small cut, big surgeon?

the prof always used to say,
"small cut, small surgeon. big cut, big surgeon." in trauma this made sense. but when the world was moving towards less invasive methods this seemed somewhat redundant. and yet when the world had all but rejected open cholecystectomies in favour of laparoscopic procedures, in the prof's firm we were still cutting 20cm incisions below the right costal margin.

in my private assistances i was learning things the prof didn't even dream about. it all came to the fore one fateful day.

i was in the prof's firm. my medical officer was a rotating orthopod, a massive guy with a massive sense of humour and, unfortunately a massive mouth. we were on call. and as with calls, we were busy. the orthopod was sorting out the constant stream of patients in casualties and i was operating way into the wee hours. every now and then he would come into theater to update me on what he had done and ask my advice when he wasn't sure what to do.

that night i did, among other things, two appendisectomies on two young women. as was my habit by this time, i removed the appendixes through incisions slightly smaller than 1cm. i somehow thought young girls would appreciate this from a cosmetic point of view. it also made the operation more challenging. the orthopod was amazed. he had never seen such a small incision for an appendix before. in fact he could not stop speaking about it. truth be told, i appreciated the attention. after the operations i placed nice large plasters over the wounds to hide the evidence from the prof.

next morning we did rounds with the prof. when we got to the first patient, the orthopod leaned over to me and whispered that i should show the prof the wounds. i told him in no uncertain terms that he was not to mention anything to the prof at all about the size of the incisions. i could see the disappointment on his face.

when we got to the next appendix patient, the orthopod was literally biting his bottom lip to stop himself from speaking. again i warned him not to say a word. unfortunately he could no longer hold his mouth.
"prof, take a look at the size of bongi's wound!" my heart sank. i hoped if i just maintained composure the prof would let the comment pass and move on. and it looked as if he would. but then big mouth went on about it being such a small wound. this was too much for the prof's inquisitiveness. he opened the wound. then all hell broke loose.

the rest of the rounds entailed the prof berating me consistently and in front of all the students and patients that i must never ever make such a small incision ever again. it went on and on and on. in the end i phased out, just repeating 'yes prof, sorry prof' when there was a lull in his constant stream of chastisement. the orthopod also realized his mistake and looked quite sheepish. afterwards he did apologize. i appreciated that.

there was one more funny sequel to this story. about a month later once the orthopod had moved on and had been replaced by a general surgeon medical officer i once again did an appendisectomy. i was quite careful to make a 3cm incision this time around. on the rounds the next day, the prof decided to check the incision to make sure i had taken his advice.

he slowly lifted the plaster. he took one look at the incision and stepped back.
"no, bongi, no! what have you done?" my medical officer looked confused. he turned to the prof and said.
"is the wound too big or too small?" that did not go down well, especially when i laughed.

there is no pill for stupidity

when the superintendent of the referring hospital phoned, he said;
"there is something funny on the x-ray!" what exactly the funny thing was he could not tell me. he could tell me what it was not. it was apparently not free air in the peritoneal cavity (indicating perforation of some part of the intestinal canal) and it was not air fluid levels in the small bowel (indicating obstruction). it was simply something funny. he also mentioned the abdomen was acute (a surgical term pretty much meaning an operation was indicated). i told them to send.

when the patient arrived, the abdomen was acute as they had said. there was also no free air in the abdomen as they had said. but i found that i did not burst into spontaneous laughter when i reviewed the x-rays. it was not as funny as the referring doctor had said.

what it did show was a full colon. but it was the most loaded colon i've ever seen on x-ray. usually feces is a mix of solid and gas, but this showed only solid matter filling the entire colon. i asked the patient when last she had passed a stool.
"i don't pass stools." was her simple factual reply. i wanted to ask her if she thought it was normal to not pass stools and where did she think all the stuff that she was throwing in above was going. but it was late and i wanted to get the operation behind me. so i tasked the junior doctor with getting the patient to theater and waited for his call.

i opened in the midline. there was a perforation in the sigmoid caused by pressure inside the lumen of the bowel, causing necrosis of the retroperitoneal region. that was something i've dealt with many times. but what was 'funny' was the content of the colon. the entire colon was filled with what looked like feces but was as hard as rock. i spent most of the operation milking this stuff out and dumping it in a large basin. in the end i had removed about 4kg of rock hard feces as well as the sigmoid. it was not fun.

while i was evacuating this colon i had time to reflect. i couldn't help once again considering the fact that this woman had just accepted that she did not pass stools as normal. she had not sought help until the pressure had ruptured her colon and endangered her life.

yes indeed, there is no pill for stupidity. . . you must operate.

surgical ego

i don't know why surgeons have such inflated egos. maybe it's that the type of person that decides to do surgery is arrogant to start with. or maybe constantly being in a position where someone's life may hang in the balance based on your decision cultures a confidence which flows over into arrogance. whatever the reason i learned to read the ego of fellow colleagues and sometimes even swing things in my favour.

i was always short of money during training. towards the end this became much worse. i used to work in casualty units (er doctor) but when my prof found out that i was moonlighting he threatened to fire me. this door was closed and double bolted. he would only permit us to do private assistances.

so when one of the junior consultants asked me to assist him with a few private cases after a 36 hour shift with no sleep, i jumped at it. sleep be dammed. i needed the money. besides, assisting is a darn site better than casualty work.

the cases went well and i felt that i should be able to make ends meet with the amount of work i would get from assisting this surgeon. i was quite excited about it. but then, as life would have it, i got no more calls from him. once again my situation became tenuous.

then, out of the blue, he called me again. it seems his regular assistant was on call. it was my moment. but this time i knew i had to impress.

we started the operation. i did the usual things an assistant needs to do, but i watched every move he made carefully. i was looking for a way to get at his ego. then he did something that was ever so slightly better than mediocre. it was my chance.

"that was beautifully done! it is so great to assist you! i learn so much doing these assistances!" cheesy i know but i was desperate. besides it was also an interesting test to see if my theories about surgeons' egos were true. i was willing to be cheesy in the name of science. it was but a small sacrifice that i willingly made for the progress of knowledge.

and sure enough it worked. just a few choice words here and there so that the surgeon felt he was brilliant and i quickly became preferred assistant. i relied on that extra income and it made a great difference.

p.s although i had also done some great research, i unfortunately never published. somehow i just never got around to it.

boemelaar

if i were ever to write my memoirs i'd probably use my blog posts as a sort of template. that having been said i suppose i should mention the following episode on my blog (bearing in mind i'll probably be so senile by the time i write my life story that i'd otherwise forget it)

it was in the last year of my training. due to a number of circumstances that i might go into more fully in my memoirs, i found myself without a home. i also was only getting a fraction of my salary. i found myself homeless and very nearly penniless (in south africa i should say centsless or is that senseless). to quit surgery was simply not an option. desperate times called for desperate measures.

next to the hospital was a block of flats (apartment building) that the students used when they were on call. the department of surgery had three such flats allocated to the students rotating with us. the lady that handled the flats for the department was one of only a handful of people that knew of my plight and she was willing to help. she gave me the keys to one of these and 'forgot' to ask for them back.

the flat was not made for living in. firstly there were two beds in the bedroom and two beds in the lounge. there was a kettle and one coffee mug. there was nothing else. every day the flats were cleaned out, so there could be no sign of permanent occupation. if the powers that be heard that the senior registrar was squatting in one of the call rooms designated to the students i would be in trouble, but more seriously, i would have no place to lay my head down. so each day i would pack up my stuff and put it all in the boot of my car. i did have a fold up camping stool that i could hide in one of the cupboards at the top where no one would look and that was the only sign of a permanent resident that i left in that flat.

after work each day i would come 'home', put my suitcase on the one bed, take down the chair and make myself some coffee. i would study as best i could under these dismal conditions. i would then sleep in the bed next to the bed with my suitcase (usually in the lounge). in the morning i would take a bath, pack my bag, hide the chair and my coffee, evacuate the room and go to work. the one advantage is that the cleaners would always make my bed and there was always enough toilet paper. i lived like this for just over 6 months and it was not fun. to be honest i started doubting i could actually pass surgery because my mind was not focused on it to the required degree. then a friend demonstrated to me that he was indeed a friend.

when this particular friend found out about my spartan existence (i think the lady in administration accidentally let slip that i was living there) he invited me to move into his flat with him. he had a three bedroom place and he was alone. i accepted.
he never asked rent of me and when i offered what i could, he declined, saying there was bound to be a time when i could pay him back in kind. the third bedroom served as my study and this is where i spent every spare moment for about five months just before my finals.

i truly feel that if it was not for this friend's intervention in a time of my life when i really needed it, i would not be what i am today. i do not believe i would have or could have passed surgery if i had stayed in that hellhole right up to the end.

no winning

another story of the futility of trying to get it right in kalafong happend to a friend of mine.

the patient was stabbed just outside the hospital at the taxi rank. his friends immediately carried him into casualties. my friend and colleague happened to be there at the time. he immediately saw that the stab was probably to the heart and the patient was in trouble.

my friend grabbed the gurney and charged off to theater. amazingly enough he got the patient onto the table almost immediately (very nearly unheard of in kalafong). similar to my previous story, by the time he put knife to skin, the patient was in exitus.

the surgeon ripped his sternum open at double quick time. the pericard was a large sack of blood. the heart just couldn't compete against this and had stopped beating (this is not good). the surgeon opened the pericard and drained the blood. this allowed the heart to start beating again. unfortunately with the first contraction a stream of blood shot out of the left ventricle.

a steady hand and a few stitches later and the heart was no longer leaking. all that was left was to close.

the next morning, when i heard the story i was pretty impressed. a general surgeon had moved into a domain that he was not fully comfortable with and managed to pull a patient through that had actually been stabbed in the heart and that in the left ventricle. when he presented the next morning, once again the professor ripped into him.

it seems, according to the professor that the correct entry should have been a thoracotomy (between the ribs) rather than a sternotomy (through the middle chest bone). the small matter of getting the patient on the table literally about 10 minutes after the incident and pulling a guy through that had received an essentially fatal wound seemed of little concern. at a stage the prof even attacked my bewildered friend personally. as usually we all sat in silence. it was not the first time and it would not be the last time that this happened. we had all at some or other stage experienced the wrath from on high and it was just his turn.

at a stage my friend rose from his seat in a seething rage. he stood for a moment. he then seemed to realise that the safest move for his career would be to just sit down again. this he then did, but i'm sure i saw steam rising from his head.

after this fiasco, i went to him and said that despite what anyone says i thought he had pulled off something amazing. i even wrote a message on the tea room notice board saying that he was the man. he laughed at this and all seemed better.

skewered

in surgical training there is bound to be bloodshed, but it is always difficult to handle when it is at the hands of your fellow surgeons.

i was in the last months of my training. i was not on call that night. then a friend of mine working at kalafong phoned me. he sounded desperate. when he sketched the situation i understood why. he had admitted a patient with rectal bleeding. the patient, however, was pouring massive amounts of blood in a constant stream from his anus and despite two large bore lines was rapidly becoming hemodynamically unstable. why doesn't he phone his consultant on call, i wanted to know. apparently he had. the consultant had made the telephonic diagnosis of an aortaenteric fistel (an opening between the largest artery in the body and the intestines causing massive bleeding and almost always fatal) and had told my friend to put him in a side ward and to leave him to die.
"but i just can't do that!" he said. "it's just not right." i understood. i told him to get the patient to theater and i'd join him there.

when i got there the patient was not doing well at all, despite a massive resus attempt. two large bore lines were running blood into him and a three lumen cvp was pumping fluid. the anesthetist also looked pale (i don't know what his hb was though).

although the probable source of bleeding would be the colon, i knew there was an outside chance that he could be bleeding from his stomach. (stomach bleeding usually comes out below as a black sticky diarrhea, but if the bleeding is so swift that there is no time for the stomach juices to change it it can still look like blood). i didn't want to waste any time once the abdomen was open, so i quickly stuck a gastroscope into his stomach. it was clean. i knew what the target organ was.

the anesthetist leaned over and said.
"if you're going to do something, you need to do it now. he is on intravenous adrenaline and only oxygen inhalation and anything more will kill him."
i got the message. we ripped the abdomen open. i clamped across the rectosigmoied junction and started clamping off the blood supply to the colon, starting distally and moving up. i reasoned that the most likely diagnosis was diverticular bleed although they seldom bled so impressively and diverticular disease is more common distally in the colon. it made sense at the time.

that was without a doubt the fastest bowel resection i've ever done, before or since. when i got to the mid transverse colon, minutes after starting, i opened the lumen. there was no more active bleeding. i handed over to my friend. i told him to pull out a colostomy and get the patient to icu.

on the way home, i felt elated. i had saved a life where it seemed there was no hope. it had been close, but we had pulled a miracle off, despite the fact that the consultant had washed his hands of the case by making a ridiculous diagnosis over the telephone.

the next day i couldn't wait for the morning meeting to bask in the glory of our night's work. the fact that the consultant who had essentially fobbed my friend off was sitting right behind me in the meeting made our escapades so much sweeter. sure enough as my friend started presenting i saw a smile of achievement cross his face as he spoke about the case. then everything went wrong.

what we didn't know is that the professor had written an article many years before about the operative approach to bleeding diverticular disease. it required segmental clamping of the colon and separately opening each segment until the bleeder was found. then only that segment was to be removed. the fact that our patient didn't have a discernible blood pressure at the time of the operation and was essentially too unstable even to receive anasthetics mattered little to him. the fact that we hadn't done it according to his prescribed method mattered a great deal. he then told us the patient would have survived if we had used his method. we pointed out that the patient was indeed alive. prof was on a roll and didn't want to be interrupted by bothersome facts.

as we say in afrikaans, teen die einde, kon die see ons nie skoon was nie. he just kept on ripping into us. the consultant sitting behind me at no stage mentioned that he had refused to come out to help. he just kept quiet and left us to be destroyed and humiliated for all to see. by the end i was actually smiling to myself. bloody typical, i thought. i was just worried about how my friend would take it.

anyway, the patient survived. my consultant who was not involved in the case later congratulated us on a job well done. he said a few other not so complimentary things about the professor that i think are better lost in the sands of time now, but made me feel a whole lot better at the time.

p.s that friend of mine not only dropped out of surgery but completely left medicine in favour of another life altogether. and he was a great surgeon.

alone

the south african sink or swim approach to medical training tends to grow on you, but in the beginning it could be quite terrifying.

i was a house doctor. in fact i had only been a doctor for about a month and a half. i was realising that there was in fact knowledge in my head. when i saw patients it seemed to come to the fore and i actually knew what to do. it was an exciting time. all those years of study seemed less in vain.

so when i saw a young lady in casualties with severe abdominal pain, one of the conditions i considered was an ectopic pregnancy. sure enough her pregnancy test came back positive. i immediately knew what confirmatory test to do (we didn't have sonar or ct scan, scanman). shortly thereafter i stood with a syringe in my hand full of blood that didn't clot. it was all coming together so well. i had single handedly made the diagnosis of a ruptured ectopic pregnancy. i was actually using my years of study. i was being a doctor!
i quickly booked theater and called the cuban gynaecology consultant. he soon arrived. like a proud cat with a dead mouse i showed him the syringe with the unclotted blood. he obviously agreed with my diagnosis and management plan. i was the man.

then he turned to me.
"i need to go to the bank" he said. "will you be able to handle her in theater?"
"definitely not!" i replied. "you'll have to come with me."
"but i'm on my way to the bank now, so you go ahead so long. i'll join you when i get back. anyway it's just like doing a sterilization, except the tube is more bulky." at that stage in my career i had in fact done maybe three sterilizations. i started sweating.
"i don't think i can do this" i retorted.
"you'll be fine." and with that he turned and walked out. i couldn't help wondering if the patient was going to be fine though.

so i took her to theater. i was so scared i could almost not talk. but what could i do? i was the only one there. and where i did my house doctor year, we operated without an assistant. there was no one available to assist anyway. i did the operation alone. my hands were shaking so much i'm surprised i got it done.

towards the end the consultant did arrive. his banking done, he was free to observe me closing the abdomen. pity, because i still didn't have steady hands by any measure and i probably looked pretty clumsy.