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. 

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.

Sabotage

Hey look, another post where Doc is unabashedly stealing a title from a popular song. How very original. 

Wow, you didn't even let me get a word in before you started attacking me for my thinly veiled unoriginality.  Besides, this has nothing to do with the Beastie Boys or their song, so thanks very much for your feedback.  I'll be sure to remember that when it comes time for Christmas presents next year. 

Aaaaaaanyway . . .

sab·o·tage

ˈsabəˌtäZH/

verb

1. 1. 

   deliberately destroy, damage, or obstruct (something), especially for political or military advantage.

   
   

Trauma is a hard job, not that I'm necessarily trying to pat myself on the back or garner any sympathy.  But it is.  In addition to fixing holes, I also sometimes need to fix people or situations, and that is always a much more difficult prospect.  A hole can be sutured or stapled, but people . . . Well, people are different.  Unlike a stab wound to the heart, people have brains and free will, and too often they use that free will for intentional self-destruction.  Sometimes they act harmfully to themselves, but all too often it is others that they harm, intentionally or otherwise.

And no matter how hard I try to fix someone or something, even my best plans can get destroyed in a second, sometimes by the most unexpected source.

Robbie (not his real name™) was transferred to my facility because the facility he first visited didn't have doctors, I can only assume.  Maybe that isn't entirely fair - they presumably had doctors, but none that knew how to evaluate a goddamned patient.  Ok, again probably unfair.  Perhaps they knew how to evaluate a patient, but clearly they had no idea what to do with the information once they collected it.  So in Robbie rolled a bit after 8 AM, just a few minutes after I walked in the door, and even fewer minutes after my morning coffee, but well before my post-coffee coffee.  It's a damned good thing too, because there is no way I would've been able to deal with him had I not yet had my coffee.  Why is that, you may be wondering?  Because I heard him well before I saw him. 

"GOD DAMN IT I'M IN FUCKING PAIN!  I NEED SOMETHING FOR PAIN!"

Sigh.  So it's going to be that kind of day, is it Call Gods?  Well good fucking morning to you, too.  Assholes. 

As he transferred from their stretcher to ours, I couldn't help but wonder why someone would have taken a bat to Robbie's face.  After all, what a polite, kind, and genuinely appreciative person Robbie clearly was.

"OW, MOTHERFUCKERS!  WHAT THE FUCK IS WRONG WITH YOU?  CAN'T YOU SEE I HAVE BROKEN BONES IN MY FACE?  GOD DAMN, BE MORE CAREFUL!"

We could all see that his face was broken, and none of us wondered why someone would want to do such a thing.

"Hey Doc, this is Robbie," the medic started, clearly trying to prevent himself from punching Robbie on the other side of his face.  "He was hit in the face with a bat or a club or something a few hours ago.  Positive loss of consciousness.  He admitted to using heroin . . ."

"I DIDN'T FUCKING ADMIT TO USING HEROIN!  I'M ON FUCKING METHADONE, ASSHOLE!  I FUCKING TOLD YOU THAT!"

". . .for a few years," the medic continued with a deep breath, "but he claims he's clean now ("I AM CLEAN, ASSHOLE!") and takes methadone.  CT showed a bunch of fractures - here's the disc with the images.  He's all yours."

I have rarely seen an ambulance crew scatter as quickly as they did.  Roaches scurry slower than these guys.  And just like that, Robbie belonged to me.

"CAN I GET SOME PAIN MEDICINE?  NOW?!  HELLO??"

I tried, and probably failed, to make my sigh inaudible.

After a quick glance at Robbie's broken face, I took the disc over to the computer and waited approximately 3.2 years (I counted) for the images to load onto the screen.  Sure enough there were several fractured facial bones on the left side of his face (I assume his attacker was right-handed).  However, the fragments were not displaced and there was no evidence that the muscles that control movement of his eye were entrapped.  I seriously doubted he would need any reconstructive surgery, so with the blessing of the facial reconstructive surgeon on call, I could most likely send Robbie home.

Aaaaaaah, yes.

"PAIN MEDICINE!"

Ah.  No.

There was still the issue of treating Robbie's pain and convincing him he didn't need A) a hospital, B) surgery, and C) more narcotics.  Obviously Robbie's most recent methadone dose had worn off, and he had every reason to have pain.  I'm not saying he deserved it, but . . .

Ahem.  The problem with pain control in narcotics abusers is multi-faceted.  First, their tolerance tends to be very high, with effective doses being high enough to kill a whole team of very large mules.  Second (and more dangerously), it feeds into their addiction.  I therefore asked the nurse to give him some ketorolac, which is a rather potent non-narcotic IV anti-inflammatory analgesic.  Robbie had obviously been through this before and knew exactly what to say.

"I'M ALLERGIC TO KETOLAC OR WHATEVER!"

Of course he is.  I asked him what his allergic reaction was, expecting him to say 1) it doesn't work, 2) it makes me die, or 3) I don't know I just am.  Instead, he went off-script and said it makes him feel nauseated.  Ha, nice try but GOTCHA.  I explained very calmly that nausea is not an allergy, but rather an intolerance, so I would just give him some anti-nausea medicine with it.  Right on cue he went back on-script and screamed that the anti-nausea medicine doesn't work for him.  Because of course it doesn't.  I de-escalated a bit and asked if he could take ibuprofen.

"I'M ALLERGIC TO IBUPROFEN!"

And of course his "allergy" was nausea again.  By this time the patience of everyone in the room was wearing thin.  Actually that's not exactly true - our patience had completely run out the second he started cursing at the ambulance crew, and we were now all completely tired of his bullshit.  A few minutes later as I was putting in an order for acetaminophen (I CAN'T TAKE ACEMATINOFEN OR WHATEVER!!"), his parents showed up.  His father hobbled in with a cane, and his mother smelled like an ashtray that hadn't been cleaned in 30 years.  They sized up the situation rather quickly, and they obviously were well aware of Robbie's drug history.  Mum started trying to sooth him with quiet, calm words mixed with tears, and dad stood back towards the door, obviously seething.  It seemed he was rather angry with Robbie, and rightfully so.  

Or so I thought.

After some back-and-forth arguing between Robbie and his mother, dad had seemingly had enough.  He set his jaw and marched forward (as quickly as he could considering his cane), and I expected to hear a thorough tongue lashing.  I did, but the object of dad's wrath was completely unexpected.

"THAT'S ENOUGH, Robbie.  Enough.  God damn it.  Let's just get the hell out of here.  These people don't know what the HELL they're doing.  I'll take you home, and I'll take care of you the way I always do."

There was nothing but stunned silence as Robbie's mother nodded solemnly.

The implication was clear, and dad was not trying to hide his intentions one iota: Since these people won't do it, I'll give you some of my narcotics.

I usually have it in me to confront situations like this, but this had me so taken aback I had no alternative but to let them leave.  This was obviously not the first time they had been in this situation, and it most assuredly will not be the last, since they both fed right into it.  My intentions were nothing but pure: 1) don't feed Robbie's addiction, and 2) treat his pain.  Dad's were the exact opposite.  He was satisfied not only sabotaging my well-intentioned plans, but his son's health too.

I'm not a babysitter.  I can't go home with my patients and make sure they do the right thing, so I damn well can't ensure everyone else does the right thing too.  All too often I have to rely on family members and friends to help their loved ones along and keep them on the right path.  But sometimes those reliable family members just don't exist.

I strongly suspect I'll see Robbie again in the near future.  And I will treat him exactly the same way as I did this day.

Bad week for science

Oh, what a bad week for science this has been, and for vaccines in particular.  If anyone even remotely follows science news (or me) on any social media, you know exactly what I'm about to talk about.  No, I'm not even going to focus on the story two days ago about Donald Trump purportedly talking with anti-vaccine lunatic Robert Kennedy Jr. about possibly heading a possible presidential commission on vaccine safety and scientific integrity.

*pause for laughter*

Having an anti-vaccine advocate head up a commission on vaccine safety would just as ridiculously stupid as

• having Bernie Madoff lead a commission on stock trading ethics
• having Clint Eastwood lead a board on gun control
• electing Donald Trump be president of the United States of America

No, we're going to ignore that utter travesty for a bit since Trump's team seems to be denying that they offered Kennedy anything (and thank god for that) despite the fact that Kennedy said, and I quote, "[Trump] asked me to chair a commission on vaccine safety and scientific integrity [...] and I said I would."  Fake news, indeed.

Instead we're going to focus on the other insanity that cropped up nearly a week ago.  I've been trying to figure out how exactly to write about it, because it caused such a visceral reaction of anger and pure outrage that I was forced to buy a new computer after smashing my old (new) one against the wall, throwing it out the window, running it over with my car, and setting it on fire.  Unfortunately that did not cause the ridiculousness in question to disappear from the internet.

What I'm talking about is a piece written on Cleveland.com by an actual, real doctor at the actual, real Cleveland Clinic, which hit on so much antivax bullshit I can't even begin to count.  How many?

All of them, I think.

I'll start by saying that this was written by Daniel Niedes, MD, who is the director . . . THE DIRECTOR of the Cleveland Clinic Wellness Institute.  For me, that's a clear strike 1.  Whenever I see the word "wellness" or "integrative" or "holistic" (or "organic", for that matter), it stirs within me an unease that can only be mollified by coffee or a full fat, GMO, mostly gluten, chock-full-of-real-non-organic-sugar doughnut.  Or coffee and a doughnut.

Dr. Niedes isn't some naturopath.  He isn't a homeopath.  He isn't a chiropractor.  No, he is by all appearances a stand-up physician, fully qualified, board certified in family medicine, and working at the prestigious Cleveland Clinic.  This isn't some fly-by-night walk-in clinic, this is THE CLEVELAND CLINIC, easily one of the most famous and well-respected medical facilities in the entire world.

That's what makes this so infuriating.

The title of Dr. Niedes' piece is "Make 2017 the year to avoid toxins (good luck) and master your domain: Words on Wellness".  And that is strike 2.  A real doctor used the word "toxins".  I'll ignore the "master your domain" bit, as I'm sure we've all seen the Seinfeld episode and remember it well, and I can't even imagine what Dr. Niedes was thinking when he used this particular phrase.

Anyway, I'll go through the piece line by line, step by step, and I will quote from it liberally so we can all bask in its bullshitty glow.  Ready?

Brace yourselves.

"I am tired of all the nonsense we as American citizens are being fed while big business - and the government - continue to ignore the health and well-being of the fine people in this country."

Whoa whoa whoa, stop right there bucko.  This is the very first line, and he's already DEEP in bullshit.  He's starting off at the very top with the BIG PHARMA WANTS TO KEEP YOU UNHEALTHY crap, and I don't give a flying fuck how tired he is with his made-up nonsense, I'm absolutely sick to fucking death of people thinking that doctors are trying to keep people sick to make money.  And this is a DOCTOR saying this!

It gets worse.  MUCH worse.

Yes, he delves into the thimerosal wastebin next.  Let's first remind ourselves that thimerosal IS NOT MERCURY.  Thimerosal is ethylmercury, which is safe and is rapidly cleared from the body, as opposed to methylmercury which is much more dangerous and commonly found in fish, and as opposed to elemental mercury, which is obviously unsafe.  But it is NOT mercury!  Also, thimerosal has been shown to be safe and does not cause autism.  And then he goes straight into the formaldehyde bullshit!  The amount of formaldehyde in a vaccine is far less than the body normally produces in a day, and it is rapidly metabolised.

Bullshit.  And we're not even out of the third paragraph yet.

Ha!  I actually laughed out loud at this.  1) He calls the flu shot an "unsafe product", and 2) getting a minuscule dose of formaldehyde landed him in bed and caused him to miss two days of work.  Are you fucking kidding me?  Are you actually accusing 0.1 mg of formaldehyde of making you that sick?  Do you even realise it took your body about 9 minutes to metabolise 99% of that formaldehyde, which your body is constantly making?

But Dr. Niedes is angry.  Angry at "toxins".

He doesn't say what these toxins are or what chronic diseases they cause.  Just nebulous nefarious TOXINS.  But whatever these TOXINS are, he's not done complaining about them.  There are just so many CHEMICALS in our environment, and evil scientists are coming up with more of them EVERY DAY:

So many toxins!  This made me laugh out loud again.  He goes full Food Babe and implies that ingredients are toxic if you can't pronounce them.  However, safety of a product is not based on your ability to pronounce the name of it.  I can pronounce "ricin" and "pit viper", but that doesn't make them remotely safe.  That is a stupid argument of a stupid person.

It gets worse.

What are these evil toxins?  And where is the evidence that these purported toxins actually cause this laundry list of diseases (including autism, of course)?  He never specifies.  He only makes these vague statements with absolutely no facts to back them up.  And if you thought this was really bad already, it's about to shoot straight down the conspiracy theory tin-hat rabbit hole with extreme alacrity.

I read this passage with my mouth literally agape.  HOLY FUCKING HELL, HE JUST WENT THERE.  I had to read it twice just to make sure my eyes were not deceiving me.  Of course he uses the typical antivax approach of "just asking questions", which makes it on the surface look like he isn't actually saying that vaccines cause autism, but it is EXTREMELY clear that he IS saying that vaccines cause autism.  He says he is not going to debate it, but there's one problem: EVIDENCE ISN'T A DEBATE, JACKASS.  The evidence clearly and convincingly shows that there is no link between autism and vaccines.  I've talked about that too many times to count here, and I won't do it again.  How does a board certified family practitioner not know this?  He claims he isn't going to debate it, but in the very next paragraph:

There.  Right there.  There is no other way to interpret that other than "Dr. Daniel Niedes believes vaccines cause autism".  But he's not done.  He goes on to the next antivax gambit about why we give Hepatitis B vaccine to newborns.

Sigh.  Exposure to the Hep B virus is unlikely, but it is not impossible, and we have a vaccine that can prevent it.  Why take the risk?  The shot is very safe, and it could prevent a horrible disease.  And what is this bullshit about "immunity may not last"?  Really?  I guess Dr. Niedes missed this article last year in the very obscurely titled JOURNAL OF INFECTIOUS DISEASE which shows quite clearly that the Hepatitis B vaccine offers immunity for at least 30 years (I say "at least" because that's how long the study has been ongoing).  Doctors who take care of children (like Daniel Niedes) need to stay up with the latest research, and Dr. Niedes clearly has not.

He then detours to a slightly less insane place, talking about eating better, avoiding unsafe food ingredients, and self education.  These are all things that no rational person could possibly disagree with.  I thought he might end on a high note, but my hopes were immediately dashed:

OH.  MY.  GOD.  He did NOT just reference Food Babe.  NO HE DID NOT.  I can't.  I can't even.  There are just no words.  I just . . .

NO.

Almost as disheartening as the bullshit piece itself is the comment section.  Way too many people believe that Dr. Niedes is a hero for "standing up" to mainstream science and medicine and voicing the opinion that they all hold.  This is the very definition of confirmation bias - they read that an actual doctor shares their opinion that vaccines and TOXINS are evil, and this reaffirms their belief that vaccines and TOXINS are evil.  Facts don't matter, evidence doesn't matter, data doesn't matter.  All that matters is that this real doctor at a real institution with a really prestigious name agrees.

For their part the Cleveland Clinic has disavowed the article and has promised "appropriate disciplinary action", whatever the hell that means.  And Dr. Niedes has since apologised for the piece (which will accomplish exactly fuck all), and said:

"I apologize and regret publishing a blog that has caused so much concern and confusion for the public and medical community. I fully support vaccinations and my concern was meant to be positive around the safety of them."

Confusion?  There's no confusion whatsoever, Dr. Niedes.  You can stomp around and claim to be pro-vaccine all you like now that there has been a firestorm of backlash against you and your institution, but your words have definitively proved otherwise.  

But in 2017 words cannot simply be withdrawn.  The proverbial cow is out of the proverbial barn, and the internet never forgets.  Just like with Andrew Wakefield's original bullshit Lancet article in 1998 that was subsequently withdrawn for being the elaborate fraud it was found to be, the damage to public health is done, and I have no doubt it will be long-lasting.  Antivaxxers for years to come will hold up this ridiculous piece as the proof that they need that they are right and scientists, immunologists, paediatricians, infectious disease doctors, the World Health Organisation, and every single major medical association on the entire planet are wrong.

In closing, I have one simple question for Dr. Niedes: Do remember that basic tenet of medicine that every medical student on Earth is tought, primum non nocere?  Well today, you caused harm.  A lot of it.  Children will literally die if their parents believe the stupid bullshit you spewed and choose not to vaccinate them.  Not a lot of them, thanks to modern medicine, that same modern medicine that you chose to denigrate with extreme prejudice.  But some inevitably will.

And in this day and age, just like your bullshit-filled column, any death from a vaccine-preventable disease is absolutely inexcusable. 

Telephone

Few inventions in human history have revolutionised communication more than the mobile telephone.  Actually, very few inventions have revolutionised anything the way the mobile has.  Ok, computers of course.  The internet, of course (I mean, how else would we be able to waste hours of our lives watching funny cat videos?).  Even as recently as 15-20 years ago, if someone wanted to get in touch with a doctor, it would mean sending a phone number to either an answering service or a pager and waiting to get a call back.  And waiting.  And waiting.  In 2017 however, nearly everyone has a mobile phone and is easily and immediately accessible from all over the world.  Myself included, unfortunately.

Since I am always so easily reachable, why the FUCK was I called multiple times by multiple different people at midnight about some stupidly ridiculously bullshitty bullshit that could (and should) have been easily cleared up well beforehand with one simple phone call NOT placed to me?

Deep breath.  Deep cleansing breath.

Exhale.  I'll explain.  Just as soon as I finish washing this radiologist's blood off my shirt.

Leonard (not his real name™) was an extremely pleasant though unfortunate 75ish year old man who had multiple medical problems, including a stroke several years ago which left him permanently confused.  His wife, who was equally pleasant and was able to answer all my questions for him, brought him to the hospital after he started vomiting uncontrollably.  Despite the fact that the janitor probably could have diagnosed his massive inguinal hernia from two rooms over, the emergency physician decided to forgo an actual physical examination and ordered a CT scan instead (or so I must assume).  Not surprisingly (read: entirely predictably), the CT showed a huge right inguinal hernia (SURPRISE!) which contained multiple loops of small intestine in his scrotum (SURPRISE!) which was causing a bowel obstruction (SURPRISE!). 

Not really.

credit: CHOP

When I saw Leonard about 30 minutes later, he looked uncomfortable and nauseated but in surprisingly very little pain.  Severe pain can be a sign that the hernia is either incarcerated (i.e. cannot be reduced back into the abdomen) or worse, perforated.  Fortunately I was fairly easily able to push the entire segment of small intestine back into his abdomen where it belonged, leaving his scrotum looking like a big floppy deflated balloon.  If you've never done this, and I suspect the vast majority of you have not, I strongly encourage you to try it sometime.  It's very satisfying.  Really.

Anyway, I watched the hernia for a few minutes for any recurrence, and his intestine stayed put.  Ha!  Victory is mine!  Take that, Call Gods!  Leonard would still likely need surgery for his huge hernia someday, but not today.  I explained the situation to Leonard's wife, who was very appreciative and thankful, and I strutted away feeling very smug and self-satisfied.

I was called first thing the next morning that the hernia was back, as was Leonard's nausea and vomiting.

Damn you, Call Gods.

When I went to see him, his hernia had indeed recurred, and though I was able to reduce it again easily, it came right back out immediately.  Damn.  Damn damn. 

Despite the fact that he was not exactly an ideal surgical candidate, Leonard would need an urgent (though not emergency) operation after all.  The cardiologists saw him that day and optimised him for surgery as best they could, and Leonard's hernia repair the following day went very smoothly, surprisingly so.  His postoperative course over the next 2 days was not unexpected as his nausea persisted.  It would pass, though.

Or so I thought.

Unbeknownst to me, his internist ordered another CT scan of his abdomen and pelvis that night due to his persistent nausea.  And just after midnight, the calls started pouring in.

"Uh, hi Doctor Bastard (not your real name™).  I'm the intern on the medical service taking care of Mr. Leonard.  I just got a call from the radiologist that his hernia has perforated."

He . . . wait, his what did what?  He doesn't have a hernia anymore because I just fixed it.  I tried to extract some more information from the intern (like what the patient's exam and vitals were), but she was flustered . . . and hadn't actually examined him.  Naturally.  As I was trying to get this information, the internist called me with the same note of panic in his voice.

Since I happened to be in the hospital for trauma call, I immediately logged on the computer and looked at the CT report.  Sure enough, the radiologist (henceforth to be known as Dr. Dumbass) had read a perforation of bowel in the hernia sac with fluid and air in the scrotum, and he recommended an immediate surgical evaluation.

For the non-surgeons out there (which, presumably, is all of you), air and fluid is normal in an area on which I just operated.  In fact it would be abnormal not to have air and fluid in the scrotum at this point.  Regardless, my Inner Pessimist started yelling and cursing profusely at me.

"Your hernia repair failed already, dummy!  It came back, and now it's perforated!  You suck!  Go see him!  NOW!"

For once I obeyed my Inner Pessimist and went to see Leonard.  He was lying very comfortably in bed, his vital signs were all rock stable, his abdomen was benign, and his scrotum, though definitely swollen, had no sign of bowel in it.  Hmmm.  I then ran (as fast as my legs decided to go at midnight) to the radiology department to look at the CT scan, and what greeted me didn't surprise me one bit.

The scan looked absolutely fine for someone who had just had a huge inguinoscrotal hernia repair 48 hours prior.  The oral contrast he had drunk had made its way through the entire small intestine, the dilation of his intestine from the obstruction had resolved, and he had exactly ZERO intestine in his groin or scrotum.

My Inner Pessimist was suddenly and noticeably silent.  I like to imagine he went off to a corner somewhere to sulk and find something I actually had screwed up.

I called back the internist first followed by his intern to reassure them that Leonard and his scrotum were both fine, and I told both of them that that was an extraordinarily irresponsible read by the radiologist.  All Dr. Dumbass (surprisingly not his real name™) had to do was make one simple phone call to the nurse, the intern, his GP, or to me (or he could have taken one look at the notes in the medical chart) to find out that Leonard had just had hernia surgery 2 days prior, and this fiasco would never have happened.  The intern assured me she would let the radiologist know, and I went back to bed, visions of plotting the radiologist's torture dancing in my head.

The rest of the night was gloriously quiet (except for a drunk assault victim at 4:00 AM), and I awoke to find a little gift in Leonard's chart: an addendum by Dr. Dumbass stating that there was in fact no bowel in his scrotum (shocking), and the air and fluid was compatible with his recent surgery (shocking).

I decided to take the sharp pincers off the torture instrument set I had assembled in my mind for Dr. Dumbass.  Everything else remained.

Leonard went home later that day feeling much better.  I told his wife about how Dr. Dumbass scared the shit out of everyone and given me a minor heart attack.  She had been equally frightened, but she made sure to tell me how thankful she was for everything I had done.  In fact she was so nice, I decided not to tell her about the torture I had planned for Dr. Dumbass, most of it with a rusty spoon.

Though now that I think about it, maybe I'll call her and tell her about it.

New organ?

I saw this headline a few days ago, and as I waited 4.294 seconds (I counted) in extreme antici...pation for the page to load (goddamned WiFi), I couldn't believe what I was seeing.  As a surgeon it struck me firmly in the gut (pun fully intended).  Another organ?  In the abdomen?  What the hell have I been missing for the last {redacted} years??  Holy shit, what have we ALL been missing?

I felt like the worst surgeon in the world.  I've been in the abdomen countless hundreds of times, and I know all the organs in there like the back of my hand.  Or so I thought.  Those 4.294 seconds ticked by interminably, which gave me enough time to tick off all those well-known organs in my head:

• stomach
• diaphgram
• small bowel
• colon
• rectum
• appendix (fuck you, appendix)
• omentum
• spleen
• liver
• gall bladder
• kidneys
• urinary bladder
• mesentery
• peritoneum
• pancreas

So what is it?  WHAT IS IT?  GODDAMMIT WHAT IS IT???  What is this new organ that Italian researchers just discovered???

It's . . . the mesentery.

Whomp whomp whoooooooooomp.

The page finished loading, and I read with some degree of incredulity that this brand new organ was, in fact, an organ which doctors, researchers, and anatomists have known about literally for centuries.  The description of the supposed discovery was somewhat confusing, stating that we thought the mesentery was multiple separate entities (no, we didn't), which is why it wasn't really considered an organ (yes, it was).  One particular bit, however, left my mouth literally ajar:

Although its function is still unclear, the discovery opens up “a whole new area of science,” according to J Calvin Coffey, a researcher at the University Hospital Limerick who first discovered it.

Wait wait wait, Coffey discovered it?  Then what the hell is this drawing by Leonardo da Vinci from 1452?

Now admittedly I'm no art expert, but that sure looks to me like a depiction of a continuous mesentery, which is oddly consistent with what we've known for over 500 years.  And what's this bullshit about not knowing the function?  What??

The mesentery suspends the entirety of the bowel (both small and large) and keeps it in place, preventing it from twisting on itself.  If the mesentery is too long or doesn't form properly, the bowel can twist about its blood supply, causing something called volvulus.  No, despite what you may have seen on House, MD, the intestines do NOT look like a continuous sausage link.  If you happened to miss that episode, no it was not lupus.  It's never lupus.

Not only that, the mesentery also contains the intestine's blood supply and lymphatic drainage.  Whenever I need to remove a section of bowel (for cancer, knife holes, or anything else), I also must remove the portion of mesentery that supports it.  Imagine if I were in there and encountered this brand new organ I'd never seen before and had no idea what function it had.

"AH!  What the hell is that?  Should I remove it?  Keep it?  What do I do?"

No.  Just, no.

The mesentery is NOT a new organ, it is NOT mysterious, and we DO know exactly what it does.  Unfortunately a quick search for "new organ" will generate countless sites all reporting the same shit.  File this under Fake News.  

Way to go, news outlets.  What a way to ring in 2017.  God damn it.