vascular cuts

anyone who knows me knows i hate vascular surgery. it is hard work with little reward. scratch that. when you actually get i nice pulsating distal artery the next day you almost think the night's hour upon hour of work may be almost worthwhile... almost. but all too often vascular operations were one small step along the road to disaster.

i suppose one of the reasons i dislike vascular so much has to do with my exposure to vascular during my registrarship. we had a very good department and there was always a vascular fellow who was not only interested in vascular but competed actively to do as many operations as possible. this meant us mere registrars didn't do too many worthwhile cases. we assisted and we did the grunt work in the wards. vascular was also amazingly busy and very demanding. these things all conspired together to leave in me an enduring dislike for the discipline.

i also don't think i was the only one who felt this way. most of us disliked and even dreaded our vascular rotation. that didn't mean we couldn't have the occasional laugh at some of the things that went on. for instance we used to have a saying about the femoro-popliteal bypass operation (to place a bypass from the femoral artery in the groin to the popliteal artery just below the knee.) you see this is generally done on people that have been smoking their whole lives as a last ditch effort to prevent amputation. the patients were usually wreaks. the smoking didn't just destroy that single artery but it destroyed all the arteries to a greater or lesser degree. at best the bypass would improve the blood supply, but not always sufficiently. all too often after hour upon hour of tedious labour, the leg would remain threatened and often an amputation would be carried out a day or two down the line. we jokingly referred to these patients as fem-pop, fem-flop, fem-chop patients. the fellow tended to get a bit annoyed about this. he took his fem pops very seriously and any suggestion that it was a small step towards the inevitable below knee amputation was met with open hostility from him. we knew not to say this in front of him.

but the one time i remember not being able to hold back my laugh even as the fellow's face became red with rage and his knuckles turned white as he grasped his dissection scissors deserves mention.

we were doing a fem-pop bypass. now part of this operation is to remove the superficial vein in the leg (the saphenous magna) and to use it as the bypass for the artery. the result is that it is necessary to make a long meandering incision from the groin all the way down to below the knee. so although the artery is only exposed where the proximal anastomosis and distal anastomosis are made, the incision runs for the entire length of the bypass. the fellow was delving into the groin looking for the artery while i dissected out the vein. there was the usual theater small talk. then one of the junior general surgery consultants trotted in. he immediately saw what operation we were busy with (there are not exactly many operations that require this length of a cut down the leg). i think i might have seen an evil grin on his face. he turned to the fellow.

"hi. my but that's a big incision just for a below knee amputation." i fell about laughing.

eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'

focus

one of the all time legends in medical blogging has to be suture for a living. she doesn't only patch people up but she sutures other stuff to make amazing works of art. i suppose this is not too surprising. in the end plastic surgeons are so much more artistic than us mere general surgeons. but i like to think that when the chips are down and the pressure is on, we can focus and place stitches almost as well as most plastic suturers.

it was one of those days. i was on call and all hell was breaking loose (again). i didn't seem to be able to get ahead of the deluge of work. too many people were trying to bleed all over the place at the same time and there were too many people in casualties demanding attention. suffice to say when the internist stopped me in the passage to discuss a patient with him, i was a bit irritable. internists have a way of drawing a story out. they are just not like us. they don't have our sense of urgency and when they stop you in the passage to discuss a patient, it shows.

i quickly realised the internist was going to string the discussion out as long as possible. it was frustrating, but it was also important to maintain a good relationship with our long winded colleagues, so i decided to accept it and be patient. in an attempt to settle down i even lifted myself onto the windowsill and consciously relaxed. i allowed him finally, after some meandering, to get to the point. i was actually amazed that i could bring my basal metabolic rate down to his for the duration of his drawn out discussion. finally he concluded his communication with me and readied himself to leave. even this took time. i jumped down from the windowsill in a smooth motion that i hoped looked emphatic. unfortunately my trousers hooked on something and i tore a massive hole in them.

great, i thought. now i had an unsightly tear in a somewhat unflattering position on my trousers, pretty much displaying my underwear for all to see and i had no time to rush home to change them. as the internist slowly sauntered off to continue his day in slow motion i even had a thought of wrestling him to the ground and stealing his trousers. however i quickly realised that would do nothing to the already strained relationship between our relevant departments and gave up on the idea. i would have to come up with a better plan. then i realised, i'm a surgeon. if i can close an abdomen then surely i can close a mere hole in my pants. the solution was obvious.

i rushed off to theater at a speed that would probably have given my internistic colleague whiplash and asked the sister there for some vicryl ( a type of suturing material). after all it was a thread i was familiar with. i then went to the surgery tea room which was adjacent to the female surgical ward. fortunately the tea room was empty so i got to work.

now vicryl (and pretty much all surgical suturing material) is made already attached to a semicircular needle. to use it properly one needs a surgical instrument. i had a leatherman which would have to suffice. unfortunately, a laceration on the nether regions of the trousers, even in the hands of a very skilled surgeon, can not be addressed while the trousers are still on. there was only one thing to do.

i sat on the bed in the tea room and dropped my trousers to around my knees. this presented to me the laceration pretty much between my knees, an easy place to work. then i started the repair job.

the sisters knew that i spent my spare time in the tea room and would therefore often first look for me there before paging for me if there was a problem in the ward. as luck would have it, one of the sisters came looking for me as i laboured over the laceration of my trousers, dropped to knee level. she walked in and addressed me. only once she was halfway through her question did she look up to see me sitting there, trousers down, working furiously with needle and thread between my legs. she doubled over in laughter before running out. i looked around to see what was so funny. not seeing anything from my point of view, i dropped my head again and continued my operation, totally focused.

moments later, pretty much every sister from the female surgical ward was crowded at the door to get a glimpse of the surgeon caught with his pants down. i watched them as their bodies shook and almost convulsed as the waves of laughter engulfed them. most of them then threw themselves into each other's arms and held each other until tears ran down their faces. i was focused. even the noise wouldn't distract me from the operation i was required to perform. the sisters then disappeared.

soon afterwards the sisters from the male surgical ward were also huddled in a tight group at the door, writhing in mirth and wiping each other's tears. again i smiled at them and returned my attention to where it was needed. finally i finished the procedure. i stood up, pulled my pants up and closed the things that needed to be closed. by then i was alone again, but the loud laughter stilled echoed through the corridors for some time afterwards.

yes i doubt my job was as neat as the work of my friend and fellow blogger, doctor bates, the plastic surgeon, but then i wonder if she has to contend with the amount of laughter i was requited to deal with while working.

in for the high jump

sometimes patients can follow you when you rotate to another discipline. sometimes this can be tragic. sometimes it can be funny. and yes sometimes it can be both.
the patient was tired of life. he addressed this problem by taking a massive amount of a large variety of pills and very nearly ended it all. however the internists would hear nothing of it and fought tooth and nail for his life, partly because of the efforts of a certain house doctor who really invested of himself to pull the patient through. every day, while the patient was in icu he visited and tried the best he could to support him. he even started learning the fine art of ventilation by simply observing the daily settings of the ventilator by his seniors. when the patient went to the ward he could be more directly involved. he did all the necessary blood work on the patient, but also consulted both the psychiatrist and the psychologist. he even spent time just trying to encourage the patient.

but in a certain sense it was a bit of a one sided relationship. you see the patient wasn't overly delighted by the fact that the suicide attempt had been thwarted and he went as far as to take it out on the poor house doctor. i suppose it was inevitable. you see the house doctor was the face that the patient associated with the hospital and the doctors and the house doctor was therefore the target for his resentment. but to his credit, the hapless doctor didn't show signs of this getting him down, although inwardly he was struggling a bit. as you can imagine, he was only too glad to rotate from the internal medicine wards on the 4th floor down to the lowly surgical wards on the 2nd floor. unfortunately his fellow house doctors rotated with him. even more unfortunately surgeons are not know for their finely developed sense of understanding and sympathy of emotional issues.

we were standing on the balcony of the doctor's tearoom. the fellow house doctors were having a bit of a go at this poor house doctor about the fact that despite his best efforts the patient ended up hating him the most. the surgical registrars gave their five cents worth about not investing too much time and effort into someone who just didn't care and essentially didn't want to live. the house doctor took it all in his stride and even laughed at the whole situation. yet even then he defended the actions of the patient, talking about decreased personal responsibility due the a defined psychiatric disease. the surgeons, who essentially stand by the dictum that if you can't fix it with a knife then there is nothing wrong with the patient, ragged the poor house doctor even more. the house doctor smiled and answered.

"anyway it doesn't matter anymore. i've been rotated to surgery and it is unlikely the patient will follow me here." with that he turned to gaze forlornly out over the balcony..... just in time to see his patient whizz past in his brief but rapid journey to the concrete floor below. life was still too much for him and he had jumped.

the house doctor rushed down and commenced the resus. in the end he was also the one to call it. the patient had tried to follow him, but had overshot the mark a bit. the words of the surgical registrar which had been shouted to him as he charged out the ward probably didn't help with his overall demeanour:-

"now at last there is something wrong with your patient."

the gift

sometimes a patient will give a thank you gift to me. sometimes they want to give more. i'm always a bit awkward with this.

the casualty officer called me and told me he had admitted a patient with an acute abdomen. this is surgical jargon pretty much meaning that the patient needed a laparotomy, most likely as a life saving procedure. i immediately went to see him.

the abdomen was supremely tender and i agreed that it looked to be a case for theater. but then the patient told me that twice before in his life he had presented at different hospitals with the same pain. the surgeons on both occasions had rushed him off to theater and found nothing. these two operations had then indirectly given rise to a multitude of other operations for obstruction. he even volunteered the information that the last surgeon who had operated him told him he had a frozen abdomen (a frozen abdomen is the condition when all your intestines are adhered to each other because of multiple previous operation. it is a nightmare to operate and associated with a high chance of injury to the bowel). red lights were going off in my mind. i decided to see if we could avoid an operation.

the ct didn't show any calamity in the abdomen but there were signs of partial obstruction which was consistent with frozen abdomen. i approached the patient and explained that we were going to try to avoid an operation, but if his conditioned worsened, then we would have no choice. i also explained that an operation in his case held a very high risk of complications. combined with his advanced years, these could be serious.

he recovered well without surgery. i was relieved. every day we would chat less about his medical condition and more about him as a person. it turned out that he worked in one of the fancy private lodges in the kruger and he was keen for me to visit. i said thank you but in myself i sort of knew i wouldn't take him up on his offer. i mean after all i hadn't necessarily gotten him through his ordeal yet.

when he left the hospital again he told me i must visit him in the kruger. again i thanked him but soon forgot about it.

some time later he presented again with abdominal pain. again the ct showed pretty much the same partial obstruction, but with impressively dilated small bowel (worryingly so). he informed me that he lived with a constant degree of abdominal pain and felt he could not go on. once again i told him that an operation would be risky but it could be considered. he felt there was nothing to consider. according to him anything was better than his present life of pain and misery. at that time he told me that i could do with him whatever i liked. he thought i was the greatest seeing that i so far was the only surgeon who didn't rush him off to theater and rip him open from stem to stern. i wanted to mention that we both had been a bit lucky, but i sort of liked the adoration so i just smiled. we decided to proceed.

just before theater the patient reminded me to visit him in the kruger and then the penny dropped. i realised the reason i was reluctant to accept is sometimes my patients die. i can't always predict who is going to die and who is going to make it. to accept such a wonderful gift from this man seemed wrong, especially in the light of the fact that i was not convinced the overall outcome would be favourable. it seemed a bit too much like taking advantage. i suppose in a way i was keeping myself at a distance from the humanity of the man in order to better do my job. i suppose i was also thereby denying myself my own humanity.

the operation was tense but it went well. he recovered and afterwards once again swore i was the best surgeon in the world. i was just glad things didn't go wrong. i didn't really feel that i could take either credit for the good outcome or his gracious gift of time in a fancy lodge in the kruger.

we parted company and i'm happy to say i never heard from him again. happy because that meant things were probably going well.

then some years later i was asked to see another patient. it was a case of severe abdominal sepsis. once again this is a condition that in certain cases can be the event that ends the patient's life, but i was confident i'd be able to pull her through. early on in the management there was talk of a private game lodge and once again i sort of brushed it aside. i pushed through the operation and the post operative period.

but as time went on, it quickly became apparent that survival was assured and i even started hoping for complete recovery. finally she went home in good health. then and only then did i questioned my usual approach of not accepting these sorts of gifts from patients. i mean in the end it was offered in good faith and with pure intentions. and it did seem unlikely that she would complicate at this late stage. i started considering it. after all i have often said my job is to return people to their humanity. now that she was back to a point where she could go on with her life and be herself again, wasn't i now stopping her from doing something that is quite human, ie the heartfelt giving of a gift. also it had something to do with my own humanity. so often when i'm treating patients i need to separate myself to a certain degree to keep perspective and to allow myself to do my job without being too clouded by human emotions. and yet essentially i am human and i do have human emotions and i do want to get to know people as they are and not just as the patients that lie before me.

so in the end, more in attempt to try to restore my own humanity, i accepted. it was a magical place with wonderful people and a real balm for my soul. m and b, thank you very much for allowing me to find my humanity again.

neurosurgery

during intermediates we were required to rotate through all the surgical disciplines. one of our rotations was therefore neurosurgery. those guys really work hard. i think it's fair to say they almost work as hard as us general surgeons. without a doubt, besides us, there was no other surgical discipline that came even close as far as hours and hard work were concerned. and yet they were very different to us.

certain conditions are considered surgical but it does not necessarily mean all surgical conditions are for operation. we will happily accept for example a bleeding peptic ulcer and treat it medically, only operating if it becomes absolutely necessary. the neurosurgeons, however, tended not to do this. if they weren't actually going to operate the patient they simply didn't accept him. so a peripheral hospital would send a scan through for their opinion. if they saw that either no operation was necessary or that the patient was in such a bad way that even an operation wouldn't save him, then they simply didn't accept the patient. cases from casualties with fractures and also some degree of suppression of consciousness who were not destined to fall under their knives they would also not accept. the poor orthopod would get stuck with a semi conscious patient that he wouldn't really know what to do with long after the bones had set.

so when we were getting tutorials from the neurosurgeons i thought it funny when they gave a long talk about the management of a patient with mild neurological suppression. i was even surprised that the consultant giving the tutorial seemed to know how to handle such a patient. being in the department i had seen no evidence whatsoever that they actually ever did handle such patients. fortunately i kept my thoughts to myself (i achieved this by biting my bottom lip every time i was tempted to say something. other than the slight taste of blood i suffered no ill effects like failing my neurosurgery rotation which is a lot worse than the taste of blood).

when the intermediate exams were around the corner i once again enjoyed the humour in the rumours that the management of mild head injuries was supposed to be a spot from the neurosurgeons. i couldn't help wondering who would mark that question. maybe they could ask the orthopaedic department to help them.

finally the exam day arrived. when i saw the question actually turn up in the exam as so many of us had guessed it would i found myself chuckling at the thought of some burly orthopod trying to read my handwriting. i also wondered if the neurosurgeon was honestly asking because he didn't know.

in the end, after considering simply writing:-
'break the patient's leg and turf him to the orthopods,' i buckled down and answered the question.

the silent treatment

misunderstandings are bound to happen. sometimes i just wish i could understand the misunderstandings

i generally got on well with the anaesthetists and this one was no exception, despite a slightly rocky beginning. in fact after that i actually looked forward to working with her. the atmosphere in theater would be light and jovial and we would exchange jokes and laughs. then a time passed when we just ended up not working together. the lists just happened to be dealt in that way. so when i saw her in the theater complex after this time i thought i should say hello. it seemed to polite thing to do.

she was chatting with one of her colleagues. i walked up and waited for a lull in their conversation. her colleague, also someone i knew well, turned to me and greeted me with a broad smile. we shook hands. then i turned to her to greet her. she turned around and walked away. i was quite surprised, but assumed she had something on her mind and let it slide.

the next time i saw her, once again i approached to greet her, but as soon as she saw me she made a speedy exit. i realised there was some or other problem that she had with me, but i didn't know what it could be. after that there were a few more similar incidents that left me in no doubt she didn't want to speak to me at all.

then we were allocated to each other for a list. she could not run from me. yet somehow she managed to avoid all human interaction with me for the duration of the list. she did her work and pretty much ignored me totally. by this time the situation was no more than an irritation to me. my feeling was that if she had something against me she should discuss it with me and if she didn't want to then i pretty much couldn't be bothered with her childish behaviour. i ended up ignoring her in equal measure.

then one of those cases that age both the surgeon and the anaesthetist came in. i was the surgeon on call and she was the anaesthetist on call. once again we were thrown together. but during these cases there has to be at least a little bit of contact between the cutter and the gasser, yet she still absolutely avoided speaking to me. while we were busy we were both so involved in our relevant roles in trying to keep the patient alive that the silence between us was at least not awkward. as it became clear that we were at least going to get the patient off the table and into icu i asked her a few questions pertaining to the stability of the patient, but i made sure i kept it business-like. she answered only as much as she was required to. it didn't bother me. the life of the patient was more important than whatever the misunderstanding she had with me.

when a patient is taken to icu while still ventilated, both the surgeon and the anaesthetist would accompany the patient together and this was no exception. and so it transpired that we ended up in the lift together with the patient. i looked at the anaesthetist. i could see her nerves were frayed. the case had been a nightmare and she had done well to keep the guy alive while i did my best to patch him up. i reflected that her efforts to ignore me must have made the whole experience even worse. i felt for her.

"well done. i really couldn't have done this without you excellent handling of the anaesthetic. thank you" i really meant it. despite whatever her problem with me was, she deserved a compliment for a job well done and i was not about to withhold it from her. that, to me, would be worse than what she was doing by ignoring me the way she was. i could see her shoulders drop as the pent up tension seeped out. she even smiled a bit, but still said nothing. it was ok. i didn't need her to.

some time after that we did a list together again and she started speaking to me. i involved myself in whatever conversation she initiated, but i remained cautious. after all i still had no idea what the episode of silence had been about and our relationship was pretty much destroyed, so i kept things fairly superficial. but i must admit i was glad that she had finally started getting over her offence. things went on pretty much like this for a while. we were civil with each other but we were not close by any stretch of the imagination.

then about a week later we ended up in theater together again. i was chatting merrily away with my assistant as is my habit during surgery and occasionally the anaesthetist would join in the conversation. things were almost back to normal. then i made one of my standard fairly weak bongi jokes. i can't seem to help myself. she turned to me.

"careful what you say, bongi, i have only just started speaking to you again after nearly a year. you don't want to mess it up." this was the first time she had acknowledged any such thing which could be seen as a breakthrough i suppose, but i was immediately annoyed. i felt that she shouldn't think her opinion of me would in any way affect who i was and how i interacted with people, especially when she thought she was punishing me with her silence. i was not impressed.

"yes i noticed something like that." i replied. "i still have no idea what all that was about."

"you know exactly what it was about." she said, almost accusingly.

"sorry to burst your pretty little bubble, but i have no idea what it was that you took offence at and quite frankly i don't really want to know."

fortunately after that she finished her specialisation and went on her way. i knew we would never work together again and, all things considered, it was probably for the best.