sand through your fingers

something that still gives the old adrenals a squeeze and a vicious kick is the opening of a blunt abdominal trauma patient with a severe internal bleed. but it is so much more than just an adrenaline rush.

the scene must be set. a patient arrives in casualties after having been involved in a massive accident. often there would be people who passed away at the scene who bypass casualties altogether on their way to the morgue. more often than not, some of these people are related to your patient, but that is something to deal with tomorrow. today's efforts need to be completely focused on getting your patient through his ordeal alive.

in casualties everything is a blur of activity. someone is tasked with getting lines up while someone else orders the bloods needed and someone else phones ahead to get theater ready. decisions need to be made about whether intubation is immediately necessary or if it can wait until theater. sometimes there is distraught family outside. they wait expectantly at the door hoping for good news. i make a point of speaking to them if i can before theater. yes, my job is primarily to get the patient through the other side alive, but in the end we are alive so we can live and part of life is love and family. they need to feel like they are at least involved, even if on a very small minor level. also they need to have an idea that things may not turn out well before the time.

on the way to theater, if the patient is not intubated or if we are not doing active cardiac massage, i often peel off to the change room and rejoin the activity as the anaesthetist receives the patient in the theater entrance area. i help with getting the patient onto the bed and then...well then i take a moment. it is a moment before the storm. it is a time when i try to prepare myself for the fight ahead. i also often think about the dissociation between the humanity and the biology of what is about to happen. it is always poignant for me to think that during the operation i will be totally focused on getting the life threatening problem fixed and i will have no place to reflect on the bigger picture. i won't have time to wonder what the person is like or what his hopes and dreams are or who is praying for him to pull through. yes, i won't be able to see him as human until it's all over.

once the gas monkey has everything ready we prepare to open the abdomen. there is a certain technique to doing this otherwise fairly routine action in these types of patients. everything is opened except the peritoneum which is left to last so there is at lease a bit of pressure still on the area of bleeding. then the peritoneum is opened and all hell breaks loose.

the peritoneum is opened from top to bottom in less than a second. masses of blood come pouring out in a wild torrent and abdominal swabs are shoved with little ceremony into the abdomen, starting in the upper quadrants and moving to the lower quadrants. this is a moment that can't be fully appreciated unless you have experienced it. there is shouting and a flurry of activity. any observer will be left with the clear impression that we are fighting for the patient's life. there can be no doubt.

once the swabs are all in and the worst of the blood has stopped flowing it is time to address the source. i usually pray it is the spleen because it can be removed and the problem is solved. the liver bleeders can be a lot more tricky. a massive tear of the liver can bleed copiously. it is relatively easy to control the blood supply to the liver but the venous drainage is a different beast. the liver drains via three veins directly into the inferior vena cava, the biggest baddest vein in the body. retrograde flow through a torn hepatic vein or worse an avulsion of the liver off the ivc itself may even be impossible to control.

with these sorts of injuries the amount of blood in the abdomen is so much when you push your hands into the abdomen to apply the swabs or to give direct pressure your entire arm disappears into the pool of blood way above the gloves. blood then runs down your arm on the inside of the gloves filling the gloves with blood and totally soaking your hand. your hand ends up inside a sort of latex balloon full of the life sustaining blood of your patient. at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate.

often at this stage of the fight, if the anaesthetist has managed to keep up his fluid and blood administration with the blood loss he may start hinting that things are looking dismal. he may, for instance hold up yet another pint of blood from the blood bank and casually remark

"would you like me to run this through the patient first or should i just pour it out directly onto the floor?" sometimes one has to stop and acknowledge the writing on the wall.

ironically as the awareness of the unvanquished foe sets in, the humanity of it all comes flooding back in torrents that rival the previous blood flow. suddenly you wonder about the patient as a person and how futile it all seems. suddenly you wonder about your own life and that it is dependant on this flimsy body working properly and may be so easily snuffed out. suddenly you think about the expectation the family has of you saving his life, even as that life flows out of the body beneath your bloody hands. the tension i feel then far exceeds any adrenal rush i get at the dramatic opening of the abdomen and during the valiant fight for a fellow human being's life.

sucker

as a registrar i made sure there was no one in my firm who worked harder than me. i would arrive early and leave late and would generally see everyone myself, not leaving it to the house doctor or students. that way when they complained about how hard you had to work in surgery i could justifiably tell them to suck it up and get on with the job. i say generally because there was one glaring and even shocking exception to this rule.

the vascular rotation was the busiest, bar none. there were two of us in the firm so we ended up on call every second night and the calls could get quite tough. one single vascular emergency could destroy your circadian rhythm. yet if there was only one we would boast about the three hours sleep we had managed to get. in that time we considered that more rest than we knew what to do with. the other problem was we had no house doctor so our days tended to get quite busy with all the administrative tasks that were needed to get things running smoothly. so after being there for a few months my enthusiasm for long hours had somewhat diminished.

then suddenly there was an extra house doctor in the department and in a moment of weakness the boss allocated him to vascular (he would often rather put two house doctors in his own firm than send one to vascular). we were ecstatic, especially after the first day when it became obvious the guy was not afraid of work and he also clearly knew what he was doing. we had been given a gem. on his second day on the job he asked us about how the calls worked and what his after hours duties would be. i was just about to tell him that his calls were going to be quite light because we handled pretty much everything, but my colleague spoke first.

"well, you are the only house doctor, so you'll have to handle all the stuff primarily and call us if there is a problem or if someone needs to go to theater." it was so clearly a joke i thought at any moment one of them was going to start laughing. then we would send him home to his new wife and we would continue to slave through the night. but they both nodded. the house doctor seemed to accept this as simply one of the hardships associated with where he had been allocated in surgery. it was my colleague's call that night so once the day's activities had ended i made my way home.

the next morning my colleague told me he had had a great call. the amazingly competent house doctor had handled everything and he had spent the night at home. i was intrigued. i wondered what it was like to spend a vascular call at home. i decided not to tell the house doctor yet that the story of him being on call every night was just ridiculous and let him do another call. the next day he would probably complain so much we would have to inform him that it was just a joke and then life would settle back into its usual rhythm.

my call was wonderful. unlike my colleague i did come out to operate, but all the other peripheral irritations were completely handled by the house doctor. the guy was good. and still he hadn't complained. i spent post call in theater and went home well after the sun had set. i didn't see the house doctor that day and just assumed he was also at home. yet the next morning i discovered he had done another call and once again my colleague had spent the night at home. i started wondering how much of this the house doctor could take. it was clear he was tough, but the question was how tough was he.

and so we sort of never really told him that it had been a bit of a joke and he just kept on working, day and night and night and day. i think we also fell into the luxury of not doing the hard yards during a call and we got used to it. also we knew he was only going to be with us for three weeks and then we would be alone again so i suppose we saw it as a rest in the eye of the storm before the reality of vascular returned in full force.

after nearly two weeks of being on call every single night the house doctor started to hint that he might need a break. they were just hints so we did what any normal male does with hints. we ignored them and hoped they would go away. they didn't. after another few nights he told us he needed to speak to us about the call situation. by this time he was looking a bit worse for wear. who could blame him? he had done a solid two weeks of call on the trot and that in vascular. that was enough to break most people, but he seemed to be at least partially alive still. we agreed to discuss it.

the house doctor explained that he had done more than his fair share and had in fact done much more than the other house doctors in surgery who were doing about one call a week. he went on to say that it wasn't that he was lazy but he just needed a break. he also told us that he was fairly recently married and although his wife was understanding there was only so much a young wife could take of this sort of lifestyle. he told us that he needed to give some attention to his marriage too and couldn't just work constantly. we knew he had a point. he had proven himself beyond our wildest expectations and he did need a break. also secretly we knew that we had expected him to do far more than what was actually required of him. he was well within his rights. we had to relent.

we gave him one night off and told him to be back at work the next day, ready for another weeks call.

albatross

when i was a child we used to hear stories of old people from primitive cultures that could wish themselves dead. they could just decide to die and they would. it was disturbingly fascinating for a young impressionable boy. but as i grew older and studied medicine i realised they were no more than simple stories. or were they?

i was a lowly medical officer joining the boss' firm for the first time. i luckily learned the registrar was a great guy and i therefore could use him as a sort of shield against the usual onslaught of the boss. when i joined there was a patient who had undergone a gastrectomy the previous day for a benign condition. it fell to me and my registrar to get her back to full health. it soon dawned on me this would not be easy.

the patient was 60 something and well fed, possibly too well fed. mobilization was difficult, but that wasn't the main problem. she was of a culture where a certain amount of self pity was the norm and where showing suffering elicited great sympathy from family members. so when we insisted she start moving soon after the operation, she was not interested. what's more, her family encouraged her to just lie in bed like a lump of clay. they felt we were downright cruel to expect such things as getting out of bed of her. but i became truly worried one day when she called my registrar and myself over to tell us something in confidence.

"i want to die. help me kill myself." she said with a pan face. we were shocked. we explained that she actually had a lot of life left in her and her condition was not terminal. with a bit of effort we expected a full recovery. but a full recovery was one thing she was not willing to give us. and eternal rest was one thing we were not willing to give her. every day we would get her out of bed and walk with her and every day she would walk a few steps with a fair amount of ease and then collapse in a heap on the floor. we would then wrestle her back into bed and muster our energy for the next day's ritual. the family complained incessantly about everything we did. they wanted her to stay in bed and wait until one day when she would just be better.

after a while her son flew in from america where he lived. he came armed with dollars and instantly decided our care was not good enough. almost immediately they had moved her to a private step down facility where she was to be pampered back to health. truth be told, we were relieved. it wasn't as if we didn't have other things to do to keep our days busy and we were quite willing to give up our daily walks and wrestling matches with this patient.

about two weeks later we got a call from a local private hospital. they told us that at the step down facility the lady had adopted a very passive stance on the matter of her recovery and not moved a muscle. she had then one day apparently stopped breathing. she was intubated and shuffled off to the local private hospital where she was bundled into an icu bed where even american dollars wouldn't last too long. when the son with the american dollars realised he had no more american dollars, they phoned us at the state hospital to take over. what could we do? i turned to my registrar.

"you realise she will absolutely refuse to recover. she will be an albatross around your neck until she dies and she is going to die. she wills it so." he tried to smile but it came out as a sort of accepting expression of suffering. we took her back but her condition had worsened. other than the endotracheal tube and the ventilator, she returned with a nice hefty bedsore on her sacrum. but we were not the types to give up too easily and we immediately got to work.

everyone was surprised when we actually managed to get her off the ventilator in less than a week. a few days later we had her back in the ward and a few days after this we even commenced our daily excursions with her. during this time once again she asked us to kill her. she assured us she wouldn't tell anyone if we did. somehow that seemed self explanatory to me but i decided not to point it out. anyway we refused, once again saying that she was not terminal and with a bit of hard work should recover completely. she wasn't happy with us telling her what to do, even if what we were saying was that she should recover. apparently, she assured us, her family were much more sympathetic. they didn't force her out of bed daily for example. we tried to look more understanding from then on when we forced her out of bed. i think it worked to an extent because just before i was rotated out of the firm and to the other hospital, we actually discharged her back to her understanding family. i was delighted, but my senior was less so. you see, he was staying on in that firm and he knew she was going to do what albatrosses do. she was going to bounce right back to him. i pretended to care but it was his albatross and not mine. i was just too delighted to finally get away from a situation that i knew would turn out badly.

and so life went on as it tends to do. i settled into my new firm and soon even forgot about the albatross. i couldn't for long though. quite soon my previous registrar phoned me. he said only one thing but the pain in his voice said so much more.

"the albatross is back." i expressed dismay and even tried to sound surprised, but it just came out as insincere, which is exactly what it was. i considered asking a bit about her condition but somehow it seemed it would rub salt into his wounds. i even considered making a light hearted joke about him granting her her wish and helping her over the threshold into the hereafter. i was just afraid he might take me seriously, so i said nothing.

not too long after that phone call i got a message on my phone.

"the albatross has flown". she was dead. she had finally managed to bypass all our attempts to get her back on her feet and despite everything we had done, against overwhelming odds, she had wished herself into the grave. in a way i was even quite impressed with her.

since then i too have had an albatross or two. i suppose it goes with the job.

flame thrower

it's funny where one sometimes finds useful pieces of information. i mean the story of the flame thrower i think was maybe told with a slight embellishment, and yet i have found it useful quite a few times.

in the old days us registrars quite often were left in deep water. it was the theory of survival of the fittest being put to the test. and it also worked on the registrars. the less fit didn't make it.

one of my friends opened up an abdomen late in the afternoon that was the sort of abdomen you actually should open early in the morning. you see after four it was pretty difficult to get a consultant back onto the hospital premises at kalafong. quite soon he realised he was in trouble. the patient had a massive inflamed brittle friable kidney on the one side that looked like it needed to be removed. yet every time he poked it it would bristle in rage and threaten to bleed. he simply didn't know what to do. he called his consultant whose name appeared on the call list. the consultant told him there was no way he was coming back and wished him the best for the rest of his call. they then phoned the consultant of the other firm who wasn't on call. this man started out in a bad mood on any given day but was also not the type to leave someone who didn't need leaving. after the obligatory frothing at the mouth he said he would come in and help.

while my friend waited he tried a few more times to tease the kidney out but when the anaesthetist started making noises about the fact that the swabs were becoming redder seemed to somehow coincide with the fact that the patient was becoming more unstable he decided to just compress and wait.

the consultant arrived, his eyes glazed over with anger. as he entered the theater everyone went silent. the urgent bleeping of the pulse oximeter suddenly sounded deafening in comparison to the sound of all the held breaths of all the people in theater. he walked up to the patient and glanced at the kidney with disdain. even the kidney went silent. it seemed to know better than to mess with this man. then without a word he walked off to the scrub room. there was an almost audible sound of everyone exhaling together.

moments later the consultant once again approached the table. the registrar gave way as he started explaining his dilemma. the consultant mumbled something, either to himself or maybe a warning to the delinquent kidney. he then reached into the abdomen and with one smooth motion ripped the kidney out. he then turned to the floor nurse and spoke for the first time.

"set the cautery to flame thrower!" with that he systematically controlled the more than liberal ooze from where the kidney had been. it was the sort of thing you could laugh about afterwards. at the time no one was so foolish.

many years later i discovered that the flame thrower setting was actually quite useful in liver and even spleen oozes when nothing else helped. and, yes, each time i would turn to the floor nurse and with the driest voice possible would bellow,

"set the cautery to flame thrower!"