Saturday, November 22, 2008
as a rule i don't swear at people (not at people) but like every rule, there are exceptions. sometimes the frustrations of old were too much to take.
i was working at 1mil (the military hospital in pretoria). because the calls were so light we were required to lessen the load of the guys at kalafong (hell). so on the day in question i found myself stalking the cold corridors of kalafong. to make it worse, my students made themselves very scarce despite numerous attempts to contact them.
late that night a gunshot wound abdomen came in. now abdominal gunshots roughly fall into two categories. the first group are hemodynamically stable. that is to say they are not trying to die at that exact moment. usually they will deliver numerous bowel perforations that can be sutured at your leisure while enjoying a casual chat with your team and theater staff. the second group are not stable. ie they are actually trying to die on you and they need fast aggressive action. in casualties they need good large bore fast intravenous access. they need fluid and they need blood. this was one of those. he was in big trouble and my students still excelled in their absence. fortunately in casualties there were previous students of mine who were rotating through internal medicine. they saw the need and stepped into the gap.
in the madness that is kalafong one of their rules to confound things is that you can't book an emergency patient telephonically. it must be done in person. i think the idea is if you leave your patient long enough to go and book the case he might die and then theater staff get to sleep rather than work. whatever the reason it can be very infuriating, especially if you don't have students. i therefore sent one of the internal students to theater to book the case. i told him to impress upon them that it was going to be fast and furious and that the patient was nearly in exitus. the other student i sent to the blood bank to organise six units of blood. i busied myself with placing a high flow central line and an intercostal drain (it was needed). soon we were ready for transport to theater.
just as we were about to push the patient to theater the student from the blood bank came back. he told me the guy at the blood bank had told him he would only issue two units of blood at a time. if we needed more thereafter we could order again. once again, just a usual kalafong ploy to try and hamstring any attempt at providing good patient care. i wondered how i would take time off from what promised to be a very tense operation to go and get more blood. i knew that the patient needed more than two units as he stood and i wasn't sure how long it would take me to get control of the bleeding once i opened. it was absolutely ridiculous.
we started pushing the patient. blood bank was on the way to theater. i peeled away from the patient as we passed it. i would have preferred to be next to my patient but blood was needed. i thought i would just take a moment to sort it out. true there was a chance the patient would crash in those few moments but what would i do without blood anyway.
i stormed in. the guy stood behind the desk with jail-like bars between us (i always assumed they were there exactly for moments like these).
"excuse me." i said as calmly as possible.
"wait. i am busy." he replied. lucky he had the bars.
"i can't wait. i have a patient in theater bleeding to death and i hear you won't give more than two units of blood."
"don't speak to me in that tone." he had taken the discussion off the point and was pretending i was being personal. i realised i could not reason with this man. he had chosen the personal route. that i could do.
"you stupid f#@king bastard!" i replied with more than just a hint of aggression.
"are you calling me a bastard?" he shouted in rage. i thought it interesting that that was the only word he linked onto. maybe he didn't hear me. i could help with that.
"yes i did. of the stupid f#@king variety." i turned to the student who was biting back a laugh.
"sorry but i don't have time for this child. i need the blood. i know it is not your job, but could you get it sorted for me? i'm going to theater for fun and games." he said it was no problem. there seemed to be a permanent broad smile tacked onto his face. i left. truth be told i prayed the blood bank guy would formally lay a complaint against me. i would have fun defending myself. there would then be no bars to protect him.
the operation went as well as could be expected. the blood did arrive, although after quite a wait. the patient got to icu where he demised the next day.
this sort of thing was fairly regular at kalafong. i knew to stay there would either make me bitter and aggressive or worse, complacent like everybody else. i needed to leave. once i qualified and was offered a consultant post there i laughed.