Saturday, August 29, 2009

sacred memories

when i got accepted into medicine as a last minute add-on due to one of their other applicants turning down the post, i knew how lucky and privileged i was. it was the first step in a very long journey and i wasn't going to mess it up.

the first year in those days was spent at the main campus and we would only be at the medical campus from second year onwards. second and third years would be spent on the pre-clinical campus and only from fourth year onwards would we be in close proximity to the big boys. all this i didn't know when, during first year orientation they bussed us to the medical campus so we could see the preclinical buildings and watch with a fair amount of jealousy when the higher year students walked past. the whole medical training thing was very hierarchical. it didn't bother me. i had been in a similar system before and had moved up the ladder. i could do it again.

the preclinical campus was a very relaxed place. there were essentially only two buildings (ok, ok there was also the dentistry building but we didn't go there) with a large grassy lawn between them. there were a few trees providing shade for groups of students lying on the grass and reading or chatting. our group of first years on orientation clearly didn't seem to fit in. none the less we found a tree to sit under during a short break in the orientation program.

and there i sat in a state close to euphoria with my hopes and my dreams all layed before me. i knew i stood at the beginning of a journey that would lead me to what i one day would be. what i was at that stage was of little significamce other than the fact that it was a pointer to what i would become.

i lay under the tree and, as best i could, told my friend who was with me about these thought. i then added that i would use the tree as a sort of temporal marker that i could come back to when i was finally what i would be. then i would stand under the tree annd remember that exact moment when i looked into the unknown future with innocent hopes and dreams.

recently i had the opportunity to go back to the preclinical campus. i remembered that moment so many years ago and was quite eager to stand under that same tree and reflect about the years that had passed and what i had become. on that day, so long ago, i would never have guessed that i would have gone on after medicine to specialise in surgery, so i actually achieved more than i dared dream. i was realy looking forward to a moment that would link one specific moment in the past with the present.

the campus was just as i remembered it. the lawn was still there and there were still students sitting in small groups. they just looked so much younger than i remember being. then i went towards the far side of the lawn to have my moment under the tree.

they had cut the tree down! it was gone. everything else was exactly the same except my tree. is there nothing sacred?

Monday, August 24, 2009

just because you're paranoid doesn't mean they're not out to get you

i had fun posting about a psych experience. but there were others less enjoyable.

it was during my psych rotation. i was trying to make the most of it and i occasionally almost got it right. one day our intern asked my colleague and i to accompany her on a call to the maximum security ward. we were up for most things and agreed. only after we had agreed did we ask why.
"because i'm too scared to go alone!" was her frank response. bright flashing lights and loud hortatory bells should have been going off in my head but i didn't want to look like a pruss in front of my friend so i became temporarily blind and deaf to them.

the psychiatric hospital was a big sprawling place with each ward discreetly placed far enough from the other wards to try to create a resort sort of effect. maybe in the addams family, i thought. anyway, one of the results was that maximum security was way up on the hill, out of sight of pretty much everything else. i had in fact never seen it before. so when i saw the eight foot concrete walls with barbed wire on the top i was impressed. they clearly were not messing about. we approached slowly, almost in awe of the monster.

when we got to the entrance i was even more impressed. there were two solid iron doors. a camera identified us as something slightly more benign than special forces or the terminator or rambo maybe and the doors swung open. we shuffled into a sort of holding cell. looking at us through what was no doubt bullet-proof glass were two guards. when they had satisfied themselves that we were in fact one doctor and two medical students and not some sort of covert attack team, the inner metal doors swung open and we entered the main compound. nothing in 5 years of medical training or for that matter twenty four years of life could ever have prepared me for what i saw after all those stringent security checks.... nothing.

there was a nondescript road ahead of us with houses on either side. but the road was totally deserted. i imagined a breeze ominously blowing through the grass but in actual fact the grass stood dead still. there was also no eerie music playing which just didn't seem to fit in with the general genre. but the thing that i found most disturbingly normal was the lack of a heavily armed escort. i mean after getting through fort knox-like security surely there should at least be a guy with a truncheon sort of standing around in a lazy way on the other side of the double locked steel doors?

i couldn't help it. i had heard my mind's logic and the final words hung silently in the air. locked steel doors!!! locked steel doors!!! i turned around and observed, now with almost wild panic that there weren't even handles on the doors. where they met the walls and each other was almost seamless perfection. i felt like i couldn't breathe. that breeze would be great right about now, i thought. i tried to take control of my mind, get a grip! i told myself. at least there are no crazies. they must have been locked up before we got here obviously. we are quite safe. the crazies suddenly appeared as if on cue.

at that moment, if sheer terror hadn't totally paralysed all my faculties, i'm sure i would have been able to draw similarities with any number of low-budget zombie movies, because that, in retrospect was how it was. people approached from all sides, walking slowly forward or maybe lurching slowly forward, arms extended and engulfed us with only one word uttered from their lips like a chant, over and over again.

"cigarettes! cigarettes!"

we fought our way through them and finally got to the medical building. we slammed the glass doors behind us as any number of zombies (for that is what my mind had decided they were and no amount of convincing is going to change my mind now thank you very much) threw themselves up against it. i could see the headlines: 'promising young medical student found dead in prominent psychiatric institute. only brain missing.'
then the sister appeared as if from nowhere. if it wasn't midday i would have sworn i saw a bat flutter in just before her human form became apparent. she charged the glass door and as if by magic the patients dissipated and were soon all gone.

she led us through to the examination room where our patient awaited us. it was a man in his thirties with a deep gash in either cheek. i was impressed by the symmetry.

"what happened to him?" i had to ask.

"he fell and cut one cheek. when he saw himself in the mirror, he broke the glass and used a shard to cut the other cheek so both sides would look the same." i wasn't surprised that he was clearly mad. what would one expect? but the fact that any one of those many zombies outside could have access to shards of broken mirror sunk down into my soul and festered like a septic wound. all i could think was we had to somehow get past them all again and this time they were waiting for us. 'remains of medical student found in prominent psychiatric institution. disfigured beyond all recognition'...somehow seemed more appropriate. i needed to get my mind off it.

"why is this patient in here?" i asked. at the time it was no more than an innocent question, i swear!!

"oh, he killed and dismembered his entire family." said the nurse as if she was reciting the day's minimum and maximum temperatures. he what exactly??? my mind screamed. i wanted to ask if that was generally the sort of thing that would get you into maximum security in this institution but i knew that her answer would have implications pertaining to the hordes waiting for us outside. i decided i just didn't want to know.

at about this stage my mind thankfully went blank. i think it was some sort of subconscious defence strategy. whatever it was i'm just grateful. i came to my senses when we were out again and getting back into the intern's car. i stared ahead in silence for some time. finally i spoke.

"mad!! they're all quite mad!!!" i said with conviction. "some of the patients are mad too." i added.

Sunday, August 23, 2009

tharrr she blows!!

occasionally i post something that scores high on my weird sh!tometer (here, here and here). it seems this is such an occasion.

i thought of this incident recently when i was privy to some doctors complaining about stupid referrals. this was the only one i could think of. in reality it was more a moronic patient than a moronic referral.

as usual it was late at night. the casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). i asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. he gave a nervous chuckle and agreed. when i started asking about possible disease processes which could give rise to this condition (which pretty much can't just happen spontaneously) he had no answers. in his voice i could almost hear him saying:

"come on. i'm tired. it is a stupid thing to come into casualties for at this hour but here she is. just come down and see her so it is no longer my problem." i answered before he was forced to actually say these words.

"ok, i'm on my way."

the patient was an old indian lady fully-clad in her robe-like traditional garb. i asked her what the problem was. she was quite a bit less than forthcoming. i asked her to show me the problem if she couldn't describe it. she lifted her robe. i was not prepared.

she presented a disfigured torso and abdomen. it seems when she was younger she had been severely burned by hot water. those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. between being young and the present she had become obese. actually that is only partly accurate. only the unburned areas had become obese. she had areas of supreme obesity interspersed by a network of amazingly slim. on one of the fat areas, towards her flank was an opening which was oozing pus. the smell was unearthly. i may have gagged a bit. but something was missing.

"where is your umbilicus?" i asked. she looked sheepishly away. she was determined to not be forthcoming. a more direct approach might work, i decided. i pointed to the suppurating hole almost on her flank and asked:

"is this your umbilicus?" she nodded. the burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. i was annoyed. she knew what the problem was from the beginning. she also knew that it wasn't something to come into casualties for in the middle of the night. she had been taking us all for a ride. but what could i do? she was there and i had to do something. something, i decided, would involve double gloving.

i inserted my finger into the oozing hole. as expected, now that i knew what it was, it tracked towards the midline where the umbilicus had been many years before. at its base i felt a tennis ball sized mass of old debris. this time i did gag. this mass i scooped out bit by bit until the umbilicus was something it hadn't been for years...clean. annoyance fell away to disgust. i almost couldn't speak because of my gag response, but i forced myself. fortunately all i really had to say was:
"have you heard of soap?"

Monday, August 17, 2009


i spoke about foreigners and relative attitudes between them and myself. but, truth be told, one of the reasons they think they are in deepest darkest africa when they are here is because they are!!!

we pick up the story roughly where i left it off. the initial accident claimed two lives. then the young son has to survive a brain bleed and a neck fracture. somehow the neourosurgeon sorts all that out. then in icu he gets acalculous cholecystitis and i meet him, almost in exitus. we fetch him from the pearly gates and tie him up in icu for a while. he survives. he can walk. his maths and science still works. miraculous!

but for a moment imagine the father, the only one not really injured in the accident. he is in a foreign country. he has just lost 50% of his family and there is a real chance his son might die or be paralysed or retarded for life. the daily icu vigil alone must have taken a toll on him. and then things slowly start improving.

after too long away from home they are ready to leave. the son is amazingly well. he is neither paralysed nor retarded. also he is alive which everyone sees as a positive thing. then they have the unpleasant task of getting the bodies of the other two members of the family. what do they find? certain body parts are missing, including one hand!!! stolen from the dead in the morgue. you just can't make this sort of thing up. i dare you to try.

i have spoken before about body parts stolen to be used by sangomas for so called traditional medicine, so i suppose i shouldn't be shocked, but i was. i couldn't help feeling for him. over and above all the terrible things that happened to this man and his family he has to endure the bodies of his departed family being desecrated.

this story so affected me i followed it in the local papers for a while and pretty much put it together. at least some of the people were actually arrested so quite a lot of the story became public. it seems there were people working in the morgue who regularly stole body parts to sell to sangomas. they would target the bodies which were to be cremated and cut out the desired organs just before cremation. no one would be the wiser. the foreigners were targeted, it seems, because the body lay in the morgue so long while the boy recovered in hospital.

so, in conclusion, this is deepest darkest africa and here you will truly be amongst us savages.

proudly south african

being south african at this moment in time comes with certain risks. recently my reaction to an incident brought this home.

i was on my way back to nelspruit from pretoria late at night. suddenly on a fairly deserted part of the road a small buck jumped out in front of my car. i didn't even have time to react before i hit it. hitting even a small buck at 140km/h does quite a bit of damage and this was no exception. the front of the car was smashed in. the radiator was ripped open and the bodywork was pushed up against the left front wheel.

i was far from anywhere so i soldiered on. fortunately i was just entering the lowveld so i turned the car off and free wheeled down the two passes. but quite soon i was forced to stop. in this time, while gently limping the car down the passes the necessary calls to insurance, and by implication, tow companies were made, so by the time i actually stopped, people had been mobilised.

when the car finally came to a stop it was in a totally deserted part of the road. there were no lights visible anywhere and an overcast sky hid any trace of the moon. i turned on my hazard lights and waited.

then i had a south african thought. what happens if someone comes past? would i be the victim of violent crime? this is a real consideration in the modern south africa and in no way reflects paranoia. on a regular basis we read about hapless victims of car breakdown who are attacked and often killed on the roadside. recently there was a criminal element that would patrol the very road i was on and pull cars over to rob the victims, quite often shooting at their cars or them. my concerns were real. suddenly the hazard lights were glaringly bright. they seemed to advertise the car's presence for miles around. i quickly turned them off. as the very occasional car drove past i used their headlights to scan the road in both directions looking for a would-be attacker. i didn't even bother trying to stop a car. south africans don't risk stopping for someone on the side of the road, ostensibly in trouble. it is too often a trap.

then i thought if i do see someone, if i jump out and run they will see me too and i'd be a lead magnet. to stay in the car wasn't safe. i turned the hazards back on and got out. i readied my knife, just in case, crossed the road and went into the veld just out of sight. there i was safe. if someone did come along i would just slip away. the hazard lights marked the car for the tow company and my friend who were on the way. when they arrived, i would join them.

the way i dealt with the situation, from flogging the nearly dead car to hiding in the veld and the thoughts that went trough my mind were typical for us south africans. in fact when i discussed it with my colleagues the next day at work there was no one that teased me or thought it strange. across the board everyone fully sympathised and agreed with my way of handling it.

once again i find myself in a reflective mood about staying in this crime-ridden society. what is a small disaster turns into a possible major catastrophe because of the serious risk of sudden violent death. does it really need to be like this? unfortunately that question would have to be directed at the government of the day who so far have shown no sign of addressing crime at all. on the contrary they have even disbanded the one effective crime fighting unit because of the danger they would also target corrupt officials. we just can't have that now can we?

Friday, August 14, 2009

mad as in crazy or just plain nuts

as anyone who knows even the slightest thing about surgeons could guess, psychiatry was not one of my favourite subjects in medical school. but even i could appreciate a bit of humour in my final practical exam in this cursed subject.

i had to get through it no matter how much i disliked the subject. i would have to 'examine' a psych patient and then present him to the examiners. ideally i'd have to come up with a diagnosis slightly better than 'he's mad!' examine basically meant i had to go through a fairly standardised interview. from that interview, using my amazing powers of deduction i would hopefully be able to label exactly what brand of crazy my patient was. the plan seemed water tight at the time.

they told us there would be translators provided if we needed them. (this is something that is actually often needed in our country, bearing in mind we have eleven official languages. i kid you not.) so when i was allocated my patient, the first thing i asked is what language he spoke. it was zulu. i quickly identified a zulu translator, but before i asked her to accompany me i enquired of the patient if he could hold his own in english or afrikaans (as you will see later in this post, this may not have been the best choice of words on my part). the patient, in a somewhat staccato voice assured me he was fluent in english. ok, i thought. and off we went.

the interview was disastrous. it seemed that the patient was simply under the delusion he was fluent in english. to my shame it took me about ten minutes to figure this out. i just thought he was somewhat stupid. turns out he had no idea what i was asking him and was trying to answer to the best of his english...which he didn't all.

finally i rushed through to get the translator. time was limited. this was after all an exam. i was getting tense.

his zulu was fluent and with the translator we were soon in full flight. the only problem was he was answering each of my questions appropriately. he didn't seem mad at all. i started hoping for a bit crazy, but with each ensuing answer he seemed just like your average joe soap (or whatever detergent of your choice).

great i thought. they have thrown me the wild card. they have actually put a totally sane patient into the exam to catch me out. what sort of sick twisted deranged mind does that sort of thing??
i resigned myself to my fate. all i could do was continue to systematically go through the questions.

the next question was about libido. the translator told me he said he had no libido. it was the closest i had to abnormal so i latched on.
"why doesn't he have a libido?" the zulu equivalent was asked and answered. the translator doubled over in laughter at his answer. there was no forthcoming (or any other form of coming it seems) answer in english. i wanted to jump up and scream at her. i had about 5 minutes left before a bunch of psychiatrists were going to determine if i was going to repeat the year or not and the translator was just laughing?? did she think when she took this job that there wouldn't be the occasional strange answer?? and now with what felt like seconds left to me i had to deal with her sudden delicate sense of embarrassment.

"what did he say?" my voice was not raised but i think there was a noticeable quiver.
"he says he doesn't have a penis." bingo, i thought. then my paranoia about the evil examiners got the better of me. i had to quickly check to make sure there was in fact a penis.
"what's this?" i asked in reference to the member that i could clearly see.
"it's not mine."
"whose is it?"
" it belongs to this tsotsi." he said, pointing to his chest. i was so relieved. he was mad. at that point i didn't even care what sort of crazy he was. the moderator was knocking at the door to tell me to present myself to the examiners. the fact that he was crazy was good enough for me. i could wing it.

p.s i passed but not with flying colours. the examiners also specifically asked me if i had physically checked to see if there was a penis or not.

Wednesday, August 12, 2009

stand back, i'm a doctor!!

surgeons are not stand back kind of people. they fall more comfortably into the category of charge in where angels fear to tread. i think the work tends to preferentially attract those type of people. but sometimes standing back can be the lesser of two very evil evils.

the call was a standard weekend consultation. the patient had hematemesis and his doctor was worried. nothing i hadn't seen many times before. but when he came in the patient's wife had a few more details to spice the story up a bit.

just about a year ago he had had a resection of his stomach for cancer. the surgeon had told his wife they couldn't get all the cancer out because it was growing into some big blood vessels behind the stomach. for some reason they both decided not to tell him this. so when he was referred for his chemotherapy (something that could not be described as awe-inspiringly effective in stomach cancer) he truly thought he was well on his way to full recovery. and now he lay before me, pale and restless.

he was a shadow of what he once must have been. his skin hung loosely as if in remembrance of the large man it once covered. i was not happy with the mass i clearly felt just under his left rib margin. the cancer was back and it seemed angry. i got the necessary drips running and ordered blood. i considered dropping to my knees but due to a back injury when i was still a student i wasn't sure i'd be able to get up onto my feet again.

the wife called me aside and told me the patient was not aware of the fact that the operation was not a roaring success and therefore that he was essentially living on borrowed time (which i grimly thought he is about to pay back with interest).
"you need to tell him." i said.
"no!! doctor!! i can't do that." she needed the truth.
"this man, your husband may die here in this hospital within a day or two. you need to speak to him." but she would hear none of it. she also didn't want me to tell him things were not so rose coloured (i suppose depending on what colour roses you're talking about of course).

the next day the patient was feeling much better. amazing what a bit of blood will do. we chatted a bit. you know, shared a moment. he even laughed at how bad he had felt the previous day in comparison to today. then it was back to business. in this case business meant i was going to take a long, not so thin pipe and stick it down his throat to take a quick look at the source of the bleeding in his stomach. i sort of lied to myself, telling myself that maybe i'd see something that could be fixed with a knife. in truth i knew what i would see. the palpable mass and the history dispelled almost all my doubt (or hope). but i knew i needed to look. i needed to know for sure how much or how little i would be able to do for him. maybe i needed evidence for one day after it all when i am called to account.

the cancer was a large fungating mass with a deep necrotic core. it was gently oozing blood but i could see it was capable of so much more. it seemed to me it had stopped its torrent of blood long enough to give me a glimpse as if to taunt me. as if to say you know me and you know you have no power here. it was right.

after the procedure the patient once again started spewing forth blood. i sat with him for quite some time. between his retching we spoke.
"this is not good doctor."
"i know." what more was there to say?
"what are we going to do?"
"we are going to hope the bleeding stops." what more was there to do?

then i went against the wishes of his wife. i told him this cancer was going to be the end of him. he looked at me with a calmness and a gentle smile.
"i know."

he probably had known for some time but i think he felt he had to go along with the charade and maintain the lie with his wife. he seemed relieved that the truth was out. he seemed to relax.

that night the sister called me to tell me he was bleeding massively. i explained the situation and asked her to push blood iv. if that didn't help nothing that i could do would. the next morning he was dead.

somehow when we sit behind our computers and in our nice expensive offices deciding about the futility of certain treatments and who should get what based on cost or whatever, the actual point is lost. the nice old man finally vanquished by the hideous monster called cancer or the old lady with heart disease or whatever who is forced to succumb to the dark inevitable is the point. it is the person, the individual. the one like me. and maybe like you.

i was just left with a sense of how difficult it is to stand back and let someone die when you know what that means. it, i assume, is much easier for the powers that be, snug in their artificial real worlds.

Saturday, August 08, 2009


recently something happened that i must admit i didn't know how to deal with. now it's funny but at the time i just felt awkward.

it was more of a convenience consultation. i suppose you could see it as a favour. one of the sisters knew a patient who would soon be going home to mozambique. she apparently needed slow release estrogen tablets implanted but was not too trusting of the local doctors in her home town. the sister asked me to do it. now generally this is not the task of a surgeon. without sounding too arrogant, we view such trivial procedures as beneath us. but i decided that i would do it as a favour to the sister.

i went to see the patient to find out exactly what it was she wanted me to insert. they were two tiny little pellets. i would have to make a small puncture in the skin, place them and place one stitch. ridiculously simple.

as i read the insert of the product, the patient made small talk.
"have you ever done this before?" she asked.
"no." i answered truthfully.
"don't worry, you'll be ok. i don't mind being a guinnae pig for you to learn." no words came to mind so that is exactly what i said. nothing.

when we got ready to start, again the patient felt the need to encourage me.
"you're going to be just fine. i'm sure you'll do the procedure perfectly." once again i gave an answer of silence. this time it may have been slightly more chilly.

i localized, made a tiny cut, inserted the pills and threw in a stitch.
"see! you did it well!" she told me helpfully. by now my reply was practised.

later i couldn't help wondering what she would do when she got her bill and realised a specialist charges more than her usual gp (even if he had done it many times before and didn't quite need so much encouragement.).

Tuesday, August 04, 2009

weighty issues

usually i try to avoid the sensitive issues. i mean this blog is mainly about entertaining stories. but the next story by its nature forces us to ask some heavy question.

casualties called.
"bongi, i think you need to come and see this. we have a hippo attack patient."
"sure thing. i'm on my way." strangely enough a few years previously i had treated another hippo attack patient so i wasn't totally blown out of the to speak.

i walked in. there were blood soaked bandages on both legs. but she looked too sick to only have leg wounds. besides any self respecting hippo isn't going to merely nibble on its victim's calves a bit. chihuahuas do that. hippos put a bit more oomph into their bite. but the one thing that really stood out in my mind was how overweight the patient was. i groaned. no matter what the injuries obese patients are prone to all the risks associated with surgery, and i'm not even taking about being the hapless chew toy of an animal that is not known for mouth hygiene. lie all day in your own sewerage water and see how clean your teeth are after a few years. i knew this wouldn't be easy.

"wow!" i said, "if the hippo is that badly injured i can only imagine how bad my patient must be." i suppose i couldn't help it. i just needed to find something light hearted in the whole situation. after enduring evil glares from the casualty officer and the sister i approached the patient.

she had massive lacerations in her legs, which i'd need to debride and clean out thoroughly. she also had a large gash on her back. these were all that she was complaining about. it was also all i was consulted about. but as is my habit i checked out the rest of her too. her abdomen was slightly tender, but not too bad. with deep palpation she grimaced. to be honest through all the fat i could feel nothing so i asked for a ct scan.

the scan showed bowel outside the abdomen in the more than spacious subcutaneous tissue. she also had a cracked rib and a mild lung contusion. this case was no longer simply a debridement case but a laparotomy case too.

the operation went well. i learned that it is not a good idea to get chomped by a hippo. one tooth had actually penetrated the abdomen without breaking the skin. but the hippo had managed to deglove almost all the abdominal fat from the abdominal sheath, creating a massive cavity between the fat and sheath. this is where most of her bowel lay, already becoming mottled from strangulation. the pancreas was bruised but ok. the rest of the abdomen was fine.

i sorted out what needed sorting out. i placed drains everywhere i could and closed. as expected, she needed icu admission where she sounded like darth vader for a day or two. then she slowly got better and finally went to the ward.

during this time i spoke to her daughter who was admitted in the orthopaedic ward with a fractured ankle (apparently a hippo had trodden on it). i asked what had happened.

there are guided walks available in the kruger from pretty much all of the camps. you go out with an armed ranger and learn a bit about the bush. you may get to see some wildlife too, but you might want to keep in mind wildlife tends to be, well, wild. these people wandered a bit too close to a pool which had a hippo in who was generally having a bad day. he took exception. he came charging out directly at them. the daughter was in front. she turned to her mother, behind her and screamed,
"run!" she then promptly tripped and fell. the hippo came rushing right past her, luckily only stepping on her ankle in its headlong charge and grabbed her mother, my patient, for a quick chew. then, just as quickly as it had started the hippo left.

my first thought was why bother telling someone who is so overweight to run when they clearly can't? a waddle just won't suffice in the face of an oncoming hippo. but more seriously i actually thought what were people like that doing on a walk in the bush? if you go for a walk in the kruger you should at the very least be able to climb a tree and that at high speed. surely they should have a weight limit for these walks?

and that is where the difficulty comes in. the idea that to put a weight limit on something like that is discrimination against the overweight. my mind wanders back to the overweight lady who refused to be told she could not go on a cave guided tour because the weight restriction was supposedly discrimination. they caved in (an occasional pun is good for the soul) and allowed her to go. she got stuck in one of the smaller tunnels. fact is she was too large.

from a medical point of view, obesity is a disease with associated co-morbidities and increased risk of death. there is definitely a much higher risk with any surgery. it is just so. it is. i am not discriminating by stating the facts.

so let me conclude that i am fully in favour of no discrimination against the overweight. but because it is a disease it must be seen as such and not just swept under the rug.

Sunday, August 02, 2009

friendly fire (eish)

the word 'eish' is so typically south african. roughly it means...well actually it can't be translated. i think it's a bit onomatopoeic. or it would be if the eish moments actually made a sound. that sound would be 'eish'. the only way i can think of to explain the meaning of the word eish is to use it in a suitable context. one such context is the story of friendly fire which you will realise after reading this post is not all that friendly.

certain conglomerations of incompetence can also only take place in the modern south africa. this story is such a case. it is unbelievable in every aspect except that it actually happened. it was all over the news and i personally spoke to one of the treating orthopods. as you will hear general surgeons weren't needed.

one fine day in the bloemfontein military base a group of soldiers were shuffled onto a troop transporting truck. as i understand it they were going to the shooting range to try out some of the heavier weapons. one such weapon was a fairly large gun designed to bring enemy aircraft not so gently to the ground. it shot 15mm rounds at extremely high velocity and could send off about two gazillion rounds in less than a second. the particular soldier tasked with lugging this along thought it wise to load it up before jumping on the back of the truck with the rest of the platoon. but with the act of jumping on the soldier's finger pulled the trigger for a fraction of a second. that fraction was long enough. the platoon was decimated.

the survivors were taken to hospital where my friend the orthopod was called. firstly there weren't too many survivors on the scene. there was quite a bit of mince meat but not too many survivors. the reason my friend the orthopod was called and not the general surgeon was because everyone who was hit above the knees and elbows was blown to pieces and didn't make it. only people hit below the knees and elbows made it to hospital. then the treatment was easy. simple amputations sufficed.

when i listened to my friend in total disbelief i could just imagine the clumsy soldier giving the typical south african response to all the carnage he had just accidentally caused;
"eish!!! sorrie ne?"

Saturday, August 01, 2009


recently i spoke a bit about interaction with foreigners. the impression i left would have been strained to say the least. but as with all things there must be balance.

they were tourists (aren't they all?) when in the kruger she developed severe abdominal pain. her son brought her to hospital.

when they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were american and that her son, the one who brought her in, was a physician. let me take a moment here just to mention a language difference between english and americaneese. in south african english, a physician is a specialist in internal medicine. in american, it seems, a physician is simply a doctor. at that time i did not know this. none of us did. so when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety md.

i mentally prepared myself for a confrontational family. usually with non medical first worlders they question you at every turn. a physician (south african definition) traditionally is sceptical of the knife happy surgeon. i couldn't help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. all i could hope for was a benign abdominal cramp which would soon pass.

the patient was in pain. she associated her discomfort with some or other something she had eaten the previous day in the kruger. but it just seemed too severe. besides, could anything bad actually come out of the kruger? she had none of the signs which indicated that she needed immediate surgery. but the pain really bothered me. it nibbled away at the back of my mind. then came the x-rays. they were worrying. i was looking at a partial obstruction, but the bowel was just too distended. one more thing to quietly eat away at my mind.

then suddenly the son appeared as if out of nowhere. he greeted me in a friendly manner. i introduced myself as the surgeon. even after hearing who or rather what i was, he remained friendly. i remained guarded. afterall i was under the impression i had to do with a physician (when in actual fact i later found out he was only a doctor).

i showed him the x-rays. he could see they were not good. i then went on to tell him i was worried and i felt an operation was in order. at this stage let me mention that a partial bowel obstruction does not need t0 be operated immediately. it can be left for the next day. but in this case there were just a few too many things eating away quietly at my mind. i had a pretty good idea what this meant. he surprised me. he said that i should do whatever i thought was needed. i did.

the operation went as i expected. i expected necrotic bowel. i resected what was needed and did all the other things that us surgeons do in these circumstances. but when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. this was no exception. we were worried about here generally and her hemodynamics and kidney function specifically. we were worried enough to send her to icu. the gas monkey even felt the need to leave her intubated. i concurred.

after i had tucked her into bed in icu i wondered where her son was. it was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. but i just felt i'd better check in the ward where his mother would have gone to if she hadn't ended up in icu. he was a colleague and besides, he might expect the worst if he found his mother in icu intubated unexpectedly. i took a stroll to the relevant ward.

i found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. i smiled. i was starting to like them.

i greeted them warmly. i didn't want them to expect the worst. i then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to icu. i reassured them that she was well and we expected no further unforeseen problems. i warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. he was pretty ok with everything but i could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to icu.

he put a stong face on it. he asked me a few questions and i did my best to reassure him on each point. then he asked a question i was afraid i would not be able to reassure him on.

"and when we go down to icu, will we be able to speak to the intensivist?"

"umm...errr....that would be me." after all, this was a peripheral town in south africa. in fact there is no real intensivist in our entire province. suddenly i felt sorry for these americans. they were far from home, their mother was very sick and the best they had to look after her in icu was a mere surgeon. there must have been at least some inkling of a misgiving in their minds. but he didn't show it. he smiled at me and simply said;

"ok. well we'll see you tomorrow morning then?" i was impressed.

the next morning i did not see them. they must have still been asleep after such a late night, i assumed. however the following few days their involvement really did leave an impression on me. it was also about this time that i realised he was not in fact a physician as i understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).

anyway the patient did well. she had the setback of a bit of wound sepsis which, considering everything, i could live with (although i have heard that some people in america want to put it onto a never event list?????). that was soon sorted out and after not too much time she was sent on her merry way.

this case also caused me to be contacted from the states. the patient herself sent a thank-you letter as soon as she got home, as did her son. she then sent a further thank you letter a year later and the year after that.

so, if i left the impression that i have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.