Sick

I'm sick.  Yeah, I have a goddamned cold and I'm fucking sick.  And when I get sick I get grouchy.  Therefore I'm pissed off and generally feeling ranty.  I don't think I'll have a lot cohesive to say here, so this may be a bit of an oddball post.  But whatever, I'm the one who's sick so fuck it.  Let's just get on with it.

Right.

I'm fucking tired of "organic".  I'm tired of people who sell organic food thinking they're somehow better, and I'm tired of people who buy organic food thinking it's healthier.  You aren't, and it isn't.  How the fuck did organic become a thing?  Organic does NOT mean "pesticide-free" (yes, "organic" farms still use pesticides), it actually just refers to any compound that contains carbon.  But now it means pretentious expensive bullshit.

And I'm tired of natural.  Yeah, pretty much anything that calls itself "natural".  There's natural shampoo, natural dog food, natural dish soap.  You know what's natural?  Fucking everything.  Everything on this earth comes from this earth (except perhaps meteorites).  And why do so many people think natural is good?  Hurricanes and tornadoes are natural.  Pit vipers are natural.  Deadly nightshade is natural.  Arsenic is fucking natural.  Nature is constantly trying to kill you, yet you think natural is good?  In case you don't believe me, check out this picture from The Naked Label, a bullshit website run by a "certified nutritionist" (a certification which does not actually exist):

What's the problem, you may ask?  That mushroom is Amanita muscaria, and it is fucking poisonous.  Yeah, I think my bolognese is better than that poisonous fungus that nature made in order to kill me.

And I'm tired of companies jumping on the non-GMO fear-mongering bandwagon, advertising anything and everything as non-GMO.  I can't tell you how many products I've seen labelled as "non-GMO verified" when they don't contain any ingredients that have ever been genetically modified.  For example, you can buy non-GMO pickles:

God damn it, there is no such thing as a GMO cucumber!  And if that wasn't bad enough, there is also non-GMO water.  Yes, really:

You can also buy non-GMO salt:

For fuck's sake, do these fucking companies even realise what the "G" in "GMO" stands for?  Genetically.  GENES!  Water and salt do NOT have genes!  And do I really have to state what the "O" stands for?  Is water a fucking organism?

Oh, and while I'm on the subject, I'm fucking sick of hearing about gluten.  Sure, gluten is very bad for you if you have cœliac disease.  But gluten is otherwise absolutely fine.  It's just a protein found in wheat, rye, and barley, and it is not dangerous or unhealthful.  But way too many people seem to think gluten is the cause of all their problems, and they simply must get it out of their diet.  Just walk through a grocery store these days to see all the new "gluten-free options".  Like these:

Do we see the problem here?  Exactly, THERE IS NO GLUTEN IN CORN OR RICE.  And there is most definitely no gluten in fucking beef.  Oh, and go back up to the picture of the bottle of water up there.  In addition to being non-GMO water, it's also gluten-free water.  FUCKING GLUTEN FREE WATER.  All these companies are doing is jumping on the very lucrative bandwagon, and it pisses me off.

And I'm tired of hearing about "real food".  Don't tell me to eat real food and avoid fake food.  Real food is anything with any nutritional value that I put in my mouth, chew, swallow, and later shit out.  Don't tell me my Oreos are fake food, because they aren't.  They contain actual food products that actually contain calories and a token tiny amount of vitamins and minerals thrown in for good measure.  You know what fake food is?  The bowl of plastic fruit my grandparents had on their coffee table that fooled me at least twice (that plastic apple looked really real).  I know Oreos are not good for me, which is why I eat them only rarely.  But they most certainly are not fake.  I have no idea why "junk food" has been replaced by "fake food".  Was someone offended by the term "junk food"?

And then there are the various waters.  There is hydrogen water, alkaline water, pH-balanced water, supercharged water, kangen water, and all other kinds of bullshit water.  Yeah, it's all bullshit.  If you want water (and yes, you do), there is an unending stream of it that comes out of your tap at any time.  It's pure, clean, safe, and costs about 0.01% (or less) of any of the bottled water you can buy.  If your municipal water supply tastes too minerally for your taste, buy a filter.  Bottled water just pisses me off almost as much as pre-peeled oranges repackaged in plastic.

I think that's about enough ranting for one day.  There's only but so much ire my body can take per day.  Besides, I think it's about time to redose my various cold medicines even though they don't fucking work.

And don't even get me started on quinoa and kale.  Because fuck that shit.

Communication

Of all the stupid clichés about communication (Communication is key, communication is a two-way street, blah blah blah etc etc), my least favourite is "It isn't what you say but how you say it".  And before anyone says anything, yes I understand the irony of saying "blah blah blah" while complaining about communication.  Whatever.  Fuck it.  Anyway, don't misunderstand me - how you say something is indeed extremely important.  But really, I don't care what the cliché says, because what you say is infinitely more important.

Don't believe me?  Then let me tell you a short yet instructive story that should illustrate my point rather emphatically.

Bryan (not his real name™) was brought to my trauma bay one fine Sunday afternoon having been stabbed by his girlfriend about 10 times following an altercation.  I didn't ask about the details, because really, who the fuck wants to know why anyone would stab someone 10 times.

"Hey there Doc, we have Bryan here.  He was stabbed 9 or 10 times, we lost count.  Heh heh (no one laughed at his stupid attempt at a joke).  The worst one is the left chest.  Oh, and the neck.  Heh heh (again, no laughter).  All the others look pretty superficial.  Bleeding is controlled, and he's been stable for us the whole time."

The medics seemed to have gone through two or three boxes of gauze of various shapes and sizes while dressing all of Bryan's myriad wounds.  Fortunately Bryan's girlfriend's knowledge of vital anatomy was on par with Donald Trump's knowledge of, well, anything, because there were no life-threatening injuries.  A quick X-ray of his chest showed no penetration of the knife into the thoracic cavity, and on examination of his neck wound the platysma had not been violated.  Whew.  Still, he had an impressive series of lacerations on his left upper arm, left forearm, left chest, neck, left thigh, and right shoulder, all of which needed to be repaired.

I was obviously going to be busy for a while.  Sigh.

After gathering all the various accoutrements required for suturing his approximately 71 cm-worth of lacerations (yes, I counted), I started irrigating each individual wound, followed by cleansing with iodine solution (yes, we still do that).  As I was infiltrating the left arm wounds with lidocaine, he started mumbling something to himself.  I couldn't understand most of it, but there were a few words here and there that were unmistakable:

"Mumble mumble bitch, I mumble mumble believe she mumble mumble fucking mumble mumble bitch . . ."

In spite of myself, I said the one thing that I shouldn't have:

"What?"

Of course, that's when the floodgates (also known as Bryan's mouth) opened.

"Man, fuck that bitch!  I can't believe she did this to me!"

God damn it!  Why the fuck did I say that?  Nooooooo!  Take it back!  TAKE IT BACK!

"What the fuck is wrong with her?  I'm gonna kill her.  That bitch stabbed me what, 20 times?  I'm gonna kill the bitch.  I'm gonna fucking kill her.  I'm gonna go home and kill her.  Dead.  Dead!"

He looked up right into my eyes.

"DEAD."

At a loss for words, I looked imploringly over at the police officer who was standing right next to me and had been apparently waiting patiently to take Bryan's statement.  He returned my quizzical glance, both of us too stunned to speak.  But Bryan wasn't done.  Not remotely.

"Fucking bitch.  Gonna kill her.  Gonna fucking kill her.  Dead.  She's dead.  Bitch you want to stab me?  You're gonna die."

I took a break from suturing, inhaled deeply, and tried my best not to sound too patronising.

"Sir, you may want to curb your violent enthusiasm until after the police officer here is done questioning you and leaves."

Bryan, however, was not to be discouraged.

"I don't give a fuck who's here!  Let the police hear me!  She stabbed me, I'm gonna stab her back.  That bitch is GOING TO DIE."

I looked back at the police officer who simply smirked, shook his head, and wrote something in his little notebook, which I have to assume was something resembling "HOMICIDAL PSYCHOPATH, DO NOT LET NEAR GIRLFRIEND".

About an hour and 2,401 sutures later (I may be exaggerating slightly), Bryan was all fixed up and ready to go.  I briefly went to check on another patient, and when I came back a few minutes later to give Bryan his discharge instructions ("1. Come see me in a week to get your sutures out, 2. Apply antibiotic ointment 2-3 times a day, 3) Don't kill your girlfriend"), he had a very fancy set of matching stainless steel bracelets on his wrists.  I tried to question one of the other police officers who had come to take Bryan away, but all he would tell me was that "the official story had changed".

I decided to accept that and move on.

Had Bryan actually done something that warranted a moderate bloodletting?  I don't know, and I will likely never find out.  And to be perfectly honest, it doesn't matter one bit, because my job is to fix holes.  Holes I can fix.  People . . . not so much.

Regardless, what Bryan said was bad enough, and the way he said it made his situation even worse.  But Bryan taught me a very important lesson: it isn't only what you say and how you say it, it's also to whom you say it.

Confessions 2018

I know I risk angering the Call Gods by saying this, but my trauma game has been rather slow lately.  I've had very few blog-worthy stories of late, and the last thing I want to do is post a "Oops, no story this week" filler bullshit.  So instead I've decided to continue a tradition from January 2015, or at least what I intended to become a tradition but instead got lost amongst the drunken idiot stories: CONFESSIONS.

Yes, I believe the best way to start a new year is not by making yet another resolution that you know will be broken by January 2 (no, you will NOT go to the gym every single day), but rather by confessing sins and starting the year clean. 

So here goes.  The Official DocBastard Annual Confessional continues.

• Though I am a die-hard heavy metal and prog rock fan, I confess to thoroughly enjoying the song "I Want It That Way" by the Backstreet Boys.  I have tried my best NOT to like it, yet I find myself singing along with it every single goddamned time I hear it, most recently this afternoon.
• While I'm on the subject of songs I'm embarrassed to like, I also confess that I like "Love Yourself" by Justin Bieber.  Fuck me, but that's a clever song. I hate myself for liking it.
• Even though the number of followers I have doesn't impact my self-worth, I really do want more followers on Twitter and more readers here.
• I want to meet Andy Wakefield, ostensibly so I can not-so-politely tell him of the irreparable harm he has done to public health, but actually so I can punch him in his stupid fucking lying face.
• I hate teaching medical students.
• I hate training new surgeons even more.
• I plan on retiring from clinical practice in less than 10 years.
• I enjoy riling idiots on Twitter and proving them wrong.
• I like challenging the Call Gods sometimes and seeing what kind of shitstorm they bring me in retaliation.
• I speak to my drunk patients in the same manner I speak to my children.
• I hate spam comments here almost as much as spam phone calls at home, and I wish I could round up all the spammers, put them in a small office building, and make them all call and email each other nonstop until they all die.
• There have been a few times on call when I wish I could have had a beer.
• I drive home drowsy after call regularly.  I know it's fairly stupid, though I haven't come anywhere close to falling asleep at the wheel in about 15 years.  
• I am a big Star Wars fan, and I loved "The Last Jedi".  It's probably my favourite Star Wars movie.  I'm sure this will anger many die-hard Star Wars fans, so COME AT ME.
• I got an email from a publisher about potentially publishing a book.
• I come dangerously close to hitting a patient at least once a month.
• Despite my palate maturing as I've aged, I still cannot bring myself to eat a mushroom.  Seriously, fuck mushrooms.

I think that's about enough for one year.  I'll be back with more confessions in 2019 unless that book deal comes through.

Feel free to add your own confessions down below.

New Year's Interview with Mrs. Bastard

It's that time yet again, ladies and gentleman.  Time once again to say goodbye to the raging shitmaelstrom that was 2017, and hello to the brand new year.  2018!  The year where everything will suddenly be so much better!  This will be the year frauds and mountebanks will cower under the supreme reign of science and evidence, and when incompetent orange quarterwits will no longer be in charge!

Ha.  Ha.  No. We all know that won't fucking happen.  But instead of wallowing in pseudoscientific misery, let's instead (as promised) enjoy this rousing interview with my wife, Mrs. Bastard (not her real name™). 

You asked the questions, and she's graciously answered them.  Questions I've deemed too personal have been unreservedly ignored and/or sent to live in the White House with Mr. Trump, because censorship is totally fucking legal (and in fact actively encouraged) in Bastardia.  So without further ado, I give you my wife.

Please.

Ha haha ha.  Siiiigh.

What's DocBastard's embarrassing secret/s? (from Timethyfx)
I don't know.  *turns to me*  Do you have any?  {No.  Of fucking course not.  I air all my dirty laundry right here.}

What is your favorite blog post? (from Casi G)
I guess I would have to have read them to be able to answer that.  No, actually Doc tells me all of the stories the second he gets back from the hospital, no matter if I'm enjoying my morning coffee or taking a shower or whatever.  I get to relive them all personally and in all their gory detail.

What is your favorite holiday and why? (from Angel)
My favourite time of year is December, as the general population tends to be kinder, more understanding, more patient, and more at peace with each other.

What is Doc's "tell" that there is a new story forming? (from Ken Brown)
Usually when he gets home, sighs, smiles, and says, "You're not going to believe this one".  And then I respond by saying, "That sounds like a blog post!"

How stressed is Doc at home about work? (anon)
He's most stressed when he's lost a patient that he feels he shouldn't have, or if he has a patient who's very sick and he can't figure out why.

What brings tough ole Doc Bastard to tears? (from Nautipirate).
I can't think of anything that's brought him to tears.  {You're goddamned right there isn't.}  Perhaps a spoiled beer.  {Nope.}  The last piece of lasagne?  {Nah.}  The end of season 7 of Game of Thrones with a year and a half to wait until season 8?  {Ok, you got me there.  *sniff*  Dammit, I got something in my eye.}

How is grocery shopping with the DocBastard? (from Cali)
Do we grocery shop together?  Have we ever been grocery shopping together?  {For the record - YES WE HAVE.  God damn it.}

Would you want your kids to be Doc Bastard juniors? (from Joan B)
Aren't they already DocBastard juniors?  But if you're asking if I want them to be doctors, no.  NO.  NO NO NO NO NO NO.

In other words, no.

Is Doc any good at carving the turkey? (from tania cadogan)
What do you think?  Does a bear shit in the woods?

Whats the best thing Doc can cook? (from Shark)
He makes a mean fresh fettuccini with bolognese.

We know what doc thinks of shows like House, but what does Mrs. Bastard think? (from Connor)
I think they're largely entertaining, as long as you buy into willful suspension of disbelief.  {And can put up with me constantly yelling at the television because they've royally fucked something else up AGAIN.  Come on, Hollywood.  I'm available for consulting work.  Call me.}

How did you come to marry Doc? Did he propose on bended knee, did you propose to him, or did you just both decide it was time? (from Cleopatra)
He proposed on bended knee.  I feel like he should have been on both knees.  And he also should have chosen a location that we could go back and visit that wasn't destroyed.  {No, I'm NOT TELLING, so don't even ask.}

How long have you two been married? (From Not your average housewife)
Long enough.  {Love you too, dear.}  No, it seems like just yesterday.  Long enough to put up with each others' idiosyncrasies and even be fond of some of them.  Long enough to finish each others' sentences and know what each other is thinking, but not long enough not to discover new things about each other.  {Aww, no seriously, I love you too, dear.} 

What's the best present Doc ever gave you? (Excluding your perfect offspring, of course.) (from RC)
My cappuccino machine.   And that big green sweater with the giant gold buttons that was probably the most hideous thing I've ever seen.  {Really?  Come on, I barely knew you then.  Are you ever going to let that go?)

How do you keep your household running smoothly? Does Doc help with the dishes? (anon)
WD40.  It keeps everything running smoothly.  No, lists, lists, and more lists.  Speaking of lists, have you changed that light bulb over the piano yet?  It's been TWO YEARS.  {No, because it's only been 2 years.}  And did you empty the dishwasher?  {Yes.}

What made you fall in love with Doc, and he with you? (anon)
I think there was instant attraction and chemistry, but I don't know what made me fall in love with him.  It must have been his charming personality and his wit.  {I swear I didn't make that up.  Those were her exact words.  Honest.}  It certainly wasn't his taste in clothes.  Or hideous green sweaters with giant gold buttons.  {Oh, har dee fucking har har.}

Do you have any advice for newly weds/ new parents/just random pieces of good general life advice? (from the small raven)
Advice for newlyweds: 1) Don't marry a trauma surgeon.  2) Never go to bed mad at each other.  3) Respect each other. 
Advice for new parents: 1) Don't throw the baby against the wall.  2) Don't throw the baby against the wall.  3) I mean it, don't throw the baby against the wall.  4) Don't worry, projectile vomit and pee do come out in the laundry and don't leave a stain.  Usually.
Random good life advice: Be good, and do good.  {See why I married her?}

What is Doc's favorite dish for you to cook and will you share the recipe? (from Promise)
His favourite thing is lasagne.  I use the Fanny Farmer recipe.  Google it.  {She doesn't like to share recipes for some reason.  Don't Google it - I've done it for you.  Just click the first picture.}

We all know that Doc Bastard has a fascination for pulling various things out of rectums. What is the best "removed from rectum" story he's ever told you? I bet it wasn't the one he told US! (from Wednesday)
Actually, it is.  It's the Coke bottle story, for sure.  I think that's one of his first blog posts.  And it was his first RFO.  Still the best.  That was a great story.  {Yes, yes it was.}

If DocB were an animal (of the non-human sort) what animal would he be? What would you be? What kind of hybrids would the Little Bastards be? (anon)
He would be a non-lazy animal.  He would be an industrious, cute animal.  I think he would be a beaver, because he can whittle things out of wood.  I, on the other hand, would be a honey badger.  Why?  Because honey badger doesn't give a shit.  Our hybrid son would be a sloth-hyena because he likes to hang off things and makes way too much noise all the time.  Our hybrid daughter would be a unicorn.  {Because why the hell not.}

Does Doc utilize any of his surgical skills at home? Can he sew a hem? (from OldFoolRN)
He uses his surgical skills all the time at home.  Let's put it this way - when a hem needs to be sewn or a button needs to be replaced, it's not Mrs. Bastard doing it.  I just say, "Daddy Bastard, can you please sew this for me or close this hole in this stuffed animal or replace its arm?"  I can also guarantee the button will never fall off again.  {For the record, MomBastard taught me to sew when I was about 8, though I do usually use surgical knots which she did not teach me.}

If you could magically change Doc's profession, what would you have it be? What type of place would be your dream retirement destination? (from Hippodamia)
I would change his profession to personal chef.  Because then I would never have to cook again.  {What, you think I'd still bring my work home with me?}  And he would have better hours.  Our dream retirement destination would be someplace where it's 28 degrees {that's Celcius} all year round, people are nice, life isn't so rushed, but has access to all the amenities and culture of a big city. {That place doesn't exist, dear.}

What kind of movies do you like and what do you watch together? (from Scott Aylor)
I like comedies. {I like sci fi}.  I can't remember the last time we watched a movie together and didn't fall asleep.  Am I asleep right now?  Are we still doing this interview right now? 

---

There you have it, folks.  Another year and another interview wrapped up.  I'll see if Mrs. Bastard is up for another interview next year.  If she hasn't killed me yet.  Maybe I'll have even changed the light bulb over the piano by then.

Probably not.

Happy New Year!

Branding

Oh, boy. We have a bit of a doozy here. As you all know this blog is mainly about stupid people doing stupid things. Sometimes, however, it is about smart people doing stupid things (namely me, if I do say so myself). This is one of those times. Except that this time, the smart person gloriously isn't me at all. Have no fear, it is still about a smart person, a surgeon even, having done a very stupid thing.

Indeed this story is about Simon Bramhall, a rather famous British transplant surgeon who gained fame in 2010 by transplanting a liver that was being transported by a plane that crashed. They managed to salvage the organ and he transplanted it successfully. I think we can all agree that that is a Very Good Thing.

But in 2013 Simon did a Very Stupid Thing. He was performing a liver transplant on February 9, when for some inexplicable reason he decided to burn his initials "SB" onto the surface of the organ he was transplanting. Before you start yelling, "Oh come on, he couldn't have done that. It was probably just misinterpreted. What type of egomaniac would do that?" Bramhall would, that's who. The instrument he used was an argon beam coagulator which is designed to effect (yes, 'effect') haemostasis on the surface of a bleeding organ, and yes he branded his initials onto the liver. Keep in mind this was a very superficial injury that he inflicted, one that would be expected to heal very quickly.

If that doesn't sound too bad, have no fear, because it gets worse. He did the exact same thing 7 months later, again branding his initials on a transplanted liver. Again, anyone who understands how livers heal knows that these marks should disappear quickly and completely. Unfortunately, they did not on one of these two patients. Another surgeon re-operating on one of the patients some time later noted "SB" still visible on the surface of the liver, and Dr. Bramhall was busted.

Dr. Bramhall was suspended initially, and he resigned from the hospital the next year. Further, he was arrested and charged with both assault occasioning actual bodily harm (to which he pleaded not guilty), and assault by beating, to which he admitted and was convicted.

Wait wait, assault by beating? How is that possible?

Right, I was as confused as you at first. It seems that the prosecutor didn't know exactly how to charge him, because this past week he stated that there was just no legal precedent for this type of injury. (Seriously, what the hell would you charge him with? Arson? I have no idea. This is one of approximately 2,490 reasons why I'm not a lawyer.) Regardless, the prosecutor did state that Bramhall's admission of guilt indicates that he admits that "what he did was not just ethically wrong but criminally wrong". Sentencing is scheduled for January 2018. I suspect the judge is just as clueless about how to punish him appropriately.

Bramhall was also issued a formal warning earlier this year from the General Medical Counsel which said regarding his behaviour, "It risks bringing the profession into disrepute and it must not be repeated. Whilst this failing in itself is not so serious as to require any restriction on Mr Bramhall’s registration, it is necessary in response to issue this formal warning."

And that is where I vehemently disagree.

In my opinion Bramhall deserves to be struck off the record, to lose his licence to practice. This falls so far outside the bounds of the normal, ethical, responsible behaviour of a physician that something more drastic than a proverbial slap on the wrist is in order. Bad behaviour by surgeons used to be tolerated, and everyone would just look the other way whenever it happened. Harassing nurses, inappropriate comments, throwing instruments, yelling at students, demeaning residents, and other assorted temper tantrums were commonplace in the operating theatre until recently. Nowadays, however, these sorts of outbursts are no longer permissible. Surgeons are now reprimanded and punished for bad behaviour.

But knowingly and purposefully injuring a patient?

Inexcusable.

I have heard the counterargument that no real harm was done, so it isn't that big a deal. Really? Is that a logical argument? Then by that same logic we should just allow people to drive drunk as long as they don't injure anyone, because no harm is done. Right? Right?

No, not right. Not right at all.

However, not everyone agrees with me. In fact, when he was suspended in 2014 one of his former patients said, "Even if he did put his initials on a transplanted liver, is it really that bad? I wouldn’t have cared if he did it to me. The man saved my life." It's true though, right? The liver heals very quickly, and even if it doesn't heal completely, having a scar on the organ won't affect its function one bit. So it's not a big deal, right?

Wrong. I've written before about the trust that patients put in their doctors, but especially their surgeons. Imagine the amount of faith people must have to allow themselves to be put completely to sleep, completely vulnerable, absolutely at our mercy, and trust that we not only do our best to put them back together but do it with dignity and respect.

Dr. Bramhall violated that dignity. He violated that trust. Not just one, twice.

I don't know if it was a momentary lapse of reason (twice), sociopathy, or simply a massive ego that led Bramhall to do what he did. Yeah, I'll be the first to admit that many surgeons have massive egos (yours truly excluded, of course). But quite frankly, I don't care a whit. I couldn't give a rattus rattus' posterior, because after pondering this since the moment this story broke, I've come to the realisation that there is literally not a single legitimate excuse in the world that would permit a surgeon to brand a patient like this. Not one.

Not one.

Now I've heard everything

Most of the mechanisms of injury I see are rather mundane and pedestrian. Auto accidents, falls, stabbings, shootings, pedestrians struck, bicycle accidents, and assaults are the mainstays of what I see, do, and fix. Sometimes I get the "other", however. These can be anything from ordinary (dog bite) to a bit strange (chainsaw to the face) to how the hell did that happen (foot run over by a lawnmower) to what the actual fuck (bitten by a camel). To be honest, it's difficult to come up with a mechanism of injury that I haven't seen.

Until someone does.

Saturday night seems to go along with alcohol just like peas and carrots, peanut butter and jelly, salt and pepper.  It just doesn't seem to flow linguistically, however.  Hm. Anyway, I'm constantly astounded at what drunk people will do to themselves or others, simply because they are drunk. It doesn't seem to matter what they do or to whom they do it, as long as they can blame alcohol.

"Hi Doc, good evening. This is Dawn (not her real name™). Dawn was assaulted with bug spray tonight, and . . ."

I don't typically interrupt the medics in the middle of a patient presentation, but this time I couldn't help myself.

"Wait wait wait . . . what?"

The medic chuckled a bit and continued. "Heh, yeah. Anyway, she was assaulted with bug spray after her and her boyfriend got into a fight after a night of heavy drinking. She's got a lac on her scalp about 5 cm, positive loss of consciousness. She's 49 years old, history of HIV, not taking any meds, no allergies. Only complaining of a headache."

If you're following along here, you probably have the same question I had.  I could not resist the temptation and just blurted it out:

"So, was she hit with the can or sprayed?"

"Heh. Yeah, Both."

Fortunately the spray didn't get in her eyes, so all she needed was a few staples to close the wound and a heavy dose of IV fluid to get her sober.  Once she was coherent, her boyfriend came to take her home.  All was forgiven, apparently.

I know I've said this several times before, but this time I really really really mean it:

NOW I've seen everything.

DNR

If you're in the States, you can rest assured that I am most assuredly NOT writing about the Department of Natural Resources.  Nor am I writing about Denbury Resources, Inc (whose unfortunate symbol on the New York Stock Exchange is DNR).  No, anyone remotely familiar with the medical field (or who ever watched House MD or Holby City or Grey's Anatomy or ER or St Elsewhere or M*A*S*H or Scrubs or Marcus Welby, MD [godDAMMIT there are a lot of medical dramas!]) knows that "DNR" stands for "Do Not Resuscitate".  It represents the primary right of the patient - to refuse medical treatment, even in the face of impending death.  Most usually it is employed by the elderly, severely infirm, or terminally ill to alert their medical care providers that they do not want any heroic measures in the event of sudden or imminent death.

There are various elements to a DNR, including orders not to intubate, not to do chest compressions, not to employ vasopressors (medication to artificially elevate blood pressure), not to give food and/or fluids, not to use dialysis, or to use comfort measures only.  The exact nature of the DNR order, including any and all therapies that may or may not be used, is explicitly elucidated in a signed document that is supposed to be readily available for medical practitioners to see.  That way there can be no ambiguity if an unconscious yet terminal patient is brought to the hospital.  The papers are supposed to be easy to find, though sometimes they can be difficult to track down.

Sometimes, however, the DNR is, well, let's just say sometimes it is slightly more prominent:

According to a case report from the New England Journal of Medicine, this 70-year old gentleman was brought by paramedics to a hospital in Miami, Florida unconscious and intoxicated.  He had a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, and he arrived without any identification or family members.  When doctors disrobed him to do their examination, they found "DO NOT RESUSCITATE" tattooed quite clearly (with "NOT" even underlined) on his chest with his signature underneath.

Open and shut case, done and done, cut-and-dried, impossible to misinterpret, right?  RIGHT?

If that were an easy question to answer, I wouldn't be writing this right about now, would I.

A few hours later his blood pressure dropped precipitously due to severe sepsis, and he developed a severe metabolic acidosis (his serum pH was 6.81 - I have never seen anyone with a pH less than 6.9 survive).  The intensive care doctors who attended to him had a decision to make: A) honour the tattoo as a legally binding DNR or B) treat him as they would any other anonymous patient.

They chose B.

According to lead author Gregory Holt, MD, the doctors chose to invoke "the principle of not choosing an irreversible path when faced with uncertainty", so they categorically ignored the tattoo, starting him on antibiotics, putting him on BiPAP, and starting vasopressors.  In other words, everything short of intubating him.

My first reaction to this story was "WHAT?  WHAT THE FUCK WERE THEY THINKING?  HIS CHEST SAYS DEE EN ARE!"  My next thought was that if they had done chest compressions, they would have been committing assault on this gentleman.  My next thought was . . . calm the fuck down and get some more information, dumbass.

*deep breath*

It turns out cases like this, while extraordinarily rare, are not entirely isolated.  In fact there is a published case report in the literature of a man with a similar "DNR" tattoo (though it is admittedly not quite as explicit) which did not reflect his actual wishes.  That patient had lost a bet while drunk many years before, the loser being required to get a tattoo of "DNR" on his chest.  

"Heh, sounds like one of your patients, Doc."

Indeed it does.  Regardless, Dr. Holt and his team obtained a consultation from their ethics team, who determined that the tattoo most likely did reflect the patient's wishes.  They advised the doctors to honour it as an ordinary paper DNR.  Out of respect for the patient's (hopefully) wishes, an actual DNR order was written.  Fortunately shortly thereafter the gentleman's real out-of-hospital DNR was obtained, and he passed the following morning without incident.

After contemplating this case for some time, I've come to the realisation that it isn't nearly so clear cut as I had originally thought.  If I got a dying trauma patient who had a prominent and unmistakable DNR tattoo, would I really be able to say "Wait, stop, don't do anything.  Look, it says DEE EN ARE right there on his chest!"?  Would that really be the right thing to do without verifying it first?  The part of me that explicitly respects patients' wishes says an very emphatic "Yes", but the entire rest of me (which is admittedly rather small) says "Not so fast".  

I believe that treating a patient who does not want to be treated is malpractice.  However, I also believe I would be obligated to verify the DNR prior to withdrawing or withholding care while consulting my own ethics team.  I also also believe doing anything short of this would be malpractice.

What do you believe?