Tuesday, 30 May 2017

Changing my mind

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

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

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

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

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

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

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

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

Sigh.  Straight to the operating theatre.

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

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

65.

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

Hmmm.  My mind seemed to be changing.  

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

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

Mind.  Changing.  Again.

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

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

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

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

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

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

36 comments:

  1. Thanks for sharing this. Thanks again for not deleting it!

    ReplyDelete
  2. So, generally speaking, being fat as f*** is generally really bad for your health, unless you are being stabbed, then it might be a life saver.

    ReplyDelete
  3. So what was going on when your finger felt a void?

    " I could feel my finger going through fat and more fat and then . . . space."

    ReplyDelete
    Replies
    1. I'm not sure how to describe it. You just feel it popping into a space.

      Delete
    2. if I am performing surgery it is usually on non living cellulose based tissue - but I would assume it is much the same - it is not so much what it feels like as what it doesn't feel like - you feel when it is in the tissue, and then the tissue isn't there to feel.

      Delete
    3. I wish I could remember the hand & scalpel feels when I was dissecting a dead cat for my human anatomy lab 9 years ago but at the time, I was too depressed to remember anything (and yes, the diagnostic came a few months after I did the course) which is too bad. I felt in my bubble, taking a lot of care to reveal the inner parts of the cat for the other teammembers to learn (I had to learn it too but couldn't).

      For more context, the sources of the depression was a campaign of harassment citywide in the previous city i lived in which was because of, first, my diagnostic of autism and people's perception that this should prevent me from using public money to attend university. Second reason was that I hosted what turned out to be a psychopath who is directly responsible for the public harassment campaign.

      The end result is that I'm just starting off with a new life and i wish I will be able to use a scalpel in a dissection lab. Couldn't find something I was better skilled at in my life.

      Alain

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    4. Poor cat..it really makes me wonder how they get animals for scientific dissections....do they just grab an otherwise healthy animal and euthanize it to be cut open?

      I had to dissect a baby pig and it was sad. fascinating, but sad. I still remember it was a female pig.

      Delete
    5. Humane societies mostly, 1.5 million animals euthanized every year, down from 2.6 million in 2011.

      Spay or neuter your pets.

      Some other species are specifically bred and reared for research.

      @Takethatsalk

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    6. Already dead cat, usually from car accidents.

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    7. @Takethatsalk: Always, and I only adopt from shelters. The shelters here don't euthanize because of space issues anymore, which makes me so happy!

      I digress.

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    8. I agree, when doing injections or PM's you can feel the difference between tissue and void.
      With IV injections you can feel the needle pop into the vein. There is resistance however slight and then you feel nothing and you are in.
      It is something you learn over time and once it 'clicks' you can hit a running vein at 20 paces :)

      Delete
  4. Your my kind of doctor. Willing to make changes in your treatment plan as information becomes available to you. Your actions saved the patient from being exposed to unnecessary risks that surgery always presents. It makes you look wise and competent.

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  5. Your finger went in deep enough to be concerning but the knife only went in 2mm? Sorry, I don't understand. Could you/someone explain that please? Am I just misunderstanding the text?

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    Replies
    1. I think what docbastard was saying, I'm not a doctor so this is an uneducated guess, his finger went through the knife wound in to a pocket of fat, fat isn't a solid mass per say but lumpy dense yellow tissue (google it, it's gross) and so his finger hit an open space between fatty tissue.. an obese person has masses of that fat collected and so it's hard to tell where it ends and the wall to the interior starts..
      I tried Doc, I'm sorry if I failed you..

      Delete
    2. The knife went into his abdominal cavity about 2mm. But there was a good 7-8 cm of fat between the outside world and the abdominal cavity. I hope that makes Danae.

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    3. Oh, I understand now. Thanks Cali & Doc. :)

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    4. I hope that makes Danae.

      Gotta love autocorrect/typos :)

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    5. What the hell is Danae, and why would it correct to that?

      Delete
  6. *Snickers* Sticking fingers in holes, aren't you glad you're​ not an obgyn? I work around men all day, I can turn anything perverse, the men taught me well.

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  7. "The radiologist actually read the scan as normal and missed the stab wound."

    SERIOUSLY?! Doesn't that qualify is incompetence? Does that kind of thing happen a lot?

    Shit like that is why I'm terrified of ending up in an E.R. anywhere...

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    Replies
    1. It was a very subtle finding, and the only reason I saw it is because I knew exactly where to look and what to look for.

      Delete
    2. If I'm going to get stabbed, I want it to be clean enough that it isn't readily visible to the radiologist.

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    3. I don't want to be stabbed.. Not today Satan!!

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    4. well, yeah, that's the preferred option.

      Delete
  8. you could write the proverbial phone book and it would be worth reading

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  9. Why not start the surgery with a camera in the existing hole instead of a laparoscopy?

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    Replies
    1. No evidence to support surgical management.

      Delete
    2. I think the question was why they would make another incision for the laproscope rather than using the wound for an incision.

      I would expect the answer to be that they want to have a controlled incision for the scope.

      Delete
    3. Exactly--if the question is whether the wound goes all the way through why not stick the scope in it and have a look?

      Obviously, once it was concluded that the wound didn't penetrate there was no need for it.

      Delete
    4. Several reasons, but the main one is that the wound was on the left flank. Putting a scope in there would severely limit my ability to assess anything but the left upper quadrant. There are technical reasons too, but I won't go into those details.

      Delete
    5. Yeah, you would only see the area with the wound. If it turned out that it went through you would have to do it the normal way. I'm just thinking that if you found it didn't go through you don't have to cut the guy at all.

      Thinking about it it seems like what I'm picturing would be the role of an instrument, not something to be done in the OR.

      Delete
  10. just to summarize the opinions of thinking people: it is much better that a person always absorb new information, and be willing to change actions accordingly, than to set a course of action and stick with it despite new information.

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  11. No bleeding. No infection. SNOM.

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  12. This comment has been removed by a blog administrator.

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