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.

abroad

i'm of the opinion south africans have a good sense of humour in general. you have to be able to laugh at the absurd with a government like ours. and yet i do think we need to be a bit cautious about how we express that sense of humour while in the presence on non south africans. in general when you are working overseas in a foreign culture, you might want to be careful in the expression of your sense of humour.

like many south african doctors he had gone overseas to make a bit of money faster than it is possible on our shores. soon he was raking in money presiding over the sleeping while foreign surgeons plied their trade. yes, he was an anaesthetist.

now quite often the relationship between anaesthetists and surgeons can be strained. i can only assume it is worse when a language and cultural barrier are added. then there is the question of being in unfamiliar surroundings where more likely than not, things are done differently to what you are used to. it is probably best to keep a low profile and to not stand on anyone's toes. this anaesthetist did not believe on standing on toes. he went straight for stomping on their feet.

it was a neurosurgery case. the anaesthetist was of the opinion it was a non-starter and i suppose that's where it all began. there was tension between the neurosurgeon and the gas monkey right from the word go. but what could the south african giver of gas do? he had to dope the patient.

the operation got underway. quite soon the anaesthetist realized it wasn't going well. he couldn't understand a word of what the neurosurgeon, his assistant and the sister were discussing, so it wasn't really something that was said that cottoned him onto the fact that things were heading south. it was more the amount of brain tissue the neurosurgeon was suctioning out of the patient's skull that the gas monkey viewed as suboptimal. and as the operation progressed he passed through being perturbed and went right on to being amazed. it seemed there was no end to the stream of brain tissue that made its way through the suction tubing into the suction container.

after a while, once the anaesthetist was sure all the maths and science had been suctioned out, he took a more philosophical approach. it seemed to him there was little he could do to make the situation any worse so he just sat back and waited for the suction crazed surgeon to stop. and finally the surgeon did stop. he then got to the work of closing up, which in neurosurgery takes quite a while in itself. then he turned to the anaesthetist and for the first time spoke in a language he could understand.

"ok, you can wake the patient up now." the anaesthetist initially thought he must be joking, but there was nothing but an earnest expression on his face. he stared at the neurosurgeon in disbelief. the neurosurgeon stared back. "i said you can wake him up now!"

the anaesthetist shrugged his shoulders, strolled over to the suction container where it stood on the floor with its grizzly content. he then crouched down and started knocking on the side of the container.

"sir, you can wake up now!" he shouted.

neurosurgery

during intermediates we were required to rotate through all the surgical disciplines. one of our rotations was therefore neurosurgery. those guys really work hard. i think it's fair to say they almost work as hard as us general surgeons. without a doubt, besides us, there was no other surgical discipline that came even close as far as hours and hard work were concerned. and yet they were very different to us.

certain conditions are considered surgical but it does not necessarily mean all surgical conditions are for operation. we will happily accept for example a bleeding peptic ulcer and treat it medically, only operating if it becomes absolutely necessary. the neurosurgeons, however, tended not to do this. if they weren't actually going to operate the patient they simply didn't accept him. so a peripheral hospital would send a scan through for their opinion. if they saw that either no operation was necessary or that the patient was in such a bad way that even an operation wouldn't save him, then they simply didn't accept the patient. cases from casualties with fractures and also some degree of suppression of consciousness who were not destined to fall under their knives they would also not accept. the poor orthopod would get stuck with a semi conscious patient that he wouldn't really know what to do with long after the bones had set.

so when we were getting tutorials from the neurosurgeons i thought it funny when they gave a long talk about the management of a patient with mild neurological suppression. i was even surprised that the consultant giving the tutorial seemed to know how to handle such a patient. being in the department i had seen no evidence whatsoever that they actually ever did handle such patients. fortunately i kept my thoughts to myself (i achieved this by biting my bottom lip every time i was tempted to say something. other than the slight taste of blood i suffered no ill effects like failing my neurosurgery rotation which is a lot worse than the taste of blood).

when the intermediate exams were around the corner i once again enjoyed the humour in the rumours that the management of mild head injuries was supposed to be a spot from the neurosurgeons. i couldn't help wondering who would mark that question. maybe they could ask the orthopaedic department to help them.

finally the exam day arrived. when i saw the question actually turn up in the exam as so many of us had guessed it would i found myself chuckling at the thought of some burly orthopod trying to read my handwriting. i also wondered if the neurosurgeon was honestly asking because he didn't know.

in the end, after considering simply writing:-
'break the patient's leg and turf him to the orthopods,' i buckled down and answered the question.

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.

faceoff

in surgery you work with what you are presented with. sometimes you simply don't have a choice but to try amazing or ridiculous things. i have mentioned my weird sh!tometer (here and here) but this is another one that scored highly.

he was mentally retarded, or so his siblings said. i actually thought he was just a bit slow of thought but had been rendered useless to society by years of being told that he was mentally retarded. he presented to us with a skin cancer (squamous) on the forehead. but it was no small thing.

it had apparently been growing for a few years. his caretakers elected not to take him to a hospital for medical treatment because they felt that evil doctors would use him as a guinea pig because he couldn't "think for himself". so they left it to grow. finally when the smell of this fungating rotting bleeding mass on his head disturbed their breakfast in the morning they brought him in to have it checked out. i considered telling them to eat breakfast in the lounge but i thought better of it.

the mass was about 10cm in diameter. it had infiltrated the left eye socket, causing the eye to look up, as if it was trying to get a glimpse of its tormentor. the ct scan revealed that not only was the eye socket and the eye a victim of invasion, but the mass had infiltrated his frontal lobe. i even wondered if the family had actually brought him in because of personality changes. then i realised that i would also struggle to enjoy breakfast with that mass across the table from me and, let's face it, the family weren't overly concerned by the actual well being of the patient.

the never-say-die prof of head and neck surgery immediately mustered the troops. the troops were the neurosurgeons and the plastic surgeons. to me the fact that the neurosurgeons were needed implied there would be no surgery. they tended to bail if there was any way out. i just assumed the radiotherapists would be asked to the party at the last minute. to my amazement all roll players (the neurosurgeons) agreed to give it a try and surgery was scheduled.

once all the subspecialities had played their roles and once all the knives had been laid to rest what was delivered to me in icu was, well to me at least, shocking. they had removed the mass, but along with it, the left eye and eye socket, the left parotid gland, a fair portion of the skull and more than just a sliver of the frontal lobe of the brain. the massive defect which was left was closed by the plastic surgeons using a free pectoral flap (they used his chest muscle with its overlying skin which they essentially transplanted onto the defect). the oddly misplaced muscle and skin lay on a liquid bed of cerebrospinal fluid and seemed to move in a way similar to a water bed when i touched it.

things went not so well and the family, now no doubt enjoying a daily hearty breakfast, threatened to sue for disfigurement. the irony was that the surgeons involved, whether judiciously or not, had attempted to fix what was presented to them. they did not cause the problem, but they simply tried to address it. they were like the pioneer surgeons of old who tackled massive fungating breast cancers with surgery as the only modality, because there was nothing else. these days no breast cancer and no squamous skin cancer should ever get that large and be that challenging, not only because of the obvious disturbance to an otherwise most enjoyable breakfast, but because they should present for surgical attention long before then. it is such a pity then when those very people who prevented this vent their misplaced wrath on the very people who did their best with the presented material and tried to help.