flatus

surgeons like flatus. it is a sign of an intestinal canal that is at least not totally dysfunctional. after most operations we ask the patient the next day if they have passed any and hold our breaths for the answer. if the answer is no, the bowel is still sulking and refuses to kick into gear. if the answer is yes, we get a warm fuzzy feeling, permeating right down to our toes. but flatus humour is not lost on us.


two stories come to mind. one happened during registrarship and one happened many years before when i was at school. lets start with the former.

i was the senior registrar in the boss's firm for so called rounding off. it was the toughest rotation as i have said before. the boss had a particular interest in everything anal, including flatus. he often waxed lyrical about how normal it was and how much wind the colon should be expected to expel in a day. but i did have a rotating orthopod (as part of surgical training you are required to rotate through the other disciplines and this guy was presently rotating through general surgery).

this guy had a very laid back approach to life. he was somehow immune to the pressures of surgery (maybe because he knew he was leaving after a short month and also, as a guest he had no direct responsibility) and he had a vibrant, spontaneous sense of humour. one day we were walking down from 54icu which, due to mad apartheid planning, was miles away from the rest of the hospital. on the way down, another prof joined us and engaged the boss in conversation. i moved back from my designated place at his right hand side and followed with the rest of the firm at about 5 paces behind, next to the rotator.

at about this stage it became apparent that someone's colon had done it's duty. the orthopod started making faces and not too quietly lamenting our lot in having to be subjected to smelling the very displeasing aroma. obviously the offending colon belonged to at least one of the professors walking in front of us, so i told the guy to put a plug in it (i qualified that i meant his mouth because i was afraid of exactly where he was likely to put the plug). but he just would not stop.

after a while the boss obviously heard the continuous tirade of disgust from his entourage following in the foul wake behind him. he turned around and said;
"'skies mense." (excuse me guys). without missing a beat this upstart orthopod replies;
"prof, i know it is normal to pass three liters of flatus per day, but do you have to pass it all at the same time?"

everyone fell apart.

resus with hands tied behind my back

from the previous post you might assume that i became quite proficient in resuscitating poison cases. you would be right. but sometimes knowledge and skill are just not enough.

during my community service year in qwaqwa we were required to do one call a month at the primary hospital. maybe hospital is a bit of a strong word for what that place was, but nonetheless, we did our duty there.

i was in casualties in this 'hospital'. a young guy came in with the typical organophosphate-like symptoms. pinpoint pupils, severe bradycardia, hypersalivation and whole body fine muscle fassiculations. i knew exactly what to do. i sent the nurse to get atropine as i quickly dripped him. i then immediately phoned for a transfer to the secondary hospital, thinking i'd start the treatment, but if he needed intubation, they would need to take over.

soon the nurse came back. he had one ampule of 1mg atropine. i thanked him but explained that we would need much more. i injected the 1mg. the pule rate sped up to a roaring 50 beats a minute and then gradually decreased again. i waited with baited breath.

after what seemed to me to be ages the nurse slowly strolled back with the news that there was no more atropine in casualties. great. i then told him to go through the entire hospital and bring me ...all... the atropine in the entire hospital. he casually strolled off.
meanwhile i shot through to the chemist, which was just about to close for the night, and asked for atropine. the lady manning (womaning???) the place was not impressed with having to help me. reluctantly with deliberately slow moves she went to the back. after a while she came back with an empty box. yes, all the atropine was finished and they hadn't bothered to order more. i told her the box looked nice but it is probably not going to work. she could keep it.

when i reached casualties the nurse was still not there. the patient looked somewhat unwell. i tubed him and set someone to bagging him. then the nurse returned. he had another ampule of atropine. that was the last of the atropine in the entire hospital. i injected it for what it was worth. then i waited.

finally after about an hour the ambulance arrived and we turfed the patient off to the secondary hospital.

the next day i heard he had made it, despite the empty box.

resus fun.
cuban resus.
tube.

cuban resus

before i get to the point, allow me to quickly take you through another resus.

i was a community service doctor in qwaqwa (absolutely unpronounceable to the western ear. there is even great variation between the nguni and sotho pronounciations). although i had been a mere house doctor the previous year the system was such that i was the senior on call. the house doctor called me to casualties. the patient's eyes were dilated. the ecg looked flatline. the house doctor had already given adrenaline to no effect. then i saw a lonely qrs complex on the ecg. it almost seemed out of place.

"give atropine!" i yelled. shortly after the atropine, the ecg improved, but only to a rate of 40. the other thing that happened which took me completely by surprise is that the pupils became pinpoint. this shouldn't happen with atropine. and then i realised. the patient had been poisoned with an organophosphate-like-something. that night we pumped 160mg atropine into him. amazingly, he made it.

this was one of a number of poisonings around that time, so when my dog was poisoned, if i had been less distraught i might have thought to pump it full of atropine. as it was i watched in horror as it convulsed and died in my arms. my cuban neighbour learned from my mistake. he stole atropine from the hospital. when his dog started convulsing and seriously threatening to die, he fulled it up with atropine and it survived. that was the first cuban canine resus i saw.

another cuban friend produced the second. in qwaqwa, biliary (a canine disease carried by ticks which is not dissimilar to human malaria) was common and killed entire litters of puppies. there was, however, one old feral dog that seemed to be immune. he belonged to no one, was completely tick ridden and survived everything. he was also the father of all the litters that were systematically wiped out by the disease. one of my cuban friends took one of these semi-wild puppies as a pet. when it got sick i advised him to dissociate himself emotionally and move on. after all it was just a pavement mongrel that was worth nothing. he disagreed. he told me that, like malaria, biliary in dogs is fatal because of haemolytic anaemia, so therefore all he needs is a blood transfusion to keep him alive. if that works he will become like his father, the dog that can't be killed.

apparently blood transfusions in dogs are not as complex as in humans. they don't have compatibility problems. any dog can donate to any dog. how do i know this? because after the cuban friend of mine drew blood out of the old dog and injected it immediately into his sick puppy, i went to the trouble of finding out about this point. amazingly enough, his puppy was the first dog in about 5 years at the hospital that survived to adulthood. and it became an immortal like it's father before him.

so, in conclusion, cubans know how to resus, even if the patient is a canine.


in the series.

resus fun.
tube.
resus with hands tied behind my back.

tube

i mentioned a possible series. i thought i better at least try. so lets talk about another tube incident.

i was in my icu rotation. our icu was 23icu. but there were about another 4 icu units in the hospital and we had a number of patients spread out throughout the hospital.

late one night i got the call.

"hello, it's sister x in 54icu. could you please come and tube mr y?" i had no patient at that time in 54icu. 54icu was the internal medicine icu.

"who's patient is mr y?" i asked.

"he is internal medicine's patient." she replied.

"well then call the physician on call for icu." i suggested.

"he is here and he asked me to call you." it was time for my standard question.

"should i run or can i walk?" 54icu was about 500m from 23icu and it was an uphill route. i hoped for a gentle walk.

"i think you should run!" i set off. en route, i thought about what i would encounter. an internal medicine registrar was asking for backup in an attempt to tube a patient. i got ready mentally to do a tracheostomy.

i charged into 54icu and what a sight i met. the patient was blue, a colour that in my humble opinion, did not suit him. he was lying in a puddle of blood and vomit. there seemed to be a flurry of activity around his bed, but not much was being done. i decided to attempt to tube him once before i turned to my trusted friend, the knife.

the intubation was quick and easy. once i had done it i couldn't help wondering what all the fuss was about. the patient regained his pink colour before i regained my breath. if i thought the guy was capable i might even have asked the physician to intubate me. i thought better of it though.

"thanks a lot!" he said.

"no problem." i replied. i thought of making some witty comment about needing the adrenal rush or that the sprint up to 54icu could only do me good, but i was still too out of breath. all comments i thought of in that moment were more than one syllable.

"can i just quickly ask you something?" he continued.

"no problem." i repeated. (i was tired.)

"when you intubate, is the trachea anterior or posterior of the epiglottis?" i did not let my face betray what i thought of the question. i just gave a factual answer. he at least had the guts to ask. at least i knew why he had struggled.

resus fun.
cuban resus.
resus with hands tied behind my back.

resus fun

some time ago i read a post about the worst resus ever. i thought i've seen worse. so here is the first installment in what might be a short series.

i was a junior registrar i was working in kalafong/hell. it was late at night. my house doctor and i were relaxing in the anesthetists' tearoom. we were the only one's there.

suddenly the phone rang. it was a sister in high care.

"hello, can you come and tube a patient?" i had no patients at that time in high care.

"whose patient is it?" i asked.

"the physician's". (small note. in south africa, we call an internist a physician. the word physician is not generally used for doctor. in fact if you were to call a surgeon a physician, he would probably be offended.)

"why doesn't he intubate his own patient?" i asked.

"he is here trying but he needs your help." the picture came into focus. i asked my standard question.

"should i run or can i walk?"

i entered high care out of breath, even though it wasn't all that far from the tearoom, my house doctor in tow. i expected to be given charge, but the physician was at the head of the patient. he immediately told me i was there to support and that he was going to tube. i took in the scenario.

there was a 20something male in clear distress. the physician was holding a mask to his face, making sure he formed an airtight seal between his skin and the mask. only problem.. it was a venturi mask that is not meant to be used in a resus and has large holes on the side. a seal, airtight or otherwise, is useless. also you can't actively pump air into the lungs, so if the patient is in trouble, in trouble he will remain. i took a step back. my house doctor and i exchanged glances.

"amazing!" she remarked. "i can't believe what i am seeing." i wasn't sure what to do. he had told me in no uncertain terms that i was not to take over and yet everything else about what he was doing was uncertain to say the least. to try to somehow get a better understanding of what was happening i tried small talk.

"what's wrong with him?"

"kidney failure and now pulmonary edema."

"he looks pretty pale."

"yes, his hb is 4" (extremely low but probably a chronic state.) "in fact i think i'd better order him some blood. here, hold the mask while i draw some blood." and with that he moved away from the head. this clown was actually going to draw blood while his patient died. before i could say anything i found myself holding the ridiculous mask to the patient's face while the physician moved to the arm and commenced drawing blood. i had two immediate thoughts. the first was that my senior registrar would walk in and see me holding this pathetic mask to a dying patient's face. i would never live that down. neither would the patient.
the second was that the physician had relinquished the head. i was in charge! immediately i told the sister to get the ambu mask and bag. (this is the correct mask to actively pump air into the lungs.)

i turned up the oxygen and began pumping. i then got the laryngoscope ready. i injected a bit of dormicum and prepared to tube. as i started to tube, the physician moved back to the head and tried to shift me out of the way. there was no way i was going to let him at the patient again. i tubed while he tried to shoulder me out the way. i just ignored him. i checked the position of the tube, told the physician to start bagging the patient and left.


other posts in the series.
tube.
cuban resus.
resus with hands tied behind my back.

surgexperiences 116

welcome to surgexperiences, a collection of surgical tales. pull up a chair and engulf yourself in close up stories of surgery.

lets kick off with what i experienced as a most disturbing story about a threat. with all the people surgeons deal with, occasionally one is bound to run into a whackjob. dr bates, keep yourself safe. my favorite quilt maker also talks about how some patients can be a nightmare. but her worst?? i think not.

the privilege of being allowed into a very intimate time of a person's life is beautifully illustrated by buckeye. he also brings us a thought provoking post looking at the line between life and death. in the present age, where exactly does this line lie?

surgical emphysema! if it didn't imply bad things, we would all love it. so go and crunch some crepitus with aggravated.

a typical story about the dangers of walking your grandmother to church is brought to us by medstudent101. i'm sure everyone in surgery has dealt with this exact patient in their practice. also take a look at the very relevant cartoon on the top left.

chris links to a story reminding us who the real victims of war are.

sterileeye brings us two great posts. the first is one more educational post about a gastrectomy and a bit more. the second touches on something dear to all surgeons' hearts. the right to say what they want to during operations. just try to remember when the patient is awake. there are also some good comments.

if you want to have an idea what it's like in an operation, there is only one place to stop. sid once again paints a beautiful picture for the less initiated. because, yes sid, it is beautiful.

herrera gives an educational piece on dealing with cholesterol. nice, but i'm just wondering about "reasonable amounts of tobacco".

i personally think keagirl has reason to be smug (even if she is a urologist).

intraoporate orates a beautiful piece about something we all feel, usually too often, exhaustion. for those of you who haven't yet found this gem of a blog, catch a wakeup and take a look.

tia. us africans know what it means. take a look at amanzimtoti's schweet blog.

alice looks at the difficult question of dnr and how to break it to the family.

terry shares a strange quirk of a nurse she had the 'pleasure' of working with.

bruce gets published in the new york times health blog. i was glad to see him discuss a point i recently touched on too, although the question of personal advocacy verses guardian advocacy makes it slightly different.

kim may be burning the candle at both ends.


last and very possibly least, take a look who is a future guest on the doctor anonymous radio show (top right)

and that's it for this edition of surgexperiences. please send submissions for the next edition to this link. also, for anyone wishing to join the growing family of surgexperience hosts, contact jeff, the mastermind behind this humble venture.

please also don't hesitate to link to this surgexperiences from your own blogs.