inferior vena cava

the inferior vena cava! we called it the black mamba. it lies to the right of the vertebral column. it drains all the blood from the lower extremities and the abdomen, delivering it back to the heart. when it is exposed, it has a dark blue colour. if you leave it alone, everything goes well. but if you hurt it, you are in for a whole world of trouble.

the first time i was nearly bitten was in my medical officer year. i was going to take a gunshot abdomen to theater...alone. just before, in an inspired moment, i phoned the senior just to tell him what was happening. when he heard the right transverse process of l2 had been injured by the bullet, he seemed disturbed. as i opened, he walked in. good thing he did, because the inferior vena cava (ivc) had been shot through and through at the level of the renal veins.

that was the first time i saw the ivc bleed. it's probably more accurate to say i heard it bleed. it sounded like a babbling brook. it seemed to spew blood, liters at a time. i could smell the adrenaline it caused (in the surgeon). somehow the surgeon got control and the guy made it.

then there was the time the consultant urologists pulled out a kidney for some reason. i was a senior registrar at the time. i happened to be in the vicinity (bad luck. i tried to run, but he saw me and called me into the theater). the urology consultant simply told me to scrub in. when i joined, he calmly tells me he injured the ivc. i looked under the finger of his registrar, indeed, the mamba was angry. he then told me that it was the realm of general surgery and therefore i should fix it. i could physically feel my adrenal glands go into spasm. what could i do? i fixed it, but not without much weeping and gnashing of teeth. afterwards i felt the usual parasympathetic overload after a severe sympathetic drive. i felt weak and tired.

but all the above examples are bearable in the sense that you deal with what is presented to you. not so when you are the one presenting it to yourself. a moment i wish i could forget and know i never will is when i myself nicked the mamba. and yes, boys and girls, he was angry, very angry.

without going into gory details, i cut it just above the liver where it dives behind the diaphragm to enter the heart. a word of advice, if you absolutely feel you must cut the ivc, this is pretty much the worst place to cut it.
i placed a finger over the hole, thereby stopping the bleeding. then i think i shat in my pants. seeing as i couldn't spend the rest of my life with my finger over the hole (although, i feared i might spend the rest of the patient's life with a finger over the hole) i started to repair it. step one was to call my associate to help. together we managed to get control and close the hole, but it was truly a terrifying few hours.

the point of this story is that in my line of work, occasionally (hopefully very very occasionally) you might find yourself in a situation where an action you take leads directly to harm or even death for another human being. to err is human, but when we err we can really f#@k up. i can honestly say it is a terrible and humbling realization.

lies, lies, all lies

the final in my lies series.

some time ago i got the message that a patient was on the way in with burns. ok. not something i'm overly fond of, but you handle what comes your way. i sort of hung around casualties, waiting.

she arrived. burn wounds are prognosticated by surface area burned as well as depth of burn. inhalation burns are casually tossed into the equation as not a good thing. so when you see a patient with 100% burns (ok, actually 95% because her hair has protected the skin of her scalp. the hair burned away and not the skin underneath) the prognosis is zero, nada, zilch, nil anywhere in the world. another interesting fact about burns is once the skin is destroyed, including the pain receptors, the patient has surprisingly little pain.

so as i was saying, she arrived. 95% burns and not looking good. the casualty officer and i approached together.
"what happened?" i asked, more to evaluate her voice, although i admit i was curious.
"it was an accident. it wasn't on purpose." replied the patient with a hoarse, croaky rasping voice. immediately a number of things went through my mind.
1) if the singed nostril hairs had not been convincing enough, her voice confirmed that she had inhalation burns. her airway would swell massively in a few hours, causing airway obstruction and death if she was not tubed.
2) she was lying. i didn't ask if it was done on purpose. up until that moment i had assumed it was an accident. now i knew it was suicide or murder. (i omit the technical word attempted, because it was soon to be removed anyway).
3) what a bloody waste to maintain some ruse in your dying hours. give it up!

i quickly threw in a cvp. there were no peripheral veins. they were all burned away. then i performed a few escarotomies (sort of like a faciotomy but on burned skin and not facia). then a sister told me there was another one. the husband was also burned. i decided to check him out.

he had mild burns on his forearms. that was all.
"what happened?"
"it was not on purpose. it was an accident."
at least they had both decided to give the same story. they had obviously discussed it on the way. i still didn't know if it was suicide and they were afraid of the scandal or murder and she was protecting him. battered wife syndrome causes some strange behaviour. the husband then went on to explain that as he arrived home he heard screaming in the kitchen. he went in to find her on fire. he did what he could. at about this stage tears started running down his cheeks. the casualty officer held his hand and bit back her tears. i did not. i remembered my friend and was cautious. i also found it too coincidental that he arrived home at the exact moment the 'accident' happened. maybe i'm too sceptical, i thought. but then again maybe i'm not.

we patched him up. as he left he took me aside, and with tears in his eyes, he asked me to at least make sure she didn't suffer. i said i would do all i could.

she, however, could not go home. i gave her the necessary fluids and pain meds, but i decided not to intubate. she was going to die. she was either going to die with a tube down her gullet or without. also a tube would effectively just prolong her suffering. hence i felt dnr and dnt (do not tube) were in order. but no matter what, it was not going to be a pleasant death. and pleasant it was not.

i did not follow the ramifications of the case, except for hearing that a murder docket had been opened against the husband. who knows what the truth is. i do, however know what it is not.

it is difficult to cut a head off with a panga

i have decided to break from my series to quickly blog about a recent patient.

i now know it is difficult to cut a head off with a panga. it is not something i wanted to know. it is most assuredly not something i wanted to find out the way i did.

i was called to theater only after she had been put to sleep. the plastic surgeon wanted me to attend to some of her many wounds while he pieced together the face. i don't think i am easily shocked, but i was. she was about 60. she had been attacked in her house by a group of men wielding (and swinging) pangas. she was transfered to our hospital where the plastic surgeon took her to theater. he then called me.

i walked in. the right side of her face had multiple slashes. the angle of attack was slanted downwards. the side of her face had been sliced off in thin slivers like a piece of roast beef. a piece of the mastoid process had been sliced off. the layers lay loose, attached only at the lower neck. i assume these were the first wounds inflicted. she must have fallen forward then. this i know because the next wound was in the posterior aspect of the upper arm. the triceps was completely transected. the humerus itself had a deep gash in it. i suspect the assailant would have had difficulty removing the panga from the humerus, the wound was so deep. by this stage the woman must have been face down...defeated. the next wound was over the right scapula. the scapula was cut right through. there were two separate pieces with all the muscles transected as well. the force mustered to deliver this blow must have been emense.

i quickly realized that an orthopod would be a better bet for the patient than me. we called one. he scrubbed up and went to work as the plastic surgeon pieced together the jigsaw (read panga) puzzle that was her face.

and her crime? she was white. yes, she was simply the victim of a racial hate crime.

i remain in shock.

not one single word

sometimes the patient is in no condition to lie for himself. then it is important that others lie for him.

i was working in a private casualty unit to make extra money during my surgery training. (don't tell the prof. it was strictly forbidden. one day i'll post about the time i got caught.) it was some ridiculous hour. i was catching a nap when i was rudely awakened. the sister said an ambulance was expected to arrive in about 5 minutes with a possible epilepsy patient. i dragged myself out of bed. a medical case! absolutely wonderful. and at this time of the morning. just the thing to warm a budding surgeon's heart.

i stumbled into resus just as the ambulance crew came casually strolling in with the patient. they told us they had been called to fetch the guy from work where his colleagues said he simply collapsed. they didn't know why. something was wrong. he was restless. he was also pale. i felt his pulse. it was thready and fast. very fast. he had no drip up. being surgically minded, i thought that if i didn't know better i would say he was bled out. fortunately the ambulance crew could tell me that his colleagues at work told them that he had been working in a dairy cold storage facility when he simply collapsed. i asked if there had been convulsions. they didn't know. meanwhile one of the sisters was getting a blood pressure. 80 over 30 didn't fit with epilepsy. a quick glucose test was normal. the only alternative was cardiogenic shock from myocardial infarction or some exotic dysrhythm. but once again, it didn't fit. the patient was black. (white south africans have about the highest incident of ischaemic heart disease in the world, but south african blacks don't have much of it at all.) then it happened. the patient, now gasping for every breath looked at me and said,
"help me doctor! i'm dying!"

if you've been in medicine for a while you'll know that most times, the reason a patient says he is about to die is because he is in fact about to die. i believed him. my blood went cold. it just didn't fit. i wanted to tell him we'd do everything we could (although i still had no idea what i was capable of doing for him). in a reassuring way, i placed my hand on his chest. with every breath i could feel bones grinding against each other. i pulled my hand back in shock. he had broken ribs!!! epilepsy or cardiogenic shock or some heart problem does not cause broken ribs!! this was trauma! this was surgical! i jumped into action.

at that moment, the patient breathed one terminal gasp and promptly stopped breathing. for good measure his heart stopped beating too. nice bloody epilepsy, this, i thought. i delegated one sister to start cpr and another two to get iv access as i moved to the head to get airway control. the sister pumping the chest immediately stopped.
"everything is crunching under my hands" she said. what could be done? circulation is fairly important for survival, so i told her to continue. at this stage i was intubating. as i inserted the laryngoscope, fresh bright red blood came frothing directly out of his trachea. the trachea was also way over to the right. i shouted for someone to prepare an intercostal drain and slid the et tube in. the sister was fast. by the time i moved around to the left flank, the set was ready. i stabbed the blade into the chest. there was a gush of old dark blood. i shoved the tube quickly between the ribs into the pleural space. immediately one bottle filled with blood.

we consolidated. the patient was on a ventilator. two lines were running full tilt. with a touch of adrenalin, the heart started beating again (although i think the removal of the tension hemothorax also had a part in that). we got emergency blood going and got x-rays. we also called the thoracic surgeon.

the x-rays showed the worst disruption of the thoracic cavity i have ever seen, before and since. every rib on the left was broken and the fractured surfaces were about 5cm from each other. this basically meant there was a tear of the lung from top to bottom which was about 5cm deep. i gingerly reflected that that would explain the constant stream of blood draining from the intercostal drain.

as could be expected, the patient decompensated again. this time there was no bringing him back. when the thoracic surgeon arrived, the patient was already dead.

as usually happens, the story did come out. what the patient and his colleagues didn't know was that the cold storage facility where they worked had closed circuit tv. this was probably to prevent night staff from stealing. or maybe to prevent them from racing around on a fork lift chasing each other. yes, dear readers, that is what they were doing when one of them lost control of the fork lift and drove into my patient, crushing him up against a pole. they figured they were in trouble already, so it seems they decided the depth didn't really matter. if you are going to be in crap for messing with the machinery at night and for killing your colleague, then why not lie also to really confound any chances of the paramedics and the doctors to try to save his life. go figure.

don't believe a word

all patients lie. or so i was told. obviously, like most things in life, this is not always the case. but one should maintain a healthy degree of skepticism when listening to the history. i've decided to write a series about a few stories where the truth only came out later.

while training as surgeons, most of us did extra work to make ends meet (financially i mean, because burning the wick at both ends seldom makes them meet in a satisfactory condition).
one of my friends was doing a stint in a private hospital casualty unit. it was early evening. suddenly a man came rushing in. he was hysterical. he said his wife had been shot and she was in the car outside. with er-like drama, everyone rushed out. sure enough, there was his wife in the passenger seat, covered in blood with a nice round hole in her head. they rushed her in, but she had been dead for some time and nothing could be done.
the husband was beside himself with grief. he was actually hysterical. my friend was also pretty shaken up, but being a good caring doctor, he put his own personal feelings aside and devoted all his attention to the man.

they went into a side room where my colleague prepared a cup of sweet tea. he asked what had happened. slowly, between sobs, the story came out. the man, who turned out to also be a doctor, and his wife were out driving somewhere. they stopped at a robot (traffic light). suddenly someone opened the door of their car and shoved a gun in his face. this is a common or garden hijacking and happens with alarming regularity in our country. apparently, then about 4 men got into the car, with the two and drove off. this is also not unheared of with hijackings here.

the man went on to explain how they had been taken to a deserted street and forced out of the car. he described how he had begged for the life of himself and his wife. he said they were forced onto their knees. the one hijacker then pointed the gun at his wife's head and, after some verbal abuse, pulled the trigger.

my friend was shocked. he could only imagine the devastation the patient was feeling. thinking about his own wife, he had to force back the tears. once again, he put it all out of his mind and focused on the patient. he held the man while he sobbed uncontrollably. my colleague admits to even crying with the man. who could blame him? he held his hands and led him in prayer. he gave the man his private cell number.
finally the man left, looking at least a bit better. my friend went back to work, feeling he had at least meant something in the darkest hours of this man's life.

some hours later, the police arrived to fetch the body. being an unnatural death, the body had to go to the forensic mortuary for a postmortem. my friend asked how things were going with the husband.

"oh, we've arrested him for murder." replies the officer casually.
"what!!!" replies my friend less casually.

as it turned out, he took his wife into the back garden and shot her in the head (the part about her being on her knees begging for her life was apparently true). they had found the bloodstains, the gun and a spent cartridge. maybe my friend had held the man up so long he couldn't rush home to hide the evidence.

i really laughed at my well meaning friend about the whole incident. (for those of you who think i'm callous, i did not laugh about the shooting, just about my friend being so taken in).

don't get me wrong, not all patients lie and those that do don't lie all of the time, but it is a good idea to be prepared for it.

rollout

a good blog to have a glance at is just up the dose. her latest post is sad in that it is true. let the politicians continue to secure their positions, no matter who they have to suppress to do it. viva anc viva.

cuts

one of the aims of this blog is to touch on things specific to surgery in south africa. i notice panda is talking about 'alternative healing' so, not to be outdone, i decided to post on the same topic.

she was massive. her bmi must have been hovering around the 50 mark. then she developed severe abdominal pain, complete obstipation and vomiting. as is common, she went to her local neighbourhood sangoma. he did what sangomas do. he made cuts over the area the patient reported to be the problem (her abdomen) and smeared his muthi (in this case, apparently cow dung) into the cuts. the idea, i think, is that the medicine can get to work directly where the problem is.

but what if the problem is an umbilical hernia with strangulated bowel? due to her first being treated by our traditional colleague, by the time she turned up at our hospital, she was not well. systemically she was in septic shock and amazingly acidotic. she had a large necrotic mass over her central abdomen. at that stage the only thing that could be seen were the multiple cuts on the necrotic skin. it seemed like necrotising faciitis. there was no way of knowing that below this necrotic skin in her abundant fat lay strangulated necrotic bowel.

it was the turn of western doctors to take up the knife, like the sangoma before had done. the difference, however, was there was method to their madness. she went to theater. the necrosis was debrided, revealing the dead bowel. a resection was done. i was only a student at the time, so i was pretty far down the table. the smell also had a numbing effect on my faculties, so, to be honest, i can't remember the details of the surgery. suffice to say, an extensive debridement was done. living bowel was brought out (somewhere). and the wound was left open. she did the obligatory time in icu with multiple follow up visits to theater. after many months, she actually made it.

i sometimes look back and wonder if we really can critisize the sangoma. he did take a knife to the patient, which was the right treatment. he did have some concept of the problem having something to do with feces. i may advise that, unlike fire, feces can't be fought with feces, though. but many of the basic concepts where there, albeit in a non western format.

when reflecting on these incidents, i am always amazed by the fact that there is so much leeway given to these 'healers'. they are never made to account. they are never held responsible. they have free license to do what they want. there was even a government statement that the sangoma's 'art' cant be scrutinized like western medicine, because it is based in a belief system rather than science. the ancestors will heal you. believe it and it will be so. and when the patient finally does turn up at our doorstep at death's door (same doorstep?) when we can't actually pull them through, sometimes the sangomas will say "you see! the western doctors just kill you". no mention of the tried and tested methods of smearing feces into open wounds over strangulated bowel.

favours

you agree to do a favour for a friend. it is sealed with a handshake. sounds so innocent, but in surgery this spells disaster.

i thought of this when i read about surgical superstitions on a blog i frequent. but can you call it superstition when experience confirms it to be true?

she had clear cut cholecystitis. but she had no medical aid, so she couldn't afford the private hospital. she knew someone at the state hospital. this someone knew me. he asked me if i would do the operation. at that time i was operating at the state hospital every tuesday, so it wasn't a problem. i said if she got into the system, when she turned up on the list on whichever tuesday, i'd do the operation. he organised it.

then politically all hell broke loose. i was officially banned from the state hospital because i was supplying a service that they couldn't take credit for. the administration ensured that i was no longer available at the state hospital. there was no one there able to do a cholecystectomy (true story). so the patient went without the needed surgery. she just accepted intermittent severe pain with each worsening attack.

finally it became too much. she came to me in private. but the private hospital fees were too much for her. her friend at the state hospital had moved up the ranks during this time. she phoned him. he phoned me. he was in a position to grant me temporary permission to do the operation there if i consented. he was a friend and i decided to do him the favour he'd asked for.

it is not often these days that i get to do an open cholecystectomy (in private it is, of course laparoscopic), so i don't often get to try out sid's mini chole. in the state hospital, there is no laparoscopic equipment, so the decision to do the procedure open is quite easy. i went for the mini chole. i made a 5cm incision. but i don't have the benefit of a clip applicator as described in the steps. i clamped the artery and duct with a roberts. the galbladder was out. i tied the duct without too much hassle. then came the artery.

when tying the artery, the suture slipped. for the non surgeons out there, to tie an artery way below the liver through a 5cm incision can be a spot difficult. when the suture has slipped off, the artery bleeds as arteries tend to do. blood obscures vision. there is an urgency to get the bleeding under control, but with active bleeding it is difficult to see what to do. there can be a bit of tension in the air (and in the surgeon).
i couldn't help thinking that i do a favour for a guy and the patient bleeds to death during a routine operation. i wonder how that would look on my resume.

also mental note, again, to do no favours for anyone. ever....


p.s, i extended the incision to 7cm, got the bloody bleeder under control and closed.

what would you do?

this is a slight break from my usual style post, but a change is like a holiday.

so for the surgeons out there, what would you do with this case i saw recently?

south africa's health policy

our health policy in picture format.