Wednesday, May 07, 2008
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.