Tuesday, 20 June 2017

Too old

I'm sure everyone reading this has heard the adage "Age is just a number".  To most, this aphorism means that you're never too old to have fun.  To a trauma surgeon, however, it sounds like an excuse for older people to do stupid shit that should be left to younger idiots.

Now before anyone accuses me of being "ageist" or something, just stop a minute and think.  Is it "ageist" to expect a 20-year-old kid to understand how the world works?  No, of course not.  Young kids just aren't old enough and therefore don't have the necessary experience.  That's why we (generally) don't elect 20-somethings to elected office; they just don't know any better.  On the other hand, it also is not ageist to expect a middle-aged person to have accumulated enough firsthand knowledge of things to avoid doing seriously stupid shit.  Older people should just know better.

Quincy (not his real name™) should just know better.

I should start by saying that Quincy is not a stupid man, or so I found out later.  That was not the initial impression I got, however.

It was early afternoon on a beautiful bright warm Saturday afternoon when Quincy was brought to my trauma bay in a rather sorry state.  I rarely get the full story from the medics, relying only on rough bits of information.  This case was no different.

"Hi everyone, this is Quincy.  54 years old.  Helmeted rider of a motorcycle, crashed at around 70 kph (about 45 mph).  Brief ell oh see (LOC: loss of consciousness), awake and alert now.  Complaining of severe abdominal pain, right hand pain, left hip pain."

Quincy was mostly awake and mostly alert, and he groaned audibly as he was moved from the gurney to our stretcher.  My Inner Optimist started whispering at me as Quincy was hooked up to the monitors, revealing a heart rate of 120 but a normal blood pressure.  "It's probably nothing.  He's probably just very amped up from the accident is all."

My Inner Optimist is annoying as hell.  And often wrong.

My initial exam showed an open fracture of his right hand and significant tenderness in his left hip.  But what really struck me was his abdominal exam.  He kept pushing my hand away whenever I pushed on his belly, something he didn't even do when I was examining his obviously badly fractured hand.  And when I did push, his rather rotund abdomen felt like a board, and it hurt a lot more when I released pressure compared to when I pushed.

1) Voluntary guarding.  2) Board-like rigidity.  3) Rebound tenderness.  All signs of peritonitis.  Quincy had something seriously wrong inside his abdomen that was killing him, and he needed surgery.  Now. 

I rather gleefully pointed out to my Inner Optimist that he was wrong again. 

Quincy's blood pressure held steady in the normal range for the next ten minutes as he was packaged up and brought down to the operating theatre.  Expecting the worst I made a large vertical laparotomy incision, and I was not disappointed.  What struck me first as I entered his abdomen was the smell of vomit, clear as day.  What struck me second was the lack of BIT (Blood In There).  Something, most likely his stomach, was clearly perforated, but somehow that something wasn't bleeding.  Perforations are bad, bleeding is bad, and the two together are worse.  Perforations without bleeding are still bad, but only slightly less bad.

Starting in the upper abdomen I began literally scooping out handfuls of onions, chicken, and corn (WHY THE FUCK IS IT ALWAYS CORN), reinforcing my assumption that his stomach had a large hole in it.  And when I finally got my hands on it, my suspicion was confirmed - a 7 cm laceration across the fundus and antrum (the lowest portion near where the stomach empties into the small intestine).  I initially controlled it with atraumatic clamps to stop any more stuff from leaking out, and I then fired a stapler across the injury to repair it.  His descending colon also had a partial-thickness laceration which did not penetrate the entire wall (fortunately) which I also repaired.  Nothing else was injured, which explained the lack of BIT.

Normally at this point in a trauma operation I would close and everyone would high-five and congratulate each other for another life saved (not really), but not today.  No, now came the really fun part: cleaning up.  

You would be surprised how large and deep the peritoneal cavity is, so now knowing that you would probably not be surprised how easily and in how many places corn (GOD DAMN IT, WHY ALWAYS CORN) can hide.  Several litres of irrigation later, I was still pulling out bits of . . . stuff ("What is that, carrot?").  This left me feeling wholly unsatisfied that he was clean enough to close, so I didn't.  I created a temporary vacuum closure and brought him to intensive care with plans to bring him back in a day or two, clean him out again, and possibly close.  IF he was clean.

Two days later his peritoneal cavity was surprisingly nearly spotless.  There were only a few partially digested bits of food left, and after irrigating with more litres of saline irrigation, I closed him.

A couple of days later after Quincy was extubated and off the ventilator, I finally got to ask him what I had wanted to know since he arrived: why had he crashed.  His answer was something I would expect from a teenager.

"Well you see Doc, I was showing off to the guys in my motorcycle club, doing a wheelie, and . . ."

"Wait," I interrupted, "you were doing a wheelie?  At 70 kph?  Are you aware you're 54 years old?"

He smiled weakly and laughed even more weakly.  "Yeah, it was probably stupid."

"Probably??"

He laughed again.

I had a very long chat with Quincy and his wife about his recklessness and how he was too old
for this shit.  I could almost excuse this kind of nonsense behaviour with a 20-year old kid (almost) because that's what 20-year old kids do - stupid shit.  But not Quincy.  It turns out he was a highly intelligent, articulate, competent middle aged man who just had a momentary lapse of judgement that nearly ended his life.  Quincy's wife looked me dead in the eye and assured me that his motorcycle was already up for sale at a bargain price.  I suspect it will be sold to a reckless kid who will probably do something equally stupid with it.

But that's probably just my Inner Pessimist talking.

17 comments:

  1. My dad who was a deputy sheriff always called motorcycles suicide machines and refused to ride them. He felt safe in his Chevy squad car.

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  2. so the moral is if we're going to do something totally stupid that causes a ruptured stomach, we shouldn't do it after a large meal?

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    1. A friend, whole a young and stupid college student, was shot through the stomach while walking off a large spaghetti dinner, through a very bad part of town (hence the "stupid" part). The doc who stitched him up told him it took way too long to get all the bits of pasta out of his abdominal cavity.

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    2. *while, not *whole. You would think I'd learn to read before hitting publish...

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    3. I recall from writing classes that it is particularly challenging to proofread your own writing because you know what you intended to type, so you misread what you actually typed.

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  3. I don't think I can ever eat corn again after reading this!

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  4. Lord, I despise motorcycles!!

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    1. You'll be glad of them if you ever need an organ transplant! Given the state of my kidneys, I'm all for healthy type-O males to go around riding overpowered motorbikes.

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  5. Seriously, was there THAT much corn? LOL, hilarious! As a nurse for 20 years I've seen and smelled horrible stuff, but I don't think there's a worse smell than a GI bleed, I know this is different, but good god, I could not have cleaned out all that food, and smelled all that! Better you than me! LOL

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  6. I've never done a wheelie on a motorcycle, but doing them on bicycles as a kid was always fun. Doing one at 45mph is kinda crazy. But I doubt you can get enough lift going much slower than that. All I'm saying is, if you'e an EXPERIENCED biker, doing a wheelie at age 54 shouldn't be any more dangerous than doing one at 24, right? Tom Cruise practically makes his living doing motorcycle stunts. He's never been seriously injured. And he's about to turn 55. IJS...

    Oh & your hand-lathed bowl from your previous post was lovely, Doc. But can't you find a somewhat safer creative pastime to do with your hands, like glass blowing? Or taxidermy maybe? Spinning things near a surgeon's hands just makes me queasy...

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    1. Molten hot glass near you doesnt sound like a good idea either

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  7. Motorcycle victims always seem to wind up with foreign matter in the wrong places. What got to me was when that sliding along the pavement at speed resulted in pea sized bits of gravel and asphalt embedded under their skin. We used acetone on the asphalt and pick ups to yank on the gravel. I wonder if the body armor worn by contemporary cyclists prevents this type of mess.

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    1. you hit the road at that speed and you are going to grind off skin. it can be your own, or it can be some other animal's. the plates in modern synthetic gear has to help spread impact, though.

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    2. I love reading Doc, but I love reading the comments for you Ken. You are always insightful/funny/or kind. Keep up the good work :)

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  8. 13 is bad luck. There.

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  9. Hi Doc, happy thursday.
    I have experienced the Vacuum-Assisted Closure Therapy, well rather my uncle did when he was in hospital for cellulitis in his whole left arm, uncontrolled diabetes and an inguinal sepsis. The cellulitis turned into necrotizing fascitis and he had several ops to removed dead and dying tissue. Whilst all that was going on and he was in ICU, his duodenum felt left out so he got a perforated duodenal ulcer.They sorted that out and all seemed weel, the first week after that op they took out half the staples, the following week he seemed ok so they took the rest out. A few mins later, he said "I don''t feel well" and the wound unzipped. He was a big boy of 22 stone at least. They decided that they wouldn't restaple since it would likely fail and all sorts of infections would join in so they used a negative therapy gizmo. His initial wound was 35x25 cm. Once he got home after 7 months going between hospitals depending on what had gone wrong this time, and rehab, where things often went wrong, he arrived home 10 stone lighter.
    The vacuum was easy to do, changing dressings a doddle once i had seen them do it a few times, i would assist.
    he kept getting blockages or the damn thing would fall out and stink the whole house out. I had a ponder as to how to stop the various blockages and other stuff that would set the alarm going all night and then once i figured out the problem suggested to the distric nurse that changed the dressings (intitally 3x weekly)that if she applied the dressing in this position rather than that position and then the varios other bits and pieces it should stop the issues. It bloody well worked, I are a genius. Once it got sorted the healing was really fast and he went down to a 10x5 wound in a matter of weeks. Since he could never remeber what it was called, we nicknamed it the suckyducky. Within a couple of months the wound fully healed leaving a nice clean scar. it is an amazing bit of kit when it works and when it falls out or doesn't suck it is a bugger.
    I had to open every door and window in my house and then clean everything with bleach and disinfetant to clear the smell. I opened his bedroom doom and it was like walking into a wall of fug.

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