a grand beginning

i am very excited to announce that grand rounds is coming to the sunny shores of south africa next week. the first day of the new year will be celebrated here on my blog with a collection of the best medical blogs of the blogosphere.

although a loose theme of new beginnings will possibly be followed, any and all submissions are welcome as they should be, so get submitting, fellow medbloggers!

send submissions to bongi at amanzi dot com. please put the words "grand rounds" in the subject line. please place a link in the message. you are welcome to give a summary of the post, but this is not required.

the deadline for submissions is sunday 30 december. late submissions may not be included.

i look forward to your submissions!!!

hijacker

hijacking is common in south africa. so common that the government has placed signs to let you know where you are likely to get hijacked. there are some people that feel more should be done, especially if one bears in mind that you have a good chance of being shot during a hijacking.

in my post practice, there was a comment which hinted at our south african view of violence, due to the fact that it is so commonplace. yes we are desensitized. but doctors are also desensitized. so what happens when you bring all three of these elements together?

it was in my registrar days. i had recently written intermediates and had less academic stress to deal with. therefore on calls, if it was quiet enough, instead of going to the call room and studying, i found myself wandering around, looking for something to do. one of my favourite places was the casualty unit. and in the casualty unit, my favourite place was the resus room. this is where all the high drama took place. this is where the adrenaline flowed (often even into the patient). this is where i felt alive and at my most alert.

so that night i wandered down to casualties to see if anything was happening. in the resus room, sure enough, there was a guy lying on the table. a friend who was almost finished with thoracic surgery specialization was standing at his head. all seemed calm. then i saw someone else in the corner of the room, looking awkward and out of place. i looked at the patient. he had a nice round hole in his chest, just to the left of the heart. i put the story together in my mind.

the guy in the corner was the shooter. he was either a cop in plain clothes or some civilian that had intercepted some crime. because of a slight paranoia due to 'a beautiful mind' about people lurking in places they shouldn't be, i asked my friend who the guy was there in the corner. i was relieved to hear that he could also see him.
"he's an off duty cop who shot this f#@ker. i don't know who the f#@k teaches them to shoot? two f#@king centimeters more medial and i'd be in my warm f#@king bed now and he would be on a cold hard f#@king slate in the morgue. now i have to operate this f#@k!" that's just the way he spoke. he could be very descriptive with only one adjective. he had the unique knack of making swearing sound elegant.

i then got the story, more chronologically and with less profane interjections (also much less colourfully) from someone else. the patient (the one my friend referred to as the f#@k) was a hijacker. at a robot (south african for traffic light) he had smashed the side window of a car and pushed his 9mm up against the head of an old woman. in the car behind was the off duty policeman. he jumped out, raised his service piece and demanded that the hijacker desist (my friend wouldn't have used the word desist). the hijacker, maybe like my friend didn't understand the word, because he turned to shoot the cop. the cop's gun was drawn, cocked and aimed. there was little doubt about who was going to squeeze the first shot off. the round entered the patient square on in his chest just lateral of the heart on the left. it exited exactly posterior to this. i surmised that if he even had mild cardiomegaly, the shot would have been fatal. i think the criticism about the cop's aim was unwarranted.

armed with this new perspective i looked at the patient (f#@k). he looked back at me. he was stable, but the intercostal drain had a constant stream of blood running out. my friend stood back as a sister was placing a cvp. he was telling her what to do. she was learning. i looked into his eyes again. i could see the fear of death there. i wondered how many times he had seen that in other people's eyes and shown no mercy. but i was not him. i felt sorry for him.

my friend, meanwhile exchanged some words with the cop. i listened in. he was giving shooting advice. he was suggesting that the best place to aim is the center of the chest and not the left. i reflected that this is good advice. although the heart is ever so slightly to the left, it is actually in the center of the chest.

then i listened to the sister who seemed to be having a bit of trouble with the cvp. she had moved from the subclavian to the internal jugular. her head was now directly above that of the patient. she was muttering. i moved closer to hear what she was saying.
she was speaking to the patient as she drove the needle repeatedly into the neck, searching for the vein.

she was saying things like:-
"this thing would think nothing of killing me on the street and now i have to try to save it's life."
and:-
"here lies the reason the death penalty should be brought back."
and similar things.

i mentioned to her something about not being a judge and having to care for whoever comes in without discrimination. she looked at me as if i wasn't a south african. i repeated what i had said, and then, knowing that my foul mouthed friend was good at what he does and the patient would be ok, if not somewhat emotionally scarred, i left.

i felt the need to tell this story to try to bring across the reality of how our job ends up messing us up. maybe being south african means we were messed up to begin with. i've often felt that we should go through some sort of debriefing. i doubt anyone can remain totally normal with all this sort of stuff constantly going on. it becomes a challenge to remain an exception. luckily i enjoy a challenge.

best medical weblog

i can't believe it. i have actually been nominated for an award. to tell the truth, i'm quite excited. however, in the same category are great names, including greats like:- Surgeonsblog, Respectful Insolence, Aetiology, Dr. Wes, The Independent Urologist, Junkfood Science, Kevin, M.D., Panda Bear, MD, retired doc's thoughts and Women's Health News.

so, truth be told, i think i have zero chance. still feels pretty good to get a nomination though.

take a look at the awards at medgadget.

practice

ever wondered why what we do is called practice? one particular story brought it into stark reality.

i was doing my internship in qwa-qwa. the hospital where i worked was a secondary hospital servicing about one million people. but it suffered from the usual problems of no supplies and theft etc. the result was that certain items in casualties were kept under lock and key. these included drip sets, needles, jelcos and at the worst of it, even syringes. you can imagine the chaos in a resus situation.

the next consideration is the difference between a surgical resus and a medical resus. a surgical resus is usually easier. there is usually one problem. keep the patient alive long enough to find the problem, fix the problem and the patient recovers. the patient is leaking blood. find the leak, plug it, fill up the container and all is well.
a medical resus is a completely different animal. once your body has crashed due to a medical problem, your reserves have been used up. there is usually not much that can be done. if you crash because your lungs have been eaten up by tb, no matter what you do, there is not enough working lung to keep the patient alive. when you crash because your liver doesn't have enough normal tissue to detox your blood, no matter what, there is not enough to keep you going. and so one can go on, organ by organ.

so, usually a medical resus is pretty much a waste of time. a surgical resus must be done efficiently and can mean the difference between life and death.

having set the stage, i was on call in casualties when a patient came in very late one night. he was wasted. there was thrush all over his mouth (often indicating terminal aids). he was very nearly not breathing and the occasinal gasping breaths he took sounded gurgling to the naked ear (no stethoscope needed). i knew tb had basically destroyed his lungs (working in qwa-qwa and hearing this breathing was almost synonymous with making this diagnosis). i could feel no pulse and hear no heart sounds (with a stethoscope). it was a pointless situation, like most medical resusses.

then a thought occured to me. bearing in mind the unit was not geared for resus due to the problems mentioned in the opening of this post and bearing in mind surgical resusses would be coming in in the future, it would be good to run through a resus where only i knew that it was pointless.

i jumped to action. i sent one sister to bring the ambubag endotracheal tubes and laryngoscope, another to unlock the closet with the needles and drips and yet another to get the drugs. soon i stood alone next to the patient. yes, that is how a resus went in that hospital all those years ago. you may better understand my desire to do a practice run in a situation where the outcome was already determined.

by the time everyone came back, the patient had stopped breathing. i moved to the head. as i was intubating, i orchestrated a full resus. one sister was put to work doing cardiac massage, two started getting iv access, one attached the ecg monitor and one started drawing up drugs. i tubed and started bagging. during the whole process i explained to the sisters what i was doing and why. i gave some pointers about how better they could perform their respective tasks. everything went well.

and then possibly the worst possible thing happened. the patient's heart started beating and his peripheral saturation began to climb. the sisters where ecstatic. i was worried. i had to find a place for him in the hospital now.

i phoned the physician (cuban). he said the patient couldn't go to icu because of the fact that there were no available beds. he asked me if the patient was breathing on his own. i stopped pumping his lungs and lo and behold, he was breathing. the physician made the call. he should be extubated and take his chances in the ward.

we extubated him and sent him to the ward. he was alive. the sisters in the ward were more than just a little annoyed with me for what they called going above and beyond the call of duty by resuscitating a corpse. they didn't call me when he crashed again. they made sure he was good and dead before they called me. even then i think they waited a few minutes to make sure there was no chance for him.

looking back on this, i realise there are a number of questions my international readers may raise. i even considered not posting it. but i think one must see these events in the context of the unique circumstances we worked under. when the surgical resus did come in, the entire casualty unit was more geared for it and it went better than it would have. those sisters there that night almost without exception thanked me for the entire thing. a rumour went around the hospital that i was the best intern to be on duty with. the only point that i didn't like was the negative attitude to me from the ward staff, but that was something i could easily get over.
then there is the point of available resources. this is a reality in south africa. this blog is supposed to portray uniquely south african stories, so that part of the story also needs to be told.
the point of the combination of hiv and tb, especially in those days when there was no available treatement here also shows a south african slant. that was the fact of the matter at that time and these deaths were commonplace. even these days, thanks to our minister's hiv policy, many people die unnecessarily all the time in similar condition.

i'd be interested to hear comments though.

'tis the season to be jolly

in our training, a friend and i tended to work together when it was the season. neither one of us really celebrated christmas (he was hindu and i didn't care for the commercialisms of the holiday), so it sort of worked out fine.

however, walking down to casualties to see yet another stab wound caused by festivities (read alcohol) and some trivial argument with his 'best friend' when pretty much everyone else was relaxing at home or some holiday destination could cause a bit of healthy scepticism in the so called meaning of the season.

we used to stroll down the deserted corridors, wiping the sleep out of our eyes on the way to casualties. one of us would say
"'tis the season to be jolly!" and the other would reply,
"fa-la-la-la-la-f#@king-la-la-la"

and that is how we truly felt.

guest

i was asked to guest post on another south african medical blog. i have in fact already posted two of my older posts there. but now i have posted one unique post there. so, all people who visit here regularly, take a turn at all scrubbed up. have a look around. let me know if you like it.

so, without further ado, take a look at the surgeon superhero!

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.

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.

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.


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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.