significant moments

i hate paediatrics. people who don't understand the life of surgery may think this means i don't like children, but in fact the contrast is true. surgery is suffering and heartache. surgery is pain and misery. it is stuff children are not supposed to experience. children are supposed to be caught up in the joys of life. they are supposed to play and smell the roses along life's paths. pain will come later, but childhood is supposed to be a sanctuary, albeit temporary from the harsh realities of life. and when life really gets harsh, you may need to come to me.

i once spoke about a very special boy who crossed my path. his death still haunts me but there was another incident which drove the wedge between myself and paediatric surgery forever.

it was during my thoracic rotation. to be honest it was one of the more enjoyable rotations. they actually occasionally allowed me to do a thoracotomy or two. most of the other disciplines used us as their underlings to get the ward work done. of course in thoracics we were also used for this but at least there was a payoff.

one day myself and a rotating registrar from another university were sent to draw the preoperative bloods on all the theater cases for the next day. i was fine with this. i secretly hoped i'd find a case i could do myself if the powers that be smiled upon me the next day.

we soon found ourselves in the paediatric ward. there was a girl of about eight years old that was going to be operated the next day. she was apparently born with a severe heart abnormality and had undergone some sort of procedure at birth that had enabled her to survive these last eight or so years. however she was now due to undergo a slightly more permanent operation that would hopefully get her through the next thirty or so years. thereafter she would apparently most likely die. the tragedy of it was already something that weighed heavily on me. it seemed so unfair. but when i saw her i was shaken.

she was blue, a colour i've never thought looks good in someone's face. she also passively sat there trying not to expend any unnecessary energy. i could see she was puffing to try to get enough oxygen. an eight year old is supposed to enjoy life, not struggle for every breath. my normal heart went out to her.

the sister called her to go with us to the procedure room, a room in most paediatric wards that the children fear because they know it is associated with pain. she, however just looked at us with a tired forlorn expression on her face. it seemed too much effort for her to be scared.

in those days we used to draw blood from children from the internal jugular vein (in the neck). i'm sure there are readers that will feel this is cruel but drawing blood from a child is cruel to start with. we were good at the jugular approach and at least we knew we would get it right with the first attempt which is a darn sight less cruel than multiple prolonged attempts from another site. we got to work. the other registrar was going to hold her in position and i was going top draw the blood.

he placed her on the bed and got her position right. she didn't resist at all. if anything, her body lay limply waiting for the inevitable. the registrar tilted her head to expose the neck and i readied the syringe. then i went for it. she went berserk. she started screaming and kicking like mad. the registrar held her down and the needle advanced. i concentrated on getting it right and that meant i had to get my mind off her experience of emotional trauma. when the blood started flowing freely into the syringe i relaxed a bit and listened to what she was screaming between her tears.

my tswana is not very good but it was good enough to understand what she was saying. the registrar holding her was also a tswana and she was speaking to him, not me.

"uncle, uncle, save me from the white man!" she cried over and over again. he quietly whispered in her ear that it was going to be alright, but she would not be consoled. i would not either. like all children she couldn't reason that, although what she was experiencing was unpleasant, we were doing it in her best interests. all she knew was that the white man was stabbing her in the neck with a needle and it traumatised her. it was the sort of thing that you don't easily forget. it was a significant moment for her.

the next day i was tasked with assisting with a few smaller cases while the prof, another consultant and the senior registrar attempted the fancy operation on the eight year old girl's heart. i wouldn't get to see how it went, which, to tell the truth at that time, suited me fine. however, as it turned out, the prof ended up walking up and down between the two theaters and giving us a sort of running commentary.

"how's it going?" asked the registrar operating with me.

"not great." replied the prof. and then he dropped one of his typical gems.

"eintlik is ons besig met een moerse fokken palliatiewe pooging langsaan" (we're actually busy with one massive f#cken palliative operation next door). he then gave his usual inappropriate giggle. i couldn't even manage a grimace.

that night i was on call. part of my job being on call in thoracics was to look after the thoracic icu patients. the girl was one of them and would be my responsibility. from the first moment things went badly. then they quickly got worse. i did all i could think to do, but as i looked at her small body lying there in the big icu bed with tubes sticking out of her all over i realised the odds were stacked against us. i phoned the prof to ask what else i needed to do and followed his advice. however just before he hung up he said that thereafter there was nothing more we could do. when he omitted his usual giggle i knew she would die.

a few hours later it was my duty to give the prof a courtesy call to tell him the girl had passed away. he simply said thanks that i had informed him. then i was left alone with my thoughts.

i thought of her looking at me the previous day with no more fight left in her tired body. i thought of the years she had had a semi-existence and had missed out on all the things that make life magical for children. i thought of whether she had had any significant moments that had put a smile on her face despite her circumstances. and then i thought about her last significant moment, the one that had traumatised her for the rest of her life, the one where the white man had driven a needle into her neck despite her vociferous supplications for him not to do it. we are supposed to make life better. we are supposed to enable people to go back into the world to enjoy the beauty and wonder of life. what we do is not an end in itself but a means to an end. the point is to have a better life and that i did not give her by any stretch of the imagination. i felt devastated, but i was alive to feel devastated. she would never feel again. i no longer wanted to go on with this painful profession. i could no longer hold back the tears. it was a significant moment in my life.

dogma

surgeons are creatures of habit. they also tend to be somewhat dogmatic. when things change they often become edgy or annoyed. however, this little fact made for a funny story once.

i was a lowly medical officer working with a senior registrar. it was a good time. i had senior cover which in those days was quite rare. also my senior was a really great guy, even though he was a surgeon. as it turned out when the time came to be rotated the prof moved us both to a new firm together. he must have assumed we didn't like each other, such was the prof's usual logic.

the new firm promised to be fun. the consultant was an old prof who no longer operated but enjoyed teaching. we would be left to do the operations without too much interference and we would get good academic input. life was sweet. we just needed to make sure we didn't annoy the old respected man. with this in mind we asked the prof's previous registrar if there was anything we needed to know about the prof in order to do everything right. he assured us there were only two things that should be dogmatically stuck to and all would be well.

firstly the prof was always exactly on time and accepted no excuses for his underlings being late. if he said rounds were to be at 07h30, then you had dam well better be there waiting for him at exactly that time. if you were busy with a resus then you should have thought of that before you allowed the patient to crash before the prof's rounds. he would not be impressed by such trivialities over his rounds. no excuse would suffice.

the next thing his registrar told us was that, after his so called grand rounds on a wednesday he would dismiss the students and invite the doctors to enjoy a cup of tea and biscuits with him. we were to supply abovementioned tea and biscuits. and, the registrar sternly warned us, the only biscuits we were permitted to supply were romany creams. apparently nothing else was good enough for the important palate of the old bull.

i was quite happy. these were easy things to do and the rotation should be a breeze. i was right. it was.

then many years later when i was the senior registrar, once again my turn came to rotate through the old prof's firm. once again i approached the incumbent registrar and once again he told me that if i'm on time and i supply romany creams for the prof's tea on a wednesday, all would go well. i was always on time and i kept a few emergency packets of romany creams ready in my locker just in case. the rotation was fabulous. the prof never said a bad word about me.

as with all good things my time with the prof soon came to an end. i was rotated into another firm and replaced by my friend and colleague. as was the habit of all of us my friend approached me to get the low down on how to stay on the prof's good side. it was obvious throughout the department that the prof was actually fond of me (well as fond as a surgical prof can be). i told him the secret. it was so simple, be on time and supply romany creams. my colleague should do well too, i thought.

about a week later, during the prof's post grand round tea party, i wandered in to the tea room. i was astounded to see an assortment of biscuits on the table. i was even more amazed to see that none of them were romany creams. had my friend lost his mind? had he decided to ignore my advice? was he tired of life? i didn't know. i left in possibly too much of a hurry.

the next day i went to my friend and asked what the hell was going on? why had he totally disregarded my advice that i knew had been passed down faithfully from registrar to registrar at least since five years previously and probably even longer? he told me.

"well, bongi, on day one i told the prof that i was told he like romany creams so much and i asked him why. he replied that he actually didn't like them at all and had been wondering for some time why his registrars always gave them to him. it didn't bother him too much so he just left it."

i couldn't help laughing. this piece of erroneous information had been passed down faithfully over possibly eons from one registrar to the next without anyone ever bothering to check with the prof to find out if it was in fact so. i could just imagine how it had all started in times gone by, maybe just after the mesolithic era. the prof had casually taken a bite out of a romany cream and made a comment that it wasn't half bad or something equally moderate. the registrar of the day probably looked up from his stone surgical tool and remarked "uhgh!" as he made a mental note to remember what he assumed was the prof's favorite biscuit. and thus he started possibly the single longest untested erroneous surgical fact of all time.

p.s it is true that you must be on time though.

compassion fatigue

a while ago i ended up in conversation with a psychologist. she mentioned the danger in her profession of compassion fatigue. the term struck a chord in me. she was referring to people moaning about how tough their lives were when their lives were nothing close to tough. it irritated her and she knew she needed to guard against this. i decided not to even mention to her what my compassion fatigue was like. it might have made her think less of me. i know i did.

he was no more than a common criminal of the south african variety. on that fateful day he decided to rob a small rural supermarket. i suppose he had gotten his hands on a gun and it seemed like the natural thing to do. anyway he entered the store with gun at the ready. he entered the outer door and was in the tiny area of about two meters between the inner and outer doors. just at this moment the owner of the shop was exiting the store and the two found themselves together in this rather cramped space. the owner immediately realised there was something amiss. this might have been due to the fact that he was staring straight down the barrel of a gun. then all hell broke loose.

the criminal didn't say a word. he started blazing away, spraying that tiny space with a hail of deadly lead. the owner dropped instinctively to the ground, drew his own weapon and fired one single shot. when all was tallied at the end, the shopkeeper had come off better. he had been hit in the arm but the damage was minimal. his shot, however had entered the criminal's head on the side just in front of the temple. it had then passed through both eyes and exited on the contralateral side at about the same place. the guy would be blind for life. i reflected that his terrible aim would now be even worse. it would definitely be a problem with his chosen profession.

the other case i thought of was a car thief i once treated. he got shot in the line of duty. he was innocently driving away at high speed in a car he had just liberated from the rightful owner when the police, who were on his tail, shot him twice. the one bullet took out his femoral artery. the other shattered his knee and tibial plateau of the other leg.

to cut to the chase, we cut his leg with the arterial injury off to save his life, he was that far gone. the orthopods stuck an exfix over the knee on the other side. and then he gradually recovered. at about this time i was transferred to orthopaedics so when he developed a pseudoaneurysm of the popliteal artery of his good leg i just heard about it via the grapevine. i also heard that they were going to give it some time before they operated, hoping that...well i don't know what they were hoping actually. anyway safely tucked up in the orthopaedic hospital it was not my problem.

then i learned that the orthopaedic surgeons were going to try to repair the tibia and i was going to be involved. step one was to get the patient down to the orthopaedic hospital from the main hospital. other than the usual administrative frustrations, he was finally loaded into an ambulance and brought down. it was the loading out that proved to be tricky.

as the ambulance drove into the parking area of the orthopaedic hospital the aneurysm burst through the skin and the patient started bleeding all over the place. he was rushed straight into theater and yet still by the time he got there once again he was flirting with death. the vascular surgeons were called and they arrived amazingly quickly. they then sort of looked at the leg for a while. after a few minutes of inaction they pointed out that the muscles of the leg were dead. it seemed that the pseudoaneurysm had gradually decreased the blood supply to the leg and by the time the thing had burst in the parking lot, the leg was already in a bad way. they then instructed us to remove it and left. the orthopaedic surgeon in turn instructed me to remove the leg and then he too left.

as i lopped off the limb i reflected on this twenty something year old who now had to face the challenges of life without a leg to stand on. it seemed sad. but then i realised my own car had been stolen only about a month before and it was not completely impossible that this person could be the very person who had stolen my car. it was the life he had chosen and the risks were part of that life. i struggled to feel sorry for him. besides, i reflected, he would no longer be so fast when running away from cops in the future.

the first time i realised i had compassion fatigue was around intermediates (roughly half way through specialising). i was warn down from cases like the two mentioned above. but there also seemed to be a run of gunshot wounds of criminals that i ended up trying to keep alive at unearthly hours with exams looming. in the end i just seemed to get sick of them and overly sceptical.

then one day i was required to go to some or other awkward social function. at that time my work was so all encompassing i didn't get out much and it showed. i ended us standing away from the normal people and whenever i was forced to speak to one of them, when i looked at them my mind kept on repeating one phrase over and over again.

"fresh meat."

i needed a holiday.

who heals the fallen

this is not really my story. but in a sense this story belongs to all south africans. it is our shame and may be part of our downfall.

we are a people at war. we war against ourselves and we war against peace. each fights for himself and bugger the rest. but who heals the fallen? it seems in south africa, quite soon maybe no one.

recently a story made the news. it was shocking, but it actually gives an inclination of how morally decayed south african society has become. an ambulance was despatched to some informal settlement after a household fire burned a child. the caretakers of the child brought the child to an intersection that the ambulance would actually be able to find. quite soon the paramedics were hard at work stabilising the screaming child. at about this stage two armed thugs turned up. they threatened the child's caretakers with their lives and forced them to flee. then, while the child continued to scream in pain, they raped the female paramedics. they were not caught.

yes it is shocking and now the ambulance personnel need to wait for police escort before they respond to calls in certain areas, greatly increasing their reaction time. we would like to believe this sort of thing is isolated but is it? just the other day i heard on the news about another case where a crowd assaulted the ambulance crew because they wanted to help the victim of a stabbing. as i said we are at war with each other and the victim was their enemy for whatever trivial reason.

but the question i end up asking has little to do with the morality of what's going on. that, it seems to me, is obvious. to discuss morality with the people involved in these stories is a waste of time and effort. i wonder when at war, which we clearly are, how is it in your interest to antagonise the medics? yes you may have won today's battle and not actually need a medic, but what about tomorrow? who will help you when you find yourself on the business end of a knife or panga? also the people who give their lives to help the injured and downtrodden are not quite as involved in their petty squabbles as they may imagine. to drag them in and try to kill them for helping the wrong person is both small minded and short sighted. we didn't really need evidence to know the people that engage in this sort of activity fit nicely into this category, but there it is if you want.

a number of years ago a paramedic friend of mine responded to a gunshot case in mamelodi outside pretoria. what he didn't know was that the mob around the patient had little interest in the survival of the patient. they actually wanted him dead. the paramedic therefore in their narrow view of events was the opposition. as far as they were concerned anyone from the opposition should also be dispatched.


he drove into the thick of things in all oblivion. when he arrived he opened the car door to find out how he could help. the crowd immediately tried to drag him out of the car, beating him with fists and the weapons they had at hand as they did so. he quickly realised he was going to share the same fate as the patient, which was, by that time, sealed. by pure accident the paramedic's safety belt was not loose and they could not pull him out. he slammed the car into gear and throttled out of there with his torso leaning out of the open door in true hollywood style.

thereafter the ambulance service refused to respond to calls from mamelodi except with a police escort. bearing in mind our police are stretched thinly on a good day, the whole situation became ludicrous. i would love to believe in some sort of karma where the people that suffered because no help was forthcoming were the people who were responsible for the problem in the first place, but, like all wars, the actual people who suffer will be the old and the weak, the vulnerable and the children. but that is the african way.

anatomy

anatomy knowledge is essential for surgeons. i'm sure most surgeons would say it is the single most important thing in surgery. i would not. knowing anatomy may just not be enough.

somehow south african pathology is unique. by the time the patient presents to us things are a bit advanced (here and here or even here). i suppose you could say it makes diagnosis a bit easier, but it sure as hell does not make treatment easier. once when i was still working quite a lot at the state hospital this became clear to me.

the medical officer called me in. they had a bleeding stomach ulcer patient who for some reason just refused to stop bleeding. it was time to operate. the medical officer was so excited he was jumping up and down. he kept on telling me that he had never seen a gastrectomy before (removal of part of the stomach) and i kept on telling him that these days it is seldom that a gastrectomy is done but rather he was likely just to see the control of the bleeding artery and all would be well. i was less excited. it was late.

when i first laid eyes on the patient a few things bothered me. firstly there was a scar from a previous upper midline operation, probably also for a peptic ulcer. the next thing is his body showed wear and tear far above what his years would have dictated. his face had the signs of both long term alcohol and nicotine use. he was thin and almost wasted. i knew without asking that he was also a habitual grandpa user. then over an above his general state of health, he was pretty bled out. oh well, i thought, you work with what you get.

as we started, my excited medical officer asked me to give him an anatomy lesson during the operation. he knew i liked to teach and what better opportunity to learn anatomy than when the textbook is open before you. yet as i started the operation i went silent.

it was clear someone had operated here before. there were many adhesions to the anterior abdominal wall and it was quite a mission to actually get into the abdomen. once i was inside however, things went very rapidly from bad to worse. what once had been the lower stomach was just one massive ulcer that had penetrated into everything. the ulcer bed consisted of liver, abdominal wall, and transverse colon mesentry. the galbladder had been incorporated into the ulcer and therefore what passed for the stomach. in an attempt to heal itself it had grown into what looked like a fungating mass. in fact for a moment i actually thought it might be a cancer until i realised there was no real galbladder and this strange growth was in fact its remnant, complaining bitterly about its lot. i needed to decide what to do. clearly some form of gastrectomy was required. i should actually say some form of reconstruction was required. the ulcer had already done the gastrectomy. a bit more than a small amount of ingenuity was needed. i got to work, still in silence as i played through the options in my mind.

the medical officer was not silent. he reminded me that he wanted to learn the anatomy of the stomach.

"anatomy?" i asked, "there is no anatomy here. in fact i think we may have stumbled onto the unborn embryo of an alien that has invaded this body. just be glad the thing hasn't burst out and attempted to eat one of us."

i removed the remainder of the alien and tacked together what needed tacking together. driving home, i looked at the starry sky nervously.

six degrees of separation

i try to treat all my patients equally. sometimes i don't get it right i suppose, but i still think i do better than most.

i was as junior as one can get. but as i have touched on before, when i started studying surgery there was a general shortage of staff in the department. this meant i was running a surgical firm long before i was actually capable of doing so. this happened in my first week of running a firm.

a general practitioner phoned about an appendix he wanted to send to us. he spent a bit too much time explaining that they had no money and he had seen the girl as a favour. he threw in that he had managed to have blood tests done at a nearby state facility under the table. with a bit more experience i would have known there was trouble brewing. i did not have that experience.

the patient arrived a few hours later, as the sun was setting. she was a 16 year old girl that looked like she should have had medical aid and therefore not be with us but rather be at some fancy private hospital. i checked her out and went over the blood results that she had been so kind to bring along. to me it looked like she had a clear cut appendicitis and she needed a clear cut to solve her problem. i organised the admission and booked her on the theater list. all i needed to do was run it by the parents who were required to sign the consent and all would be set. there was of course the small matter of never having done an appendisectomy before, but that was a bridge i was going to jump off when i got to it.

i found the mother in the waiting room. i quickly ran through my findings with her and told her that i thought an operation was in order. once again with a bit more experience i think i would have been prepared for her blatant and open aggression. i wasn't.

"and how did you come to this opinion?" she demanded with an accusing look. i was shaken, but i recovered. i went through my clinical findings and threw the blood results they had brought in themselves. then just for good measure i claimed that we were even then sending her for a sonar just to make sure. i also made a mental note to tell a student to rush her off the sonar as soon as i got clear of the mother.

"ok, but i'm not just going to take your word for it. i'll first speak to my husband and i'll get back to you."

"fine, but i'm going to book her on the list so long. we can always cancel later if needed." with that i left (after telling the student to rush the patient off to sonar of course). after that i just got on with the work of the night. we admitted a few more cases, at least one of which i would be required to call my consultant out to operate because of my total lack of experience.

about ten o'clock that night i quickly shot through theater to put yet another patient on the emergency list. the anaesthetist on call stopped me. she also stopped me in my tracks.

"bongi, why is your prof stalking the corridors at this hour?" i may not have had all that much experience but i did know the prof actually being in the hospital so late at night was one of the signs of the apocalypse. i was worried. i felt even worse when i was informed the prof had pushed that 16 year old appendix patient up the list, as high as he ethically could. i was then informed he was preparing to spend the night in the anaesthetic consultants' room. things were looking dismal. i knew i either needed to find him and find out what the hell was going on or i needed to avoid him altogether. avoiding him was not really an option because i would be required to present my call to him the next morning. if he knew that i didn't have complete control of the call, even if it was because he usurped me, it would spell disaster for me. however in the back of my mind was the nagging fact that i had never done an appendisectomy before. maybe he could do this one and i could assist. the next one which was already on the list would be left to me. hopefully watching the prof do an appendisectomy would be all the training i needed.

the anaesthetist also told me why the prof felt it important to do a procedure that was usually far below his great and mighty status. it seemed the patient was a vip. as it turned out, the patient's mother's neighbour's daughter's boyfriend was the prof's son. clearly the prof held his son in such esteem that his son's girlfriend's mother's neighbour's daughter needed his immediate attention. who says six degrees of separation doesn't come in use every now and again?

then, while i was searching the hospital for the prof, he once again snuck into theater where he was informed my consultant would be required to be called out to do one of the other operations on the list. he informed the anaesthetist to inform me that my consultant and not myself should do the appendisectomy. he then left.

telling my consultant that he was required to do the appendix just because of the long and convoluted connection between the prof and the patient was a bit awkward. at least the consultant had a sense of humour and simply accepted his fate.

finally when the patient got to theater we got ready to go. the consultant handed me the knife.

"i think the prof said you were to do the operation." i ventured helpfully.

"the prof isn't here now. i won't tell if you don't tell. cut."

and with that i started my first appendisectomy on a very special patient (or at least her mother's neighbour's daughter's boyfriend's father was important in his own eyes)

as can be expected with a first, i struggled through the operation. the fact that the appendix was very inflamed and adhered to a whole bunch of things in the abdomen didn't make it easier. however, even when i asked the consultant to take over, he refused. he told me that a surgeon can't just back off halfway through an operation and i must finish what i had started. i considered saying i had not wanted to start it, seeing that the prof had pretty much forbidden me from doing the operation and i had only raised the knife at the insistence of the consultant, but i knew what he would say. i soldiered on quietly and finally had the last stitch in.

the next day, on post operative rounds, the consultant asked the patient how she was feeling.

"much better, thank you." said the vip.

"good, "replied my consultant, "we were worried we had done the wrong operation on you."

gee thanks, i thought. imagine what the prof is going to say when he hears from his son who heard from his girlfriend who heard from her mother who heard from her neighbour who heard from our patient what the consultant said.

tutor

training as a surgeon where i trained was somehow secondary to supplying a service. often formal tuition fell away to a senior quickly showing you how to do a specific operation in a somewhat irritated way. half the time you felt embarrassed that you didn't already magically know how to do it so that you could take the immense burden of teaching off the tired shoulders of your overworked senior. the first haemorrhoidectomy i was shown fell pretty much into this mould.

i was still a lowly medical officer when we admitted a patient with a pretty severe thrombosed awkwardness in the nether regions. my senior, a final year registrar, asked me if i had ever done a haemorrhoidectomy. afraid that not having done one would not exempt me from being tasked with doing this one, i discretely pointed out that i had in fact never seen one. i could see the irritation in his face, but he remained calm and told me he would show me how it was done. he then added i'd better pay attention because after showing me one he was never again going to cast his countenance on another anus so long as i worked with him. not wanting to upset his countenance i determined to learn fast.

i remember that haemorrhoidectomy well. i was so on edge to gleam every ounce of wisdom from my senior seeing as though it was to be my only opportunity to learn the procedure. and yet even though he explained every step as he did it it just looked like a bloody mess to me. anyway, that was my training and it had to do. fortunately as the years went by i learned a few tricks, mostly by trial and error, and finally i think i became quite proficient in the procedure.

then, many years later when i had become the senior registrar in the department once again a haemorrhoidectomy found its way onto a list. i expected that i would be the one to do it as i had so many times before. then the boss perused the list. he asked me who had taught me to do a haemmorhoidectomy. when i told him he decided right there that if he had not taught me how to do it, then i probably wasn't doing it correctly. to be honest i thought he might have a point. i mean that operation i had seen so many years ago did simply look like a bloodbath to me. true i had made the operation my own over the years and i even think i had become good at it, but i hadn't really been shown the correct way to do it by someone that at least in his own eyes was an expert. i was actually quite keen to see the operation in the hands of the expert.

at the operation, the boss settled down in the hot seat and prepared to show me his masterpiece.

it was a bloodbath.