waterworks

when i rotated through urology it was great! every day all the urologists would get together in their scope theater and pretty much chat while one of them did scopes. it was friendly and festive and extremely relaxed. and not surprisingly, they were a very close knit group. but after about a week i started getting bored. but the seed was planted. still these days when i am between cases i often pop into the urologist's scope theater to see what new instrument he has to seek and destroy kidney stones. i jokingly say i'm there to learn how to do urology and they jokingly say they are thinking of including me on their call roster. only thing is that is not always a joke. they often leave town and do ask me to do their calls for them.


in a sense it is not too much of a stretch. kidney stones can be treated conservatively until the morning and most of the rest of the really urgent stuff we can pretty much do. in the old days a lot of urologists were very allergic to the night air and even the thought of having to come out once the sun had set would bring on a paralysis that could only be cured with a good night's rest. a good reflection of this is that by the time i had finished specialising i had taken out more traumatized kidneys than pretty much all of the urologists.


the way it used to work was that i would take a patient to theater with, say, gunshot abdomen where the bullet went through the kidney too. before theater i would phone the urologist. he would ask me to phone him if i had problems. i just interpreted that as i was not required to phone him. i mean what problems exactly was he referring to? then i would remove the kidney if necessary and leave it if possible. the most difficult part was explaining to the prof the next morning why there wasn't a urologist present in theater with me. the prof seemed blissfully unaware how dangerous to their health it was for urologists to come out at night. but i knew how to spin it to the prof and there were never any problems.



"well prof we were going to call him but the bleeding was a bit too much and there was no time to wait so i went ahead and removed the kidney myself." or some such line would suffice. secretly the prof was proud of us that we could handle it without the help of the urologists.



recently i had a bit of nostalgia. the bullet had shattered segment two of the liver, ripped the pancreas tail apart, ruptured the spleen and drilled a hole through the kidney. i would be busy for some time. but just to be polite i phoned our friendly neighbourhood urologist to inform him what i had. he told me to call him if i had problems. i smiled quietly to myself and put the phone down.



it was an exciting operation, what with a partial hepatectomy, a distal pancreatectomy and a splenectomy not to mention a diaphragm repair so the kidney had to wait its turn. anyway from the ct scan i knew it was unlikely that i would be removing it. while i was busy doing all the things i needed to do the urologist phoned and asked the gas monkey if i would be calling him. apparently he had poured himself a glass of wine (which was maybe the new treatment for the weakness that came over them after the sun set) and wanted to know if he could drink it or just look at it. the anaesthetist reassured him that he could take a sip or two and put the phone down.



the kidney was hit fairly laterally and in the end all i did was to close the fassia, its protective layer, and leave it. soon afterwards the abdomen was closed. then i got the idea to mess with the urologist a bit. i decided i'd phone him and ask him to come out. but i knew i had to word it correctly. if i said i needed to remove the kidney he would simply tell me to remove it then. if i told him that the kidney was ok he would thank me and take another sip of wine. i had to come up with something else.

"it's a borderline case," i lied. "it's oozing blood a bit more than i am comfortable with but i need your expert opinion to decide if it will be ok or if i need to remove it." the silence on the other end of the line spoke volumes. i could hear him thinking how he could give me his expert opinion over the phone and thereby not risking the cold night air. i could also hear him trying to evaluate just how much wine he had already had and if it was too much that he would not be able to operate or too little that coming out at night might be bad for him. i struggled not to laugh, but at least my broad smile could not be transmitted through the telephone lines. he started asking vague questions as to just how much it was oozing and how stable the patient was. i kept my answers equally vague. slowly i could hear the change in his voice as the resignation that he would actually have to come out set in. the anaesthetist, who was laughing openly couldn't take it any more.

"bongi, stop! put him out of his misery and help me push the patient to recovery." i laughed and informed the hapless waterworks doctor that all was well and he could go back to his wine. i advised another glass may be in order to steady his adrenal glands which i suspected had spasmed. his reaction was priceless. he wanted to say something sharp, but just couldn't formulate the words. finally he tried.

"jou...jou...jou...bongi, fok jou!!!"*

ah gunshot abdomens can be such fun.


*you...you...you...bongi, f#@k you!!!

difficulties

in my post mopping up there was a comment stream that had a bit to do with doctors needing to become detached in order to survive. recently this whole issue was unfortunately brought brutally home. it reminded me of an incident many years ago.

our firm had only two private external consultants which basically meant we didn't have all that much supervision and good luck trying to get a consultant out at night. they did, however do two so called academic rounds with us each week.

one day on rounds we arrived at a patient. the student started presenting. it was a lady slightly advanced in years who had presented with sudden deep painless jaundice and a palpable gallbladder. as could be expected a ct scan was done which confirmed a mass in the head of the pancreas. even before we had histology we all knew this was a pancreas head cancer, a condition with a fairly dismal prognosis. her mass was large and there was already spread to the liver.

the consultant listened to all the findings and then, without a word, walked away. we faithfully followed him. when he got to the door, he stopped and turned to us.

"now why did i just walk away?" he asked. we all gave the usual blank stares. "because there is nothing we can do for her." he said with a chuckle. those of us who needed to be in his good books gave the obligatory half hearted laugh. i could just manage a smile that i think came out more as a grimace.

you see i just felt we are not there only to fix the machine in which the person is housed but also at least in some way to mean something to the person too. i was not comfortable. afterwards i went back to the patient and spent some time explaining that although we could not cure her, we would do everything we could to make things at least a little better.

but these things are difficult. recently i once again diagnosed a delightful old lady with pancreas head cancer and once again it was beyond surgery. in the end she went for chemotherapy and had a stent placed to resolve the jaundice. but these measures only hold back the inevitable temporarily. and sure enough after a while she was back.

when a follow up scan was done the cancer was all over the place and there were quite a few other dismal findings. the chemotherapist had asked me whether she needed an emergency operation that night and the answer was a resounding no. strictly speaking i needn't have been involved any more.

but the next day i stopped by to say hello. the patient was grateful and, although in my capacity as surgeon i was doing nothing, in my capacity as human being i felt i just might be making a small difference. later that day the chemotherapist phoned me to tell me the kidneys had packed up. this was probably a pre terminal event and although neither of us said it outright the meaning hung in the air oppressively. the chemotherapist was also sort of telling me my involvement was no longer needed. i had known this for a few days actually.

the next morning i just didn't want to see her. the situation was so hopeless and it was just difficult for me to deal with it. but then i realised if it is difficult for me, how much more difficult must it be for her? after all it was her life that hung in the balance. i would survive and move on. i would get over it. i would not be the one feeling alone in the face of overwhelming odds. i knew what i needed to do.

i just kept on visiting her, usually just to say hello so that she would know she was not totally alone. i did not detatch and allowed the frailty of the human condition to influence me as the human i am.

blood sports

i love rugby. i used to play on a fairly low level, but when i injured my acromioclavicular joint i knew i needed to stop. it was fun but i was not willing to put my body on the line any more. it seemed too dangerous for me. recently i have reviewed this decision.

the first patient i touched on in a previous post. during a game of soccer the goal post fell on him and split his pancreas in two. the tail then slowly shrivelled up into a hard fibrotic mass. the story came to a happy ending when i removed that distal portion of the pancreas. by that time it was embedded in scar tissue and it was quite something to peel it off the renal vein behind it and the splenic vein above it. somehow everything went well. i was just left with a sense of how dangerous soccer can be.

the next patient was playing a game of snooker. i can only assume he was winning and by quite some margin because his opponent seemed to get annoyed at a stage during the game. i know this because he suddenly shot my patient. and he didn't shoot him once or twice. for good measure he put four bullets through him. he must have had an unassailable lead in their friendly game of snooker. unassailable by the standard rules anyway.

so, recently having treated two casualties of the blood sports of soccer and snooker, i realise rugby was really not that dangerous at all.

pancreas

recently i did a distal pancreatectomy (i removed the tail of the pancreas). it was an exciting operation. the guy was the victim of a soccer goal post falling on him, causing fracture of the pancreas. the injury was about two months old, just enough time for the pancreas tail to become a hard rubbery fibrotic mass adhered to everything. i took it out without removing the spleen (with supreme difficulty) and was very proud of myself. i thought back to the days of old.

when the prof felt we didn't have full control of the ward, he'd let us have it and he wouldn't let a thing go (as i have mentioned before). i remember once when he ripped into me in front of my students, but worse still in front of the patient i was to operate the next day. she must have felt great to hear that the guy who was going to take a knife to her the next day was 'useless and had lost all control of his ward'. it must have engendered in her a feeling of safety and comfort.

anyway, one of the imageries the prof used regularly was of someone riding a bike without handle bars, implying loss of control. i remember him telling me in front of my junior colleague, all my students and my patient that my ward was chaos and i was riding the bike without handle bars (i had failed to remember the sodium value for one patient and needed to refer to the results). as usual he went on for some time.

a while later we admitted a guy with a fracture of his pancreas. the next morning, as usual, we presented our cases to the prof in front of all the registrars. the prof asked the usual questions about diagnosis, presentation, treatment options and so forth. one of the things he wanted to know was how it had happened. it is usually the result of blunt abdominal trauma. the pancreas gets caught between the vertebral column and whatever caused the blunt trauma. in this case the patient was riding on his bike, he did a jump and came unstuck in mid air. he then fell with his abdomen onto the handle bars.

in the very formal setting of the morning meeting i had just presented the case to the room full of stern faces with the prof looking for a gap to have a go at some poor unsuspecting sod when my junior leaned across and whispered in my ear;
"that's why i think you should always only ride the bike without handle bars!"

i could not hold back my laugh. the prof was not impressed but it was worth it.