cyanosis

it has been a very long time since i gave my last anesthetic, but i still don't think blue is a good colour. i was reminded of this recently when one of my gastroscopy patients developed laryngospasm. he turned out fine but blue patients tend to age me quite a bit.

when i was a student i found anesthetics boring. that is because i didn't really know what was going on. when i was a comm serve i started off in anesthetics and was soon the number three in the department in our small hospital. in fact for that entire year i was considered an astute giver of gas to my great dismay. i was on the wrong side of the action on all calls.

i had been in anesthetics for not too long, but long enough to develop adrenal hyperplasia. i was on call and had to dope for a common or garden caesarian section, obviously late at night. i injected the contents of the big syringe followed by that of the small syringe and tubed without any difficulty. the gynae started.

almost immediately i realised there was a problem. the patient's chest was not moving with the ventilator, not a good thing. quite quickly the saturation monitor dropped its tone from its usual comforting high pitched beep to a very disconcerting low pitched boop. i started sweating. at about this stage the gynae calmly in a helpful voice said.
"the blood is looking very dark." i wanted to say something like i know the blood is f#@king dark and i don't know why. you just keep yourself busy with what you are doing and leave me the f#@k alone but all i said was
"i know. i'm on top of it." i flushed the system with oxygen and pumped. the chest lifted but soon the pressures dropped again. there was a leak somewhere and i had no idea where. i told the floor nurse to phone the cuban anesthetist, my mentor. she left to make the call. he lived on the hospital grounds and, even though it was very late at night he would be able to get there quite quickly. but quickly would not be soon enough. the fact of the situation was that when he arrived the problem would be over or the patient would be dead.

i flushed the system with oxygen again and managed to at least get a bit of air into the lungs. but it wasn't enough. i flushed again, but this time i put my ear close to the boyles machine and listened for a leak. i heard it. one of the pipes had a hole in it. i quickly made the necessary replacements and all was well.

about ten minutes later the cuban anesthetist charged in, completely out of breath from his run up to the hospital. i was probably blue myself at that stage but at least the patient was pink again. i still nearly hugged him.

nearly a year later on my last call as a comm serve just after an anesthetic the patient developed laryngospasm and also turned blue. i very casually drew up scoline. i injected it an tubed him. during the whole time i just kept saying to myself
"never again will i give anesthetics. never again." i felt good.

sign

those of you who follow this blog will know that we had an interesting prof. some might say eccentric. others might say idio(t)syncratic. whichever, there were interesting stories associated with him.

the prof demanded total silence during any operation. the silence was so absolute that the prof himself would not speak, not even to ask for instruments. he had hand signs which he used to request the next tool of his trade. his eyes never left the operation field and the sister had to make sure she palmed the instrument to him correctly if she didn't want to fall foul of the prof's sharp tongue. one incident delivered an exception.

it was an auspicious occasion. the prof was going to demonstrate the correct way to do a haemorrhoidectomy. he insisted that the whole firm was there to see how it was supposed to be done. i had lived through this demonstration once before so i was not too enthused.

soon the patient was cleaned and draped. the prof, suitably scrubbed up, settled into his chair between the patient's legs, getting ready to start. i noticed that the sister was junior. she was chatting to the floor nurse as the prof settled down, a definite no no. i actually remember thinking that it was just a matter of time before the prof got stuck into her. but, fortunately for her, he was too focused on the target zone, deep in thought, obviously planning the procedure. the sister was preparing the scalpel, also deep in thought. but her thoughts were related to the conversation she was having. her mind was far from where we all were.

she attached the blade to the handle and turned towards the prof, blade exposed. the prof, at that moment, seemed to finally have decided what his first move would be. without looking and in total silence, he swung his hand back with the index finger extended briskly in the sign demanding the scalpel. how was he to know that the sister was holding that same scalpel, sharp point towards him, exactly where his hand went. to put it bluntly (ok, maybe not the right word) the prof threw his hand onto the scalpel's point. i imagined an old japanese warrior throwing himself on his sword.

to say the prof was not impressed is somewhat of an understatement. the cut bled profusely and it took some time to settle everything down once again before the operation could get underway. that is the one and only operation i ever remember the prof doing where he spoke throughout. he let the sister have it. once he had given her a run down of her manners he went onto her upbringing and her ancestry. but at no stage did he let up until the patient was awake again.

to be honest i was chuckling on the inside, but the prof had taught me to be silent during his operations so it did not show.

the last goodbye

this is a story i considered not telling. somehow it comes too close to how we deal with the constant tragedy of life we are exposed to, both positively and negatively. then a post by buckeye reminded me of it.

the rotation through the military hospital was interesting in that the slog work was done by relatively junior doctors. that night one of them admitted a patient with abdominal pain. to be honest i didn't pay too much attention in the handover because he was admitted to another firm and that consultant would surely handle whatever the problem was.

late that afternoon, when the relevant consultant was no longer available, the medical officer of his firm asked me to evaluate the patient. the first thing that struck me was that the patient was in excruciating pain, yet his abdomen was soft. his face bore the deep grooves acquired from years of diligent smoking. his kidneys were going into shutdown and he was severely acidotic. i didn't even bother to check his phosphate levels. i had a good idea what was wrong. i called theater. i also let my consultant know i was going to do a laparotomy and asked him to hang around a bit before he went home...just in case. he was one of the few that was both a brilliant surgeon and a brilliant person. i knew i could rely on him.

as i started the laparotomy i spoke to my intern about necrotic bowel. i even went into detail about the thrombotic type, the emolic type and the low flow type. then i still remembered all that detail. sure enough, as we opened, loops of dark blue to black bowel came bursting out of the abdomen. the situation was dire. we all went silent. the bowel was dead from the duodenum to the transverse colon. a resection seemed pointless. i went through the bowel again, more to give myself time to think. but the mesentry was also dead and the slightest touch tore it. soon i found myself trying to control a persistant slow bleed from the base of the mesentry, but every time i placed a stitch it tore through the very friable tissue. i started becoming nervous. i called for my consultant. it was after hours but i knew he wouldn't have gone home. he would be waiting to hear how the operation went. he was just that type of man.

sure enough, moments later he burst through the theater doors. he looked into the abdomen. i explained the situation of the bleed that i just couldn't seem to control. in the knowledge that he would soon take over from me, i felt much reassured. i continued to work at getting control.

after a while i wondered why he was taking so long. i looked up to see what the delay was. the consultant was helping the anaesthetist adjust his suction which seemed not to be working. i was shocked and amazed. but i did not dare say anything. i just thought that that wouldn't take too long, so i would just need to be patient. it did take long.

after what seemed like ages the anaethetists suction was finally fixed. i relaxed again. but once again i looked up to see the consultant not scrubbing! he was wondering around theater, not really doing anything. occasinally he would chat to the floor nurse or the anaesthetist or just check all sorts of irrelevant fixtures in the theater.
'why is he not scrubbing to help me?' i thought! and then it struck me. he knew there was nothing that could be done. he wasn't going to tell me what to do, but, instead was patiently waiting for me to make the call.

"there is nothing to do here, colonel" i said. i think the corner of his mouth lifted in an almost smile.
"yes, bongi, there is nothing to do."
"should we stop now or close and send him to icu to die?" i asked. we did have a bed in icu organised.
"i think you can stop, but it is up to you." said the colonel.
"his family didn't get to say goodbye," i said, "so i'm going to close and see if we can get him to icu alive."
"ok." and then he left.

we got him to icu on high doses of adrenaline. the anaesthetist was annoyed with me. he felt it was a waste of time and resources. in a sense it was, but i felt it was the right thing to do.

once we had settled him, i went through to the waiting room to speak to his wife and son. i explained the situation. the wife asked me what his chances were. i told them he had no chance and would probably not see the next day. the son then asked me why, if it was pointless, had we closed and taken him to icu rather than just let him die in theater. i explained, as honestly as possible, that it had been my call so that they would at least have a moment with him to say goodbye before he died. the son was furious. i actually thought he was going to physically attack me. he did verbally abuse me quite a bit. i wonder what his reaction would have been if i left his father to die in theater.

after all the drama had subsided the doctors involved took a few moments to unwind over a cup of coffee. i remember a dentistry student who was doing her anaesthetic rotation. it was her first night with any form of clinical exposure. i wonder if she needed therapy afterwards.

injuries

every sport has its injuries. so the saying goes. and surgery is no exception.

it was a thyroidectomy for multinodular goiter. not like the monsters that the state was inclined to deliver, but a routine straightforward private thyroid. the only catch was that she was hiv positive and not on antiretrovirals. the cd4 count was low but acceptable so i went ahead.

the operation went without any hitches. quite soon i found myself placing the last skin sutures. and then... i stuck the needle into my finger. let me assure you, that is not the greatest feeling.

anyway, before the next case the first dose of antiretrovirals had passed my lips and i felt slightly consoled. only slightly.

the month flew by quite quickly actually. the only side effect i experienced was diarrhea but, truth be told, that was bad enough. i actually considered suggesting antiretrovirals as suitable bowel preparation for colonoscopies. no one took me seriously.

thereafter i needed to have the obligatory test. the only problem is in such a small place as the town where i live, if i tested positive, within a week everyone would know my status. if it were to turn out positive, i would basically have to shut down shop and find another town to ply my trade. who would go to a surgeon with hiv? i had to have the test done anonymously.

i approached my good friend, the pathologist at the lab. he understood my situation and agreed to do the test for me under an assumed name (i think it was something like 4739). that friday he drew my blood. i was on call so i immediately disappeared to theater. he assured me he would call me in an hour.

an hour passed. another hour passed. i tried not to panic as a third hour passed. to phone him would show a serious loss of cool but after another hour i didn't care about that anymore. i got his voice mail. at that stage i started making plans in my mind for my new practice in a small town in another province. a friend of mine there was looking for another surgeon to join their partnership. like most places in the country they were overworked due to the country wide shortage of general surgeons. it would be a pity to have to start from scratch but the fact that i had heard nothing from the lab implied i must be positive, or so i reasoned.

the fear of hiv is a part of the job. occasionally taking antiretrovirals is also part of the job. in a setting where probably 30 to 40% of the population has the virus it is inevitable to have contact occasionally. it is just one of the things we must face day to day.

then he finally phoned. they had done all the tests imaginable and i was negative. the relief was difficult to describe. when you've seen the effects of the virus so many times, especially the dementia syndrome it causes, the fear of it is a constant cloud over your head. the moment of sunshine then was beautiful.

supplies

i did my house doctor and community service years in a historically significant place. during the old regime the government deemed the area independent as part of the great apartheid madness. to maintain the façade the apartheid government ploughed money into this pseudo-country. even after all the officials had taken their cuts there was still enough left over to keep the hospital well stocked. when i worked there, after the fall of apartheid, all this had changed.

this 'country' became a small region in one of the 9 provinces of south africa. provisions came from a central depot. they were trucked in and there was no exchange of money locally. the bribe industry really struggled for a while. but people are ingenious. soon the trucks started turning up with very little. apparently they left the central depot fully laden, but by some inexplicable means, the supplies just disappeared somewhere en route. equally inexplicable was that some people in the area did quite well selling stock at massively reduced prices to pharmacies. as usual the poor suffered. i remember times when there was no insulin for months in the hospital. the physicians (internists) waited for dka and then transfered the patients to the other regional hospital, about 2 hour's drive away. some people died of course, but it was a small price to pay for the enrichment of the previously powerful.

but one day this all really hit home for me. i was the community service doctor on call at the primary care hospital. they called me to see a patient with a retained placenta post full term delivery. i went to the labour ward. sure enough the patient was having trouble with the placenta. i asked for gloves. there were none. i decided to quickly run to casualties to get a pair of gloves there. this would be faster than sending someone.

when i got to casualties, lo and behold, they also didn't have any gloves. there were in fact no gloves whatsoever in the entire hospital. apparently labour ward was washing gloves to use over and over again for the deliveries. they couldn't understand that i refused to use these gloves. i went back to casualties, thinking this had to be the most likely place to find gloves. but they assured me they had run out.

then an ambulance came in with a patient. i asked them if they had any gloves. they did, but they were only willing to give me one pair because they were also running low on this most basic of item.

i took the gloves to labour ward. i used one to deliver the placenta. the second glove i gave to the sister and told her to lock it in the scedule medicine cupboard and keep it for me if i needed it later.

jelly tots?

sometimes i just post funny stories. sometimes you think of the ideal punchline before the moment has passed. on both accounts this post represents one of those times.

it was one of many morning meetings. usually they were not fun. almost always the prof would have a go at someone. most of the time if you weren't actually directly in his cross hairs, you would just keep quiet and nod at the appropriate moment. this morning was no exception.

fortunately i hadn't been on call the previous night so i was basically a passive, occasionally nodding observer. the guy who had done the call was a particular target of the boss. the boss didn't like him, but, even worse, he didn't seem to have the savvy to present his cases in a way that avoided drawing fire. this day was no exception.

my friend's first case was a patient who presented with what sounded like a macerated nipple. i remember wondering why he even mentioned the patient as a call case. i would have referred her to the clinic and thereby avoided telling the prof about her at all and therefore avoiding taking a hammering at his hands. also he described her as a young woman who was breastfeeding (although the baby was three years old). it was unlikely to be a serious problem. to make things worse my friend had actually taken i biopsy of the nipple. i don't know what he was thinking, but ironically he probably did it to be thorough in an attempt to avoid the wrath of the prof. the wrath of the prof descended.

just like me the prof wondered why he had been so drastic as to take a biopsy, but, unlike me, the prof was not subtle in asking. my friend did not have the gift of the gab and soon started floundering in his explanation. (this may at least partly have been due to the fact that the exchange took place in my friend's second language). the prof let him have it.

the prof, between the constant tirade of aggression aimed at my friend, suggested that the macerated nipple was probably due to the baby (or rather toddler by now) using the nipple more as a pacifier than a source of milk. he painted a picture of a toddler keeping the nipple in his mouth until it became soggy from the constant moisture. at about this stage most of us were feeling sorry for my friend who was starting to look quite foolish, but we continued to nod when the prof's eyes turned in our direction. i just looked at the floor.

the prof had a habit of not letting a thing go. this was no exception. he explained that the nipple had become like a jelly tot that the baby had kept in its mouth for an hour or so. it would be soggy and no longer look like a normal jelly tot. the opportunity was just too good to let pass. i interjected.

"prof, strictly speaking" i said, " isn't that a jelly tit?" i asked with a straight face. i think if everyone hadn't fallen about laughing i would have been in trouble.

Arte y Pico

ruraldoctoring has bestowed upon me the arte y pico award. she praised me with possibly the nicest words ever spoken about my blog. i quote:

"One of the best writers in New Media Medicine, his posts are both gripping and intensely moving. He's like a blogging Joseph Conrad."

the rules of the award are as follows.

Here are the rules:

1. You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

so let's see if i can nominate a few.

1. just up the dose is a very well written blog and also gives a good insight into south african medicine.
2. a really worthwhile read is buckeye, a surgeon after my own heart, even if he objects to my open appendisectomies.
3. make mine trauma has such a love for her work which is clearly portrayed on her blog.
4. eishmadiskakhi may be a new blog but so typically south african and so very entertaining, it definitely deserves mention.
5. it may be a blog in hiatus, but surgeonsblog is still the best medical blog in my humble opinion.
   

please check out these worthwhile blogs.