Sunday 31 December 2017

New Year's Interview with Mrs. Bastard

It's that time yet again, ladies and gentleman.  Time once again to say goodbye to the raging shitmaelstrom that was 2017, and hello to the brand new year.  2018!  The year where everything will suddenly be so much better!  This will be the year frauds and mountebanks will cower under the supreme reign of science and evidence, and when incompetent orange quarterwits will no longer be in charge!

Ha.  Ha.  No. We all know that won't fucking happen.  But instead of wallowing in pseudoscientific misery, let's instead (as promised) enjoy this rousing interview with my wife, Mrs. Bastard (not her real name™). 

You asked the questions, and she's graciously answered them.  Questions I've deemed too personal have been unreservedly ignored and/or sent to live in the White House with Mr. Trump, because censorship is totally fucking legal (and in fact actively encouraged) in Bastardia.  So without further ado, I give you my wife.


Ha haha ha.  Siiiigh.

What's DocBastard's embarrassing secret/s? (from Timethyfx)
I don't know.  *turns to me*  Do you have any?  {No.  Of fucking course not.  I air all my dirty laundry right here.}

What is your favorite blog post? (from Casi G)

I guess I would have to have read them to be able to answer that.  No, actually Doc tells me all of the stories the second he gets back from the hospital, no matter if I'm enjoying my morning coffee or taking a shower or whatever.  I get to relive them all personally and in all their gory detail.

What is your favorite holiday and why? (from Angel)
My favourite time of year is December, as the general population tends to be kinder, more understanding, more patient, and more at peace with each other.

What is Doc's "tell" that there is a new story forming? (from Ken Brown)
Usually when he gets home, sighs, smiles, and says, "You're not going to believe this one".  And then I respond by saying, "That sounds like a blog post!"

How stressed is Doc at home about work? (anon)
He's most stressed when he's lost a patient that he feels he shouldn't have, or if he has a patient who's very sick and he can't figure out why.

What brings tough ole Doc Bastard to tears? (from Nautipirate).
I can't think of anything that's brought him to tears.  {You're goddamned right there isn't.}  Perhaps a spoiled beer.  {Nope.}  The last piece of lasagne?  {Nah.}  The end of season 7 of Game of Thrones with a year and a half to wait until season 8?  {Ok, you got me there.  *sniff*  Dammit, I got something in my eye.}

How is grocery shopping with the DocBastard? (from Cali)
Do we grocery shop together?  Have we ever been grocery shopping together?  {For the record - YES WE HAVE.  God damn it.}

Would you want your kids to be Doc Bastard juniors? (from Joan B)
Aren't they already DocBastard juniors?  But if you're asking if I want them to be doctors, no.  NO.  NO NO NO NO NO NO.

In other words, no.

Is Doc any good at carving the turkey? (from tania cadogan)
What do you think?  Does a bear shit in the woods?

Whats the best thing Doc can cook? (from Shark)
He makes a mean fresh fettuccini with bolognese.

We know what doc thinks of shows like House, but what does Mrs. Bastard think? (from Connor)
I think they're largely entertaining, as long as you buy into willful suspension of disbelief.  {And can put up with me constantly yelling at the television because they've royally fucked something else up AGAIN.  Come on, Hollywood.  I'm available for consulting work.  Call me.}

How did you come to marry Doc? Did he propose on bended knee, did you propose to him, or did you just both decide it was time? (from Cleopatra)
He proposed on bended knee.  I feel like he should have been on both knees.  And he also should have chosen a location that we could go back and visit that wasn't destroyed.  {No, I'm NOT TELLING, so don't even ask.}

How long have you two been married? (From Not your average housewife)
Long enough.  {Love you too, dear.}  No, it seems like just yesterday.  Long enough to put up with each others' idiosyncrasies and even be fond of some of them.  Long enough to finish each others' sentences and know what each other is thinking, but not long enough not to discover new things about each other.  {Aww, no seriously, I love you too, dear.} 

What's the best present Doc ever gave you? (Excluding your perfect offspring, of course.) (from RC)
My cappuccino machine.   And that big green sweater with the giant gold buttons that was probably the most hideous thing I've ever seen.  {Really?  Come on, I barely knew you then.  Are you ever going to let that go?)

How do you keep your household running smoothly? Does Doc help with the dishes? (anon)
WD40.  It keeps everything running smoothly.  No, lists, lists, and more lists.  Speaking of lists, have you changed that light bulb over the piano yet?  It's been TWO YEARS.  {No, because it's only been 2 years.}  And did you empty the dishwasher?  {Yes.}

What made you fall in love with Doc, and he with you? (anon)
I think there was instant attraction and chemistry, but I don't know what made me fall in love with him.  It must have been his charming personality and his wit.  {I swear I didn't make that up.  Those were her exact words.  Honest.}  It certainly wasn't his taste in clothes.  Or hideous green sweaters with giant gold buttons.  {Oh, har dee fucking har har.}

Do you have any advice for newly weds/ new parents/just random pieces of good general life advice? (from the small raven)
Advice for newlyweds: 1) Don't marry a trauma surgeon.  2) Never go to bed mad at each other.  3) Respect each other. 
Advice for new parents: 1) Don't throw the baby against the wall.  2) Don't throw the baby against the wall.  3) I mean it, don't throw the baby against the wall.  4) Don't worry, projectile vomit and pee do come out in the laundry and don't leave a stain.  Usually.
Random good life advice: Be good, and do good.  {See why I married her?}

What is Doc's favorite dish for you to cook and will you share the recipe? (from Promise)
His favourite thing is lasagne.  I use the Fanny Farmer recipe.  Google it.  {She doesn't like to share recipes for some reason.  Don't Google it - I've done it for you.  Just click the first picture.}

We all know that Doc Bastard has a fascination for pulling various things out of rectums. What is the best "removed from rectum" story he's ever told you? I bet it wasn't the one he told US! (from Wednesday)
Actually, it is.  It's the Coke bottle story, for sure.  I think that's one of his first blog posts.  And it was his first RFO.  Still the best.  That was a great story.  {Yes, yes it was.}

If DocB were an animal (of the non-human sort) what animal would he be? What would you be? What kind of hybrids would the Little Bastards be? (anon)
He would be a non-lazy animal.  He would be an industrious, cute animal.  I think he would be a beaver, because he can whittle things out of wood.  I, on the other hand, would be a honey badger.  Why?  Because honey badger doesn't give a shit.  Our hybrid son would be a sloth-hyena because he likes to hang off things and makes way too much noise all the time.  Our hybrid daughter would be a unicorn.  {Because why the hell not.}

Does Doc utilize any of his surgical skills at home? Can he sew a hem? (from OldFoolRN)
He uses his surgical skills all the time at home.  Let's put it this way - when a hem needs to be sewn or a button needs to be replaced, it's not Mrs. Bastard doing it.  I just say, "Daddy Bastard, can you please sew this for me or close this hole in this stuffed animal or replace its arm?"  I can also guarantee the button will never fall off again.  {For the record, MomBastard taught me to sew when I was about 8, though I do usually use surgical knots which she did not teach me.}

If you could magically change Doc's profession, what would you have it be? What type of place would be your dream retirement destination? (from Hippodamia)
I would change his profession to personal chef.  Because then I would never have to cook again.  {What, you think I'd still bring my work home with me?}  And he would have better hours.  Our dream retirement destination would be someplace where it's 28 degrees {that's Celcius} all year round, people are nice, life isn't so rushed, but has access to all the amenities and culture of a big city. {That place doesn't exist, dear.}

What kind of movies do you like and what do you watch together? (from Scott Aylor)
I like comedies. {I like sci fi}.  I can't remember the last time we watched a movie together and didn't fall asleep.  Am I asleep right now?  Are we still doing this interview right now? 


There you have it, folks.  Another year and another interview wrapped up.  I'll see if Mrs. Bastard is up for another interview next year.  If she hasn't killed me yet.  Maybe I'll have even changed the light bulb over the piano by then.

Probably not.

Happy New Year!

Monday 18 December 2017


Oh, boy. We have a bit of a doozy here. As you all know this blog is mainly about stupid people doing stupid things. Sometimes, however, it is about smart people doing stupid things (namely me, if I do say so myself). This is one of those times. Except that this time, the smart person gloriously isn't me at all. Have no fear, it is still about a smart person, a surgeon even, having done a very stupid thing.

Indeed this story is about Simon Bramhall, a rather famous British transplant surgeon who gained fame in 2010 by transplanting a liver that was being transported by a plane that crashed. They managed to salvage the organ and he transplanted it successfully. I think we can all agree that that is a Very Good Thing.

But in 2013 Simon did a Very Stupid Thing. He was performing a liver transplant on February 9, when for some inexplicable reason he decided to burn his initials "SB" onto the surface of the organ he was transplanting. Before you start yelling, "Oh come on, he couldn't have done that. It was probably just misinterpreted. What type of egomaniac would do that?" Bramhall would, that's who. The instrument he used was an argon beam coagulator which is designed to effect (yes, 'effect') haemostasis on the surface of a bleeding organ, and yes he branded his initials onto the liver. Keep in mind this was a very superficial injury that he inflicted, one that would be expected to heal very quickly.

If that doesn't sound too bad, have no fear, because it gets worse. He did the exact same thing 7 months later, again branding his initials on a transplanted liver. Again, anyone who understands how livers heal knows that these marks should disappear quickly and completely. Unfortunately, they did not on one of these two patients. Another surgeon re-operating on one of the patients some time later noted "SB" still visible on the surface of the liver, and Dr. Bramhall was busted.

Dr. Bramhall was suspended initially, and he resigned from the hospital the next year. Further, he was arrested and charged with both assault occasioning actual bodily harm (to which he pleaded not guilty), and assault by beating, to which he admitted and was convicted.

Wait wait, assault by beating? How is that possible?

Right, I was as confused as you at first. It seems that the prosecutor didn't know exactly how to charge him, because this past week he stated that there was just no legal precedent for this type of injury. (Seriously, what the hell would you charge him with? Arson? I have no idea. This is one of approximately 2,490 reasons why I'm not a lawyer.) Regardless, the prosecutor did state that Bramhall's admission of guilt indicates that he admits that "what he did was not just ethically wrong but criminally wrong". Sentencing is scheduled for January 2018. I suspect the judge is just as clueless about how to punish him appropriately.

Bramhall was also issued a formal warning earlier this year from the General Medical Counsel which said regarding his behaviour, "It risks bringing the profession into disrepute and it must not be repeated. Whilst this failing in itself is not so serious as to require any restriction on Mr Bramhall’s registration, it is necessary in response to issue this formal warning."

And that is where I vehemently disagree.

In my opinion Bramhall deserves to be struck off the record, to lose his licence to practice. This falls so far outside the bounds of the normal, ethical, responsible behaviour of a physician that something more drastic than a proverbial slap on the wrist is in order. Bad behaviour by surgeons used to be tolerated, and everyone would just look the other way whenever it happened. Harassing nurses, inappropriate comments, throwing instruments, yelling at students, demeaning residents, and other assorted temper tantrums were commonplace in the operating theatre until recently. Nowadays, however, these sorts of outbursts are no longer permissible. Surgeons are now reprimanded and punished for bad behaviour.

But knowingly and purposefully injuring a patient?


I have heard the counterargument that no real harm was done, so it isn't that big a deal. Really? Is that a logical argument? Then by that same logic we should just allow people to drive drunk as long as they don't injure anyone, because no harm is done. Right? Right?

No, not right. Not right at all.

However, not everyone agrees with me. In fact, when he was suspended in 2014 one of his former patients said, "Even if he did put his initials on a transplanted liver, is it really that bad? I wouldn’t have cared if he did it to me. The man saved my life." It's true though, right? The liver heals very quickly, and even if it doesn't heal completely, having a scar on the organ won't affect its function one bit. So it's not a big deal, right?

Wrong. I've written before about the trust that patients put in their doctors, but especially their surgeons. Imagine the amount of faith people must have to allow themselves to be put completely to sleep, completely vulnerable, absolutely at our mercy, and trust that we not only do our best to put them back together but do it with dignity and respect.

Dr. Bramhall violated that dignity. He violated that trust. Not just one, twice.

I don't know if it was a momentary lapse of reason (twice), sociopathy, or simply a massive ego that led Bramhall to do what he did. Yeah, I'll be the first to admit that many surgeons have massive egos (yours truly excluded, of course). But quite frankly, I don't care a whit. I couldn't give a rattus rattus' posterior, because after pondering this since the moment this story broke, I've come to the realisation that there is literally not a single legitimate excuse in the world that would permit a surgeon to brand a patient like this. Not one.

Not one.

Monday 11 December 2017

Now I've heard everything

Most of the mechanisms of injury I see are rather mundane and pedestrian. Auto accidents, falls, stabbings, shootings, pedestrians struck, bicycle accidents, and assaults are the mainstays of what I see, do, and fix. Sometimes I get the "other", however. These can be anything from ordinary (dog bite) to a bit strange (chainsaw to the face) to how the hell did that happen (foot run over by a lawnmower) to what the actual fuck (bitten by a camel). To be honest, it's difficult to come up with a mechanism of injury that I haven't seen.

Until someone does.

Saturday night seems to go along with alcohol just like peas and carrots, peanut butter and jelly, salt and pepper.  It just doesn't seem to flow linguistically, however.  Hm. Anyway, I'm constantly astounded at what drunk people will do to themselves or others, simply because they are drunk. It doesn't seem to matter what they do or to whom they do it, as long as they can blame alcohol.

"Hi Doc, good evening. This is Dawn (not her real name™). Dawn was assaulted with bug spray tonight, and . . ."

I don't typically interrupt the medics in the middle of a patient presentation, but this time I couldn't help myself.

"Wait wait wait . . . what?"

The medic chuckled a bit and continued. "Heh, yeah. Anyway, she was assaulted with bug spray after her and her boyfriend got into a fight after a night of heavy drinking. She's got a lac on her scalp about 5 cm, positive loss of consciousness. She's 49 years old, history of HIV, not taking any meds, no allergies. Only complaining of a headache."

If you're following along here, you probably have the same question I had.  I could not resist the temptation and just blurted it out:

"So, was she hit with the can or sprayed?"

"Heh. Yeah, Both."

Fortunately the spray didn't get in her eyes, so all she needed was a few staples to close the wound and a heavy dose of IV fluid to get her sober.  Once she was coherent, her boyfriend came to take her home.  All was forgiven, apparently.

I know I've said this several times before, but this time I really really really mean it:

NOW I've seen everything.

Monday 4 December 2017


If you're in the States, you can rest assured that I am most assuredly NOT writing about the Department of Natural Resources.  Nor am I writing about Denbury Resources, Inc (whose unfortunate symbol on the New York Stock Exchange is DNR).  No, anyone remotely familiar with the medical field (or who ever watched House MD or Holby City or Grey's Anatomy or ER or St Elsewhere or M*A*S*H or Scrubs or Marcus Welby, MD [godDAMMIT there are a lot of medical dramas!]) knows that "DNR" stands for "Do Not Resuscitate".  It represents the primary right of the patient - to refuse medical treatment, even in the face of impending death.  Most usually it is employed by the elderly, severely infirm, or terminally ill to alert their medical care providers that they do not want any heroic measures in the event of sudden or imminent death.

There are various elements to a DNR, including orders not to intubate, not to do chest compressions, not to employ vasopressors (medication to artificially elevate blood pressure), not to give food and/or fluids, not to use dialysis, or to use comfort measures only.  The exact nature of the DNR order, including any and all therapies that may or may not be used, is explicitly elucidated in a signed document that is supposed to be readily available for medical practitioners to see.  That way there can be no ambiguity if an unconscious yet terminal patient is brought to the hospital.  The papers are supposed to be easy to find, though sometimes they can be difficult to track down.

Sometimes, however, the DNR is, well, let's just say sometimes it is slightly more prominent:

According to a case report from the New England Journal of Medicine, this 70-year old gentleman was brought by paramedics to a hospital in Miami, Florida unconscious and intoxicated.  He had a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, and he arrived without any identification or family members.  When doctors disrobed him to do their examination, they found "DO NOT RESUSCITATE" tattooed quite clearly (with "NOT" even underlined) on his chest with his signature underneath.

Open and shut case, done and done, cut-and-dried, impossible to misinterpret, right?  RIGHT?

If that were an easy question to answer, I wouldn't be writing this right about now, would I.

A few hours later his blood pressure dropped precipitously due to severe sepsis, and he developed a severe metabolic acidosis (his serum pH was 6.81 - I have never seen anyone with a pH less than 6.9 survive).  The intensive care doctors who attended to him had a decision to make: A) honour the tattoo as a legally binding DNR or B) treat him as they would any other anonymous patient.

They chose B.

According to lead author Gregory Holt, MD, the doctors chose to invoke "the principle of not choosing an irreversible path when faced with uncertainty", so they categorically ignored the tattoo, starting him on antibiotics, putting him on BiPAP, and starting vasopressors.  In other words, everything short of intubating him.

My first reaction to this story was "WHAT?  WHAT THE FUCK WERE THEY THINKING?  HIS CHEST SAYS DEE EN ARE!"  My next thought was that if they had done chest compressions, they would have been committing assault on this gentleman.  My next thought was . . . calm the fuck down and get some more information, dumbass.

*deep breath*

It turns out cases like this, while extraordinarily rare, are not entirely isolated.  In fact there is a published case report in the literature of a man with a similar "DNR" tattoo (though it is admittedly not quite as explicit) which did not reflect his actual wishes.  That patient had lost a bet while drunk many years before, the loser being required to get a tattoo of "DNR" on his chest.  

"Heh, sounds like one of your patients, Doc."

Indeed it does.  Regardless, Dr. Holt and his team obtained a consultation from their ethics team, who determined that the tattoo most likely did reflect the patient's wishes.  They advised the doctors to honour it as an ordinary paper DNR.  Out of respect for the patient's (hopefully) wishes, an actual DNR order was written.  Fortunately shortly thereafter the gentleman's real out-of-hospital DNR was obtained, and he passed the following morning without incident.

After contemplating this case for some time, I've come to the realisation that it isn't nearly so clear cut as I had originally thought.  If I got a dying trauma patient who had a prominent and unmistakable DNR tattoo, would I really be able to say "Wait, stop, don't do anything.  Look, it says DEE EN ARE right there on his chest!"?  Would that really be the right thing to do without verifying it first?  The part of me that explicitly respects patients' wishes says an very emphatic "Yes", but the entire rest of me (which is admittedly rather small) says "Not so fast".  

I believe that treating a patient who does not want to be treated is malpractice.  However, I also believe I would be obligated to verify the DNR prior to withdrawing or withholding care while consulting my own ethics team.  I also also believe doing anything short of this would be malpractice.

What do you believe?

Friday 1 December 2017

Interview part 2

Those of you who have been here a while probably (hopefully) remember the interview with Mrs. Bastard from December 2015. If you don't remember it, well, look it up. I can't do everything for you. Anyway, she just shockingly mentioned that she would like to do another one, and since I had intended that to be an annual thing, I should probably keep my word or something.

So you people are officially on duty. Submit your questions in the comments below for my dear wife, and I will choose the best and/or least revealing ones for Interview 2.0, which should be published some time next month as long as the Call Gods allow it. There are no official rules on what questions you may ask, but you'd better god damn well believe that I will categorically ignore any question I deem inappropriate or too personal. I will not be revealing my name, age, location, childhood nickname, or my most ticklish spot (upper back).

Damn it. 

Everyone ready? And . . . GO.

Not dead

I'll start this post by answering a few questions that may or may not be burning in your mind: No, I'm not dead.  No, I didn't g...