Thursday, March 17, 2011

the graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.


Kalei's Best Friend said...

It takes a certain type of person to become a doctor, nurse, anyone dealing w/humans that come in need. I have a contact who is a nurse in Germany and she writes about the patients she has who have cancer- different stages and types of cancer.. Early 20's and such a brave woman whose post not only tell about how courageous her patients are but also tell her tale of being tired, tested to the max.. and her dedication to giving her all till the very end... I am glad there are people like her, u included who do what most others like me could not do...

Ruth said...

I know it doesn't help, but you did what seemed the right thing to do at the time. During the course of my 20 year nursing career, I had patients who died suddenly for no apparent reason at the time. The fact that we all do what we can doesn't erase the guilt and pain. It only eases a little with time.

rlbates said...

Sure hope yours has few headstones. So sorry

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Deborah said...

Being a Doctor is a gift - I could not do it. I amdire those who do & do it well. YOU did this man well - as others also did. Sometimes things just happen - to the 'best' of people. YOU it appears are one of those BEST.
It was a very touching - caring story, which with all the accounts you did what was to be. Be A Doctor.
Be PROUD of who you are.
I'm glad to have read this.
I Thank you for sharing your words with us all.


Duncan D. Horne - the Kuantan blogger said...

This is a very original blog and it seems to be a real heart-wrenching job. Congratulations on the blog of note!

Loz said...

Absolutely awe inspiring. Although tragic, it allows us the insight into the mind of someone who is there for us.
Thank you so much for giving us this snippet of your life.

rnraquel said...

So often as nurses we just see and remember the tempermental side of surgeons. Thank you for sharing this story and reminding me of the human, caring side and the huge responsibilities that surgeons undertake. I would be honored to have you as my physician.

aSongAboutLemons said...

Thanks for posting. I plan on becoming a doctor, but it is a while off and I'm not sure what specifically I want to do. I appreciate your insight, I'm sorry about your patient.

Kathryn said...

This is very interesting blog. This post in particular is incredibly sad, but gave m a lot to think about.

Check out my blog at

Free truths said...

Wow. I was hooked on that story. I just wish it was just that, a story and not actually reality. I once wanted to be a doctor (a surgeon particularly), but decided on pharmacy partly because I think I'd rather deal with the drugs than with the patients, if that makes sense. I admire you.

Driver AKA: Mocha Latte Gal said...

We are meant to walk this earth for a finite period of time. During that time we are spiritual creatures having a human experience. Most people believe we are humans seeking a spiritual experience. People who are healers walk a fine line, a razors edge if you will, between spirituality and humanity. I wonder where your patient was most needed? His journey passed through your path. It was not determined by you. He was on his path when he arrived at your hands and you served him well. I am so sorry.

May it be well with you...

Bongi said...

mocha, thanks for your comment. however i simply don't agree with you. i do not believe in fate or a preset path. my job is to change fate. i extend lives. i save lives. i, in fact fly in the face of fate on a daily basis.

however sometimes things do go wrong and i need to move along. then i add one more tombstone, placed i suppose as a sort of altar to the power of the god fate, my eternal enemy.

Danger Boy said...

That can't have been an easy write. Thank you for opening your experiences to us, your blog (which I found via BON) is a fascinating read.
May your graveyard have few stones.

Cal said...

Very candid, Bongi. Thank you.

purplesque said...

Thank you for telling it. Hugs.

Elizabeth said...

Unbelieveable sad. I'm sorry. :(

Anonymous said...

i like your blog.all the topics are very interesting and not boring.i wish i could do it to my own blog.

Essie said...

This is a really sad story. I'm sorry that you had to go through that, but I am sure that many people in your profession have had similar experiences. I myself wanted to go into medicine for a long time, but knowing that such things could occur would weigh too heavily on the conscience. So I admire your strength, and hope that it only encouraged you to be the best that you can possibly be.

Rene said...

Not everyone will go through the same life you lead, but everyone would be able to emphatise with you.

Glad that there are people like you around =)

Chew On This said...

I had one kid in the graveyard in the back of my mind buried there for years already. After that patient, I didn't want to pursue my medical career ever again even if people would tell me that I'm wasting my education.

Aayushi Mehta said...

A very brave post. Loved reading your blog, I am almost a doctor myself, doing my internship right now.

I can see that you tried to give your best possible care to your patient, and, more than anything, you felt for the patient and for his death. That is more than what most would be able to give, in such a scenario.
Truly applause-worthy.

And I know the secret graveyard will only help you to be a better Doctor and save more peoples' lives.

Keep up the good work. Looking forward to reading your blog in the future.

happy internist said...

i have two thoughts, bongi. one, you did not shoot him. and two, maybe secret graveyards are better off not so secret.

thank you for your wonderful writing. you keep writing and we'll keep reading.

catherine said...

I am sorry. It might be that it
was meant to be, that it was his
time to go. Sometimes people die
when every conceivable thing has been done. Maybe you were allowed
to be mistaken so he could go home.

Bongi said...

catherine, i refer back to my previous comment. i don't believe in fate and time to go and such in young people. my job is to defy his time to go, to go and fetch him at the ports as it were. perhaps he died when he shouldn't have and that is that.

dymphnasis said...

So sorry. It's hard to accept the death of a patient when you have to make a call that could go either way. For that matter it's just seems particularly hard to accept the death of young, otherwise healthy people.

Jeffrey Parks MD FACS said...

The inevitability of failure, of sitting alone, damning yourself for having supposedly let a patient down---it's the unspoken burden of being a surgeon. All we can do is learn and try to be better the next time.

Management question:
For tangential penetrating trauma to the abdomen, do you guys get triple contrast CT A/P? Any role for dx laparoscopy?

Carmen said...

Hi, I found this blog while looking in my own blog and it is very interesting. I think you did the best you could. I could see your interest in that patient.
As human beings we all have different things we have to take care of and shuffle around like you said. I know you feel guilty and that's natural, but don't, because if God would have wanted him to still be here , some how you would have made it over there. God has control of every thing and only He knows why certain things happen that we don't understand.
God Bless You

Bongi said...

carmen, sorry i can't agree with you. he should not have died. that is it. it doesn't help to shift the blame from me to god. i think god probably gets blamed too much these days. i understand the temptation to wash ones hands of responsibility and just shift it to fate or god or it was meant to be or whatever. but i won't do that.

chrisd said...

Bongi, I came across your blog through blogs of note.

First of all I must tell you that your writing is clear and it is pure. Your voice speaks through your words. Thank you for sharing them with all of us.

Also, congratulations on being a "blog of note." It is an honor and your blog is certainly worthy of it.

I'm sorry to hear about this patient named Prince. How sad that this man had to die from a gun shot wound; it was a senseless act of violence toward what appears to be a decent man who was making a difference.

I am also sorry that you will have to carry his name in your graveyard. We all have names like this, but in your profession, you will see all things beautiful and transcendent. And you will see otherwise. May all of these things mold you into a doctor of note.

medaholic said...

very touching story, thanks for sharing...

scared of the day when i'll start having my own graveyard. had some narrow escapes so far.

Unknown said...

A great story and very well written. "Personal graveyards" can be depressing places unless you brighten them with the flowers of the lives you've saved.

Anonymous said...

This issue nis closer to me than most folks, I imagine. I was the victim of a botched gall bladder removal that has left me crippled.
The doctor "manned up and faced me and apologised. The HOSPITAL, however (where I actually worked as a nurse) FIRED me (at the bedside as I was slowly recovering from a month-long coma) because "I could no longer do the work". Considering that this corporation is a Catholic organization, with their 7 "values" plastered on every wall, I have yet to fully grasp the injustice of the incident. Fortuunately, they are on the "Magnet Journey" - I am waiting to converse with the ANA Magnet team when they come out to inspect this cruel corporation.
-A medically retired Penrose RN

Bongi said...

buckeye, sorry for taking so long to answer your question. this incident happened a long time ago. in the hospital at the time it was very difficult to get a ct and we wouldn't have had one done in time.

these days, if the patient is stable i routinely do a ct scan.

then the question of a lap scope, these days i'd consider it in the asymptomatic abdomen, but i would operate if the scan showed anything.

the chances of what happened to me happening are so small that i don't expect it to happen again...ever. therefore i somehow doubt i will be doing lap scopes for clinically normal abdomens in gunshot wounds.

Anonymous said...

Bonji, it is a courageous thing to be honest! May I follow your lead? It is clear that many components created the out come for Prince. You acknowledge most but then glaze over others.

After reading the comments and noticing that many comments seemed to want to excuse the death of such a wonderful person such as you described Prince to be I wondered if it was because of lack of time to write or understanding the value of a life. Some seem to congratulate you on a wonderful story as if it where a fictitious story submitted in a contest. This was grievous. Or perhaps it is the unfamiliar, uncomfortable, and messy type of reality that causes one to be brief in their condolences.

May I say that I heard you when you noted that you were fatigued, over worked, and that the multiple exams performed on Prince appeared to be in a safer zone that did not alarm you. Yet... The matter kept coming back to you.

Following that I noticed that you see yourself as one who determines the fate of others and that God does not play a role.

My friend is sounds true that the over sights did lead to the out come of Prince's death however, you can never supersede God! Were there not opportunities for His intervention through the examinations of the other doctors? All opportunities passed by.

I know the character of God enough to say that He does not always reveal His plan to His creation and that even though you do not believe in fate or divine intervention does not mean it isn't true! The Word of God displays Him in all of these. Read Psalm 139 for just a glimpse. He is omnipotent, omniscient, and omnipresent. Not you.

Yes God does get the blame for all of the terrible and unexplainable bad things that happen, as men like to take the praise for all of the good. God clearly states that He alays uses them to turn evil into good and reveal Himself who are paying attention. Our Creator is mostly dismissed from issues that reveal Him most... A changed heart, the amazing processes of birth, and even death.

In closing, It seems that you have been humbled at the expense of Prince's life. This is crushing as it is costly to so many who were impacted by his loss. This you admitted to also. Is God crippled? Not in the least. Man can take the life of a humanbeing but only God determines the destiny of his soul, as He has stated.

Had you become complacent for a brief moment? Perhaps. Your fatigue seemed to play a huge role. The answers to the questions and the reality that you have been allowed to participate in God's work of healing His precious creation will make you a much better surgeon "if you remain teachable."

Learn and understand your place and do all that you can with this newly found awareness. God is God and you are not. Now serve Him to the best of your human ability!

Thank you for your honesty and heart to want to make the difference! Now we shall all miss Prince!

LastoftheZucchiniFlowers said...

bongi- read this after reading shadowfax's recommendation about 'graveyards', and I truly appreciate your insights and genuine remorse for this loss. I am curious and I realize any answer would me mere speculation, but do you think that a decrease in the massive level of fatigue you describe would have made any difference in the outcome? We have all heard the old school guys drone on and on about how tough it was for them back in the day when they were trained - but given what we know about profound sleep deprivation, I continue to question this aspect of surgeon training amid ridiculous sleep loss? Our critical thinking skills are the first to go when we are exhausted, and no amount of intellectual justification can alter the fact that the human organism will start to defend itself from damage after a certain point. I think the surgical tradition must acknowledge the vital importance or being well rested when our patient's lives are at stake. Nonetheless, a fantastic blog and your fearlessness makes us all 'better'.

LastoftheZucchiniFlowers said...

bongi- read this after reading shadowfax's recommendation about 'graveyards', and I truly appreciate your insights and genuine remorse for this loss. I am curious and I realize any answer would me mere speculation, but do you think that a decrease in the massive level of fatigue you describe would have made any difference in the outcome? We have all heard the old school guys drone on and on about how tough it was for them back in the day when they were trained - but given what we know about profound sleep deprivation, I continue to question this aspect of surgeon training amid ridiculous sleep loss? Our critical thinking skills are the first to go when we are exhausted, and no amount of intellectual justification can alter the fact that the human organism will start to defend itself from damage after a certain point. I think the surgical tradition must acknowledge the vital importance or being well rested when our patient's lives are at stake. Nonetheless, a fantastic blog and your fearlessness makes us all 'better'.

LvR said...
This comment has been removed by the author.
Anonymous said...

You did the best you could...get over it.

-KC in TX said...


Thank you for sharing your story. As I read through your words my first thoughts were “this patient does not belong in this surgeon’s graveyard.” Instead the memory of the young man should be haunting the thoughts and mental graveyard of his shooter -- because the responsibility of the young man's death lies squarely with the person who pulled the trigger and not the medical professionals who worked to save him.

Surgeons such as yourself must deal daily with life and death in such a close, intimate manner. Undoubtedly throughout your career and lifetime, mistakes will be made. This is true with all of us, regardless of what we do for a living. But the unavoidable truth is that for you, when you screw up, people can die. This fact of course is the fundamental, uniting burden that all doctors and surgeons must carry on their shoulders. Throughout their career, no medical professional will escape without having to deal with this issue personally.

But please don’t forget . . . if you continue to carry all the burdens from your past, you will eventually no longer be able to move forward.

So what is the best way to handle the inevitable? What do you do if a patient dies while in your care and you feel that it was your fault?

There is no perfect way and no always-right answer, since we are as individual as the burdens we carry. But below are three steps that I have seen help.

First, remember that patients die. Sometimes they live, even if we screw up at every turn. And sometimes they die regardless of everything done right. But when the patient’s death is the result of a possible medical error, it’s vital that the mistakes be acknowledged and time is spent trying to understand what went wrong and why.

From what I’ve read in your blog Bongi, you’ve already done this first step.

The second step, after some time has passed, is to take what you’ve learned and find a way to share it with others. Bare your soul and share your wisdom.

You’ve done this step too - - - in a beautiful post that not only shined the light on a surgeon’s sometime mysterious psyche but also allowed you to sincerely proclaim and share with the world that you are not perfect. No surgeon is.

And hopefully Bongi, you have also taken the third and final step, which is to lay down the burden you carry, so you can then “go on and ride past it.”

I hope that one day you will feel peace, deeply and completely in your heart. My prayer at this moment is that if you haven’t already done so, that you will be led to take the third step.

May Prince always remain in the graveyard of your mind, but not to torment your thoughts with all the “woulda, shoulda, couldas” that are out there. Instead may your graveyard become the honored and hallowed resting place of a young man who, in your own words, not only made a massive difference in the lives of young people in his community but also profoundly touched the life of a thoughtful, young surgeon.


Bongi said...

anonymous1 (05h31), thanks for your comment. i really appreciate it. but let me say a few things. firstly, it's bongi, not bonji. amazingly enough, my name is important to me. please try at least to get it right.

having said that it was a great comment. but please understand i do not think i'm god. however i also do not think it is somehow god's will that this guy took a piece of lead through his abdomen. it happened, despite what god wanted for his life. then the surgeon involved (me) didn't make the right call even though he was academically justified. i'm not saying i'm god, but i am saying god did not kill him. some guy in mamelodi killed him. no intervention came and therefore he was not saved. that is that.

i will always do the best of my ability to change the fate or the destiny of the next one.

lastofthezucchiniflower, i hear what you say and i have thought about it quite a bit. in the end i have come to certain conclusions which in the end are mine and mine alone.

firstly fatigue definitely played a role. if i wasn't so tired i might have handled the situation better. but fatigue must always be measured against available resources. it is always good and well to talk about a doctor being tired, but if there is no one to replace him, or in other words, there is no better option, then a tired doctor is better than no doctor. also these days only idiots specialize in surgery, so surgeons are not that plentiful.

in the end i weigh fatigue against available resources and let me assure you, if you have a choice, take a tired surgeon above no surgeon nine times out of ten.

anonymous (20h11) i could have done better. and i am over it. yet to forget it would be a mistake.

i think i know where you are coming from. i too despise these melodramatic renditions of life. please don't think this is what this post is about. it is a telling of a story that is fact. i should have operated. i didn't and he died. he is still dead. he remains dead. i'm alive. for that matter, you're alive. he is a reminder to me (and maybe should be to you too) of our own mortality and how our lives are dependent on all sorts of factors (call it will of god or fate or chance or whatever) that we have no power over. please don't think i'm overly emotional about it, like i suspect you think i am. but i do know my life and yours too may be snuffed out in an instant. then all we can hope for it a mention on the blog of some surgeon in a third world country like south africa.

skylarmacrae said...

I appreciate the honesty and humility with which you share this story. Surgeons are supposed to be able to fix things and it is very hard for them to admit brokenness. Sharing information and nightmares like the ones you have experienced sheds new light upon the everyday struggles that remain hidden behind the rubber gloves and drapery that patients see.
Having this kind of knowledge makes me appreciate the courage and skill with which people like you act with every day.
Thank you for your service!

skylarmacrae said...
This comment has been removed by the author.
Anonymous said...

bongi, i do understand you, i too have a graveyard of me. beeing a doctor makes the difference in understanding this post. yes, we make the difference in people´s lives, and yes, we are human too, we feel bad when our patients die because of sometinhg we didn´t see. that is only part of the difficult job we do. and part of it´s greatness too.

maria, portugal, internist

Love Stories Online by Manny said...

This is an interesting should read this real blog.

Anonymous said...

See things as they are. No need to make things what they are not. Your path becomes clearer but not always easier. Your soul will remain yours.


Anonymous said...

What else I can say?
You are such an amazing doctor,but sometimes you can't prevent a death from occurring.

Hope all is good with you :)

Saintmrdog said...

Wow I read this and I have to say, I never noticed how hard surgeons such as yourself have it. Your friend was correct indeed, I never thought of the stress that you all have to go through.

happy internist said...
This comment has been removed by the author.
happy internist said...

well, bongi, i have been checking back and this has proved to be a very provocative post. some want you to get religion, some want you to get some sleep, i just want you to keep on writing!

(sorry i deleted my other comment - i couldn't spell provocative)

Laura said...

I've also worked in hospitals (as a Respiratory Therapist) and still have many faces, names, and stories in my presonal "graveyard." I feel for you.
P.S. I really enjoy your blog. Thank you for taking the time to re-live your experiences, and share them with us.

Alex Wilde - El Experimento said...

Reading this blog really interest're a good blogger/writer. But what really struck me most is the last line "engraved on the tombstone i still clearly see his name. his name was prince." Forever you will carry in your mind and heart this person, like a first love. You will forever feel the guilt and forever say "I should have.." All I can say is all of us are not perfect. We are all meant to stumble..

skylarmacrae said...

@Alex Wilde- El Experimento: I agree with most everything you described about the memories that Bongi recalled. Your analogy comparing the lost to one's first love is a very interesting one that I hadn't considered.
One point of disagreement with what you said came in the last sentence. I realize that we are all destined to fail, but I'm not sure that we are all meant to fail. Perhaps this was simply a disagreement with diction. What are your thoughts?

Calvin Rocha Coelho said...

You did what you thought its gonna be right for him. U should leave that ghost leave with your pain and guilt to learn about this moment and carry on saving another lives. Nice blog and stories!

Helen said...

Wow, what great writing. I have nothing to do with nursing or being a doctor. But I really enjoyed reading this.

Anonymous said...

as a 2nd yr med student in south africa, this post really hit home. I do nt have a graveyard of my own to talk of but i know i will, thats the sad reality of it all. There are always going to be patients where you wonder if they would be alive today if you had done things differently, even though at the time, your decision was the right one. Someone told me its not the patients you save the you remember the most but the ones that you couldnt.

Anonymous said...

@ bongi

"however sometimes things do go wrong and i need to move along. then i add one more tombstone, placed i suppose as a sort of altar to the power of the god fate, my eternal enemy."

That has to be one of the more beautiful things I have read in a long time. Some people deny their own power and some rage against the power of the god fate as you poetically put it. They would be more satisfied if they could both claim their power to alter the story and still respect the power of the enemy that seems to relentlessly advance the plot despite all our efforts.