god's window

so i took another drive through the lowveld and ended up at god's window seen above, although this photo does not do justice to its true beauty. it is apparently called god's window because it is so beautiful that god uses it for his view when he wakes up in the morning. i dont' know if this is true, but it is spectacular. the lowveld is truly amazing in its beauty. from nelspruit where i live you can drive basically in any direction and find splendor, and that's just on the drive.

it occurred to me, nelspruit is a well kept secret. most visitors to our country will only pass through here on the way to the kruger park, if that. they usually go to all the usual destinations. don't get me wrong. i think those destinations are also beautiful. but the lowveld is really worth a bit more time than it is usually given. i think it would be slightly more in the line of the typical african experience as portrayed on tv etc. than for example cape town would be.

for people who are considering a trip to africa in general and south africa in specific, may i humbly suggest some time spent in the lowveld. it really is worth it.


p.s i am not paid by the mpumalanga tourism board or any other board to give these views. just thought i'd drop a non medical post.

disaster concluded

so for those of you who have been following these disasterous events, you'll remember i reinserted an et tube into the man's tracheostomy, thereby allowing him to breathe and then went home in full confidence he'd be wonderfully looked after in icu.

so i arrived at work the next morning, almost expecting adulation because i'd saved the guys life (we surgeons tend to have ego problems). imagine my shock when i heard he was dead!!! what had happened??why wasn't i called if he'd collapsed or if he lost his airway again??? what had happened is the following:-

although there was an icu bed as i'd been informed, there were no available nurses to man the bed (they have similar overtime pay problems in this province to what the doctors experience) so the patient was not given the bed. this had not been conveyed to me. what then happened is a total calamity. in the ward, where the patient ended up, he developed a mucus plug in his tracheostomy tube, couldn't breathe and died. no one even realised until it was all over. this is a simple thing to prevent. all that needed to happen was that his trachi pipe needed to be suctioned intermittently through the night. not exactly high intellect stuff. anyone can do it. but if it doesn't happen when it's needed the results can be dire.

when i wrote the post disaster on disaster, one of the things i wanted to comment on is the feeling this sort of thing causes in us, (or me) the surgeons. firstly i felt the total tragedy of the unnecessary loss of the life of someone who died who didn't need to. it's sort of like hearing that the guy you met at the pub last week was hit by a bus just after saying goodbye to you. you don't really know him but you feel the intensity and finality of the situation. it's terrible!!!

then there are another two feelings. the one is a feeling of guilt. shouldn't i have done more? should i not have stayed to make sure my medical officer did in fact get the guy to icu? should i not have gone to suction the trachi myself? how could i have foreseen this??? etc. etc. etc.

lastly, there is a feeling that all the work we did was futile. this is where the normal person on the street may miss what i'm talking about and even consider us a bit heartless. but remember that this is my job and just like the advertising executive who spends nights preparing a presentation and in the end doesn't get the deal will feel a sense of disappointment, i felt sabotaged. after all i'd done, someone dumps him in the ward and everyone including the nurses on duty get a good night's sleep. it's more than just frustrating!!! i suppose the problem is when we have a work associated disaster, usually someone ends up dead. somewhat like the mafia i suppose.

i feel i have so much more to say to fully express how i feel but words seem to fail now

disaster continued

so i've just come into theater to find a terrified medical officer and a patient who seems just about to cash in his chips and leave this life. i immediately splayed the hole in his neck, allowing him to breathe a bit. when non medical people think of these sort of situations i often imagine they have this idea of smoothe control and everything happening beautifully. it is not usually so. sometimes the whole thing looks pretty messy. with this man, as soon as i opened his neck he gave a greatful gasp followed by a bloody cough....all over my face. (this is actually why we wear masks). my glasses were splattered with frothy blood, but i was just too glad the guy was breathing.

once again i attempted to insert the trachi tube, but because his trachea dropped back so sharply and so deep i couldn't get it in. (it is a fairly rigid c-shaped pipe) i decided to attempt intubation through the hole with a normal endotracheal tube which is much more flexible. this worked and we all breathed. (funnily enough it seems it wasn't just the patient having trouble breathing)

i degloved, told the medical officer to put the man in icu (he told me there was a bed they could make available in about an hour) and i left. this time i didn't have a beer. it was too late.

i started this story by saying there were a number of reasons i wanted to discuss the post. i'll attempt to now without being too disjointed or tangential. the first thought once again has bearing on the discussion about the almost military like training of surgeons (where i come from anyway). i read a comment in one of the posts about a surgical registrar who turns his cell off when he's not on call. we were never permitted to do that. i was not on call during the events described above. i have no doubt that the patient would have died during his first tracheostomy if i had not gone in. once again, because of some crazy decisions by the province i will not be paid for the tracheostomy or the reintubation or going out at night. so although i do not actually believe in the brutality of our training, there must be some form of ballance. surgeons produced must be able to work inhumane hours and still function if necessary, especially in our setting where there aren't too many of us. when a surgery patient complicates it is often rapid and dramatic. it usually can't wait for the morning. i'm not sure what will bring ballance to the force though.

the next thought had to do with my reaction to the events of the second intubation and the medical officer's reaction. as i said when i arrived he didn't seem to be having too much fun any more. i almost wondered if i should first resus him before i turn my attention to the patient. i realised that this job is not for everyone. i actually enjoyed the challenge of the difficult trachi and the intensity of the whole situation. maybe i'm a bit of an adrenalin junkie. the medical officer felt the responsibility of trying to keep this guy alive when he seemed so determined to die was more than he could take. that's why i spoke in a previous post about the fact that we are not working with surgeons and need to treat them more gently than what we sometimes think is needed. there is also the whole arguement about what this type of stress does to people who are not built for it. when i started this blog i spoke of another blog by a suicidal medical student (http://other-things-amanzi.blogspot.com/2006/11/thoughts-etc.html). the guy should never have done medicine. all the horror of our daily work was killing his humanity. i really felt for him. but at the same time the fact is these gunshots or assaults or stabs or whatever are going to happen. people are needed to deal with them. i've often thought about a debriefing or trauma counselling for surgeons, because sometimes i think it is needed. unfortunately i think macho surgeons would scoff at the idea. but maybe the stereotypical bombastic surgeon is like he is as a defence mechanism??? maybe sometimes to remember that these maimed, broken, stinking bodies that we deal with daily are all as human as we are challenges our own mortality too much. it is difficult to be confronted by one's own mortality, but to be confronted a few times a day seems more than a lot can take. one of the greatest things for me about surgery is to return people to their humanity (see http://other-things-amanzi.blogspot.com/2006/11/perianal-absess-connection.html) maybe this is my way of avoiding what i see as the pitfall of forgetting the humanity of those dying around you. what does a soldier do in the heat of battle i wonder?

anyway, all very melodramatic. i did warn it would be disjointed.

the conclusion of disaster was only revealed the next morning and i'll leave that for another post.
so once again, to be continued.

disaster on disaster

recently i was involved in a case which i want to talk about on so many levels. therefore this posting is probably going to be very disjointed. a peripheral hospital sent us a patient that they said had severe stridor (an inspiratory noise usually denoting an upper airway obstruction) what they didn't tell us was that the guy could hardly breathe at all. he arrived and my medical officer quickly made the evaluation that a tracheostomy needed to be done and immediately. he phoned me. i was not on call or even standby, but he told me he couldn't get hold of the other guy. my mo had assisted in a tracheostomy recently and i told him to go for it (see one do one teach one principle). he said he would, but i could hear he was a bit nervous so i came in. in theater the man was in severe distress. he could only breathe if he sat up and leant forward. i injected his neck in this position with local. (you don't want to put this type of patient to sleep unless you're sure of getting an airway or he might asphixiate and die.) i then started the procedure with him in almost a sitting position. i decided to do this one because of the distress of the patient and i'd be able to work faster than the mo.

i dug into the neck as fast as possible. but i couldn't find the trachea in it's normal position. where it should have been was a transverse pulsating artery about the size of my little finger. in retrospect i think it was an aberant right carotid artery which ran anterior to the trachea, but i'm not sure. i reflected it inferiorly and much deeper down and travelling in the wrong direction (the trachea is usually more or less parallel to the skin, with a slight slant posteriorly. this one dropped posteriorly almost at right angles at the level of the abnormal artery) was the comforting corrugated feeling of the trachea below my finger.

at about this stage the patient became disorientated due to hypoxia (lack of oxygen) and started fighting. fighting for his life as he saw it. the anaesthetists had no choice but to put him to sleep. i continued my endeavour while they tried to intubate him from above. i heard them saying they could see a pedunculated tumor at the base of his tongue that formed a ball and socket valve over his airway. the cause of all his problems.

with much sweating and swearing i finally got the tracheostomy pipe in, casually asking the medical officer why he didn't do this one alone (a joke, just in case i get flamed). we sent him to the ward. it was the most challenging (surgical talk for difficult) tracheostomy i've ever done.

i felt my adrenals slowly recover, shrinking back to only twice the normal size. i went home and had a beer.

about 3 hours later, the same medical officer phoned me. he started with an apology that once again he couldn't get hold of the other guy, but the patient had removed his tracheostomy pipe and he couldn't get it back in again. immediately i headed off to the hospital. i went straight to theater. there i found a very pale man. the patient also looked off colour, but he was blue. the pale medical officer told me surgery was not for him. if i didn't think he'd take it badly i would have laughed. the patient seemed to almost be in exitus. not good!

to be continued.......

crash and burn

as some of you will know i instituted an m and m meeting and it's going very badly. interestingly enough the reason it's going badly has to do with the nature of a surgeon and touches on a discussion held on http://surgeonsblog.blogspot.com/2006/12/thinking-out-loud_15.html. in short it had to do with the mentality that i endured it so you should also be subject to the same treatment.

my idea with the m and m was not at all about grinding the juniors into the dirt. it was about all learning in a relatively safe environment. however, one of the surgeons in the department (there are presently 3 of us) who studied at the same institution as me feels the need to really put pressure on the juniors and basically make them feel stupid in front of everyone. i understand this (i don't agree with it, but i do understand it) because that is how we were trained. it's the example he was given and he hasn't mannaged to break free from the mould. the problem is it has become a sensitive issue. the fact that my colleague does this attests to the fact that he is not secure in who and what he is. he feels the needs to throw his weight around to feel he is in control. therefore to confront him right out may be seen as me also viewing him as inferior and only elliciting more of the same behaviour. the vicious cycle story.

the next point and the point which touches on the whole arguement on surgeonsblog (the above link) has to do with the training of a surgeon. whether or not one's opinion is that the training needs to be as brutal as ours was (and i do believe it was intensely brutal) in our setting that is irrelevant. we are not training surgeons. we're merely trying to provide a service. the doctors working in our department are not there because they want to specialise in surgery. they are just doing their community service or house doc year or simply biding time. my feeling is my colleague can't expect them to endure what we did. it also speaks about a lack of respect. i believe respect is a two way street and you are only respected as much as you are shown to respect others. his actions therefore have the opposite effect of what he wants.

i've felt for a long time that one of my attributes is that i can impart a love of what i do to those that work with me, but when one of my colleagues is causing the juniors to have all the stereotypical views of surgeons and therefore surgery, it becomes that much more difficult to do.

so what to do??? i've already subtly saved some of the medical officers from a relentless and unnecessarily harsh public gruelling, but if i constantly do that my colleague may feel that i'm undermining his authority and thereby actually become more ruthless with the juniors to drive the point home that he's to be respected (yes vicious cycle again). so i've decided to speak to him and basically try to imprint upon him that we're not training surgeons so we can't expect them to take the abuse we did. hopefully he'll assume i'm backing him in his authority, yet just gently telling him to tone down. i'm sure there are a whole bunch of readers who will feel that i need to take him to task and tell him that it's unacceptable etc.etc.etc. but then i'll also be slipping into the old autocratic ways and surely can't be taken seriously when that's exactly what i'm telling him not to do.

anyway, it is a fairly intricate problem and should be quite challangeing to suitably address.

somewhere (continued)

just a closeup of the photo in the previous post. by the way, this is really in the middle of absolutely nowhere. no mafia gunfight or war or anything like that. interesting, well at least to me.

somewhere between badplaas and machadadorp

recently i took a drive to barberton. what a beautiful winding pass. then again everything in the lowveld is beautiful. on the way back i attempted to take the road less travelled going through kaapsehoop (a quaint village on the escarpment that is really worth the visit). in retrospect i shouldn't have done this without a map. i got horribly lost and ended up driving in square circles around mpumalanga. quite a laugh actually.

anyway, on this accidental journey, i stopped somewhere between badplaas and machadadorp to take the above photo. this is a phenomenon that had intrigued me for a long time. is this south african or is this a worldwide occurrence? this is commonplace in south africa. this post could just as well have been called somewhere between bloemfontein and tweeling because i'm sure i would find a sign there with the same peculiarity.

if you look carefully, the sigh is suffering from the common south african gunshot wound about which i have blogged on numerous occasions. yes, that's right folks, south africans drive around and shoot sighnposts. not owning a gun myself i can't really say i know why or under what circumstances this occurs, but having driven aroung about the whole country, i can say it is a very common practice.

this is just something that has always tickled my interest. any comments about this practice in other countries would be most appreciated.

flogging the dead horse

i know that i've already blogged about this toppic but something happened this week that made me think about it again. for those of you who feel i'm flogging a dead horse, i apologise prophylactically.

this man well into his fifties presented to our hospital with a week's history of no stools or flatus, severely distended and tender abdomen and vomiting fecaloid material. our friends in first world countries are probably already asking why take so long to present. in our setting this is not too unusual and there are a myriad of reasons why he may have taken so long to get to us, including transport problems and the like. however in this man's case, he has been under his local sangoma's treatment for the entire week and had only sought more conventional treatment when it became clear there was no improvement.

his entire abdomen was covered in small parallel cuts, more than i have ever seen on one patient. this is the usual sign of the involvement of our traditional colleagues. often you can even get an idea if possible pathology by the location and spread of the cuts. well healed cuts for example in the right hypochondrium may indicate previous cholecystitis. this man had multiple symmetric cuts over his entire abdomen. they were also very recently administered (correct word???), so i knew his pain was intense and diffuse. who says that sangomas are not helpfull.

anyway, we operated the man. he had a colon cancer of the descending colon with total obstruction. he also had an incompetent ileocecal valve which is why he had been vomiting. he had a mixed small bowel large bowel obstruction picture. we did a resection and pulled out a colostomy of the proximal massively dilated colon.

a few thoughts, firstly when i first saw this man in casualties i chatted to him a bit about his visits to the sangoma. please don't assume i was condescending and condemning. i was not. the man was feeling sick enough without some bombastic surgeon giving him the once over. i just enquired. the main thing i enquired about is how much did he pay for these cuts on his abdomen that in the end did nothing to either treat or even diagnose his cancer, complicated by obstruction. the answer astounded me. he told me he forked out R1000 to his friendly neighbourhood sangoma. that's probably more than i would get for the operation i did, had i done it in private (as it is i will get not one cent for the operation due to wage disputes in our health depatrment at the moment which i have alluded to in previous blogs) he paid what i consider a large amount of money!! and we're not speaking about the type of person who can afford it. he was not a well off man. he's just the average poor state patient. our state health system is very nearly free for him (he had to pay R26 for his admission and operation and all post operative care), yet he went to get small cuts on his abdomen at an unaffordable cost that didn't even work. the sangoma couldn't even recognise real pathology and refer. (he was not referred by the sangoma although i have seen that happen before) but the sangoma did take the money.

next thing. the point of responsibility. in our country you can't sue a sangoma for missing a diagnosis because it's viewed somewhat in the line of faith healing. the patient didn't have the faith and was therefore not healed. he would have to sue himself. they are free to go on and do whatever without ever being called to account. very comfortable.

the one thing i must admit, the mode of treatment wasn't totally off. i too took a knife to the patient, as did the sangoma. i just cut much deeper and did a few things inside. so maybe i'm also a traditional doctor. i heal with natural substances found in nature......like cold hard steel!