the bee dance

i have more than just a passing interest in bees. in fact i used to be somewhat of an amateur beekeeper and a semi-professional bee remover. it was a way to bring in a bit of extra money while slaving away in the salt mines we called the department of surgery. during those days i learned quite a lot about the bees. i found them very interesting.

one of the interesting facts about bees is how the scouts convey to the rest of the hive where they can find nectar stores. you see the returning scout does a little dance when it returns to the hive. the dance is in the form of a figure of eight with the bee vibrating its body in the middle section. the direction he faces during this dance indicates in which direction the stash can be found. the intensity of the vibration of its body during the dance accurately depicts the distance to the nectar stores. all very fascinating.

i was rotating through icu and it was my call. all seemed to be quiet. in retrospect i should have realised it couldn't stay that way. we were waiting for one postoperative admission and then i even entertained thoughts of getting a bit of sleep.

finally she arrived. she was still intubated and ventilated but it seemed to be more cautionary than necessary. the general surgeon registrar who handed the patient over to me was even upbeat.

"let her rest through the night but she should be ready for extubation early in the morning."

"sure." i said, "any other things i need to know about?"

"she bled a bit during the operation but the anesthetist put a high flow intravenous line up so there was no problem for him to keep up with fluid replacement. other than that everything should go just fine." with that he sauntered out. i quickly checked the patient out. once i was satisfied that all did in fact seem to be fine, i continued with my evening rounds, making sure all the other patients were ok. a bit of shut eye seemed like a real possibility. i started letting my mind wonder to the cozy bed in the doctor's room behind icu. just one or two more things to check on and i could lie down and submit myself to sleep. i think a smile may actually have crept across my face, but before anyone could see it i quickly regained my stern icu-doctor-like serious composure.

"the patient has crashed!!!" it took a moment for the sister's words to fight their way through my naive musings about beautiful sleep. but then the full gravity of what she said ripped my mind back to the present. the patient had crashed and that meant i had to charge in and save the day. but what patient had crashed? they were all stable and there was no one that was due to move on to the hereafter. if someone died i would have a hard time explaining it to the prof the next morning. in fact the only patient i could think that might have crashed was the new patient that had just arrived and she was the boss' patient. if i didn't manage to pull her through, never mind trying to explain to the icu prof the next morning, it was unlikely i would survive the m&m. at least i would get more sleep in whatever other profession i ended up in once the boss threw me out of his department.

it was the boss' patient! fear and dread gripped me. i needed to do something. the most pressing thing seemed to be the fact that the patient's heart was not beating. i shook the fear from my nearly paralysed arms and jumped into action. almost immediately i was compressing the chest. her a-line gave me a good indication that my attempts at cardiac massage were very effective. at least i was keeping here alive, but why had she crashed. i mean i couldn't keep doing cardiac massage forever, although, i reflected, it would probably give me good upper body definition. still it would help if i had a better long term solution.

"should i draw a blood gas so long?" asked one of the sisters. i understood her question. it wasn't really that anyone there thought a blood gas would bring us any closer to figuring out what had caused the patient to crash, but at least she would feel she was doing something. the one thing that a blood gas could possibly tell me was if the hb was low, indicating that the patient could have bled. but her vital signs just before crashing were completely stable, meaning it was unlikely. anyway, i nodded to the sister and almost immediately she had the blood drawn and was scurrying off to the blood gas machine.

moments later she had the results.

"doctor look here!" the shock in her voice was clear. she held the printout in front of me. i couldn't take it myself. i was still applying cpr. any thoughts of a chiseled torso had long since given way to a firm knowledge that my upper body would be stiff and sore the next day. i quickly looked for the hb result. it was normal. the next thing to check would be the oxygen status. that was better than normal. even the ph balance was close enough to normal. but then why had the sister sounded so shocked?

"doctor, look at the potassium." i looked.

a normal potassium is around 4. when it gets to about 6 it can cause dysrhythmias of the heart. at about 8, pretty much all hearts will stop beating. the result that met my worried gaze was 16! was that even possible?? how did it happen?? what the hell was going on??

despite a few obvious questions at least i knew what the cause was and i could treat it. half an hour later the patient's heart was merrily beating away all on its own without the assistance of my tired arms. once the chaos that always seems to surround any resuscitation effort had subsided i finally found out what actually happened.

when the patient arrived in icu, her potassium levels, among other things, were checked. the junior sister tasked with looking after her showed the results to the charge sister. they were slightly low. the charge sister then instructed her junior to replenish them. the junior, not knowing any better, put a massive amount of potassium in a small bag and connected it to the high flown line that our anesthetic friend had so kindly put up for us in theater. the result was that all that potassium ran into the patient very nearly instantaneously, stopping the heart. in all honesty we were lucky to realize this the way we did and pull the patient through. but, still, what had transpired up to that point was the easy part. the difficult part veered up before me like a cliff. i still had to tell the prof on ward rounds the next morning.

the next morning i told the prof. as expected he didn't take it too well. as i relayed the events of the previous night, he became more and more agitated. finally he could no longer stand still. he started jumping up and down on the spot, his mouth open and his fists clenched. when i got to the part where we were all desperately trying to save the patient's life, in exasperation, the prof's body shook. he then did a little circle around to his left. a memory stirred somewhere deep in my mind. where had i seen that before?

when we got to the potassium levels and how it was that they had come to be that high, the prof's body once again vibrated. he then spun around to his right, vibrated again and then spun around to his left. a light went on in the deepest parts of my mind. i knew exactly where i had seen this dance before and what it meant.

and so the prof continued doing his little dance. he would vibrate in a mixture of rage and surprise. he would then attempt to speak, but because he was so absolutely dumbfounded by the details of my story, he just couldn't. he would then spin around and try again, but when there were no words his body would once again violently vibrate just before he spun around the other way. we stood there in silence watching him. finally my colleague spoke.

"i have never seen the prof this angry before!" he whispered quietly.

"yes," i agreed, "but  after ward rounds, follow me. i'm pretty sure he is showing us where we can find a motherload of nectar, but be warned, it is very far away!!" he looked at me as if i was mad.

physician, heal thyself

even doctors get sick, but there is often a difference.

i was rotating through orthopaedics and was on call that night. they tended to relegate us mere general surgeons to casualties during the calls so i was quite excited to get some theater time that afternoon, even if it was for a simple wound inspection and secondary closure and even if it meant there would be a backlog of patients in casualties for me to see afterwards. once i had finished operating i rushed through the change rooms to get back to casualties. while i was changing i heard the unmistakable sounds of someone throwing up in the toilet cubicle. quite soon the door opened and out came the orthopaedic registrar who was on call that night with me. he did not look good. he glanced at me but didn't seem to see me. his face was pale, verging on grey and there were fine droplets of sweat on his brow. he was staggering slightly as he made his way to the basin to throw water over his face. i greeted him but the only reply he gave was a sort of grunt.

much later that night i had to take some x-rays to theater for the senior to see. to my surprise the registrar was still there. he hadn't swapped his call out. i assume no one wanted to help so he had no choice, he had to work. however, he had come up with a practical solution. he was scrubbed up busy operating, but i noticed two drips hanging from the drip stand next to the anaesthetist. the one drip went to the patient, but the other went under the orthopod's gown and was replacing the orthopod's fluid loss that his severe case of vomiting had caused. the anaesthetist was actually maintaining hemostasis in both the patient and the surgeon simultaneously. i was quite impressed.

a few years later when i was the senior registrar in general surgery i too came down with some or other virus and i too was on call that day. in our department no weakness was tolerated and i knew it would not be a wise move to let the prof know i was ill. i just had to suck it up and go on.

the call was busy and being a bit sick i was struggling. there were too many things happening at the same time and it was becoming increasingly difficult to get to everything, but i kept on going to the best of my abilities. quite soon i found myself in theater operating. and there i stayed, doing case after case in quick succession and rushing down to casualties between cases to sort out the continuous stream of patients that were still coming in. and thus the call grinded on.

sometime in the early morning hours standing over yet one more open abdomen in theater i started to feel light headed. with the immense workload i realised i had not taken any time at all to have anything to eat or drink. this, combined with my illness had finally caught up with me. i was on the verge of passing out. fortunately i had more or less completed the operation and my medical officer was a capable guy. i turned to him.

"ninja, i need to take a seat. do you think you can close?" as i said it i staggered back. the world seemed to be moving beneath my feet. i leaned against the wall and slumped down. the ninja was saying something but his voice was far off and incoherent to me. the next moment i was aware of the house doctor leading me to the surgery tea room where i collapsed on the bed. i looked up in a haze. she was preparing a drip. i considered refusing but the words just wouldn't come out. besides i realised that fluid was exactly what i needed.

"put glucose in that drip too!" i finally managed to say.

quite soon the drip was up and the house doctor left. i reached up opened the drip to run in as fast as possible. then sleep came.

some time later i heard the house doctor return. she seemed surprised to find the drip sack empty, but changed it anyway. as soon as she was gone, once again i opened the drip to run full speed. the first liter had made a difference and i didn't want to waste any time, just in case i was needed during the call.

the next memory i had was the ninja shaking me awake.

"bongi, there is a gunshot abdomen. i've sorted everything and he's on the table. are you ok to operate or should i call the prof?" the ninja too knew that to let the prof know i had collapsed could potentially be disastrous for me.

"no. i'm ok now. get started so long and i'll be there in ten minutes."

later when i examined the timeline of events i had only been out of action for about an hour and a half. except for the people involved in the incident, no one ever found out. and, most important of all, the prof was none the wiser.

perspectives

sometimes different people see the same thing from a slightly different angle, giving a completely different perspective. in my line this can turn out to be quite macabre.

it was one of those cases. it was probably hopeless from the beginning, but he was young and we had to give it a go. as soon as the abdomen was opened everyone knew things were bad. there was blood everywhere. it took a while to even see the damage to the liver because i needed to get rid of the blood in the abdomen before i could see anything. however, once i saw the liver even i was shocked.

the liver was ripped apart with one laceration dropping down to where the ivc sat menacingly behind it. it seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. but i did what i could as fast as i could. at times like this the unsung hero is the anesthetist. if he can't get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. that day the anesthetist was great. somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.

after a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. usually, unfortunately, at this stage of these operations we are confronted by another problem. you see with massive blood loss the patient loses or uses up all their clotting factors and platelets. even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. to attack each ooze with an injudicious suture not only doesn't help a bit, but it wastes precious time that could be better spent in icu replacing these vital factors. i made the call.

"there are no more surgical bleeds that i can control here. i'm going to pack the abdomen and send him to icu to optimise his condition and we'll take him back in a day or two." the anesthetist looked up.

"if you say so, but he is not looking so great here." he pointed at the monitors.

i packed and closed. the gas monkey continued throwing every available fluid into his system as fast as he could.

"i'm just going to top him up as much as possible before we transport him to icu." he informed me. he was definitely worth his salt, this one.

this is now a time that the average surgeon doesn't like. we are not the stand back and wait types. we struggle to sit still and give it time to see what happens. but sometimes it is needed. i didn't have to wait too long before the the gas monkey told me what was happening.

"bongi, this guy is not improving on the fluid and blood i'm giving him and his abdomen is distending. are you absolutely sure there is nothing inside you can't make better?" the problem was i knew there was nothing i could do that i hadn't already done. however the anesthetist's observations were undeniable. the question was was there something i had missed or was the patient so far gone that he was lost already? it was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. there was only one thing to do. we had to open and look again.

we opened. immediately i knew everything we did from here on out was futile. the patient was in irreversible shock and had absolutely no clotting. there was nothing that i had missed from a surgical point of view which meant there was nothing i could do. after poking around a bit i packed and closed again, but this time with a heavy heart. i knew what was going to happen. the anesthetist also had no illusions about where we stood, but we both continued to go through the motions.

the motions led us eventually down the deserted passage way in the middle of the night to icu with a patient that was sort of alive in the broadest definition of the word when we left theater. both the gas monkey and i didn't want to check the vitals during that quiet sombre journey. what did it matter? we knew what was going to happen and we knew it was out of our hands. the only questions were where and when it was going to happen if it hadn't already happened. so when we entered icu we were quiet and reserved.

when icu receives a new patient, there is usually a flurry of activity and this was no exception. all the sisters descended on us like a swarm of bees, each going about their respective duties. soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. however once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. quite soon their alarms were blaring away. i glanced at my anesthetic collegue and we both shook our heads. we had done what we could. the icu sisters hadn't seen what we had seen. all they knew was we had delivered this patient and things didn't look good.

"i can't get a blood pressure. i can't feel a pulse. crash trolley!!!" she yelled to one of her juniors who scurried off in obedience. neither i nor the gas monkey moved. we just sat there, defeated at last.

"doctors, this patient is dying! aren't you going to do anything?" i laughed. i didn't mean to and i think it was more a nervous laugh. i was too emotionally exhausted at that moment to react appropriately. my colleague also laughed, but more at my response than the situation, i think. he then explained that what could be done had been done and any further resus would be in vain. we turned off the ventilator.

and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.

small beginnings

recently i caught up with an old friend. the day i started studying surgery he started in internal medicine. he is now a fancy prof. i was amazed and impressed. he really was, and i assume still is, a really great guy. yet even great people must start out small. i remember the first day we met.

i was on call in the surgical icu. i had been part of the surgery department for a full two days and was still unsure about pretty much everything. so when the internal people phoned asking if we had a bed available for one of their patients i called our prof even though there was one bed empty. the prof was a good man and told me we were obliged to help them even though the pressure on our beds was usually great. i phoned the internist on call and told him he could bring his patient.

some time later a patient was wheeled in. the first thing i noticed was that she was blue, a colour i have often said doesn't appeal to me. the next thing i noticed was that she was just barely breathing. being astute even though inexperienced, i concluded she was in the process of dying. at that moment the physician walked in and introduced himself to me. he had just started in internal medicine two days previously and was also pretty unsure of himself. after whizzing through the formalities of greeting, i pointed out to him that his patient wasn't breathing too well and that she needed intubation and ventilation soon. otherwise one could only hope her policies were all paid up. he looked at her. it was abundantly obvious i was right.

"yes, i see what you mean," he said after a moment's thought. "i'm just quickly going to call my consultant. i'll be right back." and with that, before i even had time to express surprise, he was gone. the sister and i looked at each other with bewilderment on our faces. it just seemed that intubating the patient was at that very moment more important than finding his consultant.

"well, we know what to do." i said, "get the patient into a room and let's intubate. without any further delay or looking around for wandering consultants we soon had the endotracheal tube in position and the patient connected to a ventilator. soon the blue hue was replaced by a more encouraging pink colour. not totally unlike the patient, we all breathed a sigh of relief.

after a short time, the internal registrar returned with consultant in tow. by that time the icu staff and i had settled down and were even making coffee. then i put the story together.

the registrar had been out of clinical medicine for a while doing some or other form of research. he was not confident enough to intubate the patient and just assumed that i also would not be. he therefore felt he needed to get his consultant there as fast as possible to place the tube. it was the best he knew to do at the time. unfortunately it would not have been good enough for the patient. i had to intervene. i was not the patient's best hope. i was the patient's only hope.

well, all's well that ends well.

catching up with the esteemed prof after so many years made me realise how even the mighty have humble beginnings.

the patient is gasping

in the old days at kalafong (hell), the sentence 'the patient is gasping' was euphemistic for the patient is stone dead, rigor mortis has set in and we accidentally found the body when someone noticed a strange smell emanating from his bed. fortunately, occasionally one is pleasantly surprised. one such time was in my first year as a registrar.

he was a young man. with a bit of dutch courage on board he had not maintained a good following distance behind a car while driving home late at night on his scooter. in other words he drove full speed into a parked car on an otherwise deserted road. when i saw him for the first time he was in trouble. his abdomen was distended and painful. his blood pressure was down and his heart was racing. he needed surgery and fast.

just as i was pushing the patient into theater his mother called me aside to ask about his chances etc. i gave my honest assessment with emphasis on the fact that we needed to get going as soon as possible to optimise his chances. then, as if i wasn't nervous enough being such a junior registrar with the prospect of trying to pull this guy through , the mother gave me a small piece of information that pushed my heart rate up to about the same as the patient's.
"he is dr w's cousin." dr w was the most senior registrar in our department.
"good!" i said. but 'oh f#@k' is what i thought. and then i went in to operate.

the operation was a major challenge. in the end i resected segments six and seven of the liver. actually i just scooped them out. the impact had done all the actual dissecting. i just needed to control the bleeding, which in itself was not all that easy. finally we got him off the table in a fair to good condition. after tucking him into bed in the ward i got on with the rest of the call. finally i got to sleep at about two thirty in the morning.

at four in the morning, the phone in the call room rang.
"doctor, the patient is gasping!" my blood went cold. i confess i had images of dr w taking me apart for letting his cousin die. i paniced a bit. i phoned my house doctor and told her to meet me in the ward. then i ran.

i walked in to see something i think i am the only person ever to see in kalafong, an actual attempt at a resus by the nursing staff. the patient wasn't dead, only dying. i was so relieved. then i realised if i let him die dr w would still eat me alive. i jumped to it.

after a bit of the old pounding on the chest, a tube down the wind pipe and much intravenous fluid. we pulled the guy back from the brink and put him in icu (intensive scare as we called it).

and so a near disaster was averted and for once at least 'the patient is gasping' actually meant the patient is gasping.

one shouldn't laugh, but ...

when i wrote the third principle, i was reminded of another incident. then i couldn't laugh. now i shouldn't.

i was working a casualty shift in a private hospital to make a bit of extra money (a registrar barely made enough to survive). it had been a standard night of treating the aches and pains of people who had been sick for weeks but had decided that once the sun set on friday evening they could no longer endure. maybe they just wanted to torture me.

anyway, finally a real casualty case came in. it was a young lady who had fallen and hit her head. she was fine except for an unsightly gash on her forehead just at the hairline. i prepared to clean and suture the wound. being a state doctor i had hardly sutured any face wounds on sober people, so i remember telling myself to make a point of chatting to her during the procedure to ease her fears. usually good old ethanol did all the fear easing and i was left to my own thoughts while placing the sutures.

so there i was at the head of the patient being as friendly as i could. i'd cleaned the wound and had placed the first suture. the second was going in when an ambulance pulled up. two paramedics brought a guy in on a stretcher. i had my back to them so i wasn't really watching them too closely. then the sister shouted,
"this man is not breathing!"

i left my suture just where it was and ran. as i changed my gloves the ambulance men were asking the patient to shift to the next bed. he wasn't listening to them. they seemed indignant. the sister grabbed him and dragged him over as i arrived.

there was no sign of life whatsoever. he was extremely pale. his trousers were bloodied. he had no drip. we commenced a full resus. after going through all the motions, i called it. the man was dead. i then looked over his body. he had a massive laceration in his groin. his femoral artery was visibly transected. that could be why he didn't respond when the ambulance chaps had asked him to move across to the resus bed. i asked my usual question.
"when you picked him up, was he bleeding?"
"no." they answered. that is why they didn't put up a drip, apparently.
"was there blood at the scene?"
"yes." the one man replied. "he was lying in a puddle of blood."
"was it maybe about five liters of blood?" i wondered aloud.

surgical principle number 8: we do it to impress the chicks

what is the point of even having surgical principles if you can't finish them off with a light hearted one.

general surgery is roughly divided into two categories. ie. blood and guts. the guts side of things involves feces, stomach content, bowel content, bad smells and the like. the blood side of things is often high drama and adrenaline and is the stuff that the medical tv shows are made of. most of the general public don't really want to hear about the time i did a rectal examination and my glove broke or the fact that the smell of a septic abdomen somehow seeps through the gloves and it can't be washed off your hands afterwards leaving a most unpleasant stench. i considered trying to market whatever it is in abdominal puss that causes that stench as a deterrent for fingernail biting, but it seemed too much effort.

but if you talk about someone bleeding to death and you intervene, this causes an entirely different reaction. it makes school children who watch these tv programms think that they would love to become surgeons. i just hope they don't bite their nails. so, bearing in mind we can only really be glamorous in half of our work, it is sometimes nice when one can get a bit of this glory.

it was post intermediates and i tended to stroll around casualties as i have mentioned before. a good friend of mine and i were in the same firm, so the night in question, we were both together checking out what was happening there. we had nothing better to do for a change.
as we casually walked through casualties (why can't more people be casual in casualties i wonder) we heard a bit of commotion in resus. we walked over and glanced in. what a sight.

there was a guy lying on the table. he had a large gash in his chest just left of the sternum. out of this hole bright red blood was gushing out in torrents. there were two casualty officers poking away with artery forceps but in that amount of blood it was clear they were losing the battle badly. the patient was still moving but his movements lacked conviction and were getting weaker as we watched. obviously they had called the thoracic guy but just as obviously, unless he was just around the corner the patient would be dead when he arrived. i thought that the heart was probably lacerated.
i turned to my friend.
"shall we?" i asked.
"why not?" he replied. and we walked in.

the casualty officers acknowledged our presence with nervous smiles. i asked for a knife. there were only loose blades. i took one and extended the wound. the patient didn't flinch. he was on his way out. i shoved a swab in. my friend hooked the edge of the wound with a retractor, but because of the ribs we couldn't really open too wide.
"i see it , i see it!!" he shouted. he reached for an artery clamp and grabbed the upper end of the transected internal thoracic artery (also known as the internal mammary artery, but because this guy was a guy i've decided to go with internal thoracic). immediately the amount of blood was less. i shifted my retractor and quickly identified the lower end of the transected artery. it's a lot easier when you know what you are looking for. i clamped it. soon we were tying the bleeders off.
we spent a bit more time to put up acceptable lines and call theater to book the thoracotomy for when the thoracic guy actually did turn up.

in just moments we had turned a hopeless situation into at least a salvageable one. when the thoracic guy finally did turn up all he had to do was wait for theater and fix up the hole in the guy's chest (which admittedly we were more than partly responsible for).

then my friend turned to me.
"have you seen outside resus?"
"what do you mean?" i asked.
"go look."
i walked outside. there were about five nursing students, all wide eyed and all looking at us as if we were absolute heroes. being a surgeon and already being under the influences of an over active ego, i felt pretty good. i did not want to be the one to tell them we had just been lucky with the injury and that a true stab to the heart would most likely not have turned out quite so rose coloured (except maybe a blood red rose of course).

resus with hands tied behind my back

from the previous post you might assume that i became quite proficient in resuscitating poison cases. you would be right. but sometimes knowledge and skill are just not enough.

during my community service year in qwaqwa we were required to do one call a month at the primary hospital. maybe hospital is a bit of a strong word for what that place was, but nonetheless, we did our duty there.

i was in casualties in this 'hospital'. a young guy came in with the typical organophosphate-like symptoms. pinpoint pupils, severe bradycardia, hypersalivation and whole body fine muscle fassiculations. i knew exactly what to do. i sent the nurse to get atropine as i quickly dripped him. i then immediately phoned for a transfer to the secondary hospital, thinking i'd start the treatment, but if he needed intubation, they would need to take over.

soon the nurse came back. he had one ampule of 1mg atropine. i thanked him but explained that we would need much more. i injected the 1mg. the pule rate sped up to a roaring 50 beats a minute and then gradually decreased again. i waited with baited breath.

after what seemed to me to be ages the nurse slowly strolled back with the news that there was no more atropine in casualties. great. i then told him to go through the entire hospital and bring me ...all... the atropine in the entire hospital. he casually strolled off.
meanwhile i shot through to the chemist, which was just about to close for the night, and asked for atropine. the lady manning (womaning???) the place was not impressed with having to help me. reluctantly with deliberately slow moves she went to the back. after a while she came back with an empty box. yes, all the atropine was finished and they hadn't bothered to order more. i told her the box looked nice but it is probably not going to work. she could keep it.

when i reached casualties the nurse was still not there. the patient looked somewhat unwell. i tubed him and set someone to bagging him. then the nurse returned. he had another ampule of atropine. that was the last of the atropine in the entire hospital. i injected it for what it was worth. then i waited.

finally after about an hour the ambulance arrived and we turfed the patient off to the secondary hospital.

the next day i heard he had made it, despite the empty box.

resus fun.
cuban resus.
tube.

cuban resus

before i get to the point, allow me to quickly take you through another resus.

i was a community service doctor in qwaqwa (absolutely unpronounceable to the western ear. there is even great variation between the nguni and sotho pronounciations). although i had been a mere house doctor the previous year the system was such that i was the senior on call. the house doctor called me to casualties. the patient's eyes were dilated. the ecg looked flatline. the house doctor had already given adrenaline to no effect. then i saw a lonely qrs complex on the ecg. it almost seemed out of place.

"give atropine!" i yelled. shortly after the atropine, the ecg improved, but only to a rate of 40. the other thing that happened which took me completely by surprise is that the pupils became pinpoint. this shouldn't happen with atropine. and then i realised. the patient had been poisoned with an organophosphate-like-something. that night we pumped 160mg atropine into him. amazingly, he made it.

this was one of a number of poisonings around that time, so when my dog was poisoned, if i had been less distraught i might have thought to pump it full of atropine. as it was i watched in horror as it convulsed and died in my arms. my cuban neighbour learned from my mistake. he stole atropine from the hospital. when his dog started convulsing and seriously threatening to die, he fulled it up with atropine and it survived. that was the first cuban canine resus i saw.

another cuban friend produced the second. in qwaqwa, biliary (a canine disease carried by ticks which is not dissimilar to human malaria) was common and killed entire litters of puppies. there was, however, one old feral dog that seemed to be immune. he belonged to no one, was completely tick ridden and survived everything. he was also the father of all the litters that were systematically wiped out by the disease. one of my cuban friends took one of these semi-wild puppies as a pet. when it got sick i advised him to dissociate himself emotionally and move on. after all it was just a pavement mongrel that was worth nothing. he disagreed. he told me that, like malaria, biliary in dogs is fatal because of haemolytic anaemia, so therefore all he needs is a blood transfusion to keep him alive. if that works he will become like his father, the dog that can't be killed.

apparently blood transfusions in dogs are not as complex as in humans. they don't have compatibility problems. any dog can donate to any dog. how do i know this? because after the cuban friend of mine drew blood out of the old dog and injected it immediately into his sick puppy, i went to the trouble of finding out about this point. amazingly enough, his puppy was the first dog in about 5 years at the hospital that survived to adulthood. and it became an immortal like it's father before him.

so, in conclusion, cubans know how to resus, even if the patient is a canine.


in the series.

resus fun.
tube.
resus with hands tied behind my back.

tube

i mentioned a possible series. i thought i better at least try. so lets talk about another tube incident.

i was in my icu rotation. our icu was 23icu. but there were about another 4 icu units in the hospital and we had a number of patients spread out throughout the hospital.

late one night i got the call.

"hello, it's sister x in 54icu. could you please come and tube mr y?" i had no patient at that time in 54icu. 54icu was the internal medicine icu.

"who's patient is mr y?" i asked.

"he is internal medicine's patient." she replied.

"well then call the physician on call for icu." i suggested.

"he is here and he asked me to call you." it was time for my standard question.

"should i run or can i walk?" 54icu was about 500m from 23icu and it was an uphill route. i hoped for a gentle walk.

"i think you should run!" i set off. en route, i thought about what i would encounter. an internal medicine registrar was asking for backup in an attempt to tube a patient. i got ready mentally to do a tracheostomy.

i charged into 54icu and what a sight i met. the patient was blue, a colour that in my humble opinion, did not suit him. he was lying in a puddle of blood and vomit. there seemed to be a flurry of activity around his bed, but not much was being done. i decided to attempt to tube him once before i turned to my trusted friend, the knife.

the intubation was quick and easy. once i had done it i couldn't help wondering what all the fuss was about. the patient regained his pink colour before i regained my breath. if i thought the guy was capable i might even have asked the physician to intubate me. i thought better of it though.

"thanks a lot!" he said.

"no problem." i replied. i thought of making some witty comment about needing the adrenal rush or that the sprint up to 54icu could only do me good, but i was still too out of breath. all comments i thought of in that moment were more than one syllable.

"can i just quickly ask you something?" he continued.

"no problem." i repeated. (i was tired.)

"when you intubate, is the trachea anterior or posterior of the epiglottis?" i did not let my face betray what i thought of the question. i just gave a factual answer. he at least had the guts to ask. at least i knew why he had struggled.

resus fun.
cuban resus.
resus with hands tied behind my back.

resus fun

some time ago i read a post about the worst resus ever. i thought i've seen worse. so here is the first installment in what might be a short series.

i was a junior registrar i was working in kalafong/hell. it was late at night. my house doctor and i were relaxing in the anesthetists' tearoom. we were the only one's there.

suddenly the phone rang. it was a sister in high care.

"hello, can you come and tube a patient?" i had no patients at that time in high care.

"whose patient is it?" i asked.

"the physician's". (small note. in south africa, we call an internist a physician. the word physician is not generally used for doctor. in fact if you were to call a surgeon a physician, he would probably be offended.)

"why doesn't he intubate his own patient?" i asked.

"he is here trying but he needs your help." the picture came into focus. i asked my standard question.

"should i run or can i walk?"

i entered high care out of breath, even though it wasn't all that far from the tearoom, my house doctor in tow. i expected to be given charge, but the physician was at the head of the patient. he immediately told me i was there to support and that he was going to tube. i took in the scenario.

there was a 20something male in clear distress. the physician was holding a mask to his face, making sure he formed an airtight seal between his skin and the mask. only problem.. it was a venturi mask that is not meant to be used in a resus and has large holes on the side. a seal, airtight or otherwise, is useless. also you can't actively pump air into the lungs, so if the patient is in trouble, in trouble he will remain. i took a step back. my house doctor and i exchanged glances.

"amazing!" she remarked. "i can't believe what i am seeing." i wasn't sure what to do. he had told me in no uncertain terms that i was not to take over and yet everything else about what he was doing was uncertain to say the least. to try to somehow get a better understanding of what was happening i tried small talk.

"what's wrong with him?"

"kidney failure and now pulmonary edema."

"he looks pretty pale."

"yes, his hb is 4" (extremely low but probably a chronic state.) "in fact i think i'd better order him some blood. here, hold the mask while i draw some blood." and with that he moved away from the head. this clown was actually going to draw blood while his patient died. before i could say anything i found myself holding the ridiculous mask to the patient's face while the physician moved to the arm and commenced drawing blood. i had two immediate thoughts. the first was that my senior registrar would walk in and see me holding this pathetic mask to a dying patient's face. i would never live that down. neither would the patient.
the second was that the physician had relinquished the head. i was in charge! immediately i told the sister to get the ambu mask and bag. (this is the correct mask to actively pump air into the lungs.)

i turned up the oxygen and began pumping. i then got the laryngoscope ready. i injected a bit of dormicum and prepared to tube. as i started to tube, the physician moved back to the head and tried to shift me out of the way. there was no way i was going to let him at the patient again. i tubed while he tried to shoulder me out the way. i just ignored him. i checked the position of the tube, told the physician to start bagging the patient and left.


other posts in the series.
tube.
cuban resus.
resus with hands tied behind my back.