breaking the news

there is a fair amount of talk about how to break bad news. truth be told i think i'm fairly good at it. sometimes, however it can leave quite an impression.

i was a community service doctor in qwa-qwa. i was working in casualties when they came in. two young children had been playing on the side of the street with a spinning top when a drunk driver came careening off the tar and ran them down. apparently in his drunken state he couldn't negotiate the turn.

the patients were cousins. we shuffled them both into the resus room and closed the door. one was about four and the other was six. the bigger one was dead. the smaller one had only minor abrasions. we covered the body of the big boy and cleaned and bandaged the wounds of the little boy. then we waited for the family.

a side story here was that the drunk driver who realised he was in trouble asked me to only draw the blood for alcohol levels the next day and lie about it. he even offered me money. he didn't specify how much. i was amazed at the inherent selfishness of people. there was a dead child in the resus room and this man was only concerned about the consequences as they pertained to him and him alone.

finally two family members arrived. the old woman was the grandmother of both children. her daughter who was with her was the mother of one child and the aunt of the other child. we moved them into a closed room where i was to speak to them. there was not going to be an easy way to do this, but i remember thinking that i really hoped the mother was the mother of the living child. it would make my job easier and their job when they got home more difficult.

i started by explaining the nature of the accident. i went on to explain that these types off accidents can cause severe injury. i then as gently as possible said that one child was already dead when he arrived and we couldn't help him, but the other child was ok. the mother immediately looked at me directly, something she had not done up to that point and asked with desperation both in her voice and etched into the lines on her face;
"which one? which one is dead?" the grandmother did not react outwardly, but a tear rolled down her one cheek.

i remember clenching my jaws, hoping that the woman before me was the mother of the living child and not the dead one. the news would still be bad, but at least for her personally there would be a good slant on it.
"the older child is dead."

it looked like someone shot her. her entire body contorted and she dropped to the floor. she started screaming. the grandmother didn't move, but the tears flowed more freely down both her cheeks. between the screams of the mother of the big boy, for that is what she was, the grandmother simply said;
"this is a terrible and difficult thing"

i was shaken. i didn't want to let the casualty staff see me cry so i swallowed hard, wiped my eyes and went back to work. besides casualties was full and i didn't have the privilege of taking time off to get over my trauma. anyway it didn't compare to the woman lying crumpled up on the floor of the office sobbing .

beautiful

another trip to the kruger produced a beautiful sighting of the above lion. her face is stained by the remains of a dead hippo that they were scavenging off. she walked so close to the car that i actually had to stop taking photos to quickly close the window just in case she decided to have my arm for dessert.

the above picture is what remains of the hippo after two days. the lion still monopolised the carcass but the trees were heavy with vultures patiently waiting their turn. the maggots had also had a good innings.

it is difficult to explain how cleansing for my soul a visit to the park is. suffice to say it is.

it flows in the blood

there is something about being african. there is almost a covenant between the land and the individual. it is not something you can avoid or ignore. it flows in the blood.

true sometimes i consider whether i should leave, based only on the fact that i may one day pick up a not-so-stray bullet like so many of my patients, but somehow i know i won't. everything is messed up (thank you anc) but somehow i live under the delusion that staying may just be better for the country than leaving.

the real reason i wanted to post quickly was just to link to a great post on a most excellent site that shows the beauty of this land that does indeed flow through my blood.

the best

when i was a registrar i used to tell my students that all surgeons believe they are the best surgeon there is. with only limited logic one can clearly see this is obviously a load of rubbish. how can every single surgeon be the best there is...when i am the best!! for some reason they always laughed.

there has to be a certain self confidence in a surgeon's work. and yes sometimes it does flow over into arrogance. i knew this before i really knew this. i was still in my community service year and had only just decided to do surgery. one of my old friends was a medical officer in the surgery program at tukkies so i went to pretoria to discuss it with him. to be honest he spent most of the time just speaking about the primaries he had just passed and was of little help to me. then he told a story.

he was in paediatric surgery at kalafong. a patient came in with a condition which was on the outer limits of his abilities. it was actually just on the other side of his limits. he felt totally out of his depths, but what could he do? there was no one else. he sucked it up and did what was needed. i found the story frightening and told him so. then he shared some hard wisdom. he was not the best surgeon there was for that child, but he was the only one available at the time. so for that patient at that moment, he was the best there was.

recently i was required to open a chest in the state for a gunshot wound that just kept pumping bright red blood (the best type of blood to have inside the vasculature but the worst type to have outside). i phoned the thorax guy who informed me he was on leave and far away. he then helpfully suggested i refer the patient to pretoria. i mentioned that a ten minute trip for this guy was pushing it and there was no way he'd see the other end of a three hour trip. then i did what i needed to do even though i am not overly comfortable on the inside of a chest. what choice was there?

i try to refer away whatever i feel is not in my scope but once the knife goes through the skin you become suddenly very alone. it is too late to think there is someone else who can do the job better than you. you must be the best for that patient at that moment. this becomes more acutely true when something goes wrong and you have to dig yourself out of a difficult situation. the thing about difficult situations in my line of work is if you handle them not too well someone may just end up dead. somehow to believe you are the best does seem to give just that little more of an edge.

i am not justifying surgeon's arrogance and i hope never to be arrogant. but i can't imagine being able to do what i do without just a little more than the normal amount of self confidence.

weblog awards

once again i'm humbled and amazed. let's face it i'm more amazed than humbled (i am a surgeon after all). but i've been nominated in two categories for this year's medgadget medical weblog awards. they are:

Best Medical Weblog

The Best Evidence in Emergency Medicine Investigator Group

Edwin Leap, M.D.

Ivor Kovic, M.D.

other things amanzi

Running a hospital

Science-Based Medicine

ScienceRoll

Unprotected Text

and:

Best Literary Medical Weblog

Notes of an Anesthesioboist

other things amanzi

Reflections in a Head Mirror

Rural Doctoring

Science-Based Medicine

take a look at the amazing blogs i have the priveledge of standing next to. to be honest i think the best blog award is a far cry for me. i semi-wonder if i have a chance in the literary category, but time will tell.

i suggested they make a new category about the hilarious and the sublime where i think i should be able to clean up, but they thought i was being hilarious and sublime.

anyway, thanks for the nomination.

textbook case

what the textbooks say and what happens in real life do not always agree fully. for one, the textbooks are seldom funny.

i was on call. a slam dunk came in. he had a two day history of sudden onset severe abdominal pain. clinically he had a rigid abdomen and x-rays confirmed free air under the diaphragm. not that it changed the decision, but he was also feverish and his white cells were through the roof. it was clearly a perforated peptic ulcer with generalised severe peritonitis (his stomach had burst and everything inside was rotten). the only question really was how had he managed to survive two whole days without seeking medical help.

i informed him he needed an operation. he said no. i was astounded. i pushed on his abdomen again. he went through the roof. i explained that there was clearly something severely wrong and an operation was absolutely needed. he said he wanted a medical alternative. the more i explained that there was a physical hole in his stomach requiring a physical solution and that no magic drug was going to close that hole the more he stubbornly refused. i tried the fear angle. i told him that in all probability he would die without surgery. he simply disagreed with me. he thought he'd first try non-surgical treatment and if that didn't work he would consent to surgery. and then he left. he simply took his free will and walked out the door.

the next morning when i presented the cases of the previous night i told everyone to keep an eye out for him. i expected him to turn up again in one or two days in septic shock and kidney failure. it would be decidedly more difficult to pull him through then, if even possible.

for the next few mornings, before the hand over meeting, i would ask the team on call if he had returned. the answer was always in the negative. after four days i accepted he must be dead. finally my turn to be on call came around again, almost a week later. and who should turn up on the proverbial doorstep but that same patient. my house doctor came to me saying he is begging to be operated.
"how sick is he?" i asked. "is he nearly dead?"
"actually he looks surprisingly well, but he is adamant he wants his operation now."

i walked into his room.
"so you're back?" i asked. "you have decided that you actually do need an operation?"
"yes doctor, you were right. the pain has been too much." i examined him. his abdomen was actually quite soft. it was much better than when i'd seen him last. the x-ray showed no free air in the abdomen. his blood work was nearly normal. his white cells were only marginally elevated. i was amazed. i knew that a very small fraction of people with a perforated peptic ulcer could heal if left alone, but generally they are all operated, so it is really only a theoretical posibility. in all reality most people would die. this was amazingly enough a man that had defied the odds. he was now just tired of the pain. and even the pain was no longer excruciating but now only severe.

i thought it quite ironic. when i was adamant that he needed an operation he disagreed. now that he was ready for an operation i was in doubt. i went through all the results and knew what needed to be done.

"doctor, you were right. i do need an operation! i'm begging you, please operate me! please doctor." i admit i smiled a bit as i looked at him and answered;
"no!!"

panel of experts

my blogger friend enrico managed to hijack doctor anonymous's blogtalkradio show this morning. he invited me as a member of what he termed a panel of experts. i think i was there for the comic relief, but i was in the midst of giants. the other experts were ramona, dr val and mother jones. later vijay phoned in too. it was great fun. thanks enrico!

doctors for africa

a previous minister of health (who was then married to the present president of the anc and the future president of this country. can you guess who it is?) made the comment that she wants to train african doctors for africa. then she proceeded to degrade the degree. after all, life in africa is cheap and africans don't need quality health care. i couldn't help thinking back to my own experience of african doctors for africa.

in the apartheid era russia was kind enough to train a few doctors up for africa. interesting to note that their qualification was not recognised in russia. they were only good enough to treat africans. i worked with a few of them. here follows one story.

she was a russian qualified doctor. she had been chucked out of a surgical registrar post at medunsa (who gets chucked out of medunsa?) and by some administrative shocker, she had been given a post at our university. she and i wrote primaries together. it was my first attempt there. it was her third.

the last exam was the anatomy oral. basically they showed cadaver specimens and asked us questions and to point out specific structures. my oral didn't go too well. when they went on about waldayer's fassia i struggled a bit. most of the other stuff i answered. her oral was a feast.

when she went in, the first specimen they showed was an open abdomen with everything removed except the retroperitoneum. they started easy. they pointed to the ivc, only the biggest vein in the human body, and asked her to identify it. she could not. after an awkward silence they moved on. maybe the ivc was a bit too difficult. they pointed at the left kidney. even in a second rate russian medical school the kidney must be an organ that can be identified without too much difficulty. she smiled;
"that i know," she piped up with confidence, "that's the spleen!" the examiners were a bit shocked. where do you go after a kidney is mistaken for a spleen? maybe they needed another specimen. they went for a pelvis cut through the middle. there was a clear bladder with a pipe exiting below and moving through a gland. it then continued on its merry way towards the penis. they asked her to identify the gland that pipe went through. she moved uneasily. it was clear she had no idea. then suddenly she redeemed herself, but only a little. she suddenly grabbed the penis and proudly proclaimed;
"i know what this is. this is the penis!"

the examiners did not share the anc's enthusiasm for producing pathetic doctors in a possible attempt to thin out the population. they therefore felt it was important to give a proportional mark. they felt that zero percent was too low because she did know what the penis was and it is as anatomical structure. however even twenty percent seemed a bit high because all she knew was the penis and that is maybe a bit too little for a future surgeon, even an anc approved surgeon. they settled on 5%. i thought it was a bit high, but possibly fair.

after failing three times and killing a quite a number of hapless patients she was thrown out of our university. many years later i saw her hanging with wits registrars at a symposium. the future looks bright.