Friday, 20 April 2018

Colleague

As everyone should know based on my tagline, I usually write stories about stupid things a patient of mine has done.  I will occasionally write a story about myself, mainly stupid things I've done or said, and every now and then I will write about something stupid another doctor has done.  But I recently realised that of all the posts I've written, there is one thing woefully and glaringly absent: stories of my very smart colleagues doing very stupid things.  The reason for this is probably obvious - I don't care to write about other surgeons' blunders, preferring to focus on my own.  Sure, I talk about emergency physicians and the stupid things they've done, but they're emergency physicians and likely deserve the abuse.  (A note to all my emergency associates out there: shush, you know I secretly respect you.  And that you deserve the abuse.)

The main reason I don't write about my colleagues is that I rarely get detailed enough stories from them.  I have no reason to believe my patients and their antics are special or unique in any way, and I'm sure the other trauma surgeons have just as many stories as I do.

Except Dr. John (not his real name™).  Not because he doesn't have as many, but because he has more.

Way more.

Dr. John always seems to have bad stuff happen around him and has been described as having a bit of a black cloud over him.  I think this is quite understated: He is a certified, bona fide, 100% undisputed shit magnet.  Wherever there is a shitstorm, you can rest assured that Dr. John is at the center of it.  It obviously isn't his fault - he isn't the one out there crashing cars into trees, toppling motorcycles over ravines, or stabbing people in the face.  No, he's just the trauma surgeon taking care of the people who have all decided to have these terrible things happen to them all at the same time.

Lest you think I'm exaggerating, I'm not.  At all.  He will often still be in the operating theatre four or five hours after his shift is over, still fixing the mess from the previous day.  Fortunately he is a very good surgeon, but the patients that he acquires always seem sicker, more badly injured, and more bizarre than mine.  This was almost exactly the case recently, except instead of finishing surgery four hours after his shift was over, it was twelve hours.

And I finally discovered why.

I was on call one recent Sunday after John had been on call the previous day.  I instantly knew it had been another Dr. John Shitstorm because his stuff was still littering the call room when I got there and the bed looked not-at-all-slept-in.  So I got out my computer and started reading (Ready Player One, if you're curious), waiting for him to come and gather his stuff.

And I waited.  (Good book)

Aaand I waited more.  (Very good book)

Aaaaand I waited more (Wow, that was a fun book)

About ten hours, zero traumas, and no John later, my pager finally went off with my first patient of the day: a fall.  Sigh.  I walked down to the trauma bay where I was greeted with an elderly person who fell out of a chair the previous day and had no injuries.  While I was working her up, another trauma came in, this one a very lightly injured car accident victim.  Two patients, two discharges.  It was shaping up to be a very light day . . . until Trauma Nurse Martha (not her real name™) decided to pipe up.

"Doctor Bastard," she said with a grin, "we're going to have a good night.  I can feel it.  You're going to get some sleep tonight!"  There was dead silence as everyone stared at her, mouths agape.

WHAT THE FUCK DID YOU JUST SAY TO ME?

Martha has been a trauma nurse for about 20 years, so she obviously knows about the Call Gods.  She also knows that what she just said is never to be even thought about, let alone uttered aloud. 

After finishing discharging the two traumas, I went back to my call room, muttering something about Martha fucking knowing better the entire way.  It was now just past 8 PM, just over halfway through my shift.  Still, it had been very quiet for a Sunday as I had had only had two patients so far.  I could feel the sense of foreboding rising inside me when I got a text from John.

Hey is my stuff in the call room?

It seemed John was finally done with whatever the hell he was doing.  He came to the call room a few minutes later, and with a huge grin on his face he recounted the two car accident victims he had gotten 15 minutes before his shift was up, both of whom had suffered lacerations to their mesentery (the blood supply to the intestine), both of whom had segments of bowel which were dead and required resection, and both of whom were now barely clinging to life.  I listened, rapt, as he detailed the procedures he had done, amazed at his bad luck.  

"Wow, rough shift," I told him when he finally took a breath.

"I love this stuff!" he replied with a laugh.  

What?  Despite having been awake for at least 38 hours and looking completely exhausted, he was as giddy as a schoolboy.  We chatted for a few more minutes as he collected his things.  On his way out the door, he said something that made me understand the Dr. John Shitstorm:

"I hope your night is quiet.  Have a great night!"

WHAT THE FUCK DID YOU JUST SAY TO ME?

The rest of my night went exactly as you expect after both Martha and John decided to give a big "FUCK YOU" to the Call Gods.  Keeping in mind that I only had two traumas over the previous 14 hours, I then got a drunk man who fell down the stairs at 11 PM, a drunk driver who crashed into a tree just before midnight, a stabbing at 1 AM, a drunk man who fell off a bicycle at 2 AM and an elderly woman who fell out of bed at 4 AM. 

The end of my shift finally rolled around, ending my misery.  I may have said a few not-so-subtle curses under my breath, but they were directed not at the Call Gods, but rather at John and Martha.  After what Martha and John said, I couldn't even blame the Call Gods for what they did to me.

But at least now I got it.  I finally understood why John is a shit magnet.  Because John doesn't give a fuck about the Call Gods.  He challenges them.  He taunts them.  He uses them to fuel his desire to operate on fucking everyone.

John is a shit magnet because he wants to be.

Monday, 9 April 2018

Compartment syndrome

NOTE: I realise I have not published any new posts in 4 weeks.  That is highly unusual for me, and I do not expect it to become a trend.  This was a combination of a dearth of interesting stories and a well-deserved holiday.  It turns out {redacted} is quite nice this time of year.

There are several absolute surgical emergencies in trauma.  These are operations which need to be done right now (or ideally 30 minutes ago) in order to save a life or limb.  Some are rather obvious:
  • active arterial bleeding
  • open skull fracture
  • intestines outside body
  • hole in heart
Some are decidedly less obvious:
  • bowel ischaemia (loss of blood supply to the intestine)
  • compartment syndrome
That last one is probably one you've never heard of, but it certainly belongs on the "Get To Theatre Now" list.  In short, the pressure inside a compartment (leg, arm, abdomen) rises higher than the systolic blood pressure, which then essentially chokes off the blood supply to the things in (and beyond) that body part.  Massive bleeding or swelling in the abdomen, for example, causes blood supply to the intestines and kidneys (among other things) to be cut off, leading to acute renal failure, bowel necrosis, and rapid death.  Injuries to the lower leg can cause swelling of the muscles in any of its four compartments, leading to muscle death, eventual limb death, and even more eventualler (that's a technical term), death.

Diagnosing lower extremity compartment syndrome is fairly straightforward despite its relative rarity.  As the swelling worsens and blood supply is gradually cut off, it presents with the 5 P's: Pain, Paraesthesia (decreased sensation), Pallor (paleness), Paralysis, Poikilothermia (inability to regulate temperature), and finally Pulselessness.  Anyone with a cold, insensate, paralysed, pulseless leg needs emergent surgery.  Now.  NOW.

NOW!

Unfortunately there is no medical treatment for compartment syndrome.  The only available recourse is to open the affected compartment to allow the contents room to swell and expand, thus re-establishing blood supply to the dying tissue.  Without it, the limb will die within a few hours, as will the patient not too long afterwards.

And Erik (not his real name™) had compartment syndrome (not his real diagnosis™).

I'll explain.

It was a rather slow day, though I made damned sure not to remind the Call Gods of this fact.  One of the nurses seemed not to give much of a fuck about the Call Gods, because out of nowhere I heard "Gee, it's been rather quiet today."

WHAT THE FUCK DID YOU JUST SAY?

Not five minutes later, the phone rang.  Of fucking course.  It was Outside Hospital (not its real name™) with a trauma consult.  Sigh.  These are rarely interesting, usually rib fractures after a car accident or facial fractures after an assault.  My ears seldom perk up when taking these consults.

"Hell Doctor Bastard, I'm calling from Outside Hospital.  I have a guy here with compartment syndrome I need to send over right away."

My ears perked up.  Something real?  On a slow day?  I waited for the story with bated breath.

"His name is Erik.  He is 29 years old, was struck by a car and was seen here earlier, but he looked ok so we sent him home.  He came back because of persistent pain in his left leg.  The leg is swollen and tight, and he needs to be decompressed."

Well now, this is some real trauma!  Huzzah!  But before the fanfare and sending troops to get him, I needed some additional information.

Me: Ok, does he still have a pulse {the pulse is usually the last thing to go}?
Her: Oh yes, it's normal.
Me: Well that's good.  How is his sensation and motor function?
Her: Normal.  He's been walking just fine.  Actually he said his pain is a little better today.
Me: ...
Her: Hello?
Me: Um, is the leg cold?
Her: No, it's warm.
Me: ...
Her: Hello?
Me: ...
Her: So can we send him over?
Me: ...
Her: Hello?
Me: This doesn't sound like compartment syndrome. At all.  He has a warm, sensate, normally functioning leg with a pulse?  And you said he was hit earlier today?
Her: Oh no, not today.  The accident was 16 days ago.
Me: It was . . . wait, WHAT?
Her: He said the swelling got worse, but it's been better the past two days. 
Me: ...
Her: So can I send him over?

WHAT. THE. FUCK.

The major problem was that I could not afford to say no.  If I told her to send this ridiculous-sounding bullshit consult home and he actually did have compartment syndrome, he would lose his leg and I would deserve to lose my licence.  So I grudgingly accepted the transfer (but not before thoroughly educating the emergency doc on what compartment syndrome actually is), knowing full well I would most likely be discharging him from my trauma bay 20 minutes after he arrived.

But I was wrong.  It was 15 minutes.

He walked into my trauma bay (yes, really) 5 hours later.  His leg was not cold, it was not tight, it had normal sensation, and it had a normal pulse.  In fact it was barely swollen at all.  And all his bruises were in their final stages of healing.

The good news was that the Call Gods must have taken pity on me, because they sent me nothing the entire rest of the evening.  Don't you worry though, they got their revenge next time.  But that's a story for another time.

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