Tuesday 18 July 2017


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.


  1. That is a different kind of continuity

  2. Well, I suppose if you have a son like Mikel, you've probably already won the lottery once. Glad to hear good guys like him actually exist, though...

  3. I have a really good friend whose mother for some reason doesn't believe in doctors or modern medicine? She's always walking out of hospitals against the recommendation of her doctors and it worries me because I can tell that her distrust of medical professionals is rubbing off on her kids. I mean I understand that she's from a different culture and grew up in a different era, but it's just so weird to have the people I went to school with question science.

  4. I have to confess, as far as I can recall, I have had one occasion where I went to the same doctor for two different things. maybe when I was young I had the same doctor for a couple of checkups, but since then, it seems after I've seen a doctor, they retire before I feel a need for another visit.

  5. continuity of care is a thing of the past. docs' schedules are packed weeks in advance, so routine things like strep and UTIs are handled by urgent care. Most docs have no one on call at night or weekends -- just a message that says wait until morning or call 911 or just go to ER. Plus, docs don't talk to each other. Still love your stories though

    1. Doc is talking about modern healthcare systems in first world countries.

      not the US system.

      yes, I went there. I have a reputation to uphold.

    2. Ugh.. my comment got eaten. Basically: US system sucks.

  6. The transfer of care or continuity of care should occur smoothly and seamlessly without errors or omissions. But they still depend on the the skills and knowledge of the physician OR nurse to make sure that there are no errors or omissions.

    1. Correction: physician AND nurse. Nurses turn over 3 times a day, and there is always a chance of miscommunication and error with every turnover.

    2. depends on the facility - some facilities have their nurses on 12 hour shifts. some want longer shifts, because they apparently think having their nurses logy from pulling long shifts is better than having more handoffs.

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

    4. Anon - This comment was off topic and derogatory. STOP.

  7. It is always nice to be remembered for doing someone a good service or good deed.

  8. (I know its technically not the right blogpost but F it) Charlie gard's parents ended their appeal and have decided to let him go.

  9. HI Doc. The parents have dropped their appeal and are now blaming GOSH for not letting him have the treatment way back to the beginning of the year and by doing that caused Charlie too much damage. They fail to mention that GOSH were going to try the treatment but decided not to after Charlie had constant fits for 17 days.
    The american doctor that the parents had pinned their hopes on and who originally said his treatment wouldn't help and withdrew his offer, it now turns out that he hadn't seen Charlie, read all his notes etc when he claimed he might be able to help after all. It also turns out he had a financial interest in the drugs used in the treatment.

    In a damning assessment of his claims the hospital said: 'On July 13 he stated that not only had he not visited the hospital to examine Charlie but in addition, he had not read Charlie's contemporaneous medical records or viewed Charlie's brain imaging or read all of the second opinions about Charlie's condition.

    'Further, GOSH was concerned to hear the Professor state, for the first time, whilst in the witness box, that he retains a financial interest in some of the compounds he proposed prescribing for Charlie.

    The parents still seem to be in denial regarding how sick Charlie was,the effects of his disease on him and,encouraged by their doctor, believing Charlie would be a normal healthy little boy after said nucleoside treatment.

    At least Charlie will now be allowed to die in peace, pain free and with dignity.



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