covert operations

the consultants didn't always need to know what was happening on the floor. but sometimes keeping things away from them became downright clandestine.

i was a senior registrar at kalafong (hell). an old friend of mine had just taken up a post as consultant in the department of internal medicine. one day he approached me.

"bongi, what are the chances you can do the occasional open lung biopsy for me?" now there was no thoracic department in kalafong so it seemed to me to be a reasonable request. in fact i was quite excited. it would give me a chance to do a few thoracotomies, something us general surgeons don't do all that regularly.

"sure! anytime. just let me know and i'll book them on my list."

"uhmmm, there is just one small problem," he continued, "i've already asked your consultant when the previous registrar was here and he bluntly refused, so i suppose you would need to convince him." this was no small problem. my consultant tended to be a bit hard headed and i knew if he had already decided, then there would be no convincing him. if i were to ask his permission he would refuse and that would be the end of it. if i just went ahead at least i could claim ignorance, that is until he catches me out. there was only one thing for it.

"ok, i'll do it on one condition. at no point must you discuss the matter again with my consultant. everything must go through me." and so it was arranged.

a short while later the internist approached me with the first patient he wanted a piece of lung from. i took her name down and booked her on the back of my list. i then re-wrote the list, carefully omitting her name and took it to my consultant. we went through the somewhat abbreviated list together. he was happy. i didn't want to be the one to erode that fragile joy.

halfway through the theater list, as was his habit, my consultant asked me if i'd be able to handle the rest and went back to his office. i assured him i had everything under control and sent him on his way.

the thoracotomy went well and the hiding of the patient from the consultant in the ward for the next few days also went well. i was feeling good. i suppose i knew it couldn't last.

two more thoracotomies were pulled off in similar fashion. and then we prepared for the whole charade for the next one. again i put the patient on the list and again i discussed the abbreviated list with my consultant the day before. again everything looked good. i went home, looking forward to a great list culminating in a nice thoracotomy to obtain a piece of lung for my internist friend. but this time something went wrong.

how was i to know that my consultant decided to pass by theater that evening before he went home to check something on the list? how was i to know that he discovered my thoracotomy that until then he knew nothing about? how was i to know that when i walked into the morning meeting i was walking into a fire fight?

the consultant was clearly angry. before the meeting he called me over and asked me why there was a thoracotomy on the list that he knew nothing about. i told him the internist had asked for a lung biopsy and i had added the patient because we had some extra time on the list. he went mad (or slightly more mad). leaving no room for any misunderstanding he informed me, with much frothing at the mouth, that there would be no thoracotomies on his list....not now....not ever. i apologized. i thought that was the end of it. i was wrong.

after the meeting the prof asked if there were any announcements. my consultant raised his hand. it was so unusual for him to say anything during the morning meeting because of a certain amount of animosity between him and the prof that everyone sat up and paid attention. he then moved to the front of the room.

"it has come to my attention that bongi has been doing thoracotomies on my lists." he started. "now if this ever happens again i give you my word that i will personally see to it that the guilty party is put up against the wall in front of a firing squad and he will be executed! we will reinstate public executions here in kalafong. we will make it compulsory for all the registrars to attend so they can see what will happen to them if they step out of line. if he wants he can have a blindfold, or he can go without, but he will be executed. the registrars watching will not be permitted to use blindfolds."

i considered the question of the blindfold, but in the end i decided to rather stop doing the thoracotomies.

significant moments

i hate paediatrics. people who don't understand the life of surgery may think this means i don't like children, but in fact the contrast is true. surgery is suffering and heartache. surgery is pain and misery. it is stuff children are not supposed to experience. children are supposed to be caught up in the joys of life. they are supposed to play and smell the roses along life's paths. pain will come later, but childhood is supposed to be a sanctuary, albeit temporary from the harsh realities of life. and when life really gets harsh, you may need to come to me.

i once spoke about a very special boy who crossed my path. his death still haunts me but there was another incident which drove the wedge between myself and paediatric surgery forever.

it was during my thoracic rotation. to be honest it was one of the more enjoyable rotations. they actually occasionally allowed me to do a thoracotomy or two. most of the other disciplines used us as their underlings to get the ward work done. of course in thoracics we were also used for this but at least there was a payoff.

one day myself and a rotating registrar from another university were sent to draw the preoperative bloods on all the theater cases for the next day. i was fine with this. i secretly hoped i'd find a case i could do myself if the powers that be smiled upon me the next day.

we soon found ourselves in the paediatric ward. there was a girl of about eight years old that was going to be operated the next day. she was apparently born with a severe heart abnormality and had undergone some sort of procedure at birth that had enabled her to survive these last eight or so years. however she was now due to undergo a slightly more permanent operation that would hopefully get her through the next thirty or so years. thereafter she would apparently most likely die. the tragedy of it was already something that weighed heavily on me. it seemed so unfair. but when i saw her i was shaken.

she was blue, a colour i've never thought looks good in someone's face. she also passively sat there trying not to expend any unnecessary energy. i could see she was puffing to try to get enough oxygen. an eight year old is supposed to enjoy life, not struggle for every breath. my normal heart went out to her.

the sister called her to go with us to the procedure room, a room in most paediatric wards that the children fear because they know it is associated with pain. she, however just looked at us with a tired forlorn expression on her face. it seemed too much effort for her to be scared.

in those days we used to draw blood from children from the internal jugular vein (in the neck). i'm sure there are readers that will feel this is cruel but drawing blood from a child is cruel to start with. we were good at the jugular approach and at least we knew we would get it right with the first attempt which is a darn sight less cruel than multiple prolonged attempts from another site. we got to work. the other registrar was going to hold her in position and i was going top draw the blood.

he placed her on the bed and got her position right. she didn't resist at all. if anything, her body lay limply waiting for the inevitable. the registrar tilted her head to expose the neck and i readied the syringe. then i went for it. she went berserk. she started screaming and kicking like mad. the registrar held her down and the needle advanced. i concentrated on getting it right and that meant i had to get my mind off her experience of emotional trauma. when the blood started flowing freely into the syringe i relaxed a bit and listened to what she was screaming between her tears.

my tswana is not very good but it was good enough to understand what she was saying. the registrar holding her was also a tswana and she was speaking to him, not me.

"uncle, uncle, save me from the white man!" she cried over and over again. he quietly whispered in her ear that it was going to be alright, but she would not be consoled. i would not either. like all children she couldn't reason that, although what she was experiencing was unpleasant, we were doing it in her best interests. all she knew was that the white man was stabbing her in the neck with a needle and it traumatised her. it was the sort of thing that you don't easily forget. it was a significant moment for her.

the next day i was tasked with assisting with a few smaller cases while the prof, another consultant and the senior registrar attempted the fancy operation on the eight year old girl's heart. i wouldn't get to see how it went, which, to tell the truth at that time, suited me fine. however, as it turned out, the prof ended up walking up and down between the two theaters and giving us a sort of running commentary.

"how's it going?" asked the registrar operating with me.

"not great." replied the prof. and then he dropped one of his typical gems.

"eintlik is ons besig met een moerse fokken palliatiewe pooging langsaan" (we're actually busy with one massive f#cken palliative operation next door). he then gave his usual inappropriate giggle. i couldn't even manage a grimace.

that night i was on call. part of my job being on call in thoracics was to look after the thoracic icu patients. the girl was one of them and would be my responsibility. from the first moment things went badly. then they quickly got worse. i did all i could think to do, but as i looked at her small body lying there in the big icu bed with tubes sticking out of her all over i realised the odds were stacked against us. i phoned the prof to ask what else i needed to do and followed his advice. however just before he hung up he said that thereafter there was nothing more we could do. when he omitted his usual giggle i knew she would die.

a few hours later it was my duty to give the prof a courtesy call to tell him the girl had passed away. he simply said thanks that i had informed him. then i was left alone with my thoughts.

i thought of her looking at me the previous day with no more fight left in her tired body. i thought of the years she had had a semi-existence and had missed out on all the things that make life magical for children. i thought of whether she had had any significant moments that had put a smile on her face despite her circumstances. and then i thought about her last significant moment, the one that had traumatised her for the rest of her life, the one where the white man had driven a needle into her neck despite her vociferous supplications for him not to do it. we are supposed to make life better. we are supposed to enable people to go back into the world to enjoy the beauty and wonder of life. what we do is not an end in itself but a means to an end. the point is to have a better life and that i did not give her by any stretch of the imagination. i felt devastated, but i was alive to feel devastated. she would never feel again. i no longer wanted to go on with this painful profession. i could no longer hold back the tears. it was a significant moment in my life.

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