knot a good story

probably my favourite operation is a laparoscopic nissen fundoplication. it is a mixture of intricate dissection and technical skills. and probably my favourite part of a nissen is the laparoscopic knot tying. it's just fun and i am usually quite good at it. yet recently while i was doing a particularly difficult nissen with a massive hernia, when i got to about the sixth knot, somehow i just couldn't seem to throw a laparoscopic knot anymore. it gave the assistants a bit of a laugh and a window to tease me a bit. i too had a good laugh, took a moment, and the problem was gone. the rest of the operation was no problem. but i couldn't help reminiscing about another knot tying incident from the old days.

surgeons generally tie knots with only one hand, their left hand. it is a fairly easy skill to learn and yet it is poorly taught. i remember when some registrar tried to teach it to me when i was still a medical student. he sort of took my hands and positioned the fingers as if they were made of wire and would just bend into any position he chose. he then started twisting the fingers into ever increasingly strange contortions as he shouted:-
"now you do this and then you do this and then you do this!" interspersed with "not like that, idiot!" each time my hands didn't immediately fall into the position he demanded them to be in. when i finally got it right by sheer chance i wasn't entirely sure of the correct sequence of d0-this-es to be able to repeat it.

so when i became a registrar in surgery and i was required to teach students how to do the elusive surgical knot i sat down and formulated a way of explaining the steps using words other than 'do this' and 'do that' and without grabbing their hands and forcing their fingers into strange contortions. i then simplified the steps so that even if the student's hands forgot how to do the knot, when they went home they would be able to go through the steps again and reteach themselves to do it. and i had great success. even the most ten-thumbed students could sort of throw a knot after going through my steps.

then one fine day swimmer's chest and i were doing a laparotomy together and i decided to show my good friend, swimmers chest, my surefire way of teaching the knot. of course it wouldn't count if i simply tied with my trusty left hand so i decided to use my right hand for the demonstration. i set up for the knot, explaining the steps. but just as i was about to throw the first knot, the boss walked in to check how things were going. my wrong hand (the right hand) was set up to do the knot so i thought i'd better just get on with it. yet with the boss breathing down my neck and the initial point to tying the knot with my right hand being gone, i somehow floundered. the boss was (k)not one to let such an opportunity slip by. he immediately knotted onto the fact that i was struggling. he leaned in and focused his entire attention on my hands. i needed to get his attention off me. i asked the sister for a needle holder so i could tie with an instrument rather than with my hands. the boss was quick to respond.

"no no no no no bongi. use your hands." i grabbed the suture, but by this time the hands were shaking. i went back to my trusty left hand but as i set up everything just fell apart. the boss' eyes seemed to burn holes into my finders and it felt like so many years ago when the registrar twisted my fingers to their heart's content. swimmer's chest looked at me in amazement. he leaned across and laughingly asked,

"bongi, what's wrong with your hands? why have they gone all stupid?"

"swimmer's chest, here is the suture. i seem to not be on form today. you do the rest." but the boss would have none of it

"no! bongi will continue and throw the knots until the operation is finished."

and so i struggled through the last few sutures that needed to be thrown with the boss' disapproving glare and swimmer's chest trying not hard enough not to laugh.

still to this day when swimmer's chest and i get together he rags me about the day my hands suddenly became dumb and i forgot how to tie knots.

perspectives

somehow we see things differently. i'm not saying we are not part of the common human experience but we are involved in this experience on such an acute level we just end up seeing things differently. i mean if someone drops the word 'urgent' into a message for me i get visions of someone bleeding to death rather than images of having to stop at the shops to buy milk on the way home. maybe what i'm trying to say is we can come across as slightly glib at times. there are so many stories to illustrate this that maybe this needs to be discussed in a number of posts, but i remember when i was confronted by my own attitudes to the realities of life.

i was in casualties resus, a place i really felt at home in. i was stabilising a gunshot abdomen patient and preparing him for theater. it seemed the bullet probably went through the liver and the patient was bleeding enough that i was quite concerned. i was determined to stay with him until i had him under my knife, just in case something went wrong. but once the lines were up and the blood was running in there was little more to do than to wait for our turn in theater. it was a time to sort of stand around and maybe share a joke or two with the rest of the team. it is also a time to see what else is going on in resus.

the patient lying next to mine was a neurosurgery patient. he had been attacked in his house during a break in. for good measure his assailants had driven his skull in with some sort of blunt object. i had nothing better to do so i took a look at the scan. it was clear my neurosurgical colleagues were also not going to get too much sleep that night either. we laughingly teased each other about whose job was the worst.

all this time i noticed there was someone standing just outside the back door of the resus room. he had an expression somewhere between awkwardness and sheer terror on his face. he was clearly totally out of place but he wasn't bothering anyone and i sort of just ignored him. but he looked very familiar, so in between making sure my patient wasn't about to die and teasing the neurosurgeons i racked my brains to try to remember where i had seen him before. suddenly i remembered. he was a pastor at a local church and many years ago, when i was still a medical student, i had seen him there. the polite thing to do would be to greet him, i thought. i moved towards him.

as soon as he saw me approaching he seemed to take a deep breath and gird up his loins and he set out directly towards me much faster than i was moving in his direction. he walked with such a determinedness i wouldn't even have been surprised if he decked me when he got to me. i readied myself to say something, but suddenly realised the usual 'hello, and how are you' somehow just didn't seem to work in this setting. i was formulating a slightly less formal 'hi there' in my mind when he beat me to it and started speaking.

"excuse me," he said with an intense expression etched into his face, "but would it be ok if i prayed with this man who has the head injury?" somehow my 'hi there' suddenly seemed so out of place. even a 'i once saw you in church many years ago' seemed a bit unimportant compared to the fact that his friend would be lucky ever to talk again without saliva running down his chin, assuming he survived. i felt stupid.

i went through it afterwards in my mind. you see when people come into contact with me it is more often than not at one of those extremely important moments in their lives. often the only question to ask is whether they are going to survive or not. things like what ply toilet paper they prefer becomes somewhat irrelevant. but on any given day i may be faced with many people at these crucial crossroads, but each of them will maybe be faced with the situation only once or twice in their entire lives. maybe in a sense sometimes we become used to things no one should ever be used to.

and therein lies the secret. we may never become blasé or glib about the sharp edge of the human condition just because we see it every day. for me it may be just run of the mill or just another gunshot, but for the patient in question it is probably the single most significant moment in his life. even if we can't empathise with each and every patient, we need to remember these facts and respect the patient's experience for what it is, deeply significant.

in the end i mentioned quickly and in passing to the man that i recognised him and then left him to support his severely injured friend in whichever way he saw fit.

silence

one expects a certain level of dignity and decorum from your surgeon. there was an incident when this was so not the case the ensuing astoundment caused such a deep silence one could almost hear a pin drop. it's a pity we didn't.

it was one of those cases you see where some kid has swallowed some object he shouldn't have. this time the x-ray revealed a pin which seemed to be in the kid's stomach. amazingly enough if it gets through the stomach it most likely will make its way throughout the entire intestinal canal and can be left on its somewhat crappy journey. but being in the stomach it is also quite accessible with a simple gastroscope which is not too invasive. the parents were keen for me to try to get it out and i was up for that.

we settled the kid on the scope table and inserted the drip with much weeping and gnashing of teeth. the kid was doing the weeping and i was doing the gnashing of teeth. but once it was up the sedation and procedure we knew would be no problem.

the sedation was injected and quite soon i was peeping into the stomach with my trusty scope. only problem was there was no pin to be seen. i looked at the x-rays again. there the pin was clearly in the stomach and the x-rays had just been taken. that meant the pin couldn't have gone too far. i advanced the gastroscope into the first part of the duodenum (the part of the bowel just distal from the stomach). still no pin. not to be discouraged by disappearing pins i just kept on advancing the scope but still the pin was nowhere to be seen.

finally when i came to the part of the duodenum that straddles the aorta (a big pulsating artery) sure enough there was the pin jumping up and down with apparent glee with each pulsation. it seemed a pity to go to so much trouble to find it and then just leave it there, even if it looked like it was having fun, so i asked the sister to ready the biopsy forceps (that was the only grasping scope instrument we had) and i prepared to remove it.

as i discovered it is not so easy to grab the head of a pin with something not much bigger than the head of a pin, especially when with every attempt the pin bounces around in rhythm to the patient's beating heart. the procedure started getting a bit longer than i thought it was going to be. i wondered what the parents waiting outside would be thinking by this time.

i was just considering giving the whole idea up for lost when the pin seemed to jump into the mouth of the biopsy forceps and we grabbed it. we had a moment or two of panic when the now immobile pin seemed ready to stab the aorta with each pulsation that had so recently been its play mate (pins can be so fickle). so we quickly withdrew it into the stomach...where we accidentally let it go.

the procedure was getting a bit too long and the parents were probably wondering exactly what i meant when i told them it would take no more than five minutes. nevertheless, after working so hard to return the pin to the stomach where it was supposed to be in the first place, i couldn't exactly stop the procedure then. i soldiered on.

it is surprisingly difficult to pick up a pin in the stomach with biopsy forceps through a gastroscope, even for those practised in the fine are of retrieving pins from the distal duodenum as i was. i started to sweat a bit, but i was now in it for the long run. and finally i did get a hold of that blasted elusive pin. i told the sister to hold the forceps as tightly closed as possible and we withdrew it.

we stood there looking at this pin now held by the forceps, but outside the body with what i think was a sort of grudging admiration. i reached for it and the sister released the forceps and...well the pin just disappeared. we looked at each other in silent horror.

"did you see where it dropped?" the sister asked.

"no."

"did you hear it drop?"

"it wasn't that quiet."



yet even then the humour of it was not lost on me. i could just imagine explaining to the parents;

"sorry we took so long but the pin was much further than we thought it would be."

"so you didn't get it out?"

"no we did get it out."

"great. can i see it please?"

"uuuummm...."

the child was still asleep so we had a bit of time. we both dropped to our knees and started searching the floor. but the pin had disappeared. it seemed its super powers weren't just limited to when it was inside the kid, but it retained its elusiveness outside of him as well.

then i wondered what the child would think if he woke up just at that moment to see his surgeon and the sister scurrying around on their hands and knees with their noses right up against the floor. i considered sedating him a bit more so we could find the pin in peace but that somehow seemed wrong. the next thought got to my mouth before i had even properly formulated it.

"sister, don't we have a similar pin somewhere here that we can give to the parents and just tell them it's the one we removed from their kid?" she laughed. i was just about to tell her i wasn't making a joke when the patient started groaning as he slowly woke up. i jumped to my feet, a bit too quickly i fear and brushed myself off. to her credit the sister continued on her quadrupedal quest.

about a minute later, as the child started looking around and demanding his mother, the sister suddenly jumped up with the pin firmly grasped between her fingers. we quickly put it into a specimen container so that it could no longer escape.

i then walked casually out of the procedure room with all the dignity and decorum i could muster and presented this prize to the parents. they had no idea how hard i had worked for it.

grand rounds on south african shores.

it's not just the soccer world cup that is on south african shores but the great grand rounds, something that some would say is far more important than the world cup (ok only one guy would actually say that and he is in a psychiatric institution in outer mongolia) is also presently hosted in south africa!!! proudly south african!!!

but time to see what the bloggers have dished up for us this week.



here is an interesting article sent by preeti kaur which is relevant in the context of the world cup. i must say i think that fifa should stick to soccer and plundering african countries and keep out of healthcare but i may be wrong.


greenpoint stadium

amy tendrich reflects on the lessons learned by the ada.

another blogger making her voice heard in the diabetic community is kerri sparling.


a kuduzela, an variation of the vuvuzela










philip hickey, a psychologists questions the tendency of modern medicine to add a diagnosis to pretty much anything, in this case sexual disorders.



in a somewhat related post james baker wonders if some things that modern medicine has labelled a disease may only be problems of living this thing we call life.


jo'burg stadium










a south african reflects on lessons learned from soccer. fifa, with their autocratic laws imposed on previously free south africans may demand royalties, but then again she has moved to far away shores, so i think she might be safe


the great doctor anonymous touches on an issue that i often think about, the end of a blog. this one touches a nerve with me because i also sometimes consider how long my own blog will live.

a sotho blowing a kuduzela

how to cope with chronic pain has a nice piece on professional sports stars and pain they feel. he concentrates on retired nfl players. if he were to look at soccer players i'm sure he would find the active players cry all the time, especially when the ref is looking.


polokwane stadium

bob vineyard of insureblog shines a light on an aspect of medical insurance that ultimately played a part in the demise of a cancer patient.




south african supporters armed with vuvuzelas, makarapas and glasses (to see better of course)

andrew holtz of mditv tells us that watching soccer may even be more dangerous than playing it, despite the expressions of pain and agony on the faces of the numerous world cup players forever diving.

a man i consider a great blog academic, doctor rich wonders about the motives of people trashing the jupiter trial in an otherwise respected journal.




an old style makarapa with matching spectacles. we can make a spectacle of ourselves if we want to













robin mockenhaupt looks at some financial aspects of prevention of disease in the elderly.


true style south african supporter

louise discusses how some clinics will get hit hard by delays in payments by medicaid.



the goal that wasn't. well done fifa!

walter jessen tells us about a certificate that has recently been launched by the health on the internet foundation. this will hopefully help advice seekers to be a bit more critical about the things they read online.




david harlow looks at health information from a slightly different angle.
good old south african soccer glasses












dr deb gives us advice in the form of tips for mental fitness. have a look how many you do.




the now famous soccer city in soweto

the happy hospitalist has stumbled on a much cheaper alternative to using a translator when you and your patient don't share a communal language. happy, i too have seen this technique used in south africa with similar results.


a band maybe? they at least all play the same note.

jill of all trades talks about something that has always been close to my heart, the training of the future doctors of the world. some day i hope to once again become involved.





the cheating devious uruguay understanding of foot in the word football.

the legendary blogger, dr charles takes a look at an isolation experiment that is supposed to mimic a trip to mars. in the end maby it only mimics isolation. besides, what's a surgeon doing in such an experiment? do they want them to fight?

makes me proud.

doctor bates relays a short humorous story.




my team, although they went out early (and after all it's not rugby)

alan dappen writing for get better health discusses a pleasant encounter with a patient, even though money issues were discussed.

maradona was often more entertaining to watch than the soccer.

and that's it for this week's edition. i hope it supplied a nice few posts for your enjoyment. please feel free to link here.

next week's grand rounds will be held over at captain atopic's place.

grand rounds

i have been bestowed the great and grand honour of hosting grand rounds this coming tuesday. i thought that a general soccer world cup theme may be in order seeing that my country is presently the host of the tournament, so fire up your vuvuzelas and get writing.

all medical or medically related posts will be welcome. of course, with me being african, any submissions from uruguay will not be considered. posts from fifa will also be rejected.

please send all submissions to bongi (that's me) at amanzi dot com not later than sunday 11 july at midnight south african time (i don't know what time that is wherever you are). please put grand rounds in the subject line.

sand through your fingers

something that still gives the old adrenals a squeeze and a vicious kick is the opening of a blunt abdominal trauma patient with a severe internal bleed. but it is so much more than just an adrenaline rush.

the scene must be set. a patient arrives in casualties after having been involved in a massive accident. often there would be people who passed away at the scene who bypass casualties altogether on their way to the morgue. more often than not, some of these people are related to your patient, but that is something to deal with tomorrow. today's efforts need to be completely focused on getting your patient through his ordeal alive.

in casualties everything is a blur of activity. someone is tasked with getting lines up while someone else orders the bloods needed and someone else phones ahead to get theater ready. decisions need to be made about whether intubation is immediately necessary or if it can wait until theater. sometimes there is distraught family outside. they wait expectantly at the door hoping for good news. i make a point of speaking to them if i can before theater. yes, my job is primarily to get the patient through the other side alive, but in the end we are alive so we can live and part of life is love and family. they need to feel like they are at least involved, even if on a very small minor level. also they need to have an idea that things may not turn out well before the time.

on the way to theater, if the patient is not intubated or if we are not doing active cardiac massage, i often peel off to the change room and rejoin the activity as the anaesthetist receives the patient in the theater entrance area. i help with getting the patient onto the bed and then...well then i take a moment. it is a moment before the storm. it is a time when i try to prepare myself for the fight ahead. i also often think about the dissociation between the humanity and the biology of what is about to happen. it is always poignant for me to think that during the operation i will be totally focused on getting the life threatening problem fixed and i will have no place to reflect on the bigger picture. i won't have time to wonder what the person is like or what his hopes and dreams are or who is praying for him to pull through. yes, i won't be able to see him as human until it's all over.

once the gas monkey has everything ready we prepare to open the abdomen. there is a certain technique to doing this otherwise fairly routine action in these types of patients. everything is opened except the peritoneum which is left to last so there is at lease a bit of pressure still on the area of bleeding. then the peritoneum is opened and all hell breaks loose.

the peritoneum is opened from top to bottom in less than a second. masses of blood come pouring out in a wild torrent and abdominal swabs are shoved with little ceremony into the abdomen, starting in the upper quadrants and moving to the lower quadrants. this is a moment that can't be fully appreciated unless you have experienced it. there is shouting and a flurry of activity. any observer will be left with the clear impression that we are fighting for the patient's life. there can be no doubt.

once the swabs are all in and the worst of the blood has stopped flowing it is time to address the source. i usually pray it is the spleen because it can be removed and the problem is solved. the liver bleeders can be a lot more tricky. a massive tear of the liver can bleed copiously. it is relatively easy to control the blood supply to the liver but the venous drainage is a different beast. the liver drains via three veins directly into the inferior vena cava, the biggest baddest vein in the body. retrograde flow through a torn hepatic vein or worse an avulsion of the liver off the ivc itself may even be impossible to control.

with these sorts of injuries the amount of blood in the abdomen is so much when you push your hands into the abdomen to apply the swabs or to give direct pressure your entire arm disappears into the pool of blood way above the gloves. blood then runs down your arm on the inside of the gloves filling the gloves with blood and totally soaking your hand. your hand ends up inside a sort of latex balloon full of the life sustaining blood of your patient. at that moment you are so close to him in so many ways. his life essence is on your hands. sometimes it feels like it is slipping through your fingers and no matter what you do the inevitability of the end seems predetermined. somehow the blood on your hands feels appropriate.

often at this stage of the fight, if the anaesthetist has managed to keep up his fluid and blood administration with the blood loss he may start hinting that things are looking dismal. he may, for instance hold up yet another pint of blood from the blood bank and casually remark

"would you like me to run this through the patient first or should i just pour it out directly onto the floor?" sometimes one has to stop and acknowledge the writing on the wall.

ironically as the awareness of the unvanquished foe sets in, the humanity of it all comes flooding back in torrents that rival the previous blood flow. suddenly you wonder about the patient as a person and how futile it all seems. suddenly you wonder about your own life and that it is dependant on this flimsy body working properly and may be so easily snuffed out. suddenly you think about the expectation the family has of you saving his life, even as that life flows out of the body beneath your bloody hands. the tension i feel then far exceeds any adrenal rush i get at the dramatic opening of the abdomen and during the valiant fight for a fellow human being's life.

sucker

as a registrar i made sure there was no one in my firm who worked harder than me. i would arrive early and leave late and would generally see everyone myself, not leaving it to the house doctor or students. that way when they complained about how hard you had to work in surgery i could justifiably tell them to suck it up and get on with the job. i say generally because there was one glaring and even shocking exception to this rule.

the vascular rotation was the busiest, bar none. there were two of us in the firm so we ended up on call every second night and the calls could get quite tough. one single vascular emergency could destroy your circadian rhythm. yet if there was only one we would boast about the three hours sleep we had managed to get. in that time we considered that more rest than we knew what to do with. the other problem was we had no house doctor so our days tended to get quite busy with all the administrative tasks that were needed to get things running smoothly. so after being there for a few months my enthusiasm for long hours had somewhat diminished.

then suddenly there was an extra house doctor in the department and in a moment of weakness the boss allocated him to vascular (he would often rather put two house doctors in his own firm than send one to vascular). we were ecstatic, especially after the first day when it became obvious the guy was not afraid of work and he also clearly knew what he was doing. we had been given a gem. on his second day on the job he asked us about how the calls worked and what his after hours duties would be. i was just about to tell him that his calls were going to be quite light because we handled pretty much everything, but my colleague spoke first.

"well, you are the only house doctor, so you'll have to handle all the stuff primarily and call us if there is a problem or if someone needs to go to theater." it was so clearly a joke i thought at any moment one of them was going to start laughing. then we would send him home to his new wife and we would continue to slave through the night. but they both nodded. the house doctor seemed to accept this as simply one of the hardships associated with where he had been allocated in surgery. it was my colleague's call that night so once the day's activities had ended i made my way home.

the next morning my colleague told me he had had a great call. the amazingly competent house doctor had handled everything and he had spent the night at home. i was intrigued. i wondered what it was like to spend a vascular call at home. i decided not to tell the house doctor yet that the story of him being on call every night was just ridiculous and let him do another call. the next day he would probably complain so much we would have to inform him that it was just a joke and then life would settle back into its usual rhythm.

my call was wonderful. unlike my colleague i did come out to operate, but all the other peripheral irritations were completely handled by the house doctor. the guy was good. and still he hadn't complained. i spent post call in theater and went home well after the sun had set. i didn't see the house doctor that day and just assumed he was also at home. yet the next morning i discovered he had done another call and once again my colleague had spent the night at home. i started wondering how much of this the house doctor could take. it was clear he was tough, but the question was how tough was he.

and so we sort of never really told him that it had been a bit of a joke and he just kept on working, day and night and night and day. i think we also fell into the luxury of not doing the hard yards during a call and we got used to it. also we knew he was only going to be with us for three weeks and then we would be alone again so i suppose we saw it as a rest in the eye of the storm before the reality of vascular returned in full force.

after nearly two weeks of being on call every single night the house doctor started to hint that he might need a break. they were just hints so we did what any normal male does with hints. we ignored them and hoped they would go away. they didn't. after another few nights he told us he needed to speak to us about the call situation. by this time he was looking a bit worse for wear. who could blame him? he had done a solid two weeks of call on the trot and that in vascular. that was enough to break most people, but he seemed to be at least partially alive still. we agreed to discuss it.

the house doctor explained that he had done more than his fair share and had in fact done much more than the other house doctors in surgery who were doing about one call a week. he went on to say that it wasn't that he was lazy but he just needed a break. he also told us that he was fairly recently married and although his wife was understanding there was only so much a young wife could take of this sort of lifestyle. he told us that he needed to give some attention to his marriage too and couldn't just work constantly. we knew he had a point. he had proven himself beyond our wildest expectations and he did need a break. also secretly we knew that we had expected him to do far more than what was actually required of him. he was well within his rights. we had to relent.

we gave him one night off and told him to be back at work the next day, ready for another weeks call.