Monday, 12 February 2018

Almost

It should come as no surprise that most of my patients, well over 90%, come in to my trauma bay alive and leave the hospital the same way.  Don't worry, I'm not patting myself on the back here.  It isn't because I'm some sort of spectacular trauma surgeon, but rather because most of these people are just not critically injured.  The ones who are critically injured but still survive are what I consider the Good Saves, the ones I occasionally share with you good people.  Rarer than this (luckily) are folks that come in dead and stay dead.  Fortunately very few people come in alive and leave via the morgue.  I sometimes share those stories too. 

But the most unusual type of patients, the fleetingly rare ones, are the patients who come in dead and leave alive.  Those are the patients whom we as a trauma team consider not just a Good Save, but a Great Save.  They are the ones that stick in our memory, the ones we talk about for years to come when swapping war stories and trying to one-up each other.  They are the Holy Grail of trauma, each one a once-or-twice-in-a-career event.

And I almost had one of those.  Almost.

Dale (not his real name™) was one of those rare stabbing victims that was not brought in at 2 AM.  Somehow he had managed to get stabbed at 7:30 in the evening when most people are either eating or getting ready for bed (I guess . . . at least that's what I am usually doing at that time).  I haven't the slightest idea what Dale was doing or who stabbed him, but whoever it was wanted Dale dead.  He was called in as a code-in-progress, meaning his heart had already stopped en route.  When the medics got him to me about 30 minutes after he was stabbed, they looked a bit frantic and completely exhausted.

"Hey Doc, (pant pant) this is Dale.  He's 20-ish, (huff puff), one stab wound to the right upper chest.  Huge amount of (puff puff) blood loss on the scene.  He's been down for about 30 minutes.  We couldn't get an IV on him but we got him (puff puff) intubated."

One three-second glance at Dale told me two very important things: 1) Dale had seemingly exsanguinated from a single stab wound to the right upper chest, and 2) Dale was dead.  He had no pulse (meaning his heart was either not beating or not beating hard enough to generate a blood pressure), and his pupils were both 4 mm and non-reactive, meaning his brain was critically deprived of oxygen.  But in addition to all that, Dale was also cold.  Very cold.  His core temperature was about 32° C (about 90° F), but when we put him on the cardiac monitor he still had some cardiac activity (a condition known as pulseless electrical activity).

His heart was trying to beat, it just didn't have any blood to pump.

The easy thing to do in this situation would have been to call the code and pronounce Dale dead.  Because he was dead.  However, I chose not to do the easy thing for two very good reasons:
  1. Perhaps with some oxygen-carrying capacity (read: blood) Dale could be revived (however unlikely that may be), and
  2. you're not dead until you're warm and dead.
As nurses were getting a couple of large-bore IV's started, an assistant was inserting a chest tube into his right chest which yielded very little blood, which meant he had bled out into the outside world (as the medic had indicated), not into his chest.  We continued doing CPR and very quickly squeezed two warmed units of blood into him, and immediately afterwards I heart someone yell something that gave me significant pause:

"I GOT A PULSE HERE!"

Somehow, Dale now had a measurable blood pressure.  And with that blood pressure he now resumed bleeding torrentially from his stab wound, which was obviously a lacerated subclavian arterySHITSHITSHITSHITSHIT  This is one of the most difficult injuries to repair, as the approach is extraordinarily complex.  So I did the only thing I could do in that moment: I stuck my finger in the hole.

This was extremely effective at controlling the bleeding while we continued transfusing him, but it is also extremely temporary.  I shouted for the operating theatre to get ready for us, because the only thing that could save Dale's life was a sternotomy

One very large question remained, however: was his brain already cooked?  His brain had been deprived of oxygen for at least 45 minutes, but I had no time to find out just then.  That would have to wait until either A) I got the bleeding stopped or B) he was really most sincerely dead.

By some minor miracle Dale's blood pressure held as we wheeled him to theatre, my finger remaining firmly planted in the hole the entire time as I dodged door frames and wall corners.  Once in theatre I made a quick 1-second finger switch with an assistant so I could scrub.  Ten minutes later I was sawing through Dale's sternum, and his heart was staring me in the face, pumping away. 
Not actually Dale's heart

I got control of his brachiocephalic artery first, then I extended the incision across his right upper chest towards the entrance wound.  I continued dissecting the artery distally until I got to the point where his subclavian artery split from his common carotid artery.  Finally I had proximal control.  Unfortunately that was only half the battle, and even more unfortunately it was the easy half.  Now I had to get distal control, which was a much more difficult prospect.

The dissection towards the wound continued, my assistant's finger still plugging the hole.  To get access to the injury, however, I had to remove the middle section of the clavicle (and my assistant's by-now very cramped finger).  Once this was done the injury finally came into view as it was audibly bleeding.  Yes, I could actually hear the blood rushing out.  Somehow the knife had missed the subclavian vein and had hit only the subclavian artery.  With the artery now clamped both proximal and distal to the injury, I carefully placed a few sutures in the artery, trying to stop the hæmorrhage but still maintain some flow into the right arm.  My main objective, however, was to stop the bleeding, not to save the arm, which was a distant secondary goal (life over limb).

Just like that, the bleeding stopped.  Voilà!  Success!  I took a few minutes to exchange high fives all around (not really) before thoroughly checking for other injuries (there were none) and closing.  But as I closed him that one big question still hung over everyone's head:

THE BRAIN.  What was the status of Dale's brain?  I had no way to predict how his brain would react to prolonged oxygen deprivation before we had been able to get his heart restarted.

Over the next two days his blood pressure stabilised, he stopped bleeding, and he actually began to open his eyes.  On the third day I was stunned and even cautiously optimistic to find that he even seemed to follow some simple commands. 

A Great Save!  Huzzah!  We did it!

The optimism wouldn't last.

Now that he was stable we were finally able to get a CT scan of his brain, and finally the devastation of his brain injury became apparent.  He had widespread ischæmic damage to his entire cerebellum and various large portions of his cerebrum with extensive œdema to the point where his brain was starting to push his brainstem down into his foramen magnum (so-called transtentorial herniation). 

My cautious optimism immediately vanished.  Dale was actively dying again.

There was but one option left and it was a drastic and rather terrible one.  But I had no choice because Dale was in immediate danger of dying.  Again.  In a last-ditch effort to save him, one of my neurosurgery colleagues took him back to theatre to remove a portion of his skull to give his brain space to swell and allow the herniation to improve. 

It didn't work.  Two days later he was completely unresponsive, his pupils were both blown, he had lost his cough, gag, and corneal reflexes, and both an apnœa study and brain flow study confirmed that he was brain dead.

GOD DAMN IT.

I went through the entire gamut of emotions during Dale's course, from frustration to elation, worry to optimism, fear to dejection.  Just when I thought Dale was dead, he came back, and just when I thought he would make it, he didn't.

The entire time I worked on Dale, every single moment, my Inner Pessimist kept reminding me that he had a 99% chance of dying.  But goddammit that also meant he had a 1% chance of surviving.  While that isn't very high (obviously), it also wasn't zero. 

Until it was.

Wednesday, 7 February 2018

Influenza

NOTE: THIS POST WAS WRITTEN SOMEWHERE BETWEEN 0 AND 12 MONTHS AGO DURING FLU SEASON HERE.  NO, I WILL NOT TELL YOU WHERE "HERE", BUT I WILL TELL YOU THAT FLU SEASON IS DURING THE WINTER HERE, JUST LIKE IT IS WHEREVER THE HELL YOU LIVE.

I'm a healthy guy in my {redacted} decade of life.  I've had very few serious maladies in my life, the most dangerous of which (so far) was appendicitis in my 20s.  I don't take any prescription medication, I have no allergies, and I have no chronic health problems, so I have very little reason to complain about my health.

And now I have the goddamned flu.

Let me clarify something quite clearly: I do not have a cold.  Yes, I have nasal congestion, a nasty productive cough, and a headache.  But I do not have a cold.  I also have generalised body aches and a high fever of 39.6° (that's 103.3° Fahrenheit for you Americans out there).  Yeah . . . this is not a cold.  I have the fucking flu, and it sucks.  It sucks a lot.  I've had dozens of colds in my life, some of them worse than others, but none of them was ever bad enough to land me in bed.  I have spent exactly 0 days of my adult life in bed with a cold.

Until now.  I spent the first three days of last week in bed with this goddamned plague.

It started off innocently enough while I was on call, just a mild cough and some congestion.  I figured it was just another cold, because my wife recently got over a cold and everyone around me seems to be sick with something.  The next day, however, I felt like I had been run over by a truck, and I chalked it up to it being the day after another tough trauma call with no sleep.  I managed to trudge through that day, but when I woke up the next morning that truck that had hit me had turned into a freight train.

My body temperature that morning: 39.6.

That day the mild cough turned into a constant, hacking cough, and I would have been amazed at the stuff my lungs were able to produce if I had been able to muster the energy to become amazed.  Ibuprofen was able to bring my temperature down to the point where it didn't feel like my head was ready to explode, and oxymetazoline gave me the ability to breathe for several hours.  Realising that this was not just a cold, I quarantined myself in a spare bedroom (Mrs. Bastard's orders), and Mrs. Bastard was vigilant in keeping the Little Bastards far, far away from me.

And for the first time in my adult life, I spent all day in bed.

The next morning my temperature was still 39.5.  I discovered I was scheduled to be back on trauma call the next day, but I was absolutely unwilling to expose any of my prospective patients (and coworkers) to this scourge.  Fortunately I was able to switch call with a colleague.  Again, all day in bed.

I will reiterate that I am a healthy guy and I tend to get over colds quickly, usually within a day or two, so I expected to be better by day three.  But that morning my temperature was still 38.5.  The coughing had not improved at all, my head was still pounding, and I could barely breathe.  This is not just a cold, dummy, I kept reminding myself.  There were several times when I considered going to the hospital, but I wasn't quite there.

It was three days in bed and three more days after that before I felt able to go to work.  I wore a surgical mask in the hospital for the next several days to avoid exposing patients.  I wore gloves and washed my hands religiously.  But just walking through the halls seemed to take my breath away.  I even tried taking the stairs once - big mistake.

It has now been two full weeks since I felt my first symptoms, and I am finally very close to 100%.  I still have a very occasional cough, but I haven't taken any medicine in well over a week.

Now I'm sure many of you are wondering one very important thing: did I get a flu shot?  Yes, you know I got a flu shot.

So the flu shot failed!  It's worthless!  Why bother!

This seems to be one of several arguments I have seen people make against getting a flu shot:
  • It is ineffective.
  • The strains in the flu shot are nothing more than a guess.
  • The flu shot gave me the flu.
  • I've never gotten a flu shot, and I've never gotten the flu.
  • Why bother getting a flu shot?  It's just the flu.
I could give you the short version and just say that all those arguments are ridiculous bullshit.  However, that would be the lazy way out and would convince exactly no one, and since I'm no longer sick, I can no longer use that excuse.  So instead I shall address all these issues in order:
  1. Yes, the flu shot failed to prevent me from getting the flu.  Yes, the flu shot is the least effective vaccine in existence.  However, the flu shot is not ineffective, as the efficacy averages around 45% (though it may be as low as 10% this year).  However, even if the efficacy is 45%, that is literally an infinite times more effective than not getting the flu shot, which would have an efficacy of exactly ZERO PERCENT.  Not getting a flu shot is a guarantee not to be protected, but getting a flu shot may protect you.  That should be a no-brainer.
  2. The strains in each year's flu shot are an educated guess based on worldwide surveillance.  It isn't like the scientists throw a dart against a dart board.
  3. It is a 100% biological impossibility to get the flu from a flu shot (I'm not talking about the nasal mist here).  It is an inactivated vaccine, which means the viruses in it are dead and are thus NOT capable of infecting you.  At all.  EVER.  No one in the history of flu shots has ever gotten the flu from the shot.  The "flu" you think you got was your body's immune response to the vaccine, and it lasts for a day or two.  That is NOT the flu.  If you did get the flu immediately after getting the flu shot, you already had it when you got the shot since influenza has an incubation period of 1-4 days.
  4. If you've never gotten the flu despite never getting a flu shot, that doesn't make you smart or correct, it just makes you lucky.  If you survive a hurricane despite staying in your house, that doesn't make you smart for staying, it makes you a complete fucking idiot for staying, just a lucky complete fucking idiot.
  5. "Just the flu" infected nearly 1/3 of the planet in 1918 and killed about 50 million people that year.  Remember the H1N1 "bird flu" from a few years ago?  Yeah, that was the same H1N1 that caused the Spanish flu epidemic.  "Just the flu" still kills hundreds of thousands of people each year worldwide, and up to 50,000 people in the US each year, most of whom are either very old or very young.  The flu is not a cold, and the common cold is not the flu.  There is no such thing as "just the flu".  The flu kills.
I don't often do recaps, but I'm going to do a goddamned recap:
  • The flu sucks.
  • The flu is not a cold.
  • The flu kills.
  • You can't get the flu from a flu shot.
  • The flu shot mostly sucks, but it's better than nothing.
  • Get your goddamned flu shot.
So having gotten the flu despite getting a flu shot, is there any chance I'll be getting a flu shot next year?

You're goddamned right I will.  I'll be first in line.

EDIT February 2018:
I got my goddamned flu shot the first day it was available.  Get your goddamned flu shot.

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