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."

one shouldn't laugh, but ...

when i wrote the third principle, i was reminded of another incident. then i couldn't laugh. now i shouldn't.

i was working a casualty shift in a private hospital to make a bit of extra money (a registrar barely made enough to survive). it had been a standard night of treating the aches and pains of people who had been sick for weeks but had decided that once the sun set on friday evening they could no longer endure. maybe they just wanted to torture me.

anyway, finally a real casualty case came in. it was a young lady who had fallen and hit her head. she was fine except for an unsightly gash on her forehead just at the hairline. i prepared to clean and suture the wound. being a state doctor i had hardly sutured any face wounds on sober people, so i remember telling myself to make a point of chatting to her during the procedure to ease her fears. usually good old ethanol did all the fear easing and i was left to my own thoughts while placing the sutures.

so there i was at the head of the patient being as friendly as i could. i'd cleaned the wound and had placed the first suture. the second was going in when an ambulance pulled up. two paramedics brought a guy in on a stretcher. i had my back to them so i wasn't really watching them too closely. then the sister shouted,
"this man is not breathing!"

i left my suture just where it was and ran. as i changed my gloves the ambulance men were asking the patient to shift to the next bed. he wasn't listening to them. they seemed indignant. the sister grabbed him and dragged him over as i arrived.

there was no sign of life whatsoever. he was extremely pale. his trousers were bloodied. he had no drip. we commenced a full resus. after going through all the motions, i called it. the man was dead. i then looked over his body. he had a massive laceration in his groin. his femoral artery was visibly transected. that could be why he didn't respond when the ambulance chaps had asked him to move across to the resus bed. i asked my usual question.
"when you picked him up, was he bleeding?"
"no." they answered. that is why they didn't put up a drip, apparently.
"was there blood at the scene?"
"yes." the one man replied. "he was lying in a puddle of blood."
"was it maybe about five liters of blood?" i wondered aloud.

surgical principle number 3: all bleeding stops

this is not originally my principle, but it is so true that it somehow found its way into the surgical principles of bongi.

i first saw this principle in action many years ago when i was a community service doctor in qwaqwa. i was doing a call in casualties. actually, the way it worked there meant i was doing more than just a casualties call. i was also the anaesthetist on call and the overall backup for the two interns. for any big surgery we'd call the cuban surgeon out. otherwise we were it. the interns would do the caesarian sections. i would dope the patients and resuscitate the baby if needed. the interns would also do the debridements and ectopics. here i would dope and give useful advice about what to cut off and out and how. anyway i digress.

one of the hospitals that referred to us phoned. the guy had a stab wound neck. he told me it was bleeding profusely and he wanted to send it for surgery. i naturally accepted the patient. but i told him to somehow apply pressure to the wound to control the bleeding for the trip (his hospital was about 40 minutes away). i actually suggested he send someone with a bit of savvy who could put their finger in the wound to directly stop the bleeding.

once i had gotten off the phone i got casualties ready for a big resus. in qwaqwa this took some doing. the charge sister had to unlock the cupboard where the drip needles were kept (they tended to go missing leaving the hospital with no means to put up a line). i checked the intubation equipment and discovered the batteries in the laryngoscope were not working. this resulted in a protracted search through the hospital for either batteries or another laryngoscope. finally we found a working one. i soon gave up on getting a working defibrillator, although some nurses said they heard there was one somewhere on the second floor. i then phoned the surgeon to give him a heads up. he told me to phone back once the patient arrived. then we waited.

about an hour after the initial call, an ambulance came tearing in. the paramedics jumped out and came rushing in with a patient on a stretcher. the patient was tubed. one paramedic was bagging him. another was giving chest compressions. but there were two other things i noticed right away.

the first was that the neck wound was open with no clear signs of any attempt made to stop the bleeding. the second was that the patient was not bleeding.
"when you left the other hospital, was the patient bleeding?" i asked.
"yes!" replied the guy pumping the ambubag. "he was bleeding like crazy!" he seemed to be the one in charge.
"and when did he stop bleeding?"
"about five minutes after we loaded him."

i called it right there, thereby saving everyone a whole lot of paperwork.

and thus i learned that all bleeding stops....eventually.