smug

recently i was involved in a discussion with a guy that was explaining how we should understand criminals. the emphasis was on farm murders but we touched on murderers in general, rapists and child molesters. my point of view was that i did not understand them and felt that he was justifying their actions. in the end i was informed that i was smug. apparently that is the word for people that couldn't see the point of view of the poor misunderstood murderers and rapists and molesters.

so smug is what i am, it seems. you see the fact is i can't understand his beloved murderers. i just can't. i also in my smugness wonder how he can, but i think i know.

it has to do with not being in the trenches. it has to do with not being faced with the blood and the tears and the guts and the screams...mostly the screams. it is probably easy to be nice and philosophical sitting snugly (not smugly apparently) in a nice air-conditioned office, philosophizing on the reasons people point a gun at people and pull the trigger. or worse...

the thing is i can't forget. i am scarred. i remember the patient lying in a pool of his own blood, looking up at me and asking, beseeching even to tell him he is going to be ok. i remember wanting to tell him that it would all turn out just fine. i even remember wanting to hold his hand because his mother wasn't there to take care of the emotional side of things. in the end i remember not telling him he would be ok because i wasn't sure he would. i also remember not being the mother he needed in the last moments of his life because that is what it turned out to be. after we had plough through the blood and feces floating around in his abdomen, violated by the bullet fired from the gun of someone my friend feels i must understand, the patient died. he did not die well with his mother or wife holding his hand in love. he died alone in some icu ward with adrenaline being pumped into his veins and oxygen being pumped into his lungs with a scarred doctor who felt that his time may have been better spent holding the patient's hand rather than pouring time and energy into a futile attempt to save his life. you see the reason i can't see the side of the killer is that the killer is still alive and has the sentiments of my learned friend to feel for him. my patient is dead and there was no one next to his bed when he died. there is no one to state his case now.

i remember the baby violated by her uncle. i was just a house doctor, but i had to examine her. the pediatrician couldn't face it. it is quite a thing to see the perineum of a four month old after it has been ripped apart by the penis of one of the people my friend understands so well. feces runs out of the vagina. it leaves a mark on the soul. but worse than that is the cry. the child did not scream anymore. i think it used up all its scream for its entire life during the deed. all that was left was a quiet constant moan. it is the ghostly moan of someone who has learned in her four month existence that there is no one who will come to her aid. there is no one to understand her. it will never leave me. my friend who is quick to understand the violator will call me smug, but may i suggest i might just be jaded?

the women raped is difficult to examine. somehow you feel you are violating her again. you feel you are making the whole ordeal worse. they don't resist. they are already broken. anyway, rape in our country is so commonplace, it may be the one area where i understand that my friend mat have sympathy with the perpetrator, but, sorry, i cannot. for me to examine those women tears me apart. it leaves me with a feeling that my own soul has been violated. that i am forced to do something because someone else destroyed a life. i refuse to see the point of that someone else. if that makes me smug, then smug i must be, but again i suspect i might be jaded.

a bullet can do a lot of damage. physically i think i might have been a witness to pretty much all of it, but there is another side to the story. i remember an old man, shot in his home when he tried to defend his wife from the killers that broke into their house in the early hours, people that my friend chooses to understand. we did pull him through, but not without a massive operation and the obligatory icu time. i remember when he came to me for follow up some time later. i was so proud that he had made it. but somehow he was the shell of the man he used to be. he was alive, but broken. his confidence was gone. he lived in fear. he felt helpless because he knew he could do nothing against the lead of the people who i hear from my friend i must understand and sympathize with. but who sympathizes with my patient whose peace has been stolen from him? the smug or the jaded?

recently i enjoyed my christmas eve over the open abdomen of a woman shot in her bed by strangers, strangers whom my friend has endless sympathy for. i did not enjoy my holiday period, but more than that, my patients didn't either. hopefully my friend, while maybe enjoying a beer with the killers he understands so well had a really festive time. i do not understand him.

pink and purple

recently i discovered the blog of a good friend. only problem is that he is a pathologist. i understand nothing of it, just like in the old days.

in the old days when i was still a registrar we had a joint meeting with the pathologists once every three months. if you ask me it was way too much. you see surgeons and pathologists are poles apart. for one thing, they are quite clever. for another their patients are all stable so there is never any urgency with them. i've heard they have to deal with bleeding a lot less too. but i suppose the clever bit got to me the most.

the way the meeting went was based on patient presentations. we would get a list of the cases they wanted to discuss. the surgeon involved in the case would then be required to present the case in front of everyone. he would talk about the clinical presentation, the findings an then the operation. it would usually end in a description of some or other thing that was cut out and sent to the pathologists. we would then hand over to them. i remember how their eyes would light up when we got to the bit about the thing we'd cut out. you see when they were handed the whatever it was we had removed or excised they got to work turning it into shades of pink and purple.

no matter what it was we presented them with, they would cut it into fine strips, put it on slides, colour it different shades of pink and purple and get very excited. at these meetings they would show us these slides. the thrill of it could often be detected in their voices as they spoke and could always be seen on their faces. they would wax lyrical as they increased the magnification, showing us the pink and purple ever closer. we would look, probably with visible expressions of increasing bewilderment with each new magnification, and nod knowingly. it probably didn't fool them. but the thing that irritated me the most was their standard opening line before they interpreted these pink and purple patterns to the room full of either excited or bewildered nodding faces. they always said the same thing. i think they might have been taunting us.

"as you can see..."

abroad

i'm of the opinion south africans have a good sense of humour in general. you have to be able to laugh at the absurd with a government like ours. and yet i do think we need to be a bit cautious about how we express that sense of humour while in the presence on non south africans. in general when you are working overseas in a foreign culture, you might want to be careful in the expression of your sense of humour.

like many south african doctors he had gone overseas to make a bit of money faster than it is possible on our shores. soon he was raking in money presiding over the sleeping while foreign surgeons plied their trade. yes, he was an anaesthetist.

now quite often the relationship between anaesthetists and surgeons can be strained. i can only assume it is worse when a language and cultural barrier are added. then there is the question of being in unfamiliar surroundings where more likely than not, things are done differently to what you are used to. it is probably best to keep a low profile and to not stand on anyone's toes. this anaesthetist did not believe on standing on toes. he went straight for stomping on their feet.

it was a neurosurgery case. the anaesthetist was of the opinion it was a non-starter and i suppose that's where it all began. there was tension between the neurosurgeon and the gas monkey right from the word go. but what could the south african giver of gas do? he had to dope the patient.

the operation got underway. quite soon the anaesthetist realized it wasn't going well. he couldn't understand a word of what the neurosurgeon, his assistant and the sister were discussing, so it wasn't really something that was said that cottoned him onto the fact that things were heading south. it was more the amount of brain tissue the neurosurgeon was suctioning out of the patient's skull that the gas monkey viewed as suboptimal. and as the operation progressed he passed through being perturbed and went right on to being amazed. it seemed there was no end to the stream of brain tissue that made its way through the suction tubing into the suction container.

after a while, once the anaesthetist was sure all the maths and science had been suctioned out, he took a more philosophical approach. it seemed to him there was little he could do to make the situation any worse so he just sat back and waited for the suction crazed surgeon to stop. and finally the surgeon did stop. he then got to the work of closing up, which in neurosurgery takes quite a while in itself. then he turned to the anaesthetist and for the first time spoke in a language he could understand.

"ok, you can wake the patient up now." the anaesthetist initially thought he must be joking, but there was nothing but an earnest expression on his face. he stared at the neurosurgeon in disbelief. the neurosurgeon stared back. "i said you can wake him up now!"

the anaesthetist shrugged his shoulders, strolled over to the suction container where it stood on the floor with its grizzly content. he then crouched down and started knocking on the side of the container.

"sir, you can wake up now!" he shouted.

thyroid fun

the way i do thyroidectomies (removal of thyroid) these days and the way i did them in my training differ radically. these days i use a fancy instrument that cuts and seals the vessels simultaneously. it also can cut through the thyroid tissue with little to no bleeding. during my training we simply didn't have these sorts of fangled tools. we had to painstakingly deal with each minute vessel individually, tying them off one at a time. also when it came to cutting through the thyroid tissue it could get a bit bloody. we would put clamps directly onto the thyroid itself and cut above the clamps. then we would quickly suture the cut surface closed before there was too much blood loss. it could be exciting. it was once a scream.

i was a lowly medical officer but i was working with the best registrar in the department. but on this particular day he was quiet and pensive. he just didn't seem to be himself.

"what's eating you?" i asked. he looked up at me.

"the thyroidectomy on the list this morning. the patient has graves disease. these days you're not supposed to operate graves disease but the prof doesn't like all these new fangled radiotherapy treatments and has instructed me to operate the patient." it didn't seem such a problem to me. if the prof had decreed it so then it was so and there was nothing to do but to operate the patient. he continued.

"only thing is there is a very good reason we don't operate graves disease anymore. you see they bleed like stuck pigs. a graves thyroid is super vascular and brittle. it is difficult and a bit risky to operate. i'm not sure i can do it. also you know the prof is actually semi-retired and he won't scrub in with me. anyway he won't be much help. his hands are no longer steady." i could see his point. still he had no option. he would have to simply put his head down and do it.

we exposed the thyroid nicely. it was massive. it sat there in the neck definantly throbbing, daring us to challenge it. what it didn't realise was that although it was very intimidating it was not nearly as intimidating as the prof. we went ahead.

as the registrar placed the clamps onto the thyroid i could see his hands shaking visbly. it seemed ironic that hands that were not steady was the reason given that the prof could no longer operate. maybe my registrar was doomed to have a very short career. i didn't share these thoughts with him. i thought it better to just be supportive and encourage him. by the time the clamps were in position the monster was already oozing quite a bit. now it was time to cut it.

it's difficult to fully explain what it looks like when you slice through a thyroid afflicted with graves disease. the effect it had on my registrar and myself was also profound. as the blade slid through the tissue blood just started pouring out in multiple streams of differing intensities. it was quite an impressive display. by this time my hands were shaking too. this was going to be difficult. as the knife finished its course through the now angry thyroid and the registrar lifted the offending tissue free of the patient we suddenly heard a voice behind us.

"hello. how are things going?" it was the prof who had quickly come in to check on us. my registrar spun around, grabbed a swab and shoved it onto the bleeding thyroid tissue still in the neck and pushed as hard as he could down on it to try to control the now liberal bleed with pressure while he spoke to the prof. it was never ever a good thing to let the prof wait.

"ok, prof. it's just bleeding a bit." a bit? i thought. i would have used words like 'gushing' or 'exsanguinating' or 'please help us mere mortals', but my registrar simply said 'a bit'. the prof took a closer look. i could clearly see the white swab changing colour to bright red under the registrar's hands. the prof moved back and then spake he.

"yes, graves thyroids can ooze a little, but you seem to have everything under control." his eyes must be the real reason he can't operate, i reflected. again it seemed prudent not to share this opinion. "i'll be in my office. let me know how the rest of the operation went when you are finished." and with that he was gone.

we stood there in the silence of the wake of the prof. i just started laughing. it was all so absurd i couldn't help it. my laugh shook the registrar out of his trance and he got back to work.

once it was all over, unlike my prof, i was a firm believer in radioactive ablation for graves disease.

reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.

vascular cuts

anyone who knows me knows i hate vascular surgery. it is hard work with little reward. scratch that. when you actually get i nice pulsating distal artery the next day you almost think the night's hour upon hour of work may be almost worthwhile... almost. but all too often vascular operations were one small step along the road to disaster.

i suppose one of the reasons i dislike vascular so much has to do with my exposure to vascular during my registrarship. we had a very good department and there was always a vascular fellow who was not only interested in vascular but competed actively to do as many operations as possible. this meant us mere registrars didn't do too many worthwhile cases. we assisted and we did the grunt work in the wards. vascular was also amazingly busy and very demanding. these things all conspired together to leave in me an enduring dislike for the discipline.

i also don't think i was the only one who felt this way. most of us disliked and even dreaded our vascular rotation. that didn't mean we couldn't have the occasional laugh at some of the things that went on. for instance we used to have a saying about the femoro-popliteal bypass operation (to place a bypass from the femoral artery in the groin to the popliteal artery just below the knee.) you see this is generally done on people that have been smoking their whole lives as a last ditch effort to prevent amputation. the patients were usually wreaks. the smoking didn't just destroy that single artery but it destroyed all the arteries to a greater or lesser degree. at best the bypass would improve the blood supply, but not always sufficiently. all too often after hour upon hour of tedious labour, the leg would remain threatened and often an amputation would be carried out a day or two down the line. we jokingly referred to these patients as fem-pop, fem-flop, fem-chop patients. the fellow tended to get a bit annoyed about this. he took his fem pops very seriously and any suggestion that it was a small step towards the inevitable below knee amputation was met with open hostility from him. we knew not to say this in front of him.

but the one time i remember not being able to hold back my laugh even as the fellow's face became red with rage and his knuckles turned white as he grasped his dissection scissors deserves mention.

we were doing a fem-pop bypass. now part of this operation is to remove the superficial vein in the leg (the saphenous magna) and to use it as the bypass for the artery. the result is that it is necessary to make a long meandering incision from the groin all the way down to below the knee. so although the artery is only exposed where the proximal anastomosis and distal anastomosis are made, the incision runs for the entire length of the bypass. the fellow was delving into the groin looking for the artery while i dissected out the vein. there was the usual theater small talk. then one of the junior general surgery consultants trotted in. he immediately saw what operation we were busy with (there are not exactly many operations that require this length of a cut down the leg). i think i might have seen an evil grin on his face. he turned to the fellow.

"hi. my but that's a big incision just for a below knee amputation." i fell about laughing.

eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'