kalahari

after looking at the first world i got a bit contemplative about the point of staying in this god forsaken place. then i was privileged enough to spend some time in the kalahari. my soul was once again restored and i remembered quite a few reasons to stay. here are just a few.
the endlessness went on and on ...well, endlessly.
unfortunately this doesn't even come close to showing what it really looked like.
the kalahari is an interesting desert. although rain is very scarce, it seems to be teeming with life.
a tree with a communal bird's nest.

bell bottoms

i recently went to prague. what a culture shock. the place is clean and beautiful and safe. i travelled quite a bit on the public transport and not once felt in danger even though i'm south african.

there is generally law and order. on the first day i went on the underground i did not stamp my day ticket because, being south african, i just assumed there would be someone to stop me and check. there was not. they rely on the people there being honest. being south african i rode the whole day essentially for free. then my conscience got the better of me and i bought another ticket so they would not lose money.

you see we south africans have no law and no order. we get away with whatever we can. we all speed and we all jay walk and we all bend all the rules as far as we won't get caught. in prague it is exactly the opposite.

but getting back to the story. one reason it was such a culture shock is because a while ago, to travel on public trains in south africa was quite risky. you see there were gangs that would throw people off moving trains for a laugh. there was also a time when certain trains would get attacked by automatic wielding thugs that would indiscriminately shoot people. these days there is more security (all armed of course) so it isn't quite so bad. there still is the occasional torching of a carriage if it turns up late. let it never be said south africans can't express their anger at trains not being on time.

anyway, while i was safely travelling on the czech (for americans, that is where prague is) public trains, i thought about a few of the patients i had seen. i don't think i'll talk about the guy that got corkscrewed between the train and the platform here. the bell bottom patient came more strongly to mind.

it was in the days of the indiscriminate throwing people off and in front of trains. most died on the scene, but a few got to us. for those who don't know, to get injured on south african train tracks is a sure recipe for sepsis. the trains drop their sewer directly onto the tracks, so to get an open fracture there usually ends up quite a mess. my patient was thrown in front of an oncoming train from the station platform. i suppose the people who threw him there thought it was quite funny at the time. we at the hospital did not.

the poor victim of this senseless crime fell with most of his body over the further track. in fact only one leg lay over the one track. unfortunately he had no time to pull his leg away before the train went over it.

now, to fully appreciate what happened one must realise the patient was fully awake and fully sober. he had in fact started extricating himself when the first wheel cut and mangled his leg about mid thigh. he continued to pull himself away. the second wheel therefore hit his leg about two inches lower down. the next wheel then struck about two inches below that and so on. so the leg was mangled worse than any mangled limb that i have ever seen and more than likely will ever see. it had deep cuts at two inch intervals. the femur was severely broken but it was not nearly as bad as his lower leg. the lower leg spread out like a bloody and distorted bell bottom ending in a very wide flat thing that had once been a foot.

suffice to say he lost his leg that day. (for up and coming south african surgeons, leave the wounds open from train track injuries, like we did. otherwise sepsis will set in and things will get worse.)

so while in prague, i was really confronted by the many acts of meaningless violence we see in our country because i had a clear picture what life could be like in a peaceful place. i honestly wondered what the point is here.

anger

in the old days sometimes confrontation was the only way to get things done. but sometimes anger lead one into useless and unnecessary confrontation. i recently spent some time with my old friend, swimmer's chest and a story came to mind when that swimmer's chest saved me from my own anger.

we were on call together. quite early in the day the chemotherapist called me. he had apparently put a patient on the emergency list the previous day for a portacath and the case didn't get done. this was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. something like a portacath would tend to get shifted down the list and may even stand over to the next day. this is what had happened here. he now wanted me to do the case.

"sure i'll do it" i said. "as long as it's on the list as soon as it comes up i'll be there."
"i want it done now!" he retorted. i was not impressed.
"well phone the anaesthetist on call and motivate for him to move it up the list." i said helpfully.
"that is not my job! you will do that!"

it was clear we had a communication problem. whenever i had a telephonic communication problem i would put down the phone and take the effort to go to the relevant person to sort it out face to face. not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). this is what i did here. i turned to swimmer's chest and told him to accompany me. off we set at speed.

we walked into the chemotherapy ward and asked to see the relevant doctor. soon he was there in front of me. swimmer's chest hung back. i introduced myself and explained that i was more than willing to do the surgery but i had no control over the order of the list. that was entirely in the hands of the anaesthetists. if he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.

"you will phone the anaesthetist yourself and you will do this case right now!" he said.
i could feel my anger slowly turning into fury.
"no! you will!" as i said it i clenched my fists and took a step towards him. swimmer's chest realised things were on the verge of going south. he later told me he thought i was going to punch the guy. i denied this, but the thought was going through my mind at the time, i confess.

so my good friend stepped in front of me with his broad chest and nudged me backwards. he then started speaking to the chemo doc in a calm diplomatic voice. he also subtly and slowly (almost so one didn't notice) ushered the guy further and further away from me. by the end of it we left with the chemo guy feeling that we were there for him and would do all we could. i don't think he even had an idea of how enraged he had made me.

walking away swimmer's chest asked me if i was mad. i had only a few month's of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.

those times in the end brought out the worst in me. by the end of my studies i knew i needed to get away from it all. i had very nearly become something i did not like. after leaving pretoria i gradually rediscovered the true me again. it was still there to my relief.

eccentric

sometimes eccentricity is excused by brilliance. the old prof of thorax in my humble opinion fell into this category. i quite enjoyed his lackadaisical approach to training, especially because i was not required to know thoracic surgery to the depth that a thorax surgeon was required to know it. i could sit back and observe.

during my rotation in thoracic surgery i enjoyed the morning meetings. the prof was very knowledgeable in all things. truth be told i never heard him teach any thoracics. he taught pretty much everything else. he would walk into the thorax lounge, sit back, light a cigarette and drink coffee. as long as you kept his cup of coffee full he would just keep on talking about all sorts of topics (except thorax surgery. he reasoned the registrars were supposed to be reading current articles and therefore were supposed to be more up to date than he was. if that were the case then how could he be so audacious to assume he had something to teach them?).
he also had what i considered a sort of inappropriate giggle. after almost every sentence he spoke he would slightly lift his shoulders and let out an almost inaudible giggle. no one else dared laugh unless it was clearly a joke. he was, after all the prof.

finally one day i witnessed him giving a thoracic surgery opinion on a thoracic surgery patient. as usual he was sipping and puffing away waxing lyrical about some or other topic which he seemed to be an expert on (i think he was explaining how he had written the program that his department used for patient records or how the cities electric supply was wired). one of the thorax registrars stood up with a ct scan. he placed it on the x-ray board and waited for a gap to ask the prof's opinion. sure enough, after the next giggle, the prof turned to see what he was doing.
"excuse me prof but could i ask you for an opinion on this patient please?" the prof put down his cigarette and coffee mug (which i duly quickly refilled). he then reached into his top pocket where he kept his fold up reading glasses. all eyes were on him as he clumsily unfolded them and placed them precariously on the tip of his nose. he then threw his head back in order to be able to look through the said glasses. everything went silent. then spake he.
"hierdie pasient is gefok!*" followed by a gentle lifting of the shoulders and the usual giggle. he whipped the glasses off his face, folded them up and returned them to his pocket in one smooth movement. i laughed. it seemed i still couldn't tell the difference between the prof trying to be funny and being deadly serious because everyone in the room stopped what they were doing and stared at me as if i had disrespected the great man. i swallowed hard and shut up. after all the prof was exactly right.

*this patient is f#@ked

skande

let me just start by saying that i personally think joost van der westhuizen may be the best scrum half the world has ever seen and besides possibly advising steve hofmeyr not to add the line "'n blou bul snuif nie van 'n hoer af nie" to his blou bul song because it can't be substantiated, i don't particularly care about the recent media frenzy about the man. i think they should just leave him alone, whether the stories are true or not.

however, after one of my old interns related a story to me many years ago i never viewed him as too bright. i suppose you don't need to be bright to be the best scrum half the world has ever seen.

my house doctor was going out with a rugby mad guy (i suppose a bit like me actually). her boyfriend was a particular fan of joost van der westhuizen (as i was too). one day she was walking through the streets of pretoria when who should she run into but none other than joost himself. she was not a great fan of rugby and by implication of joost but she was quite a fan of her boyfriend. she therefore decided to ask him for an autograph which she would give to her boyfriend and thereby earn many brownie points. the way she tells the story, the exchange went something like this.

"excuse me mr van der westhuizen, but could i please have an autograph?" says she presenting him with paper and pen in order to facilitate the exchange.
"ok, if it doesn't take too long." replies the legend.
"why? do you have a problem writing your own name?"

she did not get the autograph and the associated brownie points. she did, however get a good laugh from me.

ruthless kindness

in my line of work there is sometimes a fine line between cruelty and kindness. sometimes the line can seem to blur. hang around me long enough and you will probably be shocked at some stage.

the guy had apparently fallen asleep next to his fire. when he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. someone found him and brought him in late that night.

when i walked into casualties i could smell him. you can almost always smell the burns patients. i took a look. the one leg actually wasn't too bad. it had an area of third degree wounds but they weren't circumferential. i could deal with that later. the other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. this could not wait for later.

in third degree circumferential burns, the damaged skin becomes very tight. constricting is actually a better description because unless it is released the taught skin will so constrict the leg's bloodflow that if left untreated the patient's leg will die. it is like a compartment syndrome only the entire leg is the compartment. interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. that means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. you just cut the skin and as soon as you hit an area that the patient feels you've gone too far. if you do it right they will feel nothing. the longer you wait the higher the chance that he will lose his leg. i knew what i needed to do. i also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.

i asked for a blade and gathered my students around me. i sunk the knife through the dead skin and ran it down the length of the leg. the wound burst open as the pressure was released. the patient didn't flinch. quite a number of the students did. one excused herself and ran out. i think she might have been crying. despite me telling them that it wasn't painful and it was in the best interests of the patient to actually see it was more than most normal people could take.

when i wrote my last post and expressed a form of traumatic stress i found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. i was ok doing what that one student obviously thought was gruesome and bizarre because i was convinced it was in the best interests of the patient. when i did this procedure which, on the face of it, is so much more brutal than taking someone to shower, i was ok, but the shower incident was terrible for me. i ended up hoping the student didn't see me as quite that monsterous. i also hoped she would get over the trauma i had inadvertently caused her.

the patient kept his leg.