Monday, 31 August 2015

Wild coincidences

I was glancing back at some of my previous posts recently, and I realised I hadn't mentioned anything about seat belts in a while.  As an aside, I hope it doesn't sound too narcissistic to admit that I occasionally read my old posts, mainly to make sure I'm not repeating myself.  Because who the hell wants to read another repeated story about another repeated subject.

But I digress.  As I was saying, seat belts are a very sensitive subject for me (as I'm sure you can easily tell), one that I feel quite passionate about.  Obviously.  I wasn't planning on bringing up the subject for a while, because who the hell wants to read yet another story about yet another idiot who failed to put on his seat belt and sustained much more serious injuries than he otherwise would have.  Blah blah blah, we've heard it all a million times before.  Wait, am I repeating myself? 

Damn it.

Anyway, I was going to lay off the Seat Belt Preaching for a while, but after meeting Ryan and Douglas (not their real names™), it became instantly clear that not everyone in the world reads my blog (why the hell not?).  These two had apparently missed all my previous Seat Belt Preaching and had therefore not gotten the message. 

Theirs is a story I can't afford not to share.

The vast majority of patients I get in my trauma bay come one at a time.  Occasionally I get multiple victims from the same incident - 2 stabbing victims, 2 guys who beat each other up over a stolen bar stool, 2 occupants of the same car . . . you get the idea.  So when I heard a helicopter would be bringing me two car accident victims, both trauma bays were readied immediately.  Equipment was gathered, personnel arrived, coffee was finished.  The first young man rolled in about 15 minutes later looking very anxious but relatively uninjured.

Feel that foreshadowing yet?

"Morning Doc, this is Ryan.  He was in a high-speed MVC," the medic began.  "Front-end collision, major damage to the driver's side."

I started my evaluation, but less than a minute later the second victim arrived looking markedly sicker than Ryan.  I left Ryan's trauma bay immediately to tend to Victim 2, and the medic started his story.

"Morning, Doc.  Here we have Doug, high-speed head-on crash, major damage to the car, driver's side.  He's the other guy's best friend," he said as he pointed his thumb towards the other trauma bay.

Ok, I asked, which one was driving?  It's not a terribly important bit of data, but one I always ask anyway.

"Both of them," the medic responded.

Oh, ok . . . wait, what?  

"How . . . how is that possible?"  I asked, completely bewildered, trying to imagine one sitting on the other's lap.

"They were driving separate cars," he explained.

Oh, ok.  Wait, what?

"But . . . but you said they were best friends", I continued, my bewilderment not improving at all.

"Yes.  Yes I did," quoth he.

His smug grin did nothing to make me feel better.  I rarely have the desire to smack another man.  This was one of those times.

It probably makes just as little sense to you now as it did to me at the time.  I'm sure you'd like to avoid the stupid "WTF???" face I'm sure I was wearing just then, so I'll explain better than the medic did in hopes that you won't want to smack me in the face.

Apparently Ryan's truck's steering locked up and he lost control, crossing into oncoming traffic.  He tried desperately to regain control, but he was unable to.  When he looked up he immediately recognised the car he was coincidentally about to hit as his best friend Doug's.

They smashed into each other at a combined 225 kph (140 mph), utterly destroying both vehicles.  The bad news is that neither Ryan nor Doug normally wore his seat belt.  The good news is that Ryan, for reasons only known to him, decided to put his on that day.  And because of his seat belt, Ryan walked out of my trauma bay with a few scratches and bruises and a demolished truck.

Doug, on the other hand, suffered a subdural haematoma, an open fracture of his femur, a broken spine, and a broken foot.  After a month in hospital, two surgeries on his leg, one on his brain, a feeding tube, and a tracheostomy, he finally started to wake up.  Over the ensuing two weeks, his mental status improved to the point where he could look at me and give me a thumbs-up when I asked him to, but he was still unable to talk.  A few days later I transferred him to a rehabilitation facility that specialises in children.

He is just 17 years old.

There is no telling what kind of permanent neurological dysfunction Doug will have, if any.  The brain is a funny organ, and its recovery is highly unpredictable.  It can take a year or more to recover, but there is no way to foresee how much will come back.  What I do know is that his life (and those of his parents) has been permanently altered because he didn't listen to his mother, who badgered him daily about fastening his seat belt.  Ryan, on the other hand, will be left with a few minor scars and a damaged best friend to remind him.  I don't suspect he'll need any other reminders.

Seat belts are there for a reason.  They don't hurt.  They take one second to fasten, less to unfasten.  And they save lives.  SO PUT IT THE HELL ON GOD DAMN IT YOU IDIOTS.  NOW.

And now I'm done repeating myself.  For now.

Monday, 24 August 2015

Learning lessons

I know, I know, there's a very good chance that Lincoln never said that.  In addition to that one, there are plenty of other famous misattributed quotes, but regardless of its inauthenticity I must admit it sure looks good on a meme.  That's my second favourite quote meme, my favourite of course being this one:
Unfortunately the likelihood that Einstein actually said that is about as high as the probability that Lincoln said the first one.  Nevertheless I use that line with my daughter all the time whenever she forgets to learn from a mistake she's made.  "Life is a series of mistakes," I tell her, "but it's how you react to those mistakes that determine who you are."

For example, I dare say that nearly everyone who smokes cigarettes knows it is a mistake every time a new one is lit up, but nicotine is so addictive that no matter how much many smokers want to quit, their body simply won't let them.  Nicotine gum, nicotine patches, prescription medicines, hypnosis, cold-turkey . . . nothing seems to work for far too many smokers.  But I'm proud to announce a new discovery, a method that gets people to quit smoking (or not start at all).  It's not a medicine, and it's not therapy.  This amazing new technique is . . .

Well, you're reading it.

Yes indeed, SftTB is officially a Smoking Cessation Device.  That's right folks, it's Toot My Own Horn Time™ again.  After all the self-deprecation and major troll abuse I've endured recently, I think I deserve to pat myself on the back just a bit, though I run the risk of spraining my shoulder while doing so.

I'll start off with Susan (not her real name™) who emailed me some time back to tell me about her mother who had been smoking for 30 years.  She had tried several times to . . . hell, I'll just let Susan tell you:
Hey, Doc, me again! I have some news and I wasn't sure who to share it with...My mother has decided to quit smoking.  To most people it wouldn't seem like such a big deal, but to me it really is.  In the past three years she's had three people she deeply cared about die.  I've begged her to quit before. She understood why, but it terrified her.  I wanted to tell you this because, and in spite of knowing the risks and how disgusted I find the smell, a combination of peer pressure and depression almost made me try.  I made a promise to my mum when I was six that I'd never smoke.  She would understand if I did, because people follow their parents examples, but she wanted better for me. 
12 years later your blog helped me stand by my promise even when I was tempted.  I finally feel like I can breathe again, figuratively and literally.  I can also proudly declare that the only thing this girl has ever lit a lighter or a match for was to start a candle, see in the dark, and boredom. 
I've never, nor will I ever, stick one of those things in my face.
Just like Susan, I've never had a lit cigarette in my mouth either, and I'm sure my lungs (and Susan's and her mother's) are eternally thankful.  I only hope Susan continues to keep that promise.

Next up is Lisa (also not her real name™) who had emailed me a question about Jahi McMath back in February.  In her follow-up to my response, she sent the following:
Thank you Doc for answering my question.  As a side note, I read your article on smoking last week.  I have been smoking since I was 16 or so...I have not had a cig since Saturday....(hard as hell).  The last time I quit is when I ran track for 2 years in high school.  So my thanks on a very hard eye-opening article...more people should read your blog. 
4 days clean so far phew!!!!
Husband says if I stay off of them for a year I can plan that trip to Rome...but if I don't I can't go, so I have an incentive as well...thanks again...keep us the good work...and write a damn book would ya? (sorry did I just raise my voice to you?)  :)
I followed up with her 4 months later to see how she was doing, and she somewhat abashedly admitted to having one cigarette (though not enjoying it) after her mother passed away.  The best part was that she had been smoking for 34 years before successfully quitting.  All it took was reading a past article I had written to get her to quit smoking for good.

It may seem entirely trite and ridiculous to say, but if I can help just a few people with this blog to stop smoking, put on their seatbelts, get off drugs, or not drink and drive, then I will consider myself a success.

And you can quote me on that.

Sunday, 16 August 2015

Thoughts on brain death

Anyone who has read this blog knows of my ongoing fascination with the Jahi McMath case.  If you aren't up to date with the latest information, scan back in this blog a few months and you'll get more than you ever thought you'd need.  The most recent news includes claims made by the family through their lawyer that Jahi no longer meets criteria for brain death.  Of course no concrete evidence for this has actually been presented, but the claim is out there in official court documents.

I've said many times that if this is true, it would mean that brain death is not permanent and every textbook on neurology and critical care would need rewriting.  It would also mean that Jahi would be the first documented case of recovering from brain death in human history.  

Or would it?  

Is that the only possible explanation for what's going on?  Any logical person who knows anything about central nervous system physiology knows that once those neurons are dead, they are gone for good.  That logical person would say that if there is any sign of life, then Jahi was never actually brain dead and was misdiagnosed 6 times (as unlikely as that may seem).

Or . . .

The logical person may argue that what we think we know about brain death may not actually be true.  

Instead of explaining that position myself, I'll turn the virtual podium over to Dr Cory Franklin, a retired intensive care doctor who was director of critical care at Cook County Hospital in Chicago.  He wrote an article in the San Francisco Chronicle about Jahi McMath, and due to editorial constraints was not able to explain his position adequately.  After his article was posted here, Dr Franklin managed to find my little corner of the Internet and joined in the conversation. 

He emailed me a very detailed explanation about what he thinks is going on, and he has agreed to allow me to publish it here.  I have no doubt it will spark a lively (and civil) conversation, and I suspect Dr Franklin will participate.  He's retired, so what the heck else does he have to do (other than write).

Just kidding, Cory.

So without further ado, here is Dr Franklin's full and unabridged opinion:

Doc: First off, let me say you have a great blog.  I retired from critical care after 30 years and while I teach, I don’t go to the ICU much anymore so I have to learn my critical care other places, and your blog is one of the best there is. Kudos on a job well done. Keep it up.
You’re right – I did diagnose a lot of brain death- I’ll estimate between 100-200 cases. 80% was medical, but about 20% of the time the trauma guys would call me for my opinion. I gpt along quite well with them and learned plenty from them.  I wrote the criteria for two major medical centers back in the day so I’ve been around the block.
With your indulgence, I’m going to give you a long answer. I write now, primarily for the Tribune here in Chicago, but sometimes in papers around the country and there was no way I could address the question adequately to a lay audience (and a medical one also) in the standard 750 words. In fact the SF Chronicle editor had me edit the piece down from 905 to 755 as it was. But that’s the nature of the beast.  I can give you the long version of a nuanced issue. 
The short answer to your question is no. I don’t think the girl has recovered from brain death, not in the classical sense we think of when we talk about recovery from neurologic insult.  But Fate has presented us with a more complex question, which could even be looked at as an opportunity to better understand this area.
Brain death is an artificial, but necessary construct we developed 50 years ago. When we deal with insults to the central nervous system- blunt and penetrating trauma, anoxia, bleeds and other pressure phenomena, and infections (and I believe all of those are related but slightly different insults), the question naturally arises “at what point of insult do we say the person is medically and then legally dead”. We have to ask and answer that question for public policy reasons, transplant issues, so people aren’t on life-support unnecessarily, and for compassion sake – it’s a legitimate question and one that we have a professional responsibility to answer.  (It’s clearly not the simple “she’s never going to wake up” that most Internet and newspaper commenters opine- or perhaps existentially it is, but we’ll let that go for a minute).
Now the way we have decided to answer it, quite reasonably, is cessation of measurable cortical activity, through lack of responsiveness, and cessation of measurable brain stem activity – brainstem reflexes, and apnea (although most people don’t perform a good apnea test- but for the sake of argument I’m going to assume it was done correctly here and not make it an issue).  For the most part, no problem- it’s been accepted as death and it’s as reasonable as anything.
But.
The fiction that has been passed off since the Harvard guys did this in 1968 is that this was irreversible cessation of all brain function.  You can look at their wording. You know and I know that can’t be true, simply because we can’t easily measure all brain function – hell we don’t even know what all brain function is.  And this was done before CTs (I’m old enough to remember the time before CTs) and now MRI’s and PET scans where we can actually measure brain metabolism.  I’m not saying we should get these tests, just pointing out what should be obvious.
So let’s come back to this case. As I said, I believe in all likelihood they followed the criteria and made the “right diagnosis” and that should have been that. I wrote for the Tribune at the time the right thing to have done was to have discontinued support – and I believed that. But for social reasons, which I’m not really concerned with other than their consequences, they didn’t.  And some unusual things have happened.
First she didn’t “die”. Yes I know there are a few long-term somatic survivors – but this alone clearly puts her in a small category  (the funny thing is that meningitis kid at UCLA who has been around so long scared them so much they went and got MRIs on him – that tells you they were out of their comfort zone before they actually saw brain liquefaction). Second of all she starts menstruating, which means in all likelihood there is some hypothalamic  function – not cessation of all brain activity. Third- she moves a bit – I have no idea what that means – but I sure as hell didn’t see anything more than an occasional spinal reflex in the earliest hours of brain death.  Fourth – they say there is some activity in some of the imaging. I’m prepared to say this is wrong if I see it can’t be duplicated in a reliable fashion in a major medical center but all this means she is an outlier- and any time you have a diagnosis with an outlier, it’s a good idea to review your original assumptions. In this case our assumptions about what brain death actually is. 
I bet there is a good chance, if you were to run the same brain death criteria on her today you might get the same results- brain death. But that begs the question. It may be fine to reassert those brain death criteria, but this case has given us an opportunity, which we don’t get every day, to reevaluate what the criteria mean- a very important point.
I would also guess, and it’s only a guess, that this girl is on the “edges” of brain death, straddling the line between life and death as it were. Her injury was anoxic- the outcome of which is notoriously difficult to predict. While I don’t think she has “recovered”, I would not rule out some isolated neuronal watershed recovery – some neurons may actually have recovered. The girl is young – she has a good heart, and for all we know there may also be some plasticity in this situation in her brain, which allows just enough autonomic function to permit her to "survive". I don’t know. Is that death? Depends on how you define it. It might be just as legitimate to simply say “she will never wake up’ –though I don’t believe that would be  a good line to draw to define death.
Normally none of this would matter – let the family do whatever they want and who cares? But this is exactly one of those public policy questions –legally where it’s important to define exactly what we are calling death (if for no other reason tens of millions of dollars in damages – but it would be important anyway). The judge could take a narrow view and say it’s been litigated – the experts did the test and she was dead. I think that would be understandable but a mistake. And I think doctors who understand what’s really at stake here should agree with me. This is a rare opportunity where we get to examine brain death, and brain function, more closely (PET scans, hormone assays etc.) At the end of this we may come away saying – look we don’t want to change the neurologic definition of death- keep doing it the way we always have. But it may turn out we will dispense forever with the fiction this is total cessation of all brain activity. And there is always the possibility we will redefine how we diagnose brain death in the future. That’s why the stakes- from a medical standpoint – are so high. And from a legal and public policy standpoint also. It just happened the chips fell right and that this was the case to ask the questions.
Sorry to be so long-winded. I wanted you to know where I am coming from. I don’t have the answer here. But I have a pretty good idea what the questions should be.   
As I said, keep up the great work on the excellent blog. I’m a big fan. And don't worry about being confrontational. No problem for me.  Intelligent confrontational is good. Stupid confrontational is bad. 
And hey, maybe you might want to buy my new book. It’s enjoyable reading, lots of good war stories- and no I didn’t write that SF piece to sell more books.  But I’m not going to turn down the opportunity if it arises.
That would be brain dead.
Cory           

Sunday, 9 August 2015

Statistics

Statistics are a funny thing.  Some are completely true though difficult to believe:
  • You are much more likely to get struck by lightning than win the lottery 
  • In 2009, almost 20% of all books sold in the United States were written by Stephenie Meyer.  Yes, really.
  • The average person has one ovary and one testicle.  (Think about it.)

. . . while other statistics sound completely plausible yet are complete twaddle:
  • Men think about sex every 7 seconds
  • Humans use only 10% of their brains
  • The average person swallows 8 spiders while they sleep during their lifetime
And then there are some statistics which look so ridiculous, so preposterously unlikely, that it is simply beyond the realm of possibility for them to be remotely plausible:
  • This blog has been viewed 3 million times.

Despite my gaffe a few months ago about being near 3 million hits (my aging eyes somehow erroneously saw "2,960,000" instead of "2,690,000"), as of today SftTB has officially hit 3 million pageviews.  Somehow over the past 4 years, there have been 3,000,000 distinct occasions that someone on this planet has thought, "Hm, I wonder what DocBastard has to say."  THREE MILLION TIMES.  I don't know how many of those people actually stayed to read my silly stories, but I can tell you what sites referred them here:
I can also tell you where they live:

  • 66% USA
  • 10%  Canada
  • 6% each UK and Australia
  • 1% each France and Germany
  • <1% Singapore, New Zealand, Netherlands, and Ukraine
Some other statistics:
  • Most popular post (surprisingly): "That sinking feeling"
  • Most commented-upon post (not surprisingly): "Jahi McMath update . . . sort of"
  • Top three browsers: Safari (62%), Chrome (18%), Firefox (8%)
  • Top three operating systems: iPhone (41%), Windows (20%), Android (17%)
So whoever you are, wherever you live, and however you got here, I sincerely appreciate the company.  The internet can be a pretty lonely place, and you people are the only reasons I continue to write.  Please keep coming back and commenting, and please do encourage others to join us.  And as with my other milestone posts, I humbly (and hypocritically) request that you leave a comment with your (approximate) location and how you found me.  

See you at 4 million.

Best,
Doc

Monday, 3 August 2015

Healthy not healthy

No offense, but if you ever hear anyone start a sentence with “With all due respect . . .” and expect what follows to be respectful, then you’re an idiot.  No offense.  It’s one of those phrases that is intended to deflect disrespect and immunise you from blame.  Whenever I hear it (or it’s bastard cousin “I don’t mean this in a bad way, but . . .”), I wish that the person would just be an adult and come out and say whatever offensive thing is on his mind rather than veiling it in a shroud of dismissal.

“Sorry not sorry” is similar - you are sort of apologising in advance, but at least when people use this one, they know in advance that you’re not really sorry.

So what the hell does any this have to do with Gerald (not his real name©)?  With all due respect, stop being so damned impatient and complaining so much.  You’ll just have to wait and see.  No offense.

Being on call for general surgery is usually mundane.  Since common things happen commonly, I can typically predict at least one or two patients with appendicitis, perhaps one with an infected gall bladder, maybe a bowel obstruction, or diverticulitis.  Pretty normal stuff, really.  Very seldom do I see anything really bizarre, but it does happen . . . hence, this blog.  Gerald (as you’ve probably guessed by now) falls firmly under the category of "bizarre".

“So I, uh . . . I got this guy with this . . . this . . . thing.”

When an emergency physician leads off with that, I am guaranteed to be presented with something odd, so I sit down and prepare myself for whatever hideousness is about to be dropped in my lap.  My brain cogs immediately started spinning as they usually do:  What kind of "thing"?  A bleeding thing?  An infected thing?  A needs-to-be-removed-from-his-rectum thing?  The emergency doc continued, and I must say I was more than a little disappointed that it wasn't a rectal foreign body.

“So this guy is 70 and healthy, no medical problems," he went on.  "But he came here because his co-workers were telling him that he was starting to smell like a rubbish bin.”

Well that was . . . unexpected.  The cogs spun a bit faster.

“And, well, he has this . . . thing on his back.  It’s kind of, um, big.  And, uh, bleedy.”

Bleedy?  What the . . . That's not even a real goddamned word!  The cogs spun yet faster.

“So I don’t really know what to do with it, so I’m hoping you do.”

The cogs flew off the machine.  Fucking greeeeaaaat.

I got to the hospital a short while later, and Gerald was sitting on his stretcher, smiling, chatting with his neighbour, and looking absolutely fine.  However, I could immediately see (and smell) why his co-workers had been concerned.  As I walked in an odour like death punched me in the face like walking into Ronda Rousey's fist (Ronda - call me).  The nurses were all wearing surgical masks, but the look on their faces told me that even that wasn’t nearly enough.  Having removed dead colons before (stories to come in the future, I promise), I’ve smelled worse, so it didn’t bother me quite as much.

“Hi, Doc!  How are you today?” Gerald greeted me with a big, warm smile.

Nauseated, I almost said.  I chatted with him for a few minutes, somehow resisting the urge to retch.  He told me that he was never sick a day in his life, took no medicine, had no allergies, and had never had surgery.  “I’m just a healthy guy.  I haven’t been to the doctor in 50 years!”

Considering the stench, that last part didn’t surprise me one bit.

He certainly didn’t look sick, but his fetid odour told me otherwise; healthy people don’t smell like a garbage dump.  When he removed his gown and turned around, what greeted me reminded me of this:



He had a mass on his back at least 20 cm in diameter.  It was cracked and bleeding in places, draining pus in other places, and it smelled like it belonged in a horror movie.  All around it were numerous smaller dark lesions, each around 1-2 cm.

Weeeeeeeell this isn’t good.

Within the first 0.253 seconds of seeing it (I timed it), and even without a biopsy, I was 99% sure that this was a large melanoma and that all the smaller lesions around it were satellite lesions, signs that the melanoma was spreading.

Gerald was quite clearly not the perfect specimen of health he thought he was.

It took a bit of encouragement and convincing before Gerald actually believed that there was something seriously wrong with him.  I informed him that, assuming my suspicion was correct, he would need an extensive surgical resection followed by a large and difficult reconstruction, best done by a team of specialists at a university hospital.  Despite maximum efforts, it was still nearly a certified guarantee that his melanoma would kill him in the next few months.  “But Doc, I’ve always been healthy!” he kept arguing, somehow still in disbelief.

No, Gerald.  You haven't been healthy for many years.  You just didn't know it because you've been ignoring the fact that your body has been screaming at you for all this time.

Gerald inspired me to coin my own new phrase: Healthy not healthy.

See, I told you I’d get to the point.  Sorry for making you wait.

Not sorry.

Weekly Troll Update

WARNING: IF YOU ARE NOT INTERESTED IN A TROLL UPDATE, TURN BACK NOW.  

I generally don't feed trolls, nor do I give them much thought.  I liken them to pocket lint - you mostly don't even notice it's there, but when you do it's very mildly annoying (if at all) but nearly impossible to get rid of permanently.  Ever since I altered the commenting policy here about a month ago I have been ignoring my personal troll, deleting all (almost) of his comments as they have come in.  But that didn't stop The Troll from nearly soiling himself trying to get a comment through.  Since initiating his ban I have deleted no less than 40 of his comments (though it may actually be as many as 50).

It really was quite amusing for several days - he continued commenting not just on the Jahi McMath posts but on multiple other posts as well, each comment less coherent than the last.  Perhaps his addled little mind allowed him to think I'd let a bit of his idiocy slide through, but he just couldn't seem to crack the code (though I did let a couple through just so I and others could debunk them).  I kept imagining his spittle-flecked lips screaming at the screen as he tried to squeeze another ridiculous screed through my bulwark.  So in lieu of actually allowing his nonsensical comments, I took a few screenshots of his insane ramblings to share with the group.  They may be a bit difficult to read, so I apologise in advance.

We start with "an actual real example" of his which is, of course, complete and utter cow manure.  Somehow The Troll, who still claimed to be a surgeon and lawyer, believes that a patient who presents to the emergency department would be seen by two surgeons (no he wouldn't), one of whom is a trauma surgeon (no he wouldn't) because there could be a rupture of the diaphragm (that wouldn't cause sepsis), the trauma surgeon would then assist the general surgeon (that would never happen because a trauma surgeon would never be called for this), and that this is "standard of care" in the US (that isn't standard of care anywhere).  This was on my "Crazy" post, which ironically describes his comment perfectly.  Wow, starting off with a bang!   Next!


He's trying to scare me by claiming to have reported me both to the AMA and JCAHO (in addition to several other physician groups).  This is rather cute, but let's stop and think for a moment.  I don't suspect anyone at the AMA would be interested in the musings of an anonymous blogger who calls himself "DocBastard".  And why does he suppose JCAHO, an organisation that accredits hospitals and health care organisations in the US and has nothing to do whatsoever with how any individual physician acts, would have any interest whatsoever in a lone doctor's blog?  This is so ridiculous I actually laughed out loud.  In case you're wondering (I hope you're sitting down), no professional groups have contacted me.  Please do control your surprise.

Here he doubles down on the "two surgeons in the OR is standard of care" bilge, and he nonsensically misuses "pontificate" and misspells "roughshod" in the same comment.  Somehow he expects me to believe he is a lawyer and a doctor yet has no understanding of grammar or syntax.  Oh, and he and thinks this "incites" me.  Amuses?  Yes.  Incites?  Hardly.  There are also some rather incoherent ramblings that are a bit concerning, but I'm apparently a fraud and a "proven liar" (this is a recurring theme in his comments).  Oh, and I'm an idiot too.

Apparently he believes Ken Brown is a dummy-account that I operate (or vice versa).  I'm sure Ken will be very disappointed to hear that, just as I'm sure that Mrs. (misses?) Bastard will be upset to find out she doesn't exist either.

"Kim" (who he mentioned in at least 2 other deleted comments) apparently is a surgeon to whom he has shown my blog, and she has supposedly laughed at my writing.  And this guy (who is supposedly a surgeon yet clearly knows nothing about medicine) continues trying to claim that CT scans are mandatory before surgery (they most assuredly are not).  And I'm still an idiot. 

"I have no shame in who I am", he posts anonymously.  Irony at its finest.  But I wasn't aware that I was torturing anyone.  Perhaps he should report me to the UN also for crimes against humanity.  He won't back down, he claims.  Yet two days later he did exactly that.

He's claiming that I stole the picture from my post Indefensible from Figure1.com, a medical-picture-sharing site I had never heard of until I read this silliness.  A 0.211 second reverse Google image search proves him wrong, obviously.  {Though this is another laughable bit of wackiness, unfortunately he's right about one thing- someone did create a profile with the username "DocBastard" on that site, even with the same capitalisation I use.  However, that usurper is a medical student (according to his profile).  It's very frustrating, but it's not the first "DocBastard" usurper I've encountered around the 'net.}


Wait wait wait, is he actually claiming to have reported me to the International Olympic Committee?  What the . . . And that was supposed to scare me?  Well regardless, it seems like he's failing at preventing me from posting just like he's failing at convincing anyone of anything.

Really?  We never lounge?  Ever?  So what he's claiming is that we have patients rolling in 24-hours a day and never have time to relax?  How strange then that every hospital has a lounge, and every trauma surgeon has time to take breaks throughout the day (and night), though some call days are busier than others.  Sometimes those breaks are short, but they always exist to some extent.


I think it's clear that though The Troll may be adept at googling, he has no idea how to understand or apply the vast amount of knowledge with which he is then confronted.  Nor does he have any idea how to construct sentences or coherent thoughts and arguments properly.  If he did in fact go to law and/or medical school (HA!) I would strongly suggest that one or both institutions revoke his diplomas immediately.

I wonder if this post will provoke The Troll to start commenting again.  Though I'm glad he's gone (mostly), I almost hope he does start again, only because I get a good chuckle at his expense.  Not to worry, though - the stupid patient stories will resume again immediately.

Monday, 27 July 2015

Lifestyle

When it comes to a healthy lifestyle, the phrase that I do my best to live by is "Practice what you preach."  Unfortunately I rarely live up to this lofty standard, and the phrase that much more closely resembles my reality is "Do what I say, not what I do."  Yes, I freely admit that I am terrible at taking care of myself, and even Mrs. Bastard's efforts often aren't enough.  She always encourages me to eat a balanced diet, exercise, floss my teeth . . . you know, all the stuff we all know we really ought to be doing but just don't.  Because of reasons.  Instead, my diet usually consists of skipping breakfast, a Coke for lunch (fuck you, Pepsi), and a ridiculous dinner that provides me an entire day's calories and several day's worth of fat and cholesterol.  Mmmm . . . fat and cholesterol.

Any semblance of real exercise has been difficult for me to achieve ever since I finished medical school.  I used to run or play basketball almost every day, but then life just . . . happened.  I got married, had children, and chose a career that precludes nearly everything other than my family.  I tried to keep up with staying active; I even tried yoga.  Yes, I tried yoga.  Fuck yoga.

These days the only exercise I get is running from idiot to idiot while trying to keep my head screwed on straight.  I can't say this actually gets my heart rate up very much, so in lieu of actual running, I decided some time ago to take advantage of my busy work situation.  Instead of taking the lift (elevator), I now take the stairs whenever possible.  It may not be much, but at least it's more than nothing.

Perhaps not surprisingly I've found that walking up from the ground level to the 8th floor has gotten progressively easier as time as elapsed (what an amazing thing), so I decided to start giving this excellent activity advice to my busy, overworked patients.  I thought the first time would go over well.

I thought wrong.

I was asked to see Otis (not his real name™) by one of my internal medicine colleagues due to severe abdominal pain.  It had come on rather suddenly and rapidly, encompassing his entire abdomen.  Though he had no prior similar episodes, he did have some rather pertinent medical history, including a myocardial infarction (heart attack) and subsequent coronary artery bypass graft three months prior.  As soon as I heard this, the alarm bells started ringing in my head:

WOOP!  WOOP!  Acute mesenteric ischaemia!  Acute mesenteric ischaemia!  Operating theatre, stat!

I feared that the blood supply to his intestine was compromised just like the blood supply to his heart had been three months ago.  The same mechanism that had caused the blockage in his coronary arteries may very well also be happening in his gut.  The treatment for ischaemia is the same everywhere in the body- get rid of the blockage before tissue starts dying.

For confirmation, I got him down to the CT scanner rather quickly, as I did not want surgery to be delayed.  However, what greeted me was a bit of a surprise, and not a bad one for a change.  His mesenteric (gut) vasculature had some atherosclerotic disease, but it was mostly open.  However, his ascending colon was inflamed.  His clinical picture was consistent with chronic mesenteric ischaemia, a longstanding decrease in blood supply to the intestine that had gotten slightly (and temporarily) worse.  Fortunately for Otis this is treated with supportive care and bowel rest rather than surgery.  Otis was unsurprisingly pleased that I would not have to whack out half his colon.

Over the next few days Otis improved rapidly and was discharged home with his colon intact.  He came back to see me in my office several days later for a follow-up visit, and he reported continued improvement.  After I finished my examination, I began discussing how his lifestyle choices, including smoking, poor dietary habits (ahem), and lack of exercise (AHEM), had all contributed to both his recent heart attack and subsequent intestine attack (yes, "intestine attack".  Why not?  It's the exact same as a heart attack, just with the intestine, damn it).

"Yeah but Doc, I'm really really busy.  I work 12 hours a day and I got no time for exercise."

Fully expecting that excuse (which I use with regularity), I immediately launched into my prepared activity speech.  As soon as I got to the "take the stairs and avoid the lift" portion, he stared at me intently.  And silently.

"Um, did I say something?" I asked him after an uncomfortable silence.

Otis continued to stare at me.

I started to fear that I had inadvertently said something patently offensive and started silently reviewing every word I had just said.  What was it?  What did I say?

And still he stared.

Just as I started to open my mouth to apologise for saying . . . whatever it was I had said, his lips curled into a smile.

"Doc, that would be kinda hard for me.  I'm an elevator repairman."

He laughed.  I laughed with him.  Because he actually was an elevator repairman.  Really, what are the odds?

For me: 100%.