Monday, January 18, 2010
in the dead of night
after having spoken about when you seem to know more than your consultant, i was reminded of another incident from my internship year where a colleague of mine taught me that sometimes it is best to do certain things under cover of darkness.
the patient (a sangoma) turned up at the surgery clinic one day. my colleague asked her what the problem was. without uttering a word she lifted up her shirt to expose her breasts. the left one had a massive tumour that had fungated through the skin probably some time ago. there was a large stinking cauliflower-like mass with central ulceration that caused a fist sized cavity right up to the chest wall. the smell was also remarkable. we couldn't help asking why the patient hadn't sought help earlier, especially seeing that she was supposed to be a so called traditional healer. i mean you didn't have to be a rocket scientist to know that that stinking monstrosity growing right through the chest was not supposed to be there. she simply said that it hadn't been painful, but now she had a cough.
my colleague knew what to do. she would refer the patient to the academic center in bloemfontein in the morning, probably for palliative radiotherapy. to make sure everything was up to date, she took a chest x-ray. it was so impressive she showed it to me. the breast cancer had grown right through the chest wall and had infiltrated the lung below. that is what caused the cough. it was a truly amazing case of neglected breast cancer.
then the cuban surgeon strolled in. this was the sort of thing you just didn't see in cuba. their health system is just too good for something like this to slip through. i suspect they don't have the sangoma problem we are burdened with so on the whole there will be less late stage sicknesses presenting. he was clearly astounded. then he said something that confused both my colleague and myself.
"put her on tomorrow morning's list for me to do a debridement." we looked at him in amazement. my colleague whipped out the x-ray, assuming that after seeing it no sane person would want to put a knife to that thing. i mean where would you stop cutting? in the lung? he looked at the x-ray casually but said nothing.
"you still want me to put her on your list tomorrow?" asked my colleague with more than just a hint of sarcasm in her voice.
"yes." we glanced at each other. maybe there was something we were missing. my colleague entered into a lively debate with him about the rationality of what he was demanding. anyway it was not my patient and i had other things to do so i left as the level of their discussion escalated. i did not envy her position in that she was being asked to do something she knew was not a good idea by any stretch of the imagination.
the next morning i ran into my colleague. she had a broad smile on her face and a somewhat mischievous glint in her eye. obviously the resolution of the matter had been to her liking.
"so," i asked, "did he finally see the light and drop his mad idea?"
"no." she said. the smile didn't falter.
"then what happened?"
"well i was on call last night. so as soon as the sun set and our illustrious consultant went home i bundled the patient into an ambulance and sent her off to the academic hospital. when he got to work this morning the patient was gone. there was nothing he could do." the smile took on an almost sinister look. i was impressed.
years later i employed a similar strategy, but maybe that is better left for another post?