tamponade

at least in the old days, our medical training was pretty darn good. but as with all things, confidence comes with experience and experience comes with time. being in the bush with cuban seniors often the confidence was more lacking than the knowledge.

it was late at night. the patient was just one more stab wound chest, one of the most common conditions we dealt with. but this one was different. he writhed around and seemed to be gasping for air. i threw in the needed intercostal drain, expecting a sudden improvement. it didn't happen. the lungs were fine, but the patient's neck veins were severely distended. his blood pressure was low and his pulse was fast and thready. his heart sounds sounded muffled and distant. then, if i wasn't already sure about the gravity of the situation, he said those words which strike dread into any doctor who has even a little experience.

"help me doctor, i'm dying!"

i knew what was wrong. he had a pericardial tamponade (the heart had been stabbed and was bleeding into the sack around the heart, slowly crushing its attempts at normal contractions) and without intervention the patient was going to do exactly what he had said he was going to do. i even knew what to do, but had never even seen it being done before. he needed a needle to be stuck into this sack to draw off the blood. this would win time to get him to theater to fix the hole in the heart. it was time to phone my senior.

the cuban surgeon on call sounded sleepy. he listened to my presentation of the patient, but didn't seem to fully appreciate how grave i felt the situation was. so i told him.

"this patient has a tamponade and without intervention soon he will die!"
"how can you diagnose a tamponade without a chest x-ray? get an x-ray and phone me back!" i was astounded. i knew what i had and didn't need a chest x-ray to help me. in fact i was worried about the delay the getting of said x-ray would cause. nevertheless, he was the consultant and i was merely the intern. i had to obey.

not too much later i phoned the consultant again.
"i have the x-ray as you requested and it shows a very globular heart." this confirmed the diagnosis. "will you please come out and help?"

finally he arrived. i had been sitting next to the patient the whole time trying to reassure him that everything was going to be just fine even though i was not convinced everything was in fact going to be fine. the consultant looked at the x-ray for some time. he then listened to the ever fainter heart and examined his now engorged neck veins. i was pacing by this time. i just couldn't understand the consultant's tentativeness. after all he was supposed to be a surgeon.

"bring me a needle!" finally!! i presented him with the needle and syringe that i had already gotten ready. he seemed surprised. i wanted to say that i was south african trained, but thought better of it and just smiled. he then started cleaning the chest just next to the sternum. now once again due to my south african training i had expected him to clean the area just below the sternum in the angle between the left ribs and the sternum. where he was cleaning i feared that he may stick the needle straight through the thin sliver of lung that lies over the heart in this position. i mentioned my misgivings and suggested the method we had been taught. glared at me accusingly and drove the needle in through his original site. the syringe quickly filled with blood. the change in the patient was dramatic and instantaneous. i started to breathe easier too.

"wonderful!" i said. "theater is ready. i took the liberty of booking him already."
"why?" said the cuban. i was taken off guard. it seemed to me to be self evident. the stab to the heart had to be addressed otherwise the tamponade could recur and then we'd have to operate in the early hours of the morning anyway.
"ummm...to fix the hole in the heart?" i ventured.
"no. we have treated him. he is fine now. admit him to the ward!" and with that he walked out.

what could i do? i was an intern. i could not do a thoracotomy on my own. if the surgeon refused to operate the patient was not going to get operated. i hesitantly admitted him to the ward as instructed.

through the night i intermittently stopped by to see how my patient was doing to the irritation of the night staff whose sleep i constantly interrupted. by the next morning the patient was amazingly still alive. sometimes patients are just lucky i suppose.

i'm on my way

some lessons are learned the hard way. and it's no easier if you are thrown out to the wolves.

i was in vascular, arguably the toughest rotation. i was doing 15 calls a month, most with little or no sleep. i was not having fun. so i was delighted when the powers that be (the general surgery prof and the vascular prof) made the decision that all stabwonds of the neck must be referred to the general surgeon on call first. if he made the assessment that it was a vascular problem then he would call the vascular surgeon. this would decrease the number of unnecessary referrals and slightly decrease our workload.

so on a particular night when the casualty officer called me in the early hours for a stabbed neck, my first question was whether she had already spoken to the general surgeon. she informed me he was already there to see another patient and she would ask him to evaluate the guy. i told her that if he felt it was vascular then he should call me and i'd be there like a flash. i rolled over and returned to my stupor. strangely enough i wasn't called again that night.

in the morning my pager went off. it was the casualty officer again. her first sentence sent shivers down my spine.
"while you were sleeping nicely let me tell you what has been happening here!"
this could not be good.

as it turned out the general surgeon (a rotating belgian registrar) had felt it was indeed vascular, but the casualty officer told him i had refused to come out. in desperation he had phoned the thorax surgeon who also refused to come out. he then did a chest x-ray which showed apical capping. with this new information he phoned the thorax guy again and after some threatening demanded that he come to take a look.

when the thorax surgeon got there the patient was apparently not doing too well. he dove into the neck with the belgian assisting him right there in casualties. apparently the ensuing bloodbath could only be contained with a few blind clamps onto the source of the bleed which just happened to be the subclavian artery. as we say in afrikaans, ek ken kak en ek ken pudding en hierdie is nie pudding nie (this is not good). i rushed there as fast as i could, adrenals pumping.

the general surgeon was still there. he looked rattled but glad to see me. i told him i would take it from there and he could go to the morning meeting with the prof. i asked him to excuse me from that same meeting which the vascular team was also required to attend.

i organized theater (with the obligatory blood and products ordered) and without too much delay my consultant and i started the operation. the operation, as vascular operations tend to do, took hours. some time that afternoon we delivered a severely compromised patient to icu.

i walked out of theater worn out from both the effort and the adrenaline. i ran into a friend. he asked me how it went.
"not good!" i replied.
"you'd better hope he doesn't die!" he told me. he then went on to warn me that the general surgeon had told the prof that he had phoned me personally and i had blankly refused to come out, thereby leaving him with a problem he was not equipped to deal with. the prof was apparently furious. he had already dictated a letter to the thorax department, complaining about the lax behaviour of their registrar and had decided to take me to task at the next m&m (morbidity and mortality meeting). if the patient died the depth of the sh!t i would be in would be considerably deeper.

i lived in fear waiting for the m&m meeting. i had images of my career coming to an abrupt end. sure enough, as if on cue, the patient died the day before the meeting. suffice to say the meeting did not go well. however, with me being present, the belgian did not repeat that i had refused to come out to see the patient. i survived.

from that day on, if i get called, even if i think it is not an appropriate referral, among the things i say on the phone, i always end the call with the words;
"i'm on my way!"

'tis the season to be jolly

in our training, a friend and i tended to work together when it was the season. neither one of us really celebrated christmas (he was hindu and i didn't care for the commercialisms of the holiday), so it sort of worked out fine.

however, walking down to casualties to see yet another stab wound caused by festivities (read alcohol) and some trivial argument with his 'best friend' when pretty much everyone else was relaxing at home or some holiday destination could cause a bit of healthy scepticism in the so called meaning of the season.

we used to stroll down the deserted corridors, wiping the sleep out of our eyes on the way to casualties. one of us would say
"'tis the season to be jolly!" and the other would reply,
"fa-la-la-la-la-f#@king-la-la-la"

and that is how we truly felt.