Monday, 27 October 2014

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.

Monday, 20 October 2014

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.

Monday, 13 October 2014

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.

Monday, 6 October 2014

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:
Embedded image permalink
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.

Wednesday, 1 October 2014

Participation

WARNING #1: I MAY SOUND LIKE A CALLOUS ASSHOLE IN THIS POST
WARNING #2: I'M NOT TRYING TO SOUND LIKE A CALLOUS ASSHOLE
WARNING #3: I DON'T GIVE A FUCK IF I SOUND LIKE A CALLOUS ASSHOLE

I wear two hats on a daily basis.  Under the first hat is a general surgeon who is trying to save the world from appendiceal disease one goddamned appendix at a time at 2 AM (always at 2 AM).  I'm also trying to cure the world of breast cancer, gall bladder disease, colon cancer, chronic wounds, skin cancer, hernias, and a host of other problems, some big and some small.  But under the trauma surgeon hat, I'm mainly dealing with stupidity.  And as comedian Ron White said, "You can't fix stupid".

As a trauma surgeon, all I deal with are injured people.  After practicing trauma surgery for {redacted} years, I have a very good sense for how long people should be in pain, how long people should be in hospital, and who should be able to go straight home to finish recovering versus going to a rehabilitation facility.  Most people are anxious to get out of the hospital and get back to their normal lives.  Some tragically misinformed people think spending extra time in hospital will make them better.  A few people try and take advantage of my good will by trying to wheedle extra time off work.

And then there are people like Stuart (not his real name©).

Superficially, Stuart was little different than many of the other motorcycle victims I've seen over the years.  He was a large fellow in his mid-20s, covered with tattoos, and he fell off his bike when he took a turn too fast and hit a patch of gravel.  He tumbled over and over, narrowly avoiding getting run over by the car behind him.  When he arrived at my trauma bay, he was clearly in discomfort, mainly in his lower back, left chest, and right thigh.  A quick look at his right thigh told me something bad was going on - it was swollen and deformed, a sure sign that his femur was broken.  When I touched his chest he yelped, so I immediately thought of rib fractures.  An X-ray confirmed a simple fracture of his femur, and a CT of his torso showed a pneumothorax (collapsed lung) on the left but no broken ribs.  He did have three minor fractures in his lower back, but they were clinically insignificant, the type of fracture that is annoying but doesn't cause any disability.

About 18 hours, one chest tube insertion, and one femur repair later, I entered his room on my morning rounds, and Stuart barely opened his eyes to greet me.  "How are you?" I asked in my cheeriest voice (as cheery as I can be at 7 AM before my first cup of coffee).

"Terrible," he droned.  I didn't expect him to be nearly as cheerful as I was less than 24 hours after his accident, but I would have at least appreciated him making an attempt to open his eyes and acknowledge my presence.  Typically pain starts to improve dramatically the day after surgery, so the next morning I figured he would be a bit peppier.

Day 3: "Terrible," he moaned, again without even bothering to look at me.  After discovering that he hadn't even tried to work with the physical therapist the day before, I nicely explained that today was the day for him to get out of bed and start working on his recovery.  I also gave him some good news - I would be removing his chest tube that morning, so hopefully that would help alleviate his pain and encourage him to get out of bed.  I expected to be able to send him home later that day, or the next morning at the latest.

Day 4: "Terrible," he groaned.  He barely opened his eyes before telling me that he didn't bother trying to get up the day before.  Again.  "Ok, I know you're in pain, but let's work on getting that under control and getting you up and walking today so I can get you home," is what came out of my mouth while GET UP is what was going through my mind.

Day 5: "Terrible," he whined.  He still hadn't even made an attempt to get out of bed despite my encouragement.  His nurse the day before had also tried encouraging him, giving him a bit of tough love that he obviously needed.  She tried to get him to be an active participant in his recovery.  His response was to demand a different nurse, a request that I flatly refused.  GET UP!!

Day 6: "Terrible," he whimpered.  Somehow he had still avoided getting up out of bed.  I tried explaining how bedrest doesn't make you better.  Quite the opposite - the longer you stay in bed, the weaker you get.  He just turned over in bed.  GET YOUR ASS UP!

Day 7: "Terrible," he cried.  The therapists, with the assistance of 4 nurses and aides, had finally managed to get him up into a chair.  It had also been the first day he had even allowed the nurses to change his bedsheets since his admission.  Despite our encouragement, he continued to actively prevent his own recovery.  GET YOUR LAZY ASS OUT OF THIS FUCKING BED, YOU GODDAMNED SLUG!

I won't bore you with days 8-10, because they were eerily similar to 1-7.  His array of injuries should have resulted in a 3-4 day hospital stay and him walking out of the hospital.  Instead, he stayed for well over a week and ended up going to a rehabilitation facility to finish recovering, all because he refused to participate in his own care.

If you're ever unfortunate enough to be a patient of mine or one of my colleagues, keep one very important thing in mind: the biggest advocate you have for your own health is you.

Tuesday, 23 September 2014

Good will

Most of the patients I see aren't injured severely enough to warrant time off from work and are able to go immediately back.  Some I estimate will need a few days off, some need a week or two, and a few likely even need several months to recuperate.  I don't mind writing excuse letters for those with severe injuries, and I'm typically rather lenient with granting time off to recover, partially because I feel bad for them, but mainly because I don't feel like arguing with people (I realise that may come as a surprise to you).

Unfortunately some people decide to take advantage of my good will. 

Kevin (not his real name©) was brought to me a short while back in excruciating agony.  The medics wheeled him in to my trauma bay quickly, in a bit of a panic, because of the "large" amount of blood loss at the scene.  He had some blood on his pant leg and more on his hand, and both his left thigh and left hand were heavily bandaged.  He was writhing around on the gurney like a snake on acid. 

"AHHH!  My leg!  Oh my god, am I going to lose my leg??  Oh god I'm dying!"

As usual, step 1 is to inspect the wounds.  I quickly unwrapped his hand and thigh and then paused, staring agape at what confronted me. 

"How bad is it, Doc?  Tell me straight.  Am I going to live?"

The 2 cm laceration on his outer thigh and the 1 cm laceration on his ring finger, neither of which was bleeding, did not make me fear for his life. 

"Yes, sir," I said flatly, doing my best not to slap the shit out of him for his histrionics.  "I suspect you're going to be just fine.  May I ask what happened here?

It turns out that Kevin carried a pocket knife but had forgotten to close the blade before putting it back in his pocket.  He then sat on the blade, lacerating his thigh, and when he reached into his pocket to retrieve the knife, he cut his finger.  

Twenty minutes and 5 stitches later, we were writing up his discharge papers.  And that's when he hit me with this:

"So how much time off work am I gonna get for this?  I think I'll probably need a week.  Maybe two.  Yeah, I think two."

I explained in no uncertain terms that he could go back to work the next day.  

My good will only goes so far before running out.  

Thursday, 18 September 2014

Most injured

I may glamorise my job from time to time (read: all the time) to make myself and what I do seem more interesting.  The sad reality (from my own skewed point of view) is that the majority of my patients are only mildly injured (and sometimes not injured at all).  Most patients get worked up in A&E/ER/ED/casualty department and sent home the same day with stitches, staples, splints, bandages, and/or a stern lecture from me about how to prevent this sort of thing, whatever it may be, from happening again.  For me repeat customers, though good for the bottom line, are bad for business.  If that makes any sense at all.

But who the hell wants to read about someone who was in a minor car accident but was brought to me just as a precaution?  Who wants to know about the old lady who loses her balance and bonks her head on an end table and ends up with nothing but a bump on the head and a mild concussion?  Who cares about yet another drunk guy who falls off his bar stool, spends a couple of hours with me sobering up, and then endures a real sobering drive home with his wife appropriately yelling at him from the driver's seat?  Is anyone even remotely interested in any of that?

I'm certainly not, but I have no choice in the matter.  But I spare you good people the details about the mundane and boring people who come in with minor injuries, mainly because if I didn't you would all run away faster than teens from a Wiggles concert.  No?  Ok, faster than men from a Taylor Swift concert.  Still no?  Ok, faster than sane people from a Miley Cyrus concert.  

Yes.  Perfect.

Anyway, this next guy is not one of those boring people.

I mentioned Orville (not his real name©) briefly in a prior post (he was Victim #2) and promised I would get back to him, so now I'm keeping my damned promise.  Orville is in his mid-20s, and like many young men his age he hasn't outgrown the immature belief that he's immortal and/or indestructible.  Seat belts are too good for him, apparently, because he wasn't wearing his when the car in which he was a passenger went off the road at around 160 kph (100 mph) and struck a tree.  As usual, the tree won.  The tree always wins.  Orville was thrown from the car and landed somewhere near the orbit of Venus, I believe.

When Orville got to me, he wasn't moving at all and was obviously close to death: his heart was beating around 160 times per minute because it was trying to compensate for his dangerously low blood pressure.  About 60 seconds later, his heart gave up and stopped. 

With CPR, several units of blood, and some medications, we restarted his heart a few minutes later, and we continued transfusing even more blood as we were finally able to start our evaluation.  The first and most obvious thing I noticed is that his head looked completely uninjured, unusual for someone in such a severe accident. 

"He is a complete mess," I mentioned to one of the assistants.  "But at least his head looks ok.  But that's about the only thing that looks ok."

Unfortunately looks can be deceiving.

Ultimately his workup revealed the following injuries:
  • 5th cervical vertebra fracture
  • 5th thoracic vertebra fracture
  • 5th lumbar vertebra fracture
  • cervical spinal cord injury
  • Sacrum fracture
  • Open-book pelvic fracture
  • Three rib fractures on the left
  • Left hemopneumothorax (bleeding, punctured lung)
  • Cardiac contusion
  • Bilateral (both sides) severe lung contusion 
  • Bilateral scapula (shoulder blade) fractures
  • Bilateral acetabulum (hip socket) fractures (left side shattered)
  • Bilateral Grade IV (that's bad) kidney lacerations
  • Urethra laceration
  • Bladder laceration
  • Mesentery (blood supply of small bowel) laceration
  • Multiple small bowel and colon contusions
  • Multiple deep left arm lacerations and abrasions
  • Subdural haematoma (bleeding under the dura mater, the tough covering over the brain)
His liver (and all the other internal organs) suffered contusions and/or ischaemic injuries from his initial haemorrhagic shock.  There are only a few things on his entire body that weren't injured.  I would say that his arms and legs were uninjured (other than innumerable lacerations and deep abrasions on his left arm), but since he ended up quadriplegic (unable to move his arms and legs due to his spinal cord injury), that doesn't seem to matter quite so much.



It always amazes me when I hear idiots claim that getting thrown from a car is safer than staying in it.  Would you rather get thrown out of a car and deal with all the kinetic energy of hitting the ground, or would you rather stay in the car where all the seat belts, airbags, roll cages, and crumple zones surrounding you and keeping you safe are?

Exactly.