Tuesday, 16 December 2014

Compliments

WARNING: I WILL BE SHAMELESSLY RISKING SPRAINING MY SHOULDER BY PATTING MYSELF ON THE BACK IN THIS POST.  

Admittedly this blog is dedicated to idiots and stupidity, and as I've said numerous times my favourite idiot remains me.  So having told several stories where I am the goat, I think I've disparaged myself enough to have earned myself a complimentary update.

If you want more idiot stories, you'll have to wait.  Probably not very long.

Since finishing my training I have spent very little time around other doctors in clinical situations, so I therefore have no idea how my colleagues speak to patients.  I don't know what kind of terminology they use, if they have prepared speeches for certain situations, or how they treat patients in general.  I have a fairly well-established bedside manner, and it seems to serve me very well in the vast majority of situations.  Though my demeanor rarely changes much, every now and then I have to tailor it for certain types of patient (those who are very difficult, very drunk, very upset, very young, very old, etc).  Some people need a bit more care, some need a stern talking-to, others need massive doses of sedatives to shut them up.

Kidding, kidding.  Sort of.

Generally speaking, my philosophy is this: If you're nice to me, I'll be nice to you.  Because of this ideology, every so often patients tell me (compliment warning) that I make them feel better just by sitting with them for a few minutes, talking with them, and explaining everything in excruciating detail, probably more detail than they want or need.

Apparently this is not the norm for surgeons.

Nathaniel (not his real name©) was the unfortunate driver of a petrol (gasoline) tanker truck.  In the wee hours of the morning Nathaniel swerved to avoid another driver, and his truck lost control and flipped on its side.  Incidentally, I hate the term "wee hours".  "Small hours" is no better.  I don't know why it bothers me so much.  Non sequitur over.  Anyway, sparks began to fly from the now-exposed underside of the truck, and despite debilitating pain in his chest, Nathaniel wisely decided not to be anywhere near his truck when those sparks interacted with the several thousand gallons of highly-explosive fuel he had been hauling, and he ran.

When he was brought to me about 30 minutes later, he was clearly agitated, clutching his chest and having trouble breathing.  When I pushed lightly on his chest, he grunted and looked at me as if I were Satan.  His chest felt unstable to me, and an X-ray confirmed that he had 4 fractured ribs.  Fortunately his lung had not collapsed, he had no bleeding in his chest, and he had no other serious injuries.  I explained that his injuries were painful but not life-threatening and that the only treatment was pain medicine and time.  That seemed to calm him somewhat.

Over the next several days, I quickly assessed that he would be a patient who required a bit more TLC than my typical patients.  My daily rounds with him, which should have taken no more than 3 minutes to press on and listen to his chest, assess his pain, and go over his X-ray, took at least 15 minutes while I sat with him, listened to him describe his pain, and reassured him that he would heal, but it would simply take time.

A few days later his pain had improved to the point where he could walk without difficulty, and he no longer needed IV narcotics.  I discharged him, telling him he could continue his recovery at home, though it would be several more weeks until he felt completely better.

As I was sitting in my office about a week later, I got a call from Nathaniel, asking if he could transfer his care to me.  Confused, I told him I was already his doctor, so I asked him what he meant.  "Well, I really liked the way you cared for me in the hospital.  You were so patient with me and you really listened to me, so I want you to be my primary doctor."

I told him that while I don't do primary care, I was truly honoured by the request, and that simple question was one of the best compliments a surgeon could get.  I gave him the phone number for an internist whose philosophy is very similar to mine - be direct and honest, and above all else listen to the patient.

To the medical students reading this, I hope you take this vignette to heart and learn a valuable lesson that DadBastard and GrandpaBastard taught me a long time ago.  Ultimately all patients want the same thing: to be treated like a human being.  What I did isn't difficult, it isn't special, and it isn't unique.

All I did was treat Nathaniel like I treat everyone - with respect.

Monday, 8 December 2014

Just when you think...

Ok, NOW I've seen everything.

That's a phrase that enters my brain almost every time I am on call.  After seeing children shot in the head, grown men crying like babies over minor abrasions, a woman kicked in the head by a deer, a man impaled in the boy-parts by a piece of his broken motorcycle, fingers cut off by power saws, and every conceivable traumatic injury in between, it seems like the Call Gods can't possibly find something I've never seen.  I think that everything that could possibly happen has happened, and I've seen it.  But then the Call Gods throw me a curve ball, something that even my wildest imagination couldn't envisage.
Yes, it happened again.

My second patient of the day was another fall victim.  The first one had been an elderly lady who fell down the stairs and broke her back.  This one, however, had fallen from a standing position.  When I heard that mechanism of injury, I groaned.  Audibly.  LOUDLY.  For patients like these, I think of it this way: if you fall from a standing position badly enough to pass out, you probably are A) drunk, B) drunk, C) drunk, or D) otherwise unhealthy enough to have passed out merely from falling down.  They are usually not the worst injured patients, and I rarely get too excited at the prospect of seeing another elderly ground-level fall "victim" with bumps and bruises and little else.

A few minutes later Arthur (not his real name©) arrived moaning and groaning, yelling that his hands hurt, his head hurt, his neck hurt, his legs hurt . . . pretty much everything from the tips of his hair to his toenails hurt.  He was a rather burly guy, about 120kg, but he was acting like a 15kg toddler.  His only outward signs of trauma were some abrasions on the bridge of his nose and his forehead, but whenever I touched his hands or legs, he screamed.

His workup was essentially negative - bumps and bruises, a cervical strain (whiplash), and a concussion.  So if he sounds like most of the other ground-level falls, why the hell am I writing about him?

Because he wasn't drunk.  He didn't trip and fall.  No, Arthur was wrestling with his wife who got the better of him, jumped on his back, and put him in a choke hold until he passed out and fell flat on his face.  Five minutes later when he still hadn't awakened, his wife freaked out and called emergency services.

As he explained what had happened, his wife walked in.  She couldn't possibly have been as tall as Arthur's chest, and she might have weighed 1/3 what he did.  I listened to Arthur intently, my eyes flitting from him to her, trying to look him in the eye while all the time doing my best not to break out in a fit of raucous laughter.

Did he let her win, or is she some kind of human honey badger?  I have no idea, but fortunately the little Tasmanian devil didn't do any major damage.  As I walked out, only one thought crossed my mind:

NOW I've seen everything.

Tuesday, 2 December 2014

Sign from above

Based on the title you may be worried this post will be some theistic diatribe.  Nay, never fear, intrepid readers.  I would never subject you to such nonsense which I would never want to read and which, I'm fairly certain, violates several portions of the Geneva Conventions.  However, Mrs. Bastard has often told me that everything happens for a reason and that things may be signs from above, so while I don't have any idea what those reasons may be, I sometimes wonder if she's right.

What happened recently with Claudette (not her real name©) made me rethink things and wonder if Mrs. Bastard could be right.

Claudette was the passenger in a car accident early one morning.  Incidentally, why is it always 1 AM?  Doesn't anyone want to get into an accident and let me take care of them at 2 o'clock in the afternoon?  I'm fully awake, I'm done with lunch, I have nothing better to do, so get into your accidents then!  Come on!  Wait, where was I?  Oh right, 1 AM.  Apparently her boyfriend (who was driving) fell asleep at the wheel and went off the road, hitting a tree.  The tree, which was not moving at the time of the accident, didn't give one flying fuck that a car just hit it at 120 kph and remained exactly where it had been before the car hit it.  Trees are kind of funny that way.  Anyway, I have no idea what happened to her boyfriend, but Claudette was brought to me in a bit of a daze.  She didn't have a scratch on her, but she clearly had a concussion.  A CT of her brain showed a small subarachnoid haemorrhage.  Fortunately she had no other injuries, and three days later she went home, sore as hell, but otherwise ok.

She followed up with me in my office about a week later.  When I walked into the examination room, the first thing I noticed was the sheaf of papers from the hospital sitting on the exam table, along with her mobile phone and a cigarette lighter.

Bad move, Claudette.

If you know anything about me, you know that I look for any reason to get on people's cases for smoking, but I knew my "WHY THE FUCK DO YOU SMOKE?!" tirade would have to wait until I finished my exam and explanation about what she should expect as she recovers from her brain injury.

Wait wait wait, aren't you going way off topic here, Doc?  Quitting smoking is great and all, but since when is this post about that?

Oh pipe down, you.  I'm getting to it.  Stop being so damned impatient.

As I was saying, after a thorough physical examination, I explained how her symptoms may last for several more weeks, but that I expected a full recovery.  She told me how she couldn't bring herself to drive yet, and that she still freaked out whenever she tried to get in a car or saw headlights.  She went through her long list of questions for me, and when she was finally done, I took a deep breath and gave her my best "STOP SMOKING, DUMMY!" speech.  She looked rather embarrassed the entire time, but she nodded along compliantly.  When I was done, she looked up with a sad little smile and said,

"You know, it's funny . . . when we got in the accident, we were on our way to the store to buy cigarettes."

. . . Aaaaaaaaaaaaaaand there it is.  If that isn't a clear sign that she is supposed to stop smoking, I don't know what is.

Monday, 24 November 2014

Danger

I'd like to start this post by stating in no uncertain terms that I don't advocate people hurting themselves intentionally in any way.  That being said, IF one ever decided one really wanted to hurt oneself, here are a few reasonable options one could consider:
  • Boisterously proclaim your hatred of the home team in any football arena in Ireland
  • Go 150kph on a motorcycle through rush-hour traffic with your eyes closed
  • Attend a New York Yankees game wearing a Boston Red Sox hat and jersey
  • Jump out of the Eiffel Tower without a parachute
  • Walk barefoot on Legos
Or you could simply do what Sammy (not his real name©) did.

It had been a rather boring day for me.  So far I had gotten only 1) an 80-year old woman who had mistaken her accelerator for the brake pedal, crashed into a wall, and fractured her ankle, knee, and wrist, and 2) a 20-year old who had gotten hit by a bus and had a broken ankle.  Since I don't do bones, I called the orthpaedic surgeon so he could work his magic on both of them, and I waited until something truly epic arrived.

My wait would be long and tragically fruitless.

Around 10 PM I got a call that my next patient would be a 15-year old boy who had been hit by a car while riding his bicycle.  Fifteen years old.  Ten o'clock at night.  On a bicycle.  I'll give that a second to sink in.  

Ok, ready?

Hopefully you're all thinking the same thing I was at the time - What the hell is a 15-year old boy doing riding his bicycle at night?  If you were thinking anything else, I'd like to invite you to leave now, since we're clearly not on the same page.  Anyway, for those few of you still remaining, as I waited without bated breath, I had already started mentally reviewing the lecture I would surely be giving him about not being stupid.  Sammy arrived a few minutes later looking entirely uninjured.  It took me all of  about 18.2 seconds (I timed it) to discover that his only outward sign of trauma was a small abrasion on his right ankle.  About 5 minutes later I was looking at his completely normal X-ray, so I gave him the good news that all he had was a sprained ankle and opened my mouth to start the diatribe.

And then Mom got to to the hospital.

She had a look of sheer panic on her face, and I immediately realised that she had no idea what had happened and was imagining her son dead in a ditch.  I put my harangue on hold and quickly ushered her in to reassure her that Sammy was fine, but that I needed to talk to them both.

Ready.  Steady.  GO.

"My first question for you," I asked Sammy, "is what the hell you were doing riding your bicycle at night."  It wasn't so much a question as an opening statement.

Sammy looked a bit stunned, hung his head, and sheepishly turned away, clearly choosing not to respond rather than giving an answer that he too knew would be stupid.  I looked at Mom who was staring intently at her son with the painfully-obvious "WHAT THE HELL DID YOU JUST DO?  ANSWER THE MAN'S QUESTION!" look (Note to MomBastard: yes, I remember that look well).

But I wasn't nearly finished with him yet.  Not remotely.  I waited a moment until he looked back at me, and then I fixed him with a stare dead in his eye.

"I see a lot of injured patients in this trauma bay, and most of them have done something really stupid that landed them here.  You just did something REALLY stupid."  He looked away again.

I glanced up at Mom, expecting her to look shocked at my words, but she only nodded, silently giving her consent for me to continue.  I obliged.

"Were you wearing a helmet?"  He shook his head no.  "THAT was stupid.  Riding your bike at night?  THAT was stupid.  Riding your bike A) at night, B) without a helmet, and C) while wearing black sweatpants and a black shirt?  THAT was REALLY stupid."

He couldn't even bring himself to look me in the eye.

"You got lucky, Sammy.  This time, you got lucky.  Next time you do something stupid you might not be so lucky.  I do NOT want to see you back here in my trauma bay.  Understood?"

He nodded, almost imperceptibly.

I turned to go and caught Mom's eye.  She mouthed "Thank you" to me and started crying as I walked out without another word.

Sammy is still a young, impressionable teenager, one who still has the capacity to learn from a mistake that was indeed very stupid, though fortunately not costly.  This time.  Perhaps next time he won't be so lucky.  But with a little reinforcement from Mom after my little tirade, maybe there won't be a next time.  Maybe, just maybe, I gave Sammy something he can take with him forever.

Monday, 17 November 2014

Humour

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

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

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

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

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

And she was stark raving naked.

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

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

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

I wish I had more patients like Bess.

Monday, 10 November 2014

Football

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

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

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

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

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

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

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

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

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

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

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

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

For a bruise.

Monday, 3 November 2014

Jewelry

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

. . . buy a gift for my wife.

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

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

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

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

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

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

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

But while I'm on the subject of jewelry, I was reminded of this little gem (har har har) from some time back.  It's my second-favourite actual real X-ray of an actual real patient of mine.  He was in a car accident at 2 AM, the details of which are entirely unimportant.  Part of our workup included an X-ray of his pelvis, which didn't show any fracture.  What it did show, however . . . actually, I don't want to give away the punch line.  Take a look and see if you can make the diagnosis:
In case you aren't a radiologist and/or have never seen a cock ring before, that's . . . ah shit, I just gave it away.  Yes, that round thing at the base of his penis in the lower middle portion of the X-ray is indeed a cock ring.  So what was he doing driving around by himself while wearing that bit of jewelry at 2 AM?  

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

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