bariatric surgery

bariatric surgery is on the up and coming in our country. i understand it is very common in the us of a. being from a country that openly advocates alternative forms of medicine (our minister of health publicly supports the eating of garlic and beetroot as an alternative treatment for hiv and aids and does not support antiretrovirals at all and our previous deputy president in open court described taking a shower as effective prophylaxis against hiv after having unprotected sex with a known hiv positive partner. it was a rape case) i decided also to give an alternative opinion about weight loss therapy based on a case i once saw.

a lady presented in casualties. her history was as follows. she had read somewhere (possibly the internet, but i don't really know) that there is something in the urine of pregnant women that causes weight loss. i'm not personally aware of this substance but i don't claim to be an expert on weight loss or chemicals found in the urine of pregnant women. anyway, as it happens, her domestic servant was pregnant at the time. she did what i'm sure we all see as the logical thing armed with her new knowledge; she asked her domestic servant to urinate in a bowl, she drew up the urine and injected it into her abdominal fat. i never heard where she got the syringe and the needle. like many overweight people the patient also had type two diabetes (predisposing to some degree of decreased immunity).

when she presented, she was not in a good way. she was in diabetic ketoacidosis, was in shock and worst of all had subcutaneous crepitations on her abdominal wall around the site of the injection. this is an ominous sign, indicating necrotising faciitis (hyped in the media as the flesh eating disease). she needed to get to theater and fast. the only way to treat this very rapidly spreading infection is to cut away all the affected tissue, right down to the muscle. to get the desired results (arrest of the spread of infection) sometimes takes more than one visit to theater. if she survives the initial onslaught, at a later stage the wounds can get skin grafts.

a colleague of mine did the initial debridement (cutting away the offending tissue) after the appropriate rapid resus. she ended up in icu where she actually improved. the colleague asked me to accompany her on the second visit to theater where we finalised the debridement (mannaged to get rid of all the infection).

once we were finished, the patient was missing all her subcutaneous tissue and skin of half of her abdomen, from the loin region to the shoulder, from the midline to posterior on her flank (almost onto her back). because she had a generous layer of fat, this constituted a massive tissue loss.

fortunately enough, she then recovered pretty much without further incident and was soon discharged to the ward. we then embarked on the ordeal of getting the exposed tissue covered with skin grafts, but after a few more visits to theater, that too was done. she was ready for discharge, alive.

when she left the hospital, she struck a rather pathetic and maybe frightening figure. her left side was still fairly overweight, although the overall ordeal had caused considerable metabolic utilisation of remaining fat. the right side of her abdomen, however, had no fat whatsoever. the skin was directly on the underlying muscle. she was totally asymmetrical.

as she left i couldn't help wryly reflecting that her plan to lose weight had worked better than she ever thought possible. it seems a multidisciplinary approach to weight loss, medical mannagement (in this case the ill advised injection) combined with surgery (debridement) with just the right dose of stupidity can have very dramatic results. i only hope our good minister of health never reads this. she will probably make it part of the national weight loss program.

this is an interesting case our hospital recently saw. i was not personally involved so i had the advantage of viewing it through the retrospectoscope from the beginning.

quick history. blunt abdominal trauma. abdomen completely soft.

for now that's all i'm saying. please give opinions, especially from surgeons. tell other surgeons to take a look. i'm sure someone should get the right diagnosis. (i'm purposely withholding one piece of information, but only because it was initially withheld from me and the surgeon on the floor didn't pick up on it.

a world in one country

last week i drove down to nelspruit to do a locum there over the christmas period. while driving down i remembered how much i love this country! witbank is on the highveld and heading off towards the lowveld one first drives through open grasslands. it is vast and open. although i have never seen the american praries, i assume that must be a good comparison. after the grasslands you drop off the escarpment into the lowveld. the drop itself is beautiful with passes, clifs and quaint little villages.

once in the lowveld it is a different world. it is subtropical. very hot and humid. everything is lush and green and the abundance of life is almost tangible. nelspruit must be one of the most beautiful places i've ever seen. i felt totally at home, which i suppose is a bit odd for someone like me who has lived on the highveld all his life.

but driving there the love for this country was deeper than just the physical beauty. i felt a connection to the land. a deep belonging and understanding of it. often people talk about a respect for the sea. that is the closest comparison i can think of. africa somehow is always wild at heart and demands a level of respect. every inch of our country has been fought over numerous times and i have ancestors on differing sides in some of those conflicts. maybe this gave me a feeling of belonging. almost earned permission from the land to walk upon it's soil. all very melodramatic i suppose.

on the way there i took the photo shown above. i think only a south african can fully appreciate this photo. it was taken at a place next to the road where cargo trucks stop at night so the drivers can get a quick nap. they sleep in their trucks. this sign attests to the fact that some of these drivers have woken up in the morning to find their wheels gone! if you stop there, you may have your wheels literally stolen from under you. in true south african fashion the government solves this not by trying to catch the perpetrators, but by placing the onus on the drivers. don't stop there any more unless you want to donate your wheels to the less (or more) fortunate. if you stop there, don't blame us if your wheels are stolen. these things are reclassified as normal. it has become part of the south african experience.

in an earlier post i referred to signs warning of hijacking hotspots. it is a similar phenomenon. if you stop in those areas you have a very real chance of being hijacked. in our country this means you will be forced from your vehicle at gunpoint and your car will be stolen. sometimes (more often than not) they will shoot you just for good measure. once again this has moved into the realm of normality. the average south african knows where not to stop and where he must not go at all. i remember once driving past some european tourists walking in an area i wouldn't be caut dead in (if i was caught there i would probably be dead). they seemed oblivious to what i perceived as clear danger.

but as wierd as this sounds, when i saw the sign, i laughed and felt truly south african. the combination of the beauty of the land, the historical complexity and the understanding of the present situation all came together in a rather confusing mix, reawakening in me my deep love for this country and its people.

origional man

earlier this week there was an interesting bit of news about a small group of bushmen that won a court battle against the botswana government allowing them to return to their traditional hunting grounds in the central kalahari game reserve. i thought this very interesting on many levels.

most westerners don't know about bushmen at all. bushmen, or san as they are more correctly termed are a group of hunter gatherers that are the origional inhabitants of southern africa. in fact if national geographic is to be believed in their quest to genetically map human migratory routes they are the closest genetically to the origional human beings. it seemed that they stayed more or less in africa while the rest of us wandered off a bit, thereby undergoing certain adaptive changes. i assume the san also changed, but less than the rest of us. the san and the khoi-khoi (or as the first whites in southern africa called them, the hottentots) are both part of a distinct racial group called the khoisan. the khoi-khoi were the most recent branching of the san (about 2000 years ago). i find it interesting to think of the multiple branchings off of them over the years, each one probably giving rise to some branch of mankind and in relatively modern times we actually have a living example of how it happened.

but back to the court case. the bushmen are going to move back to the lands they were evicted from from about 1997 to 2002 to make way for the conservation area. what's interesting is that the botswana government isn't goig to change the status of the area, so it will still be a national park. the other interesting point is that one of the reasons the government gave for not allowing them to continue their nomadic lifestyle was that it was impossible to provide them with sanitation, water, medical and the like. the court ruling apparently absolves the state from these responsibilities for those in the park. they will therefore truly have to return to the old ways.

san of old lived in total harmony with the environment in strong contrast to the rest of mankind. the fact that they will now be living in a national park seems to imply that their old culture will also be preserved. this could raise certain questions of possible discrimination. are they being equated to animals that are being preserved in a game reserve? the next interesting question is the question of hunting. in the past, the san used to hunt using poisoned arrows. they would then track the animal for a few days while the poison slowly took effect through some of the most inhospitable and arid areas of africa. if they are in a national park, will their be restrictions on their hunting? will they only be allowed to hunt by quota or will they be given free reign? will they be forbidden from using modern weapons like guns, thereby forcing them to revert totally back to the old ways?

there are so many interesting permutations to consider. the fact is they are returning to their old ways by choice after a hard fought court battle and for my part i wish them well and god speed.

military precision

i have been in the priveledged position to observe the systematic destruction of health care in the beautiful province of mpumalanga first hand. a military operation i doubt could have been planned and executed so well.
the first thing they did was to appoint a man who had been fired by a previous province for missmanagement as the head of department of health to the position of head of department of health in our province. i suppose it seemed he had the ideal qualification. once he was in power, he made a few changes. firstly he could not be contacted by mere mortals like superintendents or lesser doctors. only a select few were granted the priveledge of being allowed to speak to him and even fewer were granted the honour of gazing upon his countenance. the next thing he did was to decree that he and he alone had the power to sign for payment of extra overtime. in our country all state doctors are contractually oblidged to work 80 hours overtime per month. however the system requires that almost everyone must work more than that. any extra hours worked are claimed for separately. it's these hours i refer to. this would not have been a problem, but for the fact that the man simply did not sign any forms. quite soon people were a few months behind on overtime payment. by people i mean nurses, doctors, radiographers, porters and even some cleaners. actually the doctors were not the hardest hit, because the other groups don't work the 80 hours contractual overtime that we work, so any overtime by them at all was not paid.

once the overtime payments were about 4 to 6 months behind, people started refusing to do extra overtime. doctors continued to work to keep the call lists full.

the next step was to cut specialists extra overtime to only 25%. this works out to about $1 per hour. so they were asking us to do our overtime at next to nothing. the specialists stopped doing extra overtime. the administration did not see this as a problem. soon the medical officers stopped doing extra overtime too. the reasons given were that they weren't getting paid and they felt unsafe, especially in surgery to work without the backing of a senior.

the administration replied that they had now approved payment of overtime up to the month of september. no word on october or november or december.

during all this the single general surgeon (registered only for state service) in the capital of the province, nelspruit, left. the administration responded by doing nothing again. they had no surgical service in the capital and only cover for about ten days in the other center(witbank). during this time the plan was to send patients to private to be operated there. the costs to the state would far outweigh the costs of just paying their doctors for services rendered.

the administration has now decided to respond by downgrading witbank hospital from a regional hospital to a local hospital. the problem with this is certain appointments at our hospital are joint appointments, meaning they work partly for the university of pretoria and partly for mpumalanga. they would all be withdrawn. there would be almost no specialists of any kind.

the next problem they decided to address is the question of interns and community service officers, both of which are not supposed to work without supervision. suggestions have already been made to stop them coming to this hospital because there are seldom specialists on call after hours. that would destroy about half of the working force of doctors here. the remaining doctors would then be expected to handle everything that comes their way. the old true generalist would emerge from the flames once again. one wonders how long they will last.

meanwhile the sisters are jumping ship and resigning in droves. who can blame them? theater time is already bare minimum, so the next step would be to only do emergency operations. i think that's not too far off.

anyway, i will be moving to nelspruit to replace their lost surgeon, so i won't be here to see the total destruction of this hospital. i however have no doubt that nelspruit is also on their to do list of things to destroy. we'll see what the new year holds.

we as south africa have a northern neighbour to remind us what rock bottom is. because of them i know we are not yet there, but it should be exciting to see how close we get.

"thank you doctor, you saved my life"

sometimes i used to wonder what the students thought of us when we were registrars. one particular story springs to mind that i thought quite humorous.

myself and a very good friend were on call together one thursday night. we got a call from a peripheral hospital. they wanted to send us two gunshot wound patients. the first was a man who was apparently winged and sounded relatively ok over the phone. the second one was apparently his sister-in-law. the doctor informed me that she was 38 weeks pregnant and had been shot in the abdomen. he added that she was in shock and wasn't responding too well to fluid resus. i gave my usual preamble about good lines, catheters and nasogastric tubes. (hope sid schwab isn't too opposed to the use of nasogastric tubes in these cases) and then i told him to send as fast as possible.

i then phoned theater and told them not to start with any new cases until i got back to them about this lady. as i've mentioned in previous blogs, this step would be necessary to make sure we actually got theater time at all for such a patient. i contacted the gynae on call just to give them a heads up and then i went to casualties expecting the worst.

the patient arrived. the entrance wound was on top of the dome of her very pregnant abdomen. she was pale and shocked to hell and gone. to make a long story slightly shorter, soon we were in theater with the relevant bloods and lines etc. we also brought the gynae with us. the gynae brought a paediatrician.

i opened. blood and uterus was all we could see. the gynae removed the baby. on a good day there is a fair amount of bleeding from a caesarian section, which the gynaes seem to take as normal. this time i was very edgy about any extra bleeding. this patient couldn't afford too much. amazingly the baby was still alive but it's maths and science seemed to be severely affected judging by the resus effort the paediatrician was putting in. the other unexpected event was that as soon as the uterus had returned to normal size the liver started bleeding profusely. the uterus had itself tamponaded the liver. soon the gynae was closing the uterus. i meanwhile applied pressure to the bleeding liver. at last the gynae left.

the stomach was shot through. segment four of the liver had also been shot through. the bullet had also transected an aberrant left hepatic artery that the patient had. to be honest at the time i thought it was the main hepatic artery by the amount it was pumping and due to the fact that in these sort of trauma cases it is not always possible to be totally sure of anatomy. the bullet had then entered the posterior wall of the uterus and come to a standstill just posterior of where the baby's head would have been. 2cm anteriorly and the baby would have been hit. once again, to shorten the story, i tied off the bleeding artery, closed the stomach, tacked the liver as best as i could and packed the rest (this is part of dammage control surgery, the principle being that you at least stop the bleeding and get the patient to icu to try to better her condition for a more definitive procedure. the packs are supposed to keep pressure on the liver and thereby prevent bleeding. in this case, because the abdominal wall was so distended from the pregnancy, the packing applied little pressure and caused us endless stress later on. to the credit of our icu, they managed to reverse her coagulopathy and to stabilise her hemodynamically) we took her back after 48 hours, removed the packs and just made sure there was no further calamity. the liver looked fine which was quite a relief to me.

and then the icu phase started in earnest. the woman developed a severe sirs response. her lungs fought our attempts to ventilate them, her whole body swelled up with fluid which leaked out of the vascular system, her heart was reliant on industrial doses of adrenaline and her kidneys tethered on failure for just over a week. after probably a month she slowly began to improve. her recovery from then on was slow but steady and finally she was sent to the normal ward. there we pampered her further. we got to know her quite well and finally also heard the story of the shooting.
her husband was the owner of a taxi business. now in south africa that is nothing like what people in the first world may be thinking. a taxi is more like a mini bus service, completely without government control, which means more often than not they are controlled by somewhat less than savory people. anyway, one of the rival businesses decided to do a hit on him. the night in question they broke into his house and blazed away. the target was killed on the spot. his pregnant wife ended up with me and his brother who happened to be visiting picked up a lead trinket in his arm.

with each new group of students we would proudly describe her wounds and how we had pulled her through. we stopped short of openly bragging, usually.
finally the time of discharge drew nearer. but because she had had such a torrid time and because we had become quite attached to her we postponed it as long as possible. we eventually told her we would discharge her the next friday.
the thursday before once again we were on call (we were the thursday firm). that night we admitted a guy who had had too much to drink and presented with a bit of bloody vomiting and mild pain. a touch of sucrulphate and he was fine. the next day we got an entirely new group of students. most students fear the surgical rotation and these were no exception. they timidly followed us around on our ward rounds, trying not to draw too much attention to themselves. we got to the alcoholic gastritis guy. the students obviously had no idea what was wrong with him. i examined his abdomen and casually told the house doctor to discharge him via gastroscopy. he turned to me and said "thank you doctor, you saved my life!" my friend and colleague started laughing. i think i might have chuckled. we turned away both saying under our breath things like "yeah right" and "what a moron". the students i'm sure thought that surgeons are a lot worse than the stories about them.
then we got to the gunshot woman. we casually told her that it was time to go home. she turned to us and said "thank you doctor, you saved my life!" i could almost feel the students cringing for the expected aggressive response. how surprised they must have been when my friend and i both stood there biting back the tears.

mpumalamga is burning

the capital of our province is a beautiful town called nelspruit in the lowveld (subtropical region in the east). actually i should give it it's dues and call it a city, because that's what it has become over the last few years. at independence roughly twelve years ago, witbank was the bookie's favorite for the capital, but the politicians had other plans. i suspet nelspruit was chosen because of it's beauty, which is a far cry from the dusty wind swept plains of the highveld upon which witbank situated. witbank is also the source of most of the country's coal, a large proportion of which is burned in many nearby power stations supplying the country with electricity. the pollution is therefore quite something.
having said all this, there is one thing that witbank does have and that is proximity to pretoria, the capital. witbank is merely one hour's drive away. nelspruit is about three and a half hours away.

for some reason this proximity to pretoria makes witbank with it's pollution and grasslands a more attractive option for many professionals, including surgeons. but despite this there is an absolute shortage of surgeons in the state sector in the entire province. there are only two with full registration in the whole province and both of them are in witbank. therefore i wasn't surprised when the state approached me about 4 months ago and offered me a post in the capital, nelspruit. brimming with enthusiasm, i rushed to nelspruit the next day to scout the place out. it is quite a drive and the toll gates add exponentially to the irritation thereof. but still the beauty of the place seemed to get under my skin and i was quite keen, especially that they mentioned a significant increase in salary.
i waited for the official offer. and i waited. and waited. nothing happened. i knew from a friend in nelspruit that they only had one surgeon with limited registration and he was only covering half the month's calls. that meant they were referring most of their serious cases to witbank after hours. this didn't seem to bother the administration. not only did this not bother them, but they decided to further sabbotage services by no longer paying the by now severely overstretched surgeon for after hours services rendered (actually they said they'd pay 25% which ammounts to about R300 for a night's work probably in the region of $40). he cut his overtime by half. now nelspruit, the capital only has surgical cover for 4 days every month.

during this time, surgical services in the entire province collapsed, partly due to the 25% after hours policy by the government, but also due to the fact that the overtime owed to the medical officers was three months behind. they felt that they could no longer go on working in excess of 80 hours overtime per month with no renumeration.

with this as a backdrop, the province once again engaged me in dialogue about a move to nelspruit. they were also canvassing a recently qualified surgeon from pretoria, who was soon to be unemployed because his time at the academic hospital had come to an end. the head of the depatrment of health for the province was however reluctant to ok the ammount initially offered to us. he seemed not at all phased by the total lack of surgical cover in his own city. he clearly has medical aid, and would never have to receive treatment from one of the hospitals he administrates, so he doesn't care.

the last i heard was that they would take at least a month or two to simply organise a transfer for me and between 4 to 6 months to appoint the new surgeon. the question of a higher salary has totally fallen by the wayside. apparently desperate times do not in fact call for desperate measures. the fact that they don't consider what the new surgeon is going to do to make ends meet in that time is absolutely typical. what he will most likely do is find a cushy post in private and earn three times what they are offering. once he is settled, why would he then move.

from my side, possibly because i'm foolhardy, i'm still thinking about the nelspruit offer, but i have slowly come to the sobering realisation that this province does not care for the health of it's people.
last weekend, the administration was forced to send a gunshot abdomen patient to be operated in private because there was not one single state surgeon on call in the entire province. the costs of that alone could start approaching the amount they would be required to pay for an entire month's overtime of one surgeon in the state. the money is there, it's the will on the part of the administration to make it work that is lacking.

every day i find my resolve to stay in the state more difficult to maintain. i still feel that evil prospers where good men do nothing, but in a system that simply does not care about the lives of it's people it is very difficult to not be seen as part of that system by the casual observer. most people that hear i work for the province of mpumalanga assume i'm on some form of remedial community service imposed by the council for some or other medical misdemeaner. maybe it is time to consider another avenue of employment and allow the ship to finally sink as the administration so badly wants it to do.