sealed with a hand-shake

shaking hands is not really such a good idea, especially in a hospital where there are all sorts of nasty bugs floating around, seeking whom they may devour. so generally i do not shake hands unless the patient absolutely insists and i think the cultural slight may be more than he can bear. but one incident highlighted to me the reason you generally don't want to shake hands so well it could just have well been written all over the hospital in bright neon lights. in fact in my opinion, it was.

i was on call that night so it fell to me to evaluate and treat the patient in casualties which the casualty officer said had a perianal abscess. i approached the bed and introduced myself, but i made a point of positioning myself in such a way that the patient wouldn't be able to greet me with the traditional handshake. experience had taught me that this was one case where this cultural idiosyncracy was patricularly ill-advised.

i asked what the problem was. without saying a word his hand moved to his gluteal cleft in one smooth motion. moments later i found myself staring with morbid fascination as he pulled his butt cheeks apart and started prodding what was clearly an abscess with his finger. it had already broken open slightly so there was a thin stream of pus oozing out and following the natural pull of gravity. the patient's grubby finger scratched, prodded and poked this poor stream of sepsis, completely disrupting its attempt to soil the bed linen.

i was so disturbed and disgusted that my senses seemed to heighten and the pus took on an almost luminous yellow colour in my mind. this, after a very short while, was visible on most of his hand and under his nails. but in fairness to me i managed to fight my gag reflex right up until he wiped his lip with that same hand. i had theater to organize so i fled. i felt dirty and used.

after the obligatory wait it was finally our time to go to theater. i got there early and as is my habit chatted a bit to the anaesthetist. we then went together to the preoperative holding area to see the patient. the gas monkey, a very gregarious fellow, immediately moved to the side of the patient's bed and introduced himself, extending his hand as is customary.

as we pushed the bed to theater i kept glancing over my shoulder at my anaesthetic colleague until he asked me what was wrong. i found it surprising that he couldn't see the bright yellow luminous marks on his hand which seemed so obvious to my mind's heightened senses.

christmas meal

often on christmas i think back to a story from long ago that was based on a christmas meal but had nothing to do with a christmas meal. the man in question was unique to say the least.

it was about february. we were on one of the painful yet entertaining rounds with our eccentric consultant. up to that stage he had actually been so contained that some of us could even have been described as being bored.he just didn't seem to be ranting as much as he usually did. he was also not spewing forth his particular brand of black humour.

then we got to a new admission from the previous night. the patient was a middle aged female with cellulitis, but the thing that struck us all the most was that she was morbidly obese. she must have weighed in at 220kg. obviously we displayed the necessary tact and didn't make a big fat deal of it. the consultant, however had no such scruples.

"you are the fattest person i have ever seen in all my life and let me tell you, i have seen fat people in my many years in this hospital." we all looked around awkwardly, hoping his verbal indiscretion would end. those that knew him well had little illusion that this would be the case. he then turned to the student nearest him;

"you! go and get me a carrot!" the student looked on incredulously. "you heard me!" he bellowed, "fetch me a carrot! and when you bring it give it to her to eat!" we still didn't quite understand what new madness had taken over the faculties of our master. we mutely looked on.

"and then on christmas day give her a second carrot to eat!" he then turned to her. "christmas!" for that is the name he bestowed upon her and indeed the name he used to address her every day until she was discharged, "you are about to make history. you are going to take part in the biggest diet in the history of medicine!"

close call

i have already spoken about the hazards of doing favours, but recently i was reminded of another example when i was still a registrar where i only just escaped the proverbial falling anvil.

it was not an unusual case but still fairly challenging for a registrar like myself. the old man presented with an acutely tender abdomen and free air revealed on x-rays. if you ignore the outside horses for a while, this is either a perforated peptic ulcer or complicated diverticulitis (some people would throw complicated appendicitis into the mix, but i'm going to leave it in the stable with the outside horses if there are no objections). the patient needed an operation and soon. so with the sun shining happily over australia somewhere, i took him to theater.

it turned out to be diverticulitis, but what a mess. the entire abdomen was full of pus and there was a big inflammatory mass in the region of the sigmoid colon. i knew what to do. i whipped out the offending sigmoid colon and, because the risk of reattaching the bowel in that level of sepsis was too high and because the patient couldn't afford a further complication, i pulled out a colostomy. after the surgery the patient started recovering at an acceptable rate. the plan was to reverse the colostomy in the future.

now usually, this sort of colostomy would be left in place for quite a while (in the order of six months) to give the abdomen time to recover fully from the severe inflammation that accompanies free pus throughout the abdomen. inflamed bowel is very friable and difficult to work with. thereafter it would be closed in a second operation. however there was a private consultant with sessions at the university who strongly advocated for what he called early closure of colostomy. he said that as soon as the sepsis had cleared up, long before the inflammation had settled, you could re operate and reverse the colostomy. he advised that the second operation be done before the patient even leaves the hospital, even within a week of the first procedure. he actually approached me about this patient specifically and told me i should try it. i started contemplating the idea.

then something happened that i should have seen as a big warning sign; an old friend asked me for a favour.

you see this friend was related to my patient in some way. apparently he had visited him in hospital and discovered i was the one who had done the operation. as can be expected from someone who wakes up from surgery with an unexpected colostomy, the patient was bemoaning his lot in life. in the end he asked my friend to ask me for a favour. the friend asked me to close the colostomy, sooner rather than later. i should have seen warning lights. i didn't.

so i decided this would be the case where i listen to the often contentious advice of this specific private surgeon. i took the patient back to theater to close the colostomy about a week after the first operation.

quite soon i was in trouble. everything was adhered to everything. over and above this, because the inflammation was far from resolved, everything was oozing blood at somewhat more than an acceptable rate. but it was too late. i was elbow deep in the abdomen. i had no choice but to continue. the other catch was that i was doing the operation at the advice of the outside consultant and not with the consent of my own consultant. this essentially meant i would experience a severe loss of cool if i asked my consultant to come in to help me *read bail me out*.

the details need not be dwelled upon (truth be told i have filed them deep in the forget folder in the darkest archives of my mind) but suffice to say it was an almost impossible dissection to get the two ends of the colon together to reattach them. finally, almost miraculously, i approximated the two ends in a somewhat acceptable manner and attached them.

during the postoperative period i almost expected a leak. day after day i'd check the patient out and be surprised to see there was no leak. finally i discharged him in good health. but not before i swore to myself never ever to attempt an early closure of colostomy again. also i reminded myself of the dangers of doing favours.

p.s many years later i ran into this friend and was pleasantly surprised to hear the old man was still going strong.

crash course in trauma

surgery is a nice mix of theory and practical, but, unlike many other fields in medicine, if you don't learn the practical, you will never be a good surgeon. i had an interesting baptism of fire in the trauma surgery division.

when i joined the surgery department as a medical officer, there was an overall shortage of registrars, apparently because the powers that be had placed a moratorium on new recruits which had only just then been lifted. so although under normal circumstances i should have been placed under the protective wing of a senior registrar for the entire medical officer year, there were simply not enough registrars available. quite soon i found myself running a surgical firm with a fellow medical officer. the boss reasoned two medical officers equalled one registrar. this was all good and well until it came to the hands on (or knife in) side of surgery. we had very little experience. our consultant was not impressed with the fact that we would be calling him in to help much more than what was considered the norm in the department (never), so he gave us a few lectures on the sorts of things we were likely to encounter on a call and how to handle them. i called it the how-to-handle-pretty-much-everything-on-call-so-that-i-don't-need-to-be-called-out-at-night lectures. yet lectures don't teach you how to actually do the surgery. luckily for that consultant we got a veritable textbook of a trauma case right in the beginning. we called him out.

the patient had been shot in the back with a shotgun. the spread of the entrance wound was about 50cm. and the damage was incredible. i could list all the abdominal organs that were hit, but it would be quicker to list those that weren't hit. so here it is in alphabetical order:-
1) the abdominal aorta.

yes, folks, only the aorta was not hit. it was shielded by the vertebral body and therefore was spared. every other conceivable thing in the abdomen took a bullet.

during the ensuing operation i got to see every possible permutation of a gunshot abdomen operation and according to our training principle of see one, do one, teach one, i was thereafter fully equipped to handle all future gunshot abdomen cases on my own.

i saw it all. i got to see a nefrectomy (removal of a kidney), kidney conserving surgery (not removing a kidney, the other one of course), repairing injuries to the inferior vena cava (the biggest vein in the body), handling of gunshot liver, splenectomy for bleeding (removal of spleen), bowel resection, bladder repair, pancreas tail resection and possibly a few more things that don't come to mind now. i also learned about damage control surgery and relook surgery. in the end i also got to feel what it feels like to lose a patient after pouring hour after hour of effort into him.

crimes against humanity?

recently i read a post that really touched me. it got me thinking a bit about the recent suggestion to charge mbeki with genocide because of the fact that his denialist policy has resulted in so many hiv related deaths. politicians always amaze me.

the story in the post is not unique in south africa. truth be told, those children actually have it quite good. they have someone who loves them looking after them and that someone is on antiretrovirals, so she should be around to bring them up. there are many more aids orfans in a much worse situation. there are also thousands of children infected with the virus today as a direct result of the mbeki regime.

now i'm but a lowly surgeon. i can't see the big picture. my mind gets stuck with the individuals. i'm touched by the plight of these children and i'm shocked that mbeki washes his hands of them. when blinded as i am by the suffering of these little ones, i just can't seem to appreciate the important effects of mbeki's decisions, like his career and the anc maintaining a façade of having things under control. somehow the little people are more important to me than all those anc fat cats.

interesting to note julius malema's reasons for not pursuing the charge of genocide against mbeki. he says they should not charge one of their own. i just wonder, why are those innocent children not one of their own too? is one man, mbeki, more important than thousands of lives and the devastated lives of all these children? a good anc answer would no doubt be most definitely! but somehow i have my lingering doubts.

as usual the anc takes no responsibility and the people that suffer are the innocent.

maybe not genocide, but what about charging mbeki with crimes against humanity?

decisions

i recently read a post by a greatly respected blogger. she relayed a story about why someone chose primary care as a speciality, but it turned out to be more about why they didn't chose surgery (or why you should read the contents of anything you eat). i felt compelled to reply.

in all honesty there are many reasons i decided to specialise in surgery, not the least of which was that i wanted to be able to deal with pretty much everything. i also really enjoy operating. there is something magical about cutting a fellow human being open. intuitively it seems so wrong, and yet we do it and we do it for the good of the patient. it's truly mystical. but there was one incident that happened in my student days that clinched the deal.

i've never considered myself too bright (with the possible exception of two separate occasions). so exam times were always quite stressful for me. the finals of fifth year were no exception. so when i found myself waiting to be called in during the surgery practical finals my nerves were pretty frayed. the patient i had examined had a large smooth thyroid. clinically she didn't have hyperfunction, but that could be due to medical treatment. i had no blood results so i would have to go through all the causes and finally settle on what i thought was actually wrong with her. the prof was bound to grill me on my diagnosis and try to catch me out. at times like this your entire career feels as if it is the balance and may be lost to you for the slightest reason. as usual i wasn't feeling too bright. and to top it all, the student that had just come out had been grilled for not wearing his name tag. the prof had apparently almost gotten personal and totally rattled him. i had just lost my name tag the previous week. this did not bode well for me.

and then it happened. while i was sitting there waiting and trying to remember and sort out all the bits of information floating around in my exhausted, overly stressed brain, one of the senior consultants of internal medicine walked past. he saw me there with red, sleep deprived eyes and anxiety written all over my face and immediately realised i was just about to go in for a grilling by the surgeons. he gave his bit of advice.

"remember, when in doubt, cut it out." when in doubt, cut it out. when in doubt, cut it out. it went through my mind over and over. a sort of charge in, sword brandished where angels feared to tread. now that was simple and easy enough for even me to remember. right there i decided i could become a surgeon. i knew i had what it took to handle the petty onslaughts of the surgeons, so that didn't bother me too much, and now, intellectually i knew i would be able to remember the essence of surgery, when in doubt, cut it out.

claustrophobia

a comment on my previous post by undead doctor, reminded me of another story about a lift in the old academic building in the old hospital.

every morning all the registrars, medical officers and interns in the surgery department would meet in the boss' office for a report on the previous night's activities and to deal with whatever other administration had to be taken care of. after this meeting the day's work would begin. the surgery department was on the seventh floor of the academic building. the lifts in that building were fairly small, so we did what any normal surgeon-type would have done in our situation...we tried to see exactly how many people we could cram into the lifts on the way back down after the meeting. as it turns out the lifts couldn't take more than thirteen. i know this from the time we crammed fourteen into one lift and it got stuck between floor three and floor four.

now the mental image you need to create here is of fourteen bodies crammed into a space that can comfortably accommodate about six people. it was the sort of situation where we could not all breathe in at the same time because there was simply not enough space for everyone's thoraxes to expand simultaneously. also it was hot, very hot. quite soon the metal walls showed small drops of water from the combined evaporation of our bodies. i would like to say it was not too comfortable, but that somehow just doesn't convey quite how we felt.

to be honest, the first minute was quite fun, with one or two people making jokes about the fact that pretty much the entire surgery department had been wiped out. it was not the ideal time for a bus accident to come into casualties. after the first minute, however, the next eighty nine or so minutes (for that is about how long we spent in that lift together) somehow were not quite as much of a laugh.

one of the interns, it turned out, suffered severely from claustrophobia and had only gotten into the lift in the first place because he didn't want his registrar to think he was weak. after that there was not too much pretence left. his registrar got to see him cry, drop to the floor and call for his mother.

i had a leatherman which someone used to pry the door open about one inch. the above mentioned intern pushed his face up against this tiny window on freedom and started to hyperventilate even more than he had up to that point. i suggested we allow the doors to close again, hoping it would allow the lift to resume its normal activities and hopefully stop on the correct floor and permit the doors to open normally. after that suggestion something happened to me that had never happened before or since...the intern started shouting at me hysterically, even taking the effort to call me a few derogatory names. i could not hit him. my arms were pinned to my sides by the mass of humanity. besides, i assumed outside that lift he would quickly become normal again. i decided to leave it at that.

after about an hour and a half i decided to push my theory once more. i moved slowly towards the doors. it was surprisingly easy..the combined sweat acted as a lubricant and we slid against each other in what i can only describe as an amoeba-like fashion. i moved right up to the intern who was on his knees with his nose pushed through the gap in the doors doing all he could to drop his carbon dioxide partial pressures. with one hand i grabbed my leatherman wedged between the doors. i placed the other on his head. in one movement i yanked the leatherman out and pulled his nose out from between the doors. the doors closed. at that moment the intern got to his feet in one smooth amoebic action. his face was in my face and his eyes glazed over with hatred. i prepared to defend myself, but almost expected a phagocytotic attack. how does one defend against phagocytosis?

then there was a jolt. the doors having been allowed to close sent some signal to the great engines of the lift (not great enough to handle fourteen people mind you) and it jumped into action. five seconds later it arrived on the correct floor and the doors swung fully open. the intern rolled out. the tears of rage turned suddenly to tears of joy. everything he had said to me was immediately forgotten by him. it took me slightly longer.

other than very hot and mildly dehydrated we were mostly none the worse for wear.