nervous

the professors used to say there are two nerves that give you trouble with a superficial parotidectomy, the facial nerve and the surgeon's nerves. this is true.

for whatever reason you need to do a superficial parotidectomy (removing the superficial lob of the parotid gland, the main salivary gland) the disection is fine and finicky. the facial nerve, the nerve that supplies the muscles of the face, runs right through the gland, breaking up into its tiny branches right in the middle. the operation requires the surgeon to find the root of the nerve where it comes out of the skull and to painstakingly follow it through the gland, identifying each of its branches as he goes. nerve injury is a real consideration. at best this may cause paralysis of a certain area of the face, depending on what branch is injured. but at worst this can cause total paralysis of one side of the whole face. the patient would have a drooping mouth on the one side and an eye that just won't close. this is a disaster as any attempt to smile would result in a weird distorted facial expression. but even worse, the eye would dry out and finally be damaged too.

so when the state hospital asked me to remove a tennis ball sized mass in the parotid gland, i was apprehensive, but eager. it is a fairly rare operation so it is an opportunity to get the chance to do one. after suitable preparation the operation commenced. usually one would find the nerve behind the gland just below the ear where it comes out of the skull, but with the massive size of the tumour, there was just no space to get into this area. i decided to go for plan b. to find one of the branches of the nerve where it comes out of the gland on the other side and work back. this went quite well until...

most surgery text books discuss in detail how to do a superficial parotidectomy. thereafter most text books mention that sometimes the mass is in the deep lob of the gland. they mention how the branches of the nerve get stretched over the mass and maybe even give a hint or two as to how one should go about getting the mass out without damaging the nerve. but you usually get the feeling that the writer is actually saying with a chuckle; 'good luck with that! you're on your own there!'

and this is what i found. the branches of the nerve had been stretched so tightly over the massive tumour that they had formed groves in the mass. i was not amused. i imagined the patient with a distorted one side of the face after the operation. i also imagined the writers of the chapters about parotid surgery all having a good laugh at my expense. i could not remember in that moment why i had decided to study surgery. i regretted it.

and then, because there was no other choice, i slowly went ahead and removed the tumour between two branches of the facial nerve. by the end my nerves were frayed. but i put a good face on it (symmetrical) and told the state doctor to close the skin and let me know later how much function she had left in the nerve. i feared the worst.

the next day, because they hadn't let me know, i phoned the relevant doctor. he informed me the face was fine. the patient had a normal, symmetrical smile and could close her eye normally. then i remembered again why i had studied surgery.

dignity

he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.

in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.

the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.

then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.

he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.

i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.

i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.

maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.

but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.

too little too late

when i was working at witbank hospital i had financial problems based on not being paid. i touched on it in a very early post. as part of the solution i approached a private surgeon working in the private hospital. i asked if there was any possibility that i could do after hours work there to augment my salary. the guy was overjoyed and even delt me into the calls of the next month. he, however, said that i'd need to chat to the other two private surgeons to get their blessing.so i made appointments with them and both said that it sounded good.

i then approached the administration. they too were overjoyed. they even took me on an orientation through the hospital. i looked forward to at last getting some money.

about a week later the administration called me back for a meeting. they informed me that two of the surgeons had held a meeting with them (the last two that i met with). they had basically said that if the administration permitted me to do any work there whatsoever, they would withdraw from calls. this caused the first guy to also lose enthusiasm for the plan. he was hoping to do one in four calls instead of one in three. if the other two withdrew he would have to do one in two, which didn't appeal to him.

the administration assured me they wanted me to stay in witbank and would approach the delinquent surgeons to see if they could sway them. i said i'd approach the other guy and ask his advice. the administration then assured me they would get back to me. until such time, i was not to do any work in the private hospital.

i went to the first surgeon. he told me he really wanted me to be involved but was not willing to sacrifice his relationship with the other two guys to help me. i was on my own.

i left and waited for the call. it never came. in fact part of the reason that i went to nelspruit was the promise of being able to do after hours work in their private hospital.

but strangely enough, today i got a call from witbank private hospital administration. it seems there is too much work there now for the surgeons working there and they are desperately looking for another guy to help with the load. it also seems that the instigator of their initial resistance to me is becoming less willing to do after hours work. in short, they are in a difficult situation.

i thanked them for the call (i didn't mention that it was about a year and a half too late), but i politely declined. they asked me if i knew of anyone who would be willing to go there. i considered reminding them that, due to the many coal burning power stations in the area, the pollution was quite bad and no one in their right mind would take a job there if there was absolutely any other option. i also mentioned to them that there is an overall deficit of general surgeons in the country and they would struggle to find someone. i wanted to say that they should have invested in me when they had the chance and when i really needed a financial boost, but i also kept that inside of me. to be honest i did have a malicious thought aimed at the surgeons there (two of them at least) hoping that they suffer under their loads.

in the end i thought about the beautiful place i live in now and the fact that if i had established myself there i may never have moved here. so in the end i have no real bad feelings to them.

zombie

i once wrote about something that scored high on my weird sh!tometer. but the strangest thing i ever saw was much more macabre.

i was on call. my house doctor called me to casualties. she wouldn't tell me over the phone why. she just said i must come and see for myself.

whenever i went to casualties i went through a specific routine. i read the referral. then, if there are x-rays, i look at them and discuss them with the students. then i go to the patient.

the referral was strange. it was for a facial ulcer. but they mentioned that the patient was known to the vascular department, almost as if it was something that they remembered afterwards. i was a bit annoyed. why all the fuss about an ulcer? anyway, who comes to casualties in the middle of the night with an ulcer?

"here is the arteriogram they came in with." there's an arteriogram? i thought. ok. at least something to show the students. i gathered them around, telling the final years they'd have to read the x-rays. then i put them up. i was astounded.

it was an aorta and outflow. but all that i could see..all that was there in fact.. was the aorta and one renal artery. there were no visible vessels to the arms or legs. if you looked carefully you could see faint vertebral vessels snaking their way up to the brain. but there were no carotids (the normal dominant arteries in the neck going to the brain). if these x-rays are accurate, i thought, then the patient should have no palpable pulse. i was no longer annoyed.

i went down the casualties passage. from a distance i identified the patient. in a wheelchair was an ashen faced man with blue lips. he only had one arm and half a leg. obviously his vascular condition had already claimed the other limbs in the past. on his one cheek he did not have an ulcer but a large full thickness necrotic (dead tissue) area. i greeted him. he opened his eyes and moaned something in reply. his caregiver (his daughter if i remember correctly) told me that he was known to vascular and gave me a letter that they had written on his last discharge. as i expected they concluded that they could do nothing more for him and had essentially discharged him to die.

while we were chatting, i saw a junior nursing student approach the patient to take his vitals. i considered telling her that she would find no signs of life except consciousness but the imp in me took over and i watched on in silence. sure enough the more she looked for a pulse the wider her eyes got. but the man was still responding to her, so she could not conclude that he was dead.

i then examined him myself. he had absolutely no palpable pulse anywhere on his body, including all central pulses. i listened with a stethescope. his severe emphysema meant that there was a large piece of lung over the heart and no heart sounds could be heard. also due to the emphysema, no breath sounds were audible. there were truly no discernible signs of life. and a large area on his face had died and was rotting off. but he was awake and even lucid to a degree.

i was amazed. it was tragic to the extreme. and yet i couldn't help noticing the similarities between a so called zombie and this man. we could not document any clear indication that he was alive. and yet he was alive because. . .well he was alive if you spoke to him.

i considered what i could do for him. if i debrided the necrosis on his cheek, there would be a big hole through which his teeth would be clearly visible. that would only add to his zombie-like appearance. besides he would not survive any form of anesthetics. i had to face the fact that the vascular department had already faced. there was no helping him. in the end we adjusted his pain medication (quite a bit) and sent him on his way.

this tragic story both moved and amazed me.

killer bees

this is not a medical post, so beware all seeking medical entertainment.

i used to be a beekeeper and in fact plan on taking it up again soon. i live in africa, so i worked with the african bee, or as our american readers will call it, the killer bee!!

i was recently watching an american documentary about this 'deadly' bee and was amazed to see what efforts and money they pump into combating this bee's spread. and yet even in this documentary they mentioned that the african bee is a better honey producer than their own bee.
i didn't understand the maths.

bearing in mind the simple fact that the americans will not be able to stop the relentless march of the african bee and bearing in mind it is a more productive bee and bearing in mind us backward south africans only work with this 'dangerous' bee (so it can be done) why don't you just bow to the inevitable and make more honey? not only will it be cheaper, but you would actually make more money. just a thought.

interview

so i was interviewed on doctor anonymous' blogtalkradio show. the co-host was none other than the great sid schwab of surgeonsblog. i must say i really enjoyed it. if you missed it you can catch it here.

however, it seems i made a mistake about the size of the kruger. i have been corrected, though.

anyway, it was great. thanks to doctor anonymous for the opportunity.

blogtalkradio

i'm not sure if i'm excited or nervous, but i'm scheduled to be the guest on the doctor anonymous show on blogtalkradio this coming friday morning (ok, thursday for all of you in america).

i have recently discovered that sid schwab will also be guest hosting. maybe that's why i'm nervous. maybe i should study up a bit? maybe he asks a few questions that i don't know the answers to?

anyway, go over to this site and set a reminder for yourself if you want me to come under the scrutinizing eye of doctor anonymous and sid schwab.

rest and relaxation

i've taken some time off. during this time i went to the blyde river and the kruger park. both were great. so as a break from my usual blogging, here are a few photos. the above photo is of a baobab in mopani camp.


a panoramic view from mopani camp





i have never before seen an albino buffalo, but here is one. i suspect it will soon be lion food


















blyde river has a number of tufa waterfalls. this is a beautiful one falling into a turquoise pool.














an elephant skull.




















moments after this photo, the elephant did a mock charge. he pulled up about 5 meters from the car. a moment of mild stress.














a nice side view of a lone bull
















a lion print near punda maria














and another



















and a last photo. it is a bit far in the distance, but this is apparently the biggest tusker alive today (in the world). zoom in and check out his 2 meter tusks.