Time heals all wounds

I hate waiting.  I simply can't stand waiting for pretty much anything - lines in the airport, test results, advertisements on TV, everything.  I can't even stand waiting for diseases to get better, and that's exactly why I chose surgery.   Do you have high blood pressure?  Well your doctor can give you a pill that may work...but you won't know for several weeks.  If it doesn't work, he can give you more.  Or less.  Or a different drug.  Or another drug.  Will that work?  JUST WAIT A FEW MORE WEEKS.  On the other hand, do you have gallstones in your gall bladder?  I can take that out.  Colon cancer?  I can cure that!  Perforated stomach ulcer?  I can fix it instantly.  So because it's been 11 days since my last post, I figured my next update should be about waiting.

Appendicitis almost never shows up during the day.  I have no idea why, but it seems no one EVER comes to the ER at 10AM with appendicitis.  Everyone likes to wait until the middle of the night before coming in.  I can't understand how or why they do this, because I've had appendicitis.  And let me tell you, it SUCKS.  It feels like you're being stabbed in the gut with a huge, dull, rusty sword.  And the longer you wait, the higher your risk of the appendix rupturing.  When that happens, it becomes an entirely different disease.  People with mild appendicits usually go home within 24 hours.  People with ruptured appendicitis, however, typically are in the hospital for a week, and some even die.  I only waited about 4 hours before I went to the ER, and my appendix had already nearly ruptured by then.  So how the hell can someone wait a day or even longer before seeking medical attention?  God damn it people, listen to your bodies!  Sorry, sorry.  I digress.

The ER called me a few days ago at 1 AM (of course) to tell me about a 34 year old woman who had just flown back from week vacation on a tropical island.  She had been doubled over in abdominal pain for her entire trip, but she had waited until she got home before coming to the hospital.  Naturally, her CT scan showed ruptured appendicitis.  Greeeeaaat.  After explaining the situation in detail, I took her to the operating theatre where I found this:

Ok, it really wasn't that, but that's what it looked like had happened inside her.  Her appendix had indeed ruptured, there was pus everywhere, and everything was inflamed and stuck to everything else.  I cleaned up all the pus and I managed to chisel her appendix out of the intense inflammatory response (all done laparoscopically, much to my satisfaction).  After a very difficult case, I went out to the waiting room to talk to her husband and his father, who were waiting anxiously to find out the results.

After I told them what I found, her husband said, "That's about the same thing that happened to me!  Remember, Dad?" 

Wait...what?

My mouth probably agape, I stared in disbelief as his father recounted how his son, this woman's husband, had also had ruptured appendicitis when he was a kid on a skiing holiday.  He had also waited a week before seeking medical attention because he didn't want to cut the ski trip short. 

So even though she had been complaining of pain all week, and even though he had been through the exact same thing, they never went to the hospital.  Granted, most people can't diagnose appendicitis that easily, but MOST of us would go to the damned hospital if we were doubled over in pain FOR A WEEK like she was.  Just like her husband, she spent a week in the hospital before she finally went home.  I saw her in my office a few days ago, and she's doing much better.


They say "Time heals all wounds."  But that doesn't quite apply when it comes to surgery.

Experts

The Internet is both the best and the worst thing to happen to medicine ever.  Well, ok maybe penicillin was pretty important.  And I guess anesthesia was also a big break - rather than simply getting people drunk and hoping they didn't wake up during the procedure, it allowed us to do whatever we wanted for however long we wanted.  But I digress.  These days everybody seems to think that they can google something and instantly become a medical expert.  Nevermind the fact that becoming a doctor actually takes around a decade of school and training.  A 5-second internet search apparently allows people to skip years of training and practice.

A short while ago I admitted a young man who had been involved in a fairly serious car accident.  He had bonked his head pretty hard (that's the technical term) and had a small contusion in his brain.  As per our protocol, I had repeated his CT scan several hours after he arrived, and it confirmed that the contusion had not changed at all.  I admitted him to the intensive care unit, and though he was initially very confused, he improved dramatically over the next few days.  The night before I was going to discharge him home, I got a very irate phone call from his very irate mother.

"How the hell can you be thinking about sending my son home?" she asked me.  "You haven't even done an MRI of his brain!"

No of course I hadn't, I told her.  I very calmly explained to her that her son was getting much better and there wasn't any need to do any further imaging.  The only reason to do a test is if you plan on potentially changing the treatment based on the result.  No matter what any test showed, his treatment wouldn't change.  I tried to explain calmly that not every brain injury patient needed an MRI.  It was a very expensive test that wouldn't change anything. 

Oops.

As soon as the words escaped my mouth, I regretted saying them.  Her screaming grew louder.  She accused me of not doing anything and not caring about how her son was doing.  She then accused me of simply trying to save the hospital money.  I held my own, and nearly an hour later, I finally hung up the phone, absolutely satisfied that I had not convinced her one bit.

Not surprisingly, her son continue to do well, and I sent him home.  He did not get an MRI.

All I ask is that you just please let me do my job. I'm not saying you can't ask questions and challenge me, because I'm not perfect.  I actually appreciate questions.  But you have to understand that google doesn't make you an expert, and unless you've been to medical school, I know a hell of a lot more about this than you do.

I wonder if I can use Google to search how to deal with idiots with a smart phone who think they know more than they do.

Compliments

WARNING: I may word this post slightly in my favour, so there's a small chance I'll end up looking like a braggart. It isn't my intention, I assure you. But I do have a point. Stay tuned.

One of the worst parts of surgery is that patients really have no idea what actually goes on in the operating theatre. I don't mean the shenanigans and hijinx (just kidding...sort of), I mean the actual operation. The only parts of my work that the patient can see are the bandage and the scar. If those looks good, that seems to be all that matters. Your surgeon could be the biggest hack in the world, but if he can close your skin nicely, he's a superhero. But heaven forbid you get a drop of blood on the bandage, because then you're clearly a butcher. So the only real thing on which a patient can judge their surgeon is his personality - his bedside manner, attentiveness, attention to detail, mannerisms, etc. These things are important, but not as important as his skill in the OR. That's not to say it isn't a wonderful compliment when a patient tells me that she was referred by another patient of mine (I took out her friend's gall bladder, so when she needed surgery, her friend told her to come see me). I even had a woman track me down several years after I took out her appendix to do her breast biopsy when she found a lump. But how do they know if I'm actually any good?

One of our local magazines has their annual "Best Doctors" issue, in which they mail surveys to doctors and ask them who they would go to see if they needed medical care. But here's the problem with that question - I almost never see my colleagues operate. I know who's nice and who's an arrogant asshole, but I don't know who's good! I wouldn't have a clue who to see if I needed surgery. In that regard, I'm no better off than my patients! So who the hell can you trust to judge a surgeon's skill?

Anaesthesiologists and OR nurses, that's who. Think about it - all they do is watch surgeons operate, so you know damned well they know who is good and who is much more likely to remove the wrong kidney.

A man came to see me last week about getting his hernia fixed. He had no primary care doctor, so I wondered how it was that he got my name and number. Did he go to the ER? Did I operate on a family member or friend? As I was about to ask him, his wife knocked and stepped in the room - she's one of the anaesthesiologists I've worked with the past few years. And of all the surgeons at the hospital, she had him come to see me.

I've gotten some nice compliments over the years - it's great when someone tells me that my suit is nice or my haircut looks good. But I think this was one of the best compliments I've ever received.

Wait a minute, what was the point I was trying to make? Oh right, now I remember - don't sprain your shoulder when you pat yourself on the back. Make sure you stretch first.

Perseverance

per·se·ver·ance

[pur-suh-veer-uhns]

noun

1. steady persistence in a course of action, a purpose, a state, etc., especially in spite of difficulties, obstacles, or discouragement.

When faced with adversity, some people simply throw in the towel.  Others just don't know when to quit.  And it's a damned good thing this next patient didn't know when to quit, because if she did, she would only have one leg. 

Wait...damn, I'm getting way ahead of myself again.   

This next story comes from Miss C (not her real name).  And prepare yourself for some gory pictures...ok, they aren't really gory, but they are a bit graphic.  Now that I've set it up, here goes:

Hi Doc.  From reading your blog you seem like a really great caring doctor. We need more doctors like you. I've had my fair share of being in hospitals...not for me but for my mother.

My mother was in a horrible accident 7 years ago when I was 12. After a family wedding, my mother was walking to our car and a drunk driver pulled out behind her, pinning her between the cars. It was a hit and run - the bastard just left. The muffler of the car gave her a third degree burn and the bumper of the car shattered her fibula and tibia.  The ambulance came for her and took her to a local hospital.  We arrived at 1:00 am, and we waited in the ER for 12 hours to see a doctor!  Can you believe that?  The orthopaedic surgeon's explanation was that he went out that night and had a few drinks and couldn't do surgery or come in at all.  And there were no other doctors.

When the doctor finally saw her, he told us she needed surgery immediately.  When the doctor was finished with the surgery, there was almost nothing left.  He put a titanium rod in her leg, but the tibia and fibula were protruding out of her leg along with muscle.  The next day, the surgeon came in the room without any compassion and said to my mother, "We're going to have to amputate your leg; you're never going to walk again."

My mother was in shock and in disbelief and asked why.  He replied that he didn't think the bone was going to grow around the titanium rod.  My mother asked why he put the rod in if she was diabetic.  He angrily said, "YOU'RE DIABETIC!? No one told me!"  He grabbed the chart and said, "Either way, it's not going to work out, so we're going to have to amputate."

My mother refused to believe that she wasn't going to walk again, so she refused the surgery and we took my mother home while my father was looking for another hospital.  My sister and I cared for her for weeks.  After two months my father finally found a hospital that specialised in bones. 

We were told she needed surgery immediately.  The first surgery was to take out the titanium rod, shave off the broken bone that was infected, clean out the infection, and place an external fixator {external hardware that holds the fractured bone in place}.  They did many cleaning surgeries before another major surgery.

They then did a muscle flap {taking muscle from her calf muscle and flipping around to the front of the leg to cover the bone} and two skin graphs.  After four months, several surgeries, and more antibiotics than I can count, she finally went home.   

A month after that, after learning how to walk with the external fixator, the external fixator was removed.

Six years and 10 surgeries later, my mother walks.  So much for never being able to walk right?

Well Doc, I thank you for being such a great doctor.  I truly appreciate doctors who take their time to get to know their patients and not just try to get rid of them.
 

You'll notice the horrendous scarring on her leg.  You'll also notice HER LEG, which is still firmly attached to her body.

I give absolutely no excuse for the first surgeon, but I give full credit to Miss C's mother (not her real name) for her almost-ridiculous perseverance in the face of a near-catastrophe.  It's people like this who refuse to give up who make my job worthwhile.

Knowing better

Everyone knows the saying "Doctors make the worst patients", and it's completely true. Even though we know something's wrong, we tend to neglect ourselves in order to take care of others first. It's selfless and altruistic...and stupid. But some people know exactly what's wrong with themselves and still choose to put not only their own life in harm's way, but others' as well.

A woman was brought to me around 8PM a few nights ago after she lost control and rolled her car over several times. The medics informed us that when they arrived on the scene of the accident, the patient seemed "post-ictal" - like she had just had a seizure. That report always makes me very nervous because a seizure can be a sign of a serious head injury. This time was no different.

Or was it?

We did our workup, and she didn't appear to have any serious injuries. Her X-rays and CT scans all looked completely normal, as did her physical examination. As I was finishing her exam, she told me that she did, in fact, have a seizure disorder. She swore that she took her anti-seizure medicine that morning just like every morning. But she also admitted that what typically brings on a seizure for her was fatigue.

Sound strange? Oh, just you wait.

It turns out this was her first day back to work after having a baby three months ago. Now in case you weren't aware, babies make you really, really tired. No, let me rephrase that - babies make you so tired that you forget what sleep feels like. But not only was it her first day back to work, she decided that a double shift would be a great idea.

BZZZT! Wrong! It was a really stupid idea that made her exhausted. An even worse idea, one that put her and every other person on the roads (including my wife and children) at risk, was to drive home. She could have called her husband for a ride. She could have asked a colleague to drive her home. No, she drove herself.

As I was explaining how lucky she was not to have injured anyone, I glanced over to her bedside stand and noticed an ID badge from another local hospital.

"Oh, you work at a hospital?" I asked her.

Yes, she told me. She's a nurse. I felt my ire rising. "What field of nursing are you in?"

She couldn't even look me in the eye when she told me: neurology.

That's right, she's a damned neurology nurse who takes care of seizure patients on a daily basis, one who has had a seizure disorder herself for several decades, one who knows exactly what triggers her own seizures, and one who deliberately broke nearly every possible seizure rule and is lucky she isn't dead. I made sure that her husband was in the room to hear all this. From now on, I told him, if you can't drive her to work, make sure she takes the bus.

Whenever I see a stupid driver, I want the power to revoke driving licences. Never has that desire been stronger than that night.

Seatbelt story

In case people still aren't convinced by the stories I've told about seatbelts, I got an email from a reader a few days ago with a story of her own.  (Coincidentally, my last seatbelt post was exactly a year ago today.  Strange.)  Miss X (not her real name) not only gave me permission to post her story, but she asked if I would share it.

To protect her identity, some names and details have been changed.

Doc,

A few days ago I found a tree at 40mph on a back country road and I have always worn my seat belt but I had never been saved by one.

My friend (whose truck it was) had pulled over because she was crying about unrelated marital issues, so I took over driving and was trying to turn around to go home for ice cream and a chick night.  Instead, the Chevy Silverado hit the tree head on.  I had never driven the truck before and it was dark and raining on the curvy back country road.  I broke the metal pedal on impact.  We were three inches from being legless and five inches from being crushed.  My chest broke the steering wheel off and pushed the steering column down three inches.   I broke my 3rd, 4th and 5th metacarpals in my right hand when the impact caused me to punch the radio.  My friend did the same, but she spiral fractured her left middle finger.  So we have matching purple casts on opposite hands.  We joke that we fist bumped mid impact.  My ribs are sore and my back muscles are not happy but because of our seat belts we walked away from what should have been a fatal accident with a collective four broken bones in our hands, sore ribs, minor airbag burns, and deep seat belt bruising.  Without our seat belts we would have been thrown headlong into a tree and possibly died on impact.  With them we both walked away with relatively minor injuries.

In the pictures, the big dent in the side of the truck shows that when we impacted there was enough force to wrench the truck bed back two inches, and it also dropped the spare tire from under the bed.  If you look below the buttons on the steering wheel you can see how I broke it.  The tire in the picture is at an odd angle because the front axle was cut in half by the transmission being forced into the manifold by the engine.  The X-ray is my hand.  It was actually scarier to see the truck afterwards than the actual accident was.

Thank you for being a wonderful person and doctor.  The world needs more people like you.

In addition to the story, she also sent me several pictures.  Here is what remains of the front of the truck:

Here is the broken steering wheel:

And this, of course, is her hand with the three broken bones.

This is the sort of accident where you could say, "It could have been worse."  You could try to argue that she was just lucky.  No - I prefer to think of her as smart for using the very device that was designed to save her life.

Thanks, Miss X, for sharing your story.  I hope others will learn from you.

Technology

If you're looking for a stupid patient story, you'll be disappointed by this update, and I apologise in advance.  If you're looking for a really cool picture, you're in the right place.

If you were in a car accident 25 years ago, chances are very good you have a little scar above your belly button where the trauma surgeon performed a DPL - Diagnostic Peritoneal Lavage.  A small incision was made, a catheter was inserted into the abdomen, and a liter saline was instilled.  That saline was then immediately drained out, and if blood, bile, or stool came out with it, you would have gone straight to the operating room for an exploratory laparotomy where the surgeon makes a much larger incision to get into the abdomen to take a look around.  A very large number of these operations turned out to be unnecessary, because if it was the spleen or liver bleeding (which it usually is), that bleeding almost always stops by itself (over 90% of the time). 

The trauma world has been vastly changed in the past 20 years by the advent of CT scans.  "CT" stands for "computerised tomography", and it's essentially a cross-sectional X-ray.  In the 1990's, a CT scan of the head alone used to take about 30 minutes, since the machine was only able to take one picture at a time.  But we were able to see inside the head for the first time.  These days, a full body scan only takes about 20 seconds because the machine takes 64 or 128 pictures at a time.  The best part is that the really fancy (read: expensive) machines automatically reformat the raw data into 3-D pictures.  But CT scans aren't just for looking at the brain or the guts.  They are also great at finding broken bones, and they are much more sensitive than regular X-rays.  Plus, the pictures just look cool.

In case you don't believe me, here's some proof.  This is an actual 3-D rendering of a patient of mine this past week who was jumped by a gang of misfits who punched and kicked him repeatedly in the face:

In case you don't see it immediately, look at the mandible (that's the jaw bone) on the lower left side of the picture just behind the last molar.  There's a second fracture on the right lower side of the picture just next to the midportion of the mandible. 

Getting all these scans may be a bit more expensive (ok, a LOT more expensive), but it has also enabled us to find a lot of injuries that plain X-rays just can't see.  It has also saved patients from a lot of unnecessary operations.  If I see a bleeding liver or spleen, I know that patient will most likely not need surgery.

Hey, wait a second...I'm operating less than before because of these damned CT scans!  But I love doing surgery!  I'm supposed to hate that, right?  But I just can't...they're just too cool.