Monday, 25 November 2019

Seat belts

Let's face it, seat belts are a good idea. This statement is in no way controversial, and all who try to argue against it aren't just "expressing an opinion" or "arguing the other side", they are just plain fucking wrong. Seat belts were designed to keep you safely in the car in the event of a crash rather than getting blasted through a window to land on a fence post, over a guardrail down an embankment, or into oncoming traffic. They are a Very Good Idea that have been implemented spectacularly well all over the world (mostly) (fuck you, New Hampshire).

As simple and effective as they are, I can not believe that there are people living and driving today who still don't put them on, but there are. And because these people exist, I get to take care of them.

And then I get to write about them when they are inevitably injured much more severely than they should have been.

Judy (not her real name™) and her husband Mickey (not his real name™) decided to take a break from their door-to-door Xanax business and take a little drive. Now before I continue, please go back and read that last sentence again. I'll wait right here.

*pleasing hold music, but not the boring twaddle you hear while on hold on the phone*

You're back? Excellent hold music, right? Anyway, I assume you read it back at least twice, because I know I sure did, and I wrote the damned thing. Yes, Judy and Mickey had a little neighbourhood benzodiazepine business. They literally went door to door asking their friends and neighbours if they wanted any pills. Where they got these pills is anyone's guess, but I have to assume business was booming because the police officer who came with them described their stash as a "large grocery bag full".

In case you thought that was stupid, what made it even stupider (yes, that's a word) is that they dipped into their own cache and then mixed the pills with alcohol.

And what made it even stupider is that on their break they decided to go for a little drive while drunk and stoned out of their minds.

And what made it even stupider was then choosing to engage in a street race while stoned out of their minds.

And then what made it the stupidest (yes, that's also actually a word) is that they failed to put on their seat belts.

Ironically I can't even fault them for not putting their seat belts on, because they were both too drunk/stoned to keep their eyes open let alone perform a complex task such as inserting tab A into slot B. How Mickey managed to navigate the controls of a motor vehicle is one of life's great mysteries. Regardless, engage in a street race they did, and I believe it is a safe assumption that they lost. Crashing into a bridge abutment at 120 kph (75 mph) in a 50 kph (30 mph) zone will usually lose you any race fairly instantaneously, unless the objective of the race was to see who dies the fastest (or tries, at least).

And because Judy and Mickey were not wearing their seat belts, both were ejected from the car, far, far away from all the various safety mechanisms that had been designed, extensively tested, and installed specifically to protect them. Mickey was thrown through the windscreen, presumably striking his head and/or neck on the bridge or the ground or a tree or it doesn't really fucking matter what. Judy was partially ejected through the passenger window, bending her lower spine at a rather awkward angle.

Both of them were awake when they arrived in the trauma bay. Neither was moving.

"Hey trauma team, this is Mickey and Judy. He's 50, she's 35. They were in a street race, high speed, struck a bridge. He was ejected, not moving anything below the neck. She was partially ejected, moving her arms but not her legs. Doesn't look good, Doc."

No, no it sure didn't.

Mickey had fractured his sixth cervical vertebra, and a portion of the fractured bone had been pushed into his spinal cord, paralysing him from that point down instantly. He also had a few broken ribs, but those would only pose minor problems (relatively speaking). Judy had fractured her first lumbar vertebra, also injuring her spinal cord at that location. Mickey had no motor or sensory function below his neck, and it was a minor miracle that he was still able to breath on his own, since the nerves that control the diaphragm come from just above that level (C3-5). Judy had no motor or sensory function below her waist in addition to a minor laceration of her spleen.

Both required major spine surgery. Both survived.

I had several opportunities to sit and chat with Judy during her two weeks with me. She was actually a reasonably intelligent woman, polite, appreciative, and apologetic (even though she hadn't been the one driving at the time). Mickey, on the other hand, remained recalcitrant despite his quadriplegia. Despite his horrific and life-changing injury, he was adamant that he had only survived because he had been "thrown clear of the wreck". Judy at least understood that remaining in the car with the seat belts and airbags would have been much less harsh on their bodies than, you know, hitting concrete at 1/10 the speed of sound (yes, really).

She too failed to convince him before she went to a spinal rehabilitation facility.

Mickey had some respiratory complications and ended up needing a tracheostomy. He stayed with me for about a six weeks before going to the same spinal rehab facility, arguing the entire time that he still would never ever wear "that damned belt".

I saw Judy about a month later. She had finished her inpatient rehabilitation and was starting to regain some use of her legs. I saw Mickey about two weeks later, and owing only to the quick response of our neurosurgeon had regained near full use of his arms, though he will remain paralysed from the chest down for the rest of his life. But unfortunately that had only strengthened his bewildering belief that not wearing his seat belt had saved his arms. I again tried to explain that, had he stayed in the car and been buffered by the seat belt and airbag, his injuries would have been significantly less, and he may have literally walked away from the accident, but he only cut me off.

"I'll never wear that damned belt. It would have killed me."

I seldom give up, especially when it comes to something as important and life-saving (and simple) as using a seat belt. But after several attempts and an equal number of rude interruptions, I gave up.

And if you're wondering, I have no idea what happened to their Xanax business. I forgot to ask.

Monday, 18 November 2019

Unpredicted

I often look at my pager sitting next to my mobile phone and think, "How the fuck are we still using this 1950's technology in 2019?" But we still unfortunately rely on these outdated, grossly obsolete prehistoric monstrosities. Regardless, if my pager tells me I'm getting a car accident, I can predict that I will be getting some kind of car accident - rollover, car vs tree, car vs car, etc. If it says I'm getting a fall victim, I can predict with at least 90% accuracy that it will be either an elderly person who lost his footing and fell from standing position, a drunk person who fell from standing position, or a construction worker who fell off a ladder or partially completed building. If I see I'm getting a stabbing victim, I can be fairly well assured it will be a young man in his late teens or early 20's. What I do when they get to my trauma bay varies based on the location and severity of the injuries, of course, but the patterns remain the same.

Until they don't.

This particular day's pattern had been falls. Over my previous 42 hours of call (24 from the last shift and 18 from this one . . . wait, carry the 1 . . . yeah, 42), my last fourteen patients had been falls. ALL of them. Elderly falls from standing, elderly fall off a roof (yes, really), elderly fall off a ladder (yes, really), elderly fall off a toilet, elderly fall out of a wheelchair . . . you get the idea. As you may (though probably don't) remember from earlier posts, I don't much care for falls because they are very rarely exciting or fulfilling (though I did have one guy rupture his bladder jumping off a roof while trying to jump into a swimming pool (and missing) several years back, but that's another story). I was beginning to think that everyone over the age of 70 in the entire {redacted} metropolitan area had decided to fall that day, until my pager finally told me my next trauma would be a level 1 stabbing. My Inner Pessimist seemed excited.

YES! FINALLY!

I know, I know.  It's awfully macabre to want someone to get stabbed, but there are only so many nonagenarian falls I can see in one day before going completely insane. Technically I didn't really want anyone to get stabbed, I just wanted to see someone who had been stabbed. Sort of. Technically. Dammit, you know what I mean.

As my team and I prepared for the patient's arrival by donning our personal protection gear (masks, gowns, and gloves, that is, not guns), I was also mentally preparing for said patient to be another 20-something male rolling through the door with various and sundry stab wounds. So you can imagine my surprise when that 20-something male turned out to be a 70-something female. My Inner Pessimist began pestering me:

They made a mistake! This is obviously yet another elderly fall! Will I ever get anything other than a fall? Am I now officially an Elderly Fall Trauma Surgeon?

As these thoughts rolled around my brain and the medics transferred her from their gurney to mine, the blanket fell from around her neck, revealing a large, bloody bandage. My Inner Pessimist refused to back down, trying to convince me "She probably just fell in the shower against something sharp!"

Shut up, Inner Pessimist.

"Hi Doc, this is Bess.  She's 72, stabbed once in the right neck.  No loss of consciousness.  Bleeding is controlled.  It's pretty big though."

Other than my elderly lady several years ago that was nearly decapitated by her seat belt (that's yet another story for yet another time), this was the first elderly female stabbing victim I could remember. Ever.

Bess was stunningly calm for someone with a 10 cm laceration on the side of her neck. She was also completely alert and sharp as a tack, which made her somewhat different than most of my septuagenarian patients. Her laceration was on the posterolateral aspect of her right neck over the posterior cervical triangle. Whew. I breathed a small sigh of relief. If you simply must get stabbed in the neck (which you shouldn't), that's a good place to do it, mainly because the only really important structures in the area are the transverse cervical artery and accessory nerve (and a few sensory nerves), none of which were close to this particular laceration.

There was no active bleeding and the laceration was well above the subclavian artery, and her neurological exam was normal, so I was not worried about any major vascular or nerve injury. I started to tell her that she would just need a whole bunch of stitches when my pager went off again.

Another fall? Nope, another level 1 stabbing, arriving in 2 minutes.

Hey, at least it isn't another fall! That's two in a row! Woo!

Shut up, Inner Pessimist.

Rhys (not his real name ™) arrived exactly 2 minutes later and looked much more like what I had been expecting with Bess - young, male, healthy, thin, and 25 years old. I was back in my comfort zone. Until Rhys started talking. Well, ranting actually:

"I'm Tupac Shakur's son! You hear me? Tupac's son! You can't hurt me! YOU CAN'T HURT MEEEE! Tupac ShaKUUUUR!!!"

Hey, at least it isn't another fall!

SHUT THE FUCK UP, Inner Pessimist. I fucking hate that guy sometimes.

"Ok Doc, Rhys is 25. Healthy, no meds, history, or allergies. Single stab wound to the right upper abdomen, we think self-inflicted. He's been talking like this the whole time. Oh, and he stabbed his grandmother in the neck too."

Yeah. Because that's what you do to, especially to your own grandmother.

Rhys had a single stab wound to his upper right abdomen, directly in The Box.This is a danger zone where nearly anything in the chest and/or abdomen could be hit, depending on 1) where exactly the patient was in the respiratory cycle when the knife went in, 2) the angle of entry, and 3) how deep it went. Heart, great vessels, lung, diaphragm, liver, gall bladder, colon, stomach, and small intestine are all potential targets.

Fortunately (or unfortunately, depending on how you look at it) Rhys had managed to do significantly more damage to himself than to Bess. He managed to lacerate his right lung, right diaphragm, and liver. Liver lacerations (especially penetrating ones) tend to stop bleeding by themselves, and small right diaphragm lacerations rarely need to be repaired. All he needed was a chest tube, a few sutures, and a few days in hospital to make sure his liver and lung stopped bleeding (they did).

Oh, and restraints. And a psychiatrist. And one metric fuckton (that's the technical term) of sedatives.

Rewind to Bess who, on the other hand, merely needed a few sutures and a new grandson. Ok, a lot of sutures. But yeah, definitely a new grandson. Still, she was completely fine, though sporting a new badass neck scar. Though she had no idea why Rhys stabbed her, she nevertheless remained incredibly stoic (though perplexed) as I fixed her up. As I was placing the dressings and giving her her discharge and follow up instructions, she said probably the most grandmother thing any grandmother has ever said in the history of grandmothers:

"I'm still giving him that shirt and tie I bought him for Christmas. It'll look so nice on him."

Thursday, 7 November 2019

Save

I've said it before, but I'll say it again: trauma is usually boring. I know, I make it sound so utterly fascinating here. I mean, if trauma is so devoid of excitement, why do I do it, and even more importantly, why the hell are you people here to share in my banality?

But it is sadly true: the car accidents, elderly falls, and bicycle accidents are just not typically exciting. Sure they may have some serious injuries, but there are only but so many broken ankles and concussions I can see before I feel ready to pack up and go home. Even the penetrating injuries often fail to inspire my intellectual curiosity. Indeed, most stabbings are mere flesh wounds. When I see a stab to the chest in a man who is awake and talking to me, chances are the knife just went into his chest wall, the bleeding is just from the underlying soft tissue, and a few sutures or staples are all that is necessary to staunch the not-really-exsanguination.

Until it isn’t.

Troy (not his real name™) decided that it would be a great idea to take some PCP before engaging in a high stakes poker match. This may not sound like a very bright idea, but that’s only because it isn’t. While I highly doubt Troy’s poker skills were scintillating while sober, they took a noticeable dive after the PCP, probably because he couldn’t tell an ace from a potato. After he lost everything including his shirt (literally (yes really)), the drugs told Troy that the only reasonable thing to do would be to demand his money (and his shirt) back in a language only he could understand. They guy who won both Troy's shirt and money fair and square said no (or something very closely approximating "no"), so Troy and his addled brain said something incomprehensible and then lunged at him. And the other guy predictably whipped out a knife and stabbed him in the chest.

Troy was brought to me in a still-incomprehensible mass of outrage and paranoia, bleeding very mildly from his chest.

“Hey Doc, this is Troy, 26, healthy. Two small stab wounds in the right chest. Vitals have been good, a bit tachycardic, breath sounds are equal. We put some occlusive dressings over the wounds, but they look pretty small and superficial.”

His vital signs were normal other than a slightly high heart rate of 100 which could easily be explained by the PCP, and he indeed had two small stab wounds, about 1 cm each, in his right chest over his pectoralis muscle, neither of which was actively bleeding. I started to assume that this would be just another “staple and go” stabbing victim, but my Inner Pessimist, on the other hand, wouldn’t let me assume anything and began whispering his usual obnoxious sweet nothings in my ear:

He's awfully thin, and you don't know how big the knife was. Maybe it went into his lung. Or his heart. Or his aorta. Maybe he's bleeding to death and YOU JUST DON'T KNOW.

Yeah. Maybe.

But sure enough a few minutes later a chest X-ray showed a haemothorax, a collection of blood in the thoracic cavity.

I hate when my Inner Pessimist is right.

I inserted a chest tube which drained about 800 ml of dark blood, indicating that the bleeding was not from an arterial source, which you can probably imagine would be a Very Bad Thing. The treatment for a simple haemothorax is chest tube drainage for a few days, at which point the tube comes out and the patient goes home. Another patient saved. Huzzah, or something.

But my Inner Pessimist kept pestering me. What about the heart? Maybe it hit his heart! Look at the heart!

What are the odds, I was thinking. But making assumptions in my line of work is both a very bad diagnostic and therapeutic technique. So I did a bedside ultrasound on his heart and found once again that my Inner Pessimist was right - there was fluid in his pericardium, the sac that surrounds the heart.

Have I mentioned that I hate when my Inner Pessimist is right?

Fluid in the pericardium can be benign in someone with congestive heart failure, but fluid in the pericardium in someone who has been stabbed in the chest is unquestionably a Very Bad Thing. That fluid is blood until proven otherwise, because it means there’s a hole in the heart allowing that blood to escape and collect around the heart. Given enough volume, that fluid can compress the heart and not allow it to function properly, causing tamponade and death. And death is a Very Bad Thing.

What it truly means is I need to fix that goddamned hole. Most people with holes in their heart are either dead or actively dying, and Troy was neither.

Yet.

Ten minutes later we were in the operating theatre, and five minutes after that I was using a very fancy saw to cut down Troy’s sternum. As the saw was doing its job, the slightly larger of the two wounds in his right chest started bleeding bright red blood. A lot. Now he was actively dying.

SHIT.

One of my assistants put her finger in the hole to try to slow the bleeding as the anaesthesiologist started pouring blood into Troy from above. I got his chest open and found about half his blood volume, now bright red, in his right chest. I opened his pericardium and found a very small hole, perhaps 3 or 4 mm, in his right atrium which I quickly repaired. It was clear, however, that was not where this bright red blood was coming from, as the blood in the right heart is deoxygenated and much darker, and the blood kept coming even with the heart repaired.

Hmmmmmmmmmmmmm. . .

A cursory evaluation of the right hemithorax showed that there were no injuries to the great vessels or the hilum of the lung. Well that's all fine and dandy, but that bright red blood was coming from somewhere in there. A closer inspection of the underside of the chest wall, however, showed that the knife had completely transected the internal mammary artery, which had clotted off initially but then started bleeding profusely once his blood pressure increased.

It took about 75 seconds to get that under control and then ligate it. We all then paused to take a breath and take notice of the complete lack of any further bleeding from anywhere. After the fact it all seemed rather trivial, though everyone in the room knew it was nothing of the sort. We all high-fived (not really), I cleaned him up, put in a bunch of tubes, and closed.

The next morning Troy was extubated in the intensive care unit, his haematocrit was rock stable, he was awake alert and talking, and he was shockingly unappreciative of our efforts at saving his life. He had two chest tubes draining the minimal residual blood from his right chest and another drainage catheter coming out of the middle of his chest which we had left in the mediastinum over his heart. I was rather stunned to see him looking so stable after everything that had happened, and after explaining his injuries and what we did for him, I asked him how he was feeling. Without missing a beat (and without answering the question), he demanded, “I need to go home today.”

“Um, no. No you don't. You just had open heart surgery less than 12 hours ago. You understand that, right?”

“But I need to get home to pick up a cheque. I have to go.”

No you don’t. I assumed he needed that money to pay off a gambling debt, but regardless I tried to explain that someone else would have to pick up his cheque. Troy was rather insistent that he had to leave. Unfortunately for him I was even more insistent that he stay.

Troy spent four contentious days in hospital with me, every day asking if he could go home irrespective of the number of tubes hanging out of his body (“I can come back to your office so you can remove it.”) and his inability to complete the most basic of self-care tasks, like walking and peeing. Finally the day of his discharge came, and even up until the moment he left he remained completely, utterly, and in all other ways devoid of any appreciation for what my team and I did for him, never once offering even the briefest of thanks for saving his life.

What did not shock me, however, is that he failed to return for any follow up. It’s been months, and Troy is either doing great or he’s dead, quite possibly of another knife wound. I guess I’ll never know.

COVID-19 Mythbusting (clean)

Due to popular demand (well, two polite requests, actually), I have decided to create a clean version of my post about COVID-19 myths . If...