the doctor is in 6

It’s good to get back into the cyber-office after the Holidays. Trust yours was enjoyable and nobody got hurt too badly – remember, it’s all fun and games until the cops show up.

Today’s case is called, “Swelling and Pain in the Back and Hip of a 35-Year-Old Man.”

Let’s start out with an exterior shot.


Dang! That boy got some butt. No hair, cute little cheeks. Ut oh! What’s that up the top of the ole crack in the china? A little protruding buddy, eh, son? Sensitive to touch? Bet you have to hang up the thongs for a bit.

We need a better look. Have to go inside. No, not the anal-intrusion instrument – I am an internet doc; only “real” docs invade the chubster on any excuse. We’re gonna use one of those machines with letters for a name, whichever one is available. “Hey, tell the tech, top down, 32 degree lateral shots from points A to B, C to F, and X to A1.” I have no idea what that means, but everything I say they write down and these picture thingeys come back, so it must be something.

Let’s see what they found …


YOWO! Lookey here! The boy’s got an ALIEN in his BUTT! AN ALIEN!! This is so cool! It’s got floppy ears! The protrusion out of his butt is its HEAD! It must have parked itself there for the food supply. Smart, them aliens are. Got a bunch of fat to suckle and, of course, the ultimate food supply – the colon – food’s already digested, got that dark chocolate nutty flavor. This is a first in the annals of medical science! A documented alien in the butt!

Another pic? What’s this?


Oh, no! This guy is in trouble. See those two circles? Alien eggs embedded in his butt cheeks. Toast. Better schedule an untimely death and burn this dude’s carcass. He’s got one alien already hatched, ears fully deployed, and two more coming. Them butt cheeks ain’t gonna be so cute in another few weeks. I estimate about 4 to 6 weeks max gestation left. I wonder if we can toss him into coma somehow, then fix the records to show his brain waves isoelectric. That hatched alien decides to exit, it’ll get ugly! They sneak right out the butt when you are aren’t looking! Let’s hope it’s a mama alien and will stay put until the eggs hatch. Man, this is so sad.

Let’s hear the guy’s story …

BACKGROUND. A 35-year-old man presents to the emergency department (ED) complaining of sacral pain and right hip pain (damn straight. Hatched aliens HURT!). The pain is associated with increasing swelling in these regions that began 3 days before presentation (the little alien dude hatched just a little time ago. That’s good news, actually. Not likely to venture out soon.). The patient otherwise denies having any systemic symptoms, such as fevers, chills, nausea, or vomiting (I agree. Aliens don’t like it warm. Anyway, they eat vomit like ice cream before it ever gets a chance to leave). His past medical history is significant for a recent admission to the hospital after an accident with a motor vehicle approximately 2 weeks before presentation (I don’t like the sounds of this). As a pedestrian, the patient was struck by a car and sustained multiple rib fractures and facial lacerations (an alien hit-and-run. Typical. Once he was dazed, this stick the eggs in his butt. Notice the precision with which they placed the eggs – right cheek, left cheek, top of the crack. Very common in alien-egg insertions. This poor guy.). He was discharged to home from the hospital 10 days before presentation and has been doing relatively well, with adequate pain control for his rib fractures.

On physical examination, the patient’s temperature is 98.96°F(37.20°C) (I can tell you right now that everything is normal – aliens cover their tracks well. We’re lucky to have found these), with a blood pressure of 129/67 mm Hg and a heart rate of 89 bpm. His respiratory rate is 20 breaths/min, and his O2 saturation is 95% while breathing room air. The patient is not in acute distress. The head, eyes, ears, nose, and throat (HEENT) examination shows well-healing facial lacerations with intact sutures. His chest is clear to auscultation on both sides, with normal cardiovascular and abdominal findings. The lower extremities have normal sensation and 5/5 strength (on a scale of 0-5, with 0 being no strength and 5 being normal strength) (see? Normal across the board. Aliens in the butt. Man, I hate aliens).

A visible fluid collection is observed in the proximal lateral aspect of his right thigh (aliens gotta pee, too; it’s building up in his legs. We gotta act fast.). The fluid seems to track up (track UP? Idiots. It is flowing DOWN. Alien pee) around the gluteus maximus muscle to the lumbosacral region, with slight crossing of the midline to the left. The fluid appears to be a free-flowing, low-viscosity collection without evidence of erythema or ecchymosis (that is EXACTLY how alien pee presents). No loculation is noted on palpation, and the patient has no thickening or induration of the skin in the overlying and surrounding areas (all normal … see what I told you?).

What is the diagnosis? (One hatched alien distal to the butt crack; two alien eggs embedded one in each of his butt cheeks; accumulation of alien pee in his legs – simple – we’re done here!)

HINT. This fluid collection was not appreciated during the patient’s previous admission to the hospital. (Of course it wasn’t! The dang thing just hatched! What kind of hint was that? Ah, I get it! See, they are telling you they KNOW it is a recently hatched alien! A-HA!)

ANSWER. Closed, internal degloving injury (“degloving” is code for floppy-eared alien): The patient underwent computed tomography (CT) scanning of the pelvis, which showed a large, subcutaneous fluid collection extending from the region of the lumbosacral spine along the right lateral buttock to the thigh and down to the level of the femoral shaft (alien; pee). The fluid collection was not present on a previous CT scan that was obtained 2 weeks before presentation (the time of the motor vehicle collision) (you mean, before they implanted their eggs INTO him? Of course not!). The patient’s laboratory studies showed a white blood cell (WBC) count of 8.38 × 109/L; hematocrit, 0.363 (36.3%); platelet count, 953 × 109/L (953 × 103/µL); and an international normalized ratio (INR) of 1.0 (yep, yep, yep, yep – alien, alien, alien, alien. Wait until the pee starts to accumulate – that’ll crank his white count!).

The patient underwent CT-guided aspiration of the fluid collection under local anesthesia. An 8F catheter was used to aspirate 800 mL of dark red fluid (alien blood – careful, they bite!). Postaspiration CT images demonstrated near-complete resolution of the fluid collection (yeah, do you think they are stupid? It went to lunch! Just parked itself INSIDE the colon for a spell), and the catheter was removed (and the alien came back). A pressure dressing (elastic spica dressing) was applied. An elastic bandage was wrapped around the entire thigh, beginning just proximal to the knee, and continued upward across the proximal thigh and buttock. The bandage was wrapped around the waist several times and then brought back over the thigh to compress the entire lower back, buttock, and proximal thigh. The patient tolerated the procedure well and was discharged to home the following day. He was instructed to wear the compression dressing as much as possible, and a follow-up visit was scheduled. The aspirated fluid was sent for bacterial culture and found to be negative for bacteria (aliens don’t have Earth bacteria! Bet you didn’t scan for non-Earth bacteria, did you?).

(I can’t listen to these idiots anymore. Aspirate, my ass! This dude has a serious alien infestation. Let’s put him under, flat-line his results, fake an autopsy, and burn him. These things lay eggs like turtles – all plop, plop, plop until the hole is filled – and the hole, in this instance, is his two butt cheeks! I’m outta here – office closed!)

A closed, internal degloving injury is a clinically significant soft-tissue injury that is associated with pelvic trauma. The subcutaneous tissue is torn away from the underlying fascia, which creates a potential space that can fill with serous fluid and/or a hematoma caused by the disruption of the arteries that perforate through the fascia mixed with viable and necrotic fat. The condition commonly occurs over the greater trochanter, but it can occur anywhere over the trunk, buttock, or thighs. When a closed, internal degloving injury occurs over the greater trochanter, the condition is known as a Morel-Lavallee lesion. As mentioned, this condition usually occurs in association with pelvic and acetabular fractures, but it can also occur in the absence of fractures. Direct crush injury to the pelvis or a high-speed motor vehicle crash are the most common mechanisms of injury. The importance of this soft-tissue injury may not be initially apparent; some patients present months after the initial event, complaining of soft-tissue swelling or contour abnormalities that are not resolving.

The diagnosis of a closed, internal degloving injury is usually based on physical findings (ie, a soft, fluctuant area over the lesion and a loss of local sensation). Diagnostic aids may include ultrasonography and CT imaging. Various methods or combinations of techniques for treating degloved areas have been suggested, including the application of compression dressings, fluid aspiration or liposuction, injection of sclerosing agents, deep fascial fenestration, prolonged closed surgical drainage, and open surgical debridement (ie, leaving the degloved area open for closure by secondary intention). A review of the available literature, while failing to reveal prospective comparisons, did demonstrate variable outcomes with different therapeutic approaches, ranging from complete resolution to the development of various complications, including infections and skin necrosis or breakdown. The complications associated with closed, internal degloving injuries often require extensive therapy and surgical management.

Hi, my name is Clyde. I'm left-handed.

I always note how many left-handed people are in a group. I was training faculty yesterday in New England – seemed to be at least three out of 25. Could have been more, but that exceeds the 10% in the general population, particularly when you add me. Four out of 26 is 15%. (I’ve seen general population numbers claiming that we be up to 25%, but I have never encountered anything close to one in four – and I’ve been looking!)

The most obvious mark is choice of hand in writing. Something I use that seems highly reliable but not foolproof is placement of jewelry on wrists and fingers. You people put your watch on your left wrist; we reverse it, generally. T’aint much more annoying than writing with a watch on the same wrist – gets caught on everything and makes noise. The same logic extends to bracelets and rings.

I’m the only left-hander up and down my genetic pool for one generation – that’s three generations inclusive. I am told that one other person – maternal grandmother’s twin brother – was left-handed, but that is it for that generation on both sides. So four generations yielded two people. Pretty small harvest.

I should be on the Endangered Species List. I wonder if I can get a National Park Ranger to follow me around in bars and arrest people with whom I get into fights. I could be entry #1239 on the Endangered Species List (Animals). I’d be classified under “Vertebrate Animals: Mammals,” in this species list. I would be among such animals as the Chinese alligator, giant sable antelope, African wild ass, the Mexican grizzly bear, and the koala. Pop quiz: Why are all of these animals endangered? Because they taste good.

The Delta (CA) Smelt is on the list. I think I remember that on the menu when I lived in California. Guess it was pretty popular! It’s all in the preparation: hot pan, little EVOO and garlic, very light breading, squeeze a freshly cut lemon over them when you plate on a bed of arugula, and be sure to have a thinly sliced and warmed sourdough on the side.

Isn’t putting the Brazilian three-toed sloth on the list a contradiction? I thought all these bleeding hearts were God-less in the sense that Darwin knows better how all this evolution thing works and that ain’t nuttin been “created.” Let’s set aside the patent illogic of the position: Darwin wrote of evolution – one thing became another – which presupposed the existence of that “one thing.” Creationism says, “here is where that one thing came from.” The two positions have nothing to do with one another. Besides that, not a shred of evidence exists for macro-evolution – species to species, only micro – intra-species. Don’t get me started on irreducibly complex systems and Darwin’s own renunciation of his theory.

Where was I? Oh, yeah, the three-toed sloth is stupid and ugly. It deserves to become extinct. Just like the guy that zoomed past me yesterday at 95 MPH yesterday on Route 95 in NY in some car held together by duct tape. The whine of his engine made me think of a lawnmower about to go super nova – or a Viagra-induced pocket rocket cranking into its fifth hour. The only question in my mind was whether I would see the guy and the “car” a few miles down the road in a thousand pieces none bigger than a softball or something vaguely resembling an Uncle Buck pancake. Fortunately, I exited to the Tappen Zee Bridge; I dislike seeing survival of the fittest in action.

So the bleeders in this world create the Endangered Species List and mess with Darwin, yet we can’t pray before a football game – go figure.

Here’s a great fact: In 2007, researchers discovered LRRTM1, the first gene linked to increased odds of being left-handed. The researchers also claim that possessing this gene slightly raises the risk of psychotic mental illnesses. The principal researcher? Clyde Francks. A coincidence? There is no such thing as coincidences, just unknown connections.

Now, what the hell is this crack about “psychotic mental illness”? WTF do they think they are talking about? I get so fricking angry when people think they can much broad statements – because they are jealous, yeah, that’s right, JEALOUS - just because I can use my left hand like a standing-erect homo sapien! You people are pathetic. Condemning someone because of an immutable characteristic. It’s ok to be gay; it’s ok to be a heroin addict or an alcoholic; it’s even ok for Johnny to have his dick surgically removed so he can become Joan. But, hey, pick up a pen with your left hand and you’re labeled psychotic! F*CK YOU PEOPLE! A**HOLES!! YOU CAN KISS MY A**! HERE! JAMMIES DOWN, BENT OVER! KISS IT! NOW!!! PECKERHEAD! I HATE YOU, WITH A WELL-CONSIDERED DEEP LOATHING, I JUST HATE YOU. HERE’S MY LAWNMOWER, A ROLL OF DUCT TAPE, AND A MAP – GO FIND AN INTERSTATE! IF I'M PSYCHOTIC THEN I WANT A HANDICAP LICENSE PLATE SO I CAN ENTER AND EXIT QUICKLY AND YOU PEOPLE WON'T HAVE TO LOOK ME! WHERE'S THE PHONE BOOK? I WANT TO CALL MY CONGRESSMAN!

I have to take my meds. I’ll be right back.

Alright, better. It’s a pretty day outside, isn’t it? I love how flowers look in early fall. So soft and cuddly! I want to nap in them. I’ll get my stuffed mouse and blankey later, and use the flowers as my pillow and dream of clouds and the Moon and walking on the beach. Smile soooo big!!!!

So 92% of left-handers use their left hand to hold their toothbrush. I’ve hurt my left hand and had to use the other one – felt like someone was cramming something into my mouth with all the grace of a speed boat chewing up a three-toed sloth. Almost a third of us use scissors with the wrong hand – I am not included in that group of traitors. But a good point is made – society makes its tools for wrong-handed people: Scissors, watches, can openers, even the angle on spatulas. Here’s a good source for thoughtfully designed items. Do you realize tape measures are wrong-handed? Think about it. You designers are a bunch of pricks. I better double up on my meds. brb …

Smile.

I lifted this text from here: “Some researchers claim that we are more intelligent and eloquent that our right-handed counterparts. In tests conducted by Dr. Alan Searleman from St Lawrence University in New York, he found that left-handers can be considerably more intellectually gifted.

“There were more left-handed people with IQs over 140 than right-handed people – which is the ‘genius’ bracket. This is perhaps why there are more ‘lefties’ in creative professions – such as music, art and writing – and more left-handed astronauts and leaders than would be expected.”

More – on an absolute basis – lefties than wrongies with high IQs. Interesting. Let’s presume “more” is 6 out of 10. I found this reference to IQ frequency: 1% are 135 or over. “135” is close enough to “140.”

Assume a general population of 1,000 people: 100 are left; 900 are wrong; 10 are “genius.” (You following me? Able to keep up? Maybe there’s a left-hander around that could help you.)

If 60% of the 10 are left, that is 6 geniuses in the left-handed population; the wrong group is the remaining 4. (Still with me?)

6 out of 100 base left population are geniuses, or 6%. 4 out of the 900 base wrong population are geniuses, or 0.4%. So, we are 13.5X more likely to be … well, I hope even you can figure out the end to that sentence.

Kinda explains the crack about there being a “fine line” between genius and insanity, eh? I got no problem with that. Let me know if I need to explain to you. Who you labeling with that word “insanity”?

Some interesting people that were correct-handed: Napoleon, Julius Caesar, Alexander the Great, Joan of Arc, Aristotle, Nietzsche, Ramses II, Queen Victoria, Helen Keller, Thomas Jefferson, Winston Churchill, Euell Gibbons (the “many parts of the pine tree are edible” guy who died of a heart attack at age 64; guess there’s more cholesterol in trees than is generally reported), and me. Another list: Billy the Kid, John Dillinger, the Boston Strangler, and Jack the Ripper. My homies. Bad-ass boys just acting out. I bet if there were more thoughtful household-product designers through history, these guys would not have been angry. Think about it. All Jack ever wanted was to do was to pick up a surgical instrument that cut from right to left. Simple. But, noooo! Just can’t design it that way, can we? You people think we have forges to create our own stuff! You make me sick. I would just as soon ta … MEDIC!

Mmmm. Much better. I’ve never tripled up on my meds before. This could get interesting.

Did you see that? It was purple. Had yellow spots. It looked right at me and smiled. Does it know something? Why would it smile at me? Wait a sec … what? What did you say? No, I am not hungry right now, but thank you. Alright, I will. I guess a banana sounds good. Would you like one? Here you go. Oh, let me open it for you. I am sorry that I didn’t see your lack of arms. Yes, it is good. I am so glad you sugges …. Zzzz zzzz zzzz …

{Sniff}, {cough}, {hick-up}, {burp} Oh, hey, I’m back. Must have dozed off for a second. Where was I?

Remember the 10% of the general pop that is left-handed? It seems that 25% of the general pop that s-s-s-st-stut-ters is l-l-left h-ha-handed. I am included in that group. I used to stutter involuntarily a lot. I thought it began when I was five years old and got run over by a bus in Scranton – well, not run over, the clown hit me and I flew some distance. It was 1964 or 1965. He carried my unconscious body into my house, gave me to the biological fount, and left – “Sure am sorry, ma’am. Hope your boy is ok.” “B-b-b-bye, M-m-mr. B-b-b-bus D-dr-driver. T-t-th-thanks f-f-f-for h-h-it-ting m-m-me.” I use stuttering purposefully now when I speak in front of crowds; it tends to interrupt people’s wanderings – they refocus on me. I still stutter involuntarily, but only when my emotions are crushed and my lifeless heart is left for dead.

I shouldn’t overlook the basic stuff: a left-handed person has the right hemisphere of their brain control their intellectual processes; a wrong-handed person has the left hemisphere dominate.

The left hemisphere (yous guys) has a unique functional profile. Sequential Analysis: systematic, logical interpretation of information. Interpretation and production of symbolic information: language, mathematics, abstraction and reasoning. Memory stored in a language format.

The right hemisphere (us) has its functional profile. Holistic Functioning: processing multi-sensory input simultaneously to provide "holistic" picture of one's environment. Visual spatial skills. Holistic functions such as dancing and gymnastics are coordinated by the right hemisphere. Memory is stored in auditory, visual and spatial modalities.

So I see the world in intellectual 3D. Must suck to be you.

I’m gonna sit back and construct a model in my head to minimize line loss in the transport of electricity to remote areas – I am curious whether utilizing thermal protections naturally occurring three to six feet underground will have a statistically significant impact vis-à-vis running conveyance media above ground. I would think that increased installation costs would be offset by decreased maintenance. What's the breakeven for loss recapture to make this worthwhile? I've always thought that low-voltage thermal tape can be a net gain - what if you moderated the temperature inside the encasement to even 40 degrees F? You could balance depth (and initial cost) of installation with low-voltage thermal supplementation. I think roadways should be contructed with the same ability to heat above freezing - easy enough to make the flows sufficiently redundant to handle frost heave and other movement. Think of the saved costs in property and humans from removing the variable of ice from roadways. Let me think of this some more - why don’t you lean forward, pick up the remote with your right hand, and watch some TV?