Humour

What makes the earth spin?  Forget everything you think you know about science, astronomy, gravity, the Big Bang theory, relativity, and Kim Kardashian's ass.  No, what really makes the world go round is humour.  The gravity (har har) of any situation can be lightened by a well-placed quip, and nothing is ever so serious that a joke can't help.  Nowhere is this fact more evident than in the medical world.  Hospitals are big buildings full of sick, infected people, and some of these unlucky people die every day.  The mood in any hospital is typically somber at best, so anything that lightens the atmosphere can help.

Bess apparently understands this about as well as anyone I've ever met. 

When a 70-ish year old woman falls for no apparent reason, everyone around her starts to worry.  Was it a stroke?  A heart attack?  Anaemia?  Something else?  When Bess fell it was no different, except instead of simply crumpling to the ground, she bonked her head (yes, "bonk" is the technical term) on the corner of her kitchen counter.  There was a large pool of blood on the ground when emergency services arrived to her house, and they brought her quickly to me.  

On arrival Bess was completely alert, though she had neither memory of falling nor any idea why she fell.  She had a small laceration on the side of her head, but no other obvious injuries.  She maintained a smile throughout her initial workup, which fortunately showed no evidence of serious injury.   After giving her the good news, I dutifully went to tend to another patient when I heard a clamour coming from another part of the department.  We have crazed lunatics in there regularly, and the antics of someone high on PCP can instantly elevate the mood of me and my staff on an otherwise dreary night.  But nothing could have prepared me for what I was about to experience.

I walked into the main treatment area and saw what I can only describe as the closest thing I've ever seen to an actual bull in a china shop: a 250-kg woman (that's around 550 lb) was lumbering through the department, poking her head into every room, with 4 nurses trying to surround her.

And she was stark raving naked.

Several security guards were trying to usher her back towards her room, but she easily outweighed them all.  One of the nurses had a gown (extra large, if you're wondering) and was trying to lasso it around her neck to help her maintain some semblance of decorum.  Despite all this the woman continued her tirade, giving each and every patient a bit of a show.  At last the parade ended at my trauma bay . . . and Bess.  The look on Bess' face when the procession entered the trauma bay was a mixture of horrifying shock and bemused merriment.  The woman took one look at Bess, shook her head (I suppose Bess didn't have what she wanted), turned around, and trudged slowly back to her room, her entourage in tow.  I looked at Bess, a look of terror and desperation on my face.  I opened my mouth to apologise, my brain still trying to fully process what I had just witnessed.  But before I was able to formulate any words, Bess, her face completely straight, said,

"That sure is a lot of beef on those hooves."

I couldn't decide if I wanted to give Bess a hug or a high five.  So I decided to do both.

I wish I had more patients like Bess.

Football

For all of my American readers, I'm going to clarify this at the very beginning so there is no confusion: when I say "football" I am referring to the game where you ACTUALLY USE YOUR FOOT ON THE BALL ALL THE TIME, not the game where they throw the ball or hand it to a teammate but only kick the ball a few times a game.  I don't have anything against people who enjoy that flavour of football, but how the hell is that game called "football" anyway??  Who decided that "football" would be an apt moniker?  It makes no goddamned sense!  The only way they use their feet during that game is to run away from the behemoths who are trying to smother them like and knock them unconscious!  So when I say "football", I don't mean your American football, I mean what the other 95% of the world means.  Sorry, mini-rant over. 

Alright, now that that bit of nastiness is out of the way . . .

Football is not usually a dangerous sport.  Some of the tackles may look a bit violent, but serious injuries are fortunately rare.  However, considering the commonness of the game, I get plenty of football players in my trauma bay.  Most of them have collided violently with another player and thankfully suffer no more than a concussion and some bumps and bruises at worst.  But I do see the odd tibia fracture from someone getting kicked in the shin (usually during a "friendly" game where shin pads aren't being worn), but they are few and far between.  So recently when my pager told me I was getting another football player in 10 minutes, I figured it would be another quick workup, another minor injury, and I could get back to reading A Game of Thrones.

I didn't know just how right I would be.

Morris (not his real name©) was playing a friendly game of football (striker, if you're curious) when he was kicked in the thigh.  He immediately fell to the ground in agony, and emergency services was called.  They felt he had an "obvious femur fracture" (so they told us over the box before they arrived), so they placed a traction device to stabilise his leg and help his pain.  When he arrived, his thigh looked . . . completely normal.  He wasn't in that much pain; in fact, he looked rather comfortable.  Actually, he didn't have a scratch on him, despite the pre-hospital report, so I started wondering why the medics had seen fit to deem him a trauma patient.  And then things went directly from "Strange" to "What the ever-loving fuck" when I asked him what happened to him and he started his story with "Well, six weeks ago . . ."

Wait, wait wait . . . six weeks ago?  "No sir," I said, "not six weeks ago.  What happened to you today?"

"I was getting to that, doc.  So six weeks ago I was playing football, and I got kicked in my right thigh.  It really hurt, but I played through the pain.  I took some pain medicine and it got better and it's been feeling ok since, until this morning when it started hurting a bit again.  But I decided to play through the pain again.  Then I got kicked in the thigh again during our match today.  It really hurt again, so here I am."

This seemed utterly ridiculous.  He hadn't struck his head, he hadn't lost consciousness, he had no lacerations or abrasions or ANY other injuries, and was an otherwise healthy young man.  Why did the medics designate him a trauma?

I had no idea, and by the time I realised I wanted to ask the medics what the fuck they were thinking, they had left.  In a bit of a hurry, I would say.  I had even less of an idea when I saw his completely normal femur X-ray.

"Yeah, I didn't think it was broken either, doc," he told me.  "But they said it looked bad so I should get it checked out."  

Fifteen minutes after he arrived, he walked out of the hospital with a prescription for ibuprofen and instructions to avoid football for a while. 

I'm used to caring for people with life-threatening injuries.  I take care of shattered spleens and lacerated bowels and eviscerations and gunshot wounds to the heart.  These are the injuries that I typically deal with.  So I should have been glad he wasn't seriously hurt.  I should have been happy he didn't need surgery.  But instead I was merely annoyed that the medics brought this kid to me unnecessarily and thoroughly wasted his time.  And mine. 

For a bruise.

Jewelry

Of the many questions I've gotten, the most common is some version of "What is the hardest thing you've had to do as a surgeon?"  My answer has generally been to tell some long, drawn-out, maudlin story of my most difficult and complicated surgical case.  But after answering that question way too many times, I thought more about what the most appropriate answer should be, and much to my own surprise I've decided to change my response completely.  In fact, the toughest thing I've ever had to do, by far, is . . .

. . . buy a gift for my wife.

Yes, shopping for Mrs. Bastard is more difficult and more nerve-wracking than removing a shattered spleen and repairing a torn colon while doing internal cardiac massage because the patient is actively bleeding to death.  I tried buying clothes for my wife once.  Once.  That's a mistake I'll never make again.  I once bought her a gift certificate to a very nice spa thinking she could enjoy a day getting pampered, but she never redeemed it.  My one great success was a surprise birthday vacation to a remote tropical island, but how often can I really get away with that?

I know a few of you out there are thinking, "Just buy her jewelry, you idiot!"  Wait, why didn't I think of that?  Oh wait . . . I have.  It's the most obvious answer, so of course I've thought of it.  Unfortunately my taste in jewelry is completely different than Mrs. Bastard's.  That is to say, pieces that I think are beautiful, she thinks are hideous.  And pieces that she loves I wouldn't think to buy her in a million years.  She almost never wears any piece of jewelry I've ever bought her (that she hadn't picked out herself in the first place).

Anyway, another recent failed trip to the jewelry store got me thinking about the subject (segue alert).

Several months ago I was explaining to a patient exactly how I was going to remove her gall bladder - the number of incisions (3), the size of the incisons (10 mm, 5 mm, and 5 mm), where each instrument would go and what they would be doing.  When I paused to ask if she had any questions, she only had one:  "Can I keep the stones?"  As odd as that sounds, it wasn't the first time I've been asked, not by a long shot.  But it was the first time I thought to ask why.

"I'm going to make a pendent out of it and wear it."

I laughed, thinking she was kidding.  She just stared at me with a perfectly straight face.  A 0.195 second Google search told me that not only wasn't she kidding, but the idea wasn't even hers:

Apparently there's an actual market out there for people who want . . . this.  There's really nothing more that I can really add, so I'm just going to leave that there.

But while I'm on the subject of jewelry, I was reminded of this little gem (har har har) from some time back.  It's my second-favourite actual real X-ray of an actual real patient of mine.  He was in a car accident at 2 AM, the details of which are entirely unimportant.  Part of our workup included an X-ray of his pelvis, which didn't show any fracture.  What it did show, however . . . actually, I don't want to give away the punch line.  Take a look and see if you can make the diagnosis:

In case you aren't a radiologist and/or have never seen a cock ring before, that's . . . ah shit, I just gave it away.  Yes, that round thing at the base of his penis in the lower middle portion of the X-ray is indeed a cock ring.  So what was he doing driving around by himself while wearing that bit of jewelry at 2 AM?  

It remains a very strange, exotic mystery.  THAT is a question I did not ask.

But speaking of questions, I wonder what Mrs. Bastard would think of getting some gallstone earrings for her next birthday . . .

Common sense

There are certain things in life that shouldn't need to be said, things that should be self-explanatory and only require common sense, things that most people with more than 17 neurons should be able to figure out on their own:

• Don't touch a wall that says "Fresh Paint"
• Don't touch an electric fence that says "WARNING: ELECTRIC FENCE"
• Don't run with scissors
• Don't throw knives at your brother
• Don't drink and drive

I like to think that the term "common sense" was invented for a reason.  That reason, of course, is that common sense is common.  Or at least it should be.  It's a very simple concept, one that boils down to three simple words that my father (DadBastard) told me on my wedding day: DON'T BE STUPID.  Those three little words cover a lot of ground and will keep a lot of people out of a lot of trouble if they just bothered to remember them every now and then.

I think anyone who has lived on this planet for more than a decade can definitively tell you that common sense is in no way common.

Thom (not his real name ©), a healthy young man in his thirties (ie old enough to know better) stumbled out of a pub after drinking more than his fair share, wandered into the road, and was promptly struck by a car.  His head bounced off the windscreen, shattering it, and he was launched (purportedly) 10 meters through the air, landing in a crumpled, beer-soaked heap on the side of the roadway.  When the medics first got to him, he was completely unconscious, so he was brought to me as a level 1 (high level) trauma about 20 minutes later.  Because of his altered level of consciousness, it was unclear to the medics if he had a severe brain injury, but when he woke up and vomited about a liter of undigested ale (it may have been lager) on my shoes, the issue started to become clear.

On my initial head-to-toe assessment, it was difficult for me to get past Thom's head since there were at least 10 separate lacerations on his scalp, all of them bleeding to some degree.  I fashioned a makeshift turban to staunch the bleeding, and my survey continued southward.  He miraculously appeared to have no broken bones or other serious injures.  A CT scan ruled out any serious brain injury, but his labwork revealed the true nature of his problem: his blood alcohol level was about 6 times the legal limit.

I went through two stapling devices (which contain 25 staples each) to get all his scalp lacerations closed.  I then hydrated the hell out of him, let him sleep it off, and sent him home.

A week later Thom came back to see me to get the staples removed, and something seemed a bit off with him in the waiting room.  I watched him get up and walk into my examination room, and though it was rather subtle, he seemed to be off-balance slightly.  My first thought was that he actually had a serious brain injury that I had somehow missed.  Not two seconds later when he approached me, my worry was allayed and my ire started rising:

Thom had shown up to his follow-up appointment drunk.

He wasn't nearly as intoxicated as he had been when we first met and he was clearly trying to hide it as best he could, but the smell on his breath was unmistakable, as were his bloodshot eyes and his slurred speech.  And the bottle of whiskey in his jacket pocket.

I wish I could eliminate the term "common sense" from the lexicon since it is an obviously glaring misnomer.  Unfortunately "rare sense" and "unheard-of sense" just don't have the same ring to it.

Requests

Over the past few years that I've been writing, I've gotten more requests than I care to count.  Some have been very thought-provoking -

• write a post about GMOs
• write a post about the anti-vaccine movement
• write about the most difficult case you've had

Others have been, well, let's just say I chose not to fulfill them -

• tell us your name
• tell us where you live
• will you be my mentor and/or write me a letter of recommendation?

I wish I were kidding on that last one.  As much as I appreciate my young readers, and as grateful that I am that people have been inspired by me to go into medicine and/or surgery, I just don't think any dean at any institution in the world would be remotely impressed by getting a letter from a "Doctor Bastard, Bastardia Medical College, Bastardia (not its real name©)".

That being said, I've also gotten several requests from folks asking me to advertise or promote something.  If you have never noticed the distinct lack of adverts on this blog, you will now, and there's a very good reason for that.  Because of that ad-free philosophy, every shameless request for every shameless promotion I've gotten, I've politely declined.

Until now.

This one is just too important.  I got an email from Sandra (her real name) from RegencyShop.com about a charity auction they are running for breast cancer awareness.  Yes, October is Breast Cancer Awareness Month.  Now I will happily admit I have little doubt that there are likely few people out there who aren't aware of breast cancer, but I have even less doubt that every little bit helps, especially considering how prevalent and pervasive breast cancer is.  I've met very few people who don't know someone who has personally been affected by breast cancer.

One great part about this auction is that all the proceeds will go directly to breast cancer research.  Wait, that's not the best part?  So what is?

Ball chair

JUST LOOK AT THIS FURNITURE!  IT'S ONE-OF-A-KIND!  IT'S PINK!  YOU WANT THIS!  YOU NEED THIS!

Hanging bubble chair

Ibiza chair

Come on, who wouldn't want one of these in their living room?  Just look at them!  They're pink!  They're retro-yet-modern!  They're ultra-cool!

And they're for a good cause.  If you can - bid, win, and be someone's hero.

Emotion

• Sadness
• Frustration
• Grief
• Relief
• Bewilderment
• Happiness
• Amusement
• Fear
• Curiosity
• Anger

These are a few of the emotions that try to run through my mind as I evaluate every new trauma patient, especially the tough ones.  Not every emotion rears its ugly head for every patient, but there is usually some combination of several of them.  I say they "try" to get through, because in order to get through my day, I am forced to suppress every one of them and yield only to "Rational Thought".  It's the only thing that allows me to do my job thoughtfully, professionally, thoroughly, and without yelling at people and going completely bonkers.  I've been asked innumerable times how I'm able to separate my emotions from my actions and stay calm in the midst of turmoil and chaos, and there's one very simple answer:

I have no goddamned clue.

No really, I haven't the slightest idea.  I don't meditate, I don't say any calming words to myself, I don't try to align my qi, and I don't use any other techniques (that I know of) to remain unflustered.  But however I do it, you'd better be damned happy that I can, because as a trauma patient lying on a gurney and staring up at the ceiling with your intestines hanging out, the last thing you want is your trauma surgeon freaking out and losing his mind.

Several months ago, however, I experienced a case that threw my entire system into sheer turmoil and threw my qi right out of alignment.  Or something.

There are three B's in the trauma arena that I just don't do: bones, burns, and babies.  I let the orthopaedic surgeons do bones, I transfer any burn victims to the local burn centre, and any injured children are supposed to be taken to the local children's trauma centre.  Yes, I said "supposed to", so if you're reading between the lines, you can probably see where this is going.

After a full day of mostly uninteresting patients, I was just sitting down to eat a sandwich (meatball, of course) when my pager went off.  Meh, probably another elderly person who fell and bonked her head, I thought.

"HAHA not even close, jackass!" the Call Gods laughed.  "Try a gunshot wound!  Level 1!  In the trauma bay now!  Put the sandwich down."

Damn you, Call Gods.  Damn every one of you.

A "trauma in the trauma bay NOW" call usually means a family member or friend (or occasionally an ambulance) drove the patient in, and the triage nurse upgraded the patient to a trauma on arrival.  When it's a "gunshot wound in the trauma bay NOW", it usually means a car drove up to the emergency entrance, pushed a gang member with several new holes in him out the car door, and sped away.

If only it were something that mundane.

I ran down to the trauma bay, and what greeted me was a crowd of approximately 195 people milling about.  I pushed my way through the throng and what I saw made my mouth go dry and my heart sink: a little boy about my daughter's age with a bullet hole in his forehead.

WHAT. THE. HELL. IS. THIS, I thought to myself as I tried to force out of my head the image of one of my children lying on a gurney like this.

Despite the chaos I managed to compose myself and get the story from one of the police officers in the room.  He had found the child on the ground at a local park, and instead of waiting for an ambulance, he picked the boy up, put him in his car, and drove him directly to the hospital.

I couldn't get the picture of my children out of my mind.

The little boy was still breathing and his heart was beating, but he was obviously in very bad shape.  We inserted a breathing tube and took him straight to the CT scanner, where I saw exactly what I was hoping not to see: the bullet entered his forehead and went through most of the right side of his brain before stopping in his occipital lobe.  His brain was already swelling dramatically, and there was almost no space left for it to go.

My son . . . my daughter . . . lying on the ground . . . 

My hands were shaking.

I got on the phone immediately with the local children's trauma centre and told them the story, and they said they would send a team immediately to pick him up.  As I hung up the phone and sat down, the raw emotions flooded over me like a tidal wave washing over a defenseless beach.  I looked at one of my assistants who looked like she was about to cry too.  Fortunately for the sake of the boy's mother (whom I had just brought into the trauma bay), both of us were able to keep our composure.

If anyone has ever wondered why I only treat adults, now you know.

The minute I got home the next morning I grabbed both of my children, hugged them, kissed them, and told them over and over again how much I love them.  They both seemed very confused why Daddy wouldn't let them go, but I finally let them wriggle free after I was sure they knew.  Even Mrs. Bastard started crying when I told her about it.

It takes a lot to get me riled up, but cases like these shake me to my very core and make me appreciate what (and who) I have that much more.

Jahi McMath - Here we go again

NOTE: If you haven't heard of Jahi McMath's story, you can read about it here.  I go into more details here, here, here, and here, and my personal Jahi FAQ is here.

About nine months ago I left the sad saga of Jahi McMath behind and moved on, thinking everyone else (including her family) would do the same.  Boy, was I ever wrong.

Now this is not the first time I've ever been wrong about something (just ask Mrs. Bastard), but unlike many people, I have no problem admitting when I'm wrong when I've been proven so.  I see no purpose in continuing to argue even in the face of overwhelming evidence against me.

But just when I had thought I had heard the end of the story, Jahi's family (along with their lawyer Chris Dolan) came roaring back into the news this week with some rather astonishing claims, and an even more unbelievable request: based on some purported new tests, they are petitioning the court to overturn her death and declare her alive.

I'll give you all a moment to bask in the glow of that mind numbing stupidity before I move on.

One of the main reasons for this request is the contention that Jahi is responding to and following commands.  Two videos were released that appear to show just that:


Before anyone rushes to judgment ("It's a hoax!  It's a fake!  There are strings attached!"), I am reserving judgment on these videos myself.  It is possible that she was moving her hand and foot before the camera started rolling (which, by the way, is an obsolete phrase.  Cameras don't roll anymore.  Non sequitur over.), and that Jahi's family took advantage of her pre-existing spinal reflex movements and recorded them.  And before anyone asks, studies show that these type of movements in brain dead patients are not that unusual, occuring in about 1 in 7 brain dead patients.  From the article:

The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet.

In case you didn't (or couldn't) watch the videos, these are exactly the movements that Jahi is making.

If that weren't enough, there are other claims made by the family and their lawyer.  Apparently she has started menstruating, and Dr. Alan Shewmon, a well-renowned and rather famously anti-brain-death neurologist, claims this proves that she is not brain dead, since the pituitary gland is responsible for secreting the hormones that are responsible for menses.  Game, set, and match.  Right?

Ah ah ah, not so fast.  Studies on brain dead women have revealed that function in both the hypothalamus and the anterior pituitary gland (the portion that produces FSH and LH), is preserved even in brain death.  So the fact that Jahi now has her period is interesting, but meaningless.

The family's next assertion to support the "Jahi is alive" line is that an MRI shows preserved brain tissue.  Here is a screenshot of her MRI:

If there are any radiologists looking at this, a comment would be gratefully appreciated.  What this shows is catastrophic damage to her midbrain and brain stem, but it does show some preserved cerebral cortex (brain tissue).  What this means functionally is impossible to assess based on this one image.  This alone doesn't mean she is alive.  All I can really say is that there is some brain tissue there.  Again, interesting but meaningless.

Perhaps the most astonishing claim is that she has electrical activity in her brain based on a recent EEG.  I haven't seen her EEG, but this is enough to make me stop and think.  Brain death means a silent brain, so there should be no electrical activity in there at all.  If she does have electrical activity, that raises a lot of question marks.

The most telling part of this news is that the doctors supporting these claims hail from the International Brain Research Foundation which is based in the United States.  I sure was impressed that such an impressive-sounding foundation would support the idea that Jahi could come back from brain death . . . until I looked into the IBRF and discovered that they are a collection of alternative therapy-driven self-described "mavericks" of brain injury research.  To give you an idea of who these people are, their chief medical officer Dr. Jonathan Fellus lost his medical licence this year for having sexual relations with one of his brain-injured patients.  It's unethical enough having an extra-marital affair with a patient, but doing it with a brain-injured patient is simply unconscionable (pun intended).  If you really want to be creeped out, read the full article.

Not all the doctors who are looking at Jahi are like ex-Dr. Fellus, however.  Dr. Calixto Machado, a well-respected Cuban neurologist and author of numerous articles on brain death (including one I have referenced myself), has been asked to evaluate her.  Dr. Charles Prestigiacomo, chair of neurosurgery at Rutgers University, has also raised questions based on the results of the various studies (though I'm not sure if either Dr. Machado or Dr. Prestigiacomo has actually examined her).

Damn, this ended up much longer than I was expecting.

Anyway, the bottom line here is that no objective evidence that Jahi McMath is alive has been presented.  There must be independent confirmation of the family's claims by a competent doctor.  If the claims are verified, then one of the following two statements must be true:

1. All six doctors who examined her back in December and declared her brain dead were wrong, they all interpreted her brain death studies incorrectly, and all of the studies showing she was brain dead were wrong, or
2. Brain death is not absolute and it is possible to recover, even somewhat.

If the claims are verified, then she is most certainly not dead, and every medical textbook publisher on the planet will have to revise every medical textbook on the subject of brain death.  If that time comes, I will readily and freely admit that I was wrong, and every other doctor that believes that brain death equals death and is finite and irreversible will have to do the same.

But if the claims are untrue and/or this turns out to be nothing more than a cruel hoax, then shame on the family, shame on the lawyer, shame on the IBRF, and shame on the media for drawing out this incredibly tragic affair even longer.