Changing my mind

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

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

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

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

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

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

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

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

Sigh.  Straight to the operating theatre.

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

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

65.

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

Hmmm.  My mind seemed to be changing.  

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

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

Mind.  Changing.  Again.

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

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

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

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

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

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

Instant dislike

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

How is that even possible?

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

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

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

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

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

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

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

Ouch.

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

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

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

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

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

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

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

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

"Ow!  My teeth hurt!"

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

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

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

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

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

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

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

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

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

No, I did not like Charlene.

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

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

Names

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

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

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

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

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

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

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

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

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

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

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

Not really.

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

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

It was more than just a bit unnerving.

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

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

Humpty Dumpty was back together again.

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

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

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

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

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

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

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

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

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

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

GOD. DAMN. IT.

Call Gods are weird

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

1) Yeah, we fucking get it, Doc.  Call Gods.  Get over it!

2) There are no such things as Call Gods!  It's pure coincidence.  Get over it!

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

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

"THEY. ARE. REAL."

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

What, you want examples?  I thought you'd never ask.

A few months ago I had a relatively slow day, only 8 patients over the whole shift.  It was typical stuff, mostly car accidents, a fall, and one gunshot wound.  However, in that mix of patients I had two patients who had suffered one injury and one injury only; one of the two had fallen down stairs, the other was shot.  But both had just one body part hurt.  Only one.  What body part?

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

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

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

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

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

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

Always.