small beginnings

recently i caught up with an old friend. the day i started studying surgery he started in internal medicine. he is now a fancy prof. i was amazed and impressed. he really was, and i assume still is, a really great guy. yet even great people must start out small. i remember the first day we met.

i was on call in the surgical icu. i had been part of the surgery department for a full two days and was still unsure about pretty much everything. so when the internal people phoned asking if we had a bed available for one of their patients i called our prof even though there was one bed empty. the prof was a good man and told me we were obliged to help them even though the pressure on our beds was usually great. i phoned the internist on call and told him he could bring his patient.

some time later a patient was wheeled in. the first thing i noticed was that she was blue, a colour i have often said doesn't appeal to me. the next thing i noticed was that she was just barely breathing. being astute even though inexperienced, i concluded she was in the process of dying. at that moment the physician walked in and introduced himself to me. he had just started in internal medicine two days previously and was also pretty unsure of himself. after whizzing through the formalities of greeting, i pointed out to him that his patient wasn't breathing too well and that she needed intubation and ventilation soon. otherwise one could only hope her policies were all paid up. he looked at her. it was abundantly obvious i was right.

"yes, i see what you mean," he said after a moment's thought. "i'm just quickly going to call my consultant. i'll be right back." and with that, before i even had time to express surprise, he was gone. the sister and i looked at each other with bewilderment on our faces. it just seemed that intubating the patient was at that very moment more important than finding his consultant.

"well, we know what to do." i said, "get the patient into a room and let's intubate. without any further delay or looking around for wandering consultants we soon had the endotracheal tube in position and the patient connected to a ventilator. soon the blue hue was replaced by a more encouraging pink colour. not totally unlike the patient, we all breathed a sigh of relief.

after a short time, the internal registrar returned with consultant in tow. by that time the icu staff and i had settled down and were even making coffee. then i put the story together.

the registrar had been out of clinical medicine for a while doing some or other form of research. he was not confident enough to intubate the patient and just assumed that i also would not be. he therefore felt he needed to get his consultant there as fast as possible to place the tube. it was the best he knew to do at the time. unfortunately it would not have been good enough for the patient. i had to intervene. i was not the patient's best hope. i was the patient's only hope.

well, all's well that ends well.

catching up with the esteemed prof after so many years made me realise how even the mighty have humble beginnings.

dignity

he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.

in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.

the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.

then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.

he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.

i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.

i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.

maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.

but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.

resus with hands tied behind my back

from the previous post you might assume that i became quite proficient in resuscitating poison cases. you would be right. but sometimes knowledge and skill are just not enough.

during my community service year in qwaqwa we were required to do one call a month at the primary hospital. maybe hospital is a bit of a strong word for what that place was, but nonetheless, we did our duty there.

i was in casualties in this 'hospital'. a young guy came in with the typical organophosphate-like symptoms. pinpoint pupils, severe bradycardia, hypersalivation and whole body fine muscle fassiculations. i knew exactly what to do. i sent the nurse to get atropine as i quickly dripped him. i then immediately phoned for a transfer to the secondary hospital, thinking i'd start the treatment, but if he needed intubation, they would need to take over.

soon the nurse came back. he had one ampule of 1mg atropine. i thanked him but explained that we would need much more. i injected the 1mg. the pule rate sped up to a roaring 50 beats a minute and then gradually decreased again. i waited with baited breath.

after what seemed to me to be ages the nurse slowly strolled back with the news that there was no more atropine in casualties. great. i then told him to go through the entire hospital and bring me ...all... the atropine in the entire hospital. he casually strolled off.
meanwhile i shot through to the chemist, which was just about to close for the night, and asked for atropine. the lady manning (womaning???) the place was not impressed with having to help me. reluctantly with deliberately slow moves she went to the back. after a while she came back with an empty box. yes, all the atropine was finished and they hadn't bothered to order more. i told her the box looked nice but it is probably not going to work. she could keep it.

when i reached casualties the nurse was still not there. the patient looked somewhat unwell. i tubed him and set someone to bagging him. then the nurse returned. he had another ampule of atropine. that was the last of the atropine in the entire hospital. i injected it for what it was worth. then i waited.

finally after about an hour the ambulance arrived and we turfed the patient off to the secondary hospital.

the next day i heard he had made it, despite the empty box.

resus fun.
cuban resus.
tube.