the baby story

the life of a medical student is somewhat left of normal. most people shy away from blood and guts and gore. as a medical student you need to embrace it. but in the beginning it is quite an adjustment. sometimes you don't know how much to adjust. what falls within the parameter of normal medical student desensitization and what is way too far?

i was a fourth year which in clinical terms meant i was at the bottom of the rung. i was doing my obstetrics rotation which meant i needed to deliver a certain quota of babies in a given time. we all tended to be goal orientated then. our registrar was the most junior obstetrics registrar in their department so she was even more goal orientated than we were. she was also a bit skittish.
so that day, when a lady came in fully dilated and then popped out a dead baby she seemed to go to ground. don't get me wrong. i do not enjoy the whole emotional roller-coaster involved in delivering a dead baby, but once it's done you need to move on, especially in kalafong where the constant stream of bursting women is never ending.

so there we were in kalafong labour ward in the middle of the night with a somewhat unstable registrar who suddenly seemed incapable of pretty much anything because she was so distraught. i had the thought that she should maybe try dermatology as a speciality. it wasn't too late to change. the house doctor spent quite a bit of time consoling her. time i thought could be better spent in consoling the mother who had just lost her child. but a fourth year's opinion was much less sought than listened to. finally the night went on.

some time later when the distraught mother was bundled off to the ward and the dead baby was bundled off to the morgue and the registrar bundled herself off to the doctor's room the call finally continued. we continued delivering babies while the registrar went through the prenatal record of the mother to try to see if there was a possible reason for the death. she discovered the mother's blood group was rhesus negative. this basically meant if the baby was rhesus positive the mother needed to get an injection of antibodies to prevent her developing her own antibodies against the rhesus factor. if this happened her chances of successfully bringing her next pregnancy to term would be greatly reduced. the registrar hadn't drawn the chord blood from the baby which is the normal method of getting blood to determine the baby's blood group. she therefore didn't know if the mother needed the injection or not. i simply thought it's not worth taking the risk and we should rather just give the mother the injection on the grounds that the baby was most probably rhesus positive. but the real reason the registrar was in a spin had to do with what the professor was going to say in a few short hours at handover about her not drawing chord blood from the baby. she settled on a plan.

"you!" she indicated my friend and i, "you are going to go down to the morgue and get that baby's blood. and you'd better move it. the sun will be up soon.

the morality of what she was asking didn't occur to me then. it was late and we were tired. also we were junior. if the registrar told us to do something then we were required to do it. so off we went.

kalafong is a scary place on a good night. the morgue was in a ditch along a deserted corridor. all was dark and foreboding. but we were on a mission and our over active imaginations weren't going to stop us. we finally found the poor baby and got to trying to get blood. then we discovered something. you actually need to be living for your blood to be drawn out of conventional veins. after a few attempts we graduated to trying to get blood through the frontal fontanelle. this also didn't work, probably because the small amount of blood there had clotted and couldn't be drawn up in a standard syringe. finally we stuck the biggest needle we had right into the heart and managed to get a small amount of blood. by this stage my own blood was curdling, the hairs on the back of my neck were standing up and i felt sick to my soul. we left.

the registrar took the blood without so much as a small acknowledgement towards us that we had done something terrible so that she could avoid the wrath of the professor.

many times since then i have been haunted by how wrong what we had done there in the dank corridors of kalafong was, but it was a lifetime ago and maybe time does wash at least some sins away.

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)

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.

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.

the death of a fellow human being

recently we admitted a patient with 80% surface area burn wounds. in most centers in the world this is equal to a death sentence. in africa there is no chance at all of survival. we knew she would die. it was just a matter of when. she also had mild inhalation burns. usually in the case of inhalation burns the patient would be intubated(tube stuck in trachea ie windpipe to keep airway open and allow breathing) but because she had no chance we ellected not to do this, secretly hoping she would asphixiate in the night. (this is a better way to die than the prolonged agony of the burns and the sepsis that would soon set in) her inhalation burns were however not so bad and she did not die in the night. every day when we saw her on rounds i would ask her how she was and she would give the generic reply that she was fine. this was not true of course. she was in pain and on the brink of death.

we discussed her with the students. the medical facts were simple. she would die and there was nothing to be done. the human tragedy was somewhat more complex. i found myself wishing that she had already lost her humanity because it would then be easier for me to deal with her imminent death. she did not. she remained human to the end, every day telling me that she was 'fine'. every day i found myself wanting not to go into her room. this was selfish of course, because it had to do with me dealing with her death and not with being there for her in this time of her need. i was confronted with the fact that our patients are human and therefore equal to us in every way. i was therefore confronted by my own mortality. most of my colleagues would just cut off from the situation. this i fully understand because there are too many opportunities where one is confronted by this, so as a defence mechanism one cuts off. but if we are really doing this job to make a difference in the lives of fellow human beings, we need to guard against becoming callous. true as surgeons our first priority is to treat the physical person. but why do we do this? it should be to allow the person to get back to the more important aspects of life that define us as human. things like reading poetry and falling in love and the like.

anyway, as expected she died, but only after confronting me with my own mortality every day for a week. some people may think you should never be glad at the death of another human being, but i disagree. i was happy when she died. don't get me wrong, i was not happy that she had to go through the whole ordeal. i was not happy that she got burned in the first place, but once she was burned, i wanted her suffering to end. i was happy for her that she died. but if truth be told i was also relieved for myself that i didn't have this constant reminder of how fragile my own life is and how we rely so much on this shell we call a body to transport us through life.