Gish gallop Part 1

WARNING: This is another anti-vaccine post, so proceed at your own risk.  If you don't like that, then turn back now etc etc.

WARNING #2: This may be my most ambitious undertaking yet.  Hold onto your hats.

If you've never heard of a Gish Gallop, prepare to be inundated.  Named after creationist Duane Gish, the Gish gallop is a fallacious debating strategy in which one buries his opponent in a torrent of information which may or may not actually support his platform yet makes it impossible for said opponent to rebut each one due to sheer volume.  It is a frequent tactic of pseudoscientists, especially antivaxxers, as we saw here quite recently.

If you think that post was long and involved, you ain't seen the proverbial nothin' yet.

With that out of the way, I'm a fan of vaccines.  Obviously.  I like them a lot.  I think I've made that clear here, and I make it abundantly clear on Twitter as well.  Vaccines are wonderfully complex little concoctions that stimulate the immune system and prevent several relatively benign disease which can become horrific and potentially deadly diseases, scourges on mankind that tortured humans for centuries.  Entire hospitals were devoted to treating smallpox victims: POOF, they're now obsolete.  Millions of children were hospitalised and thousands were killed every year by diphtheria and measles; outbreaks of those are now mostly relegated to history books (though there are still a handful of mortalities annually).

But as with everything, vaccines have risks.  Fortunately these risks are either fairly innocuous (malaise, injection site pain, fever, febrile seizure) or fleetingly rare (anaphylaxis 1:1,000,000, ADEM so rare that statistical analysis is difficult).  Other purported side effects (such as autism, autoimmune diseases, etc) have either not been definitively linked to vaccines or have been definitively not linked.

Still, the antivaccine cohort presses on for reasons known only to them.  Their claims seemingly are getting more outlandish by the day:

• vaccines don't work (of course they do)
• vaccines are injected directly into the bloodstream (no they aren't)
• vaccines cause autism (no they don't)
• vaccines cause autoimmune diseases (hasn't been proven)
• vaccines are filled with "toxic garbage" (seriously?)
• vaccines are being used for population control (SERIOUSLY?)
• vaccines are being delivered via chemtrails (no really, they actually claim this)

Despite the mounting lunacy, the antivaccine group remains relatively small, though extremely vociferous.  And it is exactly this vociferousness which makes them seem larger than they actually are.  One of them (who respectfully asked not to be named and will henceforth be called Kelly (not her real name™)) was "educating" several pro-vaxxers on Twitter  about "vaccine damage" and mentioned that she had compiled a list of resources.

Normally I don't butt my nose into others' conversations unless there is a good reason, but this seemed a Very Good Reason.  A document?  Sixteen pages??  Sources???  Though I was suspicious that her "sources" would be rabid antivax websites such as truthkings.com, whale.to, naturalnews.com, and the paradoxically named vaxtruth.org, I was holding out hope that I was wrong.  And if I was wrong, it should be absolutely marvelous.  As we just saw recently with Ginger Taylor's ridiculous list of 124 studies purporting to show a link between vaccines and autism (SPOILER ALERT: it doesn't), antivaccine "research" is usually poorly thought out and/or doesn't show remotely what they think it does.  But Kelly seemed different . . . somehow.

I asked Kelly for a copy of her document (WITH SOURCES!) and she emailed me one forthwith (available for your downloading pleasure here).  In her email, she not only attached the document, she also made some, ah, shall we say questionable recommendations.  For example, she suggested I watch the movie "Trace Amounts", a rabidly antivaccine "documentary" not dissimilar to disgraced former-doctor Andy Wakefield's recent catastrophe "Vaxxed".  She also suggested I read several antivaccine books including Raising a Healthy Child In Spite of Your Doctor by Robert Mendelsohn, MD, and Saying No to Vaccines by . . . ugh, fucking seriously?  Sherri Fucking Tenpenny (not her real middle name™)?  When someone has their own page on the Encyclopedia of American Loons where she is called "an abysmally crazy promoter of woo", you know something bad is about to happen.

I felt like Kelly and I were getting off on the wrong foot, not that she knew that.

In her email Kelly also revealed that she belongs to a nonprofit group which includes the words "Vaccine Choice" in its name (she politely asked that I not name the group).  While that may superficially sound fine, "vaccine choice" is a thinly veiled façade for "antivaccine".  These ridiculously disingenuous people actually expect us to believe that they are actually pro-vaccine, but they are only pro-SAFE-vaccine.  But wait . . . "Pro-safe-vaccine" sure sounds great, right?  I mean, who in their right mind would be against safe vaccines!  No no no, in their strangely addled minds, "safe" means "100% risk free".  And nothing, not even this organic recycled non-GMO BPA-free gluten-free bottle of water, is 100% risk free.  So based on all that preamble, I fully expected Kelly's list to be some combination of A) not terribly factual, B) cherry-picked, and C) utterly unreliable.

I would not be disappointed.

Still, Kelly was very gracious and polite, so I promised to return the favour.  She asked me not to "blast" her on Twitter, so I assured her I would go over her list thoroughly, thoughtfully, carefully, and with an open mind.  I offered her the opportunity to rebut any critiques, but she declined, saying, "It's quite presumptuous that you believe that you can not only educate me, but also an entire community of people that include doctors, nurses, and attorneys with a specialization in vaccine law."

Yes, we had definitely gotten off on the wrong foot.

I felt it was rather hypocritical of Kelly to expect me be educated by her "sources" and yet believe that she had nothing to learn from me.  Shame on me, I suppose, for assuming an antivaxxer would be as open-minded and willing to learn as she expected me to be.  As is usually (always) the case with antivax "literature" I expected it to get deep very quickly, and I was again not at all disappointed.

Believe it or not, that's my thoughtful and open-minded opinion.

Kelly's list starts off innocently enough with a website containing vaccine package inserts.  There is no comment, just the link.  I therefore can't comment on the purpose of that, but I have my suspicions.  You know what . . . No, fuck that, I will comment.  The package inserts are on her list because they contain the word "autism", and these people seem to think that is either the pharmaceutical company or the FDA (or both) admitting that the vaccine causes autism.  Of course it means no such thing.  It is simply a statement that someone was diagnosed with autism at some point after getting the vaccine.  It doesn't suggest or imply that the vaccine caused it.  Everyone who knows the purpose of pharmaceutical inserts and what they mean understands this.  Antivaxxers still don't despite having been told it umpteen times.

Perhaps Kelly could have learned something after all.  Oh well.

The next three items on her list are Gish Gallop blog posts which supposedly contain peer-reviewed research.  While I hypocritically dislike blog posts being used as evidence, in the interest of fairness I decided to sift through it nonetheless.  The first, which prominently displays links to the NVIC and Why Not Vaccinate, is comprised of 87 articles, so I knew cherry picking was dead ahead.  And yet again, I was not disappointed.  No, I will not be going over all of them because I have neither the time nor the patience to do THAT bullshit all over again, and anyway I suspect many of them were in Ginger's list that I thoroughly obliterated a few months ago.  But I picked a few at random before I smashed my keyboard and had to go buy another one (ok, that may not be precisely true).  The first article describes increases in cardiorespiratory events after immunising premature infants.

OH EM GEE!  CARDIORESPIRATORY EVENTS IN BABIES!  WE ARE KILLING BABIES!  HOW CAN WE BE SO BARBARIC!

Now slow down there, chief.  First, these "events" are just a transient decrease in oxygen levels or a transient decrease in heart rate, either of which comes back to normal after a bit of tactile stimulation.  A Dutch study found the same thing, and both sets of researchers do not recommend not vaccinating, simply monitoring the babies for 1-2 days after vaccination.  And this only pertains to premature infants.

Not impressed AT ALL.  Next!

The next article describes supposed increases in neurodevelopmental problems after thimerosal-containing vaccines.  There are several problems with this ridiculous "study": first, the "study" was based on VAERS reporting.  Just like with the vaccine inserts, all the occurrences in VAERS mean is that something happened at some point in time after a vaccine was given - no causality, just afterwards (otherwise known as the post hoc ergo propter hoc fallacy).  To illustrate just why this sort of VAERS-based study is such horseshit, there are deaths from car accidents on VAERS.  No, seriously:

Second, thimerosal has been taken out of every single childhood vaccine except certain multi-dose influenza vaccines, and thimerosal-free flu vaccines are available.  Third, thimerosal has been shown not to cause autism and autism-spectrum disorders quite definitively in this meta-analysis of over 1.2 million children.  Oh, and in case you forgot, IT ISN'T IN CHILDHOOD VACCINES ANYWAY.

Since the title of the article includes "neurodevelopmental disorders" and thimerosal", I was surprised and disappointed that Ginger Taylor hadn't put it on her list of 124 studies.  Maybe she'll put it in her next update.

Sigh.  0 for 2.  Next.

Ooh here we go!  Next is an article from the British Medical Journal!  Excellent, finally some meat, right!  It's the BMJ!  Well . . . no.  It's not a study at all, rather a letter stating that the flu vaccine caused side effects in Australia, including febrile seizures in 1/110 children who got it.  Unfortunately for Kelly (and the letter's author), 1) this is a well-known fact, 2) febrile seizures are common after vaccines, 3) febrile seizures are benign, and 4) febrile seizures do not increase risk of seizure disorders or other developmental problems later in life.

Well this isn't going very well at all for Kelly, is it.  0 for 3.  How about the next source?

HAHAHAHA  no.  The next is a link to "The Greater Good" movie, an antivax "documentary" like "Vaxxed".  I skipped it with alacrity and decided to move on to the next source.

Next is another Gish Gallop, this one courtesy of The Refurbished Rogue (What a great pseudonym!  Maybe I should change mine from DocBastard to something with a little more ZING).  I wasn't terribly hopeful when the author started with "This list is just a thrown together list and pretty helter skelter", but I started dutifully at the top.  First off is . . . wait wait wait, is that really an article from the "Medical Hypotheses" journal about how vaccines may cause autism?  Goodness yes, yes it is.  Where shall I begin?  Well, A) It is merely a hypothesis and nothing more, and B) vaccines don't cause autism.  Do they not understand what "hypothesis" means?

Next is the Singh article that appears as #26 on Ginger's list that I thoroughly razed previously.  After that is an article about the effectiveness of the pertussis vaccine, which states that the vaccine was 53-64% effective and concludes, "Tdap vaccination was moderately effective at preventing PCR confirmed pertussis among adolescents and adults".  Apparently Kelly believes "moderately effective" means either "ineffective", "dangerous", or both.  It is common knowledge that the acellular pertussis vaccine is less effective and does not confer as long-lasting immunity compared to the whole cell vaccine, but guess what the effective rate of not vaccinating is?  FUCKING ZERO.  50-60% is literally infinitely better than 0%!  In their minds, anything less than 100% safe and 100% effective means it is 0% useful.

God damn it.  Moving on.

The next one on the list appears to be an opinion piece on ethics with a broken link, so instead of chasing after it like I did with Ginger's broken links, I skipped it.  Next is the other Singh paper (#13 on Ginger's list) which I discussed (read: trashed) previously.  In case you couldn't slog through that one, the author has been criticised for using unsubstantiated and unvalidated lab tests, and his finding has not only not been replicated, it has been refuted by several other studies.  In other words, everything that guy just said is bullshit.

For fuck's sake, enough with the goddamned Gish Gallops.  Let's get off this train and find another ride, and we'll see where Kelly takes us.  Well, next we have the CDC website for lists of vaccine ingredients.  Again, no comments from Kelly here, but it's clear she's trying to point out the scary-sounding ingredients like aluminum hydroxide, formaldehyde, monosodium glutamate, polysorbate 80, thimerosal, and all the other not-so-actually-terrifying ingredients for those who either understand science or trust those of us who do.  Fortunately they are all really only scary to those who don't understand not only the tiny doses but also that they have all been studied exhaustively for decades and have all been found to be safe.

We're not even halfway through the first page here, folks.  Fifteen-and-a-half pages left to go.  I'm not even kidding.

In the interest of time and my own sanity, I'm going to pause here.  I literally cannot take another minute of your time (or mine) to continue this.

For now.

Part 2 will be coming next week.  Depending on how thoroughly I dissect the remaining 15 1/2 pages, there may be Parts 3, 4, 5, 6, 7, and 5682.

Obesity

For those of you who follow this stupid blog and understand how it works, you've probably already guessed that the title of this post compared to one of my previous posts is no coincidence.  For those of you who don't follow, well why the hell don't you?  There's a little "Subscribe to SftTB" button over on the right, just under the "Follow me on Twitter, dammit" button.  So go push one of them.  Or both of them.  It takes less than 2 seconds and will make me happy.  Or happier.  A little bit, at least.  Dammit.

Anyway, even though I'm a surgeon, I still believe in promoting healthy habits.  I know, I know, I'm supposed to be a stupid automaton with a scalpel and no brain, and public health is supposed to be the domain of general practitioners and blah blah blah.  Fuck that.  I see obese patients, I treat obese patients, and I operate on obese patients, and they happen to be much harder to take care of.  Their surgeries are much harder than those of thin patients, there is a much thicker layer of fat to get through, it's more difficult to visualise the structures I need to see (read: not accidentally poke a hole in), and there is a much higher risk of wound problems.  So though you may consider this to be a tad self-serving, I'm very interested in keeping people a healthy weight.  When it comes to trauma surgery, being obese just isn't helpful.

Or so I thought.

If you believe TV and movies (*cough* Game of Thrones *cough*), any penetrating knife wound to the torso is immediately fatal, unless you're the hero, in which case you have at least 18 seconds to either A) breathe the name of the attacker so you may be avenged, or B) tell the nearest bystander to tell your wife you love her; only then will you exhale your last breath so that the aforementioned bystander may run his hand down your face and close your eyelids which I'm pretty sure wouldn't really work at all in real life.

In reality, stabbings are bad (obviously), but not usually fatal.  I've written about this subject before, but for a really quick recap, most stabbing victims have entirely treatable injuries.  Though the various injuries may be life threatening, most of these folks not only make it to the hospital alive, but due to the intervention of hard-working trauma surgeons, they leave it alive too.  Like Liam (not his real name™).

Only not for the reason you may think.

I don't know if people keep their knives locked up during the day or what, but stabbings only seem to happen at night, usually around 3 AM.  Sometimes people surprise me and come in at 2:45 or 3:15, but it's pretty consistent.  Liam was no different - he got stabbed just before 3 and came in right after 3.  I was having a dream about bacon when my pager woke me (god damn it), so off to the trauma bay I went.

I got there a few minutes before Liam arrived, and a nurse filled me in on the details she had gotten from the crew en route - youngish male, multiple stab wounds to the chest and flank, tachycardic (fast heart rate), but a normal blood pressure.  In the ensuing 6 minutes before Liam arrived, I continually ran through my mind all the possible injured organs, which included . . . well, all of them.  Literally.

The medics didn't seem too concerned as they moseyed down the hall a few minutes later.  Liam, on the other hand, looked near death.  He was sweaty, his eyes were glazed over, and he was thrashing all over the bed.  In the trauma bay this is almost always a sign of shock - real haemorrhagic shock, not the "Oh my, I just saw a dead animal on the side of the road and now I'm in shock!" bullshit.  So I again ran through my internal list of potential Very Bad Things that could be causing his impending death.

"Hey Doc, this is Liam," the medics started.  "Thirty years old.  Stab wound to the left upper abdomen and left flank.  He's been tachy the whole time, last blood pressure was 155/90.  Diminished breath sounds on the left, but his sats have been fine."

I absorbed this information quickly as they moved Liam from their stretcher to ours.

• Tachy - fast heart rate, could be bleeding.  If not bleeding, it's probably bleeding.  If it isn't bleeding, it's still probably bleeding.
• Normal blood pressure - if he's in hypovolemic shock, it's stage 1 or 2.  Good.
• Diminished breath sounds on the left - he probably has a pneumothorax or haemothorax. 
• Oxygen saturation is fine - he's young and has healthy lungs, so he's compensating for his injury.

This internal evaluation took exactly the two seconds that elapsed until Liam was settled on our stretcher.  He was already completely undressed, so I examined his wounds:

1. A 2-cm wound in the left lower chest (not the upper abdomen . . . maybe)
2. A 2-cm wound in the left lower flank/back
3. A 2-cm wound in the left lower abdomen

None of the wounds was bleeding, so my job became to figure out where the knife went and what (if anything) it penetrated. The first could have entered the abdomen, hitting the stomach or intestine; or it could have gone into the chest, hitting the lung (bad) and/or heart (really bad).  The second wound could have hit the kidney and/or colon, and the third could have injured the small intestine, colon, or both.  The easiest (and most painful) method to determine this is also the most obvious: stick a finger in the hole and see where it goes, and if the finger enters a body cavity, you have your answer in 2 seconds.  I must have been in a good mood that night because I injected some local anaesthetic before digitally probing all three wounds.  Fortunately all of them seemed to go nowhere, just into soft tissue.  Other than the fact that Liam was morbidly obese, the remainder of his examination was completely normal, including completely normal lung sounds (not diminished on the left as was reported).

My Inner Pessimist began yelling at me.  "The medics are wrong, stupid!"

I actually agreed with my Inner Pessimist for a change, though Liam still looked near death.  Something didn't add up.

Sadly digital wound probings are notoriously unreliable, and any trauma surgeon that relies solely on that modality is making a grave (and possibly fatal) mistake.  So off to the CT scanner we went.  By this time Liam had calmed down significantly, his vital signs had completely normalised, and he was no longer sweating.

Ten minutes later my Inner Pessimist started laughing his ass off.  The scan showed that the knife had penetrated only Liam's rather copious subcutaneous fat in all three locations.  There were no serious injuries, no injured organs, nothing.  Just a guy freaking out over a few tiny lacerations.  He wasn't in shock he was just shocked.

Liam's wounds were irrigated, anaesthetised, and repaired within the half hour, and he was walking out of the trauma bay with a huge smile on his face a few minutes later.  It must be awfully satisfying to go from thinking you're going to die to walking home in the span of an hour.

Had Liam been thinner, the knife could have easily done some major damage, and he could have been facing a major surgery (or two or three) or even death instead of leaving the trauma bay in an hour.

Don't misunderstand me, I am in no way advocating major weight gain here.  But if you do plan on getting stabbed in the future (which I wouldn't recommend), you may as well stock up on ice cream, Oreos, and Coke and get started now.  After all, you have a life to save - yours.

Rum

I don't tend to ask my drunk patients what they drank to make them drunk, because ultimately it doesn't really matter.  Wine, liquor, beer, absinthe, cough syrup, Listerine (yes, really) . . . no matter what type of alcohol they drink, when it ends up inside them it makes them act like idiots, and that ultimately leads to them to be guests (though uninvited) in my trauma bay.  But regardless what it smelled like going in, when that alcohol ends up on my trauma bay floor it smells like pure, unadulterated evil.  When my children vomit (rarely, thank goodness) I can clean it up without any problem.  Adult vomit is just . . . different.  I can't really say why and you parents out there are surely nodding along with me.  But what I can really say is that it is disgusting.

That all said, my patients' drink of choice seems to be beer.  Sometimes whiskey, rarely vodka, even more rarely wine, and once methanol (yes, really).  A bit of advice for you methanol drinkers: in chemistry (and everything else, for that matter) an "m" on the beginning of a word can make a profound difference.

Anyway, Wes (not his real name™) preferred rum.  I have no idea if he preferred rum because he was a pirate, because I didn't ask him.  Come to think of it, he did say "ARRRR" a lot, but I think that was more a factor of the copious amount rum rather than any buccaneering history.  Nevertheless, the only reason I know that it was rum was because he told me.  Repeatedly.

Wes was a bit of an anomaly that day.  The Call Gods were having a bit of fun at my expense by sending me a series of "found down" patients: folks who are presumed to be trauma patients because they were found on the ground and no one knew how they got there (I always suspect gravity plays a significant role).  These patients are seldom severely injured, and even more seldom do they actually require my acute services.  Usually they just need either fluids and time to sober up (if they are drunk) or a medical doctor (if they have had a stroke).  Fluids I can give.  Medical doctoring . . . not so much.

This particular day none of my Found Downs (Founds Down?) had been injured at all, but I still had to determine that for each of them, and it was taking an inordinate amount of time and effort.  Then amidst the drunk people found on the restroom floor, old people found on the floor next to their beds, and drunk people found on the ground outside the pub, along came Wes.  His mechanism of injury was different.  Not a Found Down!  FINALLY!  Some variety!  The word coming in was that Wes had been in a bicycle accident.

It wasn't anything particularly earth-shattering, but at least it was something else.  On a day like that, anything different was good.  Or so I thought.

When Wes was wheeled through the door, the smell of alcohol and vomit came right in with him, mingling nauseatingly with the pungent odour of alcohol and vomit from the previous five patients.  When the medics started their story, I wanted to scream.

"Hey Doc, this here is Wes.  We found him on the ground . . ."

Really?  REALLY!?  Another Found Down??  God damn you, Call Gods.  GOD DAMN YOU.

"He was riding a bicycle . . ."

Oh, ok.  Whew.

". . . when he crashed into a tree.  He wasn't wearing a helmet."

Of course he wasn't.  But at least he wasn't found fucking down.

When I first looked at Wes, the first thing I noticed was that it looked like he was trying to smuggle a pomegranate in his cheek.  Well, that's not exactly true - that came second.  The first thing I noticed was that odour of ethanol and vomit wafting off him.  Though he was conscious, he was slurring badly.

"Heysre Doc, smthingsong withmfaysh.  Fucknhurtsh."

I had to feed this nonsense through my Idiot-English Translation Engine (which fortunately had just come back from the shop), and what came back was "Good evening, doctor.  Something is wrong with my face.  It really hurts.  Thank you for taking care of me.  I truly appreciate everything you are doing."

Hm . . . I think the Translation Engine is embellishing a bit.  Back to the shop with you, damn it.

My head-to-toe evaluation found no obvious injuries other than fairly impressive swelling of the entire left side of his face, and a CT of his facial bones demonstrated a fracture of his zygomatic arch (cheekbone).  It was pretty badly displaced, so a call to the facial surgeon went out (I still don't do bones).  Based on the fracture pattern, Wes would need surgery to put Humpty Dumpty's formerly beautiful (maybe) face back together again.

The following morning found Wes sober (HUZZAH!) but hungover (aww).  Even my knock on the door aggravated his headache.  He had no complaints other than his face and his massive headache, so after another head-to-toe evaluation (the "tertiary evaluation"), I determined that I hadn't missed anything.  Good.  That's when my coffee-deprived brain decided that asking him what had happened was a good idea.  As usual, I regretted the decision.

"Well Doc (ow), I keep having this pain on the left (ugh) side of my face after I broke my jaw a few weeks back.  I ran out of (ow) pain medicine a few days back, so I've been getting it from my friend.  I took three shots of rum to try to (ah) dull the pain before riding my bike to my buddy's house to get more pills.  I guess I lost (ugh) control and crashed into a tree (ow) or something."

So how stupid was Wes?  Let us count the ways:

1. Not seeking medical care after breaking your mandible is stupid.
2. Taking narcotics you acquire "from a friend" is stupid.
3. Using alcohol as pain medicine is Very Stupid.
4. Drinking enough alcohol to raise your blood alcohol level to three times the legal limit is Very Very Stupid.
5. Riding a bicycle a) with no helmet and b) while that drunk is Just Plain Idiotic.

I broke the news that he had broken his cheekbone (since he didn't remember the conversation we had the previous night) and would require surgery later in the day to fix it.  He seemed surprised and tried to correct my error-that-wasn't-an-error.

"No no, Doc, it's my jaw that's broken, not my cheekbone."

I slowly explained that now his mandible and cheekbone were broken, and both required surgery.  The facial surgeon would install a few titanium plates to repair the zygoma, and his jaw would have to be wired shut for 6-8 weeks to allow the mandible to heal.  That means no solid food for nearly 2 months.  He again tried to argue with me that that wouldn't be necessary, but the pain in his mandible not only shut him up but also convinced him that I was right.

He went home the following day in slightly less pain, but still swollen like a chipmunk.  Along with his instructions on eating a liquid diet and other discharge paperwork, he got a prescription for some liquid pain medicine.

NOT rum.

A reason for that

Have you ever heard the advice that if you're ever in a car accident, do not get out of your car and just stay in it until help arrives?  I've heard countless police officers give that advice, but unlike most people I encounter the police regularly.  No, not while I'm driving.  Unless you're either in my position or are a police officer yourself, I certainly hope you don't have regular meetings with the police because if you do, you have a serious problem.  Anyway, they know a thing or two about traffic safety, so they happen to be experts in the field.  So why do they say that?

Instead of me teaching you, let's allow Alfred (not his real name™) to be your guide.

Alfred is a normal, average 28-year old guy - healthy, gainfully employed, and not too bright.  He was on his way to work one bright sunny morning when he had some car trouble.  Unfortunately this did not occur on a quiet neighbourhood street, but rather on a main thoroughfare where the speed limit is somewhere between 100 and 120 kph.  Alfred had a mobile phone, but instead of calling for help, he decided to get out and take a look.

I should also specify that Alfred does not work with cars or know anything about cars (as I found out later), so he should have no idea why his should have suddenly stalled.  Still, out he went to take a gander.

Unfortunately for Alfred, very little makes for better drive-time ogling than a stalled, smoking car on the side of the road.  One particular driver was paying more attention to checking to see if Alfred was a young lady (he most assuredly is not), and by the time his eyes got back on the road, he was too late to avoid the car in front of him, which had also slowed down to look at the smoking car.  So he swerved . . . right into Alfred.

Before I go on, let's do a little thought experiment.  Think of the height of an average car's front bumper.  That happens to be exact height of the average man's tibia.  And as I mentioned earlier, Alfred was an average guy.  Now think what might happen if a car bumper were to impact a tibia at high speed, keeping in mind that the average tibia is not anywhere close to as strong as the average car's bumper so . . .

NOT Alfred's leg

Ouch.  That is not Alfred's tibia - his actually looked worse.

When Alfred arrived, there was a large gauze pad with a large blood stain in the middle covering his left leg.  Blood outside the body is never a good sign, but even worse than blood outside the body is bone outside the body.  I moved the gauze away to see the fragmented end of his tibia staring back at me.  Although he may not have felt lucky at the time, Alfred was incredibly lucky that the car was slowing down when it hit him, because this was his only injury.

The police officer interviewing him in the trauma bay asked him why he got out of the car.  Alfred gave some silly excuse about trying to figure out the problem, even though he admitted he knew nothing whatsoever about cars.  The officer then told him that he should have stayed in his car.

"I know, officer.  I know.  But I just didn't want my girlfriend to think I didn't know anything about cars."

Sigh.  The things we do for love.

The orthopaedic surgeon took him to the operating theatre a few short hours later where, after cleaning up the wound, he inserted a titanium rod into the shaft of the tibia.  Alfred was up and walking the next day, and he walked out of the hospital the day after that.

But not before learning an invaluable lesson - when an expert gives you advice that could save your life (or limb), take it.

Police

You may not want to hear this, but ladies and gentlemen, it's about that time again.  No, not another insufferable, unreadable vaccine post (though as a fair warning a series of that is coming up soon).  Even though I talked about seat belts fairly recently, it's once again time to talk about . . .

Nutrition!

Just kidding, just kidding.  It's seat belts.  Oh be quiet, I can hear you groaning from all the way over here.  Yes, I realise I talk about them a lot, and you realise I talk about them a lot, and I realise that you realise that I talk about them a lot, and because I won't shut my damned mouth about them you therefore probably also realise just how important they are.  If you do, this post is not for you.  Instead this is directed to the people who still think seat belts are either A) not that important, or B) dangerous.

Something else (that ties into this story) that is even more important than seat belts is the police (the men and women who uphold the law, not the British rock band (though they were pretty damned cool too)).  I'm sure many people here, especially those who have ever been stopped for speeding, aren't such big fans of these folks.  Though I've been stopped a couple of times for speeding myself (though not in the last decade or two), and though I was admittedly righteously pissed off at the time, I only had myself and my stupid heavy foot to blame.  I now thoroughly respect the officers who were simply doing their job trying to protect me and the drivers around me.  As a trauma surgeon, this respect has only deepened.  It turns out that the people they deal with on a daily basis correlate quite nicely with my patient population.

But unfortunately police officers aren't perfect.  They are human, and they make mistakes.  Just like Colby (not his real name™).

When a group of police officers gathers outside my trauma bay, it can mean only one of two things: A) they are protecting everyone from the asshole they just brought to me, or B) one of their own was just brought in.  In Colby's case, it was the latter.  He was chasing a suspect at high speed in the rain when he hydroplaned and spun out.  This launched his car into the woods where he struck a tree and got knocked out.  When he came to, the medics were pulling him from the back seat of his cruiser.

At this point the clever readers are probably wondering, "Hey, how in the hell did he end up in the back seat if he was wearing his seat belt?"  Never fear, intrepid reader.  I'll get to that.

He arrived looking in not-too-bad shape, but his oxygen saturation was only 90%.  For a healthy (and very muscular) 25-year old kid, his oxygen level should have been no less than 98% unless something seriously wrong was seriously wrong.  I asked him what hurt, assuming it would be his chest.

"My chest, sir.  It's not so bad though, Doc."

Sir.  Heh.  I have to admit I thoroughly enjoy the "sir" whenever I hear it, which is almost never.  Getting "sir" from a patient is like eating filet mignon - something you experience very rarely but enjoy the hell out of it whenever you get the opportunity.

But why was he in the back seat, Doc?

Quiet, you.  I'm getting there.

A chest X-ray confirmed my suspicion - a couple of broken ribs, a lung contusion, and a pneumothorax big enough to require a chest tube.  Chest tubes are designed to evacuate the air (or fluid) that has accumulated around a punctured lung, allowing it to re-expand fully.  Colby wasn't enthralled with the idea of me shoving a tube the size of my thumb into his chest between his ribs, but he tolerated the procedure with hardly a grunt.  As soon as it was in, his oxygen level normalised and his shortness of breath disappeared.  A follow-up X-ray predictably showed that his lung was now fully inflated (HUZZAH!), so he was admitted and taken up to the trauma ward a short while later.

But Doc . . .

SHUSH.

The following day I went to see Colby, and he was doing very well and in rather high spirits.  He was a model patient - eager to get up and walk despite the large tube hanging out of his chest and the constant pain in it that stabbed him every time he coughed.  I decided this was the right time to get the answer to the question that everyone was asking: how did he end up in the back seat of the car if he was wearing his seat belt?

He gave me a rather abashed glance towards the floor as he gave me his a very simple explanation: he wasn't.  His colleague sitting in the chair next to him looked down and shook his head.

As he explained it, none of the officers in his district wears a seat belt.  He gave me some vague (read: bullshit) excuse about possibly maybe needing to jump out of the car suddenly and not wanting to risk getting ensnared in the seat belt or some crap.  I just gave him the look.  The Look.  You know, that look you give your kid when she tries to claim she didn't steal that last Oreo when you actually watched her do it five seconds ago.  Yeah, that look.

He gave me a sheepish smile and said, "I know, sir.  I know.  I'm sorry."

I gave him The Look again and asked him if he was going to give himself a ticket.  He chuckled as I reminded him that he was the one who needed to make sure that we wear out seat belts, and that in addition to protecting us, he needs to protect himself too.  It is his sworn duty to keep us safe, but a large part of that is setting a good example.  His colleague started nodding solemnly.

"Yes, sir.  If I had been wearing it, I probably wouldn't be here.  I mean, I'd be here, I just wouldn't be . . . you know, here . . . in this hospital, here.  I probably would've been fine and walked away.  I will from now on, sir."

Now that is what I was waiting to hear.

Coincidence vs fate

"Aren't you going to do something to help her?  Why aren't you helping her?!"

These were the very first words that Marilyn's grandmother yelled at me as I walked through the door of her ICU room before I even had a chance to introduce myself.  She was visibly shaking, Marilyn's mother's makeup was smeared down her cheeks, and her father was sitting quietly in the corner in stunned disbelief.  Meanwhile, Marilyn (not her real name™) was lying on the bed motionless, which is exactly the way she would stay. 

But I'm getting ahead of myself.  Let me start at the beginning. 

I don't really believe in fate or destiny.  The idea that everything is planned for us or that "everything happens for a reason" is something my sciencey brain can't seem to abide.  The Call Gods may disagree with me, but I prefer to think we're all in control of our own present and hence have control over our future as well, so anything chalked up to fate is simply a coincidence.

Enter Marilyn.

This particular Friday was nearly silent.  I sat around (not really) waiting all day (not really) for trauma patients to arrive, but none came.  At 2 AM that night (well, Saturday morning I suppose, but my brain doesn't give a shit about semantics at 2 AM) the Call Gods decided it was finally time to fuck with me as my pager told me I would be getting a Level 1 stabbing in five minutes.  That means wounds to the head, torso, or neck typically - you know, the type that can kill you.  I swept out of bed and power-walked (as fast as I can power-walk at 2 AM) down to the trauma bay where my team awaited the patient's arrival.  When he arrived 2 minutes later, I anticipated a long night ahead of me. 

Wait wait wait.  You said "When he arrived".  Marilyn isn't exactly a man's name.  Are you confused, Doc?  

Not at all, you're just jumping the gun.  This obviously was not Marilyn, who was not to arrive for a few more minutes.

As I was examining his stab wound to the left lower chest, one of the nurses ran in to the trauma bay to tell me that another Level 1 would be coming in 10 minutes, this one a car accident victim, stable vitals, but unresponsive.

Fabulous.  Just what I needed, two patients, at the same time, at 2 AM, both level 1s, after a quiet day.  What a strange coincidence.

Just before the new trauma arrived I was able to determine that the stab wound was superficial and threw some staples into the wound (perfectly straight, thank you very much).  When Marilyn rolled through the door, everyone in the room, from the nurses to the janitor, could immediately tell that something was seriously wrong.  Though her eyes were open, they had a vacant, dead look in them.

And she wasn't breathing.

The ABC's of trauma dictate securing an airway before anything else, so the anaesthesiologist inserted a breathing tube as I did a cursory evaluation.  There was a touch of blood on the back of her head, an abrasion on her great toe, and fixed, blown pupils.  SHIT SHIT SHIT.  That usually means one of two things: death or impending death.  The two immediate questions were 1) why, and 2) what can I do to stop it.  Starting with question number 1, I had absolutely no idea.  I usually have a suspicion why someone may be dying, but not with Marilyn.  She barely had a scratch on her.

Something didn't add up.

The possibilities ran through my mind.  Internal decapitation . . . drug overdose . . . massive internal bleeding . . . alien mind abduction.  Admittedly some were more plausible than others.  A few minutes later her CT scans revealed the answers to both questions.  Question #1) Why was Marilyn dead or dying: bleeding in her brainstem.  A lot of it.  Bleeding on the brain itself can be drained and the cranium decompressed to reduce pressure.  But the brainstem is a different story.  In that location it doesn't take much to cause major problems, but there was enough that her brainstem was herniating through her foramen magnum.  And that detail answered question #2) What can I do to stop it: absolutely fucking nothing.  Though I couldn't confirm it yet, Marilyn was likely already brain dead, and there was nothing I (or anyone else) could do to help.

Her parents lived several hours away, and as I waited for them to arrive, yet more information came in from the lab, the police, and Marilyn's boyfriend.  As the police interviewed the boyfriend (who got there well ahead of Marilyn's parents), the seemingly endless stream of coincidences began stacking up.  Marilyn was 20 years old, healthy, no medical issues other than a history of drug abuse.  And her boyfriend had been driven to the hospital from the hospital by the police. 

Wait Doc, wait just a minute.  "To the hospital from the hospital"??  What the hell does that mean?  Are you confused again?

Yes, "from the hospital".  According to the police officer, Marilyn's boyfriend had been taken to Outside Hospital earlier in the evening after overdosing on heroin.  Not coincidentally, Marilyn had been on her way to Outside Hospital to pick him up when she veered over three lanes and was broadsided by a tractor trailer/semi/18-wheeler.  

I coincidentally was looking at her labs as the police officer was telling me all this.  Her blood alcohol level was 0, but not coincidentally her urine tox screen was positive for marijuana and heroin.

Indeed, Marilyn had been doing heroin with her boyfriend when he overdosed, and she hadn't yet come down when she got in the car to drive.

The aforementioned meeting with Marilyn's family came a few hours later after she had been moved to intensive care.  After I let Marilyn's grandmother scream at me and (finally) got a chance to introduce myself, I explained that A) this is a nearly universally fatal injury, B) the bleeding was not treatable due to its location, and C) Marilyn was not going to survive.  

That went over exactly as well as you would expect.  But after listening to the consulting neurosurgeon tell them the exact same thing, Marilyn's mother took a few minutes and several deep breaths before putting it in perspective: "I believe in God and I believe He has the power to heal, but if that's what He chose for her, then I'm sure He has a reason."

The following day an apnea test and cerebral angiogram both confirmed she was brain dead.  Marilyn's father gave me a firm handshake as he thanked me for being so kind and understanding, and her grandmother refused to look me in the eye.  I had the impression that she somehow thought it was my fault, that I had forced Marilyn to do heroin, get in her car, and crash into a vehicle 10 times larger than hers.  Her mother, as despondent as she was, was somehow much more forgiving in her grief.  Unlike other parents that we've discussed on this stupid blog, she opted to pursue organ donation.  

I have no idea how many lives Marilyn's tragedy was able to change for the better.  Was her death predetermined?  I don't know, but I somehow doubt it.  Maybe it was fate, or maybe it was just a series of bad circumstances combined with bad luck.  Regardless, I have no doubt that the recipients are more than grateful for their second chance at life.

Orlando

What can I really say.  I mean really, what can I say that hasn't already been said.  Though this tragedy was far from me, the impact is truly global.  Add Paris, Brussels, Tel Aviv, innumerable attacks in Iraq, Syria, Afghanistan, and Nigeria, and all the other recent (and not so recent) attacks, and it's enough to make me want to cry.

I've stayed notably silent through these tragedies.  What else can I do?  Offer prayers?  Say that my heart goes out to the victims?  Offer condolences to people I don't know?  Say that my thoughts are with them?  Change my Facebook profile picture?

Anyone can do those things, and none of them actually accomplishes anything.  Would I feel comforted by strangers offering me condolences if I were affected by such an event?  I don't know.  I honestly don't.  I hope I never discover the answer to that question.

All I can do is express my heartfelt gratitude to the trauma teams, each and every one of them.  I do not just mean the trauma surgeons, though we are the ones who tend to get what little thanks there is.  I'm also talking about the nurses, technicians, X-ray techs, orthopaedic surgeons, neurosurgeons, respiratory therapists, anaesthesiologists, radiologists, OR staff, recovery room staff, ward staff, physical therapists, and janitors whose job it is to clean up the mess that we make.  Every single person has a vital role whether they know it or not, whether they get acknowledged or not, and whether they get appreciated or not.  Ultimately it may be the trauma surgeon's name on the patient's chart, but we all have a role, and all of those roles are vital in some way.

Though my brain knows it will not be useful, my heart hurts, and I grieve.

I grieve.