diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.

la mancha

the man was an enigma. those who knew him soon realised he was the only person in kalafong (hell) that cared anymore. somehow that terrible place hadn't eroded his soul to such an extent that he no longer gave a damn about his patients. yet to those who only had a fleeting acquaintance with him, he seemed course and even harsh. he didn't fit into kalafong (hell), yet he would not have fitted into any other place quite as well as he fitted into kalafong (hell). yes, he was an enigma.

my consultant in kalafong (hell), the enigma, had a certain way of bringing his point across (here and here). on the face of it it was never pretty but it was always funny in some twisted sort of way, despite that never being his intention. he also had a knack of going off on some wild tangent for seemingly no reason. what we may have thought was normal would more often than not set our own don quixote off on some wild quest chasing what seemed to us to be little more than windmills. but who were we to argue? he was after all the consultant.

so on that particular morning, when the house doctor showed the don the official consultation form from the internal department requesting us to drain an abscess on one of their patients there really was no way for him to know that this would cause the old man to fly into a frenzy and charge off towards the wards of the unsuspecting internal medicine department, his entire entourage, myself included, in tow. i was a very junior medical officer so i kept to the back and just observed.

"where are the doctors?" he bellowed at no one in particular as he stormed through the doors. "are you all deaf? i said where are your doctors? i want them here right now!" from behind a few curtains here and there the house doctors of that department peered, eyes wide, like frightened rabbits. still they froze and moved no closer.

"i said come here!" he shouted pointing directly at the closest one. "you! are you a doctor?" it seemed like a silly question. of course he was a doctor. but our master continued, "i said are you a doctor?"

"yes sir." wrong choice of words.

"don't call me sir!! do i look like i've been smacked on the shoulder by some foreign queen?"

"no, professor."

"don't call me professor!" his face went red with rage and despite it seeming impossible, the volume of his rantings increased. "i am not one of those academic professors in that ivory tower on the other side of town who operate by remote control from the comfort of their large chairs in their studies! i am a real surgeon!"

"sorry doctor."

"that's better." his voice dropped down back to jet plane decibels. "i asked you a question. are you a doctor?" the poor guy's lip quivered as he carefully and deliberately chose his words.

"yes doctor."

"what degree do you have?" we all cowered out of the direct line of sight of the man just in case he asked us the same seemingly easy question. at least we now knew not to call him sir or professor. but the poor internal house doctor had no such privilege.

"i have an mbchb, doctor." he almost whispered.

"yes you do. and do you know what that means?" before the confused victim could answer this next seemingly easy question our consultant blundered forth. "bring me a blade and show me where this patient is with the abscess.

a few moments later we were all standing around the patient wondering what was going to happen next. the house doctor was visibly shaking.

"i asked you a question?" continued our mentor, toying with the knife in his hand that the doctor had fetched for him "what does mbchb mean? or what does the chb part mean? the mb part is easy. that means you can give pills out. any old monkey can give pills out, but now i want you to tell me what the chb means"

"i'm not sure sir, i mean doctor!"

"if you call me sir again i will have you thrown up against the wall and i will bring a firing squad in here and have you summarily shot!" our consultant believed a firing squad covered a multitude of sins. "well let me tell you what it means. you see this sharp shiny thing in my hand? this is a blade. chb means you are trained to use one of these. it means you have a bachelors degree in surgery and it means you can lance an abscess. now watch me." he turned towards the unsuspecting patient. "you see now. this is the blade and this is the abscess. and this is the blade draining the abscess." with that he sunk the blade deep into the abscess. the patient winced, but, surprisingly made no other objection. i assumed he felt the threat of the firing squad may have been a general threat and that it was not limited to the poor house doctor. also once the thick stream of puss came out, there even seemed to be relief on the patient's face.

"there you go, mb and chb. now never consult us to drain an abscess again!" he turned and strode out. we had to follow. i was right at the back so i think i was the only one who heard the quiet and slightly bewildered voice of the house doctor as he said;

"i didn't consult you. that isn't even my patient."

physician, heal thyself

even doctors get sick, but there is often a difference.

i was rotating through orthopaedics and was on call that night. they tended to relegate us mere general surgeons to casualties during the calls so i was quite excited to get some theater time that afternoon, even if it was for a simple wound inspection and secondary closure and even if it meant there would be a backlog of patients in casualties for me to see afterwards. once i had finished operating i rushed through the change rooms to get back to casualties. while i was changing i heard the unmistakable sounds of someone throwing up in the toilet cubicle. quite soon the door opened and out came the orthopaedic registrar who was on call that night with me. he did not look good. he glanced at me but didn't seem to see me. his face was pale, verging on grey and there were fine droplets of sweat on his brow. he was staggering slightly as he made his way to the basin to throw water over his face. i greeted him but the only reply he gave was a sort of grunt.

much later that night i had to take some x-rays to theater for the senior to see. to my surprise the registrar was still there. he hadn't swapped his call out. i assume no one wanted to help so he had no choice, he had to work. however, he had come up with a practical solution. he was scrubbed up busy operating, but i noticed two drips hanging from the drip stand next to the anaesthetist. the one drip went to the patient, but the other went under the orthopod's gown and was replacing the orthopod's fluid loss that his severe case of vomiting had caused. the anaesthetist was actually maintaining hemostasis in both the patient and the surgeon simultaneously. i was quite impressed.

a few years later when i was the senior registrar in general surgery i too came down with some or other virus and i too was on call that day. in our department no weakness was tolerated and i knew it would not be a wise move to let the prof know i was ill. i just had to suck it up and go on.

the call was busy and being a bit sick i was struggling. there were too many things happening at the same time and it was becoming increasingly difficult to get to everything, but i kept on going to the best of my abilities. quite soon i found myself in theater operating. and there i stayed, doing case after case in quick succession and rushing down to casualties between cases to sort out the continuous stream of patients that were still coming in. and thus the call grinded on.

sometime in the early morning hours standing over yet one more open abdomen in theater i started to feel light headed. with the immense workload i realised i had not taken any time at all to have anything to eat or drink. this, combined with my illness had finally caught up with me. i was on the verge of passing out. fortunately i had more or less completed the operation and my medical officer was a capable guy. i turned to him.

"ninja, i need to take a seat. do you think you can close?" as i said it i staggered back. the world seemed to be moving beneath my feet. i leaned against the wall and slumped down. the ninja was saying something but his voice was far off and incoherent to me. the next moment i was aware of the house doctor leading me to the surgery tea room where i collapsed on the bed. i looked up in a haze. she was preparing a drip. i considered refusing but the words just wouldn't come out. besides i realised that fluid was exactly what i needed.

"put glucose in that drip too!" i finally managed to say.

quite soon the drip was up and the house doctor left. i reached up opened the drip to run in as fast as possible. then sleep came.

some time later i heard the house doctor return. she seemed surprised to find the drip sack empty, but changed it anyway. as soon as she was gone, once again i opened the drip to run full speed. the first liter had made a difference and i didn't want to waste any time, just in case i was needed during the call.

the next memory i had was the ninja shaking me awake.

"bongi, there is a gunshot abdomen. i've sorted everything and he's on the table. are you ok to operate or should i call the prof?" the ninja too knew that to let the prof know i had collapsed could potentially be disastrous for me.

"no. i'm ok now. get started so long and i'll be there in ten minutes."

later when i examined the timeline of events i had only been out of action for about an hour and a half. except for the people involved in the incident, no one ever found out. and, most important of all, the prof was none the wiser.

friends?

there is a sort of love/hate relationship between the surgeons and the anesthetists. neither one can survive without the other. we supply them with work and they get the work to lie still while we cut and dice. yet their job is to keep the patient alive while we challenge their ability to stay alive. at the moment of surgery they play good cop and we play bad cop. of course after surgery the good cop is suddenly the surgeon through and through. but that is another story.

i really appreciate a good anesthetist (i've had bad ones) and to tell the truth these days i'm spoiled by the quality of the gas monkeys that i work with. however many years ago i remember a case where the anesthetist and i had a misunderstanding about time frame.

i was doing a laparotomy in kalafong. the gas monkey was a long term medical officer. he had attempted to specialize in anesthetics but simply had not been able to pass. in the end he found himself stuck in a senior medical officer job with no way of advancing himself. he was a bitter little man and it was easy for him to take his bitterness out on surgeons.

towards the end of the operation when i started closing the sheath the patient's abdominal muscles were so stiff that he was pushing all his intestines through the wound. this did not mean the patient was awake. it simply meant that his muscle relaxant had worn off. it was a tricky time. i needed the patient to be at least partly relaxed, but if the gas monkey fully relaxed the patient he would not be able to wake the patient directly after the operation, thereby wasting all of our time. a good gas monkey will find a compromise between these two extremes. i did not have a good anesthetist. he was also more stuck on the hate side of the relationship between our two disciplines.

"the patient is pushing a bit." i hinted.

"the operation is almost over," he snapped, "i'm not going to relax him any more. otherwise he'll still be asleep half an hour from now". i was annoyed to say the least, but i knew it was a fight i couldn't win. it seemed so important to him to get this patient off the table in half an hour. i smiled. i could close this abdomen with the patient pushing against me, but i couldn't do it in half an hour. it would take longer. i decided not to share this information with my touchy friend. i buckled down and got to work.

it turned out more difficult than i initially thought it would be. each stitch was an effort and my assistant ended up straining against the patient to keep the tension on the suture. the gas monkey started becoming edgy, but i ignored him. if anything i slowed down my pace, making sure that, despite his best efforts, i closed the sheath properly.

about an hour later when i finally had it closed the qwasi-gas monkey was so irritated that he couldn't sit still. i was smiling behind my theater mask. i knew i had closed the sheath properly despite his inadvertent attempt at sabotage. and maybe next time he would pay slightly more attention to my seemingly ridiculous demands.

pink and purple

recently i discovered the blog of a good friend. only problem is that he is a pathologist. i understand nothing of it, just like in the old days.

in the old days when i was still a registrar we had a joint meeting with the pathologists once every three months. if you ask me it was way too much. you see surgeons and pathologists are poles apart. for one thing, they are quite clever. for another their patients are all stable so there is never any urgency with them. i've heard they have to deal with bleeding a lot less too. but i suppose the clever bit got to me the most.

the way the meeting went was based on patient presentations. we would get a list of the cases they wanted to discuss. the surgeon involved in the case would then be required to present the case in front of everyone. he would talk about the clinical presentation, the findings an then the operation. it would usually end in a description of some or other thing that was cut out and sent to the pathologists. we would then hand over to them. i remember how their eyes would light up when we got to the bit about the thing we'd cut out. you see when they were handed the whatever it was we had removed or excised they got to work turning it into shades of pink and purple.

no matter what it was we presented them with, they would cut it into fine strips, put it on slides, colour it different shades of pink and purple and get very excited. at these meetings they would show us these slides. the thrill of it could often be detected in their voices as they spoke and could always be seen on their faces. they would wax lyrical as they increased the magnification, showing us the pink and purple ever closer. we would look, probably with visible expressions of increasing bewilderment with each new magnification, and nod knowingly. it probably didn't fool them. but the thing that irritated me the most was their standard opening line before they interpreted these pink and purple patterns to the room full of either excited or bewildered nodding faces. they always said the same thing. i think they might have been taunting us.

"as you can see..."

thyroid fun

the way i do thyroidectomies (removal of thyroid) these days and the way i did them in my training differ radically. these days i use a fancy instrument that cuts and seals the vessels simultaneously. it also can cut through the thyroid tissue with little to no bleeding. during my training we simply didn't have these sorts of fangled tools. we had to painstakingly deal with each minute vessel individually, tying them off one at a time. also when it came to cutting through the thyroid tissue it could get a bit bloody. we would put clamps directly onto the thyroid itself and cut above the clamps. then we would quickly suture the cut surface closed before there was too much blood loss. it could be exciting. it was once a scream.

i was a lowly medical officer but i was working with the best registrar in the department. but on this particular day he was quiet and pensive. he just didn't seem to be himself.

"what's eating you?" i asked. he looked up at me.

"the thyroidectomy on the list this morning. the patient has graves disease. these days you're not supposed to operate graves disease but the prof doesn't like all these new fangled radiotherapy treatments and has instructed me to operate the patient." it didn't seem such a problem to me. if the prof had decreed it so then it was so and there was nothing to do but to operate the patient. he continued.

"only thing is there is a very good reason we don't operate graves disease anymore. you see they bleed like stuck pigs. a graves thyroid is super vascular and brittle. it is difficult and a bit risky to operate. i'm not sure i can do it. also you know the prof is actually semi-retired and he won't scrub in with me. anyway he won't be much help. his hands are no longer steady." i could see his point. still he had no option. he would have to simply put his head down and do it.

we exposed the thyroid nicely. it was massive. it sat there in the neck definantly throbbing, daring us to challenge it. what it didn't realise was that although it was very intimidating it was not nearly as intimidating as the prof. we went ahead.

as the registrar placed the clamps onto the thyroid i could see his hands shaking visbly. it seemed ironic that hands that were not steady was the reason given that the prof could no longer operate. maybe my registrar was doomed to have a very short career. i didn't share these thoughts with him. i thought it better to just be supportive and encourage him. by the time the clamps were in position the monster was already oozing quite a bit. now it was time to cut it.

it's difficult to fully explain what it looks like when you slice through a thyroid afflicted with graves disease. the effect it had on my registrar and myself was also profound. as the blade slid through the tissue blood just started pouring out in multiple streams of differing intensities. it was quite an impressive display. by this time my hands were shaking too. this was going to be difficult. as the knife finished its course through the now angry thyroid and the registrar lifted the offending tissue free of the patient we suddenly heard a voice behind us.

"hello. how are things going?" it was the prof who had quickly come in to check on us. my registrar spun around, grabbed a swab and shoved it onto the bleeding thyroid tissue still in the neck and pushed as hard as he could down on it to try to control the now liberal bleed with pressure while he spoke to the prof. it was never ever a good thing to let the prof wait.

"ok, prof. it's just bleeding a bit." a bit? i thought. i would have used words like 'gushing' or 'exsanguinating' or 'please help us mere mortals', but my registrar simply said 'a bit'. the prof took a closer look. i could clearly see the white swab changing colour to bright red under the registrar's hands. the prof moved back and then spake he.

"yes, graves thyroids can ooze a little, but you seem to have everything under control." his eyes must be the real reason he can't operate, i reflected. again it seemed prudent not to share this opinion. "i'll be in my office. let me know how the rest of the operation went when you are finished." and with that he was gone.

we stood there in the silence of the wake of the prof. i just started laughing. it was all so absurd i couldn't help it. my laugh shook the registrar out of his trance and he got back to work.

once it was all over, unlike my prof, i was a firm believer in radioactive ablation for graves disease.

the master has spoken

i have touched on how to spin the story correctly to your consultant in order to achieve the best possible outcome for all involved. there was another scenario where i worked it to a fine art.

the toughest firm to work in was the boss' firm. i have mentioned this before but it was difficult to avoid his wrath. generally you were placed in charge of his firm only as the most senior registrar in the department. this gave me a good few years to observe how the other guys presented their cases to him in the morning meeting and to learn from their mistakes. one thing about the boss is he was an exception to the general rule of consultants not coming out to help in theater at night. if you called him, he would come. this sounds good, but the down side is that it was not all that much fun to operate with him. he demanded dead silence and always operated himself, seldom letting his junior at the knife which meant he didn't teach too well. i learned a lot from him as far as technique is concerned but it was mostly through observation rather than through tuition. so, in summary, it was not ideal to call him out at night. quite frankly it was a pain in the neck.

but there was another side to phoning the boss at night. as a junior i often observed a hapless registrar presenting a difficult case to the prof the next morning and facing all forms of the proverbial sh!tstorm for not phoning the prof. it didn't matter if he had single handedly raised the patient from the dead or broken down the gates of hades to claim his patient back. if he hadn't called the boss it simply wasn't good enough. and yet, without fail, the registrars endured this tirade rather than endure the prof coming out at night. i wondered if there was a happy middle ground somewhere. it didn't take long for me to find it.

basically the prof was a surgeon and therefore had a very fragile ego. it wasn't that he wanted his sleep to be interrupted to come out in the early hours and operate. he just wanted to be acknowledged as the guy in charge. he didn't want to be surprised the next morning with weird and wonderful stories of heroism, especially when he was not the hero. i understood this and worked with it. in the end it was all about timing.

a good example of how it went when i finally worked it to a fine art is illustrated quite well by a case i still remember.

the patient was the victim of severe blunt abdominal trauma. from the first moment it was clear he was in deep trouble. there was no question about doing a ct scan or not. he was simply too unstable. to go via scan would be to lose precious time which he could ill afford. we had to get him to theater as fast as possible and that is what we did.

after opening the abdomen i was confronted with a massive amount of blood. it was the sort of thing we sometimes do see but it is always a tense situation. i went through the motions and quickly identified the liver as the source of the bleeding. segments six and seven had been totally crushed and had been pretty much ripped off the rest of the liver. being astute as i am i quickly realised this was not good. i must admit there were a few subtle hints like the anaesthetist shouting that the patient was almost in exitus and my house doctor's wide eyes. but the absolute giveaway was when the house doctor spoke.

"aren't you going to call the prof?" he asked.

"do you want the prof here?" i retorted.

"of course not but you know what he is going to say tomorrow morning if you don't call him!" i smiled.

"watch and learn my young paduwan. watch and learn."

i then deftly whipped out the damaged segments of the liver, controlled the bleeding and started rinsing the abdomen. the anaesthetist was looking less tense so i assumed i was on the right track. i then turned to the house doctor.

"it is time." i then turned to the floor nurse. "please get the prof on the phone for me." soon after she was holding the phone to my ear.

"sorry to bother you so late at night prof, but i just wanted to let you know about this patient i'm operating. he had a liver laceration. there wasn't time to call earlier because he was unstable and we were rushing him to theater but i thought i should tell you how it's going. i have the bleeding under control now."

"sounds good. do you need me to come in?"

"not now prof. everything seems ok now, but thank you for offering." the house doctor stared in amazement. i knew the hero worship would come later.

the next morning, in the presence of all the registrars and house doctors i was required to present the night's activities. when i started on the patient in question i could see some of the registrars' ears perk up. i think some of them might even have been delighting in what they saw as my inevitable misery. as i got to the bit about the liver looking like mince soup, the prof intervened.

"yes, bongi phoned me about this case. i advised him how to get the bleeding under control. the patient is fine now. well done bongi." the expression on the face of the house doctor was unmistakable. it was indeed hero worship. who could blame him?

knot a good story

probably my favourite operation is a laparoscopic nissen fundoplication. it is a mixture of intricate dissection and technical skills. and probably my favourite part of a nissen is the laparoscopic knot tying. it's just fun and i am usually quite good at it. yet recently while i was doing a particularly difficult nissen with a massive hernia, when i got to about the sixth knot, somehow i just couldn't seem to throw a laparoscopic knot anymore. it gave the assistants a bit of a laugh and a window to tease me a bit. i too had a good laugh, took a moment, and the problem was gone. the rest of the operation was no problem. but i couldn't help reminiscing about another knot tying incident from the old days.

surgeons generally tie knots with only one hand, their left hand. it is a fairly easy skill to learn and yet it is poorly taught. i remember when some registrar tried to teach it to me when i was still a medical student. he sort of took my hands and positioned the fingers as if they were made of wire and would just bend into any position he chose. he then started twisting the fingers into ever increasingly strange contortions as he shouted:-
"now you do this and then you do this and then you do this!" interspersed with "not like that, idiot!" each time my hands didn't immediately fall into the position he demanded them to be in. when i finally got it right by sheer chance i wasn't entirely sure of the correct sequence of d0-this-es to be able to repeat it.

so when i became a registrar in surgery and i was required to teach students how to do the elusive surgical knot i sat down and formulated a way of explaining the steps using words other than 'do this' and 'do that' and without grabbing their hands and forcing their fingers into strange contortions. i then simplified the steps so that even if the student's hands forgot how to do the knot, when they went home they would be able to go through the steps again and reteach themselves to do it. and i had great success. even the most ten-thumbed students could sort of throw a knot after going through my steps.

then one fine day swimmer's chest and i were doing a laparotomy together and i decided to show my good friend, swimmers chest, my surefire way of teaching the knot. of course it wouldn't count if i simply tied with my trusty left hand so i decided to use my right hand for the demonstration. i set up for the knot, explaining the steps. but just as i was about to throw the first knot, the boss walked in to check how things were going. my wrong hand (the right hand) was set up to do the knot so i thought i'd better just get on with it. yet with the boss breathing down my neck and the initial point to tying the knot with my right hand being gone, i somehow floundered. the boss was (k)not one to let such an opportunity slip by. he immediately knotted onto the fact that i was struggling. he leaned in and focused his entire attention on my hands. i needed to get his attention off me. i asked the sister for a needle holder so i could tie with an instrument rather than with my hands. the boss was quick to respond.

"no no no no no bongi. use your hands." i grabbed the suture, but by this time the hands were shaking. i went back to my trusty left hand but as i set up everything just fell apart. the boss' eyes seemed to burn holes into my finders and it felt like so many years ago when the registrar twisted my fingers to their heart's content. swimmer's chest looked at me in amazement. he leaned across and laughingly asked,

"bongi, what's wrong with your hands? why have they gone all stupid?"

"swimmer's chest, here is the suture. i seem to not be on form today. you do the rest." but the boss would have none of it

"no! bongi will continue and throw the knots until the operation is finished."

and so i struggled through the last few sutures that needed to be thrown with the boss' disapproving glare and swimmer's chest trying not hard enough not to laugh.

still to this day when swimmer's chest and i get together he rags me about the day my hands suddenly became dumb and i forgot how to tie knots.

night walker

one of my senior registrars once said that the night belongs to surgical registrars and prostitutes. we all had a good laugh. it didn't strike us as odd being compared to prostitutes at all. if anything in those days we often got the feeling we were being screwed over, however the remuneration wasn't as good. but there was another time the comparison was a bit odd.

on a certain sunny day i decided i should do my duty and donate blood. i felt it was not right that i complain when there is a shortage in the hospital if i am not at least trying to make a difference by donating myself. so off i went to the nearest blood bank with my phobia of needles and my sweaty palms, all trembling in fear to donate. the lady behind the desk took my details down and pricked my finger to make sure i was not anaemic. after that formality (which in itself did nothing but heighten my dread of sharp objects), she gave me a questionnaire that i was required to full out. i thanked her and moved off to a table to nurse my painful finger and full out the form.

the form was pretty much what one would expect. it asked if i was aware if i had had any blood born diseases that i knew about like hepatitis b or hiv etc. it touched on family histories and the usual medical things that may have an influence on whether one should donate blood or not. then it fired out a question that i though quite interesting.

"are you involved in any high risk professions like prostitution or surgery?" prostitution and surgery were sort of lumped in to the same question together. also they were both considered professions of, as far as i could tell, the same standing. there was a block to mark yes and a block to mark no. i marked yes.

i took my questionnaire to the lady behind the desk. she scanned all the answers until she came to the one i had marked yes. she froze. she then glanced up at me. actually i think she maybe looked me up and down. she then hurriedly disappeared into the back room. after a few hushed whispers she emerged with another lady and i was led away to a room with a sign above the door that proudly identified it as the counselling room. now where i come from, the word counselling is pretty much always what happens just before you get tested for hiv. i considered telling them that my last test was about a month ago and it was negative, but i was somewhat bewildered and still beset with fear for the large needle that i still expected would be sunk into my arm.

once we had settled down into comfortable seats in the counselling room the lady asked me what i had meant by answering yes to that particular question. i told her i was a surgical registrar and was therefore quite often engaged in high risk surgical activity. she then also looked me up and down and gave a sort of smirk. she clearly didn't believe me. i was obviously much too good looking to be a surgeon and better fitted the profile of one who sells his body for cash. then, without missing a beat she went on to talk about the dangers of hiv and all the ways you can get it (she meant by selling your body of course). i wasn't sure if i should point out that other than getting screwed by the system in the state hospital on a regular basis i was not a prostitute but rather a surgeon. but she hadn't believed me the first time and nothing had changed between then and now so i decided to just keep quiet. after all, maybe i was simply too good looking to be a surgeon after all.

suffice to say they did not want my tainted blood and i therefore never had to face the business end of their needle. i just wish they had only checked my blood for anaemia after the counselling session rather than before.

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.

dogma

surgeons are creatures of habit. they also tend to be somewhat dogmatic. when things change they often become edgy or annoyed. however, this little fact made for a funny story once.

i was a lowly medical officer working with a senior registrar. it was a good time. i had senior cover which in those days was quite rare. also my senior was a really great guy, even though he was a surgeon. as it turned out when the time came to be rotated the prof moved us both to a new firm together. he must have assumed we didn't like each other, such was the prof's usual logic.

the new firm promised to be fun. the consultant was an old prof who no longer operated but enjoyed teaching. we would be left to do the operations without too much interference and we would get good academic input. life was sweet. we just needed to make sure we didn't annoy the old respected man. with this in mind we asked the prof's previous registrar if there was anything we needed to know about the prof in order to do everything right. he assured us there were only two things that should be dogmatically stuck to and all would be well.

firstly the prof was always exactly on time and accepted no excuses for his underlings being late. if he said rounds were to be at 07h30, then you had dam well better be there waiting for him at exactly that time. if you were busy with a resus then you should have thought of that before you allowed the patient to crash before the prof's rounds. he would not be impressed by such trivialities over his rounds. no excuse would suffice.

the next thing his registrar told us was that, after his so called grand rounds on a wednesday he would dismiss the students and invite the doctors to enjoy a cup of tea and biscuits with him. we were to supply abovementioned tea and biscuits. and, the registrar sternly warned us, the only biscuits we were permitted to supply were romany creams. apparently nothing else was good enough for the important palate of the old bull.

i was quite happy. these were easy things to do and the rotation should be a breeze. i was right. it was.

then many years later when i was the senior registrar, once again my turn came to rotate through the old prof's firm. once again i approached the incumbent registrar and once again he told me that if i'm on time and i supply romany creams for the prof's tea on a wednesday, all would go well. i was always on time and i kept a few emergency packets of romany creams ready in my locker just in case. the rotation was fabulous. the prof never said a bad word about me.

as with all good things my time with the prof soon came to an end. i was rotated into another firm and replaced by my friend and colleague. as was the habit of all of us my friend approached me to get the low down on how to stay on the prof's good side. it was obvious throughout the department that the prof was actually fond of me (well as fond as a surgical prof can be). i told him the secret. it was so simple, be on time and supply romany creams. my colleague should do well too, i thought.

about a week later, during the prof's post grand round tea party, i wandered in to the tea room. i was astounded to see an assortment of biscuits on the table. i was even more amazed to see that none of them were romany creams. had my friend lost his mind? had he decided to ignore my advice? was he tired of life? i didn't know. i left in possibly too much of a hurry.

the next day i went to my friend and asked what the hell was going on? why had he totally disregarded my advice that i knew had been passed down faithfully from registrar to registrar at least since five years previously and probably even longer? he told me.

"well, bongi, on day one i told the prof that i was told he like romany creams so much and i asked him why. he replied that he actually didn't like them at all and had been wondering for some time why his registrars always gave them to him. it didn't bother him too much so he just left it."

i couldn't help laughing. this piece of erroneous information had been passed down faithfully over possibly eons from one registrar to the next without anyone ever bothering to check with the prof to find out if it was in fact so. i could just imagine how it had all started in times gone by, maybe just after the mesolithic era. the prof had casually taken a bite out of a romany cream and made a comment that it wasn't half bad or something equally moderate. the registrar of the day probably looked up from his stone surgical tool and remarked "uhgh!" as he made a mental note to remember what he assumed was the prof's favorite biscuit. and thus he started possibly the single longest untested erroneous surgical fact of all time.

p.s it is true that you must be on time though.

tutor

training as a surgeon where i trained was somehow secondary to supplying a service. often formal tuition fell away to a senior quickly showing you how to do a specific operation in a somewhat irritated way. half the time you felt embarrassed that you didn't already magically know how to do it so that you could take the immense burden of teaching off the tired shoulders of your overworked senior. the first haemorrhoidectomy i was shown fell pretty much into this mould.

i was still a lowly medical officer when we admitted a patient with a pretty severe thrombosed awkwardness in the nether regions. my senior, a final year registrar, asked me if i had ever done a haemorrhoidectomy. afraid that not having done one would not exempt me from being tasked with doing this one, i discretely pointed out that i had in fact never seen one. i could see the irritation in his face, but he remained calm and told me he would show me how it was done. he then added i'd better pay attention because after showing me one he was never again going to cast his countenance on another anus so long as i worked with him. not wanting to upset his countenance i determined to learn fast.

i remember that haemorrhoidectomy well. i was so on edge to gleam every ounce of wisdom from my senior seeing as though it was to be my only opportunity to learn the procedure. and yet even though he explained every step as he did it it just looked like a bloody mess to me. anyway, that was my training and it had to do. fortunately as the years went by i learned a few tricks, mostly by trial and error, and finally i think i became quite proficient in the procedure.

then, many years later when i had become the senior registrar in the department once again a haemorrhoidectomy found its way onto a list. i expected that i would be the one to do it as i had so many times before. then the boss perused the list. he asked me who had taught me to do a haemmorhoidectomy. when i told him he decided right there that if he had not taught me how to do it, then i probably wasn't doing it correctly. to be honest i thought he might have a point. i mean that operation i had seen so many years ago did simply look like a bloodbath to me. true i had made the operation my own over the years and i even think i had become good at it, but i hadn't really been shown the correct way to do it by someone that at least in his own eyes was an expert. i was actually quite keen to see the operation in the hands of the expert.

at the operation, the boss settled down in the hot seat and prepared to show me his masterpiece.

it was a bloodbath.

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.

decisions

i recently read a post by a greatly respected blogger. she relayed a story about why someone chose primary care as a speciality, but it turned out to be more about why they didn't chose surgery (or why you should read the contents of anything you eat). i felt compelled to reply.

in all honesty there are many reasons i decided to specialise in surgery, not the least of which was that i wanted to be able to deal with pretty much everything. i also really enjoy operating. there is something magical about cutting a fellow human being open. intuitively it seems so wrong, and yet we do it and we do it for the good of the patient. it's truly mystical. but there was one incident that happened in my student days that clinched the deal.

i've never considered myself too bright (with the possible exception of two separate occasions). so exam times were always quite stressful for me. the finals of fifth year were no exception. so when i found myself waiting to be called in during the surgery practical finals my nerves were pretty frayed. the patient i had examined had a large smooth thyroid. clinically she didn't have hyperfunction, but that could be due to medical treatment. i had no blood results so i would have to go through all the causes and finally settle on what i thought was actually wrong with her. the prof was bound to grill me on my diagnosis and try to catch me out. at times like this your entire career feels as if it is the balance and may be lost to you for the slightest reason. as usual i wasn't feeling too bright. and to top it all, the student that had just come out had been grilled for not wearing his name tag. the prof had apparently almost gotten personal and totally rattled him. i had just lost my name tag the previous week. this did not bode well for me.

and then it happened. while i was sitting there waiting and trying to remember and sort out all the bits of information floating around in my exhausted, overly stressed brain, one of the senior consultants of internal medicine walked past. he saw me there with red, sleep deprived eyes and anxiety written all over my face and immediately realised i was just about to go in for a grilling by the surgeons. he gave his bit of advice.

"remember, when in doubt, cut it out." when in doubt, cut it out. when in doubt, cut it out. it went through my mind over and over. a sort of charge in, sword brandished where angels feared to tread. now that was simple and easy enough for even me to remember. right there i decided i could become a surgeon. i knew i had what it took to handle the petty onslaughts of the surgeons, so that didn't bother me too much, and now, intellectually i knew i would be able to remember the essence of surgery, when in doubt, cut it out.

claustrophobia

a comment on my previous post by undead doctor, reminded me of another story about a lift in the old academic building in the old hospital.

every morning all the registrars, medical officers and interns in the surgery department would meet in the boss' office for a report on the previous night's activities and to deal with whatever other administration had to be taken care of. after this meeting the day's work would begin. the surgery department was on the seventh floor of the academic building. the lifts in that building were fairly small, so we did what any normal surgeon-type would have done in our situation...we tried to see exactly how many people we could cram into the lifts on the way back down after the meeting. as it turns out the lifts couldn't take more than thirteen. i know this from the time we crammed fourteen into one lift and it got stuck between floor three and floor four.

now the mental image you need to create here is of fourteen bodies crammed into a space that can comfortably accommodate about six people. it was the sort of situation where we could not all breathe in at the same time because there was simply not enough space for everyone's thoraxes to expand simultaneously. also it was hot, very hot. quite soon the metal walls showed small drops of water from the combined evaporation of our bodies. i would like to say it was not too comfortable, but that somehow just doesn't convey quite how we felt.

to be honest, the first minute was quite fun, with one or two people making jokes about the fact that pretty much the entire surgery department had been wiped out. it was not the ideal time for a bus accident to come into casualties. after the first minute, however, the next eighty nine or so minutes (for that is about how long we spent in that lift together) somehow were not quite as much of a laugh.

one of the interns, it turned out, suffered severely from claustrophobia and had only gotten into the lift in the first place because he didn't want his registrar to think he was weak. after that there was not too much pretence left. his registrar got to see him cry, drop to the floor and call for his mother.

i had a leatherman which someone used to pry the door open about one inch. the above mentioned intern pushed his face up against this tiny window on freedom and started to hyperventilate even more than he had up to that point. i suggested we allow the doors to close again, hoping it would allow the lift to resume its normal activities and hopefully stop on the correct floor and permit the doors to open normally. after that suggestion something happened to me that had never happened before or since...the intern started shouting at me hysterically, even taking the effort to call me a few derogatory names. i could not hit him. my arms were pinned to my sides by the mass of humanity. besides, i assumed outside that lift he would quickly become normal again. i decided to leave it at that.

after about an hour and a half i decided to push my theory once more. i moved slowly towards the doors. it was surprisingly easy..the combined sweat acted as a lubricant and we slid against each other in what i can only describe as an amoeba-like fashion. i moved right up to the intern who was on his knees with his nose pushed through the gap in the doors doing all he could to drop his carbon dioxide partial pressures. with one hand i grabbed my leatherman wedged between the doors. i placed the other on his head. in one movement i yanked the leatherman out and pulled his nose out from between the doors. the doors closed. at that moment the intern got to his feet in one smooth amoebic action. his face was in my face and his eyes glazed over with hatred. i prepared to defend myself, but almost expected a phagocytotic attack. how does one defend against phagocytosis?

then there was a jolt. the doors having been allowed to close sent some signal to the great engines of the lift (not great enough to handle fourteen people mind you) and it jumped into action. five seconds later it arrived on the correct floor and the doors swung fully open. the intern rolled out. the tears of rage turned suddenly to tears of joy. everything he had said to me was immediately forgotten by him. it took me slightly longer.

other than very hot and mildly dehydrated we were mostly none the worse for wear.

lift me up

getting things done in south africa is subject to numerous unique frustrations, some of which i might have allured to in the past. one such typical case had to do with the lifts (elevators) in the old academic hospital in pretoria.

the old academic hospital was made many years ago. then over time as medicine advanced it got bigger in increments. finally it was a poorly designed conglomeration of buildings with multiple small wings all connected with sometimes tiny corridors. over and above that the eastern half of the hospital was totally different. it was a single story sprawling mass of wards, all opening to the outside world. the theaters were on the second story in the western half of the hospital. to get a patient to theater from casualties therefore you needed to take the lifts.

the hospital had a total of ten lifts, a few for each section of the strangely laped together place, but, as is typical of the maintenance ethic in south african state hospitals, only one lift worked at any given time. this added a unique aspect to an already high stress resus effort in casualties.

so generally in the high stress resus efforts, when you get to the exciting stage when you rush the patient to theater with all the fanfair usually only seen on american television medical dramas, one of the things that must be added to the mix is the identifying of the working lift. at this stage, what is required is to send three students ahead to the different lift areas to identify the working lift and to summon said lift. he then was required to shout down the passage to the other students that he had the lift. they, in turn, would relay the message to us and we would go directly towards that lift. i would always stay with the patient, usually bagging the patient with an ambubag.

after this usually the operation itself could not really deliver any more stress than had already been experienced.

hear this

recently a plastic surgeon i know was called out to fix a lacerated ear. it is the domain of plastic surgeons pretty much all over the world. but in my neck of the woods it may be tricky to extricate a plastic surgeon from his warm bed on a cold night. let me also say that back in those days all registrars of all disciplines earned the same overtime each month. even opthalmologists and dermatologists and pathologists earned exactly the same overtime as surgeons. they weren't complaining. we, however, were.

as calls went it was fairly standard for us general surgeons. i had found a moment to empty my bladder which was a nice change, but other than that one reprise there had not been a moment to even realise that i hadn't eaten all day. at least there hadn't been any lethal disasters...yet.

somewhere in the madness the house doctor asked me to evaluate a patient with a lacerated ear. he had had half his ear detached in a bar brawl. it was hanging precariously from what still connected it to the body. now at this time in that hospital there was a policy that once a patient had been referred by a casualty officer they would not take the patient back. if the referral was erroneous then we would be required to refer further as appropriate. so when i heard my house doctor had accepted the patient i was not impressed.

"you suture his ear." i told him. poor guy, he hadn't studied at our university and therefore wasn't used to our sink or swim approach to medical training. he freaked. my level of being impressed dropped even more. i'd have to phone the plastic surgeon myself.

the plastic surgeon was not keen. by that i mean he basically said he was not coming out. by the tone of his voice i assumed he was getting a back rub from his significant other under the warm duvet on his bed. who could blame him. if you're not in the trenches why would you want to go into them, even for a short while to suture an ear.

"anyone can suture an ear. you're there now. i'd have to come in to the hospital. you just do it." i considered telling him that i'm at the hospital because i have so much bloody work to do and that he is drawing the same overtime that i am and that it is his bloody job and not mine. but i knew that at that stage, even if i walked on water and then turned it into wine he was not going to come out. i hung the phone up. my house doctor looked at me questioningly. he had already told me he couldn't do it. but he was not from our neck of the woods. i needed a student. one walked past, unsuspectingly.

"you! have you ever sutured an ear back on?"
"no."
"when i ask this same question tomorrow, you will answer yes. come with me."

he did quite well.

looking good

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.

anger

in the old days sometimes confrontation was the only way to get things done. but sometimes anger lead one into useless and unnecessary confrontation. i recently spent some time with my old friend, swimmer's chest and a story came to mind when that swimmer's chest saved me from my own anger.

we were on call together. quite early in the day the chemotherapist called me. he had apparently put a patient on the emergency list the previous day for a portacath and the case didn't get done. this was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. something like a portacath would tend to get shifted down the list and may even stand over to the next day. this is what had happened here. he now wanted me to do the case.

"sure i'll do it" i said. "as long as it's on the list as soon as it comes up i'll be there."
"i want it done now!" he retorted. i was not impressed.
"well phone the anaesthetist on call and motivate for him to move it up the list." i said helpfully.
"that is not my job! you will do that!"

it was clear we had a communication problem. whenever i had a telephonic communication problem i would put down the phone and take the effort to go to the relevant person to sort it out face to face. not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). this is what i did here. i turned to swimmer's chest and told him to accompany me. off we set at speed.

we walked into the chemotherapy ward and asked to see the relevant doctor. soon he was there in front of me. swimmer's chest hung back. i introduced myself and explained that i was more than willing to do the surgery but i had no control over the order of the list. that was entirely in the hands of the anaesthetists. if he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.

"you will phone the anaesthetist yourself and you will do this case right now!" he said.
i could feel my anger slowly turning into fury.
"no! you will!" as i said it i clenched my fists and took a step towards him. swimmer's chest realised things were on the verge of going south. he later told me he thought i was going to punch the guy. i denied this, but the thought was going through my mind at the time, i confess.

so my good friend stepped in front of me with his broad chest and nudged me backwards. he then started speaking to the chemo doc in a calm diplomatic voice. he also subtly and slowly (almost so one didn't notice) ushered the guy further and further away from me. by the end of it we left with the chemo guy feeling that we were there for him and would do all we could. i don't think he even had an idea of how enraged he had made me.

walking away swimmer's chest asked me if i was mad. i had only a few month's of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.

those times in the end brought out the worst in me. by the end of my studies i knew i needed to get away from it all. i had very nearly become something i did not like. after leaving pretoria i gradually rediscovered the true me again. it was still there to my relief.

eccentric

sometimes eccentricity is excused by brilliance. the old prof of thorax in my humble opinion fell into this category. i quite enjoyed his lackadaisical approach to training, especially because i was not required to know thoracic surgery to the depth that a thorax surgeon was required to know it. i could sit back and observe.

during my rotation in thoracic surgery i enjoyed the morning meetings. the prof was very knowledgeable in all things. truth be told i never heard him teach any thoracics. he taught pretty much everything else. he would walk into the thorax lounge, sit back, light a cigarette and drink coffee. as long as you kept his cup of coffee full he would just keep on talking about all sorts of topics (except thorax surgery. he reasoned the registrars were supposed to be reading current articles and therefore were supposed to be more up to date than he was. if that were the case then how could he be so audacious to assume he had something to teach them?).
he also had what i considered a sort of inappropriate giggle. after almost every sentence he spoke he would slightly lift his shoulders and let out an almost inaudible giggle. no one else dared laugh unless it was clearly a joke. he was, after all the prof.

finally one day i witnessed him giving a thoracic surgery opinion on a thoracic surgery patient. as usual he was sipping and puffing away waxing lyrical about some or other topic which he seemed to be an expert on (i think he was explaining how he had written the program that his department used for patient records or how the cities electric supply was wired). one of the thorax registrars stood up with a ct scan. he placed it on the x-ray board and waited for a gap to ask the prof's opinion. sure enough, after the next giggle, the prof turned to see what he was doing.
"excuse me prof but could i ask you for an opinion on this patient please?" the prof put down his cigarette and coffee mug (which i duly quickly refilled). he then reached into his top pocket where he kept his fold up reading glasses. all eyes were on him as he clumsily unfolded them and placed them precariously on the tip of his nose. he then threw his head back in order to be able to look through the said glasses. everything went silent. then spake he.
"hierdie pasient is gefok!*" followed by a gentle lifting of the shoulders and the usual giggle. he whipped the glasses off his face, folded them up and returned them to his pocket in one smooth movement. i laughed. it seemed i still couldn't tell the difference between the prof trying to be funny and being deadly serious because everyone in the room stopped what they were doing and stared at me as if i had disrespected the great man. i swallowed hard and shut up. after all the prof was exactly right.

*this patient is f#@ked