exemplary

part of the job is to treat some unsavoury people. sometimes you know what it is they have done. mostly you don't. sometimes you even may make a difference. but mostly you just do your job. after all it is not our part to play judge and jury (and, in our case, executioner). but recently i heard a story from some fellow surgeons about one of their colleagues that i'm sure creates a warm fuzzy feeling in the hearts of all south african surgeons.

i can attest to the fact that after a long night on call your general mood is usually not the best it can be. also it becomes more difficult to see the humour in situations that on a normal day you might be able to laugh off. so when this particular registrar finally wrapped up his post call work and meandered off to his car to go home he was not delighted to find someone busy stealing it. he did what any south african surgeon would want to do in his situation...he shot the guy.

the person in question was, however a surgeon, so his training kicked in. they were already at the hospital so all he needed to do was drag the punctured villain to casualties and get him ready for theater, which is exactly what he did. despite the fact that he was post call, he even took the time to operate the guy himself. i suppose he had the best idea of the tractus of the bullet?

i can just imagine how the post operative ward round went when he presented the case to the prof. how would he have worded it?

"well prof, i shot the guy and then i did a laparotomy. well you always told us we should actively look for work to do if we wanted to get experience."

you can't win them all

the myth of the glory of war is perpetuated in part due to the fact that the stories are only told by survivors. if the guy that took one through the neck in no man's land in world war one and then slowly faded away in a mess of saliva mixed with blood, lying in his own stools, crying for his mother were to tell his story from beyond the grave it wouldn't look so glorious at all. it would maybe be a better reflection, though, of the reality of it. in a certain sense we run the risk of glossing over medicine too. i would hope this blog does not.

i am extremely affected by the patient calling out to me to save him in strained monosyllabic speech at the last moment of his life. it is almost too much to bear. and yet i am the survivor. i walk away to live another day or to tell the story or to enjoy a sunrise in the african bush.

i remember him well. he was a kidney failure patient who was leading a fairly normal life thanks to the wonder of peritoneal dialysis. he was the breadwinner for an extended family even. and then he got the call.

there was a kidney available. i was even involved in procuring the kidney (this is always a sad and poignant story in itself. it is the coming together of life and death, of hope and despair) . the relevant tests were done and this specific patient was found to be the best match. quite soon he was in the hospital going through the needed preoperative preparations. after the usual administrative delays that are so particular to south african state medicine we even actually got him to theater and without too much fanfare soon had the new kidney in and peeing like there was no tomorrow. everything was going so well i almost thought it was too good to be true.

after theater he did well for about three days before things turned. initially it was just a decrease in the amount of urine the kidney was producing but soon it was so much more than that. without going into too much detail, the patient developed systemic inflammatory response syndrome (sirs). this put pressure on his new kidney which started faltering. he developed water retention which put strain on the lungs which were already under pressure from the sirs that he had. after that things started spiralling downwards.

we had long given up on the kidney and put the patient back on dialysis, but nothing seemed to make the situation better. then two days before my rotation in the transplant firm ended the patient collapsed in the ward. i happened to be there and commenced a full resus.

i remember clearly the terror i felt at the prospect of the patient dying. his heart wasn't supposed to have stopped! he was supposed to do well. i felt terrible! but with a bit of good luck i brought him back from the brink of death and delivered him to icu with a tube down his gullet and highly dependant on inotropic support (his heart was dependant on drugs to maintain a barely survivable blood pressure). his kidney had long since ceased to function and we dialysed him constantly at a low rate to try to not put more strain on his borderline heart. then i was rotated to the icu unit, so in essence i followed my patient there.

his sirs just got worse and soon he developed a coagulopathy (the normal clotting mechanisms in the blood stopped working) and was soon bleeding from every orifice. we gave him what we could for that but the fine balance between not giving too much fluid yet giving the needed clotting factors and the balance between dialysis and the heart that was on the verge of giving up altogether was very difficult to manage.

the last night i remember too well. i often wish i could forget. i was on call that night in icu, so it was up to me to get him through to the morning. he had been bleeding from the mouth and nose a bit all day. his blood pressure hovered just above the unacceptable level. his lungs were full of fluid and the ventilation was tricky to say the least. but as the night progressed things got worse. the first thing was the bleeding. quite soon blood was oozing from everywhere. he even had a trickle of blood running down his cheeks like bloody tears from both his eyes. and as he bled his blood pressure started falling. he became too unstable to dialyse so that was stopped. the inotropes were increased to industrial doses but that did little. i became desperate. i phoned the transplant consultant.

after i had verbalised all the parameters to the consultant over the phone it was like i had told them to myself. i knew what the consultant was going to say. if i were him i would say the same thing. the situation was beyond repair. the patient was going to die and nothing we could do would change this fact.

"he is going to die, bongi. you can't win them all."

i knew he was right. i hung the phone up and just sat for a while. i thought of the fact that this man, the sole breadwinner of his family, had walked into the hospital with hopes of a better life without dialysis and would be leaving on a cold morgue slate. it just seemed so unfair, so wrong. had we killed him? i didn't know but at the time i felt we had. my consultant had advised me to stop active treatment and see if i could get some sleep. i stopped active treatment but i refused to sleep. it just seemed to me that i was supposed to at least be with him to the end even if that was all that i was going to do.

i sat in the patient's cubicle and waited, like him, for the end. when it came it was horrible. blood was now streaming out everywhere. his breathing tube was bubbling with the pink frothy liquid seen in pulmonary edema and the ventilator strained against the pressures needed. the colour slowly seeped out of his face giving him the countenance of death before the fact. and then slowly his life force left him.

i turned off the ventilator and all the infusions and left. but even then sleep and the peace that could possibly come from it eluded me. to be honest i did not have that peace for some time thereafter.

focus

specialists tend to be focused specifically on their field. some might say narrow minded even. way back during my psychiatry block i was made acutely aware of this.

one thing i noticed quite early on in the psychiatry rotation was that, with few exceptions, the consultants weren't interested in teaching us. it seemed to interfere with their tea time and their going-home-ridiculously-early time. so when we were told to go to a particular ward to get a tutorial from one of them i wasn't expecting much. i got exactly what i was expecting.

we walked into the tea room where the consultants were hard at work drinking tea and introduced ourselves. the designated tutorial giver groaned audibly. he then glanced over at his colleagues and rolled his eyes. they chuckled. funnily enough i think they thought they were being subtle. after all we were mere medical students and therefore couldn't easily pick up on the finer points of non-verbal communication like specialist psychiatrists could. i was immediately annoyed, but i chose to hide it.

"you medical students think that when you rotate through psychiatry you don't need to examine patients anymore. where are your stethoscopes?" we all pulled our stethoscopes out of our lab coats and presented them. i considered asking him where his was but decided this was already an unpleasant experience and i wouldn't be popular with my friends if i further antagonised our antagonist. i held my mouth with difficulty. he continued.

"go to the ward on the other side of the hospital and ask to see mr g. examine him fully and report back to me." with that he turned his head back to the tea and seemed to drift off in thought. glad to know our future mental health is in such good hands, i thought.

we entered the ward and soon found mr g. we had all rotated through both surgery and internal medicine so we were quite confident in our examination skills but still we were taken aback by what we saw. with a simple glance it was clear mr g was not well. he lay almost motionless in bed except for the movement of his chest with every laboured breath. we got to work.

during the examination it was clear he was in heart failure and had a massively dilated heart. he also seemed to have pneumonia on the left. his abdomen was tender but we put that down to en engourged liver secondary to the heart failure. his mental faculties were almost non existent but were in keeping with someone who was on the verge of death as we thought him to be. as a side note we noticed he had one glass eye.

as we walked back to the consultant still sitting in the tea room sipping on his so-many-th cup of tea we chatted. we were actually quite worried about the guy. at least we could let the consultant know that he needed some real and urgent medical help at the hands of consultants that actually do have stethoscopes.

"you're back!" he greeted us, "why did you take so long? did you stop at the cafeteria for tea?" tea was clearly an integral part of his life.

"umm, no. we were examining the patient like you told us to."

"ok. present your findings to me." we started with a formal patient presentation the way we had been taught to do in internal medicine and surgery, methodically going through all the systems, one by one. as we spoke and the condition of the patient was painted in increasingly grave hues the consultant seemed to become more and more edgy. at least we were getting through to him, we thought. when we had just explained that the patient was struggling for every breath and his last ounce of strength was being drained from his body even as we spoke, the psychiatrist could no longer contain himself.

"did you at least notice he had a glass eye?" he exclaimed with a bit too much irritation. it seemed his edginess was nothing more than boredom.

"umm, yes. his right eye is a prosthetic eye." we ventured helpfully.

"ok. that is all i wanted you to find. well done." i couldn't help laughing. this guy had probably noticed by chance that the eye was fake when he admitted him some time ago. since then the patient had not been examined at all. also one would like to think that the fact that the guy was just about to die trumps a glass eye, but apparently not.

law and order

south african society is a completely lawless society. pretty much everyone does just what they like and more often than not they get away with it. red lights are just a suggestion, yet it is not uncommon to see a taxi stop in the middle of the road without warning. this attitude goes through almost all levels.

yet there are some laws that people do obey. the law of gravity comes to mind. mostly if you trip or fall off a wall or out a window you do approach the earth with increasing velocity and finally come to rest in some form of disrepair when you finally meet said earth, even if you are south african. another law that is obeyed was well illustrated by a patient we once saw in the old days.

the patient came in in a bad way. all sorts of bones were broken. most of his ribs were also fractured in numerous places, causing areas of his chest wall to move paradoxically with each breath (so called flail chest). his abdominal wall had burst and all his guts were hanging out. his left hemidiaphragm had also ruptured. suffice to say he was not having a good day. neither were we.

we got to work and with quite a bit of effort and no small number of hours we got him through theater and delivered him to icu. only after all the excitement had dissipated did we get to hear the circumstances surrounding his injuries.

as it turns out our patient had some form of confrontation on the road with a truck driver. this resulted in the two of them racing each other and cutting each other off, all the while hooting wildly and raising the middle finger in salutation at each other. as time went by tempers frayed. finally our patient decided on an ill advised course of action.

now my understanding of the law of momentum is twofold. firstly momentum is mass times velocity. this basically means the object with the larger mass and greater velocity is going to maintain its course of motion more easily than a smaller stationary object. secondly momentum is one of the laws that even us south africans are subject to.

so when our patient raced ahead in his car, stopped on the side of the road and got out of his car to stand in the middle of the road to stop the oncoming speeding truck with nothing more than his outstretched hand, maybe he hadn't thought it through too well.

choices

a while ago i treated a woman with rhabdomyolysis. you see her husband beat her so severely that she had enough muscle injured that she ran the risk of kidney damage due to breakdown products. i spent some time chatting to her. i couldn't understand that this beautiful intelligent woman could find herself in this sort of situation, especially seeing that the bastard had assaulted her twice before. but actually this post isn't about her. she had finally realised there is no chance that this sort of person is going to change and that she needs to leave him before he kills her. no, this post is about someone else.

it was when i was rotating through the military hospital. she came in as a gunshot wound patient. actually she was quite lucky (as lucky as one can be called when one ends up with a surgeon i suppose). her wound was to the chest and a simple intercostal drain was all she needed. a bit of recovery time and she'd be fit to go. then the story came out.

you see she was in an abusive relationship and was no stranger to the hospital's trauma unit. but each time she went back for more. this time, however, her partner came home with a gun. there was an alcohol fueled argument during which the gun was produced and he threatened to kill her. she grabbed their infant child and ran. however, like most of our patients, she couldn't outrun a speeding bullet. the bullet went straight through her chest and into the infant's arm, shattering his humerus.

to say i was shocked is somewhat of an understatement. i mean i can accept that if someone has such self destructive behaviour that they continue to put themselves in harm's way in the end it is their choice. but the infant has no choice. i needed to say something.

i asked her if she had made a case with the police. apparently she hadn't. i wanted to know why. well according to her the man involved was actually a good man. he had visited her in the hospital and confessed his undying love to her. all was forgiven. she was going to go back to him with her child.

now please understand me. i know that i can't judge someone until i've walked a mile in her shoes and other such cute sayings. but i wasn't thinking about her. i was thinking about the child whose security had already allowed him to take a bullet to the arm and was gearing up to subject him to more of the same. that little bit of tact that i do have left me.

"you know there is a good chance he kills you or your child next time. actually i'm not concerned for you. if you want to put your life in danger, you're a big girl and that is your choice. but that baby of yours has no say in the matter. the one person who is supposed to protect him it seems is willing to put his life on the line because some psychopath says he loves you. let me tell you, people don't shoot people they love."

i said a few other things but the gist was the same. not one word penetrated. she was determined. apparently prince charming had pulled the wool (or executioner's hood??) over her eyes and she was going back. i felt despair for the baby.

crushing

we can sometimes look good in our jobs. i suppose it comes with the territory. but sometimes this is not a good thing.

danville is an interesting place. actually the place itself is drab but it is full of interesting people. to say it is populated by the lower echelons of the gene pool is an understatement of note. for some reason every reprobate and inbreed seems to have found their way there. throw a few generations of fetal alcohol syndrome into the mix and you have the average danville resident. then add a strong predilection to grandpa (a local aspirin caffeine headache powder) to round off with. usually when they presented to the hospital it is usually with a bleeding peptic ulcer or a perforated peptic ulcer. in fact they seldom present to us with anything else.



she was a typical danville special. she lay there on the bed holding her abdomen in pain. the sheets were stained with a dark coffee like substance from her last episode of vomiting and her face had taken on a complexion similar to the original colour of those same sheets. although she was about 50, she didn't look a day older than 65. her face was etched with the marks a pack a day of the finest tobacco for about 30 years will leave. she had also probably consumed a small country's fair share of brandy in her time. i groaned. all i could hope for was that she wouldn't end up going to theater because the operative risk for such a patient is high.

fortunately for her, and for me i might add, she responded very well to our conservative measures and it seemed like we would be able to avoid taking a knife to her. when i saw her later in the ward she had even regained some of the colour back in her cheeks. this was of course due to the blood we had given her, but i didn't mind. the fact was things were looking up.

her daughter was with her. it was clear they were family. if anything the genetic material had deteriorated somewhat passing from mother to daughter. as was typical of danville, her face looked about 45 although she was probably only 30 years old. the daughter stared at me with what i can only describe as a grimace on her face. even when i looked back at her she did not break her gaze. she was obviously unhappy with the treatment we were giving her mother i assumed. i wasn't particularly worried about her opinion in the matter so i just ignored her. i was just too happy that we were getting her mother better without subjecting her to surgery. i left as soon as i could.

the next day on academic rounds we discussed the usual causes of bleeding peptic ulcers. the prof even made mention of the fact that the ones from danville are almost always caused by grandpa use. he added that he was impressed we had managed to avoid theater. i knew i should be proud but during the whole conversation through the corner of my eye i could see the daughter sitting there staring at me with those accusing eyes. i had a feeling there was going to be a complaint laid against me, but for what i did not know. i had no idea what i had done that had incurred her wrath so.

the rounds went on and finally ended. i walked back to the doctor's tea room to organise and delegate the necessary ward work. as i went through the door leading to the balcony the daughter came from the other side. we almost collided. she smelt of the cheap cigarette she had just smoked. up close the deep crevices in her face could possibly have put the grand canyon to shame in complexity. her makeup was also wildly overdone, unless you believe eye shadow should be sky blue and lipstick should go over the lip and be applied half way to the nose too. i stared. i couldn't help it. it seems i have a tendency to be overcome with morbid fascination. she held my gaze, unflinchingly, despite the considerable weight of her fake eyelashes. then she spoke.

"doctor." i felt trapped. i could no longer ignore her. i had to answer.

"yes."

"can i ask you something?" as she spoke her false teeth floated up and down, completely separately to the movement of the rest of her mouth. again i found myself staring.

"yes." i lied.

"are you single?" what the hell??

"no."

"that's a pity because you are f#@king sexy."

i had to actively prevent myself from gagging. i'm convinced i ran as i left although i tried not to give the impression of a traumatised buck fleeing a horrible death at the hands of a leopard, albeit one that had tried to change its spots with too much makeup.

make your mark

as has already been mentioned, this blog is a finalist in the category 'best literary medical weblog of 2009'. seeing that the awards are supposed to be for 2009 i thought i would give a link or two, more for the people who are new to the blog. if you think these links are worthwhile, browse around a bit and see if there is anything else you like.

psychiatry was never my thing.

the moulding of the surgical personality.

pressures in surgery.

i don't want to live forever.

eish.

this post links to my surgical principles, some of which i think are sort of ok.

as i said, these are just a few samples of the 2009 stuff. if you do think it's sort of ok, please feel free to vote for me here. i'm up against some pretty good competition.