200%

m and m was never fun. sometimes i would walk out feeling i'd just escaped by the skin of my teeth. sometimes i would feel like my teeth had had too close a shave. but once...just once, it could have been worse.

it was a pretty standard call. it was very busy. in the early evening i was called to casualties for a patient with severe abdominal pain. when i examined him it was clear there was something seriously wrong inside. he had a classical acute abdomen with board-like rigidity. he clearly had a perforated peptic ulcer and needed surgery. i set my house doctor to work to get him admitted and on the list. meanwhile i went back to theater to work through the number of equally critical patients already on the list.

things then settled down into a rhythm. i was in theater with a student operating the cases one after the other while the house doctor separated the corn from the chaff in casualties. finally it was time to do the laparotomy for the guy with the acute abdomen. i needed to shoot through casualties before we started so i decided to swing past the ward and make sure the guy was still ok.

the ward was dark. pretty much everyone was asleep. without wanting to wake the other patients i turned on the small bedside light of my patient. even in that dim light i could see a bit of oral thrush. i was surprised. i was thinking to myself how the hell did i miss that in casualties. i felt his abdomen. it was no longer quite so tender. i turned to the student.
"see why it is important to make your decision before giving opioids?" i said with an air of authority. "now he is actually not so tender but he definitely had an acute abdomen. we must go ahead with the operation."

i quickly felt for lymph nodes. he had them everywhere. once again i was quietly thinking that my clinical skills must be slipping because that i also didn't pick up in casualties. i kept this new information to myself. imagine the shock to the student if he realised i was not all knowing. i just didn't want to be responsible for that level of devastation in his life. but i started considering other causes for his condition. it was clear he had aids and tb abdomen started looking like a possibility.

while we were still with the patient, the theater personnel arrived to take him to theater. i told them to get things going so long while i quickly shot down to casualties to evaluate a patient the house doctor was unsure about. and off i went at a brisk walk.

i walked into casualties. the house doctor led me to the patient in question, but as we approached his bed my blood went cold. in the exact bed where my acute abdomen had been lying about four hours previously was my acute abdomen still lying there!! i turned and ran back to theater. fortunately i was in time.

later i found out what had happened. once we had admitted the acute abdomen, the porter had come in to take him to the ward. one of the patients lying in casualties was a guy that had just come in. his hiv had wreaked havoc in his life causing a number of unpleasant things, including aids dementia syndrome. the exchange went something like this;

"timothy mokoena? is there a timothy mokoena here?" the porter called out.
"here i am, but it's not mokoena. it's magagula."
"ok, timothy magagula, i'm going to take you to the ward."
"ok, but it's not timothy. it's michael."
"ok, michael magagula. let's go."

and thus michael magagula, the aids dementia patient (not to be confused with timothy mokoena, the acute abdomen patient), thinking he had just jumped the queue to see a doctor was carted off to the ward and prepared for theater. he even signed for a laparotomy without even having seen a doctor.

in the end it all turned out well. timothy got his operation and the hole in his stomach was patched. michael was referred appropriately to the physicians. but i couldn't help wondering how this could have looked in the next m and m meeting.

"well, prof, the patient died on the table basically because i operated him unnecessarily."
"and how is the other patient? the one you should have operated?"
"well, he died too because i didn't operate him."

200% mortality for one operation. not easy to achieve.

(of course names have been changed)

byeboer

my good blog friend ramona suggested i do a post about my other interest, beekeeping. one story immediately sprung to mind which sort of connects to surgery.

i was in my vascular rotation. it was busy. we did 15 calls a month and the days were really full. yet, somehow, in my off time, i made extra money by removing wild beehives from people's houses. naturally most of this work was done after hours, when the sun had set. this is the best time to work with the somewhat aggressive african bee so it suited me fine.

then one monday the theater list ended up being cut short due to a lack of icu beds (a common problem in our neck of the woods). this gave me a few hours off that afternoon before i had to be back for the m&m meeting (morbidity and mortality meeting). it seemed ideal to quickly remove a hive i had on my to do list. that way i would actually be able to have an early night. but i would have to rush.

i charged home, bundled my equipment into the car and drove to the house which happened to be in one of the outlying suburbs of pretoria. only when i got there did i realise i didn't have my smoker with me. not too bright, i thought to myself. but at least i could check out the hive and come back later, more prepared. it was too far to go back home, come back and do the job before the m&m meeting.

i introduced myself to the owner. immediately her Rottweiler started...well, hounding me. i'm nervous about rottweilers on a good day and the fact that the owner informed me they only get aggressive after two years of age didn't help (she was also kind enough to tell me he was two years old). she left him to his own devices which included jumping up on me and nipping my heels. i should have left then. i didn't.

the hive was in a hole in the wall in the garden. the opening was flush with the ground and therefore very difficult to access, especially because when i bent down the dog would jump onto my back. it was not a hive that i would be able to recover. that meant it was going to be an extermination job. armed with this new information i decided the smoker wouldn't be necessary seeing that i was going to kill them anyway. i had my poison (a tablet that, once lit, gives off clouds of billowing poisonous smoke. the idea is to light one, throw it into the hive and try to block up the entrance.) and at the time i thought that would be enough. looking back, i was foolish. i was not fully prepared (i didn't have my smoker), i was rushed (i needed to get back in time for the m&m meeting) and the dog was making sure that my mind was not on the task at hand. the fact that the owner did nothing about her dog was also a source of intense irritation to me. i should have left then. i didn't.

i asked the lady for a spade to access the hive more easily and suited up. i approached the hive with the dog still all over me and started digging. it was at that moment that i became acutely aware of how effective smoking bees is. these bees that hadn't been smoked immediately came pouring out of the hive in an almost solid mass and attacked as only african bees can.

two things happened simultaneously. one caused me great personal delight and the other caused me great personal consternation. the first was that the bees did not only attack me, but they also attacked the dam dog. i heard him yelping in pain from multiple stings as he finally left me alone and ran for cover. the second is i came to the shocking realization that, due to being rushed and harassed i had not pulled the zippers around my ankles down. there were two circles of exposed skin at this level. the problem was with my gloves on i could no longer pull them down. to remove a glove would be catastrophic. i had no choice. i had to proceed.

without going into too much detail, i finally got the smoking tablet into the hive and closed the entrance. most of the bees were probably out at that stage, trying to kill me, so i'm not too sure how many i actually killed. the queen and all the brood would be dead so the hive would not survive. my work was done. however i had sustained so many stings on my exposed ankles that, although i'm not allergic, the shear volume of poison that my body had taken was making me a bit dizzy. i needn't elaborate on the level of pain that that many stings causes, but it is enough that you tend to notice it.

the owner paid me by pushing the money under the door. clever move. besides i was feeling so light headed i thought i might pass out and look really stupid. i already felt that this was not the most professional job i had ever done. to collapse on her doorstep would not be a good idea. then i finally left.

i drove to the nearest chemist where i bought celestamine, an antihistamine steroid combination. to be honest i was considering buying adrenaline but decided against it. then i rushed back to work, charged into the m&m meeting and collapsed into my chair. moments later i was presenting my cases for the week with a throbbing headache, slightly blurred vision, a ringing in my ears and excruciating pain around both my ankles. relatively speaking the m&m went very well.

m and m

i'm instituting the m and m meeting in our department starting in february. m and m stands for morbidity and mortality meeting. i thought i'd drop a blog about it seeing as though it can be quite an emotive issue. i also realise i've come full circle, starting with my first m and m as a house doctor (a story i'd rather forget) up to me being the one to launch the meeting as a formal part of the weekly activities of the department of surgery in our hospital.

my first m and m can maybe wait its turn for a complete blog, so let me start with when i joined the department of surgery at the university of pretoria.
in your first year, you are a medical officer. that's to say your formal training hasn't started yet, but you are earmarked for a post as registrar (kliniese assistent) the next year if you pass your primary exams and if you survive the year. for a number of reasons, when i started there was a general shortage of registrars, so i was put in charge of a firm even though i was only a lowly medical officer. this was very daunting. if you're clever the one thing you should know is that you know nothing. i was clever and therefore scared. but you learn fast. you must. i remember the first sigmoid colectomy that i ever saw. i remember it so well because i did it. it was for necrosis due to volvulus. i opened the rigid acute abdomen in the early hours, got one helluve fright, being so wet behind the ears, and phoned a senior. he informed me he was in messina (about a 6 hour drive away) and told me over the phone what to do. i did it and the patient didn't turn a hair.

i realise i digress. the fact that he didn't turn a hair means he didn't end up on the m and m and therefore shouldn't end up on this blog. but the point i'm attempting to long windedly emphasise is that i was thrown in in the deep end and had to swim. because i was only too aware of my total lack of knowledge and ability i was always scared i'd killed someone accidentally and was therefore terrified of each and every m and m meeting. i would sometimes even lie awake the night before planning how best to present the cases. i never ate on a monday before the m and m (which was at 17h00) because i just couldn't get any food down. it seems you actually do need saliva to be able to swallow food and all my salivary glands routinely took monday off.
at the end of each m and m, which seldom went as badly as i had been expecting, i would walk out with a type of post adrenalin euphoria and triumphantly anounce 'survived another m and m!' seems a bit juvenile now.

as time went on and i became somewhat less of a danger to the population at large, the m and m also became much less daunting. it never totally lost its sting, however. it will always be unpleasant to explain to a room full of experienced professors why someone died, even if they did have terminal colon cancer growing right out of their abdominal wall and about no remaining normal liver.

and now it's me starting up the totally new concept in this hospital in the middle of the lowveld and the doctors 'please explain' to me. seems surreal. please don't think my aim is to put them through what i went through (i think of a guy called anonymous commenting on another blog that us surgeons do that). on the contrary. the idea is to learn and better the service and even protect out junior staff. knowledge is power and as long as i know what happened with each case i can defend my people when the stories do the rounds.

and when something happens there are always stories. i soon learned in the days of the dreaded m and m never ever to hide a case. people will be talking about you anyway. the best thing you can do to preempt this form of gossip is to beat them to it. i saw other people hide cases and suffer silent whispers in the corridors sometimes for years. whereas if you just come out with the whole story, it passes and usually there is even sympathy for your plight.

anyway, enough blogging for one day. we'll see how the softer bongi m and m goes.