Monday, October 11, 2010

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."

Sunday, October 10, 2010

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.

Saturday, October 09, 2010


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.

Thursday, October 07, 2010

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.