colleagues????

the more i read this above sick note from a sangoma the more i find in it to appreciate. there are so many subtleties that just make it priceless.

and our equally ridiculous government wants to put these clowns on equal footing with proper doctors.

alone

this is not a medical post. it is also not a surgical post, except it describes an incident which had an influence on what i became later in life. i suppose it may have to do with the moulding of a surgeon.

in my post the best i touched on the fact that "once the knife goes through the skin you become suddenly very alone." it is a state you need to get used to and be comfortable with.

i was in a hostel when i was in high school. it was an old style hostel based on almost regimental rituals and punishments, often imposed by the older boys themselves. some may describe it as savage. others might say it had a military origin. still others will say it was just a bunch of boys being boys.

i was in form one. my boss (the matric whose shoes i shone and whose bed i made and whose laundry i took care of) lived in the matric dorm. the matric prefects were distributed through the other dorms. the non-prefects who were semi-decent were also distributed through the other dorms. only the dregs of our hostel matrics ended up in the matric dorm. it was not a good place for a form one skiv to have his boss live. the chances that you fell foul of one or more of the matric dorm matrics was high to say the least. on this particular day the matrics of the dreaded matric dorm decided they wanted to teach us, their skivs, a lesson. why, i don't remember. but the lesson was to take the form of kangaroo court. kangaroo court is basically when a group of boys beats the crap out of one single boy. i think a form of it is illustrated in the movie 'a few good men'.

the matrics told us to clean their dorm. we did. then they did an inspection. one took a white glove. i don't know where he got it so don't ask. he then ran his fingers along the top of the curtain pelmet. we had not cleaned that. it was pretty much the only thing we hadn't cleaned. it hadn't occurred to us to clean it. obviously there was dust on the glove. they then pronounced sentence. we were all to receive kangaroo court.

in queues to receive punishment in the hostel there was a form of auto sorting. the toughest guys ended up at the front. the more scared you were the further you moved back. i wanted to run away, but i ended up third in line. my two friends in front of me were what i considered the toughest hardest boys of my age i'd ever met. (interesting to note both boys ahead of me were expelled from the school years later).

so there i was, a scared fourteen year old boy who had only just left the protection of home, just about to be called in to be beaten up by about five eighteen year old guys. somehow i didn't believe it was happening. i somehow thought at the last minute it would stop. it didn't.

my first tough friend went in. we heard the punches and the matrics shouting and laughing. after a while he came out. he was crying. i remember thinking if they reduced him to tears then i was dead. the second one went in. this time i think i might have heard a muffled groan from the victim through the raucous laughter of the matrics. he was also in tears when he walked past me, his eyes downcast in shame. then it was my turn.

i walked in. one matric took two steps towards me and without a word threw his fist into my left thigh. the muscle spasmed. the leg would not obey my commands. they all seemed to be shouting at me and i wasn't sure what i was supposed to do. i remember my boss laughing at me. one of them told me to put my nose on the floor. for a moment i hesitated. it seemed a strange demand. their loud verbal tirade and the fact that one grabbed me and shoved my face into the ground made the demand more clear to me. i put my nose on the ground. someone stood on my head. i shifted my forehead to the ground. and then it happened.

at that moment with my forehead on the ground and someone's foot on my head with all those boys shouting and laughing i had an epiphany. i realised i was alone. there was no cavalry that was going to come in and save me at the last minute. the house master wasn't suddenly going to realise just then that this sort of thing was happening and put a stop to it. my boss wasn't going to stand up for me and defend me. no, i was truly alone and i would go through this no matter how scared i was or how i longed for it not to happen. that moment i changed. i never again expected help from someone else. i just expected to face what life threw at me, alone.

the rest of the kangaroo court is not all that relevant. i crawled into a ball to try to protect myself. they punched me in the ribs until i moved my arms over my ribs to expose my face and then they punched my face. these two scenarios alternated for some time. someone caned me and someone kicked my right thigh. but the humiliation of the foot on my head was somehow the worst of it all. when it was all over i was in tears, but there was something deeper that was cut.

i walked out of that room that day, also looking down ashamed of having cried. i was alone and somehow it suited me.

down time

just a few photos from my last jaunt to the kruger. above is a large group of dwarf mongoose.


the olifants river was in flood.




an early morning drive delivered an inquisitive hyena.




bateleur eating some roadkill.




a lion on the side of the road after a hearty meal.



mother and baby bats.



a woodlands kingfisher whose call is as beautiful as the bird itself.



and some elephants.




the maribou somehow makes ugly look beautiful.

orchestrator

team work in an operation is essential. usually i can just get on with my job and trust the anaesthetist to keep the patient going (alive). i don't have to worry too much about him. however in state sometimes i need to orchestrate everything.

the case was unusual. blunt trauma to the abdomen often causes the left diaphragm to burst, causing the intestines to migrate into the chest. this time the trauma was to the chest. the diaphragm burst from above. the x-ray picture was the same with the stomach in the left chest, but at operation it looked quite different.

they had apparently already done a full resus in casualties before even getting the patient to theater, so the patient wasn't in the best of shape.

the anaesthetist was a doctor from some outlying peripheral hospital that usually didn't do more than very simple cases and didn't even have a diploma in anaesthetics. he was doing his best and at least trying to meet a need in our local state facility. i opened in the midline. i found it a tad disturbing to find the heart free in the abdomen, just above the liver. i considered saying,
"i don't think this is supposed to be here!" but i thought better of it.

the diaphragm was destroyed. the pericard was destroyed. the heart had wondered off to the left and the lung had shrivelled up to hide somewhere out of sight. it didn't take a genius to realise this was not good. i realised this was not good.

i started the repair. then the heart stopped. it was easy to diagnose. i could clearly see the heart in front of me. i informed the gas monkey (anaesthetist). he looked at me. i put my hand around the heart and started to squeeze. the gas monkey looked at me. i realised he simply didn't have the beginning of an idea what to do. i realised this was not a team work situation. i needed to take control of everything. i was the gas monkey consultant suddenly. i took control. i orchestrated what needed to be orchestrated.

"you!" to the gas monkey, "give adrenaline now! you" to house doctor floating around like an unwanted fart on the wind, " draw up x ampoules of adrenaline and put it into y ml saline!" all the time i compressed the heart. now i have occasionally compressed a heart against the sternum from inside the abdomen, but seldom have i stood with the heart completely in my hand. i quickly adjusted to the correct amount of pressure to apply directly to a naked heart. it is quite a bit less than one on the other side of a diaphragm and decidedly less than one hiding behind a sternum. soon i was applying compressions with thumb and two fingers. that was all the pressure that was needed.

the adrenaline did the work and the patient came back. we went on. then things went south again. this time i put my hand around the heart and clearly felt the gentle vibrations of ventricular fibrillation.
"you!" to the wide eyed floor nurse "get the defibrillator now! you!" to the surgical medical officer, "get ready to shock and give me ample bloody warning because if you shock me i will not be happy!" all the time the heart was cradled in my hand with my three fingers doing the necessary.

we defibbed once and the patient came back.

the patient crashed twice more and i orchestrated the relevant resus. i then sent the house doctor to icu to ensure they prepared an adrenaline infusion and started closing. the patient had had better days but she was alive. i closed, gave the last necessary instructions and left.

when working with true gas monkeys we work as a team. but it is times like these when i work with junior doctors who find themselves in deep water that i remember what a priveledge it is to have well trained colleagues.

philosophical

this is not an easy post.

i try to be philosophical. i really do. if i'm not there worse would happen, i tell myself. but somehow i struggle to believe my own spin.

the state hospital is struggling. if i get called there it is usually in the middle of the night and i usually am not that enthusiastic about it. but if i must, then i must.

recently i was called to help with a complicated appendix. i use the word complicated, but i really mean african complicated. it was a mess worse than i can describe. suffice to say a cuban trained (the south african government send a handful of medical students to get trained in cuba) medical officer (junior doctor) was doing calls as the surgeon on call. he cut into a hapless victim without having clinically evaluated her. truth be told, i think he did evaluate her but he didn't have the clinical savvy to figure out what he was dealing with. his south african trained junior had actually made the right clinical call but was out ranked and had to concur. only when the wrong incision had been made and wrongly extended, all just after midnight, was i called to try to save what remained to be saved. fortunately i am not particularly intimidated by such surgical challenges. i dealt with what i got.

but if what i got was not enough, what i was told i truly struggled to deal with. you see, i try to be philosophical. in december when i did a thoracotomy for a gunshot wound, a procedure that is not actually supposed to be in the armamentarium of a general surgeon, all went well. later i heard second hand that the patient had died because he was transferred to another hospital because of a lack of icu beds at the local hospital. the only problem was he was transferred in a sub optimal ambulance. the short version is he died. i was devastated, but philosophical. i reasoned i had done my best and he would have died anyway if i wasn't there. i did my bit but my bit was not enough in the greater scheme of things. philosophically i try to reason with myself that in a war situation there will be casualties. there will be people who die unnecessarily. i must do all i can to prevent and limit this but it will happen none the less.

then that night, the cuban trained junior doctor who was doing calls in surgery in a setting where he in all reality could not be expected to cope, told me about another consultation he had turned away. i knew he had the habit of turning people away and because i knew he was not equipped to deal with most of what came his way i sort of understood. however the night in question i was on cover for him. there was no excuse.

he calmly informed me a peripheral hospital had phoned about a stab wound neck that was bleeding actively. the hospital in question had no surgical cover and couldn't operate such a case. he apparently refused the transfer on the grounds that the patient was bleeding. simple logic i thought would inform most people that the bleed needed to be controlled before there was any hope of survival and this could only be achieved surgically. it seems simple logic was not one of the subjects in the cuban medical curriculum. he refused the patient on the grounds that the patient was bleeding when that was the exact reason the referring doctor was seeking to refer the patient. i told the medical officer the patient would die without surgery. he cooly and calmly said in that case the patient will already be dead because they phoned six hours ago. i was shocked. even my usual philosophical outlook could not justify this. my philosophy relied on me doing my best and after that accepting the outcome based on the system. to accept the patient died because a junior doctor refused to accept a transfer because he hoped for a bit more sleep that night was just a bit too much even for my flimsy philosophy.

he maybe slept well. i did not.