power to the people

i watched recently in amazement as a story, so incredible it was difficult to believe even as i saw it, unfolded. but before we get to the crunch, allow me to take it back about a year and a half.

about a year and a half ago there was an expose on tv about a 'doctor' at our hospital that had lied on his application. he had in fact not passed medical school and was therefore not registered at the board. no one had bothered to check these most basic of credentials. probably no one thought to check. who would lie about such a thing? anyway, he was dismissed, or so it seemed. this individual promptly went to a certain university and after paying due fees to the correct corrupt officials, he was furnished with a degree. with this in hand he fairly easily overcame the minor obstacle of registration at the board. he was reinstated at our somewhat too forgiving (in my humble opinion) hospital.
anyway by all outward appearances he went on with his duties. his duties were in obstetrics and gynaecology. here he soon developed a reputation. the one story that stuck in my mind was as follows:- he diagnosed a ruptured ectopic pregnancy, correctly i might add. he booked the patient for theater. the patient went to theater. the patient lay in theater waiting for her doctor. the doctor went to visit an old friend who was in town. the doctor only returned to do the operation 5 hours later. if this is not gross negligence, then the definition of gross negligence has recently changed (possible i suppose. what would i know?)
after multiple such stories, the head of obs and gynae had had enough. he told the doctor that he was no longer welcome in his department. and this is where my story actually begins.

the doctor in question was a member of nehawu (national health and allied workers union). he approached his union, complaining of unfair dismissal. the union immediately organised industrial action on the hospital grounds. this comprises people taking time off work to toyi-toyi with placards basically stating that the head of obs and gynae is an evil man and should resign etc. the poor head, unaware of this drama innocently strolled from his office to the wards that day, right through the strike. imagine his surprise when he saw his own name, probably poorly spelled on their banners. imagine his shock when he was physically accosted and manhandled by this angry mob, because that is exactly what happened. he was physically driven off the grounds by these swept up nehawu members (mostly cleaners with a few nurses and one or two sisters). when the superintendent was told by one of the astounded doctors watching this pantomime to phone the police, he replied that only the ceo of the hospital has the authority to do that and therefore refused (from a previous blog, you may recall that our ceo was also basically chased from the premises recently, but through more official channels. the point is we do not have a ceo. he was therefore saying that only a person who does not exist could call the police) the head of o et g, knowing what is good for his personal health, left. i do not think any other course of action would have been prudent.

through the waves of amazement and disgust that swept over me, i had one or two thoughts. firstly, without sounding too classist, i find it bizarre that mere cleaners etc should have such power to essentially make policy decisions at our hospital and to be arrogant enough to accost a specialist (usually i have nothing good to say about the gynaes but this was just beyond ridiculous). secondly if this is about power to the people, who will suffer most now that we no longer have a specialist gynae in the hospital. i can't help secretly hoping one of the mob's family members will come into the hospital with the usual vaginal bleeding, only to be told that the quack i initially referred to would be handling the case (or rather not handling it which is more likely from him). thirdly i made a mental note that if my juniors are grossly negligent, i would have to be very careful how i handle the matter.

i am out if time, unfortunately, so i'll have to leave this matter hanging for now.

the power of the ring

recently there has been turmoil in the theaters in our hospital, all caused by me. it all started about 2 months ago. i was getting ready to do some operation when i noticed the senior sister, who was training the junior sister to scrub had not removed her rings. this is absolutely against internationally accepted protocol. the reasoning is the area between the ring and the finger can't be readily accessed by the soap and therefore organisms can escape eradication there. this obviously has implications as far as sepsis and therefore post operative complications are concerned.
i, as politely as possible, informed the sister that she needs to remove her rings. she continued to scrub, basically ignoring me. i slightly less politely insisted she remove her rings. about here there was a verbal fight. i refused to back down and the rings were removed "to preserve the peace" as she stated to me. amazingly enough i was the bad guy in the story! i agreed but said if we couldn't speak about the problem here, i would have to address it later.

at the official meeting between the department of surgery and other departments including theater staff i brought it up again. theater staff came prepared. i was told that i'm infringing on their culture by demanding that they remove the rings. (this entire aspect of modern south african society i may address in a future blog) more than half of all the theater sisters officially stated they would rather resign before removing their rings to scrub.
i responded by stating that i'm not appointed to pander to their or anyone elses culture. i'm there for the patients and if they are doing something that is detrimental to the patients i couldn't care if they have a cultural or religious or other reason for doing it. they simply may not do it with my patients. if they have a problem with this i agreed they should resign.

things were left somewhat in the air. a few days later i was again scrubbing and again saw the sister hadn't removed her ring. i insisted she did. she replied that it is hospital policy that it is not necessary. i refused to allow her to scrub with me. i was given the most junior sister to scrub with me (i was doing a gastrectomy!!!). at about this stage i decided that i would make sure that i did not get dragged down into the quagmire of apathy and couldn't give a dam attitude that permeates health care in the province. i would at least make sure that my slate is clean, no matter what everyone else does. no one would scrub with me wearing a ring!!

some time later, again i was preparing to do a mastectomy on a lady that had recently undergone chemotherapy (neo adjuvant). due to the chemo her immunity was already partially compromised. the sister scrubbing was wearing a ring. i told her to remove it or remove herself. she ignored me completely. i asked my assistant if he could hear me speak and see me because maybe i'd moved into another plane of existance and she wasn't ignoring me, but genuinely couldn't see and hear me. but apparently i was still in this physical realm. i went to the hear matron of theater and complained (why should something like this be necessary?). she solved the problem be simply reassigning the sister to the other theater. she did not remove her ring. again i was given the most junior sister.

during the operation i spoke my mind, unfortunately to the converted, but none the less.
the point is we work for the state and therefore we treat the poor. we are the doctors of the lower eschelons of society. but does this give us the right to offer an inferior service? we need to decide if we are working for money only and to hell with the rest or do we really do it for the calling that medicine should be? the attitude of all the sisters who refused to relinquish the ring are giving a clear message to the population as a whole. that is we in the state hospitals will go through the motions but we don't care about you, our patients. you are the poor and the lowly. why should we care if you get sick and die? just as long as no trail of guilt can be traced back to me.

i refuse to accept this! i will not be changed by the apathy of my province! if that means i must fight every day then so be it. if i forever am given the junior sisters, then at least they will be teachable. i will not compromise what i know to be right just because we work on what society deems the dregs. i do not deem our patients less worthy that the well off and i will afford them the best i have to give!!

the other thought i had was the thought about what most peoplke think of me for staying in the state. most people have this idea the state doctors are inferior. otherwise why wouldn't they do out and make money? the truth of the matter is many doctors in the state have only limited registration to work only in the state. that means there is truth in the concept of the inferior state doctor. so when someone like me that is fully trained and fully registered stays on out of free will it is really the exception. but someone has to start somewhere to try to fix the overwhelming rot that has set into state health care. would i be justified if i critisised standing on the sidelines?? i think not.

so i will remain a state doctor and hopefully i will gradually make a small change. hopefully i will have number of big influences in individual lives. this is all i can really ask for

the perianal absess connection

recently i read a blog by a doctor who complained about people asking questions like what's the worst thing you've ever seen. reading the comments i realised that it seems to be universally agreed that this is an inappropriate question. i was also quickly placed under the impression that most people working with human suffering and especially trauma seemed to have some level of post traumatic stress disorder. (this is obviously somewhat of a generalisation) one person spoke about crying on the way home every day after work. there was also a comment that these sort of questions are like asking a cop if he's ever shot anyone. i also thought back to my motivation to start this blog. (it was based on the blog of a depressed suicidal medical student who according to himself has almost been destroyed by the trauma of studying medicine)

all this spawned many thoughts in me. firstly i began wondering if there was maybe something wrong with me because i'm not falling apart. on the contrary i enjoy a good old fashioned gunshot abdomen. i initially felt the abovementioned medical student should never have studied medicine. it simply is not for him. but now i began to wonder if i'm the one who's a bit odd. if i enjoy a gunshot as i say i do, does that mean that i have borderline psychopathic tendencies???

then i was reminded of an arguement i once had with medical students who were not entirely surgically inclined but rotating through surgery at the time. it all revolved around the perianal absess. most doctors reading this now will probably cringe at the mention of this condition. people who trained in pretoria, south africa will associate even more negative emotions with it, bearing in mind that, due to pressure on theater time, they are always drained in the early morning hours. (see previous postings to better understand this madness) for the non medical people reading this, let me explain. a perianal absess is a pus collection very near your anus due to the infection and blockage of one of the glands in the anal canal. the treatment is to take the patient to theater and open the absess up, draining all the puss and leaving it open to heal on it's own. most normal people don't exactly associate this with the glamour of surgery portrayed by any number of television shows.
anyway, the students were basically saying that to study surgery was insane, in part due to the fact that you condemned yourself to a lifetime of cutting these absesses open. i explained that my view was completely different, i.e. most people don't want to even be aware of the fact that they have an anus. yes we must perform our daily ablutions but this is fairly universally seen as a necessary evil. no normal person in everyday conversation discusses his last stool and the experience of passing it. no, we rather see it as something that infringes on other activities that define us as human and not simply biological (this may become a reccurring theme in my writings, i realise now). we would rather just forget the whole experience and that is in fact what we do.
but when you are unfortunate enough to get a perianal absess, that part of your body that we all want to ignore becomes the center of your existance. the pain reminds you constantly of the presence of that specific section of your anatomy. you can no longer stop and smell the roses on the path of life because of the bloody pain in your rear. that which makes us human is put on hold and must move to a position of less importance to that part of the body that always occupies the position of least importance. if you see the perianal absess in this light, to drain it is to return the patient's humanity to him. and if you see it as such, what a priveledge i have to be the one to perform this task. the perianal absess is a reason to study surgery, rather than a deterrant.

now i hear many sceptics saying that this is hardly a traumatic experience for the doctor and doesn't apply to the arguements i read on the blog site previously mentioned. let me recall another incident that happened to me that was and is traumatic. (this one i mentioned in passing on the site) when i was doing my internship (year directly after medical school) i was working in a peripheral hospital in one of the former so called homelands. someone brought a 4 month old girl in who had been sodomised by her uncle. i was the most junior doctor on duty. my senior, a paediatrician of about 15 years experience, heard the story and literally fell apart. she could not bring herself to go behind the curtains to examine the baby. she finally told me that i would have to do it (let me remind you that i was young and green behind the ears. or wet behind the ears and green everywhere else). i had no choice. i examined the child. there was no distinction between the vagina and the rectum. it was all torn open and there was feces and blood everywhere. the child wasn't screaming as one would expect, but emitted a constant eery moaning sound. i did the best i could as the doctor, which due to my inexperience and state of shock was not much. what i did do, though is i held the baby's hand. i made human contact in a situation that is so far removed from what should be the human experience. maybe it meant nothing, but it definitely meant more than my senior doctor meant to the child because of the fact that she selfishly fell apart. yes i say selfish. she put her own emotional wellbeing before even the physical wellbeing, not to mention the emotional wellbeing of the patient.
i don't hold it against her really. she's just not made for that type of work. and that's why i wonder if some people are not meant to do this job.

as with all things in life there are no absolutes and there must be balance. yes we all go through stages when it all becomes too much and, yes sometimes we need to 'debrief', but if one is in a constant state of a low level of shock at doing what we do, something must be wrong.

in conclusion, no i don't think i have psychopathic tendencies. on the contrary, i do what i do to fix the biology so the patient can return to the wonder of life.

hope these thoughts weren't too incoherent.

the paradox that is mpumalanga

recently there was an audit of how many state specialist posts were vacant in south africa. mpumalanga fared the worst. 86% of all specialist posts lay empty. there was only one registered surgeon working for the state in the province and he didn't work in the capital, nelspruit. it therefore was not surprising that they actively canvassed for three recently qualified surgeons to work there, two in nelspruit and one in witbank. i was the witbank candidate. the administration held interviews, made promises and generally seemed excited at the prospect of increasing their surgeon numbers from one to four.
and then we waited. my one colleague finally phoned the admin people in nelspruit to remind them he needed to know if and when he was to start. they didn't know. he told them they were messing him around and found work elsewhere. my second colleague soon followed suit. i then phoned them. no help was forthcoming. i have always felt i want to work for the state where i feel the need is greater, so i wasn't going to give up so soon. i suggested that i start working and we can sort out the paper work later in the month. the administrative contact in nelspruit seemed excited at this prospect and so this is what i did. little did i realise they saw this as the perfect opportunity to do nothing. and that is exactly what they did. (i must admit they did it very well. they have had plenty of experience)
i remained in this state of limbo for just over 4 months. it took them that long to get the paper work through!!! they are not serious about filling their posts, that's for sure. i think any other of my colleagues would long ago have raised the middle finger in salute to their total ineptitude. that makes me all the more irritated. it feels that they saw my goodwill as weakness and took advantage of it.

another thing that compounded the insult and the financial difficulty i developed was how they dealt with certain promises they had made right in the interview phase of it all. because i would be moving to a new town they promised to pay my first three month's rent. when i approacher the ceo (chief executive officer, otherwise known as the boss) to simply sign the relevant forms (i sign my name quite quickly so i mistakenly assumed she would not have difficulty signing hers) she told me to place them on her desk and she would get to them. i did. thereafter i went daily to her office to retrieve the forms. each day i was met with the story that she hadn't done it yet (the spelling of her name was quite tricky i admit so maybe she was getting up courage to face that) it finally culminated in her being given 24 hours to leave her office by the head of department in nelspruit because of some political difference they had. in mpumalanga to be fired usually means you were fairly efficient and that you are showing up your colleagues for their laziness. anyway, as she left her office on the last day i was standing there. she brushed me off. some financial clerk who was with her laughed at me. i considered punching him, but decided against it.
despite all this i resolutely decided to stick it out because i truly believe i'm needed it the province.

the next bit of madness from our bureaucrats was a unilateral decision to only pay 25% of our rates when we do overtime. some places in the world pay more than the going rate for overtime, which in our line of work is obviously night work. not in our country. no, they pay less. strange??? the result of this is no surgical cover in the state sector in the entire province on most nights. do the bureaucrats care? not in the least. they have medical aid so they're ok. who cares about the poor anyway???

so if you are in our province make sure your medical aid is fully paid up. otherwise don't gat into any trouble. when you drive past the signs that say hijacking hotspot, don't stop to take a picture. you may get a lead pill and they you're really screwed.

how does it feel

occasionally i've been asked what it feels like to lose a patient. there are a few thoughts that i can share about this. firstly every case and every patient is unique so there are a spectrum of feelings that can be ellicited. two specific cases come to mind.

the first happened when i was still a medical officer in surgery. this means i hadn't officially started my training, but was working in the department with the intention to go on to become a registrar (someone in training). a patient came in who had been shot through the pelvis. he had lost a fair amount of blood but he responded well to resusitation (his blood pressure improved with the administration of fluid). he clearly needed an operation because his abdomen was very tender and rebound was ellicited (general clinical sign denoting some form of calamity in the abdomen, in this case probably due to perforated bowel). i booked theater immediately, simultaneously getting my house doctor (in the doctor hierarchy this is the most junior doctor) to order the necessary bloods etc. what happened next will be very difficult for first world people to understand, but is fairly commonplace in south africa. we waited for theater time!!! the vascular surgeons were busy operating a gunshot of some or other artery and due to staff shortages, financial constraints etc etc we were told we could take our patient next. next of course did not specify how long we would wait. i attempted to get another theater open, phoning the matron as well as the superintendent. apparently it was not possible. so i sat next to my patient and watched. i watched as he moved from stable towards unstable. i kept on filling him up with fluid and blood as required, but this is pretty futile if he's just leaking it out somewhere as fast as we put it in. he needed an operation to control the source of the bleeding. that was the fact of the matter. and so the day dragged on with me doing my best to keep the man alive while phoning the whole world to try to get an available theater and watching as he flirted on the brink of shock and finally plummeted over the precipice into shock. in total i spent about 4 hours like this, all the time getting more and more worked up. the last thing the man said before he floated off into a delirium was "doctor, am i going to be ok?" i didn't know what to say because i didn't know if he was going to be ok. i just replied that we would do everything possible to ensure that he would be ok. and so we finally went to theater. my senior did the operation. the man had been shot through his internal iliac vein (a large vein in the pelvis) and the presacral plexus (a rich network of small veins overlying the sacrum) my senior mannaged to control the bleeding from the iliac vessel eventually, but he just couldn't stop the bleeding from the plexus. by this stage the patient had probably lost about four and a half liters of blood (bearing in mind his origional volume of blood was probably around 5 liters, this is massive blood loss. his blood now consisted of the resusitation fluid ringers lactate with the occasional lonely donor red blood cell floating merrily along.) we finally packed his pelvis with swabs (an accepted dammage control procedure) closed up and delivered him to icu. (the acquisition of an icu bed in that hospital in itself is a story, but not for today.) the idea was if the icu staff could reverse his coagulopathy (get his blood to be able to clot again) and keep him alive we would do a follow up operation and remove the swabs. the first hct measured in icu was 5. ( normal about 45 but we're usually happy with about 30). that was also the only one done because he died soon after.

the next story was that of a 16 year old girl. i was a senior registrar at the time. i just happened to be in casualties seeing a patient with haemmorhoids when she came in. she had been shot about 6 times, with at least three bullets having gone through the abdomen. she was severely shocked. we simultaneously commenced a resusitation, phoned theater to tell them we were on our way (we got lucky. they were between cases so they kept theater open for us) ordered blood and plasma and phoned the icu people to tell them to make a bed available so long. we had her in theater within about ten minutes (which in our setting is somewhat of a miracle). the anaesthetist basically gave her inhalation oxygen and intravenous adrenalin as anaesthetic ( this means she was so shocked normal agents would have killed her. she was already comatose form lack of blood to the brain). we opened. i forget her exact injuries, but if my memory serves me correctly the aorta was hit (biggest artery in the body). anyway she was soon dead. i left theater, still pumped from the adrenalin rush i'd had from the whole case. outside theater her entire family eagerly awaited news. this is was not expecting. the fact that i'd been in theater for such a short time must have at least aroused suspicions amongst them that the news could not be good. i calmly explained what we had done and the injuries and the final outcome. the news of the death of a 16 year old girl is something that is not supposed to be endured by any mother or brother or father and their reaction was as could be expected. i answered what questions they had and then left them to their grief. i then went to icu to tell them they no longer needed to reserve a bed for us and also to unwind and breathe a bit.

the first death really got to me. to this day i think we could have saved him if we had gone to theater immediately. the system let him down and we were the face of the system. it's difficult not to become bitter towards the beurocrats that sit in their offices making decisions that lead to the death of people, never seeing the people they kill, while we sit through the night watching some man slowly slip through our fingers. that man had no family with him that night and died amongst strangers. it was terrible.

the second death did not affect me. she was so badly injured it was incredible that we even got her to theater. i doubt anyone would have been able to save her. i also believe that i have a nack with the telling of this sort of news to the family. i reasoned therefore that even if it was slightly unpleasant for me to be there when they hear about the loss of a dear one, it is better for them to hear it from me than from most of my surgical colleagues who tend to be too callous in these circumstances in my opinion.

i often tell people that ask what it's like that it's like reading the newspaper. when we read that someone shot and killed someone else in the paper, we're obviously affected. we might pass a comment that it's terrible or so sad or something of the kind. but it's not someone we know so we feel it at a distance. the only difference with me is i'm there to see the person that most people only read about. i can actually alsoi do something constructive.
i think there is a fine ballance that must be reached. on the one hand you must think about it as one would reading the paper. it is terrible etc, but it's not me and not mine. there needs to be some ellement of distance or we'd all have post traumatic stress disorder. but on the other hand i strongly believe we need to always remember that this is a person we're working with and as such equal to me in importance (no matter who they are). the humanity of the patient and the reason we do our job (to fix the shell thereby allowing the person to get back to the business of being human) must not be lost.

this entry turned out somewhat longer than i planned.

the death of a fellow human being

recently we admitted a patient with 80% surface area burn wounds. in most centers in the world this is equal to a death sentence. in africa there is no chance at all of survival. we knew she would die. it was just a matter of when. she also had mild inhalation burns. usually in the case of inhalation burns the patient would be intubated(tube stuck in trachea ie windpipe to keep airway open and allow breathing) but because she had no chance we ellected not to do this, secretly hoping she would asphixiate in the night. (this is a better way to die than the prolonged agony of the burns and the sepsis that would soon set in) her inhalation burns were however not so bad and she did not die in the night. every day when we saw her on rounds i would ask her how she was and she would give the generic reply that she was fine. this was not true of course. she was in pain and on the brink of death.

we discussed her with the students. the medical facts were simple. she would die and there was nothing to be done. the human tragedy was somewhat more complex. i found myself wishing that she had already lost her humanity because it would then be easier for me to deal with her imminent death. she did not. she remained human to the end, every day telling me that she was 'fine'. every day i found myself wanting not to go into her room. this was selfish of course, because it had to do with me dealing with her death and not with being there for her in this time of her need. i was confronted with the fact that our patients are human and therefore equal to us in every way. i was therefore confronted by my own mortality. most of my colleagues would just cut off from the situation. this i fully understand because there are too many opportunities where one is confronted by this, so as a defence mechanism one cuts off. but if we are really doing this job to make a difference in the lives of fellow human beings, we need to guard against becoming callous. true as surgeons our first priority is to treat the physical person. but why do we do this? it should be to allow the person to get back to the more important aspects of life that define us as human. things like reading poetry and falling in love and the like.

anyway, as expected she died, but only after confronting me with my own mortality every day for a week. some people may think you should never be glad at the death of another human being, but i disagree. i was happy when she died. don't get me wrong, i was not happy that she had to go through the whole ordeal. i was not happy that she got burned in the first place, but once she was burned, i wanted her suffering to end. i was happy for her that she died. but if truth be told i was also relieved for myself that i didn't have this constant reminder of how fragile my own life is and how we rely so much on this shell we call a body to transport us through life.

thoughts etc

going through blogs i found an interesting one written by a depressed medical student, talking about his many experiences during his training. at one stage he waxed on about having seen things that he was never supposed to see. i thought it fairly melodramatic. i read most of his stuff and realised he probably never should have studied medicine. it's just not for him. but, having said that he did say many things that were true. i found him quite inciteful.

i am a surgeon working in the province of mpumalanga in south africa. i love my job but the administration of the province and things like our country's aids policy can be frustrating to say the least.

anyway after reading his blog i was motivated to write something myself because:-
1) i think i can possibly bring a balance between his negativity and the true joy of actually making a difference in the world through medicine
2) when he spoke about all the things he saw etc i realised that those things have become commonplace to me. this does not mean they are commonplace to the average person. the point is i have quite a few amazing stories.
3)i am confronted daily with the frustrations of working in an underfunded government hospital in a province that is corrupt and doesn't care about it's people in the continent that the world traditionally also doesn't care about.

i'm not sure how this will go, but it may be interesting. it may also be boring as hell.