no winning

another story of the futility of trying to get it right in kalafong happend to a friend of mine.

the patient was stabbed just outside the hospital at the taxi rank. his friends immediately carried him into casualties. my friend and colleague happened to be there at the time. he immediately saw that the stab was probably to the heart and the patient was in trouble.

my friend grabbed the gurney and charged off to theater. amazingly enough he got the patient onto the table almost immediately (very nearly unheard of in kalafong). similar to my previous story, by the time he put knife to skin, the patient was in exitus.

the surgeon ripped his sternum open at double quick time. the pericard was a large sack of blood. the heart just couldn't compete against this and had stopped beating (this is not good). the surgeon opened the pericard and drained the blood. this allowed the heart to start beating again. unfortunately with the first contraction a stream of blood shot out of the left ventricle.

a steady hand and a few stitches later and the heart was no longer leaking. all that was left was to close.

the next morning, when i heard the story i was pretty impressed. a general surgeon had moved into a domain that he was not fully comfortable with and managed to pull a patient through that had actually been stabbed in the heart and that in the left ventricle. when he presented the next morning, once again the professor ripped into him.

it seems, according to the professor that the correct entry should have been a thoracotomy (between the ribs) rather than a sternotomy (through the middle chest bone). the small matter of getting the patient on the table literally about 10 minutes after the incident and pulling a guy through that had received an essentially fatal wound seemed of little concern. at a stage the prof even attacked my bewildered friend personally. as usually we all sat in silence. it was not the first time and it would not be the last time that this happened. we had all at some or other stage experienced the wrath from on high and it was just his turn.

at a stage my friend rose from his seat in a seething rage. he stood for a moment. he then seemed to realise that the safest move for his career would be to just sit down again. this he then did, but i'm sure i saw steam rising from his head.

after this fiasco, i went to him and said that despite what anyone says i thought he had pulled off something amazing. i even wrote a message on the tea room notice board saying that he was the man. he laughed at this and all seemed better.

skewered

in surgical training there is bound to be bloodshed, but it is always difficult to handle when it is at the hands of your fellow surgeons.

i was in the last months of my training. i was not on call that night. then a friend of mine working at kalafong phoned me. he sounded desperate. when he sketched the situation i understood why. he had admitted a patient with rectal bleeding. the patient, however, was pouring massive amounts of blood in a constant stream from his anus and despite two large bore lines was rapidly becoming hemodynamically unstable. why doesn't he phone his consultant on call, i wanted to know. apparently he had. the consultant had made the telephonic diagnosis of an aortaenteric fistel (an opening between the largest artery in the body and the intestines causing massive bleeding and almost always fatal) and had told my friend to put him in a side ward and to leave him to die.
"but i just can't do that!" he said. "it's just not right." i understood. i told him to get the patient to theater and i'd join him there.

when i got there the patient was not doing well at all, despite a massive resus attempt. two large bore lines were running blood into him and a three lumen cvp was pumping fluid. the anesthetist also looked pale (i don't know what his hb was though).

although the probable source of bleeding would be the colon, i knew there was an outside chance that he could be bleeding from his stomach. (stomach bleeding usually comes out below as a black sticky diarrhea, but if the bleeding is so swift that there is no time for the stomach juices to change it it can still look like blood). i didn't want to waste any time once the abdomen was open, so i quickly stuck a gastroscope into his stomach. it was clean. i knew what the target organ was.

the anesthetist leaned over and said.
"if you're going to do something, you need to do it now. he is on intravenous adrenaline and only oxygen inhalation and anything more will kill him."
i got the message. we ripped the abdomen open. i clamped across the rectosigmoied junction and started clamping off the blood supply to the colon, starting distally and moving up. i reasoned that the most likely diagnosis was diverticular bleed although they seldom bled so impressively and diverticular disease is more common distally in the colon. it made sense at the time.

that was without a doubt the fastest bowel resection i've ever done, before or since. when i got to the mid transverse colon, minutes after starting, i opened the lumen. there was no more active bleeding. i handed over to my friend. i told him to pull out a colostomy and get the patient to icu.

on the way home, i felt elated. i had saved a life where it seemed there was no hope. it had been close, but we had pulled a miracle off, despite the fact that the consultant had washed his hands of the case by making a ridiculous diagnosis over the telephone.

the next day i couldn't wait for the morning meeting to bask in the glory of our night's work. the fact that the consultant who had essentially fobbed my friend off was sitting right behind me in the meeting made our escapades so much sweeter. sure enough as my friend started presenting i saw a smile of achievement cross his face as he spoke about the case. then everything went wrong.

what we didn't know is that the professor had written an article many years before about the operative approach to bleeding diverticular disease. it required segmental clamping of the colon and separately opening each segment until the bleeder was found. then only that segment was to be removed. the fact that our patient didn't have a discernible blood pressure at the time of the operation and was essentially too unstable even to receive anasthetics mattered little to him. the fact that we hadn't done it according to his prescribed method mattered a great deal. he then told us the patient would have survived if we had used his method. we pointed out that the patient was indeed alive. prof was on a roll and didn't want to be interrupted by bothersome facts.

as we say in afrikaans, teen die einde, kon die see ons nie skoon was nie. he just kept on ripping into us. the consultant sitting behind me at no stage mentioned that he had refused to come out to help. he just kept quiet and left us to be destroyed and humiliated for all to see. by the end i was actually smiling to myself. bloody typical, i thought. i was just worried about how my friend would take it.

anyway, the patient survived. my consultant who was not involved in the case later congratulated us on a job well done. he said a few other not so complimentary things about the professor that i think are better lost in the sands of time now, but made me feel a whole lot better at the time.

p.s that friend of mine not only dropped out of surgery but completely left medicine in favour of another life altogether. and he was a great surgeon.

alone

the south african sink or swim approach to medical training tends to grow on you, but in the beginning it could be quite terrifying.

i was a house doctor. in fact i had only been a doctor for about a month and a half. i was realising that there was in fact knowledge in my head. when i saw patients it seemed to come to the fore and i actually knew what to do. it was an exciting time. all those years of study seemed less in vain.

so when i saw a young lady in casualties with severe abdominal pain, one of the conditions i considered was an ectopic pregnancy. sure enough her pregnancy test came back positive. i immediately knew what confirmatory test to do (we didn't have sonar or ct scan, scanman). shortly thereafter i stood with a syringe in my hand full of blood that didn't clot. it was all coming together so well. i had single handedly made the diagnosis of a ruptured ectopic pregnancy. i was actually using my years of study. i was being a doctor!
i quickly booked theater and called the cuban gynaecology consultant. he soon arrived. like a proud cat with a dead mouse i showed him the syringe with the unclotted blood. he obviously agreed with my diagnosis and management plan. i was the man.

then he turned to me.
"i need to go to the bank" he said. "will you be able to handle her in theater?"
"definitely not!" i replied. "you'll have to come with me."
"but i'm on my way to the bank now, so you go ahead so long. i'll join you when i get back. anyway it's just like doing a sterilization, except the tube is more bulky." at that stage in my career i had in fact done maybe three sterilizations. i started sweating.
"i don't think i can do this" i retorted.
"you'll be fine." and with that he turned any walked out. i couldn't help wondering if the patient was going to be fine though.

so i took her to theater. i was so scared i could almost not talk. but what could i do? i was the only one there. and where i did my house doctor year, we operated without an assistant. there was no one available to assist anyway. i did the operation alone. my hands were shaking so much i'm surprised i got it done.

towards the end the consultant did arrive. his banking done, he was free to observe me closing the abdomen. pity, because i still didn't have steady hands by any measure and i probably looked pretty clumsy.

nervous

the professors used to say there are two nerves that give you trouble with a superficial parotidectomy, the facial nerve and the surgeon's nerves. this is true.

for whatever reason you need to do a superficial parotidectomy (removing the superficial lob of the parotid gland, the main salivary gland) the disection is fine and finicky. the facial nerve, the nerve that supplies the muscles of the face, runs right through the gland, breaking up into its tiny branches right in the middle. the operation requires the surgeon to find the root of the nerve where it comes out of the skull and to painstakingly follow it through the gland, identifying each of its branches as he goes. nerve injury is a real consideration. at best this may cause paralysis of a certain area of the face, depending on what branch is injured. but at worst this can cause total paralysis of one side of the whole face. the patient would have a drooping mouth on the one side and an eye that just won't close. this is a disaster as any attempt to smile would result in a weird distorted facial expression. but even worse, the eye would dry out and finally be damaged too.

so when the state hospital asked me to remove a tennis ball sized mass in the parotid gland, i was apprehensive, but eager. it is a fairly rare operation so it is an opportunity to get the chance to do one. after suitable preparation the operation commenced. usually one would find the nerve behind the gland just below the ear where it comes out of the skull, but with the massive size of the tumour, there was just no space to get into this area. i decided to go for plan b. to find one of the branches of the nerve where it comes out of the gland on the other side and work back. this went quite well until...

most surgery text books discuss in detail how to do a superficial parotidectomy. thereafter most text books mention that sometimes the mass is in the deep lob of the gland. they mention how the branches of the nerve get stretched over the mass and maybe even give a hint or two as to how one should go about getting the mass out without damaging the nerve. but you usually get the feeling that the writer is actually saying with a chuckle; 'good luck with that! you're on your own there!'

and this is what i found. the branches of the nerve had been stretched so tightly over the massive tumour that they had formed groves in the mass. i was not amused. i imagined the patient with a distorted one side of the face after the operation. i also imagined the writers of the chapters about parotid surgery all having a good laugh at my expense. i could not remember in that moment why i had decided to study surgery. i regretted it.

and then, because there was no other choice, i slowly went ahead and removed the tumour between two branches of the facial nerve. by the end my nerves were frayed. but i put a good face on it (symmetrical) and told the state doctor to close the skin and let me know later how much function she had left in the nerve. i feared the worst.

the next day, because they hadn't let me know, i phoned the relevant doctor. he informed me the face was fine. the patient had a normal, symmetrical smile and could close her eye normally. then i remembered again why i had studied surgery.

dignity

he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.

in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.

the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.

then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.

he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.

i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.

i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.

maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.

but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.

too little too late

when i was working at witbank hospital i had financial problems based on not being paid. i touched on it in a very early post. as part of the solution i approached a private surgeon working in the private hospital. i asked if there was any possibility that i could do after hours work there to augment my salary. the guy was overjoyed and even delt me into the calls of the next month. he, however, said that i'd need to chat to the other two private surgeons to get their blessing.so i made appointments with them and both said that it sounded good.

i then approached the administration. they too were overjoyed. they even took me on an orientation through the hospital. i looked forward to at last getting some money.

about a week later the administration called me back for a meeting. they informed me that two of the surgeons had held a meeting with them (the last two that i met with). they had basically said that if the administration permitted me to do any work there whatsoever, they would withdraw from calls. this caused the first guy to also lose enthusiasm for the plan. he was hoping to do one in four calls instead of one in three. if the other two withdrew he would have to do one in two, which didn't appeal to him.

the administration assured me they wanted me to stay in witbank and would approach the delinquent surgeons to see if they could sway them. i said i'd approach the other guy and ask his advice. the administration then assured me they would get back to me. until such time, i was not to do any work in the private hospital.

i went to the first surgeon. he told me he really wanted me to be involved but was not willing to sacrifice his relationship with the other two guys to help me. i was on my own.

i left and waited for the call. it never came. in fact part of the reason that i went to nelspruit was the promise of being able to do after hours work in their private hospital.

but strangely enough, today i got a call from witbank private hospital administration. it seems there is too much work there now for the surgeons working there and they are desperately looking for another guy to help with the load. it also seems that the instigator of their initial resistance to me is becoming less willing to do after hours work. in short, they are in a difficult situation.

i thanked them for the call (i didn't mention that it was about a year and a half too late), but i politely declined. they asked me if i knew of anyone who would be willing to go there. i considered reminding them that, due to the many coal burning power stations in the area, the pollution was quite bad and no one in their right mind would take a job there if there was absolutely any other option. i also mentioned to them that there is an overall deficit of general surgeons in the country and they would struggle to find someone. i wanted to say that they should have invested in me when they had the chance and when i really needed a financial boost, but i also kept that inside of me. to be honest i did have a malicious thought aimed at the surgeons there (two of them at least) hoping that they suffer under their loads.

in the end i thought about the beautiful place i live in now and the fact that if i had established myself there i may never have moved here. so in the end i have no real bad feelings to them.

zombie

i once wrote about something that scored high on my weird sh!tometer. but the strangest thing i ever saw was much more macabre.

i was on call. my house doctor called me to casualties. she wouldn't tell me over the phone why. she just said i must come and see for myself.

whenever i went to casualties i went through a specific routine. i read the referral. then, if there are x-rays, i look at them and discuss them with the students. then i go to the patient.

the referral was strange. it was for a facial ulcer. but they mentioned that the patient was known to the vascular department, almost as if it was something that they remembered afterwards. i was a bit annoyed. why all the fuss about an ulcer? anyway, who comes to casualties in the middle of the night with an ulcer?

"here is the arteriogram they came in with." there's an arteriogram? i thought. ok. at least something to show the students. i gathered them around, telling the final years they'd have to read the x-rays. then i put them up. i was astounded.

it was an aorta and outflow. but all that i could see..all that was there in fact.. was the aorta and one renal artery. there were no visible vessels to the arms or legs. if you looked carefully you could see faint vertebral vessels snaking their way up to the brain. but there were no carotids (the normal dominant arteries in the neck going to the brain). if these x-rays are accurate, i thought, then the patient should have no palpable pulse. i was no longer annoyed.

i went down the casualties passage. from a distance i identified the patient. in a wheelchair was an ashen faced man with blue lips. he only had one arm and half a leg. obviously his vascular condition had already claimed the other limbs in the past. on his one cheek he did not have an ulcer but a large full thickness necrotic (dead tissue) area. i greeted him. he opened his eyes and moaned something in reply. his caregiver (his daughter if i remember correctly) told me that he was known to vascular and gave me a letter that they had written on his last discharge. as i expected they concluded that they could do nothing more for him and had essentially discharged him to die.

while we were chatting, i saw a junior nursing student approach the patient to take his vitals. i considered telling her that she would find no signs of life except consciousness but the imp in me took over and i watched on in silence. sure enough the more she looked for a pulse the wider her eyes got. but the man was still responding to her, so she could not conclude that he was dead.

i then examined him myself. he had absolutely no palpable pulse anywhere on his body, including all central pulses. i listened with a stethescope. his severe emphysema meant that there was a large piece of lung over the heart and no heart sounds could be heard. also due to the emphysema, no breath sounds were audible. there were truly no discernible signs of life. and a large area on his face had died and was rotting off. but he was awake and even lucid to a degree.

i was amazed. it was tragic to the extreme. and yet i couldn't help noticing the similarities between a so called zombie and this man. we could not document any clear indication that he was alive. and yet he was alive because. . .well he was alive if you spoke to him.

i considered what i could do for him. if i debrided the necrosis on his cheek, there would be a big hole through which his teeth would be clearly visible. that would only add to his zombie-like appearance. besides he would not survive any form of anesthetics. i had to face the fact that the vascular department had already faced. there was no helping him. in the end we adjusted his pain medication (quite a bit) and sent him on his way.

this tragic story both moved and amazed me.