Monday, November 24, 2008

out of benoni

when charlize won her oscar, south africans weren't surprised that a fellow south african achieved such a great thing. what we couldn't believe was that benoni could produce anything even remotely worthwhile. having said that i actually know of the other good thing benoni produced (yes, there were only two).

when i left school, my headmaster taught me never to look down on someone who actually might still achieve something in his life. the way he did this is that he wrote me a letter. in that letter he said;
"you are a lout! your five years in this school have meant nothing and you will amount to nothing in life." just in case i didn't get the message (i think he thought i couldn't read) he wrote a letter to my father. in that letter he said;
"your son is a lout! his five years in this school have meant nothing and he will amount to nothing in life." i thought he was a sad old man who had risen as high as he ever would and he was just a headmaster. i felt sorry for him. but throughout my medical and surgical training i never looked down on someone below me on the pecking order. one day they just might surpass me.

my friend came from benoni. he was brought up there and went to school there. like any self respecting benoni boy he only just scraped through matric, probably close to the top of his class. he was lucky. at that stage the university of pretoria had a sort of remedial science course for the intellectually challenged. most of the candidates would drop out in first year. some might actually achieve a watered down degree or diploma. one or two might actually get into the mainstream bsc course and get a real degree. some say it had actually happened before. my friend managed to get into this class. i'm sure most of benoni was proud of him.

right at the beginning of the year the class mentor (not too sure what the english word for voog is) called each student to the front of the class and asked what they hoped to achieve with this opportunity. most had realistic expectations. not my friend. he stood up and said he wanted to use it to get into medicine and maybe one day do orthopaedics. the voog laughed at him in front of everyone. people in that class just didn't have the goods upstairs to go that far. in this case, however, removing the boy from benoni allowed him to come into his own and actually work for something. quite soon he was in the mainstream bsc course and then moved on to medicine where he was always close to the top of the class.

i worked with him when he was a house doctor and he was the hardest working house doctor i ever knew. he even took the occasional gunshot abdomen to theater and only called his registrar when he got stuck. i thought he was going to become a surgeon. but alas... i visited him recently in bloemfontein where he is presently half way through his orthopaedic training.

so i often think back thankfully to that letter my headmaster took time to write for me. he helped me never to look down on my juniors and never to despise small beginnings, even if they were in benoni.

Saturday, November 22, 2008


as a rule i don't swear at people (not at people) but like every rule, there are exceptions. sometimes the frustrations of old were too much to take.

i was working at 1mil (the military hospital in pretoria). because the calls were so light we were required to lessen the load of the guys at kalafong (hell). so on the day in question i found myself stalking the cold corridors of kalafong. to make it worse, my students made themselves very scarce despite numerous attempts to contact them.

late that night a gunshot wound abdomen came in. now abdominal gunshots roughly fall into two categories. the first group are hemodynamically stable. that is to say they are not trying to die at that exact moment. usually they will deliver numerous bowel perforations that can be sutured at your leisure while enjoying a casual chat with your team and theater staff. the second group are not stable. ie they are actually trying to die on you and they need fast aggressive action. in casualties they need good large bore fast intravenous access. they need fluid and they need blood. this was one of those. he was in big trouble and my students still excelled in their absence. fortunately in casualties there were previous students of mine who were rotating through internal medicine. they saw the need and stepped into the gap.

in the madness that is kalafong one of their rules to confound things is that you can't book an emergency patient telephonically. it must be done in person. i think the idea is if you leave your patient long enough to go and book the case he might die and then theater staff get to sleep rather than work. whatever the reason it can be very infuriating, especially if you don't have students. i therefore sent one of the internal students to theater to book the case. i told him to impress upon them that it was going to be fast and furious and that the patient was nearly in exitus. the other student i sent to the blood bank to organise six units of blood. i busied myself with placing a high flow central line and an intercostal drain (it was needed). soon we were ready for transport to theater.

just as we were about to push the patient to theater the student from the blood bank came back. he told me the guy at the blood bank had told him he would only issue two units of blood at a time. if we needed more thereafter we could order again. once again, just a usual kalafong ploy to try and hamstring any attempt at providing good patient care. i wondered how i would take time off from what promised to be a very tense operation to go and get more blood. i knew that the patient needed more than two units as he stood and i wasn't sure how long it would take me to get control of the bleeding once i opened. it was absolutely ridiculous.

we started pushing the patient. blood bank was on the way to theater. i peeled away from the patient as we passed it. i would have preferred to be next to my patient but blood was needed. i thought i would just take a moment to sort it out. true there was a chance the patient would crash in those few moments but what would i do without blood anyway.

i stormed in. the guy stood behind the desk with jail-like bars between us (i always assumed they were there exactly for moments like these).
"excuse me." i said as calmly as possible.
"wait. i am busy." he replied. lucky he had the bars.
"i can't wait. i have a patient in theater bleeding to death and i hear you won't give more than two units of blood."
"don't speak to me in that tone." he had taken the discussion off the point and was pretending i was being personal. i realised i could not reason with this man. he had chosen the personal route. that i could do.
"you stupid f#@king bastard!" i replied with more than just a hint of aggression.
"are you calling me a bastard?" he shouted in rage. i thought it interesting that that was the only word he linked onto. maybe he didn't hear me. i could help with that.
"yes i did. of the stupid f#@king variety." i turned to the student who was biting back a laugh.
"sorry but i don't have time for this child. i need the blood. i know it is not your job, but could you get it sorted for me? i'm going to theater for fun and games." he said it was no problem. there seemed to be a permanent broad smile tacked onto his face. i left. truth be told i prayed the blood bank guy would formally lay a complaint against me. i would have fun defending myself. there would then be no bars to protect him.

the operation went as well as could be expected. the blood did arrive, although after quite a wait. the patient got to icu where he demised the next day.

this sort of thing was fairly regular at kalafong. i knew to stay there would either make me bitter and aggressive or worse, complacent like everybody else. i needed to leave. once i qualified and was offered a consultant post there i laughed.

Wednesday, November 19, 2008

the african dream

i had been working too hard and long hours. i found that i was a bit irritable on the whole. usually i enjoyed talking to people and hearing about their hopes and joys, but i found myself rushing through consultations. then an old couple came in. he needed a hernia repair but had no medical aid. they had heard i did some work in the state and wondered if i could help. i explained that i could not book my own patients there but would do operations at the request of the normal state staff. i was willing, however, to put in a good word for them. shortly thereafter i found myself waiting to get the relevant state doctor on the line. so we got chatting.

they lived in a small flat and it apparently drove him mad. you see he was born on a farm and had farmed his whole life. he went on to tell me that all his old neighbours, like him and his wife, had left their farms. life became too dangerous. you see farm murders are a fact of life in our country.

they explained that life on the farm became too stressful. they always had to carry guns with them, even when going to church. when approaching the farm house they would drive slowly looking for any movements in the bushes. i asked if anything ever happened. no, they said, not to them. then i got to hear about their one neighbour who was killed at night in his bed (he had erected an electric fence around his farm house to no avail). and the close family member who took a bullet through the chest but survived. then they went on to talk about the night they heard cattle rustlers and went out in their bakkie, the old woman on the back with a shotgun and the old man at the wheel with a hunting rifle. the lights had apparently driven the criminals away. there were other stories, all boiling down pretty much to the same thing.

the man looked at me and said. "you know, doc, we thought we would live our entire lives on the farm and die in peace. but it became too dangerous. now we live in a tiny flat and i hate it." i thought of how somehow our dreams don't work out. it was a poignant thought and i felt quite depressed.

like in zimbabwe the farmers here are being driven off the farms. the lucky ones survive and end up with shattered dreams in small flats (apartments) in the city. we read about it all the time, but when you speak to them in the privacy of your consulting room waiting for a state doctor so you can maybe help him get an operation he can't afford and hear the longing in his voice for the african farm he loves, it somehow makes more of an impact.

Monday, November 17, 2008


in surgery you work with what you are presented with. sometimes you simply don't have a choice but to try amazing or ridiculous things. i have mentioned my weird sh!tometer (here and here) but this is another one that scored highly.

he was mentally retarded, or so his siblings said. i actually thought he was just a bit slow of thought but had been rendered useless to society by years of being told that he was mentally retarded. he presented to us with a skin cancer (squamous) on the forehead. but it was no small thing.

it had apparently been growing for a few years. his caretakers elected not to take him to a hospital for medical treatment because they felt that evil doctors would use him as a guinea pig because he couldn't "think for himself". so they left it to grow. finally when the smell of this fungating rotting bleeding mass on his head disturbed their breakfast in the morning they brought him in to have it checked out. i considered telling them to eat breakfast in the lounge but i thought better of it.

the mass was about 10cm in diameter. it had infiltrated the left eye socket, causing the eye to look up, as if it was trying to get a glimpse of its tormentor. the ct scan revealed that not only was the eye socket and the eye a victim of invasion, but the mass had infiltrated his frontal lobe. i even wondered if the family had actually brought him in because of personality changes. then i realised that i would also struggle to enjoy breakfast with that mass across the table from me and, let's face it, the family weren't overly concerned by the actual well being of the patient.

the never-say-die prof of head and neck surgery immediately mustered the troops. the troops were the neurosurgeons and the plastic surgeons. to me the fact that the neurosurgeons were needed implied there would be no surgery. they tended to bail if there was any way out. i just assumed the radiotherapists would be asked to the party at the last minute. to my amazement all roll players (the neurosurgeons) agreed to give it a try and surgery was scheduled.

once all the subspecialities had played their roles and once all the knives had been laid to rest what was delivered to me in icu was, well to me at least, shocking. they had removed the mass, but along with it, the left eye and eye socket, the left parotid gland, a fair portion of the skull and more than just a sliver of the frontal lobe of the brain. the massive defect which was left was closed by the plastic surgeons using a free pectoral flap (they used his chest muscle with its overlying skin which they essentially transplanted onto the defect). the oddly misplaced muscle and skin lay on a liquid bed of cerebrospinal fluid and seemed to move in a way similar to a water bed when i touched it.

things went not so well and the family, now no doubt enjoying a daily hearty breakfast, threatened to sue for disfigurement. the irony was that the surgeons involved, whether judiciously or not, had attempted to fix what was presented to them. they did not cause the problem, but they simply tried to address it. they were like the pioneer surgeons of old who tackled massive fungating breast cancers with surgery as the only modality, because there was nothing else. these days no breast cancer and no squamous skin cancer should ever get that large and be that challenging, not only because of the obvious disturbance to an otherwise most enjoyable breakfast, but because they should present for surgical attention long before then. it is such a pity then when those very people who prevented this vent their misplaced wrath on the very people who did their best with the presented material and tried to help.

Saturday, November 08, 2008

i am not special

just when you get a lift life tends to slap you in the face again.

the state hospital was supposed to get a surgeon. all indications were that he was supposed to start on the first of the month. the medical officers booked elective cases for him to do with excitement and anticipation. the first of the month came and the first of the month went, but no surgeon turned up. the poor medical officers now had the nasty problem of having a whole bunch of people needing operations with no one to operate them. they phoned me.

i could not do all the operations. not even close. but i told them that i would try to make myself available on tuesday afternoons. they just needed to book the most critical cases and i would do them. they organised a typical state thyroid for the first tuesday. (not quite as bad as all that but still bad)

the monday before i was on call. a pretty hectic gunshot wound came in late that night. at the same time an appendix patient also arrived. i called the anaesthetist out and we got to work on the gunshot guy. a splenectomy, distal pancreatectomy, nefrectomy and liver repair later we delivered him to icu in a surprising good state. (there was not only a great deal of blood on the part of the patient but also a goodly amount of sweat and tears on the part of all of us). we finished at about three o'clock in the morning. everyone was tired and irritable. then i suggested we do the appendix. truth be told, i was laughed at.

i considered my position. it was reasonable to postpone to the morning when i would be at least slightly rested. there would be a smaller chance of cutting something i should rather not cut. but i knew i had a full day in the rooms with consultations and scopes. thereafter i was supposed to go to the state hospital. if i left the appendix for daytime, it would clash with that appointment in all likelihood. so i simply refused to take no for an answer. i pretty much insisted that we do it there and then. all concerned finally succumbed and the appendix was removed some time after three o clock in the morning.

after a deep two hours sleep my day began in all earnest. i spent the morning in consultation and doing gastroscopies and colonoscopies. i only just finished to rush off to the state hospital to be there at two pm as had been arranged.

when i entered theater, the anaesthetist casually told me they had a child who had a foreign body stuck in the esophagus that they were going to do before my case. i was annoyed, but i knew that in state hospitals you must learn to go with the flow. otherwise constant frustration will kill you or drive you to drink.

sure enough they put the little kid to sleep and for expediency i took the thing out myself. still the anaesthetic and the usual state delay had lost us a full hour.

finally the thyroid was doped and we got under way. true to form they had booked me a monster. it was the sort of thyroid that was so big you feel you need to take it out as fast as possible because it's bullying all the other thyroids in the ward. to be honest i struggled. it was all the way up to the skull, all the way down behind the sternum and around the back to behind the esophagus. it was stressful surgery. i was trying to get it out of that neck but i swear it was trying to pull me in to devour me.

during all this, the sister who was obviously annoyed at the slow pace of the operation started berating the medical officer for starting a case that wouldn't finish before four, the time in the state hospital when all elective cases are supposed to stop. i piped in that an emergency case had been pushed in before us and therefore they owed us another hour so we were therefore still within time constraints. she looked at me.
"these rules are for everyone. you are not special!" and just to make sure there was no misunderstanding, she repeated,
"you are not special!"

i joked about it at the time saying my mother had always told me i am, but i could feel irritation welling up. i needed to finish the task at hand so i took my mind off the comment and returned it to the thyroid which i think had just tried to bite me.

when i got home, fairly tired from work and lack of sleep and put together the entire sequence of events, including me depriving myself of sleep in order to be able to go and help at the state hospital, i became angry. it had nothing to do with if i thought i was special, but rather to do with what other options that patient had of being operated. the answer is simply none. if i didn't do it there was no one else who was going to step in and do it. then despite pretty much standing on my head in order to be available and still getting knocked back an hour on the list the sister tells me i'm not special because she has to stand 20 minutes longer than she was expecting to. i became mad with rage. i considered phoning the super and telling him to stuff his hospital and theater staff and that i was no longer willing to help.

then i thought of all the doctors there trying their best beyond their abilities to at least provide some service. slowly the rage dissipated. then the anger subsided. then i slept.

Friday, November 07, 2008

i am special

sometimes it is good to get a bit of recognition. if you don't the job can sometimes slowly erode away at your spirit. so recently i got a boost and i think my spirit may be good for a few more calls.

one of the state hospital doctors invited me out for a casual get together to celebrate his birthday. most of the guys i work with when i help out there would be attending so i thought it should be fun. the night started off slowly. i sat with the man of the hour and his girlfriend and two of their friends from the real world (not medical). i concentrated on their conversation, sedately sipping my beer. i was the outsider and i didn't want to draw attention to myself. then the doctors started dribbling in. the senior guys came over and greeted me. the house doctors would occasionally nod an acknowledgement and move off. in the hierarchical medical system they were used to they weren't sure how to relate to a real live consultant in a social setting, so they sheepishly avoided me. i started wondering if i'd made a mistake by coming along.

then someone came in that i didn't know. i asked my friend who he was. turns out he was a house doctor that simply hadn't rotated through surgery yet and therefore i hadn't worked with him. being a house doctor i expected him to avoid me like all the others had done. but just as i didn't know him, so he didn't know me either. he came over.

"hi, my name is g." he said warmly extending his hand.
"pleased to meet you." i replied. "i'm bongi."
"bongi? the legend? i've heard so much about you and now i finally get to meet the man himself!" i was taken aback. i wasn't sure what to say. i couldn't just leave it at that.
"what do you mean?"
"well i hear you always help despite the fact that you don't get paid and that you ruthlessly rip the house doctors to shreds when you're operating." (the hospital sometimes does pay so that is not entirely true. also i think i may tease the house doctors a bit, especially about their universities of origin if their anatomy is not up to scratch.)

as it turns out all those nights going out at all hours to help the skeleton staff who are desperately trying to keep things together on the sinking ship that is the state hospital has made an impression on some people. i felt good.