coma

one of the curses of kalafong (hell) was that there was no neurosurgical service. this meant us mere general surgeons had to handle the many head injuries that came in. so, for example, when some guy decided to cave in the head of his so-called best friend with a five iron on the golf course because they had started with the nineteenth hole instead of the first, we ended up either dumping them in icu with a tube down the trachea to wait to see what happened or trying to turf them to a neurosurgeon that could actually operate them. it was far easier to dump them in icu. mind you, it was easier to turn lead into gold than to successfully transfer a patient to neurosurgery. so generally we hated it when we were called to casualties to handle someone with a head injury.

my colleague got the call. an old lady had apparently fallen and hit her head. the paramedic had intubated her on the scene and rushed her in. he proudly stood there admiring his handiwork as he presented the patient to my friend.

"well, doctor, her gcs was three so i had to intubate her. she fought the tube so much that we had to inject her with 30mg dormicum." it was the usual story the paramedics spun explaining why they had intubated someone and at the same time illustrating that they thought we were idiots. you see, the gcs (glascow coma score) is a scale that gives one an idea what depth of coma the patient is in. it is a measure of the patient's normal responses as far as eye movements, verbal response and response to pain is concerned. a score of 15, the maximum, is essentially a normal person. a score of three is the lowest you can get and is equivalent to a corpse or maybe a brick. a person with a gcs of 3 does not fight a tube and doesn't need dormicum. then again 30mg of dormicum would pretty much drop a gcs of 15 to 3 or thereabouts. my friend was understandably skeptical when he entered the room.

"oh, doctor, the other thing i forgot to tell you is the right pupil is blown." this was lingo meaning the one pupil was severely dilated while the other was not. this was in fact a true sign which did indicate intracranial damage, usually bleeding with unilateral increased pressure. maybe, despite the supposed need for 30mg dormicum, the patient really was in trouble.

the surgeon walked in. the patient lay dead still with only the rhythmic up and down movements of the chest as the ventilator pumped away. he took a quick glance at the eyes. sure enough, the right pupil was massively dilated and absolutely unresponsive to light. this was not a good sign. he turned to his students.

"look at the eyes. see the difference in the pupils? that is a very bad sign. this poor old lady has pretty much no chance of survival." immediately the patient lifted her head off the bed and shook it vigorously. the surgeon took a double take. that wasn't supposed to be possible.

"tannie, can you hear me?" the patient nodded. "disconnect the ventilator immediately!" commanded my friend. the sister complied. the patient blinked a bit with her asymmetrical eyes, but breathed normally. my friend pulled the endotracheal tube out, to the absolute horror of the paramedic who had been so proud of his actions. with that the old lady sat up, lifting one hand to her throat.

"daardie fokken buis het my rerig seergemaak! (that f#@king tube really hurt me)"

"tannie, what is wrong with your right eye?" asked my friend.

"when i was only five years old i was injured when a stick poked me in the eye. since then it has always been like that." the paramedic went a bit pale and quietly left the room.

after listening to this story i too often extubated patients that the paramedics had overzealously intubated after flattening them with ridiculous amounts of dormicum.

evil

doctors can be naughty sometimes too. i suppose boredom can be fertile ground for all sorts of mischief and what speciality tends to leave plenty of room for boredom more than anasthetics, especially when you have to sit around with a stable patient while an orthopod labours through the night fixing all sorts of bones.

the anesthetist in question was on call for the orthopedic list. the list tended to start at about four in the afternoon and go pretty much right through the night. by midnight it could be quite a challenge to maintain enthusiasm, unless of course you had something to keep your mind busy.

after a few cases the gas monkey and the bone doctor took a break to replenish fluids and caffeine levels. however, while the poor unsuspection orthopod wasn't looking the evil anesthetist decided to lace his coffee with a strong diuretic. to ensure the best comic effect he put four times the usual dose in the coffee. i suppose he thought it would be four times as funny.

quite soon into the next operation, a fairly long procedure to fix a fracture of the femur (thigh bone), the poor unsuspecting orthopod started looking uncomfortable. he seemed to be struggling to stand still and resorted to crossing his legs quite a bit. finally he just couldn't hold out anymore.

"sorry guys, but that cup of coffee seems to have really settled on my bladder. i'm going to have to unscrub and go to the toilet." with that he walked out. the theater erupted in raucous laughter. only the bone doctor wasn't in on the joke. soon he was back, looking a lot more comfortable, no doubt hiding a contented smile behind his theater mask. he scrubbed up and continued the operation. unfortunately as the bladder distended again his easygoing nature gradually was replaced with irritation and impatience about the fact that the operation seemed to be taking longer than he and his bladder thought it would. quite soon the same restlessness and leg crossing started up and once again he excused himself and ran from the theater in embarrasment.

when he returned the theater staff were trying to remain composed, but there were a few snickering sounds escaping here and there as well as a giggle or two as the process repeated itself. the bone doctor stopped dead in his tracks.

"what the hell have you done to me?" he demanded. everyone burst out into raucous laughter as he charged out one more time to empty his tormented bladder.

buff and turf

the concept of the buff and turf is common to all the disciplines of medicine. sometimes it works. sometimes it doesn't.

the call came in, but i struggled to believe it. yet i had to go to casualties anyway. i mean how do you tell the casualty officer that you don't really believe anyone can survive a lion attack? lions are killing machines. any normal human being who gets attacked by a lion should have the decency to expire and maybe even be eaten. and here i was expected to believe the patient on the way had actually survived. the upside was that i would probably be home in about half an hour or so. that is about how long it would take to look at a mangled piece of flesh and declare it dead and maybe partly digested.

he arrived. not only was he alive, he was stable. he even greeted me in a friendly manner. we chatted a bit. after all i was quite interested to hear how it came to pass that he was attacked by a lion and more specifically how was it that he was alive. it turned out that he works in the local game reserve and was out in the veld when it happened. apparently he had managed to fire one shot with a standard issue national parks rifle and blown the lion's jaw clean off. the lion that had done the dammage was therefore only capable of using its claws and could not finish him off with a bite. that is why he had survived. i quickly checked him out. both his arms had massive lacerations from the elbows down to the hands, but other than that there was nothing wrong with him. it is quite amazing that a lion could maintain an attack after taking a bullet in the head and still do a substantial amount of damage. still, i started having evil thoughts.

lacerations of the arms below the elbow is an area of overlap between general surgeons and orthopods. in my rotation in the old days in orthopedics, their profs were pertinent in telling their underlings that any laceration below the elbow should be explored by an orthopod and not a general surgeon. i think they thought us mere common or garden variety surgeons might miss a tendon or nerve injury and they felt they could do it better than we could. i had no objections. so i started playing with the idea of turfing him off to the friendly neighbourhood bone doctor. i turned to the casualty officer.

"he doesn't seem to have any injuries needing my attention. consult the orthopod!" i tried to sound authoritative, but just in case, i added, "and if he refuses, then call me and i'll operate him. with that i left. after all i still had an appendix or two waiting for me in theater.

it was a relatively quiet call and i soon found myself sauntering out of the hospital on my way home. i knew the orthopod would be operating next and i knew what he was going to be doing. just before going home i quickly checked casualties to make sure there was nothing else waiting and also to ask what reaction the casualty officer had gotten from the orthopod.

"he was not happy," i was informed. "he went on for quite some time about the general surgeons being lazy and turfing cases to him, but in the end he accepted the patient." oh well. what could i do about that now? going home sounded like just the right thing.

one of the things i hate the most about being on call is when my phone rings the moment i get home. the phone rang the moment i got home. immediately i was tense and irritated.

"hi bongi, it's rb here. how are things there with you?" it was my friend, the vet from the game reserve. that meant it was a social call. well anything is better than a work related call once i was at home so i was actually quite excited. and what a coincidence that he should call the very day that we received a patient from his neck of the bush. for a moment i even forgot i don't believe in coincidences. "bongi, i'm actually phoning about a friend of mine who was sent to your hospital. he was attacked by a lion. you wouldn't possibly know who is treating him would you?" i knew very well who was treating him. more than that, i knew why that doctor was treating him. it was because i was apparently lazy and had turfed the patient. i decided rb didn't need to know the gory details of hospital politics. a simple "yes" would suffice.

"well you see, bongi, working here in the park, i've seen quite a few attacks by wild animals and quite often the city doctors close the wounds primarily. i know i'm just a vet but i've seen enough of these to know that this simply doesn't work. these animals have all sorts of nasties growing in their mouths and if the wounds are not debrided thoroughly and then left open for a few days, they will all become septic." i knew all these things to be true. i also knew that if i had been operating the patient i sure as hell would leave the wounds open and only close them a few days later. the only problem is i wasn't operating. he went on. 

"so, bongi, if i could ask you a favour?" i cringed. never mind my usual reservations about favours, i knew what this favour was going to be. if only i hadn't turfed that patient, it would be easy, but i had turfed the patient and this wasn't going to be fun.

"sure! no problem." i lied.

"great. could you maybe speak to the doctor handling my friend and just tell him not to close the wounds primarily?"

"ok." the lie was less convincing. my hesitant voice betrayed me. but somehow rb didn't seem to notice.

"great! thanks a lot, bongi."

moments later i found myself phoning theater where i knew the orthopod was busy debriding the wounds of a lion attack victim that the surgeon was too lazy to treat. i couldn't help wondering exactly how i was going to word it.

"remember that patient that i dumped on you? well now that i'm snugly at home and you are still slaving away in theater, let me now tell you how you should be doing your job!"

the bee dance

i have more than just a passing interest in bees. in fact i used to be somewhat of an amateur beekeeper and a semi-professional bee remover. it was a way to bring in a bit of extra money while slaving away in the salt mines we called the department of surgery. during those days i learned quite a lot about the bees. i found them very interesting.

one of the interesting facts about bees is how the scouts convey to the rest of the hive where they can find nectar stores. you see the returning scout does a little dance when it returns to the hive. the dance is in the form of a figure of eight with the bee vibrating its body in the middle section. the direction he faces during this dance indicates in which direction the stash can be found. the intensity of the vibration of its body during the dance accurately depicts the distance to the nectar stores. all very fascinating.

i was rotating through icu and it was my call. all seemed to be quiet. in retrospect i should have realised it couldn't stay that way. we were waiting for one postoperative admission and then i even entertained thoughts of getting a bit of sleep.

finally she arrived. she was still intubated and ventilated but it seemed to be more cautionary than necessary. the general surgeon registrar who handed the patient over to me was even upbeat.

"let her rest through the night but she should be ready for extubation early in the morning."

"sure." i said, "any other things i need to know about?"

"she bled a bit during the operation but the anesthetist put a high flow intravenous line up so there was no problem for him to keep up with fluid replacement. other than that everything should go just fine." with that he sauntered out. i quickly checked the patient out. once i was satisfied that all did in fact seem to be fine, i continued with my evening rounds, making sure all the other patients were ok. a bit of shut eye seemed like a real possibility. i started letting my mind wonder to the cozy bed in the doctor's room behind icu. just one or two more things to check on and i could lie down and submit myself to sleep. i think a smile may actually have crept across my face, but before anyone could see it i quickly regained my stern icu-doctor-like serious composure.

"the patient has crashed!!!" it took a moment for the sister's words to fight their way through my naive musings about beautiful sleep. but then the full gravity of what she said ripped my mind back to the present. the patient had crashed and that meant i had to charge in and save the day. but what patient had crashed? they were all stable and there was no one that was due to move on to the hereafter. if someone died i would have a hard time explaining it to the prof the next morning. in fact the only patient i could think that might have crashed was the new patient that had just arrived and she was the boss' patient. if i didn't manage to pull her through, never mind trying to explain to the icu prof the next morning, it was unlikely i would survive the m&m. at least i would get more sleep in whatever other profession i ended up in once the boss threw me out of his department.

it was the boss' patient! fear and dread gripped me. i needed to do something. the most pressing thing seemed to be the fact that the patient's heart was not beating. i shook the fear from my nearly paralysed arms and jumped into action. almost immediately i was compressing the chest. her a-line gave me a good indication that my attempts at cardiac massage were very effective. at least i was keeping here alive, but why had she crashed. i mean i couldn't keep doing cardiac massage forever, although, i reflected, it would probably give me good upper body definition. still it would help if i had a better long term solution.

"should i draw a blood gas so long?" asked one of the sisters. i understood her question. it wasn't really that anyone there thought a blood gas would bring us any closer to figuring out what had caused the patient to crash, but at least she would feel she was doing something. the one thing that a blood gas could possibly tell me was if the hb was low, indicating that the patient could have bled. but her vital signs just before crashing were completely stable, meaning it was unlikely. anyway, i nodded to the sister and almost immediately she had the blood drawn and was scurrying off to the blood gas machine.

moments later she had the results.

"doctor look here!" the shock in her voice was clear. she held the printout in front of me. i couldn't take it myself. i was still applying cpr. any thoughts of a chiseled torso had long since given way to a firm knowledge that my upper body would be stiff and sore the next day. i quickly looked for the hb result. it was normal. the next thing to check would be the oxygen status. that was better than normal. even the ph balance was close enough to normal. but then why had the sister sounded so shocked?

"doctor, look at the potassium." i looked.

a normal potassium is around 4. when it gets to about 6 it can cause dysrhythmias of the heart. at about 8, pretty much all hearts will stop beating. the result that met my worried gaze was 16! was that even possible?? how did it happen?? what the hell was going on??

despite a few obvious questions at least i knew what the cause was and i could treat it. half an hour later the patient's heart was merrily beating away all on its own without the assistance of my tired arms. once the chaos that always seems to surround any resuscitation effort had subsided i finally found out what actually happened.

when the patient arrived in icu, her potassium levels, among other things, were checked. the junior sister tasked with looking after her showed the results to the charge sister. they were slightly low. the charge sister then instructed her junior to replenish them. the junior, not knowing any better, put a massive amount of potassium in a small bag and connected it to the high flown line that our anesthetic friend had so kindly put up for us in theater. the result was that all that potassium ran into the patient very nearly instantaneously, stopping the heart. in all honesty we were lucky to realize this the way we did and pull the patient through. but, still, what had transpired up to that point was the easy part. the difficult part veered up before me like a cliff. i still had to tell the prof on ward rounds the next morning.

the next morning i told the prof. as expected he didn't take it too well. as i relayed the events of the previous night, he became more and more agitated. finally he could no longer stand still. he started jumping up and down on the spot, his mouth open and his fists clenched. when i got to the part where we were all desperately trying to save the patient's life, in exasperation, the prof's body shook. he then did a little circle around to his left. a memory stirred somewhere deep in my mind. where had i seen that before?

when we got to the potassium levels and how it was that they had come to be that high, the prof's body once again vibrated. he then spun around to his right, vibrated again and then spun around to his left. a light went on in the deepest parts of my mind. i knew exactly where i had seen this dance before and what it meant.

and so the prof continued doing his little dance. he would vibrate in a mixture of rage and surprise. he would then attempt to speak, but because he was so absolutely dumbfounded by the details of my story, he just couldn't. he would then spin around and try again, but when there were no words his body would once again violently vibrate just before he spun around the other way. we stood there in silence watching him. finally my colleague spoke.

"i have never seen the prof this angry before!" he whispered quietly.

"yes," i agreed, "but  after ward rounds, follow me. i'm pretty sure he is showing us where we can find a motherload of nectar, but be warned, it is very far away!!" he looked at me as if i was mad.