Tuesday, December 01, 2009

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.


Vijay said...

call me pessimistic, but i sort of expected that last line.

rlbates said...

How many of these have you done since that first one?

Bongi said...

vijay, realist.

rlbates, i have done more gunshot abdomens than i can count. i suppose during training i averaged about one or two a month but i have done three in one day. surprisingly enough that was the only shotgun abdomen i ever did (not the only shotgun, but the only shotgun abdomen).

SeaSpray said...

Wow Bongi ..what a way to get broken in! I guess you did do it all after that one.

I'm curious ..in moments like that..does time get suspended and you are in your own world..or are you very much aware of the clock and time running out?

Were you afraid? Or is there no time for fear? Do you look at it as a chance of a lifetime ..opportunity to learn?

I ask this because ..and bear with me docs... in Grey's Anatomy ..they are all competitive (I know that's true) and excited about the most difficult and/or unusual cases. Things that would gross us regular people out..they are practically giddy over seeing/doing.

What fascinates me is that it seems your scientific minds see the human body in a dimension that we non medicals don't appreciate. I think the human body is beautiful inside and out and is proof (to me) there is a creator beyond us. So I see beauty in how important each part is and how magnificently designed it is to work together. But..I feel like you surgeons..see things in a way we don't or can't ..and it intrigues me.

I'm sorry ..not articulating this well.

Dr Schwab said something once also fascinating.. that a surgeon has to be able to see 3 dimensionally..also fascinating..because how do you know?

Sorry..for digressing a bit.

And then the pressure of trying to fix this guy as he's going south.

Maybe you have personalities that like living on the edge?

It has to be a calling?

Anonymous said...

Dear God. Speaking of baptism by fire.

Vijay said...

SeaSpray, I don't know about surgeons, but radiologists definelty used to see & think in 3D (before the advent of fancy-shmancy 3D Ultrasound, CT & MRI).

SeaSpray said...

Wow Vijay that's interesting too. I never would've thought of that but you would need to to give a better picture (no pun intended) to the doc in you reports.

I have to admit that anytime i have seen x-rays hanging up at work..I am so clueless on less it is something so obvious. I think even with the x-rays ..you need x-ray vision! i guess that's where cts, etc come in real handy. :)

You all must be thrilled with the modern technology.

I wish we could all have one of those very comprehensive scans that Dr Oz demonstrated/discussed on Oprah a while back. You could see right into this person's heart and her life was saved because of it. If only we all could do that. Expensive and I assume a lot of radiation.. but amazing.

Msasa said...

i wonder what happened to that blogger "boerewors emergency chronicals" i always felt sorry for the bloke: he was obviously quite a trauma fundi in his day. i hope that when Bonji finally decides to leave darkest Africa and go to other parts of the old Empire (australia, uk,canada........probably not india) well then i hope he keeps up a cheerful ironic look on life like this boerwors person did; although i could always tell his heart wasnt really into it. Maybe he is dead? maybe he has returned to SA to teach the next generation? hope Bonji doesnt go to Australia and become ultimately a raconteer: always starting with "when i was in Nilspruit",,,,,,,,,,,,,,

Mal Content said...

Several things happened to Boerewors...me...I fell in love and am having more sex than God....and I've been on holiday In Joburg for 3 weeks ,drinking wine and eating steak...will be starting up again soon!

Bongi said...

vijay, we see in three dimensions and in colour.

anne said...

What a pity. I was hoping that he had made it. How long did he survive? You mentioned a second-look surgery, that's why I ask.

Bongi said...

anne, about a week or so. he made like an old soldier and just slowly faded away.

gastrectomies and then tripe for lunch said...

i was working in theaters and the surgeon started on a pelvic fracture. the patient just bled and bled. the floors and roof of theater went red. the surgeon ended up helping the cleaners to mop up. all his bravado left him: he looked like a little boy mopping the floor. later on all his collegues gave him a hard time in the coffee room: which considering how tired the surgeon was............was a bit cruel really. this guy was the goldern boy of surgery and had a very successful private practise: i suspect they just could not wait to say "oh how the mighty have fallen". anyhow there is this costmetic plastic surgeon who has a theater there: he does facelifts and liposuction and boob jobs. He is very tall and is known Suddenly he stood up and went over to the pelvic fracture surgeon and put his hand on his shoulder. then he spoke about how he worked in a burns unit: about chemical burns and all sorts of other horrors and I remember we all went quiet: this guy was truely an expert in his field. i remember what he said: "you can have an early death or a late death" in burns. either way you will have a death.