salt water wells up

the rooms were full. i was moving through the patients as fast as i could. then it was her turn. she had presented the previous week with a 7cm mass in her breast. she worked in the medical field, so she must have at least suspected it couldn't be good. but sometimes we all hope bad things will just go away. they seldom do.

i had told her it looks suspicious of a cancer but we had to wait for histological confirmation. and now i had it. as i walked her to the room, i glanced at the report. it was cancer.

as a surgeon, i treat many people simultaneously, seeing each one for a short time. i therefore must be able to jump between thinking about someone with mild abdominal pain and someone who is facing death and back many times each day. the trivial and the grave alternate through a typical day. this was grave. i consciously slowed down.

i went through her previous examination with her. i repeated that clinically i had been suspicious of cancer. and then i told her the news, as gently as i could. this is never fun, but i think i do it better than most and i'm always encouraged that it is better for her to hear it from me than from someone with little or no empathy.

she asked questions about treatment options. as i answered i could see her mind wandering off. she was probably thinking about her family and the grandchildren whom she would not be able to see grow up. she was being human and i understood. she asked the same questions numerous times and i patiently repeated the answers.

as she sat there with a far off gaze, trying to hear what i was saying and failing dismally, her eyes slowly filled with tears. she was being brave and my heart was breaking for her. i slowed down even more, giving her time, repeating once again how we were going to fight this thing, trying to give her hope.

finally we decided on a course of action and she left. i took a short moment to get my mind back to the day's tasks and moved on.

i moved on, having seen one more breast cancer patient and broken the news once more, but for her, she had just experienced possibly the single most devastating moment in her life.

sometimes our work is very sad.

2010

as you've already heard, we are having power problems in south africa. one of the commenters said something about south africans being innovative. well, seeing as though we are hosting the soccer world cup in 2010, i have the above suggestion for the evening games.


but on a lighter (lighter!! get it??) note, the spartan way of dealing with our problem.

toughen up

during the old days of training, the prof believed in toughening us up. looking back i still wonder whether it was necessary.

there is a lot said these days on some blogs about the 80 hour work week. in those days we hadn't even heard of such a thing. there was no such thing as time off post call. any day of the week you had to be available for your patients. there was no such thing as handing a patient over to someone else because you were tired or upset or whatever. i remember being on call on friday night, working through the night. working through the next day to work off the leftovers and only getting home at about 9 the next night. then being on call the next day and night and doing a full day's theater list the day after on monday. after the list you operate the leftovers and the comebacks from the call. by tuesday you struggle to remember your name.

but i digress, as usual. this story comes from much later on in my training. i was the senior, the number one dog. i was in the toughest firm, the rounding off. after call, the prof would take us on academic rounds. as a junior i always struggled to stay awake during these rounds, having often only had one or two hours sleep the previous night, but somehow as the senior registrar in this particular firm the tension on the round was always enough to keep me wide awake.

without fail, on these rounds, the prof would tell us to take one patient back to theater for some or other reason. we used to bet about which one he'd chose. we were usually unpleasantly surprised. at a certain patient, usually towards the end of the rounds, the prof would look at me and with a wry smile say, 'you need to take this patient to theater.'

'yes prof.' i always replied and smiled back. in front of that prof it was important to show no weakness. he was like a pack of wild dogs. if he sensed fear he would tear you apart. he would then volunteer to join me if it happened before home time. this would never happen. by the time we booked the patient on the emergency list after the rounds, the list would be so full that we usually operated late at night.

this sort of behaviour is, of course, questionable. one wonders if it really was necessary to operate the patients. the answer is mostly yes, but not necessarily immediately. it wasn't so much about the patients but about training surgeons who would have the ability to put their own needs (even physiological needs) on hold if need be in order to be able to do what is needed for the patients, be they only future patients.
i'm not presenting answers to these questions. i'm only stating things that happened.

however recently i have had the dubious pleasure of operating quite a number of patients with very complicated gallbladder disease. interestingly enough, although the surgeries were complex and challenging, at no stage was i even slightly phased. i realised this had a lot to do with many complicated gallbladders that i operated post call at the prof's beck and whim so many years ago.
so one can't help wondering at the method in his madness.

surgexperiences

surgexperiences 113 is up at counting sheep. it is a blog carnival dealing mainly but not only with surgical posts. take a look.

also, for those interested in hosting a future edition, contact jeff.

eishkom

our electricity provider, eskom, is having problems. this stems from them not keeping up with increased demands over the last 12 or so years. it seems that our great and wonderful government didn't feel it was necessary. turns out they were wrong. now they can't produce enough electricity for the country. well that is not entirely true. they export electricity to a number of our neighbours, so there is probably enough for south africa, but not enough for southern africa.

this results in what they euphemistically refer to as load shedding. what it is, is to simply cut the power to large areas of the country during the day. (interesting to note that our neighbours don't lose power. only we do). we in nelspruit have been having blackouts on a daily basis for quite a number of hours every day. this means that almost everything grinds to a halt. many borderline businesses will go under and a lot of money will be lost by the larger companies. this will have a dramatic effect on our economy. but at least our neighbours won't be affected. eskom, it seems, cares more about the economy of our neighbours than it does about our own.

why am i writing about this? because hospitals are also getting hit. the other day i was operating in the government hospital when the power was cut. the entire list was canceled. emergency cases only could be done. so no lives were lost, but if you were booked for a hernia repair, sorry. and seeing that these cuts are happening every day, when you come back, you have a good chance of being canceled again.
and in private? the same. the theaters stand empty for hours. ct scans can't be done. sonars wait for the power to come back on. i know of one case where a cardiac angiogram was delayed because of these cuts. one can only hope that it wasn't critical.
and what do we do while the power is off? we wait until it comes back on. what else can we do. in fact the photo above is a photo of us waiting in the doctor's tea room (i'm just out of shot on the left). note our alternative light source.

so, zimbabwe, we are well on our way in following your example of moving back into the dark ages.

the state of it

some readers may have been following this blog for some time. some of those readers might be interested in what has been happening in surgery in the state hospital. for this small group of readers, this is the state of it as it stands now.

well after i was instructed to stop operating in the state hospital (which you may remember i was doing for no charge) i left them to their own devices. the one remaining surgeon, partially registered, took an extended leave of absence. the junior doctors went on as best they could. as you can imagine, chaos reigned.

this went on for some time. after a number of months, the mec of health in the province (politician in charge of health) decided he should meet with the doctors working on the ground. when he did, he was 'surprised' to hear that there were no surgeons at all in the hospital in the capital of the province. he also didn't seem to be aware that the state was sending patients to the private hospital for treatment at astronomical costs. by chance, the person that i had crossed swords with had been replaced by someone else who, on the face of it, seemed more determined to fix the problem and less focused on saving face. the mec placed her in charge of sorting things out. he wisely gave her authority over her boss who, in my opinion was the cause of most of the chaos and as it turns out was the person who had instructed the hospital to give me my marching orders.

she got to work. she approached all the private surgeons. only two responded. i was one. a meeting was called and a path forward was discussed. without going into too much detail, the final result is that the two private surgeons are on standby for the government hospital. instead of sending patients to the private hospital and thereby paying that hospital we would operate at the state hospital and charge per patient. they would therefore save a massive amount of money but not get the free ride that i often referred to in my earlier posts.

so these days i once again operate (quite a bit actually) at the state hospital. it still remains to be seen if they are true to their word and pay us. (hasn't happened yet)

briefing the president

grand rounds is up at sharp brains. take a look. hang around the blog a bit too. it is pretty good.

the matrix move

these days, my blog is full of medical stories. but some stories are best forgotten.

during my registrar years i had an intern who worked for me with the most amazing story. what is more amazing was that the incident happened in cape town, where she studied. when she moved to pretoria, she could have buried the story in her home town, more than a thousand kilometers away. but no... a group of the interns working together got together one night for a braai (south african word most closely translated as barbecue). as the beers flowed, they started swapping stories. i suppose in an attempt to fit in, she relayed the story of the matrix move. she will never live it down.

she was a student rotating through urology. she was sent to insert a catheter into some guy. she had never done this before, but her registrar had explained to the group when they started briefly how it was done, she went for it.
step one, the registrar had explained, was to squirt remicaine jelly, a local anaesthetic cream, into the meatus opening and milk it down. this is to ensure that the entire urethra was at least slightly deadened to the otherwise extremely unpleasant procedure.
being a caring person, she squirted a generous amount of the jelly into the meatus and began milking it down, possibly a bit too vigorously.
being a somewhat naive girl, i assume she was only too grateful that she didn't need to support the member too much as she readied the catheter.

then came the insertion of the catheter. as she started, assuming it would be fairly painful, she milked a bit more to make sure the urethra was well covered by the remicaine jelly and started the procedure. almost immediately the patient called out, "ek kannie meer nie!!" (i can't any more). the caring student, assuming the patient was experiencing discomfort, immediately started milking the jelly down with possibly too much enthusiasm. it was just after this that the student realised the patient's prior supplication had nothing to do with pain, at the exact moment that she was forced to do the matrix move to evade oncoming substances.

like, i'm sure, most of my readers, i just could not believe this story. so i did the obvious thing. i asked the person involved. she did not deny it which was enough for me.

revenge

when i wrote about doctor's attitudes there were some who mentioned something about the police. so here is a story about police attitudes.

i was an intern in a rural hospital. one night a young lady was brought in. she had gunshot wounds. but strangely enough, her wounds were symmetrical. on her left arm she had an entrance wound mid forearm posterior aspect, fractured distal ulnar and exit wound distal forearm anterior aspect. on her right arm she had an entrance wound distal forearm anterior aspect, a fractured distal ulnar and an exit wound mid forearm posterior aspect. she was shaken and couldn't tell me what happened. i asked her escort.

her escort was a cop. he was head of the local police station. he explained to me that she was the girlfriend of one of his colleagues. she and her boyfriend had gone for a drive. they had stopped somewhere to...um.....enjoy the scenery. while they were there they were attacked by a gang that worked the area. the boyfriend had been killed on the spot with multiple gunshot wounds. she had taken one shot, through both arms.

when she had relaxed a bit, i asked her what happened. she said they were sitting in the car when all hell broke loose. she screamed and put her fingers in her ears. and was in that position when she got shot. when reconstructing the trajectory i realised the bullet must have passed just in front of her face on its way from the one arm to the other arm. she was lucky, in a sense.

her escort took me aside. he said, "i assure you, doc, we will get the people responsible for this!" i somehow believed him.

about two weeks later we got a call that four critically injured patients were on their way in. all we knew is that they all had gunshot wounds. the ambulances arrived. one patient was declared dead on arrival. three were taken into casualties. one died in casualties. two were taken to theater. one died before they could operate. one got operated, but died on the table.

the police started coming in. surprise surprise, but that same cop who swore revenge was one of them. he told us that they had found out where the 'hideout' of the gang was and had gone there to arrest them. apparently the bad guys had shot first (i love it the way that always happens). even though they had shot first, they had only winged one cop. they, however, were all killed. apparently there were about five dead at the scene. interesting to note that the winged cop specifically asked me to be transfered to another town because he was afraid of a retaliation assassination. i imagined a whole bunch of gun toting gangsters coming into the hospital. i transferred him immediately.

of course i knew that it hadn't been a fair shootout. of course the bad guys didn't shoot first. but in the climate of crime in south africa, i wasn't really too worried about such details.

if the comments some of my latest posts have generated are anything to go by, for those who want to stereotype this to some or other race war, let me just point out that everyone involved, including the surgeon, was black. (ok the anaesthetist was a cuban, but the rest were all black)

grand rounds

grand rounds vol 4 number 15, welcome to south africa. and a happy new year to all!!




rlbates is suturing for a living. she gives an informative overview on post hematoma in plastic surgery. how to decrease the chances.













jolie bookspan challenges us to extend the spirit of christmas in more than one way.








rita schwab talks about her experience starting up a new business involved in tracking and responding to patient comments, complaints and grievances in the healthcare setting. sounds like a worthwhile endeavour. "this is great, rita, but what about...?"










henry stern tackles a tough issue. it puts focus on the cost involved in healthcare and who should pay when the procedure may not make a difference to the prognosis. it reminded me that bad things happen to good people and sometimes it is no one's fault.










one of my favourite bloggers (and 'radio' hosts), doctor anonymous, discusses medical myths even doctors believe. but is it doctors that say they believe these myths or is it a myth that doctors believe them? take a look.















coming from a country as i do where the rate of intervention in childbirth is, in my opinion, ridiculously high, i really enjoyed myra's post about home birth. it is good to be reminded that pregnancy and childbirth are not illnesses. keep it up, myra.




















shauna puts a personal face on the effects of ms. this is a very brave blog and definitely worth a look.
















ernursey has a great post about a patient that gave the er staff their daily dose of adrenaline. i love these personal accounts. i must admit, it reminded me how little i enjoyed cardiac patients. each to his own, though. well done.












paul auerbach has an interesting post about wearing a helmet while skiing. i know i'm probably the last one to give an opinion about skiing, but wearing a helmet does strike me as a good idea. take a look what he says.














barbara kivowitz questions how equal we are in health care. or are some truly more equal than others?


















dr emer gives some good suggestions for new year's resolutions. will we be able to pull it off this year?
















a psychiatrist discusses an itch and how to scratch it. who would have thunk there is so much more than just getting that special person to scratch it.














eric turkewitz brings the legal perspective to the fore. it's good to know politicians mess things up everywhere and not just in africa. i'm also glad that medical litigation is not as prevalent where i come from.













gerald pugliese and doctor fuhrman discuss whether cooking vegetables really makes such a difference. being very allergic, as i am, to the multitude of dogmatic fads that intermittently turn up, i really enjoyed a scientific look at this.











david e williams has a somewhat scary look at the chance that google can diagnose you of some illness before your doctor. maybe big brother is really watching us???















alvaro discusses how we got expensive brains and what it means today. very interesting stuff.
















vitum medicinus writes a post reminding himself what an honour he has to be in the profession he is in. i'm glad to see that his emphasis is in the right place.














terry talks about epidurals in labour. it seems that you need to get them in to transform the patient into a relaxed, cooperative being before another transformation takes place. imagine if dr jeckyl had known this stuff.














jenni prokopy takes us through a post dealing with the social aspects of living with a chronic condition. i liked this article because it reminded me that the task of going about our business of being human is actually what it is all about. us medical types sometimes forget this.













clinical cases shows us that av blocks can be cool. well if not cool, then at least funny. take a look and a laugh.






















in allergy notes we learn that carbon dioxide can help with allergic rhinitis. i can't help wondering what al gore would say about that.
















susan palwick takes us through a night of trauma and its effects on the family and the chaplain.
i love these personal blogs. i often get asked how i do what i do, but i really wonder how susan does what she does. not for me thank you.














kenneth f. trofatter takes a look at low hormone levels in early pregnancy. very informative without losing the human touch. well done.














toni brayer has a wonderful post about resolutions for patients and doctors. good luck with that.














dr val helps us understand the jumble of conflicting studies, or more specifically why there are conflicting studies in the first place.













finally, i thought it was tough in south african hospitals and i'm sure many bloggers feel that they have it quite hard in their american hospitals. but we can all be glad we are not down under! all i can say is that it is obviously universal...white men can't dance.









and that's it from africa. please feel free to drop by here any time for surgical and uniquely south african stories.












next week's grand rounds will be hosted at pathtalk.