banter

of all the specialities, i like the anesthetists the most. some of them are even my friends. this doesn't mean there isn't some degree of niggling that goes on between us.

during anesthetics there are two crucial times when things can go horribly wrong. the first is when the patient is put to sleep and the second is when the patient is woken up. during most operations the time between can be quite routine and even mundane. the patient can almost be put on autopilot and the anesthetist has very little to do except maybe catch up on a bit of reading (there are exceptions). yet strangely enough the one quality gas monkeys appreciate above all else in a surgeon is speed. somehow they seem to want to get through the stress free stage of the operation (for them at least) and move on to the part where things could potentially go frighteningly wrong. maybe they get bored, i don't know.

so the anesthetist thinks the surgeon is great if he gets the operation done fast and he also takes a certain amount of pride in waking the patient up moments after the operation is finished. this way the surgeon, who usually does not appreciate waiting around for anything, doesn't end op waiting around for changeover time. i suppose you could say we work fast to impress them so that they will work fast to get the one patient awake and the next one on the bed as fast as possible and thereby impress us. yet in my opinion there are things worse than waiting a minute or two longer between cases. i don't like working on awake patients. also for some reason that i can't fully explain if you finish the operation before the gas monkey is completely ready to wake the patient up, they tend to get the impression you are super fast.

then of course you get the two basic types of anesthetists. the first type shows an interest in the operation and knows when to start decreasing the gas. the second type has little interest in the operation and is possibly more dedicated solely to his craft. he will often ask for a heads up when the operation is nearing its conclusion (i once wrote about such an anesthetist)

if you put all this together, due to the fact that i can't always predict how far i am from the end of an operation and that i've had a previous nasty experience with patients moving while i'm trying to place the last stitches i tend to wait a while before i warn the gas monkey (that's if he asks) that things are coming to an end. so a typical conversation with a good gas monkey friend of mine would typically go like this.

"bongi, give me a warning five minutes before you've finished."

"sure." i'd answer, wondering how exactly i would know when five minuted before the end would be. then i'd go on merrily, secretly keeping one eye on my sandman friend to see if he was following the operation. if he was not i'd pretty much wait until i had only one more stitch to place. i'd then glance up and announce;

"five minutes to go." i would then bow my head and carefully place the last stitch. once i was happy with that stitch, i'd look up.

"finished."

i'd be lying if i said i didn't enjoy the reaction this usually elicits from my friend. he tends to go on about now having to wait for the patient to wake up, something i'm not overly worried by as i have said. i also enjoy the illusion it creates with him that i operate fast.

it is all done in a very good nature and our friendship is not at all affected by my possibly juvenile behaviour (i hope).

friends?

there is a sort of love/hate relationship between the surgeons and the anesthetists. neither one can survive without the other. we supply them with work and they get the work to lie still while we cut and dice. yet their job is to keep the patient alive while we challenge their ability to stay alive. at the moment of surgery they play good cop and we play bad cop. of course after surgery the good cop is suddenly the surgeon through and through. but that is another story.

i really appreciate a good anesthetist (i've had bad ones) and to tell the truth these days i'm spoiled by the quality of the gas monkeys that i work with. however many years ago i remember a case where the anesthetist and i had a misunderstanding about time frame.

i was doing a laparotomy in kalafong. the gas monkey was a long term medical officer. he had attempted to specialize in anesthetics but simply had not been able to pass. in the end he found himself stuck in a senior medical officer job with no way of advancing himself. he was a bitter little man and it was easy for him to take his bitterness out on surgeons.

towards the end of the operation when i started closing the sheath the patient's abdominal muscles were so stiff that he was pushing all his intestines through the wound. this did not mean the patient was awake. it simply meant that his muscle relaxant had worn off. it was a tricky time. i needed the patient to be at least partly relaxed, but if the gas monkey fully relaxed the patient he would not be able to wake the patient directly after the operation, thereby wasting all of our time. a good gas monkey will find a compromise between these two extremes. i did not have a good anesthetist. he was also more stuck on the hate side of the relationship between our two disciplines.

"the patient is pushing a bit." i hinted.

"the operation is almost over," he snapped, "i'm not going to relax him any more. otherwise he'll still be asleep half an hour from now". i was annoyed to say the least, but i knew it was a fight i couldn't win. it seemed so important to him to get this patient off the table in half an hour. i smiled. i could close this abdomen with the patient pushing against me, but i couldn't do it in half an hour. it would take longer. i decided not to share this information with my touchy friend. i buckled down and got to work.

it turned out more difficult than i initially thought it would be. each stitch was an effort and my assistant ended up straining against the patient to keep the tension on the suture. the gas monkey started becoming edgy, but i ignored him. if anything i slowed down my pace, making sure that, despite his best efforts, i closed the sheath properly.

about an hour later when i finally had it closed the qwasi-gas monkey was so irritated that he couldn't sit still. i was smiling behind my theater mask. i knew i had closed the sheath properly despite his inadvertent attempt at sabotage. and maybe next time he would pay slightly more attention to my seemingly ridiculous demands.

doing nothing

surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. i remember one time that this turned out to be slightly humorous in a morbid sort of way.

i was in my vascular rotation which was not too much fun (except for a short moment). generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. and there was pretty much nothing worse than an abdominal aorta aneurysm (aaa). scratch that. a bleeding aaa was a lot worse than an aaa. so when casualties called and said they had a bleeding aaa my heart sank.

the patient was pale and clammy and his heart was racing. but the thing that struck me the most was his age. the man was 89 years old. the casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. so, in summary we had a man just this side of ninety with comorbidities and a condition that was know to kill most of its victims thirty years younger than him. the chances of him surviving the operation were dismal. i called my senior.

my senior (the vascular fellow) examined the patient and went through his file. like me he concluded that an operation would push him over the cliff whose edge he was standing next to. in consultation with the patient's son, the decision was made to make the patient comfortable and leave him to the inevitable. i confess i had the thought that at least i'd get to sleep, but i also knew the sort of sleep one gets while waiting for death to take one of your patients is a broken and rocky sleep.

the next morning i arrived for my rounds. i hoped the patient was dead but when i walked past his son just outside the ward i knew i would find him alive in the ward. after a patient dies the family always seem to flee the hospital. the stress of the night was etched into the face of the son. i could tell his night had been worse than mine.

sure enough when i entered the ward, there was the old man lying in bed just where i had left him the night before. it seemed the pain medication was working though. he wasn't quite as restless as the day before. i walked into his room. i didn't bother checking his vitals. what would be the point? he looked up at me. i was surprised to see he was doing so well. i remember hoping the fellow hadn't told the family it would be all over by the morning because the old man seemed to be set on proving him wrong. the one problem with him still being alive was that i'd have to take over the role as the intermediate with the family. the fellow would make himself scarce now that the initial footwork had been done.

i greeted the old man.

"môre oom." i said. he looked at me.

"môre neef" he replied, using a greeting that had gone out of circulation many years before i was even born. i smiled. he seemed quite spritely for someone in his position. but his next statement really gave me a chuckle.

"neef, is it true that you are not going to operate?"

"yes it is true, oom." i replied.

"well then if you are not going to operate why don't you send me home? there are things i need to do on the farm you know." how could one not admire that sort of attitude? i smiled broadly.

he took another day and a half to die. it was tough on his son, but i suspect he sucked the marrow out of every one of his last moments of life.

the graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.

a dead giveaway

amazingly enough, no matter how crazy our country gets we are a darn sight better than many of our neighbours. many people from countries around us flee to south africa for a better life. only problem is for the better life you sometimes have to produce a south african identity document. these can be easily bought from corrupt government officials, but why buy one if you can borrow one.

i was working in qwaqwa. it was an amazingly poverty-stricken place with what seemed to me to be almost total joblessness. i truly don't know how the people survived. an yet people from neighbouring lesotho would still move there illegally. i've never been to lesotho personally but if qwaqwa was a better proposition, then i can't even imagine how bad life in lesotho must have been.

anyway, one day i got to work and was confronted with a sticky problem. the police were there and they apparently needed my help. you see as it turns out, a lesotho illegal had died a week before in our hospital. in order to qualify for admission to our hospital she needed to be south african. luckily her sister was the proud owner of a south african identity document and had simply lent it to her, along with her name. i assume they looked similar enough that the clerk working in admissions hadn't noticed the picture in the book wasn't that of the patient. more likely she simply didn't check. the problem was that the patient had been declared dead by the doctor on call that particular night. or rather the patient's sister and her id had been declared dead. at that stage no one yet knew who the patient was.

however, when the sister attempted to draw money at her local bank a day or two later, she was shocked to find out that her assets had been frozen on account of her being dead. this upset her because even thought she had been declared dead in her absence, aside from a sick feeling in the pit of her stomach, she felt quite alive. suddenly it seemed the right thing to do to come clean and admit that she had lent her sister her identity document and therefore her identity.

now the problem that the police at the hospital had was that they needed a fresh death certificate for the person lying in the freezer in the morgue whose identity they now knew. they presented me with the papers to sign. a small difficulty was the papers required me to identify the body as this new dead person. the police were quite willing to forego this technicality and get my signature. however i felt the entire problem had started because of a casual disregard for the finer points of the law. i was simply not willing to sign a document saying i had identified someone as dead if i had not identified said person as being in fact dead. logic may have dictated that someone who had been lying in the morgue freezer for a week, even if they had not been dead when they got there would probably be dead by then, even if they had simply succumbed to boredom, but i felt i needed to look if the forms that i was required to sign stated that i had looked.

and so the sister, the cop and i took a stroll down to the morgue. the sister and the cop went on, a bit too much if you ask me, about the madness of the doctor in insisting on seeing the body. the last time i had been forced to go to the morgue was in the dead of night so actually i was, relatively speaking, in fairly good spirits.

even being in good spirits and even in the light of day a morgue is not a great place to be and identifying the body of someone who had been on ice (along with her sister's identity and bank account) is actually quite difficult. the normal human features seemed withered and pulled back, revealing a sort of grimace, as if she knew what cruel trick she had played on us all. i was not impressed. the form required me to see the body and see the body i had. i left, signed the form and walked away.

later i could see the humour of the whole thing. i also couldn't help thinking only in south africa could such absurdities take place.

empathy

while i am on the topic of the amazing ability surgeons have to show empathy, i thought i'd share a story one of my friends once told me about a professor he had in another university. but it also touches somewhat on where the priorities of a surgeon should be during surgery.

it was late at night and the prof was actually at the table operating (something so rare in our place of learning it also made me wonder if i'd maybe chosen the wrong university). it was in fact around the time when students struggle to stay awake. but on the whole it is not the best idea to display this weakness while scrubbed in with the prof.

the prof was the primary surgeon (something that made me glad i didn't choose that university), the registrar stood opposite him as the first assistant and some poor tired student stood next to the prof as the second assistant. i use the word stood in its loosest possible definition because he was struggling to remain in the upright position. every now and again he would slouch against the professor until in irritation the prof would thump his elbow into the student's ribs. this would result in a good five to ten minutes of good assistance from the student. thereafter his head would sag and come to rest once again on the shoulder of the prof. i'm sure it made a pretty and even touching picture. pity the prof didn't feel the same.

and so the operation went on with the student's sporadic moments of wakefulness and the prof's temper becoming equally short. finally the prof decided on another strategy. as the student's head once again sagged, looking for that warm and snug nook on the prof's shoulder, the prof took one large step back. the student's limp sleeping body found no comforting shoulder where one had been previously and went down like a ton of bricks, right in front of the feet of the prof. he then looked down at the dazed student lying at his feet, carefully stepped over him, back to the table and spoke.

"bring vir my 'n student wat nie stukkend is nie!"*

*bring me a student that isn't broken/defective

bedside manner

if nothing else, this previous post illustrates that surgeons are not that great with the whole bedside manner thing. i would like to think i'm an exception...but i still am a surgeon.

i make a point of communication with my patient. obviously if he is a child, i use the same measure of effort in communicating with the parents. but few things irritate me more than some or other family member that insists on forcing their way into the fairly personal interaction between patient and the guy that in all likelihood is going to carve him up in the very near future. i refer to the person who insists on answering my questions directed at the patient as if they know better. i mean if i ask what the pain is like and, before the poor patient can express himself, his well meaning irritating wife or mother begins to describe to me what he is feeling as if she is feeling it too. i often want to tell them to get sick themselves before i give a dam what they feel or think. i'm usually at least slightly more diplomatic.

i was a senior registrar. a private consultant friend of mine asked me if i could look after his patients while he was on leave for two weeks. apparently he did not trust the other private surgeon working in that hospital. to be frank neither did i (but we'll keep that story for another post, shall we). we went on a sort of handover round together and i got a feel for what was going on. after rounds he mentioned to me that there was still one more patient coming in from a general practitioner that apparently had a bowel obstruction due to a previous operation as a child. the patient was apparently going to be admitted via x-rays. i could evaluate him and operate if i felt it was indicated. all seemed well. he would be my first ever private patient.

the patient arrived and i was called to evaluate him. i walked into the room and took in the scene before me. the patient, a young man that i estimated must be about 26 years old, was lying in bed and what had to be his father was standing next to him. i greeted them both and introduced myself. i then turned to the patient.

"what seems to be the problem?" i asked, looking at him. the father answered before the patient even had a chance to open his mouth.

"well doctor, he started with..." i cut him short right there.

"uhmm, excuse me, but i did not ask you. i asked him." i said. then turning towards the patient with possibly too much of an ostentatious flick of my head i started again.

"what seems to be the problem?" the moment the patient opened his mouth was the moment i became acutely aware that he was mentally retarded. he very nearly could not string a sentence together and certainly couldn't express himself in terms above that of about a five year old boy. i felt like a total idiot and could feel my cheeks flush in embarrassment, but what could i do? i just had to soldier on. i mean i could hardly now turn to the father and admit that after careful consideration i did want to hear from him what sort of pain the patient was experiencing, especially seeing that i had just brushed him aside rather unceremoniously.

the entire interview and examination was painful (i think the patient also experienced a bit of pain) but i just kept on slugging through it. i then looked at the x-rays. it was a clear case and i knew i needed to operate. for the consent i fortunately could turn to the father. it was clear the patient didn't have the mental faculties to sign his own consent, if he even could write at all.

fortunately the operation and the post operative phase went well and quite soon i discharged the patient into the care of his parents.

just over a week later i followed the patient up. luckily everything was in order and i informed him and his father that all was well and they could go in peace. they left the consultation rooms, but then the father turned back to me. i had been expecting something like this from the first moment i had realized the patient was mentally retarded. i was just surprised it had taken so long in coming.

"doctor, i'd just like to have a word with you in private." oh, well, i thought. it's not as if i don't deserve some backlash for my unintentional indiscretion at our first meeting. i braced myself for the worst.

"doctor, at our first meeting, from that first moment when you refused to hear from me what was wrong with my son, but instead insisted on speaking only to him," i cringed. "well from that moment i knew we were with the right doctor. thank you so much for all you have done for him and for the respect you showed him. we as a family will forever remember everything you have done."

i didn't see that coming. i decided to just keep quiet about the fact that i hadn't realized the child was mentally retarded. we all went our separate ways, me with my pride and hide intact and the family chuffed at how i had treated them. i was relieved.