Wednesday, 23 July 2014

Premonition

Before I start this, no I can't see into the future, and yes I'm a damned pessimist.  But then you probably knew that anyway.  If I could see the future I would have sunk every penny I had into Apple stock in 1982 and I'd be retired by now.  Despite this severe shortcoming, I do get premonitions now and then.  You know, that overwhelming feeling that something really bad is about to happen.

You guessed it - my Inner Pessimist reared his ugly, stupid head again recently. 

"I have a bad feeling about this," I said to my assistant just prior to my patient being wheeled back into the operating theatre.  Those are 7 words you never want your surgeon to think, let alone say aloud.  Esther (not her real name) was 50ish and not terribly healthy coming into her ordeal, having had a stroke and heart attack in the past several years.  And now she was actively dying in front of my eyes.  By the time the emergency physician called me, she was floridly septic - her heart was racing, her blood pressure was dangerously low, her kidneys were failing, and she was delirious, barely able to keep her eyes open.  When I got there her entire family had gathered around her bedside, looking more like a funeral procession than anything else.  They could tell by the look on my face that the situation was grave.

Why was Esther dying?  Well, if you ever needed proof that perforated appendicitis is a different disease than regular appendicitis, Esther is your proof.

As I waited for the staff to ready the operating theatre, I thought back to the last patient I had who developed sepsis from perforated appendicitis.  He was half dead by the time he got to the hospital, and over the next two days he completed the process.  Now the seconds ticked by interminably, and with each passing minute I had a stronger and stronger feeling this case would be a tough one.  Little did I know how right I would be . . . sort of.  Well, not really.  Kind of.  Ok, the case itself wasn't hard, it was just that, well . . .

Hang on, let me back up a moment. 

We finally got Esther into the room and placed her on the operating table right at midnight (since appendicitis always happens in the middle of the night, apparently).  After putting on the appropriate monitoring equipment, the anaesthesiologist was supposed to quickly put the patient to sleep, put a breathing tube in, and let me get to work.  But that's not precisely what happened.  Ok, that's putting it mildly - it's not even remotely what happened.  Instead, this is exactly what I heard, word-for-word, as Dr. C (not her real name) tried putting the tube in:

Nurse: "Do you see something?"
Dr. C: "Yes, but I don't know what it is."

Wait, what the hell is going on up there?

She tried to put the breathing tube in five times, and five times she managed to get it into the oesophagus rather than the trachea.  WRONG, WRONG, WRONG.  After nearly an hour of trying, she called a second anaesthesiologist, who had to drive in from home, to assist.  While she was waiting, she tried putting in an radial arterial line so she could monitor her blood pressure directly.  True to form, she couldn't get that in either.

At this point my blood pressure was rising even more than Esther's was falling. 

The second anaesthesiologist arrived as Dr. C tried again.  Finally after an hour and 26 minutes, a temporary tube finally was in the trachea.  Her oxygen saturation, which had been hovering around 88%, increased to 97%, and I started prepping.  And then, trying to exchange her temporary tube for the permanent tube, she pulled the tube out.

GOD.  DAMN.  IT.  Back to square one. 

As I fumed in the corner of the room, trying to regain my sanity and keep my blood from boiling, she tried again.  A minute later I heard her yell "The tube is in something!" (her exact words).  Wait, something?  SOMETHING??  There are only two tubes there!  Which something is it in?!

It was the wrong something.  Again.

I wanted to scream "JUST STICK IT IN THE GOD DAMNED HOLE ALREADY!" but as the only man in the room, I didn't think that would go over too well.  So, taking a note from almost two decades of marriage, I wisely kept my mouth shut. 

Finally, FINALLY, after trying for 1 hour and 51 minutes (yes, I timed it), the endotracheal tube was in (the right something this time), and I could finally start the actual procedure.  The surgery itself, which consisted of removing the necrotic (ie dead) appendix and draining her pelvic abscess, only took 35 minutes.

We kept her on the ventilator overnight as a precaution and removed the breathing tube the next day.  Esther's vital signs, bloodwork, and kidney function all improved rapidly once the infection was controlled, and a week later she walked out of the hospital and went home.  Not surprisingly, her biggest complaint as she left wasn't abdominal pain; it was a sore throat. 

I can't for the life of me imagine why.

Wednesday, 16 July 2014

More seatbelt stupidity

I haven't discussed the merits of seatbelts in quite some time, so I thought I would throw this out there.  Whenever I go a few months without getting reminded of their importance, the universe hits me with something as subtle as getting slapped in the face with a fish.

I will start by saying that this story is boring.  If you'd like to tune out now and go watch some videos of cats, feel free.  It'll probably be more interesting, much funnier, and far more educational.  Hell, I think I'll go watch some myself instead of writing this stupid, boring post.

No, no, no.  This is far too important, and Steve was far too stupid.

Steve was a lovely gentleman in his 60's who, based on his slovenly appearance, was apparently never properly taught how to use a toothbrush, a hairbrush, or a bar of soap.  Though I suspect his relative dearth of teeth and crazy Albert Einsteinesque hair had nothing to do with him running his truck into a utility pole at over 100 kph, I have a strong feeling that his truck was simply trying to commit suicide to avoid his stench.  The fact that he was ejected from the vehicle after the crash only strengthened my suspicion that the truck was desperate to get rid of him.

He was unconscious when the medics first found him in a ditch about 10 meters from his truck, having been thrown out the roof (which had torn open like a tin can).  His dog had been thrown 5 meters further and had not survived.  He started to wake up in the ambulance and was unfortunately appropriately obnoxious when he arrived.

"This is Steve", the medics started.  "He was the unrestrained (read: no seatbelt) driver of a truck which ran into a pole.  The pole won.  He's complaining of chest and back pain."

"Not wearing your seatbelt?  Why not?" I asked him.  I am quite certain the look he returned me was one of absolute defiance.  What he said, however, was so ridiculous I nearly laughed.

"Because if I had been wearing it, I'd be dead now!" he said.

I decided not to press the issue at that very moment, because I knew there would be plenty of time for that later.  I pushed on his chest which earned me an "OW!" from his mouth and a distinct *crunch* from his chest wall.  An X-ray confirmed multiple rib fractures on both sides, but fortunately his lungs hadn't collapsed.  In addition to lacerations on his scalp and lip, he had fractures in his thoracic spine, lumbar spine, multiple ribs, and sternum (breast bone).

Steve stayed with me in the hospital for several days, mainly because he hurt all over and couldn't walk.  All the while I was biding my time, waiting for the right opportunity to bring up the seatbelt issue again.  I like to do that when family members are around just to strengthen the effect.  Not surprisingly, no one came.  Steve went home a few days later, the opportunity to educate him lost.

I had the opportunity a week later when he came back to see me in my office.  With his wife.

He was only slightly less disheveled and smelled slightly better (that is, slightly less worse) than when I met him.  His wife, on the other hand, looked surprisingly well-put together.  After doing my examination and determining that he was healing just fine, I launched into my seatbelt tirade.  His wife was nodding through the entire speech, but Steve himself remained with a defiant look on his face.

"Look Doc, I've been in car accidents before," he started.  "I've broken this leg, this ankle, this arm, this shoulder, and a bunch of ribs in other accidents.  I probably would've died if I had been wearing one of those damned death traps.  The only thing that saved me was getting thrown free of the wreck."

I looked at him dumbfounded.  Other accidents?  How many?  Are you the worst driver in the world?

"No, Steve.  That is not the way that physics works.  Have you ever considered that if you had been wearing your seatbelt, you wouldn't have broken all those bones?

Silence.

"Put it on, Steve.  Or else the next time you might not be so lucky.  Just PUT IT ON."

That goes for all of you, too.

Friday, 11 July 2014

Badass

All sorts of guys who fancy themselves badasses end up in my trauma bay.  They are large men often covered in tattoos including such macho things as "TENACIOUS", "BAMF", "BADASS", and the like.  They've spent a good amount of time at the gym working on their manly physiques and are obviously quite proud of themselves. 

And these are the same grown men who scream out for mama the moment an IV is placed.

I'm sorry sir, but if you can't tolerate an 18g catheter going into your arm, you are most assuredly not a tenacious badass.

After I saw yet another one of these crybabies in my trauma bay whining about how the 2cm laceration on his knee was killing him (it wasn't), I started wondering what a real badass - someone who isn't afraid to look danger directly in the eye and growl "BRING IT ON" - looks like. 

I didn't have to wait long to find out.

The 20ish year old gentleman, covered from the waist up in tattoos, happened to be at the wrong place at the wrong time, and he was shot in the leg with a large caliber handgun.  The bullet entered his left outer thigh, went through his quadriceps muscles, exited the inner thigh, re-entered the right thigh, traveled directly behind his knee (exactly where the blood vessels and nerves run), and exited his outer thigh just above the knee.  He predictably had no sensation below the knee, and he was actively pumping blood from his leg into the outside world from one of the holes in his right leg. 

My physician assistant Anne (not her real name) immediately jumped into action and placed her finger in the hole to stop the bleeding, the proverbial finger in the dike.  I had to attend to another man (brought at the same time by a different ambulance) who, in a failed attempt to end it all, had stabbed himself twice in the abdomen and was actively emptying his blood volume onto the floor as well. 

The janitors are going to be busy tonight, I muttered to no one in particular as I stepped over another blood pool and did a quick evaluation of Dude #2 (not his real name).  I immediately saw that it was indeed an arterial bleed, but fortunately it was superficial.  I needed to get his bleeding stopped, but I could do that under local anaesthesia right here in the trauma bay.  He didn't need the operating theatre - the other guy did.  NOW.  I grabbed one of the students milling around the room and stuck her finger in his dike and ran back to the first guy.

Hm . . . I wonder if this post will show up on searches for lesbian pornography because of that last sentence.  Well if not, it will now because of that last sentence. 

Anyway, I did a cursory examination of Badass #1, and he had no movement, no sensation, and no pulses in his right leg below the knee, a sure sign that the bullet had transected his popliteal artery and tibial/peroneal nerve. 
He needed immediate operative attention.  But before he could go to the operating theatre to try to repair the damage, we had to get that bleeding under control.  Despite Anne's finger in the hole, he was continuing to bleed to death around it.  I placed a tourniquet just above his knee, but when I tried to tighten it down, the mechanism jammed, and the tourniquet failed.  And of course that was the only tourniquet in the entire trauma bay.  I yelled to the entire room for anyone to call the operating theatre and have them send up one of their surgical tourniquets, but I knew that it would take at least 5 minutes to arrive.  

That's five minutes we didn't have.

With Anne's finger still in the hole trying to stem the tide and a flood of people running around looking for something, anything to use as a tourniquet, I ran off to look myself.  I chanced a quick glimpse at Dude #2 (no active bleeding) and then bolted.  

Though it seemed like an hour, in reality it took me no longer than 2 minutes to run around the entire emergency department and determine that there were no other working tourniquets.  Dejected but determined, I ran back into the trauma bay, but what greeted me was not hysteria or chaos, but a quiet, serene scene.  Was I too late?  Had he bled to death and died?

Nope.  The bleeding had stopped.

Dumbfounded, I walked up to Badass #1.  Around his lower thigh there was a makeshift tourniquet comprised of a waistband tie from a pair of scrub bottoms and trauma shears that was fabulously effective. 
I looked over at Anne and immediately noticed four things: 1) she was covered in blood, 2) she had a sheepish, though triumphant, grin on her face, 3) her trauma shears were missing from her waist, and 4) her scrubs' entire waistband, tie included, had been roughly cut off.

That's right - in the 2 minutes I was gone, Anne had cut the waistband from her own scrubs, fashioned a tourniquet using the very shears she had used to cut the pants, and probably saved the guy's life.

Forget the burly guy with the tattoos - THAT is bad ass.

Saturday, 5 July 2014

Love-Hate Relationship

Anyone who knows anything about me knows that I have a love-hate relationship with emergency physicians.  I hate them, and I love to hate them.  I'm sure many people out there think that I'm just some asshole with a vendetta against these fine folks, and that may be true.  But there's a very good reason for my feelings - those people torture me.   They don't just torture me, they do it often.  And I'm firmly convinced that they enjoy torturing me, they collude to figure out exactly how to torture me best, and they do it at every opportunity.

What, you want proof?  Yes?  Then read on and be amazed and satisfied.  Or hopefully at least just satisfied.

A few weeks ago I got a call at 1 AM (Hey Call Gods, why the hell is it always 1 AM?  Call me at noon, damn you!) from an emergency physician at Outside Hospital.  Doctor Stupid (not her real name) had a young man who was shot in the femur (not shot in the leg, "shot in the femur" - the distinction will become crucially important in a moment), and because they do not care for trauma patients at that hospital, she wanted to transfer him to me.  It sounded like a perfectly reasonable request, and I had no dispute.  "Fine, send him over," I yawned, knowing that I might at least get about 2 more hours of sleep, since that's how long it would take for the ambulance to drive him the 10 km from there to here.  Why it takes that long, I have no idea.  Perhaps they walk the patient over.

Regardless, when he finally arrived (3 hours later, in fact), I went down to see him, and there were two innocent-looking bullet holes on the side of his leg, nowhere near where his femur should be.  It looked suspiciously like mere flesh wounds, and when I looked at his X-ray, what I saw was a completely, totally, 100% intact femur.  I bandaged his wounds and sent him home, grumbling the whole time about how ridiculous it is to trump up a story just to get the patients out of their emergency department and into my trauma bay.  I not-so-silently cursed Doctor Stupid and prayed to the Call Gods to send her 273 "I Just *cough* Don't Feel Right" patients that night.

How's that for proof.  Enough for you?  No?  Really??

You're awfully demanding, aren't you.  Fine.  You obviously aren't one to believe that history tends to repeat itself. 

FORESHADOWING ALERT

This past week I got a call at midnight (at least it wasn't 1 AM, I suppose) from Outside Hospital #2.  Dr. Fuckwit (not his real name) had a patient with - are you sitting down? - a gunshot wound to the leg.  He must have heard me chuckle as he told me the patient's story.

"Wait, what's so funny?" he asked testily.

Nothing, I told him.  Remembering what had happened just a few weeks prior, I made sure to ask him if the femur was broken.  "Yes, there's a femur fracture," he assured me.  

"I just want to be sure," I said in a flat, emotionless voice as red flags went up all over the place.  "Because I had a purported GSW to the femur transferred to me a few weeks ago, and the femur turned out to be fine."

"Yes, it's broken" is what he actually said next, but the tone in his voice made it sound much closer to "Yes, it's fucking broken, you raging asshole."

Four hours later, the young lady arrived.  I was entirely unsurprised (though appropriately irritated) when I looked at her X-ray and saw another perfectly normal, intact femur.  (You can't possibly be surprised either - come on, you DO know what foreshadowing is, right?)  When I informed her of her normal X-ray and that she would be going home, she, on the other hand, was very surprised.

"Why did they bother sending me here then?" she asked as we patched her up.

Why indeed.

I know I give ER docs a bad rap.  I know it.  But how can anyone blame me?  It's very easy to do when stuff like this happens routinely.  I don't want to feel like beating the shit out of ER docs just for calling me, because I do enjoy taking care of legitimate surgical problems.  I would be much happier if we could co-exist in peace rather than fighting like cats and dogs.  But as long as they keep treating me like their own personal garbage dump, I will continue to love to hate them.

Saturday, 28 June 2014

Is this thing on?

After nearly 3 years and over 2 million pageviews, I'm finally getting the idea that there are more than a few people who read this blog.  Ow . . . wait, I think I strained my shoulder patting myself on the back there.  Maybe I should take some homeopathy for the pain.  Anyway, several dozen young people (students in high school or university) have emailed to tell me that I've inspired them to pursue a career in medicine, and a couple have even told me they are interested in trauma surgery.  Every email like that makes me feel as warm and fuzzy inside as if I'd eaten a stuffed bear.

But is that it?  As great as it feels being someone's inspiration to go into medicine, can't I do more?  I'm not sure I succeeded changing any minds with my rants on homeopathy, the antivax insanity, and marijuana (though I do try).  So am I a lousy writer like Stephenie Meyer (incidentally, why "Stephenie"?  Can no one spell a name properly anymore?) with no ability to sway opinion and convince anyone about anything?  Or can I actually educate and change people's minds regarding subjects I am passionate about?

After getting this email from Taylor (not her real name), I'm ready to do away with my personal Amanda McKittrick Ros comparison and say "yes I can".
Hi,

Though you've undoubtedly heard this hundreds of times by now, I found your blog through FML, and I really do love reading. It's rare, at least where I come from, to find a doctor who seems to be as well grounded and sincere as you come across, so, good on you! Cliché comment aside, I'll get to my point.  

Ever since I was a child, it had been my dream to ride a motorbike. My father owned several, and rode them daily until an accident left him pretty traumatized. I was too young to know of the details, but as I understand it, he was thrown from his bike when hit by a car from the back. He had some pretty heavy duty injuries, and even thirteen years later, he says his shoulder and knee have never been the same. 

Despite this, I was still utterly obsessed with motorbikes. Perhaps it was because I was too young to fully understand the accident, but it hadn't discouraged me in the slightest. Now, I know what you're thinking. She's an idiot. But here's the good news! From your many, many posts surrounding the issue of motorbikes, I have been entirely converted. It's serious stuff. I don't want to get myself killed. I don't want to find myself in a situation similar to those on your blog.

I'd really like to thank you for putting your stories out there. They've made a difference to me. I'm aware of the dangers, and I've come to the realization that it's just not worth running the risk. Thanks for taking the time out to read this. Keep it up, Doc!
Huzzah!  It works!  Taylor, you're listening to your brain (and to me, perhaps) rather than to your heart.  Well done!  Your heart is stupid anyway.  Seriously though, why does everyone say "Listen to your heart"?  It just sits there and beats repeatedly.  Faster, slower, faster, slower.  But your brain is what does all the thinking.  Listen to your brain, damn it.

Regardless, it's gratifying to know that there will now be one fewer motorcyclist on the roads, so I have one fewer person to worry about.  And one fewer prospective patient . . . the patients who pay my salary and allow me to buy food for my family . . .

Hm, maybe I'm looking at this all wrong.

UPDATE: Just after posting this, I got this email from Angela (not her real name):
I emailed you several months (I think) ago about me deciding to quit smoking after reading one of your stories.  I just wanted to tell you I have successfully quit smoking, and my mother has too. I told the story (for lack of a better word at the moment) that motivated me to quit smoking to my mother, and that is what helped her quit.  I'm much happier that my mother quit smoking, as she has enough medical problems.  Thank you very much for sharing your stories, because thanks to just one of them, I was able to motivate myself (and stop making excuses) to quit. 

Thank you again, ~Angela
Double huzzah!  Congratulations Angela, to you and your mother.

Wednesday, 25 June 2014

Mrs. Bastard Update

If anyone heard a huge sigh sigh of relief coming from this direction yesterday, that was me after I heard that my wife was being released from the hospital.  I may have yelped and jumped for joy just a little too, but that's just a rumour.

This was no ordinary pneumonia.  This was . . . well, just look for yourself.  Here is what a normal chest X-ray looks like (unceremoniously stolen from Wikipedia):
Notice the nice clear lung fields.  Notice how there is no vicious, nasty plague abiding in there.  Now, compare that to this:


That is my wife's actual chest X-ray last week when she was first admitted.  Almost the entire right upper lung (that's on the left of the picture, by the way) is involved with some kind of evil nastiness.  What you can't see (that the CT scan showed) is that in addition to a very dense consolidation of her entire right upper lobe, she had areas of pneumonia in the left upper lobe, lower lobe, and lingula as well.  That explains why she was having fevers, chills, and a nearly-constant cough.  And THAT is what she was living with while still going to work, making dinner, doing laundry, and taking care of her family.  

After three days of intravenous antibiotics, her X-ray had already improved to this:
It's still markedly abnormal, but by this point she was breathing much more easily, her white blood cell count had nearly normalised, and she was ready to come back home to me.  It takes nearly a month to recover fully from pneumonia - in the meantime it feels like you've been run over by a very large truck.

But she's still trying to make dinner and do laundry despite my protests.

Friday, 20 June 2014

Fear

There is very little that fazes me.  I've seen the worst of the worst - gunshot wounds to the head with brain oozing onto the gurney, blood spurting to the ceiling (literally), stabbings to the abdomen with loops of bleeding bowel sitting outside the abdomen, dead ruptured colons with bellies full of stool . . .

So now that I have you all thoroughly disgusted, you're probably wondering what the hell my point is.  No, it isn't to see how many keyboards/iPads/tablets/phones I can ruin by getting as many readers as possible to vomit on them.

I've been asked several times what scares me.  If all of those vile things I mentioned before don't bother me (I'll defer from describing the really disgusting stuff I've dealt with), what does?  What really gets my blood pressure up?  If a necrotic scrotum doesn't make me feel nervous (sorry, that just slipped out), what does make my anal sphincter tighten?  What does scare the hell out of me?

Well I found out the answer to that question tonight: my wife in the hospital.

Mrs. Bastard has been sick with a cold for over a week.  Coughing, body aches, congestion, the usual viral stuff.  Nothing to do, just rest and hydrate.  Well Mrs. Bastard doesn't believe in rest.  She believes in powering through whatever is ailing her, and she's continued working through this plague.  Even when her temperature was approaching 39 degrees Celcius (that's around 102 degrees Fahrenheit in case you still cling to that antiquated scale), she went to work, made dinner, did laundry, and took care of our kids while I was out on call.  She persevered, refusing to give in to whatever was trying to take her down.

But this afternoon it got acutely worse.  She started having difficulty breathing, her chest felt tight, and she was having difficulty moving air.  When I heard her say "I think I need to go to the hospital", I knew something was seriously wrong.  This woman doesn't believe in seeing doctors.  She practically needs to have a limb missing to request medical treatment, and even then she'd probably finish cooking just because she doesn't have time for missing legs.

When we got to the hospital, her heart rate was elevated, her oxygen levels were low, and she was sweating profusely even though it wasn't warm.  Blood tests showed her white blood cell count was elevated (a sign of infection), and her chest X-ray scared the bejeezus out of me.  It was so obvious that it could have been read by the woman mopping the floor - pneumonia.  Not just in one lung, but in both.  The radiologist actually said to me, "She's been walking around with this big pneumonia?  She must be really tough!  This should have knocked her sideways!"

That's right - my wife has been walking and driving around, going to work, and taking care of her family with bilateral pneumonia for the past 3 days.

I'm used to being the captain of my ship - I'm supposed to be the one in control.  I tell people what to do, and they do it.  But seeing my wife in a hospital gown, being on the opposite side of the patient-doctor relationship, having to sit idly by while some other doctor examines my wife . . . it's a feeling of utter helplessness that is difficult to explain.  I see patients with pneumonia all the time - most make it, some don't.  But when it's your own partner, the person you swore to love and cherish and take care of for the rest of her life . . . it's a completely different story.

That is what scares me.

Mrs. Bastard, if you're reading this (and there's a good change you are), please get well soon.  Please come back to me.  Please come back home.