behind closed doors

most non medical people have little idea what a general surgeon does on a day to day basis (unless, of course, they read this blog). few can imagine us elbow deep in blood and guts in an eternal battle against the angel of death. this is partly due to the fact that what we do borders upon the unimaginable, but it is also due to the rigid controls about who is allowed into the holy realm of the theater. understandably, not just anyone can be present at that most sacred of moments when the knife slides through the skin, opening that which is not meant to be opened. the average lay person will tend to simplify the whole process in their minds. the doctor has operated, so now what could possibly go wrong? i know what could possibly go wrong and sometimes it fills me with dread.

but at the moment when it is all happening, when the family are waiting outside, barred from the hallowed events performed within by a surgeon overcome with dread, it is all in the hands of that surgeon. then the family can only wait. as they wait they don't even know what they are waiting for. i understand it engulfs them in a feeling of immense helplessness. i also understand people don't like to be helpless.

it was a bad injury. the bullet hit him on the lower edge his left chest anterior and exited through his back about 5 cm below this level. the medical officer called me to see the patient in casualties at about 9 o' clock in the morning. 

"who gets shot at 9 in the morning?" i joked over the phone, but there was something in his voice that told me i'd better get there fast. maybe it was that he wasn't laughing at my joke.

i walked into casualties. the patient was pale and confused. he turned to me and tried to focus, but i realised he wasn't seeing me. it was as if he was looking straight through me, possibly at some distant object only visible to him. i quickly evaluated him. hemodynamically he was not in a good way. clearly there was some serious bleeding happening somewhere. equally as clearly we would need to operate him fast if he was to have any chance at all. i barked commands.

"you, five units packed cells and six plasma. i want them in theater immediately. go!" i went on. "you, go to theater and tell them we are going to be there in 10 minutes. i want a theater ready now. go!  you," i looked at my medical officer, "i have nothing for you to do. help me get this guy to theater. don't go!"

"uum, doctor." he replied, "i'll take the patient to theater but i need you to speak to the family. his parents are outside and they are very worried. i'll get everything ready in theater so long, but please don't make me speak to them?" hmmm, not the best time to mentally gear down enough to calmly reassure family members that i had things under control, especially when i didn't even know what things would need controlling yet.

"sure!" i said, remembering it's always important to look in control in front of the medical officers. moments later he was wheeling the patient to theater and i was introducing myself to the parents.

"doctor, i feel terrible!" was there something i didn't know? could it be that this guy's mother had shot him? just as i was trying to picture this frail old woman as a ruthless killer, she went on. "you know, doctor he was fetching his daughter from our house to take her to school. he is a night shift worker and we look after our grand daughter when he is at work. he got hijacked outside our house and that's where he was shot. i actually heard the shot doctor." she started crying. "i looked out the window, but when i didn't see his car...the hijacker had already driven off... i locked the door and stayed inside because i was afraid. only after ten minutes did i go outside to find my son lying in a puddle of his own blood. doctor, if he dies it will be my fault!" i felt for her.

"i'll do my best." it is difficult, really to say anything meaningful at such a junction in life. especially when my best may not be good enough. i said it anyway. no matter how inadequate it was, there didn't seem to be anything else to say.

soon thereafter i was in theater, just about to scrub up.

"doctor, the mother is outside. she wants to speak to you again." this was a bit ridiculous. her son was literally bleeding to death and the only thing that could save him was a very prompt operation, which we were about to embark on and here the mother wanted to use up some valuable time with a bit of chit chat? i was not impressed. yet i probably could spare about 30 seconds or so, i thought. after all it is important to maintain a certain rapport with family members, especially if there is a very real chance that the patient may not survive the operation. if the last emotion of the family towards the doctor before an operation is one of animosity, if the patient dies, that animosity will continue and may manifest afterwards, potentially even in accusations and court cases. i decided 30 seconds may just be worth the effort. i ran out.

"doctor," she grabbed my hands, "while you are operating, i just want you to know that we will be holding you up in prayer." i tried to pull my hands gently free. after all the 30 seconds i had allotted myself were almost up. she continued, "we will be praying that god will guide your hands and be in control of your every move. ok?" i had nothing to say to that, even though it seemed to be a question, so that is exactly what i said, nothing. i understood her. it was her way of not feeling totally helpless during the operation when she would be barred from her son in the most critical moment of his life. she already felt responsible for leaving him shot and bleeding outside her house for ten minutes before she went to him. if he died on my theater table she would live with guilt forever because she had not been with him at that moment. she was essentially telling me that she was not leaving him alone as he went into the restricted area of theater to face his tribulations. she was going to go with him by sitting outside and praying for my hands not to mess up. i smiled.

"ok, but i must go. time is of the essence here." i managed to work my hands from her grip, the same hands that would later be covered in the spilled blood of her son while i fought for his life.

the bullet had done its job. there was quite a mess inside, but the major injury was a transection of the splenic artery about 2cm from its origin. the open ends were pissing blood all over the place creating more than just a small challenge to get under control.

once the operation was over i was exhausted. the weight of being the only thing standing in the way of a human being and his demise drains one. also the emotional gymnastics involved in moving from the human interactions with the family and the patient to the simple mechanics of working with the blood and guts of a lump of meat on the theater table and then back to the raw hopes of the family directly after the operation can often be almost more than one can bear.

"we did what we could. he's going to icu where we will continue to do whatever we can to keep him alive, but we'll have to see how things go."

"doctor, we know god's hands, and not yours, were over him in there. we have faith." i wondered then why i felt so tired, if, as it turns out, i had apparently done nothing. i was too tired to bother about that then.

once the patient finally left the hospital alive i was so proud of all our efforts to pull him through. the patient and the family never said thank you. yes, normal people have little to no idea what happens behind the closed theater doors or in the minds and hearts of the surgeon, fighting on their behalf.

high fiber (regular)

granted, the prof had good hand skills. but i personally had doubts about the depth of his academic knowledge. i wish i could say that as i studied and got up to date towards my finals, i gradually realized that the prof may have been a little behind the times. but there was a more subtle sign that i cottoned on to much sooner.

even as a mere medical officer in the prof's firm, i was always amazed that on academic rounds he tended to swing the conversation towards constipation and how to avoid it with the consumption of enough fiber. far be it from me to criticize a good high fiber diet, but i did wonder how one ended up speaking about the colon, even when we were discussing a patient with breast cancer. but to be fair, it wasn't that the prof was clueless about other things pertaining to surgery, so in the end i just assumed he had a great interest in and a love for all things relating to the colon and how they could be managed with fiber. maybe he wasn't really trying to hide his lack of knowledge about other things but couldn't help always swinging the conversation back to his one true love.

many years later, when i was the senior registrar and it once again fell to me to rotate through the prof's firm just before my finals i at least knew what to expect to be taught on academic ward rounds.

when joining a firm, more often than not there are already a group of students there that know the ropes. sometimes they even view you as the new guy and it can be quite difficult to assert your authority. the first day in the prof's firm i realized i was likely to have problems with the incumbent group of students. on the morning rounds there was a silent resistance to everything i said, a sort of unspoken 'who do you think you are?'. it annoyed me. i was so close to finals i really didn't feel like having to stamp my authority on a bunch of snotty nosed students. i started wondering if there could be another way of approaching the problem. in the end i understood working for the prof changed one somewhat. maybe just the fact that they had been in his firm for a while was why they were being subtly aggressive. maybe to hammer them in the prof's typical style would achieve something in the short term, but it would further affirm their belief of the stereotypical surgeon. another approach was called for. i decided to bide my time and wait for the right opportunity.

the academic round with the prof was as painful as i remembered it always being so many years before. and yet somehow he didn't swing every patient and every condition towards constipation, which was at least a relief. finally we got to the last patient. the student presented and the prof gave instructions about how to further handle him. and that was it. the rounds were over. i was quite excited to move on to the ward work and get on with the rest of the day, which in my case would probably entail putting my tail on a chair and my nose in a book. we all walked to the door, but i could see the prof wasn't walking with his usual determined stride. he wasn't finished with us yet. suddenly he stopped.

"you know, constipation is a very real problem." at last, the old prof was back. by the reaction of the students i could see they had heard it all before. the one rolled his eyes. another's shoulders sagged, almost too obviously. i smiled. i'm sure they were all thinking i'm smiling out of naivety, seeing that, in their minds at least, i didn't know the prof's favourite topic. i was smiling for another reason.

"yes," continued the prof, "it is a problem that i have been struggling with for all of my professional career." too easy, i thought.

"well then prof," i looked at him, trying to mimic an expression of sympathy, "why don't you just try a high fiber diet."

once the students had composed themselves after fits of what i'm sure the prof viewed as inappropriate laughter, i never had another problem with them again. the prof?...well that's another story.

entrepreneur

i would like to say this is a south african story, but , truth be told, when people see the opprtunity to make money off the backs of the stupid and vulnerable, then it is pretty much a free for all (eg, eg.)

at the local state hospital, as it should be, there is an hiv clinic. as the name would imply they treat the many people in our area with hiv using modern antiretroviral medication which is proven to lower the viral load and can turn a once deadly disease into a manageable one, not unlike diabetes.

yet still there is a stigma associated with hiv and it gets treated unlike any other disease. you can't simply test someone for it like you would for diabetes. before testing someone, they have to be counseled so they fully understand the implications of knowing about the disease. if they refuse testing, then they are allowed to continue in their ignorance, without treatment of course. also, if they choose to be tested and are found to be positive, before they are permitted to see the doctor who will be managing their newly diagnosed disease, they are required to speak to the councilor once more. this is supposed to be a time where the councilor explains to the patient that hiv is no longer a death sentence and explains the importance of adhering to the treatment plan. yet this is also an opportunity for an enterprising charlatan.

the patient in question was back after having her hiv test the previous week. i think in her mind she actually knew she was positive. there was little else that could explain her symptom complex and she had already accepted the inevitable. all she wanted to do was to get through the obligatory counseling and to get to the doctor so they could work out a treatment plan. she sat down with the councilor.

"you are hiv positive,"

"yes, i thought as much."

"now you are going to see the doctor shortly and he is going to discuss treatment with you." this is exactly  what she wanted. she just wanted to get through this and see the doctor after all. "he will tell you about all sorts of western medicine that you will have to take every day for the rest of your life." again, no surprises. "but there is an alternative." what? this was not in the script. she thought she would rush through this so called post counseling and get to the doctor. yet humans are inquisitive creatures.

"what do you mean?"

"i mean there is another way." with this, she reached under the table and produced a second hand pepsi bottle full of some liquid. the patient looked at it in surprise. it had a slightly green hue to it. the lid had scratches on it indicating that it was probably quite old and had been used many times before. "this is a cure for hiv. it is a mixture that a sangoma has created. unlike the western treatment that the doctor is going to offer you, it has no side effects. the other advantage is, because it is a cure, you only need to buy two bottles and use it for only two weeks and you will be cured. and each bottle costs only two hundred rand." she smiled. it was meant to be a warm, reassuring smile, but the patient saw it for what it really was, an evil smile hoping to snare yet another victim and send her down a slippery slope after fleecing her of her hard earned money.

yes south africans can be entrepreneurs. i don't have it in me though.

diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.