Friday, December 21, 2007


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."
"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.


Sid Schwab said...

i doubt its in any way unique to south africa, meaning that people who work in "resus" (does that make them monkeys?) necessarily have to develop thick skin. i wrote what surely would have been an inflammatory post about why er doc/bloggers seem so angry. since i'd already run out i didnt want that to be my last contribution to cybersurgery, so i didnt post it.

parts of some of our cities are nearly as dangerous as you describe. still it seems you put up with much more than most of us, within and without your chosen field. now, may i go back to capitalizing?

Bongi said...

Sid, thanks for the comment. I was hoping there would be input from the first world, because I think these attitudes have more to do with being in the profession than being South African.
Keep that post somewhere safe for later.
Now can i please stop Capitalizing?

Greg P said...

Every once in a while I will see a prisoner in consultation, wearing a bright orange jumpsuit, manacles and ankle chains. There is some small element of curiosity about what he or she did, but only small, so I don't bother to ask.

Just go about my job with the officer accompanying, undoing manacles or whatever as needed for the exam. Invariably, the prisoners are pleasant, cooperative, somewhat model patients.

Bongi said...

greg, i'm somewhat different. i always asked. i never believed them, but i always asked. if you believe them you would be surprised how dangerous selling bibles is.

Anonymous said...

Call me crazy, but I would feel sorry for him and I most certainly would treat him with dignity. Lot's of South African's would frown on this, but I don't want to judge neither them (because they might have been victims of crime) or the perpetrator (and yes, I too have been a victim of crime in our country - twice - so I think I'm allowed an opinion). Nothing could justify the hi-jackers actions, but surely you realise when you become a nurse / doctor that situations like this would arise and surely it’s not ethical to treat him any different to any other patient. If you are going to treat this patient (who has not had his day in court I might add) like dirt, I don't see much difference between you and him (and of course I'm not referring to gentleman-superhero-doctor Bongi). That might be a little harsh but you know what I mean. Furthermore, I'm ashamed to say that I don't trust our Police. Combined with racial hatred, (and this is VERY possible and a reality in SA) for all we know, the off-duty Policeman was not entirely truthful. Then again he might have been. The point is whilst the patient is being treated, YOU DON’T KNOW the truth. All I'm saying is life is not black and white.

Greg P said...

The flip side of what roer is saying, though, is that, regardless of how pleasant, cooperative, and considerate these people might be, they have a bent sense of right and wrong, good and bad, and some kind of mental mismatch between what they do to others and what others do to them.

So after you treat them, get them back to good health, they go back out on the street where they're not necessarily any less likely to yank you out of your car and shoot you. They might even "feel badly about it" afterward, but they don't see much reason to learn from past behavior -- things happen.

Bongi said...

roer, lees my pos, i made a difference. ek kan nie onthou waar dit is nie, maar ek is seker jy sal dit kan kry.

i did feel sorry for him and i did say something in that line to the sister. i agree. you can't play judge, jury and executioner. and i don't. but i have many stories about coming face to face with these people and it is different when you see them up close and lay your hands on them to try to help them and put them back on the streets to continue their chosen profession rather than read about them in a newspaper or reflect about the moment when you were a victim (i too have been a number of times as is typical of being south african). it is just different. i will personally never treat them differently but i do understand the desire to and as long as the guy is not being medically discriminated against i let it go.

greg, yes you're right. we put them back on the streets to continue the killing. that is the fact of it. it is an interesting thing to consider while you do your best for him. maybe i should post a few more stories of my encounters with these types.

i think my personal answer is to stick with what i know. i fix them. i make sure i treat them with the respect i would like, not the respect they would give me.

Barbara Kivowitz said...

I just discovered your blog (through Grand Rounds) and I am glad I did.

Many years ago, as a Spanish-speaking social worker, I treated Central American refugees - some who were fleeing the death squads and some who were on the death squads. I came to believe that in my thoughts I can hold any dark, malevolent wishes. But in my behavior, I am there as helper, not judge. I think you said it well in your comment - I treat them with the respect I would like, not with the respect they would give me.

Unknown said...

Jeepers bongi,

You got me with this one. Your post has bothered me greatly in lots of directions. Not sure where to go with this...

I have been a victim too. So I do know about generalizing fear to anyone who resembles the one who harmed you.

Have also been close to some who have done terrible things they are now incarcerated for but also, like a lot of us, did good things that went unnoticed.

But all the ER staff know here, in your post, is a fragment of one side of the story.

No right to be making up all sorts of generalizations about the patient. No matter what they were "caught in the act" of...

There are probably nice, respectable sorts who fell off a ladder or whatever and ended up in your resus and have far blacker hearts and deeds and would be more deserving of the scorn of the healers.

So you say "South African" and carjacking and I am assuming the disparaged patient is a black guy, the one who is shot in the chest? Hmm. We all make assumptions and prejudices. But should you be forcefully articulating them in front of someone who is completely helpless? Nope. I think the doctor and nurse you describe were wrong to do so... obviously you do too. But yep, lots of muddiness here.

Great post, it hurts and I am going to be thinking about it for a while...

Bongi said...

yes laundress, it is controversial. you are right in saying i don't agree with their behaviour. but i'm telling a story that is true that is supposed to make the reader think. the main gist of it has to do with the desensitized nature of doctors. i could also have spoken about how there is a very high turnover of casualty doctors because of burnout. seeing the dregs of humanity one can only take for so long.

i disagree with your reasons for not judging the man. he was a hijacker. in south africa that is almost synonymous with being a killer. in all probability this man was a killer. but that is not the point. i treat killers. it is a big part of my job. i do my job to the best of my ability even though and despite the fact that the patient before me is a killer. as i said in a previous comment, i treat them with the respect i would like, not the respect they give. you see to say we should treat him well because he may be innocent implies that the guilty we can treat badly. that, i think, is equally wrong.

your assumptions about prejudice based on him possibly being black i think is american where blacks are a minority group. here the blacks outnumber the whites about 10 to 1. to think that someone is a bad person because he is black would mean that i think of almost all my patients as bad. that night i probably saw only one or two whites but many many blacks. i could not possibly have been prejudiced against them all. also in this country the majority of cops are black, so you are making an assumption that the cop was white.

anyway, this illustrates how circumstances can change some people. i've said before and i'll probably say again, i think a sort of post traumatic counseling should be mandatory for people working up against the coal face, so to speak.