Blasé

i suppose reading my previous post that one can possibly get the idea that i am a bit blasé about gunshot wounds. i hope not, but sometimes i think i may be.

i was doing a casualty session in a private hospital far from my usual stomping grounds. it was one of the ways that i used to get a bit of extra money to buy luxuries like bread and butter. truth be told i hated most of it. i mean at heart i am a surgeon and not a colds and flu doctor, which is what most of the casualty work is comprised of. it was usually frustrating but i needed the money and i couldn't sell my soul. it already belonged to the professor.

on this particular day we got a call from the state ambulance service. they informed us that they had a gunshot patient in tow and they wanted to stop at our unit so that we could stabilise him before they took him onwards to the state hospital for definitive management. they basically said that he was not going to survive the drive to the state hospital and they were rushing to the nearest facility (us) so that we could quickly save his life. it all sounded a bit dramatic but at least it wasn't another runny nose. i just couldn't help wondering what we were required to do if the patient needed to go to theater immediately which, according to the story we were getting, sounded likely. we all lined up at the ambulance bay with our gloves on and waited in true grey's anatomy style.

the ambulance came blaring in and skidded to a dramatic stop. the driver also obviously watched grey's anatomy. they jumped out and soon had the patient in the resus bay. i got the history from the paramedic as i did a primary survey of the wounds.

the single gunshot wound was more a chest wound on the left hand side, but due to the tenderness of his abdomen i concluded the bullet had spent at least some time in the abdomen before exiting through the back. the patient was stable and didn't seem to be anaemic at all (he hadn't bled too much). all things considered he seemed quite well actually. (well for someone that had been shot that is. i mean i felt better than him even if i was forced to do casualty locums.) but he did have a pneumothorax clinically so he did at least need an intercostal drain. he would also need a nasogastric tube because there was a chance the stomach had been hit.

moments later i had the intercostal drain inserted and swinging comfortingly. i then threw a nasogastric tube in quickly without too much ceremony. the patient seemed to breath with slightly less difficulty. i looked at the paramedics with a glint of pride in my eyes. i doubted they had ever seen such a fast and slick insertion of an intercostal drain and nasogastric tube. they stood against the wall with their arms folded staring at me blankly. tough crowd, i thought. it seemed they expected me to do something more before they were willing to take the patient back. i wondered what i should do. he already had two good intravenous lines up and i had inserted the intercostal drain and placed the nasogastric tube. as far as i was concerned he was ready to go but they didn't seem to think so. i tried for an encore.

"sister bring me a set for a central venous line please." if they wanted to see me in action then who was i to deny them that? soon the line was in. i stood smiling at them. they stood nonchalantly looking back at me. i felt a bit irritated. didn't they know us surgeons had very fragile egos and that they were supposed to make some comment about how good i was if they weren't going to outright cheer in unbridled delight at the privilege of seeing me at work. i needed to get rid of them.

"ok, there he is. sorted and stable." i neglected to mention that he was essentially stable when they brought him in. "you can take him to the state hospital now." they left.

the rest of the night went as a session in a private casualty unit goes. the colds and flus were interspersed with an ear ache here and there and the occasional baby that didn't want to let his parents sleep. finally i got to lie down a bit at about 1o'clock in the morning.

i had just dozed off when the phone rang. it was the sister. she informed me that there was someone on the phone from the trauma unit of the university hospital of that city. (i mentioned that i did these locums far from home). i remember being amazed they had a trauma unit. we just handled whatever came our way when we were on call, trauma or otherwise. but still i wondered what they wanted to speak to me about.

"is that the casualty officer?" asked the voice with a typical jo'burg accent.

"yes." i ventured tentatively.

"did you handle a gunshot wound earlier tonight before he was transferred to us?" oh sh!t i thought. i must have missed something and the guy died. now they are going to nail me to the wall. other than the slight problem of being responsible for a death if something came of this and my professor discovered i did locum work there was a good chance that i would lose my post in surgery and my career would be over before it began. i felt my sympathetic system kick into gear. i was instantly fully awake.

"yes." i said in almost a whisper, my mouth suddenly bone dry.

"well i'm the surgical registrar in trauma and my consultant has instructed me to phone you immediately." i wanted to express surprise that there was a consultant on the floor with him at 2 o'clock in the morning. i wanted to say something like these english universities are soft or something equally tongue in cheek, but my tongue just stuck to the roof of my mouth and didn't seem to be able to find it's way to my cheek. waves of terror were now washing over me. if i had screwed up enough that a consultant was involved i really must have screwed up badly. maybe i was going to get struck from the roll and i would have to pursue a career as a street sweeper. (i would need to find a job that i used my hands with. street sweeping seemed like a good option)

"uugh." i tried to say something but only dry guttural sounds came out of my mouth.

"yes my consultant and i received the patient here. he said i must phone you to tell you what an excellent resus you did. it's seldom we get patients in such optimal condition." my sympathetic system easily transitioned from flight to fight in one split second. bastard!!! i thought. didn't he know what the time was? didn't he have a bloody watch?!! didn't he know that i didn't need compliments from registrars at his university, especially not at 2 bloody o'clock in the bloody morning? finally my tongue came loose from the roof of my mouth.

"thank you." it was all i could manage.

experience

different places deliver different opportunities for experience. it is just a fact. a surgeon working in hollywood is going to see a different spectrum of patients than what one in, say, delhi would. it doesn't mean one is better than the other but it does mean one would feel more at home treating certain conditions than the other. therefore when the belgians rotated with us it stood to reason that they would feel a little unsure on their feet in our environment, initially at least.

when i started in surgery there was already a belgian there. our department had an arrangement with a university in belgium which meant there was at least one belgian registrar with us for one whole year at a time. each year the belgian would go back and another would come to our shores to replace him. so i got to know quite a few belgians in my time. chatting to them i realised the vast difference between the approach to training in their country and in our humble department.

when i first joined the department, in an effort to make small talk i engaged the belgian. i didn't really know what to talk about so i decided to ask him about the differences in the sorts of things they saw there and the sorts of things we saw in south africa. i started with things that were common to us.

"so have you ever seen a gunshot wound in belgium?" i asked.

"of course! i saw one that went in the thigh anterior midline and exited on the lateral aspect just before i came out to south africa." i decided to rather ask him about the weather. it would bore me less.

a year later when the new belgian had joined us i decided to strike up a conversation so that he at least felt there was someone he could speak to in this new strange country. at that stage we were so consumed by surgery there was little else we were capable of talking about.

"so have you ever seen a gunshot wound in belgium?"

"of course! about a year ago there was one that went in the thigh anterior midline and exited on the lateral aspect."

"and what's the weather like there?"

my third year there when the third belgian came out i decided to test what was becoming a theory of mine.

"have you ever seen a gunshot wound in belgium?"

"of course!"

"let me guess. it went in the thigh anterior midline and exited on the lateral aspect?" he assured me the weather in belgium could be quite pleasant in the summer.

so the first three belgians had seen the exact same gunshot case. gunshots were so rare in their hospital that when one came in the entire surgery department was called to casualties to see it. i was amazed. they also didn't quite have the same sink or swim way of training that we had. they pretty much didn't operate at all without a consultant being present. in our way of thinking it was madness, but in reality it was just a different road to the same destination.

so imagine the culture shock when one particular belgian registrar started in our department. he was shuffled off to kalafong and put on call alone his very first night. now as i have mentioned before, getting a consultant out to kalafong at night was only fractionally easier than turning lead into gold. the senior south african registrars informed him of this fact and availed themselves to be called if he needed advice. they quickly added that they would help him telephonically but they would not actually come in. he would have to sort everything out on his lonesome.

the next day he was a wreak. he was talking about packing it all up and going back to belgium (where the weather was pleasant in the summer). to his credit he stayed.

you see, that night, not only did he see his first gunshot abdomen, but he was required to operate it. after that he did his second one and after that his third. on his very first night on call in this glorious country of ours this poor first worlder really got a taste of what it can be like. i really felt for him. but then again at least we no longer had to discuss the weather.

coin a phrase

recently i went to germany for a laparoscopic course. it was great fun. among other things i saw snow for the first time. this caused me to spend the night at hamburg airport after being snowed in with a few south african colleagues and drinking whisky mixed with freshly fallen snow out of paper cups. then we caught a train to frankfurt to fly back to sunny south africa. it was great!!! but there was another story which i got a chuckle out of. us south africans are truly a unique brand.

after a long day listening to a german professor who was totally devoid of a sense of humour (and we did try to elicit one) we all decided to go out for a bit of enteral feeding (and drinking of course). we found a quaint little place under a building somewhere which was at least warm (did i mention germany was the coldest place i have ever been!!). also they had german beer which they served directly out of a wooden barrel. it was the only time i have seen a german barrel of laughs actually. so we were essentially in what we viewed as heaven and as the barrels came rolling out full and quickly returned empty our already festive mood just got better.

quite some time into the night when we were all feeling pretty good, a lady came around in what i assume was some sort of german traditional dress selling a new brand of shooter that she was promoting. she quickly ascertained that we couldn't speak german when we replied to her overly friendly supplications with blank stares (we were all conversing in afrikaans) but seemed relieved to discover that we were all pretty fluent in english, as was she. she sang her song again.

"i'm promoting this new shooter which blah... blah... blah..."

"how much?" asked my one colleague.

"two euro" she replied with a plastic smile.

"i'll give you five rand." now two euro, when exchanged for south african currency, translates into about twenty rand, so, five rand was clearly not going to be enough. we wondered if this artificial german barmaid would have any idea what a rand was and where it came from. we were surprised.

"no! five rand is not enough." she replied with what we were learning was a standard german sense of humour. "you may all be surprised to hear this but i have actually been to south africa and i know what five rand is worth. so do you want one or not?" she said sternly.

"sure. i'll take one." said my friend. he took a shooter off her tray and threw it back. he then handed her a coin. she seemed to be interested to hear what he thought of it. i think she was actually hoping to sell a few more shooters to a group that clearly at least didn't have a moral objection to the occasional drink. we all watched for a verdict. finally one of us asked (in afrikaans of course) what he thought of it.

"nie te kak nie. maar dink net hoe verbaas gaan sy wees as sy agterkom ek het wel vir haar 'n vyf rand stuk gegee.*" we all fell about laughing uncontrollably. she stood there with a quizzical look, oblivious to our joke, which, with the effects of the social lubricant, in our minds, made it all the more hilarious. were essentially lost to her. she turned and left with she sounds of our mirth no doubt driving her away.



as i discovered later when looking at the two coins, they were similar enough in design that in a dark german bar and if you were feeling particularly annoyed by a bunch of foreign slightly tipsy surgeons it would be quite easy to mistake one for the other.


* not too bad but just imagine how surprised she is going to be when she discovers i did in fact give her a five rand coin.

knot a good story

probably my favourite operation is a laparoscopic nissen fundoplication. it is a mixture of intricate dissection and technical skills. and probably my favourite part of a nissen is the laparoscopic knot tying. it's just fun and i am usually quite good at it. yet recently while i was doing a particularly difficult nissen with a massive hernia, when i got to about the sixth knot, somehow i just couldn't seem to throw a laparoscopic knot anymore. it gave the assistants a bit of a laugh and a window to tease me a bit. i too had a good laugh, took a moment, and the problem was gone. the rest of the operation was no problem. but i couldn't help reminiscing about another knot tying incident from the old days.

surgeons generally tie knots with only one hand, their left hand. it is a fairly easy skill to learn and yet it is poorly taught. i remember when some registrar tried to teach it to me when i was still a medical student. he sort of took my hands and positioned the fingers as if they were made of wire and would just bend into any position he chose. he then started twisting the fingers into ever increasingly strange contortions as he shouted:-
"now you do this and then you do this and then you do this!" interspersed with "not like that, idiot!" each time my hands didn't immediately fall into the position he demanded them to be in. when i finally got it right by sheer chance i wasn't entirely sure of the correct sequence of d0-this-es to be able to repeat it.

so when i became a registrar in surgery and i was required to teach students how to do the elusive surgical knot i sat down and formulated a way of explaining the steps using words other than 'do this' and 'do that' and without grabbing their hands and forcing their fingers into strange contortions. i then simplified the steps so that even if the student's hands forgot how to do the knot, when they went home they would be able to go through the steps again and reteach themselves to do it. and i had great success. even the most ten-thumbed students could sort of throw a knot after going through my steps.

then one fine day swimmer's chest and i were doing a laparotomy together and i decided to show my good friend, swimmers chest, my surefire way of teaching the knot. of course it wouldn't count if i simply tied with my trusty left hand so i decided to use my right hand for the demonstration. i set up for the knot, explaining the steps. but just as i was about to throw the first knot, the boss walked in to check how things were going. my wrong hand (the right hand) was set up to do the knot so i thought i'd better just get on with it. yet with the boss breathing down my neck and the initial point to tying the knot with my right hand being gone, i somehow floundered. the boss was (k)not one to let such an opportunity slip by. he immediately knotted onto the fact that i was struggling. he leaned in and focused his entire attention on my hands. i needed to get his attention off me. i asked the sister for a needle holder so i could tie with an instrument rather than with my hands. the boss was quick to respond.

"no no no no no bongi. use your hands." i grabbed the suture, but by this time the hands were shaking. i went back to my trusty left hand but as i set up everything just fell apart. the boss' eyes seemed to burn holes into my finders and it felt like so many years ago when the registrar twisted my fingers to their heart's content. swimmer's chest looked at me in amazement. he leaned across and laughingly asked,

"bongi, what's wrong with your hands? why have they gone all stupid?"

"swimmer's chest, here is the suture. i seem to not be on form today. you do the rest." but the boss would have none of it

"no! bongi will continue and throw the knots until the operation is finished."

and so i struggled through the last few sutures that needed to be thrown with the boss' disapproving glare and swimmer's chest trying not hard enough not to laugh.

still to this day when swimmer's chest and i get together he rags me about the day my hands suddenly became dumb and i forgot how to tie knots.

perspectives

somehow we see things differently. i'm not saying we are not part of the common human experience but we are involved in this experience on such an acute level we just end up seeing things differently. i mean if someone drops the word 'urgent' into a message for me i get visions of someone bleeding to death rather than images of having to stop at the shops to buy milk on the way home. maybe what i'm trying to say is we can come across as slightly glib at times. there are so many stories to illustrate this that maybe this needs to be discussed in a number of posts, but i remember when i was confronted by my own attitudes to the realities of life.

i was in casualties resus, a place i really felt at home in. i was stabilising a gunshot abdomen patient and preparing him for theater. it seemed the bullet probably went through the liver and the patient was bleeding enough that i was quite concerned. i was determined to stay with him until i had him under my knife, just in case something went wrong. but once the lines were up and the blood was running in there was little more to do than to wait for our turn in theater. it was a time to sort of stand around and maybe share a joke or two with the rest of the team. it is also a time to see what else is going on in resus.

the patient lying next to mine was a neurosurgery patient. he had been attacked in his house during a break in. for good measure his assailants had driven his skull in with some sort of blunt object. i had nothing better to do so i took a look at the scan. it was clear my neurosurgical colleagues were also not going to get too much sleep that night either. we laughingly teased each other about whose job was the worst.

all this time i noticed there was someone standing just outside the back door of the resus room. he had an expression somewhere between awkwardness and sheer terror on his face. he was clearly totally out of place but he wasn't bothering anyone and i sort of just ignored him. but he looked very familiar, so in between making sure my patient wasn't about to die and teasing the neurosurgeons i racked my brains to try to remember where i had seen him before. suddenly i remembered. he was a pastor at a local church and many years ago, when i was still a medical student, i had seen him there. the polite thing to do would be to greet him, i thought. i moved towards him.

as soon as he saw me approaching he seemed to take a deep breath and gird up his loins and he set out directly towards me much faster than i was moving in his direction. he walked with such a determinedness i wouldn't even have been surprised if he decked me when he got to me. i readied myself to say something, but suddenly realised the usual 'hello, and how are you' somehow just didn't seem to work in this setting. i was formulating a slightly less formal 'hi there' in my mind when he beat me to it and started speaking.

"excuse me," he said with an intense expression etched into his face, "but would it be ok if i prayed with this man who has the head injury?" somehow my 'hi there' suddenly seemed so out of place. even a 'i once saw you in church many years ago' seemed a bit unimportant compared to the fact that his friend would be lucky ever to talk again without saliva running down his chin, assuming he survived. i felt stupid.

i went through it afterwards in my mind. you see when people come into contact with me it is more often than not at one of those extremely important moments in their lives. often the only question to ask is whether they are going to survive or not. things like what ply toilet paper they prefer becomes somewhat irrelevant. but on any given day i may be faced with many people at these crucial crossroads, but each of them will maybe be faced with the situation only once or twice in their entire lives. maybe in a sense sometimes we become used to things no one should ever be used to.

and therein lies the secret. we may never become blasé or glib about the sharp edge of the human condition just because we see it every day. for me it may be just run of the mill or just another gunshot, but for the patient in question it is probably the single most significant moment in his life. even if we can't empathise with each and every patient, we need to remember these facts and respect the patient's experience for what it is, deeply significant.

in the end i mentioned quickly and in passing to the man that i recognised him and then left him to support his severely injured friend in whichever way he saw fit.

silence

one expects a certain level of dignity and decorum from your surgeon. there was an incident when this was so not the case the ensuing astoundment caused such a deep silence one could almost hear a pin drop. it's a pity we didn't.

it was one of those cases you see where some kid has swallowed some object he shouldn't have. this time the x-ray revealed a pin which seemed to be in the kid's stomach. amazingly enough if it gets through the stomach it most likely will make its way throughout the entire intestinal canal and can be left on its somewhat crappy journey. but being in the stomach it is also quite accessible with a simple gastroscope which is not too invasive. the parents were keen for me to try to get it out and i was up for that.

we settled the kid on the scope table and inserted the drip with much weeping and gnashing of teeth. the kid was doing the weeping and i was doing the gnashing of teeth. but once it was up the sedation and procedure we knew would be no problem.

the sedation was injected and quite soon i was peeping into the stomach with my trusty scope. only problem was there was no pin to be seen. i looked at the x-rays again. there the pin was clearly in the stomach and the x-rays had just been taken. that meant the pin couldn't have gone too far. i advanced the gastroscope into the first part of the duodenum (the part of the bowel just distal from the stomach). still no pin. not to be discouraged by disappearing pins i just kept on advancing the scope but still the pin was nowhere to be seen.

finally when i came to the part of the duodenum that straddles the aorta (a big pulsating artery) sure enough there was the pin jumping up and down with apparent glee with each pulsation. it seemed a pity to go to so much trouble to find it and then just leave it there, even if it looked like it was having fun, so i asked the sister to ready the biopsy forceps (that was the only grasping scope instrument we had) and i prepared to remove it.

as i discovered it is not so easy to grab the head of a pin with something not much bigger than the head of a pin, especially when with every attempt the pin bounces around in rhythm to the patient's beating heart. the procedure started getting a bit longer than i thought it was going to be. i wondered what the parents waiting outside would be thinking by this time.

i was just considering giving the whole idea up for lost when the pin seemed to jump into the mouth of the biopsy forceps and we grabbed it. we had a moment or two of panic when the now immobile pin seemed ready to stab the aorta with each pulsation that had so recently been its play mate (pins can be so fickle). so we quickly withdrew it into the stomach...where we accidentally let it go.

the procedure was getting a bit too long and the parents were probably wondering exactly what i meant when i told them it would take no more than five minutes. nevertheless, after working so hard to return the pin to the stomach where it was supposed to be in the first place, i couldn't exactly stop the procedure then. i soldiered on.

it is surprisingly difficult to pick up a pin in the stomach with biopsy forceps through a gastroscope, even for those practised in the fine are of retrieving pins from the distal duodenum as i was. i started to sweat a bit, but i was now in it for the long run. and finally i did get a hold of that blasted elusive pin. i told the sister to hold the forceps as tightly closed as possible and we withdrew it.

we stood there looking at this pin now held by the forceps, but outside the body with what i think was a sort of grudging admiration. i reached for it and the sister released the forceps and...well the pin just disappeared. we looked at each other in silent horror.

"did you see where it dropped?" the sister asked.

"no."

"did you hear it drop?"

"it wasn't that quiet."



yet even then the humour of it was not lost on me. i could just imagine explaining to the parents;

"sorry we took so long but the pin was much further than we thought it would be."

"so you didn't get it out?"

"no we did get it out."

"great. can i see it please?"

"uuuummm...."

the child was still asleep so we had a bit of time. we both dropped to our knees and started searching the floor. but the pin had disappeared. it seemed its super powers weren't just limited to when it was inside the kid, but it retained its elusiveness outside of him as well.

then i wondered what the child would think if he woke up just at that moment to see his surgeon and the sister scurrying around on their hands and knees with their noses right up against the floor. i considered sedating him a bit more so we could find the pin in peace but that somehow seemed wrong. the next thought got to my mouth before i had even properly formulated it.

"sister, don't we have a similar pin somewhere here that we can give to the parents and just tell them it's the one we removed from their kid?" she laughed. i was just about to tell her i wasn't making a joke when the patient started groaning as he slowly woke up. i jumped to my feet, a bit too quickly i fear and brushed myself off. to her credit the sister continued on her quadrupedal quest.

about a minute later, as the child started looking around and demanding his mother, the sister suddenly jumped up with the pin firmly grasped between her fingers. we quickly put it into a specimen container so that it could no longer escape.

i then walked casually out of the procedure room with all the dignity and decorum i could muster and presented this prize to the parents. they had no idea how hard i had worked for it.

grand rounds on south african shores.

it's not just the soccer world cup that is on south african shores but the great grand rounds, something that some would say is far more important than the world cup (ok only one guy would actually say that and he is in a psychiatric institution in outer mongolia) is also presently hosted in south africa!!! proudly south african!!!

but time to see what the bloggers have dished up for us this week.



here is an interesting article sent by preeti kaur which is relevant in the context of the world cup. i must say i think that fifa should stick to soccer and plundering african countries and keep out of healthcare but i may be wrong.


greenpoint stadium

amy tendrich reflects on the lessons learned by the ada.

another blogger making her voice heard in the diabetic community is kerri sparling.


a kuduzela, an variation of the vuvuzela










philip hickey, a psychologists questions the tendency of modern medicine to add a diagnosis to pretty much anything, in this case sexual disorders.



in a somewhat related post james baker wonders if some things that modern medicine has labelled a disease may only be problems of living this thing we call life.


jo'burg stadium










a south african reflects on lessons learned from soccer. fifa, with their autocratic laws imposed on previously free south africans may demand royalties, but then again she has moved to far away shores, so i think she might be safe


the great doctor anonymous touches on an issue that i often think about, the end of a blog. this one touches a nerve with me because i also sometimes consider how long my own blog will live.

a sotho blowing a kuduzela

how to cope with chronic pain has a nice piece on professional sports stars and pain they feel. he concentrates on retired nfl players. if he were to look at soccer players i'm sure he would find the active players cry all the time, especially when the ref is looking.


polokwane stadium

bob vineyard of insureblog shines a light on an aspect of medical insurance that ultimately played a part in the demise of a cancer patient.




south african supporters armed with vuvuzelas, makarapas and glasses (to see better of course)

andrew holtz of mditv tells us that watching soccer may even be more dangerous than playing it, despite the expressions of pain and agony on the faces of the numerous world cup players forever diving.

a man i consider a great blog academic, doctor rich wonders about the motives of people trashing the jupiter trial in an otherwise respected journal.




an old style makarapa with matching spectacles. we can make a spectacle of ourselves if we want to













robin mockenhaupt looks at some financial aspects of prevention of disease in the elderly.


true style south african supporter

louise discusses how some clinics will get hit hard by delays in payments by medicaid.



the goal that wasn't. well done fifa!

walter jessen tells us about a certificate that has recently been launched by the health on the internet foundation. this will hopefully help advice seekers to be a bit more critical about the things they read online.




david harlow looks at health information from a slightly different angle.
good old south african soccer glasses












dr deb gives us advice in the form of tips for mental fitness. have a look how many you do.




the now famous soccer city in soweto

the happy hospitalist has stumbled on a much cheaper alternative to using a translator when you and your patient don't share a communal language. happy, i too have seen this technique used in south africa with similar results.


a band maybe? they at least all play the same note.

jill of all trades talks about something that has always been close to my heart, the training of the future doctors of the world. some day i hope to once again become involved.





the cheating devious uruguay understanding of foot in the word football.

the legendary blogger, dr charles takes a look at an isolation experiment that is supposed to mimic a trip to mars. in the end maby it only mimics isolation. besides, what's a surgeon doing in such an experiment? do they want them to fight?

makes me proud.

doctor bates relays a short humorous story.




my team, although they went out early (and after all it's not rugby)

alan dappen writing for get better health discusses a pleasant encounter with a patient, even though money issues were discussed.

maradona was often more entertaining to watch than the soccer.

and that's it for this week's edition. i hope it supplied a nice few posts for your enjoyment. please feel free to link here.

next week's grand rounds will be held over at captain atopic's place.