see one, do one, teach one

i was a first year registrar. the senior guy was in the month of his finals and therefore, due to a new concession from the department, he did not have to do calls (only for that one month). therefore his calls were evenly divided between the other registrars. i was the most junior. the medical officer (a year done in surgery before your training officially begins) in the firm was to handle the call. i would only be required if there were problems. i was essentially only one year her senior. i've already mentioned the fact that i was used to being thrown in the deep end, so i was ok with it.

early in the evening, she (the medical officer) phoned and told me about a blunt abdominal trauma patient. the spleen was dammaged and she was going to theater. i told her to call if there were problems. she phoned before the incision, asking me to join her. i was surprised, but i went in.

i let her open. i was going to assist. she hesitantly got into the abdomen...eventually. it was full of blood. she stood back and asked me to take over. once again i was surprised. i stepped up. the spleen was severely ruptured and oozing quite convincingly. the medical officer immediately said-
"i'm so glad you're here. i've only ever seen two splenectomies and done none." i considered telling her that i'd never in my life even seen a splenectomy, but decided she seemed to be in enough of a flat spin without that morsel of information. i had been surprised by her twice. twice was enough. i simply realised she did not have the heart of a surgeon. i couldn't blame her. it is not for everyone.

so i did the splenectomy. (when i was a medical officer in a firm without a registrar due to an overall lack of them, my consultant, in an attempt to not have to come out in the middle of the night when he was on call, had given me a quick lecture on all-you-can-expect-to-see-on-call-and-how-to-handle-it-without-calling-me. in this lecture he had dedicated about 10 minutes to how to whip out a spleen for dummies. i was a dummy so i felt fully equipped).

where was i? oh yes. so i did the splenectomy. the medical officer on a number of occasions repeated that this was above her and that she was so glad i was there. she spurred me on to get that spleen out in double quick time. after all i wasn't sure i could endure her thanking me one more time.

the spleen removed and the patient saved, i left. i figured she could close. (i'll save dehiscence for another day)

so they say see one, do one, teach one, but i sometimes look back and wonder if they really intended you to do all of that in the same procedure.


p.s that medical officer didn't go on with surgery after her medical officer year. she went into obs and gynae where the pressure was somewhat less.

sudwala

for those that actually frequent my blog, you will know that i occasionally wax lyrical about the beautiful lowveld where i live. if you want medical, turn back now.

recently i went to the sudwala caves. what an amazingly beautiful place. the above photo was taken in those caves. it shows a stalagtite, stalagmite, flow combination. but there is so much more there. there is even an amphitheater (nothing like an operating theater) where they even occasionally have music performances and the like.

anyway, for those of you planning to visit south africa, once again, do not overlook the lowveld. and if you find yourself in the lowveld, stop by at the caves. it is worth your while.

michaelangelo

apparently michaelangelo sculptured like no other. he would not first get a rough shape, but would immediately work down to the final product. the result, a perfect form partially liberated from a block of stone. when asked how he did it, he apparently said he just chissels away whatever doesn't look like the final product he sees in his head. i imagine chipping a human out of the stone in which he is trapped. the chances of injury to the human must be high. sid has often spoken about tissue plains, but there is another side to it.

she was overweight. she had apparently had a previous nissen repair, which had turned ugly and ended in an open splenectomy. thereafter, by her account, she had had a laparotomy for bowel obstruction (must have been a vicious splenectomy?). then someone had been thoughtful enough to repair her ensuing incisional hernia with a dual mesh (gortex apparently). on gastroscopy i could see no evidence of a nissen. what i could see was a very large hernia. it looked like half her stomach was an illegal alien in the chest. i bet the heart was pretty pissed off, not to mention the lungs. the lungs were even more annoyed about the nightly visitations of gastric juice in their bronchi.

i did what any self respecting surgeon would do in my situation. i referred her to the guru in pretoria who taught me laparoscopic surgery (prof heine van der walt). for whatever reason the patient couldn't go there. damn, turf and bounce. i was stuck.

i then did the next best thing. i phoned the prof and asked what i should do. on his advice, i put my head down and went for it...open.

frozen abdomen. there are no tissue plains. on the contrary, you find yourself trying to chip someone out of a block of stone. if you actually find human tissue, you've probably injured it already. and yet that is exactly what you must do. separate everything. find the anatomy and repair what needs to be repaired. as i suspected, there had been no actual previous nissen repair, but one stitch had been inserted into the crus anterior of the esophagus-stomach complex. so i soldiered on. and finally, after a good few hours i had everything as it more or less should have been. i did the repair and ran for the hills (closed).

sometimes in the life of a surgeon you can't help wondering if it's worth it. when you get bogged down and your next move might be the patient's last and there is an irritating voice in your head screaming "first do no harm", at times like this it may not seem worthwhile. but in all honesty, once you get yourself and the patient through, there are few feelings as exhilarating as it. one more accomplishment to feed the already inflated surgeon's ego.

in the deep end

when i started surgery it was just after the government's unfreezing of training posts. (they put a hold on things they thought weren't so important, like training surgeons). the result was there weren't too many senior guys. i was thrown in at the deep end. i have already sort of discussed this in m&m earlier this year. but suffice to say i got used to going for it and hoping for the best. when there is no backup, then you are the best chance the patient has. no use whining. get on with the job. i also tended to throw my juniors in the deep end. the one difference is i was always available to bail them out.

i had been consulted by the physicians to do a lymph node biopsy. one of my students, who showed incredible surgical acumen, came with me. i held his hand through the procedure. it was straight forward and all went well. at this point let me mention that it is pretty unusual for students to do these types of procedures. in fact, this particular student was the only one in all my years of training that did an appendisectomy, with my assistance of course.

about a week later, again i get consulted to take out a lymph node. i tell the same student to do it and sommer (afrikaans word not easily translated here) teach his colleague how to do it. i say i'll be in the tea room, so they can call. off they go. my plan was to give them time to get into it and check up on them anyway. thus they would be able to feel a certain amount of confidence but i would still make sure everything worked out.

about half an hour later, the phone rings. someone answers and says it's for me. without answering the phone i jump up and start running for the ward where they are working, as i charge up the stairs, a colleague and i almost collide, he stops me.
"do you know your students are taking out a lymph node up there?"
"yes." i reply, "i told them to!" i was trying to sound in charge, but wondering if all hell had already broken loose. i would be the one to take final responsibility. a strolled on until my colleague was out of sight. then i bolted again.

i came into the ward. there were two students, both white as sheets. there was a modest puddle of blood on the bed. bearing in mind how pale the students were i wondered if it was their blood and not the patients. the one was picking away at a very superficial cut in the neck. i asked the one i'd taught the previous week how things were going. his face was a picture of terror. his eyes were pleeding for me to bail him out, yet in a clear steady voice (remembering the patient was awake) he calmly said,
"we're struggeling a bit. i wonder if you could maybe help?" i wanted to laugh.
"sure!" i replied. " slightly more difficult than the previous one?"
"decidedly!!" was his response. yet his eyes and his body language made me realise that that was the mother of all euphamisms. then i nearly did laugh.

i realised what had happened. they had been going at it to the best of their ability. my colleague had walked in. he is the prototypical surgeon. thus and therefore he had let them have it, cutting into them with his sharp tongue. the one i had taught the previous week admirably stood his ground, using my name in his defence. my colleague had come rushing down to confront me. this exchange more than surgical trouble had made them phone for backup. the confidence that i was trying to instill in the student that he could handle any situation had been shot to blazes by my bombastic colleague.

still, it made for a pretty good laugh.

i understand the student in question went into anaesthetics.

madiba

i have heroes. the man above, affectionately referred to as madiba by south africans, is one. this is just a short blog to say happy birthday madiba!! may the day only hold special things for you!!

time to leave?

recently i posted on the effect some stories of violence had on me. but recently i heard another story that once again made me think.

the doctor who starred in my post bringing balance to the force was the main character. as it turns out, he was on his way home after what i assume was a busy day at work. he got hijacked. common in south africa and very often fatal. the two hijackers, apparently both about 18 years of age, made him drive to his house. there they stole what they could. thereafter they forced the doctor back into his car (as if they hadn't done enough damage) and drove off to some deserted area.
the hijackers then tried to suffocate the doctor using a piece of an inner tube of a tyre. he fought back. can you imagine the scene? a 60 year old man fighting for his life against two strong young boys almost in their prime? he must have done well for himself because they had to try three times. on the third attempt, the doctor realised he wasn't getting out of this easily. fighting hadn't worked. so he went for plan b. he held his breath, struggled a bit and then went limp.
they left him for dead. he was not and that's how i know his story.

amazingly enough, the man is still positive about staying in this country we both love so much. i am starting to wonder.

there were a few things about this incident that worried me. in sangoma, one of my commenters was so keen on knowing the racial breakdown of the players. that made me think she had once been south african, but was no longer. maybe i was wrong. but south africans that watched the trc when it happened would, like me, have been horrified to hear that one of the methods emplyed by the apartheid regime to torture and kill their opponents was to suffocate them with the inner tube of a tyre. for that commenter, i mention that the doctor was white and the perpetrators were black. yet they were too young to have known first hand anything about apartheid and such. they just heard the stories. a coincidence that they employed this method to try to dispose of their victim when a bullet to the brain would have been faster and more certain? somehow i think not. there was at least an element of racial selection in their crime. they wanted to be able to say they had killed a whitey (not that there are so many left, relatively speaking, in the country). they can no longer claim their crimes were motivated by some political ideology or fight for freedom. but in their minds it is about us vs them. it's black and white. no shades of grey here.

anyway it seems to me we have gone through so much to revert back to our racist ways like these two youths did. south african violence is maybe too much now. yes, maybe it is time to leave.

tough surgeon

in the line of the previous post, there was another story that i thought quite funny at the time, illustrating us macho surgeons.

sigmoid volvulus. a wonderful condition which is very common in africa. not the type the textbooks talk about found in institutionalised old folk, but the type found in young black adult males. prevalence highest in uganda, decreasing as one moves south, but still pretty common in south africa. so in my registrarship, i became quite good at detorting the volvulus which is the emergency treatment in casualties. if this doesn't work or on sigmoidoscopy (siggy as we called it) if you see any questionable bowel, immediate laparotomy is performed.

anyway the patient came in and had a clear sigmoid volvulus on examination and x-rays. i got the siggy ready to detort and place a flatus tube. now, for the lay person, in this area of blocked colon, the feces has been rotting. yes rotten feces, the only thing to top regular or garden variety feces. the feces is also under extreme pressure, so as you insert the siggy, it deflates with vigor (explosively). many of my friends got showered with this rotten projectile fecal matter and often in their face when they detorted sigmoid volvulus on more than one occasion. i had evolved a way of doing it that decreased my chances of being the proverbial fan that was just about to get hit. yes, i think i was pretty good at it. in fact the picture above is me with my trusty siggy ready to detort a volvulus.

so, getting back to the story; i called the students to see the procedure, because this could be their only chance to see it. i set everything up and started the siggy, with an enterage of students, a house doctor and a rotating medical officer standing to observe. i got to the twist, observed to make sure there was no necrosis and started gently inserting the flatus tube. it slipped easily in. and as usual there was a sudden and massive release through the tube of rotten feces and particularly rancid flatus. i stood there trying to control my gag reflex. it would be considered an acute loss of cool if the tough surgeon was seen to be gaging at anything by his awe struck juniors (tongue in cheek for those who wonder). i just couldn't. i gagged over and over again. now i was struggeling to prevent myself from vomiting. despite this, my prominent thought was that the students would think i was a wimp.

then i looked up. every last one of them had bolted. not one had mannaged to overcome the stench to stay and watch. i laughed. all my ego driven worries about what they would think of me were in vain. obviously if a surgeon nearly gagged then mere mortals (tongue in cheek, flamers) like medical students and doctors would obviously not be able to be in the near vicinity of such a thing.

the patient did well, got his elective colectomy the next week and went on his merry way.

fettuchini

surgeons are supposed to be tough. surgeons have seen some pretty wierd stuff, but occasionally you see something that really churns the stomach.

the patient came in after being involved in a car accident. he had an acute abdomen, but was otherwise stable. x-rays confirmed free air in the abdomen. easy call. the patient went to theater.

we opened the abdomen. it was full of intestinal content. not too surprising. and then...lying in this soup, free in the abdomen we found a meter long tape worm! i'm not embarrased to say i gagged. i threw it in a kidney dish where it entertained us with its peristaltic movements.

i found the perforation. it was mid small bowel. in the lumen i saw two more strands of fettuchini. i removed them. each was also about a meter long. (note at this point that in no way do i advocate surgery as treatment for tapeworm. i mean poor surgeons! that's just gross). soon all three worms were in the kidney dish writhing around merrily. they pretty much filled the entire dish.

the rest was easy. repaire, rinse, close up and go home.

but i have not felt comfortable about eating fettuchini since then.

madness

so here i am, innocently watching the news. there is a story about a guy who gets sentenced to twelve consecutive life sentences for raping some young girls with the clear knowledge that he is hiv positive. at the end of the story they mention, almost in passing that the girls were all virgins.

now why do i blog this? the news did not talk about the point of the story because it is not pc in the present day south africa. the news writer probably wrote it but it was edited out by the power seekers. the writer did manage to leave one line in that gets to the point. the girls were all virgins.

the point that those in this line of work in our country will immediately click onto is that our great and wonderful sangomas some time ago propogated sex with a virgin as a cure to hiv. i kid you not. the reasoning is something along the lines that you get the virus from sleeping with a not-so-pure woman. therefore you can get rid of the virus by sleeping with a pure girl.

so this man is an example, hopefully, that the modern south africa will no longer endure this. i doubt it though due to the importance the community attaches to these wonderful healers otherwise known as sangomas.

a few questions. what are twelve life sentences? how do you serve that? which girls will not truly get justice? and they conveniently don't mention how many of his victims ended up hiv positive. besides will anyone ever know how many virgin girls he actually raped. (it's interesting to mention that quite recently parents encouraged their children to hide their virgin status because of this belief)

but i wonder who is the real culprit here and who is the scape goat, especially bearing in mind that our ministry of health has put more emphasis on integration of so called traditional medicine to counteract aids than antiretrovirals. not that i would bat an eyelid at the extermination of this particular scape goat.