bongi reads

recently i was asked to do a reading of my blog for a sort of art evening for some of the doctors at our hospital. i read only four posts. i have decided to post the first one i read here.

doctor's visit

doctors don't like to go to doctors. i suppose we might see it as a failure or more likely it is pure intellectual arrogance. whatever the reason, there can be no excuses when you need to get an insurance examination form filled out. one way of taking the edge off it is possibly to try to use your conversational skills to awe the poor general practitioner forced to see a colleague in these uncomfortable circumstances.

dr peter swann, a tall dark and handsome man, wise and hyperintelligent, popular amongst women, with a vodka martini (or was that an austin martini, i forget), was required by his insurance company to get a signature on a form at least saying he was not quasimodo and had a blood pressure no more than moderately elevated. there was no option. he had to go to one of the local general practitioners.

as consultations went, this one was going quite well, except for the awkwardness inherent in having to examine a colleague. the gp had managed to establish that is was unlikely that dr swann would suddenly drop dead in the next hour or two, thereby defrauding his insurance company of millions and millions of rands (about a dollar fifty). in fact dr swann was even beginning to relax. so when the gp asked about any previous surgery it didn't seem at all inappropriate for dr swann to discuss in detail his recent minor surgery in the local hospital. in fact he decided it would be a good idea to wax lyrical.

"i recently had a small procedure done. everything went well, but it was a strange, somewhat unnerving experience."

"why is that?" the gp feigned interest.

"well, as you, know, in my line of work we don't really get to know the anesthetists too well. so i was quite surprised when this elderly blond haired wild looking lady introduced herself to me as the person who would be keeping me safe and soundly asleep while under the knife. when i told her i was a colleague she seemed much more nervous, and that's saying quite a lot because her general appearance and demeanor hardly radiated the impression of someone in control." the gp seemed suddenly a lot more interested in doctor swann's story, so, feeling encouraged, he continued.

"everything went ahead as i suppose it does just before an operation. i was moved across to the theater bed and all the necessary wires were attached to me. of course i was nervous, but i was trying to put a brave face on it. i even tried to make a joke or two, but she seemed much too tense to laugh and in the end her reaction just made me more nervous, so i decided to just quietly lie there and pray that everything went well. then she started to inject the white stuff that brings sleep. but just as she did, she suddenly stopped and spun around in a panic. she then turned to the nurse and spoke.

"where is the thing? you know that think i need? dam, why does this always happen when i'm working on a colleague?" obviously i was terrified. what was this thing that she referred to and how important was it in keeping me alive during my operation? why does what always happen when she is working on a colleague? was i going to survive or were these my last thoughts on this earth? i just started trying to ask her these questions, but it was too late. the white stuff she had injected was doing its job and i drifted off to sleep with more than a little concern for my safety." he stopped for effect. the gp was looking on intently. swann smiled. it was a funny story and he felt he had told it well. in fact he felt sure any ice that may have existed between him and the gp had surely now been properly broken. it even seemed strange that there had been any tension between them earlier.

"do you know the anesthetists at all?" asked doctor swann.

"yes, some of them"

"do you know the one i'm talking about?"

"yes. she is my wife."

the ice froze over instantaneously.

rambo

south africa is such an interesting place. things happen here that surely can't happen anywhere else in the world. take illegal mining in barberton for example.

barberton has some of the oldest deep gold mines in the country, maybe even the world. the gold rush in barberton happened long before gold was even discovered in johannesburg. of course the massive amounts of gold in johannesburg drew all the prospectors away and left barberton as a tiny, insignificant lowveld town with ghost mines. as time went on, it once again became financially worthwhile for the mines to be opened, although really only on a much smaller level. but once it became clear that there was still gold in the mines, the illegal miners were born.

it is difficult to fully understand what an illegal miner is. imagine people going down air vents and other such unmapped openings into deep underground labyrinths of once sprawling mines where they apparently stay for up to a month or two at a time illegally. they work mainly at night when the legitimate miners are no longer there and melt into the many unchartered tunnels during the day. being south africa, of course the propensity for violence is always there, so, when you put together your mental picture, add quite a number of ak47 assault rifles smuggled in from neighbouring mozambique.

so of course when the people in power  decided to rid their mines of illegals, it wasn't going to be enough to simply leave pamphlets lying around asking them to please leave. they decided force might be a more traditionally south african option. fortunately after our bush wars in namibia and angola we have an abundance of highly trained soldiers so to find hired guns is no problem at all. and in the end, that is what the mine executives did. they hired guns.

i was on call the night the barberton hospital phoned. they apparently had a gunshot patient shot with an assault rifle they wanted to send to me. it was different from the normal 9mm wounds i was used to seeing so i was frankly quite keen to accept the patient no matter what the injuries. it was going to be exciting, i thought, except of course a head injury. then the doctor said something even more left of the ordinary.

"bongi, they are going to bring him in themselves. it will take too long to wait for an ambulance." i was confused. who were the they he was referring to that were going to bring him in? how were they going to bring him in? was he going to be dead when they brought him in? these thoughts slowly migrated through my mind on their way to my mouth but before i could ask, my colleague had put the phone down. i was left with almost no idea of what to expect, but i at least knew it was going to be interesting.

half an hour later i was waiting at the entrance to casualties in true grey's anatomy style. for a split second i even felt more like an actor than a surgeon and nearly went back inside. but in the end my curiosity got the better of me and there i stood like the leading part in a hollywood production in the warm lowveld night waiting for something that i somehow knew was going to be out of the ordinary.

they arrived. it was out of the ordinary. a bakkie roared into the hospital parking area, apparently totally oblivious of the speed humps in its way. it came to a skidding halt just in front of me. immediately the driver got out and moved around to the back. his most striking feature was the r4 assault rifle strung over his shoulder, but it was only fractionally more striking than the rest of the man. he wasn't a particularly tall man, but he was well built. he wore black leather clothes, contrasted sharply with a dirty red bandana tied around his head. on his belt he had about four magazines for his rifle. quite clearly he was ready for quite a fight. then i noticed his face. it was calm and very nearly devoid of expression.

suddenly i noticed a second man standing on the back of the bakkie. he too was dressed like an action hero out of a low budget eighties movie, complete with assault rifle at his side and once again his face was without discernible expression. they reached down to lift something. only then, only when i heard the soft groan of pain, did i realize that the gunshot guy was lying on the back of the bakkie and this had been the they that were going to transport him. immediately i knew they must be the hired guns to flush the illegals out of the mines. there was ordinary and then there were these guys who were definitely out of it. i was intrigued.

they lifted the injured man and started carrying him to the doors.  they did glance at me as they went past but to them i think i looked too much like a tv doctor waiting outside to be taken too seriously. i scurried in after them, feeling somewhat sheepish.

the patient was in a fairly good condition for someone who had taken an ak47 round somewhere deep in the bowels of the earth and then been transported by rambo and sons over the mountain to our humble hospital, although he had quite obviously taken fashion advice from chuck norris.  i quickly rushed through the preliminary steps  to prepare the him for theater. then i went outside to speak to his colleagues, for quite clearly that is what they were.

"i'm doctor bongi. i'll be looking after your friend" probably the wrong choice of word, seeing as though i still had seen no display of emotion from any one of these guys, except possibly stoic resignation in my patient. "i think he will be ok." even this didn't move them. they looked exactly the same as they did when they still thought their colleague was sure to be dead by the morning. "tough crowd" i  mumbled to myself.

then i spent a bit of time trying to find out what had happened. i quickly understood their facial expressions.

they were part of a team hired to flush the illegal miners out. the plan was to go down the official shaft after all the legitimate miners had knocked off. then they were to push the illegals back and drive them out through the numerous secret tunnels that only they knew about. the only problem was this was day two of operations, so the illegals were expecting them. i put it together in my mind. a small group was going to go down in a lift into a mine full of armed criminals who knew exactly where they would be arriving.

"you went down in a lift into a war zone?"

"yes." expressionless.

"but they knew where you were going to get out. all they needed to do was wait for you at the lift."

"yes."

"yet you still did it?"

"yes." still no sign of anything close to emotion.

"why?"

"it's our job." did i detect the slightest hint of pride? no. it was probably the outside light reflecting off the wall giving a certain glint to his eyes.

"so what happened?"

"they were waiting for us. when the lift doors opened, they opened fire and hit our friend." i though he was using the word friend in a very broad definition of the word because i was fairly convinced the only interest he had in the survival or otherwise of my patient had more to do with who would they get to replace him when they went down the lift the next night.

"and once they had opened fire, how is it that you guys survived?"

"we fought our way out." at this stage the total lack of any expression on their faces was expected, but still i didn't expect it. it seemed to me that someone who goes into a death trap, sees his 'friend' get shot and then fights his way out to survival should maybe at least have the hint of something in his face at least resembling human expression or emotion.

i operated their colleague. i dissociated myself from his humanity, cut him open and got the job done. and then i realized. in so many senses, i too go down the lift into the dark depths of the earth full of people only out to see my demise. i too put myself in harm's way for some greater benefit and i too face trauma, albeit not my likely death. then i understood their blunted emotions. they were not too different from a surgeon.

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.

chicken feet

i hate kalafong (hell). there are many reasons for this (here, here, here, here, here), most emotional, i confess. but if i am honest there is one incident that stands head and shoulders above the myriad of traumas that i experienced there.

one of the strange idiosyncrasies of kalafong (hell) is that some time during each night shift, all the sisters of each ward get together in the duty room and eat chicken feet. i have no explanation for this. maybe there is an abundance of chicken feet in the area. maybe the sisters are paid in part with chicken feet that absolutely must be eaten before they leave for home after their shift. maybe it is part of some bizarre ritual that initiates all kalafong sisters into some secret evil cult. i simply do not know.

i was a mere fourth year medical student which meant i was at the absolute bottom of the rung that night on call for internal medicine. i knew nothing and was of almost no help to anyone. the only thing that i could do was to put up drips, so the senior medical students would send me to the wards whenever they got a call that a drip needed inserting. for some reason kalafong sisters never put up drips. maybe there was a fear that the patients were allergic to chicken feet and the residue of the no doubt scrumptious delicacy on the fingers of the sisters could potentially cause the patients harm. they were clearly not about to take that chance, so there was plenty of opportunity for me to hone my already very well honed drip inserting skills.

i had just left the female medical ward after inserting a whole host of drips and was quite keen to see what was going on in casualties. i walked in.

"drip to be inserted in female medical." the sixth year student smiled. i don't think it was really meant to be malicious although it felt that way at the time. i think it was more a relief that he had done his years of continuous drip insertion honing and was glad that he honed no more. it was the natural cycle of things and he had passed the batton to the next group. it was simply my turn.

"i was just there!" i protested at no one in particular, turning to leave with my shoulders sagging just enough to be noticable to the discerning eye.

i entered the ward through the back door. the main door had been locked by the sisters. this was another thing one got used to there. it was just something the sisters did at night.  the reason for this behaviour elluded me, especially when they had just called for someone to insert a drip. you would think that they would unlock the door in anticipation of that person actually arriving to insert the drip. maybe they needed their privacy while performing strange initiation rites with chicken feet.

as i entered the ward, a patient looked at me.

"doctor, help me! i'm dying!" i froze. it was dark. i could only make out the patient's shape, silhouetted against the dirty cream coloured wall. yet her eyes were so wide with fear that i could see her white sclera. i felt a shiver go down my spine. what was i to do? i was only a fourth year. i didn't know this patient and even if i did, i had no knowledge to actually help her. in my naivety i hadn't yet learned the rule that more often than not, if a patient tells you they are dying, it is because they are in fact dying. the one thing i knew is that i couldn't ignore her.

i walked up to her. she lifted her arm weakly. then suddenly her fingers encircled my arm and all her remaining strenght seemed to go into her grip. her nails bit into my flesh as she pulled me close to her face.

"help me doctor, i'm dying!" she repeated. she scared me, so i pried myself loose and checked her file. she had been admitted the previous day with the diagnosis of meningitis. antibiotics had been prescribed but only one dose had been signed for since admission. probably the drip had been out when the other doses were due and once some poor fourth year had reinserted it, the sisters hadn't bothered to put up the dose that had been missed. at least there was something i could do, i thought. i could check to make sure the drip was working and get the sisters to give the last dose of missed antibiotics. somehow i allowed this thought to make me feel better. i would help this lady and all would be well.

i checked the drip. it was working well.

"don't worry, mamma, i'll send someone to help right away." i said as i turned to leave. she lunged for my arm again when she saw that i was going, but there was no strengh left and she missed. as i walked away a knot developed in my stomach. i felt that i had failed this old lady. i had done the little bit my knowledge had permitted me to but i had also allowed my fear of her and of what she was facing to intimidate me to such an extent that i hadn't really stayed to comfort her. i was determined to be a change in her circumstances and her life. i would speak to the sisters.

i walked to the duty room. the door was closed but there was an almighty din emanating from inside. the sisters seemed to all be shouting and laughing in unison. i knocked and opened the door. for a moment the bright light from their happy little room blinded my eyes that had become accustomed to the darkness of the ward. the light seemed to pour out into the gloomy ward behind me. all the sisters were sitting around the table eating chicken feet. when they saw me they all went silent, but continued eating.

"good evening sisters." no answer, unless silence is an answer. "sorry to bother you but the patient in bed 5 in cubicle d is in a bit of distress."

"we'll check on her now now." i knew what now now meant in our strange south african english. now now was not as soon as now and implied no urgency. now now was not as now as i wanted it to be.

"ok," i said, knowing that if i antagonised them they would purposely postpone checking on her just to teach me a lesson. "also i see that she hasn't yet received her last dose of antibiotics. her drip is working, i checked, so please give it to her when you go to her." the sister looked up from the chicken foot she was now toying with between her fingers. i saw in her eyes that she despised me, although i had never laid eyes on her before in my life. some things in kalafong one learned to accept.

"i said we would see to it now now!" she repeated. then her head dropped back down to give the chicken feet the full attention they seemed to deserve. i stood still for a minute. then i quietly closed the door.

as i walked away to do the drip i had actually come to the ward to do, raucous laughter errupted from that small brightly lit room. it brought me to a stop in the middle of the floor in the dark ward. i felt tears well up. i didn't know if i wanted to cry because the sisters were clearly enjoying a joke at my expense or at the futility of an old woman who lay in bed 5 in cubicle d all alone with the fear of death over her. i just knew there was something horribly wrong with the whole picture.

i got the drip up and running in double quick time. i then rushed off back to casualties, but not before quickly checking on the patient again. when i approached her she still had the same stare. this time her arms lay still on the bed beside her.

"don't worry, mamma," i said, "i have asked someone to come and help you. it is all going to be ok." she didn't react. "i promise i'll also come back myself tonight to check on you." a little of the fear went out of her eyes. only a little.

on the way back to casualties i made sure i composed myself. it wouldn't be good to show the senior students that i had been so affected by something they no doubt had seen quite a lot of. anyway everyone always said not to let kalafong get to you, otherwise it could change you forever. at that moment forever seemed like such a long time. the sixth years were busy doing a lumbar puncture behind one of the flimsy curtains in the casualty unit that seemed designed to give the impression of privacy without actually delivering any real privacy. one of them looked up.

"sorry dude, but they just called for another drip in male medical." i turned and walked out without saying a word. the quiet of the open air kalafong corridors could possibly afford my soul a bit more peace than the overwhelming noise of human suffering of casualties. usually i could handle it, but then i felt a despondency and futility that was too much to bare.

in the end there were three drips in male medical so it took me longer than expected to get them all up and running. this time it didn't bother me. i was in no rush to get back to casualties. also i knew i had told the old lady in female madical i would check on her and i was afraid. i was afraid of what i could not do for her. i was afraid i would be inadequate. i was afraid of the face of fear that i had seen in her eyes. somehow her reality at that moment was too real and i didn't want to face it. i wanted to be at home in my warm bed, ignorant of how terrible life could be. but i knew i had to go to her. if for nothing else, i had to just be with her so that she was not alone. i walked slowly to female medical.

i walked past the duty station. this time the door was open, but besides that there was no discernible difference. all the sisters still sat exactly where they had been. some of them were still eating the last of the chicken feet. the light from their room lit up half the ward, but did not reach all the way to cubicle d. they didn't see me slip past them so their laughter must have been aimed either at someone else or just part of the normal merriment associated with people sharing a meal together. still, just like the light, it seemed to me to be out of place.

"mamma, i'm here" i whispered as i approached her bed, just in case she was asleep. she lay with her head to one side. she didn't stir. i walked closer and took her hand. it was cold and clammy. i leaned towards her face. even in the darkness i could see her eyes were open, but they were fixed in the stare of death. she had died alone and i had failed her completely.

i have hated the sight of chicken feet ever since.

understandings

anaesthetists and surgeons work together quite a bit, but they are very different creatures. sometimes it takes a bit of effort for them to understand each other and get along. some would say it takes effort from pretty much anyone to get along with a surgeon. so it is nice to hear a story occasionally of an anesthetic colleague that is willing to do what is needed to understand and get along with the general surgeon he was working with. these were the observations of a student during his rotation through the anesthetics department.

when the student in question arrived at work, he was quite excited to hear that he was dealt into the emergency theater.

"off you go," said the prof to him, "they are still busy with a trauma case from last night."

when he entered theater it was clear that there had been quite a lot of action. the floor was covered in blood which had been smeared around by the feet of the surgeon and the floor nurse, creating a macabre work of art with bold red strokes of the brush on the canvas which was the floor of theater. against the wall on a rack hung multiple blood soaked swabs, bearing testimony to the battle that had already taken place in that small room. the surgeon was still frantically busy working in the open abdomen, his arms besmirched with dark blood to his elbow. the front of his gown was similarly stained. the student looked around and took in the complete picture of this fight between life and death, yet immediately he noticed something that didn't seem to fit in with the high stress situation that met the astonished student.

off to one side, the anesthetist sat quietly in his chair with his arms folded and a calm expression on his face. he wasn't even looking at the monitor. in fact he sat slightly behind it. from this vantage point he glanced up, greeted the student and offered him a chair. the student sat down wondering at the steel nerve of this anesthetist in the face of such a tense situation.

then an alarm went off on the monitor. the student jumped up to get out of the way as his senior finally moved to see what was happening. but all he did was to turn the alarm off and sit down again. and so the student sat there with him, too nervous to speak and wondered what was going on.

after quite some time the intense concentration of the surgeon was broken. he turned to the anesthetist.

"how are things going up there?" he asked and then as an afterthought added, "the bleeding is now under control."

the anesthetist slowly looked up and spoke for the first time with a wry smile plastered across his face.

"well actually the patient has been dead for quite some time now," he said, "but i know how much you surgeons like to operate and it looked like you were having so much fun, i didn't want to disturb you."

la mancha

the man was an enigma. those who knew him soon realised he was the only person in kalafong (hell) that cared anymore. somehow that terrible place hadn't eroded his soul to such an extent that he no longer gave a damn about his patients. yet to those who only had a fleeting acquaintance with him, he seemed course and even harsh. he didn't fit into kalafong (hell), yet he would not have fitted into any other place quite as well as he fitted into kalafong (hell). yes, he was an enigma.

my consultant in kalafong (hell), the enigma, had a certain way of bringing his point across (here and here). on the face of it it was never pretty but it was always funny in some twisted sort of way, despite that never being his intention. he also had a knack of going off on some wild tangent for seemingly no reason. what we may have thought was normal would more often than not set our own don quixote off on some wild quest chasing what seemed to us to be little more than windmills. but who were we to argue? he was after all the consultant.

so on that particular morning, when the house doctor showed the don the official consultation form from the internal department requesting us to drain an abscess on one of their patients there really was no way for him to know that this would cause the old man to fly into a frenzy and charge off towards the wards of the unsuspecting internal medicine department, his entire entourage, myself included, in tow. i was a very junior medical officer so i kept to the back and just observed.

"where are the doctors?" he bellowed at no one in particular as he stormed through the doors. "are you all deaf? i said where are your doctors? i want them here right now!" from behind a few curtains here and there the house doctors of that department peered, eyes wide, like frightened rabbits. still they froze and moved no closer.

"i said come here!" he shouted pointing directly at the closest one. "you! are you a doctor?" it seemed like a silly question. of course he was a doctor. but our master continued, "i said are you a doctor?"

"yes sir." wrong choice of words.

"don't call me sir!! do i look like i've been smacked on the shoulder by some foreign queen?"

"no, professor."

"don't call me professor!" his face went red with rage and despite it seeming impossible, the volume of his rantings increased. "i am not one of those academic professors in that ivory tower on the other side of town who operate by remote control from the comfort of their large chairs in their studies! i am a real surgeon!"

"sorry doctor."

"that's better." his voice dropped down back to jet plane decibels. "i asked you a question. are you a doctor?" the poor guy's lip quivered as he carefully and deliberately chose his words.

"yes doctor."

"what degree do you have?" we all cowered out of the direct line of sight of the man just in case he asked us the same seemingly easy question. at least we now knew not to call him sir or professor. but the poor internal house doctor had no such privilege.

"i have an mbchb, doctor." he almost whispered.

"yes you do. and do you know what that means?" before the confused victim could answer this next seemingly easy question our consultant blundered forth. "bring me a blade and show me where this patient is with the abscess.

a few moments later we were all standing around the patient wondering what was going to happen next. the house doctor was visibly shaking.

"i asked you a question?" continued our mentor, toying with the knife in his hand that the doctor had fetched for him "what does mbchb mean? or what does the chb part mean? the mb part is easy. that means you can give pills out. any old monkey can give pills out, but now i want you to tell me what the chb means"

"i'm not sure sir, i mean doctor!"

"if you call me sir again i will have you thrown up against the wall and i will bring a firing squad in here and have you summarily shot!" our consultant believed a firing squad covered a multitude of sins. "well let me tell you what it means. you see this sharp shiny thing in my hand? this is a blade. chb means you are trained to use one of these. it means you have a bachelors degree in surgery and it means you can lance an abscess. now watch me." he turned towards the unsuspecting patient. "you see now. this is the blade and this is the abscess. and this is the blade draining the abscess." with that he sunk the blade deep into the abscess. the patient winced, but, surprisingly made no other objection. i assumed he felt the threat of the firing squad may have been a general threat and that it was not limited to the poor house doctor. also once the thick stream of puss came out, there even seemed to be relief on the patient's face.

"there you go, mb and chb. now never consult us to drain an abscess again!" he turned and strode out. we had to follow. i was right at the back so i think i was the only one who heard the quiet and slightly bewildered voice of the house doctor as he said;

"i didn't consult you. that isn't even my patient."

live and learn

i am not an orthopod. i don't drive a four by four. i don't wear a checkered shirt and i sure as hell don't use a tourniquet when doing an amputation. to be fair, i have nothing against four by fours and a checkered shirt just makes me look like i'm wearing a dishcloth. but the tourniquet rule is absolute.

there are a few sound clinical reasons general surgeons don't use tourniquets for amputations. we tend to do amputations on people with compromised arterial blood supply so we tend not to want to make things worse by constricting the artery upstream from where we are working. we are maybe a bit scared that that constriction will be just enough to cut the artery off permanently, the proverbial last straw. also the bleeding in our patients with such poor blood supply is much less so a tourniquet is consequently less helpful. in my case, however i think the decision is also based on previous emotional trauma.

i was a community service doctor in a rural hospital. quite early on in that hospital i had already been schooled in the fine art of surviving without senior cover, so when my cuban orthopedic consultant asked me to handle the rest of the theater list i pretty much knew i had no choice in the matter.

"uum, doctor, the last case is a below knee amputation. i've never done one of those." i objected, not that i had any hope of my gentle supplication bearing any fruit.

"yes, but you assisted me with one just last week. just put the tourniquet on, cut the leg off, tie the vessels and close like you saw me doing. i'm tired and i'm going home now." with that, even before waiting to see the pained expression on my face, he turned and left. i had no choice. i was about to do my first amputation.

i carefully placed the tourniquet, pumped it up to the required pressures to prevent any blood supply to the doomed leg and went to scrub. quite soon i stood with only the theater sister to help with my knife poised, ready to do my thing. i mean how hard could it be? i just needed to get the leg off and the wound closed. so with this misplaced reassuring thought in my mind i got to work.

half an hour into the operation (i was a lot slower in those days) i was feeling quite good. i had identified the major vessels and tied them off. the bone had been cut and i was handing the leg to the floor nurse. i thought to myself that this is what it feels like to be a surgeon. you look important and in control. it was quite a rush. i should have known it was too good to last long.

at about this stage i decided all that remained for me to do was to let the tourniquet down, to make sure i had control of all the bleeders and close the wound. i was already thinking of all the people i needed to phone to tell them i had lopped a leg off. my friends in internal medicine would be so jealous. pity when i had assisted the orthopod the previous week i hadn't paid much attention to when and more specifically how he let the tourniquet down. i decided i would decrease the pressure by half. that way if there was an arterial bleed, i reasoned to myself, i would see it and control it before it got out of hand. it didn't occur to me at that heady moment of my life that if i allowed the artery to pump blood into the leg but maintained a tourniquet pressure high enough to prevent that blood from getting back into the body via the veins the result would be venous engorgement with resultant venous bleeding. even when every tiny microscopic vein started oozing like there was no tomorrow, i still didn't make the logical deduction. i just kept on clamping the veins one by one and tying them off with trusty vicryl. but the more i tied off, the more new bleeders seemed to sprout into life and start oozing uncontrollably. i suddenly wondered if one could die of vicryl toxicity. it sure seemed i would find out with the amount of vicryl i was systematically putting into that stump.

and so this scenario continued for quite some time. all the bravado and gusto that had swollen my head only moments before was long gone. i felt alone and scared. i even considered calling the cuban consultant, but he had made it quite clear i was expected to handle this myself. i was determined to soldier on.

"doctor, maybe you should blow the tourniquet up again?" the sister's suggestion seemed logical but somehow it just annoyed me. if i hadn't used the bloody (pun?) tourniquet in the first place i wouldn't be in this mess, i answered her in my mind, but that didn't seem to make sense. somewhere from my deep subconscious i started hearing a little voice. i suspect it had been screaming at me all along, but in the heat of battle i had been too distracted to pay any attention. at last i stopped to listen. the tourniquet was the problem, not the solution. that is why the thought of blowing it up again was so annoying to me, even if on the face of it it seemed like a good suggestion. i immediately knew what to do.

"please blow the tourniquet completely down." i said, trying to sound as in command as my quivering voice would permit me to. i then took a swab, pushed it against the oozing open wound and took a moment.

after not too long i ventured a quick peek at the wound. i lifted the swab and was relieved to see a dry wound with absolutely no bleeding. even the tiniest of vessels donned a vicryl tie and i think the few remaining capillaries were too scared to permit even one red blood cell to escape lest the same fate befell them.

at last i got the stump closed and left theater, completely worn out form the high levels of adrenaline i'd been exposed to, albeit directly due to my stupidity. oh well, live and learn.

never again did i use a tourniquet for an amputation.

twisted testicles

testicular torsion, to put it mildly, is a terrible condition. the testis twists around on its axis, cutting off its own blood supply. over and above the excruciating pain, if it is not operated within about six hours of it happening, well then you can pretty much kiss that testis goodbye. and to make things worse, it strikes young boys who have just entered puberty while they are awkward and unsure of themselves. it is seldom that they ask for help until long after it is all to late. at least that makes the operation easy... you simply cut out the necrotic testis, easy as pie. but at the operation, it is always important to remember that if the one testis has twisted, the other one tends to follow suit in due course, so, while chopping out the twisted testis, it is absolutely imperative that you suture the other testis to the scrotum so that it can't twist. of course if you omit this step, in all probability, in a few years time, the poor awkward teen is going to loose his second testis and this is really going to mess with his mojo, pretty much for the rest of his life.

but testicular torsion is not something that i deal with all that much. you see the condition falls into the realm of the urologists and if these humble creatures are to be found in your local hospital, then torsions go their way. however, even mighty urologists need to take time off. then us humble general surgeons step up and cut out on their behalf. recently i was put in this position and handled a testis torsion. but it reminded me of another one i dealt with a few years ago.

the patient, an eighteen year old young man, turned up at casualties about 20 minutes after developing excruciating pain in his right testicle. on examination it was clearly a torsion. but what i noticed immediately was the missing left testicle. i asked him about it.

as it turns out the patient had had a similar problem with the left testicle about a year previously. then, as was typical of young men of his age, he had waited a full day before he worked up the courage to go to hospital to seek help. of course the left testicle was already necrotic and had to be removed. the urologist tending to him at the time had done the right thing to the right testicle and fixed it to the scrotum so that it would not twist like its troublesome left counterpart. but still here i was faced with a patient with only one testicle and that one was twisted and in real danger of moving on to the hereafter (testicle heaven). also the urologist had previously operated the patient and, despite that, his remaining jewel was in danger. now that all the urologists were gone or on leave or dead or whatever, what chance did that poor nut have in my mere general surgeon hands? yet i felt the necessary urgency of the moment. one testicle is bad enough, but none??? unthinkable!!! i booked him for theater and demanded immediate theater time (something somewhat more scarce and valuable than fine gold in south africa).

surprisingly, soon i found myself (and the endangered testis) in theater. i opened the scrotum. the testis was twisted as i knew it would be, but, luckily, it was still viable. what was interesting was that the stitch that the urologist had placed a year or so earlier was still there. the testis had managed to rotate around the axis created between the stitch and its blood supply. this was clearly a testis hell bent of causing havoc and depriving its owner of full manhood. i was not about to let it do that.

i twisted the testicle back to its natural position, but somehow i needed to keep it there. one standard stitch by a urologist clearly had not been sufficient. luckily i was not a urologist. i would not be shown up by some young, single, upstart testicle, especially when my patient's very manhood rested on my actions. i fixed it and i fixed it good.

i replaced the urological stitch, then i placed four more stitches at the four points of the compass. i felt pretty sure that nothing would convince that testis to twist again. yet i still wasn't willing to take the chance of this young lad having to face life without all the questionable advantages of testosterone, so i felt compelled to do more. i used my cautery to burn multiple small scars into the surface of the testicle so that once i closed it in the scrotum, each little scar would attach to the scrotum, fixing it absolutely and permanently so that there would be and could be no question of any further gyrating and twisting. that testicle would do nothing without the scrotum knowing about it. i felt good. i had done my (or rather the urologist's) job and i had done it well. i had made a difference to a small testicle and his boy.

the next monday when the urologists had come streaming back from their no doubt deserved respite, they were quite eager to hear if i had handled anything for them. when i relayed the story of the stubbornly rotating testicle to the very one who had placed the first stitch a year or two previously, to no avail, apparently, i was not impressed when he questioned if i had sufficiently fixed the testis in place.

"are you sure that testicle won't rotate again?" he asked.

"no, i am not!" i replied, "but i can assure you if it tries to rotate again, it's going to take the whole patient with it, so look out for a guy walking down the streets doing a pirouette every so often and you'll know that's the guy i operated!"

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.