any time (so don't get caught out)

the usual story. gunshot abdomen. his father apparently took one in the chest and had already been whisked off to theater, bled out and not doing too well. my guy, however was stable.

on examination, the bullet had passed very laterally through his abdomen on the right hand side just below the ribs. in fact it was so lateral that i wondered if it had in fact even entered the abdomen at all. the left side of his abdomen was soft and seemed unaffected. however the right iliac fossa region was exquisitely tender, suitably far from the tractus of the bullet to convince me there was something amiss inside.

so off to theater for a routine exploration of a common or garden gunshot abdomen.

i opened in the midline. is there any other way with a gunshot wound?
what i found inside was surprising to say the least and downright confusing to be more specific. lateral to the peritoneum there was extraperitoneal bruising, but no penetration of the actual peritoneal cavity. to be very sure i mobilized the colon and confirmed an uninjured retroperitoneal ascending colon. but what i did find was a severely inflamed appendix!?!?!

what the hell!!! i thought. but of course all i said was "hmmm?" and whipped it out in double quick time. (it's quite easy when the abdomen is splayed open like the pages of an old book)

obviously i started trying to explain this to myself. had the appendix been just next to where the bullet passed the peritoneal cavity and had been injured by the shock wave? but then why was the rest of the bowel totally normal? and why was the inflammation so well established? i mean it wasn't as if i had tarried for a week or so in getting him to theater.
in the end all i could do was close and move on.

post operatively the patient recovered very well. the next day i struck up a conversation.
"was there anything wrong with your abdomen before the incident?"
"well now that you mention it doc, there had been this constant pain here on my right" indicating mcburney's point, "but it seems to be gone now. i even got some antibiotics from the chemist two days before the gunshot incident, but they didn't seem to help"

the guy had appendicitis at the time he got shot!!! so don't get caught out! appendicitis can in fact happen to anyone at any time! who would have thunk? looking back now, i wonder if i could have approached the history in any other way. can you imagine the strange looks i would get if i asked my gunshot abdomen patients from now on:-
"and when exactly did this pain start?"

tag?

i see little karen has tagged me. in fact tagging seems to be reaching epidemic proportions. i have decided to only partly play along. i will state 8 random facts, but i don't intend to tag anyone else sorry little.

8 random facts:-

1) i used to do bee keeping and removal. in fact while studying surgery i augmented my income by removing bee hives. good business with the prolific african bee (known in america as the killer bee)

2) i almost didn't study medicine because i considered the course too long. funny in retrospect seeing that i went on to study surgery, more than doubling the time i took to fully qualify.

3)i'm interested in south african history, especially the history of individual groups. the boer war is of particular interest to me, although i haven't read too much in the last many years.

4)other jobs i did pregrad to make money include waitering, working for a short time in a petrol station and working in a pathology lab where i drew blood.

5)just like Someone Interested in Medical Student and Resident Education, i am interested in medical student and registrar education. however, for all sorts of reasons, those things are on a backburner. hopefully a time will still come.

6)i still get a rush out of operating. it strikes me as a totally abnormal thing to do. cut another human being open. and to be allowed to do it. freaky.

7)i still ask all gunshot victims what happened although experience has taught me the answer is usually (not always) a lie.

8) i'm tired and going to bed now.

harvest

organ transplant is a noble and wonderful endeavour. however before the transplant comes the harvest.

one experience that will stick with me for many a year (ever), which scored very high on my weird sh!tometer, happened when i was a very junior registrar.
she was about 16 years old. except for the massive head trauma there was nothing wrong with her. in fact when i became involved, the neurosergeons had already declared her brain dead. the transplant coordinators had done the ground work with her parents, getting consent to harvest the organs. (i never envied their job. can you imagine having to get consent as fast as possible when the people you need consent from have just had their world turned upside down? sort of 'sorry about your loss but can we have her kidneys?') all we had to do was operate to get the kidneys. we had to time it in conjunction with the heart transplant team which was flying up from cape town (the only place where the state still does heart transplants. why, you ask? i don't know).

as soon as we heard they had landed we started the operation. we got the kidneys as close as we could to out without compromising the heart. instead of waiting, we opened the chest so the thorax team would have less to do when they arrived. then we waited.

the thorax surgeon finally arrived. he walked in, glanced into the open thorax, glibly said in an almost inaudible voice, "too small." and walked out. we were left wondering if we had heard right. he had just flown 1500km (a whole bunch of miles) only to turn around and fly back with nothing. i couldn't help thinking he could at least have said hello to us. but i think that may have been beneath him. (looking back it seems a strange thought to have)

the surgeon then quickly carried out the final steps to remove the kidneys.

meanwhile, the transplant coordinator immediately told us to take the heart anyway because the valves could be harvested even if the heart itself was too small. my senior volunteered me. i was young and keen. she assured me it was easy. just cut the large vessels off as far away from the heart as possible so as not to dammage the valves. sounded easy enough.

the surgeon left. the anaesthetic machine was turned off, creating an eerie quiet instead of the reassuring beeping noise of the monitors. i could still see the heart beating though. it seemed wrong to cut it out, but i grabbed the scissors and went to work.

moments later, the heart was loose. it's not too difficult to remove a heart when the outcome is predetermined. i lifted it out. then the weird set in. the heart was young and strong. while i held it in my hand it was still beating. two things went through my head simultaneously. the first was a flashback to the movie raiders of the lost ark when the priest ripps the heart out of his victim for him to see just before he dies.

the second was much more intense. there i stood with a human heart, still beating in my hand. yes my head knew she was brain dead and had been so for some time. but somehow my emotions (i was going to say heart, but...) didn't seem to be agreeing with my head. i felt awful. up until then it had all been business. get the organs and get a good night's sleep. somehow after standing with that girl's heart beating in my hand i felt for her. i felt for her parents. i felt the tragedy of the whole situation. i was touched.

i passed the heart to the transplant coordinator. she left. i was now alone with the shell of the dead girl in theater. my job was to close what we had opened. but because she was dead, there was no anaesthetist and no sister. just me and my thoughts of intimacy with this poor girl who i did not know. i cried as i placed the stitches.

i did not get that good night's sleep.

surgexperiences 104

when i was a registrar a friend of mine told me he had been offered a job in a surgical practise in pietermaritzburg (hi henry). i said i couldn't imagine surgeons (general) working together. we are all too aggressive and individualistic. we are all too type a. he went there and proved me wrong. now i work in an association with two other surgeons and i prove myself wrong on a daily basis.

when first i saw surgexperiences, once again i had the thought that we surgeons couldn't pull something like this off. team work is not our forte. happily, it seems that i was wrong again. i hope that all readers of surgexperiences will continue to prove me wrong and make this a regular must stop for all surgeons and other interested bloggers.

the contenders:-

respectful insolence writes a neat post about how to royally irritate a surgeon.
why you should read it?
well for a surgeon this may not be news, but it does clear up a few misconceptions that are prevalent in the general population.


rlbates writes a story about a friend who gets shot.
why you should read it?
i had a bit of a chuckle when i read this. i maintain that when a surgeon says you are lucky, you're not really lucky. it would have been luckier not to have been shot in the first place. but a few interesting pictures and some good advice. well posted rl.


chris writes an interesting piece about operating on a newborn.
why should you read it?
well it is an interesting blog about a surgeon going to iraq. but, the post for me touched very nicely on some of the reasons and rewards for doing what we do. in the end, it is a priveledge.


dr campbell very skillfully gives a story of insomnia.
why should you read it?
it is a very well written post to start with. but mostly because it is very funny. it illustrates how patients sometimes cross a line and have no idea.


college and finance puts a spotlight on nursing.
why should you read it?
some of the medblog addicts are still students contemplating careers. if this is you and nursing is in your list of options, take a look.


make mine trauma posted a nice piece on colectomy.
why should you read it?
firstly i think this is a pretty cool blog to start with. but this post specifically nicely captures the magic of actually operating. mmt, i know how you feel. in fact it was similar feelings i had while assisting that pointed me down the career path i finally chose. the title picture comes from her blog. even the picture testifies to her excitement and enthusiasm about surgery. (iassume you took this photo yourself?)



aggravated docsurg writes a humorous post on the relationship between gerds treatment and sexual behaviour disorders.
why should you read it?
are you kidding me?? if you are not inquisitive about that title, then nothing i say will convince you to read it. if i love doing laparoscopic nissens, i wonder what can be deduced about my sexual behaviour disorders.


just up the dose once again entertains with a story about a drama queen.
why should you read it?
little karen writes as well as we all wish we could. her blog is definitely one i always enjoy. this post has our usual african flavour that we no doubt are used to but may be unusual to others. it also touches on our unique style of training, ie. throw the junior in the deep end and leave him to sink or swim.


mitch writes a riveting account of circ arrest cases from the head of the table.
why should you read it?
it gives another perspective, that of the anaesthetist, during these trickey cases. without these great people our jobs would be impossible.


sid never fails to amaze and entertain. here he is again with a story about dentures (or chickens)
why should you read it?
firstly, if you're not reading the master blogger's blog yet, where have you been? secondly, we all enjoy a good well told story of the unusual.


buckeye gives us some nice hernia photos and sparks a small debate.
why should you read it?
i think buckeye is a good regular port of call, especially when he discusses a case.


someonetc is a good place to visit for people interested in orthopedics.
why should you read it?
the guy loves rugby! that is reason enough! someone, i hope you watched the south africa, england game.


thanks to surgexperiences maintained by jeffrey at monash medical student and surgexperiences for allowing me to host this carnival. may it grow from strength to strength. please support his worthwhile endeavour.



next edition of surgexperience:-
Surgexperiences 105
To be hosted at: Suture for a Living, http://rlbatesmd.blogspot.com/
Date: 30 September 2007
2wks away.

boerhaave

i had just started my mo year in surgery. i was going to save lives. i was going to make a difference. nothing could disillusion me.

it was my second day and first call. it was surprisingly quiet, probably because the entire population of pretoria was at the coast for the december holiday. then the thorax guys called us to see a patient. i followed my senior, knowing i would be of little help in any situation at this junction in my career. (i had just come out of the bush where i did my internship and community service years. in fact, i had only recently begun to walk on my hind legs and was just mastering rudimentary tools)

the guy was admitted just after christmas (about 6 days previously) with severe chest pain and a left sided 'pleural effusion'. they had placed an intercostal drain and drained a bubbly type of foul smelling liquid. and thus he had remained for almost a week. the only change was that the drainage became much more offensive.

my senior asked him about christmas. how much he had eaten and how drunk he had gotten. had he vomited etc. the patient, although in severe pain, answered that it had been a party to remember. he could remember very little of it. he had vomited copious amounts though and that's when the pain started.

the patient looked up at my senior and said,
'please help me doctor. i can't take much more of this'
'don't worry, we'll help you. you're going to be just fine.' and with that, we turned and left. this is what i signed up for. we were going to get this guy through whatever was wrong. i was, indirectly going to make a difference. i felt excited.
'that guy is dead!' says my senior as we walk away. i was floored. hadn't he just moments ago told the patient he was going to be ok and given a creepy smile of reassurance? hadn't he held the guy's hand and given a squeeze when the patient said 'thank you doctor, thank you so much'?

we got him to theater. the consultant came out. we opened the chest and found that the esophagus as well as the surrounding tissue was necrotic. it had the dirty dishwater appearance that i would later associate with necrotising faciitis. we debrided, but it is a difficult place to debride. you don't want to debride the heart, for instance. it could cause an unpleasant bleed. i was too junior and too far down the table to really follow the finer details of the operation, but we did deliver him, sort of alive, to icu. they pumped precious money and resources into him for a further two days before the inevitable.

he had boerhaave syndrome, a tearing of the esophagus, usually into the left hemithorax, associated with overeating and drinking which in turn causes discoordinated vomiting and voila! if you diagnose it immediately and operate, they have a chance (fair to good). if you give the sepsis time to set in, causing a mediastinitis, the chances drop. if necrosis of the mediastinum has been allowed to develop, no chance at all.

i was totally dissillusioned. my first call and i stood there innocently believeing in our noble profession while my senior lied to someone. ok, the guy maybe felt better emotionally in the last moments of his life, but i could not justify lying to the guy. i also realised there are some fights you just can't win.

crouch, touch, hold, engage

for those of you who don't know, the rugby world cup has just started. i just watched the first game between argentina and france (the host nation). against expectations, the argentinians won. i support neither team, but it was one of the best games i've ever seen. spectacular to say the least.

our team, the springbokke have a very real chance of taking the cup this year. so all the readers of this blog, unless your team is playing, i expect you to support the bokke.

the picture above is of os du rand. he played in the 1995 squad that won the world cup and amazingly enough is in the 2007 squad that is just about to win the world cup.

carnival time

i have been invited by jeffrey from monash medical student to present the next edition of surgexperiences. it is a new carnival focussing slightly more on surgical blogs. it is very new, so i'm making a request that as many of you as possible support it, especially friends (i hope) like buckeye, sid, makeminetrauma, rlbates, someonetc, etc. let's see how it develops over time.

you can send your submissions to here or email me directly at amanzi dot com (that would be bongi at etc)

it will be published on 16 september. please have all submissions in by 14 september.

thanking you in advance.

ascaris

i know why i'm not a microbiologist. in one word, worms.

i was doing a gastroscopy. the patient had a previous gastroenterostomy (small bowel attached to the stomach) somewhere else for unknown reason. the result was, over and above the pyloris (the normal stomach outlet) which was normal, he had another stoma which had an afferent loop and an efferent loop of small bowel. i took a look at all three pipes leaving the stomach, intubating them one at a time.

in the efferent loop is where i saw them!! ascaris!! (see above picture to fully appreciate this little critter). they seemed pissed off that the patient was npo because they were writhing around and moving like mad. even worms get hungry. obviously every one gathered around to take a look. i think it has to do with the fascination of all that is gross.

i just wanted to run. i think i now understand that some people have a rather robust vaso vagal reaction to blood etc, because the same happens with me when confronted with worms.

one of the sisters suggested i take a biopsy. why i wondered. it's not as if i have any doubt as to what it is i'm looking at. anyway, can you imagine how the thing will go crazy if i start taking bites out of it. biopsy is just out of the question here.

i woke him up, gave him deworming treatment and sent him on his merry way.

too good to be true

just a quick update.

if something sounds too good to be true, it probably is. the possibility of the downfall of manto therefore won't happen. interestingly the anc has now claimed they were always aware of her conviction of theft. maybe they viewed that as an attribute that perfectly qualifies her for a top position.

seems she got her liver transplant legitimately (hmmm?). she has at no stage questioned allegations of alcoholism, so i think we can assume that the reason for the liver failure is self evident.

thabo mbeki, the president has publically praised the minister as a hero of the people (the hiv negative ones maybe) and stated that she is doing a great job.

meanwhile some guy writes a book about what a great leader thabo mbeki is. he then goes on to say that all people who have been advocating antiretroviral drugs as treatment for hiv owe the afforementioned 'great leader' an apology. this has to do with the fact that antiretrovirals have more side effects than garlic and beetroot (which is what thabo and manto propose as first line treatment of hiv)

so, in summary, our convicted thief health minister who denies the use of antiretrovirals as important in the fight against aids is not only still in control but fully backed by the government of the day, the anc.