buff and turf

the other day i read a post about the age old medical practice of the buff and turf. bearing in mind i also recently posted about icu, i was reminded of one of the worst turfs i ever saw.

it was during my icu rotation. we were on morning rounds with the consultant when a medical technologist came running in.
"there is a major disaster in casualties. can someone please come as fast as possible to help?"
naturally we all rushed over there. we were not prepared for what we saw.

in resus was a patient in severe shock. he was extremely pale and had almost no blood pressure. his abdomen was severely distended and sported a midline scar which had been crudely closed with a running nylon suture. the picture that is forever impregnated into my mind is the blood squirting out between the sutures. there were multiple streams of blood literally shooting up in a neat little line. as the patient rolled from side to side it reminded me of the sprinkler my parents had when i was a child. each line seemed to arch elegantly one way and as he rolled the other way, these fountains seemed to slowly follow. it may even have been beautiful in a sense if the setting was not so dire.

we jumped to work. one started cpr (it was needed) while another threw a high flow line into his subclavian vein (we used a schwann sheath). the third made some desperate, probably futile attempt to apply direct pressure to the abdomen. it seemed like a good idea at the time. during all this action we not so quietly and much less subtly enquired where the patient came from and why the surgeon on call wasn't waiting in casualties when he arrived. everyone pled ignorance. it seemed the patient arrived from a peripheral hospital without there being any warning that he was coming. with all the action that was all we discovered about his history then. our energies were concentrated on getting him to theater which we pretty quickly did. being the icu team, we then handed over to the guys in general surgery.

later we heard his story. the patient had been shot through the abdomen. at the hospital he presented to he was taken to theater. there the medical officer who operated him started by repairing all the bowel injuries. thereafter he decided to explore the retroperitoneal haematoma. as it turned out this action would reveal that the bullet had gone straight through the ivc.

i can just imagine his thought process. just before 'oh sh!t!!!' he probably thought 'i wonder what i'll find under here?' together with the 'oh sh!t!!!' which had no doubt evolved to 'oh f#@k!!!' he probably thought 'help!!!'. with this he decided to pack the abdomen and post the patient to anywhere away from where he was. we were that anywhere. in his raw panic he neglected to phone ahead and give any form of warning that this disaster was turfed to us.

truth be told i feel for the medical officer thrown into situations he is ill equipped to handle. but i find his overall actions difficult to justify. i think the reason he didn't phone is that he was afraid the academic hospital wouldn't accept a patient in mid operation for an ivc injury (his best chance which was slim under the circumstances was the operation he was undergoing at the time) and the rattled doctor wasn't willing to take that chance. all he knew is he wanted that patient far away from him and nothing was going to get in the way of that.


p.s the patient actually survived his operation and only died shortly after. well done to the operative team.

i'm on my way

some lessons are learned the hard way. and it's no easier if you are thrown out to the wolves.

i was in vascular, arguably the toughest rotation. i was doing 15 calls a month, most with little or no sleep. i was not having fun. so i was delighted when the powers that be (the general surgery prof and the vascular prof) made the decision that all stabwonds of the neck must be referred to the general surgeon on call first. if he made the assessment that it was a vascular problem then he would call the vascular surgeon. this would decrease the number of unnecessary referrals and slightly decrease our workload.

so on a particular night when the casualty officer called me in the early hours for a stabbed neck, my first question was whether she had already spoken to the general surgeon. she informed me he was already there to see another patient and she would ask him to evaluate the guy. i told her that if he felt it was vascular then he should call me and i'd be there like a flash. i rolled over and returned to my stupor. strangely enough i wasn't called again that night.

in the morning my pager went off. it was the casualty officer again. her first sentence sent shivers down my spine.
"while you were sleeping nicely let me tell you what has been happening here!"
this could not be good.

as it turned out the general surgeon (a rotating belgian registrar) had felt it was indeed vascular, but the casualty officer told him i had refused to come out. in desperation he had phoned the thorax surgeon who also refused to come out. he then did a chest x-ray which showed apical capping. with this new information he phoned the thorax guy again and after some threatening demanded that he come to take a look.

when the thorax surgeon got there the patient was apparently not doing too well. he dove into the neck with the belgian assisting him right there in casualties. apparently the ensuing bloodbath could only be contained with a few blind clamps onto the source of the bleed which just happened to be the subclavian artery. as we say in afrikaans, ek ken kak en ek ken pudding en hierdie is nie pudding nie (this is not good). i rushed there as fast as i could, adrenals pumping.

the general surgeon was still there. he looked rattled but glad to see me. i told him i would take it from there and he could go to the morning meeting with the prof. i asked him to excuse me from that same meeting which the vascular team was also required to attend.

i organized theater (with the obligatory blood and products ordered) and without too much delay my consultant and i started the operation. the operation, as vascular operations tend to do, took hours. some time that afternoon we delivered a severely compromised patient to icu.

i walked out of theater worn out from both the effort and the adrenaline. i ran into a friend. he asked me how it went.
"not good!" i replied.
"you'd better hope he doesn't die!" he told me. he then went on to warn me that the general surgeon had told the prof that he had phoned me personally and i had blankly refused to come out, thereby leaving him with a problem he was not equipped to deal with. the prof was apparently furious. he had already dictated a letter to the thorax department, complaining about the lax behaviour of their registrar and had decided to take me to task at the next m&m (morbidity and mortality meeting). if the patient died the depth of the sh!t i would be in would be considerably deeper.

i lived in fear waiting for the m&m meeting. i had images of my career coming to an abrupt end. sure enough, as if on cue, the patient died the day before the meeting. suffice to say the meeting did not go well. however, with me being present, the belgian did not repeat that i had refused to come out to see the patient. i survived.

from that day on, if i get called, even if i think it is not an appropriate referral, among the things i say on the phone, i always end the call with the words;
"i'm on my way!"

surgexperiences

once again surgexperiences will be hosted on my blog on the third of august. please get submissions in by the second of august. posts can be submitted here. also, for all those budding surgeons out there, anyone interested in hosting future editions of the only surgical blog carnival, contact the boss here.

the theme is that there is no theme, so if you have a post that fits the theme, send it immediately!!

family

my last post was about icu. while on the topic i couldn't help thinking about family and what that implies.

i was the icu guy. as usual, late at night, i got a message from theater that i needed to make a bed available for a gunshot wound patient. as usual, i pretty much had to stand on my head to do this. as usual, it was a criminal that took a bullet through some organ that he probably needed and nearly died. and as usual one of my surgical colleagues pulled him through.

he came in pretty messed up. he had lost a lot of blood and had gone into coagulopathy (the little bit of blood he had just didn't want to clot any more). then i heard his story.

my patient and three of his friends held up and old couple trying to eek out a living as real estate agents. it was late one afternoon when they found themselves faces by four gun wielding men. this is south africa so they immediately handed over everything they had. the criminals wanted more. they wanted blood. they took the old lady into a back room.

two things happened then. the man, left alone, had a chance to unlock his safe and get his own gun out. the criminals, meanwhile made the woman kneel down and as a sort of initiation type thing, one of them put a bullet through her. they then came out of the room, assumably to do the same to the old man. imagine their surprise when they walked into a blazing gun.

the first one he dropped dead on the spot. the second would become my patient after taking one through the liver. the third picked up an arm injury and got away. the fourth was not hit.

it was the usual story and i didn't think too much of it until the next morning.
the next morning, other than the usual police visitors, the patient's mother came in to see how he was. i have treated numerous criminals, but this was a first. i found it interesting so i decided to chat to her to find out where such a criminal comes from.

the first thing she told me is that she was a theater sister and worked night shift in a local hospital. this took me totally by surprise. firstly i wanted to believe that my patient came from a broken home or had some similar pathology in his past. but more importantly, a theater sister is like family to me. i have spent countless nights across an open abdomen with theater sisters. i couldn't help philosophizing about the fact that while i tried to save the lives of criminals through many nights with theater sisters at my side, was the system i worked in actually creating the criminals by making their mothers not available during their developmental years. such thought literally kept me awake at night.

then i got to hear my patient's story. he was an up and coming in some or other business. then he decided that there was either not enough money or not enough excitement in that venture. he and some friends went into the hijacking trade (good business in south africa). apparently this went well for some time. but soon they felt the need to upgrade. they decided the right business move would be to go into a bit of armed robbery. that's when the whole incident happened.

i spent some time in conversation with his mother. she was devastated. she never tried to excuse his choices. she just cried. one day she said that no one could tell what went through his mind the moment of the tragedy. she meant that maybe he repented from all his sins, so i didn't mention that what went through his friend's mind was a bullet. it seemed inappropriate at the time.

one day his brother visited. he was a lawyer, so i didn't speak to him. but i did find it interesting to see that my patient's career choice was not the result of opportunity.

this was not one of those stories with a happy ending. in the end, after some time and exorbitant expenses, the patient died. when he came in i felt nothing for him and, truth be told, his death is a good thing for south africa, but when he died i was shaken. you see, his mother was like family and he was definitely her family. i couldn't be as detached as all the rest of the icu staff.

captive

icu is icu is icu, but some icu stories could only happen in south africa.

i was doing my icu rotation. the work wasn't so tough but the hours were long and we did one in three calls, so it became a bit tedious. part of the job was shuffling patients to make space for the next critical patient coming in. bed occupation was always 100% or more (makeshift icu beds were often created in side wards). so late one night i get a call that they are operating some guy the cops winged in a shootout. apparently he lost quite a bit of blood and would come in intubated. great, i thought. probably a bad man and i needed to perform almost a miracle to create a bed for him.

sure enough, after transfering our most stable patient to another hospital, which required speaking to their superintendent, no small feat at night, i got a bed ready.
the patient arrived after a somewhat eventful surgery. he was intubated and needed ventilation, but was actually otherwise relatively stable. to keep him alive through the night should not be too difficult.

the next morning the patient wasn't only alive, but he was doing very well. he was still on a ventilator, but we expected to wean him in a day or two.

then two cops walked in carrying a ridiculous amount of heavy chains and shackles. they walked up to my patient and sort of dumped them on the bed with a loud clang. they then told me they were going to chain him down. you see, it seems, my patient was a known cop killer. he had chalked up quite a number of 'kills' and they weren't too keen on him getting away. my mind wandered to my student days when we once had an ethics discussion about chaining prisoners while they were in hospital. i had thought those morals sounded decidedly first world and didn't really have a place in south africa. but this patient/prisoner was different. he was intubated and couldn't escape for the simple reason that he couldn't breathe on his own. i explained this to his would be shacklers. the cops reluctantly left, taking their chains with them. they did leave the obligatory heavily armed guard at the door. i handed my patients over and went home.

next morning, when i got to work, one of the sisters greeted me at the door.
"did you hear what happened last night?" her eyes sparkled with the excitement of someone who has some hot gossip to spread. as it turned out, as the night went on and as our bad man patient gradually got stronger thoughts of escape dominated his mind. he knew he had a tube in his throat, but how was he to know that that tube was helping him to breathe? also, i assume, through the haze of the drugs he was getting, maybe his mind wouldn't have responded to logical arguments.

so at a stage, when there was less activity, he took his chances. he jumped out of bed and ran for the door. the endotracheal tube was ripped out as was the urinary catheter. he apparently almost made it to the above mentioned door before he collapsed in a heap. everyone, including the heavily armed cop at the door had to help to get him back into bed. he was then reintubated and his blue colour soon gave way to a more healthy looking pink.

i listened in disbelief, but, i confess, with a smile. as soon as i heard the story i walked to the police outside icu and demanded they chain the patient with everything they had. they complied.

p.s in retrospect i often wondered if it was the lack of the endotracheal tube that brought the patient to a heap on the floor or the urinary catherer being ripped out with the balloon still inflated.