running with the big dogs

on the topic of urologists, sometimes we actually do operate together. it happens seldom but it does happen. it is actually usually during these operations that i realise i no longer enjoy assisting so much. i think it has something to do with the surgical personality. you see we don't like to play second fiddle. it's a bit boring. having said that, when assisting the urologists, boring is what you want. the alternative can be quite terrifying. i mean there is usually a good reason that the urologists ask the big dogs to accompany them to theater.

i was senior registrar. one of the other firms had some sort of dispute with the urologists about a patient. you see after both disciplines reviewed the ct scan of the patient, the urologists felt it was clearly an inflamed gallbladder that was the problem and the surgical firm felt it was an inflamed kidney. neither one wanted to actually operate the guy. finally the boss intervened. he told the surgical registrar to take the guy to theater and call the urologists if necessary. the fact that the registrar in the relevant firm was a junior and could hardly take out a straight forward gallbladder didn't worry the boss too much. he simply instructed me to assist in the operation. not that i had a choice but i consented. however i decided i would be doing no assisting. if i had to be there then i was going to bloody well operate myself.

the gallbladder part of the operation was a walk in the park. it was completely normal and practically climbed out of the abdomen on its own. of course as soon as we saw that it was in fact the kidney that was inflamed we called for the urologists. things were looking up for me. i had it planned. as soon as the urologists arrived i was going to hit the road and leave the junior surgical registrar to assist. after all it wasn't even my patient. also, the boss wouldn't be looking for me for the rest of the day so i could catch a beer with a friend at the local tavern. i could already taste it.

the urologist registrar entered. he was a good friend of mine and as i took off my theater gown and gloves we exchanged a few laughs. but then their prof walked in. i was a bit surprised. they were obviously taking this kidney quite seriously. or at least more seriously than when they reviewed the ct scan. i stayed to see whether the prof was going to scrub in. he did. i should have left then but i sort of hung around for a while.

suddenly their prof looked up at me.

"aren't you a senior in the surgery department?" i considered lying. to say yes could only lead to trouble.

"yes." it led to trouble.

"well then scrub in. you can't go now. i need you here to look after the ivc." absolutely great!! i thought. now not only would i miss out on a beer but i would end up assisting anyway. again it wasn't really as if i had a choice, so quite soon i was scrubbed up and standing opposite the prof as he wrestled with the kidney. it was then that i realised why they had brought their prof along. the kidney seemed angry, very angry.

the inflammation and fibrosis around the kidney was immense. there were no normal anatomical planes but instead everything just adhered to everything else. one of those everythings was the ivc. i understood that the prof was worried about it. i was too.

finally he lifted the kidney out free of the patient. the urologists let off a whistle of congratulations but i remained silent as did the prof. you see i was watching his other hand which shot into the wound as the kidney came out to put pressure on the ivc amid a sudden torrent of blood. also as he passed the kidney off he didn't remove his hand from the wound. there was something under that hand and it was something that wasn't going to lie down without a fight. then coolly and calmly spake the prof.

"i think i have torn the ivc." he said it as if it wasn't a problem, as if it wasn't something that often was followed by the ending of life. i was amazed that he could be so calm when faced with such a calamity. and then i found out why. he looked at me.

"that's why you are here," he said, "it's your job to fix the ivc." he was calm when faced with such a calamity for the simple reason that he was not faced with such a calamity. i was. the realization set into my heart like a pick axe. i felt nauseous. i thought of that beer that i was busy not drinking because i was required to somehow perform a miracle on a patient that was never mine. but it didn't help to bemoan my position or to shy away from this immense responsibility that had been thrust upon me. i had to put my head down and fix it.

i fixed it. i remained calm on the outside and got to work and got the job done. but i think i shaved a few years off my life during that operation. when i was finished i was exhausted. i left the junior to close and finally went for that long overdue beer.

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.

buff and turf

the other day i read a post about the age old medical practice of the buff and turf. bearing in mind i also recently posted about icu, i was reminded of one of the worst turfs i ever saw.

it was during my icu rotation. we were on morning rounds with the consultant when a medical technologist came running in.
"there is a major disaster in casualties. can someone please come as fast as possible to help?"
naturally we all rushed over there. we were not prepared for what we saw.

in resus was a patient in severe shock. he was extremely pale and had almost no blood pressure. his abdomen was severely distended and sported a midline scar which had been crudely closed with a running nylon suture. the picture that is forever impregnated into my mind is the blood squirting out between the sutures. there were multiple streams of blood literally shooting up in a neat little line. as the patient rolled from side to side it reminded me of the sprinkler my parents had when i was a child. each line seemed to arch elegantly one way and as he rolled the other way, these fountains seemed to slowly follow. it may even have been beautiful in a sense if the setting was not so dire.

we jumped to work. one started cpr (it was needed) while another threw a high flow line into his subclavian vein (we used a schwann sheath). the third made some desperate, probably futile attempt to apply direct pressure to the abdomen. it seemed like a good idea at the time. during all this action we not so quietly and much less subtly enquired where the patient came from and why the surgeon on call wasn't waiting in casualties when he arrived. everyone pled ignorance. it seemed the patient arrived from a peripheral hospital without there being any warning that he was coming. with all the action that was all we discovered about his history then. our energies were concentrated on getting him to theater which we pretty quickly did. being the icu team, we then handed over to the guys in general surgery.

later we heard his story. the patient had been shot through the abdomen. at the hospital he presented to he was taken to theater. there the medical officer who operated him started by repairing all the bowel injuries. thereafter he decided to explore the retroperitoneal haematoma. as it turned out this action would reveal that the bullet had gone straight through the ivc.

i can just imagine his thought process. just before 'oh sh!t!!!' he probably thought 'i wonder what i'll find under here?' together with the 'oh sh!t!!!' which had no doubt evolved to 'oh f#@k!!!' he probably thought 'help!!!'. with this he decided to pack the abdomen and post the patient to anywhere away from where he was. we were that anywhere. in his raw panic he neglected to phone ahead and give any form of warning that this disaster was turfed to us.

truth be told i feel for the medical officer thrown into situations he is ill equipped to handle. but i find his overall actions difficult to justify. i think the reason he didn't phone is that he was afraid the academic hospital wouldn't accept a patient in mid operation for an ivc injury (his best chance which was slim under the circumstances was the operation he was undergoing at the time) and the rattled doctor wasn't willing to take that chance. all he knew is he wanted that patient far away from him and nothing was going to get in the way of that.


p.s the patient actually survived his operation and only died shortly after. well done to the operative team.