you've got to hand it to him

some students refused to listen to good practical advice. sometimes it hurt us all, but sometimes it was good for a laugh.

general surgeons have a reputation amongst doctors. they are viewed as crude, arrogant and even aggressive. this might be because they are often crude, arrogant and aggressive. but yet they are simple folk and can easily be pacified.

he was a private consultant. he was a typical surgeon but he was also a great teacher, if you could look past his rough mannerisms. he only came in one day a week and did a sort of a ward round. but in all reality it wasn't a ward round at all. he would ask us to show him some interesting patients and then he would teach us all about the condition of the first patient we showed him. he never addressed the patient. he never examined the patient. it was more coincidental that we would be standing next to the bed of a wide eyed patient while we listened to his tutorial. he taught us so much, including what a bedside manner should not be. he was also a great example of how not to present a patient to the professors.

"when you present a patient to doctor l," i would coach the students before the time, "do not go into all the detail!! he doesn't care. simply point at the patient and in a loud clear voice shout the diagnosis. then have a piece of paper and a pen ready. every word you hear after that is worth its weight in gold for your exams, so take notes." they all nodded, but i somehow knew they thought i was exaggerating.

the allotted time of the allotted day arrived and we all stood around waiting for the consultant. true to form he was exactly on time. he ignored the students as was his habit and only acknowledged me with an almost imperceptible nod of the head. i greeted him curtly and headed off in the direction of our first patient, which i had specifically chosen because i felt he had the condition the students most needed to brush up on.

we arrived at the patient and the consultant turned to the students. normal human interaction always seemed to be an effort for him. more looking at his own feet as anyone in particular he asked;

"right, whose patient is this?" the student stepped forward.

"mine!" he whimpered.

"well? what are you waiting for? present!" i had trained them well how to present to this consultant and yet i somehow knew what was going to happen.

"uhmm, the patient is a 25 year old black male..." the consultant lifted his head. his eyes were suddenly ablaze with what seemed like years of pent up frustration and anger. he cut the student short.

"do you think i am a blerrie idiot?? i can see the patient is male. i can see he is black. i can see he is about 25 years old! next thing you are going to tell me he is the third child in a broken home? i don't care about all of this. and if you even try to tell me he lives in a house with running water or no running water or whatever i think i'll kill you!! just tell me what is wrong with him!!!" i managed not to laugh, but as the student looked to me in supplication i confess a smile darted across my face. i had warned him. he shrugged his shoulders, pointed at the patient and in a clear voice shouted;

"alcoholic pancreatitis."

the consultant grumbled under his breath and extended his hand to the side, in the true fashion of a surgeon in theater. i was ready with the pen and slapped it sharply into his waiting hand. as if by magic, a sheet of paper appeared before the consultant. i remember thinking that they were at last listening to my practical advice.

thereafter the students (and patient if he was paying attention) got the best tutorial on alcoholic pancreatitis that they would ever be exposed to. i confess i didn't pay too much attention. i was otherwise occupied trying to suppress a laugh.

just when you thought it was safe to come out of the woods

amazingly enough i have been deemed a finalist in the literary category of medical weblog awards of 2010. i am truly honoured and yet...

this nomination comes at a time of reflection and introspection for me. it comes at a time when my writing has waned somewhat and i have even wondered at its point. yet when something like this comes along i truly am humbled and i do consider either continuing this blog or possibly finding another forum for these musings.

anyway, for those that think there may be something to be gleamed from my scrawlings, please feel free to vote for me. however i actually advise you all to use these awards to more thoroughly explore the blogs of my worthy opponents, and if you find their writings more inspiring or more creative then please do not vote for me but rather for them. also the awards are for 2010, so please do not judge me by the recent stuff that finds its way onto this blog. rather delve into some of the posts that landed here in the year gone by. some of them are worth the read i think.

to see the categories and contestants go here.

to vote, go to this page and chose your favourite.

smug

recently i was involved in a discussion with a guy that was explaining how we should understand criminals. the emphasis was on farm murders but we touched on murderers in general, rapists and child molesters. my point of view was that i did not understand them and felt that he was justifying their actions. in the end i was informed that i was smug. apparently that is the word for people that couldn't see the point of view of the poor misunderstood murderers and rapists and molesters.

so smug is what i am, it seems. you see the fact is i can't understand his beloved murderers. i just can't. i also in my smugness wonder how he can, but i think i know.

it has to do with not being in the trenches. it has to do with not being faced with the blood and the tears and the guts and the screams...mostly the screams. it is probably easy to be nice and philosophical sitting snugly (not smugly apparently) in a nice air-conditioned office, philosophizing on the reasons people point a gun at people and pull the trigger. or worse...

the thing is i can't forget. i am scarred. i remember the patient lying in a pool of his own blood, looking up at me and asking, beseeching even to tell him he is going to be ok. i remember wanting to tell him that it would all turn out just fine. i even remember wanting to hold his hand because his mother wasn't there to take care of the emotional side of things. in the end i remember not telling him he would be ok because i wasn't sure he would. i also remember not being the mother he needed in the last moments of his life because that is what it turned out to be. after we had plough through the blood and feces floating around in his abdomen, violated by the bullet fired from the gun of someone my friend feels i must understand, the patient died. he did not die well with his mother or wife holding his hand in love. he died alone in some icu ward with adrenaline being pumped into his veins and oxygen being pumped into his lungs with a scarred doctor who felt that his time may have been better spent holding the patient's hand rather than pouring time and energy into a futile attempt to save his life. you see the reason i can't see the side of the killer is that the killer is still alive and has the sentiments of my learned friend to feel for him. my patient is dead and there was no one next to his bed when he died. there is no one to state his case now.

i remember the baby violated by her uncle. i was just a house doctor, but i had to examine her. the pediatrician couldn't face it. it is quite a thing to see the perineum of a four month old after it has been ripped apart by the penis of one of the people my friend understands so well. feces runs out of the vagina. it leaves a mark on the soul. but worse than that is the cry. the child did not scream anymore. i think it used up all its scream for its entire life during the deed. all that was left was a quiet constant moan. it is the ghostly moan of someone who has learned in her four month existence that there is no one who will come to her aid. there is no one to understand her. it will never leave me. my friend who is quick to understand the violator will call me smug, but may i suggest i might just be jaded?

the women raped is difficult to examine. somehow you feel you are violating her again. you feel you are making the whole ordeal worse. they don't resist. they are already broken. anyway, rape in our country is so commonplace, it may be the one area where i understand that my friend mat have sympathy with the perpetrator, but, sorry, i cannot. for me to examine those women tears me apart. it leaves me with a feeling that my own soul has been violated. that i am forced to do something because someone else destroyed a life. i refuse to see the point of that someone else. if that makes me smug, then smug i must be, but again i suspect i might be jaded.

a bullet can do a lot of damage. physically i think i might have been a witness to pretty much all of it, but there is another side to the story. i remember an old man, shot in his home when he tried to defend his wife from the killers that broke into their house in the early hours, people that my friend chooses to understand. we did pull him through, but not without a massive operation and the obligatory icu time. i remember when he came to me for follow up some time later. i was so proud that he had made it. but somehow he was the shell of the man he used to be. he was alive, but broken. his confidence was gone. he lived in fear. he felt helpless because he knew he could do nothing against the lead of the people who i hear from my friend i must understand and sympathize with. but who sympathizes with my patient whose peace has been stolen from him? the smug or the jaded?

recently i enjoyed my christmas eve over the open abdomen of a woman shot in her bed by strangers, strangers whom my friend has endless sympathy for. i did not enjoy my holiday period, but more than that, my patients didn't either. hopefully my friend, while maybe enjoying a beer with the killers he understands so well had a really festive time. i do not understand him.

pink and purple

recently i discovered the blog of a good friend. only problem is that he is a pathologist. i understand nothing of it, just like in the old days.

in the old days when i was still a registrar we had a joint meeting with the pathologists once every three months. if you ask me it was way too much. you see surgeons and pathologists are poles apart. for one thing, they are quite clever. for another their patients are all stable so there is never any urgency with them. i've heard they have to deal with bleeding a lot less too. but i suppose the clever bit got to me the most.

the way the meeting went was based on patient presentations. we would get a list of the cases they wanted to discuss. the surgeon involved in the case would then be required to present the case in front of everyone. he would talk about the clinical presentation, the findings an then the operation. it would usually end in a description of some or other thing that was cut out and sent to the pathologists. we would then hand over to them. i remember how their eyes would light up when we got to the bit about the thing we'd cut out. you see when they were handed the whatever it was we had removed or excised they got to work turning it into shades of pink and purple.

no matter what it was we presented them with, they would cut it into fine strips, put it on slides, colour it different shades of pink and purple and get very excited. at these meetings they would show us these slides. the thrill of it could often be detected in their voices as they spoke and could always be seen on their faces. they would wax lyrical as they increased the magnification, showing us the pink and purple ever closer. we would look, probably with visible expressions of increasing bewilderment with each new magnification, and nod knowingly. it probably didn't fool them. but the thing that irritated me the most was their standard opening line before they interpreted these pink and purple patterns to the room full of either excited or bewildered nodding faces. they always said the same thing. i think they might have been taunting us.

"as you can see..."

abroad

i'm of the opinion south africans have a good sense of humour in general. you have to be able to laugh at the absurd with a government like ours. and yet i do think we need to be a bit cautious about how we express that sense of humour while in the presence on non south africans. in general when you are working overseas in a foreign culture, you might want to be careful in the expression of your sense of humour.

like many south african doctors he had gone overseas to make a bit of money faster than it is possible on our shores. soon he was raking in money presiding over the sleeping while foreign surgeons plied their trade. yes, he was an anaesthetist.

now quite often the relationship between anaesthetists and surgeons can be strained. i can only assume it is worse when a language and cultural barrier are added. then there is the question of being in unfamiliar surroundings where more likely than not, things are done differently to what you are used to. it is probably best to keep a low profile and to not stand on anyone's toes. this anaesthetist did not believe on standing on toes. he went straight for stomping on their feet.

it was a neurosurgery case. the anaesthetist was of the opinion it was a non-starter and i suppose that's where it all began. there was tension between the neurosurgeon and the gas monkey right from the word go. but what could the south african giver of gas do? he had to dope the patient.

the operation got underway. quite soon the anaesthetist realized it wasn't going well. he couldn't understand a word of what the neurosurgeon, his assistant and the sister were discussing, so it wasn't really something that was said that cottoned him onto the fact that things were heading south. it was more the amount of brain tissue the neurosurgeon was suctioning out of the patient's skull that the gas monkey viewed as suboptimal. and as the operation progressed he passed through being perturbed and went right on to being amazed. it seemed there was no end to the stream of brain tissue that made its way through the suction tubing into the suction container.

after a while, once the anaesthetist was sure all the maths and science had been suctioned out, he took a more philosophical approach. it seemed to him there was little he could do to make the situation any worse so he just sat back and waited for the suction crazed surgeon to stop. and finally the surgeon did stop. he then got to the work of closing up, which in neurosurgery takes quite a while in itself. then he turned to the anaesthetist and for the first time spoke in a language he could understand.

"ok, you can wake the patient up now." the anaesthetist initially thought he must be joking, but there was nothing but an earnest expression on his face. he stared at the neurosurgeon in disbelief. the neurosurgeon stared back. "i said you can wake him up now!"

the anaesthetist shrugged his shoulders, strolled over to the suction container where it stood on the floor with its grizzly content. he then crouched down and started knocking on the side of the container.

"sir, you can wake up now!" he shouted.

thyroid fun

the way i do thyroidectomies (removal of thyroid) these days and the way i did them in my training differ radically. these days i use a fancy instrument that cuts and seals the vessels simultaneously. it also can cut through the thyroid tissue with little to no bleeding. during my training we simply didn't have these sorts of fangled tools. we had to painstakingly deal with each minute vessel individually, tying them off one at a time. also when it came to cutting through the thyroid tissue it could get a bit bloody. we would put clamps directly onto the thyroid itself and cut above the clamps. then we would quickly suture the cut surface closed before there was too much blood loss. it could be exciting. it was once a scream.

i was a lowly medical officer but i was working with the best registrar in the department. but on this particular day he was quiet and pensive. he just didn't seem to be himself.

"what's eating you?" i asked. he looked up at me.

"the thyroidectomy on the list this morning. the patient has graves disease. these days you're not supposed to operate graves disease but the prof doesn't like all these new fangled radiotherapy treatments and has instructed me to operate the patient." it didn't seem such a problem to me. if the prof had decreed it so then it was so and there was nothing to do but to operate the patient. he continued.

"only thing is there is a very good reason we don't operate graves disease anymore. you see they bleed like stuck pigs. a graves thyroid is super vascular and brittle. it is difficult and a bit risky to operate. i'm not sure i can do it. also you know the prof is actually semi-retired and he won't scrub in with me. anyway he won't be much help. his hands are no longer steady." i could see his point. still he had no option. he would have to simply put his head down and do it.

we exposed the thyroid nicely. it was massive. it sat there in the neck definantly throbbing, daring us to challenge it. what it didn't realise was that although it was very intimidating it was not nearly as intimidating as the prof. we went ahead.

as the registrar placed the clamps onto the thyroid i could see his hands shaking visbly. it seemed ironic that hands that were not steady was the reason given that the prof could no longer operate. maybe my registrar was doomed to have a very short career. i didn't share these thoughts with him. i thought it better to just be supportive and encourage him. by the time the clamps were in position the monster was already oozing quite a bit. now it was time to cut it.

it's difficult to fully explain what it looks like when you slice through a thyroid afflicted with graves disease. the effect it had on my registrar and myself was also profound. as the blade slid through the tissue blood just started pouring out in multiple streams of differing intensities. it was quite an impressive display. by this time my hands were shaking too. this was going to be difficult. as the knife finished its course through the now angry thyroid and the registrar lifted the offending tissue free of the patient we suddenly heard a voice behind us.

"hello. how are things going?" it was the prof who had quickly come in to check on us. my registrar spun around, grabbed a swab and shoved it onto the bleeding thyroid tissue still in the neck and pushed as hard as he could down on it to try to control the now liberal bleed with pressure while he spoke to the prof. it was never ever a good thing to let the prof wait.

"ok, prof. it's just bleeding a bit." a bit? i thought. i would have used words like 'gushing' or 'exsanguinating' or 'please help us mere mortals', but my registrar simply said 'a bit'. the prof took a closer look. i could clearly see the white swab changing colour to bright red under the registrar's hands. the prof moved back and then spake he.

"yes, graves thyroids can ooze a little, but you seem to have everything under control." his eyes must be the real reason he can't operate, i reflected. again it seemed prudent not to share this opinion. "i'll be in my office. let me know how the rest of the operation went when you are finished." and with that he was gone.

we stood there in the silence of the wake of the prof. i just started laughing. it was all so absurd i couldn't help it. my laugh shook the registrar out of his trance and he got back to work.

once it was all over, unlike my prof, i was a firm believer in radioactive ablation for graves disease.

reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.