the warning shot

south africa can be a violent place, but sometimes one can't help cracking a smile.

one case i remember was basically a form of domestic violence. a woman was shot. the bullet entered her right breast, passed through her diaphragm, through her liver, through the upper pole of the right kidney and out her back. her abdomen was soft. she remained stable. the ct showed no signs of continuous bleeding or any intra abdominal calamity. i observed her in icu and she did well. the hematuria cleared up. the liver sorted itself out. the intercostal drain was removed after about a week and she went home.*

i can't help myself. i always ask what happened. her story i remember well. she, her boyfriend and a friend of her boyfriend were together somewhere. they were either drowning their sorrows or celebrating something. whichever of the two, it was facilitated and lubricated by large amounts of alcohol.
the boyfriend and his friend were both cops and one or both of them had their service guns that night. at some stage, the friend apparently stole the boyfriend's gun. he went off to hide it, but my patient saw him. she confronted him and told him to give it back.
in the ensuing argument, according to her, the friend fired a warning shot into the air and then a second shot into my patient.

in my mind i pictured the scene. i don't know why the one cop stole the other's gun. i don't even know if he really did. maybe he had lost his and was afraid of repercussions at work and in his drunkenness it seemed like a good solution. maybe the ethanol caused a more imaginative version from my patient. but i do know she was shot.

the thing that made me laugh about this story was the warning shot. i could just imagine the thought process that went through his inebriated mind. in the moment of anger that drove him to commit this crime he must have remembered his police training. instead of just shooting her outright he had the presence of mind to first fire a warning shot into the air. i can't think what the warning shot was warning her to do. was she supposed to stop nagging him? was she supposed to just keep quiet? or was it just a warning of what was about to befall her?
she clearly didn't heed whatever warning it was.

*although that is not the aim of this post, maybe i should say a bit about the so called conservative management of gunshot abdomen. the literature only supports two cases where it may be possible. the first is gunshot abdominal wall (this is strictly speaking not actually a gunshot abdomen). the second is gunshot of the dome of the liver without any real intra abdominal trajectory of the bullet. i personally think that it can be extremely dangerous to even attempt so called conservative management of gunshot abdomen and it is usually best to open if there is any question at all.

stories of guns

recently i heard or was involved in a number of stories about guns. they had a profound effect on me. strangely i think i have understood slightly better a theme that reccurs in my blog because of this effect

story one. one of the senior doctors at the government hospital was visiting a friend. they were sitting in the lounge chatting when he felt a gun pushed up against his head. the robbers forced them to lie down and relieved them of their wallets and cell phones. they were not shot. in south africa we all tell him he was lucky. sort of "get over it dude! usually they shoot you anyway for the hell of it! you're lucky". the guy was pretty shaken, but got very little sympathy.

story two. a community service doctor in the neighbouring community of hazyview was at home one evening when he felt a gun pushed up against his head. this story is basically the same as story one, so enough said.

story three. this one was actually a patient of mine. an old man and his wife were sleeping when she heard a noise in the house and woke him up. before he could get out of bed, two youths entered their bedroom with guns. one pointed his weapon at the old man's wife. he shouted at him, saying he must not point a gun at his wife. the burglar slowly turned the gun towards him, fired one shot through his abdomen and one at his head. the gut shot went through his liver, through his stomach, through the right gastroepiploic artery, through the diaphragm and out the side of his chest. the head wound was just a glancing blow. much later, when i followed him up i couldn't help laughing when he said to me, "dok, to hy my in die kop geskiet het het ek my moer gestrip!" (doc when he shot me in the head i lost my temper) the patient then grabbed his own gun and chased the burglars out, firing a few shots at them. they didn't present to any hospitals i know of. the patient did. he bled a good three liters of blood into his abdomen. after the operation, he did some time in icu for the sins of his youth and then slowly recovered. actually he recovered physically. emotionally he remained pretty shaken when i followed him up two months after the incident.

story four. i recently had an old gp as an assistant. his daughter incidentally studied surgery a few years ahead of me. (small world). he told me a story about what happened to him in 1999. he had a gp practise somewhere in gauteng. one day one of his staff came to him and said that he'd heard that there was a group on the way to his practise to steal his money. even the type of car they would be driving was divulged. the fact that this was public knowledge in itself is disturbing. anyway, sure enough, he saw the car drive up. he quickly got his gun. two men entered, guns drawn. he fired one shot and his gun jammed. their guns did not jam. when the smoke cleared, he had taken five shots. he was operated numerous times and also spent some time in icu. apparently most of the staff thought he had no chance. he recovered.... physically. his practise did not. interesting his psyche also recovered.

the reason i'm relaying all these stories is because of a eureka moment i had while reading a post in my favourite blog. i was slightly perturbed to see that i seem fairly unique amongst surgeons in my view that i am confronted by my own mortality every time i deal with the death of my patients. but when i read this specific post i realised it was slightly more complex. in this post, the master blogger referrs to his time in vietnam. he admitted that he had it pretty easy compared to the soldiers. however the fact that he could copp it at any moment still nagged at his mind. the soldiers came to him complained that they couldn't take it any more. and what was the it? the possibility of picking up the ultimate lead ticket. but that was war. i am in an urban war. the fact of the matter is the above stories are about people like me living in the same place i live and sometimes doing the same work i do. they didn't get shot or have guns pressed up against their heads because they are drug dealers or bad people. these things happened because that is the state of our country today. i could in fact be the next one and i could end up the superlative of dead. yes i am constantly confronted by my mortality but that is because i am also the potential next victim in the war which is normal life in south africa. but because this is not a recognised war, to simply say i can't take it any more is not an option. somehow we must integrate it into our normality. and then the question remains, what is normality if normality is not normal? so the answer is to somehow channel these feelings for some good. in my case it is the feeling of unity with my patients and the constant reminder that i'm just as mortal as they are.

but anyway, even if the concluding arguement is a bit iffy, the stories are quite cool.