albatross

when i was a child we used to hear stories of old people from primitive cultures that could wish themselves dead. they could just decide to die and they would. it was disturbingly fascinating for a young impressionable boy. but as i grew older and studied medicine i realised they were no more than simple stories. or were they?

i was a lowly medical officer joining the boss' firm for the first time. i luckily learned the registrar was a great guy and i therefore could use him as a sort of shield against the usual onslaught of the boss. when i joined there was a patient who had undergone a gastrectomy the previous day for a benign condition. it fell to me and my registrar to get her back to full health. it soon dawned on me this would not be easy.

the patient was 60 something and well fed, possibly too well fed. mobilization was difficult, but that wasn't the main problem. she was of a culture where a certain amount of self pity was the norm and where showing suffering elicited great sympathy from family members. so when we insisted she start moving soon after the operation, she was not interested. what's more, her family encouraged her to just lie in bed like a lump of clay. they felt we were downright cruel to expect such things as getting out of bed of her. but i became truly worried one day when she called my registrar and myself over to tell us something in confidence.

"i want to die. help me kill myself." she said with a pan face. we were shocked. we explained that she actually had a lot of life left in her and her condition was not terminal. with a bit of effort we expected a full recovery. but a full recovery was one thing she was not willing to give us. and eternal rest was one thing we were not willing to give her. every day we would get her out of bed and walk with her and every day she would walk a few steps with a fair amount of ease and then collapse in a heap on the floor. we would then wrestle her back into bed and muster our energy for the next day's ritual. the family complained incessantly about everything we did. they wanted her to stay in bed and wait until one day when she would just be better.

after a while her son flew in from america where he lived. he came armed with dollars and instantly decided our care was not good enough. almost immediately they had moved her to a private step down facility where she was to be pampered back to health. truth be told, we were relieved. it wasn't as if we didn't have other things to do to keep our days busy and we were quite willing to give up our daily walks and wrestling matches with this patient.

about two weeks later we got a call from a local private hospital. they told us that at the step down facility the lady had adopted a very passive stance on the matter of her recovery and not moved a muscle. she had then one day apparently stopped breathing. she was intubated and shuffled off to the local private hospital where she was bundled into an icu bed where even american dollars wouldn't last too long. when the son with the american dollars realised he had no more american dollars, they phoned us at the state hospital to take over. what could we do? i turned to my registrar.

"you realise she will absolutely refuse to recover. she will be an albatross around your neck until she dies and she is going to die. she wills it so." he tried to smile but it came out as a sort of accepting expression of suffering. we took her back but her condition had worsened. other than the endotracheal tube and the ventilator, she returned with a nice hefty bedsore on her sacrum. but we were not the types to give up too easily and we immediately got to work.

everyone was surprised when we actually managed to get her off the ventilator in less than a week. a few days later we had her back in the ward and a few days after this we even commenced our daily excursions with her. during this time once again she asked us to kill her. she assured us she wouldn't tell anyone if we did. somehow that seemed self explanatory to me but i decided not to point it out. anyway we refused, once again saying that she was not terminal and with a bit of hard work should recover completely. she wasn't happy with us telling her what to do, even if what we were saying was that she should recover. apparently, she assured us, her family were much more sympathetic. they didn't force her out of bed daily for example. we tried to look more understanding from then on when we forced her out of bed. i think it worked to an extent because just before i was rotated out of the firm and to the other hospital, we actually discharged her back to her understanding family. i was delighted, but my senior was less so. you see, he was staying on in that firm and he knew she was going to do what albatrosses do. she was going to bounce right back to him. i pretended to care but it was his albatross and not mine. i was just too delighted to finally get away from a situation that i knew would turn out badly.

and so life went on as it tends to do. i settled into my new firm and soon even forgot about the albatross. i couldn't for long though. quite soon my previous registrar phoned me. he said only one thing but the pain in his voice said so much more.

"the albatross is back." i expressed dismay and even tried to sound surprised, but it just came out as insincere, which is exactly what it was. i considered asking a bit about her condition but somehow it seemed it would rub salt into his wounds. i even considered making a light hearted joke about him granting her her wish and helping her over the threshold into the hereafter. i was just afraid he might take me seriously, so i said nothing.

not too long after that phone call i got a message on my phone.

"the albatross has flown". she was dead. she had finally managed to bypass all our attempts to get her back on her feet and despite everything we had done, against overwhelming odds, she had wished herself into the grave. in a way i was even quite impressed with her.

since then i too have had an albatross or two. i suppose it goes with the job.

anatomy

anatomy knowledge is essential for surgeons. i'm sure most surgeons would say it is the single most important thing in surgery. i would not. knowing anatomy may just not be enough.

somehow south african pathology is unique. by the time the patient presents to us things are a bit advanced (here and here or even here). i suppose you could say it makes diagnosis a bit easier, but it sure as hell does not make treatment easier. once when i was still working quite a lot at the state hospital this became clear to me.

the medical officer called me in. they had a bleeding stomach ulcer patient who for some reason just refused to stop bleeding. it was time to operate. the medical officer was so excited he was jumping up and down. he kept on telling me that he had never seen a gastrectomy before (removal of part of the stomach) and i kept on telling him that these days it is seldom that a gastrectomy is done but rather he was likely just to see the control of the bleeding artery and all would be well. i was less excited. it was late.

when i first laid eyes on the patient a few things bothered me. firstly there was a scar from a previous upper midline operation, probably also for a peptic ulcer. the next thing is his body showed wear and tear far above what his years would have dictated. his face had the signs of both long term alcohol and nicotine use. he was thin and almost wasted. i knew without asking that he was also a habitual grandpa user. then over an above his general state of health, he was pretty bled out. oh well, i thought, you work with what you get.

as we started, my excited medical officer asked me to give him an anatomy lesson during the operation. he knew i liked to teach and what better opportunity to learn anatomy than when the textbook is open before you. yet as i started the operation i went silent.

it was clear someone had operated here before. there were many adhesions to the anterior abdominal wall and it was quite a mission to actually get into the abdomen. once i was inside however, things went very rapidly from bad to worse. what once had been the lower stomach was just one massive ulcer that had penetrated into everything. the ulcer bed consisted of liver, abdominal wall, and transverse colon mesentry. the galbladder had been incorporated into the ulcer and therefore what passed for the stomach. in an attempt to heal itself it had grown into what looked like a fungating mass. in fact for a moment i actually thought it might be a cancer until i realised there was no real galbladder and this strange growth was in fact its remnant, complaining bitterly about its lot. i needed to decide what to do. clearly some form of gastrectomy was required. i should actually say some form of reconstruction was required. the ulcer had already done the gastrectomy. a bit more than a small amount of ingenuity was needed. i got to work, still in silence as i played through the options in my mind.

the medical officer was not silent. he reminded me that he wanted to learn the anatomy of the stomach.

"anatomy?" i asked, "there is no anatomy here. in fact i think we may have stumbled onto the unborn embryo of an alien that has invaded this body. just be glad the thing hasn't burst out and attempted to eat one of us."

i removed the remainder of the alien and tacked together what needed tacking together. driving home, i looked at the starry sky nervously.