mobilization

like most surgeons i can't overemphasize the importance of mobilization after an operation. it is good on so many levels. the lungs enjoy it. the vascular system enjoys it. the bowels sure do enjoy it.

ironically smokers mobilize quickly. it seems after an operation the only thing on their mind is that first drag. unfortunately you must make it to the balcony to get that payoff. no amount of pain will get in the way of a fully fledged nicotine addiction. there are less common motivations to mobilize in south africa.

it was a normal call. then very late that evening my pager went off. it was mamelodi hospital. as usual they were phoning about a gunshot would. actually there were two but they were exactly the same. both were through the right iliac fossa area and both turned out to be caecum injuries. the only difference was that one was in a 25 year old male and the other was in a 23 year old female. fortunately both patients were stable so i decided to operate the female first. the male just had to wait for his turn. both operations were identical and both went without any problems and the call proceeded as calls tend to do.

the next morning on my early morning rounds, as could be expected, both patients were still groggy from the previous night's anaesthetic. i was groggy for different reasons. other than that both seemed as well as could be expected.

however, about an hour later, on the academic round with the prof, both patients were missing from their beds. i remember thinking that the cases were truly identical in all respects. i also remember the prof's questioning eyes looking at me, wondering if my story was indeed true seeing that both patients were nowhere to be found and therefore could not substantiate what i said.

after the rounds my curiosity got the better of me. i went looking for my missing patients. they weren't smokers so they weren't on the balcony where i looked first. but i soon found them tucked away in a corner together holding hands and whispering sweet nothings to each other. it was about then that i decided to ask how they got shot. being amazingly astute as i am i had already figured out that they knew each other. there story went like this.

they were a young couple deeply in love. for some reason that i can only attribute to the madness that seems to overtake the lovestruck they decided to go for a stroll together in mamelodi that evening. during this stroll they got stopped by a gun toting thug that seemed to be in need of a cell phone. the male, trying to avoid confrontation, gave his cell phone up without any arguement. apparently he also threw his wallet into the deal. the thug took both and then with precision aiming, just for good measure, he put a bullet through both of them, exactly in the same place.

so it seems that is not just smoking that motivates patients to mobilize early after major surgery. two lovers getting shot together seems to have the same effect.

old school

sometimes old school surgeons are interesting to watch. one of my 'mentors' was a real study. he came across as hard and even cruel. and yet there was no one who truly cared for his patients as much as this man. you had to know him quite well to be aware of the fact that he cared so much. he usually hid it well.

the patient had stomach outlet obstruction due to benign stricture. the consultant in question decided that a dilatation would be a better option for the patient as he could therefore avoid an operation with all its associated morbidities. he told me to get it done.

the gastro unit at that hospital was not fully functional so it came as no surprise to me that they said they didn't have the necessary equipment to dilate a pylorus. i knew my consultant was not the type of guy to let trivialities like lack of equipment get in the way of what he perceived as a good idea so i phoned the parent hospital.

the gastro unit at the parent hospital assured me they had the necessary dilatation balloon but unfortunately it was broken at the time. i could see my consultant going mad at this news so i insisted they tell me exactly when they would have everything working properly. they told me to phone back in two days time.

on the rounds i had to break this news to the consultant. he was not happy. he wanted to take this ineptitude to the highest court in the land. he wanted someone to fix it now. it took me quite a lot of convincing to calm him down, telling him that the gastro unit would be able to help us in two days time. finally he relaxed.

when i phoned the gastro unit again, as could be expected, they still were not able to help. once again i asked when we could expect satisfaction and once again i was told to call back in two days time. this i knew would not go down well with my consultant. i decided to attempt another tactic in the delivery of this information.

my basic plan was to express as much or more dismay and indignation at the pathetic gastro unit than my consultant. thereby his attack wouldn't be focused on me but he would rather see me as a fellow crusader for all things good.
"can you believe it, doctor!" i almost shouted, "and i suppose when i phone again in two days time they are going to tell me to phone back in another two days!" i could see the frustration on his face. his plan to save the patient the morbidity of a laparotomy was not working out. now because i had come out in agression against the evils of the gastro department he couldn't even take his rage out on me. after all, i was now on his side. i went for the master stroke.
"maybe we should just operate him and be done with. otherwise we're going to wait forever in two day increments until the patient wastes away from malnutrition!" i piped up.

it seemed to hit a nerve. he started pacing. i could see his mind working, looking for release for all its pent up rage at the broken system. despite his best efforts the patient was going to get operated and there was nothing he could do about it. and he couldn't even take it out on me. finally he snapped. he charged towards the patient and shouted:-

"ons gaan jou oop sny van bo tot onder en ons gaan jou slukderm vasmaak aan jou kakderm sodat as jy ietsie eet sal jy dit onmiddelik net so uitkak!" (a paraphrase is roughly, 'we're going to open you fairly widely and do a bypass that will cause a noticeable decrease in transit time') i confess i laughed, but not in front of the patient.

fortunately, just like most of my readers the patient didn't understand afrikaans.

collateral damage

i'm not a war doctor. well not in the truest sense of the word. but sometimes i think there are similarities between whatever it is i am and a war doctor. i'm not talking about the fact that i have operated more gunshot wounds than i can count because of the amazingly high crime rate in our country, although that is probably part of it, but i'm talking about being first hand witness to collateral damage.

when the new government came to power they decreed that no state doctor could do private work. bearing in mind almost all state hospitals were run by private doctors, in one fell swoop they got rid of almost all their senior doctors. they realized their mistake, but it was too late. those doctors did not return. the next plan was to import doctors from cuba. but having doctors from a somewhat less than free country working in an essentially free one was wrought with problems. their numbers gradually decreased as they defected. the next plan was to introduce a community service year after the intern year. they then had enough doctors but they were always junior. this is pretty much the way it has stayed up until now. then there was a change in the training of doctors. it seems that the powers that be felt that it shouldn't be so difficult. some pretty dodgey doctors were created.

the problem with having your hospitals manned by junior doctors is that they tend to be junior. junior doctors are quite often not so clued up. experience may be lacking. and this brings me to a story by way of explanation. unfortunately this is not an unusual story.

there is a physician (internist) who does a session in the state hospital in a smallish town some distance away. one day when he was there they asked him to evaluate an x-ray of a patient they said had heart failure. they had made the diagnosis largely due to laboured breathing which they attributed to pulmonary edema. they had been treating her for three days to no effect. he took one look at the x-ray and was dismayed to see free air under the diaphragm (this pretty much implied that the actual diagnosis was a perforated peptic ulcer). the physician was shocked. he told them to send the patient to some place where she could be operated.

i was doing a gunshot wound in our local state hospital as a good war doctor should when i heard the patient was on the way. i knew it would take some time, so after finishing i shot off to the private hospital to quickly do another case. after that they phoned me back to the state hospital to oversee another gunshot abdomen. while there i was informed that the patient had in fact arrived but promptly died. i suppose three days with a perforation and fluid restriction (which is part of the management of heart failure but not too good for perforation) were just too much for her to handle.

one thing i have realized is i can't change the world, much less do much about the government's policies of death and destruction. all i can do is the best where i am. just like in a war there will be people who die, people who have nothing to do with the corridors of power, because of the decisions of their leaders. it is also not really the fault of the poorly equipped (intellectually) junior doctors in these small towns. they are simply the results of political blundering. so yes in many ways i am a war doctor. sometimes that is the only way i can deal with some of the things i see.

aaargh

some time ago i wrote a story about clothes (or the lack of them) we wear in theater. it was a strange post, stranger still because it was true and reflected something a bit too common in state hospitals in south africa. it is also one of my better posts (i think anyway). this is in the same vein.

i was called to the state hospital. it was a gunshot wound through the liver. the patient had been transferred from another hospital and had therefore missed the so called golden hour. he wasn't feeling too spritely. my main problem, however (excluding the pringle maneuver and putting hemostatic sutures in the liver of course) was to find something to wear on my head. finally i found a discarded theater cap and, being in somewhat of a hurry, i donned it.

as these things often go, i ended up packing the liver with the idea of taking the patient back to theater once his metabolic acidosis and coagulopathy had been reversed in icu (damage control surgery). and this is what i did.

the next day, when i arrived in theater for the relook lapatoromy, once again there where no theater caps, but, seeing that it was now in the middle of the day rather than in the middle of the night, i simply went to the sister in charge and asked for headgear. there was none. none in the change rooms, none in the stores, none in the hospital at all.

well i was not willing to operate without headgear, so i found myself a piece of cloth, tore it into a square and fashioned a pirate style bandanna. with this appropriately placed upon my head, i scrubbed and did the operation. i swear i heard at least one wise ass howl;
"aaargh!"

swimmer's chest

the following story isn't really mine, but because the meeting of the two protagonists happened in my presence during an event that i've previously posted about and because it touches on a very relevant south african topic, i thought i would pen it down.

when i was in my training, a very good friend and i had the privilege of treating a pregnant woman with a gunshot abdomen (take a look at the incident here). when we took her back a private consultant who was associated with our firm offered to join us in theater. but he was no ordinary private surgeon. he was one of only a few hepatopancreatobiliary surgeons in town and a particularly good one at that. truth be told, the reason he offered to join us had to do with the fact that i initially thought that the hepatic artery proper had been shot off. as it turned out the artery in question was an aberrant left hepatic artery and didn't count for much so his presence was not needed, but that is beside the point.

the consultant had never met my junior colleague who was a bit late for theater that day because he needed to sort something out in the wards. when he joined us we had just opened.
"sorry i'm late" he said "i just had to sort something out in the wards."
"doctor 'consultant' this is my colleague and friend doctor b." i said by way of introduction.
"are you a swimmer?" asked the consultant. there was a moment of silence.
"no." answered my friend, somewhat surprised.
"you look like a swimmer. you have a swimmer's chest." at this my friend looked down at his own chest concealed by his theater gown as if to see what a swimmer's chest looks like. even in the presence of this prestigious surgeon and, it seems, swimmer enthusiast, i laughed out loud. from that moment on i always referred to him as the swimmer's chest.

time passed. it seems to do that quite well. then in true south african form, the consultant's family was the victim of violent crime. his house was targeted. his daughter and wife were held at gunpoint as the place was cleaned out. by south african standards it went quite well. nobody was shot and nobody was raped. but by standards of humanity it was too much. it helped him with the decision to leave these shores. thus south africa lost a great surgeon.

before he left he gave the swimmer's chest a call. basically he handed his very successful and lucrative practice over to him, lock, stock and barrel. what a gift. what a privilege to just fall into such a tub of butter, rear end first. what an extraordinary result of the ridiculously high level of crime in this beloved country.

aggression

on a recent post greg p made the comment "this is a strange system of teaching over there. all stick, no carrot." this is true. those who have followed my blog will see that i don't have too many fond memories of my training. truth be told, most of us became punch drunk and developed certain survival tactics. most of these i look back on with regret. but at the time it was the way of things.

we could do very little when we took beatings from our own seniors (except resign which quite a few did) but when attacked by other departments often all that pent up fury would come pouring out.

i was in the boss' firm. i was the most senior registrar in the final phase of training. it was our call day which was also our clinic day. fortunately i had an orthopod rotating with me so we divided to be able to handle everything. i did the clinic and he handled casualties, only phoning me every now and then for advice. at a stage he phoned about two patients. one had obstructive jaundice. the other clinically had cholecystitis. i told him to organize a sonar for both of them and continued wading through the patients in the clinic.

at about four in the afternoon my phone rang for about the ten thousandth time that day. however this one was unique.
"hello." my standard answer.
"who are you?" the voice said. interesting question. i considered asking him who he was looking for, but, being on call i thought i'd better be polite.
"it's dr bongi speaking. how can i help?"
"what are you?" ok, i thought. at least now i know i'm dealing with someone looking for a fight. polite is no longer needed.
"what are you?" i retorted. he let rip.
"i am a registrar in radiology and i want to know why you've sent two patients now for sonar!" his apparent complaint was that the sonars hadn't been organized with him and had apparently just turned up. the house doctor, on the instruction of the rotating orthopod had written my name on the request form. the fact that he didn't recognize my name told me that he was very junior. the fact that he decided to pick a fight with a surgeon told me that he was a fool. i considered going to sonar and sorting him out but decided i wanted to make sure my team had done nothing wrong before thumping someone unnecessarily. also to take a bit of time would allow me to calm down to a rage and maybe react with more circumspection.

by the time i had spoken to my team and ascertained that the fault did not lie with us (the house doctor had phoned sonar and organized the sonars with the head. she had left before relaying this information to her junior) he had gone home. later that night i stopped by radiology and chatted to the call guy. i had a good relationship with almost all of them. i relayed my story, asking who this aggressive guy was. they only knew there was a new registrar in the department who had only started that month. i decided to confront him the next day.

the next day, after the post call rounds, i went to sonar and asked to see him. the head heard i was there and came to me. the guy i was looking for was conveniently not there. i discussed the incident with the head of sonar, ending the conversation with two statements. this sort of thing was not acceptable and i would be expecting an apology from him. no apology came.

not too long thereafter i was on call again. we sent a patient to scan. when the scan came back i called my students around to teach them how to read a ct scan. after going through the ct, one student told me i had missed some free air in the abdomen.
"rubbish!" i said. "there is no free air in this abdomen." he then presented the radiology report which clearly stated there was free air in the abdomen. i was amazed. i went through the scan carefully but i just couldn't see what the report said was there. then i read the name of the radiologist. it was my friend from sonar. i smiled.

i phoned the radiology department and asked to speak to him. i introduced myself and then told him that i had a query about his report. i asked him to explain it to me in person. he invited me down to radiology. i said that i required him to come up to the surgeon's tea room. he said he'd be there in a half an hour.

when he arrived i had an x-ray viewing box set up. all my students were still with me to watch the show. when the radiologist came in i showed him his report and asked him to show me the air. when he showed me what he thought was the free air i admit i felt a bit sorry for him. he was clearly so junior he couldn't read a scan properly. without saying a word i pointed out on the scan why that was not free air and could easily be identified as lung in the thorax by simply following it out onto other images. he apologized for the mistake. still i said nothing. he owed me an apology for something else still. the students were snickering in the background at the fact that a surgeon read a ct better than a radiologist. he looked sheepish and left.

when i look back i'm not proud of my behaviour. and this is probably not the best first post dealing with the constant fights we had with other departments. but the actual point of this post has to do with our general frame of mind in those days. unfortunately it was not good and we were not the most loved people in the hospital.

surgexperiences 203

welcome to another edition of surgexperiences!!!

surgexperiences is a fortnightly carnival of surgically related posts in the blogosphere. so without further ado, let's see what's to be seen out there.

t gives an absolutely brilliant piece about the effect of the inevitable on the treating doctors.
We do feel it in the O.R., even after years in practice. A sad diagnosis cuts a wide swathe. Even with the patient anesthetized on the table, totally unaware of our presence and our sympathy, we express our pain and our care, in awkward murmurs and pregnant pauses. The dye seeps into our stories as well; the fringes touch and mingle. We are changed.
t also gives us a more light hearted look at the 'scrubs' we wear.

little karen brings back to mind the horror that is necrotising faciitis. as always well written.

frankie explains the differences between an internist and a surgeon. it is clear that frankie leans more towards the surgical side of the spectrum. otherwise he would have done the comparison in table form.

half md throws a life raft for students about to rotate through surgery. i must say i loved this post. it reminded me so much of what i like to refer to the bad old days. unfortunately it's mostly true.

someonetc hopefully brings balance to the view of training with a post about calm and assertive leadership. for others interested in training, this blog is a good place to stop most days.

from the other side of the blood brain barrier the sandman gives what i view as a must read. it addresses a frustration that us surgeons sometimes have to face. but it also illustrates that the fear of consequence (litigation???) may be eroding the quality of care rendered.

dr penna talks about molecular orthopaedics. who would have thunk? on a sister blog, doctor penna talks about direct observation of procedural skills in surgery.

thus spake zuska writes a post giving the personal perspective of what her doctor probably viewed as just another quick procedure. nice to be reminded that there is really no such thing as just another quick procedure.

one of my all time favorite bloggers, dr bates, gives us a taste of medical history. (i just tried to pronounce the blalock-taussig-thomas collaboration.). dr bates also tells what can only be seen as an absolutely shocking story. i only hope that this does not tarnish the general public's opinion of surgeons in general.

dr r touches on the same topic as dr bates in temporary tattoos for surgeons.

orac joins the fray.

and aggravated docsurg drives the point home.
aggravated also gives what i thought a brilliant look at work hour restrictions. you can't learn if you don't get the opportunity (read time).

dr alice also touches the prickly issue of decreased work hours.


dr shock gives us a psychiatric perspective of the post operative period. i can certainly attest to the increased difficulties and therefore complications associated with operating these patients.

radiology picture of the day shows a great ct of an endoleak. take a look and remind yourself of the classification.

dr b writes a post expressing one of the numerous frustrations associated with the job. i too would have felt abused.

sometimes collegeal relations can be quite confusing as the independent urologist discovered to his surprise.

buckeye surgeon tells us about surgery on the elderly. he also gives us an absolute masterpiece about really making a difference in someone's life.

medzag takes us through a few recent patients. a look from a different angle.

jeff wonders if surgeons should be taught all the things they are. i must say i couldn't disagree more.

ic disease takes a look at a few miscellaneous treatments for interstitial cystitis.

sandy robinson from fighting fatigue gives a list people suffering from chronic fatigue should give their surgeon before undergoing surgery.

well folks, that's surgexperiences 203. for the next edition take a look at jeffreymd. you can simply submit posts here.
also, for those who want to host future editions, drop a line to jeffrey leow here.