other things amanzi

coma

2012-01-28T14:27:00.000+02:00

one of the curses of kalafong (hell) was that there was no neurosurgical service. this meant us mere general surgeons had to handle the many head injuries that came in. so, for example, when some guy decided to cave in the head of his so-called best friend with a five iron on the golf course because they had started with the nineteenth hole instead of the first, we ended up either dumping them in icu with a tube down the trachea to wait to see what happened or trying to turf them to a neurosurgeon that could actually operate them. it was far easier to dump them in icu. mind you, it was easier to turn lead into gold than to successfully transfer a patient to neurosurgery. so generally we hated it when we were called to casualties to handle someone with a head injury.

my colleague got the call. an old lady had apparently fallen and hit her head. the paramedic had intubated her on the scene and rushed her in. he proudly stood there admiring his handiwork as he presented the patient to my friend.

"well, doctor, her gcs was three so i had to intubate her. she fought the tube so much that we had to inject her with 30mg dormicum." it was the usual story the paramedics spun explaining why they had intubated someone and at the same time illustrating that they thought we were idiots. you see, the gcs (glascow coma score) is a scale that gives one an idea what depth of coma the patient is in. it is a measure of the patient's normal responses as far as eye movements, verbal response and response to pain is concerned. a score of 15, the maximum, is essentially a normal person. a score of three is the lowest you can get and is equivalent to a corpse or maybe a brick. a person with a gcs of 3 does not fight a tube and doesn't need dormicum. then again 30mg of dormicum would pretty much drop a gcs of 15 to 3 or thereabouts. my friend was understandably skeptical when he entered the room.

"oh, doctor, the other thing i forgot to tell you is the right pupil is blown." this was lingo meaning the one pupil was severely dilated while the other was not. this was in fact a true sign which did indicate intracranial damage, usually bleeding with unilateral increased pressure. maybe, despite the supposed need for 30mg dormicum, the patient really was in trouble.

the surgeon walked in. the patient lay dead still with only the rhythmic up and down movements of the chest as the ventilator pumped away. he took a quick glance at the eyes. sure enough, the right pupil was massively dilated and absolutely unresponsive to light. this was not a good sign. he turned to his students.

"look at the eyes. see the difference in the pupils? that is a very bad sign. this poor old lady has pretty much no chance of survival." immediately the patient lifted her head off the bed and shook it vigorously. the surgeon took a double take. that wasn't supposed to be possible.

"tannie, can you hear me?" the patient nodded. "disconnect the ventilator immediately!" commanded my friend. the sister complied. the patient blinked a bit with her asymmetrical eyes, but breathed normally. my friend pulled the endotracheal tube out, to the absolute horror of the paramedic who had been so proud of his actions. with that the old lady sat up, lifting one hand to her throat.

"daardie fokken buis het my rerig seergemaak! (that f#@king tube really hurt me)"

"tannie, what is wrong with your right eye?" asked my friend.

"when i was only five years old i was injured when a stick poked me in the eye. since then it has always been like that." the paramedic went a bit pale and quietly left the room.

after listening to this story i too often extubated patients that the paramedics had overzealously intubated after flattening them with ridiculous amounts of dormicum.

evil

2012-01-26T14:48:00.001+02:00

doctors can be naughty sometimes too. i suppose boredom can be fertile ground for all sorts of mischief and what speciality tends to leave plenty of room for boredom more than anasthetics, especially when you have to sit around with a stable patient while an orthopod labours through the night fixing all sorts of bones.

the anesthetist in question was on call for the orthopedic list. the list tended to start at about four in the afternoon and go pretty much right through the night. by midnight it could be quite a challenge to maintain enthusiasm, unless of course you had something to keep your mind busy.

after a few cases the gas monkey and the bone doctor took a break to replenish fluids and caffeine levels. however, while the poor unsuspection orthopod wasn't looking the evil anesthetist decided to lace his coffee with a strong diuretic. to ensure the best comic effect he put four times the usual dose in the coffee. i suppose he thought it would be four times as funny.

quite soon into the next operation, a fairly long procedure to fix a fracture of the femur (thigh bone), the poor unsuspecting orthopod started looking uncomfortable. he seemed to be struggling to stand still and resorted to crossing his legs quite a bit. finally he just couldn't hold out anymore.

"sorry guys, but that cup of coffee seems to have really settled on my bladder. i'm going to have to unscrub and go to the toilet." with that he walked out. the theater erupted in raucous laughter. only the bone doctor wasn't in on the joke. soon he was back, looking a lot more comfortable, no doubt hiding a contented smile behind his theater mask. he scrubbed up and continued the operation. unfortunately as the bladder distended again his easygoing nature gradually was replaced with irritation and impatience about the fact that the operation seemed to be taking longer than he and his bladder thought it would. quite soon the same restlessness and leg crossing started up and once again he excused himself and ran from the theater in embarrasment.

when he returned the theater staff were trying to remain composed, but there were a few snickering sounds escaping here and there as well as a giggle or two as the process repeated itself. the bone doctor stopped dead in his tracks.

"what the hell have you done to me?" he demanded. everyone burst out into raucous laughter as he charged out one more time to empty his tormented bladder.

buff and turf

2012-01-11T16:40:00.003+02:00

the concept of the buff and turf is common to all the disciplines of medicine. sometimes it works. sometimes it doesn't.

the call came in, but i struggled to believe it. yet i had to go to casualties anyway. i mean how do you tell the casualty officer that you don't really believe anyone can survive a lion attack? lions are killing machines. any normal human being who gets attacked by a lion should have the decency to expire and maybe even be eaten. and here i was expected to believe the patient on the way had actually survived. the upside was that i would probably be home in about half an hour or so. that is about how long it would take to look at a mangled piece of flesh and declare it dead and maybe partly digested.

he arrived. not only was he alive, he was stable. he even greeted me in a friendly manner. we chatted a bit. after all i was quite interested to hear how it came to pass that he was attacked by a lion and more specifically how was it that he was alive. it turned out that he works in the local game reserve and was out in the veld when it happened. apparently he had managed to fire one shot with a standard issue national parks rifle and blown the lion's jaw clean off. the lion that had done the dammage was therefore only capable of using its claws and could not finish him off with a bite. that is why he had survived. i quickly checked him out. both his arms had massive lacerations from the elbows down to the hands, but other than that there was nothing wrong with him. it is quite amazing that a lion could maintain an attack after taking a bullet in the head and still do a substantial amount of damage. still, i started having evil thoughts.

lacerations of the arms below the elbow is an area of overlap between general surgeons and orthopods. in my rotation in the old days in orthopedics, their profs were pertinent in telling their underlings that any laceration below the elbow should be explored by an orthopod and not a general surgeon. i think they thought us mere common or garden variety surgeons might miss a tendon or nerve injury and they felt they could do it better than we could. i had no objections. so i started playing with the idea of turfing him off to the friendly neighbourhood bone doctor. i turned to the casualty officer.

"he doesn't seem to have any injuries needing my attention. consult the orthopod!" i tried to sound authoritative, but just in case, i added, "and if he refuses, then call me and i'll operate him. with that i left. after all i still had an appendix or two waiting for me in theater.

it was a relatively quiet call and i soon found myself sauntering out of the hospital on my way home. i knew the orthopod would be operating next and i knew what he was going to be doing. just before going home i quickly checked casualties to make sure there was nothing else waiting and also to ask what reaction the casualty officer had gotten from the orthopod.

"he was not happy," i was informed. "he went on for quite some time about the general surgeons being lazy and turfing cases to him, but in the end he accepted the patient." oh well. what could i do about that now? going home sounded like just the right thing.

one of the things i hate the most about being on call is when my phone rings the moment i get home. the phone rang the moment i got home. immediately i was tense and irritated.

"hi bongi, it's rb here. how are things there with you?" it was my friend, the vet from the game reserve. that meant it was a social call. well anything is better than a work related call once i was at home so i was actually quite excited. and what a coincidence that he should call the very day that we received a patient from his neck of the bush. for a moment i even forgot i don't believe in coincidences. "bongi, i'm actually phoning about a friend of mine who was sent to your hospital. he was attacked by a lion. you wouldn't possibly know who is treating him would you?" i knew very well who was treating him. more than that, i knew why that doctor was treating him. it was because i was apparently lazy and had turfed the patient. i decided rb didn't need to know the gory details of hospital politics. a simple "yes" would suffice.

"well you see, bongi, working here in the park, i've seen quite a few attacks by wild animals and quite often the city doctors close the wounds primarily. i know i'm just a vet but i've seen enough of these to know that this simply doesn't work. these animals have all sorts of nasties growing in their mouths and if the wounds are not debrided thoroughly and then left open for a few days, they will all become septic." i knew all these things to be true. i also knew that if i had been operating the patient i sure as hell would leave the wounds open and only close them a few days later. the only problem is i wasn't operating. he went on.

"so, bongi, if i could ask you a favour?" i cringed. never mind my usual reservations about favours, i knew what this favour was going to be. if only i hadn't turfed that patient, it would be easy, but i had turfed the patient and this wasn't going to be fun.

"sure! no problem." i lied.

"great. could you maybe speak to the doctor handling my friend and just tell him not to close the wounds primarily?"

"ok." the lie was less convincing. my hesitant voice betrayed me. but somehow rb didn't seem to notice.

"great! thanks a lot, bongi."

moments later i found myself phoning theater where i knew the orthopod was busy debriding the wounds of a lion attack victim that the surgeon was too lazy to treat. i couldn't help wondering exactly how i was going to word it.

"remember that patient that i dumped on you? well now that i'm snugly at home and you are still slaving away in theater, let me now tell you how you should be doing your job!"

the bee dance

2012-01-04T10:47:00.000+02:00

i have more than just a passing interest in bees. in fact i used to be somewhat of an amateur beekeeper and a semi-professional bee remover. it was a way to bring in a bit of extra money while slaving away in the salt mines we called the department of surgery. during those days i learned quite a lot about the bees. i found them very interesting.

one of the interesting facts about bees is how the scouts convey to the rest of the hive where they can find nectar stores. you see the returning scout does a little dance when it returns to the hive. the dance is in the form of a figure of eight with the bee vibrating its body in the middle section. the direction he faces during this dance indicates in which direction the stash can be found. the intensity of the vibration of its body during the dance accurately depicts the distance to the nectar stores. all very fascinating.

i was rotating through icu and it was my call. all seemed to be quiet. in retrospect i should have realised it couldn't stay that way. we were waiting for one postoperative admission and then i even entertained thoughts of getting a bit of sleep.

finally she arrived. she was still intubated and ventilated but it seemed to be more cautionary than necessary. the general surgeon registrar who handed the patient over to me was even upbeat.

"let her rest through the night but she should be ready for extubation early in the morning."

"sure." i said, "any other things i need to know about?"

"she bled a bit during the operation but the anesthetist put a high flow intravenous line up so there was no problem for him to keep up with fluid replacement. other than that everything should go just fine." with that he sauntered out. i quickly checked the patient out. once i was satisfied that all did in fact seem to be fine, i continued with my evening rounds, making sure all the other patients were ok. a bit of shut eye seemed like a real possibility. i started letting my mind wonder to the cozy bed in the doctor's room behind icu. just one or two more things to check on and i could lie down and submit myself to sleep. i think a smile may actually have crept across my face, but before anyone could see it i quickly regained my stern icu-doctor-like serious composure.

"the patient has crashed!!!" it took a moment for the sister's words to fight their way through my naive musings about beautiful sleep. but then the full gravity of what she said ripped my mind back to the present. the patient had crashed and that meant i had to charge in and save the day. but what patient had crashed? they were all stable and there was no one that was due to move on to the hereafter. if someone died i would have a hard time explaining it to the prof the next morning. in fact the only patient i could think that might have crashed was the new patient that had just arrived and she was the boss' patient. if i didn't manage to pull her through, never mind trying to explain to the icu prof the next morning, it was unlikely i would survive the m&m. at least i would get more sleep in whatever other profession i ended up in once the boss threw me out of his department.

it was the boss' patient! fear and dread gripped me. i needed to do something. the most pressing thing seemed to be the fact that the patient's heart was not beating. i shook the fear from my nearly paralysed arms and jumped into action. almost immediately i was compressing the chest. her a-line gave me a good indication that my attempts at cardiac massage were very effective. at least i was keeping here alive, but why had she crashed. i mean i couldn't keep doing cardiac massage forever, although, i reflected, it would probably give me good upper body definition. still it would help if i had a better long term solution.

"should i draw a blood gas so long?" asked one of the sisters. i understood her question. it wasn't really that anyone there thought a blood gas would bring us any closer to figuring out what had caused the patient to crash, but at least she would feel she was doing something. the one thing that a blood gas could possibly tell me was if the hb was low, indicating that the patient could have bled. but her vital signs just before crashing were completely stable, meaning it was unlikely. anyway, i nodded to the sister and almost immediately she had the blood drawn and was scurrying off to the blood gas machine.

moments later she had the results.

"doctor look here!" the shock in her voice was clear. she held the printout in front of me. i couldn't take it myself. i was still applying cpr. any thoughts of a chiseled torso had long since given way to a firm knowledge that my upper body would be stiff and sore the next day. i quickly looked for the hb result. it was normal. the next thing to check would be the oxygen status. that was better than normal. even the ph balance was close enough to normal. but then why had the sister sounded so shocked?

"doctor, look at the potassium." i looked.

a normal potassium is around 4. when it gets to about 6 it can cause dysrhythmias of the heart. at about 8, pretty much all hearts will stop beating. the result that met my worried gaze was 16! was that even possible?? how did it happen?? what the hell was going on??

despite a few obvious questions at least i knew what the cause was and i could treat it. half an hour later the patient's heart was merrily beating away all on its own without the assistance of my tired arms. once the chaos that always seems to surround any resuscitation effort had subsided i finally found out what actually happened.

when the patient arrived in icu, her potassium levels, among other things, were checked. the junior sister tasked with looking after her showed the results to the charge sister. they were slightly low. the charge sister then instructed her junior to replenish them. the junior, not knowing any better, put a massive amount of potassium in a small bag and connected it to the high flown line that our anesthetic friend had so kindly put up for us in theater. the result was that all that potassium ran into the patient very nearly instantaneously, stopping the heart. in all honesty we were lucky to realize this the way we did and pull the patient through. but, still, what had transpired up to that point was the easy part. the difficult part veered up before me like a cliff. i still had to tell the prof on ward rounds the next morning.

the next morning i told the prof. as expected he didn't take it too well. as i relayed the events of the previous night, he became more and more agitated. finally he could no longer stand still. he started jumping up and down on the spot, his mouth open and his fists clenched. when i got to the part where we were all desperately trying to save the patient's life, in exasperation, the prof's body shook. he then did a little circle around to his left. a memory stirred somewhere deep in my mind. where had i seen that before?

when we got to the potassium levels and how it was that they had come to be that high, the prof's body once again vibrated. he then spun around to his right, vibrated again and then spun around to his left. a light went on in the deepest parts of my mind. i knew exactly where i had seen this dance before and what it meant.

and so the prof continued doing his little dance. he would vibrate in a mixture of rage and surprise. he would then attempt to speak, but because he was so absolutely dumbfounded by the details of my story, he just couldn't. he would then spin around and try again, but when there were no words his body would once again violently vibrate just before he spun around the other way. we stood there in silence watching him. finally my colleague spoke.

"i have never seen the prof this angry before!" he whispered quietly.

"yes," i agreed, "but after ward rounds, follow me. i'm pretty sure he is showing us where we can find a motherload of nectar, but be warned, it is very far away!!" he looked at me as if i was mad.

gatekeeper

2011-11-05T00:10:00.000+02:00

i am somewhat known for not knowing when to keep my mouth shut. but, fortunately for me i once managed to put a watch in front of my mouth, but only just in time.

i was on rotation just before intermediate exams. this was a difficult time when generally you had to make sure you didn't make enemies in other departments. you always ran the risk that the guys you irritated would be in the exam or write a scathing report to your own prof. then, no matter how well you knew your work, you would not get through. it's just the way things were.

interestingly enough the obstetric and gynaecology department stood apart from all other surgical disciplines. for many years they had not done the rotation and therefore did not write the intermediate exams common to all the rest of us. other than the fact that this meant that they didn't share with us the burden of running the icu department (which they did use, however) it also meant that they could be very narrow minded. they didn't have an overall knowledge of physiology and the management of acutely sick patients. to them a patient was simply a vagina and a uterus of varying size, with or without a bun in the oven. in short, the rest of us thought of them as lazy and stupid.

i was on call in the icu at kalafong (hell). the way things worked there is we all knew all the patients in the finest detail. on a call day that knowledge was absolute. we could recite the finest details of any patient under our care in an instant. so late that afternoon when i walked into icu and saw the prof of obstetrics standing at the bed of one of my patients who we were treating with severe pre-eclampsia and hellp syndrome with his entire entourage i immediately walked towards them to answer any questions they might have.

as i approached i remembered that prof from my pre-grad days. we used to call him red beard which was some sort of a reference to a scary pirate, but more a comment on his interesting choice of facial hair. he always seemed to try to intimidate and to be honest i think we were all scared of him. looking at him now i couldn't understand that anyone could be scared of an obstetric prof. thinking back it seemed to me that his so called intimidation tactics were no more than posturing. he must have been trying to hide something. i walked up the the group of gynaecologists milling around my patient.

"hello prof." i greeted.

"oh, are you in charge here?" he asked looking up at me. i could see his underlings shifting uneasily. maybe he still had the power to intimidate them.

"yes prof, i am." i smiled in what i thought was a friendly, disarming way. i readied myself to help them with any and all questions they might have. after all there was absolutely nothing about the patient that was not at the tip of my fingers.

"good, because we are trying to make head or tail of what is going on here." simultaneously a few things happened. firstly i realized he was not going to lower himself to the point of actually asking me anything in front of his hordes. secondly, right there i decided that i would not be intimidated by what i now saw as the posturings of an old sad man. i stepped, back and folded my arms. secretly i enjoyed watching him struggle and flounder as he went through the patient notes. lastly the perfect sentence popped into my mind. by some miracle i actually kept my mouth shut and did not actually say.

"of course you are prof. after all the only thing more stupid than a gynaecologist is an obstetrician."

senior assistant

2011-11-01T23:22:00.000+02:00

a good surgeon does not imply a good assistant. i personally don't like my assistant to be equally qualified with me. more qualified assistants can sometimes be a nightmare.

one of my role models in the department of surgery was my registrar when i started there. he was just a very nice guy. he was in fact such a decent guy most people wondered what the hell he was doing studying surgery at all. he just didn't seem like the type. but no matter how good an individual he was, he still had to learn how to operate.

the boss believed in teaching us to remove gallbladders the old fashioned way. therefore in his firm there was no such thing as a laparoscopic cholecystectomy. this was good in the sense that we all ended up being very comfortable with open cholecystectomies. however it was bad in the sense that you didn't get that much opportunity to learn the laparoscopic procedure, which is the standard modern procedure throughout the world. so when we moved together to the firm of the older semi-retired prof, ironically my senior would get to do some laparoscopic cholecystectomies. i remember when we got the first one on the list.

"doctor, this patient needs a laparoscopic cholecystectomy and you are going to do it." i watched my senior's face. i knew he had never done one alone before, but i also knew he would not pass up this opportunity.

"thank you prof." he looked a bit worried but he seemed determined not to let the prof know.

"and i will assist you." announced the prof with a broad smile which i'm sure he meant to be reassuring. now my senior looked very worried indeed. the prof was old and hadn't operated for years. in fact i had never seen him scrub into a case at all. i wasn't even sure he could operate any more. the problem was that with the prof there if there was any trouble it was unlikely the prof could help and his presence meant we would not be able to call anyone else that could. we'd just have to soldier through.

the operation started well enough although slowly. even the dissection of the artery and the duct progressed acceptably well. but it was here that the prof's assistance skills started to interfere. i personally suspected that the poor old man was nodding off intermittently. the reason was that every now and then the camera would wander away from the operation field. my poor colleague would be just about to apply a clip to the cystic duct when we would suddenly be given a wonderful view of the stomach or the abdominal wall or some other random organ. obviously everything would come to a grinding halt, with both of us trying to decide how best to tell the mighty prof that he needs to keep the camera on where the surgeon is trying to operate. in the end, neither one of us was brave enough to chastise the prof and we ended up just waiting for him to realise his mistake and return the camera to the correct position. i thought it was comical, mainly because i wasn't operating. i'm sure my poor colleague didn't quite appreciate the humour in it at the time, though.

finally the awkward pause was too long as we admired a pristine view of the colon. my colleague had to say something.

"um, prof, could i ask you to move the camera slightly." slightly wasn't going to be enough, i mused, but i was not about to say anything. if someone was to face the wrath of the prof, it sure as hell wasn't going to be me. yet somehow this request seemed to do the trick. maybe the prof realized his camera work had been suboptimal and he decided to try harder. i suspect that he had had his nap and was no longer tired. whatever the reason the camera settled on the cystic duct and did not move. at last the registrar could clip and cut the duct unimpeded. at last the operation was proceeding at what i considered a reasonable pace. quite soon the registrar was carefully dissecting the gallbladder out of where it was embedded in the liver. but then gradually i realized there was another possible dilemma on the brew.

you see, although the camera position was perfect for the cystic duct, as my colleague dissected the gallbladder loose i realized that the prof was not following his progress with the camera. the dissection progressed across the screen of the monitor and finally moved right out of sight. the dissection progressed beyond the limits of what the prof was looking at and finally it came to a grinding blind halt. again we sat in an awkward silence. it just could not go on like this. maybe bolstered by the success of his last request to the prof to drive the camera better my colleague decided to address the prof again. but this time the prof was awake.

"sorry prof but ..." the prof cut him short.

"doctor you must operate in the middle of the screen, not on the side!"

more and more i came to appreciate the real reason we wore theater masks while operating. they were to hide the fact that we were laughing so often.

physician, heal thyself

2011-10-30T14:23:00.004+02:00

even doctors get sick, but there is often a difference.

i was rotating through orthopaedics and was on call that night. they tended to relegate us mere general surgeons to casualties during the calls so i was quite excited to get some theater time that afternoon, even if it was for a simple wound inspection and secondary closure and even if it meant there would be a backlog of patients in casualties for me to see afterwards. once i had finished operating i rushed through the change rooms to get back to casualties. while i was changing i heard the unmistakable sounds of someone throwing up in the toilet cubicle. quite soon the door opened and out came the orthopaedic registrar who was on call that night with me. he did not look good. he glanced at me but didn't seem to see me. his face was pale, verging on grey and there were fine droplets of sweat on his brow. he was staggering slightly as he made his way to the basin to throw water over his face. i greeted him but the only reply he gave was a sort of grunt.

much later that night i had to take some x-rays to theater for the senior to see. to my surprise the registrar was still there. he hadn't swapped his call out. i assume no one wanted to help so he had no choice, he had to work. however, he had come up with a practical solution. he was scrubbed up busy operating, but i noticed two drips hanging from the drip stand next to the anaesthetist. the one drip went to the patient, but the other went under the orthopod's gown and was replacing the orthopod's fluid loss that his severe case of vomiting had caused. the anaesthetist was actually maintaining hemostasis in both the patient and the surgeon simultaneously. i was quite impressed.

a few years later when i was the senior registrar in general surgery i too came down with some or other virus and i too was on call that day. in our department no weakness was tolerated and i knew it would not be a wise move to let the prof know i was ill. i just had to suck it up and go on.

the call was busy and being a bit sick i was struggling. there were too many things happening at the same time and it was becoming increasingly difficult to get to everything, but i kept on going to the best of my abilities. quite soon i found myself in theater operating. and there i stayed, doing case after case in quick succession and rushing down to casualties between cases to sort out the continuous stream of patients that were still coming in. and thus the call grinded on.

sometime in the early morning hours standing over yet one more open abdomen in theater i started to feel light headed. with the immense workload i realised i had not taken any time at all to have anything to eat or drink. this, combined with my illness had finally caught up with me. i was on the verge of passing out. fortunately i had more or less completed the operation and my medical officer was a capable guy. i turned to him.

"ninja, i need to take a seat. do you think you can close?" as i said it i staggered back. the world seemed to be moving beneath my feet. i leaned against the wall and slumped down. the ninja was saying something but his voice was far off and incoherent to me. the next moment i was aware of the house doctor leading me to the surgery tea room where i collapsed on the bed. i looked up in a haze. she was preparing a drip. i considered refusing but the words just wouldn't come out. besides i realised that fluid was exactly what i needed.

"put glucose in that drip too!" i finally managed to say.

quite soon the drip was up and the house doctor left. i reached up opened the drip to run in as fast as possible. then sleep came.

some time later i heard the house doctor return. she seemed surprised to find the drip sack empty, but changed it anyway. as soon as she was gone, once again i opened the drip to run full speed. the first liter had made a difference and i didn't want to waste any time, just in case i was needed during the call.

the next memory i had was the ninja shaking me awake.

"bongi, there is a gunshot abdomen. i've sorted everything and he's on the table. are you ok to operate or should i call the prof?" the ninja too knew that to let the prof know i had collapsed could potentially be disastrous for me.

"no. i'm ok now. get started so long and i'll be there in ten minutes."

later when i examined the timeline of events i had only been out of action for about an hour and a half. except for the people involved in the incident, no one ever found out. and, most important of all, the prof was none the wiser.

tangled tassels

2011-09-10T17:34:00.000+02:00

in quite a few of the cultures in south africa people tie ribbons, strings and tassels around their own and their children's wrists and waists. these tassels are imbibed with power to keep evil spirits at bay, i am told. if these tassels come off then the patient is completely unprotected from any and all marauding evil spirits that may be lurking around. of course, not wanting to be responsible for the unopposed assault by multiple evil spirits, most people are fairly reticent to remove these things. i saw it slightly differently.

as a student i took my lead from my senior. if he removed the tassels then i would be ok with it. if he felt that we should respect the culture of the patient and sort of try to move the tassels out of the way of the operating area or even operate around them, despite the increased infection risk, i sort of reasoned it was his patient and even if i medically didn't agree with him, the reasoning of respecting the patient's culture surely held some water at least and i didn't argue. the fact of the matter was that quite a number of the sisters would become quite aggressive with the doctor if they thought he was going to remove the tassels and strip the patient of his evil spirit protection and i think some of the doctors were scared. then one day something happened that cemented my views and actions for the future.

i was working with a senior doctor that had grown up in one of the 'tassel cultures' of south africa, so when i prepared the gunshot abdomen patient in theater for him to operate, i left the tassels alone. it was one thing calling down the wrath of evil spirits upon me but i was not willing to call down the wrath of my senior. it was not worth it.

my senior walked in. he took one look at the patient lying on the theater table, already anesthetized with a nice round bullet hole in his mid abdomen oozing a mixture of blood and feces and with the tassels tied securely around his waist, left in position by me. without saying a word he grabbed a pair of scissors, walked up to the patient and unceremoniously cut the tassels off and threw them away. the sister immediately layed into him.

"doctor! what the hell do you think you are doing? that is the patient's culture and you have no right to remove that!" i saw the corner of the doctor's mouth edge upwards in a mischievous smile as he answered.

"come now sister. besides the obvious medical and hygienic reasons that i could give for removing a dirty piece of string before we operate, even you must agree, this tassel just doesn't work. i mean it didn't protect him from getting shot in the first place so i think it is safe to assume it is pretty much not going to protect him from anything else. so i am removing it and i don't really care what you have to say about that." his logic was flawless and the sister had to keep quiet. i also tried to keep quiet but the faint sound of a laugh did escape from behind my theater mask.

since then i have cut every tassel off, explaining to everyone that will listen that it clearly is no longer working.

it's all in the detail

2011-08-11T17:52:00.000+02:00

working in the boss' firm i quickly realized he only had a limited number of stories. with each new group of students that came through i was forced to listen to all the same stories and jokes over and over again and give the obligatory chuckle at the appropriate moment. to tell the truth it became a bit tedious towards the end. then one day he threw a curveball and caught me out.

i spent a lot of time and effort trying to make the surgical rotation fun and worthwhile for the students. i would teach them as much about surgery as i could, but i tried to emphasize life itself, rather than just surgery. there was a typical idea of the stereotypical surgeon and i confess i sometimes tried too hard to make sure i wasn't seen like that. i also had a feeling that we saved lives, but if those lives didn't actually go out and make the most of living, then what was the actual point of what we were doing? i tried to get the students to make the most of living and, as it were, to suck the marrow out of life. who knew, at any stage they might end up on the table under the knife with their lives in the balance. we all had better get on with living while there was still life for the living. i would quote movies and poems and recite the lyrics of songs and try to let everyone see that life needed to be actively lived. flowers waiting to be smelt needed to be sought along life's paths. on the whole most students enjoyed working with me.

so that day, towards the end of their rotation, when the boss asked a strange question, i had extreme confidence that my students would shine.

"so, what have you learned in this surgery rotation other than surgery?" asked the boss. inwardly i was smiling. all my students smiled outwardly immediately. they all thought they had struck gold by being in my firm and then being asked that question. but still it seemed tricky to answer.

"an appreciation of quotes from movies and poems as they pertain to life." ventured one. it was as if the boss didn't register.

"yes but what have you learned other than surgery?" i was confused. i mean the student had said nothing even remotely related to surgery or cutting or blood or any of the favourites of the department. it begged the question, what answer was the boss looking for? i confess, despite the fact that i thought i knew all his stories, i did not know where this story was going. it seemed to be a new one. i was even tempted to venture the answer, 'it seems, after all, that you can actually teach an old dog new tricks' but i knew this old dog still had bite and i thought better of it. the next student tried.

"we learned to really appreciate life and to live it to its fullest." i was proud. that was essentially what i aimed at teaching them. i felt i had achieved more than i dared hope for. the boss was unfazed. he went on as if he was deaf.

"yes, but what have you learned in this rotation above and beyond surgery?" i knew it was time to simply say we didn't know and wait for the 'pearls of wisdom to drop from the glorious lips of our most gracious master'. the pearls came rolling towards us swine.

"attention to detail." spake he. "attention to detail." it was his new mantra. i wondered where he had heard it. the good news was that i knew exactly what to tell the next group of students to answer when he asked the same question at the end of their rotation.

sure enough, towards the end of the rotation of the next group of students, once again the boss asked his new question. it seemed it would become a constant feature. this time i had given the students ample warning.

"well, prof, i think the main thing we learned, other than all the great surgery bongi taught us of course, is the importance of attention to detail." the prof's face lit up like a kid that had just been given a toy. i think he felt proud for some strange reason.

it was an evil smile that crept across my face.

die taal

2011-08-04T19:28:00.000+02:00

dit moes 'n misverstand gewees het, ek weet nie. watookal dit was het dit 'n slegte smaak in my mond gelos.

toe die nuwe regering oorgeneem het het hulle stelselmatig ontslaegeraak van alles wat hulle geassosieer het met die ou regering. een van die dinge wat moes waai was afrikaans. volgens hulle was dit blykbaar sleg vir een of ander rede. ek het nie saamgestem nie. so toe ons afrikaanse prof druk op ons uitgeoefen het om net engels te gebruik by alle amptelike vergaderings het ek hom min of meet geignoreer. ek onthou 'n saalrondte 'n maand of twee daarna.

ek was die senior kliniese assistent in die prof se firma. volgens sy nuwe beleid het hy net engels op die rondte gepraat. tussen die pasiente, as hy net met my gepraat het het hy wel afrikaans gepraat. dit was natuurlik sy moedertaal. ek het al sy engelse vrae in afrikaans geantwoord en al die pasiente in afrikaans voorgedra. hoe meer hy probeer het om vir my die boodskap oor te dra dat ek engels moes praat hoe meer het ek volgehou om afrikaans te praat. by omtrend die derde pasient kon hy homself nie meer inhou nie.

"bongi, speak english. why do you refuse to speak english on rounds?"

"prof, my english is perfect. i don't have any reason to practise it." het ek in engels geantwoord.

hy was kwaad, maar hy het dit redelik goed weggesteek.

'n maand of wat daarna was ons almal by een van ons m&m bespreekings. die was 'n gesamentlike m&m met die vaskulere departement. die prof van vaskuler het ook sterk gevoel oor die taal beleid, maar sy gevoel was presies die teenoorgestelde van die prof s'n. hy het gevoel ons moet aangaan om afrikaans te praat in die universiteit, want engels was klaar so dominant in die land as 'n mens nie moeite gedoen het om afrikaans as 'n taal wat op 'n tersiere vlak goed kon funksioneer op daardie vlak te hou nie, sou dit vinnig agteruitgaan. ek het met hom saamgestem. baie van die afrikaans spreekende studente het klaar gesukkel om pasiente in afrikaans voor te dra, self as hulle aan 'n afrikaanssprekende dokter voorgedra het. hulle het medisyne in engels geleer en kon nie mediese afrikaans praat nie.

die m&m het voortgegaan. toe dit die beurt van die vaskulere kliniese assistent was om sy pasient voor te dra het hy in engels begin. onmiddelik het die vaskulere prof iets op 'n stukkie papier geskryf en dit vir sy kliniese assistent gegee. die kliniese assistent het dit gelees en onmiddelik in afrikaans oorgeslaan. dit was nie nodig om einstein te wees om te weet wat op daardie stukkie papier gestaan het nie. sy prof het duidelik vir hom opdrag gegee om afrikaans te praat en hy het wel so gemaak. die res van die vaskulere gedeelte van die m&m het min of meer gegaan soos my saalrondtes met die prof. die prof het al sy vrae in engels gevra en die vaskulere kliniese assistent en prof het albei alles in afrikaans geantwoord. dit was vir my nogal komieklik. na die m&m het ek maar aangegaan met my lewe.

omtrend 'n uur later het die vaskulere kliniese assistent vir my gebel.

"bongi, daar is groot kak in die land," het hy gese. "die prof het my vaskulere prof ingeroep en ordentlik in sy broek gekak oor die feit dat mense in sy departement weier om net engels te praat by enige bespreking of saalrondte. hy het drie kliniese assistente uitgesonder. dis ek en jy en dr b (ek het al van hom geskryf). natuurlik het my prof vir ons al drie opgekom en toe ek uitgejaag is was hulle amper op die punt om mekaar te lyf te gaan. hoe dit ookal sy dis blykbaar ons drie wat die prof se woede gaan voel. hy het self gese dat as ons volhou om te weier om engels te praat gaan hy bedank as hoof van die departement."

ek kon dit nie glo nie. in een opsig het ek amper trots gevoel dat ek so 'n invloed gehad het oor die prof dat hy 'n persoonlike beroepsbesluit sou maak gebaseer op my doen en late. maar eintlik was dit nooit my plan om soveel aandag van die grootkoppe te lok nie. daardie tiepe aandag was nooit 'n goeie ding nie.

"hy kan seker bedank as hy wil." het ek vir my mede beskuldigde gese, maar toe onthou ek wie in sy plek sou oorneem. ons prof het sy probleme, maar tog was hy beter as die moontlike alternatief. moontlik was die beste ding om maar engels te begin praat.

die volgende week by die m&m was ek 'n bietjie verbaas om te sien dat my vriend en kollega, dr b sy gevalle in afrikaans voorgedra het. dit was weer die geval van die prof wat sy vrae in engels gestel het en my vriend wat alles in afrikaans geantwoord het. tog as dit die prof geirriteer het, het hy dit goed weggesteek.

onmiddelik na die bespreking het ek met my vriend gaan praat.

"b, is jy mal?" vra ek toe. "na verlede week se storie, hoekom weier jy om engels te praat." hy het effens geglimlag toe hy geantwoord het.

"ek weet nie wat die prof se fokken probleem is nie. voor verlede week het ek nooit afrikaans gepraat by al die amptelike besprekings nie. ek het wel engels gepraat. en tog is ek een van die ouens wat in die kak beland het. wel, nou het ek klaar die straf gekry omdat ek afrikaans gepraat het al het ek dit nie eintlik gedoen nie. omdat die straf klaar uitgedeel is moet ek dit darem die moeite werd maak. daarvoor se ek nou vir jou, ek sal nooit weer engels in hierdie plek praat nie!"

en volgens my kennis het hy nie.

doll eyes

2011-06-16T23:09:00.000+02:00

it affected me. not just it, but the fact that it didn't seem to affect my colleague.

i was a lowly fourth year medical student, delivering babies for all i was worth. looking back, i realize i enjoyed it. the whole 'joy of a baby coming into the world' really gave me joy that a baby was coming into the world. call me sentimental but i saw each birth as beautiful. somehow i could look past the meconeum and the amniotic fluid and the episiotomies and see what was actually going on. it was a happy time for the mother (mostly). it was the beginning of hopes and dreams. it was a new start for the baby (obviously) and for the mother and in a sense each new birth may have signified a potential new start for me.

she was excited about her new baby, but there was a cloud over her entire admission. the reason she had come in to hospital was because she hadn't felt the baby kicking for the last 24 hours and she was worried. quite soon we were worried too. not only could we detect no movement but we couldn't hear the fetal heart beat with our fetoscopes. my registrar was one of those amazing people who really felt for each and every patient despite the massive torrent of humanity that moved through the labour ward on a daily basis. this patient was no exception.

actually we all new what had happened, but the registrar wanted to make sure. i suppose she just didn't want to tell the mother her baby was dead before she had confirmed it on sonar. actually i think she wanted to use the sonar to show the mother there was no heartbeat to avoid problems of denial once the news was broken. whatever the reason i followed the whole drama as it unfolded, as did my fellow fourth year green medical students.

i remember sitting there in that small labour room where mothers are usually introduced to their new babies while the registrar ran the sonar probe over the mother's swollen abdomen. i remember her bringing the probe to a standstill over the heart. we could clearly see the heart, but there was no movement. the heart was not beating. as we actually already knew, the baby was dead. all that remained was to tell the mother. with genuine sympathy and very sensitively the registrar broke the tragic news to the mother. i saw her face drop as the realization of the loss set in. i could see her fighting back the tears. i was too.

finally it was over and we all slowly filed out to leave the mother to absorb the blow. of course we still had to decide how to deal with the problem of getting the baby out so we didn't have the privilege of dwelling on the human drama that had just unfolded before us. still i took a moment to allow myself to feel it. this involved no small amount of swallowing back the tears.

the registrar turned to us.

"and that is that. which of you is going to deliver this baby?" my colleague was the first to speak.

"excuse me, but when the baby is delivered, can we practice endotracheal intubations on the body?"

i felt nauseous and slightly dizzy. it hadn't occurred to me before then but suddenly i realized the entire humanity of what had just happened had gone completely over the head of my colleague. all he was interested in was the possible so called learning opportunity that he could get out of the 'situation'. quite frankly he had felt nothing for the baby and he had felt nothing for the mother. i couldn't help wondering what sort of a doctor he would one day turn out to be. i never wanted to be like that.

in the end i was the one that had to deliver the baby. there were a lot of tears.

perspectives

2011-06-07T00:03:00.000+02:00

sometimes different people see the same thing from a slightly different angle, giving a completely different perspective. in my line this can turn out to be quite macabre.

it was one of those cases. it was probably hopeless from the beginning, but he was young and we had to give it a go. as soon as the abdomen was opened everyone knew things were bad. there was blood everywhere. it took a while to even see the damage to the liver because i needed to get rid of the blood in the abdomen before i could see anything. however, once i saw the liver even i was shocked.

the liver was ripped apart with one laceration dropping down to where the ivc sat menacingly behind it. it seemed to spit and splutter at my efforts to bring the bleeding under control in defiance of me. but i did what i could as fast as i could. at times like this the unsung hero is the anesthetist. if he can't get fluid and blood into the patient fast enough, no matter what the surgeon does, it will be in vain. that day the anesthetist was great. somehow he kept some semblance of a blood pressure in the patient against overwhelming odds.

after a while with large compressing stitches in the liver, the worst of the bleeding finally subsided. usually, unfortunately, at this stage of these operations we are confronted by another problem. you see with massive blood loss the patient loses or uses up all their clotting factors and platelets. even if the hole in the vasculature is closed, there is a general ooze of blood from pretty much everywhere. to attack each ooze with an injudicious suture not only doesn't help a bit, but it wastes precious time that could be better spent in icu replacing these vital factors. i made the call.

"there are no more surgical bleeds that i can control here. i'm going to pack the abdomen and send him to icu to optimise his condition and we'll take him back in a day or two." the anesthetist looked up.

"if you say so, but he is not looking so great here." he pointed at the monitors.

i packed and closed. the gas monkey continued throwing every available fluid into his system as fast as he could.

"i'm just going to top him up as much as possible before we transport him to icu." he informed me. he was definitely worth his salt, this one.

this is now a time that the average surgeon doesn't like. we are not the stand back and wait types. we struggle to sit still and give it time to see what happens. but sometimes it is needed. i didn't have to wait too long before the the gas monkey told me what was happening.

"bongi, this guy is not improving on the fluid and blood i'm giving him and his abdomen is distending. are you absolutely sure there is nothing inside you can't make better?" the problem was i knew there was nothing i could do that i hadn't already done. however the anesthetist's observations were undeniable. the question was was there something i had missed or was the patient so far gone that he was lost already? it was clear that despite a valiant and heroic resus effort from the anesthetist, the patient was clearly dying. there was only one thing to do. we had to open and look again.

we opened. immediately i knew everything we did from here on out was futile. the patient was in irreversible shock and had absolutely no clotting. there was nothing that i had missed from a surgical point of view which meant there was nothing i could do. after poking around a bit i packed and closed again, but this time with a heavy heart. i knew what was going to happen. the anesthetist also had no illusions about where we stood, but we both continued to go through the motions.

the motions led us eventually down the deserted passage way in the middle of the night to icu with a patient that was sort of alive in the broadest definition of the word when we left theater. both the gas monkey and i didn't want to check the vitals during that quiet sombre journey. what did it matter? we knew what was going to happen and we knew it was out of our hands. the only questions were where and when it was going to happen if it hadn't already happened. so when we entered icu we were quiet and reserved.

when icu receives a new patient, there is usually a flurry of activity and this was no exception. all the sisters descended on us like a swarm of bees, each going about their respective duties. soon the patient was connected to the ventilator and the reassuring rhythmic sound of it pumping away filled the room. however once his pulse oxymeter and blood pressure cuff were connecter they did not give any comforting sounds. quite soon their alarms were blaring away. i glanced at my anesthetic collegue and we both shook our heads. we had done what we could. the icu sisters hadn't seen what we had seen. all they knew was we had delivered this patient and things didn't look good.

"i can't get a blood pressure. i can't feel a pulse. crash trolley!!!" she yelled to one of her juniors who scurried off in obedience. neither i nor the gas monkey moved. we just sat there, defeated at last.

"doctors, this patient is dying! aren't you going to do anything?" i laughed. i didn't mean to and i think it was more a nervous laugh. i was too emotionally exhausted at that moment to react appropriately. my colleague also laughed, but more at my response than the situation, i think. he then explained that what could be done had been done and any further resus would be in vain. we turned off the ventilator.

and so there we sat, feeling like the very life had been wrung out of our souls as the patient expired and some of the sisters looked at us as if we were heartless bastards for laughing.

tongue twister

2011-04-22T14:27:00.000+02:00

in the old days at kalafong (hell) we sometimes had to deal with obnoxious people. alcohol tends to make the worst of a personality come to the fore. most of us tended to ignore these irritations and get on with the job, but there were exceptions.

he was a senior registrar at the time. before going into the whole surgery thing he had been in the army and had served in the angolan war in the special forces. i occasionally asked him about those days, but he never spoke about it. i think it messed him up a bit and he probably didn't want to dwell on that stage of his life too much. only once did he ever actually say anything to me that alluded to what he had gone through.

"bongi, when you are in battle and people are shooting at you with the intention of killing you, it somehow changes your perspective on life." i suppose part of his changed perspective was that he tended not to take crap from mere mortals (hy vat nie kak van kabouters nie), especially those with more than a liberal dose of dutch courage.

the patient was drunk beyond description. he lay there in casualties with a nice neat bullet hole through his chest. however the injury had done nothing to his foul mouth. he maintained a constant stream of verbal abuse directed against anyone and everyone who had anything to do with him. when the poor house doctor inserted the intercostal drain she had to contend with both his sharp tongue as well as the occasional flying fist. he even managed to land a blow which had reduced the house doctor to tears. to her credit, she had continued the procedure but was unwilling to go near him after that. she called her senior, the registrar, to make sure the patient had no other injuries.

my friend walked into casualties, quickly found out what the trouble was about and approached the patient. he stood just outside the reach of the patient and casually observed his fists flying around, keeping everyone away. he listened as the patient flung a stream of obscenities at him. he seemed unmoved, but the wry smile that until then had been on his face slowly slipped away to be replaced by a stern grimace. he tried to speak to the patient to explain that he needed to check him out but this was met with such aggression that he ended up walking away. the house doctor tried once more to approach the patient, but caught a heavy body blow and slumped to the floor in pain. that, it seemed, was too much for the registrar.

"sister, put the patient in the procedure room. i'll be back in five minutes."

five minutes later the registrar returned. he went straight to the procedure room. just before he entered he turned to the sister.

"sister, call the maxillofacial surgeon and tell him we have a patient for him with a broken jaw."

"does the patient have a broken jaw?" she asked, surprised.

"well not yet." and with that he entered the room and closed the door.

after that, so the story goes, the patient was as tame as a lamb, albeit a lamb with a very swollen face.

covert operations

2011-04-17T20:47:00.000+02:00

the consultants didn't always need to know what was happening on the floor. but sometimes keeping things away from them became downright clandestine.

i was a senior registrar at kalafong (hell). an old friend of mine had just taken up a post as consultant in the department of internal medicine. one day he approached me.

"bongi, what are the chances you can do the occasional open lung biopsy for me?" now there was no thoracic department in kalafong so it seemed to me to be a reasonable request. in fact i was quite excited. it would give me a chance to do a few thoracotomies, something us general surgeons don't do all that regularly.

"sure! anytime. just let me know and i'll book them on my list."

"uhmmm, there is just one small problem," he continued, "i've already asked your consultant when the previous registrar was here and he bluntly refused, so i suppose you would need to convince him." this was no small problem. my consultant tended to be a bit hard headed and i knew if he had already decided, then there would be no convincing him. if i were to ask his permission he would refuse and that would be the end of it. if i just went ahead at least i could claim ignorance, that is until he catches me out. there was only one thing for it.

"ok, i'll do it on one condition. at no point must you discuss the matter again with my consultant. everything must go through me." and so it was arranged.

a short while later the internist approached me with the first patient he wanted a piece of lung from. i took her name down and booked her on the back of my list. i then re-wrote the list, carefully omitting her name and took it to my consultant. we went through the somewhat abbreviated list together. he was happy. i didn't want to be the one to erode that fragile joy.

halfway through the theater list, as was his habit, my consultant asked me if i'd be able to handle the rest and went back to his office. i assured him i had everything under control and sent him on his way.

the thoracotomy went well and the hiding of the patient from the consultant in the ward for the next few days also went well. i was feeling good. i suppose i knew it couldn't last.

two more thoracotomies were pulled off in similar fashion. and then we prepared for the whole charade for the next one. again i put the patient on the list and again i discussed the abbreviated list with my consultant the day before. again everything looked good. i went home, looking forward to a great list culminating in a nice thoracotomy to obtain a piece of lung for my internist friend. but this time something went wrong.

how was i to know that my consultant decided to pass by theater that evening before he went home to check something on the list? how was i to know that he discovered my thoracotomy that until then he knew nothing about? how was i to know that when i walked into the morning meeting i was walking into a fire fight?

the consultant was clearly angry. before the meeting he called me over and asked me why there was a thoracotomy on the list that he knew nothing about. i told him the internist had asked for a lung biopsy and i had added the patient because we had some extra time on the list. he went mad (or slightly more mad). leaving no room for any misunderstanding he informed me, with much frothing at the mouth, that there would be no thoracotomies on his list....not now....not ever. i apologized. i thought that was the end of it. i was wrong.

after the meeting the prof asked if there were any announcements. my consultant raised his hand. it was so unusual for him to say anything during the morning meeting because of a certain amount of animosity between him and the prof that everyone sat up and paid attention. he then moved to the front of the room.

"it has come to my attention that bongi has been doing thoracotomies on my lists." he started. "now if this ever happens again i give you my word that i will personally see to it that the guilty party is put up against the wall in front of a firing squad and he will be executed! we will reinstate public executions here in kalafong. we will make it compulsory for all the registrars to attend so they can see what will happen to them if they step out of line. if he wants he can have a blindfold, or he can go without, but he will be executed. the registrars watching will not be permitted to use blindfolds."

i considered the question of the blindfold, but in the end i decided to rather stop doing the thoracotomies.

surgeon superhero

2011-04-16T19:49:00.000+02:00

this is a post i wrote as a guest post for another blog a few years ago. since then that blog has been retired, so i decided to import the post back here.

yes i have an alter ego. yes, i dress in funny clothes with a cap covering my head and a mask covering my face. and yes, dressed as such i try to fight the powers of evil (mainly sepsis and bleeding and cancer and the like). i am ... a superhero. but there is often little understanding for what goes on under the paper thin masks and baggy gowns we wear. certain …um…occurrences, well, occur with us just as much as with other people.

a common cold behind a theatre mask is no small thing. remember you can’t blow your nose. sniffing loudly only works for a while and attracts all sorts of strange stares. just leaving it is really the only option. the positive side of this is you suffer less from the mild dehydration that accompanies massive loss of …mucus. there is, after all, fluid replacement (it is a very short trip from your nostrils to your mouth over your upper lip). ‘nuf sed. somehow this never appealed to me though. so, for all you budding surgeons out there, when you have a cold, plug your nostrils with tissue before scrubbing up. once you’re scrubbed, it is too late. The side effects are only a slight change in voice which is a small price to pay to avoid the constant lip licking and salty taste throughout the operation.

then there is a running stomach. this may be one reason to excuse yourself, handle the situation and rescrub. however, there is the real problem of dehydration, confounded by long hours of standing and concentration. here may i suggest a drip. the gas monkey (anaesthetist) can quite easily give a quick bolus or change the vaculiter when needed. (quick note, i’m not pulling this out of my thumb. i have actually seen this). stay at home, i hear you say? somehow that just doesn’t work with us doctors. i’m not sure why, but it is very rare that a doctor will stay at home merely because he is sick. what sort of a superhero would that be.

the last problem that can be encountered is best explained by thinking back to my registrarship. i was assisting the prof with some or other laparotomy. my stomach had been giving me trouble for some time. up until just before scrubbing up with the prof i had found it necessary to quietly leave polite conversation to allow the release of colonic gas quite a number of times. but once scrubbed up, this avenue was no longer open to me. what could i do? i simply puckered up and held it all in. this worked well, but became progressively difficult. we were approaching the end of the operation, but i could pucker no more. finally i reached a point where i had no choice. i needed release. i decided to quietly let one slip as to not attract too much attention with loud noises. so, as the professor started to close the sheath, i did just that. i was just inwardly congratulating myself for the stealth with which the…um…operation had been executed when the professor stopped closing and dived back into the abdomen. in a dry voice he quietly says, “someone cut the colon.” as he started carefully moving bowel out of the way to better examine the colon. now imagine my embarrassment when i was forced to say’...

“colon? yes. cut? no”

lingua franca

2011-04-08T18:30:00.000+02:00

recently i was privileged enough to go overseas to france for a laparoscopic course. unlike my last trip to deepest coldest europe, this time there was only one other south african on the course, but, as luck would have it, it was the same guy who gave us all a laugh last time. i think the laugh might have been on us this time though.

it didn't take too much time in france to realize theirs is a totally foreign culture to ours. what they are is simply called rude and obnoxious in our country. after a while one gets used to it and can only but look forward to returning home. however when there you sort of have to endure it. our usual south african responses to their behaviour might not go down too well.

the one night i went for a walk in the town (something not generally done in my country for safety reasons). at a stage towards the end of my walk i saw a quaint take-away place and decided to go in for a quick bite. i walked in. the place was totally empty except for the one single employee behind the counter standing with his back to me. he mumbled something in french which sounded to me like their usual greeting phrase, but only glanced up momentarily before he turned his back on me again. by this stage i was quite accustomed to being treated poorly by them so i greeted him back in two languages, both of which he probably understood just as well as i understood his french. he ignored me. i patiently waited for him to finish ignoring me. after a while he turned around and repeated his french phrase. i greeted him again, hiding my irritation well, i thought. i then went through the painful process of ordering something akin to a hamburger. he seemed to resist these attempts of mine, but finally took my order and got to work preparing it.

just about this time my south african colleague coincidentally walked past. he saw me in the small cafe and entered. i was just too grateful to see a friendly face and quite soon we were chatting away in a language there was no chance our french friend could understand. i informed him i had had difficulty with what i perceived as typical french rudeness but had managed to order something i was hoping would be a hamburger-esque thing. my friend greeted the guy in english and received the same french phrase i'd heard.

my friend then attempted to order something for himself to eat. it seemed to go even worse than it had with me. the menu was written on the wall so he simply pointed at an item. the french guy shook his head, indicating that that specific item was not available. not to be put off my friend moved from item to item, pointing to each one in turn and each time without joy. it was quite a comical scene to see him move systematically through the menu and be denied each time. after what must have been about the tenth item he selected, finally the guy indicated that he could supply it. my friend sighed, more from relief that the ordeal was over and we continued our light hearted conversation in our own language, somehow comforted in the knowledge that our words would confuse his ears as much as his did ours.

finally our food arrived and we tucked in.

while we were eating alone in that quaint french cafe late at night chatting in a language that reminded us of the open spaces of africa, probably too loudly for the refined french sentiment, something happened that gave me cause to reflect.

half way through our meal a local walked in. he greeted the guy behind the counter. the guy answered in the phrase that we had heard when we first came in. somehow hearing it just after the french greeting, it no longer sounded like the french greeting. just as i was wondering what he had actually said to us and therefore to this new local, the guy apologized and left. shortly after the same process repeated itself. someone came in, heard the phrase, said sorry and left. i then put it together.

the phrase obviously meant that the shop was closed. the whole time he had been ignoring us was more to do with him no longer being on duty than the usual french rudeness. i couldn't help laughing as i shared my suspicions with my colleague. i could just imagine what was going through his mind as he struggled to make himself understood to us;

"what is the quickest way i can get rid of these people that just refuse to leave? maybe if i just feed them then they will at least eat and go away."

banter

2011-04-06T17:21:00.000+02:00

of all the specialities, i like the anesthetists the most. some of them are even my friends. this doesn't mean there isn't some degree of niggling that goes on between us.

during anesthetics there are two crucial times when things can go horribly wrong. the first is when the patient is put to sleep and the second is when the patient is woken up. during most operations the time between can be quite routine and even mundane. the patient can almost be put on autopilot and the anesthetist has very little to do except maybe catch up on a bit of reading (there are exceptions). yet strangely enough the one quality gas monkeys appreciate above all else in a surgeon is speed. somehow they seem to want to get through the stress free stage of the operation (for them at least) and move on to the part where things could potentially go frighteningly wrong. maybe they get bored, i don't know.

so the anesthetist thinks the surgeon is great if he gets the operation done fast and he also takes a certain amount of pride in waking the patient up moments after the operation is finished. this way the surgeon, who usually does not appreciate waiting around for anything, doesn't end op waiting around for changeover time. i suppose you could say we work fast to impress them so that they will work fast to get the one patient awake and the next one on the bed as fast as possible and thereby impress us. yet in my opinion there are things worse than waiting a minute or two longer between cases. i don't like working on awake patients. also for some reason that i can't fully explain if you finish the operation before the gas monkey is completely ready to wake the patient up, they tend to get the impression you are super fast.

then of course you get the two basic types of anesthetists. the first type shows an interest in the operation and knows when to start decreasing the gas. the second type has little interest in the operation and is possibly more dedicated solely to his craft. he will often ask for a heads up when the operation is nearing its conclusion (i once wrote about such an anesthetist)

if you put all this together, due to the fact that i can't always predict how far i am from the end of an operation and that i've had a previous nasty experience with patients moving while i'm trying to place the last stitches i tend to wait a while before i warn the gas monkey (that's if he asks) that things are coming to an end. so a typical conversation with a good gas monkey friend of mine would typically go like this.

"bongi, give me a warning five minutes before you've finished."

"sure." i'd answer, wondering how exactly i would know when five minuted before the end would be. then i'd go on merrily, secretly keeping one eye on my sandman friend to see if he was following the operation. if he was not i'd pretty much wait until i had only one more stitch to place. i'd then glance up and announce;

"five minutes to go." i would then bow my head and carefully place the last stitch. once i was happy with that stitch, i'd look up.

"finished."

i'd be lying if i said i didn't enjoy the reaction this usually elicits from my friend. he tends to go on about now having to wait for the patient to wake up, something i'm not overly worried by as i have said. i also enjoy the illusion it creates with him that i operate fast.

it is all done in a very good nature and our friendship is not at all affected by my possibly juvenile behaviour (i hope).

friends?

2011-04-02T20:16:00.000+02:00

there is a sort of love/hate relationship between the surgeons and the anesthetists. neither one can survive without the other. we supply them with work and they get the work to lie still while we cut and dice. yet their job is to keep the patient alive while we challenge their ability to stay alive. at the moment of surgery they play good cop and we play bad cop. of course after surgery the good cop is suddenly the surgeon through and through. but that is another story.

i really appreciate a good anesthetist (i've had bad ones) and to tell the truth these days i'm spoiled by the quality of the gas monkeys that i work with. however many years ago i remember a case where the anesthetist and i had a misunderstanding about time frame.

i was doing a laparotomy in kalafong. the gas monkey was a long term medical officer. he had attempted to specialize in anesthetics but simply had not been able to pass. in the end he found himself stuck in a senior medical officer job with no way of advancing himself. he was a bitter little man and it was easy for him to take his bitterness out on surgeons.

towards the end of the operation when i started closing the sheath the patient's abdominal muscles were so stiff that he was pushing all his intestines through the wound. this did not mean the patient was awake. it simply meant that his muscle relaxant had worn off. it was a tricky time. i needed the patient to be at least partly relaxed, but if the gas monkey fully relaxed the patient he would not be able to wake the patient directly after the operation, thereby wasting all of our time. a good gas monkey will find a compromise between these two extremes. i did not have a good anesthetist. he was also more stuck on the hate side of the relationship between our two disciplines.

"the patient is pushing a bit." i hinted.

"the operation is almost over," he snapped, "i'm not going to relax him any more. otherwise he'll still be asleep half an hour from now". i was annoyed to say the least, but i knew it was a fight i couldn't win. it seemed so important to him to get this patient off the table in half an hour. i smiled. i could close this abdomen with the patient pushing against me, but i couldn't do it in half an hour. it would take longer. i decided not to share this information with my touchy friend. i buckled down and got to work.

it turned out more difficult than i initially thought it would be. each stitch was an effort and my assistant ended up straining against the patient to keep the tension on the suture. the gas monkey started becoming edgy, but i ignored him. if anything i slowed down my pace, making sure that, despite his best efforts, i closed the sheath properly.

about an hour later when i finally had it closed the qwasi-gas monkey was so irritated that he couldn't sit still. i was smiling behind my theater mask. i knew i had closed the sheath properly despite his inadvertent attempt at sabotage. and maybe next time he would pay slightly more attention to my seemingly ridiculous demands.

doing nothing

2011-03-23T20:10:00.000+02:00

surgeons are not so good at standing back, yet sometimes doing nothing is exactly what needs to be done. i remember one time that this turned out to be slightly humorous in a morbid sort of way.

i was in my vascular rotation which was not too much fun (except for a short moment). generally if a patient came in in the late afternoon requiring an operation, your entire night would be destroyed. and there was pretty much nothing worse than an abdominal aorta aneurysm (aaa). scratch that. a bleeding aaa was a lot worse than an aaa. so when casualties called and said they had a bleeding aaa my heart sank.

the patient was pale and clammy and his heart was racing. but the thing that struck me the most was his age. the man was 89 years old. the casualty officer also mentioned that he had previously been diagnosed with ischaemic heart disease. so, in summary we had a man just this side of ninety with comorbidities and a condition that was know to kill most of its victims thirty years younger than him. the chances of him surviving the operation were dismal. i called my senior.

my senior (the vascular fellow) examined the patient and went through his file. like me he concluded that an operation would push him over the cliff whose edge he was standing next to. in consultation with the patient's son, the decision was made to make the patient comfortable and leave him to the inevitable. i confess i had the thought that at least i'd get to sleep, but i also knew the sort of sleep one gets while waiting for death to take one of your patients is a broken and rocky sleep.

the next morning i arrived for my rounds. i hoped the patient was dead but when i walked past his son just outside the ward i knew i would find him alive in the ward. after a patient dies the family always seem to flee the hospital. the stress of the night was etched into the face of the son. i could tell his night had been worse than mine.

sure enough when i entered the ward, there was the old man lying in bed just where i had left him the night before. it seemed the pain medication was working though. he wasn't quite as restless as the day before. i walked into his room. i didn't bother checking his vitals. what would be the point? he looked up at me. i was surprised to see he was doing so well. i remember hoping the fellow hadn't told the family it would be all over by the morning because the old man seemed to be set on proving him wrong. the one problem with him still being alive was that i'd have to take over the role as the intermediate with the family. the fellow would make himself scarce now that the initial footwork had been done.

i greeted the old man.

"môre oom." i said. he looked at me.

"môre neef" he replied, using a greeting that had gone out of circulation many years before i was even born. i smiled. he seemed quite spritely for someone in his position. but his next statement really gave me a chuckle.

"neef, is it true that you are not going to operate?"

"yes it is true, oom." i replied.

"well then if you are not going to operate why don't you send me home? there are things i need to do on the farm you know." how could one not admire that sort of attitude? i smiled broadly.

he took another day and a half to die. it was tough on his son, but i suspect he sucked the marrow out of every one of his last moments of life.

the graveyard

2011-03-17T20:42:00.000+02:00

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.

a dead giveaway

2011-03-17T18:09:00.000+02:00

amazingly enough, no matter how crazy our country gets we are a darn sight better than many of our neighbours. many people from countries around us flee to south africa for a better life. only problem is for the better life you sometimes have to produce a south african identity document. these can be easily bought from corrupt government officials, but why buy one if you can borrow one.

i was working in qwaqwa. it was an amazingly poverty-stricken place with what seemed to me to be almost total joblessness. i truly don't know how the people survived. an yet people from neighbouring lesotho would still move there illegally. i've never been to lesotho personally but if qwaqwa was a better proposition, then i can't even imagine how bad life in lesotho must have been.

anyway, one day i got to work and was confronted with a sticky problem. the police were there and they apparently needed my help. you see as it turns out, a lesotho illegal had died a week before in our hospital. in order to qualify for admission to our hospital she needed to be south african. luckily her sister was the proud owner of a south african identity document and had simply lent it to her, along with her name. i assume they looked similar enough that the clerk working in admissions hadn't noticed the picture in the book wasn't that of the patient. more likely she simply didn't check. the problem was that the patient had been declared dead by the doctor on call that particular night. or rather the patient's sister and her id had been declared dead. at that stage no one yet knew who the patient was.

however, when the sister attempted to draw money at her local bank a day or two later, she was shocked to find out that her assets had been frozen on account of her being dead. this upset her because even thought she had been declared dead in her absence, aside from a sick feeling in the pit of her stomach, she felt quite alive. suddenly it seemed the right thing to do to come clean and admit that she had lent her sister her identity document and therefore her identity.

now the problem that the police at the hospital had was that they needed a fresh death certificate for the person lying in the freezer in the morgue whose identity they now knew. they presented me with the papers to sign. a small difficulty was the papers required me to identify the body as this new dead person. the police were quite willing to forego this technicality and get my signature. however i felt the entire problem had started because of a casual disregard for the finer points of the law. i was simply not willing to sign a document saying i had identified someone as dead if i had not identified said person as being in fact dead. logic may have dictated that someone who had been lying in the morgue freezer for a week, even if they had not been dead when they got there would probably be dead by then, even if they had simply succumbed to boredom, but i felt i needed to look if the forms that i was required to sign stated that i had looked.

and so the sister, the cop and i took a stroll down to the morgue. the sister and the cop went on, a bit too much if you ask me, about the madness of the doctor in insisting on seeing the body. the last time i had been forced to go to the morgue was in the dead of night so actually i was, relatively speaking, in fairly good spirits.

even being in good spirits and even in the light of day a morgue is not a great place to be and identifying the body of someone who had been on ice (along with her sister's identity and bank account) is actually quite difficult. the normal human features seemed withered and pulled back, revealing a sort of grimace, as if she knew what cruel trick she had played on us all. i was not impressed. the form required me to see the body and see the body i had. i left, signed the form and walked away.

later i could see the humour of the whole thing. i also couldn't help thinking only in south africa could such absurdities take place.

empathy

2011-03-13T20:06:00.000+02:00

while i am on the topic of the amazing ability surgeons have to show empathy, i thought i'd share a story one of my friends once told me about a professor he had in another university. but it also touches somewhat on where the priorities of a surgeon should be during surgery.

it was late at night and the prof was actually at the table operating (something so rare in our place of learning it also made me wonder if i'd maybe chosen the wrong university). it was in fact around the time when students struggle to stay awake. but on the whole it is not the best idea to display this weakness while scrubbed in with the prof.

the prof was the primary surgeon (something that made me glad i didn't choose that university), the registrar stood opposite him as the first assistant and some poor tired student stood next to the prof as the second assistant. i use the word stood in its loosest possible definition because he was struggling to remain in the upright position. every now and again he would slouch against the professor until in irritation the prof would thump his elbow into the student's ribs. this would result in a good five to ten minutes of good assistance from the student. thereafter his head would sag and come to rest once again on the shoulder of the prof. i'm sure it made a pretty and even touching picture. pity the prof didn't feel the same.

and so the operation went on with the student's sporadic moments of wakefulness and the prof's temper becoming equally short. finally the prof decided on another strategy. as the student's head once again sagged, looking for that warm and snug nook on the prof's shoulder, the prof took one large step back. the student's limp sleeping body found no comforting shoulder where one had been previously and went down like a ton of bricks, right in front of the feet of the prof. he then looked down at the dazed student lying at his feet, carefully stepped over him, back to the table and spoke.

"bring vir my 'n student wat nie stukkend is nie!"*

*bring me a student that isn't broken/defective

bedside manner

2011-03-01T13:46:00.000+02:00

if nothing else, this previous post illustrates that surgeons are not that great with the whole bedside manner thing. i would like to think i'm an exception...but i still am a surgeon.

i make a point of communication with my patient. obviously if he is a child, i use the same measure of effort in communicating with the parents. but few things irritate me more than some or other family member that insists on forcing their way into the fairly personal interaction between patient and the guy that in all likelihood is going to carve him up in the very near future. i refer to the person who insists on answering my questions directed at the patient as if they know better. i mean if i ask what the pain is like and, before the poor patient can express himself, his well meaning irritating wife or mother begins to describe to me what he is feeling as if she is feeling it too. i often want to tell them to get sick themselves before i give a dam what they feel or think. i'm usually at least slightly more diplomatic.

i was a senior registrar. a private consultant friend of mine asked me if i could look after his patients while he was on leave for two weeks. apparently he did not trust the other private surgeon working in that hospital. to be frank neither did i (but we'll keep that story for another post, shall we). we went on a sort of handover round together and i got a feel for what was going on. after rounds he mentioned to me that there was still one more patient coming in from a general practitioner that apparently had a bowel obstruction due to a previous operation as a child. the patient was apparently going to be admitted via x-rays. i could evaluate him and operate if i felt it was indicated. all seemed well. he would be my first ever private patient.

the patient arrived and i was called to evaluate him. i walked into the room and took in the scene before me. the patient, a young man that i estimated must be about 26 years old, was lying in bed and what had to be his father was standing next to him. i greeted them both and introduced myself. i then turned to the patient.

"what seems to be the problem?" i asked, looking at him. the father answered before the patient even had a chance to open his mouth.

"well doctor, he started with..." i cut him short right there.

"uhmm, excuse me, but i did not ask you. i asked him." i said. then turning towards the patient with possibly too much of an ostentatious flick of my head i started again.

"what seems to be the problem?" the moment the patient opened his mouth was the moment i became acutely aware that he was mentally retarded. he very nearly could not string a sentence together and certainly couldn't express himself in terms above that of about a five year old boy. i felt like a total idiot and could feel my cheeks flush in embarrassment, but what could i do? i just had to soldier on. i mean i could hardly now turn to the father and admit that after careful consideration i did want to hear from him what sort of pain the patient was experiencing, especially seeing that i had just brushed him aside rather unceremoniously.

the entire interview and examination was painful (i think the patient also experienced a bit of pain) but i just kept on slugging through it. i then looked at the x-rays. it was a clear case and i knew i needed to operate. for the consent i fortunately could turn to the father. it was clear the patient didn't have the mental faculties to sign his own consent, if he even could write at all.

fortunately the operation and the post operative phase went well and quite soon i discharged the patient into the care of his parents.

just over a week later i followed the patient up. luckily everything was in order and i informed him and his father that all was well and they could go in peace. they left the consultation rooms, but then the father turned back to me. i had been expecting something like this from the first moment i had realized the patient was mentally retarded. i was just surprised it had taken so long in coming.

"doctor, i'd just like to have a word with you in private." oh, well, i thought. it's not as if i don't deserve some backlash for my unintentional indiscretion at our first meeting. i braced myself for the worst.

"doctor, at our first meeting, from that first moment when you refused to hear from me what was wrong with my son, but instead insisted on speaking only to him," i cringed. "well from that moment i knew we were with the right doctor. thank you so much for all you have done for him and for the respect you showed him. we as a family will forever remember everything you have done."

i didn't see that coming. i decided to just keep quiet about the fact that i hadn't realized the child was mentally retarded. we all went our separate ways, me with my pride and hide intact and the family chuffed at how i had treated them. i was relieved.

steeped in blood

2011-02-26T13:25:00.000+02:00

this post is a bit of a diversion from my usual posts but i think it may still be worthwhile. you see i want to promote a book.

i've just read the book steeped in blood (paperback or kindle) by david klatzow. what a stunning book. it really gives insight into the south africa of old and possibly what south africa of the future may end up being like. i really suggest that everyone gets hold of it and reads it.

unfortunately, david, i do feel i must challenge you on one point. towards the end of your book you say one of your surgeon friends told you a story of one of our cuban import surgeons who tried to do a tonsillectomy through the neck rather than through the mouth, the normal way of doing it. i know this story and have heard it often myself in the corridors in pretoria. unfortunately it is urban legend and nothing more.

i have worked with the cubans and they aren't too shabby. don't get me wrong, they are not a scratch on a south african specialist (although the standards are dropping as you rightly pointed out and quite soon they may be far better than home grown specialists) but the point is they wouldn't do something so bizarrely stupid.

i even suspect i know who your surgeon friend might be, especially if he presently finds himself in pretoria rather than johannesburg where you no doubt got to know him.

anyway, still an absolutely brilliant read for anyone who wants to get a peek into the workings of the apartheid government of old. go and buy it now.

you've got to hand it to him

2011-02-07T20:41:00.000+02:00

some students refused to listen to good practical advice. sometimes it hurt us all, but sometimes it was good for a laugh.

general surgeons have a reputation amongst doctors. they are viewed as crude, arrogant and even aggressive. this might be because they are often crude, arrogant and aggressive. but yet they are simple folk and can easily be pacified.

he was a private consultant. he was a typical surgeon but he was also a great teacher, if you could look past his rough mannerisms. he only came in one day a week and did a sort of a ward round. but in all reality it wasn't a ward round at all. he would ask us to show him some interesting patients and then he would teach us all about the condition of the first patient we showed him. he never addressed the patient. he never examined the patient. it was more coincidental that we would be standing next to the bed of a wide eyed patient while we listened to his tutorial. he taught us so much, including what a bedside manner should not be. he was also a great example of how not to present a patient to the professors.

"when you present a patient to doctor l," i would coach the students before the time, "do not go into all the detail!! he doesn't care. simply point at the patient and in a loud clear voice shout the diagnosis. then have a piece of paper and a pen ready. every word you hear after that is worth its weight in gold for your exams, so take notes." they all nodded, but i somehow knew they thought i was exaggerating.

the allotted time of the allotted day arrived and we all stood around waiting for the consultant. true to form he was exactly on time. he ignored the students as was his habit and only acknowledged me with an almost imperceptible nod of the head. i greeted him curtly and headed off in the direction of our first patient, which i had specifically chosen because i felt he had the condition the students most needed to brush up on.

we arrived at the patient and the consultant turned to the students. normal human interaction always seemed to be an effort for him. more looking at his own feet as anyone in particular he asked;

"right, whose patient is this?" the student stepped forward.

"mine!" he whimpered.

"well? what are you waiting for? present!" i had trained them well how to present to this consultant and yet i somehow knew what was going to happen.

"uhmm, the patient is a 25 year old black male..." the consultant lifted his head. his eyes were suddenly ablaze with what seemed like years of pent up frustration and anger. he cut the student short.

"do you think i am a blerrie idiot?? i can see the patient is male. i can see he is black. i can see he is about 25 years old! next thing you are going to tell me he is the third child in a broken home? i don't care about all of this. and if you even try to tell me he lives in a house with running water or no running water or whatever i think i'll kill you!! just tell me what is wrong with him!!!" i managed not to laugh, but as the student looked to me in supplication i confess a smile darted across my face. i had warned him. he shrugged his shoulders, pointed at the patient and in a clear voice shouted;

"alcoholic pancreatitis."

the consultant grumbled under his breath and extended his hand to the side, in the true fashion of a surgeon in theater. i was ready with the pen and slapped it sharply into his waiting hand. as if by magic, a sheet of paper appeared before the consultant. i remember thinking that they were at last listening to my practical advice.

thereafter the students (and patient if he was paying attention) got the best tutorial on alcoholic pancreatitis that they would ever be exposed to. i confess i didn't pay too much attention. i was otherwise occupied trying to suppress a laugh.