call it

i noticed my use of the phrase 'call it' a few times recently. it is something i saw on american tv and not at all something that is common in my neck of the woods. the sort of scene that you would get in gray's when the junior doctor is pumping the chest shouting 'i will not let you die, dammit!' while the senior doctors stand one side and instruct him to 'call it!' is pretty foreign to our way of doing things. i even got ragged a bit for using the phrase at all. i thought i'd relate a story from days gone by that illustrates this point.

it was the time of the taxi wars. now taxis in our country are nothing like you might be thinking. they are fleets of mini-buses, quite often owned by people of questionable legal character. occasionally rival groups try to take each other out (i mentioned this before here). but roughly at the turn of the millennium there was outright war. when the war came to pretoria we saw quite a few of the victims, but neurosurgery got the most. a friend of mine was rotating through neurosurgery and this story came from him.

there had been a contact between two different taxi organisations. the casualties were streaming in. the neurosurgeon and my friend, his trusty lackey, were overworked and i think it had affected their sense of humour. so while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. when the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. and this is what they did.

the neurosurgeon looked at each patient in turn. the first three he told them to send into casualties for his attention. but the fourth...he took one look at the fourth and exclaimed;
"vat hom weg! hierdie een is gefok!*"

my colleague laughed the next day when the newspapers reported;
"on arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty." fortunately they did not quote him verbatim.

*take him away! this one is f#@ked!

mopping up

sometimes before you are even called the sh!t has already hit the fan. the mopping up is not fun.

i was on call. as usual i was hanging around in the radiology suite (i spend a lot of my free time there sharpening up my ct scan reading skills. the radiologists even think i'm a frustrated radiologist, poor fools). the urologist phoned me. he had a nervous laugh. most types of laughs of urologists i quite enjoy. but the nervous laugh i do not. he then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. i quickly called the scan up on the monitor and sure enough there it was. the patient was mine.

there was an 8cm aneurysm. but just anterior to this there were signs of recent retroperitoneal bleeding. this was not good. the guy was just one step away from a fatal rupture. i phoned my vascular colleague in pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. then another call came through.
"doctor, the urologist says i must call you about his patient. he says it is now your patient. something has happened." i knew i needed to run.
"i'm on my way!"

as i rushed through the ward i saw what must have been the family. they were all looking anxious and some had tears in their eyes. i rushed on. i needed to focus.

in the patient's room it looked like well orchestrated chaos. lying on the floor was a massive man who was as pale as a sheet. the casualty officer was intubating. a sister was doing cpr. the urologist looked up.
"glad to see you! well then i am no longer needed. see you around." and with that he walked out. someone was trying to place a drip with little to no success. a large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. i needed to take control. only thing is i had seen the scan and i knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).

i told the nurse to stop cpr long enough for me to check for signs of life. there were none. she continued. i then did some basic tests to gauge brain stem function. there was no detectable brain stem function. i called it right there.

after a dramatic unsuccessful resus there is usually an eery silence in the room. maybe it is a sort of respect for the departed or maybe it has to do with confronting one's own mortality. i think it has a lot to do with thinking who is going to say what to the family.
"are you going to speak to the family?" i asked the casualty doctor. i had to try.
"no! you are!" great! i thought. i walk in on the closing act and i'm left with the hot potato.

i took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. then i went quiet. i needed to focus.

the family had been taken into the sisters' tea room. they then sent me in. the mopping up had begun.

i have spoken before about breaking bad news. fact is it is never easy and i'm not sure there is any easy way to do it. i try not to leave the family in the dark too long. once they know i try to be as supportive as possible and to answer their questions as best as i can. usually i am struck by the human tragedy and i allow it to affect me as it should. sometimes when i have been overcome by the relentless nature of my work i must stand back and observe. this was one of those times.

strategy

while i'm on the topic of how to handle consultants i was reminded of another consultant who was somewhat peculiar. also while in prague one of my old colleagues from the old days who actually reads this blog asked why i never wrote about this very interesting individual. so here goes. lets just call him doctor d.

doctor d had dogmatic views on pretty much everything and his views were usually fairly odd. he had developed a way of discussing one or other of his views during operations. he could time a discussion about a given topic to last just long enough that as he placed the last stitch he would wrap up his talk. so with a short operation he would just launch into his theories, but with a longer operation he would start by asking each person in theater what they thought of whatever topic he had chosen for that specific operation. i used to enjoy listening to him during operations and sometimes even felt disappointment when the last stitch would be placed while he said,
"and that is why you should not send your children to school but should home school them." or "and that is why you should always wear long sleeved shirts" or "and that is why cremation is wrong" or some such statement.

but on ward rounds my feelings about these discussions were completely different. an operation had a predetermined end, but ward rounds could go on indefinitely. with this in mind i'd instructed the students how to respond to doctor d so as to shorten the discussion as much as possible. i explained to them that if he asks their opinion about anything not related to surgery he is not asking because he wants to know their opinion, but rather that he wants to expound his own theories. if they gave their opinions he would first take time, a lot of time, to debunk their theories before explaining his own. they were under strict instructions to make sure they didn't give their opinion but rather just immediately ask doctor d what he thought. and then after he had expounded his often bizarre theories the students were not permitted to question him on the rounds. if they wanted to argue some point they could do it in their own time when the rest of us would not be forced to stand there, often post call, and listen too.

generally this approach worked quite well and ward rounds usually didn't drag on more than a half hour after seeing the last patient while we heard why a contraception was wrong etc. that was until one day.

we had just seen the last patient on our post call rounds and ward rounds were as good as over. the students were a new group but i had already orientated them about what to do when asked questions unrelated to surgery. so i didn't worry too much when doctor d started.
"what do you think of rugby?" he asked each student. they dutifully were non committal and quickly turned the question back on him. i was smiling inwardly. we could wrap this up in about 5 minutes if no one questioned him afterwards and he still would be none the wiser i was sabotaging his beloved so called philosophical discussions. he continued.
"rugby is a homosexual game and anyone that plays it must be homosexual." i could almost hear my bed calling. we just had to nod and soon we'd be on our way. and then things went south.

one of the students seemed to be turning slightly red. he also seemed to be bouncing up and down on the spot.he seemed disturbed. i realised he was going to go against my instructions and ask something or worse, challenge doctor d. i started recalculating how long it would take for the rounds to end. but what happened then i hadn't expected.

suddenly the student jumped forward with index finger extended, first towards me;
"i know you forbade us from questioning doctor d about any of his crazy theories, but this i just can't take!" and then towards doctor d:
"doctor d how the hell can you say rugby is for homosexuals? do you really think all the springboks are homosexual?"

i wanted to cry. not only were we forced to endure the full length explanation of doctor d as to why rugby was indeed a homosexual sport, but afterwards i was personally taken to task for instructing the students as to how they were to ensure the good doctor d's talks did not go on for quite as long as he liked them to. worse still, the good doctor d adjusted his way of discussing his theories on ward rounds to bypass my influence on the students. never again did we have a short discussion after rounds, whether the students asked questions or not. doctor d also i think trusted me much less after that episode.

looking good

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.

kalahari

after looking at the first world i got a bit contemplative about the point of staying in this god forsaken place. then i was privileged enough to spend some time in the kalahari. my soul was once again restored and i remembered quite a few reasons to stay. here are just a few.
the endlessness went on and on ...well, endlessly.
unfortunately this doesn't even come close to showing what it really looked like.
the kalahari is an interesting desert. although rain is very scarce, it seems to be teeming with life.
a tree with a communal bird's nest.

bell bottoms

i recently went to prague. what a culture shock. the place is clean and beautiful and safe. i travelled quite a bit on the public transport and not once felt in danger even though i'm south african.

there is generally law and order. on the first day i went on the underground i did not stamp my day ticket because, being south african, i just assumed there would be someone to stop me and check. there was not. they rely on the people there being honest. being south african i rode the whole day essentially for free. then my conscience got the better of me and i bought another ticket so they would not lose money.

you see we south africans have no law and no order. we get away with whatever we can. we all speed and we all jay walk and we all bend all the rules as far as we won't get caught. in prague it is exactly the opposite.

but getting back to the story. one reason it was such a culture shock is because a while ago, to travel on public trains in south africa was quite risky. you see there were gangs that would throw people off moving trains for a laugh. there was also a time when certain trains would get attacked by automatic wielding thugs that would indiscriminately shoot people. these days there is more security (all armed of course) so it isn't quite so bad. there still is the occasional torching of a carriage if it turns up late. let it never be said south africans can't express their anger at trains not being on time.

anyway, while i was safely travelling on the czech (for americans, that is where prague is) public trains, i thought about a few of the patients i had seen. i don't think i'll talk about the guy that got corkscrewed between the train and the platform here. the bell bottom patient came more strongly to mind.

it was in the days of the indiscriminate throwing people off and in front of trains. most died on the scene, but a few got to us. for those who don't know, to get injured on south african train tracks is a sure recipe for sepsis. the trains drop their sewer directly onto the tracks, so to get an open fracture there usually ends up quite a mess. my patient was thrown in front of an oncoming train from the station platform. i suppose the people who threw him there thought it was quite funny at the time. we at the hospital did not.

the poor victim of this senseless crime fell with most of his body over the further track. in fact only one leg lay over the one track. unfortunately he had no time to pull his leg away before the train went over it.

now, to fully appreciate what happened one must realise the patient was fully awake and fully sober. he had in fact started extricating himself when the first wheel cut and mangled his leg about mid thigh. he continued to pull himself away. the second wheel therefore hit his leg about two inches lower down. the next wheel then struck about two inches below that and so on. so the leg was mangled worse than any mangled limb that i have ever seen and more than likely will ever see. it had deep cuts at two inch intervals. the femur was severely broken but it was not nearly as bad as his lower leg. the lower leg spread out like a bloody and distorted bell bottom ending in a very wide flat thing that had once been a foot.

suffice to say he lost his leg that day. (for up and coming south african surgeons, leave the wounds open from train track injuries, like we did. otherwise sepsis will set in and things will get worse.)

so while in prague, i was really confronted by the many acts of meaningless violence we see in our country because i had a clear picture what life could be like in a peaceful place. i honestly wondered what the point is here.

anger

in the old days sometimes confrontation was the only way to get things done. but sometimes anger lead one into useless and unnecessary confrontation. i recently spent some time with my old friend, swimmer's chest and a story came to mind when that swimmer's chest saved me from my own anger.

we were on call together. quite early in the day the chemotherapist called me. he had apparently put a patient on the emergency list the previous day for a portacath and the case didn't get done. this was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. something like a portacath would tend to get shifted down the list and may even stand over to the next day. this is what had happened here. he now wanted me to do the case.

"sure i'll do it" i said. "as long as it's on the list as soon as it comes up i'll be there."
"i want it done now!" he retorted. i was not impressed.
"well phone the anaesthetist on call and motivate for him to move it up the list." i said helpfully.
"that is not my job! you will do that!"

it was clear we had a communication problem. whenever i had a telephonic communication problem i would put down the phone and take the effort to go to the relevant person to sort it out face to face. not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). this is what i did here. i turned to swimmer's chest and told him to accompany me. off we set at speed.

we walked into the chemotherapy ward and asked to see the relevant doctor. soon he was there in front of me. swimmer's chest hung back. i introduced myself and explained that i was more than willing to do the surgery but i had no control over the order of the list. that was entirely in the hands of the anaesthetists. if he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.

"you will phone the anaesthetist yourself and you will do this case right now!" he said.
i could feel my anger slowly turning into fury.
"no! you will!" as i said it i clenched my fists and took a step towards him. swimmer's chest realised things were on the verge of going south. he later told me he thought i was going to punch the guy. i denied this, but the thought was going through my mind at the time, i confess.

so my good friend stepped in front of me with his broad chest and nudged me backwards. he then started speaking to the chemo doc in a calm diplomatic voice. he also subtly and slowly (almost so one didn't notice) ushered the guy further and further away from me. by the end of it we left with the chemo guy feeling that we were there for him and would do all we could. i don't think he even had an idea of how enraged he had made me.

walking away swimmer's chest asked me if i was mad. i had only a few month's of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.

those times in the end brought out the worst in me. by the end of my studies i knew i needed to get away from it all. i had very nearly become something i did not like. after leaving pretoria i gradually rediscovered the true me again. it was still there to my relief.