neurosurgery

during intermediates we were required to rotate through all the surgical disciplines. one of our rotations was therefore neurosurgery. those guys really work hard. i think it's fair to say they almost work as hard as us general surgeons. without a doubt, besides us, there was no other surgical discipline that came even close as far as hours and hard work were concerned. and yet they were very different to us.

certain conditions are considered surgical but it does not necessarily mean all surgical conditions are for operation. we will happily accept for example a bleeding peptic ulcer and treat it medically, only operating if it becomes absolutely necessary. the neurosurgeons, however, tended not to do this. if they weren't actually going to operate the patient they simply didn't accept him. so a peripheral hospital would send a scan through for their opinion. if they saw that either no operation was necessary or that the patient was in such a bad way that even an operation wouldn't save him, then they simply didn't accept the patient. cases from casualties with fractures and also some degree of suppression of consciousness who were not destined to fall under their knives they would also not accept. the poor orthopod would get stuck with a semi conscious patient that he wouldn't really know what to do with long after the bones had set.

so when we were getting tutorials from the neurosurgeons i thought it funny when they gave a long talk about the management of a patient with mild neurological suppression. i was even surprised that the consultant giving the tutorial seemed to know how to handle such a patient. being in the department i had seen no evidence whatsoever that they actually ever did handle such patients. fortunately i kept my thoughts to myself (i achieved this by biting my bottom lip every time i was tempted to say something. other than the slight taste of blood i suffered no ill effects like failing my neurosurgery rotation which is a lot worse than the taste of blood).

when the intermediate exams were around the corner i once again enjoyed the humour in the rumours that the management of mild head injuries was supposed to be a spot from the neurosurgeons. i couldn't help wondering who would mark that question. maybe they could ask the orthopaedic department to help them.

finally the exam day arrived. when i saw the question actually turn up in the exam as so many of us had guessed it would i found myself chuckling at the thought of some burly orthopod trying to read my handwriting. i also wondered if the neurosurgeon was honestly asking because he didn't know.

in the end, after considering simply writing:-
'break the patient's leg and turf him to the orthopods,' i buckled down and answered the question.

decisions

i recently read a post by a greatly respected blogger. she relayed a story about why someone chose primary care as a speciality, but it turned out to be more about why they didn't chose surgery (or why you should read the contents of anything you eat). i felt compelled to reply.

in all honesty there are many reasons i decided to specialise in surgery, not the least of which was that i wanted to be able to deal with pretty much everything. i also really enjoy operating. there is something magical about cutting a fellow human being open. intuitively it seems so wrong, and yet we do it and we do it for the good of the patient. it's truly mystical. but there was one incident that happened in my student days that clinched the deal.

i've never considered myself too bright (with the possible exception of two separate occasions). so exam times were always quite stressful for me. the finals of fifth year were no exception. so when i found myself waiting to be called in during the surgery practical finals my nerves were pretty frayed. the patient i had examined had a large smooth thyroid. clinically she didn't have hyperfunction, but that could be due to medical treatment. i had no blood results so i would have to go through all the causes and finally settle on what i thought was actually wrong with her. the prof was bound to grill me on my diagnosis and try to catch me out. at times like this your entire career feels as if it is the balance and may be lost to you for the slightest reason. as usual i wasn't feeling too bright. and to top it all, the student that had just come out had been grilled for not wearing his name tag. the prof had apparently almost gotten personal and totally rattled him. i had just lost my name tag the previous week. this did not bode well for me.

and then it happened. while i was sitting there waiting and trying to remember and sort out all the bits of information floating around in my exhausted, overly stressed brain, one of the senior consultants of internal medicine walked past. he saw me there with red, sleep deprived eyes and anxiety written all over my face and immediately realised i was just about to go in for a grilling by the surgeons. he gave his bit of advice.

"remember, when in doubt, cut it out." when in doubt, cut it out. when in doubt, cut it out. it went through my mind over and over. a sort of charge in, sword brandished where angels feared to tread. now that was simple and easy enough for even me to remember. right there i decided i could become a surgeon. i knew i had what it took to handle the petty onslaughts of the surgeons, so that didn't bother me too much, and now, intellectually i knew i would be able to remember the essence of surgery, when in doubt, cut it out.

mad as in crazy or just plain nuts

as anyone who knows even the slightest thing about surgeons could guess, psychiatry was not one of my favourite subjects in medical school. but even i could appreciate a bit of humour in my final practical exam in this cursed subject.

i had to get through it no matter how much i disliked the subject. i would have to 'examine' a psych patient and then present him to the examiners. ideally i'd have to come up with a diagnosis slightly better than 'he's mad!' examine basically meant i had to go through a fairly standardised interview. from that interview, using my amazing powers of deduction i would hopefully be able to label exactly what brand of crazy my patient was. the plan seemed water tight at the time.

they told us there would be translators provided if we needed them. (this is something that is actually often needed in our country, bearing in mind we have eleven official languages. i kid you not.) so when i was allocated my patient, the first thing i asked is what language he spoke. it was zulu. i quickly identified a zulu translator, but before i asked her to accompany me i enquired of the patient if he could hold his own in english or afrikaans (as you will see later in this post, this may not have been the best choice of words on my part). the patient, in a somewhat staccato voice assured me he was fluent in english. ok, i thought. and off we went.

the interview was disastrous. it seemed that the patient was simply under the delusion he was fluent in english. to my shame it took me about ten minutes to figure this out. i just thought he was somewhat stupid. turns out he had no idea what i was asking him and was trying to answer to the best of his abilities...in english...which he didn't speak...at all.

finally i rushed through to get the translator. time was limited. this was after all an exam. i was getting tense.

his zulu was fluent and with the translator we were soon in full flight. the only problem was he was answering each of my questions appropriately. he didn't seem mad at all. i started hoping for a bit crazy, but with each ensuing answer he seemed just like your average joe soap (or whatever detergent of your choice).

great i thought. they have thrown me the wild card. they have actually put a totally sane patient into the exam to catch me out. what sort of sick twisted deranged mind does that sort of thing??
i resigned myself to my fate. all i could do was continue to systematically go through the questions.

the next question was about libido. the translator told me he said he had no libido. it was the closest i had to abnormal so i latched on.
"why doesn't he have a libido?" the zulu equivalent was asked and answered. the translator doubled over in laughter at his answer. there was no forthcoming (or any other form of coming it seems) answer in english. i wanted to jump up and scream at her. i had about 5 minutes left before a bunch of psychiatrists were going to determine if i was going to repeat the year or not and the translator was just laughing?? did she think when she took this job that there wouldn't be the occasional strange answer?? and now with what felt like seconds left to me i had to deal with her sudden delicate sense of embarrassment.

"what did he say?" my voice was not raised but i think there was a noticeable quiver.
"he says he doesn't have a penis." bingo, i thought. then my paranoia about the evil examiners got the better of me. i had to quickly check to make sure there was in fact a penis.
"what's this?" i asked in reference to the member that i could clearly see.
"it's not mine."
"whose is it?"
" it belongs to this tsotsi." he said, pointing to his chest. i was so relieved. he was mad. at that point i didn't even care what sort of crazy he was. the moderator was knocking at the door to tell me to present myself to the examiners. the fact that he was crazy was good enough for me. i could wing it.

p.s i passed but not with flying colours. the examiners also specifically asked me if i had physically checked to see if there was a penis or not.