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.

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.

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.

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.

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.

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.

tangled tassels

in quite a few of the cultures in south africa people tie ribbons, strings and tassels around their own and their children's wrists and waists. these tassels are imbibed with power to keep evil spirits at bay, i am told. if these tassels come off then the patient is completely unprotected from any and all marauding evil spirits that may be lurking around. of course, not wanting to be responsible for the unopposed assault by multiple evil spirits, most people are fairly reticent to remove these things. i saw it slightly differently.

as a student i took my lead from my senior. if he removed the tassels then i would be ok with it. if he felt that we should respect the culture of the patient and sort of try to move the tassels out of the way of the operating area or even operate around them, despite the increased infection risk, i sort of reasoned it was his patient and even if i medically didn't agree with him, the reasoning of respecting the patient's culture surely held some water at least and i didn't argue. the fact of the matter was that quite a number of the sisters would become quite aggressive with the doctor if they thought he was going to remove the tassels and strip the patient of his evil spirit protection and i think some of the doctors were scared. then one day something happened that cemented my views and actions for the future.

i was working with a senior doctor that had grown up in one of the 'tassel cultures' of south africa, so when i prepared the gunshot abdomen patient in theater for him to operate, i left the tassels alone. it was one thing calling down the wrath of evil spirits upon me but i was not willing to call down the wrath of my senior. it was not worth it.

my senior walked in. he took one look at the patient lying on the theater table, already anesthetized with a nice round bullet hole in his mid abdomen oozing a mixture of blood and feces and with the tassels tied securely around his waist, left in position by me. without saying a word he grabbed a pair of scissors, walked up to the patient and unceremoniously cut the tassels off and threw them away. the sister immediately layed into him.

"doctor! what the hell do you think you are doing? that is the patient's culture and you have no right to remove that!" i saw the corner of the doctor's mouth edge upwards in a mischievous smile as he answered.

"come now sister. besides the obvious medical and hygienic reasons that i could give for removing a dirty piece of string before we operate, even you must agree, this tassel just doesn't work. i mean it didn't protect him from getting shot in the first place so i think it is safe to assume it is pretty much not going to protect him from anything else. so i am removing it and i don't really care what you have to say about that." his logic was flawless and the sister had to keep quiet. i also tried to keep quiet but the faint sound of a laugh did escape from behind my theater mask.

since then i have cut every tassel off, explaining to everyone that will listen that it clearly is no longer working.

a dead giveaway

amazingly enough, no matter how crazy our country gets we are a darn sight better than many of our neighbours. many people from countries around us flee to south africa for a better life. only problem is for the better life you sometimes have to produce a south african identity document. these can be easily bought from corrupt government officials, but why buy one if you can borrow one.

i was working in qwaqwa. it was an amazingly poverty-stricken place with what seemed to me to be almost total joblessness. i truly don't know how the people survived. an yet people from neighbouring lesotho would still move there illegally. i've never been to lesotho personally but if qwaqwa was a better proposition, then i can't even imagine how bad life in lesotho must have been.

anyway, one day i got to work and was confronted with a sticky problem. the police were there and they apparently needed my help. you see as it turns out, a lesotho illegal had died a week before in our hospital. in order to qualify for admission to our hospital she needed to be south african. luckily her sister was the proud owner of a south african identity document and had simply lent it to her, along with her name. i assume they looked similar enough that the clerk working in admissions hadn't noticed the picture in the book wasn't that of the patient. more likely she simply didn't check. the problem was that the patient had been declared dead by the doctor on call that particular night. or rather the patient's sister and her id had been declared dead. at that stage no one yet knew who the patient was.

however, when the sister attempted to draw money at her local bank a day or two later, she was shocked to find out that her assets had been frozen on account of her being dead. this upset her because even thought she had been declared dead in her absence, aside from a sick feeling in the pit of her stomach, she felt quite alive. suddenly it seemed the right thing to do to come clean and admit that she had lent her sister her identity document and therefore her identity.

now the problem that the police at the hospital had was that they needed a fresh death certificate for the person lying in the freezer in the morgue whose identity they now knew. they presented me with the papers to sign. a small difficulty was the papers required me to identify the body as this new dead person. the police were quite willing to forego this technicality and get my signature. however i felt the entire problem had started because of a casual disregard for the finer points of the law. i was simply not willing to sign a document saying i had identified someone as dead if i had not identified said person as being in fact dead. logic may have dictated that someone who had been lying in the morgue freezer for a week, even if they had not been dead when they got there would probably be dead by then, even if they had simply succumbed to boredom, but i felt i needed to look if the forms that i was required to sign stated that i had looked.

and so the sister, the cop and i took a stroll down to the morgue. the sister and the cop went on, a bit too much if you ask me, about the madness of the doctor in insisting on seeing the body. the last time i had been forced to go to the morgue was in the dead of night so actually i was, relatively speaking, in fairly good spirits.

even being in good spirits and even in the light of day a morgue is not a great place to be and identifying the body of someone who had been on ice (along with her sister's identity and bank account) is actually quite difficult. the normal human features seemed withered and pulled back, revealing a sort of grimace, as if she knew what cruel trick she had played on us all. i was not impressed. the form required me to see the body and see the body i had. i left, signed the form and walked away.

later i could see the humour of the whole thing. i also couldn't help thinking only in south africa could such absurdities take place.

empathy

while i am on the topic of the amazing ability surgeons have to show empathy, i thought i'd share a story one of my friends once told me about a professor he had in another university. but it also touches somewhat on where the priorities of a surgeon should be during surgery.

it was late at night and the prof was actually at the table operating (something so rare in our place of learning it also made me wonder if i'd maybe chosen the wrong university). it was in fact around the time when students struggle to stay awake. but on the whole it is not the best idea to display this weakness while scrubbed in with the prof.

the prof was the primary surgeon (something that made me glad i didn't choose that university), the registrar stood opposite him as the first assistant and some poor tired student stood next to the prof as the second assistant. i use the word stood in its loosest possible definition because he was struggling to remain in the upright position. every now and again he would slouch against the professor until in irritation the prof would thump his elbow into the student's ribs. this would result in a good five to ten minutes of good assistance from the student. thereafter his head would sag and come to rest once again on the shoulder of the prof. i'm sure it made a pretty and even touching picture. pity the prof didn't feel the same.

and so the operation went on with the student's sporadic moments of wakefulness and the prof's temper becoming equally short. finally the prof decided on another strategy. as the student's head once again sagged, looking for that warm and snug nook on the prof's shoulder, the prof took one large step back. the student's limp sleeping body found no comforting shoulder where one had been previously and went down like a ton of bricks, right in front of the feet of the prof. he then looked down at the dazed student lying at his feet, carefully stepped over him, back to the table and spoke.

"bring vir my 'n student wat nie stukkend is nie!"*

*bring me a student that isn't broken/defective

focus

one of the all time legends in medical blogging has to be suture for a living. she doesn't only patch people up but she sutures other stuff to make amazing works of art. i suppose this is not too surprising. in the end plastic surgeons are so much more artistic than us mere general surgeons. but i like to think that when the chips are down and the pressure is on, we can focus and place stitches almost as well as most plastic suturers.

it was one of those days. i was on call and all hell was breaking loose (again). i didn't seem to be able to get ahead of the deluge of work. too many people were trying to bleed all over the place at the same time and there were too many people in casualties demanding attention. suffice to say when the internist stopped me in the passage to discuss a patient with him, i was a bit irritable. internists have a way of drawing a story out. they are just not like us. they don't have our sense of urgency and when they stop you in the passage to discuss a patient, it shows.

i quickly realised the internist was going to string the discussion out as long as possible. it was frustrating, but it was also important to maintain a good relationship with our long winded colleagues, so i decided to accept it and be patient. in an attempt to settle down i even lifted myself onto the windowsill and consciously relaxed. i allowed him finally, after some meandering, to get to the point. i was actually amazed that i could bring my basal metabolic rate down to his for the duration of his drawn out discussion. finally he concluded his communication with me and readied himself to leave. even this took time. i jumped down from the windowsill in a smooth motion that i hoped looked emphatic. unfortunately my trousers hooked on something and i tore a massive hole in them.

great, i thought. now i had an unsightly tear in a somewhat unflattering position on my trousers, pretty much displaying my underwear for all to see and i had no time to rush home to change them. as the internist slowly sauntered off to continue his day in slow motion i even had a thought of wrestling him to the ground and stealing his trousers. however i quickly realised that would do nothing to the already strained relationship between our relevant departments and gave up on the idea. i would have to come up with a better plan. then i realised, i'm a surgeon. if i can close an abdomen then surely i can close a mere hole in my pants. the solution was obvious.

i rushed off to theater at a speed that would probably have given my internistic colleague whiplash and asked the sister there for some vicryl ( a type of suturing material). after all it was a thread i was familiar with. i then went to the surgery tea room which was adjacent to the female surgical ward. fortunately the tea room was empty so i got to work.

now vicryl (and pretty much all surgical suturing material) is made already attached to a semicircular needle. to use it properly one needs a surgical instrument. i had a leatherman which would have to suffice. unfortunately, a laceration on the nether regions of the trousers, even in the hands of a very skilled surgeon, can not be addressed while the trousers are still on. there was only one thing to do.

i sat on the bed in the tea room and dropped my trousers to around my knees. this presented to me the laceration pretty much between my knees, an easy place to work. then i started the repair job.

the sisters knew that i spent my spare time in the tea room and would therefore often first look for me there before paging for me if there was a problem in the ward. as luck would have it, one of the sisters came looking for me as i laboured over the laceration of my trousers, dropped to knee level. she walked in and addressed me. only once she was halfway through her question did she look up to see me sitting there, trousers down, working furiously with needle and thread between my legs. she doubled over in laughter before running out. i looked around to see what was so funny. not seeing anything from my point of view, i dropped my head again and continued my operation, totally focused.

moments later, pretty much every sister from the female surgical ward was crowded at the door to get a glimpse of the surgeon caught with his pants down. i watched them as their bodies shook and almost convulsed as the waves of laughter engulfed them. most of them then threw themselves into each other's arms and held each other until tears ran down their faces. i was focused. even the noise wouldn't distract me from the operation i was required to perform. the sisters then disappeared.

soon afterwards the sisters from the male surgical ward were also huddled in a tight group at the door, writhing in mirth and wiping each other's tears. again i smiled at them and returned my attention to where it was needed. finally i finished the procedure. i stood up, pulled my pants up and closed the things that needed to be closed. by then i was alone again, but the loud laughter stilled echoed through the corridors for some time afterwards.

yes i doubt my job was as neat as the work of my friend and fellow blogger, doctor bates, the plastic surgeon, but then i wonder if she has to contend with the amount of laughter i was requited to deal with while working.

looking good

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.

pancreas

recently i did a distal pancreatectomy (i removed the tail of the pancreas). it was an exciting operation. the guy was the victim of a soccer goal post falling on him, causing fracture of the pancreas. the injury was about two months old, just enough time for the pancreas tail to become a hard rubbery fibrotic mass adhered to everything. i took it out without removing the spleen (with supreme difficulty) and was very proud of myself. i thought back to the days of old.

when the prof felt we didn't have full control of the ward, he'd let us have it and he wouldn't let a thing go (as i have mentioned before). i remember once when he ripped into me in front of my students, but worse still in front of the patient i was to operate the next day. she must have felt great to hear that the guy who was going to take a knife to her the next day was 'useless and had lost all control of his ward'. it must have engendered in her a feeling of safety and comfort.

anyway, one of the imageries the prof used regularly was of someone riding a bike without handle bars, implying loss of control. i remember him telling me in front of my junior colleague, all my students and my patient that my ward was chaos and i was riding the bike without handle bars (i had failed to remember the sodium value for one patient and needed to refer to the results). as usual he went on for some time.

a while later we admitted a guy with a fracture of his pancreas. the next morning, as usual, we presented our cases to the prof in front of all the registrars. the prof asked the usual questions about diagnosis, presentation, treatment options and so forth. one of the things he wanted to know was how it had happened. it is usually the result of blunt abdominal trauma. the pancreas gets caught between the vertebral column and whatever caused the blunt trauma. in this case the patient was riding on his bike, he did a jump and came unstuck in mid air. he then fell with his abdomen onto the handle bars.

in the very formal setting of the morning meeting i had just presented the case to the room full of stern faces with the prof looking for a gap to have a go at some poor unsuspecting sod when my junior leaned across and whispered in my ear;
"that's why i think you should always only ride the bike without handle bars!"

i could not hold back my laugh. the prof was not impressed but it was worth it.

gossip

the community of registrars in a university like pretoria is small. a small community is nice, but it is always important to remember whatever you say will probably find it's way back to the person you are gossiping about.

i was rotating through orthopaedics. rotation generally is not too much fun and ortho was no exception. finally they allowed me to operate. they put together a list of wound inspections and secondary closures and the like, claiming they would handle the ward and clinic (later i found out they used the opportunity to take an early day and go and play golf). anyway, there i found myself all on my lonesome, closing some wound on a forearm in the company of a green anaesthetist that i'd never met before. i tried to be friendly and i thought it was working. i was making small talk and stupid jokes. the gas monkey was even laughing.

then i approached the end of the operation. i placed the last stitch and asked for a plaster. the anaesthetist looked up with an expression of surprise on her face.
"are you finished?" she asked.
"yes"
"you didn't tell me you were almost finished!" she complained.
"sorry." it seemed like the right thing to say, but it didn't work. she really let me have it between frantic exaggerated turning down of the vapours and drawing up of reversal. i listened to her tirade for a while but it quickly bored me. i walked out to the scrub room to wash my hands.

there i removed my mask, adjusted the cap on my head slightly up and washed my hands. afterwards i slowly walked back into theater. the anaesthetist looked straight at me.
"can you believe it?" she said
"believe what?" i replied.
"the bloody surgeon!" i wondered what surgeon she was complaining about now. by this time i had figured our that she was not overly fond of surgeons. i decided to listen patiently to her tirade.
"who and what did he do?"
"the surgeon who was just here! he didn't tell me he was finished and then he just left me with this sleeping patient!"

it took me a moment, but i realised she didn't recognise me with my mask off and my cap donned slightly differently. i considered drawing the situation out but truth be told, at that stage i just couldn't be bothered any more.
"i said i'm sorry. what more can i say?" i said in a pseudo-annoyed voice. she looked at me with a blank expression. then suddenly she went bright red. i smiled broadly.
"pleased to meet you. i'm dr bongi."

yes there will always be people bad mouthing you, but, if i could be so bold as to suggest, do not gossip directly to the subject of your gossip. it just makes you look foolish.