pointless

i've put off posting about a patient i once had in paediatric surgery because my writing could never justify how i really felt about him, but i suppose i should at least try.

when i rotated through paediatric surgery, there was a memorable patient. let's call him k. when i knew him he was 2, but his story started long before that.

k was one of a set of twins. for whatever reason his mother favoured the other one. this means she lavished what she could on his brother. what she could lavish was nothing more than food. k became very malnourished. around roughly their first birthday the mother decided she was tired of k, but how do you get rid of a baby? she decided to poison him. she gave this poor malnourished child something to eat that was supposed to kill him.

i still don't know for sure what she gave him, but it was amazingly corrosive because it burned his epiglottis almost completely away, it destroyed the opening to his trachea and it essentially destroyed his esophagus. he had a tracheostomy through which he breathed, a gastrostomy through which he was given food and because he couldn't swallow, there was a constant stream of drool running over his lower lip. he also could only mannage a strange low pitched moan if he tried to make a noise.

when i worked there, he had been in hospitals for a full year. he was a delightful child. i started work every day by giving him a hug. i figured love was something he hadn't seen too much of in his short life and it was something i could do for him. he seemed to enjoy it.

then one day, while we were in the morning meeting, we got a call that little k was dying. we rushed down. in the ward we found that he was blue and had stopped breathing. my senior colleague ran up to him, ripped out his tracheostomy tube that was blocked and quickly inserted a new one. he quickly recovered. i did not.

such a simple problem like a blocked trache tube had almost meant his death and that in an academic hospital. what chance did he have for the future? i considered adopting him then, but after much thought decided that if i wanted to adopt every child that i met in my profession that had a raw deal in life i'd have to start an orphanage and drop aspirations of becoming a surgeon.

time went by as it tends to do and my time in paediatric surgery came to an end. i saw k a number of times because i often went to his ward to give him a hug if i had a moment. then one day when i got there i heard he had been sent back to his referring hospital. he was supposed to follow up again in one year for a more definitive surgical repair.

about a year later i asked the senior colleague who had saved his life when i was working there what happened to little k. without batting an eye he calmly told me he was dead. his trache tube had blocked in his referral hospital. there was no one there who knew what to do and he suffocated. that was the end of k. the colleague went on to say that it was probably better because his life was doomed to be miserable etcetcetc. i just felt sick.

to this day i can't forget little k. i still wonder about the permutations if i had adopted him.

boere

i love history. i am fascinated by where we come from and its influence on who we are today.

from 1899 to 1902 two small boer republics held off the onslaught of what then was the local world power, britain. they had no standing army. they were basically a group of farmers fighting for their freedom. but they could ride and they could shoot. these days most of their descendants live in cities and have lost most of the skills of their forefathers.

last week i went hunting with one that hadn't lost this connection with his past. he was brought up on the back of a horse and his father had taught him to place a bullet exactly where it needed to go from very young. to top it off, he lent me his 100 year old mauser, the same make of weapon that the boers had used in that war against the british so many years ago.

yes i love history and i enjoyed the connection i felt to my great grandfather who took up the same make weapon i had strung over my shoulder when he was called on to resist the might of the british nation.

south african crime

i recently watched the movie capote. i enjoyed it. but, being south african, i was interested in the reaction the movie portrayed of the american community to the murders that the movie is indirectly about. their reaction was shock and dismay. their reaction was right.

but in south africa there is a similar incident every day. i don't read the newspaper because it depresses me too much. you might wonder why i, a surgeon, am posting on this. one reason may be because i often deal with the survivors (two previous posts found here and here). at the moment i have three patients who are victims of violent crime. one is the victim of a farm attack. an old man who had his head caved in with a spade. why? just for fun, it seems. but maybe the reason i'm writing this post is because i'm south african. this is my country and i'm gatvol.

just three recent stories. some guys broke into a house. they gaged the man. it seemed that whatever they shoved into his mouth was shoved in too deep, because as they lay on the bed violating his wife, he fought for breath and finally died of asphyxiation.
then there is a woman alone at home. some thugs broke in and asked where the safe was. they were looking for guns. she told them she had no safe and no guns. they then took a poker, heated it to red hot and proceeded to torture her with it so that she would tell them what they wanted to hear. because she could not, the torture went on for a number of hours.
then there is the story of a group of thugs that broke in to a house. they shot the man and cut the fingers of the woman off with a pair of garden shears. while the man lay on the floor dying, the criminals took some time off to lounge on the bed eating some snacks they had found in the fridge and watch a bit of television.

these are only three stories, but, if you do read the papers, you can hear about similar stories on a daily basis. and our great and mighty president, the eminently blind thabo mbeki, believes there is no problem with crime here.

yes, you americans were right to be horrified by the story upon which capote is based. we south africans, through the leadership of possibly the worst leader of a country in the world today, well we just get used to it.

gee thanks

i've often blogged about the tendency in our training to be left on your own (here, here and here to name at least a few), but some of the stories have a funny twist.

i was in my medical officer year. in those days there was a general shortage of registrars so the boss used us to fill the gaps. he put myself and another medical officer in charge of a firm, reasoning two medical officers add up to one registrar.

being two, we decided to split the call. and i was the guy who got the night. so when i came in i tracked my friend down. he was in theater doing an appendisectomy. i asked him if he had anything to hand over to me.
"sure. there are just two appendixes to be done."
"straightforward or any catches?"
"no catches, just appendicectomies"
the first one went well. i used it to show the house doctor how to do an appendisectomy, so that she could do the second one.

at this point i'd like to point out that i was very junior. i did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it.

she did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out. i calmly told her it looked like the appendix was going to be pretty sick. and then she found it.

it was normal. my heart sank. there was clearly something else wrong with the patient. i remained silent and told the house doctor to go on with the operation. my mind was racing. most probable diagnosis was perforation of a peptic ulcer. i calmly asked if there were any x-rays with the patient file. there were and they were put up on the x-ray board which was behind the house doctor and therefore in my direct line of vision. there on the x-rays for all to see was free air under the diaphragm, a clear sign of peptic ulcer perforation.

shit! i thought, but stayed silent. i knew i would need to take over. only problem is i'd never done the necessary operation before (omentopexy). i had seen it once before as a medical student about three years beforehand. it was definitely in the class of operation where you would make enemies if you called the consultant in. it was meant to be in the armamentarium of a registrar and, according to the boss, i was at least half a registrar.

the house doctor swiveled her head around to take a look at the x-rays.
"shit!" she said out loud.
"don't worry," i lied. "that's why i'm here. you have no responsibility here. i'll take over now."
"shit!shit!shit!shit" she replied. i don't think she imagined her first appendisectomy to go quite like this.

for an omentopexy, the first thing that needs to happen is a midline incision, rather than the usual mcburney incision for an appendix. the patient would have two cuts. oh well, can't be helped now. i told the house doctor to swap places with me.
"shit!shit!shit!shit!" she said in acknowledgment to my request and moved around the table. i confess i laughed a bit at her total loss of vocabulary, but it was a nervous strained laugh. i felt that i needed to reassure her that i had the situation under control. she did not need to know that i had only seen the procedure once before and that a number of years ago.

"don't worry," i said, "that's why i'm here to back you up. you are not in charge here. you have no responsibility."
"shit!" she said with what i assume was a forced smile behind her mask.

i got to work. soon i had the hole nicely exposed and the abdomen cleaned out. all i had to do was plug the hole with omentum, place drains and close. only problem is although i theoretically knew what to do and even how to do it, i had no idea what suturing material to use. this was a dilemma. i knew i couldn't really phone for backup for an operation i was supposed to be able to do late at night. but more importantly i didn't want the house doctor to feel any more insecure about the situation than she already did. if i told her that i was unsure of what i was doing i was pretty sure i would get another string of her most recent favourite word and maybe turn her off surgery forever. the situation seemed to be traumatic enough for her without me adding to it with trivial facts about it being pretty traumatic for me too. i decided what to do.

as casually and as nonchalant as possible i turned to the sister.
"sister, when the other guys do an omentopexy, what suturing material do they use?" so clever, i thought. i would find out what to use without causing any further stress to the fragile house doctor and without looking too stupid myself.
"oh," she answered, "they use whatever they want."

gee thanks. i thought. well that didn't work. even in the acute phase i could appreciate the humour of the situation though. i might even have laughed, more at myself and my situation than anything else. the sister had no idea that i was in what at that stage was deep water for me.
so i asked for vicryl and did the necessary. the patient did well.

next morning, on ward rounds with the prof, i took the blame on myself. i did not mention that my colleague had misdiagnosed because, in the end, i should not have gone into the operation without double checking everything myself, so, i reasoned the blame did in fact lie with me. i also neglected to mention that the house doctor had done the initial appendisectomy. she was never in the firing line. despite all this, just for good measure, my colleague who had assured me that it was just a simple appendix, covered his own ass and informed the prof that he had told me he suspected perforation and reminded me to check the x-ray. nice to have friends like that, i thought, but i just apologized for missing it and moved on.

small cut, big surgeon?

the prof always used to say,
"small cut, small surgeon. big cut, big surgeon." in trauma this made sense. but when the world was moving towards less invasive methods this seemed somewhat redundant. and yet when the world had all but rejected open cholecystectomies in favour of laparoscopic procedures, in the prof's firm we were still cutting 20cm incisions below the right costal margin.

in my private assistances i was learning things the prof didn't even dream about. it all came to the fore one fateful day.

i was in the prof's firm. my medical officer was a rotating orthopod, a massive guy with a massive sense of humour and, unfortunately a massive mouth. we were on call. and as with calls, we were busy. the orthopod was sorting out the constant stream of patients in casualties and i was operating way into the wee hours. every now and then he would come into theater to update me on what he had done and ask my advice when he wasn't sure what to do.

that night i did, among other things, two appendisectomies on two young women. as was my habit by this time, i removed the appendixes through incisions slightly smaller than 1cm. i somehow thought young girls would appreciate this from a cosmetic point of view. it also made the operation more challenging. the orthopod was amazed. he had never seen such a small incision for an appendix before. in fact he could not stop speaking about it. truth be told, i appreciated the attention. after the operations i placed nice large plasters over the wounds to hide the evidence from the prof.

next morning we did rounds with the prof. when we got to the first patient, the orthopod leaned over to me and whispered that i should show the prof the wounds. i told him in no uncertain terms that he was not to mention anything to the prof at all about the size of the incisions. i could see the disappointment on his face.

when we got to the next appendix patient, the orthopod was literally biting his bottom lip to stop himself from speaking. again i warned him not to say a word. unfortunately he could no longer hold his mouth.
"prof, take a look at the size of bongi's wound!" my heart sank. i hoped if i just maintained composure the prof would let the comment pass and move on. and it looked as if he would. but then big mouth went on about it being such a small wound. this was too much for the prof's inquisitiveness. he opened the wound. then all hell broke loose.

the rest of the rounds entailed the prof berating me consistently and in front of all the students and patients that i must never ever make such a small incision ever again. it went on and on and on. in the end i phased out, just repeating 'yes prof, sorry prof' when there was a lull in his constant stream of chastisement. the orthopod also realized his mistake and looked quite sheepish. afterwards he did apologize. i appreciated that.

there was one more funny sequel to this story. about a month later once the orthopod had moved on and had been replaced by a general surgeon medical officer i once again did an appendisectomy. i was quite careful to make a 3cm incision this time around. on the rounds the next day, the prof decided to check the incision to make sure i had taken his advice.

he slowly lifted the plaster. he took one look at the incision and stepped back.
"no, bongi, no! what have you done?" my medical officer looked confused. he turned to the prof and said.
"is the wound too big or too small?" that did not go down well, especially when i laughed.

there is no pill for stupidity

when the superintendent of the referring hospital phoned, he said;
"there is something funny on the x-ray!" what exactly the funny thing was he could not tell me. he could tell me what it was not. it was apparently not free air in the peritoneal cavity (indicating perforation of some part of the intestinal canal) and it was not air fluid levels in the small bowel (indicating obstruction). it was simply something funny. he also mentioned the abdomen was acute (a surgical term pretty much meaning an operation was indicated). i told them to send.

when the patient arrived, the abdomen was acute as they had said. there was also no free air in the abdomen as they had said. but i found that i did not burst into spontaneous laughter when i reviewed the x-rays. it was not as funny as the referring doctor had said.

what it did show was a full colon. but it was the most loaded colon i've ever seen on x-ray. usually feces is a mix of solid and gas, but this showed only solid matter filling the entire colon. i asked the patient when last she had passed a stool.
"i don't pass stools." was her simple factual reply. i wanted to ask her if she thought it was normal to not pass stools and where did she think all the stuff that she was throwing in above was going. but it was late and i wanted to get the operation behind me. so i tasked the junior doctor with getting the patient to theater and waited for his call.

i opened in the midline. there was a perforation in the sigmoid caused by pressure inside the lumen of the bowel, causing necrosis of the retroperitoneal region. that was something i've dealt with many times. but what was 'funny' was the content of the colon. the entire colon was filled with what looked like feces but was as hard as rock. i spent most of the operation milking this stuff out and dumping it in a large basin. in the end i had removed about 4kg of rock hard feces as well as the sigmoid. it was not fun.

while i was evacuating this colon i had time to reflect. i couldn't help once again considering the fact that this woman had just accepted that she did not pass stools as normal. she had not sought help until the pressure had ruptured her colon and endangered her life.

yes indeed, there is no pill for stupidity. . . you must operate.

surgical ego

i don't know why surgeons have such inflated egos. maybe it's that the type of person that decides to do surgery is arrogant to start with. or maybe constantly being in a position where someone's life may hang in the balance based on your decision cultures a confidence which flows over into arrogance. whatever the reason i learned to read the ego of fellow colleagues and sometimes even swing things in my favour.

i was always short of money during training. towards the end this became much worse. i used to work in casualty units (er doctor) but when my prof found out that i was moonlighting he threatened to fire me. this door was closed and double bolted. he would only permit us to do private assistances.

so when one of the junior consultants asked me to assist him with a few private cases after a 36 hour shift with no sleep, i jumped at it. sleep be dammed. i needed the money. besides, assisting is a darn site better than casualty work.

the cases went well and i felt that i should be able to make ends meet with the amount of work i would get from assisting this surgeon. i was quite excited about it. but then, as life would have it, i got no more calls from him. once again my situation became tenuous.

then, out of the blue, he called me again. it seems his regular assistant was on call. it was my moment. but this time i knew i had to impress.

we started the operation. i did the usual things an assistant needs to do, but i watched every move he made carefully. i was looking for a way to get at his ego. then he did something that was ever so slightly better than mediocre. it was my chance.

"that was beautifully done! it is so great to assist you! i learn so much doing these assistances!" cheesy i know but i was desperate. besides it was also an interesting test to see if my theories about surgeons' egos were true. i was willing to be cheesy in the name of science. it was but a small sacrifice that i willingly made for the progress of knowledge.

and sure enough it worked. just a few choice words here and there so that the surgeon felt he was brilliant and i quickly became preferred assistant. i relied on that extra income and it made a great difference.

p.s although i had also done some great research, i unfortunately never published. somehow i just never got around to it.