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).
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.
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:
- Patch him up and sent him home, which was a terrible idea.
- 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.
- Take Oliver to the operating room, insert a laparoscope into his abdomen, and take a look around.
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.
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.