high fiber (regular)

granted, the prof had good hand skills. but i personally had doubts about the depth of his academic knowledge. i wish i could say that as i studied and got up to date towards my finals, i gradually realized that the prof may have been a little behind the times. but there was a more subtle sign that i cottoned on to much sooner.

even as a mere medical officer in the prof's firm, i was always amazed that on academic rounds he tended to swing the conversation towards constipation and how to avoid it with the consumption of enough fiber. far be it from me to criticize a good high fiber diet, but i did wonder how one ended up speaking about the colon, even when we were discussing a patient with breast cancer. but to be fair, it wasn't that the prof was clueless about other things pertaining to surgery, so in the end i just assumed he had a great interest in and a love for all things relating to the colon and how they could be managed with fiber. maybe he wasn't really trying to hide his lack of knowledge about other things but couldn't help always swinging the conversation back to his one true love.

many years later, when i was the senior registrar and it once again fell to me to rotate through the prof's firm just before my finals i at least knew what to expect to be taught on academic ward rounds.

when joining a firm, more often than not there are already a group of students there that know the ropes. sometimes they even view you as the new guy and it can be quite difficult to assert your authority. the first day in the prof's firm i realized i was likely to have problems with the incumbent group of students. on the morning rounds there was a silent resistance to everything i said, a sort of unspoken 'who do you think you are?'. it annoyed me. i was so close to finals i really didn't feel like having to stamp my authority on a bunch of snotty nosed students. i started wondering if there could be another way of approaching the problem. in the end i understood working for the prof changed one somewhat. maybe just the fact that they had been in his firm for a while was why they were being subtly aggressive. maybe to hammer them in the prof's typical style would achieve something in the short term, but it would further affirm their belief of the stereotypical surgeon. another approach was called for. i decided to bide my time and wait for the right opportunity.

the academic round with the prof was as painful as i remembered it always being so many years before. and yet somehow he didn't swing every patient and every condition towards constipation, which was at least a relief. finally we got to the last patient. the student presented and the prof gave instructions about how to further handle him. and that was it. the rounds were over. i was quite excited to move on to the ward work and get on with the rest of the day, which in my case would probably entail putting my tail on a chair and my nose in a book. we all walked to the door, but i could see the prof wasn't walking with his usual determined stride. he wasn't finished with us yet. suddenly he stopped.

"you know, constipation is a very real problem." at last, the old prof was back. by the reaction of the students i could see they had heard it all before. the one rolled his eyes. another's shoulders sagged, almost too obviously. i smiled. i'm sure they were all thinking i'm smiling out of naivety, seeing that, in their minds at least, i didn't know the prof's favourite topic. i was smiling for another reason.

"yes," continued the prof, "it is a problem that i have been struggling with for all of my professional career." too easy, i thought.

"well then prof," i looked at him, trying to mimic an expression of sympathy, "why don't you just try a high fiber diet."

once the students had composed themselves after fits of what i'm sure the prof viewed as inappropriate laughter, i never had another problem with them again. the prof?...well that's another story.

entrepreneur

i would like to say this is a south african story, but , truth be told, when people see the opprtunity to make money off the backs of the stupid and vulnerable, then it is pretty much a free for all (eg, eg.)

at the local state hospital, as it should be, there is an hiv clinic. as the name would imply they treat the many people in our area with hiv using modern antiretroviral medication which is proven to lower the viral load and can turn a once deadly disease into a manageable one, not unlike diabetes.

yet still there is a stigma associated with hiv and it gets treated unlike any other disease. you can't simply test someone for it like you would for diabetes. before testing someone, they have to be counseled so they fully understand the implications of knowing about the disease. if they refuse testing, then they are allowed to continue in their ignorance, without treatment of course. also, if they choose to be tested and are found to be positive, before they are permitted to see the doctor who will be managing their newly diagnosed disease, they are required to speak to the councilor once more. this is supposed to be a time where the councilor explains to the patient that hiv is no longer a death sentence and explains the importance of adhering to the treatment plan. yet this is also an opportunity for an enterprising charlatan.

the patient in question was back after having her hiv test the previous week. i think in her mind she actually knew she was positive. there was little else that could explain her symptom complex and she had already accepted the inevitable. all she wanted to do was to get through the obligatory counseling and to get to the doctor so they could work out a treatment plan. she sat down with the councilor.

"you are hiv positive,"

"yes, i thought as much."

"now you are going to see the doctor shortly and he is going to discuss treatment with you." this is exactly  what she wanted. she just wanted to get through this and see the doctor after all. "he will tell you about all sorts of western medicine that you will have to take every day for the rest of your life." again, no surprises. "but there is an alternative." what? this was not in the script. she thought she would rush through this so called post counseling and get to the doctor. yet humans are inquisitive creatures.

"what do you mean?"

"i mean there is another way." with this, she reached under the table and produced a second hand pepsi bottle full of some liquid. the patient looked at it in surprise. it had a slightly green hue to it. the lid had scratches on it indicating that it was probably quite old and had been used many times before. "this is a cure for hiv. it is a mixture that a sangoma has created. unlike the western treatment that the doctor is going to offer you, it has no side effects. the other advantage is, because it is a cure, you only need to buy two bottles and use it for only two weeks and you will be cured. and each bottle costs only two hundred rand." she smiled. it was meant to be a warm, reassuring smile, but the patient saw it for what it really was, an evil smile hoping to snare yet another victim and send her down a slippery slope after fleecing her of her hard earned money.

yes south africans can be entrepreneurs. i don't have it in me though.

diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.

chicken feet

i hate kalafong (hell). there are many reasons for this (here, here, here, here, here), most emotional, i confess. but if i am honest there is one incident that stands head and shoulders above the myriad of traumas that i experienced there.

one of the strange idiosyncrasies of kalafong (hell) is that some time during each night shift, all the sisters of each ward get together in the duty room and eat chicken feet. i have no explanation for this. maybe there is an abundance of chicken feet in the area. maybe the sisters are paid in part with chicken feet that absolutely must be eaten before they leave for home after their shift. maybe it is part of some bizarre ritual that initiates all kalafong sisters into some secret evil cult. i simply do not know.

i was a mere fourth year medical student which meant i was at the absolute bottom of the rung that night on call for internal medicine. i knew nothing and was of almost no help to anyone. the only thing that i could do was to put up drips, so the senior medical students would send me to the wards whenever they got a call that a drip needed inserting. for some reason kalafong sisters never put up drips. maybe there was a fear that the patients were allergic to chicken feet and the residue of the no doubt scrumptious delicacy on the fingers of the sisters could potentially cause the patients harm. they were clearly not about to take that chance, so there was plenty of opportunity for me to hone my already very well honed drip inserting skills.

i had just left the female medical ward after inserting a whole host of drips and was quite keen to see what was going on in casualties. i walked in.

"drip to be inserted in female medical." the sixth year student smiled. i don't think it was really meant to be malicious although it felt that way at the time. i think it was more a relief that he had done his years of continuous drip insertion honing and was glad that he honed no more. it was the natural cycle of things and he had passed the batton to the next group. it was simply my turn.

"i was just there!" i protested at no one in particular, turning to leave with my shoulders sagging just enough to be noticable to the discerning eye.

i entered the ward through the back door. the main door had been locked by the sisters. this was another thing one got used to there. it was just something the sisters did at night.  the reason for this behaviour elluded me, especially when they had just called for someone to insert a drip. you would think that they would unlock the door in anticipation of that person actually arriving to insert the drip. maybe they needed their privacy while performing strange initiation rites with chicken feet.

as i entered the ward, a patient looked at me.

"doctor, help me! i'm dying!" i froze. it was dark. i could only make out the patient's shape, silhouetted against the dirty cream coloured wall. yet her eyes were so wide with fear that i could see her white sclera. i felt a shiver go down my spine. what was i to do? i was only a fourth year. i didn't know this patient and even if i did, i had no knowledge to actually help her. in my naivety i hadn't yet learned the rule that more often than not, if a patient tells you they are dying, it is because they are in fact dying. the one thing i knew is that i couldn't ignore her.

i walked up to her. she lifted her arm weakly. then suddenly her fingers encircled my arm and all her remaining strenght seemed to go into her grip. her nails bit into my flesh as she pulled me close to her face.

"help me doctor, i'm dying!" she repeated. she scared me, so i pried myself loose and checked her file. she had been admitted the previous day with the diagnosis of meningitis. antibiotics had been prescribed but only one dose had been signed for since admission. probably the drip had been out when the other doses were due and once some poor fourth year had reinserted it, the sisters hadn't bothered to put up the dose that had been missed. at least there was something i could do, i thought. i could check to make sure the drip was working and get the sisters to give the last dose of missed antibiotics. somehow i allowed this thought to make me feel better. i would help this lady and all would be well.

i checked the drip. it was working well.

"don't worry, mamma, i'll send someone to help right away." i said as i turned to leave. she lunged for my arm again when she saw that i was going, but there was no strengh left and she missed. as i walked away a knot developed in my stomach. i felt that i had failed this old lady. i had done the little bit my knowledge had permitted me to but i had also allowed my fear of her and of what she was facing to intimidate me to such an extent that i hadn't really stayed to comfort her. i was determined to be a change in her circumstances and her life. i would speak to the sisters.

i walked to the duty room. the door was closed but there was an almighty din emanating from inside. the sisters seemed to all be shouting and laughing in unison. i knocked and opened the door. for a moment the bright light from their happy little room blinded my eyes that had become accustomed to the darkness of the ward. the light seemed to pour out into the gloomy ward behind me. all the sisters were sitting around the table eating chicken feet. when they saw me they all went silent, but continued eating.

"good evening sisters." no answer, unless silence is an answer. "sorry to bother you but the patient in bed 5 in cubicle d is in a bit of distress."

"we'll check on her now now." i knew what now now meant in our strange south african english. now now was not as soon as now and implied no urgency. now now was not as now as i wanted it to be.

"ok," i said, knowing that if i antagonised them they would purposely postpone checking on her just to teach me a lesson. "also i see that she hasn't yet received her last dose of antibiotics. her drip is working, i checked, so please give it to her when you go to her." the sister looked up from the chicken foot she was now toying with between her fingers. i saw in her eyes that she despised me, although i had never laid eyes on her before in my life. some things in kalafong one learned to accept.

"i said we would see to it now now!" she repeated. then her head dropped back down to give the chicken feet the full attention they seemed to deserve. i stood still for a minute. then i quietly closed the door.

as i walked away to do the drip i had actually come to the ward to do, raucous laughter errupted from that small brightly lit room. it brought me to a stop in the middle of the floor in the dark ward. i felt tears well up. i didn't know if i wanted to cry because the sisters were clearly enjoying a joke at my expense or at the futility of an old woman who lay in bed 5 in cubicle d all alone with the fear of death over her. i just knew there was something horribly wrong with the whole picture.

i got the drip up and running in double quick time. i then rushed off back to casualties, but not before quickly checking on the patient again. when i approached her she still had the same stare. this time her arms lay still on the bed beside her.

"don't worry, mamma," i said, "i have asked someone to come and help you. it is all going to be ok." she didn't react. "i promise i'll also come back myself tonight to check on you." a little of the fear went out of her eyes. only a little.

on the way back to casualties i made sure i composed myself. it wouldn't be good to show the senior students that i had been so affected by something they no doubt had seen quite a lot of. anyway everyone always said not to let kalafong get to you, otherwise it could change you forever. at that moment forever seemed like such a long time. the sixth years were busy doing a lumbar puncture behind one of the flimsy curtains in the casualty unit that seemed designed to give the impression of privacy without actually delivering any real privacy. one of them looked up.

"sorry dude, but they just called for another drip in male medical." i turned and walked out without saying a word. the quiet of the open air kalafong corridors could possibly afford my soul a bit more peace than the overwhelming noise of human suffering of casualties. usually i could handle it, but then i felt a despondency and futility that was too much to bare.

in the end there were three drips in male medical so it took me longer than expected to get them all up and running. this time it didn't bother me. i was in no rush to get back to casualties. also i knew i had told the old lady in female madical i would check on her and i was afraid. i was afraid of what i could not do for her. i was afraid i would be inadequate. i was afraid of the face of fear that i had seen in her eyes. somehow her reality at that moment was too real and i didn't want to face it. i wanted to be at home in my warm bed, ignorant of how terrible life could be. but i knew i had to go to her. if for nothing else, i had to just be with her so that she was not alone. i walked slowly to female medical.

i walked past the duty station. this time the door was open, but besides that there was no discernible difference. all the sisters still sat exactly where they had been. some of them were still eating the last of the chicken feet. the light from their room lit up half the ward, but did not reach all the way to cubicle d. they didn't see me slip past them so their laughter must have been aimed either at someone else or just part of the normal merriment associated with people sharing a meal together. still, just like the light, it seemed to me to be out of place.

"mamma, i'm here" i whispered as i approached her bed, just in case she was asleep. she lay with her head to one side. she didn't stir. i walked closer and took her hand. it was cold and clammy. i leaned towards her face. even in the darkness i could see her eyes were open, but they were fixed in the stare of death. she had died alone and i had failed her completely.

i have hated the sight of chicken feet ever since.

understandings

anaesthetists and surgeons work together quite a bit, but they are very different creatures. sometimes it takes a bit of effort for them to understand each other and get along. some would say it takes effort from pretty much anyone to get along with a surgeon. so it is nice to hear a story occasionally of an anesthetic colleague that is willing to do what is needed to understand and get along with the general surgeon he was working with. these were the observations of a student during his rotation through the anesthetics department.

when the student in question arrived at work, he was quite excited to hear that he was dealt into the emergency theater.

"off you go," said the prof to him, "they are still busy with a trauma case from last night."

when he entered theater it was clear that there had been quite a lot of action. the floor was covered in blood which had been smeared around by the feet of the surgeon and the floor nurse, creating a macabre work of art with bold red strokes of the brush on the canvas which was the floor of theater. against the wall on a rack hung multiple blood soaked swabs, bearing testimony to the battle that had already taken place in that small room. the surgeon was still frantically busy working in the open abdomen, his arms besmirched with dark blood to his elbow. the front of his gown was similarly stained. the student looked around and took in the complete picture of this fight between life and death, yet immediately he noticed something that didn't seem to fit in with the high stress situation that met the astonished student.

off to one side, the anesthetist sat quietly in his chair with his arms folded and a calm expression on his face. he wasn't even looking at the monitor. in fact he sat slightly behind it. from this vantage point he glanced up, greeted the student and offered him a chair. the student sat down wondering at the steel nerve of this anesthetist in the face of such a tense situation.

then an alarm went off on the monitor. the student jumped up to get out of the way as his senior finally moved to see what was happening. but all he did was to turn the alarm off and sit down again. and so the student sat there with him, too nervous to speak and wondered what was going on.

after quite some time the intense concentration of the surgeon was broken. he turned to the anesthetist.

"how are things going up there?" he asked and then as an afterthought added, "the bleeding is now under control."

the anesthetist slowly looked up and spoke for the first time with a wry smile plastered across his face.

"well actually the patient has been dead for quite some time now," he said, "but i know how much you surgeons like to operate and it looked like you were having so much fun, i didn't want to disturb you."

la mancha

the man was an enigma. those who knew him soon realised he was the only person in kalafong (hell) that cared anymore. somehow that terrible place hadn't eroded his soul to such an extent that he no longer gave a damn about his patients. yet to those who only had a fleeting acquaintance with him, he seemed course and even harsh. he didn't fit into kalafong (hell), yet he would not have fitted into any other place quite as well as he fitted into kalafong (hell). yes, he was an enigma.

my consultant in kalafong (hell), the enigma, had a certain way of bringing his point across (here and here). on the face of it it was never pretty but it was always funny in some twisted sort of way, despite that never being his intention. he also had a knack of going off on some wild tangent for seemingly no reason. what we may have thought was normal would more often than not set our own don quixote off on some wild quest chasing what seemed to us to be little more than windmills. but who were we to argue? he was after all the consultant.

so on that particular morning, when the house doctor showed the don the official consultation form from the internal department requesting us to drain an abscess on one of their patients there really was no way for him to know that this would cause the old man to fly into a frenzy and charge off towards the wards of the unsuspecting internal medicine department, his entire entourage, myself included, in tow. i was a very junior medical officer so i kept to the back and just observed.

"where are the doctors?" he bellowed at no one in particular as he stormed through the doors. "are you all deaf? i said where are your doctors? i want them here right now!" from behind a few curtains here and there the house doctors of that department peered, eyes wide, like frightened rabbits. still they froze and moved no closer.

"i said come here!" he shouted pointing directly at the closest one. "you! are you a doctor?" it seemed like a silly question. of course he was a doctor. but our master continued, "i said are you a doctor?"

"yes sir." wrong choice of words.

"don't call me sir!! do i look like i've been smacked on the shoulder by some foreign queen?"

"no, professor."

"don't call me professor!" his face went red with rage and despite it seeming impossible, the volume of his rantings increased. "i am not one of those academic professors in that ivory tower on the other side of town who operate by remote control from the comfort of their large chairs in their studies! i am a real surgeon!"

"sorry doctor."

"that's better." his voice dropped down back to jet plane decibels. "i asked you a question. are you a doctor?" the poor guy's lip quivered as he carefully and deliberately chose his words.

"yes doctor."

"what degree do you have?" we all cowered out of the direct line of sight of the man just in case he asked us the same seemingly easy question. at least we now knew not to call him sir or professor. but the poor internal house doctor had no such privilege.

"i have an mbchb, doctor." he almost whispered.

"yes you do. and do you know what that means?" before the confused victim could answer this next seemingly easy question our consultant blundered forth. "bring me a blade and show me where this patient is with the abscess.

a few moments later we were all standing around the patient wondering what was going to happen next. the house doctor was visibly shaking.

"i asked you a question?" continued our mentor, toying with the knife in his hand that the doctor had fetched for him "what does mbchb mean? or what does the chb part mean? the mb part is easy. that means you can give pills out. any old monkey can give pills out, but now i want you to tell me what the chb means"

"i'm not sure sir, i mean doctor!"

"if you call me sir again i will have you thrown up against the wall and i will bring a firing squad in here and have you summarily shot!" our consultant believed a firing squad covered a multitude of sins. "well let me tell you what it means. you see this sharp shiny thing in my hand? this is a blade. chb means you are trained to use one of these. it means you have a bachelors degree in surgery and it means you can lance an abscess. now watch me." he turned towards the unsuspecting patient. "you see now. this is the blade and this is the abscess. and this is the blade draining the abscess." with that he sunk the blade deep into the abscess. the patient winced, but, surprisingly made no other objection. i assumed he felt the threat of the firing squad may have been a general threat and that it was not limited to the poor house doctor. also once the thick stream of puss came out, there even seemed to be relief on the patient's face.

"there you go, mb and chb. now never consult us to drain an abscess again!" he turned and strode out. we had to follow. i was right at the back so i think i was the only one who heard the quiet and slightly bewildered voice of the house doctor as he said;

"i didn't consult you. that isn't even my patient."

live and learn

i am not an orthopod. i don't drive a four by four. i don't wear a checkered shirt and i sure as hell don't use a tourniquet when doing an amputation. to be fair, i have nothing against four by fours and a checkered shirt just makes me look like i'm wearing a dishcloth. but the tourniquet rule is absolute.

there are a few sound clinical reasons general surgeons don't use tourniquets for amputations. we tend to do amputations on people with compromised arterial blood supply so we tend not to want to make things worse by constricting the artery upstream from where we are working. we are maybe a bit scared that that constriction will be just enough to cut the artery off permanently, the proverbial last straw. also the bleeding in our patients with such poor blood supply is much less so a tourniquet is consequently less helpful. in my case, however i think the decision is also based on previous emotional trauma.

i was a community service doctor in a rural hospital. quite early on in that hospital i had already been schooled in the fine art of surviving without senior cover, so when my cuban orthopedic consultant asked me to handle the rest of the theater list i pretty much knew i had no choice in the matter.

"uum, doctor, the last case is a below knee amputation. i've never done one of those." i objected, not that i had any hope of my gentle supplication bearing any fruit.

"yes, but you assisted me with one just last week. just put the tourniquet on, cut the leg off, tie the vessels and close like you saw me doing. i'm tired and i'm going home now." with that, even before waiting to see the pained expression on my face, he turned and left. i had no choice. i was about to do my first amputation.

i carefully placed the tourniquet, pumped it up to the required pressures to prevent any blood supply to the doomed leg and went to scrub. quite soon i stood with only the theater sister to help with my knife poised, ready to do my thing. i mean how hard could it be? i just needed to get the leg off and the wound closed. so with this misplaced reassuring thought in my mind i got to work.

half an hour into the operation (i was a lot slower in those days) i was feeling quite good. i had identified the major vessels and tied them off. the bone had been cut and i was handing the leg to the floor nurse. i thought to myself that this is what it feels like to be a surgeon. you look important and in control. it was quite a rush. i should have known it was too good to last long.

at about this stage i decided all that remained for me to do was to let the tourniquet down, to make sure i had control of all the bleeders and close the wound. i was already thinking of all the people i needed to phone to tell them i had lopped a leg off. my friends in internal medicine would be so jealous. pity when i had assisted the orthopod the previous week i hadn't paid much attention to when and more specifically how he let the tourniquet down. i decided i would decrease the pressure by half. that way if there was an arterial bleed, i reasoned to myself, i would see it and control it before it got out of hand. it didn't occur to me at that heady moment of my life that if i allowed the artery to pump blood into the leg but maintained a tourniquet pressure high enough to prevent that blood from getting back into the body via the veins the result would be venous engorgement with resultant venous bleeding. even when every tiny microscopic vein started oozing like there was no tomorrow, i still didn't make the logical deduction. i just kept on clamping the veins one by one and tying them off with trusty vicryl. but the more i tied off, the more new bleeders seemed to sprout into life and start oozing uncontrollably. i suddenly wondered if one could die of vicryl toxicity. it sure seemed i would find out with the amount of vicryl i was systematically putting into that stump.

and so this scenario continued for quite some time. all the bravado and gusto that had swollen my head only moments before was long gone. i felt alone and scared. i even considered calling the cuban consultant, but he had made it quite clear i was expected to handle this myself. i was determined to soldier on.

"doctor, maybe you should blow the tourniquet up again?" the sister's suggestion seemed logical but somehow it just annoyed me. if i hadn't used the bloody (pun?) tourniquet in the first place i wouldn't be in this mess, i answered her in my mind, but that didn't seem to make sense. somewhere from my deep subconscious i started hearing a little voice. i suspect it had been screaming at me all along, but in the heat of battle i had been too distracted to pay any attention. at last i stopped to listen. the tourniquet was the problem, not the solution. that is why the thought of blowing it up again was so annoying to me, even if on the face of it it seemed like a good suggestion. i immediately knew what to do.

"please blow the tourniquet completely down." i said, trying to sound as in command as my quivering voice would permit me to. i then took a swab, pushed it against the oozing open wound and took a moment.

after not too long i ventured a quick peek at the wound. i lifted the swab and was relieved to see a dry wound with absolutely no bleeding. even the tiniest of vessels donned a vicryl tie and i think the few remaining capillaries were too scared to permit even one red blood cell to escape lest the same fate befell them.

at last i got the stump closed and left theater, completely worn out form the high levels of adrenaline i'd been exposed to, albeit directly due to my stupidity. oh well, live and learn.

never again did i use a tourniquet for an amputation.