perspectives

sometimes different people see the same thing from a slightly different angle, giving a completely different perspective. in my line this can turn out to be quite macabre.

it was one of those cases. it was probably hopeless from the beginning, but he was young and we had to give it a go. as soon as the abdomen was opened everyone knew things were bad. there was blood everywhere. it took a while to even see the damage to the liver because i needed to get rid of the blood in the abdomen before i could see anything. however, once i saw the liver even i was shocked.

the liver was ripped apart with one laceration dropping down to where the ivc sat menacingly behind it. it seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. but i did what i could as fast as i could. at times like this the unsung hero is the anesthetist. if he can't get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. that day the anesthetist was great. somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.

after a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. usually, unfortunately, at this stage of these operations we are confronted by another problem. you see with massive blood loss the patient loses or uses up all their clotting factors and platelets. even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. to attack each ooze with an injudicious suture not only doesn't help a bit, but it wastes precious time that could be better spent in icu replacing these vital factors. i made the call.

"there are no more surgical bleeds that i can control here. i'm going to pack the abdomen and send him to icu to optimise his condition and we'll take him back in a day or two." the anesthetist looked up.

"if you say so, but he is not looking so great here." he pointed at the monitors.

i packed and closed. the gas monkey continued throwing every available fluid into his system as fast as he could.

"i'm just going to top him up as much as possible before we transport him to icu." he informed me. he was definitely worth his salt, this one.

this is now a time that the average surgeon doesn't like. we are not the stand back and wait types. we struggle to sit still and give it time to see what happens. but sometimes it is needed. i didn't have to wait too long before the the gas monkey told me what was happening.

"bongi, this guy is not improving on the fluid and blood i'm giving him and his abdomen is distending. are you absolutely sure there is nothing inside you can't make better?" the problem was i knew there was nothing i could do that i hadn't already done. however the anesthetist's observations were undeniable. the question was was there something i had missed or was the patient so far gone that he was lost already? it was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. there was only one thing to do. we had to open and look again.

we opened. immediately i knew everything we did from here on out was futile. the patient was in irreversible shock and had absolutely no clotting. there was nothing that i had missed from a surgical point of view which meant there was nothing i could do. after poking around a bit i packed and closed again, but this time with a heavy heart. i knew what was going to happen. the anesthetist also had no illusions about where we stood, but we both continued to go through the motions.

the motions led us eventually down the deserted passage way in the middle of the night to icu with a patient that was sort of alive in the broadest definition of the word when we left theater. both the gas monkey and i didn't want to check the vitals during that quiet sombre journey. what did it matter? we knew what was going to happen and we knew it was out of our hands. the only questions were where and when it was going to happen if it hadn't already happened. so when we entered icu we were quiet and reserved.

when icu receives a new patient, there is usually a flurry of activity and this was no exception. all the sisters descended on us like a swarm of bees, each going about their respective duties. soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. however once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. quite soon their alarms were blaring away. i glanced at my anesthetic collegue and we both shook our heads. we had done what we could. the icu sisters hadn't seen what we had seen. all they knew was we had delivered this patient and things didn't look good.

"i can't get a blood pressure. i can't feel a pulse. crash trolley!!!" she yelled to one of her juniors who scurried off in obedience. neither i nor the gas monkey moved. we just sat there, defeated at last.

"doctors, this patient is dying! aren't you going to do anything?" i laughed. i didn't mean to and i think it was more a nervous laugh. i was too emotionally exhausted at that moment to react appropriately. my colleague also laughed, but more at my response than the situation, i think. he then explained that what could be done had been done and any further resus would be in vain. we turned off the ventilator.

and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.

sand through your fingers

something that still gives the old adrenals a squeeze and a vicious kick is the opening of a blunt abdominal trauma patient with a severe internal bleed. but it is so much more than just an adrenaline rush.

the scene must be set. a patient arrives in casualties after having been involved in a massive accident. often there would be people who passed away at the scene who bypass casualties altogether on their way to the morgue. more often than not, some of these people are related to your patient, but that is something to deal with tomorrow. today's efforts need to be completely focused on getting your patient through his ordeal alive.

in casualties everything is a blur of activity. someone is tasked with getting lines up while someone else orders the bloods needed and someone else phones ahead to get theater ready. decisions need to be made about whether intubation is immediately necessary or if it can wait until theater. sometimes there is distraught family outside. they wait expectantly at the door hoping for good news. i make a point of speaking to them if i can before theater. yes, my job is primarily to get the patient through the other side alive, but in the end we are alive so we can live and part of life is love and family. they need to feel like they are at least involved, even if on a very small minor level. also they need to have an idea that things may not turn out well before the time.

on the way to theater, if the patient is not intubated or if we are not doing active cardiac massage, i often peel off to the change room and rejoin the activity as the anaesthetist receives the patient in the theater entrance area. i help with getting the patient onto the bed and then...well then i take a moment. it is a moment before the storm. it is a time when i try to prepare myself for the fight ahead. i also often think about the dissociation between the humanity and the biology of what is about to happen. it is always poignant for me to think that during the operation i will be totally focused on getting the life threatening problem fixed and i will have no place to reflect on the bigger picture. i won't have time to wonder what the person is like or what his hopes and dreams are or who is praying for him to pull through. yes, i won't be able to see him as human until it's all over.

once the gas monkey has everything ready we prepare to open the abdomen. there is a certain technique to doing this otherwise fairly routine action in these types of patients. everything is opened except the peritoneum which is left to last so there is at lease a bit of pressure still on the area of bleeding. then the peritoneum is opened and all hell breaks loose.

the peritoneum is opened from top to bottom in less than a second. masses of blood come pouring out in a wild torrent and abdominal swabs are shoved with little ceremony into the abdomen, starting in the upper quadrants and moving to the lower quadrants. this is a moment that can't be fully appreciated unless you have experienced it. there is shouting and a flurry of activity. any observer will be left with the clear impression that we are fighting for the patient's life. there can be no doubt.

once the swabs are all in and the worst of the blood has stopped flowing it is time to address the source. i usually pray it is the spleen because it can be removed and the problem is solved. the liver bleeders can be a lot more tricky. a massive tear of the liver can bleed copiously. it is relatively easy to control the blood supply to the liver but the venous drainage is a different beast. the liver drains via three veins directly into the inferior vena cava, the biggest baddest vein in the body. retrograde flow through a torn hepatic vein or worse an avulsion of the liver off the ivc itself may even be impossible to control.

with these sorts of injuries the amount of blood in the abdomen is so much when you push your hands into the abdomen to apply the swabs or to give direct pressure your entire arm disappears into the pool of blood way above the gloves. blood then runs down your arm on the inside of the gloves filling the gloves with blood and totally soaking your hand. your hand ends up inside a sort of latex balloon full of the life sustaining blood of your patient. at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate.

often at this stage of the fight, if the anaesthetist has managed to keep up his fluid and blood administration with the blood loss he may start hinting that things are looking dismal. he may, for instance hold up yet another pint of blood from the blood bank and casually remark

"would you like me to run this through the patient first or should i just pour it out directly onto the floor?" sometimes one has to stop and acknowledge the writing on the wall.

ironically as the awareness of the unvanquished foe sets in, the humanity of it all comes flooding back in torrents that rival the previous blood flow. suddenly you wonder about the patient as a person and how futile it all seems. suddenly you wonder about your own life and that it is dependant on this flimsy body working properly and may be so easily snuffed out. suddenly you think about the expectation the family has of you saving his life, even as that life flows out of the body beneath your bloody hands. the tension i feel then far exceeds any adrenal rush i get at the dramatic opening of the abdomen and during the valiant fight for a fellow human being's life.

flame thrower

it's funny where one sometimes finds useful pieces of information. i mean the story of the flame thrower i think was maybe told with a slight embellishment, and yet i have found it useful quite a few times.

in the old days us registrars quite often were left in deep water. it was the theory of survival of the fittest being put to the test. and it also worked on the registrars. the less fit didn't make it.

one of my friends opened up an abdomen late in the afternoon that was the sort of abdomen you actually should open early in the morning. you see after four it was pretty difficult to get a consultant back onto the hospital premises at kalafong. quite soon he realised he was in trouble. the patient had a massive inflamed brittle friable kidney on the one side that looked like it needed to be removed. yet every time he poked it it would bristle in rage and threaten to bleed. he simply didn't know what to do. he called his consultant whose name appeared on the call list. the consultant told him there was no way he was coming back and wished him the best for the rest of his call. they then phoned the consultant of the other firm who wasn't on call. this man started out in a bad mood on any given day but was also not the type to leave someone who didn't need leaving. after the obligatory frothing at the mouth he said he would come in and help.

while my friend waited he tried a few more times to tease the kidney out but when the anaesthetist started making noises about the fact that the swabs were becoming redder seemed to somehow coincide with the fact that the patient was becoming more unstable he decided to just compress and wait.

the consultant arrived, his eyes glazed over with anger. as he entered the theater everyone went silent. the urgent bleeping of the pulse oximeter suddenly sounded deafening in comparison to the sound of all the held breaths of all the people in theater. he walked up to the patient and glanced at the kidney with disdain. even the kidney went silent. it seemed to know better than to mess with this man. then without a word he walked off to the scrub room. there was an almost audible sound of everyone exhaling together.

moments later the consultant once again approached the table. the registrar gave way as he started explaining his dilemma. the consultant mumbled something, either to himself or maybe a warning to the delinquent kidney. he then reached into the abdomen and with one smooth motion ripped the kidney out. he then turned to the floor nurse and spoke for the first time.

"set the cautery to flame thrower!" with that he systematically controlled the more than liberal ooze from where the kidney had been. it was the sort of thing you could laugh about afterwards. at the time no one was so foolish.

many years later i discovered that the flame thrower setting was actually quite useful in liver and even spleen oozes when nothing else helped. and, yes, each time i would turn to the floor nurse and with the driest voice possible would bellow,

"set the cautery to flame thrower!"

inferior vena cava

the inferior vena cava! we called it the black mamba. it lies to the right of the vertebral column. it drains all the blood from the lower extremities and the abdomen, delivering it back to the heart. when it is exposed, it has a dark blue colour. if you leave it alone, everything goes well. but if you hurt it, you are in for a whole world of trouble.

the first time i was nearly bitten was in my medical officer year. i was going to take a gunshot abdomen to theater...alone. just before, in an inspired moment, i phoned the senior just to tell him what was happening. when he heard the right transverse process of l2 had been injured by the bullet, he seemed disturbed. as i opened, he walked in. good thing he did, because the inferior vena cava (ivc) had been shot through and through at the level of the renal veins.

that was the first time i saw the ivc bleed. it's probably more accurate to say i heard it bleed. it sounded like a babbling brook. it seemed to spew blood, liters at a time. i could smell the adrenaline it caused (in the surgeon). somehow the surgeon got control and the guy made it.

then there was the time the consultant urologists pulled out a kidney for some reason. i was a senior registrar at the time. i happened to be in the vicinity (bad luck. i tried to run, but he saw me and called me into the theater). the urology consultant simply told me to scrub in. when i joined, he calmly tells me he injured the ivc. i looked under the finger of his registrar, indeed, the mamba was angry. he then told me that it was the realm of general surgery and therefore i should fix it. i could physically feel my adrenal glands go into spasm. what could i do? i fixed it, but not without much weeping and gnashing of teeth. afterwards i felt the usual parasympathetic overload after a severe sympathetic drive. i felt weak and tired.

but all the above examples are bearable in the sense that you deal with what is presented to you. not so when you are the one presenting it to yourself. a moment i wish i could forget and know i never will is when i myself nicked the mamba. and yes, boys and girls, he was angry, very angry.

without going into gory details, i cut it just above the liver where it dives behind the diaphragm to enter the heart. a word of advice, if you absolutely feel you must cut the ivc, this is pretty much the worst place to cut it.
i placed a finger over the hole, thereby stopping the bleeding. then i think i shat in my pants. seeing as i couldn't spend the rest of my life with my finger over the hole (although, i feared i might spend the rest of the patient's life with a finger over the hole) i started to repair it. step one was to call my associate to help. together we managed to get control and close the hole, but it was truly a terrifying few hours.

the point of this story is that in my line of work, occasionally (hopefully very very occasionally) you might find yourself in a situation where an action you take leads directly to harm or even death for another human being. to err is human, but when we err we can really f#@k up. i can honestly say it is a terrible and humbling realization.

favours

you agree to do a favour for a friend. it is sealed with a handshake. sounds so innocent, but in surgery this spells disaster.

i thought of this when i read about surgical superstitions on a blog i frequent. but can you call it superstition when experience confirms it to be true?

she had clear cut cholecystitis. but she had no medical aid, so she couldn't afford the private hospital. she knew someone at the state hospital. this someone knew me. he asked me if i would do the operation. at that time i was operating at the state hospital every tuesday, so it wasn't a problem. i said if she got into the system, when she turned up on the list on whichever tuesday, i'd do the operation. he organised it.

then politically all hell broke loose. i was officially banned from the state hospital because i was supplying a service that they couldn't take credit for. the administration ensured that i was no longer available at the state hospital. there was no one there able to do a cholecystectomy (true story). so the patient went without the needed surgery. she just accepted intermittent severe pain with each worsening attack.

finally it became too much. she came to me in private. but the private hospital fees were too much for her. her friend at the state hospital had moved up the ranks during this time. she phoned him. he phoned me. he was in a position to grant me temporary permission to do the operation there if i consented. he was a friend and i decided to do him the favour he'd asked for.

it is not often these days that i get to do an open cholecystectomy (in private it is, of course laparoscopic), so i don't often get to try out sid's mini chole. in the state hospital, there is no laparoscopic equipment, so the decision to do the procedure open is quite easy. i went for the mini chole. i made a 5cm incision. but i don't have the benefit of a clip applicator as described in the steps. i clamped the artery and duct with a roberts. the galbladder was out. i tied the duct without too much hassle. then came the artery.

when tying the artery, the suture slipped. for the non surgeons out there, to tie an artery way below the liver through a 5cm incision can be a spot difficult. when the suture has slipped off, the artery bleeds as arteries tend to do. blood obscures vision. there is an urgency to get the bleeding under control, but with active bleeding it is difficult to see what to do. there can be a bit of tension in the air (and in the surgeon).
i couldn't help thinking that i do a favour for a guy and the patient bleeds to death during a routine operation. i wonder how that would look on my resume.

also mental note, again, to do no favours for anyone. ever....


p.s, i extended the incision to 7cm, got the bloody bleeder under control and closed.