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.

i am not special

just when you get a lift life tends to slap you in the face again.

the state hospital was supposed to get a surgeon. all indications were that he was supposed to start on the first of the month. the medical officers booked elective cases for him to do with excitement and anticipation. the first of the month came and the first of the month went, but no surgeon turned up. the poor medical officers now had the nasty problem of having a whole bunch of people needing operations with no one to operate them. they phoned me.

i could not do all the operations. not even close. but i told them that i would try to make myself available on tuesday afternoons. they just needed to book the most critical cases and i would do them. they organised a typical state thyroid for the first tuesday. (not quite as bad as all that but still bad)

the monday before i was on call. a pretty hectic gunshot wound came in late that night. at the same time an appendix patient also arrived. i called the anaesthetist out and we got to work on the gunshot guy. a splenectomy, distal pancreatectomy, nefrectomy and liver repair later we delivered him to icu in a surprising good state. (there was not only a great deal of blood on the part of the patient but also a goodly amount of sweat and tears on the part of all of us). we finished at about three o'clock in the morning. everyone was tired and irritable. then i suggested we do the appendix. truth be told, i was laughed at.

i considered my position. it was reasonable to postpone to the morning when i would be at least slightly rested. there would be a smaller chance of cutting something i should rather not cut. but i knew i had a full day in the rooms with consultations and scopes. thereafter i was supposed to go to the state hospital. if i left the appendix for daytime, it would clash with that appointment in all likelihood. so i simply refused to take no for an answer. i pretty much insisted that we do it there and then. all concerned finally succumbed and the appendix was removed some time after three o clock in the morning.

after a deep two hours sleep my day began in all earnest. i spent the morning in consultation and doing gastroscopies and colonoscopies. i only just finished to rush off to the state hospital to be there at two pm as had been arranged.

when i entered theater, the anaesthetist casually told me they had a child who had a foreign body stuck in the esophagus that they were going to do before my case. i was annoyed, but i knew that in state hospitals you must learn to go with the flow. otherwise constant frustration will kill you or drive you to drink.

sure enough they put the little kid to sleep and for expediency i took the thing out myself. still the anaesthetic and the usual state delay had lost us a full hour.

finally the thyroid was doped and we got under way. true to form they had booked me a monster. it was the sort of thyroid that was so big you feel you need to take it out as fast as possible because it's bullying all the other thyroids in the ward. to be honest i struggled. it was all the way up to the skull, all the way down behind the sternum and around the back to behind the esophagus. it was stressful surgery. i was trying to get it out of that neck but i swear it was trying to pull me in to devour me.

during all this, the sister who was obviously annoyed at the slow pace of the operation started berating the medical officer for starting a case that wouldn't finish before four, the time in the state hospital when all elective cases are supposed to stop. i piped in that an emergency case had been pushed in before us and therefore they owed us another hour so we were therefore still within time constraints. she looked at me.
"these rules are for everyone. you are not special!" and just to make sure there was no misunderstanding, she repeated,
"you are not special!"

i joked about it at the time saying my mother had always told me i am, but i could feel irritation welling up. i needed to finish the task at hand so i took my mind off the comment and returned it to the thyroid which i think had just tried to bite me.

when i got home, fairly tired from work and lack of sleep and put together the entire sequence of events, including me depriving myself of sleep in order to be able to go and help at the state hospital, i became angry. it had nothing to do with if i thought i was special, but rather to do with what other options that patient had of being operated. the answer is simply none. if i didn't do it there was no one else who was going to step in and do it. then despite pretty much standing on my head in order to be available and still getting knocked back an hour on the list the sister tells me i'm not special because she has to stand 20 minutes longer than she was expecting to. i became mad with rage. i considered phoning the super and telling him to stuff his hospital and theater staff and that i was no longer willing to help.

then i thought of all the doctors there trying their best beyond their abilities to at least provide some service. slowly the rage dissipated. then the anger subsided. then i slept.

interesting thyroid

not the greatest picture, but i took it with my cell phone. massive thyroids seem to be the order of the day. this lady's supposed "asthma" got so bad they had to intubate her. on the ct note the retrosternal mass totally displacing the trachea and esophagus. note the aorta arch as well as the superior vena cava.

i'm thinking sternotomy, but i'm open to suggestions.

two heads are better than one?

this is a patient i have at the moment. i plan on operating as soon as the consultant anaesthetist sees his way clear to dope her. this is not too unusual in south africa. it shows a tendency to wait a long time before seeking help. this next photo will show something that south african doctors will immediately recognise, but may need a note to explain to our international audience. roughly in the middle of the mass are two small parallell scars. these are markings made by a sangoma. they are meant to be therapeutic. as you can see they were not. i have already posted about that (here and here) so i will not labour the point any more.

but, if there is any sage advice from surgeons out there for when i do attack this lady with my blade, i'm open to any suggestions. after all, two heads are better than one (except of course in the case above)