Monday, July 19, 2010


somehow we see things differently. i'm not saying we are not part of the common human experience but we are involved in this experience on such an acute level we just end up seeing things differently. i mean if someone drops the word 'urgent' into a message for me i get visions of someone bleeding to death rather than images of having to stop at the shops to buy milk on the way home. maybe what i'm trying to say is we can come across as slightly glib at times. there are so many stories to illustrate this that maybe this needs to be discussed in a number of posts, but i remember when i was confronted by my own attitudes to the realities of life.

i was in casualties resus, a place i really felt at home in. i was stabilising a gunshot abdomen patient and preparing him for theater. it seemed the bullet probably went through the liver and the patient was bleeding enough that i was quite concerned. i was determined to stay with him until i had him under my knife, just in case something went wrong. but once the lines were up and the blood was running in there was little more to do than to wait for our turn in theater. it was a time to sort of stand around and maybe share a joke or two with the rest of the team. it is also a time to see what else is going on in resus.

the patient lying next to mine was a neurosurgery patient. he had been attacked in his house during a break in. for good measure his assailants had driven his skull in with some sort of blunt object. i had nothing better to do so i took a look at the scan. it was clear my neurosurgical colleagues were also not going to get too much sleep that night either. we laughingly teased each other about whose job was the worst.

all this time i noticed there was someone standing just outside the back door of the resus room. he had an expression somewhere between awkwardness and sheer terror on his face. he was clearly totally out of place but he wasn't bothering anyone and i sort of just ignored him. but he looked very familiar, so in between making sure my patient wasn't about to die and teasing the neurosurgeons i racked my brains to try to remember where i had seen him before. suddenly i remembered. he was a pastor at a local church and many years ago, when i was still a medical student, i had seen him there. the polite thing to do would be to greet him, i thought. i moved towards him.

as soon as he saw me approaching he seemed to take a deep breath and gird up his loins and he set out directly towards me much faster than i was moving in his direction. he walked with such a determinedness i wouldn't even have been surprised if he decked me when he got to me. i readied myself to say something, but suddenly realised the usual 'hello, and how are you' somehow just didn't seem to work in this setting. i was formulating a slightly less formal 'hi there' in my mind when he beat me to it and started speaking.

"excuse me," he said with an intense expression etched into his face, "but would it be ok if i prayed with this man who has the head injury?" somehow my 'hi there' suddenly seemed so out of place. even a 'i once saw you in church many years ago' seemed a bit unimportant compared to the fact that his friend would be lucky ever to talk again without saliva running down his chin, assuming he survived. i felt stupid.

i went through it afterwards in my mind. you see when people come into contact with me it is more often than not at one of those extremely important moments in their lives. often the only question to ask is whether they are going to survive or not. things like what ply toilet paper they prefer becomes somewhat irrelevant. but on any given day i may be faced with many people at these crucial crossroads, but each of them will maybe be faced with the situation only once or twice in their entire lives. maybe in a sense sometimes we become used to things no one should ever be used to.

and therein lies the secret. we may never become blasé or glib about the sharp edge of the human condition just because we see it every day. for me it may be just run of the mill or just another gunshot, but for the patient in question it is probably the single most significant moment in his life. even if we can't empathise with each and every patient, we need to remember these facts and respect the patient's experience for what it is, deeply significant.

in the end i mentioned quickly and in passing to the man that i recognised him and then left him to support his severely injured friend in whichever way he saw fit.

Thursday, July 15, 2010


one expects a certain level of dignity and decorum from your surgeon. there was an incident when this was so not the case the ensuing astoundment caused such a deep silence one could almost hear a pin drop. it's a pity we didn't.

it was one of those cases you see where some kid has swallowed some object he shouldn't have. this time the x-ray revealed a pin which seemed to be in the kid's stomach. amazingly enough if it gets through the stomach it most likely will make its way throughout the entire intestinal canal and can be left on its somewhat crappy journey. but being in the stomach it is also quite accessible with a simple gastroscope which is not too invasive. the parents were keen for me to try to get it out and i was up for that.

we settled the kid on the scope table and inserted the drip with much weeping and gnashing of teeth. the kid was doing the weeping and i was doing the gnashing of teeth. but once it was up the sedation and procedure we knew would be no problem.

the sedation was injected and quite soon i was peeping into the stomach with my trusty scope. only problem was there was no pin to be seen. i looked at the x-rays again. there the pin was clearly in the stomach and the x-rays had just been taken. that meant the pin couldn't have gone too far. i advanced the gastroscope into the first part of the duodenum (the part of the bowel just distal from the stomach). still no pin. not to be discouraged by disappearing pins i just kept on advancing the scope but still the pin was nowhere to be seen.

finally when i came to the part of the duodenum that straddles the aorta (a big pulsating artery) sure enough there was the pin jumping up and down with apparent glee with each pulsation. it seemed a pity to go to so much trouble to find it and then just leave it there, even if it looked like it was having fun, so i asked the sister to ready the biopsy forceps (that was the only grasping scope instrument we had) and i prepared to remove it.

as i discovered it is not so easy to grab the head of a pin with something not much bigger than the head of a pin, especially when with every attempt the pin bounces around in rhythm to the patient's beating heart. the procedure started getting a bit longer than i thought it was going to be. i wondered what the parents waiting outside would be thinking by this time.

i was just considering giving the whole idea up for lost when the pin seemed to jump into the mouth of the biopsy forceps and we grabbed it. we had a moment or two of panic when the now immobile pin seemed ready to stab the aorta with each pulsation that had so recently been its play mate (pins can be so fickle). so we quickly withdrew it into the stomach...where we accidentally let it go.

the procedure was getting a bit too long and the parents were probably wondering exactly what i meant when i told them it would take no more than five minutes. nevertheless, after working so hard to return the pin to the stomach where it was supposed to be in the first place, i couldn't exactly stop the procedure then. i soldiered on.

it is surprisingly difficult to pick up a pin in the stomach with biopsy forceps through a gastroscope, even for those practised in the fine are of retrieving pins from the distal duodenum as i was. i started to sweat a bit, but i was now in it for the long run. and finally i did get a hold of that blasted elusive pin. i told the sister to hold the forceps as tightly closed as possible and we withdrew it.

we stood there looking at this pin now held by the forceps, but outside the body with what i think was a sort of grudging admiration. i reached for it and the sister released the forceps and...well the pin just disappeared. we looked at each other in silent horror.

"did you see where it dropped?" the sister asked.


"did you hear it drop?"

"it wasn't that quiet."

yet even then the humour of it was not lost on me. i could just imagine explaining to the parents;

"sorry we took so long but the pin was much further than we thought it would be."

"so you didn't get it out?"

"no we did get it out."

"great. can i see it please?"


the child was still asleep so we had a bit of time. we both dropped to our knees and started searching the floor. but the pin had disappeared. it seemed its super powers weren't just limited to when it was inside the kid, but it retained its elusiveness outside of him as well.

then i wondered what the child would think if he woke up just at that moment to see his surgeon and the sister scurrying around on their hands and knees with their noses right up against the floor. i considered sedating him a bit more so we could find the pin in peace but that somehow seemed wrong. the next thought got to my mouth before i had even properly formulated it.

"sister, don't we have a similar pin somewhere here that we can give to the parents and just tell them it's the one we removed from their kid?" she laughed. i was just about to tell her i wasn't making a joke when the patient started groaning as he slowly woke up. i jumped to my feet, a bit too quickly i fear and brushed myself off. to her credit the sister continued on her quadrupedal quest.

about a minute later, as the child started looking around and demanding his mother, the sister suddenly jumped up with the pin firmly grasped between her fingers. we quickly put it into a specimen container so that it could no longer escape.

i then walked casually out of the procedure room with all the dignity and decorum i could muster and presented this prize to the parents. they had no idea how hard i had worked for it.

Tuesday, July 13, 2010

grand rounds on south african shores.

it's not just the soccer world cup that is on south african shores but the great grand rounds, something that some would say is far more important than the world cup (ok only one guy would actually say that and he is in a psychiatric institution in outer mongolia) is also presently hosted in south africa!!! proudly south african!!!

but time to see what the bloggers have dished up for us this week.

here is an interesting article sent by preeti kaur which is relevant in the context of the world cup. i must say i think that fifa should stick to soccer and plundering african countries and keep out of healthcare but i may be wrong.

greenpoint stadium

amy tendrich reflects on the lessons learned by the ada.

another blogger making her voice heard in the diabetic community is kerri sparling.

a kuduzela, an variation of the vuvuzela

philip hickey, a psychologists questions the tendency of modern medicine to add a diagnosis to pretty much anything, in this case sexual disorders.

in a somewhat related post james baker wonders if some things that modern medicine has labelled a disease may only be problems of living this thing we call life.

jo'burg stadium

a south african reflects on lessons learned from soccer. fifa, with their autocratic laws imposed on previously free south africans may demand royalties, but then again she has moved to far away shores, so i think she might be safe

the great doctor anonymous touches on an issue that i often think about, the end of a blog. this one touches a nerve with me because i also sometimes consider how long my own blog will live.

a sotho blowing a kuduzela

how to cope with chronic pain has a nice piece on professional sports stars and pain they feel. he concentrates on retired nfl players. if he were to look at soccer players i'm sure he would find the active players cry all the time, especially when the ref is looking.

polokwane stadium

bob vineyard of insureblog shines a light on an aspect of medical insurance that ultimately played a part in the demise of a cancer patient.

south african supporters armed with vuvuzelas, makarapas and glasses (to see better of course)

andrew holtz of mditv tells us that watching soccer may even be more dangerous than playing it, despite the expressions of pain and agony on the faces of the numerous world cup players forever diving.

a man i consider a great blog academic, doctor rich wonders about the motives of people trashing the jupiter trial in an otherwise respected journal.

an old style makarapa with matching spectacles. we can make a spectacle of ourselves if we want to

robin mockenhaupt looks at some financial aspects of prevention of disease in the elderly.

true style south african supporter

louise discusses how some clinics will get hit hard by delays in payments by medicaid.

the goal that wasn't. well done fifa!

walter jessen tells us about a certificate that has recently been launched by the health on the internet foundation. this will hopefully help advice seekers to be a bit more critical about the things they read online.

david harlow looks at health information from a slightly different angle.
good old south african soccer glasses

dr deb gives us advice in the form of tips for mental fitness. have a look how many you do.

the now famous soccer city in soweto

the happy hospitalist has stumbled on a much cheaper alternative to using a translator when you and your patient don't share a communal language. happy, i too have seen this technique used in south africa with similar results.

a band maybe? they at least all play the same note.

jill of all trades talks about something that has always been close to my heart, the training of the future doctors of the world. some day i hope to once again become involved.

the cheating devious uruguay understanding of foot in the word football.

the legendary blogger, dr charles takes a look at an isolation experiment that is supposed to mimic a trip to mars. in the end maby it only mimics isolation. besides, what's a surgeon doing in such an experiment? do they want them to fight?

makes me proud.

doctor bates relays a short humorous story.

my team, although they went out early (and after all it's not rugby)

alan dappen writing for get better health discusses a pleasant encounter with a patient, even though money issues were discussed.

maradona was often more entertaining to watch than the soccer.

and that's it for this week's edition. i hope it supplied a nice few posts for your enjoyment. please feel free to link here.

next week's grand rounds will be held over at captain atopic's place.

Wednesday, July 07, 2010

grand rounds

i have been bestowed the great and grand honour of hosting grand rounds this coming tuesday. i thought that a general soccer world cup theme may be in order seeing that my country is presently the host of the tournament, so fire up your vuvuzelas and get writing.

all medical or medically related posts will be welcome. of course, with me being african, any submissions from uruguay will not be considered. posts from fifa will also be rejected.

please send all submissions to bongi (that's me) at amanzi dot com not later than sunday 11 july at midnight south african time (i don't know what time that is wherever you are). please put grand rounds in the subject line.