tongue twister

in the old days at kalafong (hell) we sometimes had to deal with obnoxious people. alcohol tends to make the worst of a personality come to the fore. most of us tended to ignore these irritations and get on with the job, but there were exceptions.

he was a senior registrar at the time. before going into the whole surgery thing he had been in the army and had served in the angolan war in the special forces. i occasionally asked him about those days, but he never spoke about it. i think it messed him up a bit and he probably didn't want to dwell on that stage of his life too much. only once did he ever actually say anything to me that alluded to what he had gone through.

"bongi, when you are in battle and people are shooting at you with the intention of killing you, it somehow changes your perspective on life." i suppose part of his changed perspective was that he tended not to take crap from mere mortals (hy vat nie kak van kabouters nie), especially those with more than a liberal dose of dutch courage.

the patient was drunk beyond description. he lay there in casualties with a nice neat bullet hole through his chest. however the injury had done nothing to his foul mouth. he maintained a constant stream of verbal abuse directed against anyone and everyone who had anything to do with him. when the poor house doctor inserted the intercostal drain she had to contend with both his sharp tongue as well as the occasional flying fist. he even managed to land a blow which had reduced the house doctor to tears. to her credit, she had continued the procedure but was unwilling to go near him after that. she called her senior, the registrar, to make sure the patient had no other injuries.

my friend walked into casualties, quickly found out what the trouble was about and approached the patient. he stood just outside the reach of the patient and casually observed his fists flying around, keeping everyone away. he listened as the patient flung a stream of obscenities at him. he seemed unmoved, but the wry smile that until then had been on his face slowly slipped away to be replaced by a stern grimace. he tried to speak to the patient to explain that he needed to check him out but this was met with such aggression that he ended up walking away. the house doctor tried once more to approach the patient, but caught a heavy body blow and slumped to the floor in pain. that, it seemed, was too much for the registrar.

"sister, put the patient in the procedure room. i'll be back in five minutes."

five minutes later the registrar returned. he went straight to the procedure room. just before he entered he turned to the sister.

"sister, call the maxillofacial surgeon and tell him we have a patient for him with a broken jaw."

"does the patient have a broken jaw?" she asked, surprised.

"well not yet." and with that he entered the room and closed the door.

after that, so the story goes, the patient was as tame as a lamb, albeit a lamb with a very swollen face.

Blasé

i suppose reading my previous post that one can possibly get the idea that i am a bit blasé about gunshot wounds. i hope not, but sometimes i think i may be.

i was doing a casualty session in a private hospital far from my usual stomping grounds. it was one of the ways that i used to get a bit of extra money to buy luxuries like bread and butter. truth be told i hated most of it. i mean at heart i am a surgeon and not a colds and flu doctor, which is what most of the casualty work is comprised of. it was usually frustrating but i needed the money and i couldn't sell my soul. it already belonged to the professor.

on this particular day we got a call from the state ambulance service. they informed us that they had a gunshot patient in tow and they wanted to stop at our unit so that we could stabilise him before they took him onwards to the state hospital for definitive management. they basically said that he was not going to survive the drive to the state hospital and they were rushing to the nearest facility (us) so that we could quickly save his life. it all sounded a bit dramatic but at least it wasn't another runny nose. i just couldn't help wondering what we were required to do if the patient needed to go to theater immediately which, according to the story we were getting, sounded likely. we all lined up at the ambulance bay with our gloves on and waited in true grey's anatomy style.

the ambulance came blaring in and skidded to a dramatic stop. the driver also obviously watched grey's anatomy. they jumped out and soon had the patient in the resus bay. i got the history from the paramedic as i did a primary survey of the wounds.

the single gunshot wound was more a chest wound on the left hand side, but due to the tenderness of his abdomen i concluded the bullet had spent at least some time in the abdomen before exiting through the back. the patient was stable and didn't seem to be anaemic at all (he hadn't bled too much). all things considered he seemed quite well actually. (well for someone that had been shot that is. i mean i felt better than him even if i was forced to do casualty locums.) but he did have a pneumothorax clinically so he did at least need an intercostal drain. he would also need a nasogastric tube because there was a chance the stomach had been hit.

moments later i had the intercostal drain inserted and swinging comfortingly. i then threw a nasogastric tube in quickly without too much ceremony. the patient seemed to breath with slightly less difficulty. i looked at the paramedics with a glint of pride in my eyes. i doubted they had ever seen such a fast and slick insertion of an intercostal drain and nasogastric tube. they stood against the wall with their arms folded staring at me blankly. tough crowd, i thought. it seemed they expected me to do something more before they were willing to take the patient back. i wondered what i should do. he already had two good intravenous lines up and i had inserted the intercostal drain and placed the nasogastric tube. as far as i was concerned he was ready to go but they didn't seem to think so. i tried for an encore.

"sister bring me a set for a central venous line please." if they wanted to see me in action then who was i to deny them that? soon the line was in. i stood smiling at them. they stood nonchalantly looking back at me. i felt a bit irritated. didn't they know us surgeons had very fragile egos and that they were supposed to make some comment about how good i was if they weren't going to outright cheer in unbridled delight at the privilege of seeing me at work. i needed to get rid of them.

"ok, there he is. sorted and stable." i neglected to mention that he was essentially stable when they brought him in. "you can take him to the state hospital now." they left.

the rest of the night went as a session in a private casualty unit goes. the colds and flus were interspersed with an ear ache here and there and the occasional baby that didn't want to let his parents sleep. finally i got to lie down a bit at about 1o'clock in the morning.

i had just dozed off when the phone rang. it was the sister. she informed me that there was someone on the phone from the trauma unit of the university hospital of that city. (i mentioned that i did these locums far from home). i remember being amazed they had a trauma unit. we just handled whatever came our way when we were on call, trauma or otherwise. but still i wondered what they wanted to speak to me about.

"is that the casualty officer?" asked the voice with a typical jo'burg accent.

"yes." i ventured tentatively.

"did you handle a gunshot wound earlier tonight before he was transferred to us?" oh sh!t i thought. i must have missed something and the guy died. now they are going to nail me to the wall. other than the slight problem of being responsible for a death if something came of this and my professor discovered i did locum work there was a good chance that i would lose my post in surgery and my career would be over before it began. i felt my sympathetic system kick into gear. i was instantly fully awake.

"yes." i said in almost a whisper, my mouth suddenly bone dry.

"well i'm the surgical registrar in trauma and my consultant has instructed me to phone you immediately." i wanted to express surprise that there was a consultant on the floor with him at 2 o'clock in the morning. i wanted to say something like these english universities are soft or something equally tongue in cheek, but my tongue just stuck to the roof of my mouth and didn't seem to be able to find it's way to my cheek. waves of terror were now washing over me. if i had screwed up enough that a consultant was involved i really must have screwed up badly. maybe i was going to get struck from the roll and i would have to pursue a career as a street sweeper. (i would need to find a job that i used my hands with. street sweeping seemed like a good option)

"uugh." i tried to say something but only dry guttural sounds came out of my mouth.

"yes my consultant and i received the patient here. he said i must phone you to tell you what an excellent resus you did. it's seldom we get patients in such optimal condition." my sympathetic system easily transitioned from flight to fight in one split second. bastard!!! i thought. didn't he know what the time was? didn't he have a bloody watch?!! didn't he know that i didn't need compliments from registrars at his university, especially not at 2 bloody o'clock in the bloody morning? finally my tongue came loose from the roof of my mouth.

"thank you." it was all i could manage.

choices

a while ago i treated a woman with rhabdomyolysis. you see her husband beat her so severely that she had enough muscle injured that she ran the risk of kidney damage due to breakdown products. i spent some time chatting to her. i couldn't understand that this beautiful intelligent woman could find herself in this sort of situation, especially seeing that the bastard had assaulted her twice before. but actually this post isn't about her. she had finally realised there is no chance that this sort of person is going to change and that she needs to leave him before he kills her. no, this post is about someone else.

it was when i was rotating through the military hospital. she came in as a gunshot wound patient. actually she was quite lucky (as lucky as one can be called when one ends up with a surgeon i suppose). her wound was to the chest and a simple intercostal drain was all she needed. a bit of recovery time and she'd be fit to go. then the story came out.

you see she was in an abusive relationship and was no stranger to the hospital's trauma unit. but each time she went back for more. this time, however, her partner came home with a gun. there was an alcohol fueled argument during which the gun was produced and he threatened to kill her. she grabbed their infant child and ran. however, like most of our patients, she couldn't outrun a speeding bullet. the bullet went straight through her chest and into the infant's arm, shattering his humerus.

to say i was shocked is somewhat of an understatement. i mean i can accept that if someone has such self destructive behaviour that they continue to put themselves in harm's way in the end it is their choice. but the infant has no choice. i needed to say something.

i asked her if she had made a case with the police. apparently she hadn't. i wanted to know why. well according to her the man involved was actually a good man. he had visited her in the hospital and confessed his undying love to her. all was forgiven. she was going to go back to him with her child.

now please understand me. i know that i can't judge someone until i've walked a mile in her shoes and other such cute sayings. but i wasn't thinking about her. i was thinking about the child whose security had already allowed him to take a bullet to the arm and was gearing up to subject him to more of the same. that little bit of tact that i do have left me.

"you know there is a good chance he kills you or your child next time. actually i'm not concerned for you. if you want to put your life in danger, you're a big girl and that is your choice. but that baby of yours has no say in the matter. the one person who is supposed to protect him it seems is willing to put his life on the line because some psychopath says he loves you. let me tell you, people don't shoot people they love."

i said a few other things but the gist was the same. not one word penetrated. she was determined. apparently prince charming had pulled the wool (or executioner's hood??) over her eyes and she was going back. i felt despair for the baby.

tamponade

at least in the old days, our medical training was pretty darn good. but as with all things, confidence comes with experience and experience comes with time. being in the bush with cuban seniors often the confidence was more lacking than the knowledge.

it was late at night. the patient was just one more stab wound chest, one of the most common conditions we dealt with. but this one was different. he writhed around and seemed to be gasping for air. i threw in the needed intercostal drain, expecting a sudden improvement. it didn't happen. the lungs were fine, but the patient's neck veins were severely distended. his blood pressure was low and his pulse was fast and thready. his heart sounds sounded muffled and distant. then, if i wasn't already sure about the gravity of the situation, he said those words which strike dread into any doctor who has even a little experience.

"help me doctor, i'm dying!"

i knew what was wrong. he had a pericardial tamponade (the heart had been stabbed and was bleeding into the sack around the heart, slowly crushing its attempts at normal contractions) and without intervention the patient was going to do exactly what he had said he was going to do. i even knew what to do, but had never even seen it being done before. he needed a needle to be stuck into this sack to draw off the blood. this would win time to get him to theater to fix the hole in the heart. it was time to phone my senior.

the cuban surgeon on call sounded sleepy. he listened to my presentation of the patient, but didn't seem to fully appreciate how grave i felt the situation was. so i told him.

"this patient has a tamponade and without intervention soon he will die!"
"how can you diagnose a tamponade without a chest x-ray? get an x-ray and phone me back!" i was astounded. i knew what i had and didn't need a chest x-ray to help me. in fact i was worried about the delay the getting of said x-ray would cause. nevertheless, he was the consultant and i was merely the intern. i had to obey.

not too much later i phoned the consultant again.
"i have the x-ray as you requested and it shows a very globular heart." this confirmed the diagnosis. "will you please come out and help?"

finally he arrived. i had been sitting next to the patient the whole time trying to reassure him that everything was going to be just fine even though i was not convinced everything was in fact going to be fine. the consultant looked at the x-ray for some time. he then listened to the ever fainter heart and examined his now engorged neck veins. i was pacing by this time. i just couldn't understand the consultant's tentativeness. after all he was supposed to be a surgeon.

"bring me a needle!" finally!! i presented him with the needle and syringe that i had already gotten ready. he seemed surprised. i wanted to say that i was south african trained, but thought better of it and just smiled. he then started cleaning the chest just next to the sternum. now once again due to my south african training i had expected him to clean the area just below the sternum in the angle between the left ribs and the sternum. where he was cleaning i feared that he may stick the needle straight through the thin sliver of lung that lies over the heart in this position. i mentioned my misgivings and suggested the method we had been taught. glared at me accusingly and drove the needle in through his original site. the syringe quickly filled with blood. the change in the patient was dramatic and instantaneous. i started to breathe easier too.

"wonderful!" i said. "theater is ready. i took the liberty of booking him already."
"why?" said the cuban. i was taken off guard. it seemed to me to be self evident. the stab to the heart had to be addressed otherwise the tamponade could recur and then we'd have to operate in the early hours of the morning anyway.
"ummm...to fix the hole in the heart?" i ventured.
"no. we have treated him. he is fine now. admit him to the ward!" and with that he walked out.

what could i do? i was an intern. i could not do a thoracotomy on my own. if the surgeon refused to operate the patient was not going to get operated. i hesitantly admitted him to the ward as instructed.

through the night i intermittently stopped by to see how my patient was doing to the irritation of the night staff whose sleep i constantly interrupted. by the next morning the patient was amazingly still alive. sometimes patients are just lucky i suppose.

selfish bastard

of the things i encounter in my work, the one i find most disturbing is family murders. for some reason they happen with too much frequency in our country. it seems that some people, when life is too much for them are not happy to only put a bullet through their own head, but they feel the need to wipe out their entire family first. in my opinion it is a dastardly and cowardly act for which there is no excuse...ever.

the last one i was indirectly involved in was a typical story of a man that had lost it. he killed himself. but just before doing that he shot his wife and two children. his little girl made it to the hospital. i was asked to evaluate her, but she died before i even got to her. i was so disturbed i decided i didn't want to see the body. i did, however see the scan. besides the two bullet wounds through the head, the thing that struck me most were the two hair clips clearly visible on the scan in her hair on the back of her head. it was somehow disturbingly poignant and it stayed with me for some time.

but this post is about another attempted family murder that i thought much less disturbing and, truth be told, a bit humorous.

it started out as usual. the man felt he could no longer live (not sure that was a bad decision, actually) but he decided he was going to kill his wife first (that was a selfish shocking decision which i believe speaks of the character and substance of the man). anyway, he got his wife on her knees, apparently begging for her life. he put a 9mm up against her head and pulled the trigger. the gun misfired. she was ok. he then put the gun up against his own chest where he believed his heart to be and pulled the trigger. now suddenly the gun was working quite well.

i was rotating through thoracic surgery at the time so he became my patient. i have previously mentioned gunshot wounds to the chest and the general idea the public has that the heart is on the left, so let me not bore you further with anatomic considerations. let me just say the patient shot himself through his left lung. he simply needed an intercostal drain and was otherwise fine. i suppose he thought he needed a bit of sympathy from me too. he didn't get it.

the next day, when i was doing rounds he was clinically fine and doing well. he was feeling very sorry for himself and complaining about the intercostal drain. seems he had no feelings towards his wife but was particularly concerned by matters pertaining to his own comfort. again i can say i was not wearing my sympathy on my sleeve. i informed him the drain would be staying exactly where it was until i was happy to remove it. i explained the decision would be made purely on clinical grounds and not on whether he was whining and complaining. he then asked a strange question.

"do you suspect any internal damage?"
"a bullet went straight through your lung! what do you think? of course there is internal damage."

later i had a good laugh about his moronic comment. it is the only family murder scenario where the outcome was good, in my opinion.