Saturday, September 26, 2009

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.

Monday, September 21, 2009

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.

Sunday, September 20, 2009

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.

Friday, September 18, 2009

hear this

recently a plastic surgeon i know was called out to fix a lacerated ear. it is the domain of plastic surgeons pretty much all over the world. but in my neck of the woods it may be tricky to extricate a plastic surgeon from his warm bed on a cold night. let me also say that back in those days all registrars of all disciplines earned the same overtime each month. even opthalmologists and dermatologists and pathologists earned exactly the same overtime as surgeons. they weren't complaining. we, however, were.

as calls went it was fairly standard for us general surgeons. i had found a moment to empty my bladder which was a nice change, but other than that one reprise there had not been a moment to even realise that i hadn't eaten all day. at least there hadn't been any lethal disasters...yet.

somewhere in the madness the house doctor asked me to evaluate a patient with a lacerated ear. he had had half his ear detached in a bar brawl. it was hanging precariously from what still connected it to the body. now at this time in that hospital there was a policy that once a patient had been referred by a casualty officer they would not take the patient back. if the referral was erroneous then we would be required to refer further as appropriate. so when i heard my house doctor had accepted the patient i was not impressed.

"you suture his ear." i told him. poor guy, he hadn't studied at our university and therefore wasn't used to our sink or swim approach to medical training. he freaked. my level of being impressed dropped even more. i'd have to phone the plastic surgeon myself.

the plastic surgeon was not keen. by that i mean he basically said he was not coming out. by the tone of his voice i assumed he was getting a back rub from his significant other under the warm duvet on his bed. who could blame him. if you're not in the trenches why would you want to go into them, even for a short while to suture an ear.

"anyone can suture an ear. you're there now. i'd have to come in to the hospital. you just do it." i considered telling him that i'm at the hospital because i have so much bloody work to do and that he is drawing the same overtime that i am and that it is his bloody job and not mine. but i knew that at that stage, even if i walked on water and then turned it into wine he was not going to come out. i hung the phone up. my house doctor looked at me questioningly. he had already told me he couldn't do it. but he was not from our neck of the woods. i needed a student. one walked past, unsuspectingly.

"you! have you ever sutured an ear back on?"
"when i ask this same question tomorrow, you will answer yes. come with me."

he did quite well.

Sunday, September 13, 2009


i have once again been given the honour of hosting surgexperiences on 20 september (next week sunday), so please get your submissions in as soon as possible via this form.

also for all medbloggers please contact jeff here if you are interested in hosting a future edition of surgexperiences.

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)

Wednesday, September 09, 2009

mixed feelings

i hate working in the state. i would quit it altogether if i didn't love it so much. such mixed feelings

recently i was called to the state hospital, as usual at an obscene hour. somehow i dragged myself out of bed. i think i woke up half way to the hospital which was a good thing. it makes parking so much easier.

now generally at this time my sense of humour is not at an all time high and i'm not feeling my usual cheery self. yet ironically it is exactly at these times when one needs to be the most malleable in attitude. if not, you will not continue in the state for long. and these were my thoughts as i walked towards theater that night. i thought of past experiences and prepared myself.

i approached the theater. i could see the main door now had a security gate that was locked. i think i was more than partially responsible for this. but the door to the change room was at least open. as i entered i remember saying to myself that if the door was open then nothing i encountered inside would get me down. i knew it would need to be a decision.

in the change room, i found only shirts. at least there were shirts, i thought. i took one and soon had put it on. tucked away in a different corner, away from the other clothes, with less effort than i expected, i found the pants. they were duly donned. there were no shoe covers. it was in the middle of the night so i just assumed that the owner of the boots i loaned would be none the wiser. anyway, it wasn't as if i had much choice. then there was the small matter of head gear. i did not have to resort to things i had done in the past. looking in the female changing room turned out to be all that was needed.

i then made my way past the sleeping theater nurse towards the operating theater. as usual i had to use plaster to stick the inferior mask to my face to prevent my glasses from fogging up. and only then could i scrub in to join the medical officer who had asked for my help.

truth be told, i accept the small irritations of the state. when i'm there i feel like i'm making a difference. i also like teaching and these days it is the only chance i get.

yes, i love working in the state. i would do it all the time if i didn't hate it so much.