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)

gee thanks

i've often blogged about the tendency in our training to be left on your own (here, here and here to name at least a few), but some of the stories have a funny twist.

i was in my medical officer year. in those days there was a general shortage of registrars so the boss used us to fill the gaps. he put myself and another medical officer in charge of a firm, reasoning two medical officers add up to one registrar.

being two, we decided to split the call. and i was the guy who got the night. so when i came in i tracked my friend down. he was in theater doing an appendisectomy. i asked him if he had anything to hand over to me.
"sure. there are just two appendixes to be done."
"straightforward or any catches?"
"no catches, just appendicectomies"
the first one went well. i used it to show the house doctor how to do an appendisectomy, so that she could do the second one.

at this point i'd like to point out that i was very junior. i did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it.

she did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out. i calmly told her it looked like the appendix was going to be pretty sick. and then she found it.

it was normal. my heart sank. there was clearly something else wrong with the patient. i remained silent and told the house doctor to go on with the operation. my mind was racing. most probable diagnosis was perforation of a peptic ulcer. i calmly asked if there were any x-rays with the patient file. there were and they were put up on the x-ray board which was behind the house doctor and therefore in my direct line of vision. there on the x-rays for all to see was free air under the diaphragm, a clear sign of peptic ulcer perforation.

shit! i thought, but stayed silent. i knew i would need to take over. only problem is i'd never done the necessary operation before (omentopexy). i had seen it once before as a medical student about three years beforehand. it was definitely in the class of operation where you would make enemies if you called the consultant in. it was meant to be in the armamentarium of a registrar and, according to the boss, i was at least half a registrar.

the house doctor swiveled her head around to take a look at the x-rays.
"shit!" she said out loud.
"don't worry," i lied. "that's why i'm here. you have no responsibility here. i'll take over now."
"shit!shit!shit!shit" she replied. i don't think she imagined her first appendisectomy to go quite like this.

for an omentopexy, the first thing that needs to happen is a midline incision, rather than the usual mcburney incision for an appendix. the patient would have two cuts. oh well, can't be helped now. i told the house doctor to swap places with me.
"shit!shit!shit!shit!" she said in acknowledgment to my request and moved around the table. i confess i laughed a bit at her total loss of vocabulary, but it was a nervous strained laugh. i felt that i needed to reassure her that i had the situation under control. she did not need to know that i had only seen the procedure once before and that a number of years ago.

"don't worry," i said, "that's why i'm here to back you up. you are not in charge here. you have no responsibility."
"shit!" she said with what i assume was a forced smile behind her mask.

i got to work. soon i had the hole nicely exposed and the abdomen cleaned out. all i had to do was plug the hole with omentum, place drains and close. only problem is although i theoretically knew what to do and even how to do it, i had no idea what suturing material to use. this was a dilemma. i knew i couldn't really phone for backup for an operation i was supposed to be able to do late at night. but more importantly i didn't want the house doctor to feel any more insecure about the situation than she already did. if i told her that i was unsure of what i was doing i was pretty sure i would get another string of her most recent favourite word and maybe turn her off surgery forever. the situation seemed to be traumatic enough for her without me adding to it with trivial facts about it being pretty traumatic for me too. i decided what to do.

as casually and as nonchalant as possible i turned to the sister.
"sister, when the other guys do an omentopexy, what suturing material do they use?" so clever, i thought. i would find out what to use without causing any further stress to the fragile house doctor and without looking too stupid myself.
"oh," she answered, "they use whatever they want."

gee thanks. i thought. well that didn't work. even in the acute phase i could appreciate the humour of the situation though. i might even have laughed, more at myself and my situation than anything else. the sister had no idea that i was in what at that stage was deep water for me.
so i asked for vicryl and did the necessary. the patient did well.

next morning, on ward rounds with the prof, i took the blame on myself. i did not mention that my colleague had misdiagnosed because, in the end, i should not have gone into the operation without double checking everything myself, so, i reasoned the blame did in fact lie with me. i also neglected to mention that the house doctor had done the initial appendisectomy. she was never in the firing line. despite all this, just for good measure, my colleague who had assured me that it was just a simple appendix, covered his own ass and informed the prof that he had told me he suspected perforation and reminded me to check the x-ray. nice to have friends like that, i thought, but i just apologized for missing it and moved on.