RFO time yet again

WARNING: NSFW PICTURES BELOW

Seriously . . . very NSFW pictures DO NOT read this in the presence of children. 

YOU HAVE BEEN WARNED.

Several people have emailed me over the past two months to ask if I'm ok because my blog has been silent. I thank you good people very kindly for your concern, but I assure you I'm fine. But good lord, you people are right! It's been over two months since I've written anything. Well, that isn't exactly true - I've tried to sit down and write several times, and I now have 10 (!!) posts partially written and sitting abandoned in my "Drafts" folder. And by "partially written" I mean "a paragraph or two". And by "a paragraph or two" I mean "a sentence". Or a title.

Sigh. Writer's block sucks.

It isn't that I don't have material, it's just that lately I don't seem to have the desire to sit and do it for whatever reason. It isn't mentally exhausting to write and it isn't terribly difficult. Hell, I could sit in my car and dictate a blog post if I wanted to. It's just that I didn't want to.

Until now. Because it's rectal foreign object time again!

If I seem excited, it's because I am. Call it macabre or bizarre, call it weird, call it really fucking disgusting if you prefer. But these cases are, well, fun. There's no way around it - they're just fun. And lest you think it's just me, it isn't.

I always worried that it was just me until yesterday, because yesterday I had the opportunity to have an RFO Battle Royale with one of my colleagues, Dr. T (not his real name™).

And I lost.

I lost.

I told Dr. T about my latest RFO, which happened to be a small pill bottle. Wrapped in a condom. Wrapped in yet another condom. Unfortunately the bottle had slipped up way too high and could not be extracted from below. Normally we can reach up (yes, really) either with our fingers or some surgical grasper, grab the . . . thing, and then pull it out the way it went in. But this bottle was so high (like 25 cm high) it could not be reached. So I was forced to enter his abdomen the old fashioned way ("Never let the skin get between you and a diagnosis"), and squeeze the bottle down his colon into his rectum. As I pushed it through, I said to the assistant who was waiting down below to catch it, "Ok, it should be crowning".

If you aren't laughing right now, then you don't have kids, because that's fucking hilarious.

As I related this story (and my infamous Coke bottle story) to Dr. T, he merely stood there impassive with a slight smile on his face, because he knew that he had already won. Apparently those stories didn't even come close to Dr. T's best (worst?). He then told me not his best story, not his two best, but his three best stories, any one of which could beat any one of mine.

Yeah, I lost badly.

3) The third best story starts with "He was bored". Normally when I get bored I read a book or something, but not this guy. Nooooooo. This guy (yes, it's always a guy) put an enormous dildo in his rectum and then lost it. It could be felt from below, but it could also be felt from above. WAY above. Like at his umbilicus (navel (belly button)). Because this wasn't just a normal dildo, it was one of these:

I warned you there were NSFW pictures. I fucking warned you.

Anyway, Dr. T took him to the operating theatre, put him to sleep, and grabbed it from below with a surgical clamp like we always do. There was one problem - if you look at the bottom of that, uh, device, you'll see a little dial. Dr. T, unfortunately, couldn't, because he didn't yet know it was there. I'm sure by now you see where this is going. Dr. T grabbed the dial, twisted to try to extract the object, and turned the damned thing on. Apparently this one didn't just vibrate, it also rotated. After the initial shock and panic, the rotation actually helped free it from its environment and it slid back out to freedom.

One loss.

2) The objects we remove are mostly phallic, for obvious reasons. Mostly. The second best story Dr. T told me involved a bone cutter.

What?

You heard me. Indeed, this man had inserted a pair of metal cooking tongs. I'm sure you've seen them before. You know, one of these:

If you're wondering, he inserted the small end first, "small" of course being a relative term. If you look carefully at the grasping end you'll see a very small gap between the end of the metal and the body of the tongs. As they were being removed, that little gap had been able to trap a tiny ridge of rectal mucosa and was unable to let go, so Dr. T had to use a bone cutters to snip off the tip of the tongs, being careful not to snip anything else by mistake.

Loss #2.

1) Dr. T was almost in tears as he told me this last story, his best. It was another guy who was "just bored". But when he got to the hospital he refused to tell anyone what it was, just that "it" had been there for several hours. An X-ray showed . . . something round. A CT scan also showed something. Round. I looked at a picture of the scan and could not figure out what the hell it could be. It looked to me like the head of a toilet brush:

Dr. T just laughed harder and had to stop to wipe his eyes. No, not a toilet brush. Not even close.

He took the patient to theatre, and once he was under anaesthesia he was able to feel the object. It felt rough though somehow also smooth and supple. Organic, one could say. He couldn't get his fingers around it, and regular graspers kept slipping off. So he tried a larger grasper and was able to gain purchase on it, but then the thing tore.

Shit.

He grabbed it again and tore it again. And again. Finally after several attempts he managed to spear the object, and was able to extract it in its entirety:

If you're wondering, this wasn't a little clementine or tangerine. No, this was a big orange. A really big orange. According to Dr. T, the only thing that allowed him to remove it was the fact that the patient was "a professional".

And with that, tears streaming down his face, Dr. T defeated me soundly.

But I will have other opportunities.

Until next time, Dr. T. Until next time.

No good deed

I'm sure you've all heard the phrase "No good deed goes unpunished". If you haven't, you really need to get out and/or read more. Seriously. Anyway, it is typically said in a sarcastic way after something bad happens after you've done something nice ("I raked my neighbourss leaves and then watched as they were strewn all over the yard by their obnoxious children"). Sometimes, however, the phrase can be taken literally.

Like with Ted (not his real name™).

Ted is an auto mechanic and the nice guy of the neighbourhood. Though he had a large beard and unkempt hair and generally looked like my usual Friday night assault victim, Ted was quiet, kind, and respectful, proving once again that you shouldn't judge a book by its cover (read: I shouldn't be an idiot and prejudge people based on their looks because I'm too often wrong).

Ted is the guy who would fix your blender if it stopped working, clean your gutters when they got clogged with leaves, and change your tyre while you were at work. You know, just because. He is a true Nice Guy, that one-in-a-million fellow that you hope to find next door when you move to a new house.

So when one of his neighbour's needed a new engine for his car, of course Ted volunteered not only to buy him a new engine at his cost, but also to install it for him at no charge. All he asked was for his neighbour to reimburse him the cost of the engine.

Apparently that wasn't good enough.

After the job was finished, Ted presented his neighbour with his now-functional car and asked him to pay him for the engine. Not for labour and not for his time (which would normally be approximately an arm and a leg), just for the engine. The neighbour bafflingly said no.

Ted was confused, as I think anyone in his right mind would be. Still being a Nice Guy, Ted asked again, nicely. The neighbour refused again (somewhat less-than-nicely) and stormed off.

Ted was still confused. Obviously.

The neighbour returned a short while later with several friends in tow. I have no idea what the neighbour could have possibly told them ("This fucking guy actually wants me to PAY for my new engine that he bought and then installed for me for free! What an asshole!"), but I suspect Ted was expecting him to be bringing payment.

Ha. No. The group of men proceeded to beat Ted half to death resulting in:

• fractured mandible
• seven fractured ribs
• two punctured lungs
• fractured nose
• forehead laceration
• knee laceration
• ear laceration

Ted needed surgery for his mandible and bilateral chest tubes to reinflate his lungs, and he spent nearly two weeks in hospital recovering. But no matter how much pain he was in, regardless of the fact that he couldn't open his mouth after his jaw was wired shut, he always took the time to say "Thank you, Doc" and tell me how a great a job the nurses were doing.

Yes, Ted truly was a Nice Guy.

I saw him in my office a week or so later for follow up. The first thing he did was give me a bear hug (again, despite his broken ribs) to thank me for saving his life, which I didn't really do and tried to explain to him. He was never in a whole lot of danger of dying, though I suppose if I hadn't put in the chest tubes that was possible. Regardless, Ted looked great and was feeling great (relatively speaking), and though I didn't ask, that's when he told me the whole story of how he got hurt.

The neighbour is behind bars. The friends are behind bars. And Ted is back to being Ted, fixing refrigerators and painting fences. And just before leaving (and after giving me another bone-crushing hug), he said he would invite me to his house next time he brews up a batch of beer. And I absolutely believe he will.

And I believe I will take him up on that offer.

Really REALLY over?

I am not a lawyer, nor do I claim any specific expertise in any field having to do with law. But I do know what the word "dismissed" means, and I do know what the phrase "with prejudice" means, so when I saw these words in a Request for Dismissal, written by Bruce Brusavich (who happens to be the lawyer representing Jahi McMath's mother Nailah Winkfield), and submitted to Alameda County Superior Court on September 7, 2018, my eyes got a bit wide.

In case you aren't quite following, it appears that the Jahi McMath saga may finally finally FINALLY be over. Professor Thaddeus Pope posted this document to his website:

Again, I claim no expertise in law, but this certainly appears to me to be a request by Nailah Winkfield to dismiss all complaints against Dr. Rosen with prejudice. This means case closed, never to be reopened, etc.

If that is in fact true, I have no doubt that the two sides reached a settlement, which I (and everyone else) have predicted from the very beginning. I am also not surprised that there has been no media coverage of this whatsoever. I am also not the least bit surprised that no autopsy results have been produced, as I highly suspect Ms. Winkfield would never have let an autopsy happen. As the world learned with Terry Shiavo, autopsy results can refute family members' claims better and more soundly than any expert.

If any lawyers happen to come around, I would appreciate some verification on this. But to my untrained and extremely amateur eyes, it appears the Jahi ordeal is finally, actually, really, and in all other ways over.

Until the next one happens.

A tale of two patients

It's been over two months since I wrote anything, which is by far the longest interregnum I've ever taken.  And by "interregnum" I mean "I've been too goddamned lazy and/or distracted to sit down at my computer and get some writing done".  Sure, I've seen many blog-worthy patients in the past 8 weeks, but I've just had some trouble framing them into what I thought would be an interesting story.

Until now.

I'd like to present a pair of patients whom I admitted on the same date just a few hours apart.  Both were seriously injured and both spent considerable time with me recovering.  But I found the differences between the two rather startling.  So for this post I've decided to do something a little bit different and see who can spot the differences.

Ready?

Let's begin.

Patient 1: Ivan (not his real name™) was the victim of a hit-and-run pedestrian accident.  He was walking home from work when a car struck him at high velocity.  He suffered a complex fracture of his left tibial plateau, a right humerus fracture, an open right ankle fracture, several broken ribs, and a ruptured urinary bladder.  I performed an exploratory laparotomy and repair of his bladder laceration, and an orthopædic surgeon performed a surgery for his humerus, two surgeries for his right ankle, and 3 surgeries for his left knee (so far).  He had an external fixator on his left knee for several weeks while his œdema improved before his final two surgeries, he had an uncomfortable urinary catheter in his penis for several weeks while his bladder healed, and he was unable to bear any weight on his right (dominant) arm and both legs for 2 months.  In short: he was broken.

Patient 2: Tera (not her real name™) was driving her car down a dark road at night with a blood alcohol level over twice the legal limit when she went off the road and struck a tree.  In the process she fractured her left acetabulum (the socket of the hip) and a bone in her right hand.  She required one surgery on her left hip and was unable to bear weight on her left leg for 6 weeks (no surgery was required for the right hand).  In short: she was mostly fine.

Every day that I went to see Ivan, he was kind, respectful, and polite despite his multiple injuries and significant pain.  "Thank you, doctor" was his closing statement each morning as I walked out of his room.  Even though I had cut him open and inserted a large, uncomfortable tube into his penis, he thanked me.

On the other hand, every day that I went to see Tera, she had nothing but complaints.  The nurse took too long to get my medicine (20 minutes), the nurse took too long cleaning me up (15 minutes), it's too hot (it wasn't), my leg is swollen (it's broken, of course it is), my splint on my hand is too tight (it wasn't), it took too long getting back from getting X-rays (30 minutes), no one is telling me what's going on (yes I was), I want to be transferred to another hospital.

Anyone see the difference yet?

I sure did.  As I walked from one room to the other day after day, the difference in their attitudes astounded me.

Tera (who you will remember caused her own injuries by driving drunk) did nothing but complain.  She even refused physical therapy on multiple successive days because of pain despite the fact that it was the only thing keeping her in hospital.  I wanted to suggest to her nicely (read: scream in her face) that she had a team of people whose entire job was to take care of her so she could try showing some basic gratitude, but I didn't.  No, I just listened.  Standing there and listening to her many grievances was a far, far better thing that I did than I had ever done.  And yet she never once said "Thank you".  She showed no appreciation or gratitude at any time before I finally was able to send her to rehab.

Ivan, on the other hand, who was much more severely injured through no fault of his own, who was completely unable to walk, who had a catheter hanging out of his penis, who had three broken limbs, and who had a huge incision on his abdomen, was still able to smile and cooperate and participate with his own care.  No matter what was asked of him, no matter how much pain he was in, Ivan simply gave a weak smile, said "Ok", and then did it (or at least tried).

Look, I understand that no one wants to be in the hospital.  My patients are in pain and I'm asking them to get out of bed and walk.  I get that.  But all I ask for is a little civility and a little gratitude.  Trust me, I don't want to be seeing your obnoxious drunk ass in the trauma bay at 2 AM either or repairing your bladder at midnight, but here we both are.  So let's try our damnedest to make the worst of times into the best of times.

Finally over

It's over.  After nearly 5 years, the Jahi McMath saga is finally over.

Almost.

If you aren't aware of the Jahi McMath story, then you obviously have not been reading this blog very carefully, because I have written about her rather extensively, first here, then here, here, here, here, here, here, and most recently here.  The short version is that Jahi was a 13-year-old girl who underwent a series of upper airway procedures for sleep apnoea in December 2013 which was complicated by bleeding, cardiac arrest, anoxic brain injury, and brain death.  Jahi's family refused to accept the diagnosis, and thus began a battle between Jahi's mother, Nailah Winkfield, and Children's Hospital Oakland over whether Jahi was really brain dead (she was) and what should have been done with her (nothing).

Eventually Nailah and CHO came to an agreement that Jahi would be released from the hospital to her mother's care, and after moving from California to New Jersey (one of only two states where brain death can be refused on religious grounds), Jahi has remained on a ventilator, completely unresponsive, still brain dead, at a private apartment.

Over the ensuing years there was a report that she had started menstruating, despite evidence to the contrary that she had already had her first period prior to surgery.  There was a video supposedly showing her breathing over her ventilator, despite the fact that in April while she was in hospital she never did.  There were videos released by the family purportedly showing Jahi moving her finger or a foot to voice commands despite radiologic evidence that her cerebral audio pathways were completely destroyed and she had no anatomic mechanism by which that could be possible.  A neurologist rather ludicrously claimed, based solely on these videos, that Jahi was not brain dead, but rather severely disabled.  Despite these claims, Jahi never woke up, never opened her eyes, never showed any sign of life other than a beating heart.

Ever since this adventure began, I've been rather adamantly averring that Jahi was dead and that delaying her burial was unethical and nothing short of cruel to her and her siblings.  There have been a multitude of deniers, people full of hope and wishes and thoughts and prayers, that claimed Jahi would wake up.  Through it all I have continued to maintain that brain dead is dead, that Jahi would never wake up, that no one in human history who was properly diagnosed as brain dead had ever recovered from it, even a little bit.  While that may on the surface seem callous and uncaring, it is in fact quite the opposite.

And though sometimes I don't want to be right, I was right.

On June 22, 2018, over 4 1/2 years after she lost her life, Jahi finished passing on.  For the sake of simplicity, I will refer to this event as her death, even though she actually died on December 9, 2013 and was declared dead on December 12, 2013.  I have known about her final death since it happened, but I decided not to write about it until it was reported in the news out of respect for her family and what they are going through. 

Jahi had been hospitalised several times for various issues, including January and April of this year for some kind of undisclosed "intestinal issue".  I suspect it was intestinal ischaemia (decreased blood flow to the gut), though I cannot confirm this.  She was treated with antibiotics both of those times, and the surgeons seemed unwilling to operate on her.  Finally in early June she was taken to surgery, where they apparently found nothing grossly wrong.  Nailah and her supporters of course declared this as some kind of miracle.  I, on the other hand, knew that it was simply the beginning of the end. 

Jahi started a slow but steady decline since then, including renal failure and lactic acidosis, culminating in disseminated intravascular coagulation, multi-system organ failure, and fulminant liver failure causing uncontrollable bleeding.  She was apparently brought back to the operating theatre for "one last look" on June 22, got back to the intensive care unit, promptly coded, and died.  Again.

It's finally over.

I suspect Nialah will continue her legal battle against CHO, though I would be shocked if CHO doesn't immediately settle the wrongful death lawsuit out of court just to get it over and done.  But Nailah plans to pursue a federal civil rights lawsuit to get the date of death on the death certificate changed from December 12, 2013 to June 22, 2018.  I haven't a clue what she thinks that would accomplish nor how much time and effort this would take away from her caring for her three other children.

I don't know details of Jahi's various illnesses or operations, nor can I divulge how I know this information, nor is that in any way important.  What is important is that Jahi can finally be laid to rest after being abused for so many years.  And her siblings can finally move on with their lives.  And I can finally stop writing about this case. 

Until the next one comes along.

NOTE: I realise it has been over a month since I have written anything here, and for that I apologise.  It isn't that I haven't had any interesting cases, because I have.  However, it has become increasingly difficult to frame my stories in a way that I have not before, and I don't want to risk becoming boring and/or repetitive.

Likely story

I read a little story on the internet some time back (and because it was on the internet, it simply must be true) about a young man who was brought to the trauma bay (not mine) after being shot, and though he definitely looked like he was up to no good, he claimed he was shot while waiting for his grandmother to pick him up to take him to church.  No one in the trauma bay believes his ludicrous story, of course, until Grandma shows up a short while later in her Sunday Best, looking for her grandson to take him to church.

We often joke about what nefarious deeds our trauma patients have been perpetrating immediately preceding their injuries, and I have no idea if that vignette is true, but whether you believe it or not, it makes for a great fucking story.  This story is kind of like that.

Not really.

Mondays are supposed to be slow, easy trauma days.  After all, the Call Gods should be exhausted after harassing the unlucky weekend trauma surgeons for 72 straight hours (Friday counts as a weekday in the Call God Calendar for some damned reason), but this Monday was most definitely not easy.  The chaos started exactly 2 minutes after I walked through the door (fall), and it continued with a new fall or car accident or motorcycle crash every 30 minutes or so for the next 10 hours.  For a while it appeared that I would break my personal record for trauma patients in one shift, but finally right around dinner time it slowed down, giving me just enough time to shovel a cold hamburger (leftover from lunch) into my face before my pager started screaming again:

level 1 GSW 5 minutes

God damn it.

Exactly 12 minutes later (damned rush hour) Ryan (not his real name™) rolled through the door.  Screaming.

Sigh.

"Hi Doc, this is Ryan.  19 years old.  We've found 3 gunshot wounds - one to the right upper chest, looks like an exit wound in the right upper back, and one in the right hand.  Vitals stable, decreased breath sounds on the right.  Got two large bore IV's in his AC's."

"AH GOD DAMN MY HAND DAMN GOD DAMN"

I knew at once Ryan and I would get along swimmingly.

On my initial assessment, his breath sounds sounded clear and equal to me (I don't know how the hell the medics hear anything in those ambulances with the sirens wailing), so I doubted he had a pneumothorax (collapsed lung).  He indeed had a gunshot wound to the anterior right shoulder and a corresponding wound (entry? exit?) in the back of the shoulder.  Fortunately he was moving his shoulder and arm perfectly and had a bounding radial pulse, so I seriously doubted the bullet hit his humeral head or the neurovascular supply to the arm (which is much closer to the armpit).  His hand, on the other hand (har har har) was Seriously Fucked Up.

X-rays confirmed that he had no injury to the bones of the shoulder and no pneumothorax, but what he did have were several broken bones and lacerated tendons in his hand.  As I was consulting the hand specialist, I overheard Ryan giving his story to the police:

"I was sitting in my kitchen eating dinner when I heard a bunch of shots outside, and I guess a couple of them hit me."

Yeah, sure you were, Ryan.  I wonder if they actually expect anyone to believe this bullshit story.

After I patched Ryan up temporarily until the hand specialist could come in, I went back to reassess the last 172 traumas (or so it seemed) who had come in that day, suture up some lacerations, and discharge a few who had managed to sober up.  About 3 hours later I was finally nearly caught up when my pager went off again:

level 1 GSW 7 minutes

GOD DAMN IT.  IT IS FUCKING MONDAY, CALL GODS!

We cleared the trauma bay and readied ourselves for the next young man who was about to arrive.  Or at least we thought we did.

The 67-year-old woman who rolled through the door was not what we were expecting.  Nor did she really look like she had been shot.

"Hey Doc, this is Doris (not her real name™).  She was sitting in her kitchen eating dinner with her grandson a few hours ago when a bunch of bullets came through the window.  I think her grandson was brought here earlier, wasn't he?  Anyway, she has one gunshot wound to the left buttock.  No exit wound.  Bleeding is controlled."

Uh . . .

Ahem.  Hm.

I assessed Doris while eating some serious crow, and all I found was a single wound with the bullet retained in her rather voluminous left buttock.  A CT scan confirmed no serious injuries, and a short while later she was walking upstairs to visit her grandson.  I, on the other hand, had several days of making rounds on Ryan and Doris (who was always there visiting) to remind me just how stupid and wrong my stupid and wrong preconceived notions usually are.

If you're wondering about the three hour delay, Doris initially decided to forgo medical treatment when the medics arrived to pick up Ryan because, as she explained it, her wound wasn't really bleeding, she was walking normally, and she thought a few paper towels would do the trick.  And she was probably right.

Anyway, I guess this story proves once again what happens when you make an assumption: it makes an ass out of you and umption.  Or something.  Whatever, I just need to get some goddamned sleep.  Fuck you, Call Gods.

The Resident, part 2

I can't remember if I promised I would never watch an episode of The Resident ever again, but if I did, I am officially rescinding that promise.  Don't worry, it's for a very good reason.

If you have no idea what "The Resident" is, I urge you to click here and read this.  In short, it is a very terrible TV show written by a very terrible writer about very terrible doctors doing very terrible things.  I got into a bit of a feud with the show's creator and writer, Amy Holden Jones (which is detailed in the post linked above), regarding the blatant and rampant anti-doctor rhetoric that suffuses the entire first episode.  As bad as the pilot was, I told myself I would never watch another episode.

Until now.

Amy seemed to take great offence at my twitter profile picture (if you're not familiar with it, it's right over there).  She seemed to think it was an example of patient shaming and that its use would somehow prevent people who inserted a foreign object into their rectums from seeking medical care.  I have no idea if Ms. Holden has ever had any foreign objects impacted in her rectum, but in my experience with many patients who have, they do not tend to wait long, nor do they allow profile pictures from anonymous trauma surgeons on the internet from finding someone to remove the offending object as quickly as fucking possible.

But I digress.

During my little tiff with Amy a few months ago, she threatened to write an episode of her soap opera that related to shaming of rectal foreign object patients and/or an incompetent trauma surgeon (unfortunately I believe that was in a series of tweets which have since been deleted or which I otherwise cannot find).  I laughed it off at the time.

And I'm still laughing it off, because she did.

Dr. Mark Hoofnagle is a general surgeon in Philadelphia, and he has taken it upon himself to fall on his sword and watch The Resident each week, live tweeting as he does.  It is a very amusing take on the show, and it has also gotten him blocked on Twitter by Ms. Holden.  According to Dr. Hoofnagle's assessment, his past week's episode appears to feature, well, me.  Or at least a very poorly done spoof of someone like me:

What have we learned this week?

I don't know. The Austin plot was basically nonsensical. York was brought back to mock him sexually in front of his mother, and I think, they might have been making a dig at @DocBastard

— Mark Hoofnagle (@MarkHoofnagle) May 8, 2018

Of course I had to check this out.

Literally 14 seconds into the "Previously, on The Resident" recap, someone says "York, what did you shove up your rectum this time, and this flashes on the screen:

Hmmmmmmm.  Does this look familiar?  No, I can't possibly be seeing what I think I'm seeing.  I'm sure this is just an unfortunate coincidence, right?  Let's move on.

On second thought, let's temper my torture (and yours) and move way on.  In fact, let's skip all the regular soap opera bullshit and just get to the scenes in question.

A woman is struck by an ambulance and brought to the trauma bay, and the trauma surgeon, Dr. Nolan, somehow diagnoses a ruptured diaphragm from a pelvis X-ray.  I'm trying my best to ignore the pseudo-medical bullshit, so I'll simply say that while this is a major injury, we see this regularly and repair them routinely.  Dr. Nolan, however, appears confused by the diaphragm rupture, so instead of, you know, fixing it like a trauma surgeon, he calls in Dr. Austin, a cardiothoracic surgeon, to do it.  "He'll probably . . . save her life", he says.

Wait, what??

During the surgery, the trauma surgeon stands on the opposite side of the room looking at the monitor while Drs. Austin and Bell (the dangerous surgeon from the pilot) perform the trauma surgery.  Sigh.  Austin finds a lacerated spleen.  "Do you need a trauma surgeon, or . . . ?" the trauma surgeon meekly asks.  "NO", Austin replies while Nolan pathetically holds his hands in front of him, turns around, and wanders away like a chastised child.  He then stands idly by as Austin and Bell do . . . something to stop the spleen from bleeding.

I had to skip about 30 minutes of routine soap opera bullshit to get to the part I was seeking.

Dr. Austin is doing an aortic valve replacement on a nice old lady (who happens to be the mother of York, the rectal-foreign-object patient from earlier) and who, of course, codes on the table and appears to be in imminent danger of dying.  Austin coolly stands in the corner with his arms folded during the code and calls for . . . Nolan, the trauma surgeon.  When asked why he's calling for a trauma surgeon when there is no trauma, he replies gruffly, "I have my reason".  Nolan comes in a few seconds later, hands scrubbed, ready for surgery.  "I'm here.  What's going on?  What do we got?" he asks as he bursts through the doors.  He looks around confused.

"Am I needed for this surgery?" he asks hesitantly.

"No you are not needed for this surgery, Dr. Nolan", Austin chides.  He doesn't need a trauma surgeon, he merely makes him look like an idiot and uses him as an example of "someone who listens, who learns, and who understands", whatever the hell that means.  Understands what?  I have no idea, even after watching the scene five times.  Nolan then starts to quote Nietzsche before Austin cuts him off with, "You've served your purpose.  Now get out."  Nolan again turns pitifully and leaves.

Cut to advertisement.  That's the end of our trauma surgeon experience on The Resident.

I  have no idea what this scene was supposed to represent or what the message here was other than "HAHA, look at this idiot!  Trauma surgeons are totally lame!"  The scenes seem to have been poorly cobbled together for the sole purpose of making the trauma surgeon look bad, and by extension to make me look bad.  It is yet another glaring example of Amy Holden's utter contempt for doctors.

I find it amusing and rather pathetic that Amy Holden would go to these lengths to prove a point.  What that point is, I'm still trying to figure out, but I strongly suspect she watched the episode back and said, "There!  I sure showed him!"

Perhaps I'm over-reading this.  Maybe I completely misread the message being delivered.  Maybe I'm just really egotistical and this has absolutely nothing to do with me whatsoever, and the bottle-in-the-rectum X-ray and the feeble trauma surgeon appearing in the same episode just a few months after our spat are nothing but a huge coincidence.  Maybe Ms. Holden had this episode written years ago and has just been biding her time, waiting for the opportunity to present it.

But I somehow doubt it.

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.

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.

Jahi

I tried my best, I really did.  I've seen the article, I read it, and I tried to ignore it.  I had fully intended to leave it alone until I had some more actual information, and just like anything else, my resolve was firm until it wasn't.

Many of you know exactly what I mean, but for those of you shaking your head and wondering exactly what the hell I'm talking about, you obviously missed the title.  Yes, I'm talking about the article about Jahi McMath in The New Yorker magazine titled "What Does it Mean to Die".  In case you haven't read it, click the link, read it, and then come back.

No seriously, go read it.  Yeah yeah yeah, I know it's long!  JUST READ IT.

Done?  Good.

If you're anything like me, the first thing you noticed was the pictures.  There aren't many, but there is one very-obviously-posed picture of Jahi looking quite bloated though peaceful in her bed covered by an "I believe in Miracles" blanket, her mother leaning in talking to her, her step-father looking on and smiling, and her little sister peering in through the doorway.

Give me a break.

Much more striking than how Jahi looks is the overriding racial overtones that are pervasive throughout.  The article starts with this little tidbit from Jahi's mother Nailah in the fourth paragraph:

Just two paragraphs later we get this quote from Nailah's mother Sandra:

Is any of this true?  I wasn't there, so I can neither prove nor disprove these allegations.  However, the procedure was performed at a world-class children's hospital (in a city that has a larger black population than white), not a run-of-the-mill facility or some rural clinic.  I obviously can't disprove it, but I find it all but impossible to believe.  And of course the doctors and hospital in question cannot defend themselves due to privacy laws.

The article goes on to explain how Nailah failed to understand how Jahi could be pronounced dead even though "her skin was still warm and soft and she occasionally moved her arms, ankles, and hips".  This was doubtless explained to the family dozens of times both in the immediate aftermath and in the ensuing four years.  I've written about it here multiple times, though I have a strong suspicion they haven't read it.  Maybe they should.

Anyway, the article then delves back into thinly veiled racism with this passage:

And then:

Probably not surprisingly, Dr. Williams remembers the conversation differently (though her contradiction is not further explained in the article).  Unfortunately it gets even worse in the very next paragraph:

Sigh.  I nearly put the article down and stopped reading at this point, because the slant was plainly obvious.  However, Jahi's story was not about race, it was about a little girl who suffered a horrible post-operative complication and died.  It was never about race until they made it about race.

The next portion of the article is a retelling of the legal struggles Nailah went through and how she eventually got Jahi out of California to New Jersey, where she remains to this day.  It isn't until over 3000 words later that we finally get into the heart of the issue - what it means to die (you know, the title of the damned article).  The author goes into the history of how brain death criteria came into being, and she unfortunately delves into the seemingly true (yet demonstrably false) assumption that brain death was somehow invented in order to facilitate organ transplantation.

It would have taken the author 0.211 seconds (I timed it) to find an article from the Journal of Medical Ethics written by Dr. Calixto Machado (a name that should sound strikingly familiar to anyone who knows Jahi's case and who is mentioned later in the article) in 2007 that directly refutes this point.  The title is rather unambiguous: "The concept of brain death did not evolve to benefit organ transplants", and the main point is summarised quite concisely in the introduction:

It is commonly believed that the concept of brain death (BD) evolved to benefit organ transplantation.  Nonetheless, a historical approach to this issue will demonstrate that both had an entirely separate origin.  Organ transplantation was developed thanks to technical advances in surgery and immunosuppressive treatment. Meanwhile, the BD concept was developed thanks to the development of intensive care techniques.

Later the article explains how Jahi has supposedly developed the ability to move her hand and foot in response to verbal commands.  This claim is based on a series of videos that have been corroborated by exactly no one, yet they somehow have convinced neurologist Alan Shewmon to declare that she no longer meets brain death criteria.  What the article fails to mention is that Jahi had brainstem auditory evoked potentials performed back in September of 2014, which revealed that there was no auditory pathway, making it therefore an anatomic impossibility for her to hear anything.  She simply has no neural pathways that can allow her to hear the commands to which she is supposedly responding.  This hearkens back to the Terry Shiavo case, where her parents insisted that she could see them and respond to them, but an autopsy later revealed that her visual cortex had been destroyed, rendering her completely blind.

Just like with Jahi, Terri's parents had "video evidence".  Just like with Jahi, Terri's parents believed that Terri was interacting with them.  And just like with Jahi, Terri's parents were wrong.  What you can't see in Jahi's video clips (but can with Terri's) is the presumably hours and hours of footage it took for Nailah to get these cherry-picked video clips.  I have no doubt that Nailah saw Jahi twitching her hand and foot and recorded as much footage as she needed to get exactly what she wanted.  There is an excellent explanation here about why we have no reason to believe these videos.

However, the part of the article that caused me to groan the most was this:

Really?  REALLY?  She just so happened to have that conversation with her kids the previous year?  And Jahi just so happened to say "Keep me on one of those"?  Apparently we, the readers of this article, are expected to be too stupid to see right through this.  We're supposed to believe that Jahi asked for what her family is doing to her.  That she wanted this existence. 

No.

Of all the things that have never ever happened, this never happened the most.

Four B's

NOTE: I realise I have not posted anything in three weeks.  I'm sure most people don't give a rat's ass, but there may be one or two of you who have been wondering if I'm ok.  Yes.  Real life, you know.

I may have mentioned it before, but there are four B's that I just don't do in trauma: bones, brains, burns, and babies.  Bones I leave to the orthopaedic surgeons, because while I thoroughly enjoy working with saws, hammers, and chisels, I much prefer wood to bone.  Bone is just too brittle, and wood doesn't heal.  Or bleed.  Brains are a different animal altogether - no one understands how the brain works or heals, so how the hell could I try to operate on an organ that I don't understand.  Burn patients require way too much personalised care and attention, and I just don't have the attention span for that.

And then there are babies.  I don't like working with children.  Don't get me wrong, I love children.  I love my own more than anything else in this world (with the possible exception of Mrs. Bastard), but that probably explains exactly why I don't enjoy paediatric trauma.

Ok, reading that last sentence back I probably could have worded that better.  No one enjoys seeing children get hurt, but goddammit you know what I mean.

No matter how much I dislike and try to avoid paediatric trauma, and in spite of the fact that there is a paediatric trauma center less than 30 minutes from mine, every now and then I still get one.  Some parents (and some ambulance drivers) bring their children directly to me because it is the nearest hospital.  And that is exactly what Cyrus' father did.

Even the overhead page of "Level 1 trauma now" sounded somewhat harried and panicked.  Nah, that's probably just your imagination I thought as I walked down.  My Inner Pessimist reminded me that most "Level 1 traumas now" are gunshot or stabbing victims that have been unceremoniously dumped, close to death, on our doorstep.  But not this one.  This was a fall, which was unusual.

Unfortunately all of our trauma bays were occupied by other patients when Cyrus (not his real name™) was brought in by his father.  Dad was in tears as he laid Cyrus carefully on our gurney in the hallway.  He was seven years old, just a few months older (though much, much larger) than my own Little Bastard.  His eyes were closed, and he wasn't moving.  While that sounds ominous, it usually isn't.  But it could be.  And the last several decades of working in trauma have taught me that making assumptions in my line of work is generally a Very Bad Idea.

I asked Cyrus' father what happened, and he explained that he had been running away from a neighbour's dog when he tripped and fell, hitting the back of his head on the ground.  He had initially been a bit dazed, but he promptly vomited and passed out.  And he hadn't said a word since.

Whenever I hear any sort of "trip and fall" story with a child, my brain immediately snaps to potential child abuse, but not this time.  I have a very good feeling about this sort of thing, and it was entirely evident that this was simply an accident.  I did a detailed physical exam (as best I could in the hallway), and my first finding was a contusion on the back of Cyrus' head.  This isn't necessarily a big deal.  But just as I was about to explain to his father that this was probably a simple concussion, I looked at his pupils, which were unequal.

Oh, shit.

I very calmly explained to Cyrus' father that while this may be just a concussion, I was worried that something much more serious had happened in his brain.  We brought him straight to the CT scanner, and less than 5 minutes later I saw exactly what I did not want to see:

Blood.

Cyrus had a significant subdural haematoma on the right side of his brain exactly opposite his scalp contusion, something called a contrecoup injury.  As if that weren't bad enough, there was enough swelling in his brain already to cause the right cerebral hemisphere to start pushing towards the opposite side.  This is a sign of severe oedema and an indication for surgery to relieve the pressure.

I took one deep breath, knowing I was about to give a man the worst news he's probably ever gotten in his life.  I carefully and thoughtfully tried to explain as best I could what was going on, but I think as soon as he heard "severe brain injury with bleeding", he tuned out everything else.  While I was explaining the situation, my brain thought of only two things:

1. This could have been my son, and
2. I need to get this child to the paediatric trauma center NOW.

Our neurosurgeon was about 30 minutes away, and it would take less time to airlift Cyrus to the paediatric trauma center while they readied their operating theatre and got their neurosurgeon to the hospital.  

An hour later Cyrus was out of our hospital.  And that's the last I heard of him.

Thankfully I had no new patients come in for several hours afterwards, because my brain was stuck thinking about Cyrus and my own children.  This was a simple freak accident, but this adorable little boy could potentially die from it.  There is no reason for me to think the same couldn't happen to one of my children, and it made me consider ensconcing them both in bubble wrap permanently.  I know, I know.  Accidents happen, they are unavoidable, they could happen to anyone, that's why they are called "accidents", etc etc.  I know these things.  I KNOW them.  But my brain won't allow me to rationalise it.

This is why I don't do kids and why I respect the hell out of anyone who can.  Because I can't.

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 artery.  SHITSHITSHITSHITSHIT  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.

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.

There are two other major details that many people don't seem to know:

1. People who get the flu despite getting a flu shot have been shown to have a less severe course.
2. The flu shot has been shown to reduce complications and death in people (especially elderly people over 65) who still get the flu.

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.

The Resident

I recently got into it with a TV writer on Twitter.  Well, that isn't exactly true.  What really happened is that she said something wholly offensive and completely bullshit, I called her out, and she responded with some almost-worse backpeddling bullshit which I couldn't see because she simultaneously blocked me like a fucking coward.  What she actually said that incensed me I'll get back to (I promise), but who she is is somewhat more important.

The writer in question is Amy Holden Jones, who happens to be the screenwriter for "Indecent Proposal" and "Beethoven".  She also is the creator of the new Fox television series "The Resident", the newest in a series of unfortunate medical dramas that have splatted on our televisions for the past several decades.  I call them unfortunate because they all invariably fall into the abyss of Bullshit-In-The-Name-Of-Drama rather than attempt even a modicum of veracity.  It is the reason I could never watch House MD for more than five minutes without turning it off - there would always be some kind of "OH COME ON!" moment that was so full of ridiculousness that I simply could not tolerate it any further.

So after my nasty little interaction with the creator of The Resident, I decided to sit down and watch the first episode, which Ms. Jones also happens to have written.  I'm not the first doctor to do this, nor (I'm sure) will I be the last, but after seeing what Ms. Jones had to say about doctors (yes, I WILL get to that, I promise), I wanted to see how she wrote about them - what they say, how they act, etc.  Keep in mind I had no idea what the show was about when I sat down, though I suspected it was about a resident (ie student doctor, junior doctor, etc).  Obviously.  I'll be writing this live as I watch, something I've never done before.

Strap yourselves in.  I don't expect this to be a smooth ride.

The show starts in the operating theatre during what appears to be an open appendectomy, soft classical music playing in the background.  At least the lights are on.  So far so good.  Someone (a student?  A resident?  THE resident?  I have no idea) mentions it's her first surgery with this surgeon (so what?), and someone else (a nurse carrying a clipboard for some reason?) says she has to get a picture of the occasion.  What?  Weird.  She summons the anaesthesiologist from around the curtain (WHAT?), which prompts the surgeon to tell them "That is totally inappropriate".  I found this line startlingly accurate, because I expected him to pose along with them and yeah, that's completely inappropriate.  "Aw, we're just having fun!" the anaesthesiologist replies, which of course is the first "OH, COME ON!" moment of the episode, and we're only 30 seconds in, people.  The bullshit gets instantly worse when the patient wakes up, opens his eyes, and starts to move while they're all busy taking selfies.

OH, COME ON!

The anaesthesiologist runs back, but the surgeon, who is inexplicably still holding a scalpel in his hand (what does he expect to be doing with that at that point during the surgery?), nicks something right on the surface which starts squirting blood onto his face and gown.  OH, COME ON!  The bullshit gets EVEN DEEPER when this senior surgeon (who turns out to be the Chief of Surgery, by the way) freezes, apparently lost for ideas (like, you know, stop the fucking bleeding).  The nurse with the clipboard says "YOU HAVE TO CLAMP SOMETHING!" because no one else has thought of clamping something, and apparently she somehow knows that the patient has lost two litres of blood already (in literally 20 seconds) and the surgeon has no idea what to do.  Exactly one second later (yes, really) the anaesthesiologist announces the patient has lost his pulse and is in PEA arrest, (OH, COME ON!) and the surgeon starts CPR - on his abdomen.

OH, COME ON!  

"CPR isn't going to put all that blood back into his body", the clipboarded nurse says sadly as the surgeon performs his worthless abdominal compressions.  Exactly seventeen seconds later (yes, really) the anaesthesiologist says "It's no use", and the surgeon stops.

DRAMA.

"He is so dead!" says the dramatic nurse dramatically.

HAHAHAHAHAHAHA!  No seriously, the actual line that Holden wrote for this nurse is "He is so dead."  HAHAHAHAHA!  DRAMA.

Everyone dramatically takes off their masks and gloves, and after a few glances across the room, the surgeon announces, "Well I think we can all agree it was the misdosed sevo {sevoflurane, an anaesthesia drug}".

WHAT??  Sure surgeons try to blame anaesthesia all the time (mostly joking), but not right in front of everyone!  Oh don't worry, it gets worse.

The anaesthesiologist tries to argue it wasn't his fault because the surgeon had the scalpel in the field (true), but the surgeon instantly reminds him of another patient whose oropharynx he "ripped through" on a routine intubation, and he had covered for him then.

WHAT???!?  What the ever living fuck is this supposed to be?  Doctors don't cover up other doctors mistakes, especially in front of the entire operating team.  We have morbidity and mortality conferences where we actively discuss mistakes, both serious and common, and everyone learns from them so that mistake doesn't get made again.  We don't do quid pro quo where if I fuck up you cover for me, so that gives you a Get Out Of Fuckup Free card the next time you make a fatal error.  This is such egregious bullshit I am absolutely livid and frankly shocked that this made it onto television.

IT GETS WORSE.

As the members of the surgery team all discuss the situation, the nurse says "We're all on the same team here . . . right?", with the clear implication that they all need to cover for each other.  Someone else says, "Maybe he had a heart attack?"  WHAT???  The surgeon shuffles away as the anaesthesiologist looks at the chart and tremulously says "Yes, there's . . . some family history of heart disease."  "Yes," the nurse says definitively, "his left main {coronary artery} clogged.  Sudden cardiac event."

WHAT?!!!?

"That's right, that's exactly right.  There's no way to prevent this," says the surgeon.

ARE YOU FUCKING KIDDING ME??

CUT TO MAIN CREDITS.

That's right, we are that chock full of some of the most putrid, absurd, repugnant blather I've ever witnessed on television, and we're only 4-and-a-half minutes into this travesty.

And we STILL haven't even met The Resident yet.

If you're worried the bullshit starts to lessen as the episode progresses, you're in for a huge disappointment.  In the next scene Devon (The Resident) meets Conrad, his senior resident, who quite authoritatively tells Devon The Resident that he has to do everything he says or he can remove him from the program (uh, no you can't - you're both residents).  If that weren't bad enough, Conrad gives Devon The Resident a code blue on his very first day as a doctor.  Uh, no.  And then Connor slaps Devon's cheat sheet away when Devon tries to reference it.  You know, so he doesn't kill the patient.

OH, COME ON!

The one bit of truth in this episode comes in the next scene when Conrad chastises The Resident on continuing that code for too long, which ends up regaining the patient's heartbeat but leaves her brain dead (Jahi McMath, anyone?).  "All we want to do is help our patients, but what they don't teach us in medical school is there are so many ways to do harm", Conrad philosophises.

Ouch.  Very true, but very ouch.

But just when I thought the bullshit was over, it jumps right back into it with a wealthy philanthropist awaiting robotic prostate surgery which is to be done by a visiting second year resident (WHAT??), though the philanthropist wants The Surgeon to do it even though he's never even touched the robot before, not to mention the fact that prostatectomies are actually be done by urologists, not general surgeons.  This is a most basic fact-checking failure that anyone in the medical field, even the radiation oncologist who created the show with Holden Jones, should have picked up.

But then Holden Jones finally shows her true colours, her agenda behind this absurdity.  As The Resident worries over his brain dead patient's future and if there will be an investigation, a nurse (who happens to be Conrad's ex-girlfriend - DRAMA) tells him the hospital will probably give him a medal because they will bill thousands of dollars every day she's in the ICU.  Because, she explains, "It's a huge payday for them.  Medicine isn't practiced by saints . . . it's a business."

IRE RISING

If that weren't bad enough, the nurse goes on to tell The Resident of a surgical error that killed her mother after a routine test gone awry.  "This happens all the time, Devon.  Medical error is the third leading cause of death in the United States after cancer and heart disease."

Ok, fuck you Amy Holden Jones.  FUCK YOU.

I'd like to address this "third-leading cause of death" myth before I go further.  I see anti-medicine people use this "statistic" all the time, always in an attempt to make doctors in general look bad, and it drives me fucking bonkers.  Fortunately I don't really have to address it fully, because Dr. David Gorski, a surgical oncologist and prolific medical blogger, has done so already.  Long story short: no, medical error is NOT the third-leading cause of death, not by a long shot.  The only reason Holden Jones could have possibly included this line in the show is to make doctors look bad.  That is the only reason.

I had a very strong feeling that Holden Jones had an anti-doctor agenda when I started watching, but I never in a million years thought she would just put it right out there on a silver fucking platter.  The reason I had that feeling was the tweet I alluded to previously.  This one:

It's all there in black and white, a very real and very libelous declaration that cancer doctors are nothing but money-hungry ghouls who are paid kickbacks (which are illegal) to prescribe toxic chemotherapy to patients, even when it is no longer indicated.

ARE. YOU. FUCKING. KIDDING. ME.

Holden Jones tried to defend this indefensible statement by giving an example of one unscrupulous cancer doctor who made money by giving chemo to patients who did not need it.  Yeah, that guy was an immoral asshole who abused patients and deserves every minute in prison that he got.  But one example does not describe all the other oncologists around the world who chose that specialty knowing they would be dealing with some of the sickest patients, who have dedicated their lives to a specialty that can help many but save few.

On behalf of oncologists everywhere, I called her out on her bullshit:

No, oncologists are NOT paid kickbacks for giving chemo, nor are they money-hungry ghouls who give toxic drugs to sick cancer patients just to line their own pockets. This tweet is disgusting, offensive, and embarrassingly wrong. Delete it. @aholdenj @FOXTV https://t.co/UAnX4tE93Z

— Doc Bastard (@DocBastard) January 25, 2018

Unsurprisingly she did not seem to take this well, as she immediately blocked me.  She did, however, respond to me before doing so (not that I could actually see it):

Unclear?  No, Ms. Holden Jones, it was not unclear in the slightest.  What you said is a vile lie and it exposed your true motive behind your writing.  You made your anti-doctor sentiment more than clear through your tweets, but you managed to crystalise them very nicely with your bullshit script on your bullshit show.

If you're looking for some risible anti-doctor soap opera twaddle on which to waste an hour a week, look no further than The Resident (apparently there are more episodes to come).  But if you'd like an interesting new television series that won't make you want to punch your television, set it on fire, bash it with a sledgehammer, throw it in a wood chipper, and never watch it again, try Black Mirror, Stranger Things, or Star Trek: Discovery.  Or get into Game of Thrones.  You still have at least a year before the final season starts.

And if you're wondering, no I will not be watching episode two.

EDIT: Let me make one thing abundantly clear here.  I am not upset that the show features typical television-medical-drama-bullshit.  I was not looking for a scientifically accurate program, and I certainly did not find one.  What pissed me off is the anti-doctor rhetoric that was rampant throughout this episode (and that apparently features prominently in another episode, as was told to me by a reader).