breaking the news

there is a fair amount of talk about how to break bad news. truth be told i think i'm fairly good at it. sometimes, however it can leave quite an impression.

i was a community service doctor in qwa-qwa. i was working in casualties when they came in. two young children had been playing on the side of the street with a spinning top when a drunk driver came careening off the tar and ran them down. apparently in his drunken state he couldn't negotiate the turn.

the patients were cousins. we shuffled them both into the resus room and closed the door. one was about four and the other was six. the bigger one was dead. the smaller one had only minor abrasions. we covered the body of the big boy and cleaned and bandaged the wounds of the little boy. then we waited for the family.

a side story here was that the drunk driver who realised he was in trouble asked me to only draw the blood for alcohol levels the next day and lie about it. he even offered me money. he didn't specify how much. i was amazed at the inherent selfishness of people. there was a dead child in the resus room and this man was only concerned about the consequences as they pertained to him and him alone.

finally two family members arrived. the old woman was the grandmother of both children. her daughter who was with her was the mother of one child and the aunt of the other child. we moved them into a closed room where i was to speak to them. there was not going to be an easy way to do this, but i remember thinking that i really hoped the mother was the mother of the living child. it would make my job easier and their job when they got home more difficult.

i started by explaining the nature of the accident. i went on to explain that these types off accidents can cause severe injury. i then as gently as possible said that one child was already dead when he arrived and we couldn't help him, but the other child was ok. the mother immediately looked at me directly, something she had not done up to that point and asked with desperation both in her voice and etched into the lines on her face;
"which one? which one is dead?" the grandmother did not react outwardly, but a tear rolled down her one cheek.

i remember clenching my jaws, hoping that the woman before me was the mother of the living child and not the dead one. the news would still be bad, but at least for her personally there would be a good slant on it.
"the older child is dead."

it looked like someone shot her. her entire body contorted and she dropped to the floor. she started screaming. the grandmother didn't move, but the tears flowed more freely down both her cheeks. between the screams of the mother of the big boy, for that is what she was, the grandmother simply said;
"this is a terrible and difficult thing"

i was shaken. i didn't want to let the casualty staff see me cry so i swallowed hard, wiped my eyes and went back to work. besides casualties was full and i didn't have the privilege of taking time off to get over my trauma. anyway it didn't compare to the woman lying crumpled up on the floor of the office sobbing .

hijacker

hijacking is common in south africa. so common that the government has placed signs to let you know where you are likely to get hijacked. there are some people that feel more should be done, especially if one bears in mind that you have a good chance of being shot during a hijacking.

in my post practice, there was a comment which hinted at our south african view of violence, due to the fact that it is so commonplace. yes we are desensitized. but doctors are also desensitized. so what happens when you bring all three of these elements together?

it was in my registrar days. i had recently written intermediates and had less academic stress to deal with. therefore on calls, if it was quiet enough, instead of going to the call room and studying, i found myself wandering around, looking for something to do. one of my favourite places was the casualty unit. and in the casualty unit, my favourite place was the resus room. this is where all the high drama took place. this is where the adrenaline flowed (often even into the patient). this is where i felt alive and at my most alert.

so that night i wandered down to casualties to see if anything was happening. in the resus room, sure enough, there was a guy lying on the table. a friend who was almost finished with thoracic surgery specialization was standing at his head. all seemed calm. then i saw someone else in the corner of the room, looking awkward and out of place. i looked at the patient. he had a nice round hole in his chest, just to the left of the heart. i put the story together in my mind.

the guy in the corner was the shooter. he was either a cop in plain clothes or some civilian that had intercepted some crime. because of a slight paranoia due to 'a beautiful mind' about people lurking in places they shouldn't be, i asked my friend who the guy was there in the corner. i was relieved to hear that he could also see him.
"he's an off duty cop who shot this f#@ker. i don't know who the f#@k teaches them to shoot? two f#@king centimeters more medial and i'd be in my warm f#@king bed now and he would be on a cold hard f#@king slate in the morgue. now i have to operate this f#@k!" that's just the way he spoke. he could be very descriptive with only one adjective. he had the unique knack of making swearing sound elegant.

i then got the story, more chronologically and with less profane interjections (also much less colourfully) from someone else. the patient (the one my friend referred to as the f#@k) was a hijacker. at a robot (south african for traffic light) he had smashed the side window of a car and pushed his 9mm up against the head of an old woman. in the car behind was the off duty policeman. he jumped out, raised his service piece and demanded that the hijacker desist (my friend wouldn't have used the word desist). the hijacker, maybe like my friend didn't understand the word, because he turned to shoot the cop. the cop's gun was drawn, cocked and aimed. there was little doubt about who was going to squeeze the first shot off. the round entered the patient square on in his chest just lateral of the heart on the left. it exited exactly posterior to this. i surmised that if he even had mild cardiomegaly, the shot would have been fatal. i think the criticism about the cop's aim was unwarranted.

armed with this new perspective i looked at the patient (f#@k). he looked back at me. he was stable, but the intercostal drain had a constant stream of blood running out. my friend stood back as a sister was placing a cvp. he was telling her what to do. she was learning. i looked into his eyes again. i could see the fear of death there. i wondered how many times he had seen that in other people's eyes and shown no mercy. but i was not him. i felt sorry for him.

my friend, meanwhile exchanged some words with the cop. i listened in. he was giving shooting advice. he was suggesting that the best place to aim is the center of the chest and not the left. i reflected that this is good advice. although the heart is ever so slightly to the left, it is actually in the center of the chest.

then i listened to the sister who seemed to be having a bit of trouble with the cvp. she had moved from the subclavian to the internal jugular. her head was now directly above that of the patient. she was muttering. i moved closer to hear what she was saying.
she was speaking to the patient as she drove the needle repeatedly into the neck, searching for the vein.

she was saying things like:-
"this thing would think nothing of killing me on the street and now i have to try to save it's life."
and:-
"here lies the reason the death penalty should be brought back."
and similar things.

i mentioned to her something about not being a judge and having to care for whoever comes in without discrimination. she looked at me as if i wasn't a south african. i repeated what i had said, and then, knowing that my foul mouthed friend was good at what he does and the patient would be ok, if not somewhat emotionally scarred, i left.

i felt the need to tell this story to try to bring across the reality of how our job ends up messing us up. maybe being south african means we were messed up to begin with. i've often felt that we should go through some sort of debriefing. i doubt anyone can remain totally normal with all this sort of stuff constantly going on. it becomes a challenge to remain an exception. luckily i enjoy a challenge.

disaster continued

so i've just come into theater to find a terrified medical officer and a patient who seems just about to cash in his chips and leave this life. i immediately splayed the hole in his neck, allowing him to breathe a bit. when non medical people think of these sort of situations i often imagine they have this idea of smoothe control and everything happening beautifully. it is not usually so. sometimes the whole thing looks pretty messy. with this man, as soon as i opened his neck he gave a greatful gasp followed by a bloody cough....all over my face. (this is actually why we wear masks). my glasses were splattered with frothy blood, but i was just too glad the guy was breathing.

once again i attempted to insert the trachi tube, but because his trachea dropped back so sharply and so deep i couldn't get it in. (it is a fairly rigid c-shaped pipe) i decided to attempt intubation through the hole with a normal endotracheal tube which is much more flexible. this worked and we all breathed. (funnily enough it seems it wasn't just the patient having trouble breathing)

i degloved, told the medical officer to put the man in icu (he told me there was a bed they could make available in about an hour) and i left. this time i didn't have a beer. it was too late.

i started this story by saying there were a number of reasons i wanted to discuss the post. i'll attempt to now without being too disjointed or tangential. the first thought once again has bearing on the discussion about the almost military like training of surgeons (where i come from anyway). i read a comment in one of the posts about a surgical registrar who turns his cell off when he's not on call. we were never permitted to do that. i was not on call during the events described above. i have no doubt that the patient would have died during his first tracheostomy if i had not gone in. once again, because of some crazy decisions by the province i will not be paid for the tracheostomy or the reintubation or going out at night. so although i do not actually believe in the brutality of our training, there must be some form of ballance. surgeons produced must be able to work inhumane hours and still function if necessary, especially in our setting where there aren't too many of us. when a surgery patient complicates it is often rapid and dramatic. it usually can't wait for the morning. i'm not sure what will bring ballance to the force though.

the next thought had to do with my reaction to the events of the second intubation and the medical officer's reaction. as i said when i arrived he didn't seem to be having too much fun any more. i almost wondered if i should first resus him before i turn my attention to the patient. i realised that this job is not for everyone. i actually enjoyed the challenge of the difficult trachi and the intensity of the whole situation. maybe i'm a bit of an adrenalin junkie. the medical officer felt the responsibility of trying to keep this guy alive when he seemed so determined to die was more than he could take. that's why i spoke in a previous post about the fact that we are not working with surgeons and need to treat them more gently than what we sometimes think is needed. there is also the whole arguement about what this type of stress does to people who are not built for it. when i started this blog i spoke of another blog by a suicidal medical student (http://other-things-amanzi.blogspot.com/2006/11/thoughts-etc.html). the guy should never have done medicine. all the horror of our daily work was killing his humanity. i really felt for him. but at the same time the fact is these gunshots or assaults or stabs or whatever are going to happen. people are needed to deal with them. i've often thought about a debriefing or trauma counselling for surgeons, because sometimes i think it is needed. unfortunately i think macho surgeons would scoff at the idea. but maybe the stereotypical bombastic surgeon is like he is as a defence mechanism??? maybe sometimes to remember that these maimed, broken, stinking bodies that we deal with daily are all as human as we are challenges our own mortality too much. it is difficult to be confronted by one's own mortality, but to be confronted a few times a day seems more than a lot can take. one of the greatest things for me about surgery is to return people to their humanity (see http://other-things-amanzi.blogspot.com/2006/11/perianal-absess-connection.html) maybe this is my way of avoiding what i see as the pitfall of forgetting the humanity of those dying around you. what does a soldier do in the heat of battle i wonder?

anyway, all very melodramatic. i did warn it would be disjointed.

the conclusion of disaster was only revealed the next morning and i'll leave that for another post.
so once again, to be continued.