extreme

recently i had a moment to reflect on adrenaline and adrenaline inducing sports. it was a bloody moment. but i'm getting ahead of myself.

bleeding peptic ulcers occasionally cross the path of general surgeons. usually they stop bleeding with conservative treatment. but sometimes they don't. then you need to whip out the trusty knife. even then usually the operation is little more than routine. this case, however was exceptional.

he was white as a sheet. he had been bleeding for three days but only decided to come to the hospital when he started falling over. it seemed he could at least recognise falling over as not normal. the initial gastroscopy showed a penetrating duodenal ulcer with no active bleeding. the body had managed to curtail the bleeding, partially because of vasoconstriction, but mainly due to a low blood pressure which in itself was due to loss of blood.

i got drips going and ordered the necessary blood. unfortunately as the resus progressed his blood pressure normalised and the tenuous clot in the bleeding vessel could no longer hold back the inevitable. it quickly became apparent that we were not winning and soon we were in theater.

not too long after the ulcer was nicely exposed and i looked upon something squirting blood with much too much enthusiasm for my liking. a strong thick stream of blood was propelled out at great speed. the artery was also tucked up under the edge of the ulcer in a position that was pretty difficult to access. i put my finger on it and took a moment.

during my moment i had a few thoughts. the first was pretty much that the patient was going to die in the next few minutes right there in theater under my hands with my finger still probably on the point of bleeding. this thought seemed to emanate from two glands just above my kidneys. it was not a productive attitude to have and wasn't going to help me to get control of the bleeding, so i put it out of my mind. the patient dying was not an option i was willing to give in to.

the next thought was related to the adrenaline that was coursing through my veins. i automatically thought of people who go out and intentionally take part in activities for the expressed purpose of pushing their adrenaline levels up. don't get me wrong, i have nothing against that. it's just that after an adrenaline inducing operation, the last thing i want to do is go out and get some more. adrenaline inducing operations are surprisingly common in my particular line. maybe i'm getting a bit older. when i was still training i was much more keen on getting the high stress cases. these days i'm quite happy to miss them. usually, however, they do not miss me. they seem to hunt me down. so generally i just want to go home and collapse in a heap on the floor, often in the corner after a day's work. there i tend to lick my wounds or eat worms, depending pretty much on the availability of worms at that time of year.

p.s i got control and the patient did well.

fabulous las vegas

i've just returned from the blogworld expo in las vegas. what an experience. i suppose vegas is designed to be an experience. but there is so much more that impacted me.

vegas is a strange place. it comes alive at night. for a jet lagged south african like me this actually turned out to not be a problem. my body had no idea what time it was anyway, so the circadian confusion was minor.

the american people i can only describe as friendly. unfortunately i think this is more of an indication of what we are like in south africa. we are aggressive or maybe defensive, probably because of the environment we live in. they probably are normal, but compared to us they seem friendly. strangers are forever greeting and asking how you are. it's difficult to get used to. one incident caused a certain amount of introspection on my part. a group of us caught a taxi together. apparently we had too many people in the taxi (too many people in a taxi is an unknown concept in itself in south africa). one of us got out and we were off. unfortunately, by their laws, two should have gotten out. the driver didn't notice the discrepancy and we were off.
half way to our destination, about a minute later, the driver realised his mistake and questioned one of us. his tone was sarcastic. the americans brushed off his comments. i was sitting right at the back but i felt my blood boil. i wanted to move to the front and explain his ancestry to him in true cape flats fashion. but i held my tongue and waited to see what the americans did. they remained calm and even conciliatory. i stepped down.

but the true joy of this experience was the people i met. i met blogging legends and some truly fantastic people.

i met val jones of better health. i was amazed. someone who has the type of drive to get something like that up and going simply is not supposed to be so nice. she was stunning!!! what a wonderful person. and she is pretty good at her job too. she was also the reason i was allowed to attend in the first place.

then there was ramona bates of suture for a living, the great quilter of the medical blogoshpere. she is also probably the most prolific blog reader and commenter. i personally believe she has encouraged many a fledgeling medical blogger into forging ahead and building a successful blog. she is also probably the person i most wanted to meet at the conference. she is truly a selfless, giving person without equal.

the legendary nick genes of blogborygmi and the father of grand rounds was also there. he showed me karaoke can be fun, to watch at least. nick, maybe one day i'll be able to see new york for myself.

the actual driving force (yes he took a car) behind the karaoke night was enoch choi. fun and friendly guy. and he can sing!!

the last member of the karaoke team was gene ostrovsky of medgadget. gene, your pens are being spread around the lowveld as we speak.

then there was allen roberts of gruntdoc fame. as a general rule i like emergency doctors and gruntdoc fell sweetly into the reasons why.

even if his job sounds boring docwes was anything but. i suppose even cardiologists are people too.

another legend i met was the prolific kevin md. as a blogger he it totally out of my league but face to face i though he was a nice, down to earth over achiever.

i actually got to meet the llama doctor, doc rob of musings of a distractable mind. i even watched as he helped on some of the finer points of drawing a llama. i hadn't realised it was so technical. his blog is an absolutely worthwhile read.

then there was bob coffield. even though he is a lawyer he was a really decent guy. he also hung with the medical bloggers so seems to be slightly more our side of the fence.

i now have the privilege of saying i have actually met the great doctor anonymous in person. quite a privilege.

then there was mother jones of nurse ratched's place fame.


the well known patient blogger kerri morrone sparling of sixuntilme fame was also there. her inadvertent discussion with what i can only describe as an intellectually impaired taxi driver about the movie revenge of the nerds gave me quite a laugh.

also a new acquaintance was doctor v (v stands for vartabedian, as you probably could have guessed). he is a paediatric gastroenterologist, something so specialised the speciality, as far as i'm aware, doesn't even exist in south africa.

thanks to marc monseau of johnson and johnson (his son i assume) who were a great financial drive behind the medblogger track.

bob stern of medpage today was also financially significant.

i only briefly met gary schwitzer of health news review. nice to meet you.

unfortunately the legend, paul levy of running a hospital couldn't make it in person, but he did make a telephonic appearance. i suppose he had a hospital to run or something.

all in all it was an absolutely terrific experience. i hope to repeat it next year. also i tentatively hope to see some of my blogger friends on our shores some time. i'll teach you guys how to survive south africa without picking up a lead trinket.

blogworld

the medblog tract at blogworld is not only a reality but just around the corner. it is on 15 october in las vegas. thanks to the great val jones i will be there as a panelist!!! so if you want to hear my 10c worth on the topic blogging for change: how to influence healthcare through blogging, please attend the conference.

nudge nudge ... ...

i recently read a post that reminded me of an incident. depending on which side of the eyelid you found yourself that day, it could have been funny...or not.

i was doing casualty sessions after hours. it was a way of making ends meet while i was specialising, but mostly i just hated it. anyway one night, between the snotty noses and neurotic parents a patient actually came in with a casualty-worthy complaint. he had a small laceration on his forehead. we decided to glue it together with dermabond because it was so small. i decided to leave it to the sister. after all the unit was full to overflowing with snotty noses and paranoid parents that i was required to work through and get rid of.

after a while the sister came to me. she had terror written all over her face. i tried to think what had gone wrong that she looked so shocked. i started imagining i had somehow missed a life threatening injury and the patient had crashed. turns out the problem was not so deadly but just as sticky.

while the sister was applying the dermabond, which is essentially superglue, a drop fell into the patient's eye. luckily he had closed his eye on time. unluckily he had developed a permanent wink.

i confess i laughed. the sister was not impressed. she took me aside and begged me to help. i stopped laughing. it seemed it wasn't funny to her and unless the patient was deliberately winking to show he was in on the joke, it wasn't funny for him either.

the problem with gluing your eyelid together is you can't dissolve the glue with acetone because acetone would do its own damage to the eye. so i took a scalpel and very slowly and meticulously got to work. as it turned out, the eyelashes where glued together along most of the eyelid and only in certain areas was skin involved. by the end the wink had been surgically removed, along with all the eyelashes.

i often wonder if there is anyone else who can say they have surgically removed a wink, and broken bottle injuries from bar brawls don't count.

powerless

some things make me feel so powerless (yes, even i can be powerless in the face of incompetence)

i have previously mentioned a thing or two about my opinion of where medical training is going in this country. basically the powers that be are not-so-gradually degrading the degree. to them somehow it seems like a good idea. ideas i suppose can easily seem good when you are safely hidden away in your nice air conditioned office far from the reality of the consequences of essentially negligent doctors released into the community. well i get to see the consequences up close.

he was referred from an outlying hospital on a friday. the peripheral hospitals so like to empty their wards for the weekend. after all there is some good fishing in these parts. thank goodness for good fishing. otherwise many more would die unnecessarily.
anyway the patient had free air in his abdomen. this is a sign of a ruptured stomach or intestine and requires immediate operation. in fact the longer you wait the higher the chance of death. what i found interesting is the x-rays that they sent with the patient dated four days before the transfer (but admittedly not just before the weekend) clearly showed the free air.

now not all that long ago, to miss free air on an x-ray even as a student was a mistake that would fail you. these days you can easily get through medical school without worrying about trivialities like free air on x-rays. also, to have perforated bowel causes intense almost unbearable pain. even a street sweeper would be able to pick this up in the patient. yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days. that is if he even ever examined the patient. then fortunately a weekend turned up and the patient was referred, well on his way to the great hereafter.

as can be expected, when he turned up he was extremely ill and was already in kidney failure. the catheter bag remained empty. after a few hours of aggressive fluid resuscitation there was at least a bit of urine in the bag. then it was time to operate.

the abdomen was in a bad condition. to say it was rotten would be somewhat of an understatement. but the interesting thing i noticed was the full bladder. the peripheral hospital had kindly inserted a catheter not into the bladder but only into the urethra. there they had blown up the balloon, just to make sure they did the maximum amount of damage.

so not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do , because they didn't know how to do it properly, caused further damage to the poor man.

i cast my mind back to when i was still in academic circles. i remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared. i myself was asked to examine a student in a practical exam. i failed her because she was simply a danger to any person unlucky enough to become her patient. and yet the powers that be had so changed the system from when i was a pregrad that she could not be failed and was released into the community.

i'm sure the people who have orchestrated the new system that is so student friendly (but not patient friendly) don't get to see the disasters out in the periphery that are a result of their hard work. quite frankly even if they did see them i doubt they would care. after all it doesn't directly affect them.

the baby story

the life of a medical student is somewhat left of normal. most people shy away from blood and guts and gore. as a medical student you need to embrace it. but in the beginning it is quite an adjustment. sometimes you don't know how much to adjust. what falls within the parameter of normal medical student desensitization and what is way too far?

i was a fourth year which in clinical terms meant i was at the bottom of the rung. i was doing my obstetrics rotation which meant i needed to deliver a certain quota of babies in a given time. we all tended to be goal orientated then. our registrar was the most junior obstetrics registrar in their department so she was even more goal orientated than we were. she was also a bit skittish.
so that day, when a lady came in fully dilated and then popped out a dead baby she seemed to go to ground. don't get me wrong. i do not enjoy the whole emotional roller-coaster involved in delivering a dead baby, but once it's done you need to move on, especially in kalafong where the constant stream of bursting women is never ending.

so there we were in kalafong labour ward in the middle of the night with a somewhat unstable registrar who suddenly seemed incapable of pretty much anything because she was so distraught. i had the thought that she should maybe try dermatology as a speciality. it wasn't too late to change. the house doctor spent quite a bit of time consoling her. time i thought could be better spent in consoling the mother who had just lost her child. but a fourth year's opinion was much less sought than listened to. finally the night went on.

some time later when the distraught mother was bundled off to the ward and the dead baby was bundled off to the morgue and the registrar bundled herself off to the doctor's room the call finally continued. we continued delivering babies while the registrar went through the prenatal record of the mother to try to see if there was a possible reason for the death. she discovered the mother's blood group was rhesus negative. this basically meant if the baby was rhesus positive the mother needed to get an injection of antibodies to prevent her developing her own antibodies against the rhesus factor. if this happened her chances of successfully bringing her next pregnancy to term would be greatly reduced. the registrar hadn't drawn the chord blood from the baby which is the normal method of getting blood to determine the baby's blood group. she therefore didn't know if the mother needed the injection or not. i simply thought it's not worth taking the risk and we should rather just give the mother the injection on the grounds that the baby was most probably rhesus positive. but the real reason the registrar was in a spin had to do with what the professor was going to say in a few short hours at handover about her not drawing chord blood from the baby. she settled on a plan.

"you!" she indicated my friend and i, "you are going to go down to the morgue and get that baby's blood. and you'd better move it. the sun will be up soon.

the morality of what she was asking didn't occur to me then. it was late and we were tired. also we were junior. if the registrar told us to do something then we were required to do it. so off we went.

kalafong is a scary place on a good night. the morgue was in a ditch along a deserted corridor. all was dark and foreboding. but we were on a mission and our over active imaginations weren't going to stop us. we finally found the poor baby and got to trying to get blood. then we discovered something. you actually need to be living for your blood to be drawn out of conventional veins. after a few attempts we graduated to trying to get blood through the frontal fontanelle. this also didn't work, probably because the small amount of blood there had clotted and couldn't be drawn up in a standard syringe. finally we stuck the biggest needle we had right into the heart and managed to get a small amount of blood. by this stage my own blood was curdling, the hairs on the back of my neck were standing up and i felt sick to my soul. we left.

the registrar took the blood without so much as a small acknowledgement towards us that we had done something terrible so that she could avoid the wrath of the professor.

many times since then i have been haunted by how wrong what we had done there in the dank corridors of kalafong was, but it was a lifetime ago and maybe time does wash at least some sins away.

selfish bastard

of the things i encounter in my work, the one i find most disturbing is family murders. for some reason they happen with too much frequency in our country. it seems that some people, when life is too much for them are not happy to only put a bullet through their own head, but they feel the need to wipe out their entire family first. in my opinion it is a dastardly and cowardly act for which there is no excuse...ever.

the last one i was indirectly involved in was a typical story of a man that had lost it. he killed himself. but just before doing that he shot his wife and two children. his little girl made it to the hospital. i was asked to evaluate her, but she died before i even got to her. i was so disturbed i decided i didn't want to see the body. i did, however see the scan. besides the two bullet wounds through the head, the thing that struck me most were the two hair clips clearly visible on the scan in her hair on the back of her head. it was somehow disturbingly poignant and it stayed with me for some time.

but this post is about another attempted family murder that i thought much less disturbing and, truth be told, a bit humorous.

it started out as usual. the man felt he could no longer live (not sure that was a bad decision, actually) but he decided he was going to kill his wife first (that was a selfish shocking decision which i believe speaks of the character and substance of the man). anyway, he got his wife on her knees, apparently begging for her life. he put a 9mm up against her head and pulled the trigger. the gun misfired. she was ok. he then put the gun up against his own chest where he believed his heart to be and pulled the trigger. now suddenly the gun was working quite well.

i was rotating through thoracic surgery at the time so he became my patient. i have previously mentioned gunshot wounds to the chest and the general idea the public has that the heart is on the left, so let me not bore you further with anatomic considerations. let me just say the patient shot himself through his left lung. he simply needed an intercostal drain and was otherwise fine. i suppose he thought he needed a bit of sympathy from me too. he didn't get it.

the next day, when i was doing rounds he was clinically fine and doing well. he was feeling very sorry for himself and complaining about the intercostal drain. seems he had no feelings towards his wife but was particularly concerned by matters pertaining to his own comfort. again i can say i was not wearing my sympathy on my sleeve. i informed him the drain would be staying exactly where it was until i was happy to remove it. i explained the decision would be made purely on clinical grounds and not on whether he was whining and complaining. he then asked a strange question.

"do you suspect any internal damage?"
"a bullet went straight through your lung! what do you think? of course there is internal damage."

later i had a good laugh about his moronic comment. it is the only family murder scenario where the outcome was good, in my opinion.