you can't win them all

the myth of the glory of war is perpetuated in part due to the fact that the stories are only told by survivors. if the guy that took one through the neck in no man's land in world war one and then slowly faded away in a mess of saliva mixed with blood, lying in his own stools, crying for his mother were to tell his story from beyond the grave it wouldn't look so glorious at all. it would maybe be a better reflection, though, of the reality of it. in a certain sense we run the risk of glossing over medicine too. i would hope this blog does not.

i am extremely affected by the patient calling out to me to save him in strained monosyllabic speech at the last moment of his life. it is almost too much to bear. and yet i am the survivor. i walk away to live another day or to tell the story or to enjoy a sunrise in the african bush.

i remember him well. he was a kidney failure patient who was leading a fairly normal life thanks to the wonder of peritoneal dialysis. he was the breadwinner for an extended family even. and then he got the call.

there was a kidney available. i was even involved in procuring the kidney (this is always a sad and poignant story in itself. it is the coming together of life and death, of hope and despair) . the relevant tests were done and this specific patient was found to be the best match. quite soon he was in the hospital going through the needed preoperative preparations. after the usual administrative delays that are so particular to south african state medicine we even actually got him to theater and without too much fanfare soon had the new kidney in and peeing like there was no tomorrow. everything was going so well i almost thought it was too good to be true.

after theater he did well for about three days before things turned. initially it was just a decrease in the amount of urine the kidney was producing but soon it was so much more than that. without going into too much detail, the patient developed systemic inflammatory response syndrome (sirs). this put pressure on his new kidney which started faltering. he developed water retention which put strain on the lungs which were already under pressure from the sirs that he had. after that things started spiralling downwards.

we had long given up on the kidney and put the patient back on dialysis, but nothing seemed to make the situation better. then two days before my rotation in the transplant firm ended the patient collapsed in the ward. i happened to be there and commenced a full resus.

i remember clearly the terror i felt at the prospect of the patient dying. his heart wasn't supposed to have stopped! he was supposed to do well. i felt terrible! but with a bit of good luck i brought him back from the brink of death and delivered him to icu with a tube down his gullet and highly dependant on inotropic support (his heart was dependant on drugs to maintain a barely survivable blood pressure). his kidney had long since ceased to function and we dialysed him constantly at a low rate to try to not put more strain on his borderline heart. then i was rotated to the icu unit, so in essence i followed my patient there.

his sirs just got worse and soon he developed a coagulopathy (the normal clotting mechanisms in the blood stopped working) and was soon bleeding from every orifice. we gave him what we could for that but the fine balance between not giving too much fluid yet giving the needed clotting factors and the balance between dialysis and the heart that was on the verge of giving up altogether was very difficult to manage.

the last night i remember too well. i often wish i could forget. i was on call that night in icu, so it was up to me to get him through to the morning. he had been bleeding from the mouth and nose a bit all day. his blood pressure hovered just above the unacceptable level. his lungs were full of fluid and the ventilation was tricky to say the least. but as the night progressed things got worse. the first thing was the bleeding. quite soon blood was oozing from everywhere. he even had a trickle of blood running down his cheeks like bloody tears from both his eyes. and as he bled his blood pressure started falling. he became too unstable to dialyse so that was stopped. the inotropes were increased to industrial doses but that did little. i became desperate. i phoned the transplant consultant.

after i had verbalised all the parameters to the consultant over the phone it was like i had told them to myself. i knew what the consultant was going to say. if i were him i would say the same thing. the situation was beyond repair. the patient was going to die and nothing we could do would change this fact.

"he is going to die, bongi. you can't win them all."

i knew he was right. i hung the phone up and just sat for a while. i thought of the fact that this man, the sole breadwinner of his family, had walked into the hospital with hopes of a better life without dialysis and would be leaving on a cold morgue slate. it just seemed so unfair, so wrong. had we killed him? i didn't know but at the time i felt we had. my consultant had advised me to stop active treatment and see if i could get some sleep. i stopped active treatment but i refused to sleep. it just seemed to me that i was supposed to at least be with him to the end even if that was all that i was going to do.

i sat in the patient's cubicle and waited, like him, for the end. when it came it was horrible. blood was now streaming out everywhere. his breathing tube was bubbling with the pink frothy liquid seen in pulmonary edema and the ventilator strained against the pressures needed. the colour slowly seeped out of his face giving him the countenance of death before the fact. and then slowly his life force left him.

i turned off the ventilator and all the infusions and left. but even then sleep and the peace that could possibly come from it eluded me. to be honest i did not have that peace for some time thereafter.

surgical principle number 1: to swear does in fact help

don't get me wrong, i don't swear at people (except when they really deserve it). but sometimes in that critical moment in an operation it does tend to dissipate some of the tension if you let off a bit of steam. i first realised this as a medical officer working in the transplant firm.

it was late at night. we had just procured a kidney and had our recipient all prepped for theater. the only problem was we were having trouble finding someone to do the actual transplant. the guy whose name was on the call list for transplants, a private surgeon who had a session post, flatly refused. in the end i had to call the prof.

the head of the transplant unit was the best prof in the department. he was a gentleman( unusual for a surgeon). he always taught the students on rounds with patience and respect. he was an all round nice guy. but he did suffer from a fairly severe form of theater rage (somewhat like road rage but experienced behind the knife rather than behind the wheel). when i called him, despite not being impressed that he had to step into the breech left by the private surgeon, he immediately came out. and so we got to work just after midnight with a tired and somewhat cranky prof.

the mobilization went well but i could see the prof becoming more irritable with every passing minute. even the anastomoses went acceptably well. however the prof started showing signs that his blood nicotine levels were dropping. most of us also believed the prof and his prostate no longer had an amicable relationship, which meant that he did not enjoy long operations. by the time he got to the reimplantation of the ureter into the bladder he had been reduced to a tired irritable old man with a bladder of his own that was no longer going to stand for it. up to that moment, being junior and working with the best prof, i had been nervous that i would do something wrong. but with the laws of nature and old age conspiring against the poor man his hands became progressively more unsure. each movement needed to be repeated a number of times before it was done. this delay further infuriated his bladder which in turn put pressure on the prof to work faster. the faster he tried to work, the slower he got. the true gentleman that he was, he never swore at anyone in the theater (except himself, now that i think about it). but he did swear and quite a bit. ironically i started to relax. behind my mask i actually found myself laughing. i mean what else can you do when the prof starts addressing the patient's bladder (possibly in proxy for his own bladder whom he felt a certain loyalty to and couldn't directly swear at) as a separate troublesome person with sentences like.
"f#@k you bladder!" and
"you're not going to f#@k us around any more, you bastard!"
sometimes i must admit i did wonder which bladder he was speaking to, especially when just after letting the patient's bladder know who is boss the next few stitches would be disasterous and would need to be done all over again. maybe at least his bladder was no longer f#@king us around.

and thus i learned that a well timed harsh word can actually lighten the mood, if only sometimes for the assistant.

yes i swear during surgery, but not ever at anyone and actually never in anger. it is just a sort of valve to deal with what can sometimes be a loaded situation.

harvest

organ transplant is a noble and wonderful endeavour. however before the transplant comes the harvest.

one experience that will stick with me for many a year (ever), which scored very high on my weird sh!tometer, happened when i was a very junior registrar.
she was about 16 years old. except for the massive head trauma there was nothing wrong with her. in fact when i became involved, the neurosergeons had already declared her brain dead. the transplant coordinators had done the ground work with her parents, getting consent to harvest the organs. (i never envied their job. can you imagine having to get consent as fast as possible when the people you need consent from have just had their world turned upside down? sort of 'sorry about your loss but can we have her kidneys?') all we had to do was operate to get the kidneys. we had to time it in conjunction with the heart transplant team which was flying up from cape town (the only place where the state still does heart transplants. why, you ask? i don't know).

as soon as we heard they had landed we started the operation. we got the kidneys as close as we could to out without compromising the heart. instead of waiting, we opened the chest so the thorax team would have less to do when they arrived. then we waited.

the thorax surgeon finally arrived. he walked in, glanced into the open thorax, glibly said in an almost inaudible voice, "too small." and walked out. we were left wondering if we had heard right. he had just flown 1500km (a whole bunch of miles) only to turn around and fly back with nothing. i couldn't help thinking he could at least have said hello to us. but i think that may have been beneath him. (looking back it seems a strange thought to have)

the surgeon then quickly carried out the final steps to remove the kidneys.

meanwhile, the transplant coordinator immediately told us to take the heart anyway because the valves could be harvested even if the heart itself was too small. my senior volunteered me. i was young and keen. she assured me it was easy. just cut the large vessels off as far away from the heart as possible so as not to dammage the valves. sounded easy enough.

the surgeon left. the anaesthetic machine was turned off, creating an eerie quiet instead of the reassuring beeping noise of the monitors. i could still see the heart beating though. it seemed wrong to cut it out, but i grabbed the scissors and went to work.

moments later, the heart was loose. it's not too difficult to remove a heart when the outcome is predetermined. i lifted it out. then the weird set in. the heart was young and strong. while i held it in my hand it was still beating. two things went through my head simultaneously. the first was a flashback to the movie raiders of the lost ark when the priest ripps the heart out of his victim for him to see just before he dies.

the second was much more intense. there i stood with a human heart, still beating in my hand. yes my head knew she was brain dead and had been so for some time. but somehow my emotions (i was going to say heart, but...) didn't seem to be agreeing with my head. i felt awful. up until then it had all been business. get the organs and get a good night's sleep. somehow after standing with that girl's heart beating in my hand i felt for her. i felt for her parents. i felt the tragedy of the whole situation. i was touched.

i passed the heart to the transplant coordinator. she left. i was now alone with the shell of the dead girl in theater. my job was to close what we had opened. but because she was dead, there was no anaesthetist and no sister. just me and my thoughts of intimacy with this poor girl who i did not know. i cried as i placed the stitches.

i did not get that good night's sleep.