doing nothing

surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. i remember one time that this turned out to be slightly humorous in a morbid sort of way.

i was in my vascular rotation which was not too much fun (except for a short moment). generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. and there was pretty much nothing worse than an abdominal aorta aneurysm (aaa). scratch that. a bleeding aaa was a lot worse than an aaa. so when casualties called and said they had a bleeding aaa my heart sank.

the patient was pale and clammy and his heart was racing. but the thing that struck me the most was his age. the man was 89 years old. the casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. so, in summary we had a man just this side of ninety with comorbidities and a condition that was know to kill most of its victims thirty years younger than him. the chances of him surviving the operation were dismal. i called my senior.

my senior (the vascular fellow) examined the patient and went through his file. like me he concluded that an operation would push him over the cliff whose edge he was standing next to. in consultation with the patient's son, the decision was made to make the patient comfortable and leave him to the inevitable. i confess i had the thought that at least i'd get to sleep, but i also knew the sort of sleep one gets while waiting for death to take one of your patients is a broken and rocky sleep.

the next morning i arrived for my rounds. i hoped the patient was dead but when i walked past his son just outside the ward i knew i would find him alive in the ward. after a patient dies the family always seem to flee the hospital. the stress of the night was etched into the face of the son. i could tell his night had been worse than mine.

sure enough when i entered the ward, there was the old man lying in bed just where i had left him the night before. it seemed the pain medication was working though. he wasn't quite as restless as the day before. i walked into his room. i didn't bother checking his vitals. what would be the point? he looked up at me. i was surprised to see he was doing so well. i remember hoping the fellow hadn't told the family it would be all over by the morning because the old man seemed to be set on proving him wrong. the one problem with him still being alive was that i'd have to take over the role as the intermediate with the family. the fellow would make himself scarce now that the initial footwork had been done.

i greeted the old man.

"môre oom." i said. he looked at me.

"môre neef" he replied, using a greeting that had gone out of circulation many years before i was even born. i smiled. he seemed quite spritely for someone in his position. but his next statement really gave me a chuckle.

"neef, is it true that you are not going to operate?"

"yes it is true, oom." i replied.

"well then if you are not going to operate why don't you send me home? there are things i need to do on the farm you know." how could one not admire that sort of attitude? i smiled broadly.

he took another day and a half to die. it was tough on his son, but i suspect he sucked the marrow out of every one of his last moments of life.

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.

pseudoaneurysm

there is nothing pseudo about a pseudoaneurysm except that it is not actually an aneurysm. where an aneurysm expands the wall of a blood vessel, in the pseudo variety the blood escapes from the vessel altogether creating a ballooning of turbulent blood flow outside the vessel's constraints. both may burst, but, seeing that the one in a sense has already burst, when it bursts again it is not an understatement to say this is not a good thing. at that moment you hope there is someone who knows what to do. or in other words you are not in rural south africa.

it was during my witbank days (way back when i started blogging). i was up in my office (a thing no self respecting surgeon should ever have) trying to fend off the boredom, probably by blogging, when the call came in. it was the radiologist, an old man who worked in the state hospital as part of his semi retirement gig. he didn't sound happy, very unusual for a radiologist. he told me that he had done a sonar for a pseudoanuerysm of the brachial artery (the upper arm) and the thing had burst. he had then called the surgeon on call, a medical officer, which is usually the best you are going to get in the state. he felt the medical officer wasn't showing due urgency and was worried she didn't have things under control. he had therefore gone over her head and called me. i ran.

i entered the room. there was blood everywhere. the upper arm had been bandaged closed, but still there was bright red blood oozing from the bandage and expanding a new puddle of blood below it. the patient was already confused, and very pale. i was worried. i took over.

soon the medical officer had been sent off to theater to get them ready for the worst eventuality. a junior doctor had been delegated to get blood. i got better lines up for fluid and moved the patient to theater. quite soon we were ready to operate. when i took the bandages off in the controlled environment of theater, i was honestly shocked. there was about a 10cm diameter area of necrotic skin stretched tight over a very large mass that apparently had been pulsatile before the application of a tourniquet. i wanted to know how this had been allowed to happen. pressure necrosis is not something that happens suddenly without warning.

the patient had presented to a peripheral hospital with a pulsatile swelling in the brachial area about a month after a common or garden stab wound to that area. the peripheral doctor had made the tentative diagnosis of pseudoaneusysm and phoned the surgical medical officer at our hospital. she apparently told him that we would not accept the patient until there was a sonar confirming the diagnosis. the poor peripheral doctor obediently phoned the radiology department where he was given an appointment in two weeks time. he then admitted the patient and observed the aneurysm expand before his eyes. finally he was observing pressure necrosis developing in the skin overlying the aneurysm. one can say he didn't think to contact the surgical department again but he rested secure in the fact that a so called surgeon had told him he could wait and wait he would. after all it wasn't his mother or brother or friend and he wasn't going to be sued in the state health department, so why should he care? this is, after all, africa the continent of selfishness and cheap life.

when the patient finally ended up before the radiologist, he went ahead with the sonar although it was clear there was a large area of necrosis over a pulsatile mass. how could he know that the gentle pressure of his sonar probe was all that was needed to allow the pseydoaneurysm to break through the skin and cause a massive pulsatile bleed. thjat is when he called the surgical medical officer. i suppose one could say that at least it happened when the patient was at our hospital and not still at the peripheral hospital.

i had to debride the wound and repair the artery with a venous interposition. only problem was that after debridement i didn't have tissue to cover my graft. i tunneled it as best i could and hoped for the best.

a few days later we amputated when the graft burst.