awkward

recently i attended the association of south african surgeons congress. it's always strange and maybe fun for me to interact with surgeons. they are extremely interesting to me. i feel that i'm a bit of an outsider in the sense that i don't view myself as a typical surgeon, so i can sit back and observe, fooling myself that they are not looking at me in exactly the same way.

but one thing about these congresses is that you get to see and rub shoulders with the heavyweights of the profession. it took me back many years to another congress that i attended when i was still a mere mortal registrar and truly was not yet one of them.

the congress in question was in durban. at that stage i pretty much kept away from all the big names. it seemed the safer thing to do. however, one of my fellow registrars and a good friend of mine was quite friendly with the vascular prof, a greater than life man and a true legend in his own time in south africa. in fact my friend went on to specialize in vascular and is now himself a well known vascular surgeon in one of the big centers. so when my friend invited me to the vascular dinner the one night, i should have just said no. i didn't.

the vascular dinner, as i was to discover, was a fairly exclusive affair. it was sponsored by one of the companies that supplied prosthetic grafts, mainly used for the repair of abdominal aorta aneurysms. all the big names were there, including our massive prof and the vascular prof from wits, who at the time was also head of the department of surgery there as well as the president of the vascular society of south africa. in fact the only two non entities were myself and my friend. bearing in mind the entire vascular fraternity knew my friend would one day be one of them, in all reality, i was the single individual there who deserved and got sideways glances. my usual tactic of keeping my head down wasn't going to work; it stuck out like a blushing throbbing aneurysm and there was little i could do about it.

the function was advertised as a dinner on a boat that was supposed to cruise around the durban harbour, all very fancy. but, as it turned out, the weather was a bit too bad and the owner of the boat, which was a bit more like a large raft, all fitted out with tables and chairs and, of course, a bar, decided it wouldn't be safe to take the entire vascular complement of the country on a cruise where the boat had a good chance of sinking and rendering vascular surgeons in our country even more scarce than they already were. i was fine with this. besides the chance of dying, i felt it might be a bit awkward stuck with such eminent beings far from shore and no place to hide. but the sponsors of the event felt let down. they wanted to show off a bit i think and a boat safely anchored in the harbour just wasn't going to cut it. they felt they needed to make a plan, so a plan they made.

after the snacks and a fair amount of dutch courage had been consumed the plan became apparent. suddenly next to our safely moored raft appeared the biggest baddest speed boat i had ever seen. it looked like the type of thing you see on national geographic deep sea fishing specials. i wondered if we would limit ourselves to just the harbour cruise or would we venture into the big blue.

quite soon all the big names had made their way onto the boat. i, being the most junior person there, waited until last to see if there was enough space. as it turned out, it was a very big boat and there was plenty of space, so, somewhat reluctantly i followed my friend aboard. there were three areas where the vascular passengers could sit. one was the main area downstairs which was full. the next was the front portion of the boat which was fulling up quickly and seemed like not the greatest place to sit, just in case we did venture beyond the protection of the harbour. the third was a fairly quaint upstairs area. it seemed like the only real option. my friend and i climbed the ladder.

the upstairs area was the smallest of the three areas and was not yet totally crammed with vascular academia, but there was a reason for this. you see when the profs had gone aboard, they had all gone upstairs. the mere mortals, not wanting to seem forward, had decided to rather remain below. my friend and i didn't know this because we had waited until the last moment before we came aboard so when we got to the upstairs area, i was quite perturbed to see all the great profs sitting there. it was too late to go back down. for one thing, there was no space downstairs and for another all the eyes of all these great and intimidating men were staring at us as if we had just walked in on an awkward conversation. there was nothing for it but to stay there. i immediately decided i would stand as far away from everyone as possible. if there was a corner there i was determined to find it.

the president of the south african vascular society and great and mighty head of the department of surgery at our neighboring university, and more than likely someone i would be meeting soon in my final exams, looked at me and, gently tapping the seat next to him, spake he.

"come sit here next to me." he said with a wry smile.

" no thank you, prof, i'm fine here." i replied. he seemed persistent. again, almost stroking the seat next to him, he repeated his invitation.

"ag, come on, bongi, come sit here next to me." occasionally in life, you are presented with a situation where you really can say the wrong thing, and at the last minute, better judgement prevails. that day it seems i had no judgement at all. the words just seemed to roll out of my mouth, which I confess, stayed open in absolute shock at what had just escaped.

"no thank you prof, i'm not that type of boy."

the vascular prof from our university at least got a good laugh out of it.

die taal

dit moes 'n misverstand gewees het, ek weet nie. watookal dit was het dit 'n slegte smaak in my mond gelos.


toe die nuwe regering oorgeneem het het hulle stelselmatig ontslaegeraak van alles wat hulle geassosieer het met die ou regering. een van die dinge wat moes waai was afrikaans. volgens hulle was dit blykbaar sleg vir een of ander rede. ek het nie saamgestem nie. so toe ons afrikaanse prof druk op ons uitgeoefen het om net engels te gebruik by alle amptelike vergaderings het ek hom min of meet geignoreer. ek onthou 'n saalrondte 'n maand of twee daarna.

ek was die senior kliniese assistent in die prof se firma. volgens sy nuwe beleid het hy net engels op die rondte gepraat. tussen die pasiente, as hy net met my gepraat het het hy wel afrikaans gepraat. dit was natuurlik sy moedertaal. ek het al sy engelse vrae in afrikaans geantwoord en al die pasiente in afrikaans voorgedra. hoe meer hy probeer het om vir my die boodskap oor te dra dat ek engels moes praat hoe meer het ek volgehou om afrikaans te praat. by omtrend die derde pasient kon hy homself nie meer inhou nie.

"bongi, speak english. why do you refuse to speak english on rounds?"

"prof, my english is perfect. i don't have any reason to practise it." het ek in engels geantwoord.

hy was kwaad, maar hy het dit redelik goed weggesteek.

'n maand of wat daarna was ons almal by een van ons m&m bespreekings. die was 'n gesamentlike m&m met die vaskulere departement. die prof van vaskuler het ook sterk gevoel oor die taal beleid, maar sy gevoel was presies die teenoorgestelde van die prof s'n. hy het gevoel ons moet aangaan om afrikaans te praat in die universiteit, want engels was klaar so dominant in die land as 'n mens nie moeite gedoen het om afrikaans as 'n taal wat op 'n tersiere vlak goed kon funksioneer op daardie vlak te hou nie, sou dit vinnig agteruitgaan. ek het met hom saamgestem. baie van die afrikaans spreekende studente het klaar gesukkel om pasiente in afrikaans voor te dra, self as hulle aan 'n afrikaanssprekende dokter voorgedra het. hulle het medisyne in engels geleer en kon nie mediese afrikaans praat nie.

die m&m het voortgegaan. toe dit die beurt van die vaskulere kliniese assistent was om sy pasient voor te dra het hy in engels begin. onmiddelik het die vaskulere prof iets op 'n stukkie papier geskryf en dit vir sy kliniese assistent gegee. die kliniese assistent het dit gelees en onmiddelik in afrikaans oorgeslaan. dit was nie nodig om einstein te wees om te weet wat op daardie stukkie papier gestaan het nie. sy prof het duidelik vir hom opdrag gegee om afrikaans te praat en hy het wel so gemaak. die res van die vaskulere gedeelte van die m&m het min of meer gegaan soos my saalrondtes met die prof. die prof het al sy vrae in engels gevra en die vaskulere kliniese assistent en prof het albei alles in afrikaans geantwoord. dit was vir my nogal komieklik. na die m&m het ek maar aangegaan met my lewe.

omtrend 'n uur later het die vaskulere kliniese assistent vir my gebel.

"bongi, daar is groot kak in die land," het hy gese. "die prof het my vaskulere prof ingeroep en ordentlik in sy broek gekak oor die feit dat mense in sy departement weier om net engels te praat by enige bespreking of saalrondte. hy het drie kliniese assistente uitgesonder. dis ek en jy en dr b (ek het al van hom geskryf). natuurlik het my prof vir ons al drie opgekom en toe ek uitgejaag is was hulle amper op die punt om mekaar te lyf te gaan. hoe dit ookal sy dis blykbaar ons drie wat die prof se woede gaan voel. hy het self gese dat as ons volhou om te weier om engels te praat gaan hy bedank as hoof van die departement."

ek kon dit nie glo nie. in een opsig het ek amper trots gevoel dat ek so 'n invloed gehad het oor die prof dat hy 'n persoonlike beroepsbesluit sou maak gebaseer op my doen en late. maar eintlik was dit nooit my plan om soveel aandag van die grootkoppe te lok nie. daardie tiepe aandag was nooit 'n goeie ding nie.

"hy kan seker bedank as hy wil." het ek vir my mede beskuldigde gese, maar toe onthou ek wie in sy plek sou oorneem. ons prof het sy probleme, maar tog was hy beter as die moontlike alternatief. moontlik was die beste ding om maar engels te begin praat.

die volgende week by die m&m was ek 'n bietjie verbaas om te sien dat my vriend en kollega, dr b sy gevalle in afrikaans voorgedra het. dit was weer die geval van die prof wat sy vrae in engels gestel het en my vriend wat alles in afrikaans geantwoord het. tog as dit die prof geirriteer het, het hy dit goed weggesteek.

onmiddelik na die bespreking het ek met my vriend gaan praat.

"b, is jy mal?" vra ek toe. "na verlede week se storie, hoekom weier jy om engels te praat." hy het effens geglimlag toe hy geantwoord het.

"ek weet nie wat die prof se fokken probleem is nie. voor verlede week het ek nooit afrikaans gepraat by al die amptelike besprekings nie. ek het wel engels gepraat. en tog is ek een van die ouens wat in die kak beland het. wel, nou het ek klaar die straf gekry omdat ek afrikaans gepraat het al het ek dit nie eintlik gedoen nie. omdat die straf klaar uitgedeel is moet ek dit darem die moeite werd maak. daarvoor se ek nou vir jou, ek sal nooit weer engels in hierdie plek praat nie!"

en volgens my kennis het hy nie.

doing nothing

surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. i remember one time that this turned out to be slightly humorous in a morbid sort of way.

i was in my vascular rotation which was not too much fun (except for a short moment). generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. and there was pretty much nothing worse than an abdominal aorta aneurysm (aaa). scratch that. a bleeding aaa was a lot worse than an aaa. so when casualties called and said they had a bleeding aaa my heart sank.

the patient was pale and clammy and his heart was racing. but the thing that struck me the most was his age. the man was 89 years old. the casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. so, in summary we had a man just this side of ninety with comorbidities and a condition that was know to kill most of its victims thirty years younger than him. the chances of him surviving the operation were dismal. i called my senior.

my senior (the vascular fellow) examined the patient and went through his file. like me he concluded that an operation would push him over the cliff whose edge he was standing next to. in consultation with the patient's son, the decision was made to make the patient comfortable and leave him to the inevitable. i confess i had the thought that at least i'd get to sleep, but i also knew the sort of sleep one gets while waiting for death to take one of your patients is a broken and rocky sleep.

the next morning i arrived for my rounds. i hoped the patient was dead but when i walked past his son just outside the ward i knew i would find him alive in the ward. after a patient dies the family always seem to flee the hospital. the stress of the night was etched into the face of the son. i could tell his night had been worse than mine.

sure enough when i entered the ward, there was the old man lying in bed just where i had left him the night before. it seemed the pain medication was working though. he wasn't quite as restless as the day before. i walked into his room. i didn't bother checking his vitals. what would be the point? he looked up at me. i was surprised to see he was doing so well. i remember hoping the fellow hadn't told the family it would be all over by the morning because the old man seemed to be set on proving him wrong. the one problem with him still being alive was that i'd have to take over the role as the intermediate with the family. the fellow would make himself scarce now that the initial footwork had been done.

i greeted the old man.

"môre oom." i said. he looked at me.

"môre neef" he replied, using a greeting that had gone out of circulation many years before i was even born. i smiled. he seemed quite spritely for someone in his position. but his next statement really gave me a chuckle.

"neef, is it true that you are not going to operate?"

"yes it is true, oom." i replied.

"well then if you are not going to operate why don't you send me home? there are things i need to do on the farm you know." how could one not admire that sort of attitude? i smiled broadly.

he took another day and a half to die. it was tough on his son, but i suspect he sucked the marrow out of every one of his last moments of life.

reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.

vascular cuts

anyone who knows me knows i hate vascular surgery. it is hard work with little reward. scratch that. when you actually get i nice pulsating distal artery the next day you almost think the night's hour upon hour of work may be almost worthwhile... almost. but all too often vascular operations were one small step along the road to disaster.

i suppose one of the reasons i dislike vascular so much has to do with my exposure to vascular during my registrarship. we had a very good department and there was always a vascular fellow who was not only interested in vascular but competed actively to do as many operations as possible. this meant us mere registrars didn't do too many worthwhile cases. we assisted and we did the grunt work in the wards. vascular was also amazingly busy and very demanding. these things all conspired together to leave in me an enduring dislike for the discipline.

i also don't think i was the only one who felt this way. most of us disliked and even dreaded our vascular rotation. that didn't mean we couldn't have the occasional laugh at some of the things that went on. for instance we used to have a saying about the femoro-popliteal bypass operation (to place a bypass from the femoral artery in the groin to the popliteal artery just below the knee.) you see this is generally done on people that have been smoking their whole lives as a last ditch effort to prevent amputation. the patients were usually wreaks. the smoking didn't just destroy that single artery but it destroyed all the arteries to a greater or lesser degree. at best the bypass would improve the blood supply, but not always sufficiently. all too often after hour upon hour of tedious labour, the leg would remain threatened and often an amputation would be carried out a day or two down the line. we jokingly referred to these patients as fem-pop, fem-flop, fem-chop patients. the fellow tended to get a bit annoyed about this. he took his fem pops very seriously and any suggestion that it was a small step towards the inevitable below knee amputation was met with open hostility from him. we knew not to say this in front of him.

but the one time i remember not being able to hold back my laugh even as the fellow's face became red with rage and his knuckles turned white as he grasped his dissection scissors deserves mention.

we were doing a fem-pop bypass. now part of this operation is to remove the superficial vein in the leg (the saphenous magna) and to use it as the bypass for the artery. the result is that it is necessary to make a long meandering incision from the groin all the way down to below the knee. so although the artery is only exposed where the proximal anastomosis and distal anastomosis are made, the incision runs for the entire length of the bypass. the fellow was delving into the groin looking for the artery while i dissected out the vein. there was the usual theater small talk. then one of the junior general surgery consultants trotted in. he immediately saw what operation we were busy with (there are not exactly many operations that require this length of a cut down the leg). i think i might have seen an evil grin on his face. he turned to the fellow.

"hi. my but that's a big incision just for a below knee amputation." i fell about laughing.

eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'

sucker

as a registrar i made sure there was no one in my firm who worked harder than me. i would arrive early and leave late and would generally see everyone myself, not leaving it to the house doctor or students. that way when they complained about how hard you had to work in surgery i could justifiably tell them to suck it up and get on with the job. i say generally because there was one glaring and even shocking exception to this rule.

the vascular rotation was the busiest, bar none. there were two of us in the firm so we ended up on call every second night and the calls could get quite tough. one single vascular emergency could destroy your circadian rhythm. yet if there was only one we would boast about the three hours sleep we had managed to get. in that time we considered that more rest than we knew what to do with. the other problem was we had no house doctor so our days tended to get quite busy with all the administrative tasks that were needed to get things running smoothly. so after being there for a few months my enthusiasm for long hours had somewhat diminished.

then suddenly there was an extra house doctor in the department and in a moment of weakness the boss allocated him to vascular (he would often rather put two house doctors in his own firm than send one to vascular). we were ecstatic, especially after the first day when it became obvious the guy was not afraid of work and he also clearly knew what he was doing. we had been given a gem. on his second day on the job he asked us about how the calls worked and what his after hours duties would be. i was just about to tell him that his calls were going to be quite light because we handled pretty much everything, but my colleague spoke first.

"well, you are the only house doctor, so you'll have to handle all the stuff primarily and call us if there is a problem or if someone needs to go to theater." it was so clearly a joke i thought at any moment one of them was going to start laughing. then we would send him home to his new wife and we would continue to slave through the night. but they both nodded. the house doctor seemed to accept this as simply one of the hardships associated with where he had been allocated in surgery. it was my colleague's call that night so once the day's activities had ended i made my way home.

the next morning my colleague told me he had had a great call. the amazingly competent house doctor had handled everything and he had spent the night at home. i was intrigued. i wondered what it was like to spend a vascular call at home. i decided not to tell the house doctor yet that the story of him being on call every night was just ridiculous and let him do another call. the next day he would probably complain so much we would have to inform him that it was just a joke and then life would settle back into its usual rhythm.

my call was wonderful. unlike my colleague i did come out to operate, but all the other peripheral irritations were completely handled by the house doctor. the guy was good. and still he hadn't complained. i spent post call in theater and went home well after the sun had set. i didn't see the house doctor that day and just assumed he was also at home. yet the next morning i discovered he had done another call and once again my colleague had spent the night at home. i started wondering how much of this the house doctor could take. it was clear he was tough, but the question was how tough was he.

and so we sort of never really told him that it had been a bit of a joke and he just kept on working, day and night and night and day. i think we also fell into the luxury of not doing the hard yards during a call and we got used to it. also we knew he was only going to be with us for three weeks and then we would be alone again so i suppose we saw it as a rest in the eye of the storm before the reality of vascular returned in full force.

after nearly two weeks of being on call every single night the house doctor started to hint that he might need a break. they were just hints so we did what any normal male does with hints. we ignored them and hoped they would go away. they didn't. after another few nights he told us he needed to speak to us about the call situation. by this time he was looking a bit worse for wear. who could blame him? he had done a solid two weeks of call on the trot and that in vascular. that was enough to break most people, but he seemed to be at least partially alive still. we agreed to discuss it.

the house doctor explained that he had done more than his fair share and had in fact done much more than the other house doctors in surgery who were doing about one call a week. he went on to say that it wasn't that he was lazy but he just needed a break. he also told us that he was fairly recently married and although his wife was understanding there was only so much a young wife could take of this sort of lifestyle. he told us that he needed to give some attention to his marriage too and couldn't just work constantly. we knew he had a point. he had proven himself beyond our wildest expectations and he did need a break. also secretly we knew that we had expected him to do far more than what was actually required of him. he was well within his rights. we had to relent.

we gave him one night off and told him to be back at work the next day, ready for another weeks call.

fasciotomy

being south african these days sometimes means we see things in a slightly skewed way. it seems to be the way we have become. i have touched on this before, but there is another story which illustrates the point.

the recent run of hijackings were fresh in all our minds because the perpetrators had shot and killed, execution style, a mother and her three year old child just the previous week. there were reports that one specific gang was working the area and were responsible for most if not all the hijackings and associated killings in the area. so when our patient came in, even before the police told us so, we just assumed he was one of this gang.

the story was the police had intercepted this guy just after he had relieved a car owner of his mode of transport. he was good enough not to kill the victim this time around which was nice. however, not being the law abiding type, he had driven off in haste with the police hot on his tail. according to the police he fired first. whatever the truth was, bullets were moving liberally in both directions between our man and the law as they flew through the streets of pretoria in a westerly direction. unfortunately for the hijacker he had chosen the toll route and was forced to stop at the toll gate just outside kalafong hospital. he jumped out and opened fire on the cops in the now multiple cars pursuing him. they shot back. they hit him four times. they gave me real reason for concern about the aim of our police force. the only wound which was anything more than a flesh wound was the shot to his left brachial artery (the main artery in the upper arm).

ironically, the patient had comitted his initial crime in the drainage area of pretoria academic hospital, a place with a dedicated vascular unit, but had fled into the drainage area of kalafong hospital that had no vascular service at all. i thought this would have been divine justice, but, alas, his proximity to kalafong at the time of the shooting along with the fact that his shooters, the police, immediately transported him to the nearest hospital ensured that he had prompt help. the fact that my friend and colleague on call that night just happened to have a knack with vascular surgery also swung the odds heavily in the favour of our patient. obviously my views about karma were once again confirmed.

and so the next day when we went on rounds the patient was actually doing quite well. he sat up, looking at us as we stood around his bed to discuss his case. his ordeal had done nothing to his smooth mouth and arrogant attitude. in fact, the only sign of his life saving and arm saving operation in the dead of night was the large fasciotomy running along the length of his forearm (essentially a long open wound along the length of his forearm) and the police escort that lazily sat next to his bed.

my friend, the guy who had essentially saved the patient's life and limb, felt the pulse. i thought he would be proud of its strong beat, but there was something else on his mind.

"the police of today don't know how to shoot!" he said. "they shoot kak!" i think this was aimed at whoever wanted to listen. but the next statement was specifically for the patient. he turned to the patient and continued.

"i, however don't shoot that badly. if you come near me or mine, be warned i'll kill you on the spot. my bullet won't just take out some artery. i'll hit you in your heart and you won't see another sunrise. just to let you know." i'm not even sure the patient knew this was the very person who had given up his night's rest to meticulously repair the artery and thereby save the patient's life. i don't think he was the type to care, actually.

two days later, before the fasciotomy could be closed, the patient escaped from the hospital while his police escort lay lazily around. i reflected that all we could really hope for was that his open wounds would turn septic and he would succumb to systemic sepsis. we all knew he was too bad a man for that to happen.

byeboer

my good blog friend ramona suggested i do a post about my other interest, beekeeping. one story immediately sprung to mind which sort of connects to surgery.

i was in my vascular rotation. it was busy. we did 15 calls a month and the days were really full. yet, somehow, in my off time, i made extra money by removing wild beehives from people's houses. naturally most of this work was done after hours, when the sun had set. this is the best time to work with the somewhat aggressive african bee so it suited me fine.

then one monday the theater list ended up being cut short due to a lack of icu beds (a common problem in our neck of the woods). this gave me a few hours off that afternoon before i had to be back for the m&m meeting (morbidity and mortality meeting). it seemed ideal to quickly remove a hive i had on my to do list. that way i would actually be able to have an early night. but i would have to rush.

i charged home, bundled my equipment into the car and drove to the house which happened to be in one of the outlying suburbs of pretoria. only when i got there did i realise i didn't have my smoker with me. not too bright, i thought to myself. but at least i could check out the hive and come back later, more prepared. it was too far to go back home, come back and do the job before the m&m meeting.

i introduced myself to the owner. immediately her Rottweiler started...well, hounding me. i'm nervous about rottweilers on a good day and the fact that the owner informed me they only get aggressive after two years of age didn't help (she was also kind enough to tell me he was two years old). she left him to his own devices which included jumping up on me and nipping my heels. i should have left then. i didn't.

the hive was in a hole in the wall in the garden. the opening was flush with the ground and therefore very difficult to access, especially because when i bent down the dog would jump onto my back. it was not a hive that i would be able to recover. that meant it was going to be an extermination job. armed with this new information i decided the smoker wouldn't be necessary seeing that i was going to kill them anyway. i had my poison (a tablet that, once lit, gives off clouds of billowing poisonous smoke. the idea is to light one, throw it into the hive and try to block up the entrance.) and at the time i thought that would be enough. looking back, i was foolish. i was not fully prepared (i didn't have my smoker), i was rushed (i needed to get back in time for the m&m meeting) and the dog was making sure that my mind was not on the task at hand. the fact that the owner did nothing about her dog was also a source of intense irritation to me. i should have left then. i didn't.

i asked the lady for a spade to access the hive more easily and suited up. i approached the hive with the dog still all over me and started digging. it was at that moment that i became acutely aware of how effective smoking bees is. these bees that hadn't been smoked immediately came pouring out of the hive in an almost solid mass and attacked as only african bees can.

two things happened simultaneously. one caused me great personal delight and the other caused me great personal consternation. the first was that the bees did not only attack me, but they also attacked the dam dog. i heard him yelping in pain from multiple stings as he finally left me alone and ran for cover. the second is i came to the shocking realization that, due to being rushed and harassed i had not pulled the zippers around my ankles down. there were two circles of exposed skin at this level. the problem was with my gloves on i could no longer pull them down. to remove a glove would be catastrophic. i had no choice. i had to proceed.

without going into too much detail, i finally got the smoking tablet into the hive and closed the entrance. most of the bees were probably out at that stage, trying to kill me, so i'm not too sure how many i actually killed. the queen and all the brood would be dead so the hive would not survive. my work was done. however i had sustained so many stings on my exposed ankles that, although i'm not allergic, the shear volume of poison that my body had taken was making me a bit dizzy. i needn't elaborate on the level of pain that that many stings causes, but it is enough that you tend to notice it.

the owner paid me by pushing the money under the door. clever move. besides i was feeling so light headed i thought i might pass out and look really stupid. i already felt that this was not the most professional job i had ever done. to collapse on her doorstep would not be a good idea. then i finally left.

i drove to the nearest chemist where i bought celestamine, an antihistamine steroid combination. to be honest i was considering buying adrenaline but decided against it. then i rushed back to work, charged into the m&m meeting and collapsed into my chair. moments later i was presenting my cases for the week with a throbbing headache, slightly blurred vision, a ringing in my ears and excruciating pain around both my ankles. relatively speaking the m&m went very well.

i'm on my way

some lessons are learned the hard way. and it's no easier if you are thrown out to the wolves.

i was in vascular, arguably the toughest rotation. i was doing 15 calls a month, most with little or no sleep. i was not having fun. so i was delighted when the powers that be (the general surgery prof and the vascular prof) made the decision that all stabwonds of the neck must be referred to the general surgeon on call first. if he made the assessment that it was a vascular problem then he would call the vascular surgeon. this would decrease the number of unnecessary referrals and slightly decrease our workload.

so on a particular night when the casualty officer called me in the early hours for a stabbed neck, my first question was whether she had already spoken to the general surgeon. she informed me he was already there to see another patient and she would ask him to evaluate the guy. i told her that if he felt it was vascular then he should call me and i'd be there like a flash. i rolled over and returned to my stupor. strangely enough i wasn't called again that night.

in the morning my pager went off. it was the casualty officer again. her first sentence sent shivers down my spine.
"while you were sleeping nicely let me tell you what has been happening here!"
this could not be good.

as it turned out the general surgeon (a rotating belgian registrar) had felt it was indeed vascular, but the casualty officer told him i had refused to come out. in desperation he had phoned the thorax surgeon who also refused to come out. he then did a chest x-ray which showed apical capping. with this new information he phoned the thorax guy again and after some threatening demanded that he come to take a look.

when the thorax surgeon got there the patient was apparently not doing too well. he dove into the neck with the belgian assisting him right there in casualties. apparently the ensuing bloodbath could only be contained with a few blind clamps onto the source of the bleed which just happened to be the subclavian artery. as we say in afrikaans, ek ken kak en ek ken pudding en hierdie is nie pudding nie (this is not good). i rushed there as fast as i could, adrenals pumping.

the general surgeon was still there. he looked rattled but glad to see me. i told him i would take it from there and he could go to the morning meeting with the prof. i asked him to excuse me from that same meeting which the vascular team was also required to attend.

i organized theater (with the obligatory blood and products ordered) and without too much delay my consultant and i started the operation. the operation, as vascular operations tend to do, took hours. some time that afternoon we delivered a severely compromised patient to icu.

i walked out of theater worn out from both the effort and the adrenaline. i ran into a friend. he asked me how it went.
"not good!" i replied.
"you'd better hope he doesn't die!" he told me. he then went on to warn me that the general surgeon had told the prof that he had phoned me personally and i had blankly refused to come out, thereby leaving him with a problem he was not equipped to deal with. the prof was apparently furious. he had already dictated a letter to the thorax department, complaining about the lax behaviour of their registrar and had decided to take me to task at the next m&m (morbidity and mortality meeting). if the patient died the depth of the sh!t i would be in would be considerably deeper.

i lived in fear waiting for the m&m meeting. i had images of my career coming to an abrupt end. sure enough, as if on cue, the patient died the day before the meeting. suffice to say the meeting did not go well. however, with me being present, the belgian did not repeat that i had refused to come out to see the patient. i survived.

from that day on, if i get called, even if i think it is not an appropriate referral, among the things i say on the phone, i always end the call with the words;
"i'm on my way!"