pointless

i've put off posting about a patient i once had in paediatric surgery because my writing could never justify how i really felt about him, but i suppose i should at least try.

when i rotated through paediatric surgery, there was a memorable patient. let's call him k. when i knew him he was 2, but his story started long before that.

k was one of a set of twins. for whatever reason his mother favoured the other one. this means she lavished what she could on his brother. what she could lavish was nothing more than food. k became very malnourished. around roughly their first birthday the mother decided she was tired of k, but how do you get rid of a baby? she decided to poison him. she gave this poor malnourished child something to eat that was supposed to kill him.

i still don't know for sure what she gave him, but it was amazingly corrosive because it burned his epiglottis almost completely away, it destroyed the opening to his trachea and it essentially destroyed his esophagus. he had a tracheostomy through which he breathed, a gastrostomy through which he was given food and because he couldn't swallow, there was a constant stream of drool running over his lower lip. he also could only mannage a strange low pitched moan if he tried to make a noise.

when i worked there, he had been in hospitals for a full year. he was a delightful child. i started work every day by giving him a hug. i figured love was something he hadn't seen too much of in his short life and it was something i could do for him. he seemed to enjoy it.

then one day, while we were in the morning meeting, we got a call that little k was dying. we rushed down. in the ward we found that he was blue and had stopped breathing. my senior colleague ran up to him, ripped out his tracheostomy tube that was blocked and quickly inserted a new one. he quickly recovered. i did not.

such a simple problem like a blocked trache tube had almost meant his death and that in an academic hospital. what chance did he have for the future? i considered adopting him then, but after much thought decided that if i wanted to adopt every child that i met in my profession that had a raw deal in life i'd have to start an orphanage and drop aspirations of becoming a surgeon.

time went by as it tends to do and my time in paediatric surgery came to an end. i saw k a number of times because i often went to his ward to give him a hug if i had a moment. then one day when i got there i heard he had been sent back to his referring hospital. he was supposed to follow up again in one year for a more definitive surgical repair.

about a year later i asked the senior colleague who had saved his life when i was working there what happened to little k. without batting an eye he calmly told me he was dead. his trache tube had blocked in his referral hospital. there was no one there who knew what to do and he suffocated. that was the end of k. the colleague went on to say that it was probably better because his life was doomed to be miserable etcetcetc. i just felt sick.

to this day i can't forget little k. i still wonder about the permutations if i had adopted him.

boere

i love history. i am fascinated by where we come from and its influence on who we are today.

from 1899 to 1902 two small boer republics held off the onslaught of what then was the local world power, britain. they had no standing army. they were basically a group of farmers fighting for their freedom. but they could ride and they could shoot. these days most of their descendants live in cities and have lost most of the skills of their forefathers.

last week i went hunting with one that hadn't lost this connection with his past. he was brought up on the back of a horse and his father had taught him to place a bullet exactly where it needed to go from very young. to top it off, he lent me his 100 year old mauser, the same make of weapon that the boers had used in that war against the british so many years ago.

yes i love history and i enjoyed the connection i felt to my great grandfather who took up the same make weapon i had strung over my shoulder when he was called on to resist the might of the british nation.

south african crime

i recently watched the movie capote. i enjoyed it. but, being south african, i was interested in the reaction the movie portrayed of the american community to the murders that the movie is indirectly about. their reaction was shock and dismay. their reaction was right.

but in south africa there is a similar incident every day. i don't read the newspaper because it depresses me too much. you might wonder why i, a surgeon, am posting on this. one reason may be because i often deal with the survivors (two previous posts found here and here). at the moment i have three patients who are victims of violent crime. one is the victim of a farm attack. an old man who had his head caved in with a spade. why? just for fun, it seems. but maybe the reason i'm writing this post is because i'm south african. this is my country and i'm gatvol.

just three recent stories. some guys broke into a house. they gaged the man. it seemed that whatever they shoved into his mouth was shoved in too deep, because as they lay on the bed violating his wife, he fought for breath and finally died of asphyxiation.
then there is a woman alone at home. some thugs broke in and asked where the safe was. they were looking for guns. she told them she had no safe and no guns. they then took a poker, heated it to red hot and proceeded to torture her with it so that she would tell them what they wanted to hear. because she could not, the torture went on for a number of hours.
then there is the story of a group of thugs that broke in to a house. they shot the man and cut the fingers of the woman off with a pair of garden shears. while the man lay on the floor dying, the criminals took some time off to lounge on the bed eating some snacks they had found in the fridge and watch a bit of television.

these are only three stories, but, if you do read the papers, you can hear about similar stories on a daily basis. and our great and mighty president, the eminently blind thabo mbeki, believes there is no problem with crime here.

yes, you americans were right to be horrified by the story upon which capote is based. we south africans, through the leadership of possibly the worst leader of a country in the world today, well we just get used to it.

gee thanks

i've often blogged about the tendency in our training to be left on your own (here, here and here to name at least a few), but some of the stories have a funny twist.

i was in my medical officer year. in those days there was a general shortage of registrars so the boss used us to fill the gaps. he put myself and another medical officer in charge of a firm, reasoning two medical officers add up to one registrar.

being two, we decided to split the call. and i was the guy who got the night. so when i came in i tracked my friend down. he was in theater doing an appendisectomy. i asked him if he had anything to hand over to me.
"sure. there are just two appendixes to be done."
"straightforward or any catches?"
"no catches, just appendicectomies"
the first one went well. i used it to show the house doctor how to do an appendisectomy, so that she could do the second one.

at this point i'd like to point out that i was very junior. i did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it.

she did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out. i calmly told her it looked like the appendix was going to be pretty sick. and then she found it.

it was normal. my heart sank. there was clearly something else wrong with the patient. i remained silent and told the house doctor to go on with the operation. my mind was racing. most probable diagnosis was perforation of a peptic ulcer. i calmly asked if there were any x-rays with the patient file. there were and they were put up on the x-ray board which was behind the house doctor and therefore in my direct line of vision. there on the x-rays for all to see was free air under the diaphragm, a clear sign of peptic ulcer perforation.

shit! i thought, but stayed silent. i knew i would need to take over. only problem is i'd never done the necessary operation before (omentopexy). i had seen it once before as a medical student about three years beforehand. it was definitely in the class of operation where you would make enemies if you called the consultant in. it was meant to be in the armamentarium of a registrar and, according to the boss, i was at least half a registrar.

the house doctor swiveled her head around to take a look at the x-rays.
"shit!" she said out loud.
"don't worry," i lied. "that's why i'm here. you have no responsibility here. i'll take over now."
"shit!shit!shit!shit" she replied. i don't think she imagined her first appendisectomy to go quite like this.

for an omentopexy, the first thing that needs to happen is a midline incision, rather than the usual mcburney incision for an appendix. the patient would have two cuts. oh well, can't be helped now. i told the house doctor to swap places with me.
"shit!shit!shit!shit!" she said in acknowledgment to my request and moved around the table. i confess i laughed a bit at her total loss of vocabulary, but it was a nervous strained laugh. i felt that i needed to reassure her that i had the situation under control. she did not need to know that i had only seen the procedure once before and that a number of years ago.

"don't worry," i said, "that's why i'm here to back you up. you are not in charge here. you have no responsibility."
"shit!" she said with what i assume was a forced smile behind her mask.

i got to work. soon i had the hole nicely exposed and the abdomen cleaned out. all i had to do was plug the hole with omentum, place drains and close. only problem is although i theoretically knew what to do and even how to do it, i had no idea what suturing material to use. this was a dilemma. i knew i couldn't really phone for backup for an operation i was supposed to be able to do late at night. but more importantly i didn't want the house doctor to feel any more insecure about the situation than she already did. if i told her that i was unsure of what i was doing i was pretty sure i would get another string of her most recent favourite word and maybe turn her off surgery forever. the situation seemed to be traumatic enough for her without me adding to it with trivial facts about it being pretty traumatic for me too. i decided what to do.

as casually and as nonchalant as possible i turned to the sister.
"sister, when the other guys do an omentopexy, what suturing material do they use?" so clever, i thought. i would find out what to use without causing any further stress to the fragile house doctor and without looking too stupid myself.
"oh," she answered, "they use whatever they want."

gee thanks. i thought. well that didn't work. even in the acute phase i could appreciate the humour of the situation though. i might even have laughed, more at myself and my situation than anything else. the sister had no idea that i was in what at that stage was deep water for me.
so i asked for vicryl and did the necessary. the patient did well.

next morning, on ward rounds with the prof, i took the blame on myself. i did not mention that my colleague had misdiagnosed because, in the end, i should not have gone into the operation without double checking everything myself, so, i reasoned the blame did in fact lie with me. i also neglected to mention that the house doctor had done the initial appendisectomy. she was never in the firing line. despite all this, just for good measure, my colleague who had assured me that it was just a simple appendix, covered his own ass and informed the prof that he had told me he suspected perforation and reminded me to check the x-ray. nice to have friends like that, i thought, but i just apologized for missing it and moved on.