Tuesday, 12 February 2019

Recognition

Though I live in a relatively small enclave of a much larger city, there are still occasions where I will see someone I recognise. It could be hospital staff, another physician, a nurse, or a patient or their family member. One of my patients several years ago (whom I did not recognise as first) turned out to be a woman who lived just a few houses down from me. It is usually difficult for me to identify a familiar face, because while I am good at recognising the face, I am terrible at coupling a name or place to it. But there are some faces that just stand out for whatever reason, and these faces tend to belong to people who, for one reason or another, have made an impact on my brain.

Yes, that's foreshadowing.

It was right around lunch time, which my stomach kept reminding me by attempting to digest itself (or so it felt and sounded), when Paolo (not his real name™) was brought to me in a heap of mud and vodka. According to the ambulance crew, Paolo had thought it would be a really fantastic idea to drink heavily during his lunch break at work and then drive his van off the road, causing it (and him) to roll over several times. I have to assume his right foot tumbled partially out of the window as the vehicle rolled, which caused it to get crushed between the van and the road and mangled both the foot and the van nearly beyond recognition. It's difficult to describe the carnage I found around what-used-to-be his ankle, but let's just say that there were very few structures I could actually identify as belonging to a human foot. And for the first time in my career, I removed a piece of a pencil from a traumatic wound.

Seriously.

Yet despite his grisly injury, he had surprisingly very little pain as we examined him and found no other injuries (other than a few lacerations on his scrotum. No, I have no idea how that happened). I suppose there is a reason the phrase "feeling no pain" exists.

Anyway, I'll just give you the short-short version: I sutured his scrotum and Paolo lost his leg, but he lived.

Wait wait wait, that's it? 'He lost his leg'? And you sutured his scrotum and aren't going to tell us anything more about that? That's the end of the story? What the hell is this, Doc?

What this is, is not a story about Paolo.

Uh . . . what?

Haha, the old bait and switch! I teased you with what you thought was an interesting story, but I'm swapping it for (what I think is) an even-more-interesting story, which will probably fall flat and be interesting to no one but me.

Alas, woe is me.

Aaaaaanyway yes indeed, this story is not about Paolo but rather about the guy who was taking Paolo's blood pressure, getting him a warm blanket, and reporting his findings back to the trauma nurse. I had no idea who he was. He wasn't one of the trauma nurses, because there were already two of them there and he was dressed in street clothes. He was a young guy in his mid 20's, handsome, tall, long hair, and he had a hospital badge, so clearly he wasn't just some guy who walked in off the street offering to help.

I know this kid, I thought. Who is he? Is he the son of a family friend? A neighbour No wait, is he the guy who replaced my refrigerator motor last year? I just couldn't place him, but he definitely looked familiar. Very familiar.

If anyone had been watching me from across the room, it must have looked as if I were ogling this kid, which I, uh, I guess I was in a way.

This bizarre leering continued for at least five minutes as he continued bustling around helping the nurses and I continued racking my brain for some inkling as to just who the hell he was. Finally, still at a loss, I decided that I had imagined the whole thing and that I didn't actually know him and that he wasn't the guy I saw buying 10 packs of Velcro at the hardware store last week (my mind goes to some rather strange places sometimes). I started berating myself for wasting so much time in this futile endeavor, and right around then the kid finally caught my eye, cocked his head, and smiled knowingly. As he walked up to me holding his hand out for a handshake with a big grin on his face, it instantly hit me, and I smiled back, extended my hand, and said,

"Oh, hello again Theo."

His grin brought it all back to me. I had seen Theo (not his real name™) in my trauma bay almost exactly four years ago to the day. He had been working as a volunteer medic, standing on the side of the road helping the victim of a minor car crash in the middle of the night, when a drunk driver plowed into him and another volunteer at high velocity. Both of them had been brought to me, but Theo was in much worse shape. While the other young lady had a minor fracture of her thoracic spine and a few abrasions, Theo had a horrific open skull fracture and a large subdural haematoma. He underwent surgery to remove a portion of his skull and evacuation of the blood clot and then spent several weeks in hospital before going to a brain injury rehabilitation facility. I remember him as being extremely polite, always willing to participate, always thankful, and always smiling.

He had had another operation several months later to replace his portion of skull followed by many more months of rehab. And now here he was, four years later, completely recovered.

And on his way to nursing school.

Instead of being turned off to the medical field, Theo told me that his experience only strengthened his will to continue his pursuit of helping. Today he was shadowing the trauma nurses and gaining experience for the future. As Theo put it, "As stupid as it sounds Doc, after seeing firsthand what paramedics, nurses, and doctors can do, I just want to give back. Pretty corny, right?"

I didn't think it sounded corny at all. I actually thought it sounded rather wonderful.

Wednesday, 9 January 2019

Falling down

Of all the trauma alerts I get, the most frustrating has to be "FALL". These are usually elderly patients who fight gravity and lose, and their cases are seldom (if ever) satisfying. They typically are uninjured beyond bumps, bruises, and lacerations, though due to their age their recovery from such minor injuries can take several days or even longer. But if they do sustain serious injuries, they tend to be isolated to hip fractures, which I don't treat. The other types of falls (off a ladder, off a roof, off a bar stool etc) usually are from heights of 3-4 metres and are thus mostly uninjured (zzzzzzzz) or have broken ankles, which I still don't treat. All of this adds up to a very sullen me as I trot down to the trauma bay for yet another fall.

So when my pager alerted me to a fall recently (my third one of the day by 10 AM already), I got not a bit excited and tried my best to avoid the trauma bay entirely. I had only had one coffee by then, so I figured maybe the caffeine would elevate my heart rate even if the complexity of the trauma didn't. My Inner Pessimist, however, forced me to walk down to the trauma bay despite my efforts to ignore him.

The bustle when I got to the trauma bay confused me. Normally for low-level traumas the nurses and other staff sort of mill around chatting prior to the patient arriving, but in this case everyone was rushing around getting equipment. For a fall? What the hell is going on?

And about 30 seconds later, Xavier (not his real name™) arrived, and that question was quickly answered.

"Hey there Doc, this is Xavier. He fell off a cliff and . . ."

Wait, wait, wait. He fell off a what? Where the fuck is there a cliff around here??

"Yeah, you know the {Redacted} Cliffs."

Uh . . . no I really don't. I had no idea there were any cliffs in this area.

"Anyway, Xavier fell off a cliff about 30-40 metres. He woke up at the bottom and doesn't remember anything. 

No but seriously, where the hell is there a cliff?

"Ahem. Vitals have been stable though he's breathing a bit fast. He's complaining of pain all over his body."

Yeah, after falling 40 metres down a goddamned cliff I would be stunned if he weren't.

Normally the first thing I do is a full assessment, but my Inner Pessimist was insisting that I google where the fuck this cliff was. I resisted that urge and instead decided to, you know, examine my patient, an idea which seemed only slightly more important at the time. Xavier looked completely miserable. His blood pressure was fine but his heart rate was in the 140's. The most common reason for a high heart rate in trauma is bleeding, the second most common cause is bleeding, and third most common cause is fucking bleeding.  It could also be due to pain or heart injury or drugs, but bleeding is always my first concern. My concern was somewhat higher because his oxygen saturation was in the 80's (normal is 95-100%). 

On my initial head-to-toe assessment he was tender in his head cervical spine, thoracic spine, lumbar spine, chest, left hip, and left arm, though other than some rather crunchy ribs he had no obviously broken bones. His breath sounds were diminished on the left side, indicating that he likely had a pneumothorax (collapsed lung) under those fractured ribs. That concern was confirmed about 60 seconds later when I saw his chest X-ray.

His workup, which included X-rays and/or CT scans of pretty much every single body part (I think I skipped his thymus and right foot), showed that he was fucking broken. Think of a body part - go ahead, just think of one (other than the thymus and right foot, obviously). Yup, you got it, that was broken. He had fractures in his skull neck, upper back, lower back, ribs, hip, arm, and leg, along with his pneumothorax. He would need a chest tube for his lung, surgery for his hip, arm, and leg, and a neck brace and full back brace for his spine, which would not need surgery.

But the main question I had (other than "What cliff?") was, How the fuck do you fall off a cliff? And seriously, what goddamned cliff??

After several rounds of IV narcotics finally successfully controlled Xavier's pain (because of course he had a longstanding history of oral narcotic abuse), I got a chance to ask Xavier what happened. He very groggily told me that he was trying to show his in-laws the {Redacted} Cliffs while they were visiting that morning, and he simply got too close to the edge, lost his footing, and toppled.

This, I thought, is why I will never be out of a job.

As I contemplated the amount of human stupidity that it takes to get that close to the edge of a cliff (which, I learned later, has no guard rail on it), I looked at Xavier's blood work. While there was no major abnormality in either his blood counts or chemistry, his blood alcohol was about 3 times the legal limit to drive, which a quick calculation told me is approximately infinity times the amount of alcohol one should have in one's system while walking near a fucking cliff at 9 in the morning.

Xavier spent about two weeks with me before going home in a wheelchair, but it took me far less time than that to find out where these cliffs were. The moment I got in my car to go home the next morning I whipped out google and discovered that these cliffs are less than an hour's drive from the hospital. I briefly considered checking them out, but instead I decided to drive straight home and give my kids a big hug.

That seemed much more important. The cliffs can wait.