difficulties

in my post mopping up there was a comment stream that had a bit to do with doctors needing to become detached in order to survive. recently this whole issue was unfortunately brought brutally home. it reminded me of an incident many years ago.

our firm had only two private external consultants which basically meant we didn't have all that much supervision and good luck trying to get a consultant out at night. they did, however do two so called academic rounds with us each week.

one day on rounds we arrived at a patient. the student started presenting. it was a lady slightly advanced in years who had presented with sudden deep painless jaundice and a palpable gallbladder. as could be expected a ct scan was done which confirmed a mass in the head of the pancreas. even before we had histology we all knew this was a pancreas head cancer, a condition with a fairly dismal prognosis. her mass was large and there was already spread to the liver.

the consultant listened to all the findings and then, without a word, walked away. we faithfully followed him. when he got to the door, he stopped and turned to us.

"now why did i just walk away?" he asked. we all gave the usual blank stares. "because there is nothing we can do for her." he said with a chuckle. those of us who needed to be in his good books gave the obligatory half hearted laugh. i could just manage a smile that i think came out more as a grimace.

you see i just felt we are not there only to fix the machine in which the person is housed but also at least in some way to mean something to the person too. i was not comfortable. afterwards i went back to the patient and spent some time explaining that although we could not cure her, we would do everything we could to make things at least a little better.

but these things are difficult. recently i once again diagnosed a delightful old lady with pancreas head cancer and once again it was beyond surgery. in the end she went for chemotherapy and had a stent placed to resolve the jaundice. but these measures only hold back the inevitable temporarily. and sure enough after a while she was back.

when a follow up scan was done the cancer was all over the place and there were quite a few other dismal findings. the chemotherapist had asked me whether she needed an emergency operation that night and the answer was a resounding no. strictly speaking i needn't have been involved any more.

but the next day i stopped by to say hello. the patient was grateful and, although in my capacity as surgeon i was doing nothing, in my capacity as human being i felt i just might be making a small difference. later that day the chemotherapist phoned me to tell me the kidneys had packed up. this was probably a pre terminal event and although neither of us said it outright the meaning hung in the air oppressively. the chemotherapist was also sort of telling me my involvement was no longer needed. i had known this for a few days actually.

the next morning i just didn't want to see her. the situation was so hopeless and it was just difficult for me to deal with it. but then i realised if it is difficult for me, how much more difficult must it be for her? after all it was her life that hung in the balance. i would survive and move on. i would get over it. i would not be the one feeling alone in the face of overwhelming odds. i knew what i needed to do.

i just kept on visiting her, usually just to say hello so that she would know she was not totally alone. i did not detatch and allowed the frailty of the human condition to influence me as the human i am.

who actually wants to live forever?

ask almost any surgeon and he will tell you your chances of surviving a catastrophe are inversely proportional to your usefulness to society. this sentiment is expressed in different ways by different surgeons but the basic message is the same. basically put if two people come in with exactly the same injuries and one is a teacher who spends his extra time in community upliftment projects and the other is an armed robber, the armed robber will sail through treatment and be back on the streets in no time, but the teacher will slowly waste away in icu and finally die. unfortunately it seems to be true.

there was even a super clever cardiologist friend of mine who speculated as to why this was the case. he basically divided people into two groups, those with over active immune systems and those with just the basic immune system. the first group would tend to be allergic to everything and be over protected by their mothers. they would tend to grow up in a protected environment devoting their time to inside activities (safe from the dangers of the outside world, including grass and pollen and dog hairs and the like) reading and bettering themselves. the latter group would be immunologically free to run around like wild things doing whatever they liked. he then extrapolated this to the likelihood that the first group possibly had a higher chance of developing sirs (systemic inflammatory response syndrome) after major trauma and it was in fact their own immunity's overreaction that finally brought them down. amazingly enough this theory is based on logical scientific thought.

like all surgeons i too tend to think that the good guy will probably die and the bad guy will survive. i have seen it too often. but unlike my boffin cardiology friend i think it is just some sort of evil cosmic reverse karma that is just out to destroy all good people in this world. this makes much more sense to me than actually trying to understand immunology. and that is why i try to do at least one bad thing a day so that if something does befall me i at least have a chance of surviving. but there are always limits.

a few years ago our hospital organised a weekend away for all the doctors and their families. it was at a really nice lodge here in the lowveld and truth be told, it was great. the days were pretty much spent lounging around the pool. that is of course if you didn't play golf. i don't play golf.

anyway, there i was producing vitamin d for all i was worth when i glanced over at the pool. one of the other doctors had a small boy of about 4 years old that had been running around all day like a mad thing. but at that moment, as i looked at him leaning over the edge of the pool he toppled in. i was about 10 meters away so i first looked to see who was closer that would respond. no one moved. no one had seen him fall in except me. then everything went into slow motion. i could see that he could clearly not swim. his eyes were wide open as his arms an legs flayed about helplessly not bringing his head any closer to the surface. he was clearly in trouble. then a strange thought went through my mind based on my abovementioned philosophy.

"if i leave him, that is bad enough that i will probably live forever."

who actually wants to live forever so i rushed over and pulled the kid out. his mother seemed pleased.

foreign gratitude

this post is also about foreign relations, but, unlike the last, this actually has to do with surgery.

one thing about nelspruit is when people visit the kruger, if something goes wrong, they end up here. one such group was a european family that stopped by the hospital after a pretty devastating car accident. two people died on the scene, one walked away with minor injuries and one passed under the knife of our neurosurgeon for a brain bleed en route to icu where he was destined to spend some time.

after a few days in icu the patient's condition started deteriorating severely. his blood pressure just wouldn't stay up and his temperature wouldn't go down. then his kidneys started having trouble. his neurosurgeon excluded the head as a source of his sepsis. he then did a ct of the abdomen to make sure there wasn't something else alltogether that he was missing. with ct in hand he called me.

"he is deteriorating fast and the head is not the problem." he told me, "but the radiologists say he may have acalculous cholecystitis. what do you think?" acalculous cholecystitis is inflammation of the galbladder without the presence of galstones. it is usually seen in the very sick or in icu patients. however it is very rare. most consultations for this condition turn out to be false alarms. however, if you miss it you may really have a problem.

"it is very rare," i said, "however if you miss it you may really have a problem." i then went on to say the thick galbladder wall was often a result of a generalised edematous state much more commonly seen in icu patients. i however assured him i'd stop by and take a look.

the patient was still heavily sedated post craniotomy, but i could still elicit pain in the area of the gallbladder. hemodynamically he was in deep trouble. he seemed to be in septic shock and his kidneys were in early failure. i stopped by at the radiology suite and glanced at the scan. the wall was much more edematous than the rest of the patient. putting everything together i felt there was no choice but to operate. the only question was whether i should attempt a cholecystectomy, to remove the gallbladder or to just do a cholecystostomy, a less invasive drainage procedure reserved for people who may be too sick to survive the larger operation.

we started the operation late at night. i decided to start laparoscopically and decide what to do once i could see what was going on inside. the fundus of the gallbladder was totally necrotic, but lower down the tissue could still be worked with. a laparoscopic cholecystectomy looked feasible. and that is what i did with a bit of difficulty.

after the operation the patient improved in leaps and bounds and in two days time was out of the proverbial woods. i was feeling pretty chuffed. once i was quite happy a day or two later, i handed him back to the neurosurgeon for the rest of his sojurn with us.

some time after this the neurosurgeon got a call from the family doctor from their home country. he was indignant. he wanted to know why the gallbladder had been removed in such a young male, a group that usually does not have gallbladder problems and that in the absence of gallstones. he felt it was totally unnecessary and demanded an explanation. i could imagine him seeing us as knife wielding african savages seeking what we could cut out of unsuspecting civilised peoples. i mean after all what would doctors from a backward place like south africa actually know about medical conditions and the treatment thereof. fortunately the neurosurgeon wasn't in the mood to mess around. he educated the poor fool about the existence of the condition acalculous cholecystitis, which he had clearly not heard of. he then referred him to a few articles about the management of the condition and invited him to phone back afterwards if he still had questions.

when i heard all this i was not impressed. the fact of the matter is that we had saved the boy's life life. it seems from the call from his home country that there he may not have been so lucky. yet no doubt his family had been told that we were money grabbing knife mad morons randomly lopping out organs as the fancy strikes us. then i became more philosophical.

until fairly recently south african medical training was up there with the best in the world. so until fairly recently such attitudes were absolutely uncalled for, but as i have mentioned before, this high standard may be slipping a bit under the careful mentorship of the present regime. so maybe it is becoming progressively more justified when foreigners express reservation in our knowledge and skills. anyway, i knew that i could be proud of what i had done and i left it at that.

culture shocking

an interesting thing happened to me while on leave at st lucia recently. it was the sort of thing that might be considered funny by certain cultures, even maybe my own, but sometimes these sorts of things are frowned upon by the more refined cultures.

actually i wasn't even going to blog about it because it doesn't really pertain to surgery. but seeing that i recently considered the more refined cultures and seeing that i have another potential post also along these lines that does actually pertain to surgery lined up i thought i should mention it to be totally honest. be warned, those who have even a slightly good opinion of me should turn back now.

so there amanzimtoti and i were on the banks of the st lucia estuary enjoying a meal at a very pleasant outside restaurant looking at the crocodiles basking and the hippos lying in the water. now amanzimtoti and i are culturally distinct from one another. we're both south african, but we are not the same. my culture tends to be a bit more reserved. hers, not so much. at the next table were two europeans (i think they were dutch but they may have been german) who are obviously vastly different to both of us.

we had eaten and i was standing up to get a better view of the hippos. i then bent down to pick something up when it happened. the combination of a large meal, a belt that was maybe a bit too tight and a small hiatus hernia couldn't take the added intra abdominal pressure and unfortunately a somewhat loud burp was let out. immediately the european man turned around and in an angry voice reprimanded me.

now south africans are pretty aggressive people. in our culture quite a lot less than this could be construed as an act of open aggression. in fact in our context usually if you do something like this you should check that you are bigger than the other guy, just in case. he wasn't bigger than me so, being south african i checked if i could see if he was carrying a weapon. instinctively i felt for my knife. but i said nothing. i was too taken aback. also i wasn't prepared to actually fight.

amanzimtoti, however reacted instinctively according to her culture, without the restrictions of strategic thought that my culture limited me to. she told the guy where he could get off in true cape flats style. (actually she told him how. the where was implied.)

my mind put it all together then. he was european and had gravely misunderstood the severity of the implication of his words in the south african context. he was not armed and less keen on a fight than me actually. he was also way out of line by south african standards. i let rip. i was not happy to let some uppity european try to put me in my place and i let him know this. quite soon he found himself under a double barrage of extreme aggression. he also seemed to realise that he had walked into a situation he did not fully grasp and i think he thought that there was actually going to be a fight. he not only backed down, but with all due haste removed himself and his partner from the situation.

when it was all over i was not overly proud of my reaction. i did not feel good, but i did feel south african. it was however an interesting interaction of three different cultures. it is also humbling and slightly embarrassing to realise that i as yet have not risen above my culture as i often like to think i have.

call it

i noticed my use of the phrase 'call it' a few times recently. it is something i saw on american tv and not at all something that is common in my neck of the woods. the sort of scene that you would get in gray's when the junior doctor is pumping the chest shouting 'i will not let you die, dammit!' while the senior doctors stand one side and instruct him to 'call it!' is pretty foreign to our way of doing things. i even got ragged a bit for using the phrase at all. i thought i'd relate a story from days gone by that illustrates this point.

it was the time of the taxi wars. now taxis in our country are nothing like you might be thinking. they are fleets of mini-buses, quite often owned by people of questionable legal character. occasionally rival groups try to take each other out (i mentioned this before here). but roughly at the turn of the millennium there was outright war. when the war came to pretoria we saw quite a few of the victims, but neurosurgery got the most. a friend of mine was rotating through neurosurgery and this story came from him.

there had been a contact between two different taxi organisations. the casualties were streaming in. the neurosurgeon and my friend, his trusty lackey, were overworked and i think it had affected their sense of humour. so while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. when the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. and this is what they did.

the neurosurgeon looked at each patient in turn. the first three he told them to send into casualties for his attention. but the fourth...he took one look at the fourth and exclaimed;
"vat hom weg! hierdie een is gefok!*"

my colleague laughed the next day when the newspapers reported;
"on arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty." fortunately they did not quote him verbatim.

*take him away! this one is f#@ked!

mopping up

sometimes before you are even called the sh!t has already hit the fan. the mopping up is not fun.

i was on call. as usual i was hanging around in the radiology suite (i spend a lot of my free time there sharpening up my ct scan reading skills. the radiologists even think i'm a frustrated radiologist, poor fools). the urologist phoned me. he had a nervous laugh. most types of laughs of urologists i quite enjoy. but the nervous laugh i do not. he then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. i quickly called the scan up on the monitor and sure enough there it was. the patient was mine.

there was an 8cm aneurysm. but just anterior to this there were signs of recent retroperitoneal bleeding. this was not good. the guy was just one step away from a fatal rupture. i phoned my vascular colleague in pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. then another call came through.
"doctor, the urologist says i must call you about his patient. he says it is now your patient. something has happened." i knew i needed to run.
"i'm on my way!"

as i rushed through the ward i saw what must have been the family. they were all looking anxious and some had tears in their eyes. i rushed on. i needed to focus.

in the patient's room it looked like well orchestrated chaos. lying on the floor was a massive man who was as pale as a sheet. the casualty officer was intubating. a sister was doing cpr. the urologist looked up.
"glad to see you! well then i am no longer needed. see you around." and with that he walked out. someone was trying to place a drip with little to no success. a large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. i needed to take control. only thing is i had seen the scan and i knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).

i told the nurse to stop cpr long enough for me to check for signs of life. there were none. she continued. i then did some basic tests to gauge brain stem function. there was no detectable brain stem function. i called it right there.

after a dramatic unsuccessful resus there is usually an eery silence in the room. maybe it is a sort of respect for the departed or maybe it has to do with confronting one's own mortality. i think it has a lot to do with thinking who is going to say what to the family.
"are you going to speak to the family?" i asked the casualty doctor. i had to try.
"no! you are!" great! i thought. i walk in on the closing act and i'm left with the hot potato.

i took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. then i went quiet. i needed to focus.

the family had been taken into the sisters' tea room. they then sent me in. the mopping up had begun.

i have spoken before about breaking bad news. fact is it is never easy and i'm not sure there is any easy way to do it. i try not to leave the family in the dark too long. once they know i try to be as supportive as possible and to answer their questions as best as i can. usually i am struck by the human tragedy and i allow it to affect me as it should. sometimes when i have been overcome by the relentless nature of my work i must stand back and observe. this was one of those times.

strategy

while i'm on the topic of how to handle consultants i was reminded of another consultant who was somewhat peculiar. also while in prague one of my old colleagues from the old days who actually reads this blog asked why i never wrote about this very interesting individual. so here goes. lets just call him doctor d.

doctor d had dogmatic views on pretty much everything and his views were usually fairly odd. he had developed a way of discussing one or other of his views during operations. he could time a discussion about a given topic to last just long enough that as he placed the last stitch he would wrap up his talk. so with a short operation he would just launch into his theories, but with a longer operation he would start by asking each person in theater what they thought of whatever topic he had chosen for that specific operation. i used to enjoy listening to him during operations and sometimes even felt disappointment when the last stitch would be placed while he said,
"and that is why you should not send your children to school but should home school them." or "and that is why you should always wear long sleeved shirts" or "and that is why cremation is wrong" or some such statement.

but on ward rounds my feelings about these discussions were completely different. an operation had a predetermined end, but ward rounds could go on indefinitely. with this in mind i'd instructed the students how to respond to doctor d so as to shorten the discussion as much as possible. i explained to them that if he asks their opinion about anything not related to surgery he is not asking because he wants to know their opinion, but rather that he wants to expound his own theories. if they gave their opinions he would first take time, a lot of time, to debunk their theories before explaining his own. they were under strict instructions to make sure they didn't give their opinion but rather just immediately ask doctor d what he thought. and then after he had expounded his often bizarre theories the students were not permitted to question him on the rounds. if they wanted to argue some point they could do it in their own time when the rest of us would not be forced to stand there, often post call, and listen too.

generally this approach worked quite well and ward rounds usually didn't drag on more than a half hour after seeing the last patient while we heard why a contraception was wrong etc. that was until one day.

we had just seen the last patient on our post call rounds and ward rounds were as good as over. the students were a new group but i had already orientated them about what to do when asked questions unrelated to surgery. so i didn't worry too much when doctor d started.
"what do you think of rugby?" he asked each student. they dutifully were non committal and quickly turned the question back on him. i was smiling inwardly. we could wrap this up in about 5 minutes if no one questioned him afterwards and he still would be none the wiser i was sabotaging his beloved so called philosophical discussions. he continued.
"rugby is a homosexual game and anyone that plays it must be homosexual." i could almost hear my bed calling. we just had to nod and soon we'd be on our way. and then things went south.

one of the students seemed to be turning slightly red. he also seemed to be bouncing up and down on the spot.he seemed disturbed. i realised he was going to go against my instructions and ask something or worse, challenge doctor d. i started recalculating how long it would take for the rounds to end. but what happened then i hadn't expected.

suddenly the student jumped forward with index finger extended, first towards me;
"i know you forbade us from questioning doctor d about any of his crazy theories, but this i just can't take!" and then towards doctor d:
"doctor d how the hell can you say rugby is for homosexuals? do you really think all the springboks are homosexual?"

i wanted to cry. not only were we forced to endure the full length explanation of doctor d as to why rugby was indeed a homosexual sport, but afterwards i was personally taken to task for instructing the students as to how they were to ensure the good doctor d's talks did not go on for quite as long as he liked them to. worse still, the good doctor d adjusted his way of discussing his theories on ward rounds to bypass my influence on the students. never again did we have a short discussion after rounds, whether the students asked questions or not. doctor d also i think trusted me much less after that episode.

looking good

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.