night walker

one of my senior registrars once said that the night belongs to surgical registrars and prostitutes. we all had a good laugh. it didn't strike us as odd being compared to prostitutes at all. if anything in those days we often got the feeling we were being screwed over, however the remuneration wasn't as good. but there was another time the comparison was a bit odd.

on a certain sunny day i decided i should do my duty and donate blood. i felt it was not right that i complain when there is a shortage in the hospital if i am not at least trying to make a difference by donating myself. so off i went to the nearest blood bank with my phobia of needles and my sweaty palms, all trembling in fear to donate. the lady behind the desk took my details down and pricked my finger to make sure i was not anaemic. after that formality (which in itself did nothing but heighten my dread of sharp objects), she gave me a questionnaire that i was required to full out. i thanked her and moved off to a table to nurse my painful finger and full out the form.

the form was pretty much what one would expect. it asked if i was aware if i had had any blood born diseases that i knew about like hepatitis b or hiv etc. it touched on family histories and the usual medical things that may have an influence on whether one should donate blood or not. then it fired out a question that i though quite interesting.

"are you involved in any high risk professions like prostitution or surgery?" prostitution and surgery were sort of lumped in to the same question together. also they were both considered professions of, as far as i could tell, the same standing. there was a block to mark yes and a block to mark no. i marked yes.

i took my questionnaire to the lady behind the desk. she scanned all the answers until she came to the one i had marked yes. she froze. she then glanced up at me. actually i think she maybe looked me up and down. she then hurriedly disappeared into the back room. after a few hushed whispers she emerged with another lady and i was led away to a room with a sign above the door that proudly identified it as the counselling room. now where i come from, the word counselling is pretty much always what happens just before you get tested for hiv. i considered telling them that my last test was about a month ago and it was negative, but i was somewhat bewildered and still beset with fear for the large needle that i still expected would be sunk into my arm.

once we had settled down into comfortable seats in the counselling room the lady asked me what i had meant by answering yes to that particular question. i told her i was a surgical registrar and was therefore quite often engaged in high risk surgical activity. she then also looked me up and down and gave a sort of smirk. she clearly didn't believe me. i was obviously much too good looking to be a surgeon and better fitted the profile of one who sells his body for cash. then, without missing a beat she went on to talk about the dangers of hiv and all the ways you can get it (she meant by selling your body of course). i wasn't sure if i should point out that other than getting screwed by the system in the state hospital on a regular basis i was not a prostitute but rather a surgeon. but she hadn't believed me the first time and nothing had changed between then and now so i decided to just keep quiet. after all, maybe i was simply too good looking to be a surgeon after all.

suffice to say they did not want my tainted blood and i therefore never had to face the business end of their needle. i just wish they had only checked my blood for anaemia after the counselling session rather than before.

small beginnings

recently i caught up with an old friend. the day i started studying surgery he started in internal medicine. he is now a fancy prof. i was amazed and impressed. he really was, and i assume still is, a really great guy. yet even great people must start out small. i remember the first day we met.

i was on call in the surgical icu. i had been part of the surgery department for a full two days and was still unsure about pretty much everything. so when the internal people phoned asking if we had a bed available for one of their patients i called our prof even though there was one bed empty. the prof was a good man and told me we were obliged to help them even though the pressure on our beds was usually great. i phoned the internist on call and told him he could bring his patient.

some time later a patient was wheeled in. the first thing i noticed was that she was blue, a colour i have often said doesn't appeal to me. the next thing i noticed was that she was just barely breathing. being astute even though inexperienced, i concluded she was in the process of dying. at that moment the physician walked in and introduced himself to me. he had just started in internal medicine two days previously and was also pretty unsure of himself. after whizzing through the formalities of greeting, i pointed out to him that his patient wasn't breathing too well and that she needed intubation and ventilation soon. otherwise one could only hope her policies were all paid up. he looked at her. it was abundantly obvious i was right.

"yes, i see what you mean," he said after a moment's thought. "i'm just quickly going to call my consultant. i'll be right back." and with that, before i even had time to express surprise, he was gone. the sister and i looked at each other with bewilderment on our faces. it just seemed that intubating the patient was at that very moment more important than finding his consultant.

"well, we know what to do." i said, "get the patient into a room and let's intubate. without any further delay or looking around for wandering consultants we soon had the endotracheal tube in position and the patient connected to a ventilator. soon the blue hue was replaced by a more encouraging pink colour. not totally unlike the patient, we all breathed a sigh of relief.

after a short time, the internal registrar returned with consultant in tow. by that time the icu staff and i had settled down and were even making coffee. then i put the story together.

the registrar had been out of clinical medicine for a while doing some or other form of research. he was not confident enough to intubate the patient and just assumed that i also would not be. he therefore felt he needed to get his consultant there as fast as possible to place the tube. it was the best he knew to do at the time. unfortunately it would not have been good enough for the patient. i had to intervene. i was not the patient's best hope. i was the patient's only hope.

well, all's well that ends well.

catching up with the esteemed prof after so many years made me realise how even the mighty have humble beginnings.

smile

sometimes you feel the need to look around and try to find the hidden cameras. this was one such time.

i was in the boss' firm so on the whole it was a fairly tense time. at least we didn't have to deal with too much lip from the students. they were too scared of the boss to even step slightly out of line. even before the new groups arrived they would be informed by the previous groups about the many rigid idiosyncrasies of the boss and from day one they usually got most things right. in fact i was only aware of two students in the last eight years that the boss had asked to leave his ward rounds (i was one). and when this group of students arrived i expected nothing different.

i had done the early morning rounds and already the students seemed to be on the ball. we were waiting for the boss to go on academic rounds and were therefore all sitting around in front of the ward. then one of the students approached me.

she was a young attractive girl with flowing blond hair. as she got to me she dropped to one knee, threw her head back, pushed her more than adequate chest out and with a charming smile started to speak.

"hi there. i wonder if i could ask a favour of you?" i looked at her kneeling at my feet and couldn't find the words. " you see we are on call this weekend and i have tickets for a show on saturday night which i bought a number of months ago. i'd really like to go." again i couldn't find the words. part of me was thinking i can't believe that anyone would have the audacity to ask for a call off in the prof's firm. everyone knew that in the prof's firm there were no such concessions...ever. the next thought that went through my mind was to look for the hidden cameras. the situation was so bizarre that it had to be a smile, you're on candid camera moment. finally my mind kicked into gear.

when i told her there was no such thing as a call off in the boss' firm and that i was sure she could flog the tickets for something at least, her entire countenance changed in a split second. her chest dropped (a bit at least), her bright eyes turned to a scowl, her head fell forward causing her hair to fall across her face, hiding any hint of the smile that had previously animated it so. she then stood up and trundled off. just to be sure i looked around again for the cameras. i couldn't see them anywhere.

later i heard that the student in question made a habbit of flirting heavily with her male registrars and, probably mainly due to her abundant chest, could get away with pretty much anything. with me she never tried another thing.

p.s when she left the firm she wrote a scathing letter about me accusing me of unproffessional behaviour and even cruelty towards my patients. she said that i was an example of what a doctor should not be. she contrasted me with my medical officer whom she said was brilliant. what she didn't know is that he openly hated her and only my intervention prevented her from coming under his almost constant wrath. fortunately she also complained about another consultant's moustache and bowtie, so the boss didn't take her complaints too seriously.

cultural assimilation

south africa is a melting pot of many different cultures and language groups. in a state hospital it can occasionally happen that you have a patient that speaks a language from a different part of the country and no one can understand him. lucky was such a patient. interesting to note in south africa, the guy called lucky by his parents mostly turns out to be anything but what his name would suggest. i often wonder if lucky was very lucky or very unlucky. he was maybe both.

lucky was admitted with bleeding esophageal varices secondary to liver damage from bilharzia. he underwent emergency sclerotherapy and banding and was somehow alive afterwards. lucky. of course he ended up in icu where he received massive blood transfusions and was observed for further bleeding.

the guy working in icu that night had just started in the department and was in fact doing his first ever call. so when lucky started bleeding, the doctor was out of his depth. now for those of you who haven't seen it before bleeding from esophageal varices is immensely impressive and intimidating. it looks something like someone opening a tap full blast except instead of water there is a torrent of blood. junior doctors freak. senior doctors freak. patients sometimes fade away pretty rapidly.

so when the doctor phoned his consultant he learned a few new things. one was that to swear does help, if only just to dilute the panic in order to get the doctor's blood pressure up to levels that can maintain cerebral perfusion. he also learned what a sengstaken tube was. he also got a very rapid tutorial on how to put one in. trust me, when you've seen these things bleed you don't have time for a tutorial any more intricate than "just bang the thing in like a nasogastric tube and blow the stomach balloon up.".

the doctor banged the thing in like a nasogastric tube and blew the stomach balloon up. it stopped the bleeding. lucky. unfortunately because the stomach balloon was not in the stomach at the time of blowing it up but in the esophagus, the esophagus ruptured and spewed its contents into the chest cavity. unlucky.

when we heard about these events at the next m and m we all thought lucky's luck had run out. survival of bleeding esophageal varices is not so high. not many would survive a second bleed. mortality of a ruptured esophagus is particularly high. lump all these events together and he pretty much had no chance. but surgeons, being the never give up sorts, ripped his chest open anyway and tacked his tatty esophagus together. to prevent a leak and certain death they also diverted his saliva through a hole in the neck above the repair. then they stuck a pipe through the abdominal wall directly into his small bowel for feeding. most of us looked on sceptically.

but lucky survived, somehow. of course he spent a lot of time in icu with death hovering at the edge of his bed. in the end i think death got tired of waiting and left. then he started the long road to recovery. he still had to face a few operations to put all the pipes back together so that he could eat through his mouth again one day. but that was something for the future.

a few months later they took lucky back to theater and replaced his entire esophagus with a piece of large intestine. once again he would rely on tube feeding via a pipe going directly through his abdominal wall until everything healed up. postoperatively everything was going well. his registrar would stop at his bed every evening before going home and even come in whether he was on call or not for even the most mundane problems. he didn't trust his name.

then late one evening the feeding tube somehow was ripped out of his abdomen. the night sister called the house doctor on call who was new and didn't know the somewhat sensitive history of lucky. in an attempt to be proactive, she simply placed another tube through the hole in the abdominal wall left by the previous tube. unfortunately her somewhat vigorous attempts to get the tube in caused it to find a new path and end up free in the abdominal cavity. she then simply reconnected the feeding and went to bed. by the morning lucky was no longer feeling so lucky. the unlucky events of the night before had caused generalised soiling of the abdomen. a couple of hours of food being deposited into the abdominal cavity will do that.

i assisted in the operation to fix the mess. luckily his registrar found him the next morning in severe pain and actually going into shock. during that operation i thought quite a bit about old lucky. the first thing i considered was the definition of luck from a surgical point of view. to start with, if you end up with a surgeon then you are not lucky. if a surgeon tells you you were lucky, you weren't. it is simply surgical jargon for we all thought you were going to die and you surprised us all by beating the odds. i mean he was pretty unlucky to have all those things happen to him but i can only account for him surviving so many different things, each of which would kill a mere mortal, at least in part due to luck. maybe lucky was very lucky. maybe he was unlucky. maybe he was both.

but the next thing i considered was language and culture. you see lucky came from a very remote part of the country. he spoke a language which was pretty much not known in the big city. and lucky couldn't speak any one of the more common languages used by his care givers when he arrived with his bleeding varices. but by the time he was ready to be discharged once he had recovered from the last of a string of operations, he could speak afrikaans fluently. i suppose he had no choice but to learn. he definitely had plenty of time at his disposal. otherwise he wouldn't have had anyone to communicate with.

so, for those of you out there eager to learn afrikaans, may i suggest getting two esophageal variceal bleeds in quick succession followed by esophagus perforation followed by prolonged icu time followed by colon pull through followed by free leakage into abdomen followed by full laparotomy. if you survive, my experience tells me you will be fluent in afrikaans.

otherwise maybe buy a book. it might be safer.

spindoctors

i suppose politics of sorts pervades all aspects of life, medicine included. often the way you spin a story would either land you in it or get you out of it. sometimes the consultants didn't need to know the whole truth. variations on this theme often played themselves out. this is just one example.

the boy was only 15 years old. he had been admitted the previous night by a junior registrar. apparently he had developed abdominal pain after a rugby tackle during a school game. the x-ray hadn't been too spectacular and the junior registrar felt that his abdomen was tender enough to admit him but not tender enough to operate him. this essentially meant he was not willing to take the decision to operate or not himself and wanted to get the consultant's opinion the next morning. the consultant was an interesting eccentric man who tended to be a bit conservative in his approach to cutting people open. he could also be somewhat intimidating.

i met the patient for the first time on the morning rounds when the junior presented him to the consultant. i quickly examined him while they spoke immediately decided what i though. something was wrong, i felt and it was not the sort of something that was about to sort itself out all on its own. then the consultant examined him. the patient winced but tried to be brave. the consultant also made his decision.

"he probably just has a bit of bruising. he doesn't need to be operated. a rugby tackle can't cause too much damage" he pronounced. "bongi, you're on call tonight. i'm telling you now, you must not operate this patient. he'll be fine in the morning."

"yes sir." i replied, but i had plans. all sorts of things can happen once the sun has set. i knew i could spin it tomorrow, providing i ended up being right. however if i turned out to be wrong it would be a bit tricky.

when the day ended i took a walk past the parking lot to confirm the consultant's car was gone. i then booked the patient on the emergency list for a laparotomy. i remember my house doctor looking at me with an expression of shock and horror on his face. i smiled, but i remember thinking that i'd better be right. otherwise i'd be the one with shock and horror on my face the next morning (not to mention egg).

soon we were in theater and shortly thereafter the abdomen lay open before us. the intestines were floating around in a pool of bowel content and there was a neat little tear on a section of small bowel. already the peritoneum was looking pretty darn inflamed. the mood lightened. i even felt a joke or two may be in order.

"i'm right again. sometimes i get so tired of always being right." i mimicked the consultant's usual line. the house doctor shook with laughter. once he was able to assist again we finished the operation and closed up.

still there was the matter of telling the consultant the next morning that we had disobeyed his direct command. and here is where i knew i needed to put the right spin on it. he didn't need to know that i had never had any intention of obeying him. i had evaluated the patient and i was not comfortable to leave him through the night when i felt sure that he needed an urgent operation. in fact the junior that had admitted him displayed a total lack of the usual confidence associated with surgeons by not operating him the night before. i was not going to do the same. i was going to back myself and my own clinical acumen and that is why i operated. also i knew that if i had argued with the consultant on the ward rounds he would have entrenched himself in his opinion and there would be no way to spin the story the next morning. i had essentially lied to him and i knew it. he did not need to find out.

"bongi, how is that patient doing?"

"doctor, last night he suddenly got much worse. his pulse went up and his abdomen became much more tender.in fact he developed an acute abdomen so i felt obiged to operate." again the house doctor looked at me with horror. the consultant's fists clenched.

"what did you find?" i was home free. thank goodness i was right. if i had been wrong, this is where it would have all unravelled. i told him. and that was it. nothing more was said. i survived.

p.s. the patient also survived.