Friday, September 11, 2009


m and m was never fun. sometimes i would walk out feeling i'd just escaped by the skin of my teeth. sometimes i would feel like my teeth had had too close a shave. but once...just once, it could have been worse.

it was a pretty standard call. it was very busy. in the early evening i was called to casualties for a patient with severe abdominal pain. when i examined him it was clear there was something seriously wrong inside. he had a classical acute abdomen with board-like rigidity. he clearly had a perforated peptic ulcer and needed surgery. i set my house doctor to work to get him admitted and on the list. meanwhile i went back to theater to work through the number of equally critical patients already on the list.

things then settled down into a rhythm. i was in theater with a student operating the cases one after the other while the house doctor separated the corn from the chaff in casualties. finally it was time to do the laparotomy for the guy with the acute abdomen. i needed to shoot through casualties before we started so i decided to swing past the ward and make sure the guy was still ok.

the ward was dark. pretty much everyone was asleep. without wanting to wake the other patients i turned on the small bedside light of my patient. even in that dim light i could see a bit of oral thrush. i was surprised. i was thinking to myself how the hell did i miss that in casualties. i felt his abdomen. it was no longer quite so tender. i turned to the student.
"see why it is important to make your decision before giving opioids?" i said with an air of authority. "now he is actually not so tender but he definitely had an acute abdomen. we must go ahead with the operation."

i quickly felt for lymph nodes. he had them everywhere. once again i was quietly thinking that my clinical skills must be slipping because that i also didn't pick up in casualties. i kept this new information to myself. imagine the shock to the student if he realised i was not all knowing. i just didn't want to be responsible for that level of devastation in his life. but i started considering other causes for his condition. it was clear he had aids and tb abdomen started looking like a possibility.

while we were still with the patient, the theater personnel arrived to take him to theater. i told them to get things going so long while i quickly shot down to casualties to evaluate a patient the house doctor was unsure about. and off i went at a brisk walk.

i walked into casualties. the house doctor led me to the patient in question, but as we approached his bed my blood went cold. in the exact bed where my acute abdomen had been lying about four hours previously was my acute abdomen still lying there!! i turned and ran back to theater. fortunately i was in time.

later i found out what had happened. once we had admitted the acute abdomen, the porter had come in to take him to the ward. one of the patients lying in casualties was a guy that had just come in. his hiv had wreaked havoc in his life causing a number of unpleasant things, including aids dementia syndrome. the exchange went something like this;

"timothy mokoena? is there a timothy mokoena here?" the porter called out.
"here i am, but it's not mokoena. it's magagula."
"ok, timothy magagula, i'm going to take you to the ward."
"ok, but it's not timothy. it's michael."
"ok, michael magagula. let's go."

and thus michael magagula, the aids dementia patient (not to be confused with timothy mokoena, the acute abdomen patient), thinking he had just jumped the queue to see a doctor was carted off to the ward and prepared for theater. he even signed for a laparotomy without even having seen a doctor.

in the end it all turned out well. timothy got his operation and the hole in his stomach was patched. michael was referred appropriately to the physicians. but i couldn't help wondering how this could have looked in the next m and m meeting.

"well, prof, the patient died on the table basically because i operated him unnecessarily."
"and how is the other patient? the one you should have operated?"
"well, he died too because i didn't operate him."

200% mortality for one operation. not easy to achieve.

(of course names have been changed)


rlbates said...

That would have made for an especially bad M&M. Glad you can run fast.

Jabulani said...

I want to be able to say "Eish, typical Africa"; but if I'm honest, opinion is divided. Whilst a teensy little part wants to say "Africa-so-wouldn't-happen-here", the greater, more realistic, part knows this could actually happen anywhere.
I second rlbates's comment on running. Perhaps you should reconsider the rugby ...

Anonymous said...

try checking the patients ID band next time....and if they're not wearing one how the hell did they get past triage.

Bongi said...

anonymous, i generally ask the patient his name. saves me having to read the bad handwriting on those id bands.

in this case i read the name from his sticker (actually the other guy's sticker which had been taken to the ward with him). he confirmed he was the name i asked. when the porter had just assumed the name thing was a clerical error, the patient continued to believe this and started responding to the incorrect name. only after everything when i went back to him did he come clean and confess to being someone else, the person he actually was.

i thought the porter's action in this whole thing was the most interesting. i don't think his heart was in his work.

Jabulani said...

Bongi, I hesitate to do this but ... in defence of the porter, he DID at least ask instead of just assuming the patient was who he thought. Ok, he got it wrong but, ya know, he MADE an effort... howbatu

Bongi said...

jabulani, i asked the patient if he was timothy mokoena. he said yes. the porter asked him if he was timothy mokoena and he essentially said no, but the porter just wanted to shuffle the next patient off to the ward and wasn't going to let something trivial like a name get in his way.

Jabulani said...

Bongi, like I said, "I hesitate...". And I confess I sq2m at your "wasn't going to let something trivial like a name get in his way." Of course he wasn't; it was probably tea break 5 mins later. To double check would've made him late for it.
I'm amused though; efficiency is something you require in your porters?? Gracious, what a novel idea. I should mention it to someone over here...

bilirubin said...

THAT was the funniest post i've read. Try as hard as I like, I can't even imagine getting 200% strike rate.

Greg P said...

I've gotten to the point that I've seen so many patients that they all look familiar and strange at the same time, so connecting a history with a face or a name becomes surprisingly difficult, even if it was earlier that same day.

I guess it's good I'm not a surgeon.

the annester said...

that is hilarious! (not the 200% potential mortality): the whole timothy/michael/mokoena/magagula exchange: that is EXACTLY how it is.

Anonymous said...

This actually happens a lot here too in the ER late at night because they get so many dementia nursing home transfers. Different reason, same problem. We have this whole protocol for checking ID with two different people now. And numbers too, not just names.

Anonymous said...

Oh - and other times you go call a name in the ER waiting area, and someone will come in and answer because they want to go first, even if it isn't their name. Another way to get fucked up.

Anonymous said...

The first open heart surgeries also had a potential 200% death rate.

A healthy person, usually a parent, was used as a heart/lung machine while the patients defect was corrected.