i made a difference

most of the time you do your job. sometimes it means something.

when i was still a registrar, rotating through vascular we had an incident that meant something in my life. i'd like to think it meant something in the other guy's life too. yes, i'd like to think i made a difference.

it was early one saturday morning. a cop came out of his office in plain clothes carrying a laptop. 3 guys asked him if they could have his laptop.
he said no.
they asked again, this time brandishing their knives. the old saying about not bringing knives to a gunfight became appropriate in their lives at about that point.

exactly how the next few moments played out i don't know. what i do know is he shot them all. one guy he winged in the hand. i briefly saw him in casualties. not because he was my patient, but because the story interested me. (as usual he swore he was out selling bibles. a very dangerous passtime if you ask me). one guy he shot through the chest. intercostal drain and the guy was ready to steal again.

but my guy... he got it bad. this incident happened within spitting distance of the hospital. (admittedly the wind would have to be behind you and you'd have to put your back into it.) yet even though my guy was in casualties within ten minutes of the incident, he had bled to shock and was quickly progressing towards death. he took it through his common femoral artery just below the inguinal ligament. (for movie buffs, roughly where hannibal lector stabbs the cop's informant).

without going into too much detail and without even touching on the point that my consultant wasn't available for some reason, we took him to theater, patched him up and pulled him through. of course he did the obligatory icu time, due to massive blood transfusion. (i've seen enough of these to wonder if it could be employed as a cure for aids. bleed out the infected blood and replace it with uninfected blood. wait, i didn't say that!!!)

and then i got to thinking. you see in the state, most of these gunshot wounds are criminals, but this one was brought in by the cop. he was caught red handed (when i saw him, almost everything was red). the others deny everything. this guy could not. i felt a strong sense that i had a chance to say something that might change the course of his life. i might indirectly save some other guy's life a few years from now who would otherwise take a bullet from my patient. i decided i must.

when he came out of icu i approached him on rounds. i meant to say something. i'd even thought about what to say. i couldn't. i thought of my car that was stolen. i thought of my house that had been broken into. i thought of being robbed in town. i was too angry. this guy was the representative of the men that did those things to me. i walked on by. the next day was the same. the following day i realised the guy was going to go home soon and the opportunity would be lost. i had to try.

in the morning i did my usual evaluation of his leg and pulse etc. then i turned to him and started speaking. i spoke fast and almost aggressively, my anger lying very close to the surface. i told him his life was no longer his own. he had been shot dead and yet he was alive. he was alive because a stranger had saved him. (i never told him i was the one that operated on him and he never asked, so the concept of a 'stranger' hung meaningfully in the air...i hope). i told him therefore his life belonged to a stranger and he had to now go into the world, find a stranger and repay the debt. he listened. he said he heard and he would turn his life around. i wanted to say "yea right!!" but i kept quiet. i was still angry at him in proxy.

he went home.

some time later i followed him up. i was surprised to see he was not in prison (ok south africans...i wasn't surprised...shees give a guy a break). i asked him why. as it turns out he listened to my words and decided to make something of his life. he turned state witness and swore to me he was also going to go back to school to get matric.

he was probably lying, but, often, when i'm alone with my thoughts, i like to think he wasn't and that i did in fact once make a difference.

thinking back

i realized i have gotten over the trauma of studying surgery. sounds melodramatic and it is actually. don't worry, i'm not going to go into some self pity rant about sleepless nights with lives in the balance and personal abu... wait a moment, i'm already doing it.

back to the point. (tangential thought can be such a curse) the other day i was doing a cholecystectomy. the patient presented with obstructive jaundice (went yellow). the sonar revealed stones in the gall bladder as well as in the comon bile duct. what was unusual was dilated extra as well as intra hepatic ducts (stones usually don't give dilated intrahepatic bile ducts). she had hiv so i wondered about some exotic complication. anyway i posted her to pretoria (about 3 hour drive) for an ercp to remove the stones from the duct before i attacked the gallbladder.

the gastro guy phoned after the procedure. he told me there were stones as seen on the sonar which he removed, but there was also a fibrotic stenosis which he dilated with difficulty. this he attributed to chronic infection and inflamation with fibrosis and stenosis (the tube was injured and healed, sort of, with narrowing). he told me a cholecystectomy was indicated (no shit).

so i booked theater (i think in americanese that would be or). i asked my surgical colleague's wife to assist me. (remind me at some point to blog about this guy. we have an amazingly intricate relationship). usually i use very junior doctors as assistants, so it's nice to have an assistant occasionally who really knows how to assist well. i commenced with a laparoscopic cholecystectomy (in private, sid, so i couldn't employ your mini steps. still trying it in state though).

things got pretty ugly pretty quickly. everything was a mass of fibrotic tissue, hard and not allowing dissection in anatomic planes. the cystic duct, hartman's pouch and the common bile duct were all embedded in one mass of scar tissue. no wonder the gastro guy found a fibrotic stricture. surprising that's all he found. i had to convert (change from a laparoscopic procedure to an open one). even open it was a nightmate. i had to do a retrograde and ended up finding the cystic duct by opening the gallbladder (surgical gobbeldygook meaning it was bloody difficult). now the point here is the worst complication a surgeon can get is a bile duct injury. i'm working in hostile territory (we call it lion country, but i don't know what that would be in american. bear country??). i know i have a chance of causing the worst complication known to a general surgeon (except death and such) and i'm merrily operating along. my assistant and i have been exchanging good natured banter throughout. and then it happened.

my assistant randomly mentions something about the old days when her husband wrote intermediates. (we write primaries, then intermediates, then finals to become a surgeon. these are stretched over a 6 year period, post grad of course, while we work as first line surgeons in an academic hospital which is by definition a state hospital). at the mention of those exams and by definition those old days i felt my tension levels shoot up. i got such an adrenal rush i had to take a break from the operation for a moment (almost 2 seconds!!).

and then i had my usual introspective thoughts. here i am in the middle of an extremely challenging operation with the real possibility of permanently screwing up someone's life and i'm totally cool (i would say as a cucumber but what the hell does that actually mean?). then i get reminded of a time and a place i'd rather forget and i almost plutz. it was then that i realised i was no longer used to that feeling that was my constant companion for so long. even a tense operation did not compare.

how sweet. i have healed.

balance

i have often given a very critical opinion of our sangomas. to tell the truth i try not to write about them too much because if i were to write all the stories i'd probably not write too much else. but there is another side to the whole thing. so for balance, the following...

some time ago i went on a sort of tour around the lowveld to introduce myself to the doctors as a new surgeon. in one of the neighbouring little communities i met a gp. he told me a story that i actually believe. he said that a growing portion of his practice is made of hiv patients. some he keeps controlled on antiretrovirals. some present too late, basically in terminal aids. he usually tries to bustle them off to some or other hospital. (if you've been following my blog lately you'll know this is not too easy at the moment). these people, in their desparate state often ask for a drip, possibly thinking it some sort of powerful western medicine. he complies, reasoning it may not do much but a vitamine boost isn't the worst thing for them. he then told me he struggles to charge them for this. sometimes he doesn't charge. sometimes he works it out that the equipment costs about r40. he puts a small profit margin on and charges about r60. (this is probably around $5). but then he said some of his patients complained because he wasn't giving them the good drip. when he asked what they were on about he was told that other doctors in the area (medunsa graduates according to him) were charging r1000 for putting up a drip for these terminal hiv patients!

interesting. if you are charging that much you are selling the idea of a cure. even if you don't say it the fact that poor people pay that much means they believe it will cure them. the target audience is also a group that is particularly desparate for a cure. especially now that the state hospitals are basically not working. this is intensely shocking to me. they are willing to fleece poor people for their lasts cents just before they die.

now i wonder. who is worse? the sangoma who kills someone by giving him a cow horn enema that he truly believes will help or the doctor who knowingly charges more than the patient can afford for the promise of a cure he knows won't work. yes the modern sangomas are now amongst us.

steve hofmeyr

don't get me wrong!!! i don't like his music much (before my south african readers flame the crap out of me). but i can't help liking the guy on many other levels. above is a picture of him helping out in the pretoria academic hospital (where i studied and qualified both pre-grad and post-grad) during the strikes that still continue. (i gave my opinion already) international viewers, don't be alarmed by the gun toting soldiers. soldiers were brought in to help during the strikes. the ones with guns are probably to keep strikers from attacking the hospital and vandalising it or intimidating non strikers.

but the guy in the middle is an afrikaans singer. find him at steve se spoeg blok. interesting to note how wide his support is. he really is making a name for himself outside his somewhat mediocre singing.

i'm really impressed with him for his small contribution to the public health sector in helping during the strikes. i'm also impressed with him for his resistance to the government's steamrollering of the afrikaans people and culture and history. (this is something that lies close to my heart too). this is most obvious in his campaign against the name change from pretoria to tswane.

i also pretty much like the fact that we support the same rugby team. call me shallow, but hey...

amazed

i am amazed!!! someone must have made a mistake!! i have made the top 100 blogs on health and medicine! what can i say. i wonder how long it will last.

paradox

recently i heard a story that really made me laugh. about 45 minutes from nelspruit is a sponsored aids clinic. it is financed by some international group. it is manned by doctors and nurses. it also employs 'aids' (no pun intended. that's actually what they are called). the aids were all patients at one time or another. they mainly act as interpreters, but fulfill many menial tasks

anyway what happened is that a vicious rumour started up that one specific aid was not actually hiv positive. the other aids started complaining and actually wanted her fired. it caused such a rucus that the doctor working with this aid was asked to surrupticiously "please just confirm that she does have hiv".

so people discriminate. hiv positive people will even discriminate against those that don't have it. this is truly the first incident of someone almost losing their job because of not having aids.

strike

the public sector is presently engaged in industrial action. the state is offering 6% wage increase and the unions are demanding 12%. the whole thing is interesting on many levels.

firstly, having worked in the state sector recently (and still being very involved) i do feel that they are paid too little and something closer to 12% is more acceptable than 6%. but, having said this, i find it difficult to justify the nurses striking and the fact that the entire state health care has been crippled. the unions have actually said they want to close all hospitals and clinics to force the government to relent.

the question i ask is who suffers? all state employees are required to have medical aid, so all the strikers can get medical help during the strike if they need it. the people who suffer are those who don't have jobs or medical aid and rely on the state hospitals for help. the true lower class. i was at the state hospital here in nelspruit on tuesday. the normal lists were cancelled (including a mastectomy for cancer) and only emergencies were being done. wards were empty and even locked. only skeleton staff were working to handle emergencies. the strikers were toiytoiying outside the main hospital gates.

i read somewhere that 30 people have died as a result of the strike in our hospital so far. how many in the entire country?

on one of my posts a commentator spoke about dying for a cause. everyone likes to believe they are willing to die for a cause if it is good enough. but are you willing to kill for a cause. some causes maybe do need killing for. kill the enemy or kill the suppressor etc. but to cause the death of the poorest eschelons of society for 12%??? i just don't know if it's worth it.

life is cheap in africa, but it is always someone else's life that hangs in the ballance. the pawns are thrown onto the bayonettes so the kings can have a better raise in salary.

this is where i heal my hurts

in the kruger national park is a golf course. this photo was taken on that golf course. how cool is that!!!

but what i actually wanted to write about is the park. the kruger park is about as large as england, but elongated. it recently has taken down fences between it and numerous private reserves on its western border and a new game reserve in mocambique on its eastern border. the result is an enormous chunk of unspoiled african bushveld.

living only an hour's drive away as i do in nelspruit, i go there whenever i can. it is truly soul restoring. there are few things that compare to enjoying a sundowner on the banks of the letaba or olifants or even sabie river and watching the elephants come down for a drink. all the wories of life seem to melt away when you see the peace of those great beasts.

for all you non south africans reading this blog, you really need to take a moment to stop by and experience the magnificent kruger.

african down under

from the very small amanzi family i recently read a guest post on amanzi down under. i was moved. i was moved by an african post in australia written by an african in britian. and only an african would have been moved. it was about how the rest of the world sees our backward continent and how we continue to love it, maybe against all logic.

i have recently posted quite a bit about the problems which we face (here and here). i have also posted about how much i love this country and by default this continent (here and here). i also recently had a fairly good hearted arguement on another blog about the difference between our sangomas and other "enlightened" forms of alternative healings. one comment was about the fact that those other forms are 'nothing like sangomas'. i could almost hear the comentator saying 'we are western and nothing like you savage africans. i know your sangomas therefore can be nothing like the alternative healers that have my western stamp of approval'.

only an african in africa or in australia or even in britian will be able to understand why i was moved so much by the abovementioned post.

all's well in the state of denmark

yes i bitch a lot about the political state in our country, but recently i read a newspaper article about the state of public health in zimbabwe. i realise that although we are surely on the slippery slope, we have a long way to go before we reach their position.

the article spoke about the fact that doctors are now joining the ongoing strikes of other social services. apparently they are asking for 600% increase. this is not too wild bearing in mind their inflation is about 1000% per year. apparently the hospitals are so bad at the moment that they have no one to remove the bodies of the dead to the morgues so the living patients lie in between the dead. i swear i read this in a newspaper.

i spoke to a registrar surgeon from harare about a year ago. then he told me they have no anaesthetic service and therefore no operations after hours and over weekends. and that's in their capital. so possibly it is true.

so relatively speaking, all is still well in our country.