reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.

fasciotomy

being south african these days sometimes means we see things in a slightly skewed way. it seems to be the way we have become. i have touched on this before, but there is another story which illustrates the point.

the recent run of hijackings were fresh in all our minds because the perpetrators had shot and killed, execution style, a mother and her three year old child just the previous week. there were reports that one specific gang was working the area and were responsible for most if not all the hijackings and associated killings in the area. so when our patient came in, even before the police told us so, we just assumed he was one of this gang.

the story was the police had intercepted this guy just after he had relieved a car owner of his mode of transport. he was good enough not to kill the victim this time around which was nice. however, not being the law abiding type, he had driven off in haste with the police hot on his tail. according to the police he fired first. whatever the truth was, bullets were moving liberally in both directions between our man and the law as they flew through the streets of pretoria in a westerly direction. unfortunately for the hijacker he had chosen the toll route and was forced to stop at the toll gate just outside kalafong hospital. he jumped out and opened fire on the cops in the now multiple cars pursuing him. they shot back. they hit him four times. they gave me real reason for concern about the aim of our police force. the only wound which was anything more than a flesh wound was the shot to his left brachial artery (the main artery in the upper arm).

ironically, the patient had comitted his initial crime in the drainage area of pretoria academic hospital, a place with a dedicated vascular unit, but had fled into the drainage area of kalafong hospital that had no vascular service at all. i thought this would have been divine justice, but, alas, his proximity to kalafong at the time of the shooting along with the fact that his shooters, the police, immediately transported him to the nearest hospital ensured that he had prompt help. the fact that my friend and colleague on call that night just happened to have a knack with vascular surgery also swung the odds heavily in the favour of our patient. obviously my views about karma were once again confirmed.

and so the next day when we went on rounds the patient was actually doing quite well. he sat up, looking at us as we stood around his bed to discuss his case. his ordeal had done nothing to his smooth mouth and arrogant attitude. in fact, the only sign of his life saving and arm saving operation in the dead of night was the large fasciotomy running along the length of his forearm (essentially a long open wound along the length of his forearm) and the police escort that lazily sat next to his bed.

my friend, the guy who had essentially saved the patient's life and limb, felt the pulse. i thought he would be proud of its strong beat, but there was something else on his mind.

"the police of today don't know how to shoot!" he said. "they shoot kak!" i think this was aimed at whoever wanted to listen. but the next statement was specifically for the patient. he turned to the patient and continued.

"i, however don't shoot that badly. if you come near me or mine, be warned i'll kill you on the spot. my bullet won't just take out some artery. i'll hit you in your heart and you won't see another sunrise. just to let you know." i'm not even sure the patient knew this was the very person who had given up his night's rest to meticulously repair the artery and thereby save the patient's life. i don't think he was the type to care, actually.

two days later, before the fasciotomy could be closed, the patient escaped from the hospital while his police escort lay lazily around. i reflected that all we could really hope for was that his open wounds would turn septic and he would succumb to systemic sepsis. we all knew he was too bad a man for that to happen.