leaking

people are basically sacks full of water. the skin keeps the water inside. trust me when i say you want to keep your water inside.

the second post i ever wrote had to do with watching someone with burn wounds fade slowly away. in the end it had more to do with my own mortality. when i read it recently i was reminded of quite a few poignant stories. this is one.

usually things happen in groups and, it seems, burn wounds are no exception. on two successive nights two severely burned patients came in. i got the first. my colleague got the second. my patient had 98% burn wounds (usual story of being doused in petrol and being set on fire. someone didn't seem to like him). only where his hair had been was he not burned. that means that 98% of the sack that is supposed to keep the water in was leaking.

let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. this patient was as good as dead, so whatever we were going to do would only partly help. the outcome could not be changed.

the immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. the amount of fluid one gives is proportional to the surface area burned or the surface area leaking. in 98% that turns out to be quite an amazing amount of fluid. and that is what we did. i worked out the fluid needed, put up a good central line and started running it in. the next day he was still alive.

the next day was when the second burn wound patient came in. he had 95% burns and therefore was leaking pretty much the same amount as my patient. my colleague admitted him, but he treated him differently. my colleague knew that the end of the road was predetermined and didn't see the point in prolonging the inevitable. he only gave him normal maintenance fluid which a normal person would require. he considered more as treatment and didn't see the point in treating something that could not be treated. i considered that he may have a point. i went to see his patient.

his patient was not doing well. the loss of fluid had pushed him into a stuporous state. he didn't seem to have long to go. i left. he died soon after.

my patient remained alive through that day too. because of his wounds he could not lie in bed without extreme discomfort. but the soles of his feet had no skin so he could not stand either. the skin of his hands had all peeled off and they had swollen into useless immoveable paws.

the head of the firm then decided we should take him into a shower and remove all remaining loose skin. i got the feeling he was trying to teach us some sort of lesson. the only thing i learned is that it is brutal to try to remove loose skin, even gently from such a patient. the patient was not having fun at all. i kept thinking why are we making the last days of his life any more miserable than they already are? the head then decreed that we would repeat this process in two days time. i felt sick at the thought. the wisdom of my colleague not treating his patient seemed much clearer to me then.

the next day when i arrived at work i was relieved to discover my patient had finally succumbed to the inevitable. it would not befall us to have to torture him the next day in order that we learned some mysteriouis lesson.

dangers

something happened a while ago that gave me quite a stir, on more than one level.

being the only private hospital servicing the southern part of the kruger park, we quite often see tourists at our facility.
i get a call from a gp who is in practice just next to the park. 'appendicitis' he says. 'send' i reply.

she arrives in casualties, significant other in tow. i ask the usual questions about pain, nausea, appetite etc. sounds convincing. i ask the significant other if he would mind waiting outside while i examine the patient. he asks why. i explain that it is better that he not be there during the examination. he leaves.

examination is typical of appendicitis. i decide, due to the pretty clear cut history and clinical to omit a pr and pv. (don't tell the prof. he'll do his nut) to be honest i also had a feeling the significant other was going to be problematic and i felt a voice warning me or some such thing.

thereafter, to theater and appendix out (i was going to say chop chop, but...). then i handed the patient over to my colleague and went to the kruger park for my weekend off.

in the park in one of the camps, who should i run into? mr significant other (he continued his holiday rather than stay by the patient's side during her hospitalization). he confronted me. he asked why i had asked him to go out. i was thinking that i should say that i suspected she was abused and i wanted to talk to her in private, but of course i just explained that that is standard practice. and then it happened. he said,' listen doc, in this day and age if you examine a patient without a witness, there could easily be a case of rape made against you.' he threatened me. he basically accused me of raping her. i turned and walked away.

a few thoughts. firstly the patient and the patient alone is my responsibility. yes, i try to involve the family as much as possible, but in the end my contract is with the patient.
secondly, what sort of person continues his aggression after the person he is ostensibly fighting for has been helped.
but lastly, this sort of thing may make a doctor think twice before completing a full physical examination. i already felt i was taking a chance by omitting the pr and pv, which should actually be a part of all appendicitis examinations.

i quietly wished thrombosed hemorrhoids on him and felt somewhat better.

boerhaave

i had just started my mo year in surgery. i was going to save lives. i was going to make a difference. nothing could disillusion me.

it was my second day and first call. it was surprisingly quiet, probably because the entire population of pretoria was at the coast for the december holiday. then the thorax guys called us to see a patient. i followed my senior, knowing i would be of little help in any situation at this junction in my career. (i had just come out of the bush where i did my internship and community service years. in fact, i had only recently begun to walk on my hind legs and was just mastering rudimentary tools)

the guy was admitted just after christmas (about 6 days previously) with severe chest pain and a left sided 'pleural effusion'. they had placed an intercostal drain and drained a bubbly type of foul smelling liquid. and thus he had remained for almost a week. the only change was that the drainage became much more offensive.

my senior asked him about christmas. how much he had eaten and how drunk he had gotten. had he vomited etc. the patient, although in severe pain, answered that it had been a party to remember. he could remember very little of it. he had vomited copious amounts though and that's when the pain started.

the patient looked up at my senior and said,
'please help me doctor. i can't take much more of this'
'don't worry, we'll help you. you're going to be just fine.' and with that, we turned and left. this is what i signed up for. we were going to get this guy through whatever was wrong. i was, indirectly going to make a difference. i felt excited.
'that guy is dead!' says my senior as we walk away. i was floored. hadn't he just moments ago told the patient he was going to be ok and given a creepy smile of reassurance? hadn't he held the guy's hand and given a squeeze when the patient said 'thank you doctor, thank you so much'?

we got him to theater. the consultant came out. we opened the chest and found that the esophagus as well as the surrounding tissue was necrotic. it had the dirty dishwater appearance that i would later associate with necrotising faciitis. we debrided, but it is a difficult place to debride. you don't want to debride the heart, for instance. it could cause an unpleasant bleed. i was too junior and too far down the table to really follow the finer details of the operation, but we did deliver him, sort of alive, to icu. they pumped precious money and resources into him for a further two days before the inevitable.

he had boerhaave syndrome, a tearing of the esophagus, usually into the left hemithorax, associated with overeating and drinking which in turn causes discoordinated vomiting and voila! if you diagnose it immediately and operate, they have a chance (fair to good). if you give the sepsis time to set in, causing a mediastinitis, the chances drop. if necrosis of the mediastinum has been allowed to develop, no chance at all.

i was totally dissillusioned. my first call and i stood there innocently believeing in our noble profession while my senior lied to someone. ok, the guy maybe felt better emotionally in the last moments of his life, but i could not justify lying to the guy. i also realised there are some fights you just can't win.