it's probably not funny

we have a different sense of humour. we just do. what we find funny can be macabre to most people. it is probably part of our general desensitization or maybe it's a way of dealing with the things we see. you can't get emotionally involved with everything. i remember realising this many years ago. but more recently i saw it again in a very strange turn of events.

i was a fifth year student in paediatrics. for ward rounds we were accompanied by physiotherapist students and social worker students. that morning we arrived for rounds. one of the sixth years asked the sister where one of his patients was because the bed was empty. the sister informed him the patient had died during the night. i got the feeling from their interaction that it wasn't totally unexpected. the sixth year turned to one of his colleagues and laughingly said;
"yesterday i was so busy, but today seems to be my luck day. two of my patients were discharged and one died. now i only have one patient."
the social worker happened to be within earshot. her face was one of absolute horror. she was devastated. but the sixth year didn't mean it in a bad way. he was simply not emotionally connected to the clear human drama that had played itself out. maybe he had been one too many times or maybe he was just like that. i just remember being impacted by the difference in reaction to the same news by the two people.

the second story happened when i was already qualified as a surgeon. i was on call. while i was waiting for theater time i was sitting with the radiologist going through scans (this is something i tend to do still). at a stage the radiographer came through. she wanted his opinion on a scan. apparently she couldn't understand what the contrast was doing and wanted to know if she needed to do a late phase scan. we both went through to see.

the patient had been referred to the hospital as a head injury patient after a car accident. he was intubated at the referring hospital as is good practise for these patients so he was already on a ventilator. the casualty officer suspected he was coning (a preterminal event where the brain stem gets pushed through the opening where the spinal chord exits the skull due to increased intracranial pressure, usually due to trauma inside the skull) and had therefore phoned the neurosurgeon. he had in turn instructed him to do a scan of the brain. the casualty officer decided to do an abdominal scan at the same time because he wanted to make sure there wasn't also abdominal trauma. and thus the patient ended on the ct scan table with the radiographer wondering what was going on with the contrast.

as we entered the scan room i too was perturbed by where the contrast lay in the abdomen. the contrast had been injected through a central line in the neck. it had gone straight through the right atrium into the ivc. there it had moved into both the right hepatic vein as well as the right renal vein. it was nowhere else to be seen. the radiologist immediately made the obvious diagnosis (in retrospect).
"i know what's wrong," he proclaimed. "this patient is dead." of course with the patient on a ventilator it was not immediately obvious. the radiographer went through to feel for a pulse, which, looking at the scan, i knew he would not have.

i started laughing. everyone else was shocked, more at the fact that i was laughing than at the fact that there was a dead guy on their scan table.

maybe they are right, it's probably not that funny.

the leroy-burnell syndrome

when we were in medical school as with all medical students we were bombarded with many new words. not the least of these were the myriad of syndromes. and each syndrome had symptoms that overlapped with pretty much every other syndrome. it was one large conglomeration of new words all mixed together.

but there were a few other things we noticed. firstly every syndrome worth its salt had a double barrelled name with a hyphen in between. exotic sounding names worked better than simple names like mark or john. also the more symptoms associated with a syndrome the better the syndrome was.

and thus we invented the leroy-burnell syndrome. the name was perfect. and seeing that we used it to explain any conglomeration of symptoms that we could not otherwise bring to a diagnosis, any symptom known to man could be attributed to our neologistic syndrome. (if only house md had known about this syndrome the episodes would all be half the length.) if we had no idea about a patient, my clinical partner would lean across and say,
"this is a classical case of leroy-burnell syndrome." and doff his head intellectually. if the prof was not looking we would laugh.

then one day we were doing our usual ward chores in internal medicine. a group of fourth years came in with a rotating consultant. the consultant lead them to a patient. he told them to examine the patient and make a diagnosis. he would be back in 30min to discuss the case with them.
as fourth years generally were they seemed a bit nervous about direct patient contact. finally they drew the curtain and one approached the patient.

it was about then that my clinical partner decided to 'help'. he stuck his head through the curtain and said.
"you guys, this patient has the leroy-burnell syndrome so make sure you don't miss that. but don't worry, the clinical signs are easy to pick up. good luck!"

the gratitude on the nervous face of the fourth years was clear as they simultaneously thanked my friend for his kind gesture and reached for their pocket references to look up the leroy-burnell syndrome. it seems they hadn't come across it in their studies yet.
i turned away to hide my laugh. i was imagining the pride on the unsuspecting face of the fourth year when he announces to the consultant that this was a classic case of leroy-burnell syndrome.

shut up fool

some of my colleagues used to tell me i needed to learn how to keep my mouth shut. sometimes i just couldn't resist saying something choice. often this didn't go down well with the old style surgical profs. there were exceptions.

every thursday afternoon we had a gastroenterology meeting. only the surgeons, the gastro fellow and the head of gastro, who were both internists, attended. for reasons i don't know the internal department as a whole didn't feel the need to be there. so generally speaking there were far more surgeons than any other type of doctor.

that day we had already worked through a few scans and had academic discussions about diagnosis and treatment options. we were approaching the end of the meeting. the prof asked if there were any more patients to be presented. the gastro fellow moved forward with a ct scan in his hand.

"i have a patient." he smiled. "i'd like to hear what the surgical registrars have to say about him."
i was in no mood for an internist to try to catch me out in front of my profs. i remember being a bit annoyed. he started presenting. he gave the history of the patient and the clinical findings. as i listened i felt sure the conclusion of the story was going to be that the patient was referred to one of us for a laparotomy.

"i have the ct scan here." he announced proudly, "but before we look at it i have a question for the senior surgical registrars. who can tell me why i requested a scan of this patient's abdomen."
i couldn't stop myself.
"because you can't operate!" i piped up.

everyone except the fellow fell about laughing. that was the only time i remember when the profs laughed at my often injudicious comments. it brought the meeting to an end. the internist was outnumbered. sure enough, the patient had been operated and the profs cut to the chase and asked the relevant surgical registrar what he had found.

sign

those of you who follow this blog will know that we had an interesting prof. some might say eccentric. others might say idio(t)syncratic. whichever, there were interesting stories associated with him.

the prof demanded total silence during any operation. the silence was so absolute that the prof himself would not speak, not even to ask for instruments. he had hand signs which he used to request the next tool of his trade. his eyes never left the operation field and the sister had to make sure she palmed the instrument to him correctly if she didn't want to fall foul of the prof's sharp tongue. one incident delivered an exception.

it was an auspicious occasion. the prof was going to demonstrate the correct way to do a haemorrhoidectomy. he insisted that the whole firm was there to see how it was supposed to be done. i had lived through this demonstration once before so i was not too enthused.

soon the patient was cleaned and draped. the prof, suitably scrubbed up, settled into his chair between the patient's legs, getting ready to start. i noticed that the sister was junior. she was chatting to the floor nurse as the prof settled down, a definite no no. i actually remember thinking that it was just a matter of time before the prof got stuck into her. but, fortunately for her, he was too focused on the target zone, deep in thought, obviously planning the procedure. the sister was preparing the scalpel, also deep in thought. but her thoughts were related to the conversation she was having. her mind was far from where we all were.

she attached the blade to the handle and turned towards the prof, blade exposed. the prof, at that moment, seemed to finally have decided what his first move would be. without looking and in total silence, he swung his hand back with the index finger extended briskly in the sign demanding the scalpel. how was he to know that the sister was holding that same scalpel, sharp point towards him, exactly where his hand went. to put it bluntly (ok, maybe not the right word) the prof threw his hand onto the scalpel's point. i imagined an old japanese warrior throwing himself on his sword.

to say the prof was not impressed is somewhat of an understatement. the cut bled profusely and it took some time to settle everything down once again before the operation could get underway. that is the one and only operation i ever remember the prof doing where he spoke throughout. he let the sister have it. once he had given her a run down of her manners he went onto her upbringing and her ancestry. but at no stage did he let up until the patient was awake again.

to be honest i was chuckling on the inside, but the prof had taught me to be silent during his operations so it did not show.

jelly tots?

sometimes i just post funny stories. sometimes you think of the ideal punchline before the moment has passed. on both accounts this post represents one of those times.

it was one of many morning meetings. usually they were not fun. almost always the prof would have a go at someone. most of the time if you weren't actually directly in his cross hairs, you would just keep quiet and nod at the appropriate moment. this morning was no exception.

fortunately i hadn't been on call the previous night so i was basically a passive, occasionally nodding observer. the guy who had done the call was a particular target of the boss. the boss didn't like him, but, even worse, he didn't seem to have the savvy to present his cases in a way that avoided drawing fire. this day was no exception.

my friend's first case was a patient who presented with what sounded like a macerated nipple. i remember wondering why he even mentioned the patient as a call case. i would have referred her to the clinic and thereby avoided telling the prof about her at all and therefore avoiding taking a hammering at his hands. also he described her as a young woman who was breastfeeding (although the baby was three years old). it was unlikely to be a serious problem. to make things worse my friend had actually taken i biopsy of the nipple. i don't know what he was thinking, but ironically he probably did it to be thorough in an attempt to avoid the wrath of the prof. the wrath of the prof descended.

just like me the prof wondered why he had been so drastic as to take a biopsy, but, unlike me, the prof was not subtle in asking. my friend did not have the gift of the gab and soon started floundering in his explanation. (this may at least partly have been due to the fact that the exchange took place in my friend's second language). the prof let him have it.

the prof, between the constant tirade of aggression aimed at my friend, suggested that the macerated nipple was probably due to the baby (or rather toddler by now) using the nipple more as a pacifier than a source of milk. he painted a picture of a toddler keeping the nipple in his mouth until it became soggy from the constant moisture. at about this stage most of us were feeling sorry for my friend who was starting to look quite foolish, but we continued to nod when the prof's eyes turned in our direction. i just looked at the floor.

the prof had a habit of not letting a thing go. this was no exception. he explained that the nipple had become like a jelly tot that the baby had kept in its mouth for an hour or so. it would be soggy and no longer look like a normal jelly tot. the opportunity was just too good to let pass. i interjected.

"prof, strictly speaking" i said, " isn't that a jelly tit?" i asked with a straight face. i think if everyone hadn't fallen about laughing i would have been in trouble.

captive

icu is icu is icu, but some icu stories could only happen in south africa.

i was doing my icu rotation. the work wasn't so tough but the hours were long and we did one in three calls, so it became a bit tedious. part of the job was shuffling patients to make space for the next critical patient coming in. bed occupation was always 100% or more (makeshift icu beds were often created in side wards). so late one night i get a call that they are operating some guy the cops winged in a shootout. apparently he lost quite a bit of blood and would come in intubated. great, i thought. probably a bad man and i needed to perform almost a miracle to create a bed for him.

sure enough, after transfering our most stable patient to another hospital, which required speaking to their superintendent, no small feat at night, i got a bed ready.
the patient arrived after a somewhat eventful surgery. he was intubated and needed ventilation, but was actually otherwise relatively stable. to keep him alive through the night should not be too difficult.

the next morning the patient wasn't only alive, but he was doing very well. he was still on a ventilator, but we expected to wean him in a day or two.

then two cops walked in carrying a ridiculous amount of heavy chains and shackles. they walked up to my patient and sort of dumped them on the bed with a loud clang. they then told me they were going to chain him down. you see, it seems, my patient was a known cop killer. he had chalked up quite a number of 'kills' and they weren't too keen on him getting away. my mind wandered to my student days when we once had an ethics discussion about chaining prisoners while they were in hospital. i had thought those morals sounded decidedly first world and didn't really have a place in south africa. but this patient/prisoner was different. he was intubated and couldn't escape for the simple reason that he couldn't breathe on his own. i explained this to his would be shacklers. the cops reluctantly left, taking their chains with them. they did leave the obligatory heavily armed guard at the door. i handed my patients over and went home.

next morning, when i got to work, one of the sisters greeted me at the door.
"did you hear what happened last night?" her eyes sparkled with the excitement of someone who has some hot gossip to spread. as it turned out, as the night went on and as our bad man patient gradually got stronger thoughts of escape dominated his mind. he knew he had a tube in his throat, but how was he to know that that tube was helping him to breathe? also, i assume, through the haze of the drugs he was getting, maybe his mind wouldn't have responded to logical arguments.

so at a stage, when there was less activity, he took his chances. he jumped out of bed and ran for the door. the endotracheal tube was ripped out as was the urinary catheter. he apparently almost made it to the above mentioned door before he collapsed in a heap. everyone, including the heavily armed cop at the door had to help to get him back into bed. he was then reintubated and his blue colour soon gave way to a more healthy looking pink.

i listened in disbelief, but, i confess, with a smile. as soon as i heard the story i walked to the police outside icu and demanded they chain the patient with everything they had. they complied.

p.s in retrospect i often wondered if it was the lack of the endotracheal tube that brought the patient to a heap on the floor or the urinary catherer being ripped out with the balloon still inflated.

gee thanks

i've often blogged about the tendency in our training to be left on your own (here, here and here to name at least a few), but some of the stories have a funny twist.

i was in my medical officer year. in those days there was a general shortage of registrars so the boss used us to fill the gaps. he put myself and another medical officer in charge of a firm, reasoning two medical officers add up to one registrar.

being two, we decided to split the call. and i was the guy who got the night. so when i came in i tracked my friend down. he was in theater doing an appendisectomy. i asked him if he had anything to hand over to me.
"sure. there are just two appendixes to be done."
"straightforward or any catches?"
"no catches, just appendicectomies"
the first one went well. i used it to show the house doctor how to do an appendisectomy, so that she could do the second one.

at this point i'd like to point out that i was very junior. i did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it.

she did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out. i calmly told her it looked like the appendix was going to be pretty sick. and then she found it.

it was normal. my heart sank. there was clearly something else wrong with the patient. i remained silent and told the house doctor to go on with the operation. my mind was racing. most probable diagnosis was perforation of a peptic ulcer. i calmly asked if there were any x-rays with the patient file. there were and they were put up on the x-ray board which was behind the house doctor and therefore in my direct line of vision. there on the x-rays for all to see was free air under the diaphragm, a clear sign of peptic ulcer perforation.

shit! i thought, but stayed silent. i knew i would need to take over. only problem is i'd never done the necessary operation before (omentopexy). i had seen it once before as a medical student about three years beforehand. it was definitely in the class of operation where you would make enemies if you called the consultant in. it was meant to be in the armamentarium of a registrar and, according to the boss, i was at least half a registrar.

the house doctor swiveled her head around to take a look at the x-rays.
"shit!" she said out loud.
"don't worry," i lied. "that's why i'm here. you have no responsibility here. i'll take over now."
"shit!shit!shit!shit" she replied. i don't think she imagined her first appendisectomy to go quite like this.

for an omentopexy, the first thing that needs to happen is a midline incision, rather than the usual mcburney incision for an appendix. the patient would have two cuts. oh well, can't be helped now. i told the house doctor to swap places with me.
"shit!shit!shit!shit!" she said in acknowledgment to my request and moved around the table. i confess i laughed a bit at her total loss of vocabulary, but it was a nervous strained laugh. i felt that i needed to reassure her that i had the situation under control. she did not need to know that i had only seen the procedure once before and that a number of years ago.

"don't worry," i said, "that's why i'm here to back you up. you are not in charge here. you have no responsibility."
"shit!" she said with what i assume was a forced smile behind her mask.

i got to work. soon i had the hole nicely exposed and the abdomen cleaned out. all i had to do was plug the hole with omentum, place drains and close. only problem is although i theoretically knew what to do and even how to do it, i had no idea what suturing material to use. this was a dilemma. i knew i couldn't really phone for backup for an operation i was supposed to be able to do late at night. but more importantly i didn't want the house doctor to feel any more insecure about the situation than she already did. if i told her that i was unsure of what i was doing i was pretty sure i would get another string of her most recent favourite word and maybe turn her off surgery forever. the situation seemed to be traumatic enough for her without me adding to it with trivial facts about it being pretty traumatic for me too. i decided what to do.

as casually and as nonchalant as possible i turned to the sister.
"sister, when the other guys do an omentopexy, what suturing material do they use?" so clever, i thought. i would find out what to use without causing any further stress to the fragile house doctor and without looking too stupid myself.
"oh," she answered, "they use whatever they want."

gee thanks. i thought. well that didn't work. even in the acute phase i could appreciate the humour of the situation though. i might even have laughed, more at myself and my situation than anything else. the sister had no idea that i was in what at that stage was deep water for me.
so i asked for vicryl and did the necessary. the patient did well.

next morning, on ward rounds with the prof, i took the blame on myself. i did not mention that my colleague had misdiagnosed because, in the end, i should not have gone into the operation without double checking everything myself, so, i reasoned the blame did in fact lie with me. i also neglected to mention that the house doctor had done the initial appendisectomy. she was never in the firing line. despite all this, just for good measure, my colleague who had assured me that it was just a simple appendix, covered his own ass and informed the prof that he had told me he suspected perforation and reminded me to check the x-ray. nice to have friends like that, i thought, but i just apologized for missing it and moved on.

flatus

surgeons like flatus. it is a sign of an intestinal canal that is at least not totally dysfunctional. after most operations we ask the patient the next day if they have passed any and hold our breaths for the answer. if the answer is no, the bowel is still sulking and refuses to kick into gear. if the answer is yes, we get a warm fuzzy feeling, permeating right down to our toes. but flatus humour is not lost on us.


two stories come to mind. one happened during registrarship and one happened many years before when i was at school. lets start with the former.

i was the senior registrar in the boss's firm for so called rounding off. it was the toughest rotation as i have said before. the boss had a particular interest in everything anal, including flatus. he often waxed lyrical about how normal it was and how much wind the colon should be expected to expel in a day. but i did have a rotating orthopod (as part of surgical training you are required to rotate through the other disciplines and this guy was presently rotating through general surgery).

this guy had a very laid back approach to life. he was somehow immune to the pressures of surgery (maybe because he knew he was leaving after a short month and also, as a guest he had no direct responsibility) and he had a vibrant, spontaneous sense of humour. one day we were walking down from 54icu which, due to mad apartheid planning, was miles away from the rest of the hospital. on the way down, another prof joined us and engaged the boss in conversation. i moved back from my designated place at his right hand side and followed with the rest of the firm at about 5 paces behind, next to the rotator.

at about this stage it became apparent that someone's colon had done it's duty. the orthopod started making faces and not too quietly lamenting our lot in having to be subjected to smelling the very displeasing aroma. obviously the offending colon belonged to at least one of the professors walking in front of us, so i told the guy to put a plug in it (i qualified that i meant his mouth because i was afraid of exactly where he was likely to put the plug). but he just would not stop.

after a while the boss obviously heard the continuous tirade of disgust from his entourage following in the foul wake behind him. he turned around and said;
"'skies mense." (excuse me guys). without missing a beat this upstart orthopod replies;
"prof, i know it is normal to pass three liters of flatus per day, but do you have to pass it all at the same time?"

everyone fell apart.

keyhole on our world

medblog addict, in the opening of her blog says, and i quote, "It is as though someone has drilled peep holes into the walls of emergency rooms, operating rooms and doctors' offices. I can't look away." it is like er or gray's anatomy or dr house or (insert name of some medical drama here). to be honest one of the reasons i blog is because our world is so far removed from what is perceived as normality that just to talk about things that happen on a day to day basis makes for quite good entertainment.

but i know there are dangers. there has been talk of flea and butterfly and there are probably others who have fallen from the blogosphere. we as blogging doctors need to be careful. one aspect of this is to always ensure anonymity of our patients and other involved parties. hence dr rob started the ethical blogger initiative, which i think is brilliant.

but i think there is another slant to the whole thing. medblog addict sums it up when she concludes, "i can't look away". i think there is at least some onus upon the reader.

there is a paradox here. they read the blogs exactly because it is a window on a totally bizarre world, but this bizarre world may occasionally offend. the reader has to accept this.
i remember when i was in second year doing anatomy and dissecting cadavers. one of the groups named their cadaver stiffany (she was stiff). this is a type of black humour common to medical students and doctors, yet it probably seems sick or even inappropriate to the non medical blog reader. the question then is, how honest must we be as medical bloggers? too honest and we offend. not honest enough and it is not a true medical blog.

this point came home to me with two parallel events. the first was a rather harsh criticism of a comment on one of my posts, implying that a certain doctor was callous. i doubt he was. he saw the typical black humour of yet another bizarre occurrence that was described. typical medical reaction really. the other was a most entertaining and humorous post by mdod called musants. i really enjoyed it. i had a good laugh. then i thought about being one of those possible patients reading the blog. there will be a certain amount of offence taken every now and again at some of the things doctors say.

but that is why i'm making a call for understanding from both sides. doctors will have to be careful and moderate in what they blog. dr rob has taken great steps to ensure this. but medblog addicts must also understand that to have a keyhole on our world is in fact a keyhole on our world.

i invite comments.