eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'

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.

mixed feelings

i hate working in the state. i would quit it altogether if i didn't love it so much. such mixed feelings

recently i was called to the state hospital, as usual at an obscene hour. somehow i dragged myself out of bed. i think i woke up half way to the hospital which was a good thing. it makes parking so much easier.

now generally at this time my sense of humour is not at an all time high and i'm not feeling my usual cheery self. yet ironically it is exactly at these times when one needs to be the most malleable in attitude. if not, you will not continue in the state for long. and these were my thoughts as i walked towards theater that night. i thought of past experiences and prepared myself.

i approached the theater. i could see the main door now had a security gate that was locked. i think i was more than partially responsible for this. but the door to the change room was at least open. as i entered i remember saying to myself that if the door was open then nothing i encountered inside would get me down. i knew it would need to be a decision.

in the change room, i found only shirts. at least there were shirts, i thought. i took one and soon had put it on. tucked away in a different corner, away from the other clothes, with less effort than i expected, i found the pants. they were duly donned. there were no shoe covers. it was in the middle of the night so i just assumed that the owner of the boots i loaned would be none the wiser. anyway, it wasn't as if i had much choice. then there was the small matter of head gear. i did not have to resort to things i had done in the past. looking in the female changing room turned out to be all that was needed.

i then made my way past the sleeping theater nurse towards the operating theater. as usual i had to use plaster to stick the inferior mask to my face to prevent my glasses from fogging up. and only then could i scrub in to join the medical officer who had asked for my help.

truth be told, i accept the small irritations of the state. when i'm there i feel like i'm making a difference. i also like teaching and these days it is the only chance i get.

yes, i love working in the state. i would do it all the time if i didn't hate it so much.

orchestrator

team work in an operation is essential. usually i can just get on with my job and trust the anaesthetist to keep the patient going (alive). i don't have to worry too much about him. however in state sometimes i need to orchestrate everything.

the case was unusual. blunt trauma to the abdomen often causes the left diaphragm to burst, causing the intestines to migrate into the chest. this time the trauma was to the chest. the diaphragm burst from above. the x-ray picture was the same with the stomach in the left chest, but at operation it looked quite different.

they had apparently already done a full resus in casualties before even getting the patient to theater, so the patient wasn't in the best of shape.

the anaesthetist was a doctor from some outlying peripheral hospital that usually didn't do more than very simple cases and didn't even have a diploma in anaesthetics. he was doing his best and at least trying to meet a need in our local state facility. i opened in the midline. i found it a tad disturbing to find the heart free in the abdomen, just above the liver. i considered saying,
"i don't think this is supposed to be here!" but i thought better of it.

the diaphragm was destroyed. the pericard was destroyed. the heart had wondered off to the left and the lung had shrivelled up to hide somewhere out of sight. it didn't take a genius to realise this was not good. i realised this was not good.

i started the repair. then the heart stopped. it was easy to diagnose. i could clearly see the heart in front of me. i informed the gas monkey (anaesthetist). he looked at me. i put my hand around the heart and started to squeeze. the gas monkey looked at me. i realised he simply didn't have the beginning of an idea what to do. i realised this was not a team work situation. i needed to take control of everything. i was the gas monkey consultant suddenly. i took control. i orchestrated what needed to be orchestrated.

"you!" to the gas monkey, "give adrenaline now! you" to house doctor floating around like an unwanted fart on the wind, " draw up x ampoules of adrenaline and put it into y ml saline!" all the time i compressed the heart. now i have occasionally compressed a heart against the sternum from inside the abdomen, but seldom have i stood with the heart completely in my hand. i quickly adjusted to the correct amount of pressure to apply directly to a naked heart. it is quite a bit less than one on the other side of a diaphragm and decidedly less than one hiding behind a sternum. soon i was applying compressions with thumb and two fingers. that was all the pressure that was needed.

the adrenaline did the work and the patient came back. we went on. then things went south again. this time i put my hand around the heart and clearly felt the gentle vibrations of ventricular fibrillation.
"you!" to the wide eyed floor nurse "get the defibrillator now! you!" to the surgical medical officer, "get ready to shock and give me ample bloody warning because if you shock me i will not be happy!" all the time the heart was cradled in my hand with my three fingers doing the necessary.

we defibbed once and the patient came back.

the patient crashed twice more and i orchestrated the relevant resus. i then sent the house doctor to icu to ensure they prepared an adrenaline infusion and started closing. the patient had had better days but she was alive. i closed, gave the last necessary instructions and left.

when working with true gas monkeys we work as a team. but it is times like these when i work with junior doctors who find themselves in deep water that i remember what a priveledge it is to have well trained colleagues.

philosophical

this is not an easy post.

i try to be philosophical. i really do. if i'm not there worse would happen, i tell myself. but somehow i struggle to believe my own spin.

the state hospital is struggling. if i get called there it is usually in the middle of the night and i usually am not that enthusiastic about it. but if i must, then i must.

recently i was called to help with a complicated appendix. i use the word complicated, but i really mean african complicated. it was a mess worse than i can describe. suffice to say a cuban trained (the south african government send a handful of medical students to get trained in cuba) medical officer (junior doctor) was doing calls as the surgeon on call. he cut into a hapless victim without having clinically evaluated her. truth be told, i think he did evaluate her but he didn't have the clinical savvy to figure out what he was dealing with. his south african trained junior had actually made the right clinical call but was out ranked and had to concur. only when the wrong incision had been made and wrongly extended, all just after midnight, was i called to try to save what remained to be saved. fortunately i am not particularly intimidated by such surgical challenges. i dealt with what i got.

but if what i got was not enough, what i was told i truly struggled to deal with. you see, i try to be philosophical. in december when i did a thoracotomy for a gunshot wound, a procedure that is not actually supposed to be in the armamentarium of a general surgeon, all went well. later i heard second hand that the patient had died because he was transferred to another hospital because of a lack of icu beds at the local hospital. the only problem was he was transferred in a sub optimal ambulance. the short version is he died. i was devastated, but philosophical. i reasoned i had done my best and he would have died anyway if i wasn't there. i did my bit but my bit was not enough in the greater scheme of things. philosophically i try to reason with myself that in a war situation there will be casualties. there will be people who die unnecessarily. i must do all i can to prevent and limit this but it will happen none the less.

then that night, the cuban trained junior doctor who was doing calls in surgery in a setting where he in all reality could not be expected to cope, told me about another consultation he had turned away. i knew he had the habit of turning people away and because i knew he was not equipped to deal with most of what came his way i sort of understood. however the night in question i was on cover for him. there was no excuse.

he calmly informed me a peripheral hospital had phoned about a stab wound neck that was bleeding actively. the hospital in question had no surgical cover and couldn't operate such a case. he apparently refused the transfer on the grounds that the patient was bleeding. simple logic i thought would inform most people that the bleed needed to be controlled before there was any hope of survival and this could only be achieved surgically. it seems simple logic was not one of the subjects in the cuban medical curriculum. he refused the patient on the grounds that the patient was bleeding when that was the exact reason the referring doctor was seeking to refer the patient. i told the medical officer the patient would die without surgery. he cooly and calmly said in that case the patient will already be dead because they phoned six hours ago. i was shocked. even my usual philosophical outlook could not justify this. my philosophy relied on me doing my best and after that accepting the outcome based on the system. to accept the patient died because a junior doctor refused to accept a transfer because he hoped for a bit more sleep that night was just a bit too much even for my flimsy philosophy.

he maybe slept well. i did not.

i am not special

just when you get a lift life tends to slap you in the face again.

the state hospital was supposed to get a surgeon. all indications were that he was supposed to start on the first of the month. the medical officers booked elective cases for him to do with excitement and anticipation. the first of the month came and the first of the month went, but no surgeon turned up. the poor medical officers now had the nasty problem of having a whole bunch of people needing operations with no one to operate them. they phoned me.

i could not do all the operations. not even close. but i told them that i would try to make myself available on tuesday afternoons. they just needed to book the most critical cases and i would do them. they organised a typical state thyroid for the first tuesday. (not quite as bad as all that but still bad)

the monday before i was on call. a pretty hectic gunshot wound came in late that night. at the same time an appendix patient also arrived. i called the anaesthetist out and we got to work on the gunshot guy. a splenectomy, distal pancreatectomy, nefrectomy and liver repair later we delivered him to icu in a surprising good state. (there was not only a great deal of blood on the part of the patient but also a goodly amount of sweat and tears on the part of all of us). we finished at about three o'clock in the morning. everyone was tired and irritable. then i suggested we do the appendix. truth be told, i was laughed at.

i considered my position. it was reasonable to postpone to the morning when i would be at least slightly rested. there would be a smaller chance of cutting something i should rather not cut. but i knew i had a full day in the rooms with consultations and scopes. thereafter i was supposed to go to the state hospital. if i left the appendix for daytime, it would clash with that appointment in all likelihood. so i simply refused to take no for an answer. i pretty much insisted that we do it there and then. all concerned finally succumbed and the appendix was removed some time after three o clock in the morning.

after a deep two hours sleep my day began in all earnest. i spent the morning in consultation and doing gastroscopies and colonoscopies. i only just finished to rush off to the state hospital to be there at two pm as had been arranged.

when i entered theater, the anaesthetist casually told me they had a child who had a foreign body stuck in the esophagus that they were going to do before my case. i was annoyed, but i knew that in state hospitals you must learn to go with the flow. otherwise constant frustration will kill you or drive you to drink.

sure enough they put the little kid to sleep and for expediency i took the thing out myself. still the anaesthetic and the usual state delay had lost us a full hour.

finally the thyroid was doped and we got under way. true to form they had booked me a monster. it was the sort of thyroid that was so big you feel you need to take it out as fast as possible because it's bullying all the other thyroids in the ward. to be honest i struggled. it was all the way up to the skull, all the way down behind the sternum and around the back to behind the esophagus. it was stressful surgery. i was trying to get it out of that neck but i swear it was trying to pull me in to devour me.

during all this, the sister who was obviously annoyed at the slow pace of the operation started berating the medical officer for starting a case that wouldn't finish before four, the time in the state hospital when all elective cases are supposed to stop. i piped in that an emergency case had been pushed in before us and therefore they owed us another hour so we were therefore still within time constraints. she looked at me.
"these rules are for everyone. you are not special!" and just to make sure there was no misunderstanding, she repeated,
"you are not special!"

i joked about it at the time saying my mother had always told me i am, but i could feel irritation welling up. i needed to finish the task at hand so i took my mind off the comment and returned it to the thyroid which i think had just tried to bite me.

when i got home, fairly tired from work and lack of sleep and put together the entire sequence of events, including me depriving myself of sleep in order to be able to go and help at the state hospital, i became angry. it had nothing to do with if i thought i was special, but rather to do with what other options that patient had of being operated. the answer is simply none. if i didn't do it there was no one else who was going to step in and do it. then despite pretty much standing on my head in order to be available and still getting knocked back an hour on the list the sister tells me i'm not special because she has to stand 20 minutes longer than she was expecting to. i became mad with rage. i considered phoning the super and telling him to stuff his hospital and theater staff and that i was no longer willing to help.

then i thought of all the doctors there trying their best beyond their abilities to at least provide some service. slowly the rage dissipated. then the anger subsided. then i slept.

i am special

sometimes it is good to get a bit of recognition. if you don't the job can sometimes slowly erode away at your spirit. so recently i got a boost and i think my spirit may be good for a few more calls.

one of the state hospital doctors invited me out for a casual get together to celebrate his birthday. most of the guys i work with when i help out there would be attending so i thought it should be fun. the night started off slowly. i sat with the man of the hour and his girlfriend and two of their friends from the real world (not medical). i concentrated on their conversation, sedately sipping my beer. i was the outsider and i didn't want to draw attention to myself. then the doctors started dribbling in. the senior guys came over and greeted me. the house doctors would occasionally nod an acknowledgement and move off. in the hierarchical medical system they were used to they weren't sure how to relate to a real live consultant in a social setting, so they sheepishly avoided me. i started wondering if i'd made a mistake by coming along.

then someone came in that i didn't know. i asked my friend who he was. turns out he was a house doctor that simply hadn't rotated through surgery yet and therefore i hadn't worked with him. being a house doctor i expected him to avoid me like all the others had done. but just as i didn't know him, so he didn't know me either. he came over.

"hi, my name is g." he said warmly extending his hand.
"pleased to meet you." i replied. "i'm bongi."
"bongi? the legend? i've heard so much about you and now i finally get to meet the man himself!" i was taken aback. i wasn't sure what to say. i couldn't just leave it at that.
"what do you mean?"
"well i hear you always help despite the fact that you don't get paid and that you ruthlessly rip the house doctors to shreds when you're operating." (the hospital sometimes does pay so that is not entirely true. also i think i may tease the house doctors a bit, especially about their universities of origin if their anatomy is not up to scratch.)

as it turns out all those nights going out at all hours to help the skeleton staff who are desperately trying to keep things together on the sinking ship that is the state hospital has made an impression on some people. i felt good.

i smell drunk people

it's funny how smells can be so emotive. i have spent a fair amount of time in the state hospital lately. and going through casualties the smells were so familiar. it is a smell common, it seems, to all state hospital casualty units that i've ever worked in. and somehow alcohol is the constant thread.

i'm not talking about smelling alcohol on the breath of an aggressive family member, although that is also something one does see (or smell) a lot of. but it is so much more than that. i'm talking about the residual smell of alcohol laced bodily fluids after a busy trauma night. it is a smell that is resistant to being washed out.

it's difficult to explain but the smell left me with a longing for days gone by when i was the surgical registrar on the floor. i was the guy placing the nasogastric tube when the patient brings up the night's festivities all over the bed and often my shoes, leaving a sour smell of alcohol and stomach acid. when i was the one placing a high flow line into the neck of the nth drunk uncooperative gunshot wound patient, where part of the technique is to dodge his often well placed punches. in those moments you are not aware of the smell. maybe the adrenaline drowns it out. but it is always there. the next day when you walk into casualties and the smell hits you, the nigh's activities return so vividly to your mind.

i remember when i first learned the smell of alcohol in blood. strangely enough it was during an operation on a sober gunshot patient. he was bleeding profusely. i kept on thinking there was something missing. the blood didn't smell right. and then i realised that the smell i was missing was the smell of alcohol in the blood. how weird is that to know what alcohol in blood smells like.

yes i miss those days sometimes. alcohol doesn't play that prominent a role in private but you still see it. so it was a nice trip down memory lane this weekend to smell that smell again.

p.s the patient at the state hospital this weekend survived and was even extubated the next day.

the state of it

some readers may have been following this blog for some time. some of those readers might be interested in what has been happening in surgery in the state hospital. for this small group of readers, this is the state of it as it stands now.

well after i was instructed to stop operating in the state hospital (which you may remember i was doing for no charge) i left them to their own devices. the one remaining surgeon, partially registered, took an extended leave of absence. the junior doctors went on as best they could. as you can imagine, chaos reigned.

this went on for some time. after a number of months, the mec of health in the province (politician in charge of health) decided he should meet with the doctors working on the ground. when he did, he was 'surprised' to hear that there were no surgeons at all in the hospital in the capital of the province. he also didn't seem to be aware that the state was sending patients to the private hospital for treatment at astronomical costs. by chance, the person that i had crossed swords with had been replaced by someone else who, on the face of it, seemed more determined to fix the problem and less focused on saving face. the mec placed her in charge of sorting things out. he wisely gave her authority over her boss who, in my opinion was the cause of most of the chaos and as it turns out was the person who had instructed the hospital to give me my marching orders.

she got to work. she approached all the private surgeons. only two responded. i was one. a meeting was called and a path forward was discussed. without going into too much detail, the final result is that the two private surgeons are on standby for the government hospital. instead of sending patients to the private hospital and thereby paying that hospital we would operate at the state hospital and charge per patient. they would therefore save a massive amount of money but not get the free ride that i often referred to in my earlier posts.

so these days i once again operate (quite a bit actually) at the state hospital. it still remains to be seen if they are true to their word and pay us. (hasn't happened yet)