thumbs up

it was a battle. looking back i don't think we ever had a chance, but you don't just give up on a young man in the prime of his life. we had to try. he was my patient.

he was a foreigner, on a gap year in africa where he was going to learn all sorts of things about conservation and african wildlife. up until the accident, all had apparently gone well. the group of teenagers on the course had so far enjoyed every moment of their time together and some close friendships had even begun to develop. as it always is with these sorts of things, when they all climbed into the bus that day, no one expected what rippling ramifications there would be

from what was later told to me, it sounded like the accident happened in slow motion. the bus was driving along a fairly narrow mountain pass when, while negotiating one of the sharper turns, one of the back wheels went off the road into a ditch. as the bus drove on, the wheel was dragged along trying to remount the edge of the tar before a steep precipice that was looming up. it was unsuccessful. when the side of the road dropped away beneath the wheel, the undercarriage of the bus smashed into the edge of the road and slowly started getting dragged down. still the bus drove on. i suppose the driver either didn't realize the dire nature of his dilemma or he felt he still had a chance of pulling the bus back up onto the safety of the road. whatever his reasoning, it didn't work. slowly the back of the bus slipped further and further off the road. once the other back wheel also went off the edge, the bus teetered for a moment and then went crashing and rolling down towards the river below. in those moments between the realization of impending doom and the moment of the first impact of bodies colliding with the walls and roof and floor in a continuous spinning cycle, i often wonder what he thought. was he aware of the gravity of the situation or, like most people that age, did he trust in the indestructibility of his body? did he cease to look forward to the promise of a long and happy life and instead, look back to see if what had gone before would constitute a worthwhile existence? was there an awareness that the sheer abandonment of youth was over forever? or were his thoughts limited only to the constant tumbling of the bus and the melee of the bodies of his friend being thrown together and around.

for what had happened most of the people got off fairly lightly. sure, as the noise of the tumbling bus settled together with the dust it would have been replaced with screaming and sounds of pain and despair, but there were surprisingly few serious injuries, except of course my patient. there will always be chaos after such an event. somehow i think my patient didn't make too much noise. it would have been painful to breathe let alone scream. i imagine him lying quietly in blood soaked gravel, almost hidden from view of the rest of the disaster trying to make sense of all the new sounds and smells and sensations, trying to come to terms with what had happened and that it had happened. young people are usually not burdened by the ramifications of events so i doubt he thought too much about that. that would be left to others to contemplate later once all else had gone quiet.

the paramedics triaged well. only one patient was deemed serious enough to fly out with a helicopter. all the rest were stabilized and transported via more conventional means to our hospital.

so it fell to me to wait in casualties for the helicopter to land and deliver to us what was described as a severely injured young man. it was a situation i had been in many times before. it was, in fact, what i was trained to do. as usual i took the time to calm myself and reflect. experience had taught me that once the patient had arrived there would be little time to even think. everything would happen almost automatically as it had done so many times before. my body would go into a very focused state where anything that is not immediately associated with keeping the patient alive almost shuts down. i don't feel hunger or thirst or fatigue. my body doesn't require toilet breaks or to deal with any such basic needs. i even don't feel emotion. i get on with the job. get it done, that is all that matters at that moment. so when i saw my patient for the first time i was surprised by my reaction. looking at this young man with a broken and battered body touched me. he was quiet and seemed to have accepted his fate. he looked at me. there was peace in his eyes that seemed to defy what had happened to him. i like to think he smiled, but to tell the truth, my mind might have added that in later. i felt sorry for him. i didn't want him to die. i determined to do everything and anything in my power to prevent that, although i knew that is what i would have done anyway. only with him there was an emotional aspect to my determination.

once we got to work, my focus came. no longer fettered by the mist and fog of human emotion we quickly did all the necessary things to get him to theater. i stayed by his side the whole time, orchestrating everything, leaving him only once i had handed him over to the anaesthetist and then for only as long as it took me to change into my theater clothes. i joined my colleague as he was wheeling the gurney into theater. for a while i would be an onlooker until the patient was asleep, leaving my charge to my anesthetic colleague until then. after that we would battle together for the life of this young man, each carrying out our relevant roles in this drama.

i looked at my patient. his eyes were fixed on me. i wondered what was going on behind those eyes. despite being so severely injured they still seemed to be focused. the humanity was obvious. i felt for him again. i imagined myself in his position, so far from home facing such incredible odds and all that, completely alone. i had to touch the humanity of him before i engaged in the struggle that lay before me. i placed my hand on his shoulder;

"don't worry! we will do everything in our power for you." his gaze stayed as it had been. then he slowly lifted his hand and gave me a thumbs up sign. he believed in me and trusted in me. it was almost too much for me to bear.

we fought for him for hours. we fought so long and so hard that even when we knew we had lost the fight, we fought on. we hoped against the odds and against the creeping knowledge that we had lost and just kept going. only finally when my patient was absolutely dead (if that is even a concept) did we acknowledge defeat. afterwards, with this sort of thing, once the body is allowed to admit its own needs, they often come flooding back. suddenly i felt tired and hungry. the tired was more than just the fatigue of the physical body, but it was also the deep tiredness of soul, the feeling that you had been somewhere and done something that no human is supposed to have done. it is a type of tiredness you know will follow you for years to come, a tiredness that defies sleep or any other measure to combat it. i looked at my colleague. i think he felt the same. we walked out together in silence. there were no words left. they had been all used up in the preceding hours with business words like 'more blood' and 'another f#ck¡ng artery clamp now' and 'squeeze the heart now or we've lost him'. Soft words like 'are you ok?' just didn't seem appropriate anymore.

the next day, while the wounds were still fresh, the hospital administration told me that his parents far away in europe had asked what had happened in his last moments and if he had suffered much. they suggested that if i felt it appropriate, i should write to them. maybe somehow they knew i needed some sort of reassurance or healing or closure too and felt we could 'cry on each other's shoulders' as it were, i'm not sure. it all seemed a bit odd. then i thought about my patient raising his thumb to me. that surely was his last moment. the hours after that weren't his moments. they were mine. i suddenly realized that that raised thumb of trust and hope carried some beauty, some strength and i knew his parents would want to know about it. it was my duty to let them know.

i wrote a letter to them. i did not need to go into the details of the battle in theater with all the blood and guts and the slow fading of life. i just needed to tell them the strength that he demonstrated right up to the end. i wrestled with every word that i put in that letter but finally i had something that i gave to administration. they passed it on to the parents.

only  a day later the reply came and was forwarded to me. i read the words but they were so much more than words. i could see the tears and heartache and dashed hopes and regrets of parents far far away having their world ripped from under them. i knew it was a level of despair i could not understand and which i did not want to understand. to me they expressed gratitude and said they had been moved by my email and that it had helped them to deal with the grief. they went on to say they would like it very much (they came from a country where people tended to say things like 'like it very much') if i would continue a correspondence with them. 

i sat down. for me my pain was still very close to the surface but it would heal. theirs would never heal. they had lost a son. i had just lost a patient. i could feel the longing in their 'like it very much' for more. they didn't want their son to be gone and would cling to anything that could possibly fool them into thinking he was still just away in africa and would probably return any moment. i could not be that thing.

i no longer wanted to be what i am. i no longer wanted to struggle and fight in theater against the odds to stave off the inevitability of death. i no longer wanted to see the snuffing out of promise and life. i no longer wanted to think about the devastation left in the wake of the disasters that cross my table. i no longer wanted to be a surgeon.

diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.

understandings

anaesthetists and surgeons work together quite a bit, but they are very different creatures. sometimes it takes a bit of effort for them to understand each other and get along. some would say it takes effort from pretty much anyone to get along with a surgeon. so it is nice to hear a story occasionally of an anesthetic colleague that is willing to do what is needed to understand and get along with the general surgeon he was working with. these were the observations of a student during his rotation through the anesthetics department.

when the student in question arrived at work, he was quite excited to hear that he was dealt into the emergency theater.

"off you go," said the prof to him, "they are still busy with a trauma case from last night."

when he entered theater it was clear that there had been quite a lot of action. the floor was covered in blood which had been smeared around by the feet of the surgeon and the floor nurse, creating a macabre work of art with bold red strokes of the brush on the canvas which was the floor of theater. against the wall on a rack hung multiple blood soaked swabs, bearing testimony to the battle that had already taken place in that small room. the surgeon was still frantically busy working in the open abdomen, his arms besmirched with dark blood to his elbow. the front of his gown was similarly stained. the student looked around and took in the complete picture of this fight between life and death, yet immediately he noticed something that didn't seem to fit in with the high stress situation that met the astonished student.

off to one side, the anesthetist sat quietly in his chair with his arms folded and a calm expression on his face. he wasn't even looking at the monitor. in fact he sat slightly behind it. from this vantage point he glanced up, greeted the student and offered him a chair. the student sat down wondering at the steel nerve of this anesthetist in the face of such a tense situation.

then an alarm went off on the monitor. the student jumped up to get out of the way as his senior finally moved to see what was happening. but all he did was to turn the alarm off and sit down again. and so the student sat there with him, too nervous to speak and wondered what was going on.

after quite some time the intense concentration of the surgeon was broken. he turned to the anesthetist.

"how are things going up there?" he asked and then as an afterthought added, "the bleeding is now under control."

the anesthetist slowly looked up and spoke for the first time with a wry smile plastered across his face.

"well actually the patient has been dead for quite some time now," he said, "but i know how much you surgeons like to operate and it looked like you were having so much fun, i didn't want to disturb you."

coma

one of the curses of kalafong (hell) was that there was no neurosurgical service. this meant us mere general surgeons had to handle the many head injuries that came in. so, for example, when some guy decided to cave in the head of his so-called best friend with a five iron on the golf course because they had started with the nineteenth hole instead of the first, we ended up either dumping them in icu with a tube down the trachea to wait to see what happened or trying to turf them to a neurosurgeon that could actually operate them. it was far easier to dump them in icu. mind you, it was easier to turn lead into gold than to successfully transfer a patient to neurosurgery. so generally we hated it when we were called to casualties to handle someone with a head injury.

my colleague got the call. an old lady had apparently fallen and hit her head. the paramedic had intubated her on the scene and rushed her in. he proudly stood there admiring his handiwork as he presented the patient to my friend.

"well, doctor, her gcs was three so i had to intubate her. she fought the tube so much that we had to inject her with 30mg dormicum." it was the usual story the paramedics spun explaining why they had intubated someone and at the same time illustrating that they thought we were idiots. you see, the gcs (glascow coma score) is a scale that gives one an idea what depth of coma the patient is in. it is a measure of the patient's normal responses as far as eye movements, verbal response and response to pain is concerned. a score of 15, the maximum, is essentially a normal person. a score of three is the lowest you can get and is equivalent to a corpse or maybe a brick. a person with a gcs of 3 does not fight a tube and doesn't need dormicum. then again 30mg of dormicum would pretty much drop a gcs of 15 to 3 or thereabouts. my friend was understandably skeptical when he entered the room.

"oh, doctor, the other thing i forgot to tell you is the right pupil is blown." this was lingo meaning the one pupil was severely dilated while the other was not. this was in fact a true sign which did indicate intracranial damage, usually bleeding with unilateral increased pressure. maybe, despite the supposed need for 30mg dormicum, the patient really was in trouble.

the surgeon walked in. the patient lay dead still with only the rhythmic up and down movements of the chest as the ventilator pumped away. he took a quick glance at the eyes. sure enough, the right pupil was massively dilated and absolutely unresponsive to light. this was not a good sign. he turned to his students.

"look at the eyes. see the difference in the pupils? that is a very bad sign. this poor old lady has pretty much no chance of survival." immediately the patient lifted her head off the bed and shook it vigorously. the surgeon took a double take. that wasn't supposed to be possible.

"tannie, can you hear me?" the patient nodded. "disconnect the ventilator immediately!" commanded my friend. the sister complied. the patient blinked a bit with her asymmetrical eyes, but breathed normally. my friend pulled the endotracheal tube out, to the absolute horror of the paramedic who had been so proud of his actions. with that the old lady sat up, lifting one hand to her throat.

"daardie fokken buis het my rerig seergemaak! (that f#@king tube really hurt me)"

"tannie, what is wrong with your right eye?" asked my friend.

"when i was only five years old i was injured when a stick poked me in the eye. since then it has always been like that." the paramedic went a bit pale and quietly left the room.

after listening to this story i too often extubated patients that the paramedics had overzealously intubated after flattening them with ridiculous amounts of dormicum.

buff and turf

the concept of the buff and turf is common to all the disciplines of medicine. sometimes it works. sometimes it doesn't.

the call came in, but i struggled to believe it. yet i had to go to casualties anyway. i mean how do you tell the casualty officer that you don't really believe anyone can survive a lion attack? lions are killing machines. any normal human being who gets attacked by a lion should have the decency to expire and maybe even be eaten. and here i was expected to believe the patient on the way had actually survived. the upside was that i would probably be home in about half an hour or so. that is about how long it would take to look at a mangled piece of flesh and declare it dead and maybe partly digested.

he arrived. not only was he alive, he was stable. he even greeted me in a friendly manner. we chatted a bit. after all i was quite interested to hear how it came to pass that he was attacked by a lion and more specifically how was it that he was alive. it turned out that he works in the local game reserve and was out in the veld when it happened. apparently he had managed to fire one shot with a standard issue national parks rifle and blown the lion's jaw clean off. the lion that had done the dammage was therefore only capable of using its claws and could not finish him off with a bite. that is why he had survived. i quickly checked him out. both his arms had massive lacerations from the elbows down to the hands, but other than that there was nothing wrong with him. it is quite amazing that a lion could maintain an attack after taking a bullet in the head and still do a substantial amount of damage. still, i started having evil thoughts.

lacerations of the arms below the elbow is an area of overlap between general surgeons and orthopods. in my rotation in the old days in orthopedics, their profs were pertinent in telling their underlings that any laceration below the elbow should be explored by an orthopod and not a general surgeon. i think they thought us mere common or garden variety surgeons might miss a tendon or nerve injury and they felt they could do it better than we could. i had no objections. so i started playing with the idea of turfing him off to the friendly neighbourhood bone doctor. i turned to the casualty officer.

"he doesn't seem to have any injuries needing my attention. consult the orthopod!" i tried to sound authoritative, but just in case, i added, "and if he refuses, then call me and i'll operate him. with that i left. after all i still had an appendix or two waiting for me in theater.

it was a relatively quiet call and i soon found myself sauntering out of the hospital on my way home. i knew the orthopod would be operating next and i knew what he was going to be doing. just before going home i quickly checked casualties to make sure there was nothing else waiting and also to ask what reaction the casualty officer had gotten from the orthopod.

"he was not happy," i was informed. "he went on for quite some time about the general surgeons being lazy and turfing cases to him, but in the end he accepted the patient." oh well. what could i do about that now? going home sounded like just the right thing.

one of the things i hate the most about being on call is when my phone rings the moment i get home. the phone rang the moment i got home. immediately i was tense and irritated.

"hi bongi, it's rb here. how are things there with you?" it was my friend, the vet from the game reserve. that meant it was a social call. well anything is better than a work related call once i was at home so i was actually quite excited. and what a coincidence that he should call the very day that we received a patient from his neck of the bush. for a moment i even forgot i don't believe in coincidences. "bongi, i'm actually phoning about a friend of mine who was sent to your hospital. he was attacked by a lion. you wouldn't possibly know who is treating him would you?" i knew very well who was treating him. more than that, i knew why that doctor was treating him. it was because i was apparently lazy and had turfed the patient. i decided rb didn't need to know the gory details of hospital politics. a simple "yes" would suffice.

"well you see, bongi, working here in the park, i've seen quite a few attacks by wild animals and quite often the city doctors close the wounds primarily. i know i'm just a vet but i've seen enough of these to know that this simply doesn't work. these animals have all sorts of nasties growing in their mouths and if the wounds are not debrided thoroughly and then left open for a few days, they will all become septic." i knew all these things to be true. i also knew that if i had been operating the patient i sure as hell would leave the wounds open and only close them a few days later. the only problem is i wasn't operating. he went on. 

"so, bongi, if i could ask you a favour?" i cringed. never mind my usual reservations about favours, i knew what this favour was going to be. if only i hadn't turfed that patient, it would be easy, but i had turfed the patient and this wasn't going to be fun.

"sure! no problem." i lied.

"great. could you maybe speak to the doctor handling my friend and just tell him not to close the wounds primarily?"

"ok." the lie was less convincing. my hesitant voice betrayed me. but somehow rb didn't seem to notice.

"great! thanks a lot, bongi."

moments later i found myself phoning theater where i knew the orthopod was busy debriding the wounds of a lion attack victim that the surgeon was too lazy to treat. i couldn't help wondering exactly how i was going to word it.

"remember that patient that i dumped on you? well now that i'm snugly at home and you are still slaving away in theater, let me now tell you how you should be doing your job!"

smug

recently i was involved in a discussion with a guy that was explaining how we should understand criminals. the emphasis was on farm murders but we touched on murderers in general, rapists and child molesters. my point of view was that i did not understand them and felt that he was justifying their actions. in the end i was informed that i was smug. apparently that is the word for people that couldn't see the point of view of the poor misunderstood murderers and rapists and molesters.

so smug is what i am, it seems. you see the fact is i can't understand his beloved murderers. i just can't. i also in my smugness wonder how he can, but i think i know.

it has to do with not being in the trenches. it has to do with not being faced with the blood and the tears and the guts and the screams...mostly the screams. it is probably easy to be nice and philosophical sitting snugly (not smugly apparently) in a nice air-conditioned office, philosophizing on the reasons people point a gun at people and pull the trigger. or worse...

the thing is i can't forget. i am scarred. i remember the patient lying in a pool of his own blood, looking up at me and asking, beseeching even to tell him he is going to be ok. i remember wanting to tell him that it would all turn out just fine. i even remember wanting to hold his hand because his mother wasn't there to take care of the emotional side of things. in the end i remember not telling him he would be ok because i wasn't sure he would. i also remember not being the mother he needed in the last moments of his life because that is what it turned out to be. after we had plough through the blood and feces floating around in his abdomen, violated by the bullet fired from the gun of someone my friend feels i must understand, the patient died. he did not die well with his mother or wife holding his hand in love. he died alone in some icu ward with adrenaline being pumped into his veins and oxygen being pumped into his lungs with a scarred doctor who felt that his time may have been better spent holding the patient's hand rather than pouring time and energy into a futile attempt to save his life. you see the reason i can't see the side of the killer is that the killer is still alive and has the sentiments of my learned friend to feel for him. my patient is dead and there was no one next to his bed when he died. there is no one to state his case now.

i remember the baby violated by her uncle. i was just a house doctor, but i had to examine her. the pediatrician couldn't face it. it is quite a thing to see the perineum of a four month old after it has been ripped apart by the penis of one of the people my friend understands so well. feces runs out of the vagina. it leaves a mark on the soul. but worse than that is the cry. the child did not scream anymore. i think it used up all its scream for its entire life during the deed. all that was left was a quiet constant moan. it is the ghostly moan of someone who has learned in her four month existence that there is no one who will come to her aid. there is no one to understand her. it will never leave me. my friend who is quick to understand the violator will call me smug, but may i suggest i might just be jaded?

the women raped is difficult to examine. somehow you feel you are violating her again. you feel you are making the whole ordeal worse. they don't resist. they are already broken. anyway, rape in our country is so commonplace, it may be the one area where i understand that my friend mat have sympathy with the perpetrator, but, sorry, i cannot. for me to examine those women tears me apart. it leaves me with a feeling that my own soul has been violated. that i am forced to do something because someone else destroyed a life. i refuse to see the point of that someone else. if that makes me smug, then smug i must be, but again i suspect i might be jaded.

a bullet can do a lot of damage. physically i think i might have been a witness to pretty much all of it, but there is another side to the story. i remember an old man, shot in his home when he tried to defend his wife from the killers that broke into their house in the early hours, people that my friend chooses to understand. we did pull him through, but not without a massive operation and the obligatory icu time. i remember when he came to me for follow up some time later. i was so proud that he had made it. but somehow he was the shell of the man he used to be. he was alive, but broken. his confidence was gone. he lived in fear. he felt helpless because he knew he could do nothing against the lead of the people who i hear from my friend i must understand and sympathize with. but who sympathizes with my patient whose peace has been stolen from him? the smug or the jaded?

recently i enjoyed my christmas eve over the open abdomen of a woman shot in her bed by strangers, strangers whom my friend has endless sympathy for. i did not enjoy my holiday period, but more than that, my patients didn't either. hopefully my friend, while maybe enjoying a beer with the killers he understands so well had a really festive time. i do not understand him.

experience

different places deliver different opportunities for experience. it is just a fact. a surgeon working in hollywood is going to see a different spectrum of patients than what one in, say, delhi would. it doesn't mean one is better than the other but it does mean one would feel more at home treating certain conditions than the other. therefore when the belgians rotated with us it stood to reason that they would feel a little unsure on their feet in our environment, initially at least.

when i started in surgery there was already a belgian there. our department had an arrangement with a university in belgium which meant there was at least one belgian registrar with us for one whole year at a time. each year the belgian would go back and another would come to our shores to replace him. so i got to know quite a few belgians in my time. chatting to them i realised the vast difference between the approach to training in their country and in our humble department.

when i first joined the department, in an effort to make small talk i engaged the belgian. i didn't really know what to talk about so i decided to ask him about the differences in the sorts of things they saw there and the sorts of things we saw in south africa. i started with things that were common to us.

"so have you ever seen a gunshot wound in belgium?" i asked.

"of course! i saw one that went in the thigh anterior midline and exited on the lateral aspect just before i came out to south africa." i decided to rather ask him about the weather. it would bore me less.

a year later when the new belgian had joined us i decided to strike up a conversation so that he at least felt there was someone he could speak to in this new strange country. at that stage we were so consumed by surgery there was little else we were capable of talking about.

"so have you ever seen a gunshot wound in belgium?"

"of course! about a year ago there was one that went in the thigh anterior midline and exited on the lateral aspect."

"and what's the weather like there?"

my third year there when the third belgian came out i decided to test what was becoming a theory of mine.

"have you ever seen a gunshot wound in belgium?"

"of course!"

"let me guess. it went in the thigh anterior midline and exited on the lateral aspect?" he assured me the weather in belgium could be quite pleasant in the summer.

so the first three belgians had seen the exact same gunshot case. gunshots were so rare in their hospital that when one came in the entire surgery department was called to casualties to see it. i was amazed. they also didn't quite have the same sink or swim way of training that we had. they pretty much didn't operate at all without a consultant being present. in our way of thinking it was madness, but in reality it was just a different road to the same destination.

so imagine the culture shock when one particular belgian registrar started in our department. he was shuffled off to kalafong and put on call alone his very first night. now as i have mentioned before, getting a consultant out to kalafong at night was only fractionally easier than turning lead into gold. the senior south african registrars informed him of this fact and availed themselves to be called if he needed advice. they quickly added that they would help him telephonically but they would not actually come in. he would have to sort everything out on his lonesome.

the next day he was a wreak. he was talking about packing it all up and going back to belgium (where the weather was pleasant in the summer). to his credit he stayed.

you see, that night, not only did he see his first gunshot abdomen, but he was required to operate it. after that he did his second one and after that his third. on his very first night on call in this glorious country of ours this poor first worlder really got a taste of what it can be like. i really felt for him. but then again at least we no longer had to discuss the weather.

who heals the fallen

this is not really my story. but in a sense this story belongs to all south africans. it is our shame and may be part of our downfall.

we are a people at war. we war against ourselves and we war against peace. each fights for himself and bugger the rest. but who heals the fallen? it seems in south africa, quite soon maybe no one.

recently a story made the news. it was shocking, but it actually gives an inclination of how morally decayed south african society has become. an ambulance was despatched to some informal settlement after a household fire burned a child. the caretakers of the child brought the child to an intersection that the ambulance would actually be able to find. quite soon the paramedics were hard at work stabilising the screaming child. at about this stage two armed thugs turned up. they threatened the child's caretakers with their lives and forced them to flee. then, while the child continued to scream in pain, they raped the female paramedics. they were not caught.

yes it is shocking and now the ambulance personnel need to wait for police escort before they respond to calls in certain areas, greatly increasing their reaction time. we would like to believe this sort of thing is isolated but is it? just the other day i heard on the news about another case where a crowd assaulted the ambulance crew because they wanted to help the victim of a stabbing. as i said we are at war with each other and the victim was their enemy for whatever trivial reason.

but the question i end up asking has little to do with the morality of what's going on. that, it seems to me, is obvious. to discuss morality with the people involved in these stories is a waste of time and effort. i wonder when at war, which we clearly are, how is it in your interest to antagonise the medics? yes you may have won today's battle and not actually need a medic, but what about tomorrow? who will help you when you find yourself on the business end of a knife or panga? also the people who give their lives to help the injured and downtrodden are not quite as involved in their petty squabbles as they may imagine. to drag them in and try to kill them for helping the wrong person is both small minded and short sighted. we didn't really need evidence to know the people that engage in this sort of activity fit nicely into this category, but there it is if you want.

a number of years ago a paramedic friend of mine responded to a gunshot case in mamelodi outside pretoria. what he didn't know was that the mob around the patient had little interest in the survival of the patient. they actually wanted him dead. the paramedic therefore in their narrow view of events was the opposition. as far as they were concerned anyone from the opposition should also be dispatched.


he drove into the thick of things in all oblivion. when he arrived he opened the car door to find out how he could help. the crowd immediately tried to drag him out of the car, beating him with fists and the weapons they had at hand as they did so. he quickly realised he was going to share the same fate as the patient, which was, by that time, sealed. by pure accident the paramedic's safety belt was not loose and they could not pull him out. he slammed the car into gear and throttled out of there with his torso leaning out of the open door in true hollywood style.

thereafter the ambulance service refused to respond to calls from mamelodi except with a police escort. bearing in mind our police are stretched thinly on a good day, the whole situation became ludicrous. i would love to believe in some sort of karma where the people that suffered because no help was forthcoming were the people who were responsible for the problem in the first place, but, like all wars, the actual people who suffer will be the old and the weak, the vulnerable and the children. but that is the african way.

bell bottoms

i recently went to prague. what a culture shock. the place is clean and beautiful and safe. i travelled quite a bit on the public transport and not once felt in danger even though i'm south african.

there is generally law and order. on the first day i went on the underground i did not stamp my day ticket because, being south african, i just assumed there would be someone to stop me and check. there was not. they rely on the people there being honest. being south african i rode the whole day essentially for free. then my conscience got the better of me and i bought another ticket so they would not lose money.

you see we south africans have no law and no order. we get away with whatever we can. we all speed and we all jay walk and we all bend all the rules as far as we won't get caught. in prague it is exactly the opposite.

but getting back to the story. one reason it was such a culture shock is because a while ago, to travel on public trains in south africa was quite risky. you see there were gangs that would throw people off moving trains for a laugh. there was also a time when certain trains would get attacked by automatic wielding thugs that would indiscriminately shoot people. these days there is more security (all armed of course) so it isn't quite so bad. there still is the occasional torching of a carriage if it turns up late. let it never be said south africans can't express their anger at trains not being on time.

anyway, while i was safely travelling on the czech (for americans, that is where prague is) public trains, i thought about a few of the patients i had seen. i don't think i'll talk about the guy that got corkscrewed between the train and the platform here. the bell bottom patient came more strongly to mind.

it was in the days of the indiscriminate throwing people off and in front of trains. most died on the scene, but a few got to us. for those who don't know, to get injured on south african train tracks is a sure recipe for sepsis. the trains drop their sewer directly onto the tracks, so to get an open fracture there usually ends up quite a mess. my patient was thrown in front of an oncoming train from the station platform. i suppose the people who threw him there thought it was quite funny at the time. we at the hospital did not.

the poor victim of this senseless crime fell with most of his body over the further track. in fact only one leg lay over the one track. unfortunately he had no time to pull his leg away before the train went over it.

now, to fully appreciate what happened one must realise the patient was fully awake and fully sober. he had in fact started extricating himself when the first wheel cut and mangled his leg about mid thigh. he continued to pull himself away. the second wheel therefore hit his leg about two inches lower down. the next wheel then struck about two inches below that and so on. so the leg was mangled worse than any mangled limb that i have ever seen and more than likely will ever see. it had deep cuts at two inch intervals. the femur was severely broken but it was not nearly as bad as his lower leg. the lower leg spread out like a bloody and distorted bell bottom ending in a very wide flat thing that had once been a foot.

suffice to say he lost his leg that day. (for up and coming south african surgeons, leave the wounds open from train track injuries, like we did. otherwise sepsis will set in and things will get worse.)

so while in prague, i was really confronted by the many acts of meaningless violence we see in our country because i had a clear picture what life could be like in a peaceful place. i honestly wondered what the point is here.

post traumatic stress

in a previous post one of the topics i touched on is the aftermath of losing a patient or rather the effect it can have on you as the doctor. a good post i read recently also touched on the desensitisation we tend to undergo. it is often forced on us, as was demonstrated by the sister's comment to me after the patient died in my post quagmire. there was no space for feelings. she didn't follow me out to speak to the family and be confronted with feelings. she just jabbed me a bit, maybe to help with the desensitisation process.

but sometimes the reality itself doesn't allow for the luxury of emotions. there are so many stories i could tell to illustrate this point like the time one of my patients crashed while i was resuscitating another one. when patient one died i didn't have time to even register emotion. i had to get to the other one who was in the hands of my medical officer whom i had sent ahead. when i got there to find him dead too i mustered up the troops to get back to the endless streams of impatient patients in casualties. they didn't care about our emotions. they didn't want to wait and they were willing to throw abuse at us if they did.

but the real reason i'm reminiscing about all this is a recent conversation with an anaesthetic friend. he was also talking about the effects these things have on you. it is quite sometiong to have someone die literally under your hands and wonder if there is something you missed that may have changed the outcome. to possibly be partially responsible for the death of another human being seems to leave quite a mark.

he was on call. a disaster was presented and the team got to work. he describes scenes quite similar to the fan fair i spoke about in the case presented in quagmire. anyway the details are not important. the point is there was high drama and it was traumatic and shocking to all involved and the patient died in great thespian style on the operating table despite all efforts by everyone concerned.

my anaesthetic friend was shaken, as can be expected. he wanted to go home, or even just sit and let the adrenaline work out. (home would no doubt have been better). the theater matron came in. he looked at her with a blank stare. maybe he felt empty and his face reflected that. the matron asked;
"so what case are we doing next?"

just like that! the dead patient, the devastation of the family (still to be faced), the blood all over the place, the shock to the team, specifically the anaesthetist and all the matron wanted to know was what case to do next! in a certain sense you can understand it. the list is there. there is not another anaesthetist on call, so if he is not up to helping with the next patient, the next patient would not be helped. also it could easily be that the next patient is just as critical, but it could also be that it is something quite mundane. the point is my friend had no time to recover. reality steam rollered him and he had to deal with it...later...in his own time...when he would be so tired post call he would probably not be able to deal with it. somehow that is the way it usually turns out.

when we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on its rump.

breaking the news

there is a fair amount of talk about how to break bad news. truth be told i think i'm fairly good at it. sometimes, however it can leave quite an impression.

i was a community service doctor in qwa-qwa. i was working in casualties when they came in. two young children had been playing on the side of the street with a spinning top when a drunk driver came careening off the tar and ran them down. apparently in his drunken state he couldn't negotiate the turn.

the patients were cousins. we shuffled them both into the resus room and closed the door. one was about four and the other was six. the bigger one was dead. the smaller one had only minor abrasions. we covered the body of the big boy and cleaned and bandaged the wounds of the little boy. then we waited for the family.

a side story here was that the drunk driver who realised he was in trouble asked me to only draw the blood for alcohol levels the next day and lie about it. he even offered me money. he didn't specify how much. i was amazed at the inherent selfishness of people. there was a dead child in the resus room and this man was only concerned about the consequences as they pertained to him and him alone.

finally two family members arrived. the old woman was the grandmother of both children. her daughter who was with her was the mother of one child and the aunt of the other child. we moved them into a closed room where i was to speak to them. there was not going to be an easy way to do this, but i remember thinking that i really hoped the mother was the mother of the living child. it would make my job easier and their job when they got home more difficult.

i started by explaining the nature of the accident. i went on to explain that these types off accidents can cause severe injury. i then as gently as possible said that one child was already dead when he arrived and we couldn't help him, but the other child was ok. the mother immediately looked at me directly, something she had not done up to that point and asked with desperation both in her voice and etched into the lines on her face;
"which one? which one is dead?" the grandmother did not react outwardly, but a tear rolled down her one cheek.

i remember clenching my jaws, hoping that the woman before me was the mother of the living child and not the dead one. the news would still be bad, but at least for her personally there would be a good slant on it.
"the older child is dead."

it looked like someone shot her. her entire body contorted and she dropped to the floor. she started screaming. the grandmother didn't move, but the tears flowed more freely down both her cheeks. between the screams of the mother of the big boy, for that is what she was, the grandmother simply said;
"this is a terrible and difficult thing"

i was shaken. i didn't want to let the casualty staff see me cry so i swallowed hard, wiped my eyes and went back to work. besides casualties was full and i didn't have the privilege of taking time off to get over my trauma. anyway it didn't compare to the woman lying crumpled up on the floor of the office sobbing .

hijacker

hijacking is common in south africa. so common that the government has placed signs to let you know where you are likely to get hijacked. there are some people that feel more should be done, especially if one bears in mind that you have a good chance of being shot during a hijacking.

in my post practice, there was a comment which hinted at our south african view of violence, due to the fact that it is so commonplace. yes we are desensitized. but doctors are also desensitized. so what happens when you bring all three of these elements together?

it was in my registrar days. i had recently written intermediates and had less academic stress to deal with. therefore on calls, if it was quiet enough, instead of going to the call room and studying, i found myself wandering around, looking for something to do. one of my favourite places was the casualty unit. and in the casualty unit, my favourite place was the resus room. this is where all the high drama took place. this is where the adrenaline flowed (often even into the patient). this is where i felt alive and at my most alert.

so that night i wandered down to casualties to see if anything was happening. in the resus room, sure enough, there was a guy lying on the table. a friend who was almost finished with thoracic surgery specialization was standing at his head. all seemed calm. then i saw someone else in the corner of the room, looking awkward and out of place. i looked at the patient. he had a nice round hole in his chest, just to the left of the heart. i put the story together in my mind.

the guy in the corner was the shooter. he was either a cop in plain clothes or some civilian that had intercepted some crime. because of a slight paranoia due to 'a beautiful mind' about people lurking in places they shouldn't be, i asked my friend who the guy was there in the corner. i was relieved to hear that he could also see him.
"he's an off duty cop who shot this f#@ker. i don't know who the f#@k teaches them to shoot? two f#@king centimeters more medial and i'd be in my warm f#@king bed now and he would be on a cold hard f#@king slate in the morgue. now i have to operate this f#@k!" that's just the way he spoke. he could be very descriptive with only one adjective. he had the unique knack of making swearing sound elegant.

i then got the story, more chronologically and with less profane interjections (also much less colourfully) from someone else. the patient (the one my friend referred to as the f#@k) was a hijacker. at a robot (south african for traffic light) he had smashed the side window of a car and pushed his 9mm up against the head of an old woman. in the car behind was the off duty policeman. he jumped out, raised his service piece and demanded that the hijacker desist (my friend wouldn't have used the word desist). the hijacker, maybe like my friend didn't understand the word, because he turned to shoot the cop. the cop's gun was drawn, cocked and aimed. there was little doubt about who was going to squeeze the first shot off. the round entered the patient square on in his chest just lateral of the heart on the left. it exited exactly posterior to this. i surmised that if he even had mild cardiomegaly, the shot would have been fatal. i think the criticism about the cop's aim was unwarranted.

armed with this new perspective i looked at the patient (f#@k). he looked back at me. he was stable, but the intercostal drain had a constant stream of blood running out. my friend stood back as a sister was placing a cvp. he was telling her what to do. she was learning. i looked into his eyes again. i could see the fear of death there. i wondered how many times he had seen that in other people's eyes and shown no mercy. but i was not him. i felt sorry for him.

my friend, meanwhile exchanged some words with the cop. i listened in. he was giving shooting advice. he was suggesting that the best place to aim is the center of the chest and not the left. i reflected that this is good advice. although the heart is ever so slightly to the left, it is actually in the center of the chest.

then i listened to the sister who seemed to be having a bit of trouble with the cvp. she had moved from the subclavian to the internal jugular. her head was now directly above that of the patient. she was muttering. i moved closer to hear what she was saying.
she was speaking to the patient as she drove the needle repeatedly into the neck, searching for the vein.

she was saying things like:-
"this thing would think nothing of killing me on the street and now i have to try to save it's life."
and:-
"here lies the reason the death penalty should be brought back."
and similar things.

i mentioned to her something about not being a judge and having to care for whoever comes in without discrimination. she looked at me as if i wasn't a south african. i repeated what i had said, and then, knowing that my foul mouthed friend was good at what he does and the patient would be ok, if not somewhat emotionally scarred, i left.

i felt the need to tell this story to try to bring across the reality of how our job ends up messing us up. maybe being south african means we were messed up to begin with. i've often felt that we should go through some sort of debriefing. i doubt anyone can remain totally normal with all this sort of stuff constantly going on. it becomes a challenge to remain an exception. luckily i enjoy a challenge.

'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.