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.

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.