you've got to hand it to him

some students refused to listen to good practical advice. sometimes it hurt us all, but sometimes it was good for a laugh.

general surgeons have a reputation amongst doctors. they are viewed as crude, arrogant and even aggressive. this might be because they are often crude, arrogant and aggressive. but yet they are simple folk and can easily be pacified.

he was a private consultant. he was a typical surgeon but he was also a great teacher, if you could look past his rough mannerisms. he only came in one day a week and did a sort of a ward round. but in all reality it wasn't a ward round at all. he would ask us to show him some interesting patients and then he would teach us all about the condition of the first patient we showed him. he never addressed the patient. he never examined the patient. it was more coincidental that we would be standing next to the bed of a wide eyed patient while we listened to his tutorial. he taught us so much, including what a bedside manner should not be. he was also a great example of how not to present a patient to the professors.

"when you present a patient to doctor l," i would coach the students before the time, "do not go into all the detail!! he doesn't care. simply point at the patient and in a loud clear voice shout the diagnosis. then have a piece of paper and a pen ready. every word you hear after that is worth its weight in gold for your exams, so take notes." they all nodded, but i somehow knew they thought i was exaggerating.

the allotted time of the allotted day arrived and we all stood around waiting for the consultant. true to form he was exactly on time. he ignored the students as was his habit and only acknowledged me with an almost imperceptible nod of the head. i greeted him curtly and headed off in the direction of our first patient, which i had specifically chosen because i felt he had the condition the students most needed to brush up on.

we arrived at the patient and the consultant turned to the students. normal human interaction always seemed to be an effort for him. more looking at his own feet as anyone in particular he asked;

"right, whose patient is this?" the student stepped forward.

"mine!" he whimpered.

"well? what are you waiting for? present!" i had trained them well how to present to this consultant and yet i somehow knew what was going to happen.

"uhmm, the patient is a 25 year old black male..." the consultant lifted his head. his eyes were suddenly ablaze with what seemed like years of pent up frustration and anger. he cut the student short.

"do you think i am a blerrie idiot?? i can see the patient is male. i can see he is black. i can see he is about 25 years old! next thing you are going to tell me he is the third child in a broken home? i don't care about all of this. and if you even try to tell me he lives in a house with running water or no running water or whatever i think i'll kill you!! just tell me what is wrong with him!!!" i managed not to laugh, but as the student looked to me in supplication i confess a smile darted across my face. i had warned him. he shrugged his shoulders, pointed at the patient and in a clear voice shouted;

"alcoholic pancreatitis."

the consultant grumbled under his breath and extended his hand to the side, in the true fashion of a surgeon in theater. i was ready with the pen and slapped it sharply into his waiting hand. as if by magic, a sheet of paper appeared before the consultant. i remember thinking that they were at last listening to my practical advice.

thereafter the students (and patient if he was paying attention) got the best tutorial on alcoholic pancreatitis that they would ever be exposed to. i confess i didn't pay too much attention. i was otherwise occupied trying to suppress a laugh.

alone

this is not a medical post. it is also not a surgical post, except it describes an incident which had an influence on what i became later in life. i suppose it may have to do with the moulding of a surgeon.

in my post the best i touched on the fact that "once the knife goes through the skin you become suddenly very alone." it is a state you need to get used to and be comfortable with.

i was in a hostel when i was in high school. it was an old style hostel based on almost regimental rituals and punishments, often imposed by the older boys themselves. some may describe it as savage. others might say it had a military origin. still others will say it was just a bunch of boys being boys.

i was in form one. my boss (the matric whose shoes i shone and whose bed i made and whose laundry i took care of) lived in the matric dorm. the matric prefects were distributed through the other dorms. the non-prefects who were semi-decent were also distributed through the other dorms. only the dregs of our hostel matrics ended up in the matric dorm. it was not a good place for a form one skiv to have his boss live. the chances that you fell foul of one or more of the matric dorm matrics was high to say the least. on this particular day the matrics of the dreaded matric dorm decided they wanted to teach us, their skivs, a lesson. why, i don't remember. but the lesson was to take the form of kangaroo court. kangaroo court is basically when a group of boys beats the crap out of one single boy. i think a form of it is illustrated in the movie 'a few good men'.

the matrics told us to clean their dorm. we did. then they did an inspection. one took a white glove. i don't know where he got it so don't ask. he then ran his fingers along the top of the curtain pelmet. we had not cleaned that. it was pretty much the only thing we hadn't cleaned. it hadn't occurred to us to clean it. obviously there was dust on the glove. they then pronounced sentence. we were all to receive kangaroo court.

in queues to receive punishment in the hostel there was a form of auto sorting. the toughest guys ended up at the front. the more scared you were the further you moved back. i wanted to run away, but i ended up third in line. my two friends in front of me were what i considered the toughest hardest boys of my age i'd ever met. (interesting to note both boys ahead of me were expelled from the school years later).

so there i was, a scared fourteen year old boy who had only just left the protection of home, just about to be called in to be beaten up by about five eighteen year old guys. somehow i didn't believe it was happening. i somehow thought at the last minute it would stop. it didn't.

my first tough friend went in. we heard the punches and the matrics shouting and laughing. after a while he came out. he was crying. i remember thinking if they reduced him to tears then i was dead. the second one went in. this time i think i might have heard a muffled groan from the victim through the raucous laughter of the matrics. he was also in tears when he walked past me, his eyes downcast in shame. then it was my turn.

i walked in. one matric took two steps towards me and without a word threw his fist into my left thigh. the muscle spasmed. the leg would not obey my commands. they all seemed to be shouting at me and i wasn't sure what i was supposed to do. i remember my boss laughing at me. one of them told me to put my nose on the floor. for a moment i hesitated. it seemed a strange demand. their loud verbal tirade and the fact that one grabbed me and shoved my face into the ground made the demand more clear to me. i put my nose on the ground. someone stood on my head. i shifted my forehead to the ground. and then it happened.

at that moment with my forehead on the ground and someone's foot on my head with all those boys shouting and laughing i had an epiphany. i realised i was alone. there was no cavalry that was going to come in and save me at the last minute. the house master wasn't suddenly going to realise just then that this sort of thing was happening and put a stop to it. my boss wasn't going to stand up for me and defend me. no, i was truly alone and i would go through this no matter how scared i was or how i longed for it not to happen. that moment i changed. i never again expected help from someone else. i just expected to face what life threw at me, alone.

the rest of the kangaroo court is not all that relevant. i crawled into a ball to try to protect myself. they punched me in the ribs until i moved my arms over my ribs to expose my face and then they punched my face. these two scenarios alternated for some time. someone caned me and someone kicked my right thigh. but the humiliation of the foot on my head was somehow the worst of it all. when it was all over i was in tears, but there was something deeper that was cut.

i walked out of that room that day, also looking down ashamed of having cried. i was alone and somehow it suited me.

skewered

in surgical training there is bound to be bloodshed, but it is always difficult to handle when it is at the hands of your fellow surgeons.

i was in the last months of my training. i was not on call that night. then a friend of mine working at kalafong phoned me. he sounded desperate. when he sketched the situation i understood why. he had admitted a patient with rectal bleeding. the patient, however, was pouring massive amounts of blood in a constant stream from his anus and despite two large bore lines was rapidly becoming hemodynamically unstable. why doesn't he phone his consultant on call, i wanted to know. apparently he had. the consultant had made the telephonic diagnosis of an aortaenteric fistel (an opening between the largest artery in the body and the intestines causing massive bleeding and almost always fatal) and had told my friend to put him in a side ward and to leave him to die.
"but i just can't do that!" he said. "it's just not right." i understood. i told him to get the patient to theater and i'd join him there.

when i got there the patient was not doing well at all, despite a massive resus attempt. two large bore lines were running blood into him and a three lumen cvp was pumping fluid. the anesthetist also looked pale (i don't know what his hb was though).

although the probable source of bleeding would be the colon, i knew there was an outside chance that he could be bleeding from his stomach. (stomach bleeding usually comes out below as a black sticky diarrhea, but if the bleeding is so swift that there is no time for the stomach juices to change it it can still look like blood). i didn't want to waste any time once the abdomen was open, so i quickly stuck a gastroscope into his stomach. it was clean. i knew what the target organ was.

the anesthetist leaned over and said.
"if you're going to do something, you need to do it now. he is on intravenous adrenaline and only oxygen inhalation and anything more will kill him."
i got the message. we ripped the abdomen open. i clamped across the rectosigmoied junction and started clamping off the blood supply to the colon, starting distally and moving up. i reasoned that the most likely diagnosis was diverticular bleed although they seldom bled so impressively and diverticular disease is more common distally in the colon. it made sense at the time.

that was without a doubt the fastest bowel resection i've ever done, before or since. when i got to the mid transverse colon, minutes after starting, i opened the lumen. there was no more active bleeding. i handed over to my friend. i told him to pull out a colostomy and get the patient to icu.

on the way home, i felt elated. i had saved a life where it seemed there was no hope. it had been close, but we had pulled a miracle off, despite the fact that the consultant had washed his hands of the case by making a ridiculous diagnosis over the telephone.

the next day i couldn't wait for the morning meeting to bask in the glory of our night's work. the fact that the consultant who had essentially fobbed my friend off was sitting right behind me in the meeting made our escapades so much sweeter. sure enough as my friend started presenting i saw a smile of achievement cross his face as he spoke about the case. then everything went wrong.

what we didn't know is that the professor had written an article many years before about the operative approach to bleeding diverticular disease. it required segmental clamping of the colon and separately opening each segment until the bleeder was found. then only that segment was to be removed. the fact that our patient didn't have a discernible blood pressure at the time of the operation and was essentially too unstable even to receive anasthetics mattered little to him. the fact that we hadn't done it according to his prescribed method mattered a great deal. he then told us the patient would have survived if we had used his method. we pointed out that the patient was indeed alive. prof was on a roll and didn't want to be interrupted by bothersome facts.

as we say in afrikaans, teen die einde, kon die see ons nie skoon was nie. he just kept on ripping into us. the consultant sitting behind me at no stage mentioned that he had refused to come out to help. he just kept quiet and left us to be destroyed and humiliated for all to see. by the end i was actually smiling to myself. bloody typical, i thought. i was just worried about how my friend would take it.

anyway, the patient survived. my consultant who was not involved in the case later congratulated us on a job well done. he said a few other not so complimentary things about the professor that i think are better lost in the sands of time now, but made me feel a whole lot better at the time.

p.s that friend of mine not only dropped out of surgery but completely left medicine in favour of another life altogether. and he was a great surgeon.

ascaris

i know why i'm not a microbiologist. in one word, worms.

i was doing a gastroscopy. the patient had a previous gastroenterostomy (small bowel attached to the stomach) somewhere else for unknown reason. the result was, over and above the pyloris (the normal stomach outlet) which was normal, he had another stoma which had an afferent loop and an efferent loop of small bowel. i took a look at all three pipes leaving the stomach, intubating them one at a time.

in the efferent loop is where i saw them!! ascaris!! (see above picture to fully appreciate this little critter). they seemed pissed off that the patient was npo because they were writhing around and moving like mad. even worms get hungry. obviously every one gathered around to take a look. i think it has to do with the fascination of all that is gross.

i just wanted to run. i think i now understand that some people have a rather robust vaso vagal reaction to blood etc, because the same happens with me when confronted with worms.

one of the sisters suggested i take a biopsy. why i wondered. it's not as if i have any doubt as to what it is i'm looking at. anyway, can you imagine how the thing will go crazy if i start taking bites out of it. biopsy is just out of the question here.

i woke him up, gave him deworming treatment and sent him on his merry way.

tough surgeon

in the line of the previous post, there was another story that i thought quite funny at the time, illustrating us macho surgeons.

sigmoid volvulus. a wonderful condition which is very common in africa. not the type the textbooks talk about found in institutionalised old folk, but the type found in young black adult males. prevalence highest in uganda, decreasing as one moves south, but still pretty common in south africa. so in my registrarship, i became quite good at detorting the volvulus which is the emergency treatment in casualties. if this doesn't work or on sigmoidoscopy (siggy as we called it) if you see any questionable bowel, immediate laparotomy is performed.

anyway the patient came in and had a clear sigmoid volvulus on examination and x-rays. i got the siggy ready to detort and place a flatus tube. now, for the lay person, in this area of blocked colon, the feces has been rotting. yes rotten feces, the only thing to top regular or garden variety feces. the feces is also under extreme pressure, so as you insert the siggy, it deflates with vigor (explosively). many of my friends got showered with this rotten projectile fecal matter and often in their face when they detorted sigmoid volvulus on more than one occasion. i had evolved a way of doing it that decreased my chances of being the proverbial fan that was just about to get hit. yes, i think i was pretty good at it. in fact the picture above is me with my trusty siggy ready to detort a volvulus.

so, getting back to the story; i called the students to see the procedure, because this could be their only chance to see it. i set everything up and started the siggy, with an enterage of students, a house doctor and a rotating medical officer standing to observe. i got to the twist, observed to make sure there was no necrosis and started gently inserting the flatus tube. it slipped easily in. and as usual there was a sudden and massive release through the tube of rotten feces and particularly rancid flatus. i stood there trying to control my gag reflex. it would be considered an acute loss of cool if the tough surgeon was seen to be gaging at anything by his awe struck juniors (tongue in cheek for those who wonder). i just couldn't. i gagged over and over again. now i was struggeling to prevent myself from vomiting. despite this, my prominent thought was that the students would think i was a wimp.

then i looked up. every last one of them had bolted. not one had mannaged to overcome the stench to stay and watch. i laughed. all my ego driven worries about what they would think of me were in vain. obviously if a surgeon nearly gagged then mere mortals (tongue in cheek, flamers) like medical students and doctors would obviously not be able to be in the near vicinity of such a thing.

the patient did well, got his elective colectomy the next week and went on his merry way.