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.

out of benoni

when charlize won her oscar, south africans weren't surprised that a fellow south african achieved such a great thing. what we couldn't believe was that benoni could produce anything even remotely worthwhile. having said that i actually know of the other good thing benoni produced (yes, there were only two).

when i left school, my headmaster taught me never to look down on someone who actually might still achieve something in his life. the way he did this is that he wrote me a letter. in that letter he said;
"you are a lout! your five years in this school have meant nothing and you will amount to nothing in life." just in case i didn't get the message (i think he thought i couldn't read) he wrote a letter to my father. in that letter he said;
"your son is a lout! his five years in this school have meant nothing and he will amount to nothing in life." i thought he was a sad old man who had risen as high as he ever would and he was just a headmaster. i felt sorry for him. but throughout my medical and surgical training i never looked down on someone below me on the pecking order. one day they just might surpass me.

my friend came from benoni. he was brought up there and went to school there. like any self respecting benoni boy he only just scraped through matric, probably close to the top of his class. he was lucky. at that stage the university of pretoria had a sort of remedial science course for the intellectually challenged. most of the candidates would drop out in first year. some might actually achieve a watered down degree or diploma. one or two might actually get into the mainstream bsc course and get a real degree. some say it had actually happened before. my friend managed to get into this class. i'm sure most of benoni was proud of him.

right at the beginning of the year the class mentor (not too sure what the english word for voog is) called each student to the front of the class and asked what they hoped to achieve with this opportunity. most had realistic expectations. not my friend. he stood up and said he wanted to use it to get into medicine and maybe one day do orthopaedics. the voog laughed at him in front of everyone. people in that class just didn't have the goods upstairs to go that far. in this case, however, removing the boy from benoni allowed him to come into his own and actually work for something. quite soon he was in the mainstream bsc course and then moved on to medicine where he was always close to the top of the class.

i worked with him when he was a house doctor and he was the hardest working house doctor i ever knew. he even took the occasional gunshot abdomen to theater and only called his registrar when he got stuck. i thought he was going to become a surgeon. but alas... i visited him recently in bloemfontein where he is presently half way through his orthopaedic training.

so i often think back thankfully to that letter my headmaster took time to write for me. he helped me never to look down on my juniors and never to despise small beginnings, even if they were in benoni.

words

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.

the african dream

i had been working too hard and long hours. i found that i was a bit irritable on the whole. usually i enjoyed talking to people and hearing about their hopes and joys, but i found myself rushing through consultations. then an old couple came in. he needed a hernia repair but had no medical aid. they had heard i did some work in the state and wondered if i could help. i explained that i could not book my own patients there but would do operations at the request of the normal state staff. i was willing, however, to put in a good word for them. shortly thereafter i found myself waiting to get the relevant state doctor on the line. so we got chatting.

they lived in a small flat and it apparently drove him mad. you see he was born on a farm and had farmed his whole life. he went on to tell me that all his old neighbours, like him and his wife, had left their farms. life became too dangerous. you see farm murders are a fact of life in our country.

they explained that life on the farm became too stressful. they always had to carry guns with them, even when going to church. when approaching the farm house they would drive slowly looking for any movements in the bushes. i asked if anything ever happened. no, they said, not to them. then i got to hear about their one neighbour who was killed at night in his bed (he had erected an electric fence around his farm house to no avail). and the close family member who took a bullet through the chest but survived. then they went on to talk about the night they heard cattle rustlers and went out in their bakkie, the old woman on the back with a shotgun and the old man at the wheel with a hunting rifle. the lights had apparently driven the criminals away. there were other stories, all boiling down pretty much to the same thing.

the man looked at me and said. "you know, doc, we thought we would live our entire lives on the farm and die in peace. but it became too dangerous. now we live in a tiny flat and i hate it." i thought of how somehow our dreams don't work out. it was a poignant thought and i felt quite depressed.

like in zimbabwe the farmers here are being driven off the farms. the lucky ones survive and end up with shattered dreams in small flats (apartments) in the city. we read about it all the time, but when you speak to them in the privacy of your consulting room waiting for a state doctor so you can maybe help him get an operation he can't afford and hear the longing in his voice for the african farm he loves, it somehow makes more of an impact.

faceoff

in surgery you work with what you are presented with. sometimes you simply don't have a choice but to try amazing or ridiculous things. i have mentioned my weird sh!tometer (here and here) but this is another one that scored highly.

he was mentally retarded, or so his siblings said. i actually thought he was just a bit slow of thought but had been rendered useless to society by years of being told that he was mentally retarded. he presented to us with a skin cancer (squamous) on the forehead. but it was no small thing.

it had apparently been growing for a few years. his caretakers elected not to take him to a hospital for medical treatment because they felt that evil doctors would use him as a guinea pig because he couldn't "think for himself". so they left it to grow. finally when the smell of this fungating rotting bleeding mass on his head disturbed their breakfast in the morning they brought him in to have it checked out. i considered telling them to eat breakfast in the lounge but i thought better of it.

the mass was about 10cm in diameter. it had infiltrated the left eye socket, causing the eye to look up, as if it was trying to get a glimpse of its tormentor. the ct scan revealed that not only was the eye socket and the eye a victim of invasion, but the mass had infiltrated his frontal lobe. i even wondered if the family had actually brought him in because of personality changes. then i realised that i would also struggle to enjoy breakfast with that mass across the table from me and, let's face it, the family weren't overly concerned by the actual well being of the patient.

the never-say-die prof of head and neck surgery immediately mustered the troops. the troops were the neurosurgeons and the plastic surgeons. to me the fact that the neurosurgeons were needed implied there would be no surgery. they tended to bail if there was any way out. i just assumed the radiotherapists would be asked to the party at the last minute. to my amazement all roll players (the neurosurgeons) agreed to give it a try and surgery was scheduled.

once all the subspecialities had played their roles and once all the knives had been laid to rest what was delivered to me in icu was, well to me at least, shocking. they had removed the mass, but along with it, the left eye and eye socket, the left parotid gland, a fair portion of the skull and more than just a sliver of the frontal lobe of the brain. the massive defect which was left was closed by the plastic surgeons using a free pectoral flap (they used his chest muscle with its overlying skin which they essentially transplanted onto the defect). the oddly misplaced muscle and skin lay on a liquid bed of cerebrospinal fluid and seemed to move in a way similar to a water bed when i touched it.

things went not so well and the family, now no doubt enjoying a daily hearty breakfast, threatened to sue for disfigurement. the irony was that the surgeons involved, whether judiciously or not, had attempted to fix what was presented to them. they did not cause the problem, but they simply tried to address it. they were like the pioneer surgeons of old who tackled massive fungating breast cancers with surgery as the only modality, because there was nothing else. these days no breast cancer and no squamous skin cancer should ever get that large and be that challenging, not only because of the obvious disturbance to an otherwise most enjoyable breakfast, but because they should present for surgical attention long before then. it is such a pity then when those very people who prevented this vent their misplaced wrath on the very people who did their best with the presented material and tried to help.

i am not special

just when you get a lift life tends to slap you in the face again.

the state hospital was supposed to get a surgeon. all indications were that he was supposed to start on the first of the month. the medical officers booked elective cases for him to do with excitement and anticipation. the first of the month came and the first of the month went, but no surgeon turned up. the poor medical officers now had the nasty problem of having a whole bunch of people needing operations with no one to operate them. they phoned me.

i could not do all the operations. not even close. but i told them that i would try to make myself available on tuesday afternoons. they just needed to book the most critical cases and i would do them. they organised a typical state thyroid for the first tuesday. (not quite as bad as all that but still bad)

the monday before i was on call. a pretty hectic gunshot wound came in late that night. at the same time an appendix patient also arrived. i called the anaesthetist out and we got to work on the gunshot guy. a splenectomy, distal pancreatectomy, nefrectomy and liver repair later we delivered him to icu in a surprising good state. (there was not only a great deal of blood on the part of the patient but also a goodly amount of sweat and tears on the part of all of us). we finished at about three o'clock in the morning. everyone was tired and irritable. then i suggested we do the appendix. truth be told, i was laughed at.

i considered my position. it was reasonable to postpone to the morning when i would be at least slightly rested. there would be a smaller chance of cutting something i should rather not cut. but i knew i had a full day in the rooms with consultations and scopes. thereafter i was supposed to go to the state hospital. if i left the appendix for daytime, it would clash with that appointment in all likelihood. so i simply refused to take no for an answer. i pretty much insisted that we do it there and then. all concerned finally succumbed and the appendix was removed some time after three o clock in the morning.

after a deep two hours sleep my day began in all earnest. i spent the morning in consultation and doing gastroscopies and colonoscopies. i only just finished to rush off to the state hospital to be there at two pm as had been arranged.

when i entered theater, the anaesthetist casually told me they had a child who had a foreign body stuck in the esophagus that they were going to do before my case. i was annoyed, but i knew that in state hospitals you must learn to go with the flow. otherwise constant frustration will kill you or drive you to drink.

sure enough they put the little kid to sleep and for expediency i took the thing out myself. still the anaesthetic and the usual state delay had lost us a full hour.

finally the thyroid was doped and we got under way. true to form they had booked me a monster. it was the sort of thyroid that was so big you feel you need to take it out as fast as possible because it's bullying all the other thyroids in the ward. to be honest i struggled. it was all the way up to the skull, all the way down behind the sternum and around the back to behind the esophagus. it was stressful surgery. i was trying to get it out of that neck but i swear it was trying to pull me in to devour me.

during all this, the sister who was obviously annoyed at the slow pace of the operation started berating the medical officer for starting a case that wouldn't finish before four, the time in the state hospital when all elective cases are supposed to stop. i piped in that an emergency case had been pushed in before us and therefore they owed us another hour so we were therefore still within time constraints. she looked at me.
"these rules are for everyone. you are not special!" and just to make sure there was no misunderstanding, she repeated,
"you are not special!"

i joked about it at the time saying my mother had always told me i am, but i could feel irritation welling up. i needed to finish the task at hand so i took my mind off the comment and returned it to the thyroid which i think had just tried to bite me.

when i got home, fairly tired from work and lack of sleep and put together the entire sequence of events, including me depriving myself of sleep in order to be able to go and help at the state hospital, i became angry. it had nothing to do with if i thought i was special, but rather to do with what other options that patient had of being operated. the answer is simply none. if i didn't do it there was no one else who was going to step in and do it. then despite pretty much standing on my head in order to be available and still getting knocked back an hour on the list the sister tells me i'm not special because she has to stand 20 minutes longer than she was expecting to. i became mad with rage. i considered phoning the super and telling him to stuff his hospital and theater staff and that i was no longer willing to help.

then i thought of all the doctors there trying their best beyond their abilities to at least provide some service. slowly the rage dissipated. then the anger subsided. then i slept.

i am special

sometimes it is good to get a bit of recognition. if you don't the job can sometimes slowly erode away at your spirit. so recently i got a boost and i think my spirit may be good for a few more calls.

one of the state hospital doctors invited me out for a casual get together to celebrate his birthday. most of the guys i work with when i help out there would be attending so i thought it should be fun. the night started off slowly. i sat with the man of the hour and his girlfriend and two of their friends from the real world (not medical). i concentrated on their conversation, sedately sipping my beer. i was the outsider and i didn't want to draw attention to myself. then the doctors started dribbling in. the senior guys came over and greeted me. the house doctors would occasionally nod an acknowledgement and move off. in the hierarchical medical system they were used to they weren't sure how to relate to a real live consultant in a social setting, so they sheepishly avoided me. i started wondering if i'd made a mistake by coming along.

then someone came in that i didn't know. i asked my friend who he was. turns out he was a house doctor that simply hadn't rotated through surgery yet and therefore i hadn't worked with him. being a house doctor i expected him to avoid me like all the others had done. but just as i didn't know him, so he didn't know me either. he came over.

"hi, my name is g." he said warmly extending his hand.
"pleased to meet you." i replied. "i'm bongi."
"bongi? the legend? i've heard so much about you and now i finally get to meet the man himself!" i was taken aback. i wasn't sure what to say. i couldn't just leave it at that.
"what do you mean?"
"well i hear you always help despite the fact that you don't get paid and that you ruthlessly rip the house doctors to shreds when you're operating." (the hospital sometimes does pay so that is not entirely true. also i think i may tease the house doctors a bit, especially about their universities of origin if their anatomy is not up to scratch.)

as it turns out all those nights going out at all hours to help the skeleton staff who are desperately trying to keep things together on the sinking ship that is the state hospital has made an impression on some people. i felt good.

rumours

as i've already said, the small community of registrars in pretoria tended to lend itself to gossip. i had been the brunt of rumours and rumours of rumours a number of times so generally i just ignored juicy stories about other people, especially if they were friends.

and this was what i did when rumours started doing the rounds about one of the registrars of urology. she was an enigmatic girl with a fast mouth and a vibrant personality. i counted her as a friend. so when someone let slip that she was having an affair with a registrar from another discipline i quickly said i was not interested in even listening to these stories. people stopped polluting my ears with this foul gossip.

then one day someone came up to me.
"bongi what's this i hear about you?" i was willing to at least hear the gossip about myself.
"what? you tell me." i asked.
"well you know the stories about e of urology having an affair? is it true that that affair is in fact with you?" i had to laugh. i denied it without too much fanfare. then i went looking for my urological colleague.

i only ran into her a few days later. we greeted each other with our usual enthusiasm and then i asked.
"i really need to ask you something," i said with a smile. "i heard a rumour that you and i are having an affair. is it true?" her face broke into a smile when she answered;
"oh i really hope so!"

who could blame her?

gossip

the community of registrars in a university like pretoria is small. a small community is nice, but it is always important to remember whatever you say will probably find it's way back to the person you are gossiping about.

i was rotating through orthopaedics. rotation generally is not too much fun and ortho was no exception. finally they allowed me to operate. they put together a list of wound inspections and secondary closures and the like, claiming they would handle the ward and clinic (later i found out they used the opportunity to take an early day and go and play golf). anyway, there i found myself all on my lonesome, closing some wound on a forearm in the company of a green anaesthetist that i'd never met before. i tried to be friendly and i thought it was working. i was making small talk and stupid jokes. the gas monkey was even laughing.

then i approached the end of the operation. i placed the last stitch and asked for a plaster. the anaesthetist looked up with an expression of surprise on her face.
"are you finished?" she asked.
"yes"
"you didn't tell me you were almost finished!" she complained.
"sorry." it seemed like the right thing to say, but it didn't work. she really let me have it between frantic exaggerated turning down of the vapours and drawing up of reversal. i listened to her tirade for a while but it quickly bored me. i walked out to the scrub room to wash my hands.

there i removed my mask, adjusted the cap on my head slightly up and washed my hands. afterwards i slowly walked back into theater. the anaesthetist looked straight at me.
"can you believe it?" she said
"believe what?" i replied.
"the bloody surgeon!" i wondered what surgeon she was complaining about now. by this time i had figured our that she was not overly fond of surgeons. i decided to listen patiently to her tirade.
"who and what did he do?"
"the surgeon who was just here! he didn't tell me he was finished and then he just left me with this sleeping patient!"

it took me a moment, but i realised she didn't recognise me with my mask off and my cap donned slightly differently. i considered drawing the situation out but truth be told, at that stage i just couldn't be bothered any more.
"i said i'm sorry. what more can i say?" i said in a pseudo-annoyed voice. she looked at me with a blank expression. then suddenly she went bright red. i smiled broadly.
"pleased to meet you. i'm dr bongi."

yes there will always be people bad mouthing you, but, if i could be so bold as to suggest, do not gossip directly to the subject of your gossip. it just makes you look foolish.

so clever

i'm not the brightest. pregrad took a lot of studying just to scrape by. surgery nearly caused pressure sores on my butt. so i always assumed i was fairly low down on the surgical iq pecking order. we at pretoria knew we could operate better than most of the other universities, but how could we compare to a place like uct (cape town). those guys we knew didn't nearly get our operative exposure. we just assumed they used all that extra time cracking the books.

i remember a registrar's symposium i went to where they presented. at some stage a zim registrar asked a pretty poor question. the uct guys answered, but the zimbo wouldn't accept their answer (mugabe-like???). the uct guy calmly pulled the mike forward and said,
"i suggest you go back to your books!" i was impressed. i knew the zim guy was clueless but i couldn't quote chapter and page to allow me to throw the book at him like that. i really thought that the uct guys were super clever.

a few years later the international surgery conference was held in durban, south africa. we all went. i decided i'd try to get to know the uct guys better. it's always good to make friends. but i also wanted to get a chance to grade them myself.

as could be expected from capetownians, they weren't too keen on this pretoria boy in their presence and they made it pretty hard for me to get to know them. at a stage, as surgeons tend to do, some of them were sharing surgical stories. i noticed they all ended in 'and then i phoned the consultant.' well i had stories and mine didn't end like that. so i told one.

it was a midnight blunt abdominal trauma that ended in a liver resection. (truth be told the impact with the truck out there on the street had pretty much handled the resection. i just needed to tidy up a bit.) they were astounded. no consultant? i did it alone? we do that sort of thing in pretoria? and such questions.
i felt better. even if i wasn't as clever as they were i could at least operate. i had been trained to make the crucial decision at the crucial moment without needing to rely on backup.

a few days later they were once again telling their stories, but this time they had one of their consultants there. it seems one of them opened an abdomen because his junior had put the patient on the list and the diagnosis turned out to be something unexpected. my first thought was that where i come from there is no way the primary surgeon wouldn't have made the decision to operate himself. i admit i felt superior.

the uct registrar described his shock at discovering the actual diagnosis, something that is first approached non-operatively. only when this fails is surgery considered. he phoned his consultant, the guy sitting with us.
the consultant advised closing and reverting to the non-operative management. i piped in.

"but you had the abdomen open. i agree with the non-operative approach, but you're there with the abdomen already open. fix the problem with a knife." they all looked at me. the consultant asked,
"how?" i was a bit surprised. but i told him how. the registrar who was telling the story said that he didn't know how to do what i'd just said. again i was surprised.
"you do know how now. i've just told you how. you just need to do it."

they all shifted uneasily in their chairs. they didn't have the charge-in-where-angels-fear-to-tread attitude that the pretoria guys had. to argue the practicalities of an operation with a pretoria guy was not going to work. it was time for plan b.
"well i've never seen that operation in my books. maybe you should go back to the books." it was the same line that i'd heard them use years before. i was a bit confused because i had read this operation in a book. i'd actually seen it in a few books. but they were uct registrars and i doubted myself suddenly. i knew we could out operate them, but if they said that it was not in the books in the presence of a consultant and he agreed, then maybe i was wrong. i kept quiet.

that night i opened my book, the latest sabiston and sure enough, my operation was there described just as i had said.

i didn't go back to them to point out that i was right. it seemed too petty and vindictive. i just reminded myself that despite the way i felt about my spartan-type training, it was actually good and academically sound. i would never feel inferior to the uct guys again.

the big five

unlike the perception that some first worlders have about south africa, there are not wild animals walking the streets and there are not attacks every now and then by said animals (except for my cousin who was eaten by a crocodile. that is a bit too close to be discussed on my blog though). however i'm starting to have my doubts too.

quite soon after moving to the lowveld i treated a patient that was bitten by a hippo. let me assure you that that is no small bite. i think it is remarkable to survive something like that. then there were the two crocodile attacks. the one actually had a tooth embedded in the arm. it seems that crocodiles often loose teeth. to them it doesn't matter because they can replace their teeth right through their lives.

but it seems recently we are working through the big five.
i didn't treat the guy who was mauled by a leopard. i didn't even actually go and see him. he survived because the leopard itself was terminally ill and wasn't in good fighting form.
the guy who was attacked by a lion survived because he managed to get a shot off before the lion got to him. the shot apparently took out its top jaw. the lion could therefore not bite but still shredded him quite badly with its claws. i'm a bit embarrassed to say i turfed him off to the orthopod once i discovered his injuries were all to the arm muscles.
around the time of the lion patient i heard from a friend of mine in the kruger that he had a contact with a Buffalo. luckily the beast had been darted and was pretty nearly asleep already when it knocked him down. otherwise he probably wouldn't have been around to tell me about it.

then came the elephant attack. i can only assume the elephant's heart was not in his actions. otherwise how do you survive an elephant attack? but even not fully devoted to the task at hand, the pachyderm still managed to inflict severe wounds to my patient.

we haven't quite yet covered all of the big five, so there is a part of me expecting a rhino attack sometime in the next few weeks.

i smell drunk people

it's funny how smells can be so emotive. i have spent a fair amount of time in the state hospital lately. and going through casualties the smells were so familiar. it is a smell common, it seems, to all state hospital casualty units that i've ever worked in. and somehow alcohol is the constant thread.

i'm not talking about smelling alcohol on the breath of an aggressive family member, although that is also something one does see (or smell) a lot of. but it is so much more than that. i'm talking about the residual smell of alcohol laced bodily fluids after a busy trauma night. it is a smell that is resistant to being washed out.

it's difficult to explain but the smell left me with a longing for days gone by when i was the surgical registrar on the floor. i was the guy placing the nasogastric tube when the patient brings up the night's festivities all over the bed and often my shoes, leaving a sour smell of alcohol and stomach acid. when i was the one placing a high flow line into the neck of the nth drunk uncooperative gunshot wound patient, where part of the technique is to dodge his often well placed punches. in those moments you are not aware of the smell. maybe the adrenaline drowns it out. but it is always there. the next day when you walk into casualties and the smell hits you, the nigh's activities return so vividly to your mind.

i remember when i first learned the smell of alcohol in blood. strangely enough it was during an operation on a sober gunshot patient. he was bleeding profusely. i kept on thinking there was something missing. the blood didn't smell right. and then i realised that the smell i was missing was the smell of alcohol in the blood. how weird is that to know what alcohol in blood smells like.

yes i miss those days sometimes. alcohol doesn't play that prominent a role in private but you still see it. so it was a nice trip down memory lane this weekend to smell that smell again.

p.s the patient at the state hospital this weekend survived and was even extubated the next day.

tumble

i know a bit about ballistics. it's more practical knowledge. i've seen enough gunshot wounds to pick up something here and there. the high velocity ones wreak havoc inside. the more usual 9mm doesn't compare but a well placed shot is still devastating. and then you get the exceptions. ricochet shots can be confusing. they tend to take strange paths through the body, sometimes following dissection planes (like surgeons) and causing less damage than you'd expect. and then you get the tumbler.

i did a tumbler recently. it wasn't a particularly high velocity projectile. the bullet didn't even make it through the patient. the entrance wound was just below the rib edge to the left of the midline. i could feel the bullet under the skin just below the right arm (bullets that are palpable just below the skin usually mean deflected bullets, either before penetration, like a ricochet, or in the body by hitting bone). he also had a hemothorax on the right. he was sinking fast so we got him to theater without too much delay. the intercostal drain delivered a good liter and a half, but then dried up. laparotomy was the first order of business.

despite the normal entrance wound and the relative low velocity, the damage inside was impressive. there were two 5cm holes in the stomach. the bullet then continued into the liver, causing a massive tear where it entered and an equally impressive one on the dome where it exited on it's way through the diaphragm into the chest. the hemothorax (bleeding in the chest) was actually from the liver.

so, although the bullet was small as bullets go and also not of the fast variety, the fact that it was no longer stable in it's trajectory meant that it caused a relatively large amount of damage. imagine it tumbling as it travels through its victim. the amount of energy parted to the tissue is considerably more than it would be if the projectile just behaved and followed a straight line.

the other interesting thing with this case is that, for a change, i did in fact follow the advice of countless hollywood productions and i removed the bullet. (usually it is not necessary to remove a bullet, with certain exceptions of course. it is not the presence of the bullet that causes the damage, as hollywood would have us believe, but the movement of the bullet through tissue at the moment of the shot)

kruger weekend

well i had a great day in the kruger park (also mentioned here and here). besides the Buffalo, elephant, rhino, leopard, crocodile, hippo, kudu, bushbuck, nyala, etc that i saw, i also saw wild dog. and not just saw but followed a troop with about 8 pups for about 30 minutes. what an experience. it was wonderful.





here follow a few photos of these incredible animals.

specialise??

recently i had two experiences which once again reminded me that the public and medical people have contrasting views of what a general surgeon is. most readers of medical blogs would at least have some idea of what it takes to become a general surgeon, but joe public out there does not.

in the first post in sid schwab's series on deconstructing an operation, he mentions a light hearted exchange in the scrub room between an orthopaedic surgeon and a general surgeon where the ortho refers to the general surgeon as a real surgeon. in many senses this is true, not to detract at all from the other surgical specialities. but at least in my neck of the woods, when your chips are down and your life hangs in the balance, it will be a general surgeon trying to save you (severe head trauma is the exception and in some places if there is a thoracic surgeon he may be there for chest trauma). being a general surgeon means less sleep than all the rest of our surgical colleagues, but also a certain level of respect, usually expressed in;
"rather you than me dude!" then there is laughter. but they are grateful for the frontline guys.

but the public (where i am at least) has no idea.

recently i have been meeting people outside of the workplace. they usually ask me what i do.
"i'm a general surgeon." i reply.
"oh! that's nice" they respond "are you thinking about specialising some day?"
"no." i say and smile.

but the last encounter was slightly more interesting. i was with a friend whose wife is a doctor, so he was more informed. he introduced me to someone.
"what do you do?"
"i'm a general surgeon."
"oh. that's nice. are you thinking about specialising some day?"
"no." and i smiled.
but then my friend started looking uncomfortable. he felt, it seems that some impression of what a general surgeon is should be left with the fellow. he took the conversation further.
"well, it does take a lot of study and work to become a general surgeon, doesn't it." i thought, seeing as he had gone to the trouble of trying to defend my honour, i'd better continue his line of thought and not leave him in the lurch.
"yes it does," i said "in my case i essentially studied for 15 years." i could see the guy's expression. he clearly couldn't compute this. after all i was just a general surgeon, probably not even a real doctor. his answer was according to his understanding and assumptions.
"yes it is good to keep abreast of latest developments." he assumed i was not speaking about real study but just about the occasional perusing of a surgical journal or two. i decided to mess with his understanding and assumption.
"not me," i replied, "i'll never study again. in fact if someone presents with a new disease, they must die."

i thought it was funny. he did not.

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.