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%.

Friday, 24 July 2015

Musings on Jahi McMath

While I can't say the Jahi McMath news is coming fastly and furiously, at least it's coming.  Before anyone mentions it, yes I realise "fastly" is not a word, but dammit it should be.  Why isn't there an adverb form of "fast" anyway?  "Slow" has "slowly" and "quick" has "quickly."  Why not "fastly?"  But I digress, as usual.

The latest in the saga is Jahi's family's response to the demurrers by the hospital and Dr. Frederick Rosen.  The demurrers, in case you missed them, were the hospital's and Dr. Rosen's challenges of the legal sufficiency of Nailah Winkfield's case against them.  On July 17th, Nailah Winkfield's lawyer Bruce Brusavich (love that name, by the way) filed his response to their response (thanks to Professor Thaddeus Pope for posting the documents).  The way the US legal system seems to work, I expect that there will be responses to the responses to the responses, then responses to those responses, and then even more responses, and eventually the whole system will collapse under the weight of 81 million tonnes of paper.

But I digress again.

I've reviewed Brusavich's response, and a few things stood out immediately.

It seems Brusavich is taking a note from Dr. Paul Byrne's notebook and is now putting "brain dead" in quotations.  Furthermore, and even more surprising, he is continuing to claim that Jahi is "very much alive".  The rationale for this opinion is elucidated a little further on:
Yes indeed, they are saying she is not dead because her hypothalamus is functional and she has "intermittent responsiveness to verbal command".  Hypothalamic function does not equal life, though responsiveness does.  It would, however, mean that her entire brain is not dead.  Whether that would change anything is up to the lawyers to argue.  I hope that they have proof other than a few vague videos released late last year that show her moving.  If she is in fact responding to verbal commands, then that does indicate consciousness.  I will reserve judgment on that until I actually see it.

Then Brusavich goes over the details of the case with a few rather comical errors. 
I would have thought Brusavich would have learned the difference between "pallet" and palate" since the last time he made this exact same mistake.

Maybe I'm the only one who finds that funny.

Brusavich then goes on to criticise Dr. Rosen for not informing anyone about his suspicion of a medialised carotid artery.  I've been criticised by a certain someone for downplaying this point as well, so if you would indulge me for a moment, please allow me to clarify my position:  A medialised carotid artery without question increases the risk for intra-operative or post-operative bleeding after this sort of surgery.  That is not at all in doubt.  However, informing anyone in the recovery room of his suspicion was unnecessary and irrelevant, because any bleeding that occurs after ENT surgery is easily diagnosable.  Jahi obviously had a massive haemorrhage after the procedure, and everyone around her obviously knew about it.  Jahi knew, the family knew, the nurses knew, hell the custodians probably knew.  So how would informing anyone of this possible anatomic anomaly have helped?  Would it have helped them diagnose bleeding?  No.  Would it have prevented the bleeding?  NO.  Would it have stopped the bleeding?  NO.  Would it have changed anything in any way?  NO.  This is a non-issue.  Full stop.

The nurse responsible for caring for Jahi that evening recorded in her chart (several days later, mind you) that she repeatedly informed the PICU doctor about Jahi's condition, but no action was taken.  Dr. Rosen stated in his demurrer that he was not aware of Jahi's haemorrhage because he was not contacted.  I find both of these points very difficult to believe, though I am not claiming either is untrue because I was not there.  I just think it highly unlikely that intensive care doctors would ignore a bleeding patient for hours, refusing to see her.  I find it just as unlikely that the surgeon who performed the procedure wasn't called during any of this to let him know that his patient was haemorrhaging.

Was a PICU doctor called?  Probably.  Was Dr. Rosen called?  He claims not.

Unfortunately Brusavich then enters a legalese Twilight Zone and starts referring to other cases, using terms such as "judicially noticeable", "prima facie evidence", "res judicata", "collateral estoppel", andsnkseio ZZZZZZZzzzzzzzz  ZZZZZZZZZZZzzzzzzzz ZZZZZZzzzzzzz

*snort*

Wha . . . what?  Oh, sorry.  I think I fell asleep there for a bit.

Anyway, Brusavich concludes (sort of) that Jahi is alive due to some MRI results, EEG results showing neuroelectrical activity, Jahi's supposed responsiveness, and the fact that she started puberty.  Is any of this true?  We'll have to wait and see.

What I will say (yet again) is that if they can actually prove that Jahi is alive, she will be the first documented patient in history to have survived and recovered from brain death.  

I'll believe it when I see it.

Monday, 20 July 2015

Pain and humour

The amount of knowledge medical students are forced to acquire in a limited amount of time is simply staggering.  Most of the basic science courses in medical school are vitally important to the practice of medicine: pathology, anatomy, pharmacology, and physiology.  Some others are seldom useful once we are in practice, such as genetics.  And some have little (if anything) to do with the practice of medicine, like biochemistry.   We learn about how the various systems of the body work: circulatory, pulmonary, gastrointestinal, renal, endocrine, and immune.  Most medical schools are now even teaching students how to talk to patients and deliver news, both good and bad.

But one thing we are not taught in medical school is humour.  I've met far too many straitlaced doctors who wouldn't know funny if it walked right up to them and slapped them in the face with a fish.  But in my experience, patients appreciate a well-placed joke, even if it's at their expense.  "Is there any chance you could be pregnant?" is my standard bit when performing a trauma ultrasound on a man.  A few of them have looked at me like I have two heads and a pair of antennae, but most of them laugh even as they try to ignore the pain of their fractured leg.  It's a small token of humour, but even that is often enough to break tension and calm people significantly.

But several years ago John (not his real name™) taught me that humour in medicine is not just for the doctors, among other things.

John was in his late 70s when he was referred to me with a colon mass that had been found on colonoscopy after he had noticed blood in his stool.  He walked into my office with a big smile on his face, something I found unusual and concerning for someone meeting the guy who would ultimately be whacking out half his colon.  However, as soon as he began speaking, any concern I had evaporated rapidly.

"Hiya, Doc!" he greeted me with a very firm, warm, friendly handshake, the type normally reserved for your favourite uncle or your company's CEO.  "So you're the one who's going to be cutting me open and saving my life, eh?  I have five grandkids, so I need to be around to spoil them, you know."

I liked him instantly.  This is my kind of guy.

After going through his medical history and biopsy results, I explained the procedure to him in great detail, including all the potential risks: bleeding, infection, anastomotic leak, anaesthesia, reoperation, death.  He nodded along, listening intently.

"So if you take out half my colon, would that make it a semicolon?" he said with a perfectly straight face, followed immediately by a crooked grin and then a solid guffaw.

I couldn't help but laugh with him, and we traded jokes for the next 10 minutes before saying goodbye.

John's surgery soon thereafter was uncomplicated, and when I went to see him in hospital the following day, his sense of humour hadn't faded one bit despite his postoperative pain.  I took off his bandage to look at his incision (which I had closed with surgical staples), and he winced slightly as he chuckled through his pain.

"You know I've always wanted a belly button ring.  This isn't exactly what I had in mind, though.  Maybe I can hang a charm from the staples like a bracelet!"

I laughed and palpated his abdomen gently, and he winced again.  I apologised for hurting him, as I explained that I wasn't trying to hurt him, I was merely performing my routine postoperative examination.

John apparently had a visceral reaction to my word "hurt".  He suddenly got serious for the first time since I met him.  He then held up his forearm and showed me a rather faded tattoo.  As faded as it was, the string of numbers was still legible even after the passage of so many decades since the Nazis had put it there.  "Son," he almost whispered, "I've already been through more pain than you could possibly imagine," he said, his kind smile returning rapidly depite his wet eyes.  "Nothing you can do will ever hurt me."

A few days (and many jokes) later, John went home to finish recuperating, which he did.  His daughter and I kept in touch over the next few years.

I found out several years later that John died of old age, peacefully in his sleep, at home, surrounded by his family.  His daughter told me that his jokes never stopped, even after he lost his wife, and up through the very end.

There were few people left on Earth who had as much reason as John to be bitter and angry.  If he had been the biggest curmudgeon I'd ever met, I could not have faulted him one bit.  However, John instead chose to use humour instead of melancholy, puns instead of pain.  

And in doing that, he became one of my favourite patients, indeed one of my favourite people, I have ever had the good fortune of meeting.

Monday, 13 July 2015

Timing

Probably the most difficult aspect of being a trauma surgeon is not being able to control my schedule.  I don't necessarily mean my call schedule itself, though that is often outside my control as well.  What I mean is that other specialties have the ability to see patients on the days that they choose and at the hours that they choose.  I, on the other hand, get whatever patients I get whenever they decide to come in.  I can't choose to get a guy who falls off his bar stool and bonks his head at 1 PM, because those idiots don't fall off their bar stools at 1 PM, they do it at 2 AM.  What I've discovered over the course of my career is that surgery and trauma patients usually have terrible timing.  No one seems interested in letting me sleep, so instead they get appendicitis at 11 PM or stabbed at 3 AM.

Such was the case with Michael (not his real name©) and his series of friends.

My pager woke me from a dream about Scarlett Johansson (at least I wish it had been about Scarlett Johansson.  Seriously Scarlett, call me) to tell me that I would be getting a high-level stabbing victim in five minutes.  I looked at the clock and was completely unsurprised by what I saw.  

Of course.

As I was walking briskly downstairs, my pager went off again, telling me I would be getting another high-level stabbing victim in four minutes. 

My walking pace quickened.

Over the next few minutes my pager would go off three more times, all stabbing victims who, I learned later, had all been at a house party when two cars full of lunatics arrived with various sharp stabby things and a thirst for random violence.  

At least that's what Michael, who turned out to be victim number four out of five, asked me to believe.

I ran from room to room to room trying to determine who was the worst injured.  Two of them appeared to be completely fine, and two looked to be slightly less fine though still seriously injured.  And there was one whose wound looked like it should have been actively killing him, though in reality he looked as though he could have walked home. 

That, of course, was Michael.

His rather scary-looking injury was a single stab wound just to the left of his sternum.  Though it was a potentially dangerous (ie lethal) area, his heart rate was 70, his blood pressure was 120/65, and he looked calmer than I (though the fact that I kept running back and forth among four other victims may have riled me slightly).  He kept asking when I was going to patch him up and send him home.  I did a quick ultrasound which showed a bit of fluid around his heart, and a CT scan done a few minutes later (as I was putting a chest tube into Victim #3) confirmed a hemopericardium (blood around his heart).

Uh oh. 

There's only one place that blood could be coming from, so he went straight to the operating theatre where we found a small injury to his heart muscle, but no active bleeding.  His myocardium was repaired, and he was closed up.  Success!

Except that I still had 4 other victims to tend to.  Fortunately #1 and #2 just needed a few stitches and #3 and #4 both needed only chest tubes.  Nothing else life threatening.

When I went to see Michael the following morning in the intensive care unit, his very pregnant wife was sitting next to him.  When I say "very pregnant", I mean she looked like she could have popped at any second.  They asked all the usual question, including how long I expected Michael to be in hospital.  I told them probably three or four days, and his shoulders slumped.

Michael started to speak, but his wife finished the sentence for him:

"But I'm having the baby in three days!"

I asked if it was their first child, and of course it was.  I told them that I would do the best I could to get Michael to see his first child's birth, but I also told them I would make no guarantees.  I promised I would send Michael home as soon as he was ready, but not a minute before.  They were both visibly disappointed, but they also understood.

Fortunately Michael's hospital course was completely uneventful.  Over the next two days he recovered rapidly and smoothly.   By day three his chest tube was out, and he was ready to go home. I thought I would have to physically restrain him from running out the door.

I found out sometime later that I had discharged him just in time for him to make it to the other hospital to see his son being born.

Well, at least one of us has good timing.

Wednesday, 8 July 2015

The Troll

The trolling in the comments here has gone from 0-100 ever since The Troll (not his real name©) decided to flaunt his stupidity around here.  I've always enjoyed getting comments on my stories, but in the past few days it has become a burden.  I've had to delete more comments in the past week than in the previous 3 years combined.  I started moderating comments to weed out the particularly stupid ones (though still publishing the truly idiotic ones just for posterity), but the way blogspot's commenting system works, publishing or deleting comments is cumbersome and awkward, especially on my mobile.

I suspect most (if not all) of the trolling comments are coming from the same person, but some of the comments are downright ludicrous.  So I thought I would share in case you missed it.  This one is my favourite of the bunch, from the "Crazy" story (about the young girl whose mother would not let her get a CT scan):
This seems to be the same The Troll who claims to be a former general surgeon and currently a lawyer.  See the "level 2 or 1 hospital" verbiage, and compare it to this comment posted about 90 minutes before on the Easy Call Day? story:

Obviously The Troll doesn't know a thing about surgery, or else he (or she, since this person insists she is not a he) would know that no X-ray, CT scan, MRI, ultrasound, or any other supporting test is necessary to take a patient to surgery.  They can sure be helpful and they are often ordered by emergency physicians before they even call us, but they are not mandatory in any way, shape, or form.  Strange - I would think a former general surgeon would know that.

Unfortunately The Troll also doesn't know that trauma surgeons don't "assist" general surgeons, because trauma surgeons are general surgeons.  ALL OF US.  I would think a supposed former general surgeon would know that too.  And in his ridiculous haste to assume that I am only a trauma surgeon, he also seems to have missed this little nugget of information that is prominently displayed on my sidebar:
Oopsie.  I hope he feels appropriately stupid.  Because he sure looks stupid to me.

Now I will apologise to the loyal readers and loyal commenters not only for boring you with this tedious dreck, but also for requiring your comments to be approved before they are published.  This is the only way to keep The Troll away.  I have prided myself on keeping the comments wide open since I started this stupid little blog, but The Troll has necessitated this.  I will do my best to approve your comments quickly, and I will also do my best to keep The Troll off the comments.

Unfortunately that means I will have to read through all of them and try to determine which are his and which are not.  It also means that I may accidentally delete some comments that are not his.  I will apologise in advance.  To prevent this from happening, I'd encourage anyone who has been commenting anonymously to take a few seconds and create a profile.  Hopefully The Troll will slink back to his cave sooner rather than later, and this will all soon be but a happy memory.

Now that that's over, we now return you to your regularly scheduled stupid patient stories.  Yes, they're coming back, and soon.  I have a whole slew of them lined up.  The idiots have been out in droves lately.

Thursday, 2 July 2015

Easy call day?

Yes, it's yet another post about the Call Gods, those vicious, evil fucks that fiddle with me and torture me daily and make my life a living hell.  If you aren't interested in reading about them again, I'm sure Jim Carrey is saying something fascinating about vaccines, so feel free to check him out instead.

I often think that the Call Gods are truly the unhappy ones, and they feel the need to spread their unhappiness to everyone they possibly can, because that's the only way they can feel better about themselves.  It's kind of like the schoolyard bully who has such low self-esteem that he teases the other kids in a desperate attempt to boost his own pathetic morale.

But I digress.  You may have noticed the word "easy" in the title, a word that I don't use often to describe my call days.  But every now and then the Call Gods go easy on me for some inexplicable reason.  I tend not to question it, but I always wonder WHY.  Why take pity on me?  Why spare me?  And what kind of horrors will they have in store for me next time?

My call day started off with a bang.  We had a morbidity and mortality conference that lasted from 8 until 9 AM, and after that I trotted off to the lounge for a coffee.  As I was stirring in the sugar, my pager went off for the first time in the day.

Damn it.  Well at least I get my coffee, I thought with a smile as I looked at the pager.  Ah, a fall.  No big deal.

And then it went off again.  Oh, a stabbing . . . at 9 in the morning.  How lovely.

Fortunately neither patient was seriously injured, but it still took me about two hours to get them both worked up, patched up, and discharged.  I looked at my watch and thought, Perfect!  Lunch time!  And what a coincidence that I just happen to be famished.  As I was walking downstairs to get something to eat, my pager went off again.  This time it was two patients being flown in by helicopter after a car accident.

Lunch would have to wait.

And so my day progressed.  Every time my pager went off, it went off twice.  For the first 9 hours of the day, I had 10 patients, all coming in pairs.  I felt a bit like Noah at one point, marching my patients two by two into the trauma bay.  Minus the huge gopherwood boat, of course.

And then at 5 PM, it stopped.  It all just . . . stopped.  Apparently everyone in the city decided to stop crashing their cars, stabbing each other in the neck, and falling off barstools all at once.  With what I thought was just a few minutes to spare, I went downstairs to get a sandwich for dinner.  On my way down I stopped by the trauma bay just to make sure I hadn't missed anything.  But all of my previous patients had been either admitted or discharged, and the trauma bay was gloriously empty and eerily silent.

So I went back upstairs to enjoy my vending machine sandwich as much as a vending machine sandwich can be enjoyed, and I sat down to do a bit of writing.  Four hours later, my pager remained blissfully quiet, so I wasted just a bit of time online (fuck you and all your damned videos, YouTube), and then I lay down to grab what was sure to be 18 whole minutes of sleep.

And exactly 8 hours later I woke up with the sun shining on my very refreshed face.  The first thing I did was grab my pager in a panic, absolutely certain that I had somehow slept through 12 traumas.  But nay, the pager was still empty.  It appeared that the Call Gods had taken pity on me.  I don't know why and I didn't even THINK about questioning it, but I certainly appreciated it.

No wait, I wasn't complaining, Call Gods!  I was complimenting and appreciating you!  Really, I swear!  I . . .

*BEEEEEEEEEEEP*

And there goes my pager.  Of fucking course.  

Fuck you, Call Gods.  Fuck you. 

Saturday, 27 June 2015

Idiot anaesthesiologist

Several people emailed this story to me shortly after it broke, and someone posted a link to it as a comment on a previous post, so I feel like you overbearing people have harassed me into writing about it.  Ok, that's not exactly accurate - the truth is that as soon as I read this story, I knew I had to write about it.  Fortunately my editor at The Daily Beast agreed that it's an insane story and gave me the green light immediately.  I don't think I have anything additional to say that I didn't say in the article, so feel free to read all about it here.

So now you all can make your comments here and STOP OFF-TOPIC COMMENTING ON OTHER POSTS, DAMN IT.