thumbs up

it was a battle. looking back i don't think we ever had a chance, but you don't just give up on a young man in the prime of his life. we had to try. he was my patient.

he was a foreigner, on a gap year in africa where he was going to learn all sorts of things about conservation and african wildlife. up until the accident, all had apparently gone well. the group of teenagers on the course had so far enjoyed every moment of their time together and some close friendships had even begun to develop. as it always is with these sorts of things, when they all climbed into the bus that day, no one expected what rippling ramifications there would be

from what was later told to me, it sounded like the accident happened in slow motion. the bus was driving along a fairly narrow mountain pass when, while negotiating one of the sharper turns, one of the back wheels went off the road into a ditch. as the bus drove on, the wheel was dragged along trying to remount the edge of the tar before a steep precipice that was looming up. it was unsuccessful. when the side of the road dropped away beneath the wheel, the undercarriage of the bus smashed into the edge of the road and slowly started getting dragged down. still the bus drove on. i suppose the driver either didn't realize the dire nature of his dilemma or he felt he still had a chance of pulling the bus back up onto the safety of the road. whatever his reasoning, it didn't work. slowly the back of the bus slipped further and further off the road. once the other back wheel also went off the edge, the bus teetered for a moment and then went crashing and rolling down towards the river below. in those moments between the realization of impending doom and the moment of the first impact of bodies colliding with the walls and roof and floor in a continuous spinning cycle, i often wonder what he thought. was he aware of the gravity of the situation or, like most people that age, did he trust in the indestructibility of his body? did he cease to look forward to the promise of a long and happy life and instead, look back to see if what had gone before would constitute a worthwhile existence? was there an awareness that the sheer abandonment of youth was over forever? or were his thoughts limited only to the constant tumbling of the bus and the melee of the bodies of his friend being thrown together and around.

for what had happened most of the people got off fairly lightly. sure, as the noise of the tumbling bus settled together with the dust it would have been replaced with screaming and sounds of pain and despair, but there were surprisingly few serious injuries, except of course my patient. there will always be chaos after such an event. somehow i think my patient didn't make too much noise. it would have been painful to breathe let alone scream. i imagine him lying quietly in blood soaked gravel, almost hidden from view of the rest of the disaster trying to make sense of all the new sounds and smells and sensations, trying to come to terms with what had happened and that it had happened. young people are usually not burdened by the ramifications of events so i doubt he thought too much about that. that would be left to others to contemplate later once all else had gone quiet.

the paramedics triaged well. only one patient was deemed serious enough to fly out with a helicopter. all the rest were stabilized and transported via more conventional means to our hospital.

so it fell to me to wait in casualties for the helicopter to land and deliver to us what was described as a severely injured young man. it was a situation i had been in many times before. it was, in fact, what i was trained to do. as usual i took the time to calm myself and reflect. experience had taught me that once the patient had arrived there would be little time to even think. everything would happen almost automatically as it had done so many times before. my body would go into a very focused state where anything that is not immediately associated with keeping the patient alive almost shuts down. i don't feel hunger or thirst or fatigue. my body doesn't require toilet breaks or to deal with any such basic needs. i even don't feel emotion. i get on with the job. get it done, that is all that matters at that moment. so when i saw my patient for the first time i was surprised by my reaction. looking at this young man with a broken and battered body touched me. he was quiet and seemed to have accepted his fate. he looked at me. there was peace in his eyes that seemed to defy what had happened to him. i like to think he smiled, but to tell the truth, my mind might have added that in later. i felt sorry for him. i didn't want him to die. i determined to do everything and anything in my power to prevent that, although i knew that is what i would have done anyway. only with him there was an emotional aspect to my determination.

once we got to work, my focus came. no longer fettered by the mist and fog of human emotion we quickly did all the necessary things to get him to theater. i stayed by his side the whole time, orchestrating everything, leaving him only once i had handed him over to the anaesthetist and then for only as long as it took me to change into my theater clothes. i joined my colleague as he was wheeling the gurney into theater. for a while i would be an onlooker until the patient was asleep, leaving my charge to my anesthetic colleague until then. after that we would battle together for the life of this young man, each carrying out our relevant roles in this drama.

i looked at my patient. his eyes were fixed on me. i wondered what was going on behind those eyes. despite being so severely injured they still seemed to be focused. the humanity was obvious. i felt for him again. i imagined myself in his position, so far from home facing such incredible odds and all that, completely alone. i had to touch the humanity of him before i engaged in the struggle that lay before me. i placed my hand on his shoulder;

"don't worry! we will do everything in our power for you." his gaze stayed as it had been. then he slowly lifted his hand and gave me a thumbs up sign. he believed in me and trusted in me. it was almost too much for me to bear.

we fought for him for hours. we fought so long and so hard that even when we knew we had lost the fight, we fought on. we hoped against the odds and against the creeping knowledge that we had lost and just kept going. only finally when my patient was absolutely dead (if that is even a concept) did we acknowledge defeat. afterwards, with this sort of thing, once the body is allowed to admit its own needs, they often come flooding back. suddenly i felt tired and hungry. the tired was more than just the fatigue of the physical body, but it was also the deep tiredness of soul, the feeling that you had been somewhere and done something that no human is supposed to have done. it is a type of tiredness you know will follow you for years to come, a tiredness that defies sleep or any other measure to combat it. i looked at my colleague. i think he felt the same. we walked out together in silence. there were no words left. they had been all used up in the preceding hours with business words like 'more blood' and 'another f#ck¡ng artery clamp now' and 'squeeze the heart now or we've lost him'. Soft words like 'are you ok?' just didn't seem appropriate anymore.

the next day, while the wounds were still fresh, the hospital administration told me that his parents far away in europe had asked what had happened in his last moments and if he had suffered much. they suggested that if i felt it appropriate, i should write to them. maybe somehow they knew i needed some sort of reassurance or healing or closure too and felt we could 'cry on each other's shoulders' as it were, i'm not sure. it all seemed a bit odd. then i thought about my patient raising his thumb to me. that surely was his last moment. the hours after that weren't his moments. they were mine. i suddenly realized that that raised thumb of trust and hope carried some beauty, some strength and i knew his parents would want to know about it. it was my duty to let them know.

i wrote a letter to them. i did not need to go into the details of the battle in theater with all the blood and guts and the slow fading of life. i just needed to tell them the strength that he demonstrated right up to the end. i wrestled with every word that i put in that letter but finally i had something that i gave to administration. they passed it on to the parents.

only  a day later the reply came and was forwarded to me. i read the words but they were so much more than words. i could see the tears and heartache and dashed hopes and regrets of parents far far away having their world ripped from under them. i knew it was a level of despair i could not understand and which i did not want to understand. to me they expressed gratitude and said they had been moved by my email and that it had helped them to deal with the grief. they went on to say they would like it very much (they came from a country where people tended to say things like 'like it very much') if i would continue a correspondence with them. 

i sat down. for me my pain was still very close to the surface but it would heal. theirs would never heal. they had lost a son. i had just lost a patient. i could feel the longing in their 'like it very much' for more. they didn't want their son to be gone and would cling to anything that could possibly fool them into thinking he was still just away in africa and would probably return any moment. i could not be that thing.

i no longer wanted to be what i am. i no longer wanted to struggle and fight in theater against the odds to stave off the inevitability of death. i no longer wanted to see the snuffing out of promise and life. i no longer wanted to think about the devastation left in the wake of the disasters that cross my table. i no longer wanted to be a surgeon.

awkward

recently i attended the association of south african surgeons congress. it's always strange and maybe fun for me to interact with surgeons. they are extremely interesting to me. i feel that i'm a bit of an outsider in the sense that i don't view myself as a typical surgeon, so i can sit back and observe, fooling myself that they are not looking at me in exactly the same way.

but one thing about these congresses is that you get to see and rub shoulders with the heavyweights of the profession. it took me back many years to another congress that i attended when i was still a mere mortal registrar and truly was not yet one of them.

the congress in question was in durban. at that stage i pretty much kept away from all the big names. it seemed the safer thing to do. however, one of my fellow registrars and a good friend of mine was quite friendly with the vascular prof, a greater than life man and a true legend in his own time in south africa. in fact my friend went on to specialize in vascular and is now himself a well known vascular surgeon in one of the big centers. so when my friend invited me to the vascular dinner the one night, i should have just said no. i didn't.

the vascular dinner, as i was to discover, was a fairly exclusive affair. it was sponsored by one of the companies that supplied prosthetic grafts, mainly used for the repair of abdominal aorta aneurysms. all the big names were there, including our massive prof and the vascular prof from wits, who at the time was also head of the department of surgery there as well as the president of the vascular society of south africa. in fact the only two non entities were myself and my friend. bearing in mind the entire vascular fraternity knew my friend would one day be one of them, in all reality, i was the single individual there who deserved and got sideways glances. my usual tactic of keeping my head down wasn't going to work; it stuck out like a blushing throbbing aneurysm and there was little i could do about it.

the function was advertised as a dinner on a boat that was supposed to cruise around the durban harbour, all very fancy. but, as it turned out, the weather was a bit too bad and the owner of the boat, which was a bit more like a large raft, all fitted out with tables and chairs and, of course, a bar, decided it wouldn't be safe to take the entire vascular complement of the country on a cruise where the boat had a good chance of sinking and rendering vascular surgeons in our country even more scarce than they already were. i was fine with this. besides the chance of dying, i felt it might be a bit awkward stuck with such eminent beings far from shore and no place to hide. but the sponsors of the event felt let down. they wanted to show off a bit i think and a boat safely anchored in the harbour just wasn't going to cut it. they felt they needed to make a plan, so a plan they made.

after the snacks and a fair amount of dutch courage had been consumed the plan became apparent. suddenly next to our safely moored raft appeared the biggest baddest speed boat i had ever seen. it looked like the type of thing you see on national geographic deep sea fishing specials. i wondered if we would limit ourselves to just the harbour cruise or would we venture into the big blue.

quite soon all the big names had made their way onto the boat. i, being the most junior person there, waited until last to see if there was enough space. as it turned out, it was a very big boat and there was plenty of space, so, somewhat reluctantly i followed my friend aboard. there were three areas where the vascular passengers could sit. one was the main area downstairs which was full. the next was the front portion of the boat which was fulling up quickly and seemed like not the greatest place to sit, just in case we did venture beyond the protection of the harbour. the third was a fairly quaint upstairs area. it seemed like the only real option. my friend and i climbed the ladder.

the upstairs area was the smallest of the three areas and was not yet totally crammed with vascular academia, but there was a reason for this. you see when the profs had gone aboard, they had all gone upstairs. the mere mortals, not wanting to seem forward, had decided to rather remain below. my friend and i didn't know this because we had waited until the last moment before we came aboard so when we got to the upstairs area, i was quite perturbed to see all the great profs sitting there. it was too late to go back down. for one thing, there was no space downstairs and for another all the eyes of all these great and intimidating men were staring at us as if we had just walked in on an awkward conversation. there was nothing for it but to stay there. i immediately decided i would stand as far away from everyone as possible. if there was a corner there i was determined to find it.

the president of the south african vascular society and great and mighty head of the department of surgery at our neighboring university, and more than likely someone i would be meeting soon in my final exams, looked at me and, gently tapping the seat next to him, spake he.

"come sit here next to me." he said with a wry smile.

" no thank you, prof, i'm fine here." i replied. he seemed persistent. again, almost stroking the seat next to him, he repeated his invitation.

"ag, come on, bongi, come sit here next to me." occasionally in life, you are presented with a situation where you really can say the wrong thing, and at the last minute, better judgement prevails. that day it seems i had no judgement at all. the words just seemed to roll out of my mouth, which I confess, stayed open in absolute shock at what had just escaped.

"no thank you prof, i'm not that type of boy."

the vascular prof from our university at least got a good laugh out of it.

the theater cap

"bongi, i have a patient who came in last night with appendicitis. can you operate him for me?"

my colleague was known to load shed and mostly i didn't really mind. that day, however, i just didn't feel like any extra work, so it took a bit of effort to fake enthusiasm.

"sure! any time." i lied. "anything special or straight appendicitis?"
"well, i saw him two days ago, but he refused operation, so he might be a bit sick." i knew what that meant. a bit sick was surgical talk for 'good luck pulling this one through'. oh well, a challenge at least.

the patient was a young man of about 27 years old. despite the fact that he was clearly in pain he still was a striking individual. he was alert and interested in my analysis of the situation. his questions were to the point and demonstrated deep contemplation about his situation. his eyes sparkled with life and potential. he touched a chord in me and i felt for him, despite the fact that he had refused an operation a day or two ago that was clearly necessary. when i examined him it was clear that he needed surgical intervention, but his pain was no longer located just in the area of the appendix, but it had spread more diffusely through the abdomen. i decided that a lower abdominal incision would be better to fully address all potential problems.

"doc, i like your cap." we were pushing him towards theater. i was wearing one of my genuine sutured for a living caps that i always wear when i'm in theater. i smiled. this sort of small talk i took to mean that he had resigned himself to the operation and was simply trying to distract himself.

"thanks." what more was there to say?

"i would love a cap like that." there didn't really seem to be anything to say to that, so i just kept quiet.

quite soon the patient was asleep and we got to work. when i opened up the lower abdomen, a thick, suppurating appendix protruded through the wound in an apparent attempt to escape from the septic abdomen that it had actually been the cause of. it had clearly burst. i smiled to my assistant.

"looks like this is going to be easy. whip out the appendix, rinse the abdomen and home free." sometimes i wish i would learn not to tempt fate with idle talk. i mobilized the caecum. and that's when i realized something was wrong. it was an appendicitis, but it wasn't caused by a stone in the appendix lumen or thickening of the lymphoid tissue in the wall. there was an obstruction in the base of the appendix but it took the form of a hard mass that had broken through the caecum and infiltrated the abdominal wall. what we actually were dealing with was a colon cancer that had incidentally caused an appendicitis. to remove the appendix simply would not suffice. i had to be aggressive.

i removed the right side of the colon with its blood supply and lymph nodes, taking a sliver of the abdominal wall along in the specimen. yet i already knew that the cancer had probably spread throughout the abdomen along with all the inflammation when the appendix burst. that would by necessity be something for the chemotherapists later. right now my priority was to do the best i could and get him healthy enough to withstand the onslaught of the chemo drugs.

the rest of the operation went as can be expected. i stuck the necessary pieces of intestine together, rinsed, placed drains and closed. the patient did well post operatively too. of course i still had to tell him that he had a cancer and not a simple appendicitis. that was not fun. i also involved the chemotherapist as soon as the histology confirmed what i already knew. finally i discharged him and left the rest to the chemotherapist.

many months later as i was walking down the corridors i happened to run into that same chemotherapist. i hadn't heard anything about the patient so i decided to ask how it was going with him.

"well, bongi, despite my advice, he refused chemotherapy and jetted himself off to china for some sort of experimental therapy where they place radioactive beads in the bed of where the cancer was. i wish him all the best but i don't think he is going to get all the best." i was upset. in a sense it wasn't actually too surprising. after all he had initially refused surgery by my colleague. he did seem to be a bit of a free thinker, even to his detriment. maybe this stupid stubbornness was one of the things about him that made me like him on some level. still i knew he had decreased his odds dramatically and it did upset me. i felt like a young promising mind was about to be cut down and there was nothing i could do. it was as it was.

i had just about managed to nearly forget the man when, once again, walking down the main passage of the hospital, as my chemo peddler walked past he gave me some news.

"guess who i admitted last night with a malignant obstruction?"

"an obstruction? do you need me to operate?" it was grasping at straws and i knew it, but i had to ask.

"bongi, the scan shows masses throughout the abdomen and almost his entire liver is just one large metastasis. i think we are deep into the palliative stage of his treatment. an operation might actually be a form of active euthanasia." and then the words dried up. it was pointless telling each other how tragic it was that such a young man was doomed. it wouldn't help to wonder how the course could have been different if he had taken the chemotherapy when there was still a chance. it was even more futile to wonder what would have happened if he had been operated earlier or, better yet, presented earlier somehow. in the end we just walked away from each other. no words would suffice.

yet, although i could walk away from my colleague, i felt i could not just walk away from the patient. i couldn't help him as a surgeon, that i knew, but maybe i could do something else.

when i walked into his room carrying one of my very precious rlbates theater caps and presented it to him as a gift, there was surprise in his eyes. but there was something more there too. his eyes still sparkled, but most of the life had already been drained from them. his body was just the frame of what it once had been but in his eyes i could see gratitude. when i left, there was a smile on his face. i hid my face from everyone as i walked out of the ward.

two days later he passed away. it was a small gift but, maybe in that stage of the battle we call life, the gift of a smile is really not that small after all.

contested

this post will be different to any previous post on this blog. it is a complete work of fiction although it is based on a telephone conversation that did take place. all the rest is a figment of my imagination.

a while ago, a friend told me about a writing contest. the brief was to write an original story of no more than six hundred words, based on a message on an answering machine. i decided to give it a go and see how i did. unfortunately, once i'd written the story and edited it down to the required number of words, when i tried to submit it, i discovered it was only for residents of the united states. so i decided to publish it here, having nothing better to do with it. please remember it is completely fictional and was written with the aim of entering a competition. it must be viewed in this light.

so without further ado, here follows the story.

johan was messed up. how could he not be? the war in angola, a war which, according to the south african government, didn't ever even take place, had done it to him. all the things he had seen there officially didn't happen. everything he had done, far from home, deep in enemy territory, whatever that meant, hadn't happened if you were to believe official government communique. but it had messed him up even if it hadn't happened.

johan was simply not suited to normal life. he had no skills and just didn't get along with normal people... alive people anyway. he felt quite at home with the dead, his time in angola had taught him that. the other guys used to laugh at him when he was always willing to drag the bodies of the dead and load them onto the front of the armoured car for transport to the quickly dug mass graves.

"johan, your wife seems a bit stiff there." everyone would laugh, except the dead, of course. they didn't laugh and johan appreciated that. maybe they understood him just like he understood them.

back in the real world, away from the war and the killings and the dead, no one understood him and he understood them even less. he tried a few jobs, but he couldn't hold them.

finally he got a job in the anatomy department of the medical faculty in pretoria. they needed someone to embalm the bodies for dissection and johan immediately jumped at the opportunity. 

embalming was easy to learn and johan very soon had mastered all the necessary skills. quite quickly he moved up the ranks and after a few short years found himself to be the boss. it was something he felt he could be proud of. most people weren't quite as at home as he was with the dead and they simply couldn't do the work for all that long. johan, on the other hand found working with the dead therapeutic. it was also different from his days behind enemy lines where they were required to kill them before he could enjoy their solace...the killing never really appealed to him. he saw it as a necessity, initially for his government, but later for himself, but he never quite got the pleasure from it that some of the other soldiers did.

now, many years later, the dead still comforted him in a way no one could understand. he sat in his office in the mornings, before anyone else had even arrived at work, eagerly awaiting the quiet companionship that came with the day's embalming. he used this time to browse the internet or do any other necessary mundane administration of the department. and it was on one of these mornings that he listened to the voicemail recorded in the early hours of the morning.

"uum....hello?  uum, i'd like to donate my brother's body for medical research...is that ok? uum...he died about a minute ago. i don't know what from, but he just.....wait a minute.....no, he seems to still be alive. he just moved.....no, i think that was his last movement. he is dead. he is only breathing a little bit, but I think he is about dead. do i maybe get some money? hang on, he's trying to say something now. no, he's not dead yet. i'll call you back tomorrow morning. i'm sure he will be dead by then...."

johan smiled. the living never ceased to amaze him. well, he thought, another companion on the way, or at least maybe.

accolades

i was truly amazed and privileged to read an article written about none other than me in the forbes website. it was a major lift-me-up and in many respects i feel i don't deserve it, yet i'm not complaining. what i particularly liked is the way it commented on my blog as a nearly completed work rather than concentrating on only one specific post or one post at a time. it meant a lot to me, larry husten and for your more than kind words, i thank you.

for those new to this blog, it is also a nice way to link to some of the old, forgotten posts that are quite often a lot better than the current material. for established readers, the links are still refreshing in that one can rediscover old unpolished gems.

also, it in itself is a well written piece (with fancy capitals and everything!!)

for those who would like to read it, the link is here.

trust

as i have mentioned before, all surgeons think they are the best. of course when we ourselves need surgery, there is a bit of a dilemma deciding who is the best qualified to carry out the procedure. so when i realized there was a strange looking skin lesion in my right inner thigh, i decided only the best would do to operate me.

in my rooms i informed the sister i would be carrying out a minor procedure. she immediately prepared everything as she had done for me many times before. only once everything was ready did she look around suspiciously at the empty waiting room and ask where the patient was. i informed her i would be performing the procedure on myself. she was very nearly successful in suppressing a laugh.

because the patient was a bit shy, and because of the precarious positioning of the lesion, i asked the sister to rather not be in the procedure room during the procedure but to wait outside, at least within earshot, just in case the surgeon ran into trouble.

quite soon i had positioned myself in a sitting position, pants on the floor next to me and procedure trolley within easy reach. i carefully covered my important bits, just in case i would be required to call out for help, and got started.

despite my severe needle phobia, the localising of the area went well and i did not pass out, which i definitely viewed as a good thing. the only problem i had was that my left hand found it necessary to hold my block and tackle out of the operation area and this essentially left me with only my right hand free to do the operation. fortunately i am that good that i could still remove the lesion with only one hand. unfortunately, as i was soon to discover, i am not that good that i can tie surgical knots with only one hand.

i placed the first stitch without too much trouble, but i just couldn't tie the knot. every time i removed my left hand, my gear fell over the gaping wound making it impossible for me to go on. this is about the moment i discovered the walls in our rooms are surprisingly sound proof.

so, to summarize, there i sat alone in the procedure room with a large self inflicted wound in my inner thigh with one hand holding my wickets and the other trying to figure out how to close the wound, shouting in vain for the sister to come to my rescue. in the back of my mind i was a bit worried exactly what that rescue would entail. she would have to do one of two very important things. either she would have to carry on with the operation and thereby deprive me the privilege of being operated by the best surgeon, or she would have to hold the family jewels out of the way.

finally she heard my increasingly desperate supplications and came in. this time there was little laughter, what with my looking alone and forlorn with a large bleeding wound between my legs. feeling a bit sheepish i explained my predicament and without too much pomp and ceremony, quite soon i could continue with the operation, my manhood totally at the mercy of my employee. i hoped then that i had been a good employer, but it was too late to turn back. i  threw in the sutures, amazed at the severe tremor my hands had developed. it may have been that i had been overcome with a deep concern for my patient, or at the very least his equipment. whatever the reason, despite my shaking hands, i managed to get the stitches placed and close the wound with a plaster. only once my pants no longer lay beside me on the floor, but had been returned to their rightful place and i felt less vulnerable did my hands stop shaking.

bongi reads

recently i was asked to do a reading of my blog for a sort of art evening for some of the doctors at our hospital. i read only four posts. i have decided to post the first one i read here.

doctor's visit

doctors don't like to go to doctors. i suppose we might see it as a failure or more likely it is pure intellectual arrogance. whatever the reason, there can be no excuses when you need to get an insurance examination form filled out. one way of taking the edge off it is possibly to try to use your conversational skills to awe the poor general practitioner forced to see a colleague in these uncomfortable circumstances.

dr peter swann, a tall dark and handsome man, wise and hyperintelligent, popular amongst women, with a vodka martini (or was that an austin martini, i forget), was required by his insurance company to get a signature on a form at least saying he was not quasimodo and had a blood pressure no more than moderately elevated. there was no option. he had to go to one of the local general practitioners.

as consultations went, this one was going quite well, except for the awkwardness inherent in having to examine a colleague. the gp had managed to establish that is was unlikely that dr swann would suddenly drop dead in the next hour or two, thereby defrauding his insurance company of millions and millions of rands (about a dollar fifty). in fact dr swann was even beginning to relax. so when the gp asked about any previous surgery it didn't seem at all inappropriate for dr swann to discuss in detail his recent minor surgery in the local hospital. in fact he decided it would be a good idea to wax lyrical.

"i recently had a small procedure done. everything went well, but it was a strange, somewhat unnerving experience."

"why is that?" the gp feigned interest.

"well, as you, know, in my line of work we don't really get to know the anesthetists too well. so i was quite surprised when this elderly blond haired wild looking lady introduced herself to me as the person who would be keeping me safe and soundly asleep while under the knife. when i told her i was a colleague she seemed much more nervous, and that's saying quite a lot because her general appearance and demeanor hardly radiated the impression of someone in control." the gp seemed suddenly a lot more interested in doctor swann's story, so, feeling encouraged, he continued.

"everything went ahead as i suppose it does just before an operation. i was moved across to the theater bed and all the necessary wires were attached to me. of course i was nervous, but i was trying to put a brave face on it. i even tried to make a joke or two, but she seemed much too tense to laugh and in the end her reaction just made me more nervous, so i decided to just quietly lie there and pray that everything went well. then she started to inject the white stuff that brings sleep. but just as she did, she suddenly stopped and spun around in a panic. she then turned to the nurse and spoke.

"where is the thing? you know that think i need? dam, why does this always happen when i'm working on a colleague?" obviously i was terrified. what was this thing that she referred to and how important was it in keeping me alive during my operation? why does what always happen when she is working on a colleague? was i going to survive or were these my last thoughts on this earth? i just started trying to ask her these questions, but it was too late. the white stuff she had injected was doing its job and i drifted off to sleep with more than a little concern for my safety." he stopped for effect. the gp was looking on intently. swann smiled. it was a funny story and he felt he had told it well. in fact he felt sure any ice that may have existed between him and the gp had surely now been properly broken. it even seemed strange that there had been any tension between them earlier.

"do you know the anesthetists at all?" asked doctor swann.

"yes, some of them"

"do you know the one i'm talking about?"

"yes. she is my wife."

the ice froze over instantaneously.

rambo

south africa is such an interesting place. things happen here that surely can't happen anywhere else in the world. take illegal mining in barberton for example.

barberton has some of the oldest deep gold mines in the country, maybe even the world. the gold rush in barberton happened long before gold was even discovered in johannesburg. of course the massive amounts of gold in johannesburg drew all the prospectors away and left barberton as a tiny, insignificant lowveld town with ghost mines. as time went on, it once again became financially worthwhile for the mines to be opened, although really only on a much smaller level. but once it became clear that there was still gold in the mines, the illegal miners were born.

it is difficult to fully understand what an illegal miner is. imagine people going down air vents and other such unmapped openings into deep underground labyrinths of once sprawling mines where they apparently stay for up to a month or two at a time illegally. they work mainly at night when the legitimate miners are no longer there and melt into the many unchartered tunnels during the day. being south africa, of course the propensity for violence is always there, so, when you put together your mental picture, add quite a number of ak47 assault rifles smuggled in from neighbouring mozambique.

so of course when the people in power  decided to rid their mines of illegals, it wasn't going to be enough to simply leave pamphlets lying around asking them to please leave. they decided force might be a more traditionally south african option. fortunately after our bush wars in namibia and angola we have an abundance of highly trained soldiers so to find hired guns is no problem at all. and in the end, that is what the mine executives did. they hired guns.

i was on call the night the barberton hospital phoned. they apparently had a gunshot patient shot with an assault rifle they wanted to send to me. it was different from the normal 9mm wounds i was used to seeing so i was frankly quite keen to accept the patient no matter what the injuries. it was going to be exciting, i thought, except of course a head injury. then the doctor said something even more left of the ordinary.

"bongi, they are going to bring him in themselves. it will take too long to wait for an ambulance." i was confused. who were the they he was referring to that were going to bring him in? how were they going to bring him in? was he going to be dead when they brought him in? these thoughts slowly migrated through my mind on their way to my mouth but before i could ask, my colleague had put the phone down. i was left with almost no idea of what to expect, but i at least knew it was going to be interesting.

half an hour later i was waiting at the entrance to casualties in true grey's anatomy style. for a split second i even felt more like an actor than a surgeon and nearly went back inside. but in the end my curiosity got the better of me and there i stood like the leading part in a hollywood production in the warm lowveld night waiting for something that i somehow knew was going to be out of the ordinary.

they arrived. it was out of the ordinary. a bakkie roared into the hospital parking area, apparently totally oblivious of the speed humps in its way. it came to a skidding halt just in front of me. immediately the driver got out and moved around to the back. his most striking feature was the r4 assault rifle strung over his shoulder, but it was only fractionally more striking than the rest of the man. he wasn't a particularly tall man, but he was well built. he wore black leather clothes, contrasted sharply with a dirty red bandana tied around his head. on his belt he had about four magazines for his rifle. quite clearly he was ready for quite a fight. then i noticed his face. it was calm and very nearly devoid of expression.

suddenly i noticed a second man standing on the back of the bakkie. he too was dressed like an action hero out of a low budget eighties movie, complete with assault rifle at his side and once again his face was without discernible expression. they reached down to lift something. only then, only when i heard the soft groan of pain, did i realize that the gunshot guy was lying on the back of the bakkie and this had been the they that were going to transport him. immediately i knew they must be the hired guns to flush the illegals out of the mines. there was ordinary and then there were these guys who were definitely out of it. i was intrigued.

they lifted the injured man and started carrying him to the doors.  they did glance at me as they went past but to them i think i looked too much like a tv doctor waiting outside to be taken too seriously. i scurried in after them, feeling somewhat sheepish.

the patient was in a fairly good condition for someone who had taken an ak47 round somewhere deep in the bowels of the earth and then been transported by rambo and sons over the mountain to our humble hospital, although he had quite obviously taken fashion advice from chuck norris.  i quickly rushed through the preliminary steps  to prepare the him for theater. then i went outside to speak to his colleagues, for quite clearly that is what they were.

"i'm doctor bongi. i'll be looking after your friend" probably the wrong choice of word, seeing as though i still had seen no display of emotion from any one of these guys, except possibly stoic resignation in my patient. "i think he will be ok." even this didn't move them. they looked exactly the same as they did when they still thought their colleague was sure to be dead by the morning. "tough crowd" i  mumbled to myself.

then i spent a bit of time trying to find out what had happened. i quickly understood their facial expressions.

they were part of a team hired to flush the illegal miners out. the plan was to go down the official shaft after all the legitimate miners had knocked off. then they were to push the illegals back and drive them out through the numerous secret tunnels that only they knew about. the only problem was this was day two of operations, so the illegals were expecting them. i put it together in my mind. a small group was going to go down in a lift into a mine full of armed criminals who knew exactly where they would be arriving.

"you went down in a lift into a war zone?"

"yes." expressionless.

"but they knew where you were going to get out. all they needed to do was wait for you at the lift."

"yes."

"yet you still did it?"

"yes." still no sign of anything close to emotion.

"why?"

"it's our job." did i detect the slightest hint of pride? no. it was probably the outside light reflecting off the wall giving a certain glint to his eyes.

"so what happened?"

"they were waiting for us. when the lift doors opened, they opened fire and hit our friend." i though he was using the word friend in a very broad definition of the word because i was fairly convinced the only interest he had in the survival or otherwise of my patient had more to do with who would they get to replace him when they went down the lift the next night.

"and once they had opened fire, how is it that you guys survived?"

"we fought our way out." at this stage the total lack of any expression on their faces was expected, but still i didn't expect it. it seemed to me that someone who goes into a death trap, sees his 'friend' get shot and then fights his way out to survival should maybe at least have the hint of something in his face at least resembling human expression or emotion.

i operated their colleague. i dissociated myself from his humanity, cut him open and got the job done. and then i realized. in so many senses, i too go down the lift into the dark depths of the earth full of people only out to see my demise. i too put myself in harm's way for some greater benefit and i too face trauma, albeit not my likely death. then i understood their blunted emotions. they were not too different from a surgeon.

behind closed doors

most non medical people have little idea what a general surgeon does on a day to day basis (unless, of course, they read this blog). few can imagine us elbow deep in blood and guts in an eternal battle against the angel of death. this is partly due to the fact that what we do borders upon the unimaginable, but it is also due to the rigid controls about who is allowed into the holy realm of the theater. understandably, not just anyone can be present at that most sacred of moments when the knife slides through the skin, opening that which is not meant to be opened. the average lay person will tend to simplify the whole process in their minds. the doctor has operated, so now what could possibly go wrong? i know what could possibly go wrong and sometimes it fills me with dread.

but at the moment when it is all happening, when the family are waiting outside, barred from the hallowed events performed within by a surgeon overcome with dread, it is all in the hands of that surgeon. then the family can only wait. as they wait they don't even know what they are waiting for. i understand it engulfs them in a feeling of immense helplessness. i also understand people don't like to be helpless.

it was a bad injury. the bullet hit him on the lower edge his left chest anterior and exited through his back about 5 cm below this level. the medical officer called me to see the patient in casualties at about 9 o' clock in the morning. 

"who gets shot at 9 in the morning?" i joked over the phone, but there was something in his voice that told me i'd better get there fast. maybe it was that he wasn't laughing at my joke.

i walked into casualties. the patient was pale and confused. he turned to me and tried to focus, but i realised he wasn't seeing me. it was as if he was looking straight through me, possibly at some distant object only visible to him. i quickly evaluated him. hemodynamically he was not in a good way. clearly there was some serious bleeding happening somewhere. equally as clearly we would need to operate him fast if he was to have any chance at all. i barked commands.

"you, five units packed cells and six plasma. i want them in theater immediately. go!" i went on. "you, go to theater and tell them we are going to be there in 10 minutes. i want a theater ready now. go!  you," i looked at my medical officer, "i have nothing for you to do. help me get this guy to theater. don't go!"

"uum, doctor." he replied, "i'll take the patient to theater but i need you to speak to the family. his parents are outside and they are very worried. i'll get everything ready in theater so long, but please don't make me speak to them?" hmmm, not the best time to mentally gear down enough to calmly reassure family members that i had things under control, especially when i didn't even know what things would need controlling yet.

"sure!" i said, remembering it's always important to look in control in front of the medical officers. moments later he was wheeling the patient to theater and i was introducing myself to the parents.

"doctor, i feel terrible!" was there something i didn't know? could it be that this guy's mother had shot him? just as i was trying to picture this frail old woman as a ruthless killer, she went on. "you know, doctor he was fetching his daughter from our house to take her to school. he is a night shift worker and we look after our grand daughter when he is at work. he got hijacked outside our house and that's where he was shot. i actually heard the shot doctor." she started crying. "i looked out the window, but when i didn't see his car...the hijacker had already driven off... i locked the door and stayed inside because i was afraid. only after ten minutes did i go outside to find my son lying in a puddle of his own blood. doctor, if he dies it will be my fault!" i felt for her.

"i'll do my best." it is difficult, really to say anything meaningful at such a junction in life. especially when my best may not be good enough. i said it anyway. no matter how inadequate it was, there didn't seem to be anything else to say.

soon thereafter i was in theater, just about to scrub up.

"doctor, the mother is outside. she wants to speak to you again." this was a bit ridiculous. her son was literally bleeding to death and the only thing that could save him was a very prompt operation, which we were about to embark on and here the mother wanted to use up some valuable time with a bit of chit chat? i was not impressed. yet i probably could spare about 30 seconds or so, i thought. after all it is important to maintain a certain rapport with family members, especially if there is a very real chance that the patient may not survive the operation. if the last emotion of the family towards the doctor before an operation is one of animosity, if the patient dies, that animosity will continue and may manifest afterwards, potentially even in accusations and court cases. i decided 30 seconds may just be worth the effort. i ran out.

"doctor," she grabbed my hands, "while you are operating, i just want you to know that we will be holding you up in prayer." i tried to pull my hands gently free. after all the 30 seconds i had allotted myself were almost up. she continued, "we will be praying that god will guide your hands and be in control of your every move. ok?" i had nothing to say to that, even though it seemed to be a question, so that is exactly what i said, nothing. i understood her. it was her way of not feeling totally helpless during the operation when she would be barred from her son in the most critical moment of his life. she already felt responsible for leaving him shot and bleeding outside her house for ten minutes before she went to him. if he died on my theater table she would live with guilt forever because she had not been with him at that moment. she was essentially telling me that she was not leaving him alone as he went into the restricted area of theater to face his tribulations. she was going to go with him by sitting outside and praying for my hands not to mess up. i smiled.

"ok, but i must go. time is of the essence here." i managed to work my hands from her grip, the same hands that would later be covered in the spilled blood of her son while i fought for his life.

the bullet had done its job. there was quite a mess inside, but the major injury was a transection of the splenic artery about 2cm from its origin. the open ends were pissing blood all over the place creating more than just a small challenge to get under control.

once the operation was over i was exhausted. the weight of being the only thing standing in the way of a human being and his demise drains one. also the emotional gymnastics involved in moving from the human interactions with the family and the patient to the simple mechanics of working with the blood and guts of a lump of meat on the theater table and then back to the raw hopes of the family directly after the operation can often be almost more than one can bear.

"we did what we could. he's going to icu where we will continue to do whatever we can to keep him alive, but we'll have to see how things go."

"doctor, we know god's hands, and not yours, were over him in there. we have faith." i wondered then why i felt so tired, if, as it turns out, i had apparently done nothing. i was too tired to bother about that then.

once the patient finally left the hospital alive i was so proud of all our efforts to pull him through. the patient and the family never said thank you. yes, normal people have little to no idea what happens behind the closed theater doors or in the minds and hearts of the surgeon, fighting on their behalf.

high fiber (regular)

granted, the prof had good hand skills. but i personally had doubts about the depth of his academic knowledge. i wish i could say that as i studied and got up to date towards my finals, i gradually realized that the prof may have been a little behind the times. but there was a more subtle sign that i cottoned on to much sooner.

even as a mere medical officer in the prof's firm, i was always amazed that on academic rounds he tended to swing the conversation towards constipation and how to avoid it with the consumption of enough fiber. far be it from me to criticize a good high fiber diet, but i did wonder how one ended up speaking about the colon, even when we were discussing a patient with breast cancer. but to be fair, it wasn't that the prof was clueless about other things pertaining to surgery, so in the end i just assumed he had a great interest in and a love for all things relating to the colon and how they could be managed with fiber. maybe he wasn't really trying to hide his lack of knowledge about other things but couldn't help always swinging the conversation back to his one true love.

many years later, when i was the senior registrar and it once again fell to me to rotate through the prof's firm just before my finals i at least knew what to expect to be taught on academic ward rounds.

when joining a firm, more often than not there are already a group of students there that know the ropes. sometimes they even view you as the new guy and it can be quite difficult to assert your authority. the first day in the prof's firm i realized i was likely to have problems with the incumbent group of students. on the morning rounds there was a silent resistance to everything i said, a sort of unspoken 'who do you think you are?'. it annoyed me. i was so close to finals i really didn't feel like having to stamp my authority on a bunch of snotty nosed students. i started wondering if there could be another way of approaching the problem. in the end i understood working for the prof changed one somewhat. maybe just the fact that they had been in his firm for a while was why they were being subtly aggressive. maybe to hammer them in the prof's typical style would achieve something in the short term, but it would further affirm their belief of the stereotypical surgeon. another approach was called for. i decided to bide my time and wait for the right opportunity.

the academic round with the prof was as painful as i remembered it always being so many years before. and yet somehow he didn't swing every patient and every condition towards constipation, which was at least a relief. finally we got to the last patient. the student presented and the prof gave instructions about how to further handle him. and that was it. the rounds were over. i was quite excited to move on to the ward work and get on with the rest of the day, which in my case would probably entail putting my tail on a chair and my nose in a book. we all walked to the door, but i could see the prof wasn't walking with his usual determined stride. he wasn't finished with us yet. suddenly he stopped.

"you know, constipation is a very real problem." at last, the old prof was back. by the reaction of the students i could see they had heard it all before. the one rolled his eyes. another's shoulders sagged, almost too obviously. i smiled. i'm sure they were all thinking i'm smiling out of naivety, seeing that, in their minds at least, i didn't know the prof's favourite topic. i was smiling for another reason.

"yes," continued the prof, "it is a problem that i have been struggling with for all of my professional career." too easy, i thought.

"well then prof," i looked at him, trying to mimic an expression of sympathy, "why don't you just try a high fiber diet."

once the students had composed themselves after fits of what i'm sure the prof viewed as inappropriate laughter, i never had another problem with them again. the prof?...well that's another story.

entrepreneur

i would like to say this is a south african story, but , truth be told, when people see the opprtunity to make money off the backs of the stupid and vulnerable, then it is pretty much a free for all (eg, eg.)

at the local state hospital, as it should be, there is an hiv clinic. as the name would imply they treat the many people in our area with hiv using modern antiretroviral medication which is proven to lower the viral load and can turn a once deadly disease into a manageable one, not unlike diabetes.

yet still there is a stigma associated with hiv and it gets treated unlike any other disease. you can't simply test someone for it like you would for diabetes. before testing someone, they have to be counseled so they fully understand the implications of knowing about the disease. if they refuse testing, then they are allowed to continue in their ignorance, without treatment of course. also, if they choose to be tested and are found to be positive, before they are permitted to see the doctor who will be managing their newly diagnosed disease, they are required to speak to the councilor once more. this is supposed to be a time where the councilor explains to the patient that hiv is no longer a death sentence and explains the importance of adhering to the treatment plan. yet this is also an opportunity for an enterprising charlatan.

the patient in question was back after having her hiv test the previous week. i think in her mind she actually knew she was positive. there was little else that could explain her symptom complex and she had already accepted the inevitable. all she wanted to do was to get through the obligatory counseling and to get to the doctor so they could work out a treatment plan. she sat down with the councilor.

"you are hiv positive,"

"yes, i thought as much."

"now you are going to see the doctor shortly and he is going to discuss treatment with you." this is exactly  what she wanted. she just wanted to get through this and see the doctor after all. "he will tell you about all sorts of western medicine that you will have to take every day for the rest of your life." again, no surprises. "but there is an alternative." what? this was not in the script. she thought she would rush through this so called post counseling and get to the doctor. yet humans are inquisitive creatures.

"what do you mean?"

"i mean there is another way." with this, she reached under the table and produced a second hand pepsi bottle full of some liquid. the patient looked at it in surprise. it had a slightly green hue to it. the lid had scratches on it indicating that it was probably quite old and had been used many times before. "this is a cure for hiv. it is a mixture that a sangoma has created. unlike the western treatment that the doctor is going to offer you, it has no side effects. the other advantage is, because it is a cure, you only need to buy two bottles and use it for only two weeks and you will be cured. and each bottle costs only two hundred rand." she smiled. it was meant to be a warm, reassuring smile, but the patient saw it for what it really was, an evil smile hoping to snare yet another victim and send her down a slippery slope after fleecing her of her hard earned money.

yes south africans can be entrepreneurs. i don't have it in me though.

diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.

chicken feet

i hate kalafong (hell). there are many reasons for this (here, here, here, here, here), most emotional, i confess. but if i am honest there is one incident that stands head and shoulders above the myriad of traumas that i experienced there.

one of the strange idiosyncrasies of kalafong (hell) is that some time during each night shift, all the sisters of each ward get together in the duty room and eat chicken feet. i have no explanation for this. maybe there is an abundance of chicken feet in the area. maybe the sisters are paid in part with chicken feet that absolutely must be eaten before they leave for home after their shift. maybe it is part of some bizarre ritual that initiates all kalafong sisters into some secret evil cult. i simply do not know.

i was a mere fourth year medical student which meant i was at the absolute bottom of the rung that night on call for internal medicine. i knew nothing and was of almost no help to anyone. the only thing that i could do was to put up drips, so the senior medical students would send me to the wards whenever they got a call that a drip needed inserting. for some reason kalafong sisters never put up drips. maybe there was a fear that the patients were allergic to chicken feet and the residue of the no doubt scrumptious delicacy on the fingers of the sisters could potentially cause the patients harm. they were clearly not about to take that chance, so there was plenty of opportunity for me to hone my already very well honed drip inserting skills.

i had just left the female medical ward after inserting a whole host of drips and was quite keen to see what was going on in casualties. i walked in.

"drip to be inserted in female medical." the sixth year student smiled. i don't think it was really meant to be malicious although it felt that way at the time. i think it was more a relief that he had done his years of continuous drip insertion honing and was glad that he honed no more. it was the natural cycle of things and he had passed the batton to the next group. it was simply my turn.

"i was just there!" i protested at no one in particular, turning to leave with my shoulders sagging just enough to be noticable to the discerning eye.

i entered the ward through the back door. the main door had been locked by the sisters. this was another thing one got used to there. it was just something the sisters did at night.  the reason for this behaviour elluded me, especially when they had just called for someone to insert a drip. you would think that they would unlock the door in anticipation of that person actually arriving to insert the drip. maybe they needed their privacy while performing strange initiation rites with chicken feet.

as i entered the ward, a patient looked at me.

"doctor, help me! i'm dying!" i froze. it was dark. i could only make out the patient's shape, silhouetted against the dirty cream coloured wall. yet her eyes were so wide with fear that i could see her white sclera. i felt a shiver go down my spine. what was i to do? i was only a fourth year. i didn't know this patient and even if i did, i had no knowledge to actually help her. in my naivety i hadn't yet learned the rule that more often than not, if a patient tells you they are dying, it is because they are in fact dying. the one thing i knew is that i couldn't ignore her.

i walked up to her. she lifted her arm weakly. then suddenly her fingers encircled my arm and all her remaining strenght seemed to go into her grip. her nails bit into my flesh as she pulled me close to her face.

"help me doctor, i'm dying!" she repeated. she scared me, so i pried myself loose and checked her file. she had been admitted the previous day with the diagnosis of meningitis. antibiotics had been prescribed but only one dose had been signed for since admission. probably the drip had been out when the other doses were due and once some poor fourth year had reinserted it, the sisters hadn't bothered to put up the dose that had been missed. at least there was something i could do, i thought. i could check to make sure the drip was working and get the sisters to give the last dose of missed antibiotics. somehow i allowed this thought to make me feel better. i would help this lady and all would be well.

i checked the drip. it was working well.

"don't worry, mamma, i'll send someone to help right away." i said as i turned to leave. she lunged for my arm again when she saw that i was going, but there was no strengh left and she missed. as i walked away a knot developed in my stomach. i felt that i had failed this old lady. i had done the little bit my knowledge had permitted me to but i had also allowed my fear of her and of what she was facing to intimidate me to such an extent that i hadn't really stayed to comfort her. i was determined to be a change in her circumstances and her life. i would speak to the sisters.

i walked to the duty room. the door was closed but there was an almighty din emanating from inside. the sisters seemed to all be shouting and laughing in unison. i knocked and opened the door. for a moment the bright light from their happy little room blinded my eyes that had become accustomed to the darkness of the ward. the light seemed to pour out into the gloomy ward behind me. all the sisters were sitting around the table eating chicken feet. when they saw me they all went silent, but continued eating.

"good evening sisters." no answer, unless silence is an answer. "sorry to bother you but the patient in bed 5 in cubicle d is in a bit of distress."

"we'll check on her now now." i knew what now now meant in our strange south african english. now now was not as soon as now and implied no urgency. now now was not as now as i wanted it to be.

"ok," i said, knowing that if i antagonised them they would purposely postpone checking on her just to teach me a lesson. "also i see that she hasn't yet received her last dose of antibiotics. her drip is working, i checked, so please give it to her when you go to her." the sister looked up from the chicken foot she was now toying with between her fingers. i saw in her eyes that she despised me, although i had never laid eyes on her before in my life. some things in kalafong one learned to accept.

"i said we would see to it now now!" she repeated. then her head dropped back down to give the chicken feet the full attention they seemed to deserve. i stood still for a minute. then i quietly closed the door.

as i walked away to do the drip i had actually come to the ward to do, raucous laughter errupted from that small brightly lit room. it brought me to a stop in the middle of the floor in the dark ward. i felt tears well up. i didn't know if i wanted to cry because the sisters were clearly enjoying a joke at my expense or at the futility of an old woman who lay in bed 5 in cubicle d all alone with the fear of death over her. i just knew there was something horribly wrong with the whole picture.

i got the drip up and running in double quick time. i then rushed off back to casualties, but not before quickly checking on the patient again. when i approached her she still had the same stare. this time her arms lay still on the bed beside her.

"don't worry, mamma," i said, "i have asked someone to come and help you. it is all going to be ok." she didn't react. "i promise i'll also come back myself tonight to check on you." a little of the fear went out of her eyes. only a little.

on the way back to casualties i made sure i composed myself. it wouldn't be good to show the senior students that i had been so affected by something they no doubt had seen quite a lot of. anyway everyone always said not to let kalafong get to you, otherwise it could change you forever. at that moment forever seemed like such a long time. the sixth years were busy doing a lumbar puncture behind one of the flimsy curtains in the casualty unit that seemed designed to give the impression of privacy without actually delivering any real privacy. one of them looked up.

"sorry dude, but they just called for another drip in male medical." i turned and walked out without saying a word. the quiet of the open air kalafong corridors could possibly afford my soul a bit more peace than the overwhelming noise of human suffering of casualties. usually i could handle it, but then i felt a despondency and futility that was too much to bare.

in the end there were three drips in male medical so it took me longer than expected to get them all up and running. this time it didn't bother me. i was in no rush to get back to casualties. also i knew i had told the old lady in female madical i would check on her and i was afraid. i was afraid of what i could not do for her. i was afraid i would be inadequate. i was afraid of the face of fear that i had seen in her eyes. somehow her reality at that moment was too real and i didn't want to face it. i wanted to be at home in my warm bed, ignorant of how terrible life could be. but i knew i had to go to her. if for nothing else, i had to just be with her so that she was not alone. i walked slowly to female medical.

i walked past the duty station. this time the door was open, but besides that there was no discernible difference. all the sisters still sat exactly where they had been. some of them were still eating the last of the chicken feet. the light from their room lit up half the ward, but did not reach all the way to cubicle d. they didn't see me slip past them so their laughter must have been aimed either at someone else or just part of the normal merriment associated with people sharing a meal together. still, just like the light, it seemed to me to be out of place.

"mamma, i'm here" i whispered as i approached her bed, just in case she was asleep. she lay with her head to one side. she didn't stir. i walked closer and took her hand. it was cold and clammy. i leaned towards her face. even in the darkness i could see her eyes were open, but they were fixed in the stare of death. she had died alone and i had failed her completely.

i have hated the sight of chicken feet ever since.

understandings

anaesthetists and surgeons work together quite a bit, but they are very different creatures. sometimes it takes a bit of effort for them to understand each other and get along. some would say it takes effort from pretty much anyone to get along with a surgeon. so it is nice to hear a story occasionally of an anesthetic colleague that is willing to do what is needed to understand and get along with the general surgeon he was working with. these were the observations of a student during his rotation through the anesthetics department.

when the student in question arrived at work, he was quite excited to hear that he was dealt into the emergency theater.

"off you go," said the prof to him, "they are still busy with a trauma case from last night."

when he entered theater it was clear that there had been quite a lot of action. the floor was covered in blood which had been smeared around by the feet of the surgeon and the floor nurse, creating a macabre work of art with bold red strokes of the brush on the canvas which was the floor of theater. against the wall on a rack hung multiple blood soaked swabs, bearing testimony to the battle that had already taken place in that small room. the surgeon was still frantically busy working in the open abdomen, his arms besmirched with dark blood to his elbow. the front of his gown was similarly stained. the student looked around and took in the complete picture of this fight between life and death, yet immediately he noticed something that didn't seem to fit in with the high stress situation that met the astonished student.

off to one side, the anesthetist sat quietly in his chair with his arms folded and a calm expression on his face. he wasn't even looking at the monitor. in fact he sat slightly behind it. from this vantage point he glanced up, greeted the student and offered him a chair. the student sat down wondering at the steel nerve of this anesthetist in the face of such a tense situation.

then an alarm went off on the monitor. the student jumped up to get out of the way as his senior finally moved to see what was happening. but all he did was to turn the alarm off and sit down again. and so the student sat there with him, too nervous to speak and wondered what was going on.

after quite some time the intense concentration of the surgeon was broken. he turned to the anesthetist.

"how are things going up there?" he asked and then as an afterthought added, "the bleeding is now under control."

the anesthetist slowly looked up and spoke for the first time with a wry smile plastered across his face.

"well actually the patient has been dead for quite some time now," he said, "but i know how much you surgeons like to operate and it looked like you were having so much fun, i didn't want to disturb you."