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.


  1. I recently had, after almost 20 years of different doctors telling me that it was my weight, a orthopedic surgeon take a MRI of my knee. This revealed the complete tear of my ACL, cysts, torn and misplaced meniscus, muscle tears, and arthritis. I'm only 31 and walking has been painful and difficult since I was 13. Now, a little over a month after my orthoscopic surgery to repair as much of the damage as possible without doing a knee replacement, I'm walking without pain for the most part. I still have some arthritis pain and sore muscles sometimes, but I started my physical therapy within a week and went three times a week instead of just the one or two that was required. The next step is to lose the almost 100 pounds that I gained while living a mostly sedentary life. My surgeon gave me the first step, I have to take the rest on my own.

  2. Oh dear! I really hope he knows that part of his recovery process will involve staying the hell away from that sword swinging EXgirlfriend of his!

  3. Yes, Doc, your job IS incredibly hard. And you are a Rock Star at it. So fist bump your wife, take a bow & Be Deeply Proud Of Yourself. You seem to have far more wins than losses. Since I found this place, I can only remember one case you've written about where you lost the patient -- a young man with a GSW, I think it was. (If you've keeping all the ones that die to yourself, I don't wanna know!) You are damn good at your job. For Terry & all your other saves, that's a VERY great thing.

    1. Thank you, RC. I have my fair share of failures too, a few of which I've shared here.

  4. Thank you, doc. You're an inspiration!

  5. I found this lovely interview with a "Homeopathic Family Physician" while researching healthcare careers, I figured you would enjoy it, Doc.


  6. I'm 65 and facing open heart surgery. Terrified that I won't be able to handle the post op pain and whatever. Not sure where I can get the gumption to go ahead with the surgery.

    1. If the surgery is going to improve the quality of your life the post op pain and work of recovery is worth it. The doctors and nurses will be most attentive and will do everything in their power to make it as painless as possible. There will still be discomfort but don't sell yourself short. I have had 3 back surgeries in 1 year. Last one was a 2 level fusion. Yes it was not easy. It was painful at times. The rehabilitation of myself was hard, hard work. But it was so worth the outcome. Doctors and nurses work so hard to make patients whole again.Throw every thing you have into getting recovered.Thank-you to every doctor and nurse who have helped me. If you make the effort to help yourself they make the effort to help you succeed.

    2. Find an excellent doctor to work with you post-op (this will almost certainly not be the surgeon) and give it all you've got. Don't be afraid to complain about pain and ask for help when you need it. I am guessing you'll be glad you went through with it! My sister in law had open heart surgery, and while recovery was tough it was well worth it, good luck!

    3. Find an excellent doctor to work with you post-op (this will almost certainly not be the surgeon) and give it all you've got. Don't be afraid to complain about pain and ask for help when you need it. I am guessing you'll be glad you went through with it! My sister in law had open heart surgery, and while recovery was tough it was well worth it, good luck!

  7. Doc without people like you my entire family would not be here. It wasn't just one event. It has been several events throughout our lives that a trauma surgeon and a team of nurses have SAVED OUR LIVES! Because each an every time skilled professionals, like yourself, stepped up to the plate regardless of time of day or day of the week and save us. Your skills along with our effort as a patient came together as a winning team each time to make us whole again. My family thank-you an all the medical professionals with all our hearts for saving our lives!

  8. I'm a rather smart guy, or was before declining with a chronic disease. 2 thoughts, or fragments thereof:

    1. I could never do your job, including when I was reasonably healthy.
    Then, I could handle many things. Acute pain? Shock takes care of that, for a while. Hazards? whatever, anything really worth doing can possibly kill you. Open up someone's internal organs and fix things, while NEVER slicing a nerve or artery?? Nooooo! I can't, and would not because I'm the wrong hand for the job.
    Also, _most_ people could never do your job. 80% of the workforce is only interested in how fast they can clock out, how to absorb credit and deflect blame, and NotMyFault when they burn stuff.

    2. No need to be PC. My Mom was a stay-at-home Mom, and it's not exactly hard work. Sure, there's the occasional blast of boredom, there's cans to open (to feed the kid), and removing burnt stuff from the stove, but it's rather easier than any actual job where you have to please your boss.

    I've haven't been half-dead in an ER. Yet. If I ever do I hope it's attended by a doc such as yourself and not one of the new imports!

  9. very interesting article. thanks for sharing it with me.

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