weighty issues

usually i try to avoid the sensitive issues. i mean this blog is mainly about entertaining stories. but the next story by its nature forces us to ask some heavy question.

casualties called.
"bongi, i think you need to come and see this. we have a hippo attack patient."
"sure thing. i'm on my way." strangely enough a few years previously i had treated another hippo attack patient so i wasn't totally blown out of the water...so to speak.

i walked in. there were blood soaked bandages on both legs. but she looked too sick to only have leg wounds. besides any self respecting hippo isn't going to merely nibble on its victim's calves a bit. chihuahuas do that. hippos put a bit more oomph into their bite. but the one thing that really stood out in my mind was how overweight the patient was. i groaned. no matter what the injuries obese patients are prone to all the risks associated with surgery, and i'm not even taking about being the hapless chew toy of an animal that is not known for mouth hygiene. lie all day in your own sewerage water and see how clean your teeth are after a few years. i knew this wouldn't be easy.

"wow!" i said, "if the hippo is that badly injured i can only imagine how bad my patient must be." i suppose i couldn't help it. i just needed to find something light hearted in the whole situation. after enduring evil glares from the casualty officer and the sister i approached the patient.

she had massive lacerations in her legs, which i'd need to debride and clean out thoroughly. she also had a large gash on her back. these were all that she was complaining about. it was also all i was consulted about. but as is my habit i checked out the rest of her too. her abdomen was slightly tender, but not too bad. with deep palpation she grimaced. to be honest through all the fat i could feel nothing so i asked for a ct scan.

the scan showed bowel outside the abdomen in the more than spacious subcutaneous tissue. she also had a cracked rib and a mild lung contusion. this case was no longer simply a debridement case but a laparotomy case too.

the operation went well. i learned that it is not a good idea to get chomped by a hippo. one tooth had actually penetrated the abdomen without breaking the skin. but the hippo had managed to deglove almost all the abdominal fat from the abdominal sheath, creating a massive cavity between the fat and sheath. this is where most of her bowel lay, already becoming mottled from strangulation. the pancreas was bruised but ok. the rest of the abdomen was fine.

i sorted out what needed sorting out. i placed drains everywhere i could and closed. as expected, she needed icu admission where she sounded like darth vader for a day or two. then she slowly got better and finally went to the ward.

during this time i spoke to her daughter who was admitted in the orthopaedic ward with a fractured ankle (apparently a hippo had trodden on it). i asked what had happened.

there are guided walks available in the kruger from pretty much all of the camps. you go out with an armed ranger and learn a bit about the bush. you may get to see some wildlife too, but you might want to keep in mind wildlife tends to be, well, wild. these people wandered a bit too close to a pool which had a hippo in who was generally having a bad day. he took exception. he came charging out directly at them. the daughter was in front. she turned to her mother, behind her and screamed,
"run!" she then promptly tripped and fell. the hippo came rushing right past her, luckily only stepping on her ankle in its headlong charge and grabbed her mother, my patient, for a quick chew. then, just as quickly as it had started the hippo left.

my first thought was why bother telling someone who is so overweight to run when they clearly can't? a waddle just won't suffice in the face of an oncoming hippo. but more seriously i actually thought what were people like that doing on a walk in the bush? if you go for a walk in the kruger you should at the very least be able to climb a tree and that at high speed. surely they should have a weight limit for these walks?

and that is where the difficulty comes in. the idea that to put a weight limit on something like that is discrimination against the overweight. my mind wanders back to the overweight lady who refused to be told she could not go on a cave guided tour because the weight restriction was supposedly discrimination. they caved in (an occasional pun is good for the soul) and allowed her to go. she got stuck in one of the smaller tunnels. fact is she was too large.

from a medical point of view, obesity is a disease with associated co-morbidities and increased risk of death. there is definitely a much higher risk with any surgery. it is just so. it is. i am not discriminating by stating the facts.

so let me conclude that i am fully in favour of no discrimination against the overweight. but because it is a disease it must be seen as such and not just swept under the rug.

gracious

recently i spoke a bit about interaction with foreigners. the impression i left would have been strained to say the least. but as with all things there must be balance.

they were tourists (aren't they all?) when in the kruger she developed severe abdominal pain. her son brought her to hospital.

when they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were american and that her son, the one who brought her in, was a physician. let me take a moment here just to mention a language difference between english and americaneese. in south african english, a physician is a specialist in internal medicine. in american, it seems, a physician is simply a doctor. at that time i did not know this. none of us did. so when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety md.

i mentally prepared myself for a confrontational family. usually with non medical first worlders they question you at every turn. a physician (south african definition) traditionally is sceptical of the knife happy surgeon. i couldn't help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. all i could hope for was a benign abdominal cramp which would soon pass.

the patient was in pain. she associated her discomfort with some or other something she had eaten the previous day in the kruger. but it just seemed too severe. besides, could anything bad actually come out of the kruger? she had none of the signs which indicated that she needed immediate surgery. but the pain really bothered me. it nibbled away at the back of my mind. then came the x-rays. they were worrying. i was looking at a partial obstruction, but the bowel was just too distended. one more thing to quietly eat away at my mind.

then suddenly the son appeared as if out of nowhere. he greeted me in a friendly manner. i introduced myself as the surgeon. even after hearing who or rather what i was, he remained friendly. i remained guarded. afterall i was under the impression i had to do with a physician (when in actual fact i later found out he was only a doctor).

i showed him the x-rays. he could see they were not good. i then went on to tell him i was worried and i felt an operation was in order. at this stage let me mention that a partial bowel obstruction does not need t0 be operated immediately. it can be left for the next day. but in this case there were just a few too many things eating away quietly at my mind. i had a pretty good idea what this meant. he surprised me. he said that i should do whatever i thought was needed. i did.

the operation went as i expected. i expected necrotic bowel. i resected what was needed and did all the other things that us surgeons do in these circumstances. but when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. this was no exception. we were worried about here generally and her hemodynamics and kidney function specifically. we were worried enough to send her to icu. the gas monkey even felt the need to leave her intubated. i concurred.

after i had tucked her into bed in icu i wondered where her son was. it was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. but i just felt i'd better check in the ward where his mother would have gone to if she hadn't ended up in icu. he was a colleague and besides, he might expect the worst if he found his mother in icu intubated unexpectedly. i took a stroll to the relevant ward.

i found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. i smiled. i was starting to like them.

i greeted them warmly. i didn't want them to expect the worst. i then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to icu. i reassured them that she was well and we expected no further unforeseen problems. i warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. he was pretty ok with everything but i could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to icu.

he put a stong face on it. he asked me a few questions and i did my best to reassure him on each point. then he asked a question i was afraid i would not be able to reassure him on.

"and when we go down to icu, will we be able to speak to the intensivist?"

"umm...errr....that would be me." after all, this was a peripheral town in south africa. in fact there is no real intensivist in our entire province. suddenly i felt sorry for these americans. they were far from home, their mother was very sick and the best they had to look after her in icu was a mere surgeon. there must have been at least some inkling of a misgiving in their minds. but he didn't show it. he smiled at me and simply said;

"ok. well we'll see you tomorrow morning then?" i was impressed.

the next morning i did not see them. they must have still been asleep after such a late night, i assumed. however the following few days their involvement really did leave an impression on me. it was also about this time that i realised he was not in fact a physician as i understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).

anyway the patient did well. she had the setback of a bit of wound sepsis which, considering everything, i could live with (although i have heard that some people in america want to put it onto a never event list?????). that was soon sorted out and after not too much time she was sent on her merry way.

this case also caused me to be contacted from the states. the patient herself sent a thank-you letter as soon as she got home, as did her son. she then sent a further thank you letter a year later and the year after that.

so, if i left the impression that i have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.

down time

just a few photos from my last jaunt to the kruger. above is a large group of dwarf mongoose.


the olifants river was in flood.




an early morning drive delivered an inquisitive hyena.




bateleur eating some roadkill.




a lion on the side of the road after a hearty meal.



mother and baby bats.



a woodlands kingfisher whose call is as beautiful as the bird itself.



and some elephants.




the maribou somehow makes ugly look beautiful.

beautiful

another trip to the kruger produced a beautiful sighting of the above lion. her face is stained by the remains of a dead hippo that they were scavenging off. she walked so close to the car that i actually had to stop taking photos to quickly close the window just in case she decided to have my arm for dessert.

the above picture is what remains of the hippo after two days. the lion still monopolised the carcass but the trees were heavy with vultures patiently waiting their turn. the maggots had also had a good innings.

it is difficult to explain how cleansing for my soul a visit to the park is. suffice to say it is.

the big five

unlike the perception that some first worlders have about south africa, there are not wild animals walking the streets and there are not attacks every now and then by said animals (except for my cousin who was eaten by a crocodile. that is a bit too close to be discussed on my blog though). however i'm starting to have my doubts too.

quite soon after moving to the lowveld i treated a patient that was bitten by a hippo. let me assure you that that is no small bite. i think it is remarkable to survive something like that. then there were the two crocodile attacks. the one actually had a tooth embedded in the arm. it seems that crocodiles often loose teeth. to them it doesn't matter because they can replace their teeth right through their lives.

but it seems recently we are working through the big five.
i didn't treat the guy who was mauled by a leopard. i didn't even actually go and see him. he survived because the leopard itself was terminally ill and wasn't in good fighting form.
the guy who was attacked by a lion survived because he managed to get a shot off before the lion got to him. the shot apparently took out its top jaw. the lion could therefore not bite but still shredded him quite badly with its claws. i'm a bit embarrassed to say i turfed him off to the orthopod once i discovered his injuries were all to the arm muscles.
around the time of the lion patient i heard from a friend of mine in the kruger that he had a contact with a Buffalo. luckily the beast had been darted and was pretty nearly asleep already when it knocked him down. otherwise he probably wouldn't have been around to tell me about it.

then came the elephant attack. i can only assume the elephant's heart was not in his actions. otherwise how do you survive an elephant attack? but even not fully devoted to the task at hand, the pachyderm still managed to inflict severe wounds to my patient.

we haven't quite yet covered all of the big five, so there is a part of me expecting a rhino attack sometime in the next few weeks.

interview

so i was interviewed on doctor anonymous' blogtalkradio show. the co-host was none other than the great sid schwab of surgeonsblog. i must say i really enjoyed it. if you missed it you can catch it here.

however, it seems i made a mistake about the size of the kruger. i have been corrected, though.

anyway, it was great. thanks to doctor anonymous for the opportunity.

rest and relaxation

i've taken some time off. during this time i went to the blyde river and the kruger park. both were great. so as a break from my usual blogging, here are a few photos. the above photo is of a baobab in mopani camp.


a panoramic view from mopani camp





i have never before seen an albino buffalo, but here is one. i suspect it will soon be lion food


















blyde river has a number of tufa waterfalls. this is a beautiful one falling into a turquoise pool.














an elephant skull.




















moments after this photo, the elephant did a mock charge. he pulled up about 5 meters from the car. a moment of mild stress.














a nice side view of a lone bull
















a lion print near punda maria














and another



















and a last photo. it is a bit far in the distance, but this is apparently the biggest tusker alive today (in the world). zoom in and check out his 2 meter tusks.

this is where i heal my hurts

in the kruger national park is a golf course. this photo was taken on that golf course. how cool is that!!!

but what i actually wanted to write about is the park. the kruger park is about as large as england, but elongated. it recently has taken down fences between it and numerous private reserves on its western border and a new game reserve in mocambique on its eastern border. the result is an enormous chunk of unspoiled african bushveld.

living only an hour's drive away as i do in nelspruit, i go there whenever i can. it is truly soul restoring. there are few things that compare to enjoying a sundowner on the banks of the letaba or olifants or even sabie river and watching the elephants come down for a drink. all the wories of life seem to melt away when you see the peace of those great beasts.

for all you non south africans reading this blog, you really need to take a moment to stop by and experience the magnificent kruger.