six degrees of separation

i try to treat all my patients equally. sometimes i don't get it right i suppose, but i still think i do better than most.

i was as junior as one can get. but as i have touched on before, when i started studying surgery there was a general shortage of staff in the department. this meant i was running a surgical firm long before i was actually capable of doing so. this happened in my first week of running a firm.

a general practitioner phoned about an appendix he wanted to send to us. he spent a bit too much time explaining that they had no money and he had seen the girl as a favour. he threw in that he had managed to have blood tests done at a nearby state facility under the table. with a bit more experience i would have known there was trouble brewing. i did not have that experience.

the patient arrived a few hours later, as the sun was setting. she was a 16 year old girl that looked like she should have had medical aid and therefore not be with us but rather be at some fancy private hospital. i checked her out and went over the blood results that she had been so kind to bring along. to me it looked like she had a clear cut appendicitis and she needed a clear cut to solve her problem. i organised the admission and booked her on the theater list. all i needed to do was run it by the parents who were required to sign the consent and all would be set. there was of course the small matter of never having done an appendisectomy before, but that was a bridge i was going to jump off when i got to it.

i found the mother in the waiting room. i quickly ran through my findings with her and told her that i thought an operation was in order. once again with a bit more experience i think i would have been prepared for her blatant and open aggression. i wasn't.

"and how did you come to this opinion?" she demanded with an accusing look. i was shaken, but i recovered. i went through my clinical findings and threw the blood results they had brought in themselves. then just for good measure i claimed that we were even then sending her for a sonar just to make sure. i also made a mental note to tell a student to rush her off the sonar as soon as i got clear of the mother.

"ok, but i'm not just going to take your word for it. i'll first speak to my husband and i'll get back to you."

"fine, but i'm going to book her on the list so long. we can always cancel later if needed." with that i left (after telling the student to rush the patient off to sonar of course). after that i just got on with the work of the night. we admitted a few more cases, at least one of which i would be required to call my consultant out to operate because of my total lack of experience.

about ten o'clock that night i quickly shot through theater to put yet another patient on the emergency list. the anaesthetist on call stopped me. she also stopped me in my tracks.

"bongi, why is your prof stalking the corridors at this hour?" i may not have had all that much experience but i did know the prof actually being in the hospital so late at night was one of the signs of the apocalypse. i was worried. i felt even worse when i was informed the prof had pushed that 16 year old appendix patient up the list, as high as he ethically could. i was then informed he was preparing to spend the night in the anaesthetic consultants' room. things were looking dismal. i knew i either needed to find him and find out what the hell was going on or i needed to avoid him altogether. avoiding him was not really an option because i would be required to present my call to him the next morning. if he knew that i didn't have complete control of the call, even if it was because he usurped me, it would spell disaster for me. however in the back of my mind was the nagging fact that i had never done an appendisectomy before. maybe he could do this one and i could assist. the next one which was already on the list would be left to me. hopefully watching the prof do an appendisectomy would be all the training i needed.

the anaesthetist also told me why the prof felt it important to do a procedure that was usually far below his great and mighty status. it seemed the patient was a vip. as it turned out, the patient's mother's neighbour's daughter's boyfriend was the prof's son. clearly the prof held his son in such esteem that his son's girlfriend's mother's neighbour's daughter needed his immediate attention. who says six degrees of separation doesn't come in use every now and again?

then, while i was searching the hospital for the prof, he once again snuck into theater where he was informed my consultant would be required to be called out to do one of the other operations on the list. he informed the anaesthetist to inform me that my consultant and not myself should do the appendisectomy. he then left.

telling my consultant that he was required to do the appendix just because of the long and convoluted connection between the prof and the patient was a bit awkward. at least the consultant had a sense of humour and simply accepted his fate.

finally when the patient got to theater we got ready to go. the consultant handed me the knife.

"i think the prof said you were to do the operation." i ventured helpfully.

"the prof isn't here now. i won't tell if you don't tell. cut."

and with that i started my first appendisectomy on a very special patient (or at least her mother's neighbour's daughter's boyfriend's father was important in his own eyes)

as can be expected with a first, i struggled through the operation. the fact that the appendix was very inflamed and adhered to a whole bunch of things in the abdomen didn't make it easier. however, even when i asked the consultant to take over, he refused. he told me that a surgeon can't just back off halfway through an operation and i must finish what i had started. i considered saying i had not wanted to start it, seeing that the prof had pretty much forbidden me from doing the operation and i had only raised the knife at the insistence of the consultant, but i knew what he would say. i soldiered on quietly and finally had the last stitch in.

the next day, on post operative rounds, the consultant asked the patient how she was feeling.

"much better, thank you." said the vip.

"good, "replied my consultant, "we were worried we had done the wrong operation on you."

gee thanks, i thought. imagine what the prof is going to say when he hears from his son who heard from his girlfriend who heard from her mother who heard from her neighbour who heard from our patient what the consultant said.

surgical principle number 5: it is in fact always the surgeon's fault

one of my professors used to say, in jest i believe, but i'm not sure, that no matter what goes wrong in an operation, it is always the assistant's fault. i used to give the appropriate awkward laugh. it soothes the fragile surgical ego. but my laugh was never more than awkward.

i somehow could not adopt my prof's opinion. the more i thought about it, the more i disagreed. in training, your assistants are almost always students and pretty clueless. as it turns out, you need to direct them to do what you need them to do. you actually have to actively use them as additional instruments in whatever operation you happen to be doing. besides, at the m and m, it will be you and you alone before the prof when he asks the obligatory please explain.

bearing in mind most students have a dread of the surgery and bearing in mind some of the stuff that goes down can rest heavily on the conscience (and therefore your sleep) i'm not sure what advantage there is to let the poor students feel more responsible than they are. in a certain way this principle goes with 4. not only did i try to let my students enjoy surgery, i tried to protect them from some of the trauma which can be inflicted by being so intimately involved with human suffering.

fairly recently my belief in this system was somewhat put to the test. a good friend of mine was assisting me with an appendix. he is destined to become a great internist one day which sort of implies he could sometimes be somewhat absent minded with the physical practicalities of an operation. it didn't bother me. i enjoyed working with him and i reasoned i needed to be fully in control anyway.

with this appendix, every time i asked him to loosen the artery clamp as i tied off the mesoappendis he did some sort of weird hand exchange to be able to loosen the clamp with his right hand. it seems he was not capable of doing it with his left hand. easily solved, i thought. it is true the clamps are all made for right handed people and there was a specific left handed technique needed to loosen the clamp. i decided to teach him this technique. i stopped the operation and asked the sister for an artery clamp.

even though at heart he was an internist, he was a quick learner and quite soon he was easily loosening the demonstration clamp with his left hand. i had a moment of pride in him but it passed soon.

then we got back to work. he grabbed the clamp on the appendix base, the only remaining clamp holding the appendix up to the wound and with a swift smooth movement, released it. the stump slipped easily back into the abdomen. he seemed so proud, i almost didn't want to tell him that usually one ties off the appendix base before the assistant loosens the clamp and allows the appendix to fall neatly into the abdomen. somehow there is less leakage from a closed stump than an open one. but i had to.

we took quite a while longer to retrieve the stump and tie it off and then obviously to do the necessary lavage.

still i had to be true to my principles. yes, even then it was my fault.

dangers

something happened a while ago that gave me quite a stir, on more than one level.

being the only private hospital servicing the southern part of the kruger park, we quite often see tourists at our facility.
i get a call from a gp who is in practice just next to the park. 'appendicitis' he says. 'send' i reply.

she arrives in casualties, significant other in tow. i ask the usual questions about pain, nausea, appetite etc. sounds convincing. i ask the significant other if he would mind waiting outside while i examine the patient. he asks why. i explain that it is better that he not be there during the examination. he leaves.

examination is typical of appendicitis. i decide, due to the pretty clear cut history and clinical to omit a pr and pv. (don't tell the prof. he'll do his nut) to be honest i also had a feeling the significant other was going to be problematic and i felt a voice warning me or some such thing.

thereafter, to theater and appendix out (i was going to say chop chop, but...). then i handed the patient over to my colleague and went to the kruger park for my weekend off.

in the park in one of the camps, who should i run into? mr significant other (he continued his holiday rather than stay by the patient's side during her hospitalization). he confronted me. he asked why i had asked him to go out. i was thinking that i should say that i suspected she was abused and i wanted to talk to her in private, but of course i just explained that that is standard practice. and then it happened. he said,' listen doc, in this day and age if you examine a patient without a witness, there could easily be a case of rape made against you.' he threatened me. he basically accused me of raping her. i turned and walked away.

a few thoughts. firstly the patient and the patient alone is my responsibility. yes, i try to involve the family as much as possible, but in the end my contract is with the patient.
secondly, what sort of person continues his aggression after the person he is ostensibly fighting for has been helped.
but lastly, this sort of thing may make a doctor think twice before completing a full physical examination. i already felt i was taking a chance by omitting the pr and pv, which should actually be a part of all appendicitis examinations.

i quietly wished thrombosed hemorrhoids on him and felt somewhat better.

any time (so don't get caught out)

the usual story. gunshot abdomen. his father apparently took one in the chest and had already been whisked off to theater, bled out and not doing too well. my guy, however was stable.

on examination, the bullet had passed very laterally through his abdomen on the right hand side just below the ribs. in fact it was so lateral that i wondered if it had in fact even entered the abdomen at all. the left side of his abdomen was soft and seemed unaffected. however the right iliac fossa region was exquisitely tender, suitably far from the tractus of the bullet to convince me there was something amiss inside.

so off to theater for a routine exploration of a common or garden gunshot abdomen.

i opened in the midline. is there any other way with a gunshot wound?
what i found inside was surprising to say the least and downright confusing to be more specific. lateral to the peritoneum there was extraperitoneal bruising, but no penetration of the actual peritoneal cavity. to be very sure i mobilized the colon and confirmed an uninjured retroperitoneal ascending colon. but what i did find was a severely inflamed appendix!?!?!

what the hell!!! i thought. but of course all i said was "hmmm?" and whipped it out in double quick time. (it's quite easy when the abdomen is splayed open like the pages of an old book)

obviously i started trying to explain this to myself. had the appendix been just next to where the bullet passed the peritoneal cavity and had been injured by the shock wave? but then why was the rest of the bowel totally normal? and why was the inflammation so well established? i mean it wasn't as if i had tarried for a week or so in getting him to theater.
in the end all i could do was close and move on.

post operatively the patient recovered very well. the next day i struck up a conversation.
"was there anything wrong with your abdomen before the incident?"
"well now that you mention it doc, there had been this constant pain here on my right" indicating mcburney's point, "but it seems to be gone now. i even got some antibiotics from the chemist two days before the gunshot incident, but they didn't seem to help"

the guy had appendicitis at the time he got shot!!! so don't get caught out! appendicitis can in fact happen to anyone at any time! who would have thunk? looking back now, i wonder if i could have approached the history in any other way. can you imagine the strange looks i would get if i asked my gunshot abdomen patients from now on:-
"and when exactly did this pain start?"