keyhole on our world

medblog addict, in the opening of her blog says, and i quote, "It is as though someone has drilled peep holes into the walls of emergency rooms, operating rooms and doctors' offices. I can't look away." it is like er or gray's anatomy or dr house or (insert name of some medical drama here). to be honest one of the reasons i blog is because our world is so far removed from what is perceived as normality that just to talk about things that happen on a day to day basis makes for quite good entertainment.

but i know there are dangers. there has been talk of flea and butterfly and there are probably others who have fallen from the blogosphere. we as blogging doctors need to be careful. one aspect of this is to always ensure anonymity of our patients and other involved parties. hence dr rob started the ethical blogger initiative, which i think is brilliant.

but i think there is another slant to the whole thing. medblog addict sums it up when she concludes, "i can't look away". i think there is at least some onus upon the reader.

there is a paradox here. they read the blogs exactly because it is a window on a totally bizarre world, but this bizarre world may occasionally offend. the reader has to accept this.
i remember when i was in second year doing anatomy and dissecting cadavers. one of the groups named their cadaver stiffany (she was stiff). this is a type of black humour common to medical students and doctors, yet it probably seems sick or even inappropriate to the non medical blog reader. the question then is, how honest must we be as medical bloggers? too honest and we offend. not honest enough and it is not a true medical blog.

this point came home to me with two parallel events. the first was a rather harsh criticism of a comment on one of my posts, implying that a certain doctor was callous. i doubt he was. he saw the typical black humour of yet another bizarre occurrence that was described. typical medical reaction really. the other was a most entertaining and humorous post by mdod called musants. i really enjoyed it. i had a good laugh. then i thought about being one of those possible patients reading the blog. there will be a certain amount of offence taken every now and again at some of the things doctors say.

but that is why i'm making a call for understanding from both sides. doctors will have to be careful and moderate in what they blog. dr rob has taken great steps to ensure this. but medblog addicts must also understand that to have a keyhole on our world is in fact a keyhole on our world.

i invite comments.

anesthetics

without anesthetists, we couldn't do our work. but sometimes the relationship between surgeon and anesthetist may be quite odd.

having worked for some time in government hospitals where the anesthetic is seldom, if ever, given by a consultant i was not entirely used to the privilege of consultant anesthetists doping for me. in private it is always a consultant. this obviously means there is a difference in quality of anesthetics.
probably the least important of these differences has to do with changeover time between cases. but, having said that, anyone who has worked as a surgeon for the state in this country most appreciates this difference. in the state changeover time can easily be up to one hour. it is not unusual to only do three cases on a list because of this. in the typical efficiency of the state, the rest of the list is then canceled, leaving the surgeon to 'please explain' to his patients why their operations are being postponed. in private, the list can't be canceled, so it is in everyone's interest to get the one patient off the bed and the next one on as fast as possible.

with this as a backdrop, a good private anesthetist can time his doping to coincide exactly with the end of an operation. as you down tools, the patient wakes up. i think it is quite an art. in the state, when you down tools, you wait with a mixture of boredom and irritation for the patient to slowly come around before he can be bustled off to recovery.

once there was an exception to this fairly general rule. i was a house doctor, the most junior of all doctors. i was working in a fairly remote part of the country. there, the caesarian sections were done by the most junior doctors (me mainly).
so i'm cutting another baby out of one more of the continuous string of pregnant women. the anesthetist is a medical officer from pakistan. finally i get the baby out and start closing. the anesthetist was trying to perfect the art of waking the patient up as the operation ended, but hadn't quite perfected it yet.
half way through closing the skin, the patient starts moving. i mention to the gas guy that the patient is moving. he tells me he knows, but he does nothing. being very junior and not exactly full of confidence, i keep quiet. i think i sort of assumed he knew what he was doing.

as i placed the next stitch, the patient almost sat up and tried to grab my hand. i stopped dead in my tracks and once again brought the patient's near fully awake state to his attention. i expected him to crank up the gas or to inject the patient with something or both. he did neither.
instead he moved casually towards the patient's feet. i waited to see what he was going to do. maybe he is going to get some drug from somewhere, i thought. how wrong i was.
suddenly he grabbed the patient's legs and held her down. 'quickly finish!' he yelled at me. i was shocked. i swear the blood drained out of my head (not quite like later in my career, though). i didn't quite know what to do. it was a very surreal moment for me. being very junior (or did i already mention that) i listened to him. with shaking hands i placed the last stitches. (the memory has been somewhat blocked out because of the trauma of the whole event but i suspect the patient actually helped me to cut the last suture she was so awake).

so these days, when i'm working in private i take time to appreciate the speed with which the consultant anesthetist wakes the patient up after the procedure and when i'm working in the state i am only too grateful when the medical officer struggles to wake the patient up long after i've finished.

rugby world cup victors

no, this is not the president slipping the captain some garlic and beetroot before the game. this is a congratulatory hug from our president bestowed on the captain of the winning team of the 2007 rugby world cup.

yes, we are the champions!!

spoonerism

i took this photo off the net, but i once saw an identical x-ray.

it was in kalafong. the guy had the usual story of some amazingly ridiculous way he got the spoon into his rectum. it was something to do with painting his house and falling off the ladder and landing on the spoon. i did not ask why he was painting naked and i did not ask how the spoon happened to be standing on end (the narrow end) ready for the falling receptive anus. i just smiled and waved (apologies madagaskar) .

not too much to the story. i put in a proctoscope and grasped the spoon with a burkit. this i did in casualties. i only hope the patient cleaned the spoon well afterwards (depending on what he planned on doing with it of course).

when the case was presented to the prof, with a straight face he says, 'wat het jy vir hom gese? moenie roer nie, ek is nou daar.'

p.s, trust me, if you know afrikaans, this was seriously funny. to my international viewers, no translation can do it justice.

swoon

sometimes students faint. sometimes doctors faint. but surgeons??? never...

there was a funny story that happened in our university many years ago. apparently even true.

our university, according to the head of the department of surgery, is the only university in the world where the final year registrar actually has to perform an operation as part of his final exam. (when i told this to my cuban friends, they informed me that they also operate as part of their exam, so this interesting fact is no fact at all.) among the junior registrars in the department it is considered a great honour to be asked to assist in this auspicious operation.

in this particular case, the candidate had to do a thyroidectomy. he elected to use two assistants. if you can, why not. he asked two of the medical officers in the department to assist him, something that was almost unheard of. i can imagine that many registrars felt snubbed. but in all fairness, both medical officers were pretty serious about continuing their surgical training and were both apparently capable assistants.

the great and nerve racking day finally arrived. the candidate and one assistant started the operation. the second was a bit late. apparently he became engaged in the wards and couldn't free himself until the operation was in full swing. but he finally joined, somewhat out of breath, but otherwise, it seemed, none the worse for wear.

then the professors entered. to fully appreciate the tension of the situation, imagine, over the normal stress of a thyroidectomy for a registrar, adding the presence of three professors and a senior consultant, watching his every move and being more than slightly liberal with their criticism. in the theater was the head of department, the previous head of department (semi retired), the preprevious (is that a word?) head of department (an old style surgeon who was as old as the hills and, it was rumoured that you actually had to cut off his head before he would die. i think a stake through the heart might have sufficed) and the most senior consultant in the department. the mood was grave. the only talking at all was when the registrar fielded the array of difficult questions about the procedure he was doing and constantly had to defend every decision he made as well as every stroke of his blade.

and thus the operation progressed, probably a lot slower than it would have had he been alone. around this time, so the story goes, one of the assistants became progressively more pale. finally his face was chalky gray and a cold sweat had broken out on his forehead. some versions say he then promptly passed out. others have him excusing himself from the operation and quietly collapsing in the corner of theater. whichever you believe, imagine the medical officer, with a serious ambition of one day becoming a surgeon, lying crumpled up in the corner with the entire hierarchy of the department looking down (in more ways than one) on him. some would call this a career limiting move.

anyway the operation then progressed, with only one assistant, to a satisfactory end. the professors apparently hounded the candidate somewhat less. they had the collapsed assistant to pester and therefore their attentions were divided.

post script, after this somewhat embarrassing episode, i never fainted in theater again.

bring it home, boys!!

many years ago in the english town of rugby, a boy called william webb ellis while playing soccer, picked up the ball and ran. and thus rugby was born.

above is the william webb ellis trophy. the trophy given to the winner of the world cup. south africa has just convincingly beaten argentina (in a very unconvincing performance) to qualify to play the final against england (who we beat previously in this competition, but in all fairness, they are playing much better at the moment).

so next week, the final and the trophy comes back to us once more.

bring it home, boys!!!

dangers

something happened a while ago that gave me quite a stir, on more than one level.

being the only private hospital servicing the southern part of the kruger park, we quite often see tourists at our facility.
i get a call from a gp who is in practice just next to the park. 'appendicitis' he says. 'send' i reply.

she arrives in casualties, significant other in tow. i ask the usual questions about pain, nausea, appetite etc. sounds convincing. i ask the significant other if he would mind waiting outside while i examine the patient. he asks why. i explain that it is better that he not be there during the examination. he leaves.

examination is typical of appendicitis. i decide, due to the pretty clear cut history and clinical to omit a pr and pv. (don't tell the prof. he'll do his nut) to be honest i also had a feeling the significant other was going to be problematic and i felt a voice warning me or some such thing.

thereafter, to theater and appendix out (i was going to say chop chop, but...). then i handed the patient over to my colleague and went to the kruger park for my weekend off.

in the park in one of the camps, who should i run into? mr significant other (he continued his holiday rather than stay by the patient's side during her hospitalization). he confronted me. he asked why i had asked him to go out. i was thinking that i should say that i suspected she was abused and i wanted to talk to her in private, but of course i just explained that that is standard practice. and then it happened. he said,' listen doc, in this day and age if you examine a patient without a witness, there could easily be a case of rape made against you.' he threatened me. he basically accused me of raping her. i turned and walked away.

a few thoughts. firstly the patient and the patient alone is my responsibility. yes, i try to involve the family as much as possible, but in the end my contract is with the patient.
secondly, what sort of person continues his aggression after the person he is ostensibly fighting for has been helped.
but lastly, this sort of thing may make a doctor think twice before completing a full physical examination. i already felt i was taking a chance by omitting the pr and pv, which should actually be a part of all appendicitis examinations.

i quietly wished thrombosed hemorrhoids on him and felt somewhat better.

fashion statements

sometimes we as surgeons are restricted by the most mundane of things. back in my kalafong days, more often than my first world visitors could imagine, entire theater lists would get canceled because of lack of theater attire (scrubs). this gave rise to a funny story and, indirectly to a more recent and somewhat more serious story.

story one.
i arrived in theater one morning in kalafong, ready and eager to operate. there were no theater pants, only tops. i quickly found out there were none available and the matron was on the verge of canceling my list. i checked my gas monkey (anaesthetist). he got one of the last pairs and was dressed for action. the sister was also appropriately attired. it was just me that couldn't enter the theater complex.

not to be blocked by such a minor thing, which was anyway an administrative error and therefore, i reasoned, should not disrupt theater lists, i made a plan. i took a sterile drape and wrapped it around my waist like a sarong and strutted out into theater.






my fashion statement it would seem was too much for the matron, because before i had made even 5 meters, she came rushing up to me with a clean pair of theater pants (she had apparently just created them from subatomic particles using a process of fusion) and insisted i go back to the change room to make myself decent. no fashion sense it seems.

the second story was more recently.
i was called to the theater at the local provincial hospital in the early hours of the morning. it seems they started a laparotomy for a gunshot abdomen and were now in deep water. i dived into my car (i reasoned i would soon be diving into their deep water with them and i wanted to get my eye in) and raced to the hospital, trying to fully wake myself up as i went. i parked and charged to theater.

there i encountered obstacle number one. the change room door was locked. no problem, i would just go in through the main door.

obstacle number two was the main theater doors had been locked using a piece of wood wedged through the door handles. i shouted into theater, but there was no reply. i reflected that, although they had called me in at some ungodly (but not unsurgical) hour, they had not allowed easy access. the telephone call had lead me to believe that the situation was critical. i could not let a mere locked door get in my way. i broke it down. inside i found one of the sisters sound asleep. my supplications to open the door as well as my violent attack on said door had, luckily, not disturbed her no doubt well deserved rest.

obstacle number three awaited me in the change room. there were no shirts. at this stage i was feeling slightly less than my usual cheery self. i was in no mood to waste more time. i dressed in theater pants and entered theater with a naked torso.


there was stunned silence. the medical officer was speechless. he started explaining his operative dilemma, but as he looked up and saw me he went quiet. if i wasn't in such a bad mood i'm sure i would have laughed. i started scrubbing. (i suppose i should say something like my godlike torso faintly illuminated by the one light in the scrub room, but that is implied, of course).



soon i was donned with the operating gown and got to work. no longer blinded with jealousy, no doubt, the medical officer found his voice again and could explain to me the situation. my mood also improved and soon the normal intraoperative banter was being exchanged as if it wasn't 3o'clock in the morning and as if the consultant hadn't just turned up half naked after breaking down the theater door and of course as if there wasn't someone whose life hung in the balance.

giant killers

most rugby supporters will agree that there are three teams in the world that stand head and shoulders above all the rest. the all blacks (new zealand), the wallabies (australia) and the springbokke (south africa).

yet today in two quarter finals of the world cup, both the all blacks and the wallabies were eliminated!!! (new zealand went down to france and australia went down to england) wow!!! only south africa remains. (we play tomorrow against figi who have never beaten us).

i can't help feeling that, if we keep our heads and play our style of rugby, this world cup is ours.

here is to hoping!!!!

wakeup call

i once heard someone say surgery can be summed up in one sentence. eat when you can, sleep when you can and don't f#@k with the pancreas. this is true. but when you steal a quick shuteye here and there, this dictum doesn't tell you how to wake up on time. (pancreas can wait for later). i discovered a neat trick. actually this is a copyright secret, so everyone who reads this post, please forward money to me. thank you.

i was in vascular. i was doing 15 calls a month. (there were two of us). it was tough. often i would work up to 72 hours with as little as about 4 hour's sleep during that entire time. the operations were long and sometimes in extreme fatigue it was difficult not to resent the drunk with a shot off femoral artery who needed surgery at midnight in order not to lose his leg. the fellow was even more over worked and cantankerous at the best of times. in the immortal words of charles dickens:- "it was the worst of times" (he also prattled on about the best of times but i wasn't listening)

so it happened more than regularly that i would walk out of theater at about 5 in the morning and need to be at work at 7. clearly if i went to sleep i would rise from a comatose state long after i was supposed to be at work, bright eyed and bushy tailed and in deep trouble (or water?).
i was faced with a dilemma. grab a quick nap and be late or somehow fight overwhelming sleep off and be at work on time, but in a zombie state. then i stumbled on a solution.

i got home after not sleeping for who knows how long, with about 2 hours at my disposal before work. bed was not an option. my gcs would drop and someone might try to take my kidneys. so i decided to take a bath and get ready for work early.
i ran a warm bath and sank into it. moments later i was fast asleep. i couldn't help it. i was dead to the world.

and thus i slept soundly. and here lies the secret. the bath water slowly got colder. i was too far gone to notice this though. finally the water was so cold i could no longer stand it and i would wake up. there would be no choice. i would have to get up. it was impossible to warm the water up again (mainly because i couldn't feel my fingers and they wouldn't obey my brain's commands to open the hot tap). only rough actions could be carried out, like to drag myself out of the bath and collapse on the cold tiled floor of the bathroom (which felt comfortingly warm).

this whole process (including fumbling of warm clothes over my body and gradually emerging from hypothermia) took about 2 hours. just enough time to get to work, awake and on time, if somewhat grumpy.

so for those thinking of going into the wonderful career of surgery, spare a thought for your consultant. if he seems cold to you, there might be a reason.

warning, unless you are tall and will therefore not sink below the surface unconscious in a bath, this may not be a good idea.