the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.
once again surgexperiences will be visiting this blog on 2 march. surgexperiences is a blog carnival about surgical blogs. but it is really open to all medical blogs with a slight surgical slant. so all my favorite blogs and bloggers, please submit your posts here.
i recently read quite an interesting post on one of my favorite blogs. it had to do with religious zealots. it reminded me of two experiences i had, both of which i found disturbing.
i was rotating through paediatric surgery. the prof operated a 7 year old child for obstruction. intraoperatively we found intussusception in the ileocecal region with a golfball sized leading segment. we did a resection. already intraoperatively, the prof suspected a lymphoma (lymph node cancer). and histology proved him right. the child was referred to the chemotherapists for treatment.
during treatment, the child developed pancytopaenia (all blood products were low, including red blood cells) and became dangerously anaemic. at about this stage i discovered he was in foster care, because his biological parents suddenly crawled out of the woodwork. due to some legal technicality they still had a say over him in the legal sense. they then proceeded to refuse to allow a blood transfusion on the grounds that it was against their religion. i felt like i was watching a horror movie unfold before me. i could watch no more. i left it to the chemotherapists and didn't enquire about the child anymore.
the second incident was in some respects less dramatic. i saw an 8 year old girl who had fallen out of a tree onto a cast metal fence. the fence had sharp spikes and she had been impaled. when i saw her, she had four stabwounds in a row about ten centimeters apart running diagonally across her abdomen. omentum was protruding from one and she had an acute abdomen. fortunately she was stable.
i informed the mother that an operation was essential. she nodded. then she asked, "will you be giving her blood?" "i hope not." i replied. "good, because our religion doesn't allow us to receive blood." she didn't ask about the condition of the child or the nature of the operation or the chances that it would be successful or anything. she just told me that i was not allowed to give blood. "i would only give blood if it turns out to be a matter of life or death." i replied. "no, you may not!" she retorted.
i asked her if it was worth gambling her child's life (not her own life but the life of her child) on a religious ideal. but the blinds had gone up. she wouldn't even talk to me. she just kept repeating, as if in a trance, that no blood was to be given no matter what the circumstances.
the operation went well. one of the spikes had missed the aorta by about 2mm. slightly more medially and she would have been in dire need of blood to survive. while closing the multiple bowel perforations, i thought about her blase gamble with another human being's life. i also thought about the very difficult situation i would have been in had the aorta been injured. maybe the mother was willing to stand by idly while her own child expired, but it would not have sat well with me.
my feeling is that if an adult makes this sort of decision about their own life, who am i to go against it. but the children in these stories had no say. their lives were gambled with by others. they probably were too young to make decisions about religious ideals, and yet they were both being expected to possibly make the ultimate sacrifice in the name of religion. in fact they were going to be sacrificed by their own parents in the name of their religion.
south african health department, you're all a bunch of dumbasses. why do i say this? once again it has to do with our aids policy.
a doctor was suspended from work in kwazulu/natal for daring to give antiretrovirals to pregnant women with the virus. it is apparently against state protocol.
let's take a step back and look at this. the mother to child transmission rate of hiv, if my memory serves me correctly, is about 30%. if antiretrovirals are given before and during labour, this can be brought down to about 8%. if a caesarian section is thrown into the mix, the rate can be as low as 1%. now if we consider that at last count, the infection rate in pregnant women in the province was about 40%, it translates to a massive number of potential infections of infants prevented. this is apparently a violation of our brilliant government's aids policy and the doctor must be punished.
one has to wonder at the policy of the government. surely it is in the interest of the citizens to have fewer babies born with the virus? surely it is even cheaper in the long run. what possible reason could there be to not allow this?
once again the ruling anc has demonstrated their total disregard for its people. they are all, in conclusion, dumbasses.
we in south africa have been making it easier to study medicine. after all medicine should not be restricted to the 'privileged' few who have more than 3 possible synapses in their brains. we are truly the country of opportunity.
however, this may not necessarily be a good thing for patients.
when i was in witbank, we had a house doctor who could possibly be the stupidest person without diagnosed mental retardation i know. and he was a doctor. we nicknamed him blind chicken boy after the brilliant nando's ad that i've posted here. when he tried to examine patients, sometimes we had to move him up to the patient, like the trainer in the video.
he is the only guy i know who admitted a patient with a glascow coma scale (gcs) score of zero. when the other house doctors took him aside and told him the lowest gcs you get is three, he retorted that his patient's was zero. end of story. i must give him credit although for also being the only house doctor who admitted a patient with a gcs of 18. once again, if 15 is the highest, i assume the patient with 18 was hyper aware. i immediately looked for him. i wanted to ask what the meaning of this life on this mortal coil is. i couldn't find him though.
a friend of mine was in orthopaedics clinic. blind chicken boy came in and stood sedately at the door. my friend continued with his patient. it was a guy that had been operated for a fracture and needed his stitches removed. once the stitches had been removed, my friend turned to blind chicken boy. blind chicken boy said,
"doctor, i have a problem." he began everything he said with these words.
"what is your problem?" asked my friend dutifully.
"the patient in the ward with the tibula fracture has changed condition." only blind chicken boy knew what a tibula was, but we all assumed it was a bone somewhere.
"how has he changed condition?" asked my friend.
"he has just stopped breathing."
so blind chicken boy, when he came across a patient who stopped breathing, he had the presence of mind to call his senior. it seems a pity that he slowly walked to his senior, leaving the patient alone and then waited for his senior to finish with the out patient that he was busy with. no one could accuse him of being rude and interrupting people who were busy.
there was the other story when another friend was on rounds with blind chicken boy. they found a patient who was not doing as well as expected. my friend barked out instructions. get a full blood count. admit in high care. give a bolus of 300ml ringers lactate. report back.
about 2 hours later, when everyone was beginning to wonder what had happened to blind chicken boy, he suddenly turned up.
"doctor, i have a problem."
"what is your problem?"
"i have been looking everywhere and i can't find a bag of 300ml ringers lactate. there are only 1 liter bags."
in a recent post i touched on hierarchy in theater. it is necessary, but unfortunately it also adds to the notorious reputation of surgeons.
i have worked with arrogant bombastic surgeons who have blown their top during operations and shouted at and blamed everyone except themselves. i have even gotten angry with them, but i always held my tongue. you see even if i didn't respect them, i respected the institution that is theater. in theater there can be only one voice of authority and that is the voice of the surgeon. often surgeons don't understand this. they think they are in charge because it is their right or because they are so cool or some other deficient logic. i always imagine a governator voice saying: "i r surgeon! you must comply!"
but that is not what it is about. in the end it all boils down to the patient. everything that is done is done for the benefit of the patient. the cleaner in the back who gets the instruments ready does it for the patient. the sister who crisply palms instruments to the surgeon on his demand does it for the patient, not because he is so cool (although if he is a surgeon he is probably cool).
when the surgeon demands silence it is because his knife is poised precariously above the ivc and he needs to focus all his attention. when the surgeon demands silence, it is not for him, but for the patient. and for the patient, he had better get his silence.
there is also the aspect of respect, not so much for who he is but what he is. but once again, many surgeons misunderstand this. respect is a two way street. i believe i as a surgeon can't expect respect from the sister or the anaesthetist unless i respect them for what they are. even the assistant i will always respect.
so in conclusion, i am not the type of surgeon who says "i r surgeon! you must comply!" but when i'm in theater i do expect a very high level of excellence from everyone there. the hierarchy must be maintained.
south africa can be a violent place, but sometimes one can't help cracking a smile.
one case i remember was basically a form of domestic violence. a woman was shot. the bullet entered her right breast, passed through her diaphragm, through her liver, through the upper pole of the right kidney and out her back. her abdomen was soft. she remained stable. the ct showed no signs of continuous bleeding or any intra abdominal calamity. i observed her in icu and she did well. the hematuria cleared up. the liver sorted itself out. the intercostal drain was removed after about a week and she went home.*
i can't help myself. i always ask what happened. her story i remember well. she, her boyfriend and a friend of her boyfriend were together somewhere. they were either drowning their sorrows or celebrating something. whichever of the two, it was facilitated and lubricated by large amounts of alcohol. the boyfriend and his friend were both cops and one or both of them had their service guns that night. at some stage, the friend apparently stole the boyfriend's gun. he went off to hide it, but my patient saw him. she confronted him and told him to give it back. in the ensuing argument, according to her, the friend fired a warning shot into the air and then a second shot into my patient.
in my mind i pictured the scene. i don't know why the one cop stole the other's gun. i don't even know if he really did. maybe he had lost his and was afraid of repercussions at work and in his drunkenness it seemed like a good solution. maybe the ethanol caused a more imaginative version from my patient. but i do know she was shot.
the thing that made me laugh about this story was the warning shot. i could just imagine the thought process that went through his inebriated mind. in the moment of anger that drove him to commit this crime he must have remembered his police training. instead of just shooting her outright he had the presence of mind to first fire a warning shot into the air. i can't think what the warning shot was warning her to do. was she supposed to stop nagging him? was she supposed to just keep quiet? or was it just a warning of what was about to befall her? she clearly didn't heed whatever warning it was.
*although that is not the aim of this post, maybe i should say a bit about the so called conservative management of gunshot abdomen. the literature only supports two cases where it may be possible. the first is gunshot abdominal wall (this is strictly speaking not actually a gunshot abdomen). the second is gunshot of the dome of the liver without any real intra abdominal trajectory of the bullet. i personally think that it can be extremely dangerous to even attempt so called conservative management of gunshot abdomen and it is usually best to open if there is any question at all.
assisting isn't rocket science. it's not difficult. you basically need to give the surgeon exposure. if you can't do this, then just do what he tells you. that's all.
having said this, to work with a good assistant is amazing. a good assistant can predict what is going to happen next and get everything lined up so it all just goes that much easier.
as a student i assisted quite a bit. as a junior doctor i assisted a fair amount. as a registrar i assisted after hours for extra money. i can assist and therefore i can direct and teach a poor assistant. in fact, for me the ideal assistant is an inexperienced one that i can train and develop to my specifications. but i also use young doctors because they are the ones that need the money. they are the ones that work for the state and are underpaid. i remember how i needed money in those days and therefore i usually use these doctors. the practice that i work for has occasionally basically requested that i use the older gps but i feel a certain obligation to the state doctors.
but, especially when i am trying to favour those who need the money, nothing irritates me more than having to phone a whole bunch of people before i get an assistant. i mean when someone says they are on call or out of town, then i have no problem, but when they say they are tired or have a headache or need their beauty sleep or whatever they tend to fall to the bottom of the list of people i call. i recently was told by one of my assistants that another guy was wondering why i phone him so seldom. i didn't say anything, but i thought of all the times i did call him and he wasn't available because of 'social obligations'. it's at times like this that i realize i can be a typical surgeon. i don't want to know about inconvenience and the like. i just want an available assistant at midnight when i have a gunshot abdomen who is decompensating.
i recently lost two great assistants (they moved to canada where they are presently freezing). so now i am trying to reestablish an assistant base.
but it can be difficult to assist (unless it is your passion). no matter the time of day or night and no matter how little sleep you've had in the last week, when you are operating, all your senses are sharp. you are fully alert. you are fully alive. but to simply hang on a retractor at 3 in the morning while the surgeon works his magic can be mind numbing. and mind numbing when fatigued means sleep and sleep means poor assisting.
except the exceptions. many years ago while i was a medical officer in surgery (before i officially started specializing) we had a house doctor who had a special talent. awake he wasn't a particularly good assistant but in the early hours, he would hook the morris into the wound, push his feet up against the table, throw his head back and fall asleep. in this position he gave such good exposure the surgeon would demand total silence just in case someone woke him up.
in a previous post i came across as caring and in touch, but sometimes i forget to be this.
i was doing an above knee amputation. my consultant had recently explained a technique whereby one attaches the muscle to the bone stump directly and not just to the membrane around the bone (the periosteum). this required that holes be drilled into the bone which would be the anchor points for the muscle. i had never done this before and was grappling with the drill.
at this point, as serendipity would have it, the small porthole window of the door leading to the scrub room filled with the eager faces of a bunch of youngsters. a theater sister who was taking them around came in and informed me that they were school students that were considering medicine as a career and had come to the hospital on some sort of career day outing. she asked me if i'd mind if they came into theater in groups of two to get a better understanding of what we do.
now, understand, i love surgery. any opportunity i get to promote it i take, so i thought this was a great idea. of course i said yes. the first two came in.
let me take a moment to sketch the scene. i've just removed the leg. the bloody stump is sticking out like some cheap prop in a second rate horror. i'm trying to get the bloody (or should i say blasted) drill to work, so i'm not really doing anything besides getting more frustrated by the moment. the students come in and see this setup. not being overly busy, i ask them where they are from. the first guy says he is from a particularly good rugby school in town that, coincidentally, had just lost the gala match to my old school. even the drill could wait. i asked him about the game and what he had thought. he seemed a bit withdrawn and non responsive. i couldn't understand this. it had been closely contested and although his team had lost, they had played well.
then i noticed that the poor fellow was pale and his eyes seemed to be glazing over. the sister quickly took them out. no more scholars came in after that. i did see the horrified face of one young girl peep in just before they moved on. i think i even saw tears. later i heard that some of them needed to be resused with tea and sugar.
in retrospect i was a bit foolish. not all school children who think they want to be doctors are cut out for the job. and not all doctors are cut out to be surgeons. if i had had the opportunity to go into theater as a school student i'm pretty sure i would have thought, 'cool! he's actually cutting a leg off!! wow!!' but that doesn't mean these particular students are also going to think like that. i actually should have known that it was fairly unlikely that my and the sister's good intentions would have fallen on fertile ground.
once again surgexperiences will be visiting this blog on 2 march. surgexperiences is a blog carnival about surgical blogs. but it is really open to all medical blogs with a slight surgical slant. so all my favorite blogs and bloggers, please submit your posts here.
i recently read quite an interesting post on one of my favorite blogs. it had to do with religious zealots. it reminded me of two experiences i had, both of which i found disturbing.
south african health department, you're all a bunch of dumbasses. why do i say this? once again it has to do with our aids policy.
south africa can be a violent place, but sometimes one can't help cracking a smile.
assisting isn't rocket science. it's not difficult. you basically need to give the surgeon exposure. if you can't do this, then just do what he tells you. that's all.
this is a riot. i can't help loving my government. such ineptitude is difficult to fake.
