christmas meal

often on christmas i think back to a story from long ago that was based on a christmas meal but had nothing to do with a christmas meal. the man in question was unique to say the least.

it was about february. we were on one of the painful yet entertaining rounds with our eccentric consultant. up to that stage he had actually been so contained that some of us could even have been described as being bored.he just didn't seem to be ranting as much as he usually did. he was also not spewing forth his particular brand of black humour.

then we got to a new admission from the previous night. the patient was a middle aged female with cellulitis, but the thing that struck us all the most was that she was morbidly obese. she must have weighed in at 220kg. obviously we displayed the necessary tact and didn't make a big fat deal of it. the consultant, however had no such scruples.

"you are the fattest person i have ever seen in all my life and let me tell you, i have seen fat people in my many years in this hospital." we all looked around awkwardly, hoping his verbal indiscretion would end. those that knew him well had little illusion that this would be the case. he then turned to the student nearest him;

"you! go and get me a carrot!" the student looked on incredulously. "you heard me!" he bellowed, "fetch me a carrot! and when you bring it give it to her to eat!" we still didn't quite understand what new madness had taken over the faculties of our master. we mutely looked on.

"and then on christmas day give her a second carrot to eat!" he then turned to her. "christmas!" for that is the name he bestowed upon her and indeed the name he used to address her every day until she was discharged, "you are about to make history. you are going to take part in the biggest diet in the history of medicine!"

good old boy setup

i thought of not telling this story at all. recently when it was in the news here it seemed wise to rather bury it altogether. but it is something i experienced and, after all, this blog is about my experiences, so...

six years in a department gives you enough time to do a few things that can be legendary (like this story). this was one that most at the time thought was one. however, at the time it impacted me on a different level.

the surgery department had a fairly intensive academic session every tuesday. the highlight was a discussion delivered by one of the registrars on some or other topic. he was required to reference the absolutely newest literature and the standard was very high. it was a big deal. most guys spent a few months putting their talks together.

on the day in question the discussion was going to be about bariatric surgery (surgery to help obese patients lose weight). what was interesting was that the consultant (a private guy with a part time post at the university) who was designated to be the moderator of the talk was a surgeon whose practise consisted of quite a lot of small bowel bypasses. now the literature was extremely condemning of this particular operation. at the time i was rotating with the laparoscopic guru who did a fair number of gastric bypasses (an operation which the literature favoured for obesity). in passing i mentioned to the boss that it would have been more fitting if my senior had been designated the moderator of this particular discussion for obvious reasons. the boss seemed to give it some thought.

the day before the discussion the boss took me aside. he told me that he thought i was in a good position to make a comment about the gastric bypass operation verses the small bowel bypass operation because i was the one registrar at the time who had been involved in the favoured operation. he then basically instructed me to comment during the discussion. the command had been given. what could i do but obey? that night i reviewed the literature.

during the talk the registrar dedicated very little time to the small bowel bypass. he simply stated that it was an operation that has been relegated to the history books due to its dangers and the fact that there were better operations available. his moderator didn't flinch. i noted that he didn't add that the literature also stated it was unethical to even do that operation. on the whole, his talk was good. then came time for questions and comments. he fielded most questions quite well. finally the room fell silent. i stood up. i had been instructed to do so.

i started by mentioning the literature was more condemning of the small bowel bypass than the registrar had stated. and yes, i did use the word unethical. i then went on to explain that a gastric bypass causes a change in lifestyle because the patients can no longer eat so much and that their sugar intake is also curtailed whereas the small bowel bypass causes exactly the opposite. because it causes a malabsorption the patient has to make sure he eats just as much if not more just to maintain baseline health. my choice of words could have been better.

"with this operation you are actually giving the message to the patient, you are a pig and now you must really eat like a pig."

all the registrars squirmed in their seats. they seemed to be trying to quietly slip under their respective tables to avoid the accusing eyes of all the professors and consultants. they needn't have bothered. even the consultants could not maintain eye contact with me. they looked around uneasily. only the moderator maintained his steady gaze directly at me. i remember thinking i'm quite glad that looks can in fact not kill. otherwise i'm sure i would have gone up in a puff of smoke. my task was done. i sat down.

one of my colleagues leaned over.
"what have you done?" he asked. "are you completely mad? do you realise these are the guys that are going to be in your final exam in just a few short months?" i looked around. the registrars whose heads still protruded enough from behind their desks to be visible seemed to all be shaking said heads slowly. the room was absolutely dead quiet. i held my head high and gazed forward. but i also started hoping that the meeting would adjourn so that i could flee. although looks couldn't kill as i had just demonstrated maybe they could maim to within an inch of life and i wasn't willing to find out.

the next morning meeting went as morning meetings go. but just before the prof dismissed everyone he turned to me.
"bongi, you stay behind!" again the heads of all the registrars shook almost imperceptibly. sh!t!! i thought.

"bongi, dr d took me to his practise yesterday. there are fat people that he is trying to help." i considered saying that help and exploit can sometimes easily be confused with one another, but i thought better of it.
"never again will you or for that matter anyone in my department speak badly about or against any one of my consultants, in public or in private." again the thought went through my mind that i should defend myself and say that the literature backed me up with everything that i had said. i also considered pointing out that he himself had instructed me to speak and i'd just assumed he wanted me to tell the truth. fortunately i remembered something about the better part of valour and that i could not win this fight. even though it was a setup, i had hurt one of the good old boys and they would stand together, right or wrong. all i could do was hold my head high and once again prove, this time unfortunately, that looks can't kill.

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.

cuts

one of the aims of this blog is to touch on things specific to surgery in south africa. i notice panda is talking about 'alternative healing' so, not to be outdone, i decided to post on the same topic.

she was massive. her bmi must have been hovering around the 50 mark. then she developed severe abdominal pain, complete obstipation and vomiting. as is common, she went to her local neighbourhood sangoma. he did what sangomas do. he made cuts over the area the patient reported to be the problem (her abdomen) and smeared his muthi (in this case, apparently cow dung) into the cuts. the idea, i think, is that the medicine can get to work directly where the problem is.

but what if the problem is an umbilical hernia with strangulated bowel? due to her first being treated by our traditional colleague, by the time she turned up at our hospital, she was not well. systemically she was in septic shock and amazingly acidotic. she had a large necrotic mass over her central abdomen. at that stage the only thing that could be seen were the multiple cuts on the necrotic skin. it seemed like necrotising faciitis. there was no way of knowing that below this necrotic skin in her abundant fat lay strangulated necrotic bowel.

it was the turn of western doctors to take up the knife, like the sangoma before had done. the difference, however, was there was method to their madness. she went to theater. the necrosis was debrided, revealing the dead bowel. a resection was done. i was only a student at the time, so i was pretty far down the table. the smell also had a numbing effect on my faculties, so, to be honest, i can't remember the details of the surgery. suffice to say, an extensive debridement was done. living bowel was brought out (somewhere). and the wound was left open. she did the obligatory time in icu with multiple follow up visits to theater. after many months, she actually made it.

i sometimes look back and wonder if we really can critisize the sangoma. he did take a knife to the patient, which was the right treatment. he did have some concept of the problem having something to do with feces. i may advise that, unlike fire, feces can't be fought with feces, though. but many of the basic concepts where there, albeit in a non western format.

when reflecting on these incidents, i am always amazed by the fact that there is so much leeway given to these 'healers'. they are never made to account. they are never held responsible. they have free license to do what they want. there was even a government statement that the sangoma's 'art' cant be scrutinized like western medicine, because it is based in a belief system rather than science. the ancestors will heal you. believe it and it will be so. and when the patient finally does turn up at our doorstep at death's door (same doorstep?) when we can't actually pull them through, sometimes the sangomas will say "you see! the western doctors just kill you". no mention of the tried and tested methods of smearing feces into open wounds over strangulated bowel.