Monday, January 15, 2007

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.

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