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.

bariatric surgery

bariatric surgery is on the up and coming in our country. i understand it is very common in the us of a. being from a country that openly advocates alternative forms of medicine (our minister of health publicly supports the eating of garlic and beetroot as an alternative treatment for hiv and aids and does not support antiretrovirals at all and our previous deputy president in open court described taking a shower as effective prophylaxis against hiv after having unprotected sex with a known hiv positive partner. it was a rape case) i decided also to give an alternative opinion about weight loss therapy based on a case i once saw.

a lady presented in casualties. her history was as follows. she had read somewhere (possibly the internet, but i don't really know) that there is something in the urine of pregnant women that causes weight loss. i'm not personally aware of this substance but i don't claim to be an expert on weight loss or chemicals found in the urine of pregnant women. anyway, as it happens, her domestic servant was pregnant at the time. she did what i'm sure we all see as the logical thing armed with her new knowledge; she asked her domestic servant to urinate in a bowl, she drew up the urine and injected it into her abdominal fat. i never heard where she got the syringe and the needle. like many overweight people the patient also had type two diabetes (predisposing to some degree of decreased immunity).

when she presented, she was not in a good way. she was in diabetic ketoacidosis, was in shock and worst of all had subcutaneous crepitations on her abdominal wall around the site of the injection. this is an ominous sign, indicating necrotising faciitis (hyped in the media as the flesh eating disease). she needed to get to theater and fast. the only way to treat this very rapidly spreading infection is to cut away all the affected tissue, right down to the muscle. to get the desired results (arrest of the spread of infection) sometimes takes more than one visit to theater. if she survives the initial onslaught, at a later stage the wounds can get skin grafts.

a colleague of mine did the initial debridement (cutting away the offending tissue) after the appropriate rapid resus. she ended up in icu where she actually improved. the colleague asked me to accompany her on the second visit to theater where we finalised the debridement (mannaged to get rid of all the infection).

once we were finished, the patient was missing all her subcutaneous tissue and skin of half of her abdomen, from the loin region to the shoulder, from the midline to posterior on her flank (almost onto her back). because she had a generous layer of fat, this constituted a massive tissue loss.

fortunately enough, she then recovered pretty much without further incident and was soon discharged to the ward. we then embarked on the ordeal of getting the exposed tissue covered with skin grafts, but after a few more visits to theater, that too was done. she was ready for discharge, alive.

when she left the hospital, she struck a rather pathetic and maybe frightening figure. her left side was still fairly overweight, although the overall ordeal had caused considerable metabolic utilisation of remaining fat. the right side of her abdomen, however, had no fat whatsoever. the skin was directly on the underlying muscle. she was totally asymmetrical.

as she left i couldn't help wryly reflecting that her plan to lose weight had worked better than she ever thought possible. it seems a multidisciplinary approach to weight loss, medical mannagement (in this case the ill advised injection) combined with surgery (debridement) with just the right dose of stupidity can have very dramatic results. i only hope our good minister of health never reads this. she will probably make it part of the national weight loss program.