crimes against humanity?

recently i read a post that really touched me. it got me thinking a bit about the recent suggestion to charge mbeki with genocide because of the fact that his denialist policy has resulted in so many hiv related deaths. politicians always amaze me.

the story in the post is not unique in south africa. truth be told, those children actually have it quite good. they have someone who loves them looking after them and that someone is on antiretrovirals, so she should be around to bring them up. there are many more aids orfans in a much worse situation. there are also thousands of children infected with the virus today as a direct result of the mbeki regime.

now i'm but a lowly surgeon. i can't see the big picture. my mind gets stuck with the individuals. i'm touched by the plight of these children and i'm shocked that mbeki washes his hands of them. when blinded as i am by the suffering of these little ones, i just can't seem to appreciate the important effects of mbeki's decisions, like his career and the anc maintaining a façade of having things under control. somehow the little people are more important to me than all those anc fat cats.

interesting to note julius malema's reasons for not pursuing the charge of genocide against mbeki. he says they should not charge one of their own. i just wonder, why are those innocent children not one of their own too? is one man, mbeki, more important than thousands of lives and the devastated lives of all these children? a good anc answer would no doubt be most definitely! but somehow i have my lingering doubts.

as usual the anc takes no responsibility and the people that suffer are the innocent.

maybe not genocide, but what about charging mbeki with crimes against humanity?

decisions

i recently read a post by a greatly respected blogger. she relayed a story about why someone chose primary care as a speciality, but it turned out to be more about why they didn't chose surgery (or why you should read the contents of anything you eat). i felt compelled to reply.

in all honesty there are many reasons i decided to specialise in surgery, not the least of which was that i wanted to be able to deal with pretty much everything. i also really enjoy operating. there is something magical about cutting a fellow human being open. intuitively it seems so wrong, and yet we do it and we do it for the good of the patient. it's truly mystical. but there was one incident that happened in my student days that clinched the deal.

i've never considered myself too bright (with the possible exception of two separate occasions). so exam times were always quite stressful for me. the finals of fifth year were no exception. so when i found myself waiting to be called in during the surgery practical finals my nerves were pretty frayed. the patient i had examined had a large smooth thyroid. clinically she didn't have hyperfunction, but that could be due to medical treatment. i had no blood results so i would have to go through all the causes and finally settle on what i thought was actually wrong with her. the prof was bound to grill me on my diagnosis and try to catch me out. at times like this your entire career feels as if it is the balance and may be lost to you for the slightest reason. as usual i wasn't feeling too bright. and to top it all, the student that had just come out had been grilled for not wearing his name tag. the prof had apparently almost gotten personal and totally rattled him. i had just lost my name tag the previous week. this did not bode well for me.

and then it happened. while i was sitting there waiting and trying to remember and sort out all the bits of information floating around in my exhausted, overly stressed brain, one of the senior consultants of internal medicine walked past. he saw me there with red, sleep deprived eyes and anxiety written all over my face and immediately realised i was just about to go in for a grilling by the surgeons. he gave his bit of advice.

"remember, when in doubt, cut it out." when in doubt, cut it out. when in doubt, cut it out. it went through my mind over and over. a sort of charge in, sword brandished where angels feared to tread. now that was simple and easy enough for even me to remember. right there i decided i could become a surgeon. i knew i had what it took to handle the petty onslaughts of the surgeons, so that didn't bother me too much, and now, intellectually i knew i would be able to remember the essence of surgery, when in doubt, cut it out.

claustrophobia

a comment on my previous post by undead doctor, reminded me of another story about a lift in the old academic building in the old hospital.

every morning all the registrars, medical officers and interns in the surgery department would meet in the boss' office for a report on the previous night's activities and to deal with whatever other administration had to be taken care of. after this meeting the day's work would begin. the surgery department was on the seventh floor of the academic building. the lifts in that building were fairly small, so we did what any normal surgeon-type would have done in our situation...we tried to see exactly how many people we could cram into the lifts on the way back down after the meeting. as it turns out the lifts couldn't take more than thirteen. i know this from the time we crammed fourteen into one lift and it got stuck between floor three and floor four.

now the mental image you need to create here is of fourteen bodies crammed into a space that can comfortably accommodate about six people. it was the sort of situation where we could not all breathe in at the same time because there was simply not enough space for everyone's thoraxes to expand simultaneously. also it was hot, very hot. quite soon the metal walls showed small drops of water from the combined evaporation of our bodies. i would like to say it was not too comfortable, but that somehow just doesn't convey quite how we felt.

to be honest, the first minute was quite fun, with one or two people making jokes about the fact that pretty much the entire surgery department had been wiped out. it was not the ideal time for a bus accident to come into casualties. after the first minute, however, the next eighty nine or so minutes (for that is about how long we spent in that lift together) somehow were not quite as much of a laugh.

one of the interns, it turned out, suffered severely from claustrophobia and had only gotten into the lift in the first place because he didn't want his registrar to think he was weak. after that there was not too much pretence left. his registrar got to see him cry, drop to the floor and call for his mother.

i had a leatherman which someone used to pry the door open about one inch. the above mentioned intern pushed his face up against this tiny window on freedom and started to hyperventilate even more than he had up to that point. i suggested we allow the doors to close again, hoping it would allow the lift to resume its normal activities and hopefully stop on the correct floor and permit the doors to open normally. after that suggestion something happened to me that had never happened before or since...the intern started shouting at me hysterically, even taking the effort to call me a few derogatory names. i could not hit him. my arms were pinned to my sides by the mass of humanity. besides, i assumed outside that lift he would quickly become normal again. i decided to leave it at that.

after about an hour and a half i decided to push my theory once more. i moved slowly towards the doors. it was surprisingly easy..the combined sweat acted as a lubricant and we slid against each other in what i can only describe as an amoeba-like fashion. i moved right up to the intern who was on his knees with his nose pushed through the gap in the doors doing all he could to drop his carbon dioxide partial pressures. with one hand i grabbed my leatherman wedged between the doors. i placed the other on his head. in one movement i yanked the leatherman out and pulled his nose out from between the doors. the doors closed. at that moment the intern got to his feet in one smooth amoebic action. his face was in my face and his eyes glazed over with hatred. i prepared to defend myself, but almost expected a phagocytotic attack. how does one defend against phagocytosis?

then there was a jolt. the doors having been allowed to close sent some signal to the great engines of the lift (not great enough to handle fourteen people mind you) and it jumped into action. five seconds later it arrived on the correct floor and the doors swung fully open. the intern rolled out. the tears of rage turned suddenly to tears of joy. everything he had said to me was immediately forgotten by him. it took me slightly longer.

other than very hot and mildly dehydrated we were mostly none the worse for wear.

lift me up

getting things done in south africa is subject to numerous unique frustrations, some of which i might have allured to in the past. one such typical case had to do with the lifts (elevators) in the old academic hospital in pretoria.

the old academic hospital was made many years ago. then over time as medicine advanced it got bigger in increments. finally it was a poorly designed conglomeration of buildings with multiple small wings all connected with sometimes tiny corridors. over and above that the eastern half of the hospital was totally different. it was a single story sprawling mass of wards, all opening to the outside world. the theaters were on the second story in the western half of the hospital. to get a patient to theater from casualties therefore you needed to take the lifts.

the hospital had a total of ten lifts, a few for each section of the strangely laped together place, but, as is typical of the maintenance ethic in south african state hospitals, only one lift worked at any given time. this added a unique aspect to an already high stress resus effort in casualties.

so generally in the high stress resus efforts, when you get to the exciting stage when you rush the patient to theater with all the fanfair usually only seen on american television medical dramas, one of the things that must be added to the mix is the identifying of the working lift. at this stage, what is required is to send three students ahead to the different lift areas to identify the working lift and to summon said lift. he then was required to shout down the passage to the other students that he had the lift. they, in turn, would relay the message to us and we would go directly towards that lift. i would always stay with the patient, usually bagging the patient with an ambubag.

after this usually the operation itself could not really deliver any more stress than had already been experienced.

funny, death

i'm not comfortable with death. i usually meet it at the end of some life disaster like a car accident, a gunshot wound or a devastating cancer. the going gentle into that dark night i don't see too often. i suppose that's more the realm of the internists?

recently i had the pleasure of going to school reunions and seeing old friends that i hadn't seen in quite a number of years. more than one noted that i had changed beyond recognition, not physically but in some other way. i wondered what they were on about. in the end i decided it had something to do with my job. somehow it makes one see things differently.

i remember an old friend telling me his sister had stated that there was going to be a major change in her life on her birthday. he was hoping she would stop selling cigarettes (she worked in a cafe). i somehow thought that that just didn't seem like such a major change. the friend was excited. i was apprehensive. the major changes i see in people's lives tend to be pretty major. sometimes they don't survive.

sure enough, her birthday arrived. they found her in her house with a bullet through her brain. it was a major change she had brought about in her life all right. and i suppose she was also not going to sell cigarettes any more.

recently i came across a post talking about american surgeons. i think that is actually sort of what i'm speaking about. in the end we can't be totally normal. some of us will cut ourselves off from the human experience and become hard and callous. some of us will become exhausted by it all and burn out or become depressed. some of us will see things differently and become unrecognisable to our old school friends.

in the end i try to remind myself of the privilege that has been afforded to me to be able to meet with people in those critical moments in their lives when everything becomes horrendously vivid and the irrelevant things in life quietly fade away into the wings.

at last, a golden llama!

i have just been awarded the prestigious golden llama award by the illustrious doctor rob over at musings of a distractible mind. he awarded it in a nice little limerick.

a blogger from far away nation
made blogworld his lone destination
so bongi’s awarded
his praise is accorded
given sans capitalization

i'm highly impressed with this most coveted of blog awards, but i feel a bit guilty (not guilty enough not to display the award of course). you see the reason i ended up in las vegas for the blogworld expo was entirely due to the efforts of doctor val over at better health. so, as part of my acceptance speech, let me acknowledge dr val as the catalyst that flew me over the ocean to the very strange land of las vegas.

cross clamp

some things in surgery are not taught. you sort of pick them up on the way. the cross clamp was one of those for me.

the first time i heard of it was during the m and m meeting after a story i've already told. luckily i was on rotation and was therefore not in the direct line of fire. however the professors grilled my colleague on why he did not open the thorax and cross clamp the aorta before he commenced with the laparotomy. it seems, according to the professors, all would have been just rosy if they had opened the chest first and clamped the aorta, the main artery supplying everything in the abdomen and legs, before they opened the abdomen. i remember thinking the patient looked pretty screwed to me at the time and although conceptually the cross clamp idea sounded good i really doubted it would have changed the outcome. however i made a mental note of it. a while later my time came.

it was a gunshot patient, but he was hit well. however, when i saw him he was not feeling well. in fact he was in exitus. his abdomen was severely distended and his vitals were almost undetectable. i was quite impressed that we got him to theater before he moved to the great hereafter. and then it was time to do something. my mind went back to that m and m and that previous case. if there was ever a case where a cross clamp would be a good idea, then surely this was it.

i opened his chest, a region i'm not overly comfortable in, but a place i can find my way around. i found my way around to the aorta and clamped it off, thereby cutting off all blood flow to everything below the diaphragm. then i went down to my old hunting grounds, the abdomen.

when i opened the abdomen there was blood everywhere but there was very little bleeding. this was obviously because there was no more blood even getting to the abdomen. it may have had something to do with the fact that the patient had very nearly totally bled out. of course it didn't mean everything was fine. things were far from fine. his splenic artery had been shot off about half a centimetre from the aorta. there was also an impressive hole going straight through the liver, ripping a hepatic vein or two to shreds on its way. i sorted the splenic artery problem out (splenectomy in this sort of case for all you budding surgeons out there) and got to work on the liver.

some time in the whole process i asked the anaesthetist how things were going on his side of the drapes.

"the top half of him is fine. just a pitty that we can't just send the top half to icu and hope for the best." the point was at some stage we needed to remove the aorta's cross clamp. we loaded him with fluid and blood and slowly removed the clamp. sure enough once the heart had to supply the whole body and not just the upper half it started struggling. after quite a few tries we finally managed to get the clamp off without the patient crashing. he even made icu where he demised about a day later.

i was quite upset that the outcome was not what it ideally should have been, but the fact of the matter was that if we hadn't cross clamped he would have expired about 30 seconds after opening the abdomen. we gave him the best chance, but, alas, in retrospect he was shot dead.

good old boy setup

i thought of not telling this story at all. recently when it was in the news here it seemed wise to rather bury it altogether. but it is something i experienced and, after all, this blog is about my experiences, so...

six years in a department gives you enough time to do a few things that can be legendary (like this story). this was one that most at the time thought was one. however, at the time it impacted me on a different level.

the surgery department had a fairly intensive academic session every tuesday. the highlight was a discussion delivered by one of the registrars on some or other topic. he was required to reference the absolutely newest literature and the standard was very high. it was a big deal. most guys spent a few months putting their talks together.

on the day in question the discussion was going to be about bariatric surgery (surgery to help obese patients lose weight). what was interesting was that the consultant (a private guy with a part time post at the university) who was designated to be the moderator of the talk was a surgeon whose practise consisted of quite a lot of small bowel bypasses. now the literature was extremely condemning of this particular operation. at the time i was rotating with the laparoscopic guru who did a fair number of gastric bypasses (an operation which the literature favoured for obesity). in passing i mentioned to the boss that it would have been more fitting if my senior had been designated the moderator of this particular discussion for obvious reasons. the boss seemed to give it some thought.

the day before the discussion the boss took me aside. he told me that he thought i was in a good position to make a comment about the gastric bypass operation verses the small bowel bypass operation because i was the one registrar at the time who had been involved in the favoured operation. he then basically instructed me to comment during the discussion. the command had been given. what could i do but obey? that night i reviewed the literature.

during the talk the registrar dedicated very little time to the small bowel bypass. he simply stated that it was an operation that has been relegated to the history books due to its dangers and the fact that there were better operations available. his moderator didn't flinch. i noted that he didn't add that the literature also stated it was unethical to even do that operation. on the whole, his talk was good. then came time for questions and comments. he fielded most questions quite well. finally the room fell silent. i stood up. i had been instructed to do so.

i started by mentioning the literature was more condemning of the small bowel bypass than the registrar had stated. and yes, i did use the word unethical. i then went on to explain that a gastric bypass causes a change in lifestyle because the patients can no longer eat so much and that their sugar intake is also curtailed whereas the small bowel bypass causes exactly the opposite. because it causes a malabsorption the patient has to make sure he eats just as much if not more just to maintain baseline health. my choice of words could have been better.

"with this operation you are actually giving the message to the patient, you are a pig and now you must really eat like a pig."

all the registrars squirmed in their seats. they seemed to be trying to quietly slip under their respective tables to avoid the accusing eyes of all the professors and consultants. they needn't have bothered. even the consultants could not maintain eye contact with me. they looked around uneasily. only the moderator maintained his steady gaze directly at me. i remember thinking i'm quite glad that looks can in fact not kill. otherwise i'm sure i would have gone up in a puff of smoke. my task was done. i sat down.

one of my colleagues leaned over.
"what have you done?" he asked. "are you completely mad? do you realise these are the guys that are going to be in your final exam in just a few short months?" i looked around. the registrars whose heads still protruded enough from behind their desks to be visible seemed to all be shaking said heads slowly. the room was absolutely dead quiet. i held my head high and gazed forward. but i also started hoping that the meeting would adjourn so that i could flee. although looks couldn't kill as i had just demonstrated maybe they could maim to within an inch of life and i wasn't willing to find out.

the next morning meeting went as morning meetings go. but just before the prof dismissed everyone he turned to me.
"bongi, you stay behind!" again the heads of all the registrars shook almost imperceptibly. sh!t!! i thought.

"bongi, dr d took me to his practise yesterday. there are fat people that he is trying to help." i considered saying that help and exploit can sometimes easily be confused with one another, but i thought better of it.
"never again will you or for that matter anyone in my department speak badly about or against any one of my consultants, in public or in private." again the thought went through my mind that i should defend myself and say that the literature backed me up with everything that i had said. i also considered pointing out that he himself had instructed me to speak and i'd just assumed he wanted me to tell the truth. fortunately i remembered something about the better part of valour and that i could not win this fight. even though it was a setup, i had hurt one of the good old boys and they would stand together, right or wrong. all i could do was hold my head high and once again prove, this time unfortunately, that looks can't kill.

it's probably not funny

we have a different sense of humour. we just do. what we find funny can be macabre to most people. it is probably part of our general desensitization or maybe it's a way of dealing with the things we see. you can't get emotionally involved with everything. i remember realising this many years ago. but more recently i saw it again in a very strange turn of events.

i was a fifth year student in paediatrics. for ward rounds we were accompanied by physiotherapist students and social worker students. that morning we arrived for rounds. one of the sixth years asked the sister where one of his patients was because the bed was empty. the sister informed him the patient had died during the night. i got the feeling from their interaction that it wasn't totally unexpected. the sixth year turned to one of his colleagues and laughingly said;
"yesterday i was so busy, but today seems to be my luck day. two of my patients were discharged and one died. now i only have one patient."
the social worker happened to be within earshot. her face was one of absolute horror. she was devastated. but the sixth year didn't mean it in a bad way. he was simply not emotionally connected to the clear human drama that had played itself out. maybe he had been one too many times or maybe he was just like that. i just remember being impacted by the difference in reaction to the same news by the two people.

the second story happened when i was already qualified as a surgeon. i was on call. while i was waiting for theater time i was sitting with the radiologist going through scans (this is something i tend to do still). at a stage the radiographer came through. she wanted his opinion on a scan. apparently she couldn't understand what the contrast was doing and wanted to know if she needed to do a late phase scan. we both went through to see.

the patient had been referred to the hospital as a head injury patient after a car accident. he was intubated at the referring hospital as is good practise for these patients so he was already on a ventilator. the casualty officer suspected he was coning (a preterminal event where the brain stem gets pushed through the opening where the spinal chord exits the skull due to increased intracranial pressure, usually due to trauma inside the skull) and had therefore phoned the neurosurgeon. he had in turn instructed him to do a scan of the brain. the casualty officer decided to do an abdominal scan at the same time because he wanted to make sure there wasn't also abdominal trauma. and thus the patient ended on the ct scan table with the radiographer wondering what was going on with the contrast.

as we entered the scan room i too was perturbed by where the contrast lay in the abdomen. the contrast had been injected through a central line in the neck. it had gone straight through the right atrium into the ivc. there it had moved into both the right hepatic vein as well as the right renal vein. it was nowhere else to be seen. the radiologist immediately made the obvious diagnosis (in retrospect).
"i know what's wrong," he proclaimed. "this patient is dead." of course with the patient on a ventilator it was not immediately obvious. the radiographer went through to feel for a pulse, which, looking at the scan, i knew he would not have.

i started laughing. everyone else was shocked, more at the fact that i was laughing than at the fact that there was a dead guy on their scan table.

maybe they are right, it's probably not that funny.