smug

recently i was involved in a discussion with a guy that was explaining how we should understand criminals. the emphasis was on farm murders but we touched on murderers in general, rapists and child molesters. my point of view was that i did not understand them and felt that he was justifying their actions. in the end i was informed that i was smug. apparently that is the word for people that couldn't see the point of view of the poor misunderstood murderers and rapists and molesters.

so smug is what i am, it seems. you see the fact is i can't understand his beloved murderers. i just can't. i also in my smugness wonder how he can, but i think i know.

it has to do with not being in the trenches. it has to do with not being faced with the blood and the tears and the guts and the screams...mostly the screams. it is probably easy to be nice and philosophical sitting snugly (not smugly apparently) in a nice air-conditioned office, philosophizing on the reasons people point a gun at people and pull the trigger. or worse...

the thing is i can't forget. i am scarred. i remember the patient lying in a pool of his own blood, looking up at me and asking, beseeching even to tell him he is going to be ok. i remember wanting to tell him that it would all turn out just fine. i even remember wanting to hold his hand because his mother wasn't there to take care of the emotional side of things. in the end i remember not telling him he would be ok because i wasn't sure he would. i also remember not being the mother he needed in the last moments of his life because that is what it turned out to be. after we had plough through the blood and feces floating around in his abdomen, violated by the bullet fired from the gun of someone my friend feels i must understand, the patient died. he did not die well with his mother or wife holding his hand in love. he died alone in some icu ward with adrenaline being pumped into his veins and oxygen being pumped into his lungs with a scarred doctor who felt that his time may have been better spent holding the patient's hand rather than pouring time and energy into a futile attempt to save his life. you see the reason i can't see the side of the killer is that the killer is still alive and has the sentiments of my learned friend to feel for him. my patient is dead and there was no one next to his bed when he died. there is no one to state his case now.

i remember the baby violated by her uncle. i was just a house doctor, but i had to examine her. the pediatrician couldn't face it. it is quite a thing to see the perineum of a four month old after it has been ripped apart by the penis of one of the people my friend understands so well. feces runs out of the vagina. it leaves a mark on the soul. but worse than that is the cry. the child did not scream anymore. i think it used up all its scream for its entire life during the deed. all that was left was a quiet constant moan. it is the ghostly moan of someone who has learned in her four month existence that there is no one who will come to her aid. there is no one to understand her. it will never leave me. my friend who is quick to understand the violator will call me smug, but may i suggest i might just be jaded?

the women raped is difficult to examine. somehow you feel you are violating her again. you feel you are making the whole ordeal worse. they don't resist. they are already broken. anyway, rape in our country is so commonplace, it may be the one area where i understand that my friend mat have sympathy with the perpetrator, but, sorry, i cannot. for me to examine those women tears me apart. it leaves me with a feeling that my own soul has been violated. that i am forced to do something because someone else destroyed a life. i refuse to see the point of that someone else. if that makes me smug, then smug i must be, but again i suspect i might be jaded.

a bullet can do a lot of damage. physically i think i might have been a witness to pretty much all of it, but there is another side to the story. i remember an old man, shot in his home when he tried to defend his wife from the killers that broke into their house in the early hours, people that my friend chooses to understand. we did pull him through, but not without a massive operation and the obligatory icu time. i remember when he came to me for follow up some time later. i was so proud that he had made it. but somehow he was the shell of the man he used to be. he was alive, but broken. his confidence was gone. he lived in fear. he felt helpless because he knew he could do nothing against the lead of the people who i hear from my friend i must understand and sympathize with. but who sympathizes with my patient whose peace has been stolen from him? the smug or the jaded?

recently i enjoyed my christmas eve over the open abdomen of a woman shot in her bed by strangers, strangers whom my friend has endless sympathy for. i did not enjoy my holiday period, but more than that, my patients didn't either. hopefully my friend, while maybe enjoying a beer with the killers he understands so well had a really festive time. i do not understand him.

post traumatic stress

in a previous post one of the topics i touched on is the aftermath of losing a patient or rather the effect it can have on you as the doctor. a good post i read recently also touched on the desensitisation we tend to undergo. it is often forced on us, as was demonstrated by the sister's comment to me after the patient died in my post quagmire. there was no space for feelings. she didn't follow me out to speak to the family and be confronted with feelings. she just jabbed me a bit, maybe to help with the desensitisation process.

but sometimes the reality itself doesn't allow for the luxury of emotions. there are so many stories i could tell to illustrate this point like the time one of my patients crashed while i was resuscitating another one. when patient one died i didn't have time to even register emotion. i had to get to the other one who was in the hands of my medical officer whom i had sent ahead. when i got there to find him dead too i mustered up the troops to get back to the endless streams of impatient patients in casualties. they didn't care about our emotions. they didn't want to wait and they were willing to throw abuse at us if they did.

but the real reason i'm reminiscing about all this is a recent conversation with an anaesthetic friend. he was also talking about the effects these things have on you. it is quite sometiong to have someone die literally under your hands and wonder if there is something you missed that may have changed the outcome. to possibly be partially responsible for the death of another human being seems to leave quite a mark.

he was on call. a disaster was presented and the team got to work. he describes scenes quite similar to the fan fair i spoke about in the case presented in quagmire. anyway the details are not important. the point is there was high drama and it was traumatic and shocking to all involved and the patient died in great thespian style on the operating table despite all efforts by everyone concerned.

my anaesthetic friend was shaken, as can be expected. he wanted to go home, or even just sit and let the adrenaline work out. (home would no doubt have been better). the theater matron came in. he looked at her with a blank stare. maybe he felt empty and his face reflected that. the matron asked;
"so what case are we doing next?"

just like that! the dead patient, the devastation of the family (still to be faced), the blood all over the place, the shock to the team, specifically the anaesthetist and all the matron wanted to know was what case to do next! in a certain sense you can understand it. the list is there. there is not another anaesthetist on call, so if he is not up to helping with the next patient, the next patient would not be helped. also it could easily be that the next patient is just as critical, but it could also be that it is something quite mundane. the point is my friend had no time to recover. reality steam rollered him and he had to deal with it...later...in his own time...when he would be so tired post call he would probably not be able to deal with it. somehow that is the way it usually turns out.

when we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on its rump.

quagmire

hospitals are divided into neat little units, each functioning independently and each with their unique perspectives. surgeons move between these and get an overall view. however, sometimes negotiating your way through the many different ways of seeing the same case can be like finding your way through a marsh with all the dangers of being swallowed up in quicksand at every turn. one time this hit home pretty hard was just another gunshot that was anything but just another gunshot.

i was rotating through thoracic surgery, which by implication means i was the junior. then casualties called. they said they had just gotten a call from an ambulance bringing in a gunshot heart and they wanted me there when they arrived. i remember thinking that it should be a quick consultation. i mean who survives a gunshot heart?

casualties' main function is to keep the patient alive until the surgeon takes over. thereafter they play no role in the further treatment of the patient. it is usually a case of out of sight out of mind. this time around they made sure i was there when the patient arrived. finally the ambulance came blaring in.

the patient was an eighteen year old girl. she was clearly in deep trouble. the bullet had entered her side below the nipple line and had exited almost exactly the same place, but on the other side. she was already losing consciousness despite good intravenous lines flowing full speed. i quickly decided that this was not a gunshot heart. this was partly because of the lack of distended neck veins but mainly because she was still alive. i got to work.

i instructed the casualty officer to intubate the patient while i quickly threw in bilateral intercostal drains and a high flow central line. the drains in the chest drained nearly nothing. the problem was not in the chest, but in the abdomen, my usual stomping ground. the abdomen was also visibly distending and under quite a bit of pressure. however i was not in general surgery at the time. the casualty officer then took off her gloves and said:
"ok, i'm outta here. i have other patients to see." she was quite within her rights but it was just difficult to keep the patient under control while i made the necessary phone calls to get blood, call the general surgeon on call, get theater ready and phone the icu guy to organise a bed for after surgery. but, what could i do? so i did what i could.

by the time the general surgeon (my junior) arrived everything was ready for theater. the only problem was that the patient was slipping away. we grabbed the trolley and ran. as we passed an examination room i glanced in. there was the casualty officer looking into someone's ears. yes she had move on. that patient's otitis media had no chance.

in theater we met the anaesthetist. he took one look and let rip. how could we give him such an unstable patient? where was the blood? what sort of show were we running? i considered telling him that the patient had two large bore peripheral lines and a high flow central line, the only unit of emergency blood in casualties had already been given and we were waiting for more from the blood bank and to stand here arguing was more of a joke than anything we had delivered to him yet. i knew that it was in no one's interests to argue, so i just quietly suggested we get the patient on the table to see if we could find the source of bleeding which was the actual reason the patient looked so bad. delay was in fact what was killing the patient.

anaesthetics weren't needed. in fact by that time the patient was so unstable anaesthetics would have been the last straw. it is difficult to explain what it was like there in the ensuing moments. the anaesthetist was shouting for blood and fluids. the floor nurses were running in what seemed to me like ever decreasing circles. the surgeon opened the belly and liter upon liter of blood came gushing out. he threw both hands into this bright red torrent and screamed for his assistant to do the same. then, seconds later i heard the anaesthetist shout:
"heart has stopped!! heart has stopped!! give internal cardiac massage now!!!"
"i can't give f#@king internal cardiac massage at the moment!! i've got my fist on the aorta and that is the only control of bleeding we have. you give f#@king cardiac massage!!"
"i'm trying to get fluids on board!!" he said while squeezing one of the drip bags to force fluid in. they both looked at me. i gowned and gloved without scrubbing. i then slipped my hand into the abdomen under the sternum. i took the heart in my hand and began squeezing. it was just an empty sack.
soon after we called it. she was dead.

i felt drained. a young woman had just died in the most dramatic fashion, literally while i held her heart in my hand. i looked at the sister.
"what a mess you've made of my theater, dr bongi!" she said with genuine irritation, "who the hell do you think is going to clean this up?" obviously she was less affected than i was, i thought.

as we got out of our blood soaked scrubs and back into our normal clothes i noticed that one general surgery student was pretty shaken. i thought i should maybe chat to him. the surgeons left, but i waited for the student. we walked towards the door. i gave a light hearted comment and he ventured a tentative smile. i reciprocated, as we walked out the theater complex. and that is what we were doing when we unexpectedly walked into the family, smiling.

the family were in a group outside theater. they seemed in fairly good spirits, all things considered. i got the feeling that they were impressed that they had managed to get the patient to hospital so soon after the incident and they seemed to be under the impression all would now be fine. one looked up.
"excuse me, but do you know how it is going in there with the young woman with the gunshot wound?" great i thought. the surgeons had just walked past them and it was now up to me to break the news. generally when you are about to tell the family that they have just lost a loved one, it is not a good idea to be seen to be smiling and light hearted when they see you for the first time.

i went through the injuries with the family. i then told them we had done everything we could, but that she had not made it. any vestige of hope seeped out of their faces quite slowly as this information sunk in. most turned away to hide their tears. i needed to get away to maintain my composure too. i made sure i answered all their questions and then left.

i walked down the corridor to icu to tell the icu guy we wouldn't be needing his bed. when i told him he looked at me and smiled,
"good. i've already opened up a bed. now i have an available bed if i need one later tonight."

i had to sit down. it seemed to me everyone had just seen the tragedy from their own perspectives in their little windows on the whole tragedy. i felt a vacuum in my heart. the icu guy offered me a smoke. that is not a good idea i thought, but that is not what i said.