six degrees of separation

i try to treat all my patients equally. sometimes i don't get it right i suppose, but i still think i do better than most.

i was as junior as one can get. but as i have touched on before, when i started studying surgery there was a general shortage of staff in the department. this meant i was running a surgical firm long before i was actually capable of doing so. this happened in my first week of running a firm.

a general practitioner phoned about an appendix he wanted to send to us. he spent a bit too much time explaining that they had no money and he had seen the girl as a favour. he threw in that he had managed to have blood tests done at a nearby state facility under the table. with a bit more experience i would have known there was trouble brewing. i did not have that experience.

the patient arrived a few hours later, as the sun was setting. she was a 16 year old girl that looked like she should have had medical aid and therefore not be with us but rather be at some fancy private hospital. i checked her out and went over the blood results that she had been so kind to bring along. to me it looked like she had a clear cut appendicitis and she needed a clear cut to solve her problem. i organised the admission and booked her on the theater list. all i needed to do was run it by the parents who were required to sign the consent and all would be set. there was of course the small matter of never having done an appendisectomy before, but that was a bridge i was going to jump off when i got to it.

i found the mother in the waiting room. i quickly ran through my findings with her and told her that i thought an operation was in order. once again with a bit more experience i think i would have been prepared for her blatant and open aggression. i wasn't.

"and how did you come to this opinion?" she demanded with an accusing look. i was shaken, but i recovered. i went through my clinical findings and threw the blood results they had brought in themselves. then just for good measure i claimed that we were even then sending her for a sonar just to make sure. i also made a mental note to tell a student to rush her off the sonar as soon as i got clear of the mother.

"ok, but i'm not just going to take your word for it. i'll first speak to my husband and i'll get back to you."

"fine, but i'm going to book her on the list so long. we can always cancel later if needed." with that i left (after telling the student to rush the patient off to sonar of course). after that i just got on with the work of the night. we admitted a few more cases, at least one of which i would be required to call my consultant out to operate because of my total lack of experience.

about ten o'clock that night i quickly shot through theater to put yet another patient on the emergency list. the anaesthetist on call stopped me. she also stopped me in my tracks.

"bongi, why is your prof stalking the corridors at this hour?" i may not have had all that much experience but i did know the prof actually being in the hospital so late at night was one of the signs of the apocalypse. i was worried. i felt even worse when i was informed the prof had pushed that 16 year old appendix patient up the list, as high as he ethically could. i was then informed he was preparing to spend the night in the anaesthetic consultants' room. things were looking dismal. i knew i either needed to find him and find out what the hell was going on or i needed to avoid him altogether. avoiding him was not really an option because i would be required to present my call to him the next morning. if he knew that i didn't have complete control of the call, even if it was because he usurped me, it would spell disaster for me. however in the back of my mind was the nagging fact that i had never done an appendisectomy before. maybe he could do this one and i could assist. the next one which was already on the list would be left to me. hopefully watching the prof do an appendisectomy would be all the training i needed.

the anaesthetist also told me why the prof felt it important to do a procedure that was usually far below his great and mighty status. it seemed the patient was a vip. as it turned out, the patient's mother's neighbour's daughter's boyfriend was the prof's son. clearly the prof held his son in such esteem that his son's girlfriend's mother's neighbour's daughter needed his immediate attention. who says six degrees of separation doesn't come in use every now and again?

then, while i was searching the hospital for the prof, he once again snuck into theater where he was informed my consultant would be required to be called out to do one of the other operations on the list. he informed the anaesthetist to inform me that my consultant and not myself should do the appendisectomy. he then left.

telling my consultant that he was required to do the appendix just because of the long and convoluted connection between the prof and the patient was a bit awkward. at least the consultant had a sense of humour and simply accepted his fate.

finally when the patient got to theater we got ready to go. the consultant handed me the knife.

"i think the prof said you were to do the operation." i ventured helpfully.

"the prof isn't here now. i won't tell if you don't tell. cut."

and with that i started my first appendisectomy on a very special patient (or at least her mother's neighbour's daughter's boyfriend's father was important in his own eyes)

as can be expected with a first, i struggled through the operation. the fact that the appendix was very inflamed and adhered to a whole bunch of things in the abdomen didn't make it easier. however, even when i asked the consultant to take over, he refused. he told me that a surgeon can't just back off halfway through an operation and i must finish what i had started. i considered saying i had not wanted to start it, seeing that the prof had pretty much forbidden me from doing the operation and i had only raised the knife at the insistence of the consultant, but i knew what he would say. i soldiered on quietly and finally had the last stitch in.

the next day, on post operative rounds, the consultant asked the patient how she was feeling.

"much better, thank you." said the vip.

"good, "replied my consultant, "we were worried we had done the wrong operation on you."

gee thanks, i thought. imagine what the prof is going to say when he hears from his son who heard from his girlfriend who heard from her mother who heard from her neighbour who heard from our patient what the consultant said.

tutor

training as a surgeon where i trained was somehow secondary to supplying a service. often formal tuition fell away to a senior quickly showing you how to do a specific operation in a somewhat irritated way. half the time you felt embarrassed that you didn't already magically know how to do it so that you could take the immense burden of teaching off the tired shoulders of your overworked senior. the first haemorrhoidectomy i was shown fell pretty much into this mould.

i was still a lowly medical officer when we admitted a patient with a pretty severe thrombosed awkwardness in the nether regions. my senior, a final year registrar, asked me if i had ever done a haemorrhoidectomy. afraid that not having done one would not exempt me from being tasked with doing this one, i discretely pointed out that i had in fact never seen one. i could see the irritation in his face, but he remained calm and told me he would show me how it was done. he then added i'd better pay attention because after showing me one he was never again going to cast his countenance on another anus so long as i worked with him. not wanting to upset his countenance i determined to learn fast.

i remember that haemorrhoidectomy well. i was so on edge to gleam every ounce of wisdom from my senior seeing as though it was to be my only opportunity to learn the procedure. and yet even though he explained every step as he did it it just looked like a bloody mess to me. anyway, that was my training and it had to do. fortunately as the years went by i learned a few tricks, mostly by trial and error, and finally i think i became quite proficient in the procedure.

then, many years later when i had become the senior registrar in the department once again a haemorrhoidectomy found its way onto a list. i expected that i would be the one to do it as i had so many times before. then the boss perused the list. he asked me who had taught me to do a haemmorhoidectomy. when i told him he decided right there that if he had not taught me how to do it, then i probably wasn't doing it correctly. to be honest i thought he might have a point. i mean that operation i had seen so many years ago did simply look like a bloodbath to me. true i had made the operation my own over the years and i even think i had become good at it, but i hadn't really been shown the correct way to do it by someone that at least in his own eyes was an expert. i was actually quite keen to see the operation in the hands of the expert.

at the operation, the boss settled down in the hot seat and prepared to show me his masterpiece.

it was a bloodbath.

exemplary

part of the job is to treat some unsavoury people. sometimes you know what it is they have done. mostly you don't. sometimes you even may make a difference. but mostly you just do your job. after all it is not our part to play judge and jury (and, in our case, executioner). but recently i heard a story from some fellow surgeons about one of their colleagues that i'm sure creates a warm fuzzy feeling in the hearts of all south african surgeons.

i can attest to the fact that after a long night on call your general mood is usually not the best it can be. also it becomes more difficult to see the humour in situations that on a normal day you might be able to laugh off. so when this particular registrar finally wrapped up his post call work and meandered off to his car to go home he was not delighted to find someone busy stealing it. he did what any south african surgeon would want to do in his situation...he shot the guy.

the person in question was, however a surgeon, so his training kicked in. they were already at the hospital so all he needed to do was drag the punctured villain to casualties and get him ready for theater, which is exactly what he did. despite the fact that he was post call, he even took the time to operate the guy himself. i suppose he had the best idea of the tractus of the bullet?

i can just imagine how the post operative ward round went when he presented the case to the prof. how would he have worded it?

"well prof, i shot the guy and then i did a laparotomy. well you always told us we should actively look for work to do if we wanted to get experience."

you can't win them all

the myth of the glory of war is perpetuated in part due to the fact that the stories are only told by survivors. if the guy that took one through the neck in no man's land in world war one and then slowly faded away in a mess of saliva mixed with blood, lying in his own stools, crying for his mother were to tell his story from beyond the grave it wouldn't look so glorious at all. it would maybe be a better reflection, though, of the reality of it. in a certain sense we run the risk of glossing over medicine too. i would hope this blog does not.

i am extremely affected by the patient calling out to me to save him in strained monosyllabic speech at the last moment of his life. it is almost too much to bear. and yet i am the survivor. i walk away to live another day or to tell the story or to enjoy a sunrise in the african bush.

i remember him well. he was a kidney failure patient who was leading a fairly normal life thanks to the wonder of peritoneal dialysis. he was the breadwinner for an extended family even. and then he got the call.

there was a kidney available. i was even involved in procuring the kidney (this is always a sad and poignant story in itself. it is the coming together of life and death, of hope and despair) . the relevant tests were done and this specific patient was found to be the best match. quite soon he was in the hospital going through the needed preoperative preparations. after the usual administrative delays that are so particular to south african state medicine we even actually got him to theater and without too much fanfare soon had the new kidney in and peeing like there was no tomorrow. everything was going so well i almost thought it was too good to be true.

after theater he did well for about three days before things turned. initially it was just a decrease in the amount of urine the kidney was producing but soon it was so much more than that. without going into too much detail, the patient developed systemic inflammatory response syndrome (sirs). this put pressure on his new kidney which started faltering. he developed water retention which put strain on the lungs which were already under pressure from the sirs that he had. after that things started spiralling downwards.

we had long given up on the kidney and put the patient back on dialysis, but nothing seemed to make the situation better. then two days before my rotation in the transplant firm ended the patient collapsed in the ward. i happened to be there and commenced a full resus.

i remember clearly the terror i felt at the prospect of the patient dying. his heart wasn't supposed to have stopped! he was supposed to do well. i felt terrible! but with a bit of good luck i brought him back from the brink of death and delivered him to icu with a tube down his gullet and highly dependant on inotropic support (his heart was dependant on drugs to maintain a barely survivable blood pressure). his kidney had long since ceased to function and we dialysed him constantly at a low rate to try to not put more strain on his borderline heart. then i was rotated to the icu unit, so in essence i followed my patient there.

his sirs just got worse and soon he developed a coagulopathy (the normal clotting mechanisms in the blood stopped working) and was soon bleeding from every orifice. we gave him what we could for that but the fine balance between not giving too much fluid yet giving the needed clotting factors and the balance between dialysis and the heart that was on the verge of giving up altogether was very difficult to manage.

the last night i remember too well. i often wish i could forget. i was on call that night in icu, so it was up to me to get him through to the morning. he had been bleeding from the mouth and nose a bit all day. his blood pressure hovered just above the unacceptable level. his lungs were full of fluid and the ventilation was tricky to say the least. but as the night progressed things got worse. the first thing was the bleeding. quite soon blood was oozing from everywhere. he even had a trickle of blood running down his cheeks like bloody tears from both his eyes. and as he bled his blood pressure started falling. he became too unstable to dialyse so that was stopped. the inotropes were increased to industrial doses but that did little. i became desperate. i phoned the transplant consultant.

after i had verbalised all the parameters to the consultant over the phone it was like i had told them to myself. i knew what the consultant was going to say. if i were him i would say the same thing. the situation was beyond repair. the patient was going to die and nothing we could do would change this fact.

"he is going to die, bongi. you can't win them all."

i knew he was right. i hung the phone up and just sat for a while. i thought of the fact that this man, the sole breadwinner of his family, had walked into the hospital with hopes of a better life without dialysis and would be leaving on a cold morgue slate. it just seemed so unfair, so wrong. had we killed him? i didn't know but at the time i felt we had. my consultant had advised me to stop active treatment and see if i could get some sleep. i stopped active treatment but i refused to sleep. it just seemed to me that i was supposed to at least be with him to the end even if that was all that i was going to do.

i sat in the patient's cubicle and waited, like him, for the end. when it came it was horrible. blood was now streaming out everywhere. his breathing tube was bubbling with the pink frothy liquid seen in pulmonary edema and the ventilator strained against the pressures needed. the colour slowly seeped out of his face giving him the countenance of death before the fact. and then slowly his life force left him.

i turned off the ventilator and all the infusions and left. but even then sleep and the peace that could possibly come from it eluded me. to be honest i did not have that peace for some time thereafter.

focus

specialists tend to be focused specifically on their field. some might say narrow minded even. way back during my psychiatry block i was made acutely aware of this.

one thing i noticed quite early on in the psychiatry rotation was that, with few exceptions, the consultants weren't interested in teaching us. it seemed to interfere with their tea time and their going-home-ridiculously-early time. so when we were told to go to a particular ward to get a tutorial from one of them i wasn't expecting much. i got exactly what i was expecting.

we walked into the tea room where the consultants were hard at work drinking tea and introduced ourselves. the designated tutorial giver groaned audibly. he then glanced over at his colleagues and rolled his eyes. they chuckled. funnily enough i think they thought they were being subtle. after all we were mere medical students and therefore couldn't easily pick up on the finer points of non-verbal communication like specialist psychiatrists could. i was immediately annoyed, but i chose to hide it.

"you medical students think that when you rotate through psychiatry you don't need to examine patients anymore. where are your stethoscopes?" we all pulled our stethoscopes out of our lab coats and presented them. i considered asking him where his was but decided this was already an unpleasant experience and i wouldn't be popular with my friends if i further antagonised our antagonist. i held my mouth with difficulty. he continued.

"go to the ward on the other side of the hospital and ask to see mr g. examine him fully and report back to me." with that he turned his head back to the tea and seemed to drift off in thought. glad to know our future mental health is in such good hands, i thought.

we entered the ward and soon found mr g. we had all rotated through both surgery and internal medicine so we were quite confident in our examination skills but still we were taken aback by what we saw. with a simple glance it was clear mr g was not well. he lay almost motionless in bed except for the movement of his chest with every laboured breath. we got to work.

during the examination it was clear he was in heart failure and had a massively dilated heart. he also seemed to have pneumonia on the left. his abdomen was tender but we put that down to en engourged liver secondary to the heart failure. his mental faculties were almost non existent but were in keeping with someone who was on the verge of death as we thought him to be. as a side note we noticed he had one glass eye.

as we walked back to the consultant still sitting in the tea room sipping on his so-many-th cup of tea we chatted. we were actually quite worried about the guy. at least we could let the consultant know that he needed some real and urgent medical help at the hands of consultants that actually do have stethoscopes.

"you're back!" he greeted us, "why did you take so long? did you stop at the cafeteria for tea?" tea was clearly an integral part of his life.

"umm, no. we were examining the patient like you told us to."

"ok. present your findings to me." we started with a formal patient presentation the way we had been taught to do in internal medicine and surgery, methodically going through all the systems, one by one. as we spoke and the condition of the patient was painted in increasingly grave hues the consultant seemed to become more and more edgy. at least we were getting through to him, we thought. when we had just explained that the patient was struggling for every breath and his last ounce of strength was being drained from his body even as we spoke, the psychiatrist could no longer contain himself.

"did you at least notice he had a glass eye?" he exclaimed with a bit too much irritation. it seemed his edginess was nothing more than boredom.

"umm, yes. his right eye is a prosthetic eye." we ventured helpfully.

"ok. that is all i wanted you to find. well done." i couldn't help laughing. this guy had probably noticed by chance that the eye was fake when he admitted him some time ago. since then the patient had not been examined at all. also one would like to think that the fact that the guy was just about to die trumps a glass eye, but apparently not.

law and order

south african society is a completely lawless society. pretty much everyone does just what they like and more often than not they get away with it. red lights are just a suggestion, yet it is not uncommon to see a taxi stop in the middle of the road without warning. this attitude goes through almost all levels.

yet there are some laws that people do obey. the law of gravity comes to mind. mostly if you trip or fall off a wall or out a window you do approach the earth with increasing velocity and finally come to rest in some form of disrepair when you finally meet said earth, even if you are south african. another law that is obeyed was well illustrated by a patient we once saw in the old days.

the patient came in in a bad way. all sorts of bones were broken. most of his ribs were also fractured in numerous places, causing areas of his chest wall to move paradoxically with each breath (so called flail chest). his abdominal wall had burst and all his guts were hanging out. his left hemidiaphragm had also ruptured. suffice to say he was not having a good day. neither were we.

we got to work and with quite a bit of effort and no small number of hours we got him through theater and delivered him to icu. only after all the excitement had dissipated did we get to hear the circumstances surrounding his injuries.

as it turns out our patient had some form of confrontation on the road with a truck driver. this resulted in the two of them racing each other and cutting each other off, all the while hooting wildly and raising the middle finger in salutation at each other. as time went by tempers frayed. finally our patient decided on an ill advised course of action.

now my understanding of the law of momentum is twofold. firstly momentum is mass times velocity. this basically means the object with the larger mass and greater velocity is going to maintain its course of motion more easily than a smaller stationary object. secondly momentum is one of the laws that even us south africans are subject to.

so when our patient raced ahead in his car, stopped on the side of the road and got out of his car to stand in the middle of the road to stop the oncoming speeding truck with nothing more than his outstretched hand, maybe he hadn't thought it through too well.

choices

a while ago i treated a woman with rhabdomyolysis. you see her husband beat her so severely that she had enough muscle injured that she ran the risk of kidney damage due to breakdown products. i spent some time chatting to her. i couldn't understand that this beautiful intelligent woman could find herself in this sort of situation, especially seeing that the bastard had assaulted her twice before. but actually this post isn't about her. she had finally realised there is no chance that this sort of person is going to change and that she needs to leave him before he kills her. no, this post is about someone else.

it was when i was rotating through the military hospital. she came in as a gunshot wound patient. actually she was quite lucky (as lucky as one can be called when one ends up with a surgeon i suppose). her wound was to the chest and a simple intercostal drain was all she needed. a bit of recovery time and she'd be fit to go. then the story came out.

you see she was in an abusive relationship and was no stranger to the hospital's trauma unit. but each time she went back for more. this time, however, her partner came home with a gun. there was an alcohol fueled argument during which the gun was produced and he threatened to kill her. she grabbed their infant child and ran. however, like most of our patients, she couldn't outrun a speeding bullet. the bullet went straight through her chest and into the infant's arm, shattering his humerus.

to say i was shocked is somewhat of an understatement. i mean i can accept that if someone has such self destructive behaviour that they continue to put themselves in harm's way in the end it is their choice. but the infant has no choice. i needed to say something.

i asked her if she had made a case with the police. apparently she hadn't. i wanted to know why. well according to her the man involved was actually a good man. he had visited her in the hospital and confessed his undying love to her. all was forgiven. she was going to go back to him with her child.

now please understand me. i know that i can't judge someone until i've walked a mile in her shoes and other such cute sayings. but i wasn't thinking about her. i was thinking about the child whose security had already allowed him to take a bullet to the arm and was gearing up to subject him to more of the same. that little bit of tact that i do have left me.

"you know there is a good chance he kills you or your child next time. actually i'm not concerned for you. if you want to put your life in danger, you're a big girl and that is your choice. but that baby of yours has no say in the matter. the one person who is supposed to protect him it seems is willing to put his life on the line because some psychopath says he loves you. let me tell you, people don't shoot people they love."

i said a few other things but the gist was the same. not one word penetrated. she was determined. apparently prince charming had pulled the wool (or executioner's hood??) over her eyes and she was going back. i felt despair for the baby.