coma

one of the curses of kalafong (hell) was that there was no neurosurgical service. this meant us mere general surgeons had to handle the many head injuries that came in. so, for example, when some guy decided to cave in the head of his so-called best friend with a five iron on the golf course because they had started with the nineteenth hole instead of the first, we ended up either dumping them in icu with a tube down the trachea to wait to see what happened or trying to turf them to a neurosurgeon that could actually operate them. it was far easier to dump them in icu. mind you, it was easier to turn lead into gold than to successfully transfer a patient to neurosurgery. so generally we hated it when we were called to casualties to handle someone with a head injury.

my colleague got the call. an old lady had apparently fallen and hit her head. the paramedic had intubated her on the scene and rushed her in. he proudly stood there admiring his handiwork as he presented the patient to my friend.

"well, doctor, her gcs was three so i had to intubate her. she fought the tube so much that we had to inject her with 30mg dormicum." it was the usual story the paramedics spun explaining why they had intubated someone and at the same time illustrating that they thought we were idiots. you see, the gcs (glascow coma score) is a scale that gives one an idea what depth of coma the patient is in. it is a measure of the patient's normal responses as far as eye movements, verbal response and response to pain is concerned. a score of 15, the maximum, is essentially a normal person. a score of three is the lowest you can get and is equivalent to a corpse or maybe a brick. a person with a gcs of 3 does not fight a tube and doesn't need dormicum. then again 30mg of dormicum would pretty much drop a gcs of 15 to 3 or thereabouts. my friend was understandably skeptical when he entered the room.

"oh, doctor, the other thing i forgot to tell you is the right pupil is blown." this was lingo meaning the one pupil was severely dilated while the other was not. this was in fact a true sign which did indicate intracranial damage, usually bleeding with unilateral increased pressure. maybe, despite the supposed need for 30mg dormicum, the patient really was in trouble.

the surgeon walked in. the patient lay dead still with only the rhythmic up and down movements of the chest as the ventilator pumped away. he took a quick glance at the eyes. sure enough, the right pupil was massively dilated and absolutely unresponsive to light. this was not a good sign. he turned to his students.

"look at the eyes. see the difference in the pupils? that is a very bad sign. this poor old lady has pretty much no chance of survival." immediately the patient lifted her head off the bed and shook it vigorously. the surgeon took a double take. that wasn't supposed to be possible.

"tannie, can you hear me?" the patient nodded. "disconnect the ventilator immediately!" commanded my friend. the sister complied. the patient blinked a bit with her asymmetrical eyes, but breathed normally. my friend pulled the endotracheal tube out, to the absolute horror of the paramedic who had been so proud of his actions. with that the old lady sat up, lifting one hand to her throat.

"daardie fokken buis het my rerig seergemaak! (that f#@king tube really hurt me)"

"tannie, what is wrong with your right eye?" asked my friend.

"when i was only five years old i was injured when a stick poked me in the eye. since then it has always been like that." the paramedic went a bit pale and quietly left the room.

after listening to this story i too often extubated patients that the paramedics had overzealously intubated after flattening them with ridiculous amounts of dormicum.

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.