surgexperiences

once again surgexperiences will be hosted on my blog on the third of august. please get submissions in by the second of august. posts can be submitted here. also, for all those budding surgeons out there, anyone interested in hosting future editions of the only surgical blog carnival, contact the boss here.

the theme is that there is no theme, so if you have a post that fits the theme, send it immediately!!

family

my last post was about icu. while on the topic i couldn't help thinking about family and what that implies.

i was the icu guy. as usual, late at night, i got a message from theater that i needed to make a bed available for a gunshot wound patient. as usual, i pretty much had to stand on my head to do this. as usual, it was a criminal that took a bullet through some organ that he probably needed and nearly died. and as usual one of my surgical colleagues pulled him through.

he came in pretty messed up. he had lost a lot of blood and had gone into coagulopathy (the little bit of blood he had just didn't want to clot any more). then i heard his story.

my patient and three of his friends held up and old couple trying to eek out a living as real estate agents. it was late one afternoon when they found themselves faces by four gun wielding men. this is south africa so they immediately handed over everything they had. the criminals wanted more. they wanted blood. they took the old lady into a back room.

two things happened then. the man, left alone, had a chance to unlock his safe and get his own gun out. the criminals, meanwhile made the woman kneel down and as a sort of initiation type thing, one of them put a bullet through her. they then came out of the room, assumably to do the same to the old man. imagine their surprise when they walked into a blazing gun.

the first one he dropped dead on the spot. the second would become my patient after taking one through the liver. the third picked up an arm injury and got away. the fourth was not hit.

it was the usual story and i didn't think too much of it until the next morning.
the next morning, other than the usual police visitors, the patient's mother came in to see how he was. i have treated numerous criminals, but this was a first. i found it interesting so i decided to chat to her to find out where such a criminal comes from.

the first thing she told me is that she was a theater sister and worked night shift in a local hospital. this took me totally by surprise. firstly i wanted to believe that my patient came from a broken home or had some similar pathology in his past. but more importantly, a theater sister is like family to me. i have spent countless nights across an open abdomen with theater sisters. i couldn't help philosophizing about the fact that while i tried to save the lives of criminals through many nights with theater sisters at my side, was the system i worked in actually creating the criminals by making their mothers not available during their developmental years. such thought literally kept me awake at night.

then i got to hear my patient's story. he was an up and coming in some or other business. then he decided that there was either not enough money or not enough excitement in that venture. he and some friends went into the hijacking trade (good business in south africa). apparently this went well for some time. but soon they felt the need to upgrade. they decided the right business move would be to go into a bit of armed robbery. that's when the whole incident happened.

i spent some time in conversation with his mother. she was devastated. she never tried to excuse his choices. she just cried. one day she said that no one could tell what went through his mind the moment of the tragedy. she meant that maybe he repented from all his sins, so i didn't mention that what went through his friend's mind was a bullet. it seemed inappropriate at the time.

one day his brother visited. he was a lawyer, so i didn't speak to him. but i did find it interesting to see that my patient's career choice was not the result of opportunity.

this was not one of those stories with a happy ending. in the end, after some time and exorbitant expenses, the patient died. when he came in i felt nothing for him and, truth be told, his death is a good thing for south africa, but when he died i was shaken. you see, his mother was like family and he was definitely her family. i couldn't be as detached as all the rest of the icu staff.

captive

icu is icu is icu, but some icu stories could only happen in south africa.

i was doing my icu rotation. the work wasn't so tough but the hours were long and we did one in three calls, so it became a bit tedious. part of the job was shuffling patients to make space for the next critical patient coming in. bed occupation was always 100% or more (makeshift icu beds were often created in side wards). so late one night i get a call that they are operating some guy the cops winged in a shootout. apparently he lost quite a bit of blood and would come in intubated. great, i thought. probably a bad man and i needed to perform almost a miracle to create a bed for him.

sure enough, after transfering our most stable patient to another hospital, which required speaking to their superintendent, no small feat at night, i got a bed ready.
the patient arrived after a somewhat eventful surgery. he was intubated and needed ventilation, but was actually otherwise relatively stable. to keep him alive through the night should not be too difficult.

the next morning the patient wasn't only alive, but he was doing very well. he was still on a ventilator, but we expected to wean him in a day or two.

then two cops walked in carrying a ridiculous amount of heavy chains and shackles. they walked up to my patient and sort of dumped them on the bed with a loud clang. they then told me they were going to chain him down. you see, it seems, my patient was a known cop killer. he had chalked up quite a number of 'kills' and they weren't too keen on him getting away. my mind wandered to my student days when we once had an ethics discussion about chaining prisoners while they were in hospital. i had thought those morals sounded decidedly first world and didn't really have a place in south africa. but this patient/prisoner was different. he was intubated and couldn't escape for the simple reason that he couldn't breathe on his own. i explained this to his would be shacklers. the cops reluctantly left, taking their chains with them. they did leave the obligatory heavily armed guard at the door. i handed my patients over and went home.

next morning, when i got to work, one of the sisters greeted me at the door.
"did you hear what happened last night?" her eyes sparkled with the excitement of someone who has some hot gossip to spread. as it turned out, as the night went on and as our bad man patient gradually got stronger thoughts of escape dominated his mind. he knew he had a tube in his throat, but how was he to know that that tube was helping him to breathe? also, i assume, through the haze of the drugs he was getting, maybe his mind wouldn't have responded to logical arguments.

so at a stage, when there was less activity, he took his chances. he jumped out of bed and ran for the door. the endotracheal tube was ripped out as was the urinary catheter. he apparently almost made it to the above mentioned door before he collapsed in a heap. everyone, including the heavily armed cop at the door had to help to get him back into bed. he was then reintubated and his blue colour soon gave way to a more healthy looking pink.

i listened in disbelief, but, i confess, with a smile. as soon as i heard the story i walked to the police outside icu and demanded they chain the patient with everything they had. they complied.

p.s in retrospect i often wondered if it was the lack of the endotracheal tube that brought the patient to a heap on the floor or the urinary catherer being ripped out with the balloon still inflated.

pointless

i've put off posting about a patient i once had in paediatric surgery because my writing could never justify how i really felt about him, but i suppose i should at least try.

when i rotated through paediatric surgery, there was a memorable patient. let's call him k. when i knew him he was 2, but his story started long before that.

k was one of a set of twins. for whatever reason his mother favoured the other one. this means she lavished what she could on his brother. what she could lavish was nothing more than food. k became very malnourished. around roughly their first birthday the mother decided she was tired of k, but how do you get rid of a baby? she decided to poison him. she gave this poor malnourished child something to eat that was supposed to kill him.

i still don't know for sure what she gave him, but it was amazingly corrosive because it burned his epiglottis almost completely away, it destroyed the opening to his trachea and it essentially destroyed his esophagus. he had a tracheostomy through which he breathed, a gastrostomy through which he was given food and because he couldn't swallow, there was a constant stream of drool running over his lower lip. he also could only mannage a strange low pitched moan if he tried to make a noise.

when i worked there, he had been in hospitals for a full year. he was a delightful child. i started work every day by giving him a hug. i figured love was something he hadn't seen too much of in his short life and it was something i could do for him. he seemed to enjoy it.

then one day, while we were in the morning meeting, we got a call that little k was dying. we rushed down. in the ward we found that he was blue and had stopped breathing. my senior colleague ran up to him, ripped out his tracheostomy tube that was blocked and quickly inserted a new one. he quickly recovered. i did not.

such a simple problem like a blocked trache tube had almost meant his death and that in an academic hospital. what chance did he have for the future? i considered adopting him then, but after much thought decided that if i wanted to adopt every child that i met in my profession that had a raw deal in life i'd have to start an orphanage and drop aspirations of becoming a surgeon.

time went by as it tends to do and my time in paediatric surgery came to an end. i saw k a number of times because i often went to his ward to give him a hug if i had a moment. then one day when i got there i heard he had been sent back to his referring hospital. he was supposed to follow up again in one year for a more definitive surgical repair.

about a year later i asked the senior colleague who had saved his life when i was working there what happened to little k. without batting an eye he calmly told me he was dead. his trache tube had blocked in his referral hospital. there was no one there who knew what to do and he suffocated. that was the end of k. the colleague went on to say that it was probably better because his life was doomed to be miserable etcetcetc. i just felt sick.

to this day i can't forget little k. i still wonder about the permutations if i had adopted him.

boere

i love history. i am fascinated by where we come from and its influence on who we are today.

from 1899 to 1902 two small boer republics held off the onslaught of what then was the local world power, britain. they had no standing army. they were basically a group of farmers fighting for their freedom. but they could ride and they could shoot. these days most of their descendants live in cities and have lost most of the skills of their forefathers.

last week i went hunting with one that hadn't lost this connection with his past. he was brought up on the back of a horse and his father had taught him to place a bullet exactly where it needed to go from very young. to top it off, he lent me his 100 year old mauser, the same make of weapon that the boers had used in that war against the british so many years ago.

yes i love history and i enjoyed the connection i felt to my great grandfather who took up the same make weapon i had strung over my shoulder when he was called on to resist the might of the british nation.

south african crime

i recently watched the movie capote. i enjoyed it. but, being south african, i was interested in the reaction the movie portrayed of the american community to the murders that the movie is indirectly about. their reaction was shock and dismay. their reaction was right.

but in south africa there is a similar incident every day. i don't read the newspaper because it depresses me too much. you might wonder why i, a surgeon, am posting on this. one reason may be because i often deal with the survivors (two previous posts found here and here). at the moment i have three patients who are victims of violent crime. one is the victim of a farm attack. an old man who had his head caved in with a spade. why? just for fun, it seems. but maybe the reason i'm writing this post is because i'm south african. this is my country and i'm gatvol.

just three recent stories. some guys broke into a house. they gaged the man. it seemed that whatever they shoved into his mouth was shoved in too deep, because as they lay on the bed violating his wife, he fought for breath and finally died of asphyxiation.
then there is a woman alone at home. some thugs broke in and asked where the safe was. they were looking for guns. she told them she had no safe and no guns. they then took a poker, heated it to red hot and proceeded to torture her with it so that she would tell them what they wanted to hear. because she could not, the torture went on for a number of hours.
then there is the story of a group of thugs that broke in to a house. they shot the man and cut the fingers of the woman off with a pair of garden shears. while the man lay on the floor dying, the criminals took some time off to lounge on the bed eating some snacks they had found in the fridge and watch a bit of television.

these are only three stories, but, if you do read the papers, you can hear about similar stories on a daily basis. and our great and mighty president, the eminently blind thabo mbeki, believes there is no problem with crime here.

yes, you americans were right to be horrified by the story upon which capote is based. we south africans, through the leadership of possibly the worst leader of a country in the world today, well we just get used to it.

gee thanks

i've often blogged about the tendency in our training to be left on your own (here, here and here to name at least a few), but some of the stories have a funny twist.

i was in my medical officer year. in those days there was a general shortage of registrars so the boss used us to fill the gaps. he put myself and another medical officer in charge of a firm, reasoning two medical officers add up to one registrar.

being two, we decided to split the call. and i was the guy who got the night. so when i came in i tracked my friend down. he was in theater doing an appendisectomy. i asked him if he had anything to hand over to me.
"sure. there are just two appendixes to be done."
"straightforward or any catches?"
"no catches, just appendicectomies"
the first one went well. i used it to show the house doctor how to do an appendisectomy, so that she could do the second one.

at this point i'd like to point out that i was very junior. i did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it.

she did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out. i calmly told her it looked like the appendix was going to be pretty sick. and then she found it.

it was normal. my heart sank. there was clearly something else wrong with the patient. i remained silent and told the house doctor to go on with the operation. my mind was racing. most probable diagnosis was perforation of a peptic ulcer. i calmly asked if there were any x-rays with the patient file. there were and they were put up on the x-ray board which was behind the house doctor and therefore in my direct line of vision. there on the x-rays for all to see was free air under the diaphragm, a clear sign of peptic ulcer perforation.

shit! i thought, but stayed silent. i knew i would need to take over. only problem is i'd never done the necessary operation before (omentopexy). i had seen it once before as a medical student about three years beforehand. it was definitely in the class of operation where you would make enemies if you called the consultant in. it was meant to be in the armamentarium of a registrar and, according to the boss, i was at least half a registrar.

the house doctor swiveled her head around to take a look at the x-rays.
"shit!" she said out loud.
"don't worry," i lied. "that's why i'm here. you have no responsibility here. i'll take over now."
"shit!shit!shit!shit" she replied. i don't think she imagined her first appendisectomy to go quite like this.

for an omentopexy, the first thing that needs to happen is a midline incision, rather than the usual mcburney incision for an appendix. the patient would have two cuts. oh well, can't be helped now. i told the house doctor to swap places with me.
"shit!shit!shit!shit!" she said in acknowledgment to my request and moved around the table. i confess i laughed a bit at her total loss of vocabulary, but it was a nervous strained laugh. i felt that i needed to reassure her that i had the situation under control. she did not need to know that i had only seen the procedure once before and that a number of years ago.

"don't worry," i said, "that's why i'm here to back you up. you are not in charge here. you have no responsibility."
"shit!" she said with what i assume was a forced smile behind her mask.

i got to work. soon i had the hole nicely exposed and the abdomen cleaned out. all i had to do was plug the hole with omentum, place drains and close. only problem is although i theoretically knew what to do and even how to do it, i had no idea what suturing material to use. this was a dilemma. i knew i couldn't really phone for backup for an operation i was supposed to be able to do late at night. but more importantly i didn't want the house doctor to feel any more insecure about the situation than she already did. if i told her that i was unsure of what i was doing i was pretty sure i would get another string of her most recent favourite word and maybe turn her off surgery forever. the situation seemed to be traumatic enough for her without me adding to it with trivial facts about it being pretty traumatic for me too. i decided what to do.

as casually and as nonchalant as possible i turned to the sister.
"sister, when the other guys do an omentopexy, what suturing material do they use?" so clever, i thought. i would find out what to use without causing any further stress to the fragile house doctor and without looking too stupid myself.
"oh," she answered, "they use whatever they want."

gee thanks. i thought. well that didn't work. even in the acute phase i could appreciate the humour of the situation though. i might even have laughed, more at myself and my situation than anything else. the sister had no idea that i was in what at that stage was deep water for me.
so i asked for vicryl and did the necessary. the patient did well.

next morning, on ward rounds with the prof, i took the blame on myself. i did not mention that my colleague had misdiagnosed because, in the end, i should not have gone into the operation without double checking everything myself, so, i reasoned the blame did in fact lie with me. i also neglected to mention that the house doctor had done the initial appendisectomy. she was never in the firing line. despite all this, just for good measure, my colleague who had assured me that it was just a simple appendix, covered his own ass and informed the prof that he had told me he suspected perforation and reminded me to check the x-ray. nice to have friends like that, i thought, but i just apologized for missing it and moved on.