pink and purple

recently i discovered the blog of a good friend. only problem is that he is a pathologist. i understand nothing of it, just like in the old days.

in the old days when i was still a registrar we had a joint meeting with the pathologists once every three months. if you ask me it was way too much. you see surgeons and pathologists are poles apart. for one thing, they are quite clever. for another their patients are all stable so there is never any urgency with them. i've heard they have to deal with bleeding a lot less too. but i suppose the clever bit got to me the most.

the way the meeting went was based on patient presentations. we would get a list of the cases they wanted to discuss. the surgeon involved in the case would then be required to present the case in front of everyone. he would talk about the clinical presentation, the findings an then the operation. it would usually end in a description of some or other thing that was cut out and sent to the pathologists. we would then hand over to them. i remember how their eyes would light up when we got to the bit about the thing we'd cut out. you see when they were handed the whatever it was we had removed or excised they got to work turning it into shades of pink and purple.

no matter what it was we presented them with, they would cut it into fine strips, put it on slides, colour it different shades of pink and purple and get very excited. at these meetings they would show us these slides. the thrill of it could often be detected in their voices as they spoke and could always be seen on their faces. they would wax lyrical as they increased the magnification, showing us the pink and purple ever closer. we would look, probably with visible expressions of increasing bewilderment with each new magnification, and nod knowingly. it probably didn't fool them. but the thing that irritated me the most was their standard opening line before they interpreted these pink and purple patterns to the room full of either excited or bewildered nodding faces. they always said the same thing. i think they might have been taunting us.

"as you can see..."

abroad

i'm of the opinion south africans have a good sense of humour in general. you have to be able to laugh at the absurd with a government like ours. and yet i do think we need to be a bit cautious about how we express that sense of humour while in the presence on non south africans. in general when you are working overseas in a foreign culture, you might want to be careful in the expression of your sense of humour.

like many south african doctors he had gone overseas to make a bit of money faster than it is possible on our shores. soon he was raking in money presiding over the sleeping while foreign surgeons plied their trade. yes, he was an anaesthetist.

now quite often the relationship between anaesthetists and surgeons can be strained. i can only assume it is worse when a language and cultural barrier are added. then there is the question of being in unfamiliar surroundings where more likely than not, things are done differently to what you are used to. it is probably best to keep a low profile and to not stand on anyone's toes. this anaesthetist did not believe on standing on toes. he went straight for stomping on their feet.

it was a neurosurgery case. the anaesthetist was of the opinion it was a non-starter and i suppose that's where it all began. there was tension between the neurosurgeon and the gas monkey right from the word go. but what could the south african giver of gas do? he had to dope the patient.

the operation got underway. quite soon the anaesthetist realized it wasn't going well. he couldn't understand a word of what the neurosurgeon, his assistant and the sister were discussing, so it wasn't really something that was said that cottoned him onto the fact that things were heading south. it was more the amount of brain tissue the neurosurgeon was suctioning out of the patient's skull that the gas monkey viewed as suboptimal. and as the operation progressed he passed through being perturbed and went right on to being amazed. it seemed there was no end to the stream of brain tissue that made its way through the suction tubing into the suction container.

after a while, once the anaesthetist was sure all the maths and science had been suctioned out, he took a more philosophical approach. it seemed to him there was little he could do to make the situation any worse so he just sat back and waited for the suction crazed surgeon to stop. and finally the surgeon did stop. he then got to the work of closing up, which in neurosurgery takes quite a while in itself. then he turned to the anaesthetist and for the first time spoke in a language he could understand.

"ok, you can wake the patient up now." the anaesthetist initially thought he must be joking, but there was nothing but an earnest expression on his face. he stared at the neurosurgeon in disbelief. the neurosurgeon stared back. "i said you can wake him up now!"

the anaesthetist shrugged his shoulders, strolled over to the suction container where it stood on the floor with its grizzly content. he then crouched down and started knocking on the side of the container.

"sir, you can wake up now!" he shouted.

thyroid fun

the way i do thyroidectomies (removal of thyroid) these days and the way i did them in my training differ radically. these days i use a fancy instrument that cuts and seals the vessels simultaneously. it also can cut through the thyroid tissue with little to no bleeding. during my training we simply didn't have these sorts of fangled tools. we had to painstakingly deal with each minute vessel individually, tying them off one at a time. also when it came to cutting through the thyroid tissue it could get a bit bloody. we would put clamps directly onto the thyroid itself and cut above the clamps. then we would quickly suture the cut surface closed before there was too much blood loss. it could be exciting. it was once a scream.

i was a lowly medical officer but i was working with the best registrar in the department. but on this particular day he was quiet and pensive. he just didn't seem to be himself.

"what's eating you?" i asked. he looked up at me.

"the thyroidectomy on the list this morning. the patient has graves disease. these days you're not supposed to operate graves disease but the prof doesn't like all these new fangled radiotherapy treatments and has instructed me to operate the patient." it didn't seem such a problem to me. if the prof had decreed it so then it was so and there was nothing to do but to operate the patient. he continued.

"only thing is there is a very good reason we don't operate graves disease anymore. you see they bleed like stuck pigs. a graves thyroid is super vascular and brittle. it is difficult and a bit risky to operate. i'm not sure i can do it. also you know the prof is actually semi-retired and he won't scrub in with me. anyway he won't be much help. his hands are no longer steady." i could see his point. still he had no option. he would have to simply put his head down and do it.

we exposed the thyroid nicely. it was massive. it sat there in the neck definantly throbbing, daring us to challenge it. what it didn't realise was that although it was very intimidating it was not nearly as intimidating as the prof. we went ahead.

as the registrar placed the clamps onto the thyroid i could see his hands shaking visbly. it seemed ironic that hands that were not steady was the reason given that the prof could no longer operate. maybe my registrar was doomed to have a very short career. i didn't share these thoughts with him. i thought it better to just be supportive and encourage him. by the time the clamps were in position the monster was already oozing quite a bit. now it was time to cut it.

it's difficult to fully explain what it looks like when you slice through a thyroid afflicted with graves disease. the effect it had on my registrar and myself was also profound. as the blade slid through the tissue blood just started pouring out in multiple streams of differing intensities. it was quite an impressive display. by this time my hands were shaking too. this was going to be difficult. as the knife finished its course through the now angry thyroid and the registrar lifted the offending tissue free of the patient we suddenly heard a voice behind us.

"hello. how are things going?" it was the prof who had quickly come in to check on us. my registrar spun around, grabbed a swab and shoved it onto the bleeding thyroid tissue still in the neck and pushed as hard as he could down on it to try to control the now liberal bleed with pressure while he spoke to the prof. it was never ever a good thing to let the prof wait.

"ok, prof. it's just bleeding a bit." a bit? i thought. i would have used words like 'gushing' or 'exsanguinating' or 'please help us mere mortals', but my registrar simply said 'a bit'. the prof took a closer look. i could clearly see the white swab changing colour to bright red under the registrar's hands. the prof moved back and then spake he.

"yes, graves thyroids can ooze a little, but you seem to have everything under control." his eyes must be the real reason he can't operate, i reflected. again it seemed prudent not to share this opinion. "i'll be in my office. let me know how the rest of the operation went when you are finished." and with that he was gone.

we stood there in the silence of the wake of the prof. i just started laughing. it was all so absurd i couldn't help it. my laugh shook the registrar out of his trance and he got back to work.

once it was all over, unlike my prof, i was a firm believer in radioactive ablation for graves disease.

reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.

vascular cuts

anyone who knows me knows i hate vascular surgery. it is hard work with little reward. scratch that. when you actually get i nice pulsating distal artery the next day you almost think the night's hour upon hour of work may be almost worthwhile... almost. but all too often vascular operations were one small step along the road to disaster.

i suppose one of the reasons i dislike vascular so much has to do with my exposure to vascular during my registrarship. we had a very good department and there was always a vascular fellow who was not only interested in vascular but competed actively to do as many operations as possible. this meant us mere registrars didn't do too many worthwhile cases. we assisted and we did the grunt work in the wards. vascular was also amazingly busy and very demanding. these things all conspired together to leave in me an enduring dislike for the discipline.

i also don't think i was the only one who felt this way. most of us disliked and even dreaded our vascular rotation. that didn't mean we couldn't have the occasional laugh at some of the things that went on. for instance we used to have a saying about the femoro-popliteal bypass operation (to place a bypass from the femoral artery in the groin to the popliteal artery just below the knee.) you see this is generally done on people that have been smoking their whole lives as a last ditch effort to prevent amputation. the patients were usually wreaks. the smoking didn't just destroy that single artery but it destroyed all the arteries to a greater or lesser degree. at best the bypass would improve the blood supply, but not always sufficiently. all too often after hour upon hour of tedious labour, the leg would remain threatened and often an amputation would be carried out a day or two down the line. we jokingly referred to these patients as fem-pop, fem-flop, fem-chop patients. the fellow tended to get a bit annoyed about this. he took his fem pops very seriously and any suggestion that it was a small step towards the inevitable below knee amputation was met with open hostility from him. we knew not to say this in front of him.

but the one time i remember not being able to hold back my laugh even as the fellow's face became red with rage and his knuckles turned white as he grasped his dissection scissors deserves mention.

we were doing a fem-pop bypass. now part of this operation is to remove the superficial vein in the leg (the saphenous magna) and to use it as the bypass for the artery. the result is that it is necessary to make a long meandering incision from the groin all the way down to below the knee. so although the artery is only exposed where the proximal anastomosis and distal anastomosis are made, the incision runs for the entire length of the bypass. the fellow was delving into the groin looking for the artery while i dissected out the vein. there was the usual theater small talk. then one of the junior general surgery consultants trotted in. he immediately saw what operation we were busy with (there are not exactly many operations that require this length of a cut down the leg). i think i might have seen an evil grin on his face. he turned to the fellow.

"hi. my but that's a big incision just for a below knee amputation." i fell about laughing.

eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'

focus

one of the all time legends in medical blogging has to be suture for a living. she doesn't only patch people up but she sutures other stuff to make amazing works of art. i suppose this is not too surprising. in the end plastic surgeons are so much more artistic than us mere general surgeons. but i like to think that when the chips are down and the pressure is on, we can focus and place stitches almost as well as most plastic suturers.

it was one of those days. i was on call and all hell was breaking loose (again). i didn't seem to be able to get ahead of the deluge of work. too many people were trying to bleed all over the place at the same time and there were too many people in casualties demanding attention. suffice to say when the internist stopped me in the passage to discuss a patient with him, i was a bit irritable. internists have a way of drawing a story out. they are just not like us. they don't have our sense of urgency and when they stop you in the passage to discuss a patient, it shows.

i quickly realised the internist was going to string the discussion out as long as possible. it was frustrating, but it was also important to maintain a good relationship with our long winded colleagues, so i decided to accept it and be patient. in an attempt to settle down i even lifted myself onto the windowsill and consciously relaxed. i allowed him finally, after some meandering, to get to the point. i was actually amazed that i could bring my basal metabolic rate down to his for the duration of his drawn out discussion. finally he concluded his communication with me and readied himself to leave. even this took time. i jumped down from the windowsill in a smooth motion that i hoped looked emphatic. unfortunately my trousers hooked on something and i tore a massive hole in them.

great, i thought. now i had an unsightly tear in a somewhat unflattering position on my trousers, pretty much displaying my underwear for all to see and i had no time to rush home to change them. as the internist slowly sauntered off to continue his day in slow motion i even had a thought of wrestling him to the ground and stealing his trousers. however i quickly realised that would do nothing to the already strained relationship between our relevant departments and gave up on the idea. i would have to come up with a better plan. then i realised, i'm a surgeon. if i can close an abdomen then surely i can close a mere hole in my pants. the solution was obvious.

i rushed off to theater at a speed that would probably have given my internistic colleague whiplash and asked the sister there for some vicryl ( a type of suturing material). after all it was a thread i was familiar with. i then went to the surgery tea room which was adjacent to the female surgical ward. fortunately the tea room was empty so i got to work.

now vicryl (and pretty much all surgical suturing material) is made already attached to a semicircular needle. to use it properly one needs a surgical instrument. i had a leatherman which would have to suffice. unfortunately, a laceration on the nether regions of the trousers, even in the hands of a very skilled surgeon, can not be addressed while the trousers are still on. there was only one thing to do.

i sat on the bed in the tea room and dropped my trousers to around my knees. this presented to me the laceration pretty much between my knees, an easy place to work. then i started the repair job.

the sisters knew that i spent my spare time in the tea room and would therefore often first look for me there before paging for me if there was a problem in the ward. as luck would have it, one of the sisters came looking for me as i laboured over the laceration of my trousers, dropped to knee level. she walked in and addressed me. only once she was halfway through her question did she look up to see me sitting there, trousers down, working furiously with needle and thread between my legs. she doubled over in laughter before running out. i looked around to see what was so funny. not seeing anything from my point of view, i dropped my head again and continued my operation, totally focused.

moments later, pretty much every sister from the female surgical ward was crowded at the door to get a glimpse of the surgeon caught with his pants down. i watched them as their bodies shook and almost convulsed as the waves of laughter engulfed them. most of them then threw themselves into each other's arms and held each other until tears ran down their faces. i was focused. even the noise wouldn't distract me from the operation i was required to perform. the sisters then disappeared.

soon afterwards the sisters from the male surgical ward were also huddled in a tight group at the door, writhing in mirth and wiping each other's tears. again i smiled at them and returned my attention to where it was needed. finally i finished the procedure. i stood up, pulled my pants up and closed the things that needed to be closed. by then i was alone again, but the loud laughter stilled echoed through the corridors for some time afterwards.

yes i doubt my job was as neat as the work of my friend and fellow blogger, doctor bates, the plastic surgeon, but then i wonder if she has to contend with the amount of laughter i was requited to deal with while working.

in for the high jump

sometimes patients can follow you when you rotate to another discipline. sometimes this can be tragic. sometimes it can be funny. and yes sometimes it can be both.
the patient was tired of life. he addressed this problem by taking a massive amount of a large variety of pills and very nearly ended it all. however the internists would hear nothing of it and fought tooth and nail for his life, partly because of the efforts of a certain house doctor who really invested of himself to pull the patient through. every day, while the patient was in icu he visited and tried the best he could to support him. he even started learning the fine art of ventilation by simply observing the daily settings of the ventilator by his seniors. when the patient went to the ward he could be more directly involved. he did all the necessary blood work on the patient, but also consulted both the psychiatrist and the psychologist. he even spent time just trying to encourage the patient.

but in a certain sense it was a bit of a one sided relationship. you see the patient wasn't overly delighted by the fact that the suicide attempt had been thwarted and he went as far as to take it out on the poor house doctor. i suppose it was inevitable. you see the house doctor was the face that the patient associated with the hospital and the doctors and the house doctor was therefore the target for his resentment. but to his credit, the hapless doctor didn't show signs of this getting him down, although inwardly he was struggling a bit. as you can imagine, he was only too glad to rotate from the internal medicine wards on the 4th floor down to the lowly surgical wards on the 2nd floor. unfortunately his fellow house doctors rotated with him. even more unfortunately surgeons are not know for their finely developed sense of understanding and sympathy of emotional issues.

we were standing on the balcony of the doctor's tearoom. the fellow house doctors were having a bit of a go at this poor house doctor about the fact that despite his best efforts the patient ended up hating him the most. the surgical registrars gave their five cents worth about not investing too much time and effort into someone who just didn't care and essentially didn't want to live. the house doctor took it all in his stride and even laughed at the whole situation. yet even then he defended the actions of the patient, talking about decreased personal responsibility due the a defined psychiatric disease. the surgeons, who essentially stand by the dictum that if you can't fix it with a knife then there is nothing wrong with the patient, ragged the poor house doctor even more. the house doctor smiled and answered.

"anyway it doesn't matter anymore. i've been rotated to surgery and it is unlikely the patient will follow me here." with that he turned to gaze forlornly out over the balcony..... just in time to see his patient whizz past in his brief but rapid journey to the concrete floor below. life was still too much for him and he had jumped.

the house doctor rushed down and commenced the resus. in the end he was also the one to call it. the patient had tried to follow him, but had overshot the mark a bit. the words of the surgical registrar which had been shouted to him as he charged out the ward probably didn't help with his overall demeanour:-

"now at last there is something wrong with your patient."

the gift

sometimes a patient will give a thank you gift to me. sometimes they want to give more. i'm always a bit awkward with this.

the casualty officer called me and told me he had admitted a patient with an acute abdomen. this is surgical jargon pretty much meaning that the patient needed a laparotomy, most likely as a life saving procedure. i immediately went to see him.

the abdomen was supremely tender and i agreed that it looked to be a case for theater. but then the patient told me that twice before in his life he had presented at different hospitals with the same pain. the surgeons on both occasions had rushed him off to theater and found nothing. these two operations had then indirectly given rise to a multitude of other operations for obstruction. he even volunteered the information that the last surgeon who had operated him told him he had a frozen abdomen (a frozen abdomen is the condition when all your intestines are adhered to each other because of multiple previous operation. it is a nightmare to operate and associated with a high chance of injury to the bowel). red lights were going off in my mind. i decided to see if we could avoid an operation.

the ct didn't show any calamity in the abdomen but there were signs of partial obstruction which was consistent with frozen abdomen. i approached the patient and explained that we were going to try to avoid an operation, but if his conditioned worsened, then we would have no choice. i also explained that an operation in his case held a very high risk of complications. combined with his advanced years, these could be serious.

he recovered well without surgery. i was relieved. every day we would chat less about his medical condition and more about him as a person. it turned out that he worked in one of the fancy private lodges in the kruger and he was keen for me to visit. i said thank you but in myself i sort of knew i wouldn't take him up on his offer. i mean after all i hadn't necessarily gotten him through his ordeal yet.

when he left the hospital again he told me i must visit him in the kruger. again i thanked him but soon forgot about it.

some time later he presented again with abdominal pain. again the ct showed pretty much the same partial obstruction, but with impressively dilated small bowel (worryingly so). he informed me that he lived with a constant degree of abdominal pain and felt he could not go on. once again i told him that an operation would be risky but it could be considered. he felt there was nothing to consider. according to him anything was better than his present life of pain and misery. at that time he told me that i could do with him whatever i liked. he thought i was the greatest seeing that i so far was the only surgeon who didn't rush him off to theater and rip him open from stem to stern. i wanted to mention that we both had been a bit lucky, but i sort of liked the adoration so i just smiled. we decided to proceed.

just before theater the patient reminded me to visit him in the kruger and then the penny dropped. i realised the reason i was reluctant to accept is sometimes my patients die. i can't always predict who is going to die and who is going to make it. to accept such a wonderful gift from this man seemed wrong, especially in the light of the fact that i was not convinced the overall outcome would be favourable. it seemed a bit too much like taking advantage. i suppose in a way i was keeping myself at a distance from the humanity of the man in order to better do my job. i suppose i was also thereby denying myself my own humanity.

the operation was tense but it went well. he recovered and afterwards once again swore i was the best surgeon in the world. i was just glad things didn't go wrong. i didn't really feel that i could take either credit for the good outcome or his gracious gift of time in a fancy lodge in the kruger.

we parted company and i'm happy to say i never heard from him again. happy because that meant things were probably going well.

then some years later i was asked to see another patient. it was a case of severe abdominal sepsis. once again this is a condition that in certain cases can be the event that ends the patient's life, but i was confident i'd be able to pull her through. early on in the management there was talk of a private game lodge and once again i sort of brushed it aside. i pushed through the operation and the post operative period.

but as time went on, it quickly became apparent that survival was assured and i even started hoping for complete recovery. finally she went home in good health. then and only then did i questioned my usual approach of not accepting these sorts of gifts from patients. i mean in the end it was offered in good faith and with pure intentions. and it did seem unlikely that she would complicate at this late stage. i started considering it. after all i have often said my job is to return people to their humanity. now that she was back to a point where she could go on with her life and be herself again, wasn't i now stopping her from doing something that is quite human, ie the heartfelt giving of a gift. also it had something to do with my own humanity. so often when i'm treating patients i need to separate myself to a certain degree to keep perspective and to allow myself to do my job without being too clouded by human emotions. and yet essentially i am human and i do have human emotions and i do want to get to know people as they are and not just as the patients that lie before me.

so in the end, more in attempt to try to restore my own humanity, i accepted. it was a magical place with wonderful people and a real balm for my soul. m and b, thank you very much for allowing me to find my humanity again.

neurosurgery

during intermediates we were required to rotate through all the surgical disciplines. one of our rotations was therefore neurosurgery. those guys really work hard. i think it's fair to say they almost work as hard as us general surgeons. without a doubt, besides us, there was no other surgical discipline that came even close as far as hours and hard work were concerned. and yet they were very different to us.

certain conditions are considered surgical but it does not necessarily mean all surgical conditions are for operation. we will happily accept for example a bleeding peptic ulcer and treat it medically, only operating if it becomes absolutely necessary. the neurosurgeons, however, tended not to do this. if they weren't actually going to operate the patient they simply didn't accept him. so a peripheral hospital would send a scan through for their opinion. if they saw that either no operation was necessary or that the patient was in such a bad way that even an operation wouldn't save him, then they simply didn't accept the patient. cases from casualties with fractures and also some degree of suppression of consciousness who were not destined to fall under their knives they would also not accept. the poor orthopod would get stuck with a semi conscious patient that he wouldn't really know what to do with long after the bones had set.

so when we were getting tutorials from the neurosurgeons i thought it funny when they gave a long talk about the management of a patient with mild neurological suppression. i was even surprised that the consultant giving the tutorial seemed to know how to handle such a patient. being in the department i had seen no evidence whatsoever that they actually ever did handle such patients. fortunately i kept my thoughts to myself (i achieved this by biting my bottom lip every time i was tempted to say something. other than the slight taste of blood i suffered no ill effects like failing my neurosurgery rotation which is a lot worse than the taste of blood).

when the intermediate exams were around the corner i once again enjoyed the humour in the rumours that the management of mild head injuries was supposed to be a spot from the neurosurgeons. i couldn't help wondering who would mark that question. maybe they could ask the orthopaedic department to help them.

finally the exam day arrived. when i saw the question actually turn up in the exam as so many of us had guessed it would i found myself chuckling at the thought of some burly orthopod trying to read my handwriting. i also wondered if the neurosurgeon was honestly asking because he didn't know.

in the end, after considering simply writing:-
'break the patient's leg and turf him to the orthopods,' i buckled down and answered the question.

the silent treatment

misunderstandings are bound to happen. sometimes i just wish i could understand the misunderstandings

i generally got on well with the anaesthetists and this one was no exception, despite a slightly rocky beginning. in fact after that i actually looked forward to working with her. the atmosphere in theater would be light and jovial and we would exchange jokes and laughs. then a time passed when we just ended up not working together. the lists just happened to be dealt in that way. so when i saw her in the theater complex after this time i thought i should say hello. it seemed to polite thing to do.

she was chatting with one of her colleagues. i walked up and waited for a lull in their conversation. her colleague, also someone i knew well, turned to me and greeted me with a broad smile. we shook hands. then i turned to her to greet her. she turned around and walked away. i was quite surprised, but assumed she had something on her mind and let it slide.

the next time i saw her, once again i approached to greet her, but as soon as she saw me she made a speedy exit. i realised there was some or other problem that she had with me, but i didn't know what it could be. after that there were a few more similar incidents that left me in no doubt she didn't want to speak to me at all.

then we were allocated to each other for a list. she could not run from me. yet somehow she managed to avoid all human interaction with me for the duration of the list. she did her work and pretty much ignored me totally. by this time the situation was no more than an irritation to me. my feeling was that if she had something against me she should discuss it with me and if she didn't want to then i pretty much couldn't be bothered with her childish behaviour. i ended up ignoring her in equal measure.

then one of those cases that age both the surgeon and the anaesthetist came in. i was the surgeon on call and she was the anaesthetist on call. once again we were thrown together. but during these cases there has to be at least a little bit of contact between the cutter and the gasser, yet she still absolutely avoided speaking to me. while we were busy we were both so involved in our relevant roles in trying to keep the patient alive that the silence between us was at least not awkward. as it became clear that we were at least going to get the patient off the table and into icu i asked her a few questions pertaining to the stability of the patient, but i made sure i kept it business-like. she answered only as much as she was required to. it didn't bother me. the life of the patient was more important than whatever the misunderstanding she had with me.

when a patient is taken to icu while still ventilated, both the surgeon and the anaesthetist would accompany the patient together and this was no exception. and so it transpired that we ended up in the lift together with the patient. i looked at the anaesthetist. i could see her nerves were frayed. the case had been a nightmare and she had done well to keep the guy alive while i did my best to patch him up. i reflected that her efforts to ignore me must have made the whole experience even worse. i felt for her.

"well done. i really couldn't have done this without you excellent handling of the anaesthetic. thank you" i really meant it. despite whatever her problem with me was, she deserved a compliment for a job well done and i was not about to withhold it from her. that, to me, would be worse than what she was doing by ignoring me the way she was. i could see her shoulders drop as the pent up tension seeped out. she even smiled a bit, but still said nothing. it was ok. i didn't need her to.

some time after that we did a list together again and she started speaking to me. i involved myself in whatever conversation she initiated, but i remained cautious. after all i still had no idea what the episode of silence had been about and our relationship was pretty much destroyed, so i kept things fairly superficial. but i must admit i was glad that she had finally started getting over her offence. things went on pretty much like this for a while. we were civil with each other but we were not close by any stretch of the imagination.

then about a week later we ended up in theater together again. i was chatting merrily away with my assistant as is my habit during surgery and occasionally the anaesthetist would join in the conversation. things were almost back to normal. then i made one of my standard fairly weak bongi jokes. i can't seem to help myself. she turned to me.

"careful what you say, bongi, i have only just started speaking to you again after nearly a year. you don't want to mess it up." this was the first time she had acknowledged any such thing which could be seen as a breakthrough i suppose, but i was immediately annoyed. i felt that she shouldn't think her opinion of me would in any way affect who i was and how i interacted with people, especially when she thought she was punishing me with her silence. i was not impressed.

"yes i noticed something like that." i replied. "i still have no idea what all that was about."

"you know exactly what it was about." she said, almost accusingly.

"sorry to burst your pretty little bubble, but i have no idea what it was that you took offence at and quite frankly i don't really want to know."

fortunately after that she finished her specialisation and went on her way. i knew we would never work together again and, all things considered, it was probably for the best.

the urologist

i sometimes reckon i'm quite the urologist. but i'm not. even when i was rotating through urology i would often visit the general surgery tea room. i missed my real work i suppose. but the guys seemed to know i liked hanging out with the urologists and sometimes raged me a bit. i remember the one senior registrar trying to give me a hard time the one day when i visited the general surgeons.

"hi bongi. how's urology going? have you played with any good penises today?" i couldn't let that slide.

"no, but then again i haven't been home yet." he was floored.

but i realised more recently that i'm not really a urologist. it was a gunshot in the state hospital. it was the usual type of thing requiring time systematically repairing the multiple holes in the small bowel. but this case had a little bit more than just small bowel injuries. the bladder was hit too. the medical officer felt that that was beyond his scope and asked me to handle it.

gunshot injuries to the bladder aren't all that difficult, but one thing to remember is that there are always two holes in the bladder and it's the hole at the back that can be slightly more challenging. i opened the bladder by simply extending the anterior hole left by the bullet. the exit wound was clearly visible, but there was a problem. the bullet had exited the bladder exactly where the left ureter (the pipe carrying urine from the kidney to the bladder) enters the bladder. it had pretty much shot the ureter off the bladder leaving it to leak urine from its frayed end into the area behind the bladder. i honestly had a moment when i wished i could call a urologist, but that option wasn't open to me. there was no urologist doing calls in the state hospital, so i would have to sort out the problem myself.

one thing that is important when working with the ureter is to place a pipe in it to sort of stent it while it heals. the urologist have a nice pipe called a double j stent that they routinely use, but we had no such thing there that night. the other problem with a double j stent is that you need to do a cystoscopy to remove it at a later stage. although the visiting urologist could probably do that i didn't like the idea of placing something in the patient that i myself couldn't remove. i came up with a plan.

i dissected out the ureter above where it had been shot off, cleaned it up nicely and reimplanted it into the bladder over a thin tube we call a feeding tube (named after the fact that it is used to deliver food directly into a baby's stomach). this tube i then pulled out straight through the abdominal wall. when i wanted to remove it all i'd need to do would be to pull it out. the hole in the bladder would heal and all would be well. i was super impressed with my ability to think on my feet. the medical officer was also duly impressed. we closed up and i went home.

i was super keen to 'accidentally' run into my urologist friend the next day at the private hospital to tell him about my brilliant improvisation so i spent extra time on rounds wandering the corridors with the hope of seeing him. finally just by orchestrated chance i did run into him. i proudly told him about what i had done in the absence of a double j tube and how it meant i would be able to remove the tube easily in the ward later without the need of another anaesthetic. i was so impressed with myself.

"bongi, that is a well known technique which we sometimes use." my bubble was good and truly burst.

yep, i'm not a urologist. not only do i not know all their fancy techniques, but in the end i feel i must admit i have the fragile ego of a general surgeon.

the game

don't get me wrong, i'm mad about rugby. i think it's the greatest game to watch and when i physically could, i really enjoyed playing it too (when i dislocated my ac joint i took it to mean my body was saying no more). i also think john smit is the best captain this country has ever seen and despite maybe getting a bit old for the physicality of it all is still playing an absolutely superb game. but yet there is a certain perspective one needs to have about exactly what the greatest game in the world is. i thought about this when i watched john's reaction to the defeat during his 100th game as a springbok, but it is something i realised some time ago when another game was in question.

a new group of students had rotated to my firm. with the first call it became clear they were hard workers and keen to learn. that is pretty much all i required of my students so i was happy. in fact we were getting on famously. then one of them approached me.

"excuse me bongi, but i was wondering if there is any chance that i could get this saturday's call off?" as i have said before, in surgery this was pretty much not an option. and yet she had proven her willingness to work so i found myself entertaining the thought. she had better have a bloody good excuse though.

"why?"

"my husband is going to be home for three days and i want to spend some time with him," she said. "he has a really crummy job." she added for good measure.

i considered the options. i decided i'd let her go and try to cover for her with the prof. at least it wasn't the boss' firm so i didn't actually expect problems. but i was curious. what sort of job did her husband do if he was home so seldom? i had to ask.

"he is a cricket player." now there are times in life where if you just stop and take a moment to think you greatly decrease the chances of making a complete fool of yourself. i suspect this may have been one of those moments. pity i didn't take a moment. if i had taken a moment i would have realised that she shares a surname with one of our national cricket players. if i had taken a moment i may have been able to hide the fact that at that stage in my life i didn't really follow cricket too much and therefore wasn't sure if this player was even still in the team or not. if i had taken a moment i wouldn't have asked the next question.

"oh. what team does your husband play for?" she looked at me as if i was mad. i suppose being married to what some thought of as a national hero meant that everyone should know exactly who he was. i only had the vaguest of ideas. i considered saying if he was a rugby player i would know exactly who he was but i thought better of it.

after realising who her husband was i felt obliged to find out a bit more about the guy and to try and watch a few games at least. thereafter i could at least engage in a semi-intelligent conversation with her about her husband's profession. and this is what i did. quite soon we were chatting about cricket and cricket players. i was learning all sorts of interesting facts about the individual players in our squad. it was all very interesting.

one day we started speaking about the attitudes of some specific players that were considered stars (to the extent that even i knew them). i was interested to hear how one track minded they were about cricket and more specifically about their own opinions of themselves. they truly elevated themselves to almost godlike status in their own eyes. this fascinated me. i said the only thing i really felt i could say.

"well, in the end, it's only cricket and cricket is only a game."

"no. you are wrong. it is much more important than that." i considered this. i considered it in the light of what we had seen and done in the last while. i thought about the young lady that had developed overwhelming sepsis and died in icu despite all our efforts. i thought of the guy whose leg we had removed due to complications of diabetes and how he thought he was going to be fine with a prostheses, yet i knew that due to his age and general poor health, he would never learn to use a prosthetic limb to the point of independence. i thought about the teacher who got shot through the abdomen because he was at the wrong place at the wrong time and had also passed away after a high stress operation. i thought of the lady that had just been told she had breast cancer and the fact that she was wondering if she would live to see the birth of her grandchildren. i thought of the family that i had to tell that their child didn't survive the car crash they were all in. i thought of many things. after a while i replied.

"no. sorry to disappoint but it is really only a game."

the sentinel

anyone who follows this blog will know i have a tenuous relationship with the ivc (here and here). it is something i've seen only too often and each time it has me on edge. somehow i just can't get used to being up close and personal with an ivc that seems to want to bleed. but even i can laugh at some of our interactions.

i was the senior registrar so when the bone doctors decided to do a spinal fusion at the 4th and 5th lumbar vertebra and they wanted someone to expose the spine for them from the front, i was their go to guy. only problem is i didn't know how to do it. having been in surgery for long enough, it came naturally to me to show no weakness. i couldn't tell them this. i reasoned to myself i'd discuss it with the prof and if he felt i needed assistance then he could offer to help. looking back it wasn't the best thought out plan, all things considered.

the operation was booked for two days time, so the next morning i went to the prof's office and told him that i had been asked to help with exposure for a spinal fusion at level l4-5. he seemed almost not to hear me.

"good." he said as he continued with his work.

"only thing is, prof, i've never done it before." i considered telling him i'd never even seen it before but that was implied in the first statement, i thought. "should i go transperitoneally?"

"do what you are more comfortable with." great help, i thought. well transperitoneally (through the abdominal cavity) it would be then. the abdomen was after all my stomping ground.

the orthopaedic consultant who was going to do the operation was a bit of a legend. he was this super genius whiz kid that everyone doing intermediates was afraid of. he pretty much knew everything about everything and would always be able to dig out a question that you couldn't answer if he wanted to. luckily intermediates were way behind me so i didn't need to worry about offending him too much, but still it was a bit intimidating being asked to get exposure for an academic giant such as this man.

i entered theater at the predetermined time. there were about 3 orthopaedic registrars getting the patient ready. immediately when they saw me they asked how i wanted the patient to lie.

"put him on his back, " i said, oozing confidence, "i'm going through the abdomen." they nodded. and did so. once everything was ready we all started scrubbing and the sister started draping the patient. i tried to envisage what i would be doing in a while. i decided that i'd reflect the right colon up and pull the ivc out of the way, rather than reflecting the left colon up, which would mean i'd have more to do with the aorta. my reason had little to do with the blood vessels but rather had to do with the fact that the right colon can be reflected right out of the way whereas the left colon can't because it continues down to the rectum which is pretty much fixed. truth be told, the aorta is easier to work with than the ivc, but i just felt i'd get more exposure on the right. in my mind i was just trying to convince myself that it was going to be fine when the great orthopaedic consultant entered. he greeted us all and thanked me for my help before quickly going into the theater to make sure everything was in place. moments later he was back.

"the patient is on his back. are you going transperitoneally?" he asked. there was something in his question that bothered me, but this was not the time to seem unsure.

"yes, transperitoneally it is."

"for l4-5 fusion?" he asked it in such a way that the implied answer was that transperitoneally was not a good idea for l4-5 fusion. i thought back to the useful advice of my prof that i should use whatever approach i was more comfortable with. it occurred to me that this was an operation the prof possibly had never done before. besides if this legendary orthopod sounded like he knew something that neither i nor my prof knew, it was probably because he did know something that we didn't know. i felt my heart rate rise. but it was too late. i had no backup (the prof hadn't offered to help) and i would have to stand with my decisions.

"yes. we will be going transperitoneally."

"are you sure." i wasn't.

"of course i'm sure."

"well if you say so, but you are a braver man than me." he replied with a laugh. i felt my heart sink into my shoes. i just smiled.

i went through the abdomen. i flipped up the colon and exposed the ivc. i then mobilised it enough to pull it gently away from the spine....and discovered why transperitoneal approach is not good for l4-5. the ivc splits into two veins which drain the legs at roughly this level. the left one (left common iliac vein) crosses over the spine and when you try to ease the ivc away from the spine it gets pulled so tight it looks like it wants to tear off. but still i mobilised everything enough that their target area was nicely at least visible.

"there you are." i said with an air of i-told-you-so. "enjoy the rest of the operation. i'm outta here.

"what do you mean you're going?" said the giant. "you stay right where you are. it's your job to keep the ivc out of my way. you just stay there and stand guard over your ivc." this was starting to sound familiar and i was no longer happy to be part of it. but anyway, it wasn't as if i had a choice. besides, how bad could it get?

it could get pretty bad. i stood there with a retractor carefully in position putting just enough traction on my precious ivc without tearing the left iliac vein while the orthopod took the biggest badest instruments i have ever seen and ripped one entire vertebral body out bit by bit. now a vertebral body is somewhat tougher than an ivc and he used amazing amounts of power. i swear there were times he picked the patient off the theater table by his vertebra until a chunk was ripped off and the patient came crashing down again, all the while with me trying with all my might to not pull on the ivc with all my might and yet still keep it out of the way of that ferocious instrument the orthopod was wielding. in my mind he looked like a medieval barbarian with some sort of overly vicious weapon swinging around with just too much force. there were times when i thought he was going to pull the patient right off the table with me and the ivc being dragged down with him. i didn't only fear for that poor ivc but there were times i actually feared for myself.

after a while he got that condemned vertebral body out and replaced it with some sort of metal device. once that was in the ivc was allowed to return to its normal position. thereafter my frayed nerves also started recovering. once again had i stared into the dark eyes of the ivc and lived to talk about it.

p.s the patient survived too.

a close shave?

some versions of history claim that surgeons and barbers stem from a common pool. that is apparently the reason the british still refer to their surgeons as mister rather than doctor. i personally even used to believe this, but then something interesting happened which changed my mind forever.

sometimes a theater list can fall apart. sometimes some patients just neglect to turn up, sometimes anaesthetists cancel patients and sometimes the blood results preclude theater as an option. it is seldom that the powers that be conspire together for a total collapse of the list but it did once happen. when we got to theater we discovered that every single patient had fallen from the list for one reason or the other. the anaesthetist looked delighted. we were not. and yet it put us in the interesting situation of having the morning off. we weren't sure what one did with a morning off. i had been thinking about a haircut for a while and suggested we head down the road to a nearby barber. i remember my good friend and medical officer (whom we affectionately thought of as the ninja because of his amazing martial arts ability) suggesting that we go to a modern hairdresser, but i would have none of it. i told him i wasn't the type to fork out a whole wad of cash for a fancy haircut when someone who historically was linked to our noble profession could do it at a fraction of the price. the ninja looked at me as if i was mad. then he remembered i was and offered to come with me.

quite soon we were parking the car outside the barber shop. it was so early in the morning that they had just opened their doors and didn't have any customers yet. truth be told, i had often driven past them and i had never seen a customer there. it seemed to me such a pity that our brothers, the barber-surgeons were being driven out of their profession by fancy hair dressers and i for one was proud to support them.

the doors stood wide open so we walked in. there was no one there. we sort of stood around for a while but still no one came to our aid. the ninja was looking at me with this i-told-you-so smile which just made me all the more determined to stick it out. then i saw a bell on the counter. i picked it up with maybe too much of a show and rang it in ninja's face. he scowled but remained silent.

the bell had its desired effect. from an almost hidden door at the back someone entered. immediately the ninja's scowl turned to a broad smile. in fact i think it was a chuckle. the man who had entered was one of the oldest men i had ever seen. he moved slowly with a shuffling motion towards us and asked in a thin voice if he could be of assistance. he also spoke with a strange accent. the only thing fast about him was the noticeable tremor of his hands. they seemed to shake so much i couldn't imagine him picking up a pair of scissors, let alone working with them. i turned to leave but i walked right into the beaming face of the ninja.

"what are you waiting for, bongi?" he grinned. "you are the one who insisted on coming here, what, with stories of the common bond we share with grandpa here. lets see you go through with your convictions now." i was stuck. i considered fighting my way past him, but he was not the ninja for nothing. i was done for.

what could i do? i sat down in the chair. i think i more crumpled up into the chair in a defeated heap but i tried to make it look like i was sitting down. the old man threw a towel around my shoulders. it only took him five attempts to get it right. he then fixed the clasp securely around my neck. it felt like jail bars closing in on me. i was truly stuck. in the mirror i could see the ninja now openly laughing. i wished i could wipe that smug smile off his face, but i was using all my energy to try to prevent an expression of terror creeping across my own face.

the old man then shuffled off towards the door from which he had emerged. he shouted to the back. for a moment i felt a sense of relief. he was calling for someone else to take up the tools of our mutual trade. i was going to be ok and the laugh would be on the ninja for doubting his all knowing senior.

i was just practising my smug smile to use on the ninja when the person the old man was calling finally emerged from the doorway. imagine my shock and horror when i looked upon the face of what had to be the old man's grandfather.

the master has spoken

i have touched on how to spin the story correctly to your consultant in order to achieve the best possible outcome for all involved. there was another scenario where i worked it to a fine art.

the toughest firm to work in was the boss' firm. i have mentioned this before but it was difficult to avoid his wrath. generally you were placed in charge of his firm only as the most senior registrar in the department. this gave me a good few years to observe how the other guys presented their cases to him in the morning meeting and to learn from their mistakes. one thing about the boss is he was an exception to the general rule of consultants not coming out to help in theater at night. if you called him, he would come. this sounds good, but the down side is that it was not all that much fun to operate with him. he demanded dead silence and always operated himself, seldom letting his junior at the knife which meant he didn't teach too well. i learned a lot from him as far as technique is concerned but it was mostly through observation rather than through tuition. so, in summary, it was not ideal to call him out at night. quite frankly it was a pain in the neck.

but there was another side to phoning the boss at night. as a junior i often observed a hapless registrar presenting a difficult case to the prof the next morning and facing all forms of the proverbial sh!tstorm for not phoning the prof. it didn't matter if he had single handedly raised the patient from the dead or broken down the gates of hades to claim his patient back. if he hadn't called the boss it simply wasn't good enough. and yet, without fail, the registrars endured this tirade rather than endure the prof coming out at night. i wondered if there was a happy middle ground somewhere. it didn't take long for me to find it.

basically the prof was a surgeon and therefore had a very fragile ego. it wasn't that he wanted his sleep to be interrupted to come out in the early hours and operate. he just wanted to be acknowledged as the guy in charge. he didn't want to be surprised the next morning with weird and wonderful stories of heroism, especially when he was not the hero. i understood this and worked with it. in the end it was all about timing.

a good example of how it went when i finally worked it to a fine art is illustrated quite well by a case i still remember.

the patient was the victim of severe blunt abdominal trauma. from the first moment it was clear he was in deep trouble. there was no question about doing a ct scan or not. he was simply too unstable. to go via scan would be to lose precious time which he could ill afford. we had to get him to theater as fast as possible and that is what we did.

after opening the abdomen i was confronted with a massive amount of blood. it was the sort of thing we sometimes do see but it is always a tense situation. i went through the motions and quickly identified the liver as the source of the bleeding. segments six and seven had been totally crushed and had been pretty much ripped off the rest of the liver. being astute as i am i quickly realised this was not good. i must admit there were a few subtle hints like the anaesthetist shouting that the patient was almost in exitus and my house doctor's wide eyes. but the absolute giveaway was when the house doctor spoke.

"aren't you going to call the prof?" he asked.

"do you want the prof here?" i retorted.

"of course not but you know what he is going to say tomorrow morning if you don't call him!" i smiled.

"watch and learn my young paduwan. watch and learn."

i then deftly whipped out the damaged segments of the liver, controlled the bleeding and started rinsing the abdomen. the anaesthetist was looking less tense so i assumed i was on the right track. i then turned to the house doctor.

"it is time." i then turned to the floor nurse. "please get the prof on the phone for me." soon after she was holding the phone to my ear.

"sorry to bother you so late at night prof, but i just wanted to let you know about this patient i'm operating. he had a liver laceration. there wasn't time to call earlier because he was unstable and we were rushing him to theater but i thought i should tell you how it's going. i have the bleeding under control now."

"sounds good. do you need me to come in?"

"not now prof. everything seems ok now, but thank you for offering." the house doctor stared in amazement. i knew the hero worship would come later.

the next morning, in the presence of all the registrars and house doctors i was required to present the night's activities. when i started on the patient in question i could see some of the registrars' ears perk up. i think some of them might even have been delighting in what they saw as my inevitable misery. as i got to the bit about the liver looking like mince soup, the prof intervened.

"yes, bongi phoned me about this case. i advised him how to get the bleeding under control. the patient is fine now. well done bongi." the expression on the face of the house doctor was unmistakable. it was indeed hero worship. who could blame him?

running with the big dogs

on the topic of urologists, sometimes we actually do operate together. it happens seldom but it does happen. it is actually usually during these operations that i realise i no longer enjoy assisting so much. i think it has something to do with the surgical personality. you see we don't like to play second fiddle. it's a bit boring. having said that, when assisting the urologists, boring is what you want. the alternative can be quite terrifying. i mean there is usually a good reason that the urologists ask the big dogs to accompany them to theater.

i was senior registrar. one of the other firms had some sort of dispute with the urologists about a patient. you see after both disciplines reviewed the ct scan of the patient, the urologists felt it was clearly an inflamed gallbladder that was the problem and the surgical firm felt it was an inflamed kidney. neither one wanted to actually operate the guy. finally the boss intervened. he told the surgical registrar to take the guy to theater and call the urologists if necessary. the fact that the registrar in the relevant firm was a junior and could hardly take out a straight forward gallbladder didn't worry the boss too much. he simply instructed me to assist in the operation. not that i had a choice but i consented. however i decided i would be doing no assisting. if i had to be there then i was going to bloody well operate myself.

the gallbladder part of the operation was a walk in the park. it was completely normal and practically climbed out of the abdomen on its own. of course as soon as we saw that it was in fact the kidney that was inflamed we called for the urologists. things were looking up for me. i had it planned. as soon as the urologists arrived i was going to hit the road and leave the junior surgical registrar to assist. after all it wasn't even my patient. also, the boss wouldn't be looking for me for the rest of the day so i could catch a beer with a friend at the local tavern. i could already taste it.

the urologist registrar entered. he was a good friend of mine and as i took off my theater gown and gloves we exchanged a few laughs. but then their prof walked in. i was a bit surprised. they were obviously taking this kidney quite seriously. or at least more seriously than when they reviewed the ct scan. i stayed to see whether the prof was going to scrub in. he did. i should have left then but i sort of hung around for a while.

suddenly their prof looked up at me.

"aren't you a senior in the surgery department?" i considered lying. to say yes could only lead to trouble.

"yes." it led to trouble.

"well then scrub in. you can't go now. i need you here to look after the ivc." absolutely great!! i thought. now not only would i miss out on a beer but i would end up assisting anyway. again it wasn't really as if i had a choice, so quite soon i was scrubbed up and standing opposite the prof as he wrestled with the kidney. it was then that i realised why they had brought their prof along. the kidney seemed angry, very angry.

the inflammation and fibrosis around the kidney was immense. there were no normal anatomical planes but instead everything just adhered to everything else. one of those everythings was the ivc. i understood that the prof was worried about it. i was too.

finally he lifted the kidney out free of the patient. the urologists let off a whistle of congratulations but i remained silent as did the prof. you see i was watching his other hand which shot into the wound as the kidney came out to put pressure on the ivc amid a sudden torrent of blood. also as he passed the kidney off he didn't remove his hand from the wound. there was something under that hand and it was something that wasn't going to lie down without a fight. then coolly and calmly spake the prof.

"i think i have torn the ivc." he said it as if it wasn't a problem, as if it wasn't something that often was followed by the ending of life. i was amazed that he could be so calm when faced with such a calamity. and then i found out why. he looked at me.

"that's why you are here," he said, "it's your job to fix the ivc." he was calm when faced with such a calamity for the simple reason that he was not faced with such a calamity. i was. the realization set into my heart like a pick axe. i felt nauseous. i thought of that beer that i was busy not drinking because i was required to somehow perform a miracle on a patient that was never mine. but it didn't help to bemoan my position or to shy away from this immense responsibility that had been thrust upon me. i had to put my head down and fix it.

i fixed it. i remained calm on the outside and got to work and got the job done. but i think i shaved a few years off my life during that operation. when i was finished i was exhausted. i left the junior to close and finally went for that long overdue beer.

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!!!