gossip

the community of registrars in a university like pretoria is small. a small community is nice, but it is always important to remember whatever you say will probably find it's way back to the person you are gossiping about.

i was rotating through orthopaedics. rotation generally is not too much fun and ortho was no exception. finally they allowed me to operate. they put together a list of wound inspections and secondary closures and the like, claiming they would handle the ward and clinic (later i found out they used the opportunity to take an early day and go and play golf). anyway, there i found myself all on my lonesome, closing some wound on a forearm in the company of a green anaesthetist that i'd never met before. i tried to be friendly and i thought it was working. i was making small talk and stupid jokes. the gas monkey was even laughing.

then i approached the end of the operation. i placed the last stitch and asked for a plaster. the anaesthetist looked up with an expression of surprise on her face.
"are you finished?" she asked.
"yes"
"you didn't tell me you were almost finished!" she complained.
"sorry." it seemed like the right thing to say, but it didn't work. she really let me have it between frantic exaggerated turning down of the vapours and drawing up of reversal. i listened to her tirade for a while but it quickly bored me. i walked out to the scrub room to wash my hands.

there i removed my mask, adjusted the cap on my head slightly up and washed my hands. afterwards i slowly walked back into theater. the anaesthetist looked straight at me.
"can you believe it?" she said
"believe what?" i replied.
"the bloody surgeon!" i wondered what surgeon she was complaining about now. by this time i had figured our that she was not overly fond of surgeons. i decided to listen patiently to her tirade.
"who and what did he do?"
"the surgeon who was just here! he didn't tell me he was finished and then he just left me with this sleeping patient!"

it took me a moment, but i realised she didn't recognise me with my mask off and my cap donned slightly differently. i considered drawing the situation out but truth be told, at that stage i just couldn't be bothered any more.
"i said i'm sorry. what more can i say?" i said in a pseudo-annoyed voice. she looked at me with a blank expression. then suddenly she went bright red. i smiled broadly.
"pleased to meet you. i'm dr bongi."

yes there will always be people bad mouthing you, but, if i could be so bold as to suggest, do not gossip directly to the subject of your gossip. it just makes you look foolish.

so clever

i'm not the brightest. pregrad took a lot of studying just to scrape by. surgery nearly caused pressure sores on my butt. so i always assumed i was fairly low down on the surgical iq pecking order. we at pretoria knew we could operate better than most of the other universities, but how could we compare to a place like uct (cape town). those guys we knew didn't nearly get our operative exposure. we just assumed they used all that extra time cracking the books.

i remember a registrar's symposium i went to where they presented. at some stage a zim registrar asked a pretty poor question. the uct guys answered, but the zimbo wouldn't accept their answer (mugabe-like???). the uct guy calmly pulled the mike forward and said,
"i suggest you go back to your books!" i was impressed. i knew the zim guy was clueless but i couldn't quote chapter and page to allow me to throw the book at him like that. i really thought that the uct guys were super clever.

a few years later the international surgery conference was held in durban, south africa. we all went. i decided i'd try to get to know the uct guys better. it's always good to make friends. but i also wanted to get a chance to grade them myself.

as could be expected from capetownians, they weren't too keen on this pretoria boy in their presence and they made it pretty hard for me to get to know them. at a stage, as surgeons tend to do, some of them were sharing surgical stories. i noticed they all ended in 'and then i phoned the consultant.' well i had stories and mine didn't end like that. so i told one.

it was a midnight blunt abdominal trauma that ended in a liver resection. (truth be told the impact with the truck out there on the street had pretty much handled the resection. i just needed to tidy up a bit.) they were astounded. no consultant? i did it alone? we do that sort of thing in pretoria? and such questions.
i felt better. even if i wasn't as clever as they were i could at least operate. i had been trained to make the crucial decision at the crucial moment without needing to rely on backup.

a few days later they were once again telling their stories, but this time they had one of their consultants there. it seems one of them opened an abdomen because his junior had put the patient on the list and the diagnosis turned out to be something unexpected. my first thought was that where i come from there is no way the primary surgeon wouldn't have made the decision to operate himself. i admit i felt superior.

the uct registrar described his shock at discovering the actual diagnosis, something that is first approached non-operatively. only when this fails is surgery considered. he phoned his consultant, the guy sitting with us.
the consultant advised closing and reverting to the non-operative management. i piped in.

"but you had the abdomen open. i agree with the non-operative approach, but you're there with the abdomen already open. fix the problem with a knife." they all looked at me. the consultant asked,
"how?" i was a bit surprised. but i told him how. the registrar who was telling the story said that he didn't know how to do what i'd just said. again i was surprised.
"you do know how now. i've just told you how. you just need to do it."

they all shifted uneasily in their chairs. they didn't have the charge-in-where-angels-fear-to-tread attitude that the pretoria guys had. to argue the practicalities of an operation with a pretoria guy was not going to work. it was time for plan b.
"well i've never seen that operation in my books. maybe you should go back to the books." it was the same line that i'd heard them use years before. i was a bit confused because i had read this operation in a book. i'd actually seen it in a few books. but they were uct registrars and i doubted myself suddenly. i knew we could out operate them, but if they said that it was not in the books in the presence of a consultant and he agreed, then maybe i was wrong. i kept quiet.

that night i opened my book, the latest sabiston and sure enough, my operation was there described just as i had said.

i didn't go back to them to point out that i was right. it seemed too petty and vindictive. i just reminded myself that despite the way i felt about my spartan-type training, it was actually good and academically sound. i would never feel inferior to the uct guys again.

the big five

unlike the perception that some first worlders have about south africa, there are not wild animals walking the streets and there are not attacks every now and then by said animals (except for my cousin who was eaten by a crocodile. that is a bit too close to be discussed on my blog though). however i'm starting to have my doubts too.

quite soon after moving to the lowveld i treated a patient that was bitten by a hippo. let me assure you that that is no small bite. i think it is remarkable to survive something like that. then there were the two crocodile attacks. the one actually had a tooth embedded in the arm. it seems that crocodiles often loose teeth. to them it doesn't matter because they can replace their teeth right through their lives.

but it seems recently we are working through the big five.
i didn't treat the guy who was mauled by a leopard. i didn't even actually go and see him. he survived because the leopard itself was terminally ill and wasn't in good fighting form.
the guy who was attacked by a lion survived because he managed to get a shot off before the lion got to him. the shot apparently took out its top jaw. the lion could therefore not bite but still shredded him quite badly with its claws. i'm a bit embarrassed to say i turfed him off to the orthopod once i discovered his injuries were all to the arm muscles.
around the time of the lion patient i heard from a friend of mine in the kruger that he had a contact with a Buffalo. luckily the beast had been darted and was pretty nearly asleep already when it knocked him down. otherwise he probably wouldn't have been around to tell me about it.

then came the elephant attack. i can only assume the elephant's heart was not in his actions. otherwise how do you survive an elephant attack? but even not fully devoted to the task at hand, the pachyderm still managed to inflict severe wounds to my patient.

we haven't quite yet covered all of the big five, so there is a part of me expecting a rhino attack sometime in the next few weeks.

i smell drunk people

it's funny how smells can be so emotive. i have spent a fair amount of time in the state hospital lately. and going through casualties the smells were so familiar. it is a smell common, it seems, to all state hospital casualty units that i've ever worked in. and somehow alcohol is the constant thread.

i'm not talking about smelling alcohol on the breath of an aggressive family member, although that is also something one does see (or smell) a lot of. but it is so much more than that. i'm talking about the residual smell of alcohol laced bodily fluids after a busy trauma night. it is a smell that is resistant to being washed out.

it's difficult to explain but the smell left me with a longing for days gone by when i was the surgical registrar on the floor. i was the guy placing the nasogastric tube when the patient brings up the night's festivities all over the bed and often my shoes, leaving a sour smell of alcohol and stomach acid. when i was the one placing a high flow line into the neck of the nth drunk uncooperative gunshot wound patient, where part of the technique is to dodge his often well placed punches. in those moments you are not aware of the smell. maybe the adrenaline drowns it out. but it is always there. the next day when you walk into casualties and the smell hits you, the nigh's activities return so vividly to your mind.

i remember when i first learned the smell of alcohol in blood. strangely enough it was during an operation on a sober gunshot patient. he was bleeding profusely. i kept on thinking there was something missing. the blood didn't smell right. and then i realised that the smell i was missing was the smell of alcohol in the blood. how weird is that to know what alcohol in blood smells like.

yes i miss those days sometimes. alcohol doesn't play that prominent a role in private but you still see it. so it was a nice trip down memory lane this weekend to smell that smell again.

p.s the patient at the state hospital this weekend survived and was even extubated the next day.

tumble

i know a bit about ballistics. it's more practical knowledge. i've seen enough gunshot wounds to pick up something here and there. the high velocity ones wreak havoc inside. the more usual 9mm doesn't compare but a well placed shot is still devastating. and then you get the exceptions. ricochet shots can be confusing. they tend to take strange paths through the body, sometimes following dissection planes (like surgeons) and causing less damage than you'd expect. and then you get the tumbler.

i did a tumbler recently. it wasn't a particularly high velocity projectile. the bullet didn't even make it through the patient. the entrance wound was just below the rib edge to the left of the midline. i could feel the bullet under the skin just below the right arm (bullets that are palpable just below the skin usually mean deflected bullets, either before penetration, like a ricochet, or in the body by hitting bone). he also had a hemothorax on the right. he was sinking fast so we got him to theater without too much delay. the intercostal drain delivered a good liter and a half, but then dried up. laparotomy was the first order of business.

despite the normal entrance wound and the relative low velocity, the damage inside was impressive. there were two 5cm holes in the stomach. the bullet then continued into the liver, causing a massive tear where it entered and an equally impressive one on the dome where it exited on it's way through the diaphragm into the chest. the hemothorax (bleeding in the chest) was actually from the liver.

so, although the bullet was small as bullets go and also not of the fast variety, the fact that it was no longer stable in it's trajectory meant that it caused a relatively large amount of damage. imagine it tumbling as it travels through its victim. the amount of energy parted to the tissue is considerably more than it would be if the projectile just behaved and followed a straight line.

the other interesting thing with this case is that, for a change, i did in fact follow the advice of countless hollywood productions and i removed the bullet. (usually it is not necessary to remove a bullet, with certain exceptions of course. it is not the presence of the bullet that causes the damage, as hollywood would have us believe, but the movement of the bullet through tissue at the moment of the shot)

kruger weekend

well i had a great day in the kruger park (also mentioned here and here). besides the Buffalo, elephant, rhino, leopard, crocodile, hippo, kudu, bushbuck, nyala, etc that i saw, i also saw wild dog. and not just saw but followed a troop with about 8 pups for about 30 minutes. what an experience. it was wonderful.





here follow a few photos of these incredible animals.

specialise??

recently i had two experiences which once again reminded me that the public and medical people have contrasting views of what a general surgeon is. most readers of medical blogs would at least have some idea of what it takes to become a general surgeon, but joe public out there does not.

in the first post in sid schwab's series on deconstructing an operation, he mentions a light hearted exchange in the scrub room between an orthopaedic surgeon and a general surgeon where the ortho refers to the general surgeon as a real surgeon. in many senses this is true, not to detract at all from the other surgical specialities. but at least in my neck of the woods, when your chips are down and your life hangs in the balance, it will be a general surgeon trying to save you (severe head trauma is the exception and in some places if there is a thoracic surgeon he may be there for chest trauma). being a general surgeon means less sleep than all the rest of our surgical colleagues, but also a certain level of respect, usually expressed in;
"rather you than me dude!" then there is laughter. but they are grateful for the frontline guys.

but the public (where i am at least) has no idea.

recently i have been meeting people outside of the workplace. they usually ask me what i do.
"i'm a general surgeon." i reply.
"oh! that's nice" they respond "are you thinking about specialising some day?"
"no." i say and smile.

but the last encounter was slightly more interesting. i was with a friend whose wife is a doctor, so he was more informed. he introduced me to someone.
"what do you do?"
"i'm a general surgeon."
"oh. that's nice. are you thinking about specialising some day?"
"no." and i smiled.
but then my friend started looking uncomfortable. he felt, it seems that some impression of what a general surgeon is should be left with the fellow. he took the conversation further.
"well, it does take a lot of study and work to become a general surgeon, doesn't it." i thought, seeing as he had gone to the trouble of trying to defend my honour, i'd better continue his line of thought and not leave him in the lurch.
"yes it does," i said "in my case i essentially studied for 15 years." i could see the guy's expression. he clearly couldn't compute this. after all i was just a general surgeon, probably not even a real doctor. his answer was according to his understanding and assumptions.
"yes it is good to keep abreast of latest developments." he assumed i was not speaking about real study but just about the occasional perusing of a surgical journal or two. i decided to mess with his understanding and assumption.
"not me," i replied, "i'll never study again. in fact if someone presents with a new disease, they must die."

i thought it was funny. he did not.