials to maximum aural stimulation.  This test result establishes to a reasonable degree of medical certainty that J. McMath cannot respond to verbal commands because she has no cerebral mechanism to hear sound.
In plain English, the videos of Jahi moving in response to her mother's voice are nothing more than spinal reflex movements, because Jahi CAN NOT HEAR and her brain CAN NOT CAUSE MOVEMENTS because it is dead.  It is now plainly obvious that they simply caught Jahi at a time when her hand and foot were twitching, and they took a video of it while Nailah told her to move.  I don't know if this was deliberately deceptive on Nailah's part, but I suspect it was not.  I believe that she honestly believes Jahi can hear her.  However, she can not.  It is 100% impossible.

In summary, Nakagawa and Schneider exhaustively evaluated everything that had been done to and for Jahi from her surgery up until her release to her mother on August 25, 2014 (there was no evidence that Jahi had been re-evaluated for brain death since that day), and all of the brain death evaluations that were done in California were deemed completely valid.  There was no evidence that anything was awry in any way.  They also both stated, quite definitively, that nothing that had been done since her declaration of death -- no subsequent tests, no exams done at St. Peter's University Hospital, no nothing -- could . . . well, I'll let Dr. Nakagawa sum it up:
There is nothing in McMath's medical records from Saint Peter's University Hospital that would cause a reputable expert in pediatric or adult brain death to question or reconsider the accepted brain death assessments of Dr. Robin Shanahan, Dr. Robert Heidersbach, and Dr. Paul Fisher.
He makes the same statement regarding additional tests she had done in September of 2014, none of which are accepted tests for brain death.  Dr. Schneider then says this, which Nakagawa also averred:
There is absolutely no medical possibility that J. McMath has recovered, or will someday recover, from death.
It seems I may have said something very similar many, many times.

So there you have it.  That's about as definitive as it gets.  Comments, as always, are welcome.  But please keep them respectful.

Saturday, 1 April 2017

Look of disappointment

Clara looked at me with sad, red eyes, tears welling up and starting to run down her flushed cheeks.  I've seen that look before, many times.  Many, many times.  Usually the look comes when I've told someone her son was just killed and I couldn't save him, or someone whose wife has a terminal cancer that I just can't cure.  But not this time.  Clara wasn't related to the patient, she was the patient.  Her look was indeed one of deepest disappointment and sorrow, but it wasn't because she was sad, and it wasn't because she was hurt.  It was because she wasn't hurt.

If it doesn't make sense yet, it will soon.  I promise.  

My trauma shift starts at 8 AM, and it ends exactly 24 hours later.  Full-day shifts are torture; they are antiquated things that should have been retired long ago, but they persist in many places because we haven't come up with a better system.  The worst part of the shift is theh 7 AM - 8 AM portion, because it's right at the time when most people are driving to work and car accidents are likely, and it's right at the time when I'm counting the minutes until my shift is over.  So when my pager went off as I was making rounds at 7:35 AM and looking forward to my first cup of coffee, I was unsurprised but thoroughly disheartened.  What did surprise me was the mechanism of injury:

"LVL 1 GUNSHOT WOUND TO CHEST. 5 MINUTES"

Wait, what?  Who the hell gets shot at 7 o'clock in the morning?  I quickly trudged down to the trauma bay, my mind running through all the possibilities.

None of them, it turned out, proved to be correct.

Clara (not her real name™)  rolled in looking even more disheartened than I was.  That was . . . strange.  Most trauma victims look in pain, angry, half dead, or giddy (in the case of Drunk Driver type 5), but not Clara.  She just looked . . . blank.  She was staring straight ahead at nothing and no one in particular, her face slack and emotionless.  Then she slowly turned her head towards me, and while I expected a smile, a frown, a scowl, or something, her expression did not change one bit.  She simply looked at me.

"Hi Doc, this is Clara.  She's stable, oxygen sats 100% during transport.  She tried to kill herself this morning by shooting herself in the chest with a hunting rifle."

Ah.  That explained her look of sheerest despondence.

Clara dropped her head and stared at the gurney, her face still impassive.  I was half expecting her to either complain, deny, or cry, but she did none of those things.  She just sat.  While I felt terrible for her and her obviously hopeless situation, it was also a very troublesome situation for me, because I then had to say something that I knew damned well she did not want to hear.

"Hi Clara, I'm Doctor Bastard (not my real name™).  I understand you were trying to hurt yourself, but I need to make it clear to you that it is my job to make sure that you do not succeed."

She merely glanced at me briefly, nodded once, and returned to staring at her lap.

The entry wound was in the upper outer portion of her left breast, and the exit wound was on the outer portion of her left back.  Based on the trajectory (and the fact that her lung sounds were clear and equal), it didn't look to me like the bullet had entered her chest, but obviously I needed to be sure.

Her chest X-ray was completely clear (except for a few small bullet fragments in the subcutaneous tissue), an ultrasound of her chest was normal, and a CT scan confirmed that no major damage was done.  No fractured ribs, no pneumothorax, no injury to the heart.  As soon as I saw the pictures, I walked into the scanner to tell her the good news, which (I realised as I was saying it) she would take as bad news.

I put my hand on her shoulder and said simply, "Hi Clara.  I just looked at your scan.  I know you don't want to hear this, but the bullet did not enter your chest.  There's no major injury."  Before I could even finish, her emotionless expression started to break down.  "It's ok.  You're going to be ok.  We're going to get you the help you need."

With that, the flood gates opened, and Clara started openly sobbing.  "Oh no!  Oh god, no!  I can't do this anymore.  I'm 53 years old, I've lost my husband and both of my kids, and I just can't do it.  I can't do it any more.  I just can't!"  She continued to sob as I tried to figure out what to say next.  What could I say?  Is there anything that could make this hopeless situation remotely better?

Ultimately I decided that there was nothing I could say to her that would assuage anything.  I simply gave her arm one final friendly squeeze, smiled meekly at her, and walked out, while I looked up the name of the psychiatrist on call.

Yes, today is April Fools' Day, but this is not a joke or a hoax.  This is a 100% true story.  Clara is a real patient, a real person, with real problems that are clearly worse than I could possibly imagine, bad enough that I had a great amount of trouble empathising with her.

I'm posting this purposely on April 1 to give everyone a break from the silliness that reigns on this date, simply to remind everyone that life isn't a joke for everyone.  

Wednesday, 29 March 2017

Nothing

I must apologise for the lack of a post this week, but unfortunately it seems that none of my patients have done anything particularly stupid lately.  Anyone who knows my patients' proclivity for gross stupidity may find this hard or even impossible to believe, but sadly it is true.  I got nothin'.

However, I feel somewhat guilty leaving all of my readers in the proverbial lurch, so in lieu of a stupid patient story this week, I'd like to share a few things that some of my readers and followers have made.

First, we have this little gem by Marc Draco (I assume that is his real name).  In case you aren't familiar with the Dunning-Kruger effect, it quite astutely (and accurately) describes people who are incapable of assessing their level of understanding of a subject and thus deem themselves more competent than actual experts.  Vani Hari (Food Babe), David Wolfe, and antivaxxers are prime examples.  Marc absolutely nailed it with this graphic:


Then there is this one, sent to me by @viva__lala (I'm pretty sure that is not her real name).  I don't know if there is an "emergency bracelet generator" out there, but if there is my 0.121 second Google search didn't turn it up.  
If anyone knows of a manufacturer that would be willing to make these, I bet I could sell at least 10 of these!  

The next one wasn't made by a reader or a Twitter follower.  Actually, it wasn't really "made" per se.  It's just a screenshot of a snippet of a conversation I had with a chiropractor I few months back, and somehow it got buried in my phone.  So I thought this would be the perfect place to deposit it.  I believe it speaks for itself:

And in case you're wondering, yes he meant that.  Whatever "that" is.

Finally, a personal bit of artwork presented without further introduction:

Surely everyone must be wondering what institution could possibly give me a doctorate in bullshit and why I would suffer through such an ordeal.  Well, I didn't.  A similar diploma can be yours all for the bargain basement price of zero, zip, zilch, nada.  Just go to thunderwoodcollege.com, and earn a doctorate for yourself.

Now if you excuse me, I have to go back to hoping my patients start acting stupid again.

Monday, 20 March 2017

Yoots

Before anyone starts attacking me, yes I know it could be spelled "yutes" or "utes", but according to the official script, it is "yoots", so I went with Yoots.  Just like the original patent for toilet paper shows it going over the roll, I consider that orientation to be correct.  And if you have no idea what the hell I'm talking about, go watch "My Cousin Vinny".  Right now.  Go.  Do it.  And do not come back until Vinny and Mona Lisa are driving back to New York.

You're back?  Good.

I've often said that youth is wasted on the young, but then again so did George Bernard Shaw well before I first did (although his exact quote was “Youth is the most beautiful thing in this world—and what a pity that it has to be wasted on children!”).  In fact, I just told my children exactly that just a few days ago (the short version) when they were complaining about some movie not streaming fast enough.  At the time I decided not to delve into what it was like in the time before movie rentals when you just had to watch what as on TV, and then years later what it was like driving to a store to rent a movie, hoping they had the one you wanted, driving back to the store to return it, and paying late fees and fees for not rewinding (aka "The Good Old Days").  So instead I started boringly lecturing them on why they should be outside enjoying the weather, playing, frolicking, gamboling, and cavorting or whatever, rather than staring at a screen (which, ironically, is exactly what you are doing right now and also what I just instructed you to do). 

Regardless, kids should be outside playing, not inside playing, as long as they are reasonably safe about it.  But during their development most kids eventually go from "I'm not sure I can do this" to "I AM INDESTRUCTIBLE!  I CAN DO ANYTHING!  WHEEEEEEEEEE!"  It's the childhood equivalent of "Hey I saw some guy do this in a movie once.  Here, hold my beer".  At this crucial point in their development children lose the ability to judge their own 1) abilities, 2) carelessness, and 3) bravado.

And Travis (not his real name™) is a perfect example of all three.

The first thing that told me that Travis was a completely normal teenager was that he was actively texting as he rolled through the door of my trauma bay.  That prompted my first eye roll of the encounter.

"Hi everyone, this is Travis."  He barely had the decency to look up at the sound of his name as the medics gave their report, but he at least grunted, eyes (and thumbs) still glued to his mobile phone.  That prompted eye roll #2.  "Travis was riding his dirt bike, no helmet, and he lost control, and he fell onto his left side.  He was going about 60 kph (35 mph) when he crashed."

The second thing that told me that he was a normal teenager (and that caused eye roll #3) was his response to that bit of information:

"NO WAY WAS I GOING 60!  NO WAY, DUDE!  I WAS GOING AT LEAST 80!"

I think all the people in the trauma bay, myself included, groaned audibly in addition to rolling our eyes.  Clearly, everything this guy was going to say was bullshit.

Travis then flashed the universal sign for "METAL", grinned, stuck out his tongue, and went right back to texting.  Once again, he wasn't even able to muster up the decency to look at us or speak to us.

I can imagine his text was something lucid, intelligent, and well-thought-out, like this:

Travis seemed completely uninterested and unimpressed by the fact that his left leg had an extra bend in the thigh where it did not belong.  He continued grinning intermittently and making strange grunting noises under his breath as we finished our workup (still texting furiously), which demonstrated only an isolated left femur fracture.  The only thing I could think as I looked at his X-ray was, "I guess the fucking thing is broken."

Fortunately Travis' stay was short and uneventful, so I was not treated to very much of his teenage antics.  I heard about him flirting with several of the nurses, but they were just as unimpressed as I was.  And while he was with us his mother told me of several other not-quite-as-severe crashes he had recently had on his motorbike. 

Once it was time for Travis to leave, I knew I had one more job to do: make sure this didn't happen again.  I had already told him in the trauma bay and the following day that he was lucky he hadn't sustained a serious head injury yet, and he had to wear a helmet whenever riding a dirt bike.  But I decided to drill it into his fortunately thick skull one more time.  With his mother in the room, I told them both that if Travis was going to continue riding his death machine, he at least had to protect his head.  Travis looked at me as if hearing this strange information for the first time, his expression clearly saying this:

Yes. I was serious about that.

Friday, 10 March 2017

Success!

This isn't a personal success story (though I have had several recently), nor is it a professional success story (though I have had several of them too recently).  No, this is a Twitter success story.

A what??

As many of you know, I hate Twitter despite my activity there.  Trying to communicate in 140 characters or less is downright madness, and whoever thought of it should be dragged through a muddy street strewn with horse manure by his toenails, then flayed, tattooed, hanged, and then killed.  To those of you who don't know about my exploits on Twitter, why the hell not?  Go to Twitter and follow me, god damn it.  There's even a little button on the side right over there that makes it easy.  Seriously, go do it now.

Anyway, my Twitter account has metamorphosed of late to become a "Calling Out Bullshit" account.  The bullshit can be anything that I'm not particularly fond of at that moment - homeopathy bullshit, antivax bullshit, naturopathic bullshit, chiropractic bullshit, nutrition bullshit, "cancer is a fungus" bullshit, etc.  You get the idea.

But many people have asked me (in 140 characters or less, of course) why I bother.  Why do I spend (read: waste) my precious time calling out these frauds on their bullshit?  What possible benefit could it have?
Well, I'm about to tell you why.

My focus lately has been chiropractors.  I am stunned that chiropractic has managed to survive for as long as it has, considering A) its extremely poor evidence base (it has only been shown to be mildly effective for low back pain), and B) its vitalistic origins.  If you don't know, DD Palmer, the founder of chiropractor, first invented it in the late 19th century purely out of his ass after he supposedly "cured" a janitor of deafness by manipulating his neck.  A stupid light bulb apparently clicked on over his head, because he then hypothesised that "subluxations" (mystical misalignments of the spine) are responsible for blocking the flow of vital energy (whatever the hell that is) and thus are the cause of disease.  To modern chiropractors, it apparently makes no difference that a chiropractic subluxation is not visible on any X-ray, CT scan, or MRI, and indeed has never been shown to exist, nor has vital energy.  It also apparently makes no difference that chiropractic manipulation has never been shown to cure, improve, or otherwise treat anything whatsoever.

That does not stop them, however, from advertising their bogus "adjustments" for everything from pain to asthma to GERD to headaches to paediatrics.

Yes, chiropractors claim they can help children.

I came across Kristen Simpson from Leavenworth, Kansas, USA, who is a chiropractor in the Life Family Chiropractic practice.  She posted this bit of bullshit on Twitter:
Now let's break this down, shall we?  Starting with the array of hashtags: what the hell is a "crunchy kid"?  What is a "well adjusted" baby?  Moving on to the little girl's top - yes, children need to eat.  Children need sleep (a lot of it!).  But "get adjusted"?  For what exactly?  What the hell was this chiropractor claiming her adjustments could do for this child?  Babies need chiropractors in exactly the same way that Olympic athletes need cupping.

Trying to get some answers, I tweeted this at her:
I wasn't expecting a reply, since these charlatans people rarely do.  Would you want to be exposed as a fraud on international social media?  I would be mortified, embarrassed, and ashamed.  So instead of responding to the charges, instead of facing her accuser, she did what any reasonable fraud would do in that situation:

She blocked me.

I can't say I was remotely surprised, and I was actually somewhat pleased.  I saw it as a major win, because it can only mean two things:
  1. She read my tweet.
  2. She had no response.
Since I was blocked, I couldn't continue the conversation with her and ask any follow up questions (SAD).  My followers, on the other hand, were not blocked (at least not initially), and they were not exactly kind, and for good reason:



Why am I telling you this?  What the hell is the significance?  Well if you search for Ms. Simpson on Twitter now, you get this:
That's right, she deleted her account.  Rather than face the music, support her stupid claim, or provide evidence, she bravely turned her tail and fled and is now unable to propagate her ridiculous bullshit on Twitter.

Yes.

And with that, all I have to say is this:



Monday, 6 March 2017

Stupidly obviously stupid


Life on planet Earth is generally complicated.  There are way too many questions and very few definitive answers.  Why are we here?  What is our purpose?  Is there life on other planets?  If not, why not?  How can there possibly be a septillion (that's 1,000,000,000,000,000,000,000,000) stars (approximately) in the known universe with Sol being the only one to have evolved life?  But if there is other life out there, how is it possible that just one of them hasn't evolved to the point of interstellar travel and visited us?  Well, here is one possible explanation:

I didn't intend on going in this direction when I sat down to write this.  I should probably stop writing these when I'm post-call, sleep deprived, and caffeine deprived as well.  My brain starts doing strange things.  Let me try to get back on track.  Hm.

Anyway, with all the unknowns surrounding us, there are fortunately a few knowns, a few certainties, a few obviousnesses.  (Yes, I know that isn't a word.  It is now.  So there.)  For example: everyone reading this (and for that matter, everyone not reading this) will die.  Sorry if I just spoiled your day, but it's a natural part of every life (unless you are bitten by a zombie, then all bets are off).

There are a few more plainly obvious things that come to mind:
  • vaccines work (yeah, you knew I'd squeeze that in somehow)
  • homeopathy doesn't work (that too)
  • stupid people do stupid things
  • there are a lot more stupid people than smart people
Those last two might not have been too obvious to me as I grew up, but after doing what I do for as long as I have done it, they certainly are now.  One of the basic tenets of life, something that I consider to be obvious, clearly is not to far too many people: Don't be stupid.  I don't mean "Don't be unintelligent", because not everyone is born with a high IQ and can understand quantum physics and do calculus.  No, by "Don't be stupid" I mean "Don't do stupid things".  Even smart people do stupid things sometimes (myself included), but there are some things that you just don't do no matter how stupid you are.  Anyone with an intelligence above the level of "cabbage" or "chihuahua" or "antivaxxer" should know not to do things that put himself, his children, and everyone around him in immediate and extreme danger.

Howard (not his real name™) apparently didn't get that message.

It was a Saturday night much like any other, which is to say that it was full of stupid people doing stupid things.  Stupid people getting stupidly drunk at the pub and falling in the parking lot.  Stupid medics not realising that the 90-year-old woman they brought to me as a trauma who had crumpled to the ground 4 days ago was severely dehydrated and septic and not a trauma patient.  Stupid people who still haven't figured out how to call a cab instead of driving home drunk.  Howard fell into that last category of course, though I had a total of four similar patients that night, all after midnight.  Of course.

At first he seemed like any other drunk driver - just merely a guy who had drunk too much and run his car into a tree.  I'm always just a tad gratified when a drunk driver is in a single-vehicle accident, because at least he hadn't injured any innocent bystanders, bywalkers, bybicyclists, or bydrivers.  Yes, I just created "bywalkers", "bybicyclists", and "bydrivers" too.  This is a good day.

Moving on.

Howard admitted to having "Two drinks" at first, which changed to "A few drinks" several minutes afterwards, to "A lot" a bit later.  He was complaining of pain in his left thigh, which made me worried that he had fractured his femur.  But as we continued asking questions, the real Howard made himself known awfully quickly.  He started acting obnoxious and entitled, but when the police showed up, he stopped cooperating entirely.

Our workup was fortunately fairly benign - no femur fracture, just a few bumps and bruises and a minor pelvic fracture that would require nothing but pain medicine and time.  But just as quickly as my worry turned to relief, my relief turned to outrage when the police gave me the real story.

Howard had gone to a friend's house for a night of drunken carousing and debauchery (I assume), but he hadn't bothered to find a babysitter for his twin boys, so he had brought them along.  The boys, if you are curious, were all of 18 months old.  I don't know what possessed him to drive home drunk with his twin toddlers in the back of his car instead of calling a taxi.  And I definitely don't know what made him think that going close to 200 kph (around 120 mph) while drunk was a good idea.  WITH HIS TWIN TODDLERS IN THE BACK SEAT.

I was informed that the boys had been taken to the local children's hospital, but that by some stroke of good luck, both were ok.  I couldn't help but think that if Howard had been a victim of drunk driving (rather than a perpetrator), his boys probably wouldn't not have been so lucky.  Bad guys always seem to get away with it, for some stupid reason.  And if you're wondering where the boys' mother was, I didn't get that far in my questioning.  I had to go find a safe space to scream my fool head off.

If it hasn't become clear to you yet, this episode made me angry.  As a trauma surgeon, it made me livid.  But as a father, it made me so furious that it made me want to grab him by his ears, slap him repeatedly in the face, and scream in his face "WHAT THE EVER LOVING FUCK IS WRONG WITH YOU!??  Those aren't just helpless, defenseless children that you could have killed, those are YOUR helpless, defenseless children that you could have killed!!  It was luck, and ONLY luck that kept you and your entire family from dying tonight!  And not only that, but you put MY helpless, defenseless children at risk with your idiocy!  Moron!  Idiot!  Asshole!"

Excuse me, I need to go find that safe space again.  I'll be right back.

Monday, 27 February 2017

Superhero

There is a very slight chance that my decision to write this post as well as its content were strongly influenced by the fact that I finally sat down to watch "Dr. Strange" a few days ago.  A friend of mine told me it was his favourite Marvel movie and that I had to see it, but it somehow slipped by me.  Now having seen it, I agree it was pretty damned good (but then again, I'd probably see anything that Benedict Cumberbatch does).  But as with every superhero movie I've ever seen, it made me think about superheroes and their superpowers: how they get them, how they use them, why Batman is considered a superhero even though he doesn't have any superpowers and is just a rich guy with a bunch of fancy expensive gadgets, etc.

That being said, I'm fairly certain that Uri (not his real name™) is not a superhero, but I can't say I'm 100% convinced.

Uri was admittedly a bit of an anomaly in my trauma bay, in that he was shot in the late evening rather than in the middle of the night.  I don't think his attackers were thinking of me personally when they shot him in the chest, head, and neck so early (relatively) in the day, but I appreciated it nonetheless.  No one likes to be in the operating theatre at 2 AM.  NO ONE.

When the call first came in from the first responders, it sounded pretty grim (from what we could hear).  Multiple gunshot wounds to the head, multiple gunshot wounds to the torso.  That's the sort of call that prompts the nurses to put the body bag under the sheets on the gurney before the patient even arrives.  When he got to me 15 minutes later just before 9 PM, I was expecting to see them doing chest compressions.  Instead, what greeted me was a pretty awake young Uri.

"Hey Doc, this is Uri.  Multiple gunshot wounds, two to the back of the head, two to the chest.  He was pretty altered when we first got there, but he's started to come around.  His vitals have been ok though his pulse has been in the 140s the whole time."

Wait wait wait, how in the hell does someone who has been shot in the head start to come around?  This didn't make sense.  At all.  I started to try to convince myself that this would end up being nothing and I started thinking of going to bed soon, but my Inner Pessimist wouldn't let me.  "At least disrobe the patient and look at the holes first, dummy!" it wisely told me.

It took all of 2 seconds for me to realise how wrong I was.  I hate when my Inner Pessimist is right.  He had a gunshot wound to the right upper chest, one to the left lower chest, two on the back of his head, two on the left side of his neck, an exit wound on his right upper back, and another on his right lower back.

Those of you who know your anatomy can see already how bad this looked.  Those of you who don't know anatomy, well you probably got it quickly too.  An entrance on one side of the chest and an exit on the other is a Very Bad Thing.

I palpated the back of his scalp where the wounds were, and I could feel broken bits of bone underneath.  But Uri was looking at me and talking, so I figured the bullet probably went in, bounced off the skull, and came right back out.  "Don't be so sure!" my Inner Pessimist told me.  Sigh.  I next moved down to his chest.  He had decreased breath sounds on the left (that's bad), and no breath sounds on the right (that's worse), but his heart was beating.  Fast, but beating.  I then pushed on his abdomen and he groaned and tried to grab my hands.

Damn.  One thing I hadn't seen Uri do yet is move his legs.  I asked him to move them, and they didn't budge.  Maybe he didn't hear me through all the hustle and bustle going on around him.  I asked him again (louder) to move his legs.  "I'm trying, Doc.  I can't."

Shit.  SHIT. SHITSHITSHITSHIT

I now had potential injuries to the head, chest, abdomen, and spine, all at the same time.  I had no need for a chest X-ray to make the diagnosis of either pneumothorax or hemothorax (it didn't matter which) on both sides, because he needed bilateral chest tubes regardless.  But I needed a quick look into the abdomen to make sure he needed immediate surgery, because I wasn't sure the bullet had gone from the chest into the abdomen ("IT DID!  HE DOES!" yelled Inner Pessimist).  I did a quick ultrasound which showed obviously fluid around his spleen, liver, and bladder.  Blood.

Well, damn it.

We quickly put in the chest tubes and then wheeled him down to the operating theatre (2 AM is no fun, but 9 PM is reasonably ok).  In his abdomen I found holes in his left diaphragm, liver, and stomach, all of which I repaired.  After surgery we left him on the ventilator, but he still woke up and was opening his eyes and trying to talk.  Whew, at least his brain isn't injured I thought to myself.

We went straight from the operating theatre to the CT scanner to get a better look at where the bullets went.  Starting with the brain, Uri surprised the hell out of me.

Not Uri
The bullet had in fact bounced off the skull, but it had caused a significant amount of bleeding in his occipital lobe and left 3rd ventricle.  I was shocked that Uri was still awake, let alone trying to talk.  (Note this is not Uri's brain - his also had a skull fracture.)

Moving down to the chest, the bullet on the left side had indeed gone through the chest, into the abdomen, and through the spine at T11.  As I suspected, Uri was paralysed.  God damn it.  The bullet in the right chest had gone straight through his right lung, fracturing a couple of ribs on the way in and out.  No huge deal there, the chest tube should suffice.  But then I looked at the abdomen . . .
Not Uri

I almost couldn't believe my eyes when I saw that the bullet had also lacerated his aorta.  If you look at the white structure circled in red (that's the aorta), it looks like it's split in two.  Because it is.  (Note this is not Uri's abdomen - his looked much worse.)  You can probably imagine that having a laceration in the largest blood vessel in the body should result in death, and in the vast majority of cases it does.

Uri, however, had survived not one, not two, not three, not four, but five different injuries (brain, liver, lung, stomach, aorta) that could (and possibly should) have killed him.

But none of them did.

Is Uri a superhero?  That depends - is living a super power?  Well, maybe "living" isn't the right term.  Is surviving multiple horrific injuries that should have been fatal considered a super power?  And if so, what would his superhero name be?  We can't use The Boy Who Lived, because some silly wizard already took that one (yes, I'm a huge Harry Potter nerd.  Sue me).  How about The Living Kid?  No?  Survival Man?  Still no?  Oh oh oh I got it, how about Duraboy!  No no, I got it - Existo!

Hey, it's a better super power than "I have a cave and a car and a grappling hook on my belt."

Monday, 20 February 2017

Unvaluable lesson

I try my best to find valuable lessons in dealing with trauma patients.  As I've told my children repeatedly, any day you learn something is not a wasted day.  Many of these life lessons are easy - use your seat belt, slow down, don't drink and drive, don't attack the police, don't be stupid - but some of them can be slightly more obscure and difficult to discern, and it takes me a while to figure out what I've been able to take away.

As you have probably guessed, this story definitely falls into that latter category.

I know I write a lot about gun violence, and it must seem to you that anyone around me can walk into a corner store, buy a gun of his or her choosing, and immediately start firing at everyone and everything for any goddamned reason.  The truth is that it isn't nearly as common as I make it sound (fortunately).  If it were, it would be like the OK Corral with bullets whizzing around my head constantly (I assume - I wasn't actually there despite how old my children think I am).  Luckily reality isn't quite like that and guns aren't that easy to obtain.  I just write about those stories more than the 84-year-old who fell off her toilet and bonked her head on the bathtub, because who the hell wants to read about that crap.  I just re-read that last sentence and almost deleted it because it's so stupidly boring.

Oh, and before I go on and before anyone starts a pedantic comment regarding the title, I fully realise that "unvaluable" is not a real word.  Unfortunately due to a remarkably stupid quirk in the English language, "invaluable" is actually a synonym of "valuable", much like "inflammable" means "flammable".  There just is no good antonym.  So I made one up.  Sue me. 

Now where was I?  Ah right, guns and valuable lessons.  That is where our story starts.

Nancy (not her real name™) was brought to me as a Level 1 (high level) trauma, and unlike many of my Level Ones who are unresponsive because they are drunk, she was a real Level 1.  

"Hey Doc, this is Nancy.  She's 25, multiple gunshot wounds.  We saw one on the right chest, two in the right arm, two in the left wrist, and two in the neck.  She's been stable, complaining of right chest pain and shortness of breath."

Obviously. 

With all those holes you might expect Nancy to be near death (I certainly did), but she wasn't.  Not even close.  Sure, she was uncomfortable and unhappy, but her vital signs were fine.  My evaluation (read: where I found holes) was consistent with what the medics had told us:

  • Right chest
  • Right upper back
  • Right upper arm (2)
  • Left wrist (2)
  • Back of neck (2)
A quick examination of the neck (since that seemed the most immediately life-threatening injury) revealed it was a simple graze wound somehow.  Lucky girl.  An X-ray of all the other various Parts With Holes showed no fractures in the wrist or the arm (LUCKY GIRL), but she did have a few broken ribs and a haemothorax (blood in the right chest).  A simple chest tube and some pain medicine should suffice, and she would most certainly live to tell her tale. 

Which left only her tale.  What made someone shoot this young lady four times?  What had she done to deserve this?  

Nothing, it turns out.  It was her boyfriend Will (not his real name™) who has caused this. 

The police told me later that Will had wanted a gun, but instead of figuring out which hoops to jump through to buy one legally, he decided to buy one from Some Guy With Guns In His Car.  I don't think Some Guy With Guns has a permit, but that didn't stop Will.  Oh no, not at all.  

But Will had another problem.  In addition to a severe shortage of guns in his possession, he also had no money.  Most idiots who want to buy a gun illegally but have at least half a functional brain would probably find some just-as-illegal way to find some money, and that's exactly what Will did.  Sort of.  Will did acquire some money illegally, but that illegal money he illegally obtained in order to acquire his illegal gun illegally was counterfeit.

You probably see where this story is going. 

Will drove with Nancy to buy his gun and gave his funny money to Some Guy With Guns In His Car.  Unfortunately (and despite his choice of occupations) Some Guy was somehow bright enough to recognise the fake bills.  Even more unfortunately Will hadn't foreseen the very slight problem with trying to trick a guy with guns: THE OTHER GUY HAS GUNS.  So Some Guy did the only logical thing for a guy in his position: he used the gun on Will, who did not survive long enough to earn a trip to my trauma bay.  He then used it on Nancy, who did. 

WE AIN'T FOUND SHIT!
After this episode I went back over it with a fine-toothed comb to find the learning point.  What could I take away from this?  How could I enrich my life and the lives of those around me?  It took quite a while of searching, but the only thing I could glean, the only lesson I found, was "Don't buy an illegal gun with fake money".  A valuable life lesson?  Hardly.  

Unvaluable.

I somehow wonder why Aesop never wrote a fable about that little moral. 

P.S. For any of you playing on the last post, the correct answer (not counting duplicates) was 20.

Monday, 13 February 2017

Jerk

In trauma I see all kinds of patient imaginable - male, female, old, young, educated, uneducated, nice, and asshole.  There are other types too, but I'll leave the rest to your imagination.  Of all those types, the nice ones are the easiest to take care of, but they make for very boring stories.  That's why you rarely hear about them here - they just aren't very interesting.

The assholes, on the other hand, make my time in the trauma bay much more entertaining.  I can't say I prefer them per se, but this blog would frankly be impossible without them.

And thus enters Jack (not his real name™).

When Jack was first wheeled into my trauma bay, he immediately rubbed me the wrong way.  It wasn't so much that he was acting obnoxiously, because he wasn't (at least not at first).  Actually when he first got there, he was happy and giddy.  I could almost describe him as spunky.  He was smiling sharply, almost demoniacally so.  He seemed to be muttering rhythmically under his breath.  It took me a few seconds to realise he was singing.

"Hey everybody, this here is Jack," the medic started as he helped Jack off the gurney.  "He crashed his car into a tree for some reason, don't know why.  He refused to get out when the police got there, so they kinda roughed him up a bit.  I think they whacked him on the left leg a few times, but I didn't take his pants off to look at their handiwork." 

"They choked me too," Jack tossed off as the police officer shook his head No, we didn't.

He had definitely been beaten about his head, but he had no other obvious injuries.

Unbeknownst to me, Jack was well known by the emergency staff as a bit of a wanker, a jerk.  Ok, that's putting it mildly - he was an asshole.  He was also a frequent flyer - he seemed to come to our hospital on a regular basis whenever he took PCP, which was often.  I examined him from head to toe, and other than having been spanked around a bit, by some stroke of luck Jack didn't look too worse for the wear.  He tugged on my lab coat as I tried to walk away.

"Doc, they beat me.  They beat me good."

I had to hand it to him, he was definitely persistent.  But something about Jack's behaviour was rubbing me the wrong way.  I just couldn't quite put my finger on it.

About a half hour later Jack's X-rays were all done, and they were (shockingly) all normal.  I walked back in to give Jack the good news, but what greeted me was not was I expected.

Jack's hand was at his groin under the sheet, moving rather quickly.  Wait, is he . . . It took me about 0.298 seconds (I didn't count) to realise what he was doing.  Oh fucking hell, he is!  There was no mistaking it and I wasn't imagining it - this was actually happening.  Now at this point I had three options:

  1. Turn right back around, walk out, and pretend I didn't see anything.
  2. Stand and stare, completely bewildered.
  3. Ask him politely to stop.
I chose #3.

"Jack," I said, not believing the words coming out of my mouth.  "Please stop masturbating."

No one had been looking at Jack before, but as soon as I said it, every set of eyes in the room turned immediately to Jack.  "Jeez. . ." I heard several people mutter under their breath.  For me it was hard just standing there as Jack sat smiling for just a moment, obviously pondering his options.  And a second later it became obvious that the option that he went with was keep going.

Um . . . now what?  What the hell do I do now?  I was unprepared for the situation to begin with, and completely unprepared for this eventuality.  He was supposed to have stopped!  Unlike most situations, I had no prepared statements, no social norms I could fall back on, no fucking clue what to do.

So I shook my head and walked out.  I had no other ideas.

Apparently he finished a few minutes later, because when I went back, he was getting dressed and preparing to leave with the police (he was under arrest for the car accident, not for, you know, that other thing).  He had no shame on his face, no sheepish smile, seemingly no sense of remorse.  He almost looked proud of himself.  My staff, on the other hand, looked downright thrilled that he was leaving.  Obviously.

I've said it many times here before, but just when I think I've seen it all, just when I think the Call Gods can't possibly think of anything new to throw at me, they come up with something.  However, the day that the Call Gods call it quits is the day that I retire SftTB, because my source material will have officially dried up.

Note: A special prize will not be awarded to whoever finds the most.  If you don't know what I mean by "the most", then you are guaranteed not to win.  And by "special prize" I mean my undying esteem and respect.  Not really. 

Tuesday, 7 February 2017

4

I have a very nice story about an incredibly stupid person (who is not my patient) who did something incredibly stupid that lead to his death, but it will have to wait.  In lieu of a stupid patient story, I'm going to have a little fun this week.  What kind of fun?  The kind that will make little sense to some of you at first but that most of my long-time readers will catch on to almost immediately:
  • If you were to stack 4 million 1 euro coins, it would reach 9.3 km (almost 6 miles) into the troposphere.
  • If you put 4 million 500 ml Coke bottles (no particular reason why I chose that particular bottle, of course) end to end starting in Copenhagen, Denmark, they would stretch 20km past Brussels, Belgium.
  • 4 million people signed a petition calling upon the UK government to hold a second referendum on Brexit.
  • If you had $4,000,000, you could buy an 800 square meter (8500 square feet) 5-bedroom, 7-bathroom mansion in Dallas, Texas and still have $10,000 left over to pay someone to clean it for a few months.
  • 4 million dollars was the budget for the movies Lost in Translation and Annie Hall.
  • 4 million is the approximate population of Panama.
  • The four millionth digit of pi is 0.
And if you had come to this stupid blog at this time last month, you would have been the four millionth visitor.  How is that even possible?  Who are you people and why do you keep coming here?  

In all seriousness, I know I've said it many times before, and I hope no one is surprised when I say it again:


No really, thank you.  If no one came here to read my stupid stories, then I would have no reason to keep writing them, I would have no outlet for the insane amounts of stress I endure, and I would probably be forced to move to a private island (Bastardia?) with no stupid people to addle my already-addled brain.  

As a little bonus (not that you asked), here are the top 10 countries that have provided me and my ego with viewers:
  • United States
  • Canada
  • UK
  • Australia
  • France
  • Germany
  • Russia
  • Ukraine
  • New Zealand
  • Singapore
To which I feel obligated to reply . . . really?  The first four don't surprise me one bit, but Russia?  Ukraine?  Singapore?
This past week India, South Africa, and Greece are in the top 10, and Holland appears in the top 10 in the past month.  Fascinating.

I'm literally in awe of every single one of you who has taken time out of your day to spend a little time with me over the past several years.  As I've hypocritically and humbly requested with my other milestone posts, please take a second and let me know where you're from and how you found me.  If you don't have an account and don't have the time to make one, then GO AWAY AND NEVER COME BACK.  

Just kidding.  Or am I?

In all seriousness though, thank you, everyone.  Thank you.  I'll see you at 5 million.

Best,
Doc

Monday, 30 January 2017

Respect your elders

I've strongly considered writing a post about "Things They Should Teach In Medical School But Don't", but I haven't yet for reasons I can't explain.  Probably just laziness.  There are so many little details about every facet of medicine that would make it impossible to teach them all without extending med school to approximately 295 years.  One of the big things in trauma that I wish I had been taught in school is that old people fall.  A lot.  A lot a lot.  When you combine failing eyesight, poor balance, brittle bones, and forgetfulness, you get either OPFDGB (Old Person Fall Down Go Boom) or AVG (Age Versus Gravity) depending on whom you talk to.  Gravity always wins, mind.

A small percentage of my elderly fall victims have serious injuries like fractured hips or bleeding on the brain, but mostly they are only mildly injured, with contusions, lacerations, perhaps a fractured rib or seven.  The vast majority of these patients are nice older folks who, I'm sure, would all have fascinating stories to tell if I had more time to sit down with them and talk.  My grandparents died at the ages of 69, 87, 95, and 100, and some of the stories they told me about The Old Days were absolutely riveting (though I heard most of them several times).  I honestly wish I could sit with my older patients and have them tell me their life stories.

But not Dora (not her real name™).  To hell with Dora.

Dora was 92 years old and fell out of bed one morning, or so the medics thought (more on that later).  Her daughter found her on the floor around breakfast time, and she saw a decent amount of blood surrounding her head.  When the medics arrived they had to fight with Dora - literally.  She swung at them repeatedly and resisted their attempts to secure her to the stabilising equipment.  Even though it was barely 9 AM when they arrived, they already looked exhausted.

"Sigh.  Good morning, Doc.  This is Dora ("GO TO HELL!") . . . shhh!  Be quiet, Dora.  Anyway, this is Dora.  She was found on the floor and we think she fell out of bed ("I DIDN'T FALL GOD DAMN YOU!").  Her daughter found her.  She has a laceration on her head.  No blood thinners.  She hasn't been very cooperative ("THE HELL YOU SAY!") with us."

Dora turned her eyes to me, and I swear I've seen the same look in a Friday the 13th movie.  Her eyes were small, sunken, and evinced nothing but pure malice.  I think if she had a knife at that moment she would not have hesitated to use it on me.  She then glanced around the room and made sure to give that same malevolent look to everyone as she muttered various curses and spat epithets under her voice.

Respect your elders.

"So long, Doc.  Good luck," the medics breathed with relief as they almost ran away.

I looked back at Dora.  She braced me with those tiny beady eyes as if daring me to speak.  I was not about to let this little lady get the better of me, nor was I going to allow her to get the rise out of me that I thought she was looking for.

"Good morning, Dora.  What happ . . ."

"GO TO HELL!  GET ME OUT OF HERE!  YOU'RE HURTING ME!  OOOOWW!!"

I wasn't touching her, nor was anyone else.  So it's going to be like this, is it Dora?  Fine.  Let's dance.  As I approached her she held her shriveled arms out at me, revealing her nicely sharpened fingernails, trying to grab me.  I examined her head, careful to stay out of reach of her talons as she tried to claw me repeatedly.  She had a small laceration on the back of her head, less than a centimeter, that would require a few sutures.  But bleeding in the brain can cause patients to act very aggressive like this, so I needed to make sure there was no serious underlying brain injury.

She continued cursing, swinging, grabbing, pinching, and clawing as we finished working her up and transported her over to the CT scanner.  The radiology tech was helping to move her over to the CT table, and that was when it got really weird.

"Oooh, what's your name?" she cooed to the young tech with a smile that reminded me of this:


The look he gave me clearly said "Help me!"

The next few minutes were filled with the most uncomfortable flirting I have ever been unfortunate enough to witness, including Dora calling the tech her "boy toy" and asking him on a date that night.  I don't think I've seen anyone shudder quite so obviously (and appropriately) before.

Fortunately the CT was negative, so all Dora needed was a few sutures so I could get her the hell out of my trauma bay.  Unfortunately that was easier said than done.  She pinched the nurse, slapped the tech, tried to claw me as I held her arms down (veeeery gently, mind you), and then tried to bite me when her clawing failed.  Yes, she still had all her teeth, damn it.  During all of this I held my tongue despite wanting nothing more than to scream at this old lady to knock it the hell off and act like an adult, rather than a spoiled toddler who didn't get her favourite candy.

Some old folks are pleasantly demented and smile nicely at everything, while others get very frustrated at not being able to remember things, and they get angry and sometimes violent.  Without knowing her medical history, I figured Dora had dementia as the source of her violent tendencies.

And I figured absolutely wrong.

Her daughter came to pick her up a short while later, and she told us that Dora had always been this way, ever since she was a child.  She had no psychiatric diagnoses, took no medications other than one medicine for high blood pressure, and tended to act out when agitated.  She hit people, she yelled at people, and she cursed at anyone who got in her way.

In other words, there was no excuse.  She was just a horrible, cruel, evil witch. 

As Dora's daughter helped her put on her coat on her way out, my Inner Pessimist implanted a rather nasty thought into my brain.  Maybe her daughter pushed her out of bed.  After spending less than an hour with Dora, I would definitely call that justified.  I can't imagine growing up with someone like that. 

Dora made one last attempt to swing at me as she was wheeled out.  I muttered "Good riddance" under my breath but felt slightly guilty despite her multiple failed attempts at assault.  In spite of everything, my Inner Pessimist had one last fleeting thought:

Maybe I would like to sit down and ask Dora her life story.  Something must have made her this evil.  I just wonder what. 

Tuesday, 24 January 2017

Hard work

I'm not looking for sympathy or accolades, but my job is hard.  Really hard.  Really, really hard.  Unless you're a stay-at-home mother, it's probably harder than yours (with all due respect, of course).  I'm not trying to pat myself on the back or garner any "Oh, being a trauma surgeon must be so tough, you're so awesome" comments.  Seriously, don't.  I'm simply trying to establish the groundwork on what I'm about to say.

My hours are long, I spend a lot of time away from my family, my patients are obnoxious and unappreciative, and my success or failure can literally mean the difference between life and death.  Actually now that I read that back, I'm frankly surprised I'm able to convince myself to get out of bed every morning.  Hm.

But it's true.  I have a tough job, but as hard as it may be, the rewards are greater than any self-induced suffering and hardship.  Sure I have to put up with a lot of shit, but sometimes I get to save a life.  There are people walking around this planet who are alive because of me.  That's pretty damned special.

But the hard work is not just on me.  Others have to participate as well, and once my job is done, the real hard work starts.  Physical therapists, occupational therapists, speech therapists, nurses, aides, and techs all have to do their part to get my patients better once I'm finished fixing the holes.

Oh, and let's not forget the most important cog in the works: the patient.
 
The patient is by far the most significant factor in healing.  And I don't just mean mending a bone that has been set or healing an anastomosis that I've created after removing a shredded bit of intestine.  No, I mean getting better.  Sadly too many people are satisfied just being a patient.  They are more than happy just lying there in bed, moaning and whining, screaming for pain medicine, sending therapists away, generally feeling sorry for themselves, and actively preventing themselves from recovering.

But not Terry (not his real name™).

Terry was around 20 years old, thin and healthy, when he was shanked by his girlfriend.  For those of you who have 1) never heard of "shanking" and 2) never seen a prison movie, put your mobile down and go watch a damned prison movie.  

Are you back?  Good.  Anyway, Terry was stabbed in the left flank by his girlfriend, though that's not the story she told us when she drove him to our hospital and dropped him on our doorstep.  "Oh, I found him like this and I heroically drove him here because I love him oh so very much!" was her story, which quickly changed as the police interrogated her.  (I found this out much later).  Terry was white as a ghost and could barely keep his eyes open, two Very Important Signs that told me three Very Important Things: 
  1. Terry was sick as shit.
  2. Terry probably needed surgery.
  3. Terry probably needed surgery now.
As the nurses were hooking Terry up to monitors, drawing his blood, and generally running around doing everything possible to help, I looked at the 6 cm stab wound on Terry's flank.  My Inner Pessimist sounded oddly optimistic as he said "It's probably just superficial".  I then very calmly stuck my finger in the hole.  Terry wasn't a very big fan of this particular manoeuver, and he moaned audibly as my finger kept going in.  And in.  And in.

This was not a superficial wound.  Stupid Inner Pessimist.

Terry's abdomen was also markedly tender when I pushed on it.  My Inner Pessimist had already changed his tune.  "Kidney, colon, intestine!" he ticked off as the organs Most Likely To Need Repair.  I ordered a blood transfusion as I called downstairs.

I looked at the clock.  One AM.  Of course.  It's always 1 AM.  

I had him in the operating theatre 7 minutes later.  As I opened his abdomen, nearly his entire blood volume emptied onto my shoes.  After a careful exploration, I found that the weapon must have been a samurai sword, because it was long enough to have gone through a branch of the left renal artery, in the back of the jejunum (the first portion of the small intestine), out the front wall, in the back wall of the stomach, out the front wall, through the diaphragm, and finally into the chest.

Lots of holes.  Eek.

I quickly ligated the renal artery, which was the source of the majority of the bleeding.  I then repaired both holes in the intestine, repaired both holes in the stomach, repaired the diaphragm, and placed a chest tube to drain the remaining litre of blood from his chest.  As all this was happening, the anaesthesiologist was pumping him full of every blood product she could get her hands on.  Two hours later the surgery was done, but he was still bleeding from the wound tract.  I packed his abdomen and closed him temporarily, a technique called "damage control".  The idea is to finish as quickly as possible, fix what you can, pack it off, and live to fight another day.

That day was the next day.  I brought him back to the operating theatre about 24 hours later, unpacked him, and found that though the repairs were all intact, the wound tract was still oozing steadily.  I tried packing it with a pro-coagulant and closed him temporarily again.  By this time his bowel was extremely distended and swollen from all the fluids he had gotten, and I wasn't able to get his intestine back into his body.  He looked like a victim from Alien.

It took nearly a week and several more trips to the operating theatre for me to get his intestine back into his body and his abdominal wall closed.  For him it was long and painful, and for me it was grueling, difficult, exasperating, and ultimately successful.

My job was now done.  The rest was up to Terry.

About a week later Terry had improved to the point where the chest tube was removed, and ultimately he was able to breathe on his own.  When I came to see him the next day, he was sitting in bed looking at me and trying to smile.  His mother and brother were sitting next to him trying their best to smile too.  I explained in detail everything that had happened to him over the previous week, including his injuries, his surgeries, and everything I had done for him.  Or more to the point, to him

He held out his hand.  I shook it.  Terry smiled.

"What do I need to do now, Doc?" he croaked weakly.

The best thing he could do, I explained, was get out of bed and walk.  It would be difficult and painful, but also beneficial.  Without another word, Terry (who, you must remember, had spent the previous two weeks in bed on a ventilator) grabbed the bed rail, sat up, and immediately tried to stand.  His brother caught him and helped him up, and he stood.  And then he walked.

He walked.

And two days later he walked out of the hospital.

When I first saw Terry, more than halfway to the morgue, I wasn't convinced he was going to survive.  After his first and second operations I was still very unsure.  The third made me cautiously optimistic, and by the fourth I knew he would make it.  But I had no idea how motivated he would be.  Terry surprised the hell out of me not just by being a model patient, but also by understanding that I had worked extremely hard for him.  And unlike the vast majority of my patients, he also understood that now he had to work just as hard as I had.

If only all my patients were like Terry.  If only.