Expect the unexpected

Apparently Heraclitus of Ephesus was the first to say something to the effect of "Expect the unexpected", though his exact words were more like "He who does not expect will not find out the unexpected, for it is trackless and unexplored" which sounds much more "Greek philosopher"-ish and less "David Avocado Wolfe meme"-ish.  Regardless, I've always thought this phrase stupid and meaningless, because how can you expect the unexpected?  If you expect it, then it isn't actually unexpected, is it.  What a stupid adage, almost as stupid as "YOLO", am I right?

When I was younger I used to think that was just me being even more pedantic than usual.  But then I became a trauma surgeon and learned what "unexpected" really means.  It was then that "Expect the unexpected" took on a whole new meaning.

A "typical" trauma day for me will involve somewhere between 5 and 20 patients, most of them lightly-to-moderately injured (abrasions, lacerations, contusions, perhaps a broken bone here and there).  These are folks who need X-rays more than a trauma surgeon, at least initially.  Perhaps 10% are severely injured, and 1-2% have truly life-threatening injuries.  So on any given call day I can usually expect one or two "Level 1" traumas who need my immediate attention.  So you can imagine my surprise when the first 4 trauma patients who rolled into my trauma bay one recent Saturday were all Level 1s.

Fuck you, Call Gods.

The first patient was a middle-aged drunk man who was stabbed in the chest multiple times (at 9 o'clock in the morning?  Really?) but only had superficial injuries.  This story is not about him.

The second was a young man who was stabbed in the abdomen and left arm (at 10 AM?  Fucking really, Call Gods??) and had multiple lacerations to his small and large intestine as well as the left brachial artery and required a laparotomy, resection of the small intestine, repair of the colon, and repair of the brachial artery.  This story is not about him either.

The third was a teenager who was shot in the thigh (at noon?  Seriously, what the fuck, Call Gods??) and had a broken femur which required surgical fixation.  Nope, this is not about him.

The fourth guy, on the other hand . . . yeah the fourth guy threw everyone off.  I bet at this point even the Call Gods were tired of playing the same goddamned joke on me.

I was already exhausted and ready to go home by the time Quinton (not his real name™) was brought in at 1 PM (only 19 more hours to go!).  "Hi everyone, this is Quinton.  We found him on the side of the road.  Looks like he was hit by a car.  Got an abrasion on his left shoulder, looks like his face landed on a stick.  His left eye is, well, it's just missing.  He's unresponsive, not moving anything for us."

The road they found him near is a high-speed road, so everyone immediately jumped into action knowing that he had been suffered a high-velocity, high-energy strike.  The potential injuries were vast - literally anything could be injured.  Since the anaesthesiologist was intubating him, I started at his feet and made my way up.  His feet and legs were fine.  Pelvis, stable.  Abdomen was soft, flat, no obvious injuries, ultrasound negative for blood in the belly.  Chest was stable, no obvious rib fractures, breath sounds were equal.  His heart was beating a bit fast, but the sounds weren't muffled, so I doubted a blunt cardiac rupture.  Arms and hands were normal.  His neck looked normal.

And then I got to his head.  His left eye wasn't missing, but it wasn't normal either.  The globe (eyeball) was ruptured, presumably from the stick he had landed on.  I didn't so much care about the eyeball - while that injury looks seriously bad, you can live without an eye.  His scalp had some matted dried blood in it which made evaluation of his scalp impossible.

With his airway secure and his vital signs stable, we got a quick X-ray of his chest (normal) and pelvis (normal) and went immediately to the CT scanner.  When a scan is done, the tech first shoots a "scout" film, which is essentially a plain X-ray of the body part to be scanned.  The tech shot the scout intending to set up for the scan then said something entirely unexpected:

Tech: Um . . . there's a bullet in there.
Me: Wait, there's a what??
Tech: No wait, I was wrong.
Me: Whew.
Tech: There are two.

I looked at the screen, and sure enough there was a bullet sitting right in the middle of his head and another one in his face.  Uh . . . what?  I had assumed he had suffered a high-velocity, high-energy strike, but this wasn't exactly what I had in mind.

The CT images came through a few seconds later, and to say I was surprised would be a drastic understatement.  That matted blood on his scalp was hiding a gunshot wound and underlying skull fracture with a large haematoma in his brain, with the bullet coming to rest in the soft tissue of his cheek.  The second bullet had apparently gone through his eyeball and lodged in the middle of his brain.  There was severe swelling of his brain and transtentorial herniation.  If that sounds bad, it's probably even worse than it sounds.

It takes a lot to surprise me, but that SURPRISED THE HELL out of me.

About an hour later Quinton was in the operating theatre with one of my neurosurgery colleagues, despite the fact that we both knew any aggressive treatment would likely be futile.  Unfortunately we were both right - it took him two more days to finish dying.  No one ever came to identify him, so organ donation was impossible.

I like to joke that I'm a pessimist and that pessimists get more happy surprises, but in reality surprises in the world of trauma are nearly universally bad.  And expecting the unexpected sure sounds like a great way to avoid surprises.  Sometimes, however, the unexpected is just, well, unexpected.

Education

To me (and hopefully to you), education does not necessarily mean what one learns in a classroom.  Sure, there are plenty of things to learn while sitting and listening to someone with the charisma of an oak tree droning on and on about what some army general 300 years ago did to win some plot of land that doesn't even belong to that country that no longer even exists.  However, practical knowledge is more important than anything else.  Except maths - for fuck's sake, learn your maths.  How else are you going to know how much that sale is saving you?

Anyway, the most educational experience of my life has undoubtedly been in the trauma bay.  There are so many lessons I have learned there through the years, and though I'm not saying you can't learn this stuff elsewhere, I personally would likely never have learned them anywhere else for any reason.  These are pearls of wisdom that I will teach my children and take with me everywhere until the day I take my last breath.

And I'd like to share a few of them now.

Ahem . . .

Donkeys are singularly nasty creatures.

A donkey bite looks shockingly like a human bite. 

Helmets work well, but only when applied to the head.  Corollary: helmets are shit at protecting the face.

Gravel is hard to remove from skin.  

Asphalt is much harder than bone.

Many people underestimate gravity.

Trucks have the capacity to move out of the way.  Trees don't. 

Untreated schizophrenia is fucking terrifying.

PCP intoxication can look surprisingly (and terrifyingly) like untreated schizophrenia.

People will deny anything, even something glaringly obvious, for any reason.

Your dog will eat your foot if it gets hungry enough.

A bag of drugs can be hidden in literally any bodily orifice.  If one is not available, a new one can and will be created. 

Power tools can explode. 

People will lie, cheat, steal, beg, plead, wheedle, cajole, bargain, debate, and negotiate for a prescription for narcotics that they don't need. 

Children who have parents that don't give a damn will do stupid things at 2 AM.

Percocet can be a gateway to heroin. 

Holding your baby in your arms will not necessarily stop a pissed off ex from shooting or stabbing you. 

Jealousy is apparently a good enough reason to stab someone in the heart. 

A hammer can be just as lethal as a gun.  So can a deer.

There truly is no limit to the depth of human stupidity.

---

Now I fully realise that last lesson can be learned by anyone in nearly any field.  Everyone has stupid stories to tell, many of them hilarious in their absurdity.  But the difference is that only in very few occupations can your stupidity kill you.  Or others.

Continuity

Studies show that . . .

Wait wait wait, I didn't come here for a "Studies show that" article goddammit, I came here for a stupid patient story, Doc!  What the hell are you on about this time?

Wow, three whole words before I lost you.  I think that's a new record.  Yeah, there's a stupid patient story here, but I need a bit of a setup, ok?  Just shut up and listen.  Or read.  Or whatever.

Studies show that . . . still with me?  Good . . . many errors that occur in hospitals are due to miscommunication, especially between doctors during handoffs and/or signout.  When one doctor (or team of doctors) goes off duty and another comes on, the communication between the two is crucial - it must be clear, concise, and complete.  There have been studies done which show that standardised handoffs reduce these errors, and the gist of the article is as follows: fucking duh.

Even better than standardised handoffs, however, is continuity of care: the same doctor taking care of the same patient no matter what.  In the world of outpatient internal medicine, this is fairly simple - you see your doctor when you have a problem, you don't go to different doctors for the same thing, because that's where problems are born.  In surgery, however, continuity is much, much rarer, and in trauma it is nearly unheard of.  Most people don't suffer severe traumatic injuries more than once, and if they do the likelihood that they will be brought to the same trauma center where the same trauma surgeon just happens to be on call is close to zero.  Close to zero, but decidedly not zero.

I'm sure you see where this is going.

The Call Gods reared their heads recently when I received a bicyclist who crashed, striking his head and losing consciousness.  Fortunately he was wearing a helmet, but as good as helmets are at protecting the brain, they are shit at protecting the face.  Jonah (not his real name™) went face-first over his handlebars into the gravel, and he suffered a fractured nose and several lacerations near his left eye.  As I was suturing him, he happened to mention that he had a similar bicycle accident about a year ago where he broke his clavicle and ultimately required surgery.

Dun dun DUN

I am terrible with names and almost as bad with faces, not to mention the fact that I see several hundred trauma patients a year (and the fact that Jonah at that moment would have been unrecognisable to anyone but his mother), but after I was done suturing, a quick look through my list of patients told me that yes indeed, I saw Jonah last year after his most recent accident.  I didn't feel too bad about not remembering him, because he didn't remember me either.

But the Call Gods weren't done.

A few days later I was evaluating Tomas (not his real name™) who had stolen a motorcycle (but not the helmet) and had crashed into a truck.  Heads are significantly softer than asphalt, and when his head hit the pavement (or maybe the truck, I suppose) he suffered a subdural haematoma.  I was staring at the computer screen scrolling through his images when his family came into the trauma bay to see him.  And that was when I heard a rather familiar voice from Tomas' bedside:

"Hey!  Hey, Doctor Bastard!"

Normally I get critically annoyed when someone yells at me from the trauma bay, but I knew that voice, and I knew the certainty with which he repeated my name.

I looked up with a big smile and saw Mikel (still not his real name™) with an equally huge smile on his face.  Mikel, you may recall from a previous post, was shot in the abdomen and required emergent surgery to repair approximately 194 holes in his small intestine.  His injury had been severe and life-threatening and his recovery had been swift and uneventful, but his attitude had been, and still was, incredibly positive.

And he happened to be Tomas' older brother.

Mikel did nothing but grin (as did his mother) as he vigorously and firmly shook my hand and recounted his hospitalisation and subsequent recovery.  He was back to work with essentially nothing but a big scar on his abdomen to remind him of his near-death experience.  He thanked me profusely (again) before asking him to take similar care of his little brother.

That is a different kind of continuity altogether.

And if you're wondering if Tomas had an attitude as positive and inspirational as his older brother, I hate to be the one to dash your hopes for humanity against the rocks, but fuck it, I'll do it anyway: hell, no.  He walked out of the hospital against medical advice at midnight while no one was watching three days later.

Actively dying

I have a confession: most of the patients I see are not actively dying, and I'm not a superhero.  I'm sure that will come as a shock and disappointment for some of you, but I cannot sustain this facade any longer.  But sadly it's true; the vast majority of the victims I see in my trauma bay are lightly injured at most, and some are completely uninjured (other than their pride, perhaps).  Car accidents, falls, assaults, even gunshot wounds and stabbings - most of the people I see are sent home from the trauma bay without even spending a night in hospital.  Those are the people I don't write about, because who the hell wants to read that dreck.

On the other hand, there are some who come in dead and stay dead.  Despite my best efforts and plenty of practice, my resurrection skills remain poor.

And THEN there are the ones at death's door.  These are the ones we feel really good about, the ones we talk about over coffee the next morning, the ones I write about.  They are the patients that give me pause, that make me stop and think, "NOW THIS is why I went into trauma."  They are the ones who make the commitment, the loss of time with my family, and the sleep deprivation totally worth it.  These are the "Great Saves".

Bosley (not his real name™) was a Great Save.  Except that I didn't save him.

"Hey Doc, if you didn't save him, why are you writing someone else's story?  Isn't that even more arrogant than usual for you?"

Didn't your mother ever tell you what happens when you make assumptions?  Something about U and umptions.  I don't remember.

Anyway, the story we got from the ambulance crew as Bosley was en route was strange enough, but it only got stranger after he hit the door.  We were told that Bosley was the driver of a car that ran into a building, which happened to be a chemist/apothecary/pharmacy/drug store.  Coincidence?  Perhaps, but perhaps not.

Hm.  Strange things are afoot.

By the time the ambulance got to us about 10 minutes later (just before midnight), Bosley was awake and talking, though something was definitely off.  I couldn't tell exactly what it was, but he just Didn't Look Right.  The medics were acting rather cavalier, however, clearly playing off the whole "trauma" thing as nonsense.

"Hey there everyone, this is Bosley.  He's 72, healthy, never sees a doctor.  He was on his way to the drug store tonight to pick up some medicine for a stomach ache when he hit the wall of the building, low speed, basically no damage.  But he lost consciousness, so with that and his age, we made him a trauma.  No sign of trauma on him, though.  Probably just fell asleep at the wheel, right Doc?" he concluded with a grin.

No.  A quick glance at Bosley told me that was not right.  Though he was awake he looked awfully pale, and he was a bit sweaty despite it not being very warm.  When he was hooked up to the monitor, however, his vitals were all completely fine - heart rate of 71, blood pressure 121/70, oxygen saturation 98% on room air.

Hmm.

The nurses started disrobing him and asking his medical history.  He had no medical problems, no prior surgeries, took no medicines on a daily basis, no allergies, doesn't drink, smokes 1-2 packs of cigarettes a day since he was 17.  Hasn't seen a doctor in 45 or 50 years.  I started my cursory secondary survey, trying to find any body part that hurt.  His head was fine, neck was fine, chest was fine, arms and legs were fine.  But when I pushed on his abdomen, I got a bit of a grunt in return.

Hmmm.

I asked him how much it hurt when I pushed, and he replied, "Not that much, Doc.  But it's been hurting me all day.  That's why I was going to get some medicine, to try to settle my stomach.  It hurts in my back, too."

Hmmmm.

"And I passed out in the parking lot.  That's why I crashed."

Hmmmmm.

Unfortunately it was right about this time when we got two walk-in stabbing victims.  Well, that's not exactly true.  Only one of them walked in, while the other had CPR in progress.  I didn't get a chance to examine Bosley more carefully like I usually do, but I glanced at his monitor as I rushed out to try to save the dead patient and saw that his blood pressure was steady at 120/75 and his heart rate was 68.

Good, I thought.  He's stable.  His CT scans should be done by the time the dead guy finishes dying.

It took me about 20 minutes to discover that the dead guy was dead because the knife had created a big hole in his left pulmonary artery (which is generally regarded as a Very Bad Thing), and as soon as I pronounced him dead I ambled over to the CT scanner to look at Bosley's scan.  The tech flashed through the pictures quickly, and something caught my eye.

WHAT THE FUCK IS THAT IN THE MIDDLE OF HIS ABDOMEN??

I took control of the computer's mouse and scrolled through at a more human pace, and what greeted me was a huge (and I mean FUCKING HUGE) abdominal aortic aneurysm.

Not actually Bosley's huge fucking AAA

It doesn't take a radiologist to see THAT LOOKS BAD.  That huge white thing in the middle of the abdomen is an abdominal aortic aneurysm.  In layman's terms, the main artery that supplies blood to the entire body was dilated to approximately 5 times its normal diameter, and it was surrounded by blood that had leaked out of a hole.

Let me repeat that in case the gravity hadn't set in: the aorta had a big fucking hole in it and was leaking.

Bosley didn't know it, but he was actually in danger of dying at any second.  He was literally a figurative time bomb that could literally explode at any moment.  Literally.

And just in case you think I'm being hyperbolous (why the hell isn't "hyperbolous" a word?), I grabbed the radiologist and dragged him over to the screen.  This was his exact reaction:

Oh.  OH!  Oh, oh wow.  Oh, uh that's bad.  That's really bad.  That's a ruptured AAA with a huge retroperitoneal haematoma.  He needs to be in theatre.  Wow.  Just make sure you MOVE HIM REALLY CAREFULLY.

The aneurysm had nothing whatsoever to do with the car accident but rather had been slowly growing over several decades and was related to his smoking and untreated high blood pressure and general lack of medical care over 70+ years.

Eighty two seconds later (I counted) I was on the phone with the cardiovascular surgeon on call, and 29 minutes after that (you're damned right I counted), he was standing next to me looking at the scan, and Bosley was waiting for him in front of the operating theatre.

His aortic aneurysm repair was completed about 4 hours later just as I was finishing an exploratory laparotomy and right colon repair for yet another stabbing victim that came in about two hours after Bosley did (of course).  He stayed in hospital for about 2 weeks before going home with several new prescriptions for high blood pressure and diabetes, none of which I suspect he will take.

It was a great save, it just wasn't mine.  Actually now that I think about it, Bosley's car accident saved his life.  If he hadn't crashed and had simply passed out at home, his neighbours would have probably found him dead on his floor several days later.

Well, I must be off as it's time for my resurrection practice.  Now was that wave the left hand twice and then pronate the right while incanting, or . . .

Shit.

Charlie

I'm sure many of you know exactly to whom the title of this post refers.  For those of you who don't, I'll give you a hint: Charlie isn't a patient of mine.

Figured it out yet?  No?

Several people have emailed to and/or tweeted at me (I still hate that I tweet "at" people.  It seems violent somehow.), wondering why I haven't blogged about Charlie Gard yet.  Well, I haven't done any request posts in a while, so you people are finally getting your wish.

For those of you who have no idea about whom I'm talking, I'll give you the short short version.  Charlie Gard is a wee British lad who was born with an incredibly rare genetic disorder called mitochondrial DNA depletion syndrome, in which there is a drop in mitochondrial DNA in affected tissues (muscles, brain, and liver).  The affected cells can't produce the ATP they need to survive, and it typically results in death in infancy or early childhood.

As if that weren't bad enough, Charlie was unfortunately diagnosed with an incredibly rare variant of this incredibly rare disease, called RRM2B-related mitochondrial disease.  There are only 16 reported cases of this variant, and all of them have died in infancy.

Like all children with this disease, Charlie seemed like a healthy, normal boy when he was born last August, but he missed some developmental milestones, so his parents took him to the hospital when he was two months old.  Since then he has been on a ventilator, unresponsive and unable to move.  Ever since his parents received the devastating diagnosis, they have been in a legal battle with the hospital over how to treat Charlie - A) continue with aggressive treatment, or B) stop fighting and let nature take its course.

Sigh.  Here we go again.  Another tragic story of a child taken too soon.

Charlie's parents aren't ready to let go, and it seems they have been in and out of the courts every few months.  An American neurologist (who still has not been named) has averred that Charlie is in the terminal stages of his disease, but he has offered an experimental treatment called nucleoside bypass therapy, which has never been used for RRM2B (though it has had some success with a less-severe variant called TK2) and reportedly costs £1.2 million.  His parents set up a GoFundMe account that raised more than the required amount, but Charlie's doctors at Great Ormond Street Hospital argued that the therapy is untested and has risks that would outweigh any potential benefit.  In April 2017 the courts decided that the hospital could turn the ventilator off and let Charlie pass in peace.

Undeterred, Charlie's parents kept fighting.  They took the case to the Court of Appeals, which upheld the initial ruling in favour of the hospital.  The Supreme Court then heard the case, which again upheld the ruling.  They took it all the way up to the European Court of Human Rights, which just a few days ago upheld the ruling yet again.

Since the ruling, a children's hospital in the Vatican has offered to take Charlie in as has an American hospital, but his doctors have refused to allow him to fly.  Prime Minister Theresa May has agreed with the doctors, and Charlie remains at Great Ormond.  Charlie's parents have since asked his doctors to discharge him, so that he can die at home in his crib with his parents.  But he still remains where he has been for nearly his entire life.

If this is all sounding familiar to you, then you're probably aware of the similar case of Jahi McMath.  However, the two stories differ in one major way.  But how?  After all, just like Jahi, Charlie can't move, he can't cry, he can't eat, he can't even breathe on his own.  Right?  So what is this major difference?

Unlike Jahi, Charlie can feel pain.  That makes all the difference in the world (in my mind, at least).  Charlie has the capacity to feel discomfort from the pokes and prods, the uncomfortable feeling of a ventilator pushing air into his lungs every few seconds, endlessly.  And with no capacity to improve.  Ever.

But just in case you thought this was a mundane story, it doesn't stop there.  Oh, no.  Donald Trump, of all people, has thrown his hat into the ring.

If we can help little #CharlieGard, as per our friends in the U.K. and the Pope, we would be delighted to do so.

— Donald J. Trump (@realDonaldTrump) July 3, 2017

I'm not sure what Trump thinks he can do for Charlie, but I don't think a spray tan would help.

So . . .

With that very long-winded summary of the past 10 months of Charlie's life, I address the requests I've gotten, all of which have been essentially the same - "Doc, please weigh in on Charlie Gard!"

Well, you asked for it, so here goes:

I agree with everyone, and I disagree with everyone.

Thanks everyone, goodnight!

. . .

Ok, ok.

But seriously, I can honestly see everyone's point of view, and there is absolutely no good answer.  On the one hand, the doctor in me sees the futility in any attempted heroic effort, coupled with the fact that Charlie can feel pain though has no way to express it.  On the other hand, the father in me wants the parents to fight for every minute they have with their son.  But on the other hand . . .

There is no other hand.

The sad fact is that Charlie has a universally fatal and incurable disease.  The proposed treatment in America is experimental at best, has only been used a few times on a related disorder with modest success, and has never been used on anyone with such an advanced case.  There is no reason to think it will be able to reverse Charlie's terminal case, and every reason to believe it will simply cause him to endure his pain longer.  However, I can see no reason why the hospital would deny Charlie's parents' request to let them take him home.  They should at least grant them that one final wish.

I can't really say what I would do in this situation.  I'd like to think that my rational side would take over and let my child go peacefully, but just like I tell my patients, I can't guarantee it.  How can anyone think they know what they would do with such an impossible quandary?  What I can guarantee, however, is that any bullshit offer from Donald Trump would be unabashedly and vehemently rejected with alacrity and aplomb.

I welcome any respectful comments and suggestions.  Tell me I'm wrong, tell me I'm right.  Just keep it respectful.