m and m

i'm instituting the m and m meeting in our department starting in february. m and m stands for morbidity and mortality meeting. i thought i'd drop a blog about it seeing as though it can be quite an emotive issue. i also realise i've come full circle, starting with my first m and m as a house doctor (a story i'd rather forget) up to me being the one to launch the meeting as a formal part of the weekly activities of the department of surgery in our hospital.

my first m and m can maybe wait its turn for a complete blog, so let me start with when i joined the department of surgery at the university of pretoria.
in your first year, you are a medical officer. that's to say your formal training hasn't started yet, but you are earmarked for a post as registrar (kliniese assistent) the next year if you pass your primary exams and if you survive the year. for a number of reasons, when i started there was a general shortage of registrars, so i was put in charge of a firm even though i was only a lowly medical officer. this was very daunting. if you're clever the one thing you should know is that you know nothing. i was clever and therefore scared. but you learn fast. you must. i remember the first sigmoid colectomy that i ever saw. i remember it so well because i did it. it was for necrosis due to volvulus. i opened the rigid acute abdomen in the early hours, got one helluve fright, being so wet behind the ears, and phoned a senior. he informed me he was in messina (about a 6 hour drive away) and told me over the phone what to do. i did it and the patient didn't turn a hair.

i realise i digress. the fact that he didn't turn a hair means he didn't end up on the m and m and therefore shouldn't end up on this blog. but the point i'm attempting to long windedly emphasise is that i was thrown in in the deep end and had to swim. because i was only too aware of my total lack of knowledge and ability i was always scared i'd killed someone accidentally and was therefore terrified of each and every m and m meeting. i would sometimes even lie awake the night before planning how best to present the cases. i never ate on a monday before the m and m (which was at 17h00) because i just couldn't get any food down. it seems you actually do need saliva to be able to swallow food and all my salivary glands routinely took monday off.
at the end of each m and m, which seldom went as badly as i had been expecting, i would walk out with a type of post adrenalin euphoria and triumphantly anounce 'survived another m and m!' seems a bit juvenile now.

as time went on and i became somewhat less of a danger to the population at large, the m and m also became much less daunting. it never totally lost its sting, however. it will always be unpleasant to explain to a room full of experienced professors why someone died, even if they did have terminal colon cancer growing right out of their abdominal wall and about no remaining normal liver.

and now it's me starting up the totally new concept in this hospital in the middle of the lowveld and the doctors 'please explain' to me. seems surreal. please don't think my aim is to put them through what i went through (i think of a guy called anonymous commenting on another blog that us surgeons do that). on the contrary. the idea is to learn and better the service and even protect out junior staff. knowledge is power and as long as i know what happened with each case i can defend my people when the stories do the rounds.

and when something happens there are always stories. i soon learned in the days of the dreaded m and m never ever to hide a case. people will be talking about you anyway. the best thing you can do to preempt this form of gossip is to beat them to it. i saw other people hide cases and suffer silent whispers in the corridors sometimes for years. whereas if you just come out with the whole story, it passes and usually there is even sympathy for your plight.

anyway, enough blogging for one day. we'll see how the softer bongi m and m goes.

sangoma

just a quick update on my last entry about the gunshot wound. well, remember i said the spleen was enlarged and looked abnormal? because of that i decided to send it away for histology, thinking we might incidentally discover some underlying pathology, not that it would really change things. so we popped it into a bucket full of formalin. my medical officer filled in the relevant forms, requesting histology on it. the next day i was informed the spleen was stolen out of theater!!!! i kid you not!!! someone stole the spleen. now although we have no way of proving this, it is generally believed by all the staff at the hospital that it was stolen to be used by a sangoma (traditional healer or witch doctor. i use the word healer in the very loosest sense)

this now raises a number of questions with me. firstly, being totally untrained in their 'craft' i'm not sure what the therapeutic use of a spleen is. do the therapeutic properties change if the spleen came from a good man or a bad man, or must you just adjust the dose of spleen given? and what about the very real hiv risk in our country, or does one just mix the spleen with garlic and beetroot? (this being our minister of health's answer to the aids pandemic)

my next real concern is about the effect of the formalin on the healing properties of spleen. our man's spleen lay in formalin for some time. i suspect the average spleen used by a sangoma does not. have they done the necessary double blind studies to compare the therapeutic value of formalinised vs unformalinised spleen and where can one read this data?? there are so many such questions.

the next thing that i was later told, although, admittedly not necessarily from a reliable source, is what happened at the scene of the shooting before the man was taken to our hospital. apparently the paramedics initially only worked on the other guy (he was shot through his brachial artery and the bleeding probably looked more impressive) and just left my patient lying there. they only attended to him once the other guy had been packaged off to hospital. he was give plenty of time to move into the dangerous territory of shock. once they got him dripped and ready to transport, they apparently had to further wait for a police escort, seeing as though he was under arrest for attempted murder. this information explains slightly more why he did so badly with us. he didn't experience the benefits of the so called golden hour. he didn't even really get a bronze hour. maybe he got a lead hour.

now although this might be some sort of street justice metered out by the paramedics, i was pretty annoyed when i heard this. i don't think it is our role to play judge, jury and executioner. we don't know what happened. we should all do our best to do our job and save the man if we can. i also feel that we at the hospital mounted a great effort to save him at great cost, totally unaware our efforts had been sabotaged from the outset.

then again, maybe the other man was given priority because his on the scene injuries were more severe and my anger is unjustified. so if i have offended any hard working caring paramedics, i apologise. if i have offended any sangomas, i do not.

the wild west

last week i had an interesting case. actually i found the events leading up to the case and the sequelae more interesting than the actual case itself.

for me it started when i got a call from the hospital (the government hospital) saying they had a gunshot abdomen in casualties. he apparently had no recordable blood pressure (not good) and a severely distended abdomen (also not good). i was in the private hospital, attempting to augment my income at the time. i said they should get the guy to theater as soon as possible with the necessary lines etc and i'd be there as soon as possible. i rushed out of the private hospital through casualties. as i ran through i saw they were busy with a man in resus. there was quite a bit of blood on the floor and a hive of activity around his bed. not my problem, so i left.

when i arrived in casualties in the government hospital (he hadn't yet been taken to theater) sure enough the patient did not look well. he had a very low blood pressure and a severely distended abdomen. the casualty officer was saying things like fixed dilated (something doctors say just before terminating a resus, which is what they would have done if i hadn't arrived). the lines were up and going like blazes. the third (and last available) emergency blood was being given. i sent a house doc to order more blood and blood products and physically took the patient to theater. except for a 5 minute delay with the lifts (don't ask), this happened quite quickly.

in theater, i opened the thorax and cross clamped the aorta so that the blood supply to the abdomen and therefore the bleeding would be controlled before we opened the abdomen. we then opened the abdomen. there was an explosion of blood everywhere. the patient deposited probably his entire pre-incident blood volume on the floor, if not more, instantaneously. we went to work. his spleen was massively enlarged (i don't know why) and had been split open to the hilus, where the splenic artery was exposed in all its pumping glory. we whipped out the spleen. the bullet had then entered his sacrum. he was oozing massively from here as well. at this stage nothing was clotting and what he was bleeding was no longer blood, but resus fluid. we packed everything, closed up and got him to icu. the blood and products had only then just arrived (don't ask). the idea was that if he could be stabilised and his clotting could be improved we'd re operate and sort him out. he survived about 2 hours in icu with massive amounts of adrenalin before finally succumbing to his wounds and passing on to the great icu in the sky.

i went back to the private hospital. there a friend of mine was operating on the guy i saw fleetingly in casualties as i rushed past. slowly the story of what had happened emerged, mainly from family members and later a front page article in the local paper.

my patient (let's call him man A) worked for the man being operated in private (let's call him man B). man B and man A had a disagreement, which resulted in man B threatening to fire man A. man A obviously felt this could easily be solved...with a gun which he conveniently had at the ready. he produced it and blazed away. man B fled for his life, picking up small pieces of lead on the way. reports were that 8 shots were fired, but only 4 hit their mark. so thus far the picture is man B running out to his car, with man A in hot pursuit, shooting wildly. at the car, man B collapsed. he had been hit 4 times by then, 2 in the right arm, shattering his humerus and transecting his brachial artery, once in his chest and once in his abdomen. man A had him!! he stood over him pointing his weapon for the final shot. enter security guard who worked next door. the security guard, also with gun drawn, commanded man A to stop. man a turned to shoot him. the security guard fired once. once was enough. and thus A and B landed up in their respective hospitals, A to die soon after, and B to be repaired and recover (B did well).

my first thought is this is the wild west! it seems that the correct way of conflict resolution at the moment is whip out your trusty 6 (or 8) shooter and blaze away. can you believe it?? i'm not sure i can. one small piece of warped justice is the statement that if you live by the sword (or gun ) you die by the sword (or gun). and this happened in the day in the middle of the street in nelspruit! high noon type stuff.

the second interesting thing to me was the public service vs private service health care in our country. we have two parallell health care systems, one much more advanced than the other. we have a first world and a third world system right next to each other. i am presently in both. my heart lies with the state (third world) but because they pay so poorly, i work in private as well to augment my income. this was the first time i saw the same incident from both sides, almost as it happened. very interesting. let me just qualify by saying that i don't think that man A died because he went to the state hospital. and i don't think in this case man B made it because he went to the private hospital. i think, had it been the other way around the final outcome would have been exactly the same. i'm simply commenting on something that i've always known, but saw close up for the first time. interesting, that's all.

adopt a new yorker

i met a new yorker. it was a fascinating experience. it all started when i was doing a locum in private in nelspruit over christmas. i was seeing a patient in casualties and this touristy looking guy came in with his wife in clear respiratory distress. she apparently had some sort of fibrosing alveolar disease, the domain of physicians, and was duly admitted by them to icu. i just remember this guy in casualties shouting at everyone and saying if the service is not good enough, they were going to just leave. i thought he's an idiot. where is he going to go? nelspruit private hospital is about 2 hours away from any other good medical help and she looked like the ride to icu would be too much for her.

i had my own patient in icu (a gunshot abdomen who bled about 8 liters before and during operation, which means the anaesthetist was quite a wiz, but different story), so i saw her the next day huffing and puffing with a cpap mask on. (a cpap mask is a mask that delivers air under a higher residual pressure. i personally believe it may origionally have been used by the spanish inquisition to illicit a confession in days gone by). the point is she didn't look good and already i started suspecting she was not going to make it.

anyway, i left nelspruit and went back to witbank to finish the year off there. i returned to nelspruit on the second of january. initially i had no place to stay, so the hospital put me up in the local hotel (town lodge). the first evening there this same man came in and sat at the bar with me. i immediately remembered him. he soon greeted me with a twangy "how ya doin'?". i remained polite yet somewhat aloof. but soon his gregarious nature thawed even my hard surgical demeaner and quite soon we were chatting like old friends.

he didn't remember me from the night he brought his wife into the hospital and i didn't volunteer that i'd thought he was an idiot. he told me about his wife and showed me photos of her lying in her icu prison, now with a tube in her trachea, indicating that her condition had gotten worse. i feared the worst.

the poor guy and his wife had come to south africa to enjoy a dream holiday. she got sick and now he was stuck in this hotel without friends or family and also without transport. i offered to take him to the hospital whenever i could and did so a few times. i also offered to take him out just so he could get a bit of a break from what had become his dismal situation. so we spent the evenings together, joking and laughing, often until the early hours. for me it was a cultural experience. he is loud and verging on what we would call obnoxious. at every restaurant he would pepper the waiter with all sorts of demands and unusual requests, always in a loud voice. often i saw them becoming irritated, just as i had done that first day. but now that i knew him i realised that that's just how he is. he means no harm. i actually became embarrassed by the irritability of my fellow countrymen. fortunately the new yorker seemed to be oblivious to their reaction. maybe he just didn't care.

one day i arrived at the lodge in the evening and he was there waiting at the door. he approached me and said the hospital had phoned and requested that he go there as soon as possible. i immediately drove him up. as could be expected, they told him his wife had just passed away. he was devastated! this loud american that i thought so perculiar was reduced to fighting back the tears. i took him out again because he said he didn't want to be alone in his hotel room. when we went out the old man i had come to know was back, hardly giving me a chance to get a word in edgeways, joking and laughing at the slightest thing. only every now and again would he fall silent and i'd see the tears well up in his eyes.

one of the bar tenders in the lodge also befriended him and soon it would be all three of us going out making a nuissance of ourselves. what a mix of cultures and attitudes.

i learned a few things. i firstly reminded myself not to judge people so quickly, because i may not know their circumstances and i don't know them personally. i also saw the whole medical tragedy from the other side, the important side actually. the human drama of what we do we often loose. i suppose we can't always get emotionally involved, but it is still important to remember that what, to us, may be just another case, to the person involved may be the single most signifficant event in his life.

so to this new yorker who i now feel proud to call friend i say thank you for reminding me again that we only do what we do so that the patient can get back to what's really important. the task of living and enjoying life. i'm humbled.

what are we going to do today, brain?

well i've started in nelspruit. i started yesterday and today they made me head of department (mainly because the previous head feels he's wasting his time in the position because the powers that be ignore every request he makes and give him absolutely no support). this is actually a tad disturbing. i think i'm something like a sacrificial lamb.

but i decided to look on the bright side of things. if i could take over the department of surgery in nelspruit (the capital of the worst run province in probably the world mind you) in only one day, then i should be able to take over the world in about a week.

so, same as we do every day, pinky. try to take over the world!!!!