Monday 31 July 2017

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.


  1. Wow.. someone wanted him dead.

    Did his family ever come claim him?

    1. He says no at the very end. Never even identified.

    2. that doesn't mean forensics didn't track down his identity and find some family to claim him.

  2. if there is one thin being in emergency services does is completely rearrange your definition of "unexpected"

    if I was to literally expect the unexpected on duty nights, I would take my clothes off when I went to bed. - because I EXPECT a call within 15 minutes of going to bed.

  3. 'No one ever came to identify him, so organ donation was impossible.'

    That is an incredibly sad ending, poor Q. Even if he was being reckless, the guy never really had a chance, did he?

  4. You are absolutely correct. Those people who always prepare for unexpected things, they always become successful. However, those who don't prepare, they become unable to experience the good things.

  5. I wonder if he was shot somewhere else and then dumped along the road from a passing car. Did he get turned over to a medical examiner? In the states an unidentified male would be a John Doe but Quinton works.

    1. I did say that Quinton isn't his real name, after all.

      His body did go to the medical examiner.

    2. Callkng him john doe would give away the very sad ending- that he both died and was never identified.
      Quentin works

    3. SOAB MF crap!!!! Google ate my soap box, GDit..
      I fear if we come to expect everything we would never be surprised.. Perpetual, control, paranoia, anxiety, come on I was using big words.. bleah bleah, not retyping it and now I'm an angry adult..
      And what I was trying to type out was- It's how you cope with the unexpected, because life is retarded.. And, we all one day will be like Quincy, maybe not with two bullet holes and a stick crammed in our eye, but dead.
      That's right we all have two things in common, we were born and we will die..

      Btw I am really angry Google ate my message it wasn't about towing this time FFS, it was on topic for once. I don't want to adult and I don't want to cope, FU Google..

    4. hope for the best, and prepare for the worst.

    5. Lol thanks Ken..
      I'm a pessimist macabre person, I have a very strange outlook on hope and I already know to expect the worse and expect something to go really wrong with the worse while dealing with it. I always yell out no double whammys..

    6. turned up a short circuit right at quitting time, today. >:(

    7. and the bypass was successful.

    8. It's OK Cali, here is your excuse note.

      To whom it may concern.
      Please excuse Cali from adulting today.
      Google ate her well thought out bang on topic response regarding "expecting the unexpected"
      As you can tell, this was not expected and has thus ruined a perfectly good day for her.
      As a result please excuse the following non adult behaviors including but not limited to having a tantrum screaming, shouting, crying, holding her breath, having a mega strop, throwing herself on the floor, kicking random objects and then crying even louder when she hurts her delicate tootsies,language of an unladylike nature which by the way she did not learn from me (looks accusingly at Doc Bastard)running around waving her arms wildly,throwing things such as her/your keyboard/monitor/phone/mouse and so on.
      I am sure that she will calm down in a few hours just as long as you don't give her anything with sugar or E numbers and that a happy meal with her chosen toy will ameliorate her mood.

      Thank you in advance.
      Have a great day.


  6. Ugh, he was probably shot somewhere else and then the perpetrators kicked the dying man out of a van on that road...

  7. Once again your blog illustrates how much tragedy medical professionals must deal with on a daily basis. I am so glad you and your colleagues are there for us common people when we so desperately need you.

  8. Two bullets shot from two different angles? (I suppose my interest in the details is a way of ignoring the general icky awfulness.

  9. " 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."

    Fuck man. Regardless of his story and how he ended up shot, that's just sad.

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