leaking

people are basically sacks full of water. the skin keeps the water inside. trust me when i say you want to keep your water inside.

the second post i ever wrote had to do with watching someone with burn wounds fade slowly away. in the end it had more to do with my own mortality. when i read it recently i was reminded of quite a few poignant stories. this is one.

usually things happen in groups and, it seems, burn wounds are no exception. on two successive nights two severely burned patients came in. i got the first. my colleague got the second. my patient had 98% burn wounds (usual story of being doused in petrol and being set on fire. someone didn't seem to like him). only where his hair had been was he not burned. that means that 98% of the sack that is supposed to keep the water in was leaking.

let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. this patient was as good as dead, so whatever we were going to do would only partly help. the outcome could not be changed.

the immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. the amount of fluid one gives is proportional to the surface area burned or the surface area leaking. in 98% that turns out to be quite an amazing amount of fluid. and that is what we did. i worked out the fluid needed, put up a good central line and started running it in. the next day he was still alive.

the next day was when the second burn wound patient came in. he had 95% burns and therefore was leaking pretty much the same amount as my patient. my colleague admitted him, but he treated him differently. my colleague knew that the end of the road was predetermined and didn't see the point in prolonging the inevitable. he only gave him normal maintenance fluid which a normal person would require. he considered more as treatment and didn't see the point in treating something that could not be treated. i considered that he may have a point. i went to see his patient.

his patient was not doing well. the loss of fluid had pushed him into a stuporous state. he didn't seem to have long to go. i left. he died soon after.

my patient remained alive through that day too. because of his wounds he could not lie in bed without extreme discomfort. but the soles of his feet had no skin so he could not stand either. the skin of his hands had all peeled off and they had swollen into useless immoveable paws.

the head of the firm then decided we should take him into a shower and remove all remaining loose skin. i got the feeling he was trying to teach us some sort of lesson. the only thing i learned is that it is brutal to try to remove loose skin, even gently from such a patient. the patient was not having fun at all. i kept thinking why are we making the last days of his life any more miserable than they already are? the head then decreed that we would repeat this process in two days time. i felt sick at the thought. the wisdom of my colleague not treating his patient seemed much clearer to me then.

the next day when i arrived at work i was relieved to discover my patient had finally succumbed to the inevitable. it would not befall us to have to torture him the next day in order that we learned some mysteriouis lesson.

ct scans

i'm usually quite good at reading ct scans, but this one just left me with one big question mark.

suboptimal

recently i did a submandibular gland excision. i always find them challenging. i think i know why though.

i was no longer a junior registrar but i still had a long way to go. i had just been rotated to kalafong and it was my first theater list, a list that had been booked by my predecessor and one i therefore did not know. my consultant knew me from a few years before when i had worked in his firm as a junior registrar. as much as he was able to actually have human feelings, i think he almost liked me.

i assisted the first case with the consultant operating. it annoyed me a bit but i assumed he hadn't worked with me for a while and wanted me to get my eye in before he entrusted the knife to me. when he once again took the prime position in the second operation i started wondering if i was to get any operating time in his firm. what could i do?

after the second operation my boss turned to me.
"just a mastectomy and a submandibular gland excision left. have you ever done a submandibular gland?"
"no." i answered truthfully.
"have you ever seen one done?"
"only once when i was a fifth year medical student, so it hardly counts."
"i'll give you a very good article describing the technique."
and with that he turned and left.

it was kalafong so he returned long before we got the mastectomy patient on the table. he handed me the article, which he had fetched from his study, told me i'd be fine, and left.

great. i had to somehow quickly read the article between the mastectomy and the submandibular gland and then do the operation with only theoretical backing. i tried to swallow hard, but, in sympathy with the patient's soon to be excised salivary gland, my own salivary glands had simply stopped working. my mouth was suddenly very dry.

so i did the only thing i could. i cut out the offending gland, more or less how the article suggested i should. but somehow to this day, whenever i am asked to do a submandibular gland, my adrenal glands tend to contract a little bit when i think back to my first one.

lights, knife, action

i was reading a post by a really good medblogger i follow. it reminded me of an incident years ago when i was rotating through neurosurgery.

now neurosurgery lends itself to tracheostomies (long intubations in people who tend to not want to breathe on their own). i soon became pretty good at an icu unassisted trache (that was the way we did them then). then the new guy arrived.

the new guy was a rotating orthopod. the neurosurgeons knew i would be leaving soon and their reprise from doing all their own traches would come to a sudden end. when the orthopod expressed interest in learning the procedure they saw an opportunity and quickly appointed me his teacher. as usual there were a couple to do that day. i'd do the first and he'd do the second. then he would be on his own.

the demonstration trache went well. i tried to point out all the tricks i'd learned with the thirty or so tracheostomies i'd done. he watched in silence, occasionally nodding his head in acknowledgement. and then it was his turn.

we walked together to the outlying icu where our next patient was. there were quite a few icu units in that hospital. when the neurosurgical icu was full any new neurosurgery patients could find themselves landing in one of any number of outlying icu units. generally these weren't quite as geared for neurosurgical patients but they were good enough.

finally my young apprentice put steel to skin. immediately i realised this guy had a natural acumen for surgery. he seemed to intrinsically know what to do. his movements were precise and achieved exactly what was intended. he definitely didn't need any advice from me. there was only one thing not right.
"sister, please call the anaesthetist on call." the orthopod stopped dead in his tracks. his head shot around to look at the monitor. as soon as he confirmed the patient was stable his head swivelled back to stare at me almost accusingly. then he got back to work. he knew there was basically no way an anaesthetist in that hospital would actually come out of theater, much less to make the long trek up to this out of the way icu. and if he did come all the way, it better be to miraculously raise someone from the dead. anything less would be beneath the gas monkeys of that hospital.
"sister, please call the anaesthetist on call!" i repeated. she also could not believe me, but dutifully moved towards the phone.
"why?" she asked as she lifted the receiver.
"the lights are not right. tell him to come and position them for us please."

again the orthopod stopped operating, but this time it was because his body was convulsing with waves of laughter.

the patient is gasping

in the old days at kalafong (hell), the sentence 'the patient is gasping' was euphemistic for the patient is stone dead, rigor mortis has set in and we accidentally found the body when someone noticed a strange smell emanating from his bed. fortunately, occasionally one is pleasantly surprised. one such time was in my first year as a registrar.

he was a young man. with a bit of dutch courage on board he had not maintained a good following distance behind a car while driving home late at night on his scooter. in other words he drove full speed into a parked car on an otherwise deserted road. when i saw him for the first time he was in trouble. his abdomen was distended and painful. his blood pressure was down and his heart was racing. he needed surgery and fast.

just as i was pushing the patient into theater his mother called me aside to ask about his chances etc. i gave my honest assessment with emphasis on the fact that we needed to get going as soon as possible to optimise his chances. then, as if i wasn't nervous enough being such a junior registrar with the prospect of trying to pull this guy through , the mother gave me a small piece of information that pushed my heart rate up to about the same as the patient's.
"he is dr w's cousin." dr w was the most senior registrar in our department.
"good!" i said. but 'oh f#@k' is what i thought. and then i went in to operate.

the operation was a major challenge. in the end i resected segments six and seven of the liver. actually i just scooped them out. the impact had done all the actual dissecting. i just needed to control the bleeding, which in itself was not all that easy. finally we got him off the table in a fair to good condition. after tucking him into bed in the ward i got on with the rest of the call. finally i got to sleep at about two thirty in the morning.

at four in the morning, the phone in the call room rang.
"doctor, the patient is gasping!" my blood went cold. i confess i had images of dr w taking me apart for letting his cousin die. i paniced a bit. i phoned my house doctor and told her to meet me in the ward. then i ran.

i walked in to see something i think i am the only person ever to see in kalafong, an actual attempt at a resus by the nursing staff. the patient wasn't dead, only dying. i was so relieved. then i realised if i let him die dr w would still eat me alive. i jumped to it.

after a bit of the old pounding on the chest, a tube down the wind pipe and much intravenous fluid. we pulled the guy back from the brink and put him in icu (intensive scare as we called it).

and so a near disaster was averted and for once at least 'the patient is gasping' actually meant the patient is gasping.

one shouldn't laugh, but ...

when i wrote the third principle, i was reminded of another incident. then i couldn't laugh. now i shouldn't.

i was working a casualty shift in a private hospital to make a bit of extra money (a registrar barely made enough to survive). it had been a standard night of treating the aches and pains of people who had been sick for weeks but had decided that once the sun set on friday evening they could no longer endure. maybe they just wanted to torture me.

anyway, finally a real casualty case came in. it was a young lady who had fallen and hit her head. she was fine except for an unsightly gash on her forehead just at the hairline. i prepared to clean and suture the wound. being a state doctor i had hardly sutured any face wounds on sober people, so i remember telling myself to make a point of chatting to her during the procedure to ease her fears. usually good old ethanol did all the fear easing and i was left to my own thoughts while placing the sutures.

so there i was at the head of the patient being as friendly as i could. i'd cleaned the wound and had placed the first suture. the second was going in when an ambulance pulled up. two paramedics brought a guy in on a stretcher. i had my back to them so i wasn't really watching them too closely. then the sister shouted,
"this man is not breathing!"

i left my suture just where it was and ran. as i changed my gloves the ambulance men were asking the patient to shift to the next bed. he wasn't listening to them. they seemed indignant. the sister grabbed him and dragged him over as i arrived.

there was no sign of life whatsoever. he was extremely pale. his trousers were bloodied. he had no drip. we commenced a full resus. after going through all the motions, i called it. the man was dead. i then looked over his body. he had a massive laceration in his groin. his femoral artery was visibly transected. that could be why he didn't respond when the ambulance chaps had asked him to move across to the resus bed. i asked my usual question.
"when you picked him up, was he bleeding?"
"no." they answered. that is why they didn't put up a drip, apparently.
"was there blood at the scene?"
"yes." the one man replied. "he was lying in a puddle of blood."
"was it maybe about five liters of blood?" i wondered aloud.

the leroy-burnell syndrome

when we were in medical school as with all medical students we were bombarded with many new words. not the least of these were the myriad of syndromes. and each syndrome had symptoms that overlapped with pretty much every other syndrome. it was one large conglomeration of new words all mixed together.

but there were a few other things we noticed. firstly every syndrome worth its salt had a double barrelled name with a hyphen in between. exotic sounding names worked better than simple names like mark or john. also the more symptoms associated with a syndrome the better the syndrome was.

and thus we invented the leroy-burnell syndrome. the name was perfect. and seeing that we used it to explain any conglomeration of symptoms that we could not otherwise bring to a diagnosis, any symptom known to man could be attributed to our neologistic syndrome. (if only house md had known about this syndrome the episodes would all be half the length.) if we had no idea about a patient, my clinical partner would lean across and say,
"this is a classical case of leroy-burnell syndrome." and doff his head intellectually. if the prof was not looking we would laugh.

then one day we were doing our usual ward chores in internal medicine. a group of fourth years came in with a rotating consultant. the consultant lead them to a patient. he told them to examine the patient and make a diagnosis. he would be back in 30min to discuss the case with them.
as fourth years generally were they seemed a bit nervous about direct patient contact. finally they drew the curtain and one approached the patient.

it was about then that my clinical partner decided to 'help'. he stuck his head through the curtain and said.
"you guys, this patient has the leroy-burnell syndrome so make sure you don't miss that. but don't worry, the clinical signs are easy to pick up. good luck!"

the gratitude on the nervous face of the fourth years was clear as they simultaneously thanked my friend for his kind gesture and reached for their pocket references to look up the leroy-burnell syndrome. it seems they hadn't come across it in their studies yet.
i turned away to hide my laugh. i was imagining the pride on the unsuspecting face of the fourth year when he announces to the consultant that this was a classic case of leroy-burnell syndrome.

surgexperiences 222

surgexperiences 222... short and sweet.

a masterpiece by a master writer. surgeons sometimes don't allow the facts to get in the way of their hard headedness.

stupid excuses awarded.

a hospital's big five.

will boyle-o-phobia be overcome?

something off the wall. a surgeon involved in a famous controversy. i think it's monsterous.

we all make mistakes. only in surgery the stakes are higher.

a bit of lap chole fun.

buckeye helps us remember to not mess around and get back to basics.

a bit of a look at transplants.

a day in the life of a surgeon in sri lanka.

a very impressive story about minimally invasive surgery.

nightclubs remind some surgeons of lower anterior resections (for rectal cancer).

better robotic prostate surgery.

social media sites for nurses.

the surgeon and the torture memos. a must read.

patient denial leads to doctor compassion fatigue.

some people are stupid enough to try short cuts to beauty.

not something to stick your tongue out at.

a very personal look at esophagus cancer.

hairball links to bezoars.

twitter your pituitary adenoma away.

classic svc syndrome.

short link to fourniers.

beautiful laparoscopic pancreas resection.

the plucking of a mass.

a patient's points on gynecomastia.

and that's it. short and sweet. the next edition of surgexperiences will be at notes of an anesthesioboist. for eager future hosts, please contact jeffrey, the guy who runs the show.