Monday, 18 September 2017

Listen to me

There is a nearly 100% chance that I know more about trauma and trauma surgery than you.  I fully realize how arrogant that sounds, but if you think about it for one second hopefully you'll understand why I say it.  Having studied for several years in university, several more years of medical school, over half a decade of surgical training, followed by {redacted} years of surgical/trauma practice, hopefully I know a hell of a lot about surgery.  Actually now that I think about it, if I don't know more than you about trauma surgery, then my patients have a real problem.

Unless of course you also happen to be a trauma surgeon, in which case hi!  Welcome!

Because most people see the white coat as a symbol of an authority figure, I rarely get questioned on my orders and recommendations.  Most of the time people nod and say something to the effect of "Yes, doctor."  Don't get me wrong, I don't expect people to take everything I say at 100% face value, because as this blog has demonstrated I am most assuredly not always right.  Though I don't expect blind adherence, what I do expect is for my patients to listen to me.

Since I don't do kids, all of my patients are adults with adult brains (relatively speaking), so they are (unfortunately) free to listen to what I have to say and then make up their own mind.  Tragically, some of those minds are just plain stupid.

The Thursday in question was just like any other typical Thursday, in that everybody seemed to be getting assaulted.  I don't know if there was a knife show in town or if the government was spraying everybody with DocBastard's Super Aggression Chemtrails® again, but it seemed that everyone was getting stabbed, punched, or shot, Oliver included.

Oliver (not his real name™) was my second penetrating trauma victim of the day (the first will be found in a future post as well).  He had reportedly been stabbed by Some Dude for Some Reason with Some Weapon at Some Point in the past hour.  The medics were not terribly forthcoming with details, because Oliver would not tell them anything.

"Hey Doc, this is Oliver.  20 years old.  Single stab wound to the left lower chest.  Breath sounds have been equal, and he has been calm and cooperative although not talking much.  Vital signs are all stable."  By the time the medics finished their story, Oliver had already been hooked up to the monitors.  His heart rate was 61, his blood pressure was 118/68, and his oxygen saturation was 100% on room air.  Hm, I thought, he can't be too seriously injured, because vitals can't get much better than that.

As the medics correctly reported, Oliver had a single 5 cm stab wound to the left lateral chest just where it meets the abdomen.  These thoracoabdominal injuries can be a diagnostic and therapeutic nightmare, as the knife could potentially have penetrated anything in his left chest (including lung, heart, and/or great vessels) or anything in the abdomen (including colon, small intestine, stomach, spleen, and diaphragm).

Shit.

So I did what I always do in this situation – I put my finger in the hole.  Oliver was clearly unhappy with this manoeuvre, but the laceration was quite deep, extending towards his midsection underneath his 12th rib. I could not feel any obvious penetration into his chest or abdomen, but unfortunately knife blades tend to be thinner than my finger, so this is not a perfect test in any way.  Since all of his vital signs remained rock stable, his next stop (after a normal chest x-ray) was the CT scanner.  Much to my surprise and chagrin, though the scan did not show any injury in the chest, it did show a small amount of fluid (read: blood) in the left upper abdomen along with a few dots of air where they did not belong.

Shit!

While the air could have come from the outside world, it was more likely to be leaking out from a hollow organ (ie stomach, small intestine, or colon).  However, not wanting to base my decision solely on a picture on a computer screen, I went back to examine Oliver, whose vital signs were still completely normal (and probably better than mine at that moment).  His abdomen was still soft, flat, and completely nontender (except at the stab wound).  At this point my options were:
  1. Patch him up and sent him home, which was a terrible idea.
  2. Observe him for the next 12 hours to see if any signs of peritonitis develop from a perforation that I conveniently decided to ignore for half a day.  This is only a slightly less bad option, because by the time peritonitis develops, Oliver would already be (by definition) sick as hell. 
  3. Take Oliver to the operating room, insert a laparoscope into his abdomen, and take a look around. 
I went with option 3.

Ninety minutes later I had a laparoscope in his abdomen, where I was able to see a small amount of blood in the left upper abdomen as well as a small laceration to his diaphragm. 

Wait wait wait Doc, 90 minutes?  Why the hell did it take you 90 minutes to get him to theatre?  That's malpractice!  I'm going to report you etc etc.

Hold on there, bucko.  Remember how I said Oliver was my second penetrating trauma of the day?  Well the first one came in exactly two minutes before Oliver did.  He was much sicker than Oliver was, so I had to take him to theatre first.  Remember also when I said he would be addressed in a future post?  He will.  I just haven't gotten to it yet.  So hold onto your stupid report and stick it somewhere dark.

Anyway, the diaphragm laceration certainly needed to be repaired, but I also need to make sure nothing else had a hole in it that needed repair.  I remove the laparoscope and opened him up the old fashioned way, but after an exhaustive search the only other injury I found was a very small laceration to his omentum.  The air on the CT scan had indeed come from the outside world, but assuming that without doing surgery is a potentially lethal mistake.  Fortunately for Oliver this was the best possible outcome – his postoperative course should be short, about two to three days, and hopefully uneventful.  

Hopefully.  (Foreshadowing . . .)

I heaved a big sigh and repaired his diaphragm, everybody gave each other a high-five for a job well done (not really), and I closed.  I went to see Oliver the next morning at 7 AM, and he was putting his clothes on, getting ready to leave.  You know, 12 hours after major surgery.

Uh . . . 

"Oh hey Doc.  Listen, I got to go.  I have things I need to do at home," he told me with a small wince of pain as he buttoned his shirt.  I looked at him sternly and then very slowly and carefully and using very small words explained to him that he just had major surgery 12 hours earlier, and he should expect to be in the hospital for 2 to 3 more days.  But Oliver would have nothing of it. 

"Nope, sorry I got things I gotta do at home.  I've been walking, I feel fine, I need to go."  I heaved a very heavy sigh, looked at him even sternlier (yes, that should totally be a word), and explained everything that I had just explained, this time a bit more slowly, a bit more forcefully, and using even smaller words so that he would be sure to understand.  

Nope.  The nurse called me an hour later to alert me that he had indeed left the hospital against medical advice.  

And then one of the emergency physicians called me seven hours after that to tell me that he was back. 

Of course. 

When I went in to see him the following morning, he looked only mildly abashed, like he had barely done anything wrong.  "Welcome back," I told him with a scowl.  "Yeah, I probably shouldn't have left, right?" he said, finally looking up from his mobile.

"Right," I told him in that same stern voice I had used before.  "That was a stupid thing to do.  Really stupid.  I expect you to stay here in hospital this time until I discharge you.  Clear?"  He simply nodded and went back to playing a game on his mobile.

As expected, Oliver had normal post-laparotomy pain which is best treated, you know, in a hospital.  He stayed in hospital for 3 more days until his bowels woke back up (which is normal after major abdominal surgery), and he then went home again.

But not until I discharged him.

24 comments:

  1. This comment has been removed by the author.

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    1. He had stuff to do at home of course!

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  2. Why did he go back to the hospital? Was it the pain?

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    1. He took care of his stuff at home apparently

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  3. It's hard to know with these situations just what "things I gotta do" are. Does he have a Tinder date or did he leave his 3-year-old home alone and wants to get back before she starts drinking out of the toilet?

    There could be reasons why he does actually need to be home in a hurry, although I will grant you it's more likely something trivial. In fact, since he came back so quickly after, maybe he over-exerted himself on his Tinder date!

    Ugi

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    1. To quote walking dead:stuff....things...

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    2. Ugi-
      Hahahahaha 3 year old drinking out of the toilet.. lmao I'm dying over here..

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  4. but doc, you told us in a different post that putting things in the dark place is not advised because they tend to get sucked in and retained, and then you have to deal with it...

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  5. But Doc, think of how boring your job would be if you only got to treat the smart ones.

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    1. but on the other hand, he'd have more free time to write about the stupid ones.

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  6. I had a C-section and they did morphine in my epidural and IV right after I was buttoned back up..
    Two days later nurse comes in and says, "let's see if your bowels are awake", pulls on the white gloves and starts to pull back the metallic wrapping on what I eye-spy as a suppository..
    I look at the nurse and ask, "what is that and why the gloves?".. She says, "well we need you to have a BM before we can feed you"..
    I think I had a horrified look of "oh hell no, not today Satan", because she tried to comfort me and let me know she does it all the time.. My expression and statement of you don't do it all the time to me, so nope and no..
    Sorry ma'am but your professional anus touching fingers are not going to penetrate my orifice today.. I had to fight to stick my own suppository up my own ass.. Hearing the lecture about how it needs to be inserted high in to the rectum reinforced the fact I'll go knuckle deep in my own fartbox today, thank you very much..
    Sometimes Doc we want to make sure we didn't leave the toaster on at home and come back later, or in my case rectal dive by myself.
    I did do it, was getting all nice and comfy and someone knocked on my door and I got stage freight and I couldn't 💩.. So her colon escapade would have been all for not..

    It's been a long rough week/day at work- I almost walked off and quit. Thank you for letting us be a bit goofy on your awesome posts, letting us express ourselves in a respectful way.. Keep up the good work and you are my online medicine tonight when all I wanted to do was cry..

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    1. we had a very messy week over the last 7 days, here. some of it might have even made it to your news.

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    2. good news from the past week: I've been worrying about a child who ran in front of a car. got insider word the child will recover.

      one of the worst things about emergency response is that we rarely hear the outcome, unless it is a DOA. so I appreciate the person who reached out and told our person the good news.

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  7. Thanks Doc. I work with a guy, morbidly obese, smokes and yes diabetes. Like your guy, he has selective hearing. According to him, his doctor says he is healthy. Why because he does not have high blood pressure......grrr arrrg

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  8. Big Hugs Cali and Ken and thank you for what you do.

    Doc does great online medicine especially when my uncle who has just started dialysis via a neck line (12th session today) who needs a heart bypass and at least one valve replacement and is diabetic(was diet controlled now they are looking at medication) cheats on his diet/fluid restrictions and when he was sent home today with diet sheets to control his potassium and phosphorus levels (why is is one one diet is is OK and on the other it is a no no?) and in both sheets they say certain fruits are OK to eat and he has to limit them because of his diabetes, he shakes his head, mutters newp repeatedly under his breath and goes into instant mega sulk because it means he can't eat or has to limit his favorite foods that he pigs out on.
    When i say i will have to have a chatette with his dietician to see what workarounds i can come up with he bitched that you(meaning me) will get them to do what you want. He refuses to accept that my suggestions and ideas regarding treatment do work and they wouldn't do them if they knew it wouldn't work/help. He hates when they tell him that i am doing a good job at keeping him alive as long as i have.
    He went into hospital with one thing and everything else joined the party giving him a 5% chance of walking out alive. Since then he is regularly admitted because he cheats on his diet/ refuses to tell me when he isn't feeling well so i have to play 20 questions and watch his body language/ lies to the medical staff to get discharged on the grounds he doesn't want to be in hospital, he feels fine and there is nothing wrong with him (yeah right when he looked like death warmed up, got discharged, was frequently sick and not well and after 2 days admitted he felt a bit poorly and was readmitted with a massive kidney abscess and was in for 5 weeks with drains everywhere) For 18 months i was telling all his doctors,consultants, nurses that he was shwoing all the signs of heart failure and he denied it said i was fixated on his heart, it was perfectly fine etc. Turns out i was right. Severe aortic stenosis, sloppy valves and other stuff so they had to play catch up. They can't operate yet as they need to get him stable on dialysis and lose some weight and they can't put ab AV fistula in as as soon as they do the heart op it will collapse plus putting one in will make his heart failure worse. They are all now going to talk to each other to decide what can be done.

    meanwhile he has just stomped out with his walker to get his papers (albeit very slowly due to breathlessness, a little storm cloud on the move. Sigh)

    Happy wednesday xx

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    1. Someone get this girl a stiff drink! You deserve one for all the trouble you go through

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    2. good luck. nothing worse than an uncooperative patient.

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    3. I was recently re-admitted to hospital with flaring vasculitis chewing up my kidneys.. I have to admit to a huge impulse to deny/downplay my symptoms. It's very disruptive having to stay in hospital, and there is an irrational part of me that is saying 'if I'm not in hospital then this isn't happening'. On the other hand I did make sure I was fully compliant on treatment. And diet. And physio..

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  9. Hi Connor thanks, mine;s a pint of mint baileys (or orange truffle baileys) please.

    Cheer!

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  10. I don't know how the hell he did it--all I know is that every time I've been cut into, while I might love the idea of being able to recuperate in my own bed, the *last* damn thing I'd be able to do would be to get up and leave the hospital. (Granted, you were mainly just poking around in him, whereas I had a foot of my sigmoid colon yanked out, no thanks to a nasty case of hereditary diverticular disease, but my point remains: surgery is a major shock to the system, damn it.)

    I also feel your pain about the "need to have a BM before we'll feed you" bit, Cali--of course, if you're having scheduled bowel surgery, you need to do the complete prep routine to make absolutely positively sure there's *nothing* left in there to interfere in any fashion (quite reasonable, really). What's not reasonable, though, is expecting me to take a dump for you after 3 days of not eating AND a bout with Go-Lytely that the latter won in a knockout--just WTF is supposed to be in there for me to excrete, anyway? (I'd already been warned about all of this by my dad, from whom I got the messed-up colon and who had already had the same surgery, albeit at a later age than I did, and somehow I manage to produce a teeny little BM that still counted...but °damn*, people, really...)

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  12. Its been 2 weeks since doc last posted should we be worried?

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    1. either he has been on vacation, or people in his area have come down with a severe case of intelligence...

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    2. I hear contrating that amongst those with low IQs can result in a chronic case of face palming.

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