sealed with a hand-shake

shaking hands is not really such a good idea, especially in a hospital where there are all sorts of nasty bugs floating around, seeking whom they may devour. so generally i do not shake hands unless the patient absolutely insists and i think the cultural slight may be more than he can bear. but one incident highlighted to me the reason you generally don't want to shake hands so well it could just have well been written all over the hospital in bright neon lights. in fact in my opinion, it was.

i was on call that night so it fell to me to evaluate and treat the patient in casualties which the casualty officer said had a perianal abscess. i approached the bed and introduced myself, but i made a point of positioning myself in such a way that the patient wouldn't be able to greet me with the traditional handshake. experience had taught me that this was one case where this cultural idiosyncracy was patricularly ill-advised.

i asked what the problem was. without saying a word his hand moved to his gluteal cleft in one smooth motion. moments later i found myself staring with morbid fascination as he pulled his butt cheeks apart and started prodding what was clearly an abscess with his finger. it had already broken open slightly so there was a thin stream of pus oozing out and following the natural pull of gravity. the patient's grubby finger scratched, prodded and poked this poor stream of sepsis, completely disrupting its attempt to soil the bed linen.

i was so disturbed and disgusted that my senses seemed to heighten and the pus took on an almost luminous yellow colour in my mind. this, after a very short while, was visible on most of his hand and under his nails. but in fairness to me i managed to fight my gag reflex right up until he wiped his lip with that same hand. i had theater to organize so i fled. i felt dirty and used.

after the obligatory wait it was finally our time to go to theater. i got there early and as is my habit chatted a bit to the anaesthetist. we then went together to the preoperative holding area to see the patient. the gas monkey, a very gregarious fellow, immediately moved to the side of the patient's bed and introduced himself, extending his hand as is customary.

as we pushed the bed to theater i kept glancing over my shoulder at my anaesthetic colleague until he asked me what was wrong. i found it surprising that he couldn't see the bright yellow luminous marks on his hand which seemed so obvious to my mind's heightened senses.

christmas meal

often on christmas i think back to a story from long ago that was based on a christmas meal but had nothing to do with a christmas meal. the man in question was unique to say the least.

it was about february. we were on one of the painful yet entertaining rounds with our eccentric consultant. up to that stage he had actually been so contained that some of us could even have been described as being bored.he just didn't seem to be ranting as much as he usually did. he was also not spewing forth his particular brand of black humour.

then we got to a new admission from the previous night. the patient was a middle aged female with cellulitis, but the thing that struck us all the most was that she was morbidly obese. she must have weighed in at 220kg. obviously we displayed the necessary tact and didn't make a big fat deal of it. the consultant, however had no such scruples.

"you are the fattest person i have ever seen in all my life and let me tell you, i have seen fat people in my many years in this hospital." we all looked around awkwardly, hoping his verbal indiscretion would end. those that knew him well had little illusion that this would be the case. he then turned to the student nearest him;

"you! go and get me a carrot!" the student looked on incredulously. "you heard me!" he bellowed, "fetch me a carrot! and when you bring it give it to her to eat!" we still didn't quite understand what new madness had taken over the faculties of our master. we mutely looked on.

"and then on christmas day give her a second carrot to eat!" he then turned to her. "christmas!" for that is the name he bestowed upon her and indeed the name he used to address her every day until she was discharged, "you are about to make history. you are going to take part in the biggest diet in the history of medicine!"

close call

i have already spoken about the hazards of doing favours, but recently i was reminded of another example when i was still a registrar where i only just escaped the proverbial falling anvil.

it was not an unusual case but still fairly challenging for a registrar like myself. the old man presented with an acutely tender abdomen and free air revealed on x-rays. if you ignore the outside horses for a while, this is either a perforated peptic ulcer or complicated diverticulitis (some people would throw complicated appendicitis into the mix, but i'm going to leave it in the stable with the outside horses if there are no objections). the patient needed an operation and soon. so with the sun shining happily over australia somewhere, i took him to theater.

it turned out to be diverticulitis, but what a mess. the entire abdomen was full of pus and there was a big inflammatory mass in the region of the sigmoid colon. i knew what to do. i whipped out the offending sigmoid colon and, because the risk of reattaching the bowel in that level of sepsis was too high and because the patient couldn't afford a further complication, i pulled out a colostomy. after the surgery the patient started recovering at an acceptable rate. the plan was to reverse the colostomy in the future.

now usually, this sort of colostomy would be left in place for quite a while (in the order of six months) to give the abdomen time to recover fully from the severe inflammation that accompanies free pus throughout the abdomen. inflamed bowel is very friable and difficult to work with. thereafter it would be closed in a second operation. however there was a private consultant with sessions at the university who strongly advocated for what he called early closure of colostomy. he said that as soon as the sepsis had cleared up, long before the inflammation had settled, you could re operate and reverse the colostomy. he advised that the second operation be done before the patient even leaves the hospital, even within a week of the first procedure. he actually approached me about this patient specifically and told me i should try it. i started contemplating the idea.

then something happened that i should have seen as a big warning sign; an old friend asked me for a favour.

you see this friend was related to my patient in some way. apparently he had visited him in hospital and discovered i was the one who had done the operation. as can be expected from someone who wakes up from surgery with an unexpected colostomy, the patient was bemoaning his lot in life. in the end he asked my friend to ask me for a favour. the friend asked me to close the colostomy, sooner rather than later. i should have seen warning lights. i didn't.

so i decided this would be the case where i listen to the often contentious advice of this specific private surgeon. i took the patient back to theater to close the colostomy about a week after the first operation.

quite soon i was in trouble. everything was adhered to everything. over and above this, because the inflammation was far from resolved, everything was oozing blood at somewhat more than an acceptable rate. but it was too late. i was elbow deep in the abdomen. i had no choice but to continue. the other catch was that i was doing the operation at the advice of the outside consultant and not with the consent of my own consultant. this essentially meant i would experience a severe loss of cool if i asked my consultant to come in to help me *read bail me out*.

the details need not be dwelled upon (truth be told i have filed them deep in the forget folder in the darkest archives of my mind) but suffice to say it was an almost impossible dissection to get the two ends of the colon together to reattach them. finally, almost miraculously, i approximated the two ends in a somewhat acceptable manner and attached them.

during the postoperative period i almost expected a leak. day after day i'd check the patient out and be surprised to see there was no leak. finally i discharged him in good health. but not before i swore to myself never ever to attempt an early closure of colostomy again. also i reminded myself of the dangers of doing favours.

p.s many years later i ran into this friend and was pleasantly surprised to hear the old man was still going strong.

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.

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.

extreme

recently i had a moment to reflect on adrenaline and adrenaline inducing sports. it was a bloody moment. but i'm getting ahead of myself.

bleeding peptic ulcers occasionally cross the path of general surgeons. usually they stop bleeding with conservative treatment. but sometimes they don't. then you need to whip out the trusty knife. even then usually the operation is little more than routine. this case, however was exceptional.

he was white as a sheet. he had been bleeding for three days but only decided to come to the hospital when he started falling over. it seemed he could at least recognise falling over as not normal. the initial gastroscopy showed a penetrating duodenal ulcer with no active bleeding. the body had managed to curtail the bleeding, partially because of vasoconstriction, but mainly due to a low blood pressure which in itself was due to loss of blood.

i got drips going and ordered the necessary blood. unfortunately as the resus progressed his blood pressure normalised and the tenuous clot in the bleeding vessel could no longer hold back the inevitable. it quickly became apparent that we were not winning and soon we were in theater.

not too long after the ulcer was nicely exposed and i looked upon something squirting blood with much too much enthusiasm for my liking. a strong thick stream of blood was propelled out at great speed. the artery was also tucked up under the edge of the ulcer in a position that was pretty difficult to access. i put my finger on it and took a moment.

during my moment i had a few thoughts. the first was pretty much that the patient was going to die in the next few minutes right there in theater under my hands with my finger still probably on the point of bleeding. this thought seemed to emanate from two glands just above my kidneys. it was not a productive attitude to have and wasn't going to help me to get control of the bleeding, so i put it out of my mind. the patient dying was not an option i was willing to give in to.

the next thought was related to the adrenaline that was coursing through my veins. i automatically thought of people who go out and intentionally take part in activities for the expressed purpose of pushing their adrenaline levels up. don't get me wrong, i have nothing against that. it's just that after an adrenaline inducing operation, the last thing i want to do is go out and get some more. adrenaline inducing operations are surprisingly common in my particular line. maybe i'm getting a bit older. when i was still training i was much more keen on getting the high stress cases. these days i'm quite happy to miss them. usually, however, they do not miss me. they seem to hunt me down. so generally i just want to go home and collapse in a heap on the floor, often in the corner after a day's work. there i tend to lick my wounds or eat worms, depending pretty much on the availability of worms at that time of year.

p.s i got control and the patient did well.

fabulous las vegas

i've just returned from the blogworld expo in las vegas. what an experience. i suppose vegas is designed to be an experience. but there is so much more that impacted me.

vegas is a strange place. it comes alive at night. for a jet lagged south african like me this actually turned out to not be a problem. my body had no idea what time it was anyway, so the circadian confusion was minor.

the american people i can only describe as friendly. unfortunately i think this is more of an indication of what we are like in south africa. we are aggressive or maybe defensive, probably because of the environment we live in. they probably are normal, but compared to us they seem friendly. strangers are forever greeting and asking how you are. it's difficult to get used to. one incident caused a certain amount of introspection on my part. a group of us caught a taxi together. apparently we had too many people in the taxi (too many people in a taxi is an unknown concept in itself in south africa). one of us got out and we were off. unfortunately, by their laws, two should have gotten out. the driver didn't notice the discrepancy and we were off.
half way to our destination, about a minute later, the driver realised his mistake and questioned one of us. his tone was sarcastic. the americans brushed off his comments. i was sitting right at the back but i felt my blood boil. i wanted to move to the front and explain his ancestry to him in true cape flats fashion. but i held my tongue and waited to see what the americans did. they remained calm and even conciliatory. i stepped down.

but the true joy of this experience was the people i met. i met blogging legends and some truly fantastic people.

i met val jones of better health. i was amazed. someone who has the type of drive to get something like that up and going simply is not supposed to be so nice. she was stunning!!! what a wonderful person. and she is pretty good at her job too. she was also the reason i was allowed to attend in the first place.

then there was ramona bates of suture for a living, the great quilter of the medical blogoshpere. she is also probably the most prolific blog reader and commenter. i personally believe she has encouraged many a fledgeling medical blogger into forging ahead and building a successful blog. she is also probably the person i most wanted to meet at the conference. she is truly a selfless, giving person without equal.

the legendary nick genes of blogborygmi and the father of grand rounds was also there. he showed me karaoke can be fun, to watch at least. nick, maybe one day i'll be able to see new york for myself.

the actual driving force (yes he took a car) behind the karaoke night was enoch choi. fun and friendly guy. and he can sing!!

the last member of the karaoke team was gene ostrovsky of medgadget. gene, your pens are being spread around the lowveld as we speak.

then there was allen roberts of gruntdoc fame. as a general rule i like emergency doctors and gruntdoc fell sweetly into the reasons why.

even if his job sounds boring docwes was anything but. i suppose even cardiologists are people too.

another legend i met was the prolific kevin md. as a blogger he it totally out of my league but face to face i though he was a nice, down to earth over achiever.

i actually got to meet the llama doctor, doc rob of musings of a distractable mind. i even watched as he helped on some of the finer points of drawing a llama. i hadn't realised it was so technical. his blog is an absolutely worthwhile read.

then there was bob coffield. even though he is a lawyer he was a really decent guy. he also hung with the medical bloggers so seems to be slightly more our side of the fence.

i now have the privilege of saying i have actually met the great doctor anonymous in person. quite a privilege.

then there was mother jones of nurse ratched's place fame.


the well known patient blogger kerri morrone sparling of sixuntilme fame was also there. her inadvertent discussion with what i can only describe as an intellectually impaired taxi driver about the movie revenge of the nerds gave me quite a laugh.

also a new acquaintance was doctor v (v stands for vartabedian, as you probably could have guessed). he is a paediatric gastroenterologist, something so specialised the speciality, as far as i'm aware, doesn't even exist in south africa.

thanks to marc monseau of johnson and johnson (his son i assume) who were a great financial drive behind the medblogger track.

bob stern of medpage today was also financially significant.

i only briefly met gary schwitzer of health news review. nice to meet you.

unfortunately the legend, paul levy of running a hospital couldn't make it in person, but he did make a telephonic appearance. i suppose he had a hospital to run or something.

all in all it was an absolutely terrific experience. i hope to repeat it next year. also i tentatively hope to see some of my blogger friends on our shores some time. i'll teach you guys how to survive south africa without picking up a lead trinket.

blogworld

the medblog tract at blogworld is not only a reality but just around the corner. it is on 15 october in las vegas. thanks to the great val jones i will be there as a panelist!!! so if you want to hear my 10c worth on the topic blogging for change: how to influence healthcare through blogging, please attend the conference.

nudge nudge ... ...

i recently read a post that reminded me of an incident. depending on which side of the eyelid you found yourself that day, it could have been funny...or not.

i was doing casualty sessions after hours. it was a way of making ends meet while i was specialising, but mostly i just hated it. anyway one night, between the snotty noses and neurotic parents a patient actually came in with a casualty-worthy complaint. he had a small laceration on his forehead. we decided to glue it together with dermabond because it was so small. i decided to leave it to the sister. after all the unit was full to overflowing with snotty noses and paranoid parents that i was required to work through and get rid of.

after a while the sister came to me. she had terror written all over her face. i tried to think what had gone wrong that she looked so shocked. i started imagining i had somehow missed a life threatening injury and the patient had crashed. turns out the problem was not so deadly but just as sticky.

while the sister was applying the dermabond, which is essentially superglue, a drop fell into the patient's eye. luckily he had closed his eye on time. unluckily he had developed a permanent wink.

i confess i laughed. the sister was not impressed. she took me aside and begged me to help. i stopped laughing. it seemed it wasn't funny to her and unless the patient was deliberately winking to show he was in on the joke, it wasn't funny for him either.

the problem with gluing your eyelid together is you can't dissolve the glue with acetone because acetone would do its own damage to the eye. so i took a scalpel and very slowly and meticulously got to work. as it turned out, the eyelashes where glued together along most of the eyelid and only in certain areas was skin involved. by the end the wink had been surgically removed, along with all the eyelashes.

i often wonder if there is anyone else who can say they have surgically removed a wink, and broken bottle injuries from bar brawls don't count.

powerless

some things make me feel so powerless (yes, even i can be powerless in the face of incompetence)

i have previously mentioned a thing or two about my opinion of where medical training is going in this country. basically the powers that be are not-so-gradually degrading the degree. to them somehow it seems like a good idea. ideas i suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. well i get to see the consequences up close.

he was referred from an outlying hospital on a friday. the peripheral hospitals so like to empty their wards for the weekend. after all there is some good fishing in these parts. thank goodness for good fishing. otherwise many more would die unnecessarily.
anyway the patient had free air in his abdomen. this is a sign of a ruptured stomach or intestine and requires immediate operation. in fact the longer you wait the higher the chance of death. what i found interesting is the x-rays that they sent with the patient dated four days before the transfer (but admittedly not just before the weekend) clearly showed the free air.

now not all that long ago, to miss free air on an x-ray even as a student was a mistake that would fail you. these days you can easily get through medical school without worrying about trivialities like free air on x-rays. also, to have perforated bowel causes intense almost unbearable pain. even a street sweeper would be able to pick this up in the patient. yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days. that is if he even ever examined the patient. then fortunately a weekend turned up and the patient was referred, well on his way to the great hereafter.

as can be expected, when he turned up he was extremely ill and was already in kidney failure. the catheter bag remained empty. after a few hours of aggressive fluid resuscitation there was at least a bit of urine in the bag. then it was time to operate.

the abdomen was in a bad condition. to say it was rotten would be somewhat of an understatement. but the interesting thing i noticed was the full bladder. the peripheral hospital had kindly inserted a catheter not into the bladder but only into the urethra. there they had blown up the balloon, just to make sure they did the maximum amount of damage.

so not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do , because they didn't know how to do it properly, caused further damage to the poor man.

i cast my mind back to when i was still in academic circles. i remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared. i myself was asked to examine a student in a practical exam. i failed her because she was simply a danger to any person unlucky enough to become her patient. and yet the powers that be had so changed the system from when i was a pregrad that she could not be failed and was released into the community.

i'm sure the people who have orchestrated the new system that is so student friendly (but not patient friendly) don't get to see the disasters out in the periphery that are a result of their hard work. quite frankly even if they did see them i doubt they would care. after all it doesn't directly affect them.

the baby story

the life of a medical student is somewhat left of normal. most people shy away from blood and guts and gore. as a medical student you need to embrace it. but in the beginning it is quite an adjustment. sometimes you don't know how much to adjust. what falls within the parameter of normal medical student desensitization and what is way too far?

i was a fourth year which in clinical terms meant i was at the bottom of the rung. i was doing my obstetrics rotation which meant i needed to deliver a certain quota of babies in a given time. we all tended to be goal orientated then. our registrar was the most junior obstetrics registrar in their department so she was even more goal orientated than we were. she was also a bit skittish.
so that day, when a lady came in fully dilated and then popped out a dead baby she seemed to go to ground. don't get me wrong. i do not enjoy the whole emotional roller-coaster involved in delivering a dead baby, but once it's done you need to move on, especially in kalafong where the constant stream of bursting women is never ending.

so there we were in kalafong labour ward in the middle of the night with a somewhat unstable registrar who suddenly seemed incapable of pretty much anything because she was so distraught. i had the thought that she should maybe try dermatology as a speciality. it wasn't too late to change. the house doctor spent quite a bit of time consoling her. time i thought could be better spent in consoling the mother who had just lost her child. but a fourth year's opinion was much less sought than listened to. finally the night went on.

some time later when the distraught mother was bundled off to the ward and the dead baby was bundled off to the morgue and the registrar bundled herself off to the doctor's room the call finally continued. we continued delivering babies while the registrar went through the prenatal record of the mother to try to see if there was a possible reason for the death. she discovered the mother's blood group was rhesus negative. this basically meant if the baby was rhesus positive the mother needed to get an injection of antibodies to prevent her developing her own antibodies against the rhesus factor. if this happened her chances of successfully bringing her next pregnancy to term would be greatly reduced. the registrar hadn't drawn the chord blood from the baby which is the normal method of getting blood to determine the baby's blood group. she therefore didn't know if the mother needed the injection or not. i simply thought it's not worth taking the risk and we should rather just give the mother the injection on the grounds that the baby was most probably rhesus positive. but the real reason the registrar was in a spin had to do with what the professor was going to say in a few short hours at handover about her not drawing chord blood from the baby. she settled on a plan.

"you!" she indicated my friend and i, "you are going to go down to the morgue and get that baby's blood. and you'd better move it. the sun will be up soon.

the morality of what she was asking didn't occur to me then. it was late and we were tired. also we were junior. if the registrar told us to do something then we were required to do it. so off we went.

kalafong is a scary place on a good night. the morgue was in a ditch along a deserted corridor. all was dark and foreboding. but we were on a mission and our over active imaginations weren't going to stop us. we finally found the poor baby and got to trying to get blood. then we discovered something. you actually need to be living for your blood to be drawn out of conventional veins. after a few attempts we graduated to trying to get blood through the frontal fontanelle. this also didn't work, probably because the small amount of blood there had clotted and couldn't be drawn up in a standard syringe. finally we stuck the biggest needle we had right into the heart and managed to get a small amount of blood. by this stage my own blood was curdling, the hairs on the back of my neck were standing up and i felt sick to my soul. we left.

the registrar took the blood without so much as a small acknowledgement towards us that we had done something terrible so that she could avoid the wrath of the professor.

many times since then i have been haunted by how wrong what we had done there in the dank corridors of kalafong was, but it was a lifetime ago and maybe time does wash at least some sins away.

selfish bastard

of the things i encounter in my work, the one i find most disturbing is family murders. for some reason they happen with too much frequency in our country. it seems that some people, when life is too much for them are not happy to only put a bullet through their own head, but they feel the need to wipe out their entire family first. in my opinion it is a dastardly and cowardly act for which there is no excuse...ever.

the last one i was indirectly involved in was a typical story of a man that had lost it. he killed himself. but just before doing that he shot his wife and two children. his little girl made it to the hospital. i was asked to evaluate her, but she died before i even got to her. i was so disturbed i decided i didn't want to see the body. i did, however see the scan. besides the two bullet wounds through the head, the thing that struck me most were the two hair clips clearly visible on the scan in her hair on the back of her head. it was somehow disturbingly poignant and it stayed with me for some time.

but this post is about another attempted family murder that i thought much less disturbing and, truth be told, a bit humorous.

it started out as usual. the man felt he could no longer live (not sure that was a bad decision, actually) but he decided he was going to kill his wife first (that was a selfish shocking decision which i believe speaks of the character and substance of the man). anyway, he got his wife on her knees, apparently begging for her life. he put a 9mm up against her head and pulled the trigger. the gun misfired. she was ok. he then put the gun up against his own chest where he believed his heart to be and pulled the trigger. now suddenly the gun was working quite well.

i was rotating through thoracic surgery at the time so he became my patient. i have previously mentioned gunshot wounds to the chest and the general idea the public has that the heart is on the left, so let me not bore you further with anatomic considerations. let me just say the patient shot himself through his left lung. he simply needed an intercostal drain and was otherwise fine. i suppose he thought he needed a bit of sympathy from me too. he didn't get it.

the next day, when i was doing rounds he was clinically fine and doing well. he was feeling very sorry for himself and complaining about the intercostal drain. seems he had no feelings towards his wife but was particularly concerned by matters pertaining to his own comfort. again i can say i was not wearing my sympathy on my sleeve. i informed him the drain would be staying exactly where it was until i was happy to remove it. i explained the decision would be made purely on clinical grounds and not on whether he was whining and complaining. he then asked a strange question.

"do you suspect any internal damage?"
"a bullet went straight through your lung! what do you think? of course there is internal damage."

later i had a good laugh about his moronic comment. it is the only family murder scenario where the outcome was good, in my opinion.

surgexperiences 306

welcome to south africa for this week's surgexperiences. enjoy the small view of this world in one country as well as some great posts.

union buildings

about surgery brings to our attention a pretty bizarre intraoperative possible complication.

rugby world cup champions

a bit of an overview of intraperitoneal chemotherapy in malignant mesothelioma, from malignant mesothelioma.

table mountain

quietusleo recalls a humorous story about a robust surgeon flipping a patient like a pancake. he also talks about the only patient he knows who actually sang herself to sleep.

lost city

vanguard gives us news of free cardiac surgery in the sudan.

natal sardine run

sterile eye gives the english speaking world a sneak preview of one of his videos.

three rondawels

medzag writes an absolutely brilliant post about his surgery rotation. i really enjoyed this immensely.

robben island

an overview of smoking and its effects by sagarika for those of you who didn't yet know it was bad for you.

robben island

everyone remembers where they were when they heard the news. popehat was with his father who was to undergo surgery.

paarl rock

could fear of cancer be an indication for prophylactic mastectomy? unbound medicine gives a compelling argument.

our greatest statesman

life in the fast lane gives a very well put together case report and discussion on isolated volar distal ulnar dislocation.

letaba outside elephant museum

a touching story about a "surgeon" in somalia by bartamaha.

letaba river. my soul's secret place

dermmatters gives a very practical guide about taking your own clinical photos.

kimberly big hole

i've always felt that surgical drains are absolutely essential so i particularly enjoyed dr bates' post on the history of surgical drains.

golden gate

methodical madness gives a very humorous account of when a good spam filter just does not work for a gastroenterological pathologist.

golden gate

i really enjoyed this off the wall look at breast reconstruction and why it would not be overly useful for the amazons, written by plastic surgery 101.

god's window

who cuts off your leg, the doctor or the seestah? ask little karen.

bourke's luck potholes

this one touched a nerve in me. those days are over but the future turned out not so rosy hey, boereworsmedicine?

boulders beach

never underestimate aberrant anatomy in the area of the common bile duct. thanks for reminding us buckeye.

blyde river canyon

and i suppose that's it. please contact jeff, the guy who runs the show at surgexperiences if you want to host a future edition. if you are wondering if you should, the answer is yes.
also submit, submit, submit to this site to be included in the next edition of surgexperiences.

cape town

hope you enjoyed a few south african scenes as well as some really worthwhile posts.