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."

perspectives

sometimes different people see the same thing from a slightly different angle, giving a completely different perspective. in my line this can turn out to be quite macabre.

it was one of those cases. it was probably hopeless from the beginning, but he was young and we had to give it a go. as soon as the abdomen was opened everyone knew things were bad. there was blood everywhere. it took a while to even see the damage to the liver because i needed to get rid of the blood in the abdomen before i could see anything. however, once i saw the liver even i was shocked.

the liver was ripped apart with one laceration dropping down to where the ivc sat menacingly behind it. it seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. but i did what i could as fast as i could. at times like this the unsung hero is the anesthetist. if he can't get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. that day the anesthetist was great. somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.

after a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. usually, unfortunately, at this stage of these operations we are confronted by another problem. you see with massive blood loss the patient loses or uses up all their clotting factors and platelets. even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. to attack each ooze with an injudicious suture not only doesn't help a bit, but it wastes precious time that could be better spent in icu replacing these vital factors. i made the call.

"there are no more surgical bleeds that i can control here. i'm going to pack the abdomen and send him to icu to optimise his condition and we'll take him back in a day or two." the anesthetist looked up.

"if you say so, but he is not looking so great here." he pointed at the monitors.

i packed and closed. the gas monkey continued throwing every available fluid into his system as fast as he could.

"i'm just going to top him up as much as possible before we transport him to icu." he informed me. he was definitely worth his salt, this one.

this is now a time that the average surgeon doesn't like. we are not the stand back and wait types. we struggle to sit still and give it time to see what happens. but sometimes it is needed. i didn't have to wait too long before the the gas monkey told me what was happening.

"bongi, this guy is not improving on the fluid and blood i'm giving him and his abdomen is distending. are you absolutely sure there is nothing inside you can't make better?" the problem was i knew there was nothing i could do that i hadn't already done. however the anesthetist's observations were undeniable. the question was was there something i had missed or was the patient so far gone that he was lost already? it was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. there was only one thing to do. we had to open and look again.

we opened. immediately i knew everything we did from here on out was futile. the patient was in irreversible shock and had absolutely no clotting. there was nothing that i had missed from a surgical point of view which meant there was nothing i could do. after poking around a bit i packed and closed again, but this time with a heavy heart. i knew what was going to happen. the anesthetist also had no illusions about where we stood, but we both continued to go through the motions.

the motions led us eventually down the deserted passage way in the middle of the night to icu with a patient that was sort of alive in the broadest definition of the word when we left theater. both the gas monkey and i didn't want to check the vitals during that quiet sombre journey. what did it matter? we knew what was going to happen and we knew it was out of our hands. the only questions were where and when it was going to happen if it hadn't already happened. so when we entered icu we were quiet and reserved.

when icu receives a new patient, there is usually a flurry of activity and this was no exception. all the sisters descended on us like a swarm of bees, each going about their respective duties. soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. however once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. quite soon their alarms were blaring away. i glanced at my anesthetic collegue and we both shook our heads. we had done what we could. the icu sisters hadn't seen what we had seen. all they knew was we had delivered this patient and things didn't look good.

"i can't get a blood pressure. i can't feel a pulse. crash trolley!!!" she yelled to one of her juniors who scurried off in obedience. neither i nor the gas monkey moved. we just sat there, defeated at last.

"doctors, this patient is dying! aren't you going to do anything?" i laughed. i didn't mean to and i think it was more a nervous laugh. i was too emotionally exhausted at that moment to react appropriately. my colleague also laughed, but more at my response than the situation, i think. he then explained that what could be done had been done and any further resus would be in vain. we turned off the ventilator.

and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.

sand through your fingers

something that still gives the old adrenals a squeeze and a vicious kick is the opening of a blunt abdominal trauma patient with a severe internal bleed. but it is so much more than just an adrenaline rush.

the scene must be set. a patient arrives in casualties after having been involved in a massive accident. often there would be people who passed away at the scene who bypass casualties altogether on their way to the morgue. more often than not, some of these people are related to your patient, but that is something to deal with tomorrow. today's efforts need to be completely focused on getting your patient through his ordeal alive.

in casualties everything is a blur of activity. someone is tasked with getting lines up while someone else orders the bloods needed and someone else phones ahead to get theater ready. decisions need to be made about whether intubation is immediately necessary or if it can wait until theater. sometimes there is distraught family outside. they wait expectantly at the door hoping for good news. i make a point of speaking to them if i can before theater. yes, my job is primarily to get the patient through the other side alive, but in the end we are alive so we can live and part of life is love and family. they need to feel like they are at least involved, even if on a very small minor level. also they need to have an idea that things may not turn out well before the time.

on the way to theater, if the patient is not intubated or if we are not doing active cardiac massage, i often peel off to the change room and rejoin the activity as the anaesthetist receives the patient in the theater entrance area. i help with getting the patient onto the bed and then...well then i take a moment. it is a moment before the storm. it is a time when i try to prepare myself for the fight ahead. i also often think about the dissociation between the humanity and the biology of what is about to happen. it is always poignant for me to think that during the operation i will be totally focused on getting the life threatening problem fixed and i will have no place to reflect on the bigger picture. i won't have time to wonder what the person is like or what his hopes and dreams are or who is praying for him to pull through. yes, i won't be able to see him as human until it's all over.

once the gas monkey has everything ready we prepare to open the abdomen. there is a certain technique to doing this otherwise fairly routine action in these types of patients. everything is opened except the peritoneum which is left to last so there is at lease a bit of pressure still on the area of bleeding. then the peritoneum is opened and all hell breaks loose.

the peritoneum is opened from top to bottom in less than a second. masses of blood come pouring out in a wild torrent and abdominal swabs are shoved with little ceremony into the abdomen, starting in the upper quadrants and moving to the lower quadrants. this is a moment that can't be fully appreciated unless you have experienced it. there is shouting and a flurry of activity. any observer will be left with the clear impression that we are fighting for the patient's life. there can be no doubt.

once the swabs are all in and the worst of the blood has stopped flowing it is time to address the source. i usually pray it is the spleen because it can be removed and the problem is solved. the liver bleeders can be a lot more tricky. a massive tear of the liver can bleed copiously. it is relatively easy to control the blood supply to the liver but the venous drainage is a different beast. the liver drains via three veins directly into the inferior vena cava, the biggest baddest vein in the body. retrograde flow through a torn hepatic vein or worse an avulsion of the liver off the ivc itself may even be impossible to control.

with these sorts of injuries the amount of blood in the abdomen is so much when you push your hands into the abdomen to apply the swabs or to give direct pressure your entire arm disappears into the pool of blood way above the gloves. blood then runs down your arm on the inside of the gloves filling the gloves with blood and totally soaking your hand. your hand ends up inside a sort of latex balloon full of the life sustaining blood of your patient. at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate.

often at this stage of the fight, if the anaesthetist has managed to keep up his fluid and blood administration with the blood loss he may start hinting that things are looking dismal. he may, for instance hold up yet another pint of blood from the blood bank and casually remark

"would you like me to run this through the patient first or should i just pour it out directly onto the floor?" sometimes one has to stop and acknowledge the writing on the wall.

ironically as the awareness of the unvanquished foe sets in, the humanity of it all comes flooding back in torrents that rival the previous blood flow. suddenly you wonder about the patient as a person and how futile it all seems. suddenly you wonder about your own life and that it is dependant on this flimsy body working properly and may be so easily snuffed out. suddenly you think about the expectation the family has of you saving his life, even as that life flows out of the body beneath your bloody hands. the tension i feel then far exceeds any adrenal rush i get at the dramatic opening of the abdomen and during the valiant fight for a fellow human being's life.

flame thrower

it's funny where one sometimes finds useful pieces of information. i mean the story of the flame thrower i think was maybe told with a slight embellishment, and yet i have found it useful quite a few times.

in the old days us registrars quite often were left in deep water. it was the theory of survival of the fittest being put to the test. and it also worked on the registrars. the less fit didn't make it.

one of my friends opened up an abdomen late in the afternoon that was the sort of abdomen you actually should open early in the morning. you see after four it was pretty difficult to get a consultant back onto the hospital premises at kalafong. quite soon he realised he was in trouble. the patient had a massive inflamed brittle friable kidney on the one side that looked like it needed to be removed. yet every time he poked it it would bristle in rage and threaten to bleed. he simply didn't know what to do. he called his consultant whose name appeared on the call list. the consultant told him there was no way he was coming back and wished him the best for the rest of his call. they then phoned the consultant of the other firm who wasn't on call. this man started out in a bad mood on any given day but was also not the type to leave someone who didn't need leaving. after the obligatory frothing at the mouth he said he would come in and help.

while my friend waited he tried a few more times to tease the kidney out but when the anaesthetist started making noises about the fact that the swabs were becoming redder seemed to somehow coincide with the fact that the patient was becoming more unstable he decided to just compress and wait.

the consultant arrived, his eyes glazed over with anger. as he entered the theater everyone went silent. the urgent bleeping of the pulse oximeter suddenly sounded deafening in comparison to the sound of all the held breaths of all the people in theater. he walked up to the patient and glanced at the kidney with disdain. even the kidney went silent. it seemed to know better than to mess with this man. then without a word he walked off to the scrub room. there was an almost audible sound of everyone exhaling together.

moments later the consultant once again approached the table. the registrar gave way as he started explaining his dilemma. the consultant mumbled something, either to himself or maybe a warning to the delinquent kidney. he then reached into the abdomen and with one smooth motion ripped the kidney out. he then turned to the floor nurse and spoke for the first time.

"set the cautery to flame thrower!" with that he systematically controlled the more than liberal ooze from where the kidney had been. it was the sort of thing you could laugh about afterwards. at the time no one was so foolish.

many years later i discovered that the flame thrower setting was actually quite useful in liver and even spleen oozes when nothing else helped. and, yes, each time i would turn to the floor nurse and with the driest voice possible would bellow,

"set the cautery to flame thrower!"

cultural assimilation

south africa is a melting pot of many different cultures and language groups. in a state hospital it can occasionally happen that you have a patient that speaks a language from a different part of the country and no one can understand him. lucky was such a patient. interesting to note in south africa, the guy called lucky by his parents mostly turns out to be anything but what his name would suggest. i often wonder if lucky was very lucky or very unlucky. he was maybe both.

lucky was admitted with bleeding esophageal varices secondary to liver damage from bilharzia. he underwent emergency sclerotherapy and banding and was somehow alive afterwards. lucky. of course he ended up in icu where he received massive blood transfusions and was observed for further bleeding.

the guy working in icu that night had just started in the department and was in fact doing his first ever call. so when lucky started bleeding, the doctor was out of his depth. now for those of you who haven't seen it before bleeding from esophageal varices is immensely impressive and intimidating. it looks something like someone opening a tap full blast except instead of water there is a torrent of blood. junior doctors freak. senior doctors freak. patients sometimes fade away pretty rapidly.

so when the doctor phoned his consultant he learned a few new things. one was that to swear does help, if only just to dilute the panic in order to get the doctor's blood pressure up to levels that can maintain cerebral perfusion. he also learned what a sengstaken tube was. he also got a very rapid tutorial on how to put one in. trust me, when you've seen these things bleed you don't have time for a tutorial any more intricate than "just bang the thing in like a nasogastric tube and blow the stomach balloon up.".

the doctor banged the thing in like a nasogastric tube and blew the stomach balloon up. it stopped the bleeding. lucky. unfortunately because the stomach balloon was not in the stomach at the time of blowing it up but in the esophagus, the esophagus ruptured and spewed its contents into the chest cavity. unlucky.

when we heard about these events at the next m and m we all thought lucky's luck had run out. survival of bleeding esophageal varices is not so high. not many would survive a second bleed. mortality of a ruptured esophagus is particularly high. lump all these events together and he pretty much had no chance. but surgeons, being the never give up sorts, ripped his chest open anyway and tacked his tatty esophagus together. to prevent a leak and certain death they also diverted his saliva through a hole in the neck above the repair. then they stuck a pipe through the abdominal wall directly into his small bowel for feeding. most of us looked on sceptically.

but lucky survived, somehow. of course he spent a lot of time in icu with death hovering at the edge of his bed. in the end i think death got tired of waiting and left. then he started the long road to recovery. he still had to face a few operations to put all the pipes back together so that he could eat through his mouth again one day. but that was something for the future.

a few months later they took lucky back to theater and replaced his entire esophagus with a piece of large intestine. once again he would rely on tube feeding via a pipe going directly through his abdominal wall until everything healed up. postoperatively everything was going well. his registrar would stop at his bed every evening before going home and even come in whether he was on call or not for even the most mundane problems. he didn't trust his name.

then late one evening the feeding tube somehow was ripped out of his abdomen. the night sister called the house doctor on call who was new and didn't know the somewhat sensitive history of lucky. in an attempt to be proactive, she simply placed another tube through the hole in the abdominal wall left by the previous tube. unfortunately her somewhat vigorous attempts to get the tube in caused it to find a new path and end up free in the abdominal cavity. she then simply reconnected the feeding and went to bed. by the morning lucky was no longer feeling so lucky. the unlucky events of the night before had caused generalised soiling of the abdomen. a couple of hours of food being deposited into the abdominal cavity will do that.

i assisted in the operation to fix the mess. luckily his registrar found him the next morning in severe pain and actually going into shock. during that operation i thought quite a bit about old lucky. the first thing i considered was the definition of luck from a surgical point of view. to start with, if you end up with a surgeon then you are not lucky. if a surgeon tells you you were lucky, you weren't. it is simply surgical jargon for we all thought you were going to die and you surprised us all by beating the odds. i mean he was pretty unlucky to have all those things happen to him but i can only account for him surviving so many different things, each of which would kill a mere mortal, at least in part due to luck. maybe lucky was very lucky. maybe he was unlucky. maybe he was both.

but the next thing i considered was language and culture. you see lucky came from a very remote part of the country. he spoke a language which was pretty much not known in the big city. and lucky couldn't speak any one of the more common languages used by his care givers when he arrived with his bleeding varices. but by the time he was ready to be discharged once he had recovered from the last of a string of operations, he could speak afrikaans fluently. i suppose he had no choice but to learn. he definitely had plenty of time at his disposal. otherwise he wouldn't have had anyone to communicate with.

so, for those of you out there eager to learn afrikaans, may i suggest getting two esophageal variceal bleeds in quick succession followed by esophagus perforation followed by prolonged icu time followed by colon pull through followed by free leakage into abdomen followed by full laparotomy. if you survive, my experience tells me you will be fluent in afrikaans.

otherwise maybe buy a book. it might be safer.

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.