Thursday, June 16, 2011

doll eyes

it affected me. not just it, but the fact that it didn't seem to affect my colleague.

i was a lowly fourth year medical student, delivering babies for all i was worth. looking back, i realize i enjoyed it. the whole 'joy of a baby coming into the world' really gave me joy that a baby was coming into the world. call me sentimental but i saw each birth as beautiful. somehow i could look past the meconeum and the amniotic fluid and the episiotomies and see what was actually going on. it was a happy time for the mother (mostly). it was the beginning of hopes and dreams. it was a new start for the baby (obviously) and for the mother and in a sense each new birth may have signified a potential new start for me.

she was excited about her new baby, but there was a cloud over her entire admission. the reason she had come in to hospital was because she hadn't felt the baby kicking for the last 24 hours and she was worried. quite soon we were worried too. not only could we detect no movement but we couldn't hear the fetal heart beat with our fetoscopes. my registrar was one of those amazing people who really felt for each and every patient despite the massive torrent of humanity that moved through the labour ward on a daily basis. this patient was no exception.

actually we all new what had happened, but the registrar wanted to make sure. i suppose she just didn't want to tell the mother her baby was dead before she had confirmed it on sonar. actually i think she wanted to use the sonar to show the mother there was no heartbeat to avoid problems of denial once the news was broken. whatever the reason i followed the whole drama as it unfolded, as did my fellow fourth year green medical students.

i remember sitting there in that small labour room where mothers are usually introduced to their new babies while the registrar ran the sonar probe over the mother's swollen abdomen. i remember her bringing the probe to a standstill over the heart. we could clearly see the heart, but there was no movement. the heart was not beating. as we actually already knew, the baby was dead. all that remained was to tell the mother. with genuine sympathy and very sensitively the registrar broke the tragic news to the mother. i saw her face drop as the realization of the loss set in. i could see her fighting back the tears. i was too.

finally it was over and we all slowly filed out to leave the mother to absorb the blow. of course we still had to decide how to deal with the problem of getting the baby out so we didn't have the privilege of dwelling on the human drama that had just unfolded before us. still i took a moment to allow myself to feel it. this involved no small amount of swallowing back the tears.

the registrar turned to us.

"and that is that. which of you is going to deliver this baby?" my colleague was the first to speak.

"excuse me, but when the baby is delivered, can we practice endotracheal intubations on the body?"

i felt nauseous and slightly dizzy. it hadn't occurred to me before then but suddenly i realized the entire humanity of what had just happened had gone completely over the head of my colleague. all he was interested in was the possible so called learning opportunity that he could get out of the 'situation'. quite frankly he had felt nothing for the baby and he had felt nothing for the mother. i couldn't help wondering what sort of a doctor he would one day turn out to be. i never wanted to be like that.

in the end i was the one that had to deliver the baby. there were a lot of tears.

Tuesday, June 07, 2011


sometimes different people see the same thing from a slightly different angle, giving a completely different perspective. in my line this can turn out to be quite macabre.

it was one of those cases. it was probably hopeless from the beginning, but he was young and we had to give it a go. as soon as the abdomen was opened everyone knew things were bad. there was blood everywhere. it took a while to even see the damage to the liver because i needed to get rid of the blood in the abdomen before i could see anything. however, once i saw the liver even i was shocked.

the liver was ripped apart with one laceration dropping down to where the ivc sat menacingly behind it. it seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. but i did what i could as fast as i could. at times like this the unsung hero is the anesthetist. if he can't get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. that day the anesthetist was great. somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.

after a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. usually, unfortunately, at this stage of these operations we are confronted by another problem. you see with massive blood loss the patient loses or uses up all their clotting factors and platelets. even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. to attack each ooze with an injudicious suture not only doesn't help a bit, but it wastes precious time that could be better spent in icu replacing these vital factors. i made the call.

"there are no more surgical bleeds that i can control here. i'm going to pack the abdomen and send him to icu to optimise his condition and we'll take him back in a day or two." the anesthetist looked up.

"if you say so, but he is not looking so great here." he pointed at the monitors.

i packed and closed. the gas monkey continued throwing every available fluid into his system as fast as he could.

"i'm just going to top him up as much as possible before we transport him to icu." he informed me. he was definitely worth his salt, this one.

this is now a time that the average surgeon doesn't like. we are not the stand back and wait types. we struggle to sit still and give it time to see what happens. but sometimes it is needed. i didn't have to wait too long before the the gas monkey told me what was happening.

"bongi, this guy is not improving on the fluid and blood i'm giving him and his abdomen is distending. are you absolutely sure there is nothing inside you can't make better?" the problem was i knew there was nothing i could do that i hadn't already done. however the anesthetist's observations were undeniable. the question was was there something i had missed or was the patient so far gone that he was lost already? it was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. there was only one thing to do. we had to open and look again.

we opened. immediately i knew everything we did from here on out was futile. the patient was in irreversible shock and had absolutely no clotting. there was nothing that i had missed from a surgical point of view which meant there was nothing i could do. after poking around a bit i packed and closed again, but this time with a heavy heart. i knew what was going to happen. the anesthetist also had no illusions about where we stood, but we both continued to go through the motions.

the motions led us eventually down the deserted passage way in the middle of the night to icu with a patient that was sort of alive in the broadest definition of the word when we left theater. both the gas monkey and i didn't want to check the vitals during that quiet sombre journey. what did it matter? we knew what was going to happen and we knew it was out of our hands. the only questions were where and when it was going to happen if it hadn't already happened. so when we entered icu we were quiet and reserved.

when icu receives a new patient, there is usually a flurry of activity and this was no exception. all the sisters descended on us like a swarm of bees, each going about their respective duties. soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. however once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. quite soon their alarms were blaring away. i glanced at my anesthetic collegue and we both shook our heads. we had done what we could. the icu sisters hadn't seen what we had seen. all they knew was we had delivered this patient and things didn't look good.

"i can't get a blood pressure. i can't feel a pulse. crash trolley!!!" she yelled to one of her juniors who scurried off in obedience. neither i nor the gas monkey moved. we just sat there, defeated at last.

"doctors, this patient is dying! aren't you going to do anything?" i laughed. i didn't mean to and i think it was more a nervous laugh. i was too emotionally exhausted at that moment to react appropriately. my colleague also laughed, but more at my response than the situation, i think. he then explained that what could be done had been done and any further resus would be in vain. we turned off the ventilator.

and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.