where in the world is dr val? (haunted by inaction)

ian over at wait time and delayed care asked the question on almost everyone's mind. where is dr val? i say almost everyone because i don't include myself. you see i know where she is. she is hiding out (cyber hiding anyway) in south africa but i have no doubt she'll soon be gone. so while she's here let us be entertained by yet another one of her guest posts. for those familiar with my blog, i did permit the great dr val to use capitals on my blog, so this is a first.

Haunted By Inaction

By Val Jones, MD

When I was a medical student rotating at a hospital that shall remain unnamed, I witnessed a medical error that has haunted me ever since. I was partnered with a team of residents in the inpatient pediatric unit, and late one night a two month old baby was accidentally infused with an entire bottle of Foscarnet instead of normal saline. The nurse who gave the infusion was working as a locum tenens – a traveling nurse who spent a few months here and there filling in for others at various hospitals.

The Foscarnet bottle looked strikingly similar to the normal saline product, and I cringed as I imagined how easy it would be for anyone in a hurry to make the same mistake. Unfortunately, Foscarnet is a very powerful anti-viral medication, and infusing a large amount into a small baby could have deadly consequences. In fact, this drug can be toxic to the kidneys and has been known to cause seizures.

What happened after the infusion disturbed me greatly. Instead of telling the parents about the mistake, the terrified nurse begged her supervisor to keep it quiet. I overheard the charge nurse asking the resident to keep the error in confidence, but to keep an eye on the baby for potential signs of toxicity. The resident agreed not to tell anyone, since he feared that he’d ultimately be held responsible or drawn into a lengthy legal battle.

As far as I know the baby didn’t show any overt signs of toxicity – but I worried that the drug could have had a long-term adverse effect on his brain. It certainly can deposit itself in teeth and cause discoloration that lasts a lifetime. At no time were the parents informed of this error. The resident told me not to breathe a word of it to anyone.

I regret that I did not assert myself at the time. I did quietly ask my ethics professor about the issue, and he shifted uncomfortably and said that medical errors weren’t really an ethical dilemma. I tried to present the case to a student group but was told that it would be “inappropriate” to do so. I backed down, and I feel badly to this day about that little baby whom I did not defend to the utmost of my ability. I just hope that his brain is alright and that his teeth were not damaged. I guess I’ll never know.

pseudoaneurysm

there is nothing pseudo about a pseudoaneurysm except that it is not actually an aneurysm. where an aneurysm expands the wall of a blood vessel, in the pseudo variety the blood escapes from the vessel altogether creating a ballooning of turbulent blood flow outside the vessel's constraints. both may burst, but, seeing that the one in a sense has already burst, when it bursts again it is not an understatement to say this is not a good thing. at that moment you hope there is someone who knows what to do. or in other words you are not in rural south africa.

it was during my witbank days (way back when i started blogging). i was up in my office (a thing no self respecting surgeon should ever have) trying to fend off the boredom, probably by blogging, when the call came in. it was the radiologist, an old man who worked in the state hospital as part of his semi retirement gig. he didn't sound happy, very unusual for a radiologist. he told me that he had done a sonar for a pseudoanuerysm of the brachial artery (the upper arm) and the thing had burst. he had then called the surgeon on call, a medical officer, which is usually the best you are going to get in the state. he felt the medical officer wasn't showing due urgency and was worried she didn't have things under control. he had therefore gone over her head and called me. i ran.

i entered the room. there was blood everywhere. the upper arm had been bandaged closed, but still there was bright red blood oozing from the bandage and expanding a new puddle of blood below it. the patient was already confused, and very pale. i was worried. i took over.

soon the medical officer had been sent off to theater to get them ready for the worst eventuality. a junior doctor had been delegated to get blood. i got better lines up for fluid and moved the patient to theater. quite soon we were ready to operate. when i took the bandages off in the controlled environment of theater, i was honestly shocked. there was about a 10cm diameter area of necrotic skin stretched tight over a very large mass that apparently had been pulsatile before the application of a tourniquet. i wanted to know how this had been allowed to happen. pressure necrosis is not something that happens suddenly without warning.

the patient had presented to a peripheral hospital with a pulsatile swelling in the brachial area about a month after a common or garden stab wound to that area. the peripheral doctor had made the tentative diagnosis of pseudoaneusysm and phoned the surgical medical officer at our hospital. she apparently told him that we would not accept the patient until there was a sonar confirming the diagnosis. the poor peripheral doctor obediently phoned the radiology department where he was given an appointment in two weeks time. he then admitted the patient and observed the aneurysm expand before his eyes. finally he was observing pressure necrosis developing in the skin overlying the aneurysm. one can say he didn't think to contact the surgical department again but he rested secure in the fact that a so called surgeon had told him he could wait and wait he would. after all it wasn't his mother or brother or friend and he wasn't going to be sued in the state health department, so why should he care? this is, after all, africa the continent of selfishness and cheap life.

when the patient finally ended up before the radiologist, he went ahead with the sonar although it was clear there was a large area of necrosis over a pulsatile mass. how could he know that the gentle pressure of his sonar probe was all that was needed to allow the pseydoaneurysm to break through the skin and cause a massive pulsatile bleed. thjat is when he called the surgical medical officer. i suppose one could say that at least it happened when the patient was at our hospital and not still at the peripheral hospital.

i had to debride the wound and repair the artery with a venous interposition. only problem was that after debridement i didn't have tissue to cover my graft. i tunneled it as best i could and hoped for the best.

a few days later we amputated when the graft burst.

byeboer

my good blog friend ramona suggested i do a post about my other interest, beekeeping. one story immediately sprung to mind which sort of connects to surgery.

i was in my vascular rotation. it was busy. we did 15 calls a month and the days were really full. yet, somehow, in my off time, i made extra money by removing wild beehives from people's houses. naturally most of this work was done after hours, when the sun had set. this is the best time to work with the somewhat aggressive african bee so it suited me fine.

then one monday the theater list ended up being cut short due to a lack of icu beds (a common problem in our neck of the woods). this gave me a few hours off that afternoon before i had to be back for the m&m meeting (morbidity and mortality meeting). it seemed ideal to quickly remove a hive i had on my to do list. that way i would actually be able to have an early night. but i would have to rush.

i charged home, bundled my equipment into the car and drove to the house which happened to be in one of the outlying suburbs of pretoria. only when i got there did i realise i didn't have my smoker with me. not too bright, i thought to myself. but at least i could check out the hive and come back later, more prepared. it was too far to go back home, come back and do the job before the m&m meeting.

i introduced myself to the owner. immediately her Rottweiler started...well, hounding me. i'm nervous about rottweilers on a good day and the fact that the owner informed me they only get aggressive after two years of age didn't help (she was also kind enough to tell me he was two years old). she left him to his own devices which included jumping up on me and nipping my heels. i should have left then. i didn't.

the hive was in a hole in the wall in the garden. the opening was flush with the ground and therefore very difficult to access, especially because when i bent down the dog would jump onto my back. it was not a hive that i would be able to recover. that meant it was going to be an extermination job. armed with this new information i decided the smoker wouldn't be necessary seeing that i was going to kill them anyway. i had my poison (a tablet that, once lit, gives off clouds of billowing poisonous smoke. the idea is to light one, throw it into the hive and try to block up the entrance.) and at the time i thought that would be enough. looking back, i was foolish. i was not fully prepared (i didn't have my smoker), i was rushed (i needed to get back in time for the m&m meeting) and the dog was making sure that my mind was not on the task at hand. the fact that the owner did nothing about her dog was also a source of intense irritation to me. i should have left then. i didn't.

i asked the lady for a spade to access the hive more easily and suited up. i approached the hive with the dog still all over me and started digging. it was at that moment that i became acutely aware of how effective smoking bees is. these bees that hadn't been smoked immediately came pouring out of the hive in an almost solid mass and attacked as only african bees can.

two things happened simultaneously. one caused me great personal delight and the other caused me great personal consternation. the first was that the bees did not only attack me, but they also attacked the dam dog. i heard him yelping in pain from multiple stings as he finally left me alone and ran for cover. the second is i came to the shocking realization that, due to being rushed and harassed i had not pulled the zippers around my ankles down. there were two circles of exposed skin at this level. the problem was with my gloves on i could no longer pull them down. to remove a glove would be catastrophic. i had no choice. i had to proceed.

without going into too much detail, i finally got the smoking tablet into the hive and closed the entrance. most of the bees were probably out at that stage, trying to kill me, so i'm not too sure how many i actually killed. the queen and all the brood would be dead so the hive would not survive. my work was done. however i had sustained so many stings on my exposed ankles that, although i'm not allergic, the shear volume of poison that my body had taken was making me a bit dizzy. i needn't elaborate on the level of pain that that many stings causes, but it is enough that you tend to notice it.

the owner paid me by pushing the money under the door. clever move. besides i was feeling so light headed i thought i might pass out and look really stupid. i already felt that this was not the most professional job i had ever done. to collapse on her doorstep would not be a good idea. then i finally left.

i drove to the nearest chemist where i bought celestamine, an antihistamine steroid combination. to be honest i was considering buying adrenaline but decided against it. then i rushed back to work, charged into the m&m meeting and collapsed into my chair. moments later i was presenting my cases for the week with a throbbing headache, slightly blurred vision, a ringing in my ears and excruciating pain around both my ankles. relatively speaking the m&m went very well.

old rural surgery

one of my friends was sent to a homeland hospital when he did his military service (the old regime bolstered the homeland hospitals with whatever doctors they had at their disposal, which somehow makes the present government's totally disasterous management of the department of health seem so much more ironic). anyway, having spoken about war doctors, albeit in a different context, and also about my anesthetic escapades, i thought i would relay this typically south african story. (to be honest, eish reminded me of it with his last post too.)

the hospital was in the middle of nowhere (ok it was slightly to the left of the middle of nowhere, but you get the idea). when he arrived for his first day he was surprised to find that almost everyone was still on leave. only the superintendent was still there. the next surprise was that he was on call that first night. i suppose, looking at the facts, that wasn't really too surprising.

anyway, there was a caesarian section that needed to be done. the super gave my friend the option of either doping or cutting. my friend chose to cut. and soon they were working.

quite soon my friend noticed the blood was looking quite dark. he mentioned this to the super. the super snapped at him, saying he knew and was trying to fix the problem. it seemed the boyles machine (anesthetic machine that delivers a mixture of oxygenand anesthetic gasses to the patient) was broken and there was no air delivery to the patient. he decided to switch to manual mode where he would have to pump air in with a hand held bag. but, lo and behold, the bag had a hole in it. he sent the floor nurse to get another one. meanwhile he had to do something to give the patient oxygen. he resorted to blowing directly into the endotracheal tube with his mouth. desperate times call for desperate measures. at this point let me once again assure you this happened, many years ago, but still. finally, just as the patient was starting to become fairly light due to not getting enough inhalation anesthetic, they got another bag, connected it up and got things back on track. then...

the lights in theater went out. suddenly everything was pitch black. fortunately the floor nurse was a smoker and had a lighter. with this she illuminated the field while someone else rushed off to get a torch. and thus the operation was concluded by torchlight.

apparently after that nothing else that happened in his time there could phase him at all.

cyanosis

it has been a very long time since i gave my last anesthetic, but i still don't think blue is a good colour. i was reminded of this recently when one of my gastroscopy patients developed laryngospasm. he turned out fine but blue patients tend to age me quite a bit.

when i was a student i found anesthetics boring. that is because i didn't really know what was going on. when i was a comm serve i started off in anesthetics and was soon the number three in the department in our small hospital. in fact for that entire year i was considered an astute giver of gas to my great dismay. i was on the wrong side of the action on all calls.

i had been in anesthetics for not too long, but long enough to develop adrenal hyperplasia. i was on call and had to dope for a common or garden caesarian section, obviously late at night. i injected the contents of the big syringe followed by that of the small syringe and tubed without any difficulty. the gynae started.

almost immediately i realised there was a problem. the patient's chest was not moving with the ventilator, not a good thing. quite quickly the saturation monitor dropped its tone from its usual comforting high pitched beep to a very disconcerting low pitched boop. i started sweating. at about this stage the gynae calmly in a helpful voice said.
"the blood is looking very dark." i wanted to say something like i know the blood is f#@king dark and i don't know why. you just keep yourself busy with what you are doing and leave me the f#@k alone but all i said was
"i know. i'm on top of it." i flushed the system with oxygen and pumped. the chest lifted but soon the pressures dropped again. there was a leak somewhere and i had no idea where. i told the floor nurse to phone the cuban anesthetist, my mentor. she left to make the call. he lived on the hospital grounds and, even though it was very late at night he would be able to get there quite quickly. but quickly would not be soon enough. the fact of the situation was that when he arrived the problem would be over or the patient would be dead.

i flushed the system with oxygen again and managed to at least get a bit of air into the lungs. but it wasn't enough. i flushed again, but this time i put my ear close to the boyles machine and listened for a leak. i heard it. one of the pipes had a hole in it. i quickly made the necessary replacements and all was well.

about ten minutes later the cuban anesthetist charged in, completely out of breath from his run up to the hospital. i was probably blue myself at that stage but at least the patient was pink again. i still nearly hugged him.

nearly a year later on my last call as a comm serve just after an anesthetic the patient developed laryngospasm and also turned blue. i very casually drew up scoline. i injected it an tubed him. during the whole time i just kept saying to myself
"never again will i give anesthetics. never again." i felt good.

sign

those of you who follow this blog will know that we had an interesting prof. some might say eccentric. others might say idio(t)syncratic. whichever, there were interesting stories associated with him.

the prof demanded total silence during any operation. the silence was so absolute that the prof himself would not speak, not even to ask for instruments. he had hand signs which he used to request the next tool of his trade. his eyes never left the operation field and the sister had to make sure she palmed the instrument to him correctly if she didn't want to fall foul of the prof's sharp tongue. one incident delivered an exception.

it was an auspicious occasion. the prof was going to demonstrate the correct way to do a haemorrhoidectomy. he insisted that the whole firm was there to see how it was supposed to be done. i had lived through this demonstration once before so i was not too enthused.

soon the patient was cleaned and draped. the prof, suitably scrubbed up, settled into his chair between the patient's legs, getting ready to start. i noticed that the sister was junior. she was chatting to the floor nurse as the prof settled down, a definite no no. i actually remember thinking that it was just a matter of time before the prof got stuck into her. but, fortunately for her, he was too focused on the target zone, deep in thought, obviously planning the procedure. the sister was preparing the scalpel, also deep in thought. but her thoughts were related to the conversation she was having. her mind was far from where we all were.

she attached the blade to the handle and turned towards the prof, blade exposed. the prof, at that moment, seemed to finally have decided what his first move would be. without looking and in total silence, he swung his hand back with the index finger extended briskly in the sign demanding the scalpel. how was he to know that the sister was holding that same scalpel, sharp point towards him, exactly where his hand went. to put it bluntly (ok, maybe not the right word) the prof threw his hand onto the scalpel's point. i imagined an old japanese warrior throwing himself on his sword.

to say the prof was not impressed is somewhat of an understatement. the cut bled profusely and it took some time to settle everything down once again before the operation could get underway. that is the one and only operation i ever remember the prof doing where he spoke throughout. he let the sister have it. once he had given her a run down of her manners he went onto her upbringing and her ancestry. but at no stage did he let up until the patient was awake again.

to be honest i was chuckling on the inside, but the prof had taught me to be silent during his operations so it did not show.

the last goodbye

this is a story i considered not telling. somehow it comes too close to how we deal with the constant tragedy of life we are exposed to, both positively and negatively. then a post by buckeye reminded me of it.

the rotation through the military hospital was interesting in that the slog work was done by relatively junior doctors. that night one of them admitted a patient with abdominal pain. to be honest i didn't pay too much attention in the handover because he was admitted to another firm and that consultant would surely handle whatever the problem was.

late that afternoon, when the relevant consultant was no longer available, the medical officer of his firm asked me to evaluate the patient. the first thing that struck me was that the patient was in excruciating pain, yet his abdomen was soft. his face bore the deep grooves acquired from years of diligent smoking. his kidneys were going into shutdown and he was severely acidotic. i didn't even bother to check his phosphate levels. i had a good idea what was wrong. i called theater. i also let my consultant know i was going to do a laparotomy and asked him to hang around a bit before he went home...just in case. he was one of the few that was both a brilliant surgeon and a brilliant person. i knew i could rely on him.

as i started the laparotomy i spoke to my intern about necrotic bowel. i even went into detail about the thrombotic type, the emolic type and the low flow type. then i still remembered all that detail. sure enough, as we opened, loops of dark blue to black bowel came bursting out of the abdomen. the situation was dire. we all went silent. the bowel was dead from the duodenum to the transverse colon. a resection seemed pointless. i went through the bowel again, more to give myself time to think. but the mesentry was also dead and the slightest touch tore it. soon i found myself trying to control a persistant slow bleed from the base of the mesentry, but every time i placed a stitch it tore through the very friable tissue. i started becoming nervous. i called for my consultant. it was after hours but i knew he wouldn't have gone home. he would be waiting to hear how the operation went. he was just that type of man.

sure enough, moments later he burst through the theater doors. he looked into the abdomen. i explained the situation of the bleed that i just couldn't seem to control. in the knowledge that he would soon take over from me, i felt much reassured. i continued to work at getting control.

after a while i wondered why he was taking so long. i looked up to see what the delay was. the consultant was helping the anaesthetist adjust his suction which seemed not to be working. i was shocked and amazed. but i did not dare say anything. i just thought that that wouldn't take too long, so i would just need to be patient. it did take long.

after what seemed like ages the anaethetists suction was finally fixed. i relaxed again. but once again i looked up to see the consultant not scrubbing! he was wondering around theater, not really doing anything. occasinally he would chat to the floor nurse or the anaesthetist or just check all sorts of irrelevant fixtures in the theater.
'why is he not scrubbing to help me?' i thought! and then it struck me. he knew there was nothing that could be done. he wasn't going to tell me what to do, but, instead was patiently waiting for me to make the call.

"there is nothing to do here, colonel" i said. i think the corner of his mouth lifted in an almost smile.
"yes, bongi, there is nothing to do."
"should we stop now or close and send him to icu to die?" i asked. we did have a bed in icu organised.
"i think you can stop, but it is up to you." said the colonel.
"his family didn't get to say goodbye," i said, "so i'm going to close and see if we can get him to icu alive."
"ok." and then he left.

we got him to icu on high doses of adrenaline. the anaesthetist was annoyed with me. he felt it was a waste of time and resources. in a sense it was, but i felt it was the right thing to do.

once we had settled him, i went through to the waiting room to speak to his wife and son. i explained the situation. the wife asked me what his chances were. i told them he had no chance and would probably not see the next day. the son then asked me why, if it was pointless, had we closed and taken him to icu rather than just let him die in theater. i explained, as honestly as possible, that it had been my call so that they would at least have a moment with him to say goodbye before he died. the son was furious. i actually thought he was going to physically attack me. he did verbally abuse me quite a bit. i wonder what his reaction would have been if i left his father to die in theater.

after all the drama had subsided the doctors involved took a few moments to unwind over a cup of coffee. i remember a dentistry student who was doing her anaesthetic rotation. it was her first night with any form of clinical exposure. i wonder if she needed therapy afterwards.

injuries

every sport has its injuries. so the saying goes. and surgery is no exception.

it was a thyroidectomy for multinodular goiter. not like the monsters that the state was inclined to deliver, but a routine straightforward private thyroid. the only catch was that she was hiv positive and not on antiretrovirals. the cd4 count was low but acceptable so i went ahead.

the operation went without any hitches. quite soon i found myself placing the last skin sutures. and then... i stuck the needle into my finger. let me assure you, that is not the greatest feeling.

anyway, before the next case the first dose of antiretrovirals had passed my lips and i felt slightly consoled. only slightly.

the month flew by quite quickly actually. the only side effect i experienced was diarrhea but, truth be told, that was bad enough. i actually considered suggesting antiretrovirals as suitable bowel preparation for colonoscopies. no one took me seriously.

thereafter i needed to have the obligatory test. the only problem is in such a small place as the town where i live, if i tested positive, within a week everyone would know my status. if it were to turn out positive, i would basically have to shut down shop and find another town to ply my trade. who would go to a surgeon with hiv? i had to have the test done anonymously.

i approached my good friend, the pathologist at the lab. he understood my situation and agreed to do the test for me under an assumed name (i think it was something like 4739). that friday he drew my blood. i was on call so i immediately disappeared to theater. he assured me he would call me in an hour.

an hour passed. another hour passed. i tried not to panic as a third hour passed. to phone him would show a serious loss of cool but after another hour i didn't care about that anymore. i got his voice mail. at that stage i started making plans in my mind for my new practice in a small town in another province. a friend of mine there was looking for another surgeon to join their partnership. like most places in the country they were overworked due to the country wide shortage of general surgeons. it would be a pity to have to start from scratch but the fact that i had heard nothing from the lab implied i must be positive, or so i reasoned.

the fear of hiv is a part of the job. occasionally taking antiretrovirals is also part of the job. in a setting where probably 30 to 40% of the population has the virus it is inevitable to have contact occasionally. it is just one of the things we must face day to day.

then he finally phoned. they had done all the tests imaginable and i was negative. the relief was difficult to describe. when you've seen the effects of the virus so many times, especially the dementia syndrome it causes, the fear of it is a constant cloud over your head. the moment of sunshine then was beautiful.

supplies

i did my house doctor and community service years in a historically significant place. during the old regime the government deemed the area independent as part of the great apartheid madness. to maintain the façade the apartheid government ploughed money into this pseudo-country. even after all the officials had taken their cuts there was still enough left over to keep the hospital well stocked. when i worked there, after the fall of apartheid, all this had changed.

this 'country' became a small region in one of the 9 provinces of south africa. provisions came from a central depot. they were trucked in and there was no exchange of money locally. the bribe industry really struggled for a while. but people are ingenious. soon the trucks started turning up with very little. apparently they left the central depot fully laden, but by some inexplicable means, the supplies just disappeared somewhere en route. equally inexplicable was that some people in the area did quite well selling stock at massively reduced prices to pharmacies. as usual the poor suffered. i remember times when there was no insulin for months in the hospital. the physicians (internists) waited for dka and then transfered the patients to the other regional hospital, about 2 hour's drive away. some people died of course, but it was a small price to pay for the enrichment of the previously powerful.

but one day this all really hit home for me. i was the community service doctor on call at the primary care hospital. they called me to see a patient with a retained placenta post full term delivery. i went to the labour ward. sure enough the patient was having trouble with the placenta. i asked for gloves. there were none. i decided to quickly run to casualties to get a pair of gloves there. this would be faster than sending someone.

when i got to casualties, lo and behold, they also didn't have any gloves. there were in fact no gloves whatsoever in the entire hospital. apparently labour ward was washing gloves to use over and over again for the deliveries. they couldn't understand that i refused to use these gloves. i went back to casualties, thinking this had to be the most likely place to find gloves. but they assured me they had run out.

then an ambulance came in with a patient. i asked them if they had any gloves. they did, but they were only willing to give me one pair because they were also running low on this most basic of item.

i took the gloves to labour ward. i used one to deliver the placenta. the second glove i gave to the sister and told her to lock it in the scedule medicine cupboard and keep it for me if i needed it later.