in for the high jump

sometimes patients can follow you when you rotate to another discipline. sometimes this can be tragic. sometimes it can be funny. and yes sometimes it can be both.
the patient was tired of life. he addressed this problem by taking a massive amount of a large variety of pills and very nearly ended it all. however the internists would hear nothing of it and fought tooth and nail for his life, partly because of the efforts of a certain house doctor who really invested of himself to pull the patient through. every day, while the patient was in icu he visited and tried the best he could to support him. he even started learning the fine art of ventilation by simply observing the daily settings of the ventilator by his seniors. when the patient went to the ward he could be more directly involved. he did all the necessary blood work on the patient, but also consulted both the psychiatrist and the psychologist. he even spent time just trying to encourage the patient.

but in a certain sense it was a bit of a one sided relationship. you see the patient wasn't overly delighted by the fact that the suicide attempt had been thwarted and he went as far as to take it out on the poor house doctor. i suppose it was inevitable. you see the house doctor was the face that the patient associated with the hospital and the doctors and the house doctor was therefore the target for his resentment. but to his credit, the hapless doctor didn't show signs of this getting him down, although inwardly he was struggling a bit. as you can imagine, he was only too glad to rotate from the internal medicine wards on the 4th floor down to the lowly surgical wards on the 2nd floor. unfortunately his fellow house doctors rotated with him. even more unfortunately surgeons are not know for their finely developed sense of understanding and sympathy of emotional issues.

we were standing on the balcony of the doctor's tearoom. the fellow house doctors were having a bit of a go at this poor house doctor about the fact that despite his best efforts the patient ended up hating him the most. the surgical registrars gave their five cents worth about not investing too much time and effort into someone who just didn't care and essentially didn't want to live. the house doctor took it all in his stride and even laughed at the whole situation. yet even then he defended the actions of the patient, talking about decreased personal responsibility due the a defined psychiatric disease. the surgeons, who essentially stand by the dictum that if you can't fix it with a knife then there is nothing wrong with the patient, ragged the poor house doctor even more. the house doctor smiled and answered.

"anyway it doesn't matter anymore. i've been rotated to surgery and it is unlikely the patient will follow me here." with that he turned to gaze forlornly out over the balcony..... just in time to see his patient whizz past in his brief but rapid journey to the concrete floor below. life was still too much for him and he had jumped.

the house doctor rushed down and commenced the resus. in the end he was also the one to call it. the patient had tried to follow him, but had overshot the mark a bit. the words of the surgical registrar which had been shouted to him as he charged out the ward probably didn't help with his overall demeanour:-

"now at last there is something wrong with your patient."

the gift

sometimes a patient will give a thank you gift to me. sometimes they want to give more. i'm always a bit awkward with this.

the casualty officer called me and told me he had admitted a patient with an acute abdomen. this is surgical jargon pretty much meaning that the patient needed a laparotomy, most likely as a life saving procedure. i immediately went to see him.

the abdomen was supremely tender and i agreed that it looked to be a case for theater. but then the patient told me that twice before in his life he had presented at different hospitals with the same pain. the surgeons on both occasions had rushed him off to theater and found nothing. these two operations had then indirectly given rise to a multitude of other operations for obstruction. he even volunteered the information that the last surgeon who had operated him told him he had a frozen abdomen (a frozen abdomen is the condition when all your intestines are adhered to each other because of multiple previous operation. it is a nightmare to operate and associated with a high chance of injury to the bowel). red lights were going off in my mind. i decided to see if we could avoid an operation.

the ct didn't show any calamity in the abdomen but there were signs of partial obstruction which was consistent with frozen abdomen. i approached the patient and explained that we were going to try to avoid an operation, but if his conditioned worsened, then we would have no choice. i also explained that an operation in his case held a very high risk of complications. combined with his advanced years, these could be serious.

he recovered well without surgery. i was relieved. every day we would chat less about his medical condition and more about him as a person. it turned out that he worked in one of the fancy private lodges in the kruger and he was keen for me to visit. i said thank you but in myself i sort of knew i wouldn't take him up on his offer. i mean after all i hadn't necessarily gotten him through his ordeal yet.

when he left the hospital again he told me i must visit him in the kruger. again i thanked him but soon forgot about it.

some time later he presented again with abdominal pain. again the ct showed pretty much the same partial obstruction, but with impressively dilated small bowel (worryingly so). he informed me that he lived with a constant degree of abdominal pain and felt he could not go on. once again i told him that an operation would be risky but it could be considered. he felt there was nothing to consider. according to him anything was better than his present life of pain and misery. at that time he told me that i could do with him whatever i liked. he thought i was the greatest seeing that i so far was the only surgeon who didn't rush him off to theater and rip him open from stem to stern. i wanted to mention that we both had been a bit lucky, but i sort of liked the adoration so i just smiled. we decided to proceed.

just before theater the patient reminded me to visit him in the kruger and then the penny dropped. i realised the reason i was reluctant to accept is sometimes my patients die. i can't always predict who is going to die and who is going to make it. to accept such a wonderful gift from this man seemed wrong, especially in the light of the fact that i was not convinced the overall outcome would be favourable. it seemed a bit too much like taking advantage. i suppose in a way i was keeping myself at a distance from the humanity of the man in order to better do my job. i suppose i was also thereby denying myself my own humanity.

the operation was tense but it went well. he recovered and afterwards once again swore i was the best surgeon in the world. i was just glad things didn't go wrong. i didn't really feel that i could take either credit for the good outcome or his gracious gift of time in a fancy lodge in the kruger.

we parted company and i'm happy to say i never heard from him again. happy because that meant things were probably going well.

then some years later i was asked to see another patient. it was a case of severe abdominal sepsis. once again this is a condition that in certain cases can be the event that ends the patient's life, but i was confident i'd be able to pull her through. early on in the management there was talk of a private game lodge and once again i sort of brushed it aside. i pushed through the operation and the post operative period.

but as time went on, it quickly became apparent that survival was assured and i even started hoping for complete recovery. finally she went home in good health. then and only then did i questioned my usual approach of not accepting these sorts of gifts from patients. i mean in the end it was offered in good faith and with pure intentions. and it did seem unlikely that she would complicate at this late stage. i started considering it. after all i have often said my job is to return people to their humanity. now that she was back to a point where she could go on with her life and be herself again, wasn't i now stopping her from doing something that is quite human, ie the heartfelt giving of a gift. also it had something to do with my own humanity. so often when i'm treating patients i need to separate myself to a certain degree to keep perspective and to allow myself to do my job without being too clouded by human emotions. and yet essentially i am human and i do have human emotions and i do want to get to know people as they are and not just as the patients that lie before me.

so in the end, more in attempt to try to restore my own humanity, i accepted. it was a magical place with wonderful people and a real balm for my soul. m and b, thank you very much for allowing me to find my humanity again.

neurosurgery

during intermediates we were required to rotate through all the surgical disciplines. one of our rotations was therefore neurosurgery. those guys really work hard. i think it's fair to say they almost work as hard as us general surgeons. without a doubt, besides us, there was no other surgical discipline that came even close as far as hours and hard work were concerned. and yet they were very different to us.

certain conditions are considered surgical but it does not necessarily mean all surgical conditions are for operation. we will happily accept for example a bleeding peptic ulcer and treat it medically, only operating if it becomes absolutely necessary. the neurosurgeons, however, tended not to do this. if they weren't actually going to operate the patient they simply didn't accept him. so a peripheral hospital would send a scan through for their opinion. if they saw that either no operation was necessary or that the patient was in such a bad way that even an operation wouldn't save him, then they simply didn't accept the patient. cases from casualties with fractures and also some degree of suppression of consciousness who were not destined to fall under their knives they would also not accept. the poor orthopod would get stuck with a semi conscious patient that he wouldn't really know what to do with long after the bones had set.

so when we were getting tutorials from the neurosurgeons i thought it funny when they gave a long talk about the management of a patient with mild neurological suppression. i was even surprised that the consultant giving the tutorial seemed to know how to handle such a patient. being in the department i had seen no evidence whatsoever that they actually ever did handle such patients. fortunately i kept my thoughts to myself (i achieved this by biting my bottom lip every time i was tempted to say something. other than the slight taste of blood i suffered no ill effects like failing my neurosurgery rotation which is a lot worse than the taste of blood).

when the intermediate exams were around the corner i once again enjoyed the humour in the rumours that the management of mild head injuries was supposed to be a spot from the neurosurgeons. i couldn't help wondering who would mark that question. maybe they could ask the orthopaedic department to help them.

finally the exam day arrived. when i saw the question actually turn up in the exam as so many of us had guessed it would i found myself chuckling at the thought of some burly orthopod trying to read my handwriting. i also wondered if the neurosurgeon was honestly asking because he didn't know.

in the end, after considering simply writing:-
'break the patient's leg and turf him to the orthopods,' i buckled down and answered the question.

the silent treatment

misunderstandings are bound to happen. sometimes i just wish i could understand the misunderstandings

i generally got on well with the anaesthetists and this one was no exception, despite a slightly rocky beginning. in fact after that i actually looked forward to working with her. the atmosphere in theater would be light and jovial and we would exchange jokes and laughs. then a time passed when we just ended up not working together. the lists just happened to be dealt in that way. so when i saw her in the theater complex after this time i thought i should say hello. it seemed to polite thing to do.

she was chatting with one of her colleagues. i walked up and waited for a lull in their conversation. her colleague, also someone i knew well, turned to me and greeted me with a broad smile. we shook hands. then i turned to her to greet her. she turned around and walked away. i was quite surprised, but assumed she had something on her mind and let it slide.

the next time i saw her, once again i approached to greet her, but as soon as she saw me she made a speedy exit. i realised there was some or other problem that she had with me, but i didn't know what it could be. after that there were a few more similar incidents that left me in no doubt she didn't want to speak to me at all.

then we were allocated to each other for a list. she could not run from me. yet somehow she managed to avoid all human interaction with me for the duration of the list. she did her work and pretty much ignored me totally. by this time the situation was no more than an irritation to me. my feeling was that if she had something against me she should discuss it with me and if she didn't want to then i pretty much couldn't be bothered with her childish behaviour. i ended up ignoring her in equal measure.

then one of those cases that age both the surgeon and the anaesthetist came in. i was the surgeon on call and she was the anaesthetist on call. once again we were thrown together. but during these cases there has to be at least a little bit of contact between the cutter and the gasser, yet she still absolutely avoided speaking to me. while we were busy we were both so involved in our relevant roles in trying to keep the patient alive that the silence between us was at least not awkward. as it became clear that we were at least going to get the patient off the table and into icu i asked her a few questions pertaining to the stability of the patient, but i made sure i kept it business-like. she answered only as much as she was required to. it didn't bother me. the life of the patient was more important than whatever the misunderstanding she had with me.

when a patient is taken to icu while still ventilated, both the surgeon and the anaesthetist would accompany the patient together and this was no exception. and so it transpired that we ended up in the lift together with the patient. i looked at the anaesthetist. i could see her nerves were frayed. the case had been a nightmare and she had done well to keep the guy alive while i did my best to patch him up. i reflected that her efforts to ignore me must have made the whole experience even worse. i felt for her.

"well done. i really couldn't have done this without you excellent handling of the anaesthetic. thank you" i really meant it. despite whatever her problem with me was, she deserved a compliment for a job well done and i was not about to withhold it from her. that, to me, would be worse than what she was doing by ignoring me the way she was. i could see her shoulders drop as the pent up tension seeped out. she even smiled a bit, but still said nothing. it was ok. i didn't need her to.

some time after that we did a list together again and she started speaking to me. i involved myself in whatever conversation she initiated, but i remained cautious. after all i still had no idea what the episode of silence had been about and our relationship was pretty much destroyed, so i kept things fairly superficial. but i must admit i was glad that she had finally started getting over her offence. things went on pretty much like this for a while. we were civil with each other but we were not close by any stretch of the imagination.

then about a week later we ended up in theater together again. i was chatting merrily away with my assistant as is my habit during surgery and occasionally the anaesthetist would join in the conversation. things were almost back to normal. then i made one of my standard fairly weak bongi jokes. i can't seem to help myself. she turned to me.

"careful what you say, bongi, i have only just started speaking to you again after nearly a year. you don't want to mess it up." this was the first time she had acknowledged any such thing which could be seen as a breakthrough i suppose, but i was immediately annoyed. i felt that she shouldn't think her opinion of me would in any way affect who i was and how i interacted with people, especially when she thought she was punishing me with her silence. i was not impressed.

"yes i noticed something like that." i replied. "i still have no idea what all that was about."

"you know exactly what it was about." she said, almost accusingly.

"sorry to burst your pretty little bubble, but i have no idea what it was that you took offence at and quite frankly i don't really want to know."

fortunately after that she finished her specialisation and went on her way. i knew we would never work together again and, all things considered, it was probably for the best.

the urologist

i sometimes reckon i'm quite the urologist. but i'm not. even when i was rotating through urology i would often visit the general surgery tea room. i missed my real work i suppose. but the guys seemed to know i liked hanging out with the urologists and sometimes raged me a bit. i remember the one senior registrar trying to give me a hard time the one day when i visited the general surgeons.

"hi bongi. how's urology going? have you played with any good penises today?" i couldn't let that slide.

"no, but then again i haven't been home yet." he was floored.

but i realised more recently that i'm not really a urologist. it was a gunshot in the state hospital. it was the usual type of thing requiring time systematically repairing the multiple holes in the small bowel. but this case had a little bit more than just small bowel injuries. the bladder was hit too. the medical officer felt that that was beyond his scope and asked me to handle it.

gunshot injuries to the bladder aren't all that difficult, but one thing to remember is that there are always two holes in the bladder and it's the hole at the back that can be slightly more challenging. i opened the bladder by simply extending the anterior hole left by the bullet. the exit wound was clearly visible, but there was a problem. the bullet had exited the bladder exactly where the left ureter (the pipe carrying urine from the kidney to the bladder) enters the bladder. it had pretty much shot the ureter off the bladder leaving it to leak urine from its frayed end into the area behind the bladder. i honestly had a moment when i wished i could call a urologist, but that option wasn't open to me. there was no urologist doing calls in the state hospital, so i would have to sort out the problem myself.

one thing that is important when working with the ureter is to place a pipe in it to sort of stent it while it heals. the urologist have a nice pipe called a double j stent that they routinely use, but we had no such thing there that night. the other problem with a double j stent is that you need to do a cystoscopy to remove it at a later stage. although the visiting urologist could probably do that i didn't like the idea of placing something in the patient that i myself couldn't remove. i came up with a plan.

i dissected out the ureter above where it had been shot off, cleaned it up nicely and reimplanted it into the bladder over a thin tube we call a feeding tube (named after the fact that it is used to deliver food directly into a baby's stomach). this tube i then pulled out straight through the abdominal wall. when i wanted to remove it all i'd need to do would be to pull it out. the hole in the bladder would heal and all would be well. i was super impressed with my ability to think on my feet. the medical officer was also duly impressed. we closed up and i went home.

i was super keen to 'accidentally' run into my urologist friend the next day at the private hospital to tell him about my brilliant improvisation so i spent extra time on rounds wandering the corridors with the hope of seeing him. finally just by orchestrated chance i did run into him. i proudly told him about what i had done in the absence of a double j tube and how it meant i would be able to remove the tube easily in the ward later without the need of another anaesthetic. i was so impressed with myself.

"bongi, that is a well known technique which we sometimes use." my bubble was good and truly burst.

yep, i'm not a urologist. not only do i not know all their fancy techniques, but in the end i feel i must admit i have the fragile ego of a general surgeon.

the game

don't get me wrong, i'm mad about rugby. i think it's the greatest game to watch and when i physically could, i really enjoyed playing it too (when i dislocated my ac joint i took it to mean my body was saying no more). i also think john smit is the best captain this country has ever seen and despite maybe getting a bit old for the physicality of it all is still playing an absolutely superb game. but yet there is a certain perspective one needs to have about exactly what the greatest game in the world is. i thought about this when i watched john's reaction to the defeat during his 100th game as a springbok, but it is something i realised some time ago when another game was in question.

a new group of students had rotated to my firm. with the first call it became clear they were hard workers and keen to learn. that is pretty much all i required of my students so i was happy. in fact we were getting on famously. then one of them approached me.

"excuse me bongi, but i was wondering if there is any chance that i could get this saturday's call off?" as i have said before, in surgery this was pretty much not an option. and yet she had proven her willingness to work so i found myself entertaining the thought. she had better have a bloody good excuse though.

"why?"

"my husband is going to be home for three days and i want to spend some time with him," she said. "he has a really crummy job." she added for good measure.

i considered the options. i decided i'd let her go and try to cover for her with the prof. at least it wasn't the boss' firm so i didn't actually expect problems. but i was curious. what sort of job did her husband do if he was home so seldom? i had to ask.

"he is a cricket player." now there are times in life where if you just stop and take a moment to think you greatly decrease the chances of making a complete fool of yourself. i suspect this may have been one of those moments. pity i didn't take a moment. if i had taken a moment i would have realised that she shares a surname with one of our national cricket players. if i had taken a moment i may have been able to hide the fact that at that stage in my life i didn't really follow cricket too much and therefore wasn't sure if this player was even still in the team or not. if i had taken a moment i wouldn't have asked the next question.

"oh. what team does your husband play for?" she looked at me as if i was mad. i suppose being married to what some thought of as a national hero meant that everyone should know exactly who he was. i only had the vaguest of ideas. i considered saying if he was a rugby player i would know exactly who he was but i thought better of it.

after realising who her husband was i felt obliged to find out a bit more about the guy and to try and watch a few games at least. thereafter i could at least engage in a semi-intelligent conversation with her about her husband's profession. and this is what i did. quite soon we were chatting about cricket and cricket players. i was learning all sorts of interesting facts about the individual players in our squad. it was all very interesting.

one day we started speaking about the attitudes of some specific players that were considered stars (to the extent that even i knew them). i was interested to hear how one track minded they were about cricket and more specifically about their own opinions of themselves. they truly elevated themselves to almost godlike status in their own eyes. this fascinated me. i said the only thing i really felt i could say.

"well, in the end, it's only cricket and cricket is only a game."

"no. you are wrong. it is much more important than that." i considered this. i considered it in the light of what we had seen and done in the last while. i thought about the young lady that had developed overwhelming sepsis and died in icu despite all our efforts. i thought of the guy whose leg we had removed due to complications of diabetes and how he thought he was going to be fine with a prostheses, yet i knew that due to his age and general poor health, he would never learn to use a prosthetic limb to the point of independence. i thought about the teacher who got shot through the abdomen because he was at the wrong place at the wrong time and had also passed away after a high stress operation. i thought of the lady that had just been told she had breast cancer and the fact that she was wondering if she would live to see the birth of her grandchildren. i thought of the family that i had to tell that their child didn't survive the car crash they were all in. i thought of many things. after a while i replied.

"no. sorry to disappoint but it is really only a game."

the sentinel

anyone who follows this blog will know i have a tenuous relationship with the ivc (here and here). it is something i've seen only too often and each time it has me on edge. somehow i just can't get used to being up close and personal with an ivc that seems to want to bleed. but even i can laugh at some of our interactions.

i was the senior registrar so when the bone doctors decided to do a spinal fusion at the 4th and 5th lumbar vertebra and they wanted someone to expose the spine for them from the front, i was their go to guy. only problem is i didn't know how to do it. having been in surgery for long enough, it came naturally to me to show no weakness. i couldn't tell them this. i reasoned to myself i'd discuss it with the prof and if he felt i needed assistance then he could offer to help. looking back it wasn't the best thought out plan, all things considered.

the operation was booked for two days time, so the next morning i went to the prof's office and told him that i had been asked to help with exposure for a spinal fusion at level l4-5. he seemed almost not to hear me.

"good." he said as he continued with his work.

"only thing is, prof, i've never done it before." i considered telling him i'd never even seen it before but that was implied in the first statement, i thought. "should i go transperitoneally?"

"do what you are more comfortable with." great help, i thought. well transperitoneally (through the abdominal cavity) it would be then. the abdomen was after all my stomping ground.

the orthopaedic consultant who was going to do the operation was a bit of a legend. he was this super genius whiz kid that everyone doing intermediates was afraid of. he pretty much knew everything about everything and would always be able to dig out a question that you couldn't answer if he wanted to. luckily intermediates were way behind me so i didn't need to worry about offending him too much, but still it was a bit intimidating being asked to get exposure for an academic giant such as this man.

i entered theater at the predetermined time. there were about 3 orthopaedic registrars getting the patient ready. immediately when they saw me they asked how i wanted the patient to lie.

"put him on his back, " i said, oozing confidence, "i'm going through the abdomen." they nodded. and did so. once everything was ready we all started scrubbing and the sister started draping the patient. i tried to envisage what i would be doing in a while. i decided that i'd reflect the right colon up and pull the ivc out of the way, rather than reflecting the left colon up, which would mean i'd have more to do with the aorta. my reason had little to do with the blood vessels but rather had to do with the fact that the right colon can be reflected right out of the way whereas the left colon can't because it continues down to the rectum which is pretty much fixed. truth be told, the aorta is easier to work with than the ivc, but i just felt i'd get more exposure on the right. in my mind i was just trying to convince myself that it was going to be fine when the great orthopaedic consultant entered. he greeted us all and thanked me for my help before quickly going into the theater to make sure everything was in place. moments later he was back.

"the patient is on his back. are you going transperitoneally?" he asked. there was something in his question that bothered me, but this was not the time to seem unsure.

"yes, transperitoneally it is."

"for l4-5 fusion?" he asked it in such a way that the implied answer was that transperitoneally was not a good idea for l4-5 fusion. i thought back to the useful advice of my prof that i should use whatever approach i was more comfortable with. it occurred to me that this was an operation the prof possibly had never done before. besides if this legendary orthopod sounded like he knew something that neither i nor my prof knew, it was probably because he did know something that we didn't know. i felt my heart rate rise. but it was too late. i had no backup (the prof hadn't offered to help) and i would have to stand with my decisions.

"yes. we will be going transperitoneally."

"are you sure." i wasn't.

"of course i'm sure."

"well if you say so, but you are a braver man than me." he replied with a laugh. i felt my heart sink into my shoes. i just smiled.

i went through the abdomen. i flipped up the colon and exposed the ivc. i then mobilised it enough to pull it gently away from the spine....and discovered why transperitoneal approach is not good for l4-5. the ivc splits into two veins which drain the legs at roughly this level. the left one (left common iliac vein) crosses over the spine and when you try to ease the ivc away from the spine it gets pulled so tight it looks like it wants to tear off. but still i mobilised everything enough that their target area was nicely at least visible.

"there you are." i said with an air of i-told-you-so. "enjoy the rest of the operation. i'm outta here.

"what do you mean you're going?" said the giant. "you stay right where you are. it's your job to keep the ivc out of my way. you just stay there and stand guard over your ivc." this was starting to sound familiar and i was no longer happy to be part of it. but anyway, it wasn't as if i had a choice. besides, how bad could it get?

it could get pretty bad. i stood there with a retractor carefully in position putting just enough traction on my precious ivc without tearing the left iliac vein while the orthopod took the biggest badest instruments i have ever seen and ripped one entire vertebral body out bit by bit. now a vertebral body is somewhat tougher than an ivc and he used amazing amounts of power. i swear there were times he picked the patient off the theater table by his vertebra until a chunk was ripped off and the patient came crashing down again, all the while with me trying with all my might to not pull on the ivc with all my might and yet still keep it out of the way of that ferocious instrument the orthopod was wielding. in my mind he looked like a medieval barbarian with some sort of overly vicious weapon swinging around with just too much force. there were times when i thought he was going to pull the patient right off the table with me and the ivc being dragged down with him. i didn't only fear for that poor ivc but there were times i actually feared for myself.

after a while he got that condemned vertebral body out and replaced it with some sort of metal device. once that was in the ivc was allowed to return to its normal position. thereafter my frayed nerves also started recovering. once again had i stared into the dark eyes of the ivc and lived to talk about it.

p.s the patient survived too.