waterworks

when i rotated through urology it was great! every day all the urologists would get together in their scope theater and pretty much chat while one of them did scopes. it was friendly and festive and extremely relaxed. and not surprisingly, they were a very close knit group. but after about a week i started getting bored. but the seed was planted. still these days when i am between cases i often pop into the urologist's scope theater to see what new instrument he has to seek and destroy kidney stones. i jokingly say i'm there to learn how to do urology and they jokingly say they are thinking of including me on their call roster. only thing is that is not always a joke. they often leave town and do ask me to do their calls for them.


in a sense it is not too much of a stretch. kidney stones can be treated conservatively until the morning and most of the rest of the really urgent stuff we can pretty much do. in the old days a lot of urologists were very allergic to the night air and even the thought of having to come out once the sun had set would bring on a paralysis that could only be cured with a good night's rest. a good reflection of this is that by the time i had finished specialising i had taken out more traumatized kidneys than pretty much all of the urologists.


the way it used to work was that i would take a patient to theater with, say, gunshot abdomen where the bullet went through the kidney too. before theater i would phone the urologist. he would ask me to phone him if i had problems. i just interpreted that as i was not required to phone him. i mean what problems exactly was he referring to? then i would remove the kidney if necessary and leave it if possible. the most difficult part was explaining to the prof the next morning why there wasn't a urologist present in theater with me. the prof seemed blissfully unaware how dangerous to their health it was for urologists to come out at night. but i knew how to spin it to the prof and there were never any problems.



"well prof we were going to call him but the bleeding was a bit too much and there was no time to wait so i went ahead and removed the kidney myself." or some such line would suffice. secretly the prof was proud of us that we could handle it without the help of the urologists.



recently i had a bit of nostalgia. the bullet had shattered segment two of the liver, ripped the pancreas tail apart, ruptured the spleen and drilled a hole through the kidney. i would be busy for some time. but just to be polite i phoned our friendly neighbourhood urologist to inform him what i had. he told me to call him if i had problems. i smiled quietly to myself and put the phone down.



it was an exciting operation, what with a partial hepatectomy, a distal pancreatectomy and a splenectomy not to mention a diaphragm repair so the kidney had to wait its turn. anyway from the ct scan i knew it was unlikely that i would be removing it. while i was busy doing all the things i needed to do the urologist phoned and asked the gas monkey if i would be calling him. apparently he had poured himself a glass of wine (which was maybe the new treatment for the weakness that came over them after the sun set) and wanted to know if he could drink it or just look at it. the anaesthetist reassured him that he could take a sip or two and put the phone down.



the kidney was hit fairly laterally and in the end all i did was to close the fassia, its protective layer, and leave it. soon afterwards the abdomen was closed. then i got the idea to mess with the urologist a bit. i decided i'd phone him and ask him to come out. but i knew i had to word it correctly. if i said i needed to remove the kidney he would simply tell me to remove it then. if i told him that the kidney was ok he would thank me and take another sip of wine. i had to come up with something else.

"it's a borderline case," i lied. "it's oozing blood a bit more than i am comfortable with but i need your expert opinion to decide if it will be ok or if i need to remove it." the silence on the other end of the line spoke volumes. i could hear him thinking how he could give me his expert opinion over the phone and thereby not risking the cold night air. i could also hear him trying to evaluate just how much wine he had already had and if it was too much that he would not be able to operate or too little that coming out at night might be bad for him. i struggled not to laugh, but at least my broad smile could not be transmitted through the telephone lines. he started asking vague questions as to just how much it was oozing and how stable the patient was. i kept my answers equally vague. slowly i could hear the change in his voice as the resignation that he would actually have to come out set in. the anaesthetist, who was laughing openly couldn't take it any more.

"bongi, stop! put him out of his misery and help me push the patient to recovery." i laughed and informed the hapless waterworks doctor that all was well and he could go back to his wine. i advised another glass may be in order to steady his adrenal glands which i suspected had spasmed. his reaction was priceless. he wanted to say something sharp, but just couldn't formulate the words. finally he tried.

"jou...jou...jou...bongi, fok jou!!!"*

ah gunshot abdomens can be such fun.


*you...you...you...bongi, f#@k you!!!

Blasé

i suppose reading my previous post that one can possibly get the idea that i am a bit blasé about gunshot wounds. i hope not, but sometimes i think i may be.

i was doing a casualty session in a private hospital far from my usual stomping grounds. it was one of the ways that i used to get a bit of extra money to buy luxuries like bread and butter. truth be told i hated most of it. i mean at heart i am a surgeon and not a colds and flu doctor, which is what most of the casualty work is comprised of. it was usually frustrating but i needed the money and i couldn't sell my soul. it already belonged to the professor.

on this particular day we got a call from the state ambulance service. they informed us that they had a gunshot patient in tow and they wanted to stop at our unit so that we could stabilise him before they took him onwards to the state hospital for definitive management. they basically said that he was not going to survive the drive to the state hospital and they were rushing to the nearest facility (us) so that we could quickly save his life. it all sounded a bit dramatic but at least it wasn't another runny nose. i just couldn't help wondering what we were required to do if the patient needed to go to theater immediately which, according to the story we were getting, sounded likely. we all lined up at the ambulance bay with our gloves on and waited in true grey's anatomy style.

the ambulance came blaring in and skidded to a dramatic stop. the driver also obviously watched grey's anatomy. they jumped out and soon had the patient in the resus bay. i got the history from the paramedic as i did a primary survey of the wounds.

the single gunshot wound was more a chest wound on the left hand side, but due to the tenderness of his abdomen i concluded the bullet had spent at least some time in the abdomen before exiting through the back. the patient was stable and didn't seem to be anaemic at all (he hadn't bled too much). all things considered he seemed quite well actually. (well for someone that had been shot that is. i mean i felt better than him even if i was forced to do casualty locums.) but he did have a pneumothorax clinically so he did at least need an intercostal drain. he would also need a nasogastric tube because there was a chance the stomach had been hit.

moments later i had the intercostal drain inserted and swinging comfortingly. i then threw a nasogastric tube in quickly without too much ceremony. the patient seemed to breath with slightly less difficulty. i looked at the paramedics with a glint of pride in my eyes. i doubted they had ever seen such a fast and slick insertion of an intercostal drain and nasogastric tube. they stood against the wall with their arms folded staring at me blankly. tough crowd, i thought. it seemed they expected me to do something more before they were willing to take the patient back. i wondered what i should do. he already had two good intravenous lines up and i had inserted the intercostal drain and placed the nasogastric tube. as far as i was concerned he was ready to go but they didn't seem to think so. i tried for an encore.

"sister bring me a set for a central venous line please." if they wanted to see me in action then who was i to deny them that? soon the line was in. i stood smiling at them. they stood nonchalantly looking back at me. i felt a bit irritated. didn't they know us surgeons had very fragile egos and that they were supposed to make some comment about how good i was if they weren't going to outright cheer in unbridled delight at the privilege of seeing me at work. i needed to get rid of them.

"ok, there he is. sorted and stable." i neglected to mention that he was essentially stable when they brought him in. "you can take him to the state hospital now." they left.

the rest of the night went as a session in a private casualty unit goes. the colds and flus were interspersed with an ear ache here and there and the occasional baby that didn't want to let his parents sleep. finally i got to lie down a bit at about 1o'clock in the morning.

i had just dozed off when the phone rang. it was the sister. she informed me that there was someone on the phone from the trauma unit of the university hospital of that city. (i mentioned that i did these locums far from home). i remember being amazed they had a trauma unit. we just handled whatever came our way when we were on call, trauma or otherwise. but still i wondered what they wanted to speak to me about.

"is that the casualty officer?" asked the voice with a typical jo'burg accent.

"yes." i ventured tentatively.

"did you handle a gunshot wound earlier tonight before he was transferred to us?" oh sh!t i thought. i must have missed something and the guy died. now they are going to nail me to the wall. other than the slight problem of being responsible for a death if something came of this and my professor discovered i did locum work there was a good chance that i would lose my post in surgery and my career would be over before it began. i felt my sympathetic system kick into gear. i was instantly fully awake.

"yes." i said in almost a whisper, my mouth suddenly bone dry.

"well i'm the surgical registrar in trauma and my consultant has instructed me to phone you immediately." i wanted to express surprise that there was a consultant on the floor with him at 2 o'clock in the morning. i wanted to say something like these english universities are soft or something equally tongue in cheek, but my tongue just stuck to the roof of my mouth and didn't seem to be able to find it's way to my cheek. waves of terror were now washing over me. if i had screwed up enough that a consultant was involved i really must have screwed up badly. maybe i was going to get struck from the roll and i would have to pursue a career as a street sweeper. (i would need to find a job that i used my hands with. street sweeping seemed like a good option)

"uugh." i tried to say something but only dry guttural sounds came out of my mouth.

"yes my consultant and i received the patient here. he said i must phone you to tell you what an excellent resus you did. it's seldom we get patients in such optimal condition." my sympathetic system easily transitioned from flight to fight in one split second. bastard!!! i thought. didn't he know what the time was? didn't he have a bloody watch?!! didn't he know that i didn't need compliments from registrars at his university, especially not at 2 bloody o'clock in the bloody morning? finally my tongue came loose from the roof of my mouth.

"thank you." it was all i could manage.

experience

different places deliver different opportunities for experience. it is just a fact. a surgeon working in hollywood is going to see a different spectrum of patients than what one in, say, delhi would. it doesn't mean one is better than the other but it does mean one would feel more at home treating certain conditions than the other. therefore when the belgians rotated with us it stood to reason that they would feel a little unsure on their feet in our environment, initially at least.

when i started in surgery there was already a belgian there. our department had an arrangement with a university in belgium which meant there was at least one belgian registrar with us for one whole year at a time. each year the belgian would go back and another would come to our shores to replace him. so i got to know quite a few belgians in my time. chatting to them i realised the vast difference between the approach to training in their country and in our humble department.

when i first joined the department, in an effort to make small talk i engaged the belgian. i didn't really know what to talk about so i decided to ask him about the differences in the sorts of things they saw there and the sorts of things we saw in south africa. i started with things that were common to us.

"so have you ever seen a gunshot wound in belgium?" i asked.

"of course! i saw one that went in the thigh anterior midline and exited on the lateral aspect just before i came out to south africa." i decided to rather ask him about the weather. it would bore me less.

a year later when the new belgian had joined us i decided to strike up a conversation so that he at least felt there was someone he could speak to in this new strange country. at that stage we were so consumed by surgery there was little else we were capable of talking about.

"so have you ever seen a gunshot wound in belgium?"

"of course! about a year ago there was one that went in the thigh anterior midline and exited on the lateral aspect."

"and what's the weather like there?"

my third year there when the third belgian came out i decided to test what was becoming a theory of mine.

"have you ever seen a gunshot wound in belgium?"

"of course!"

"let me guess. it went in the thigh anterior midline and exited on the lateral aspect?" he assured me the weather in belgium could be quite pleasant in the summer.

so the first three belgians had seen the exact same gunshot case. gunshots were so rare in their hospital that when one came in the entire surgery department was called to casualties to see it. i was amazed. they also didn't quite have the same sink or swim way of training that we had. they pretty much didn't operate at all without a consultant being present. in our way of thinking it was madness, but in reality it was just a different road to the same destination.

so imagine the culture shock when one particular belgian registrar started in our department. he was shuffled off to kalafong and put on call alone his very first night. now as i have mentioned before, getting a consultant out to kalafong at night was only fractionally easier than turning lead into gold. the senior south african registrars informed him of this fact and availed themselves to be called if he needed advice. they quickly added that they would help him telephonically but they would not actually come in. he would have to sort everything out on his lonesome.

the next day he was a wreak. he was talking about packing it all up and going back to belgium (where the weather was pleasant in the summer). to his credit he stayed.

you see, that night, not only did he see his first gunshot abdomen, but he was required to operate it. after that he did his second one and after that his third. on his very first night on call in this glorious country of ours this poor first worlder really got a taste of what it can be like. i really felt for him. but then again at least we no longer had to discuss the weather.

coin a phrase

recently i went to germany for a laparoscopic course. it was great fun. among other things i saw snow for the first time. this caused me to spend the night at hamburg airport after being snowed in with a few south african colleagues and drinking whisky mixed with freshly fallen snow out of paper cups. then we caught a train to frankfurt to fly back to sunny south africa. it was great!!! but there was another story which i got a chuckle out of. us south africans are truly a unique brand.

after a long day listening to a german professor who was totally devoid of a sense of humour (and we did try to elicit one) we all decided to go out for a bit of enteral feeding (and drinking of course). we found a quaint little place under a building somewhere which was at least warm (did i mention germany was the coldest place i have ever been!!). also they had german beer which they served directly out of a wooden barrel. it was the only time i have seen a german barrel of laughs actually. so we were essentially in what we viewed as heaven and as the barrels came rolling out full and quickly returned empty our already festive mood just got better.

quite some time into the night when we were all feeling pretty good, a lady came around in what i assume was some sort of german traditional dress selling a new brand of shooter that she was promoting. she quickly ascertained that we couldn't speak german when we replied to her overly friendly supplications with blank stares (we were all conversing in afrikaans) but seemed relieved to discover that we were all pretty fluent in english, as was she. she sang her song again.

"i'm promoting this new shooter which blah... blah... blah..."

"how much?" asked my one colleague.

"two euro" she replied with a plastic smile.

"i'll give you five rand." now two euro, when exchanged for south african currency, translates into about twenty rand, so, five rand was clearly not going to be enough. we wondered if this artificial german barmaid would have any idea what a rand was and where it came from. we were surprised.

"no! five rand is not enough." she replied with what we were learning was a standard german sense of humour. "you may all be surprised to hear this but i have actually been to south africa and i know what five rand is worth. so do you want one or not?" she said sternly.

"sure. i'll take one." said my friend. he took a shooter off her tray and threw it back. he then handed her a coin. she seemed to be interested to hear what he thought of it. i think she was actually hoping to sell a few more shooters to a group that clearly at least didn't have a moral objection to the occasional drink. we all watched for a verdict. finally one of us asked (in afrikaans of course) what he thought of it.

"nie te kak nie. maar dink net hoe verbaas gaan sy wees as sy agterkom ek het wel vir haar 'n vyf rand stuk gegee.*" we all fell about laughing uncontrollably. she stood there with a quizzical look, oblivious to our joke, which, with the effects of the social lubricant, in our minds, made it all the more hilarious. were essentially lost to her. she turned and left with she sounds of our mirth no doubt driving her away.



as i discovered later when looking at the two coins, they were similar enough in design that in a dark german bar and if you were feeling particularly annoyed by a bunch of foreign slightly tipsy surgeons it would be quite easy to mistake one for the other.


* not too bad but just imagine how surprised she is going to be when she discovers i did in fact give her a five rand coin.

knot a good story

probably my favourite operation is a laparoscopic nissen fundoplication. it is a mixture of intricate dissection and technical skills. and probably my favourite part of a nissen is the laparoscopic knot tying. it's just fun and i am usually quite good at it. yet recently while i was doing a particularly difficult nissen with a massive hernia, when i got to about the sixth knot, somehow i just couldn't seem to throw a laparoscopic knot anymore. it gave the assistants a bit of a laugh and a window to tease me a bit. i too had a good laugh, took a moment, and the problem was gone. the rest of the operation was no problem. but i couldn't help reminiscing about another knot tying incident from the old days.

surgeons generally tie knots with only one hand, their left hand. it is a fairly easy skill to learn and yet it is poorly taught. i remember when some registrar tried to teach it to me when i was still a medical student. he sort of took my hands and positioned the fingers as if they were made of wire and would just bend into any position he chose. he then started twisting the fingers into ever increasingly strange contortions as he shouted:-
"now you do this and then you do this and then you do this!" interspersed with "not like that, idiot!" each time my hands didn't immediately fall into the position he demanded them to be in. when i finally got it right by sheer chance i wasn't entirely sure of the correct sequence of d0-this-es to be able to repeat it.

so when i became a registrar in surgery and i was required to teach students how to do the elusive surgical knot i sat down and formulated a way of explaining the steps using words other than 'do this' and 'do that' and without grabbing their hands and forcing their fingers into strange contortions. i then simplified the steps so that even if the student's hands forgot how to do the knot, when they went home they would be able to go through the steps again and reteach themselves to do it. and i had great success. even the most ten-thumbed students could sort of throw a knot after going through my steps.

then one fine day swimmer's chest and i were doing a laparotomy together and i decided to show my good friend, swimmers chest, my surefire way of teaching the knot. of course it wouldn't count if i simply tied with my trusty left hand so i decided to use my right hand for the demonstration. i set up for the knot, explaining the steps. but just as i was about to throw the first knot, the boss walked in to check how things were going. my wrong hand (the right hand) was set up to do the knot so i thought i'd better just get on with it. yet with the boss breathing down my neck and the initial point to tying the knot with my right hand being gone, i somehow floundered. the boss was (k)not one to let such an opportunity slip by. he immediately knotted onto the fact that i was struggling. he leaned in and focused his entire attention on my hands. i needed to get his attention off me. i asked the sister for a needle holder so i could tie with an instrument rather than with my hands. the boss was quick to respond.

"no no no no no bongi. use your hands." i grabbed the suture, but by this time the hands were shaking. i went back to my trusty left hand but as i set up everything just fell apart. the boss' eyes seemed to burn holes into my finders and it felt like so many years ago when the registrar twisted my fingers to their heart's content. swimmer's chest looked at me in amazement. he leaned across and laughingly asked,

"bongi, what's wrong with your hands? why have they gone all stupid?"

"swimmer's chest, here is the suture. i seem to not be on form today. you do the rest." but the boss would have none of it

"no! bongi will continue and throw the knots until the operation is finished."

and so i struggled through the last few sutures that needed to be thrown with the boss' disapproving glare and swimmer's chest trying not hard enough not to laugh.

still to this day when swimmer's chest and i get together he rags me about the day my hands suddenly became dumb and i forgot how to tie knots.