tongue twister

in the old days at kalafong (hell) we sometimes had to deal with obnoxious people. alcohol tends to make the worst of a personality come to the fore. most of us tended to ignore these irritations and get on with the job, but there were exceptions.

he was a senior registrar at the time. before going into the whole surgery thing he had been in the army and had served in the angolan war in the special forces. i occasionally asked him about those days, but he never spoke about it. i think it messed him up a bit and he probably didn't want to dwell on that stage of his life too much. only once did he ever actually say anything to me that alluded to what he had gone through.

"bongi, when you are in battle and people are shooting at you with the intention of killing you, it somehow changes your perspective on life." i suppose part of his changed perspective was that he tended not to take crap from mere mortals (hy vat nie kak van kabouters nie), especially those with more than a liberal dose of dutch courage.

the patient was drunk beyond description. he lay there in casualties with a nice neat bullet hole through his chest. however the injury had done nothing to his foul mouth. he maintained a constant stream of verbal abuse directed against anyone and everyone who had anything to do with him. when the poor house doctor inserted the intercostal drain she had to contend with both his sharp tongue as well as the occasional flying fist. he even managed to land a blow which had reduced the house doctor to tears. to her credit, she had continued the procedure but was unwilling to go near him after that. she called her senior, the registrar, to make sure the patient had no other injuries.

my friend walked into casualties, quickly found out what the trouble was about and approached the patient. he stood just outside the reach of the patient and casually observed his fists flying around, keeping everyone away. he listened as the patient flung a stream of obscenities at him. he seemed unmoved, but the wry smile that until then had been on his face slowly slipped away to be replaced by a stern grimace. he tried to speak to the patient to explain that he needed to check him out but this was met with such aggression that he ended up walking away. the house doctor tried once more to approach the patient, but caught a heavy body blow and slumped to the floor in pain. that, it seemed, was too much for the registrar.

"sister, put the patient in the procedure room. i'll be back in five minutes."

five minutes later the registrar returned. he went straight to the procedure room. just before he entered he turned to the sister.

"sister, call the maxillofacial surgeon and tell him we have a patient for him with a broken jaw."

"does the patient have a broken jaw?" she asked, surprised.

"well not yet." and with that he entered the room and closed the door.

after that, so the story goes, the patient was as tame as a lamb, albeit a lamb with a very swollen face.

covert operations

the consultants didn't always need to know what was happening on the floor. but sometimes keeping things away from them became downright clandestine.

i was a senior registrar at kalafong (hell). an old friend of mine had just taken up a post as consultant in the department of internal medicine. one day he approached me.

"bongi, what are the chances you can do the occasional open lung biopsy for me?" now there was no thoracic department in kalafong so it seemed to me to be a reasonable request. in fact i was quite excited. it would give me a chance to do a few thoracotomies, something us general surgeons don't do all that regularly.

"sure! anytime. just let me know and i'll book them on my list."

"uhmmm, there is just one small problem," he continued, "i've already asked your consultant when the previous registrar was here and he bluntly refused, so i suppose you would need to convince him." this was no small problem. my consultant tended to be a bit hard headed and i knew if he had already decided, then there would be no convincing him. if i were to ask his permission he would refuse and that would be the end of it. if i just went ahead at least i could claim ignorance, that is until he catches me out. there was only one thing for it.

"ok, i'll do it on one condition. at no point must you discuss the matter again with my consultant. everything must go through me." and so it was arranged.

a short while later the internist approached me with the first patient he wanted a piece of lung from. i took her name down and booked her on the back of my list. i then re-wrote the list, carefully omitting her name and took it to my consultant. we went through the somewhat abbreviated list together. he was happy. i didn't want to be the one to erode that fragile joy.

halfway through the theater list, as was his habit, my consultant asked me if i'd be able to handle the rest and went back to his office. i assured him i had everything under control and sent him on his way.

the thoracotomy went well and the hiding of the patient from the consultant in the ward for the next few days also went well. i was feeling good. i suppose i knew it couldn't last.

two more thoracotomies were pulled off in similar fashion. and then we prepared for the whole charade for the next one. again i put the patient on the list and again i discussed the abbreviated list with my consultant the day before. again everything looked good. i went home, looking forward to a great list culminating in a nice thoracotomy to obtain a piece of lung for my internist friend. but this time something went wrong.

how was i to know that my consultant decided to pass by theater that evening before he went home to check something on the list? how was i to know that he discovered my thoracotomy that until then he knew nothing about? how was i to know that when i walked into the morning meeting i was walking into a fire fight?

the consultant was clearly angry. before the meeting he called me over and asked me why there was a thoracotomy on the list that he knew nothing about. i told him the internist had asked for a lung biopsy and i had added the patient because we had some extra time on the list. he went mad (or slightly more mad). leaving no room for any misunderstanding he informed me, with much frothing at the mouth, that there would be no thoracotomies on his list....not now....not ever. i apologized. i thought that was the end of it. i was wrong.

after the meeting the prof asked if there were any announcements. my consultant raised his hand. it was so unusual for him to say anything during the morning meeting because of a certain amount of animosity between him and the prof that everyone sat up and paid attention. he then moved to the front of the room.

"it has come to my attention that bongi has been doing thoracotomies on my lists." he started. "now if this ever happens again i give you my word that i will personally see to it that the guilty party is put up against the wall in front of a firing squad and he will be executed! we will reinstate public executions here in kalafong. we will make it compulsory for all the registrars to attend so they can see what will happen to them if they step out of line. if he wants he can have a blindfold, or he can go without, but he will be executed. the registrars watching will not be permitted to use blindfolds."

i considered the question of the blindfold, but in the end i decided to rather stop doing the thoracotomies.

surgeon superhero

this is a post i wrote as a guest post for another blog a few years ago. since then that blog has been retired, so i decided to import the post back here.


yes i have an alter ego. yes, i dress in funny clothes with a cap covering my head and a mask covering my face. and yes, dressed as such i try to fight the powers of evil (mainly sepsis and bleeding and cancer and the like). i am ... a superhero. but there is often little understanding for what goes on under the paper thin masks and baggy gowns we wear. certain …um…occurrences, well, occur with us just as much as with other people.

a common cold behind a theatre mask is no small thing. remember you can’t blow your nose. sniffing loudly only works for a while and attracts all sorts of strange stares. just leaving it is really the only option. the positive side of this is you suffer less from the mild dehydration that accompanies massive loss of …mucus. there is, after all, fluid replacement (it is a very short trip from your nostrils to your mouth over your upper lip). ‘nuf sed. somehow this never appealed to me though. so, for all you budding surgeons out there, when you have a cold, plug your nostrils with tissue before scrubbing up. once you’re scrubbed, it is too late. The side effects are only a slight change in voice which is a small price to pay to avoid the constant lip licking and salty taste throughout the operation.

then there is a running stomach. this may be one reason to excuse yourself, handle the situation and rescrub. however, there is the real problem of dehydration, confounded by long hours of standing and concentration. here may i suggest a drip. the gas monkey (anaesthetist) can quite easily give a quick bolus or change the vaculiter when needed. (quick note, i’m not pulling this out of my thumb. i have actually seen this). stay at home, i hear you say? somehow that just doesn’t work with us doctors. i’m not sure why, but it is very rare that a doctor will stay at home merely because he is sick. what sort of a superhero would that be.

the last problem that can be encountered is best explained by thinking back to my registrarship. i was assisting the prof with some or other laparotomy. my stomach had been giving me trouble for some time. up until just before scrubbing up with the prof i had found it necessary to quietly leave polite conversation to allow the release of colonic gas quite a number of times. but once scrubbed up, this avenue was no longer open to me. what could i do? i simply puckered up and held it all in. this worked well, but became progressively difficult. we were approaching the end of the operation, but i could pucker no more. finally i reached a point where i had no choice. i needed release. i decided to quietly let one slip as to not attract too much attention with loud noises. so, as the professor started to close the sheath, i did just that. i was just inwardly congratulating myself for the stealth with which the…um…operation had been executed when the professor stopped closing and dived back into the abdomen. in a dry voice he quietly says, “someone cut the colon.” as he started carefully moving bowel out of the way to better examine the colon. now imagine my embarrassment when i was forced to say’...

“colon? yes. cut? no”

lingua franca

recently i was privileged  enough to go overseas to france for a laparoscopic course. unlike my last trip to deepest coldest europe, this time there was only one other south african on the course, but, as luck would have it, it was the same guy who gave us all a laugh last time. i think the laugh might have been on us this time though.

it didn't take too much time in france to realize theirs is a totally foreign culture to ours. what they are is simply called rude and obnoxious in our country. after a while one gets used to it and can only but look forward to returning home. however when there you sort of have to endure it. our usual south african responses to their behaviour might not go down too well.

the one night i went for a walk in the town (something not generally done in my country for safety reasons). at a stage towards the end of my walk i saw a quaint take-away place and decided to go in for a quick bite. i walked in. the place was totally empty except for the one single employee behind the counter standing with his back to me. he mumbled something in french which sounded to me like their usual greeting phrase, but only glanced up momentarily before he turned his back on me again. by this stage i was quite accustomed to being treated poorly by them so i greeted him back in two languages, both of which he probably understood just as well as i understood his french. he ignored me. i patiently waited for him to finish ignoring me. after a while he turned around and repeated his french phrase. i greeted him again, hiding my irritation well, i thought. i then went through the painful process of ordering something akin to a hamburger. he seemed to resist these attempts of mine, but finally took my order and got to work preparing it.

just about this time my south african colleague coincidentally walked past. he saw me in the small cafe and entered. i was just too grateful to see a friendly face and quite soon we were chatting away in a language there was no chance our french friend could understand. i informed him i had had difficulty with what i perceived as typical french rudeness but had managed to order something i was hoping would be a hamburger-esque thing. my friend greeted the guy in english and received the same french phrase i'd heard.

my friend then attempted to order something for himself to eat. it seemed to go even worse than it had with me. the menu was written on the wall so he simply pointed at an item. the french guy shook his head, indicating that that specific item was not available. not to be put off my friend moved from item to item, pointing to each one in turn and each time without joy. it was quite a comical scene to see him move systematically through the menu and be denied each time. after what must have been about the tenth item he selected, finally the guy indicated that he could supply it. my friend sighed, more from relief that the ordeal was over and we continued our light hearted conversation in our own language, somehow comforted in the knowledge that our words would confuse his ears as much as his did ours.

finally our food arrived and we tucked in.

while we were eating alone in that quaint french cafe late at night chatting in a language that reminded us of the open spaces of africa, probably too loudly for the refined french sentiment, something happened that gave me cause to reflect.

half way through our meal a local walked in. he greeted the guy behind the counter. the guy answered in the phrase that we had heard when we first came in. somehow hearing it just after the french greeting, it no longer sounded like the french greeting. just as i was wondering what he had actually said to us and therefore to this new local, the guy apologized and left. shortly after the same process repeated itself. someone came in, heard the phrase, said sorry and left. i then put it together.

the phrase obviously meant that the shop was closed. the whole time he had been ignoring us was more to do with him no longer being on duty than the usual french rudeness. i couldn't help laughing as i shared my suspicions with my colleague. i could just imagine what was going through his mind as he struggled to make himself understood to us;

"what is the quickest way i can get rid of these people that just refuse to leave? maybe if i just feed them then they will at least eat and go away."

banter

of all the specialities, i like the anesthetists the most. some of them are even my friends. this doesn't mean there isn't some degree of niggling that goes on between us.

during anesthetics there are two crucial times when things can go horribly wrong. the first is when the patient is put to sleep and the second is when the patient is woken up. during most operations the time between can be quite routine and even mundane. the patient can almost be put on autopilot and the anesthetist has very little to do except maybe catch up on a bit of reading (there are exceptions). yet strangely enough the one quality gas monkeys appreciate above all else in a surgeon is speed. somehow they seem to want to get through the stress free stage of the operation (for them at least) and move on to the part where things could potentially go frighteningly wrong. maybe they get bored, i don't know.

so the anesthetist thinks the surgeon is great if he gets the operation done fast and he also takes a certain amount of pride in waking the patient up moments after the operation is finished. this way the surgeon, who usually does not appreciate waiting around for anything, doesn't end op waiting around for changeover time. i suppose you could say we work fast to impress them so that they will work fast to get the one patient awake and the next one on the bed as fast as possible and thereby impress us. yet in my opinion there are things worse than waiting a minute or two longer between cases. i don't like working on awake patients. also for some reason that i can't fully explain if you finish the operation before the gas monkey is completely ready to wake the patient up, they tend to get the impression you are super fast.

then of course you get the two basic types of anesthetists. the first type shows an interest in the operation and knows when to start decreasing the gas. the second type has little interest in the operation and is possibly more dedicated solely to his craft. he will often ask for a heads up when the operation is nearing its conclusion (i once wrote about such an anesthetist)

if you put all this together, due to the fact that i can't always predict how far i am from the end of an operation and that i've had a previous nasty experience with patients moving while i'm trying to place the last stitches i tend to wait a while before i warn the gas monkey (that's if he asks) that things are coming to an end. so a typical conversation with a good gas monkey friend of mine would typically go like this.

"bongi, give me a warning five minutes before you've finished."

"sure." i'd answer, wondering how exactly i would know when five minuted before the end would be. then i'd go on merrily, secretly keeping one eye on my sandman friend to see if he was following the operation. if he was not i'd pretty much wait until i had only one more stitch to place. i'd then glance up and announce;

"five minutes to go." i would then bow my head and carefully place the last stitch. once i was happy with that stitch, i'd look up.

"finished."

i'd be lying if i said i didn't enjoy the reaction this usually elicits from my friend. he tends to go on about now having to wait for the patient to wake up, something i'm not overly worried by as i have said. i also enjoy the illusion it creates with him that i operate fast.

it is all done in a very good nature and our friendship is not at all affected by my possibly juvenile behaviour (i hope).

friends?

there is a sort of love/hate relationship between the surgeons and the anesthetists. neither one can survive without the other. we supply them with work and they get the work to lie still while we cut and dice. yet their job is to keep the patient alive while we challenge their ability to stay alive. at the moment of surgery they play good cop and we play bad cop. of course after surgery the good cop is suddenly the surgeon through and through. but that is another story.

i really appreciate a good anesthetist (i've had bad ones) and to tell the truth these days i'm spoiled by the quality of the gas monkeys that i work with. however many years ago i remember a case where the anesthetist and i had a misunderstanding about time frame.

i was doing a laparotomy in kalafong. the gas monkey was a long term medical officer. he had attempted to specialize in anesthetics but simply had not been able to pass. in the end he found himself stuck in a senior medical officer job with no way of advancing himself. he was a bitter little man and it was easy for him to take his bitterness out on surgeons.

towards the end of the operation when i started closing the sheath the patient's abdominal muscles were so stiff that he was pushing all his intestines through the wound. this did not mean the patient was awake. it simply meant that his muscle relaxant had worn off. it was a tricky time. i needed the patient to be at least partly relaxed, but if the gas monkey fully relaxed the patient he would not be able to wake the patient directly after the operation, thereby wasting all of our time. a good gas monkey will find a compromise between these two extremes. i did not have a good anesthetist. he was also more stuck on the hate side of the relationship between our two disciplines.

"the patient is pushing a bit." i hinted.

"the operation is almost over," he snapped, "i'm not going to relax him any more. otherwise he'll still be asleep half an hour from now". i was annoyed to say the least, but i knew it was a fight i couldn't win. it seemed so important to him to get this patient off the table in half an hour. i smiled. i could close this abdomen with the patient pushing against me, but i couldn't do it in half an hour. it would take longer. i decided not to share this information with my touchy friend. i buckled down and got to work.

it turned out more difficult than i initially thought it would be. each stitch was an effort and my assistant ended up straining against the patient to keep the tension on the suture. the gas monkey started becoming edgy, but i ignored him. if anything i slowed down my pace, making sure that, despite his best efforts, i closed the sheath properly.

about an hour later when i finally had it closed the qwasi-gas monkey was so irritated that he couldn't sit still. i was smiling behind my theater mask. i knew i had closed the sheath properly despite his inadvertent attempt at sabotage. and maybe next time he would pay slightly more attention to my seemingly ridiculous demands.