anatomy

anatomy knowledge is essential for surgeons. i'm sure most surgeons would say it is the single most important thing in surgery. i would not. knowing anatomy may just not be enough.

somehow south african pathology is unique. by the time the patient presents to us things are a bit advanced (here and here or even here). i suppose you could say it makes diagnosis a bit easier, but it sure as hell does not make treatment easier. once when i was still working quite a lot at the state hospital this became clear to me.

the medical officer called me in. they had a bleeding stomach ulcer patient who for some reason just refused to stop bleeding. it was time to operate. the medical officer was so excited he was jumping up and down. he kept on telling me that he had never seen a gastrectomy before (removal of part of the stomach) and i kept on telling him that these days it is seldom that a gastrectomy is done but rather he was likely just to see the control of the bleeding artery and all would be well. i was less excited. it was late.

when i first laid eyes on the patient a few things bothered me. firstly there was a scar from a previous upper midline operation, probably also for a peptic ulcer. the next thing is his body showed wear and tear far above what his years would have dictated. his face had the signs of both long term alcohol and nicotine use. he was thin and almost wasted. i knew without asking that he was also a habitual grandpa user. then over an above his general state of health, he was pretty bled out. oh well, i thought, you work with what you get.

as we started, my excited medical officer asked me to give him an anatomy lesson during the operation. he knew i liked to teach and what better opportunity to learn anatomy than when the textbook is open before you. yet as i started the operation i went silent.

it was clear someone had operated here before. there were many adhesions to the anterior abdominal wall and it was quite a mission to actually get into the abdomen. once i was inside however, things went very rapidly from bad to worse. what once had been the lower stomach was just one massive ulcer that had penetrated into everything. the ulcer bed consisted of liver, abdominal wall, and transverse colon mesentry. the galbladder had been incorporated into the ulcer and therefore what passed for the stomach. in an attempt to heal itself it had grown into what looked like a fungating mass. in fact for a moment i actually thought it might be a cancer until i realised there was no real galbladder and this strange growth was in fact its remnant, complaining bitterly about its lot. i needed to decide what to do. clearly some form of gastrectomy was required. i should actually say some form of reconstruction was required. the ulcer had already done the gastrectomy. a bit more than a small amount of ingenuity was needed. i got to work, still in silence as i played through the options in my mind.

the medical officer was not silent. he reminded me that he wanted to learn the anatomy of the stomach.

"anatomy?" i asked, "there is no anatomy here. in fact i think we may have stumbled onto the unborn embryo of an alien that has invaded this body. just be glad the thing hasn't burst out and attempted to eat one of us."

i removed the remainder of the alien and tacked together what needed tacking together. driving home, i looked at the starry sky nervously.

crushing

we can sometimes look good in our jobs. i suppose it comes with the territory. but sometimes this is not a good thing.

danville is an interesting place. actually the place itself is drab but it is full of interesting people. to say it is populated by the lower echelons of the gene pool is an understatement of note. for some reason every reprobate and inbreed seems to have found their way there. throw a few generations of fetal alcohol syndrome into the mix and you have the average danville resident. then add a strong predilection to grandpa (a local aspirin caffeine headache powder) to round off with. usually when they presented to the hospital it is usually with a bleeding peptic ulcer or a perforated peptic ulcer. in fact they seldom present to us with anything else.



she was a typical danville special. she lay there on the bed holding her abdomen in pain. the sheets were stained with a dark coffee like substance from her last episode of vomiting and her face had taken on a complexion similar to the original colour of those same sheets. although she was about 50, she didn't look a day older than 65. her face was etched with the marks a pack a day of the finest tobacco for about 30 years will leave. she had also probably consumed a small country's fair share of brandy in her time. i groaned. all i could hope for was that she wouldn't end up going to theater because the operative risk for such a patient is high.

fortunately for her, and for me i might add, she responded very well to our conservative measures and it seemed like we would be able to avoid taking a knife to her. when i saw her later in the ward she had even regained some of the colour back in her cheeks. this was of course due to the blood we had given her, but i didn't mind. the fact was things were looking up.

her daughter was with her. it was clear they were family. if anything the genetic material had deteriorated somewhat passing from mother to daughter. as was typical of danville, her face looked about 45 although she was probably only 30 years old. the daughter stared at me with what i can only describe as a grimace on her face. even when i looked back at her she did not break her gaze. she was obviously unhappy with the treatment we were giving her mother i assumed. i wasn't particularly worried about her opinion in the matter so i just ignored her. i was just too happy that we were getting her mother better without subjecting her to surgery. i left as soon as i could.

the next day on academic rounds we discussed the usual causes of bleeding peptic ulcers. the prof even made mention of the fact that the ones from danville are almost always caused by grandpa use. he added that he was impressed we had managed to avoid theater. i knew i should be proud but during the whole conversation through the corner of my eye i could see the daughter sitting there staring at me with those accusing eyes. i had a feeling there was going to be a complaint laid against me, but for what i did not know. i had no idea what i had done that had incurred her wrath so.

the rounds went on and finally ended. i walked back to the doctor's tea room to organise and delegate the necessary ward work. as i went through the door leading to the balcony the daughter came from the other side. we almost collided. she smelt of the cheap cigarette she had just smoked. up close the deep crevices in her face could possibly have put the grand canyon to shame in complexity. her makeup was also wildly overdone, unless you believe eye shadow should be sky blue and lipstick should go over the lip and be applied half way to the nose too. i stared. i couldn't help it. it seems i have a tendency to be overcome with morbid fascination. she held my gaze, unflinchingly, despite the considerable weight of her fake eyelashes. then she spoke.

"doctor." i felt trapped. i could no longer ignore her. i had to answer.

"yes."

"can i ask you something?" as she spoke her false teeth floated up and down, completely separately to the movement of the rest of her mouth. again i found myself staring.

"yes." i lied.

"are you single?" what the hell??

"no."

"that's a pity because you are f#@king sexy."

i had to actively prevent myself from gagging. i'm convinced i ran as i left although i tried not to give the impression of a traumatised buck fleeing a horrible death at the hands of a leopard, albeit one that had tried to change its spots with too much makeup.

extreme

recently i had a moment to reflect on adrenaline and adrenaline inducing sports. it was a bloody moment. but i'm getting ahead of myself.

bleeding peptic ulcers occasionally cross the path of general surgeons. usually they stop bleeding with conservative treatment. but sometimes they don't. then you need to whip out the trusty knife. even then usually the operation is little more than routine. this case, however was exceptional.

he was white as a sheet. he had been bleeding for three days but only decided to come to the hospital when he started falling over. it seemed he could at least recognise falling over as not normal. the initial gastroscopy showed a penetrating duodenal ulcer with no active bleeding. the body had managed to curtail the bleeding, partially because of vasoconstriction, but mainly due to a low blood pressure which in itself was due to loss of blood.

i got drips going and ordered the necessary blood. unfortunately as the resus progressed his blood pressure normalised and the tenuous clot in the bleeding vessel could no longer hold back the inevitable. it quickly became apparent that we were not winning and soon we were in theater.

not too long after the ulcer was nicely exposed and i looked upon something squirting blood with much too much enthusiasm for my liking. a strong thick stream of blood was propelled out at great speed. the artery was also tucked up under the edge of the ulcer in a position that was pretty difficult to access. i put my finger on it and took a moment.

during my moment i had a few thoughts. the first was pretty much that the patient was going to die in the next few minutes right there in theater under my hands with my finger still probably on the point of bleeding. this thought seemed to emanate from two glands just above my kidneys. it was not a productive attitude to have and wasn't going to help me to get control of the bleeding, so i put it out of my mind. the patient dying was not an option i was willing to give in to.

the next thought was related to the adrenaline that was coursing through my veins. i automatically thought of people who go out and intentionally take part in activities for the expressed purpose of pushing their adrenaline levels up. don't get me wrong, i have nothing against that. it's just that after an adrenaline inducing operation, the last thing i want to do is go out and get some more. adrenaline inducing operations are surprisingly common in my particular line. maybe i'm getting a bit older. when i was still training i was much more keen on getting the high stress cases. these days i'm quite happy to miss them. usually, however, they do not miss me. they seem to hunt me down. so generally i just want to go home and collapse in a heap on the floor, often in the corner after a day's work. there i tend to lick my wounds or eat worms, depending pretty much on the availability of worms at that time of year.

p.s i got control and the patient did well.

textbook case

what the textbooks say and what happens in real life do not always agree fully. for one, the textbooks are seldom funny.

i was on call. a slam dunk came in. he had a two day history of sudden onset severe abdominal pain. clinically he had a rigid abdomen and x-rays confirmed free air under the diaphragm. not that it changed the decision, but he was also feverish and his white cells were through the roof. it was clearly a perforated peptic ulcer with generalised severe peritonitis (his stomach had burst and everything inside was rotten). the only question really was how had he managed to survive two whole days without seeking medical help.

i informed him he needed an operation. he said no. i was astounded. i pushed on his abdomen again. he went through the roof. i explained that there was clearly something severely wrong and an operation was absolutely needed. he said he wanted a medical alternative. the more i explained that there was a physical hole in his stomach requiring a physical solution and that no magic drug was going to close that hole the more he stubbornly refused. i tried the fear angle. i told him that in all probability he would die without surgery. he simply disagreed with me. he thought he'd first try non-surgical treatment and if that didn't work he would consent to surgery. and then he left. he simply took his free will and walked out the door.

the next morning when i presented the cases of the previous night i told everyone to keep an eye out for him. i expected him to turn up again in one or two days in septic shock and kidney failure. it would be decidedly more difficult to pull him through then, if even possible.

for the next few mornings, before the hand over meeting, i would ask the team on call if he had returned. the answer was always in the negative. after four days i accepted he must be dead. finally my turn to be on call came around again, almost a week later. and who should turn up on the proverbial doorstep but that same patient. my house doctor came to me saying he is begging to be operated.
"how sick is he?" i asked. "is he nearly dead?"
"actually he looks surprisingly well, but he is adamant he wants his operation now."

i walked into his room.
"so you're back?" i asked. "you have decided that you actually do need an operation?"
"yes doctor, you were right. the pain has been too much." i examined him. his abdomen was actually quite soft. it was much better than when i'd seen him last. the x-ray showed no free air in the abdomen. his blood work was nearly normal. his white cells were only marginally elevated. i was amazed. i knew that a very small fraction of people with a perforated peptic ulcer could heal if left alone, but generally they are all operated, so it is really only a theoretical posibility. in all reality most people would die. this was amazingly enough a man that had defied the odds. he was now just tired of the pain. and even the pain was no longer excruciating but now only severe.

i thought it quite ironic. when i was adamant that he needed an operation he disagreed. now that he was ready for an operation i was in doubt. i went through all the results and knew what needed to be done.

"doctor, you were right. i do need an operation! i'm begging you, please operate me! please doctor." i admit i smiled a bit as i looked at him and answered;
"no!!"