spindoctors

i suppose politics of sorts pervades all aspects of life, medicine included. often the way you spin a story would either land you in it or get you out of it. sometimes the consultants didn't need to know the whole truth. variations on this theme often played themselves out. this is just one example.

the boy was only 15 years old. he had been admitted the previous night by a junior registrar. apparently he had developed abdominal pain after a rugby tackle during a school game. the x-ray hadn't been too spectacular and the junior registrar felt that his abdomen was tender enough to admit him but not tender enough to operate him. this essentially meant he was not willing to take the decision to operate or not himself and wanted to get the consultant's opinion the next morning. the consultant was an interesting eccentric man who tended to be a bit conservative in his approach to cutting people open. he could also be somewhat intimidating.

i met the patient for the first time on the morning rounds when the junior presented him to the consultant. i quickly examined him while they spoke immediately decided what i though. something was wrong, i felt and it was not the sort of something that was about to sort itself out all on its own. then the consultant examined him. the patient winced but tried to be brave. the consultant also made his decision.

"he probably just has a bit of bruising. he doesn't need to be operated. a rugby tackle can't cause too much damage" he pronounced. "bongi, you're on call tonight. i'm telling you now, you must not operate this patient. he'll be fine in the morning."

"yes sir." i replied, but i had plans. all sorts of things can happen once the sun has set. i knew i could spin it tomorrow, providing i ended up being right. however if i turned out to be wrong it would be a bit tricky.

when the day ended i took a walk past the parking lot to confirm the consultant's car was gone. i then booked the patient on the emergency list for a laparotomy. i remember my house doctor looking at me with an expression of shock and horror on his face. i smiled, but i remember thinking that i'd better be right. otherwise i'd be the one with shock and horror on my face the next morning (not to mention egg).

soon we were in theater and shortly thereafter the abdomen lay open before us. the intestines were floating around in a pool of bowel content and there was a neat little tear on a section of small bowel. already the peritoneum was looking pretty darn inflamed. the mood lightened. i even felt a joke or two may be in order.

"i'm right again. sometimes i get so tired of always being right." i mimicked the consultant's usual line. the house doctor shook with laughter. once he was able to assist again we finished the operation and closed up.

still there was the matter of telling the consultant the next morning that we had disobeyed his direct command. and here is where i knew i needed to put the right spin on it. he didn't need to know that i had never had any intention of obeying him. i had evaluated the patient and i was not comfortable to leave him through the night when i felt sure that he needed an urgent operation. in fact the junior that had admitted him displayed a total lack of the usual confidence associated with surgeons by not operating him the night before. i was not going to do the same. i was going to back myself and my own clinical acumen and that is why i operated. also i knew that if i had argued with the consultant on the ward rounds he would have entrenched himself in his opinion and there would be no way to spin the story the next morning. i had essentially lied to him and i knew it. he did not need to find out.

"bongi, how is that patient doing?"

"doctor, last night he suddenly got much worse. his pulse went up and his abdomen became much more tender.in fact he developed an acute abdomen so i felt obiged to operate." again the house doctor looked at me with horror. the consultant's fists clenched.

"what did you find?" i was home free. thank goodness i was right. if i had been wrong, this is where it would have all unravelled. i told him. and that was it. nothing more was said. i survived.

p.s. the patient also survived.

powerless

some things make me feel so powerless (yes, even i can be powerless in the face of incompetence)

i have previously mentioned a thing or two about my opinion of where medical training is going in this country. basically the powers that be are not-so-gradually degrading the degree. to them somehow it seems like a good idea. ideas i suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. well i get to see the consequences up close.

he was referred from an outlying hospital on a friday. the peripheral hospitals so like to empty their wards for the weekend. after all there is some good fishing in these parts. thank goodness for good fishing. otherwise many more would die unnecessarily.
anyway the patient had free air in his abdomen. this is a sign of a ruptured stomach or intestine and requires immediate operation. in fact the longer you wait the higher the chance of death. what i found interesting is the x-rays that they sent with the patient dated four days before the transfer (but admittedly not just before the weekend) clearly showed the free air.

now not all that long ago, to miss free air on an x-ray even as a student was a mistake that would fail you. these days you can easily get through medical school without worrying about trivialities like free air on x-rays. also, to have perforated bowel causes intense almost unbearable pain. even a street sweeper would be able to pick this up in the patient. yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days. that is if he even ever examined the patient. then fortunately a weekend turned up and the patient was referred, well on his way to the great hereafter.

as can be expected, when he turned up he was extremely ill and was already in kidney failure. the catheter bag remained empty. after a few hours of aggressive fluid resuscitation there was at least a bit of urine in the bag. then it was time to operate.

the abdomen was in a bad condition. to say it was rotten would be somewhat of an understatement. but the interesting thing i noticed was the full bladder. the peripheral hospital had kindly inserted a catheter not into the bladder but only into the urethra. there they had blown up the balloon, just to make sure they did the maximum amount of damage.

so not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do , because they didn't know how to do it properly, caused further damage to the poor man.

i cast my mind back to when i was still in academic circles. i remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared. i myself was asked to examine a student in a practical exam. i failed her because she was simply a danger to any person unlucky enough to become her patient. and yet the powers that be had so changed the system from when i was a pregrad that she could not be failed and was released into the community.

i'm sure the people who have orchestrated the new system that is so student friendly (but not patient friendly) don't get to see the disasters out in the periphery that are a result of their hard work. quite frankly even if they did see them i doubt they would care. after all it doesn't directly affect them.