tamponade

at least in the old days, our medical training was pretty darn good. but as with all things, confidence comes with experience and experience comes with time. being in the bush with cuban seniors often the confidence was more lacking than the knowledge.

it was late at night. the patient was just one more stab wound chest, one of the most common conditions we dealt with. but this one was different. he writhed around and seemed to be gasping for air. i threw in the needed intercostal drain, expecting a sudden improvement. it didn't happen. the lungs were fine, but the patient's neck veins were severely distended. his blood pressure was low and his pulse was fast and thready. his heart sounds sounded muffled and distant. then, if i wasn't already sure about the gravity of the situation, he said those words which strike dread into any doctor who has even a little experience.

"help me doctor, i'm dying!"

i knew what was wrong. he had a pericardial tamponade (the heart had been stabbed and was bleeding into the sack around the heart, slowly crushing its attempts at normal contractions) and without intervention the patient was going to do exactly what he had said he was going to do. i even knew what to do, but had never even seen it being done before. he needed a needle to be stuck into this sack to draw off the blood. this would win time to get him to theater to fix the hole in the heart. it was time to phone my senior.

the cuban surgeon on call sounded sleepy. he listened to my presentation of the patient, but didn't seem to fully appreciate how grave i felt the situation was. so i told him.

"this patient has a tamponade and without intervention soon he will die!"
"how can you diagnose a tamponade without a chest x-ray? get an x-ray and phone me back!" i was astounded. i knew what i had and didn't need a chest x-ray to help me. in fact i was worried about the delay the getting of said x-ray would cause. nevertheless, he was the consultant and i was merely the intern. i had to obey.

not too much later i phoned the consultant again.
"i have the x-ray as you requested and it shows a very globular heart." this confirmed the diagnosis. "will you please come out and help?"

finally he arrived. i had been sitting next to the patient the whole time trying to reassure him that everything was going to be just fine even though i was not convinced everything was in fact going to be fine. the consultant looked at the x-ray for some time. he then listened to the ever fainter heart and examined his now engorged neck veins. i was pacing by this time. i just couldn't understand the consultant's tentativeness. after all he was supposed to be a surgeon.

"bring me a needle!" finally!! i presented him with the needle and syringe that i had already gotten ready. he seemed surprised. i wanted to say that i was south african trained, but thought better of it and just smiled. he then started cleaning the chest just next to the sternum. now once again due to my south african training i had expected him to clean the area just below the sternum in the angle between the left ribs and the sternum. where he was cleaning i feared that he may stick the needle straight through the thin sliver of lung that lies over the heart in this position. i mentioned my misgivings and suggested the method we had been taught. glared at me accusingly and drove the needle in through his original site. the syringe quickly filled with blood. the change in the patient was dramatic and instantaneous. i started to breathe easier too.

"wonderful!" i said. "theater is ready. i took the liberty of booking him already."
"why?" said the cuban. i was taken off guard. it seemed to me to be self evident. the stab to the heart had to be addressed otherwise the tamponade could recur and then we'd have to operate in the early hours of the morning anyway.
"ummm...to fix the hole in the heart?" i ventured.
"no. we have treated him. he is fine now. admit him to the ward!" and with that he walked out.

what could i do? i was an intern. i could not do a thoracotomy on my own. if the surgeon refused to operate the patient was not going to get operated. i hesitantly admitted him to the ward as instructed.

through the night i intermittently stopped by to see how my patient was doing to the irritation of the night staff whose sleep i constantly interrupted. by the next morning the patient was amazingly still alive. sometimes patients are just lucky i suppose.

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.

friend's best friend

many years ago a friend of mine told me a story which i thought quite touching. it seems like a nice way to kick off the year.

one of my seniors in surgery had a dog that meant a lot to him. he lavished it with love and attention and they were inseparable. he had trained the dog to obey him implicitly. in fact it was so well trained that he would often go for walks with it without a leash. one word from him and the dog would stick to his leg like glue. this was one of those walks.

my friend and his best friend were out walking. it was a quiet day so my friend would send his dog out far ahead. he would then shout the command for it to stop and wait. he would then either leisurely catch up to the dog or give the command for it to return to him. then he sent the dog ahead again, but this time didn't notice the dog would be crossing a street. as the dog was half way across the street my friend saw a truck barreling down at full speed towards the dog. he panicked and, instead of shouting for the dog to return, just screamed the dog's name. the dog stopped dead in his tracks, right in the middle of the street...and was run down.

soon the dog was at the vet. most of the injuries were to the leg, but they were bad. so bad in fact that the vet said only an amputation would suffice. she then added that this breed of dog didn't do too well with an amputation because they needed to run around a lot or they became depressed and lost the will to live. she suggested euthanasia. my friend was devastated, but he agreed that the dog would not do well without a leg. he consented.

just before the injection he went through to his faithful old friend to say goodbye, but when the dog looked up at him and, despite the pain wagged its tail and smiled he knew he could not just stand by. he asked the vet if she could anaesthetise the dog. he would do the rest. he then drove to the hospital where he was training, walked into theater and pretty much stole all the orthopaedic plates and screws he thought he would need. not too long afterwards he was drilling and hammering and doing the things bone doctors do, but on his dog. somehow he got it all together, although he had to sacrifice the articulation of the wrist. a stiff wrist was better than no wrist.

and so the dog recovered and went on to have a full and happy dog life.

p.s i'm not condoning the stealing of all the hardware but when i confronted him about that he pointed out that the hospital had refused to pay him overtime well in excess of the value of the items stolen and, he said, he could therefore live with it.

sealed with a hand-shake

shaking hands is not really such a good idea, especially in a hospital where there are all sorts of nasty bugs floating around, seeking whom they may devour. so generally i do not shake hands unless the patient absolutely insists and i think the cultural slight may be more than he can bear. but one incident highlighted to me the reason you generally don't want to shake hands so well it could just have well been written all over the hospital in bright neon lights. in fact in my opinion, it was.

i was on call that night so it fell to me to evaluate and treat the patient in casualties which the casualty officer said had a perianal abscess. i approached the bed and introduced myself, but i made a point of positioning myself in such a way that the patient wouldn't be able to greet me with the traditional handshake. experience had taught me that this was one case where this cultural idiosyncracy was patricularly ill-advised.

i asked what the problem was. without saying a word his hand moved to his gluteal cleft in one smooth motion. moments later i found myself staring with morbid fascination as he pulled his butt cheeks apart and started prodding what was clearly an abscess with his finger. it had already broken open slightly so there was a thin stream of pus oozing out and following the natural pull of gravity. the patient's grubby finger scratched, prodded and poked this poor stream of sepsis, completely disrupting its attempt to soil the bed linen.

i was so disturbed and disgusted that my senses seemed to heighten and the pus took on an almost luminous yellow colour in my mind. this, after a very short while, was visible on most of his hand and under his nails. but in fairness to me i managed to fight my gag reflex right up until he wiped his lip with that same hand. i had theater to organize so i fled. i felt dirty and used.

after the obligatory wait it was finally our time to go to theater. i got there early and as is my habit chatted a bit to the anaesthetist. we then went together to the preoperative holding area to see the patient. the gas monkey, a very gregarious fellow, immediately moved to the side of the patient's bed and introduced himself, extending his hand as is customary.

as we pushed the bed to theater i kept glancing over my shoulder at my anaesthetic colleague until he asked me what was wrong. i found it surprising that he couldn't see the bright yellow luminous marks on his hand which seemed so obvious to my mind's heightened senses.

christmas meal

often on christmas i think back to a story from long ago that was based on a christmas meal but had nothing to do with a christmas meal. the man in question was unique to say the least.

it was about february. we were on one of the painful yet entertaining rounds with our eccentric consultant. up to that stage he had actually been so contained that some of us could even have been described as being bored.he just didn't seem to be ranting as much as he usually did. he was also not spewing forth his particular brand of black humour.

then we got to a new admission from the previous night. the patient was a middle aged female with cellulitis, but the thing that struck us all the most was that she was morbidly obese. she must have weighed in at 220kg. obviously we displayed the necessary tact and didn't make a big fat deal of it. the consultant, however had no such scruples.

"you are the fattest person i have ever seen in all my life and let me tell you, i have seen fat people in my many years in this hospital." we all looked around awkwardly, hoping his verbal indiscretion would end. those that knew him well had little illusion that this would be the case. he then turned to the student nearest him;

"you! go and get me a carrot!" the student looked on incredulously. "you heard me!" he bellowed, "fetch me a carrot! and when you bring it give it to her to eat!" we still didn't quite understand what new madness had taken over the faculties of our master. we mutely looked on.

"and then on christmas day give her a second carrot to eat!" he then turned to her. "christmas!" for that is the name he bestowed upon her and indeed the name he used to address her every day until she was discharged, "you are about to make history. you are going to take part in the biggest diet in the history of medicine!"

close call

i have already spoken about the hazards of doing favours, but recently i was reminded of another example when i was still a registrar where i only just escaped the proverbial falling anvil.

it was not an unusual case but still fairly challenging for a registrar like myself. the old man presented with an acutely tender abdomen and free air revealed on x-rays. if you ignore the outside horses for a while, this is either a perforated peptic ulcer or complicated diverticulitis (some people would throw complicated appendicitis into the mix, but i'm going to leave it in the stable with the outside horses if there are no objections). the patient needed an operation and soon. so with the sun shining happily over australia somewhere, i took him to theater.

it turned out to be diverticulitis, but what a mess. the entire abdomen was full of pus and there was a big inflammatory mass in the region of the sigmoid colon. i knew what to do. i whipped out the offending sigmoid colon and, because the risk of reattaching the bowel in that level of sepsis was too high and because the patient couldn't afford a further complication, i pulled out a colostomy. after the surgery the patient started recovering at an acceptable rate. the plan was to reverse the colostomy in the future.

now usually, this sort of colostomy would be left in place for quite a while (in the order of six months) to give the abdomen time to recover fully from the severe inflammation that accompanies free pus throughout the abdomen. inflamed bowel is very friable and difficult to work with. thereafter it would be closed in a second operation. however there was a private consultant with sessions at the university who strongly advocated for what he called early closure of colostomy. he said that as soon as the sepsis had cleared up, long before the inflammation had settled, you could re operate and reverse the colostomy. he advised that the second operation be done before the patient even leaves the hospital, even within a week of the first procedure. he actually approached me about this patient specifically and told me i should try it. i started contemplating the idea.

then something happened that i should have seen as a big warning sign; an old friend asked me for a favour.

you see this friend was related to my patient in some way. apparently he had visited him in hospital and discovered i was the one who had done the operation. as can be expected from someone who wakes up from surgery with an unexpected colostomy, the patient was bemoaning his lot in life. in the end he asked my friend to ask me for a favour. the friend asked me to close the colostomy, sooner rather than later. i should have seen warning lights. i didn't.

so i decided this would be the case where i listen to the often contentious advice of this specific private surgeon. i took the patient back to theater to close the colostomy about a week after the first operation.

quite soon i was in trouble. everything was adhered to everything. over and above this, because the inflammation was far from resolved, everything was oozing blood at somewhat more than an acceptable rate. but it was too late. i was elbow deep in the abdomen. i had no choice but to continue. the other catch was that i was doing the operation at the advice of the outside consultant and not with the consent of my own consultant. this essentially meant i would experience a severe loss of cool if i asked my consultant to come in to help me *read bail me out*.

the details need not be dwelled upon (truth be told i have filed them deep in the forget folder in the darkest archives of my mind) but suffice to say it was an almost impossible dissection to get the two ends of the colon together to reattach them. finally, almost miraculously, i approximated the two ends in a somewhat acceptable manner and attached them.

during the postoperative period i almost expected a leak. day after day i'd check the patient out and be surprised to see there was no leak. finally i discharged him in good health. but not before i swore to myself never ever to attempt an early closure of colostomy again. also i reminded myself of the dangers of doing favours.

p.s many years later i ran into this friend and was pleasantly surprised to hear the old man was still going strong.

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.