evil

doctors can be naughty sometimes too. i suppose boredom can be fertile ground for all sorts of mischief and what speciality tends to leave plenty of room for boredom more than anasthetics, especially when you have to sit around with a stable patient while an orthopod labours through the night fixing all sorts of bones.

the anesthetist in question was on call for the orthopedic list. the list tended to start at about four in the afternoon and go pretty much right through the night. by midnight it could be quite a challenge to maintain enthusiasm, unless of course you had something to keep your mind busy.

after a few cases the gas monkey and the bone doctor took a break to replenish fluids and caffeine levels. however, while the poor unsuspection orthopod wasn't looking the evil anesthetist decided to lace his coffee with a strong diuretic. to ensure the best comic effect he put four times the usual dose in the coffee. i suppose he thought it would be four times as funny.

quite soon into the next operation, a fairly long procedure to fix a fracture of the femur (thigh bone), the poor unsuspecting orthopod started looking uncomfortable. he seemed to be struggling to stand still and resorted to crossing his legs quite a bit. finally he just couldn't hold out anymore.

"sorry guys, but that cup of coffee seems to have really settled on my bladder. i'm going to have to unscrub and go to the toilet." with that he walked out. the theater erupted in raucous laughter. only the bone doctor wasn't in on the joke. soon he was back, looking a lot more comfortable, no doubt hiding a contented smile behind his theater mask. he scrubbed up and continued the operation. unfortunately as the bladder distended again his easygoing nature gradually was replaced with irritation and impatience about the fact that the operation seemed to be taking longer than he and his bladder thought it would. quite soon the same restlessness and leg crossing started up and once again he excused himself and ran from the theater in embarrasment.

when he returned the theater staff were trying to remain composed, but there were a few snickering sounds escaping here and there as well as a giggle or two as the process repeated itself. the bone doctor stopped dead in his tracks.

"what the hell have you done to me?" he demanded. everyone burst out into raucous laughter as he charged out one more time to empty his tormented bladder.

the sentinel

anyone who follows this blog will know i have a tenuous relationship with the ivc (here and here). it is something i've seen only too often and each time it has me on edge. somehow i just can't get used to being up close and personal with an ivc that seems to want to bleed. but even i can laugh at some of our interactions.

i was the senior registrar so when the bone doctors decided to do a spinal fusion at the 4th and 5th lumbar vertebra and they wanted someone to expose the spine for them from the front, i was their go to guy. only problem is i didn't know how to do it. having been in surgery for long enough, it came naturally to me to show no weakness. i couldn't tell them this. i reasoned to myself i'd discuss it with the prof and if he felt i needed assistance then he could offer to help. looking back it wasn't the best thought out plan, all things considered.

the operation was booked for two days time, so the next morning i went to the prof's office and told him that i had been asked to help with exposure for a spinal fusion at level l4-5. he seemed almost not to hear me.

"good." he said as he continued with his work.

"only thing is, prof, i've never done it before." i considered telling him i'd never even seen it before but that was implied in the first statement, i thought. "should i go transperitoneally?"

"do what you are more comfortable with." great help, i thought. well transperitoneally (through the abdominal cavity) it would be then. the abdomen was after all my stomping ground.

the orthopaedic consultant who was going to do the operation was a bit of a legend. he was this super genius whiz kid that everyone doing intermediates was afraid of. he pretty much knew everything about everything and would always be able to dig out a question that you couldn't answer if he wanted to. luckily intermediates were way behind me so i didn't need to worry about offending him too much, but still it was a bit intimidating being asked to get exposure for an academic giant such as this man.

i entered theater at the predetermined time. there were about 3 orthopaedic registrars getting the patient ready. immediately when they saw me they asked how i wanted the patient to lie.

"put him on his back, " i said, oozing confidence, "i'm going through the abdomen." they nodded. and did so. once everything was ready we all started scrubbing and the sister started draping the patient. i tried to envisage what i would be doing in a while. i decided that i'd reflect the right colon up and pull the ivc out of the way, rather than reflecting the left colon up, which would mean i'd have more to do with the aorta. my reason had little to do with the blood vessels but rather had to do with the fact that the right colon can be reflected right out of the way whereas the left colon can't because it continues down to the rectum which is pretty much fixed. truth be told, the aorta is easier to work with than the ivc, but i just felt i'd get more exposure on the right. in my mind i was just trying to convince myself that it was going to be fine when the great orthopaedic consultant entered. he greeted us all and thanked me for my help before quickly going into the theater to make sure everything was in place. moments later he was back.

"the patient is on his back. are you going transperitoneally?" he asked. there was something in his question that bothered me, but this was not the time to seem unsure.

"yes, transperitoneally it is."

"for l4-5 fusion?" he asked it in such a way that the implied answer was that transperitoneally was not a good idea for l4-5 fusion. i thought back to the useful advice of my prof that i should use whatever approach i was more comfortable with. it occurred to me that this was an operation the prof possibly had never done before. besides if this legendary orthopod sounded like he knew something that neither i nor my prof knew, it was probably because he did know something that we didn't know. i felt my heart rate rise. but it was too late. i had no backup (the prof hadn't offered to help) and i would have to stand with my decisions.

"yes. we will be going transperitoneally."

"are you sure." i wasn't.

"of course i'm sure."

"well if you say so, but you are a braver man than me." he replied with a laugh. i felt my heart sink into my shoes. i just smiled.

i went through the abdomen. i flipped up the colon and exposed the ivc. i then mobilised it enough to pull it gently away from the spine....and discovered why transperitoneal approach is not good for l4-5. the ivc splits into two veins which drain the legs at roughly this level. the left one (left common iliac vein) crosses over the spine and when you try to ease the ivc away from the spine it gets pulled so tight it looks like it wants to tear off. but still i mobilised everything enough that their target area was nicely at least visible.

"there you are." i said with an air of i-told-you-so. "enjoy the rest of the operation. i'm outta here.

"what do you mean you're going?" said the giant. "you stay right where you are. it's your job to keep the ivc out of my way. you just stay there and stand guard over your ivc." this was starting to sound familiar and i was no longer happy to be part of it. but anyway, it wasn't as if i had a choice. besides, how bad could it get?

it could get pretty bad. i stood there with a retractor carefully in position putting just enough traction on my precious ivc without tearing the left iliac vein while the orthopod took the biggest badest instruments i have ever seen and ripped one entire vertebral body out bit by bit. now a vertebral body is somewhat tougher than an ivc and he used amazing amounts of power. i swear there were times he picked the patient off the theater table by his vertebra until a chunk was ripped off and the patient came crashing down again, all the while with me trying with all my might to not pull on the ivc with all my might and yet still keep it out of the way of that ferocious instrument the orthopod was wielding. in my mind he looked like a medieval barbarian with some sort of overly vicious weapon swinging around with just too much force. there were times when i thought he was going to pull the patient right off the table with me and the ivc being dragged down with him. i didn't only fear for that poor ivc but there were times i actually feared for myself.

after a while he got that condemned vertebral body out and replaced it with some sort of metal device. once that was in the ivc was allowed to return to its normal position. thereafter my frayed nerves also started recovering. once again had i stared into the dark eyes of the ivc and lived to talk about it.

p.s the patient survived too.

friend's best friend

many years ago a friend of mine told me a story which i thought quite touching. it seems like a nice way to kick off the year.

one of my seniors in surgery had a dog that meant a lot to him. he lavished it with love and attention and they were inseparable. he had trained the dog to obey him implicitly. in fact it was so well trained that he would often go for walks with it without a leash. one word from him and the dog would stick to his leg like glue. this was one of those walks.

my friend and his best friend were out walking. it was a quiet day so my friend would send his dog out far ahead. he would then shout the command for it to stop and wait. he would then either leisurely catch up to the dog or give the command for it to return to him. then he sent the dog ahead again, but this time didn't notice the dog would be crossing a street. as the dog was half way across the street my friend saw a truck barreling down at full speed towards the dog. he panicked and, instead of shouting for the dog to return, just screamed the dog's name. the dog stopped dead in his tracks, right in the middle of the street...and was run down.

soon the dog was at the vet. most of the injuries were to the leg, but they were bad. so bad in fact that the vet said only an amputation would suffice. she then added that this breed of dog didn't do too well with an amputation because they needed to run around a lot or they became depressed and lost the will to live. she suggested euthanasia. my friend was devastated, but he agreed that the dog would not do well without a leg. he consented.

just before the injection he went through to his faithful old friend to say goodbye, but when the dog looked up at him and, despite the pain wagged its tail and smiled he knew he could not just stand by. he asked the vet if she could anaesthetise the dog. he would do the rest. he then drove to the hospital where he was training, walked into theater and pretty much stole all the orthopaedic plates and screws he thought he would need. not too long afterwards he was drilling and hammering and doing the things bone doctors do, but on his dog. somehow he got it all together, although he had to sacrifice the articulation of the wrist. a stiff wrist was better than no wrist.

and so the dog recovered and went on to have a full and happy dog life.

p.s i'm not condoning the stealing of all the hardware but when i confronted him about that he pointed out that the hospital had refused to pay him overtime well in excess of the value of the items stolen and, he said, he could therefore live with it.

out of benoni

when charlize won her oscar, south africans weren't surprised that a fellow south african achieved such a great thing. what we couldn't believe was that benoni could produce anything even remotely worthwhile. having said that i actually know of the other good thing benoni produced (yes, there were only two).

when i left school, my headmaster taught me never to look down on someone who actually might still achieve something in his life. the way he did this is that he wrote me a letter. in that letter he said;
"you are a lout! your five years in this school have meant nothing and you will amount to nothing in life." just in case i didn't get the message (i think he thought i couldn't read) he wrote a letter to my father. in that letter he said;
"your son is a lout! his five years in this school have meant nothing and he will amount to nothing in life." i thought he was a sad old man who had risen as high as he ever would and he was just a headmaster. i felt sorry for him. but throughout my medical and surgical training i never looked down on someone below me on the pecking order. one day they just might surpass me.

my friend came from benoni. he was brought up there and went to school there. like any self respecting benoni boy he only just scraped through matric, probably close to the top of his class. he was lucky. at that stage the university of pretoria had a sort of remedial science course for the intellectually challenged. most of the candidates would drop out in first year. some might actually achieve a watered down degree or diploma. one or two might actually get into the mainstream bsc course and get a real degree. some say it had actually happened before. my friend managed to get into this class. i'm sure most of benoni was proud of him.

right at the beginning of the year the class mentor (not too sure what the english word for voog is) called each student to the front of the class and asked what they hoped to achieve with this opportunity. most had realistic expectations. not my friend. he stood up and said he wanted to use it to get into medicine and maybe one day do orthopaedics. the voog laughed at him in front of everyone. people in that class just didn't have the goods upstairs to go that far. in this case, however, removing the boy from benoni allowed him to come into his own and actually work for something. quite soon he was in the mainstream bsc course and then moved on to medicine where he was always close to the top of the class.

i worked with him when he was a house doctor and he was the hardest working house doctor i ever knew. he even took the occasional gunshot abdomen to theater and only called his registrar when he got stuck. i thought he was going to become a surgeon. but alas... i visited him recently in bloemfontein where he is presently half way through his orthopaedic training.

so i often think back thankfully to that letter my headmaster took time to write for me. he helped me never to look down on my juniors and never to despise small beginnings, even if they were in benoni.