Sunday, September 19, 2010

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.

Sunday, September 12, 2010

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.


"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."

Saturday, September 11, 2010

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.

Tuesday, September 07, 2010

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.

Thursday, September 02, 2010

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?

Wednesday, September 01, 2010

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.