not one single word

sometimes the patient is in no condition to lie for himself. then it is important that others lie for him.

i was working in a private casualty unit to make extra money during my surgery training. (don't tell the prof. it was strictly forbidden. one day i'll post about the time i got caught.) it was some ridiculous hour. i was catching a nap when i was rudely awakened. the sister said an ambulance was expected to arrive in about 5 minutes with a possible epilepsy patient. i dragged myself out of bed. a medical case! absolutely wonderful. and at this time of the morning. just the thing to warm a budding surgeon's heart.

i stumbled into resus just as the ambulance crew came casually strolling in with the patient. they told us they had been called to fetch the guy from work where his colleagues said he simply collapsed. they didn't know why. something was wrong. he was restless. he was also pale. i felt his pulse. it was thready and fast. very fast. he had no drip up. being surgically minded, i thought that if i didn't know better i would say he was bled out. fortunately the ambulance crew could tell me that his colleagues at work told them that he had been working in a dairy cold storage facility when he simply collapsed. i asked if there had been convulsions. they didn't know. meanwhile one of the sisters was getting a blood pressure. 80 over 30 didn't fit with epilepsy. a quick glucose test was normal. the only alternative was cardiogenic shock from myocardial infarction or some exotic dysrhythm. but once again, it didn't fit. the patient was black. (white south africans have about the highest incident of ischaemic heart disease in the world, but south african blacks don't have much of it at all.) then it happened. the patient, now gasping for every breath looked at me and said,
"help me doctor! i'm dying!"

if you've been in medicine for a while you'll know that most times, the reason a patient says he is about to die is because he is in fact about to die. i believed him. my blood went cold. it just didn't fit. i wanted to tell him we'd do everything we could (although i still had no idea what i was capable of doing for him). in a reassuring way, i placed my hand on his chest. with every breath i could feel bones grinding against each other. i pulled my hand back in shock. he had broken ribs!!! epilepsy or cardiogenic shock or some heart problem does not cause broken ribs!! this was trauma! this was surgical! i jumped into action.

at that moment, the patient breathed one terminal gasp and promptly stopped breathing. for good measure his heart stopped beating too. nice bloody epilepsy, this, i thought. i delegated one sister to start cpr and another two to get iv access as i moved to the head to get airway control. the sister pumping the chest immediately stopped.
"everything is crunching under my hands" she said. what could be done? circulation is fairly important for survival, so i told her to continue. at this stage i was intubating. as i inserted the laryngoscope, fresh bright red blood came frothing directly out of his trachea. the trachea was also way over to the right. i shouted for someone to prepare an intercostal drain and slid the et tube in. the sister was fast. by the time i moved around to the left flank, the set was ready. i stabbed the blade into the chest. there was a gush of old dark blood. i shoved the tube quickly between the ribs into the pleural space. immediately one bottle filled with blood.

we consolidated. the patient was on a ventilator. two lines were running full tilt. with a touch of adrenalin, the heart started beating again (although i think the removal of the tension hemothorax also had a part in that). we got emergency blood going and got x-rays. we also called the thoracic surgeon.

the x-rays showed the worst disruption of the thoracic cavity i have ever seen, before and since. every rib on the left was broken and the fractured surfaces were about 5cm from each other. this basically meant there was a tear of the lung from top to bottom which was about 5cm deep. i gingerly reflected that that would explain the constant stream of blood draining from the intercostal drain.

as could be expected, the patient decompensated again. this time there was no bringing him back. when the thoracic surgeon arrived, the patient was already dead.

as usually happens, the story did come out. what the patient and his colleagues didn't know was that the cold storage facility where they worked had closed circuit tv. this was probably to prevent night staff from stealing. or maybe to prevent them from racing around on a fork lift chasing each other. yes, dear readers, that is what they were doing when one of them lost control of the fork lift and drove into my patient, crushing him up against a pole. they figured they were in trouble already, so it seems they decided the depth didn't really matter. if you are going to be in crap for messing with the machinery at night and for killing your colleague, then why not lie also to really confound any chances of the paramedics and the doctors to try to save his life. go figure.

don't believe a word

all patients lie. or so i was told. obviously, like most things in life, this is not always the case. but one should maintain a healthy degree of skepticism when listening to the history. i've decided to write a series about a few stories where the truth only came out later.

while training as surgeons, most of us did extra work to make ends meet (financially i mean, because burning the wick at both ends seldom makes them meet in a satisfactory condition).
one of my friends was doing a stint in a private hospital casualty unit. it was early evening. suddenly a man came rushing in. he was hysterical. he said his wife had been shot and she was in the car outside. with er-like drama, everyone rushed out. sure enough, there was his wife in the passenger seat, covered in blood with a nice round hole in her head. they rushed her in, but she had been dead for some time and nothing could be done.
the husband was beside himself with grief. he was actually hysterical. my friend was also pretty shaken up, but being a good caring doctor, he put his own personal feelings aside and devoted all his attention to the man.

they went into a side room where my colleague prepared a cup of sweet tea. he asked what had happened. slowly, between sobs, the story came out. the man, who turned out to also be a doctor, and his wife were out driving somewhere. they stopped at a robot (traffic light). suddenly someone opened the door of their car and shoved a gun in his face. this is a common or garden hijacking and happens with alarming regularity in our country. apparently, then about 4 men got into the car, with the two and drove off. this is also not unheared of with hijackings here.

the man went on to explain how they had been taken to a deserted street and forced out of the car. he described how he had begged for the life of himself and his wife. he said they were forced onto their knees. the one hijacker then pointed the gun at his wife's head and, after some verbal abuse, pulled the trigger.

my friend was shocked. he could only imagine the devastation the patient was feeling. thinking about his own wife, he had to force back the tears. once again, he put it all out of his mind and focused on the patient. he held the man while he sobbed uncontrollably. my colleague admits to even crying with the man. who could blame him? he held his hands and led him in prayer. he gave the man his private cell number.
finally the man left, looking at least a bit better. my friend went back to work, feeling he had at least meant something in the darkest hours of this man's life.

some hours later, the police arrived to fetch the body. being an unnatural death, the body had to go to the forensic mortuary for a postmortem. my friend asked how things were going with the husband.

"oh, we've arrested him for murder." replies the officer casually.
"what!!!" replies my friend less casually.

as it turned out, he took his wife into the back garden and shot her in the head (the part about her being on her knees begging for her life was apparently true). they had found the bloodstains, the gun and a spent cartridge. maybe my friend had held the man up so long he couldn't rush home to hide the evidence.

i really laughed at my well meaning friend about the whole incident. (for those of you who think i'm callous, i did not laugh about the shooting, just about my friend being so taken in).

don't get me wrong, not all patients lie and those that do don't lie all of the time, but it is a good idea to be prepared for it.