Physician's prayer

Sir Dr. Robert Hutchison's Physician's Prayer
— written on the walls of Children's Hospital, London

" From inability to leave well enough alone,
From too much zeal for the new and contempt for what is old,
From putting knowledge before wisdom,
Science before art and cleverness before common sense,

From treating patients as cases, and from making the cure of the disease
more grievous than the endurance of the same.

Good Lord, deliver us."

More fun stories

Direct quote from the electronic medical record: "23-year-old male who was found in the parking lot of a store, waving a knife and screaming.  He has a history of drug use per an acquaintance at scene who quickly fled after giving that history.  He was brought in by ambulance combative, attempting to strike EMTs, and spitting.  Head net was then placed.  He was brought in under physical restraint with police officers assisting."

"30-year-old man who presented complaining of pain in his leg after being bit by a dog." I initially felt sorry for him, but on further review of the records, it seems that the dog that chased him down and bit him was a police dog in the act of its duty. No more sympathy.

Get bent

This is an unfortunate gentleman who had a previous femur fracture that got fixed with a rod down the middle of the bone. He got hit by a car a few years afterwards and bent the rod.

More fun stories:

"20 y/o who became intoxicated with alcohol, ran into the street and fell into the bushes. He now complains of right knee and ankle pain." Just another example of how ridiculous people are when they get liquored up.

"33 y/o woman who presented with nausea and vomiting. She was also wondering why she has been so emotional lately." While looking at the patient's gallstones, the sonographer noted something moving in her abdomen. On further investigation, that something had a heartbeat! As it turns out, she is 33 weeks pregnant. It was unclear why this was such a surprise to the patient, as she already has four kids and therefore presumably knows what it is like to be with child.

"20 y/o man who punched a refrigerator. He presented the next day complaining of pain in the right hand." The following radiograph shows the classic "boxer's fracture" suffered by those who punch without being very good at punching, and therefore hit with the knuckle of the small finger instead of the index and ring fingers. Can you see the fracture?

Fashion Statement

This is not a fashion statement. This is what can happen when your nail gun ricochets.

Season's Greetings

This reflects perception more than reality, but still funny.

More stories!

"21 y/o man who presents after hearing a crack in his wrist accompanied by sharp pain after the police car in the back of which he was handcuffed made a sudden sharp turn." He broke his wrist - ouch! Of course, he then left the ER against medical advice when it became clear that he would be released from custody.

"5 y/o girl who was standing on the sidelines of a football game and was inadvertently tackled." She has a  broken collarbone, and I am sure she will never go near a football game again. Her career as a cheerleader is over before it began.

Fun Story

"21-yr old man who was in the passenger seat of a car arguing with his mother, who was driving at 35 mph. He became upset and demanded that she let him out of the car. When she refused, he opened the door and jumped out." He wound up fracturing his left elbow pretty badly. The bummer is that the interesting part of the story - what they were arguing ABOUT - may never be known.

More stories

"57 y/o man who presents after accidentally stabbing himself in the stomach with pruning shears while gardening."

Road warrior

For those who haven't heard, I have been riding my bike to and from work - about 10 miles each way - for the past couple of weeks. I have loved it - I feel like I get good exercise, I have felt invigorated when I get to work and when I get home, and have felt like my thighs are each getting to be the size of my waist.

Well, all that has come to a crashing halt. I was riding my bike home last night, and got in a wreck.

The way it happened was this: I was riding home on a relatively low-traffic road in Sacramento. I came to an intersection where the cross street had a stop sign and I did not. A lady in a late-model Mercedes stopped at the stop sign, glanced both ways, did not see me, and pulled out in front of me. I hadn't planned to stop, since I had the right-of-way. Despite slamming on the brakes, I ran into the side of her car on the driver's side.

My bike tore the driver's side rear-view mirror off the car and made a big dent in the driver's side fender. I flew off the bike, landed on the hood, then rolled off onto the ground in front of the car, taking off the hood ornament on my way. I was glad she stopped - she could have run me over.

I got up slowly, and had the following injuries, some of which are seen in the picture, though Amy points out that the picture does not do my road rash or the gauges in my fingers justice:


- Scrapes on the middle, ring, and small fingers of the right hand.
- A large road rash across my right forearm.
- A swollen, scraped right shoulder right at the point of the bones at the top of the shoulder.
- Two small scrapes across my right forearm.
- A swollen scrape across my left forearm.
- A scrape across the back of my left upper arm.
- A scraped, bruised right knee.

I also have a scraped and dented helmet, and a sore ego (as well as a sore bottom).

Thinking back, I realize that I don't remember visual images of the whole accident. I remember thinking "Oh no! I'm going to hit that car!" and yelling out loud "Noooo!" Then, I have the recollection of a series of thumps (probably me flying onto, then rolling down the hood) and a bigger thump as I landed on my right side on the ground.

Another bicyclist who had seen the accident stopped and gave me her business card, in case I need to get corroboration for my story.

The lady felt awful - she was more shaken than I was, as might be expected for one who has seen a grown man go flying across the hood of her car. She called her husband, who courteously brought his pickup truck and gave me and my somewhat-worse-for-wear bike a ride back home.

When we arrived, a troop of worried girls came out to greet me. My three-year old wore a grave expression, and kept coming up to point at my bleeding knee with both terror and fascination. My wife reports that she has been perseverating about her daddy, repeating over and over that "Daddy has big owies!" and looking out the window for me.

My wife gave me the "I told you so" look when I got home. She has never felt safe about me riding a bike, and now feels vindicated and upset that I didn't listen to her warnings. I feel wretched, but not nearly as wretched as I would have felt if I were paralyzed or dead.

I showed up to work the next day, showing off my bruises and scrapes (and kind of enjoying the attention - this story gets better every time I tell it). My father-in-law, attorney that he is, points out that I am not being a very good client - I should have stayed home, with my neck in a soft collar, moaning and groaning.

I think my days as a road warrior are over. Like Chief Joseph of the Nez Perce, "I will fight no more forever."

More stories

Favorite stories from today:

"44-y man who fell asleep while riding his motorcycle, wiped out, and hit a tree." (He broke his right hip pretty badly).

Stories

Best story from today:

"67 y/o woman fell down at home and was unable to get up. When her family came to help her, the family dog, a pit bull, bit her on the face."

Some guys have all the luck

This 19-year old man was "minding his own business" when he heard four gunshots and felt sharp pain across the front of his chest. He saw some small wounds on either side of his chest, and drove himself to the hospital.

His blood pressure and pulse remained normal. He had no trouble breathing.

A CT of his chest showed the following:



The dark spots across the front of his chest are specks of air in his pectoralis major muscles. There were skin defects at the upper right and left chest, but no other injuries. Basically, the bullet did the following, missing everything else important:

More good stories

"32-yr old man who went out to dinner with his friend. After dinner, during an argument about who would pay the bill, the friend stabbed the patient in the chest with a steak knife. In an ironic twist, neither of them wound up paying due to the arrival of police and paramedics. (Incidentally, patient's blood alcohol level was 0.400 at the time he arrived at the hospital.)"

"28-yr old man who became depressed, drank some alcohol, then jumped off the roof of a gas station."

"46-yr old woman who lost consciousness when her boyfriend assaulted her, punching her in the face. She awoke to find her house on fire and a bystander dragging her from the blaze."

"29-yr old man who presented - incidentally, on the night of his birthday - immediately after being shot in the abdomen."

Yup, those are my patients!

Histories

My favorite histories from the ER today:

"23-year old man who arrived at a party and shot several of the partygoers. The other partygoers responded by assaulting him, beating him about the head, chest and abdomen with hockey sticks and cricket bats."

"36-year old man who was attempting to shoplift some alcohol from a liquor store when another patron tackled him. He presented after he fainted while in police custody."

Yup, those are my patients!

Anti-smoking ads

These are some of the most clever advertisements I have ever seen:

Singing Cowboy

Focus on the Positive

Miscarriages

Hitchhiker

Knife and Gun Club

When I am working in the Emergency Department, I see the CT scans and X-rays of nearly every injury that comes into the hospital. I am getting really discouraged by the superabundance of some specific injuries:

1. Gunshot wounds to the spine. Way too many teenagers and young adults are forever paralyzed from the neck or mid-chest down as a result of careless or, more likely, malicious people shooting them. I'm not sure what these patients were doing to induce others to shoot them, and I really don't care that much. Although I am sure that a significant proportion of those who are shot were engaged in illegal activities at or shortly before the time they were shot, it doesn't make me feel any better about these patients whose lives are now infinitely harder than they would otherwise have been.
   
   To wit, they will, for the rest of their lives, have no bowel or bladder control. They will need surgery to enable them to put catheters into their own bladders or to divert their urine into a hole on their abdomen so that it can be collected in a bag. They will either need surgery to divert their feces into a colostomy or will need their diapers changed for the rest of their lives.
   
   Of course, they also will be unable to move independently for the rest of their lives.
   
   I am further disgusted that these patients are now wards of the state. You and I, the taxpayers, are and will be paying for the lifelong care of these patients - for both the cost of their surgeries and the salaries of those who change their diapers and roll them around in bed. It sickens me that these patients are only unable to care for themselves because some other person made a rash and/or evil decision to pull the trigger of a gun.
   
   
2. Gunshot wounds in general. Way too many people get shot around here. Gunshot wounds are devastating injuries, shattering bones and organs alike, and causing all kinds of mayhem. While many people survive their injuries, those who get shot in the head tend not to.
   
   
3. Motorcycle accidents. These are a touchy subject for many motorcycle aficionados, but let's get real - every day I see horrible injuries sustained by people who are doing innocuous things on a motorcycle. For example, this man was riding his motorcycle at 10 miles per hour.
   
   
   
   He got clipped by a car, which shattered his left foot. He had to have his leg amputated below the knee.
   
   No matter whose fault it is, a motorcycle accident will always leave the motorcyclist in a world of hurt.
   
   
4. Lung Cancer. This is another subject that gets me somewhat upset. Way, way too many people are dying early because of smoking and its deleterious effects. Take, for example, this woman. An ordinary chest CT would have lungs on both sides of the chest, with the heart on the patient's left.
   
   This woman's heart has been displaced into the right side of the chest by this enormous aggressive mass that replaces pretty much her entire left lung.
   
   
   
   It is also making its way out of the chest cavity by bulging out between the ribs. What a crummy way to die.
   
   
   

Anyway, those are four of the most preventable problems in our society, and we see far too much of them. I wish, like Alma, that I could cry repentance with the voice of thunder, that all men everywhere might repent, that there might not be more sorrow upon all the face of the earth.

EtOH

After an experience I had the other day, my conviction that alcohol is not for the body and not good for man is much stronger.

I was reading CT scans from the emergency room, and a young man came in who had been backed over by a slow-moving car. His pelvis was smashed to smithereens, and he suffered facial fractures.

I was chatting with some of my associates about how he could have sustained such an injury, when it occurred to me to ask if his blood alcohol level had been measured when he came to the ER. It was twice the legal driving limit. I am sanguine that the blood alcohol level of the driver that backed over him was also quite high.

The next patient was a man who had fallen off his bicycle while attempting to get on it. Passersby noticed that he was struggling to get up and summoned the police, who brought him to the hospital. His alcohol level was 4 times the legal limit.

The next patient had been assaulted and stabbed. He was also drunk.

For the next several patients, I inquired as to the alcohol level of the patient. Every one of them had been too drunk to legally drive when they arrived in the emergency room - meaning that their blood alcohol level when they were injured was even higher.

Now, there could be a number of confounding factors in this sample; perhaps the emergency room has a lower threshold for ordering CT scans on drunk patients because the physical exam is less reliable, or maybe it was random chance. However, it is clear based on my experience that being drunk is a risk factor for being irradiated if you go to the emergency department. I would also suggest that, based on the mechanisms of the injuries I described above, being drunk is a risk factor for being injured.

So unless you want me to see some really embarrassing pictures of your insides, it's best not to drink alcohol in Sacramento or its environs.

I like the looks of these

bakingsheet: SHF #7: Graham Crackers

Homemade Graham Crackers
1/2 cup all-purpose flour
1 3/4 cups whole-wheat flour
1/2 cup sugar
1 teaspoon baking powder
1/2 teaspoon baking soda
1/2 teaspoon salt
1/4 teaspoon ground cinnamon
1/2 cup cold butter, cut into 1/2 inch cubes
2 tablespoons honey
2 tablespoon molasses
1/4 cup cold water
1 teaspoon vanilla extract

In a food processor, mix together the flours, sugar, baking powder, baking soda, salt, and cinnamon. Add the cold butter and process until the mixture resembles coarse meal, about 30 seconds or so. Add the honey, molasses, water, and vanilla. Mix until the dough startes to come together in a ball, another 30 seconds. Scrape dough out of the mixer.
Between 2 sheets of waxed or parchment paper, roll the dough 1/8-inch thick. Chill for at least 1 hour, until firm (I chilled for several hours).
Preheat oven to 350F. Retrieve dough and roll it a bit more if it is not yet 1/8-inch thick. With a sharp knife or pizza cutter, cut into 2-inch squares. Arrange the crackers on parchment lined baking sheets. With a toothpick, prick several holes in each cracker.
Bake for 15 minutes, until lightly browned at the edges. Remove from the oven and let cool on the pan.
Yield: 48 crackers

Note: If you cut the dough through but leave the squares together, you can break them up after they're baked, just like a store-bought graham!

Literal...

Libby, my oldest, has the tendency all four-year-olds have of taking everything I tell her very literally. This sometimes has untoward consequences. A few weeks ago, we were heading to the library to check out some books and movies. We had not taken the girls in a while, so we were explaining the principles of appropriate library etiquette. Libby asked why we need to be quiet in the library. "Because," I replied, thinking quickly and trying to be clever, "if you aren't quiet the librarians tie you up."

"Why?" - of course, the standard response.

"Because there are people trying to study, and they need it to be quiet."

She nodded slowly, letting this idea sink in.

I forgot all about this conversation until last night, when, in celebration of my birthday, we went out to dinner, shopping, and finally to the library. It was very late (7:00) by the time we got there. The girls are usually being bathed by that time of day, and their ability to cope with stress was at a low ebb. Immediately the girls began fighting over the library computer, shrieking, and generally being naughty. Audrey had to be taken outside for an attitude adjustment within a few minutes, but she returned a tiny bit calmer and quieter.

Libby, not to be outdone, began screaming at the top of her lungs at Audrey a few minutes later. Amy had had it. She took Libby by the arm and marched her for the door. Libby, terrified, began yelling, "No! I don't want to be tied up!"

All heads turned toward Amy as she walked out the door, a determined look on her face, with a terrified, struggling child at her side. "Where on earth did Libby get that idea?" I wondered, still with no recollection of our prior conversation, and mortified that all the library patrons now believe that Amy and I punish our children by tying them up in the basement or something.

 

When we got home, Amy asked Libby why she had said what she did, and she said "Daddy told me they would tie me up." The recollection of our prior conversation came flooding back. Oops.

 

Amy glared at me. "You can't tell them things like that! You need to clear anything you tell the kids with me first."

 

I'm kidding about that last sentence, but I am sure that is what she is thinking.

Guns and coumadin don't mix

This is a patient who came in after reportedly shooting himself in the forehead with a 25-caliber handgun. He was reportedly taking coumadin, an agent that is used to keep the blood from clotting.


Incredibly, when he arrived in the emergency room he was alert and conversant with the ER staff. They saw the entrance wound on his forehead, but couldn't find an exit wound.

The first image they took was an x-ray of the skull.



The white thing just at the level of the nose is the bullet. The little arrow on the forehead is a marker that the emergency room put on the patient to show where the entrance wound was. It also shows the skull fracture that ensued from the bullet wound.

When he became unresponsive, they rushed the patient to the CT scanner to get a better idea of what was going on in his head. This is what they found initially on the "scout radiograph" - the initial image they take to plan where they will take "slices" with the CT scanner.





This is a side view of the skull. Again, the dot on the forehead shows where the bullet entered the head. The bright thing in about the middle of the head is the bullet, which is embedded in the soft tissues at the back of the patient's mouth. The dark oblong shapes in the middle of the head should not be there - those are indicative of air within the space that should be filled with brain or cerebrospinal fluid.




This is a slice through the patient's head at the level of the forehead sloping back just above the ears. The black dots throughout the head are collections of air that are moving around within his shattered skull. The white rounded area near the top of the image is clot and blood within the brain, marking the path the bullet took as it went down through his forehead, through his nasal cavity, and down into the soft tissues at the back of his mouth.





This image shows the exact path that the bullet took. It is a side view through the head showing the wound (at the upper left of the image) with the bone fragments traveling diagonally downward until you get to the bullet (the bright rectangle at the bottom center of the image).

Suffice to say, this was a non-survivable injury and the patient soon succumbed to increased intracranial pressure - probably from bleeding into the space that should be holding his brain. Gross!

So much stuff!

I came home from work the other day and started unloading the pockets of my scrubs onto the kitchen counter. My wife stared as I pulled out more and more things - it was reminiscent of the scene from Mary Poppins when Julie Andrews starts pulling potted plants and hat stands out of her carpet bag. Eventually, my wife shook her head and said, walking away, "you need a purse."

This is a picture of the things I carry on my person at all times. Clockwise from the top: my radiation badge (essentially a piece of Kodak film that gets tested every three months to see how much radiation I have been exposed to), my keys, my ID badge, my wallet, my cell phone, my pager, my little pre-inked stamper to put my name and ID number on orders that I write, and my car keys. In the middle are my iPod and pen.

Valentine's Daddy, part deux

This is the letter I received in response to my last one:

February 20, 2008

On behalf of our President and CEO, thank you for your letter of February 15th regarding your recent shopping experience at our _____ Market on _____ Drive. We are pleased to know that you found the quality and price of your purchases favorable even though your check out experience was less than satisfactory.

We appreciate fully the concerns you expressed regarding the magazine covers displayed at the cash registers. While it is important for us as a retailer to offer a variety of magazines and other publications that represent our customers' diverse interests, it is also important for us to exercise good judgment in our display of such merchandise. As a standard practice, we offer a 'vanity' shield at all magazine display racks and ask our store directors to place the shield over magazines with questionable or prurient covers. Generally, our store directors do a very good job in shielding these covers but, as you know, this can oftentimes be a matter of subjectivity.

Your idea of having a family-friendly checkout aisle is a great one and continues to be an item of discussion in our business. In the meantime, we extend our apologies to you and your daughters and assure you we will ask our store directors to be more attentive to our display of magazines so that a visit to our stores is not an unpleasant one.

Sincerely, etc.

Valentine's Daddy

This is a letter, slightly edited, that I sent to the CEO of one of the grocery stores where I shop regularly. Tell me what you think:

-----
Dear Sir:

I am a regular customer at the _____ store located in the _______ area. Yesterday – Valentine's Day – I went to that same store to purchase some last-minute items for my wife and for my two daughters. A couple of weeks earlier, I had brought my wife some flowers, and my daughters were excited that I might do the same for them.

I found a large and varied display of flowers, and was pleased with their quality and price. After getting a few other items, I went through the checkout stand and noticed, as I have many other times, that there are a number of magazines displayed near each checkout stand. The covers of most of these magazines are plastered with pictures of scantily clad women in alluring poses, many of which are frankly pornographic.

As I went through the checkout aisle, averting my eyes, I thought about an article I had read earlier that day about the harm done to women – particularly young women – when society convinces them that the most important attribute they can possess is "sexiness." I thought about the numerous times that I have brought my girls through those same checkout aisles and been embarrassed to have them see such exploitative photographs.

I hope to raise my girls in such a way that they will know their own inherent worth. It is not easy to teach this concept in any circumstance, but particularly difficult when objectification of women is so prominently – indeed, unavoidably – displayed.

Please make arrangements – such as removing the magazines from at least one checkout aisle in the store – that will make shopping more family-friendly. It occurs to me that having such a family-friendly checkout aisle in every one of your stores would be a valuable advertising advantage.

Sincerely, etc.

If you think you are having a bad day...

This is one of a number of images of a patient that I saw in the emergency room the other day. That is, I saw the images. I did not actually see the patient, and I am kind of glad.

This 22-year old man allowed a homeless man to stay at his house. The patient had a disagreement with his guest - I have a sneaking suspicion that alcohol was involved in the disagreement, as the patient's blood alcohol level was twice the legal driving limit when he arrived at the hospital - but regardless of the cause, the homeless man shot the patient at close range with a small-caliber weapon. The patient presented complaining of being unable to see.

The attached image is from his CT scan. The marked circles are the approximate locations of his eyeballs; the arrow shows the path of the bullet. He had no injuries to his brain, but both eyeballs were shattered and full of air, blood, and bits of bone and metal.



Surgery revealed irreparable posterior eyeball lacerations with protruding tissue and multiple metallic fragments inside both eyeballs.

Whenever you feel like you are having a bad day, just remember that it could be worse - you could be this guy. I shudder to even look at these images.