the powerful horn

the basic topic behind this post it seems to me will tend to reccur. i therefore must accept it and get on with the post.

i presently have a patient in my care who has a very tragic story. he is hiv positive with a cd4 count of 25. (not good). he works in umtata in the eastern cape. there he went to a sangoma, apparently complaining of chronic diaree and generally not feeling too well. the sangoma decided the needed treatment was an enema administered through a strong bull's horn. the horn was duly inserted into the anus, through the anteriour rectum wall and the enema was pumped freely into the peritoneal cavity. (although a strong bull's horn might be the desired mode of administration, possibly because a weak bull's horn would have lesser curing potential, i personally think that something slightly less traumatic may just suffice). as you can imagine, the patient didn't improve. in fact he got worse. he then presented to a surgeon (a few days later) who operated. the rectum was repaired, the abdomen was rinsed and that was that. or was it??

a few days later, the patient developed acute abdomen again. the surgeon took him back to theater. the notes report he found multiple spontaneous perforations of the cecum (completely the other end of the colon) as well as breakdown of the rectum repair. these were all repaired, a transverse loop colostomy was brought out and pensil drains were left in the abdomen. the abdomen was only loosely closed.

at about this stage the patient mentioned he came from nelspruit and was duly posted off to me. when he arrived here, he was in prerenal kidney failure, his liver enzymes were totally deranged (possibly overwhelming sepsis but just as possibly the direct known hepatotoxic effect of many sangoma concoctions) his viral load was as high as his cd4 count was low and his white cell count was a dismal 2,6 as opposed to a crp of over 300. he was leaking feces from everywhere. the entire laparotomy wound was one massive contaminated mess.

what to do?? i decided to operate (after appropriate attention to his fluid state). inside was a sewer. there was no corner of the abdomen spared. my basic plan was to exteriorise everything. inside the cecum was a sieve of multiple holes and necrosis. the rectum had broken down again. there was also a spontaneous hole in the small bowel (middle). i did a right hemicolectomy with an end ileostomy and brought the colon out through it's own site. i debrided and repaired the small bowel hole. i rinsed copiously. i placed drains absolutely everywhere. i placed a post treitz feeding tube. i closed with tension sutures. i bundled him off to icu. i prayed. i might have muddled the order of things, but icu was towards the end. what was interesting to note at operation was the total lack of fibrin or any adhesions in the abdomen. the body wasn't even trying to heal itself.

the patient still developed leaks. i'm now going for controlled fistulas. some things are not so bad. he is no longer intubated. his kidney function recovered. his liver function is on the mend. but quite frankly i wonder what his chances are with zero immune response and zero healing.

i wish i had more time to discuss this case. there are so many interesting points. a starting point may be the fact that my physician friends told me i should have left him to die, arguing that it was not right to dedicate a long term icu bed to someone who would die anyway, thereby depriving the bed from someone else who has a chance. besides the obvious feelings of loss and failure if he dies, i'll be the butt of many of their jokes. the converse is not true. if he lives there will be no acknowledgements or accolades.

the other point is the sangoma and his role in the treatment of hiv. bear in mind our minister of health publicly says their role is crucial. i differ somewhat. (this is not an isolated incident). it is always also fascinationg to me to see how they are totally absolved of responsibility when things go pear shaped. in fact if the patient dies there will be fingers of accusation levelled at the western medical establishment from them. "see even the western doctors couldn't save him" or worse "look how sick their western medicine made him".

but if i could give any advice, when you have hiv and your cd4 count is 25, don't get a rectal perforation. it is not a good idea.

300

recently i watched the movie 300. personal taste i suppose but i thought it was great. the scene depicted here where the barefoot boy is out on his own in the snow and slays a wolf to prove his worth reminded me of a case i saw.

when i was working at witbank in the winter we admitted two boys, about 16years old each. they came in from initiation school. they had been taken into the mountains, barefoot and left out in the cold, to prove their manhood. their toes froze off. the one ended in a forefoot amputation and the other lost a toe here and there. somehow the reality of that sort of thing took from the magic of that scene oin the movie. i couldn't help wondering how good a soldier you make if you deprive him of his feet.

to be honest in our neck of the woods we don't really get very bad initiation school injuries. in the eastern cape where the initiation culminates in circumcision, their regular gangrene results in amputations far worse than mere toes and feet. ironic to start your journey as a 'man' without that specific anatomic attachment.

what i found very interesting with our patients was that when they heard they would have to have operations, their main concern was would they be out of hospital in time for the final ceremony of the initiation school which would confirm them as men and no longer boys. the fact that they wuuld go into life partly crippled paled in comparison to the possibility of continuing life as a boy and never achieving manhood (in their view). interesting to view these sorts of things. i really felt for them. i also was once again reminded of the fragile male ego. different in different cultures, but it's amazing what we would go through to be viewed as men.

but despite all this, i still thought it was a great movie.

two heads are better than one?

this is a patient i have at the moment. i plan on operating as soon as the consultant anaesthetist sees his way clear to dope her. this is not too unusual in south africa. it shows a tendency to wait a long time before seeking help. this next photo will show something that south african doctors will immediately recognise, but may need a note to explain to our international audience. roughly in the middle of the mass are two small parallell scars. these are markings made by a sangoma. they are meant to be therapeutic. as you can see they were not. i have already posted about that (here and here) so i will not labour the point any more.

but, if there is any sage advice from surgeons out there for when i do attack this lady with my blade, i'm open to any suggestions. after all, two heads are better than one (except of course in the case above)

failure?

for those who have been following my blog, you might understand my feelings about what is happening here in mpumalanga public health. due to a number of reasons, i felt the need to write a letter to the head of surgery in pretoria. that letter follows:-


Dear Professor B

I feel it necessary to bring you up to date with events in R F hospital because you have always shown a keen interest in our hospital and I view our department as a subsidiary of the department of surgery Pretoria, of which you are head.

Firstly, some background in brief:-
As you know, with the initial recruitment of myself, Dr KS and Dr C, certain financial promises were made, which the province of Mpumalanga did not keep. As you know, both Dr C and Dr KS (who had already moved to Nelspruit in order to take up his position) therefore did not commence work here. I, however did start working in Witbank. This was mainly due to my desire to work in the state sector but also because of my desire to be involved with student education, which I could do in Witbank. I started there despite the knowledge that I would be getting considerably less than originally promised. Despite frustrations there I threw myself headlong into my work and specifically student education.

However, even though they weren’t going to pay me what was initially agreed to, they took 4 months to pay me my salary at all and another 2 months thereafter to pay me my overtime. (They only paid me overtime for 4 of the 6 months I worked there. I have accepted the loss of 2 months overtime money as bad debt but it does show a certain amount of bad faith on the part of Mpumalanga.)

During my time in Witbank, there was talk of moving me to Nelspruit. This made good sense because there were already two surgeons at Witbank, namely K and M (m is a cuban doctor and does not actually have registration as a surgeon in south africa. he is, however an excellent surgeon) and a very competent medical officer (T) who could function as a surgeon, but Nelspruit had only one surgeon (Ki). I immediately expressed interest in it, believing I would be of more use to the province in Nelspruit, but also because, once again there was talk of the initial salary that was offered at the first interview. What I did not know at the time was that K M (the guy whose job it is to ensure delivery of health care in the province) and the CEO of Witbank (Ma) had a disagreement. This translated into K M not getting back to me about the offer for about 3 months. He was therefore willing to allow the province to suffer because of his own personal agenda.

Finally he did get back to me and once again offered a higher salary if I was willing to move to Nelspruit. I expressed interest. As soon as I said I was willing to move to Nelspruit, the higher salary offer was removed from the table. I telephonically informed him that the increased distance to Pretoria in my case translated into an increased financial need. He assured me that we could look into forms of boosting my income when I get to Nelspruit. He mentioned extra overtime and private work.

Having established contact with the Nelspruit surgery department and gaged the need, I decided to take the chance and accept the transfer. I did this despite being lied to twice by K M and being treated with extreme disrespect. I refer to the abovementioned fact that he strung me along for 3 months, keeping me in the dark while he and Ma sorted out their differences. I have reason to believe that, had Ma not resigned from witbank he would not have gotten back to me at all.

When I arrived in Nelspruit, I found a very disgruntled Dr Ki. He was owed a substantial amount of money by the province for overtime performed when he was the only surgeon here. He told me he is not interested in doing overtime at all but would do the contractual 80 hours to support myself and Dr Se (the new recruit from pretoria). It is interesting to note that, when I approached the private surgeon G about the possibility of helping us with calls, he informed me that he also is owed money by the province for calls done in Rob Ferreira hospital and therefore knows he will not be paid if he does offer his services. He understandably declined. Even Dr KS expressed willingness to do calls but how could I even ask him to when I knew he wouldn’t get paid and we would therefore burn our bridges for the future when there is another administration in power.

The extra overtime became an issue. The province was offering 25% of normal fees for extra overtime. This would be unrelated to call outs or time spent in the hospital. I hoped Se would be willing to take the offer, but, like me, he refused. His feeling was that you should get paid for services rendered. I agreed and we set up a call roster accordingly. K M then phoned you. I suspect he bent the truth to his advantage but I was grateful and impressed by how you handled the situation. You phoned me and stated how overtime works in the rest of the country for specialists. I thanked you for that call when you phoned but I’m not sure you realise quite how much I appreciated it, so thank you once more.

The very next day I wrote a letter to K M, stating that we would be willing to be on standby at 25% and claim 100% for actual call outs to the hospital. Witbank was demanding 70% standby and 100% call out which I thought unreasonable. Our offer, Dr Mo (the ceo of Rob Ferreira hospital) assured me, was in line with K M’s initial proposition. However, be that as it may, he still did not accept our proposition. In fact he didn’t even reply to my letter. I couldn’t help wondering about some political agenda. Why would he refuse to correct the problem even though the solution was in his grasp?

During this time, with Se’s input, I totally revamped the department. We divided the department into 3 firms to ensure continuity of care, clear delegation of responsibility and direct consultant input. We also increased the academic level of the morning hand over meetings. We started a Wednesday morning academic meeting, the level of which is of a high standard for a peripheral hospital with direct consultant involvement. We trebled theater time as well as the gastroscopy lists. All clinics were directly run by consultants. We initiated a morbidity and mortality meeting to both improve service delivery as well as to further develop our doctors.

Meanwhile Se was not receiving his salary here. He was luckily still receiving his registrar salary but had incurred expenses related to moving across the country, making his financial situation difficult. Se had an advantage which I did not have when I started in the province. That is he somehow had direct access to someone high up in the provincial administration who quickly got his appointment letter sorted out. (Interesting to note at this stage that I still have not seen my appointment letter and wonder if it actually exists). Despite this they still didn’t sort out his salary. I was informed that the fault didn’t lie with the province, but with Se himself because he apparently did not resign in Pretoria. This is a lie as I was in the same position when I first went to Witbank. He came over as a transfer and didn’t need to resign. On the contrary, resigning would have left him with no form of income while the province dragged their feet. Se, during this time also asked the hospital for a loan car temporarily because he had problems with his car and didn’t have money to fix it. They said no because it was “an irregular request”. Se then informed me he was taking 3 weeks leave in March, as he said, “to give the province time to sort out the appointment”. I suspected that he was going to look for work elsewhere. Who could blame him? Let me just also say that while Se was here he worked hard and contributed constructively to the department and the hospital.
I recently heard that he handed in his resignation. This is somewhat comical because he is still not on the system here. He essentially resigned from a job he doesn’t have. The superintendent here told the heads of department in my presence that she would have reported him to the HPCSA for absconding if he had been on the system. To me this added insult to injury. He worked well here while he was here. He was not paid. He slept on the floor of his place the first few nights he was here. The hospital was not willing to help with a very reasonable request for transport, a need which arose from the province not paying him. And after all of this, in an act of vindictiveness there is a threat to report him? It is true he was not entirely forthright in his dealings with the province, but the province has proven that forthrightness is not their strong suit.

With all these things in mind and bearing in mind Keith Michael’s promise to explore other forms of financial augmentation I wrote a letter to the medical manager expressing my wish to change to a 5/8th post. I however clearly delineated extensive involvement in the hospital. (See enclosed letter). I also expressed my considered opinion that there is no desire from admin to develop a surgical service here. I also described my financial need to free up some time.
The medical manager called me to her office. I was told that there is a view that I am a disruptive element and intentionally being obstructive, therefore punishing the normal man in the street with my agenda. She basically said that people higher up come down on her head when they receive a letter from me and they don’t take the letters very seriously. That means they respond but not to me and not constructively but rather in irritation. I was also told that there was a suspicion that I had instigated Se to resign. I defended myself on both points. Luckily I had written that original letter to K M which proves that we were willing to do overtime. As far as instigating Se to resign, what possible gain could I get from that? I also pointed out that I was the only one of 4 surgeons recruited from Pretoria still here. I therefore am the least disruptive. On the contrary, the province has successfully chased 3 surgeons away and I am still here. She also told me that the request for a 5/8th post would not necessarily be granted and it would take some time to organise.

I came to the realization that my desire to work in the state puts me at a severe disadvantage. They feel they can abuse me and I will not leave. I therefore, with a heavy heart have decided to resign. This province so far has seen every concession I’ve made as a sign of weakness and license to further abuse me. There is no desire to fix the situation. On the contrary, as is shown in this letter, one must wonder if K M is working towards collapse of services. I can’t, with a clear conscious, be a party to that.
I therefore plan on handing my letter of resignation in on Monday. I will however consider a 5/8th post. This is because I feel a responsibility to both the people of the province and the doctors trying to do their best in the hospital. If the hospital does not accept this, I may consider doing a list on Tuesdays to help the doctors and to try to work down the substantial waiting list. This I will do for the people and doctors, not the administration. Therefore I will not ask for remuneration for this initially.

I truly feel bad for the necessity to write this letter because I dreamed big dreams for this hospital, but as I said to Dr N (the medical superintendent), surgeons are ready for R F hospital, but R F hospital is not yet ready for surgeons.

I wanted you to hear this from me first because I have no doubt that the story relayed to you from other sources will be creatively tuned to their personal agendas.

As always an advocate of surgery



Bongi

note, some names abbreviated.

so in some senses this represents a failure to do what is truly in my heart. however, as is shown in the letter, i will not totally abandon them, even if they totally abandon the people.

there are a few interesting extra bits of information that have subsequently come out. the administration had actively decided to ignore my letters pleading for a service (there were many) reasoning that i would tire of writing them. they actively planned to do nothing. they also did not see my actions as trying to fix the situation but rather as something that made their day slightly more uncomfortable and therefore no more than an irritation. i have also learned that there is resistance to giving me a 5/8th post, even if the alternative is that i resign. they would rather not have a surgeon than compromise. there are no replacements lined up nor likely to be in the foreseeable future.


so keep watching for more developments.

maybe not failure but a necessary step to put things right.

bombay gas abses

just realised i'm not sure how to spell abses in english. no matter. for this post i'll use the afrikaans spelling. i apologise to the purists.

when i was still a registrar (kliniese assistent) we used to warn our house doctors about the bombay gas abses. where the name comes from i do not know. why bombay i also do not know, but that is the name taught to me when i was pre-grad and that is the name we propagated when we told our juniors about it.
the bombay gas abses was actually more a joke than anything else. we would warn the juniors to be careful about an 'abses' that presented in the groin. they would often have an intermittent history and usually be painless. mostly, they could be pushed back into the abdomen. often they had audible bowel sounds in them. occasionally they would suddenly become very swollen and painful and could no longer be pushed away. here there would usually be signs of concommitant bowel obstruction. the stern warning we gave to our juniors was not to drain this particular form of abses, because more often than not gas would come out and it would continue to drain for many a long day. we would all then have a good chuckle and go on with our daily activities. i never actually heard of a case of a bombay gas abses being drained, that is until....

recently we got a transfer in from one of the peripheral hospitals. the history was that an abdominal wall abses had been drained. the wound, they said, continued to drain for a few days and now they noticed it was bowel content coming out. i tried to imagine what sort of hernia would present as an abdominal wall abses. spigellian maybe?

anyway, the child arrived. the call doctor took the patient to theater, but phoned me to join him. the patient lay on the table, already asleep. there was a cut over the inguinal area, not merely abdominal wall. fecal material was freely draining from the wound. the first bombay gas abses that i'd actually seen!!! the entity did exist! somehow when you see it, it's not so funny any more.

so we did a lap. the caecum was perforated. there was soiling in the right paracholic gutter. there was a bit of necrotic material in the area. so we did a right hemi, debrided, rinsed and closed. i felt uneasy about an anastomosis in what was essentially a week old abses bed, so i pulled out stomas for later closure. the patient did well.

this story is such a picture of present day south african medical state care that it really makes even the stout hearted want to cry. interns and community service doctors are scattered across the country with absolutely no senior backup. where such an inexperienced doctor in most other places should be able to ask a senior opinion, these doctors do not have that priveledge. they do what they think is right, but quite often bungle on without even a clue they are totally screwing up. i fear that if i go into the reasons that these people are without supervision and how the government of the day systematically destroyed a system that was quite functional 15 years ago only to replace it with...well nothing, i may sound a tad bitter and full of resent. i'm even likely to be accused of unpatriotic behaviour and the trump card, racism. i therefore think i'll just touch on it for now.

but what really gets me is these beurocrats still sit in their offices, actively engaged in the destruction of any remnant of service that remains. they are like generals in great battles, sending the masses onto the waiting muzzles of enemy rifles. not only are the poor and destitute without good medical care, but these poor clueless doctors are thrown into water far to deep for them to handle. they will also be dammaged and many a good healer will be lost to the profession. they will kill by their ignorance. when this happens, some will not be able to recover from the fact that they are responsible for the death of someone else, even if totally unintentionally. that is a difficult thing to get beyond.

today's post was a spot emotional and i suppose the bombay gas abses was just a catalyst for how i feel. i've decided to post it anyway, because it is how i feel at the moment and this is just one event of many. to be in what can only be likened to a battle where regularly one sees death and suffering which is quite avoidable must have an effect. i don't like to lean to the melodramatic, so maybe i'll seriously edit this later. until then...

the amanzi family

just a quick note to say i see my family down under has extended the amanzi blogging (see amanzi down under). hope to see more of your new country. go for it skoonsus.

buckle up

i was planning on posting a purely medical blog without a south african theme, but as it turns out, once the entire story of this incident surfaced, it too had a decidedly south african flavour.

sometimes all the details of an event only become apparent later once you've read the next days paper or spoken to all involved parties. i therefore decided to relay this story chronologically, rather than how the events unfolded to me.

recently a man (lets call him tax payer) was driving to work on the road from nelspruit to white river. at the same time, a thief had just stolen a car and was travelling in the opposite direction from white river to nelspruit. he, however was travelling as if the bats of hell themselves were on his tail. i don't mean the police, just before i get totally flamed. anyway, he either hit a bump in the road or a stone or something other than flat tar. eye witness reports say he became airbourne (who believes them though). he then shot across the island and ploughed headlong into tax payer. if the reports are anything to go by, the impact would have been at about 280km/hour, head on.

so tax payer gets taken to the private hospital where i'm on call. (for those new to my blog, i'm actually a government doctor who occasionally dabbles in private for financial reasons). thief gets taken to the state hospital where he is declared dead on arrival with a broken neck. tax payer had a really impressive bruise over his right flank, and a bruise over his right shoulder from his seat belt. (we drive on the left hand side of the road and therefore drive right hand drive cars. it follows that our safety belt bruises for the driver are over the right shoulder and not the left as they would be in america. but i digress) he was not at all stable and we decided to rush to theater with all haste. for those of you following my blog, let me say that in private this is actually possible (what i'm used to), which i think is pretty cool. i chatted to his sister trying to let her know we'd do our best but at the same time gently trying to let her know that he was pretty shocked and we'd only really know after the operation what his chances would be.

so we took him to theater. the bruise over his flank was caused by the seatbelt. both rectus abdomini muscles were totally transected. the sheath and overlying skin were intact. the obliques on the right were also transected. in fact they had been ripped off the iliac crest which was laid bare. about 70% of his small bowel had been destroyed, with injuries ranging from transection to a type of degloving where long strips of mucosa were ripped out of their protective serose to mesenterial disruption. there had been massive bleeding from multiple mesenteric arterial injuries as well as both inferior epigastric vessels which were ripped through with the rectus injuries. the psoas on the right was severely bruised, but intact. the right common iliac artery had also suffered a type of degloving injury with only a flimsy adventitia holding it together (intimal tear but circumferential). the sigmoied colon's serosa was torn, but there was no perforation. the right iliac vein was bruised but intact. the right ureter was denuded but not perforated. to say the patient was shocked is to understate the situation to the extreme. (the anesthetist later told me the pH was 6,9 at this stage. he didn't share this pearl with me during the operation!!!)

we had a go at dammage control surgery and actually got the guy to icu. of course he died about 2 hours later. he had been in irreversible shock probably from the outset.

so i got thinking. it's true that a seatbelt decreases the severity of injuries as is demonstrated by the fact that tax payer made it to hospital and thief did not. but the human body is just not made to handle the type of trauma it is exposed to because of advances in our technology. high speed car crashes can be fatal with no possibility of saving the guy. plan crashes are even worse. i've always wondered why they still bother to tell the passengers in a plane to assume the crash position in the event of an imminent disaster. how is that going to help? how are seatbelts going to help when you are plummeting to the ground from 10000m.

the other thing i thought is that we can all cop it at any moment. when i drive the road that my patient drove, i wonder what he was thinking just before impact. probably something along the lines of whether he should hire a dvd after work or something equally mundane. i sometimes feel the urge to think something great and profound just in case it's my last thought (i then laugh at myself for being ridiculous).

the other twist to the tale is that his sister totally flipped after her brother's death. she told her husband to load him into the car so they could go home and carry on with normal life. the husband came to me in desparation no doubt and asked me to speak to her. the whole extended family was sitting at one table, on one hand trying to deal with the loss and on the other wondering what to do with tax payer's sister. i'm sure there will be some long term resentment from some of them about that. i sat down with her and her husband and as gently as possible explained that we had done what we could etc but his injuries were overwhelming and he had passed on. she would not accept this and said that she had just been with him so he couldn't be dead. my mind was saying 'did you notice he wasn't breathing maybe' but all i could say was i'm terribly sorry. she later got some or other pharmacological assistance from the casualty officer.

so remember to buckle up next time you drive somewhere.