thumbs up

it was a battle. looking back i don't think we ever had a chance, but you don't just give up on a young man in the prime of his life. we had to try. he was my patient.

he was a foreigner, on a gap year in africa where he was going to learn all sorts of things about conservation and african wildlife. up until the accident, all had apparently gone well. the group of teenagers on the course had so far enjoyed every moment of their time together and some close friendships had even begun to develop. as it always is with these sorts of things, when they all climbed into the bus that day, no one expected what rippling ramifications there would be

from what was later told to me, it sounded like the accident happened in slow motion. the bus was driving along a fairly narrow mountain pass when, while negotiating one of the sharper turns, one of the back wheels went off the road into a ditch. as the bus drove on, the wheel was dragged along trying to remount the edge of the tar before a steep precipice that was looming up. it was unsuccessful. when the side of the road dropped away beneath the wheel, the undercarriage of the bus smashed into the edge of the road and slowly started getting dragged down. still the bus drove on. i suppose the driver either didn't realize the dire nature of his dilemma or he felt he still had a chance of pulling the bus back up onto the safety of the road. whatever his reasoning, it didn't work. slowly the back of the bus slipped further and further off the road. once the other back wheel also went off the edge, the bus teetered for a moment and then went crashing and rolling down towards the river below. in those moments between the realization of impending doom and the moment of the first impact of bodies colliding with the walls and roof and floor in a continuous spinning cycle, i often wonder what he thought. was he aware of the gravity of the situation or, like most people that age, did he trust in the indestructibility of his body? did he cease to look forward to the promise of a long and happy life and instead, look back to see if what had gone before would constitute a worthwhile existence? was there an awareness that the sheer abandonment of youth was over forever? or were his thoughts limited only to the constant tumbling of the bus and the melee of the bodies of his friend being thrown together and around.

for what had happened most of the people got off fairly lightly. sure, as the noise of the tumbling bus settled together with the dust it would have been replaced with screaming and sounds of pain and despair, but there were surprisingly few serious injuries, except of course my patient. there will always be chaos after such an event. somehow i think my patient didn't make too much noise. it would have been painful to breathe let alone scream. i imagine him lying quietly in blood soaked gravel, almost hidden from view of the rest of the disaster trying to make sense of all the new sounds and smells and sensations, trying to come to terms with what had happened and that it had happened. young people are usually not burdened by the ramifications of events so i doubt he thought too much about that. that would be left to others to contemplate later once all else had gone quiet.

the paramedics triaged well. only one patient was deemed serious enough to fly out with a helicopter. all the rest were stabilized and transported via more conventional means to our hospital.

so it fell to me to wait in casualties for the helicopter to land and deliver to us what was described as a severely injured young man. it was a situation i had been in many times before. it was, in fact, what i was trained to do. as usual i took the time to calm myself and reflect. experience had taught me that once the patient had arrived there would be little time to even think. everything would happen almost automatically as it had done so many times before. my body would go into a very focused state where anything that is not immediately associated with keeping the patient alive almost shuts down. i don't feel hunger or thirst or fatigue. my body doesn't require toilet breaks or to deal with any such basic needs. i even don't feel emotion. i get on with the job. get it done, that is all that matters at that moment. so when i saw my patient for the first time i was surprised by my reaction. looking at this young man with a broken and battered body touched me. he was quiet and seemed to have accepted his fate. he looked at me. there was peace in his eyes that seemed to defy what had happened to him. i like to think he smiled, but to tell the truth, my mind might have added that in later. i felt sorry for him. i didn't want him to die. i determined to do everything and anything in my power to prevent that, although i knew that is what i would have done anyway. only with him there was an emotional aspect to my determination.

once we got to work, my focus came. no longer fettered by the mist and fog of human emotion we quickly did all the necessary things to get him to theater. i stayed by his side the whole time, orchestrating everything, leaving him only once i had handed him over to the anaesthetist and then for only as long as it took me to change into my theater clothes. i joined my colleague as he was wheeling the gurney into theater. for a while i would be an onlooker until the patient was asleep, leaving my charge to my anesthetic colleague until then. after that we would battle together for the life of this young man, each carrying out our relevant roles in this drama.

i looked at my patient. his eyes were fixed on me. i wondered what was going on behind those eyes. despite being so severely injured they still seemed to be focused. the humanity was obvious. i felt for him again. i imagined myself in his position, so far from home facing such incredible odds and all that, completely alone. i had to touch the humanity of him before i engaged in the struggle that lay before me. i placed my hand on his shoulder;

"don't worry! we will do everything in our power for you." his gaze stayed as it had been. then he slowly lifted his hand and gave me a thumbs up sign. he believed in me and trusted in me. it was almost too much for me to bear.

we fought for him for hours. we fought so long and so hard that even when we knew we had lost the fight, we fought on. we hoped against the odds and against the creeping knowledge that we had lost and just kept going. only finally when my patient was absolutely dead (if that is even a concept) did we acknowledge defeat. afterwards, with this sort of thing, once the body is allowed to admit its own needs, they often come flooding back. suddenly i felt tired and hungry. the tired was more than just the fatigue of the physical body, but it was also the deep tiredness of soul, the feeling that you had been somewhere and done something that no human is supposed to have done. it is a type of tiredness you know will follow you for years to come, a tiredness that defies sleep or any other measure to combat it. i looked at my colleague. i think he felt the same. we walked out together in silence. there were no words left. they had been all used up in the preceding hours with business words like 'more blood' and 'another f#ck¡ng artery clamp now' and 'squeeze the heart now or we've lost him'. Soft words like 'are you ok?' just didn't seem appropriate anymore.

the next day, while the wounds were still fresh, the hospital administration told me that his parents far away in europe had asked what had happened in his last moments and if he had suffered much. they suggested that if i felt it appropriate, i should write to them. maybe somehow they knew i needed some sort of reassurance or healing or closure too and felt we could 'cry on each other's shoulders' as it were, i'm not sure. it all seemed a bit odd. then i thought about my patient raising his thumb to me. that surely was his last moment. the hours after that weren't his moments. they were mine. i suddenly realized that that raised thumb of trust and hope carried some beauty, some strength and i knew his parents would want to know about it. it was my duty to let them know.

i wrote a letter to them. i did not need to go into the details of the battle in theater with all the blood and guts and the slow fading of life. i just needed to tell them the strength that he demonstrated right up to the end. i wrestled with every word that i put in that letter but finally i had something that i gave to administration. they passed it on to the parents.

only  a day later the reply came and was forwarded to me. i read the words but they were so much more than words. i could see the tears and heartache and dashed hopes and regrets of parents far far away having their world ripped from under them. i knew it was a level of despair i could not understand and which i did not want to understand. to me they expressed gratitude and said they had been moved by my email and that it had helped them to deal with the grief. they went on to say they would like it very much (they came from a country where people tended to say things like 'like it very much') if i would continue a correspondence with them. 

i sat down. for me my pain was still very close to the surface but it would heal. theirs would never heal. they had lost a son. i had just lost a patient. i could feel the longing in their 'like it very much' for more. they didn't want their son to be gone and would cling to anything that could possibly fool them into thinking he was still just away in africa and would probably return any moment. i could not be that thing.

i no longer wanted to be what i am. i no longer wanted to struggle and fight in theater against the odds to stave off the inevitability of death. i no longer wanted to see the snuffing out of promise and life. i no longer wanted to think about the devastation left in the wake of the disasters that cross my table. i no longer wanted to be a surgeon.

awkward

recently i attended the association of south african surgeons congress. it's always strange and maybe fun for me to interact with surgeons. they are extremely interesting to me. i feel that i'm a bit of an outsider in the sense that i don't view myself as a typical surgeon, so i can sit back and observe, fooling myself that they are not looking at me in exactly the same way.

but one thing about these congresses is that you get to see and rub shoulders with the heavyweights of the profession. it took me back many years to another congress that i attended when i was still a mere mortal registrar and truly was not yet one of them.

the congress in question was in durban. at that stage i pretty much kept away from all the big names. it seemed the safer thing to do. however, one of my fellow registrars and a good friend of mine was quite friendly with the vascular prof, a greater than life man and a true legend in his own time in south africa. in fact my friend went on to specialize in vascular and is now himself a well known vascular surgeon in one of the big centers. so when my friend invited me to the vascular dinner the one night, i should have just said no. i didn't.

the vascular dinner, as i was to discover, was a fairly exclusive affair. it was sponsored by one of the companies that supplied prosthetic grafts, mainly used for the repair of abdominal aorta aneurysms. all the big names were there, including our massive prof and the vascular prof from wits, who at the time was also head of the department of surgery there as well as the president of the vascular society of south africa. in fact the only two non entities were myself and my friend. bearing in mind the entire vascular fraternity knew my friend would one day be one of them, in all reality, i was the single individual there who deserved and got sideways glances. my usual tactic of keeping my head down wasn't going to work; it stuck out like a blushing throbbing aneurysm and there was little i could do about it.

the function was advertised as a dinner on a boat that was supposed to cruise around the durban harbour, all very fancy. but, as it turned out, the weather was a bit too bad and the owner of the boat, which was a bit more like a large raft, all fitted out with tables and chairs and, of course, a bar, decided it wouldn't be safe to take the entire vascular complement of the country on a cruise where the boat had a good chance of sinking and rendering vascular surgeons in our country even more scarce than they already were. i was fine with this. besides the chance of dying, i felt it might be a bit awkward stuck with such eminent beings far from shore and no place to hide. but the sponsors of the event felt let down. they wanted to show off a bit i think and a boat safely anchored in the harbour just wasn't going to cut it. they felt they needed to make a plan, so a plan they made.

after the snacks and a fair amount of dutch courage had been consumed the plan became apparent. suddenly next to our safely moored raft appeared the biggest baddest speed boat i had ever seen. it looked like the type of thing you see on national geographic deep sea fishing specials. i wondered if we would limit ourselves to just the harbour cruise or would we venture into the big blue.

quite soon all the big names had made their way onto the boat. i, being the most junior person there, waited until last to see if there was enough space. as it turned out, it was a very big boat and there was plenty of space, so, somewhat reluctantly i followed my friend aboard. there were three areas where the vascular passengers could sit. one was the main area downstairs which was full. the next was the front portion of the boat which was fulling up quickly and seemed like not the greatest place to sit, just in case we did venture beyond the protection of the harbour. the third was a fairly quaint upstairs area. it seemed like the only real option. my friend and i climbed the ladder.

the upstairs area was the smallest of the three areas and was not yet totally crammed with vascular academia, but there was a reason for this. you see when the profs had gone aboard, they had all gone upstairs. the mere mortals, not wanting to seem forward, had decided to rather remain below. my friend and i didn't know this because we had waited until the last moment before we came aboard so when we got to the upstairs area, i was quite perturbed to see all the great profs sitting there. it was too late to go back down. for one thing, there was no space downstairs and for another all the eyes of all these great and intimidating men were staring at us as if we had just walked in on an awkward conversation. there was nothing for it but to stay there. i immediately decided i would stand as far away from everyone as possible. if there was a corner there i was determined to find it.

the president of the south african vascular society and great and mighty head of the department of surgery at our neighboring university, and more than likely someone i would be meeting soon in my final exams, looked at me and, gently tapping the seat next to him, spake he.

"come sit here next to me." he said with a wry smile.

" no thank you, prof, i'm fine here." i replied. he seemed persistent. again, almost stroking the seat next to him, he repeated his invitation.

"ag, come on, bongi, come sit here next to me." occasionally in life, you are presented with a situation where you really can say the wrong thing, and at the last minute, better judgement prevails. that day it seems i had no judgement at all. the words just seemed to roll out of my mouth, which I confess, stayed open in absolute shock at what had just escaped.

"no thank you prof, i'm not that type of boy."

the vascular prof from our university at least got a good laugh out of it.

the theater cap

"bongi, i have a patient who came in last night with appendicitis. can you operate him for me?"

my colleague was known to load shed and mostly i didn't really mind. that day, however, i just didn't feel like any extra work, so it took a bit of effort to fake enthusiasm.

"sure! any time." i lied. "anything special or straight appendicitis?"
"well, i saw him two days ago, but he refused operation, so he might be a bit sick." i knew what that meant. a bit sick was surgical talk for 'good luck pulling this one through'. oh well, a challenge at least.

the patient was a young man of about 27 years old. despite the fact that he was clearly in pain he still was a striking individual. he was alert and interested in my analysis of the situation. his questions were to the point and demonstrated deep contemplation about his situation. his eyes sparkled with life and potential. he touched a chord in me and i felt for him, despite the fact that he had refused an operation a day or two ago that was clearly necessary. when i examined him it was clear that he needed surgical intervention, but his pain was no longer located just in the area of the appendix, but it had spread more diffusely through the abdomen. i decided that a lower abdominal incision would be better to fully address all potential problems.

"doc, i like your cap." we were pushing him towards theater. i was wearing one of my genuine sutured for a living caps that i always wear when i'm in theater. i smiled. this sort of small talk i took to mean that he had resigned himself to the operation and was simply trying to distract himself.

"thanks." what more was there to say?

"i would love a cap like that." there didn't really seem to be anything to say to that, so i just kept quiet.

quite soon the patient was asleep and we got to work. when i opened up the lower abdomen, a thick, suppurating appendix protruded through the wound in an apparent attempt to escape from the septic abdomen that it had actually been the cause of. it had clearly burst. i smiled to my assistant.

"looks like this is going to be easy. whip out the appendix, rinse the abdomen and home free." sometimes i wish i would learn not to tempt fate with idle talk. i mobilized the caecum. and that's when i realized something was wrong. it was an appendicitis, but it wasn't caused by a stone in the appendix lumen or thickening of the lymphoid tissue in the wall. there was an obstruction in the base of the appendix but it took the form of a hard mass that had broken through the caecum and infiltrated the abdominal wall. what we actually were dealing with was a colon cancer that had incidentally caused an appendicitis. to remove the appendix simply would not suffice. i had to be aggressive.

i removed the right side of the colon with its blood supply and lymph nodes, taking a sliver of the abdominal wall along in the specimen. yet i already knew that the cancer had probably spread throughout the abdomen along with all the inflammation when the appendix burst. that would by necessity be something for the chemotherapists later. right now my priority was to do the best i could and get him healthy enough to withstand the onslaught of the chemo drugs.

the rest of the operation went as can be expected. i stuck the necessary pieces of intestine together, rinsed, placed drains and closed. the patient did well post operatively too. of course i still had to tell him that he had a cancer and not a simple appendicitis. that was not fun. i also involved the chemotherapist as soon as the histology confirmed what i already knew. finally i discharged him and left the rest to the chemotherapist.

many months later as i was walking down the corridors i happened to run into that same chemotherapist. i hadn't heard anything about the patient so i decided to ask how it was going with him.

"well, bongi, despite my advice, he refused chemotherapy and jetted himself off to china for some sort of experimental therapy where they place radioactive beads in the bed of where the cancer was. i wish him all the best but i don't think he is going to get all the best." i was upset. in a sense it wasn't actually too surprising. after all he had initially refused surgery by my colleague. he did seem to be a bit of a free thinker, even to his detriment. maybe this stupid stubbornness was one of the things about him that made me like him on some level. still i knew he had decreased his odds dramatically and it did upset me. i felt like a young promising mind was about to be cut down and there was nothing i could do. it was as it was.

i had just about managed to nearly forget the man when, once again, walking down the main passage of the hospital, as my chemo peddler walked past he gave me some news.

"guess who i admitted last night with a malignant obstruction?"

"an obstruction? do you need me to operate?" it was grasping at straws and i knew it, but i had to ask.

"bongi, the scan shows masses throughout the abdomen and almost his entire liver is just one large metastasis. i think we are deep into the palliative stage of his treatment. an operation might actually be a form of active euthanasia." and then the words dried up. it was pointless telling each other how tragic it was that such a young man was doomed. it wouldn't help to wonder how the course could have been different if he had taken the chemotherapy when there was still a chance. it was even more futile to wonder what would have happened if he had been operated earlier or, better yet, presented earlier somehow. in the end we just walked away from each other. no words would suffice.

yet, although i could walk away from my colleague, i felt i could not just walk away from the patient. i couldn't help him as a surgeon, that i knew, but maybe i could do something else.

when i walked into his room carrying one of my very precious rlbates theater caps and presented it to him as a gift, there was surprise in his eyes. but there was something more there too. his eyes still sparkled, but most of the life had already been drained from them. his body was just the frame of what it once had been but in his eyes i could see gratitude. when i left, there was a smile on his face. i hid my face from everyone as i walked out of the ward.

two days later he passed away. it was a small gift but, maybe in that stage of the battle we call life, the gift of a smile is really not that small after all.

contested

this post will be different to any previous post on this blog. it is a complete work of fiction although it is based on a telephone conversation that did take place. all the rest is a figment of my imagination.

a while ago, a friend told me about a writing contest. the brief was to write an original story of no more than six hundred words, based on a message on an answering machine. i decided to give it a go and see how i did. unfortunately, once i'd written the story and edited it down to the required number of words, when i tried to submit it, i discovered it was only for residents of the united states. so i decided to publish it here, having nothing better to do with it. please remember it is completely fictional and was written with the aim of entering a competition. it must be viewed in this light.

so without further ado, here follows the story.

johan was messed up. how could he not be? the war in angola, a war which, according to the south african government, didn't ever even take place, had done it to him. all the things he had seen there officially didn't happen. everything he had done, far from home, deep in enemy territory, whatever that meant, hadn't happened if you were to believe official government communique. but it had messed him up even if it hadn't happened.

johan was simply not suited to normal life. he had no skills and just didn't get along with normal people... alive people anyway. he felt quite at home with the dead, his time in angola had taught him that. the other guys used to laugh at him when he was always willing to drag the bodies of the dead and load them onto the front of the armoured car for transport to the quickly dug mass graves.

"johan, your wife seems a bit stiff there." everyone would laugh, except the dead, of course. they didn't laugh and johan appreciated that. maybe they understood him just like he understood them.

back in the real world, away from the war and the killings and the dead, no one understood him and he understood them even less. he tried a few jobs, but he couldn't hold them.

finally he got a job in the anatomy department of the medical faculty in pretoria. they needed someone to embalm the bodies for dissection and johan immediately jumped at the opportunity. 

embalming was easy to learn and johan very soon had mastered all the necessary skills. quite quickly he moved up the ranks and after a few short years found himself to be the boss. it was something he felt he could be proud of. most people weren't quite as at home as he was with the dead and they simply couldn't do the work for all that long. johan, on the other hand found working with the dead therapeutic. it was also different from his days behind enemy lines where they were required to kill them before he could enjoy their solace...the killing never really appealed to him. he saw it as a necessity, initially for his government, but later for himself, but he never quite got the pleasure from it that some of the other soldiers did.

now, many years later, the dead still comforted him in a way no one could understand. he sat in his office in the mornings, before anyone else had even arrived at work, eagerly awaiting the quiet companionship that came with the day's embalming. he used this time to browse the internet or do any other necessary mundane administration of the department. and it was on one of these mornings that he listened to the voicemail recorded in the early hours of the morning.

"uum....hello?  uum, i'd like to donate my brother's body for medical research...is that ok? uum...he died about a minute ago. i don't know what from, but he just.....wait a minute.....no, he seems to still be alive. he just moved.....no, i think that was his last movement. he is dead. he is only breathing a little bit, but I think he is about dead. do i maybe get some money? hang on, he's trying to say something now. no, he's not dead yet. i'll call you back tomorrow morning. i'm sure he will be dead by then...."

johan smiled. the living never ceased to amaze him. well, he thought, another companion on the way, or at least maybe.

accolades

i was truly amazed and privileged to read an article written about none other than me in the forbes website. it was a major lift-me-up and in many respects i feel i don't deserve it, yet i'm not complaining. what i particularly liked is the way it commented on my blog as a nearly completed work rather than concentrating on only one specific post or one post at a time. it meant a lot to me, larry husten and for your more than kind words, i thank you.

for those new to this blog, it is also a nice way to link to some of the old, forgotten posts that are quite often a lot better than the current material. for established readers, the links are still refreshing in that one can rediscover old unpolished gems.

also, it in itself is a well written piece (with fancy capitals and everything!!)

for those who would like to read it, the link is here.

trust

as i have mentioned before, all surgeons think they are the best. of course when we ourselves need surgery, there is a bit of a dilemma deciding who is the best qualified to carry out the procedure. so when i realized there was a strange looking skin lesion in my right inner thigh, i decided only the best would do to operate me.

in my rooms i informed the sister i would be carrying out a minor procedure. she immediately prepared everything as she had done for me many times before. only once everything was ready did she look around suspiciously at the empty waiting room and ask where the patient was. i informed her i would be performing the procedure on myself. she was very nearly successful in suppressing a laugh.

because the patient was a bit shy, and because of the precarious positioning of the lesion, i asked the sister to rather not be in the procedure room during the procedure but to wait outside, at least within earshot, just in case the surgeon ran into trouble.

quite soon i had positioned myself in a sitting position, pants on the floor next to me and procedure trolley within easy reach. i carefully covered my important bits, just in case i would be required to call out for help, and got started.

despite my severe needle phobia, the localising of the area went well and i did not pass out, which i definitely viewed as a good thing. the only problem i had was that my left hand found it necessary to hold my block and tackle out of the operation area and this essentially left me with only my right hand free to do the operation. fortunately i am that good that i could still remove the lesion with only one hand. unfortunately, as i was soon to discover, i am not that good that i can tie surgical knots with only one hand.

i placed the first stitch without too much trouble, but i just couldn't tie the knot. every time i removed my left hand, my gear fell over the gaping wound making it impossible for me to go on. this is about the moment i discovered the walls in our rooms are surprisingly sound proof.

so, to summarize, there i sat alone in the procedure room with a large self inflicted wound in my inner thigh with one hand holding my wickets and the other trying to figure out how to close the wound, shouting in vain for the sister to come to my rescue. in the back of my mind i was a bit worried exactly what that rescue would entail. she would have to do one of two very important things. either she would have to carry on with the operation and thereby deprive me the privilege of being operated by the best surgeon, or she would have to hold the family jewels out of the way.

finally she heard my increasingly desperate supplications and came in. this time there was little laughter, what with my looking alone and forlorn with a large bleeding wound between my legs. feeling a bit sheepish i explained my predicament and without too much pomp and ceremony, quite soon i could continue with the operation, my manhood totally at the mercy of my employee. i hoped then that i had been a good employer, but it was too late to turn back. i  threw in the sutures, amazed at the severe tremor my hands had developed. it may have been that i had been overcome with a deep concern for my patient, or at the very least his equipment. whatever the reason, despite my shaking hands, i managed to get the stitches placed and close the wound with a plaster. only once my pants no longer lay beside me on the floor, but had been returned to their rightful place and i felt less vulnerable did my hands stop shaking.