rambo

south africa is such an interesting place. things happen here that surely can't happen anywhere else in the world. take illegal mining in barberton for example.

barberton has some of the oldest deep gold mines in the country, maybe even the world. the gold rush in barberton happened long before gold was even discovered in johannesburg. of course the massive amounts of gold in johannesburg drew all the prospectors away and left barberton as a tiny, insignificant lowveld town with ghost mines. as time went on, it once again became financially worthwhile for the mines to be opened, although really only on a much smaller level. but once it became clear that there was still gold in the mines, the illegal miners were born.

it is difficult to fully understand what an illegal miner is. imagine people going down air vents and other such unmapped openings into deep underground labyrinths of once sprawling mines where they apparently stay for up to a month or two at a time illegally. they work mainly at night when the legitimate miners are no longer there and melt into the many unchartered tunnels during the day. being south africa, of course the propensity for violence is always there, so, when you put together your mental picture, add quite a number of ak47 assault rifles smuggled in from neighbouring mozambique.

so of course when the people in power  decided to rid their mines of illegals, it wasn't going to be enough to simply leave pamphlets lying around asking them to please leave. they decided force might be a more traditionally south african option. fortunately after our bush wars in namibia and angola we have an abundance of highly trained soldiers so to find hired guns is no problem at all. and in the end, that is what the mine executives did. they hired guns.

i was on call the night the barberton hospital phoned. they apparently had a gunshot patient shot with an assault rifle they wanted to send to me. it was different from the normal 9mm wounds i was used to seeing so i was frankly quite keen to accept the patient no matter what the injuries. it was going to be exciting, i thought, except of course a head injury. then the doctor said something even more left of the ordinary.

"bongi, they are going to bring him in themselves. it will take too long to wait for an ambulance." i was confused. who were the they he was referring to that were going to bring him in? how were they going to bring him in? was he going to be dead when they brought him in? these thoughts slowly migrated through my mind on their way to my mouth but before i could ask, my colleague had put the phone down. i was left with almost no idea of what to expect, but i at least knew it was going to be interesting.

half an hour later i was waiting at the entrance to casualties in true grey's anatomy style. for a split second i even felt more like an actor than a surgeon and nearly went back inside. but in the end my curiosity got the better of me and there i stood like the leading part in a hollywood production in the warm lowveld night waiting for something that i somehow knew was going to be out of the ordinary.

they arrived. it was out of the ordinary. a bakkie roared into the hospital parking area, apparently totally oblivious of the speed humps in its way. it came to a skidding halt just in front of me. immediately the driver got out and moved around to the back. his most striking feature was the r4 assault rifle strung over his shoulder, but it was only fractionally more striking than the rest of the man. he wasn't a particularly tall man, but he was well built. he wore black leather clothes, contrasted sharply with a dirty red bandana tied around his head. on his belt he had about four magazines for his rifle. quite clearly he was ready for quite a fight. then i noticed his face. it was calm and very nearly devoid of expression.

suddenly i noticed a second man standing on the back of the bakkie. he too was dressed like an action hero out of a low budget eighties movie, complete with assault rifle at his side and once again his face was without discernible expression. they reached down to lift something. only then, only when i heard the soft groan of pain, did i realize that the gunshot guy was lying on the back of the bakkie and this had been the they that were going to transport him. immediately i knew they must be the hired guns to flush the illegals out of the mines. there was ordinary and then there were these guys who were definitely out of it. i was intrigued.

they lifted the injured man and started carrying him to the doors.  they did glance at me as they went past but to them i think i looked too much like a tv doctor waiting outside to be taken too seriously. i scurried in after them, feeling somewhat sheepish.

the patient was in a fairly good condition for someone who had taken an ak47 round somewhere deep in the bowels of the earth and then been transported by rambo and sons over the mountain to our humble hospital, although he had quite obviously taken fashion advice from chuck norris.  i quickly rushed through the preliminary steps  to prepare the him for theater. then i went outside to speak to his colleagues, for quite clearly that is what they were.

"i'm doctor bongi. i'll be looking after your friend" probably the wrong choice of word, seeing as though i still had seen no display of emotion from any one of these guys, except possibly stoic resignation in my patient. "i think he will be ok." even this didn't move them. they looked exactly the same as they did when they still thought their colleague was sure to be dead by the morning. "tough crowd" i  mumbled to myself.

then i spent a bit of time trying to find out what had happened. i quickly understood their facial expressions.

they were part of a team hired to flush the illegal miners out. the plan was to go down the official shaft after all the legitimate miners had knocked off. then they were to push the illegals back and drive them out through the numerous secret tunnels that only they knew about. the only problem was this was day two of operations, so the illegals were expecting them. i put it together in my mind. a small group was going to go down in a lift into a mine full of armed criminals who knew exactly where they would be arriving.

"you went down in a lift into a war zone?"

"yes." expressionless.

"but they knew where you were going to get out. all they needed to do was wait for you at the lift."

"yes."

"yet you still did it?"

"yes." still no sign of anything close to emotion.

"why?"

"it's our job." did i detect the slightest hint of pride? no. it was probably the outside light reflecting off the wall giving a certain glint to his eyes.

"so what happened?"

"they were waiting for us. when the lift doors opened, they opened fire and hit our friend." i though he was using the word friend in a very broad definition of the word because i was fairly convinced the only interest he had in the survival or otherwise of my patient had more to do with who would they get to replace him when they went down the lift the next night.

"and once they had opened fire, how is it that you guys survived?"

"we fought our way out." at this stage the total lack of any expression on their faces was expected, but still i didn't expect it. it seemed to me that someone who goes into a death trap, sees his 'friend' get shot and then fights his way out to survival should maybe at least have the hint of something in his face at least resembling human expression or emotion.

i operated their colleague. i dissociated myself from his humanity, cut him open and got the job done. and then i realized. in so many senses, i too go down the lift into the dark depths of the earth full of people only out to see my demise. i too put myself in harm's way for some greater benefit and i too face trauma, albeit not my likely death. then i understood their blunted emotions. they were not too different from a surgeon.

tongue twister

in the old days at kalafong (hell) we sometimes had to deal with obnoxious people. alcohol tends to make the worst of a personality come to the fore. most of us tended to ignore these irritations and get on with the job, but there were exceptions.

he was a senior registrar at the time. before going into the whole surgery thing he had been in the army and had served in the angolan war in the special forces. i occasionally asked him about those days, but he never spoke about it. i think it messed him up a bit and he probably didn't want to dwell on that stage of his life too much. only once did he ever actually say anything to me that alluded to what he had gone through.

"bongi, when you are in battle and people are shooting at you with the intention of killing you, it somehow changes your perspective on life." i suppose part of his changed perspective was that he tended not to take crap from mere mortals (hy vat nie kak van kabouters nie), especially those with more than a liberal dose of dutch courage.

the patient was drunk beyond description. he lay there in casualties with a nice neat bullet hole through his chest. however the injury had done nothing to his foul mouth. he maintained a constant stream of verbal abuse directed against anyone and everyone who had anything to do with him. when the poor house doctor inserted the intercostal drain she had to contend with both his sharp tongue as well as the occasional flying fist. he even managed to land a blow which had reduced the house doctor to tears. to her credit, she had continued the procedure but was unwilling to go near him after that. she called her senior, the registrar, to make sure the patient had no other injuries.

my friend walked into casualties, quickly found out what the trouble was about and approached the patient. he stood just outside the reach of the patient and casually observed his fists flying around, keeping everyone away. he listened as the patient flung a stream of obscenities at him. he seemed unmoved, but the wry smile that until then had been on his face slowly slipped away to be replaced by a stern grimace. he tried to speak to the patient to explain that he needed to check him out but this was met with such aggression that he ended up walking away. the house doctor tried once more to approach the patient, but caught a heavy body blow and slumped to the floor in pain. that, it seemed, was too much for the registrar.

"sister, put the patient in the procedure room. i'll be back in five minutes."

five minutes later the registrar returned. he went straight to the procedure room. just before he entered he turned to the sister.

"sister, call the maxillofacial surgeon and tell him we have a patient for him with a broken jaw."

"does the patient have a broken jaw?" she asked, surprised.

"well not yet." and with that he entered the room and closed the door.

after that, so the story goes, the patient was as tame as a lamb, albeit a lamb with a very swollen face.

the graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.

smug

recently i was involved in a discussion with a guy that was explaining how we should understand criminals. the emphasis was on farm murders but we touched on murderers in general, rapists and child molesters. my point of view was that i did not understand them and felt that he was justifying their actions. in the end i was informed that i was smug. apparently that is the word for people that couldn't see the point of view of the poor misunderstood murderers and rapists and molesters.

so smug is what i am, it seems. you see the fact is i can't understand his beloved murderers. i just can't. i also in my smugness wonder how he can, but i think i know.

it has to do with not being in the trenches. it has to do with not being faced with the blood and the tears and the guts and the screams...mostly the screams. it is probably easy to be nice and philosophical sitting snugly (not smugly apparently) in a nice air-conditioned office, philosophizing on the reasons people point a gun at people and pull the trigger. or worse...

the thing is i can't forget. i am scarred. i remember the patient lying in a pool of his own blood, looking up at me and asking, beseeching even to tell him he is going to be ok. i remember wanting to tell him that it would all turn out just fine. i even remember wanting to hold his hand because his mother wasn't there to take care of the emotional side of things. in the end i remember not telling him he would be ok because i wasn't sure he would. i also remember not being the mother he needed in the last moments of his life because that is what it turned out to be. after we had plough through the blood and feces floating around in his abdomen, violated by the bullet fired from the gun of someone my friend feels i must understand, the patient died. he did not die well with his mother or wife holding his hand in love. he died alone in some icu ward with adrenaline being pumped into his veins and oxygen being pumped into his lungs with a scarred doctor who felt that his time may have been better spent holding the patient's hand rather than pouring time and energy into a futile attempt to save his life. you see the reason i can't see the side of the killer is that the killer is still alive and has the sentiments of my learned friend to feel for him. my patient is dead and there was no one next to his bed when he died. there is no one to state his case now.

i remember the baby violated by her uncle. i was just a house doctor, but i had to examine her. the pediatrician couldn't face it. it is quite a thing to see the perineum of a four month old after it has been ripped apart by the penis of one of the people my friend understands so well. feces runs out of the vagina. it leaves a mark on the soul. but worse than that is the cry. the child did not scream anymore. i think it used up all its scream for its entire life during the deed. all that was left was a quiet constant moan. it is the ghostly moan of someone who has learned in her four month existence that there is no one who will come to her aid. there is no one to understand her. it will never leave me. my friend who is quick to understand the violator will call me smug, but may i suggest i might just be jaded?

the women raped is difficult to examine. somehow you feel you are violating her again. you feel you are making the whole ordeal worse. they don't resist. they are already broken. anyway, rape in our country is so commonplace, it may be the one area where i understand that my friend mat have sympathy with the perpetrator, but, sorry, i cannot. for me to examine those women tears me apart. it leaves me with a feeling that my own soul has been violated. that i am forced to do something because someone else destroyed a life. i refuse to see the point of that someone else. if that makes me smug, then smug i must be, but again i suspect i might be jaded.

a bullet can do a lot of damage. physically i think i might have been a witness to pretty much all of it, but there is another side to the story. i remember an old man, shot in his home when he tried to defend his wife from the killers that broke into their house in the early hours, people that my friend chooses to understand. we did pull him through, but not without a massive operation and the obligatory icu time. i remember when he came to me for follow up some time later. i was so proud that he had made it. but somehow he was the shell of the man he used to be. he was alive, but broken. his confidence was gone. he lived in fear. he felt helpless because he knew he could do nothing against the lead of the people who i hear from my friend i must understand and sympathize with. but who sympathizes with my patient whose peace has been stolen from him? the smug or the jaded?

recently i enjoyed my christmas eve over the open abdomen of a woman shot in her bed by strangers, strangers whom my friend has endless sympathy for. i did not enjoy my holiday period, but more than that, my patients didn't either. hopefully my friend, while maybe enjoying a beer with the killers he understands so well had a really festive time. i do not understand him.

the urologist

i sometimes reckon i'm quite the urologist. but i'm not. even when i was rotating through urology i would often visit the general surgery tea room. i missed my real work i suppose. but the guys seemed to know i liked hanging out with the urologists and sometimes raged me a bit. i remember the one senior registrar trying to give me a hard time the one day when i visited the general surgeons.

"hi bongi. how's urology going? have you played with any good penises today?" i couldn't let that slide.

"no, but then again i haven't been home yet." he was floored.

but i realised more recently that i'm not really a urologist. it was a gunshot in the state hospital. it was the usual type of thing requiring time systematically repairing the multiple holes in the small bowel. but this case had a little bit more than just small bowel injuries. the bladder was hit too. the medical officer felt that that was beyond his scope and asked me to handle it.

gunshot injuries to the bladder aren't all that difficult, but one thing to remember is that there are always two holes in the bladder and it's the hole at the back that can be slightly more challenging. i opened the bladder by simply extending the anterior hole left by the bullet. the exit wound was clearly visible, but there was a problem. the bullet had exited the bladder exactly where the left ureter (the pipe carrying urine from the kidney to the bladder) enters the bladder. it had pretty much shot the ureter off the bladder leaving it to leak urine from its frayed end into the area behind the bladder. i honestly had a moment when i wished i could call a urologist, but that option wasn't open to me. there was no urologist doing calls in the state hospital, so i would have to sort out the problem myself.

one thing that is important when working with the ureter is to place a pipe in it to sort of stent it while it heals. the urologist have a nice pipe called a double j stent that they routinely use, but we had no such thing there that night. the other problem with a double j stent is that you need to do a cystoscopy to remove it at a later stage. although the visiting urologist could probably do that i didn't like the idea of placing something in the patient that i myself couldn't remove. i came up with a plan.

i dissected out the ureter above where it had been shot off, cleaned it up nicely and reimplanted it into the bladder over a thin tube we call a feeding tube (named after the fact that it is used to deliver food directly into a baby's stomach). this tube i then pulled out straight through the abdominal wall. when i wanted to remove it all i'd need to do would be to pull it out. the hole in the bladder would heal and all would be well. i was super impressed with my ability to think on my feet. the medical officer was also duly impressed. we closed up and i went home.

i was super keen to 'accidentally' run into my urologist friend the next day at the private hospital to tell him about my brilliant improvisation so i spent extra time on rounds wandering the corridors with the hope of seeing him. finally just by orchestrated chance i did run into him. i proudly told him about what i had done in the absence of a double j tube and how it meant i would be able to remove the tube easily in the ward later without the need of another anaesthetic. i was so impressed with myself.

"bongi, that is a well known technique which we sometimes use." my bubble was good and truly burst.

yep, i'm not a urologist. not only do i not know all their fancy techniques, but in the end i feel i must admit i have the fragile ego of a general surgeon.

experience

different places deliver different opportunities for experience. it is just a fact. a surgeon working in hollywood is going to see a different spectrum of patients than what one in, say, delhi would. it doesn't mean one is better than the other but it does mean one would feel more at home treating certain conditions than the other. therefore when the belgians rotated with us it stood to reason that they would feel a little unsure on their feet in our environment, initially at least.

when i started in surgery there was already a belgian there. our department had an arrangement with a university in belgium which meant there was at least one belgian registrar with us for one whole year at a time. each year the belgian would go back and another would come to our shores to replace him. so i got to know quite a few belgians in my time. chatting to them i realised the vast difference between the approach to training in their country and in our humble department.

when i first joined the department, in an effort to make small talk i engaged the belgian. i didn't really know what to talk about so i decided to ask him about the differences in the sorts of things they saw there and the sorts of things we saw in south africa. i started with things that were common to us.

"so have you ever seen a gunshot wound in belgium?" i asked.

"of course! i saw one that went in the thigh anterior midline and exited on the lateral aspect just before i came out to south africa." i decided to rather ask him about the weather. it would bore me less.

a year later when the new belgian had joined us i decided to strike up a conversation so that he at least felt there was someone he could speak to in this new strange country. at that stage we were so consumed by surgery there was little else we were capable of talking about.

"so have you ever seen a gunshot wound in belgium?"

"of course! about a year ago there was one that went in the thigh anterior midline and exited on the lateral aspect."

"and what's the weather like there?"

my third year there when the third belgian came out i decided to test what was becoming a theory of mine.

"have you ever seen a gunshot wound in belgium?"

"of course!"

"let me guess. it went in the thigh anterior midline and exited on the lateral aspect?" he assured me the weather in belgium could be quite pleasant in the summer.

so the first three belgians had seen the exact same gunshot case. gunshots were so rare in their hospital that when one came in the entire surgery department was called to casualties to see it. i was amazed. they also didn't quite have the same sink or swim way of training that we had. they pretty much didn't operate at all without a consultant being present. in our way of thinking it was madness, but in reality it was just a different road to the same destination.

so imagine the culture shock when one particular belgian registrar started in our department. he was shuffled off to kalafong and put on call alone his very first night. now as i have mentioned before, getting a consultant out to kalafong at night was only fractionally easier than turning lead into gold. the senior south african registrars informed him of this fact and availed themselves to be called if he needed advice. they quickly added that they would help him telephonically but they would not actually come in. he would have to sort everything out on his lonesome.

the next day he was a wreak. he was talking about packing it all up and going back to belgium (where the weather was pleasant in the summer). to his credit he stayed.

you see, that night, not only did he see his first gunshot abdomen, but he was required to operate it. after that he did his second one and after that his third. on his very first night on call in this glorious country of ours this poor first worlder really got a taste of what it can be like. i really felt for him. but then again at least we no longer had to discuss the weather.

perspectives

somehow we see things differently. i'm not saying we are not part of the common human experience but we are involved in this experience on such an acute level we just end up seeing things differently. i mean if someone drops the word 'urgent' into a message for me i get visions of someone bleeding to death rather than images of having to stop at the shops to buy milk on the way home. maybe what i'm trying to say is we can come across as slightly glib at times. there are so many stories to illustrate this that maybe this needs to be discussed in a number of posts, but i remember when i was confronted by my own attitudes to the realities of life.

i was in casualties resus, a place i really felt at home in. i was stabilising a gunshot abdomen patient and preparing him for theater. it seemed the bullet probably went through the liver and the patient was bleeding enough that i was quite concerned. i was determined to stay with him until i had him under my knife, just in case something went wrong. but once the lines were up and the blood was running in there was little more to do than to wait for our turn in theater. it was a time to sort of stand around and maybe share a joke or two with the rest of the team. it is also a time to see what else is going on in resus.

the patient lying next to mine was a neurosurgery patient. he had been attacked in his house during a break in. for good measure his assailants had driven his skull in with some sort of blunt object. i had nothing better to do so i took a look at the scan. it was clear my neurosurgical colleagues were also not going to get too much sleep that night either. we laughingly teased each other about whose job was the worst.

all this time i noticed there was someone standing just outside the back door of the resus room. he had an expression somewhere between awkwardness and sheer terror on his face. he was clearly totally out of place but he wasn't bothering anyone and i sort of just ignored him. but he looked very familiar, so in between making sure my patient wasn't about to die and teasing the neurosurgeons i racked my brains to try to remember where i had seen him before. suddenly i remembered. he was a pastor at a local church and many years ago, when i was still a medical student, i had seen him there. the polite thing to do would be to greet him, i thought. i moved towards him.

as soon as he saw me approaching he seemed to take a deep breath and gird up his loins and he set out directly towards me much faster than i was moving in his direction. he walked with such a determinedness i wouldn't even have been surprised if he decked me when he got to me. i readied myself to say something, but suddenly realised the usual 'hello, and how are you' somehow just didn't seem to work in this setting. i was formulating a slightly less formal 'hi there' in my mind when he beat me to it and started speaking.

"excuse me," he said with an intense expression etched into his face, "but would it be ok if i prayed with this man who has the head injury?" somehow my 'hi there' suddenly seemed so out of place. even a 'i once saw you in church many years ago' seemed a bit unimportant compared to the fact that his friend would be lucky ever to talk again without saliva running down his chin, assuming he survived. i felt stupid.

i went through it afterwards in my mind. you see when people come into contact with me it is more often than not at one of those extremely important moments in their lives. often the only question to ask is whether they are going to survive or not. things like what ply toilet paper they prefer becomes somewhat irrelevant. but on any given day i may be faced with many people at these crucial crossroads, but each of them will maybe be faced with the situation only once or twice in their entire lives. maybe in a sense sometimes we become used to things no one should ever be used to.

and therein lies the secret. we may never become blasé or glib about the sharp edge of the human condition just because we see it every day. for me it may be just run of the mill or just another gunshot, but for the patient in question it is probably the single most significant moment in his life. even if we can't empathise with each and every patient, we need to remember these facts and respect the patient's experience for what it is, deeply significant.

in the end i mentioned quickly and in passing to the man that i recognised him and then left him to support his severely injured friend in whichever way he saw fit.

exemplary

part of the job is to treat some unsavoury people. sometimes you know what it is they have done. mostly you don't. sometimes you even may make a difference. but mostly you just do your job. after all it is not our part to play judge and jury (and, in our case, executioner). but recently i heard a story from some fellow surgeons about one of their colleagues that i'm sure creates a warm fuzzy feeling in the hearts of all south african surgeons.

i can attest to the fact that after a long night on call your general mood is usually not the best it can be. also it becomes more difficult to see the humour in situations that on a normal day you might be able to laugh off. so when this particular registrar finally wrapped up his post call work and meandered off to his car to go home he was not delighted to find someone busy stealing it. he did what any south african surgeon would want to do in his situation...he shot the guy.

the person in question was, however a surgeon, so his training kicked in. they were already at the hospital so all he needed to do was drag the punctured villain to casualties and get him ready for theater, which is exactly what he did. despite the fact that he was post call, he even took the time to operate the guy himself. i suppose he had the best idea of the tractus of the bullet?

i can just imagine how the post operative ward round went when he presented the case to the prof. how would he have worded it?

"well prof, i shot the guy and then i did a laparotomy. well you always told us we should actively look for work to do if we wanted to get experience."

the dogs of law

i hate lawyers. i know that it comes from a few personal experiences that i've had that have forever tainted my view of them and what they do, but that is the fact of it. i hate them more than i even can say. the first time i saw their dark side may be the incident that left the deepest mark on the hate-lawyers part of my psyche.

it was late at night in kalafong. i was halfway through an omentopexy when someone phoned from casualties. the message was confusing.

"the casualty officer says he has a gunshot wound abdomen of a 16 year old girl in casualties. i told him you're busy operating. he says the patient is dying and asks you if he has your permission to open the abdomen there in casualties?" what the hell!!! i quickly put the scenario together in my mind. even a guy with considerable experience is not going to save someone with an impromptu laparotomy in a casualty situation. he obviously had already decided she was as good as dead and thought some sort of heroic-looking attempt at something might at least create the impression he was doing something. i knew what to say.

"no way at all! the guy who thinks he can do something can come and do it here in theater in a controlled environment and not try to look like some f#@king hero in casualties. i'll finish here as soon as possible and join him. get a second theater ready immediately!"

after that the situation became somewhat surreal with the floor nurse running back and forth with messages between me and the casualty officer as i started rushing my operation more and more in order to hopefully join in the fray before it was all too late.

"the casualty officer says he doesn't think he can do a laparotomy. maybe he should just leave her to die?"

"no way!! he was willing to cut her open from stem to stern just moments ago in casualties. tell him he saddled this horse and now he must ride it. tell him to pull his finger out his ass and do the f#@king laparotomy!" the nurse turned to go. "nurse!" she turned back. "try to soften what i say a bit at least." i was afraid i was going to piss the guy off.

"the casualty officer says he will start but he is calling your consultant in to take over." i knew the consultant was an hour away. he would be too late.

"fine! no problem! just get started!" by this time i was rushing my operation so much i realised i was almost doing half a job. i tried to focus so i didn't end up with two bodies and not just one.

"ok, the patient is on the table in the theater next door. the anaesthetist says she is crashing and he wants to know if she is for active resuscitation?" he would only ask if things were desperate.

"of course she is for f#@king resus. she's sixteen! she is just a kid! we don't just turn around and walk away while kids are busy croaking! we must at least try!! to try and to fail is one thing but to not try at all is inexcusable" at this stage i knew i could leave the rest of the omentopexy to my assistant to sort of close things up with hopefully only minimal complications. anyway i could no longer handle being on the sideline with the gunshot case. i ripped off my gloves and gown and went charging through.

the scene in the other theater was one of the tail end of chaos. everyone was standing around doing nothing. on the table lay a young girl completely naked with one anaesthetist still hovering over her with hands in the cpr resus position. there was no resus effort anymore. the other anaesthetist was standing to one side removing his gloves. his brow was dotted with tiny pearls of sweat. the sisters were standing around as if frozen in different acts of resuscitation. one was holding a vaculiter (a bag of intravenous fluid) as if to change the fluid bag which had just run dry. one was standing with a syringe, probably full of adrenaline, sort of swinging it idly between her fingers. the student nurse was standing in a corner as white as a sheet, probably scarred for life. it was over.

i looked at the girl. she was of slight build but her abdomen was swollen to bursting point. her face was ghostly pale. on the dome of her distended belly was a small symmetrical hole smack in the middle. there was an almost innocent gentle stream of blood and feces quietly making its way down her skin from this hole onto the theater table below. the resus efforts had stripped her not only of her clothes, but also her humanity and her dignity. and yet even though she was lying there in the mess of blood and saliva and feces she somehow seemed peaceful. i walked up to her and softly closed her eyes. she deserved at least that. that last picture of her really stuck with me and touched a deep chord of my humanity.

some time after that i happened to be visiting an old school friend who had gone on to study law after school. somehow we ended up speaking about his cases. he spontaneously mentioned a case where a 16 year old girl shot herself in the abdomen just next to kalafong. it was strange in that there was a cop in the house at the time and therefore she was transported to the hospital literally moments after the incident. despite this, my friend informed me, she died. the post mortem revealed a gunshot wound to the aorta. i asked him when this incident had happened and thereby confirmed i knew who he was speaking about.

as it turns out the cop had been called to the house because of domestic violence. the husband, my friend's client, had allegedly threatened his wife with a gun. someone, maybe their 16 year old daughter, had called the cops. that's when the incident happened. the cop was in the house downstairs with the parents trying to mediate peace when a shot went off upstairs. the gun had been found by the girl and she obviously decided that it was all too much. her shot was well placed.

my friend then casually told me that in the initial statement to the cops, the father had said he had placed the gun on the table upstairs before coming downstairs to let the cop into the house. apparently from a legal point of view this fact was the crucial one. it had to do with negligence with a weapon resulting in the death of someone. the father would be in some degree of trouble. my friend had advised his client that this fact made the case indefensible. immediately, the client changed his story to state that in fact the mother, his wife whom he had allegedly threatened with the gun, was in fact the one who had left the gun in easy reach of the daughter and not him. on these grounds they were going to defend him although they knew the man was lying. he relayed this story without flinching.



i thought back to that beautiful girl, ophelia-like, peaceful in death. i thought of the contrast of her youth and beauty with the small hole in her abdomen and the rank stench of spilled bodily fluids in that small theater. i thought of the sad resignation on the face of the anaesthetist whose resus effort had been in vain. i thought of how late at night it was and how the emotional strain had drained us all of any energy and left us tired and spent. and then i looked at my friend's face. the lawyer was smiling at me. he was happy to defend a man who was prepared to lie to save his own skin in the wake of the death of his own daughter. he hadn't seen the real human drama and frankly i don't think he cared.