other things amanzi

funny, death

2009-11-24T09:28:00.006+02:00

i'm not comfortable with death. i usually meet it at the end of some life disaster like a car accident, a gunshot wound or a devastating cancer. the going gentle into that dark night i don't see too often. i suppose that's more the realm of the internists?

recently i had the pleasure of going to school reunions and seeing old friends that i hadn't seen in quite a number of years. more than one noted that i had changed beyond recognition, not physically but in some other way. i wondered what they were on about. in the end i decided it had something to do with my job. somehow it makes one see things differently.

i remember an old friend telling me his sister had stated that there was going to be a major change in her life on her birthday. he was hoping she would stop selling cigarettes (she worked in a cafe). i somehow thought that that just didn't seem like such a major change. the friend was excited. i was apprehensive. the major changes i see in people's lives tend to be pretty major. sometimes they don't survive.

sure enough, her birthday arrived. they found her in her house with a bullet through her brain. it was a major change she had brought about in her life all right. and i suppose she was also not going to sell cigarettes any more.

recently i came across a post talking about american surgeons. i think that is actually sort of what i'm speaking about. in the end we can't be totally normal. some of us will cut ourselves off from the human experience and become hard and callous. some of us will become exhausted by it all and burn out or become depressed. some of us will see things differently and become unrecognisable to our old school friends.

in the end i try to remind myself of the privilege that has been afforded to me to be able to meet with people in those critical moments in their lives when everything becomes horrendously vivid and the irrelevant things in life quietly fade away into the wings.

at last, a golden llama!

2009-11-23T09:13:00.002+02:00

i have just been awarded the prestigious golden llama award by the illustrious doctor rob over at musings of a distractible mind. he awarded it in a nice little limerick.

a blogger from far away nation
made blogworld his lone destination
so bongi’s awarded
his praise is accorded
given sans capitalization

i'm highly impressed with this most coveted of blog awards, but i feel a bit guilty (not guilty enough not to display the award of course). you see the reason i ended up in las vegas for the blogworld expo was entirely due to the efforts of doctor val over at better health. so, as part of my acceptance speech, let me acknowledge dr val as the catalyst that flew me over the ocean to the very strange land of las vegas.

cross clamp

2009-11-18T16:11:00.004+02:00

some things in surgery are not taught. you sort of pick them up on the way. the cross clamp was one of those for me.

the first time i heard of it was during the m and m meeting after a story i've already told. luckily i was on rotation and was therefore not in the direct line of fire. however the professors grilled my colleague on why he did not open the thorax and cross clamp the aorta before he commenced with the laparotomy. it seems, according to the professors, all would have been just rosy if they had opened the chest first and clamped the aorta, the main artery supplying everything in the abdomen and legs, before they opened the abdomen. i remember thinking the patient looked pretty screwed to me at the time and although conceptually the cross clamp idea sounded good i really doubted it would have changed the outcome. however i made a mental note of it. a while later my time came.

it was a gunshot patient, but he was hit well. however, when i saw him he was not feeling well. in fact he was in exitus. his abdomen was severely distended and his vitals were almost undetectable. i was quite impressed that we got him to theater before he moved to the great hereafter. and then it was time to do something. my mind went back to that m and m and that previous case. if there was ever a case where a cross clamp would be a good idea, then surely this was it.

i opened his chest, a region i'm not overly comfortable in, but a place i can find my way around. i found my way around to the aorta and clamped it off, thereby cutting off all blood flow to everything below the diaphragm. then i went down to my old hunting grounds, the abdomen.

when i opened the abdomen there was blood everywhere but there was very little bleeding. this was obviously because there was no more blood even getting to the abdomen. it may have had something to do with the fact that the patient had very nearly totally bled out. of course it didn't mean everything was fine. things were far from fine. his splenic artery had been shot off about half a centimetre from the aorta. there was also an impressive hole going straight through the liver, ripping a hepatic vein or two to shreds on its way. i sorted the splenic artery problem out (splenectomy in this sort of case for all you budding surgeons out there) and got to work on the liver.

some time in the whole process i asked the anaesthetist how things were going on his side of the drapes.

"the top half of him is fine. just a pitty that we can't just send the top half to icu and hope for the best." the point was at some stage we needed to remove the aorta's cross clamp. we loaded him with fluid and blood and slowly removed the clamp. sure enough once the heart had to supply the whole body and not just the upper half it started struggling. after quite a few tries we finally managed to get the clamp off without the patient crashing. he even made icu where he demised about a day later.

i was quite upset that the outcome was not what it ideally should have been, but the fact of the matter was that if we hadn't cross clamped he would have expired about 30 seconds after opening the abdomen. we gave him the best chance, but, alas, in retrospect he was shot dead.

good old boy setup

2009-11-06T12:40:00.004+02:00

i thought of not telling this story at all. recently when it was in the news here it seemed wise to rather bury it altogether. but it is something i experienced and, after all, this blog is about my experiences, so...

six years in a department gives you enough time to do a few things that can be legendary (like this story). this was one that most at the time thought was one. however, at the time it impacted me on a different level.

the surgery department had a fairly intensive academic session every tuesday. the highlight was a discussion delivered by one of the registrars on some or other topic. he was required to reference the absolutely newest literature and the standard was very high. it was a big deal. most guys spent a few months putting their talks together.

on the day in question the discussion was going to be about bariatric surgery (surgery to help obese patients lose weight). what was interesting was that the consultant (a private guy with a part time post at the university) who was designated to be the moderator of the talk was a surgeon whose practise consisted of quite a lot of small bowel bypasses. now the literature was extremely condemning of this particular operation. at the time i was rotating with the laparoscopic guru who did a fair number of gastric bypasses (an operation which the literature favoured for obesity). in passing i mentioned to the boss that it would have been more fitting if my senior had been designated the moderator of this particular discussion for obvious reasons. the boss seemed to give it some thought.

the day before the discussion the boss took me aside. he told me that he thought i was in a good position to make a comment about the gastric bypass operation verses the small bowel bypass operation because i was the one registrar at the time who had been involved in the favoured operation. he then basically instructed me to comment during the discussion. the command had been given. what could i do but obey? that night i reviewed the literature.

during the talk the registrar dedicated very little time to the small bowel bypass. he simply stated that it was an operation that has been relegated to the history books due to its dangers and the fact that there were better operations available. his moderator didn't flinch. i noted that he didn't add that the literature also stated it was unethical to even do that operation. on the whole, his talk was good. then came time for questions and comments. he fielded most questions quite well. finally the room fell silent. i stood up. i had been instructed to do so.

i started by mentioning the literature was more condemning of the small bowel bypass than the registrar had stated. and yes, i did use the word unethical. i then went on to explain that a gastric bypass causes a change in lifestyle because the patients can no longer eat so much and that their sugar intake is also curtailed whereas the small bowel bypass causes exactly the opposite. because it causes a malabsorption the patient has to make sure he eats just as much if not more just to maintain baseline health. my choice of words could have been better.

"with this operation you are actually giving the message to the patient, you are a pig and now you must really eat like a pig."

all the registrars squirmed in their seats. they seemed to be trying to quietly slip under their respective tables to avoid the accusing eyes of all the professors and consultants. they needn't have bothered. even the consultants could not maintain eye contact with me. they looked around uneasily. only the moderator maintained his steady gaze directly at me. i remember thinking i'm quite glad that looks can in fact not kill. otherwise i'm sure i would have gone up in a puff of smoke. my task was done. i sat down.

one of my colleagues leaned over.
"what have you done?" he asked. "are you completely mad? do you realise these are the guys that are going to be in your final exam in just a few short months?" i looked around. the registrars whose heads still protruded enough from behind their desks to be visible seemed to all be shaking said heads slowly. the room was absolutely dead quiet. i held my head high and gazed forward. but i also started hoping that the meeting would adjourn so that i could flee. although looks couldn't kill as i had just demonstrated maybe they could maim to within an inch of life and i wasn't willing to find out.

the next morning meeting went as morning meetings go. but just before the prof dismissed everyone he turned to me.
"bongi, you stay behind!" again the heads of all the registrars shook almost imperceptibly. sh!t!! i thought.

"bongi, dr d took me to his practise yesterday. there are fat people that he is trying to help." i considered saying that help and exploit can sometimes easily be confused with one another, but i thought better of it.
"never again will you or for that matter anyone in my department speak badly about or against any one of my consultants, in public or in private." again the thought went through my mind that i should defend myself and say that the literature backed me up with everything that i had said. i also considered pointing out that he himself had instructed me to speak and i'd just assumed he wanted me to tell the truth. fortunately i remembered something about the better part of valour and that i could not win this fight. even though it was a setup, i had hurt one of the good old boys and they would stand together, right or wrong. all i could do was hold my head high and once again prove, this time unfortunately, that looks can't kill.

it's probably not funny

2009-11-03T13:55:00.003+02:00

we have a different sense of humour. we just do. what we find funny can be macabre to most people. it is probably part of our general desensitization or maybe it's a way of dealing with the things we see. you can't get emotionally involved with everything. i remember realising this many years ago. but more recently i saw it again in a very strange turn of events.

i was a fifth year student in paediatrics. for ward rounds we were accompanied by physiotherapist students and social worker students. that morning we arrived for rounds. one of the sixth years asked the sister where one of his patients was because the bed was empty. the sister informed him the patient had died during the night. i got the feeling from their interaction that it wasn't totally unexpected. the sixth year turned to one of his colleagues and laughingly said;
"yesterday i was so busy, but today seems to be my luck day. two of my patients were discharged and one died. now i only have one patient."
the social worker happened to be within earshot. her face was one of absolute horror. she was devastated. but the sixth year didn't mean it in a bad way. he was simply not emotionally connected to the clear human drama that had played itself out. maybe he had been one too many times or maybe he was just like that. i just remember being impacted by the difference in reaction to the same news by the two people.

the second story happened when i was already qualified as a surgeon. i was on call. while i was waiting for theater time i was sitting with the radiologist going through scans (this is something i tend to do still). at a stage the radiographer came through. she wanted his opinion on a scan. apparently she couldn't understand what the contrast was doing and wanted to know if she needed to do a late phase scan. we both went through to see.

the patient had been referred to the hospital as a head injury patient after a car accident. he was intubated at the referring hospital as is good practise for these patients so he was already on a ventilator. the casualty officer suspected he was coning (a preterminal event where the brain stem gets pushed through the opening where the spinal chord exits the skull due to increased intracranial pressure, usually due to trauma inside the skull) and had therefore phoned the neurosurgeon. he had in turn instructed him to do a scan of the brain. the casualty officer decided to do an abdominal scan at the same time because he wanted to make sure there wasn't also abdominal trauma. and thus the patient ended on the ct scan table with the radiographer wondering what was going on with the contrast.

as we entered the scan room i too was perturbed by where the contrast lay in the abdomen. the contrast had been injected through a central line in the neck. it had gone straight through the right atrium into the ivc. there it had moved into both the right hepatic vein as well as the right renal vein. it was nowhere else to be seen. the radiologist immediately made the obvious diagnosis (in retrospect).
"i know what's wrong," he proclaimed. "this patient is dead." of course with the patient on a ventilator it was not immediately obvious. the radiographer went through to feel for a pulse, which, looking at the scan, i knew he would not have.

i started laughing. everyone else was shocked, more at the fact that i was laughing than at the fact that there was a dead guy on their scan table.

maybe they are right, it's probably not that funny.

extreme

2009-10-30T15:04:00.001+02:00

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

2009-10-22T16:00:00.002+02:00

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

2009-10-07T22:33:00.004+02:00

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 ... ...

2009-10-04T20:06:00.000+02:00

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

2009-10-03T13:00:00.002+02:00

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

2009-09-26T23:50:00.002+02:00

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

2009-09-21T09:34:00.001+02:00

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.

surgexperiences 306

2009-09-20T00:01:00.001+02:00

welcome to south africa for this week's surgexperiences. enjoy the small view of this world in one country as well as some great posts.

union buildings

about surgery brings to our attention a pretty bizarre intraoperative possible complication.

rugby world cup champions

a bit of an overview of intraperitoneal chemotherapy in malignant mesothelioma, from malignant mesothelioma.

table mountain

quietusleo recalls a humorous story about a robust surgeon flipping a patient like a pancake. he also talks about the only patient he knows who actually sang herself to sleep.

lost city

vanguard gives us news of free cardiac surgery in the sudan.

natal sardine run

sterile eye gives the english speaking world a sneak preview of one of his videos.

three rondawels

medzag writes an absolutely brilliant post about his surgery rotation. i really enjoyed this immensely.

robben island

an overview of smoking and its effects by sagarika for those of you who didn't yet know it was bad for you.

robben island

everyone remembers where they were when they heard the news. popehat was with his father who was to undergo surgery.

paarl rock

could fear of cancer be an indication for prophylactic mastectomy? unbound medicine gives a compelling argument.

our greatest statesman

life in the fast lane gives a very well put together case report and discussion on isolated volar distal ulnar dislocation.

letaba outside elephant museum

a touching story about a "surgeon" in somalia by bartamaha.

letaba river. my soul's secret place

dermmatters gives a very practical guide about taking your own clinical photos.

kimberly big hole

i've always felt that surgical drains are absolutely essential so i particularly enjoyed dr bates' post on the history of surgical drains.

golden gate

methodical madness gives a very humorous account of when a good spam filter just does not work for a gastroenterological pathologist.

golden gate

i really enjoyed this off the wall look at breast reconstruction and why it would not be overly useful for the amazons, written by plastic surgery 101.

god's window

who cuts off your leg, the doctor or the seestah? ask little karen.

bourke's luck potholes

this one touched a nerve in me. those days are over but the future turned out not so rosy hey, boereworsmedicine?

boulders beach

never underestimate aberrant anatomy in the area of the common bile duct. thanks for reminding us buckeye.

blyde river canyon

and i suppose that's it. please contact jeff, the guy who runs the show at surgexperiences if you want to host a future edition. if you are wondering if you should, the answer is yes.
also submit, submit, submit to this site to be included in the next edition of surgexperiences.

cape town

hope you enjoyed a few south african scenes as well as some really worthwhile posts.

hear this

2009-09-18T23:22:00.004+02:00

recently a plastic surgeon i know was called out to fix a lacerated ear. it is the domain of plastic surgeons pretty much all over the world. but in my neck of the woods it may be tricky to extricate a plastic surgeon from his warm bed on a cold night. let me also say that back in those days all registrars of all disciplines earned the same overtime each month. even opthalmologists and dermatologists and pathologists earned exactly the same overtime as surgeons. they weren't complaining. we, however, were.

as calls went it was fairly standard for us general surgeons. i had found a moment to empty my bladder which was a nice change, but other than that one reprise there had not been a moment to even realise that i hadn't eaten all day. at least there hadn't been any lethal disasters...yet.

somewhere in the madness the house doctor asked me to evaluate a patient with a lacerated ear. he had had half his ear detached in a bar brawl. it was hanging precariously from what still connected it to the body. now at this time in that hospital there was a policy that once a patient had been referred by a casualty officer they would not take the patient back. if the referral was erroneous then we would be required to refer further as appropriate. so when i heard my house doctor had accepted the patient i was not impressed.

"you suture his ear." i told him. poor guy, he hadn't studied at our university and therefore wasn't used to our sink or swim approach to medical training. he freaked. my level of being impressed dropped even more. i'd have to phone the plastic surgeon myself.

the plastic surgeon was not keen. by that i mean he basically said he was not coming out. by the tone of his voice i assumed he was getting a back rub from his significant other under the warm duvet on his bed. who could blame him. if you're not in the trenches why would you want to go into them, even for a short while to suture an ear.

"anyone can suture an ear. you're there now. i'd have to come in to the hospital. you just do it." i considered telling him that i'm at the hospital because i have so much bloody work to do and that he is drawing the same overtime that i am and that it is his bloody job and not mine. but i knew that at that stage, even if i walked on water and then turned it into wine he was not going to come out. i hung the phone up. my house doctor looked at me questioningly. he had already told me he couldn't do it. but he was not from our neck of the woods. i needed a student. one walked past, unsuspectingly.

"you! have you ever sutured an ear back on?"
"no."
"when i ask this same question tomorrow, you will answer yes. come with me."

he did quite well.

surgexperiences

2009-09-13T11:30:00.003+02:00

i have once again been given the honour of hosting surgexperiences on 20 september (next week sunday), so please get your submissions in as soon as possible via this form.

also for all medbloggers please contact jeff here if you are interested in hosting a future edition of surgexperiences.

200%

2009-09-11T15:30:00.004+02:00

m and m was never fun. sometimes i would walk out feeling i'd just escaped by the skin of my teeth. sometimes i would feel like my teeth had had too close a shave. but once...just once, it could have been worse.

it was a pretty standard call. it was very busy. in the early evening i was called to casualties for a patient with severe abdominal pain. when i examined him it was clear there was something seriously wrong inside. he had a classical acute abdomen with board-like rigidity. he clearly had a perforated peptic ulcer and needed surgery. i set my house doctor to work to get him admitted and on the list. meanwhile i went back to theater to work through the number of equally critical patients already on the list.

things then settled down into a rhythm. i was in theater with a student operating the cases one after the other while the house doctor separated the corn from the chaff in casualties. finally it was time to do the laparotomy for the guy with the acute abdomen. i needed to shoot through casualties before we started so i decided to swing past the ward and make sure the guy was still ok.

the ward was dark. pretty much everyone was asleep. without wanting to wake the other patients i turned on the small bedside light of my patient. even in that dim light i could see a bit of oral thrush. i was surprised. i was thinking to myself how the hell did i miss that in casualties. i felt his abdomen. it was no longer quite so tender. i turned to the student.
"see why it is important to make your decision before giving opioids?" i said with an air of authority. "now he is actually not so tender but he definitely had an acute abdomen. we must go ahead with the operation."

i quickly felt for lymph nodes. he had them everywhere. once again i was quietly thinking that my clinical skills must be slipping because that i also didn't pick up in casualties. i kept this new information to myself. imagine the shock to the student if he realised i was not all knowing. i just didn't want to be responsible for that level of devastation in his life. but i started considering other causes for his condition. it was clear he had aids and tb abdomen started looking like a possibility.

while we were still with the patient, the theater personnel arrived to take him to theater. i told them to get things going so long while i quickly shot down to casualties to evaluate a patient the house doctor was unsure about. and off i went at a brisk walk.

i walked into casualties. the house doctor led me to the patient in question, but as we approached his bed my blood went cold. in the exact bed where my acute abdomen had been lying about four hours previously was my acute abdomen still lying there!! i turned and ran back to theater. fortunately i was in time.

later i found out what had happened. once we had admitted the acute abdomen, the porter had come in to take him to the ward. one of the patients lying in casualties was a guy that had just come in. his hiv had wreaked havoc in his life causing a number of unpleasant things, including aids dementia syndrome. the exchange went something like this;

"timothy mokoena? is there a timothy mokoena here?" the porter called out.
"here i am, but it's not mokoena. it's magagula."
"ok, timothy magagula, i'm going to take you to the ward."
"ok, but it's not timothy. it's michael."
"ok, michael magagula. let's go."

and thus michael magagula, the aids dementia patient (not to be confused with timothy mokoena, the acute abdomen patient), thinking he had just jumped the queue to see a doctor was carted off to the ward and prepared for theater. he even signed for a laparotomy without even having seen a doctor.

in the end it all turned out well. timothy got his operation and the hole in his stomach was patched. michael was referred appropriately to the physicians. but i couldn't help wondering how this could have looked in the next m and m meeting.

"well, prof, the patient died on the table basically because i operated him unnecessarily."
"and how is the other patient? the one you should have operated?"
"well, he died too because i didn't operate him."

200% mortality for one operation. not easy to achieve.

(of course names have been changed)

mixed feelings

2009-09-09T01:14:00.002+02:00

i hate working in the state. i would quit it altogether if i didn't love it so much. such mixed feelings

recently i was called to the state hospital, as usual at an obscene hour. somehow i dragged myself out of bed. i think i woke up half way to the hospital which was a good thing. it makes parking so much easier.

now generally at this time my sense of humour is not at an all time high and i'm not feeling my usual cheery self. yet ironically it is exactly at these times when one needs to be the most malleable in attitude. if not, you will not continue in the state for long. and these were my thoughts as i walked towards theater that night. i thought of past experiences and prepared myself.

i approached the theater. i could see the main door now had a security gate that was locked. i think i was more than partially responsible for this. but the door to the change room was at least open. as i entered i remember saying to myself that if the door was open then nothing i encountered inside would get me down. i knew it would need to be a decision.

in the change room, i found only shirts. at least there were shirts, i thought. i took one and soon had put it on. tucked away in a different corner, away from the other clothes, with less effort than i expected, i found the pants. they were duly donned. there were no shoe covers. it was in the middle of the night so i just assumed that the owner of the boots i loaned would be none the wiser. anyway, it wasn't as if i had much choice. then there was the small matter of head gear. i did not have to resort to things i had done in the past. looking in the female changing room turned out to be all that was needed.

i then made my way past the sleeping theater nurse towards the operating theater. as usual i had to use plaster to stick the inferior mask to my face to prevent my glasses from fogging up. and only then could i scrub in to join the medical officer who had asked for my help.

truth be told, i accept the small irritations of the state. when i'm there i feel like i'm making a difference. i also like teaching and these days it is the only chance i get.

yes, i love working in the state. i would do it all the time if i didn't hate it so much.

sacred memories

2009-08-29T01:02:00.000+02:00

when i got accepted into medicine as a last minute add-on due to one of their other applicants turning down the post, i knew how lucky and privileged i was. it was the first step in a very long journey and i wasn't going to mess it up.

the first year in those days was spent at the main campus and we would only be at the medical campus from second year onwards. second and third years would be spent on the pre-clinical campus and only from fourth year onwards would we be in close proximity to the big boys. all this i didn't know when, during first year orientation they bussed us to the medical campus so we could see the preclinical buildings and watch with a fair amount of jealousy when the higher year students walked past. the whole medical training thing was very hierarchical. it didn't bother me. i had been in a similar system before and had moved up the ladder. i could do it again.

the preclinical campus was a very relaxed place. there were essentially only two buildings (ok, ok there was also the dentistry building but we didn't go there) with a large grassy lawn between them. there were a few trees providing shade for groups of students lying on the grass and reading or chatting. our group of first years on orientation clearly didn't seem to fit in. none the less we found a tree to sit under during a short break in the orientation program.

and there i sat in a state close to euphoria with my hopes and my dreams all layed before me. i knew i stood at the beginning of a journey that would lead me to what i one day would be. what i was at that stage was of little significamce other than the fact that it was a pointer to what i would become.

i lay under the tree and, as best i could, told my friend who was with me about these thought. i then added that i would use the tree as a sort of temporal marker that i could come back to when i was finally what i would be. then i would stand under the tree annd remember that exact moment when i looked into the unknown future with innocent hopes and dreams.

recently i had the opportunity to go back to the preclinical campus. i remembered that moment so many years ago and was quite eager to stand under that same tree and reflect about the years that had passed and what i had become. on that day, so long ago, i would never have guessed that i would have gone on after medicine to specialise in surgery, so i actually achieved more than i dared dream. i was realy looking forward to a moment that would link one specific moment in the past with the present.

the campus was just as i remembered it. the lawn was still there and there were still students sitting in small groups. they just looked so much younger than i remember being. then i went towards the far side of the lawn to have my moment under the tree.

they had cut the tree down! it was gone. everything else was exactly the same except my tree. is there nothing sacred?

just because you're paranoid doesn't mean they're not out to get you

2009-08-24T23:34:00.005+02:00

i had fun posting about a psych experience. but there were others less enjoyable.

it was during my psych rotation. i was trying to make the most of it and i occasionally almost got it right. one day our intern asked my colleague and i to accompany her on a call to the maximum security ward. we were up for most things and agreed. only after we had agreed did we ask why.
"because i'm too scared to go alone!" was her frank response. bright flashing lights and loud hortatory bells should have been going off in my head but i didn't want to look like a pruss in front of my friend so i became temporarily blind and deaf to them.

the psychiatric hospital was a big sprawling place with each ward discreetly placed far enough from the other wards to try to create a resort sort of effect. maybe in the addams family, i thought. anyway, one of the results was that maximum security was way up on the hill, out of sight of pretty much everything else. i had in fact never seen it before. so when i saw the eight foot concrete walls with barbed wire on the top i was impressed. they clearly were not messing about. we approached slowly, almost in awe of the monster.

when we got to the entrance i was even more impressed. there were two solid iron doors. a camera identified us as something slightly more benign than special forces or the terminator or rambo maybe and the doors swung open. we shuffled into a sort of holding cell. looking at us through what was no doubt bullet-proof glass were two guards. when they had satisfied themselves that we were in fact one doctor and two medical students and not some sort of covert attack team, the inner metal doors swung open and we entered the main compound. nothing in 5 years of medical training or for that matter twenty four years of life could ever have prepared me for what i saw after all those stringent security checks.... nothing.

there was a nondescript road ahead of us with houses on either side. but the road was totally deserted. i imagined a breeze ominously blowing through the grass but in actual fact the grass stood dead still. there was also no eerie music playing which just didn't seem to fit in with the general genre. but the thing that i found most disturbingly normal was the lack of a heavily armed escort. i mean after getting through fort knox-like security surely there should at least be a guy with a truncheon sort of standing around in a lazy way on the other side of the double locked steel doors?

i couldn't help it. i had heard my mind's logic and the final words hung silently in the air. locked steel doors!!! locked steel doors!!! i turned around and observed, now with almost wild panic that there weren't even handles on the doors. where they met the walls and each other was almost seamless perfection. i felt like i couldn't breathe. that breeze would be great right about now, i thought. i tried to take control of my mind, get a grip! i told myself. at least there are no crazies. they must have been locked up before we got here obviously. we are quite safe. the crazies suddenly appeared as if on cue.

at that moment, if sheer terror hadn't totally paralysed all my faculties, i'm sure i would have been able to draw similarities with any number of low-budget zombie movies, because that, in retrospect was how it was. people approached from all sides, walking slowly forward or maybe lurching slowly forward, arms extended and engulfed us with only one word uttered from their lips like a chant, over and over again.

"cigarettes! cigarettes!"

we fought our way through them and finally got to the medical building. we slammed the glass doors behind us as any number of zombies (for that is what my mind had decided they were and no amount of convincing is going to change my mind now thank you very much) threw themselves up against it. i could see the headlines: 'promising young medical student found dead in prominent psychiatric institute. only brain missing.'
then the sister appeared as if from nowhere. if it wasn't midday i would have sworn i saw a bat flutter in just before her human form became apparent. she charged the glass door and as if by magic the patients dissipated and were soon all gone.

she led us through to the examination room where our patient awaited us. it was a man in his thirties with a deep gash in either cheek. i was impressed by the symmetry.

"what happened to him?" i had to ask.

"he fell and cut one cheek. when he saw himself in the mirror, he broke the glass and used a shard to cut the other cheek so both sides would look the same." i wasn't surprised that he was clearly mad. what would one expect? but the fact that any one of those many zombies outside could have access to shards of broken mirror sunk down into my soul and festered like a septic wound. all i could think was we had to somehow get past them all again and this time they were waiting for us. 'remains of medical student found in prominent psychiatric institution. disfigured beyond all recognition'...somehow seemed more appropriate. i needed to get my mind off it.

"why is this patient in here?" i asked. at the time it was no more than an innocent question, i swear!!

"oh, he killed and dismembered his entire family." said the nurse as if she was reciting the day's minimum and maximum temperatures. he what exactly??? my mind screamed. i wanted to ask if that was generally the sort of thing that would get you into maximum security in this institution but i knew that her answer would have implications pertaining to the hordes waiting for us outside. i decided i just didn't want to know.

at about this stage my mind thankfully went blank. i think it was some sort of subconscious defence strategy. whatever it was i'm just grateful. i came to my senses when we were out again and getting back into the intern's car. i stared ahead in silence for some time. finally i spoke.

"mad!! they're all quite mad!!!" i said with conviction. "some of the patients are mad too." i added.

tharrr she blows!!

2009-08-23T17:44:00.003+02:00

occasionally i post something that scores high on my weird sh!tometer (here, here and here). it seems this is such an occasion.

i thought of this incident recently when i was privy to some doctors complaining about stupid referrals. this was the only one i could think of. in reality it was more a moronic patient than a moronic referral.

as usual it was late at night. the casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). i asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. he gave a nervous chuckle and agreed. when i started asking about possible disease processes which could give rise to this condition (which pretty much can't just happen spontaneously) he had no answers. in his voice i could almost hear him saying:

"come on. i'm tired. it is a stupid thing to come into casualties for at this hour but here she is. just come down and see her so it is no longer my problem." i answered before he was forced to actually say these words.

"ok, i'm on my way."

the patient was an old indian lady fully-clad in her robe-like traditional garb. i asked her what the problem was. she was quite a bit less than forthcoming. i asked her to show me the problem if she couldn't describe it. she lifted her robe. i was not prepared.

she presented a disfigured torso and abdomen. it seems when she was younger she had been severely burned by hot water. those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. between being young and the present she had become obese. actually that is only partly accurate. only the unburned areas had become obese. she had areas of supreme obesity interspersed by a network of amazingly slim. on one of the fat areas, towards her flank was an opening which was oozing pus. the smell was unearthly. i may have gagged a bit. but something was missing.

"where is your umbilicus?" i asked. she looked sheepishly away. she was determined to not be forthcoming. a more direct approach might work, i decided. i pointed to the suppurating hole almost on her flank and asked:

"is this your umbilicus?" she nodded. the burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. i was annoyed. she knew what the problem was from the beginning. she also knew that it wasn't something to come into casualties for in the middle of the night. she had been taking us all for a ride. but what could i do? she was there and i had to do something. something, i decided, would involve double gloving.

i inserted my finger into the oozing hole. as expected, now that i knew what it was, it tracked towards the midline where the umbilicus had been many years before. at its base i felt a tennis ball sized mass of old debris. this time i did gag. this mass i scooped out bit by bit until the umbilicus was something it hadn't been for years...clean. annoyance fell away to disgust. i almost couldn't speak because of my gag response, but i forced myself. fortunately all i really had to say was:
"have you heard of soap?"

savages

2009-08-17T18:24:00.003+02:00

i spoke about foreigners and relative attitudes between them and myself. but, truth be told, one of the reasons they think they are in deepest darkest africa when they are here is because they are!!!

we pick up the story roughly where i left it off. the initial accident claimed two lives. then the young son has to survive a brain bleed and a neck fracture. somehow the neourosurgeon sorts all that out. then in icu he gets acalculous cholecystitis and i meet him, almost in exitus. we fetch him from the pearly gates and tie him up in icu for a while. he survives. he can walk. his maths and science still works. miraculous!

but for a moment imagine the father, the only one not really injured in the accident. he is in a foreign country. he has just lost 50% of his family and there is a real chance his son might die or be paralysed or retarded for life. the daily icu vigil alone must have taken a toll on him. and then things slowly start improving.

after too long away from home they are ready to leave. the son is amazingly well. he is neither paralysed nor retarded. also he is alive which everyone sees as a positive thing. then they have the unpleasant task of getting the bodies of the other two members of the family. what do they find? certain body parts are missing, including one hand!!! stolen from the dead in the morgue. you just can't make this sort of thing up. i dare you to try.

i have spoken before about body parts stolen to be used by sangomas for so called traditional medicine, so i suppose i shouldn't be shocked, but i was. i couldn't help feeling for him. over and above all the terrible things that happened to this man and his family he has to endure the bodies of his departed family being desecrated.

this story so affected me i followed it in the local papers for a while and pretty much put it together. at least some of the people were actually arrested so quite a lot of the story became public. it seems there were people working in the morgue who regularly stole body parts to sell to sangomas. they would target the bodies which were to be cremated and cut out the desired organs just before cremation. no one would be the wiser. the foreigners were targeted, it seems, because the body lay in the morgue so long while the boy recovered in hospital.

so, in conclusion, this is deepest darkest africa and here you will truly be amongst us savages.

proudly south african

2009-08-17T13:33:00.007+02:00

being south african at this moment in time comes with certain risks. recently my reaction to an incident brought this home.

i was on my way back to nelspruit from pretoria late at night. suddenly on a fairly deserted part of the road a small buck jumped out in front of my car. i didn't even have time to react before i hit it. hitting even a small buck at 140km/h does quite a bit of damage and this was no exception. the front of the car was smashed in. the radiator was ripped open and the bodywork was pushed up against the left front wheel.

i was far from anywhere so i soldiered on. fortunately i was just entering the lowveld so i turned the car off and free wheeled down the two passes. but quite soon i was forced to stop. in this time, while gently limping the car down the passes the necessary calls to insurance, and by implication, tow companies were made, so by the time i actually stopped, people had been mobilised.

when the car finally came to a stop it was in a totally deserted part of the road. there were no lights visible anywhere and an overcast sky hid any trace of the moon. i turned on my hazard lights and waited.

then i had a south african thought. what happens if someone comes past? would i be the victim of violent crime? this is a real consideration in the modern south africa and in no way reflects paranoia. on a regular basis we read about hapless victims of car breakdown who are attacked and often killed on the roadside. recently there was a criminal element that would patrol the very road i was on and pull cars over to rob the victims, quite often shooting at their cars or them. my concerns were real. suddenly the hazard lights were glaringly bright. they seemed to advertise the car's presence for miles around. i quickly turned them off. as the very occasional car drove past i used their headlights to scan the road in both directions looking for a would-be attacker. i didn't even bother trying to stop a car. south africans don't risk stopping for someone on the side of the road, ostensibly in trouble. it is too often a trap.

then i thought if i do see someone, if i jump out and run they will see me too and i'd be a lead magnet. to stay in the car wasn't safe. i turned the hazards back on and got out. i readied my knife, just in case, crossed the road and went into the veld just out of sight. there i was safe. if someone did come along i would just slip away. the hazard lights marked the car for the tow company and my friend who were on the way. when they arrived, i would join them.

the way i dealt with the situation, from flogging the nearly dead car to hiding in the veld and the thoughts that went trough my mind were typical for us south africans. in fact when i discussed it with my colleagues the next day at work there was no one that teased me or thought it strange. across the board everyone fully sympathised and agreed with my way of handling it.

once again i find myself in a reflective mood about staying in this crime-ridden society. what is a small disaster turns into a possible major catastrophe because of the serious risk of sudden violent death. does it really need to be like this? unfortunately that question would have to be directed at the government of the day who so far have shown no sign of addressing crime at all. on the contrary they have even disbanded the one effective crime fighting unit because of the danger they would also target corrupt officials. we just can't have that now can we?

mad as in crazy or just plain nuts

2009-08-14T23:51:00.001+02:00

as anyone who knows even the slightest thing about surgeons could guess, psychiatry was not one of my favourite subjects in medical school. but even i could appreciate a bit of humour in my final practical exam in this cursed subject.

i had to get through it no matter how much i disliked the subject. i would have to 'examine' a psych patient and then present him to the examiners. ideally i'd have to come up with a diagnosis slightly better than 'he's mad!' examine basically meant i had to go through a fairly standardised interview. from that interview, using my amazing powers of deduction i would hopefully be able to label exactly what brand of crazy my patient was. the plan seemed water tight at the time.

they told us there would be translators provided if we needed them. (this is something that is actually often needed in our country, bearing in mind we have eleven official languages. i kid you not.) so when i was allocated my patient, the first thing i asked is what language he spoke. it was zulu. i quickly identified a zulu translator, but before i asked her to accompany me i enquired of the patient if he could hold his own in english or afrikaans (as you will see later in this post, this may not have been the best choice of words on my part). the patient, in a somewhat staccato voice assured me he was fluent in english. ok, i thought. and off we went.

the interview was disastrous. it seemed that the patient was simply under the delusion he was fluent in english. to my shame it took me about ten minutes to figure this out. i just thought he was somewhat stupid. turns out he had no idea what i was asking him and was trying to answer to the best of his abilities...in english...which he didn't speak...at all.

finally i rushed through to get the translator. time was limited. this was after all an exam. i was getting tense.

his zulu was fluent and with the translator we were soon in full flight. the only problem was he was answering each of my questions appropriately. he didn't seem mad at all. i started hoping for a bit crazy, but with each ensuing answer he seemed just like your average joe soap (or whatever detergent of your choice).

great i thought. they have thrown me the wild card. they have actually put a totally sane patient into the exam to catch me out. what sort of sick twisted deranged mind does that sort of thing??
i resigned myself to my fate. all i could do was continue to systematically go through the questions.

the next question was about libido. the translator told me he said he had no libido. it was the closest i had to abnormal so i latched on.
"why doesn't he have a libido?" the zulu equivalent was asked and answered. the translator doubled over in laughter at his answer. there was no forthcoming (or any other form of coming it seems) answer in english. i wanted to jump up and scream at her. i had about 5 minutes left before a bunch of psychiatrists were going to determine if i was going to repeat the year or not and the translator was just laughing?? did she think when she took this job that there wouldn't be the occasional strange answer?? and now with what felt like seconds left to me i had to deal with her sudden delicate sense of embarrassment.

"what did he say?" my voice was not raised but i think there was a noticeable quiver.
"he says he doesn't have a penis." bingo, i thought. then my paranoia about the evil examiners got the better of me. i had to quickly check to make sure there was in fact a penis.
"what's this?" i asked in reference to the member that i could clearly see.
"it's not mine."
"whose is it?"
" it belongs to this tsotsi." he said, pointing to his chest. i was so relieved. he was mad. at that point i didn't even care what sort of crazy he was. the moderator was knocking at the door to tell me to present myself to the examiners. the fact that he was crazy was good enough for me. i could wing it.

p.s i passed but not with flying colours. the examiners also specifically asked me if i had physically checked to see if there was a penis or not.

stand back, i'm a doctor!!

2009-08-12T21:27:00.003+02:00

surgeons are not stand back kind of people. they fall more comfortably into the category of charge in where angels fear to tread. i think the work tends to preferentially attract those type of people. but sometimes standing back can be the lesser of two very evil evils.

the call was a standard weekend consultation. the patient had hematemesis and his doctor was worried. nothing i hadn't seen many times before. but when he came in the patient's wife had a few more details to spice the story up a bit.

just about a year ago he had had a resection of his stomach for cancer. the surgeon had told his wife they couldn't get all the cancer out because it was growing into some big blood vessels behind the stomach. for some reason they both decided not to tell him this. so when he was referred for his chemotherapy (something that could not be described as awe-inspiringly effective in stomach cancer) he truly thought he was well on his way to full recovery. and now he lay before me, pale and restless.

he was a shadow of what he once must have been. his skin hung loosely as if in remembrance of the large man it once covered. i was not happy with the mass i clearly felt just under his left rib margin. the cancer was back and it seemed angry. i got the necessary drips running and ordered blood. i considered dropping to my knees but due to a back injury when i was still a student i wasn't sure i'd be able to get up onto my feet again.

the wife called me aside and told me the patient was not aware of the fact that the operation was not a roaring success and therefore that he was essentially living on borrowed time (which i grimly thought he is about to pay back with interest).
"you need to tell him." i said.
"no!! doctor!! i can't do that." she needed the truth.
"this man, your husband may die here in this hospital within a day or two. you need to speak to him." but she would hear none of it. she also didn't want me to tell him things were not so rose coloured (i suppose depending on what colour roses you're talking about of course).

the next day the patient was feeling much better. amazing what a bit of blood will do. we chatted a bit. you know, shared a moment. he even laughed at how bad he had felt the previous day in comparison to today. then it was back to business. in this case business meant i was going to take a long, not so thin pipe and stick it down his throat to take a quick look at the source of the bleeding in his stomach. i sort of lied to myself, telling myself that maybe i'd see something that could be fixed with a knife. in truth i knew what i would see. the palpable mass and the history dispelled almost all my doubt (or hope). but i knew i needed to look. i needed to know for sure how much or how little i would be able to do for him. maybe i needed evidence for one day after it all when i am called to account.

the cancer was a large fungating mass with a deep necrotic core. it was gently oozing blood but i could see it was capable of so much more. it seemed to me it had stopped its torrent of blood long enough to give me a glimpse as if to taunt me. as if to say you know me and you know you have no power here. it was right.

after the procedure the patient once again started spewing forth blood. i sat with him for quite some time. between his retching we spoke.
"this is not good doctor."
"i know." what more was there to say?
"what are we going to do?"
"we are going to hope the bleeding stops." what more was there to do?

then i went against the wishes of his wife. i told him this cancer was going to be the end of him. he looked at me with a calmness and a gentle smile.
"i know."

he probably had known for some time but i think he felt he had to go along with the charade and maintain the lie with his wife. he seemed relieved that the truth was out. he seemed to relax.

that night the sister called me to tell me he was bleeding massively. i explained the situation and asked her to push blood iv. if that didn't help nothing that i could do would. the next morning he was dead.

somehow when we sit behind our computers and in our nice expensive offices deciding about the futility of certain treatments and who should get what based on cost or whatever, the actual point is lost. the nice old man finally vanquished by the hideous monster called cancer or the old lady with heart disease or whatever who is forced to succumb to the dark inevitable is the point. it is the person, the individual. the one like me. and maybe like you.

i was just left with a sense of how difficult it is to stand back and let someone die when you know what that means. it, i assume, is much easier for the powers that be, snug in their artificial real worlds.

awkward

2009-08-08T14:53:00.003+02:00

recently something happened that i must admit i didn't know how to deal with. now it's funny but at the time i just felt awkward.

it was more of a convenience consultation. i suppose you could see it as a favour. one of the sisters knew a patient who would soon be going home to mozambique. she apparently needed slow release estrogen tablets implanted but was not too trusting of the local doctors in her home town. the sister asked me to do it. now generally this is not the task of a surgeon. without sounding too arrogant, we view such trivial procedures as beneath us. but i decided that i would do it as a favour to the sister.

i went to see the patient to find out exactly what it was she wanted me to insert. they were two tiny little pellets. i would have to make a small puncture in the skin, place them and place one stitch. ridiculously simple.

as i read the insert of the product, the patient made small talk.
"have you ever done this before?" she asked.
"no." i answered truthfully.
"don't worry, you'll be ok. i don't mind being a guinnae pig for you to learn." no words came to mind so that is exactly what i said. nothing.

when we got ready to start, again the patient felt the need to encourage me.
"you're going to be just fine. i'm sure you'll do the procedure perfectly." once again i gave an answer of silence. this time it may have been slightly more chilly.

i localized, made a tiny cut, inserted the pills and threw in a stitch.
"see! you did it well!" she told me helpfully. by now my reply was practised.

later i couldn't help wondering what she would do when she got her bill and realised a specialist charges more than her usual gp (even if he had done it many times before and didn't quite need so much encouragement.).