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.
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.