blood sports

i love rugby. i used to play on a fairly low level, but when i injured my acromioclavicular joint i knew i needed to stop. it was fun but i was not willing to put my body on the line any more. it seemed too dangerous for me. recently i have reviewed this decision.

the first patient i touched on in a previous post. during a game of soccer the goal post fell on him and split his pancreas in two. the tail then slowly shrivelled up into a hard fibrotic mass. the story came to a happy ending when i removed that distal portion of the pancreas. by that time it was embedded in scar tissue and it was quite something to peel it off the renal vein behind it and the splenic vein above it. somehow everything went well. i was just left with a sense of how dangerous soccer can be.

the next patient was playing a game of snooker. i can only assume he was winning and by quite some margin because his opponent seemed to get annoyed at a stage during the game. i know this because he suddenly shot my patient. and he didn't shoot him once or twice. for good measure he put four bullets through him. he must have had an unassailable lead in their friendly game of snooker. unassailable by the standard rules anyway.

so, recently having treated two casualties of the blood sports of soccer and snooker, i realise rugby was really not that dangerous at all.

pancreas

recently i did a distal pancreatectomy (i removed the tail of the pancreas). it was an exciting operation. the guy was the victim of a soccer goal post falling on him, causing fracture of the pancreas. the injury was about two months old, just enough time for the pancreas tail to become a hard rubbery fibrotic mass adhered to everything. i took it out without removing the spleen (with supreme difficulty) and was very proud of myself. i thought back to the days of old.

when the prof felt we didn't have full control of the ward, he'd let us have it and he wouldn't let a thing go (as i have mentioned before). i remember once when he ripped into me in front of my students, but worse still in front of the patient i was to operate the next day. she must have felt great to hear that the guy who was going to take a knife to her the next day was 'useless and had lost all control of his ward'. it must have engendered in her a feeling of safety and comfort.

anyway, one of the imageries the prof used regularly was of someone riding a bike without handle bars, implying loss of control. i remember him telling me in front of my junior colleague, all my students and my patient that my ward was chaos and i was riding the bike without handle bars (i had failed to remember the sodium value for one patient and needed to refer to the results). as usual he went on for some time.

a while later we admitted a guy with a fracture of his pancreas. the next morning, as usual, we presented our cases to the prof in front of all the registrars. the prof asked the usual questions about diagnosis, presentation, treatment options and so forth. one of the things he wanted to know was how it had happened. it is usually the result of blunt abdominal trauma. the pancreas gets caught between the vertebral column and whatever caused the blunt trauma. in this case the patient was riding on his bike, he did a jump and came unstuck in mid air. he then fell with his abdomen onto the handle bars.

in the very formal setting of the morning meeting i had just presented the case to the room full of stern faces with the prof looking for a gap to have a go at some poor unsuspecting sod when my junior leaned across and whispered in my ear;
"that's why i think you should always only ride the bike without handle bars!"

i could not hold back my laugh. the prof was not impressed but it was worth it.

post traumatic stress

in a previous post one of the topics i touched on is the aftermath of losing a patient or rather the effect it can have on you as the doctor. a good post i read recently also touched on the desensitisation we tend to undergo. it is often forced on us, as was demonstrated by the sister's comment to me after the patient died in my post quagmire. there was no space for feelings. she didn't follow me out to speak to the family and be confronted with feelings. she just jabbed me a bit, maybe to help with the desensitisation process.

but sometimes the reality itself doesn't allow for the luxury of emotions. there are so many stories i could tell to illustrate this point like the time one of my patients crashed while i was resuscitating another one. when patient one died i didn't have time to even register emotion. i had to get to the other one who was in the hands of my medical officer whom i had sent ahead. when i got there to find him dead too i mustered up the troops to get back to the endless streams of impatient patients in casualties. they didn't care about our emotions. they didn't want to wait and they were willing to throw abuse at us if they did.

but the real reason i'm reminiscing about all this is a recent conversation with an anaesthetic friend. he was also talking about the effects these things have on you. it is quite sometiong to have someone die literally under your hands and wonder if there is something you missed that may have changed the outcome. to possibly be partially responsible for the death of another human being seems to leave quite a mark.

he was on call. a disaster was presented and the team got to work. he describes scenes quite similar to the fan fair i spoke about in the case presented in quagmire. anyway the details are not important. the point is there was high drama and it was traumatic and shocking to all involved and the patient died in great thespian style on the operating table despite all efforts by everyone concerned.

my anaesthetic friend was shaken, as can be expected. he wanted to go home, or even just sit and let the adrenaline work out. (home would no doubt have been better). the theater matron came in. he looked at her with a blank stare. maybe he felt empty and his face reflected that. the matron asked;
"so what case are we doing next?"

just like that! the dead patient, the devastation of the family (still to be faced), the blood all over the place, the shock to the team, specifically the anaesthetist and all the matron wanted to know was what case to do next! in a certain sense you can understand it. the list is there. there is not another anaesthetist on call, so if he is not up to helping with the next patient, the next patient would not be helped. also it could easily be that the next patient is just as critical, but it could also be that it is something quite mundane. the point is my friend had no time to recover. reality steam rollered him and he had to deal with it...later...in his own time...when he would be so tired post call he would probably not be able to deal with it. somehow that is the way it usually turns out.

when we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on its rump.

master and apprentice

surgical training is very hierarchical. everyone knows where they fit on the pecking order and everyone stays pretty much in their place. a basic team consists of the consultant, (or the boss), the registrar, (the guy who runs the show), the medical officer (his second in command), the house doctor (the skiv), and an assortment of students. but the registrar and the medical officer are actually the functional unit, the master and the apprentice. it is a sacred relationship. only once were those lines blurred.

a friend of mine was a phenomenal doctor and a most capable operator. he was medical officer to the senior registrar and quickly learned how to do pretty much everything. soon his senior was doing his calls from home (an almost unheard of state of affairs reserved only for those working with exceptional medical officers) where he could hit the books for his up coming finals. at the same time another medical officer was biding his time in 1military hospital. the work load between the two hospitals was incomparable. the academic hospital was always at full capacity and a call generally delivered much and severe pathology. the military hospital was very quiet and to even do a laparotomy on call was most unusual. although of the same station, the two medical officers were very different in experience and ability.

when it came time for them to write primaries, for some reason my capable friend passed up the opportunity due to a few peripheral problems in his life at the time. however, because of this, when the next year came around, he was not promoted to registrar, but remained a medical officer. as life would have it the boss put him together with the most junior registrar, the guy from the military hospital.

i was rotating through urology. the surgeons phoned us to join them in theater for a gunshot abdomen with an injury to the ureter. they would open and get the life threatening stuff sorted out. we would then be required to fix the ureter and they would handle the rest. (ahh the cushy life of a urologist.) we walked into theater just as they were about to open. i saw my friend, the medical officer, and we exchanged a quick friendly smile. he looked a bit sheepish only assisting on a type of operation which he would have been doing himself only a few short months previously.

the registrar opened. there was blood in the abdomen, pretty much the normal amount for a common or garden gunshot wound. right away i could see the registrar was out of his depth. he sort of patted the blood with a swab, lifted the swab to see how much blood was on it and patted some more. he didn't seem to even have an idea how to explore a simple abdomen, let alone one with a smidgen of blood from a bit of acute lead poisoning. i considered offering to help. after all i was a general surgeon registrar, even though i was rotating through urology and i was the most senior generalist there. i decided to wait.

my urology senior leaned across and asked;
"what do you think is hit to cause that much blood in the abdomen?"
"that is not all that much bleeding," i replied, "the patient is still stable and there is no increase in the amount of blood. this is mostly old blood."

again i considered volunteering my immense experience and skill, but i knew that this situation was well within my friend, the medical officer's abilities. i held my tongue.

"what do you think is hit?" my urology senior asked the registrar. still softly and ineffectually dabbing the blood with swabs, the registrar replied, probably more with his adrenals than his brain,
"i think the ivc is hit." i'm a bit ashamed to say i laughed, but i did. i thought he should know that if i thought there was any real danger i would have already been in there. i looked at my friend, the medical officer. i could see the frustration in his eyes. the situation was not dire enough for him to undermine his senior's authority and take control and yet nothing was happening!

he then humbly suggested he help a bit. within moments he had exposed all relevant injuries and shown them for what they were. the registrar looked in control again. we, the urologists got stuck in and fixed the bloody ureter. then we left.

that day there was a master and there was an apprentice, but which was which?

quagmire

hospitals are divided into neat little units, each functioning independently and each with their unique perspectives. surgeons move between these and get an overall view. however, sometimes negotiating your way through the many different ways of seeing the same case can be like finding your way through a marsh with all the dangers of being swallowed up in quicksand at every turn. one time this hit home pretty hard was just another gunshot that was anything but just another gunshot.

i was rotating through thoracic surgery, which by implication means i was the junior. then casualties called. they said they had just gotten a call from an ambulance bringing in a gunshot heart and they wanted me there when they arrived. i remember thinking that it should be a quick consultation. i mean who survives a gunshot heart?

casualties' main function is to keep the patient alive until the surgeon takes over. thereafter they play no role in the further treatment of the patient. it is usually a case of out of sight out of mind. this time around they made sure i was there when the patient arrived. finally the ambulance came blaring in.

the patient was an eighteen year old girl. she was clearly in deep trouble. the bullet had entered her side below the nipple line and had exited almost exactly the same place, but on the other side. she was already losing consciousness despite good intravenous lines flowing full speed. i quickly decided that this was not a gunshot heart. this was partly because of the lack of distended neck veins but mainly because she was still alive. i got to work.

i instructed the casualty officer to intubate the patient while i quickly threw in bilateral intercostal drains and a high flow central line. the drains in the chest drained nearly nothing. the problem was not in the chest, but in the abdomen, my usual stomping ground. the abdomen was also visibly distending and under quite a bit of pressure. however i was not in general surgery at the time. the casualty officer then took off her gloves and said:
"ok, i'm outta here. i have other patients to see." she was quite within her rights but it was just difficult to keep the patient under control while i made the necessary phone calls to get blood, call the general surgeon on call, get theater ready and phone the icu guy to organise a bed for after surgery. but, what could i do? so i did what i could.

by the time the general surgeon (my junior) arrived everything was ready for theater. the only problem was that the patient was slipping away. we grabbed the trolley and ran. as we passed an examination room i glanced in. there was the casualty officer looking into someone's ears. yes she had move on. that patient's otitis media had no chance.

in theater we met the anaesthetist. he took one look and let rip. how could we give him such an unstable patient? where was the blood? what sort of show were we running? i considered telling him that the patient had two large bore peripheral lines and a high flow central line, the only unit of emergency blood in casualties had already been given and we were waiting for more from the blood bank and to stand here arguing was more of a joke than anything we had delivered to him yet. i knew that it was in no one's interests to argue, so i just quietly suggested we get the patient on the table to see if we could find the source of bleeding which was the actual reason the patient looked so bad. delay was in fact what was killing the patient.

anaesthetics weren't needed. in fact by that time the patient was so unstable anaesthetics would have been the last straw. it is difficult to explain what it was like there in the ensuing moments. the anaesthetist was shouting for blood and fluids. the floor nurses were running in what seemed to me like ever decreasing circles. the surgeon opened the belly and liter upon liter of blood came gushing out. he threw both hands into this bright red torrent and screamed for his assistant to do the same. then, seconds later i heard the anaesthetist shout:
"heart has stopped!! heart has stopped!! give internal cardiac massage now!!!"
"i can't give f#@king internal cardiac massage at the moment!! i've got my fist on the aorta and that is the only control of bleeding we have. you give f#@king cardiac massage!!"
"i'm trying to get fluids on board!!" he said while squeezing one of the drip bags to force fluid in. they both looked at me. i gowned and gloved without scrubbing. i then slipped my hand into the abdomen under the sternum. i took the heart in my hand and began squeezing. it was just an empty sack.
soon after we called it. she was dead.

i felt drained. a young woman had just died in the most dramatic fashion, literally while i held her heart in my hand. i looked at the sister.
"what a mess you've made of my theater, dr bongi!" she said with genuine irritation, "who the hell do you think is going to clean this up?" obviously she was less affected than i was, i thought.

as we got out of our blood soaked scrubs and back into our normal clothes i noticed that one general surgery student was pretty shaken. i thought i should maybe chat to him. the surgeons left, but i waited for the student. we walked towards the door. i gave a light hearted comment and he ventured a tentative smile. i reciprocated, as we walked out the theater complex. and that is what we were doing when we unexpectedly walked into the family, smiling.

the family were in a group outside theater. they seemed in fairly good spirits, all things considered. i got the feeling that they were impressed that they had managed to get the patient to hospital so soon after the incident and they seemed to be under the impression all would now be fine. one looked up.
"excuse me, but do you know how it is going in there with the young woman with the gunshot wound?" great i thought. the surgeons had just walked past them and it was now up to me to break the news. generally when you are about to tell the family that they have just lost a loved one, it is not a good idea to be seen to be smiling and light hearted when they see you for the first time.

i went through the injuries with the family. i then told them we had done everything we could, but that she had not made it. any vestige of hope seeped out of their faces quite slowly as this information sunk in. most turned away to hide their tears. i needed to get away to maintain my composure too. i made sure i answered all their questions and then left.

i walked down the corridor to icu to tell the icu guy we wouldn't be needing his bed. when i told him he looked at me and smiled,
"good. i've already opened up a bed. now i have an available bed if i need one later tonight."

i had to sit down. it seemed to me everyone had just seen the tragedy from their own perspectives in their little windows on the whole tragedy. i felt a vacuum in my heart. the icu guy offered me a smoke. that is not a good idea i thought, but that is not what i said.

finalist!!

i am a finalist in the literary category!! obviously capitals are not a prerequisite.

but actually i'm honoured and inquisitive about how i compare to my very excellent co-finalists. now, believing as i do that the only thing worse than a politician is a lawyer, i morally can't campaign actively for my readers to vote for me. however, what i will say is that if you truly think i deserve this honour, please do vote.

for those who don't know my writing, i have decided to select a few posts that i thought weren't too bad.

how to wake up.

what to wear.

what not to do in front of the prof.

an icu patient.

a student's story.

a south african perspective.

anyway, please only vote for me if you think i actually deserve the award. if not, please vote for whoever you think does deserve the award.

a tribute to a friend

rest in peace.

new year's eve triage

triage is taught to us all, but unless you find yourself in a war, you don't use that skill too often. when it is needed, somehow all those lectures don't seem to help.

i was working on new year's eve in casualties in qwaqwa. the local population was about one million and the average income was pretty much on the bread line. the bread line, for those who don't know, is way above the alcohol line and significantly above the knife line. there was no shortage of drunken stabbings.

as can be imagined, that night was busy and the later it got, the busier it got. the early evening was only much worse than an average night. but by ten pm all hell had broken loose. the stab wounds started coming in. initially they came in at a rate of about one every twenty minutes, but soon they were walking or being carried through the doors at a rate of one every two to five minutes. there was no way of keeping up. also standard clinical parameters where less helpful. everyone passed out just after lying down (thanks to good old recreational ethanol).

the nurses took vitals as fast as they could, but they could not get to everyone. one of the reasons is there were not nearly enough beds so the bodies lay on the floor so thickly they blocked up the passage. you could literally not walk down the passage because you would stand on the patients.

our triage became fairly coarse. at a stage, looking for a place to plant my next foot between the bodies on my way down the passage, a patient looked up at me and asked;
"when are you going to get to me? i'm in pain!" the simple fact that the patient could speak meant that he was in a much better condition than almost everyone there. the fact that he was making a nuisance of himself meant he was going to wait a very long time.

but the ability to speak was only present in about one percent of the patients, so how did we triage the rest? in the end what it came down to was one thing and one thing only. if the puddle of blood around the patient was growing in size, that patient would get attention first. all the rest were done in the order of how they lay. the ones closest to the suturing room were treated first moving gradually away. one of the reasons for this is the people working in the suture room were figuratively snowed in by the bodies. they had to dig themselves out by suturing the patients and sending them on their way. even if they wanted to treat someone else first they literally couldn't get to him.

finally that night came to an end. everyone was exhausted and limped away from casualties. some of the patients limped too.