it's probably not funny

we have a different sense of humour. we just do. what we find funny can be macabre to most people. it is probably part of our general desensitization or maybe it's a way of dealing with the things we see. you can't get emotionally involved with everything. i remember realising this many years ago. but more recently i saw it again in a very strange turn of events.

i was a fifth year student in paediatrics. for ward rounds we were accompanied by physiotherapist students and social worker students. that morning we arrived for rounds. one of the sixth years asked the sister where one of his patients was because the bed was empty. the sister informed him the patient had died during the night. i got the feeling from their interaction that it wasn't totally unexpected. the sixth year turned to one of his colleagues and laughingly said;
"yesterday i was so busy, but today seems to be my luck day. two of my patients were discharged and one died. now i only have one patient."
the social worker happened to be within earshot. her face was one of absolute horror. she was devastated. but the sixth year didn't mean it in a bad way. he was simply not emotionally connected to the clear human drama that had played itself out. maybe he had been one too many times or maybe he was just like that. i just remember being impacted by the difference in reaction to the same news by the two people.

the second story happened when i was already qualified as a surgeon. i was on call. while i was waiting for theater time i was sitting with the radiologist going through scans (this is something i tend to do still). at a stage the radiographer came through. she wanted his opinion on a scan. apparently she couldn't understand what the contrast was doing and wanted to know if she needed to do a late phase scan. we both went through to see.

the patient had been referred to the hospital as a head injury patient after a car accident. he was intubated at the referring hospital as is good practise for these patients so he was already on a ventilator. the casualty officer suspected he was coning (a preterminal event where the brain stem gets pushed through the opening where the spinal chord exits the skull due to increased intracranial pressure, usually due to trauma inside the skull) and had therefore phoned the neurosurgeon. he had in turn instructed him to do a scan of the brain. the casualty officer decided to do an abdominal scan at the same time because he wanted to make sure there wasn't also abdominal trauma. and thus the patient ended on the ct scan table with the radiographer wondering what was going on with the contrast.

as we entered the scan room i too was perturbed by where the contrast lay in the abdomen. the contrast had been injected through a central line in the neck. it had gone straight through the right atrium into the ivc. there it had moved into both the right hepatic vein as well as the right renal vein. it was nowhere else to be seen. the radiologist immediately made the obvious diagnosis (in retrospect).
"i know what's wrong," he proclaimed. "this patient is dead." of course with the patient on a ventilator it was not immediately obvious. the radiographer went through to feel for a pulse, which, looking at the scan, i knew he would not have.

i started laughing. everyone else was shocked, more at the fact that i was laughing than at the fact that there was a dead guy on their scan table.

maybe they are right, it's probably not that funny.

ct scans

i'm usually quite good at reading ct scans, but this one just left me with one big question mark.

aggression

on a recent post greg p made the comment "this is a strange system of teaching over there. all stick, no carrot." this is true. those who have followed my blog will see that i don't have too many fond memories of my training. truth be told, most of us became punch drunk and developed certain survival tactics. most of these i look back on with regret. but at the time it was the way of things.

we could do very little when we took beatings from our own seniors (except resign which quite a few did) but when attacked by other departments often all that pent up fury would come pouring out.

i was in the boss' firm. i was the most senior registrar in the final phase of training. it was our call day which was also our clinic day. fortunately i had an orthopod rotating with me so we divided to be able to handle everything. i did the clinic and he handled casualties, only phoning me every now and then for advice. at a stage he phoned about two patients. one had obstructive jaundice. the other clinically had cholecystitis. i told him to organize a sonar for both of them and continued wading through the patients in the clinic.

at about four in the afternoon my phone rang for about the ten thousandth time that day. however this one was unique.
"hello." my standard answer.
"who are you?" the voice said. interesting question. i considered asking him who he was looking for, but, being on call i thought i'd better be polite.
"it's dr bongi speaking. how can i help?"
"what are you?" ok, i thought. at least now i know i'm dealing with someone looking for a fight. polite is no longer needed.
"what are you?" i retorted. he let rip.
"i am a registrar in radiology and i want to know why you've sent two patients now for sonar!" his apparent complaint was that the sonars hadn't been organized with him and had apparently just turned up. the house doctor, on the instruction of the rotating orthopod had written my name on the request form. the fact that he didn't recognize my name told me that he was very junior. the fact that he decided to pick a fight with a surgeon told me that he was a fool. i considered going to sonar and sorting him out but decided i wanted to make sure my team had done nothing wrong before thumping someone unnecessarily. also to take a bit of time would allow me to calm down to a rage and maybe react with more circumspection.

by the time i had spoken to my team and ascertained that the fault did not lie with us (the house doctor had phoned sonar and organized the sonars with the head. she had left before relaying this information to her junior) he had gone home. later that night i stopped by radiology and chatted to the call guy. i had a good relationship with almost all of them. i relayed my story, asking who this aggressive guy was. they only knew there was a new registrar in the department who had only started that month. i decided to confront him the next day.

the next day, after the post call rounds, i went to sonar and asked to see him. the head heard i was there and came to me. the guy i was looking for was conveniently not there. i discussed the incident with the head of sonar, ending the conversation with two statements. this sort of thing was not acceptable and i would be expecting an apology from him. no apology came.

not too long thereafter i was on call again. we sent a patient to scan. when the scan came back i called my students around to teach them how to read a ct scan. after going through the ct, one student told me i had missed some free air in the abdomen.
"rubbish!" i said. "there is no free air in this abdomen." he then presented the radiology report which clearly stated there was free air in the abdomen. i was amazed. i went through the scan carefully but i just couldn't see what the report said was there. then i read the name of the radiologist. it was my friend from sonar. i smiled.

i phoned the radiology department and asked to speak to him. i introduced myself and then told him that i had a query about his report. i asked him to explain it to me in person. he invited me down to radiology. i said that i required him to come up to the surgeon's tea room. he said he'd be there in a half an hour.

when he arrived i had an x-ray viewing box set up. all my students were still with me to watch the show. when the radiologist came in i showed him his report and asked him to show me the air. when he showed me what he thought was the free air i admit i felt a bit sorry for him. he was clearly so junior he couldn't read a scan properly. without saying a word i pointed out on the scan why that was not free air and could easily be identified as lung in the thorax by simply following it out onto other images. he apologized for the mistake. still i said nothing. he owed me an apology for something else still. the students were snickering in the background at the fact that a surgeon read a ct better than a radiologist. he looked sheepish and left.

when i look back i'm not proud of my behaviour. and this is probably not the best first post dealing with the constant fights we had with other departments. but the actual point of this post has to do with our general frame of mind in those days. unfortunately it was not good and we were not the most loved people in the hospital.