live and learn

i am not an orthopod. i don't drive a four by four. i don't wear a checkered shirt and i sure as hell don't use a tourniquet when doing an amputation. to be fair, i have nothing against four by fours and a checkered shirt just makes me look like i'm wearing a dishcloth. but the tourniquet rule is absolute.

there are a few sound clinical reasons general surgeons don't use tourniquets for amputations. we tend to do amputations on people with compromised arterial blood supply so we tend not to want to make things worse by constricting the artery upstream from where we are working. we are maybe a bit scared that that constriction will be just enough to cut the artery off permanently, the proverbial last straw. also the bleeding in our patients with such poor blood supply is much less so a tourniquet is consequently less helpful. in my case, however i think the decision is also based on previous emotional trauma.

i was a community service doctor in a rural hospital. quite early on in that hospital i had already been schooled in the fine art of surviving without senior cover, so when my cuban orthopedic consultant asked me to handle the rest of the theater list i pretty much knew i had no choice in the matter.

"uum, doctor, the last case is a below knee amputation. i've never done one of those." i objected, not that i had any hope of my gentle supplication bearing any fruit.

"yes, but you assisted me with one just last week. just put the tourniquet on, cut the leg off, tie the vessels and close like you saw me doing. i'm tired and i'm going home now." with that, even before waiting to see the pained expression on my face, he turned and left. i had no choice. i was about to do my first amputation.

i carefully placed the tourniquet, pumped it up to the required pressures to prevent any blood supply to the doomed leg and went to scrub. quite soon i stood with only the theater sister to help with my knife poised, ready to do my thing. i mean how hard could it be? i just needed to get the leg off and the wound closed. so with this misplaced reassuring thought in my mind i got to work.

half an hour into the operation (i was a lot slower in those days) i was feeling quite good. i had identified the major vessels and tied them off. the bone had been cut and i was handing the leg to the floor nurse. i thought to myself that this is what it feels like to be a surgeon. you look important and in control. it was quite a rush. i should have known it was too good to last long.

at about this stage i decided all that remained for me to do was to let the tourniquet down, to make sure i had control of all the bleeders and close the wound. i was already thinking of all the people i needed to phone to tell them i had lopped a leg off. my friends in internal medicine would be so jealous. pity when i had assisted the orthopod the previous week i hadn't paid much attention to when and more specifically how he let the tourniquet down. i decided i would decrease the pressure by half. that way if there was an arterial bleed, i reasoned to myself, i would see it and control it before it got out of hand. it didn't occur to me at that heady moment of my life that if i allowed the artery to pump blood into the leg but maintained a tourniquet pressure high enough to prevent that blood from getting back into the body via the veins the result would be venous engorgement with resultant venous bleeding. even when every tiny microscopic vein started oozing like there was no tomorrow, i still didn't make the logical deduction. i just kept on clamping the veins one by one and tying them off with trusty vicryl. but the more i tied off, the more new bleeders seemed to sprout into life and start oozing uncontrollably. i suddenly wondered if one could die of vicryl toxicity. it sure seemed i would find out with the amount of vicryl i was systematically putting into that stump.

and so this scenario continued for quite some time. all the bravado and gusto that had swollen my head only moments before was long gone. i felt alone and scared. i even considered calling the cuban consultant, but he had made it quite clear i was expected to handle this myself. i was determined to soldier on.

"doctor, maybe you should blow the tourniquet up again?" the sister's suggestion seemed logical but somehow it just annoyed me. if i hadn't used the bloody (pun?) tourniquet in the first place i wouldn't be in this mess, i answered her in my mind, but that didn't seem to make sense. somewhere from my deep subconscious i started hearing a little voice. i suspect it had been screaming at me all along, but in the heat of battle i had been too distracted to pay any attention. at last i stopped to listen. the tourniquet was the problem, not the solution. that is why the thought of blowing it up again was so annoying to me, even if on the face of it it seemed like a good suggestion. i immediately knew what to do.

"please blow the tourniquet completely down." i said, trying to sound as in command as my quivering voice would permit me to. i then took a swab, pushed it against the oozing open wound and took a moment.

after not too long i ventured a quick peek at the wound. i lifted the swab and was relieved to see a dry wound with absolutely no bleeding. even the tiniest of vessels donned a vicryl tie and i think the few remaining capillaries were too scared to permit even one red blood cell to escape lest the same fate befell them.

at last i got the stump closed and left theater, completely worn out form the high levels of adrenaline i'd been exposed to, albeit directly due to my stupidity. oh well, live and learn.

never again did i use a tourniquet for an amputation.

compassion fatigue

a while ago i ended up in conversation with a psychologist. she mentioned the danger in her profession of compassion fatigue. the term struck a chord in me. she was referring to people moaning about how tough their lives were when their lives were nothing close to tough. it irritated her and she knew she needed to guard against this. i decided not to even mention to her what my compassion fatigue was like. it might have made her think less of me. i know i did.

he was no more than a common criminal of the south african variety. on that fateful day he decided to rob a small rural supermarket. i suppose he had gotten his hands on a gun and it seemed like the natural thing to do. anyway he entered the store with gun at the ready. he entered the outer door and was in the tiny area of about two meters between the inner and outer doors. just at this moment the owner of the shop was exiting the store and the two found themselves together in this rather cramped space. the owner immediately realised there was something amiss. this might have been due to the fact that he was staring straight down the barrel of a gun. then all hell broke loose.

the criminal didn't say a word. he started blazing away, spraying that tiny space with a hail of deadly lead. the owner dropped instinctively to the ground, drew his own weapon and fired one single shot. when all was tallied at the end, the shopkeeper had come off better. he had been hit in the arm but the damage was minimal. his shot, however had entered the criminal's head on the side just in front of the temple. it had then passed through both eyes and exited on the contralateral side at about the same place. the guy would be blind for life. i reflected that his terrible aim would now be even worse. it would definitely be a problem with his chosen profession.

the other case i thought of was a car thief i once treated. he got shot in the line of duty. he was innocently driving away at high speed in a car he had just liberated from the rightful owner when the police, who were on his tail, shot him twice. the one bullet took out his femoral artery. the other shattered his knee and tibial plateau of the other leg.

to cut to the chase, we cut his leg with the arterial injury off to save his life, he was that far gone. the orthopods stuck an exfix over the knee on the other side. and then he gradually recovered. at about this time i was transferred to orthopaedics so when he developed a pseudoaneurysm of the popliteal artery of his good leg i just heard about it via the grapevine. i also heard that they were going to give it some time before they operated, hoping that...well i don't know what they were hoping actually. anyway safely tucked up in the orthopaedic hospital it was not my problem.

then i learned that the orthopaedic surgeons were going to try to repair the tibia and i was going to be involved. step one was to get the patient down to the orthopaedic hospital from the main hospital. other than the usual administrative frustrations, he was finally loaded into an ambulance and brought down. it was the loading out that proved to be tricky.

as the ambulance drove into the parking area of the orthopaedic hospital the aneurysm burst through the skin and the patient started bleeding all over the place. he was rushed straight into theater and yet still by the time he got there once again he was flirting with death. the vascular surgeons were called and they arrived amazingly quickly. they then sort of looked at the leg for a while. after a few minutes of inaction they pointed out that the muscles of the leg were dead. it seemed that the pseudoaneurysm had gradually decreased the blood supply to the leg and by the time the thing had burst in the parking lot, the leg was already in a bad way. they then instructed us to remove it and left. the orthopaedic surgeon in turn instructed me to remove the leg and then he too left.

as i lopped off the limb i reflected on this twenty something year old who now had to face the challenges of life without a leg to stand on. it seemed sad. but then i realised my own car had been stolen only about a month before and it was not completely impossible that this person could be the very person who had stolen my car. it was the life he had chosen and the risks were part of that life. i struggled to feel sorry for him. besides, i reflected, he would no longer be so fast when running away from cops in the future.

the first time i realised i had compassion fatigue was around intermediates (roughly half way through specialising). i was warn down from cases like the two mentioned above. but there also seemed to be a run of gunshot wounds of criminals that i ended up trying to keep alive at unearthly hours with exams looming. in the end i just seemed to get sick of them and overly sceptical.

then one day i was required to go to some or other awkward social function. at that time my work was so all encompassing i didn't get out much and it showed. i ended us standing away from the normal people and whenever i was forced to speak to one of them, when i looked at them my mind kept on repeating one phrase over and over again.

"fresh meat."

i needed a holiday.

bell bottoms

i recently went to prague. what a culture shock. the place is clean and beautiful and safe. i travelled quite a bit on the public transport and not once felt in danger even though i'm south african.

there is generally law and order. on the first day i went on the underground i did not stamp my day ticket because, being south african, i just assumed there would be someone to stop me and check. there was not. they rely on the people there being honest. being south african i rode the whole day essentially for free. then my conscience got the better of me and i bought another ticket so they would not lose money.

you see we south africans have no law and no order. we get away with whatever we can. we all speed and we all jay walk and we all bend all the rules as far as we won't get caught. in prague it is exactly the opposite.

but getting back to the story. one reason it was such a culture shock is because a while ago, to travel on public trains in south africa was quite risky. you see there were gangs that would throw people off moving trains for a laugh. there was also a time when certain trains would get attacked by automatic wielding thugs that would indiscriminately shoot people. these days there is more security (all armed of course) so it isn't quite so bad. there still is the occasional torching of a carriage if it turns up late. let it never be said south africans can't express their anger at trains not being on time.

anyway, while i was safely travelling on the czech (for americans, that is where prague is) public trains, i thought about a few of the patients i had seen. i don't think i'll talk about the guy that got corkscrewed between the train and the platform here. the bell bottom patient came more strongly to mind.

it was in the days of the indiscriminate throwing people off and in front of trains. most died on the scene, but a few got to us. for those who don't know, to get injured on south african train tracks is a sure recipe for sepsis. the trains drop their sewer directly onto the tracks, so to get an open fracture there usually ends up quite a mess. my patient was thrown in front of an oncoming train from the station platform. i suppose the people who threw him there thought it was quite funny at the time. we at the hospital did not.

the poor victim of this senseless crime fell with most of his body over the further track. in fact only one leg lay over the one track. unfortunately he had no time to pull his leg away before the train went over it.

now, to fully appreciate what happened one must realise the patient was fully awake and fully sober. he had in fact started extricating himself when the first wheel cut and mangled his leg about mid thigh. he continued to pull himself away. the second wheel therefore hit his leg about two inches lower down. the next wheel then struck about two inches below that and so on. so the leg was mangled worse than any mangled limb that i have ever seen and more than likely will ever see. it had deep cuts at two inch intervals. the femur was severely broken but it was not nearly as bad as his lower leg. the lower leg spread out like a bloody and distorted bell bottom ending in a very wide flat thing that had once been a foot.

suffice to say he lost his leg that day. (for up and coming south african surgeons, leave the wounds open from train track injuries, like we did. otherwise sepsis will set in and things will get worse.)

so while in prague, i was really confronted by the many acts of meaningless violence we see in our country because i had a clear picture what life could be like in a peaceful place. i honestly wondered what the point is here.

callous

in a previous post i came across as caring and in touch, but sometimes i forget to be this.

i was doing an above knee amputation. my consultant had recently explained a technique whereby one attaches the muscle to the bone stump directly and not just to the membrane around the bone (the periosteum). this required that holes be drilled into the bone which would be the anchor points for the muscle. i had never done this before and was grappling with the drill.

at this point, as serendipity would have it, the small porthole window of the door leading to the scrub room filled with the eager faces of a bunch of youngsters. a theater sister who was taking them around came in and informed me that they were school students that were considering medicine as a career and had come to the hospital on some sort of career day outing. she asked me if i'd mind if they came into theater in groups of two to get a better understanding of what we do.

now, understand, i love surgery. any opportunity i get to promote it i take, so i thought this was a great idea. of course i said yes. the first two came in.

let me take a moment to sketch the scene. i've just removed the leg. the bloody stump is sticking out like some cheap prop in a second rate horror. i'm trying to get the bloody (or should i say blasted) drill to work, so i'm not really doing anything besides getting more frustrated by the moment. the students come in and see this setup. not being overly busy, i ask them where they are from. the first guy says he is from a particularly good rugby school in town that, coincidentally, had just lost the gala match to my old school. even the drill could wait. i asked him about the game and what he had thought. he seemed a bit withdrawn and non responsive. i couldn't understand this. it had been closely contested and although his team had lost, they had played well.

then i noticed that the poor fellow was pale and his eyes seemed to be glazing over. the sister quickly took them out. no more scholars came in after that. i did see the horrified face of one young girl peep in just before they moved on. i think i even saw tears. later i heard that some of them needed to be resused with tea and sugar.

in retrospect i was a bit foolish. not all school children who think they want to be doctors are cut out for the job. and not all doctors are cut out to be surgeons. if i had had the opportunity to go into theater as a school student i'm pretty sure i would have thought, 'cool! he's actually cutting a leg off!! wow!!' but that doesn't mean these particular students are also going to think like that. i actually should have known that it was fairly unlikely that my and the sister's good intentions would have fallen on fertile ground.

p.s i never did get that drill to work.