August 31st, 2009 by Bongi in Uncategorized
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Occasionally I post something that scores high on my weird sh!tometer (here, here and here). It seems this is such an occasion.
I thought of this incident recently when I was privy to some doctors complaining about stupid referrals. This was the only one I could think of. In reality it was more a moronic patient than a moronic referral.
As usual it was late at night. The casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). I asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. He gave a nervous chuckle and agreed. When I started asking about possible disease processes which could give rise to this condition (which pretty much can’t just happen spontaneously) he had no answers. In his voice I could almost hear him saying:
“Come on. I’m tired. It is a stupid thing to come into casualties for at this hour but here she is. Just come down and see her so it is no longer my problem.” I answered before he was forced to actually say these words.
“Ok, I’m on my way.”
The patient was an old Indian lady fully-clad in her robe-like traditional garb. I asked her what the problem was. She was quite a bit less than forthcoming. I asked her to show me the problem if she couldn’t describe it. She lifted her robe. I was not prepared.
She presented a disfigured torso and abdomen. It seems when she was younger she had been severely burned by hot water. Those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. Between being young and the present she had become obese. Actually that is only partly accurate. Only the unburned areas had become obese. She had areas of supreme obesity interspersed by a network of amazingly slim. On one of the fat areas, towards her flank was an opening which was oozing pus. The smell was unearthly. I may have gagged a bit. But something was missing.
“Where is your umbilicus?” I asked. She looked sheepishly away. She was determined to not be forthcoming. A more direct approach might work, I decided. I pointed to the suppurating hole almost on her flank and asked:
“Is this your umbilicus?” She nodded. The burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. I was annoyed. She knew what the problem was from the beginning. She also knew that it wasn’t something to come into casualties for in the middle of the night. She had been taking us all for a ride. But what could I do? She was there and I had to do something. Something, I decided, would involve double gloving.
I inserted my finger into the oozing hole. As expected, now that I knew what it was, It tracked towards the midline where the umbilicus had been many years before. At its base I felt a tennis ball sized mass of old debris. This time I did gag. This mass I scooped out bit by bit until the umbilicus was something it hadn’t been for years…clean. Annoyance fell away to disgust. I almost couldn’t speak because of my gag response, but I forced myself.
Fortunately all I really had to say was:
“Have you heard of soap?”
*This blog post was originally published at other things amanzi*
August 23rd, 2009 by Bongi in Better Health Network, True Stories
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I spoke about foreigners and relative attitudes between them and myself. But, truth be told, one of the reasons they think they are in deepest darkest Africa when they are here is because they are!!!
We pick up the story roughly where I left it off. The initial accident claimed two lives. Then the young son has to survive a brain bleed and a neck fracture. Somehow the neourosurgeon sorts all that out. Then in ICU he gets acalculous cholecystitis and I meet him, almost in exitus. We fetch him from the pearly gates and tie him up in ICU for a while. He survives. He can walk. His maths and science still works. Miraculous!
But for a moment imagine the father, the only one not really injured in the accident. He is in a foreign country. He has just lost 50% of his family and there is a real chance his son might die or be paralysed or retarded for life. The daily ICU vigil alone must have taken a toll on him. And then things slowly start improving.
After too long away from home they are ready to leave. The son is amazingly well. He is neither paralysed nor retarded. Also he is alive which everyone sees as a positive thing. Then they have the unpleasant task of getting the bodies of the other two members of the family. What do they find? Certain body parts are missing, including one hand!!! Stolen from the dead in the morgue. You just can’t make this sort of thing up. I dare you to try.
I have spoken before about body parts stolen to be used by sangomas for so called traditional medicine, so I suppose I shouldn’t be shocked, but I was. I couldn’t help feeling for him. Over and above all the terrible things that happened to this man and his family he has to endure the bodies of his departed family being desecrated.
This story so affected me I followed it in the local papers for a while and pretty much put it together. At least some of the people were actually arrested so quite a lot of the story became public. It seems there were people working in the morgue who regularly stole body parts to sell to sangomas. They would target the bodies which were to be cremated and cut out the desired organs just before cremation. No one would be the wiser. The foreigners were targeted, it seems, because the body lay in the morgue so long while the boy recovered in hospital.
So, in conclusion, this is deepest darkest Africa and here you will truly be amongst us savages.
*This blog post was originally published at other things amanzi*
August 21st, 2009 by Bongi in Better Health Network, True Stories
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Surgeons are not stand back kind of people. They fall more comfortably into the category of charge in where angels fear to tread. I think the work tends to preferentially attract those type of people. But sometimes standing back can be the lesser of two very evil evils.
The call was a standard weekend consultation. The patient had hematemesis and his doctor was worried. Nothing I hadn’t seen many times before. But when he came in the patient’s wife had a few more details to spice the story up a bit.
Just about a year ago he had had a resection of his stomach for cancer. The surgeon had told his wife they couldn’t get all the cancer out because it was growing into some big blood vessels behind the stomach. For some reason they both decided not to tell him this. So when he was referred for his chemotherapy (something that could not be described as awe-inspiringly effective in stomach cancer) he truly thought he was well on his way to full recovery. and now he lay before me, pale and restless.
He was a shadow of what he once must have been. His skin hung loosely as if in remembrance of the large man it once covered. I was not happy with the mass I clearly felt just under his left rib margin. The cancer was back and it seemed angry. I got the necessary drips running and ordered blood. I considered dropping to my knees but due to a back injury when I was still a student I wasn’t sure I’d be able to get up onto my feet again.
The wife called me aside and told me the patient was not aware of the fact that the operation was not a roaring success and therefore that he was essentially living on borrowed time (which I grimly thought he is about to pay back with interest).
“You need to tell him.” I said.
“No!! Doctor!! I can’t do that.” She needed the truth.
“This man, your husband may die here in this hospital within a day or two. you need to speak to him.” But she would hear none of it. She also didn’t want me to tell him things were not so rose coloured (I suppose depending on what colour roses you’re talking about of course).
The next day the patient was feeling much better. Amazing what a bit of blood will do. We chatted a bit. You know, shared a moment. He even laughed at how bad he had felt the previous day in comparison to today. Then it was back to business. In this case business meant I was going to take a long, not so thin pipe and stick it down his throat to take a quick look at the source of the bleeding in his stomach. I sort of lied to myself, telling myself that maybe I’d see something that could be fixed with a knife. In truth I knew what I would see. The palpable mass and the history dispelled almost all my doubt (or hope). But I knew I needed to look. I needed to know for sure how much or how little I would be able to do for him. Maybe I needed evidence for one day after it all when I am called to account.
The cancer was a large fungating mass with a deep necrotic core. It was gently oozing blood but I could see it was capable of so much more. It seemed to me it had stopped its torrent of blood long enough to give me a glimpse as if to taunt me. As if to say you know me and you know you have no power here. It was right.
After the procedure the patient once again started spewing forth blood. I sat with him for quite some time. between his retching we spoke.
“This is not good, doctor.”
“I know.” What more was there to say?
“What are we going to do?”
“We are going to hope the bleeding stops.” What more was there to do?
Then I went against the wishes of his wife. I told him this cancer was going to be the end of him. He looked at me with a calmness and a gentle smile.
“I know.”
He probably had known for some time but I think he felt he had to go along with the charade and maintain the lie with his wife. He seemed relieved that the truth was out. He seemed to relax.
That night the sister called me to tell me he was bleeding massively. I explained the situation and asked her to push blood IV. If that didn’t help, nothing that I could do would. The next morning he was dead.
Somehow when we sit behind our computers and in our nice expensive offices deciding about the futility of certain treatments and who should get what based on cost or whatever, the actual point is lost. The nice old man finally vanquished by the hideous monster called cancer or the old lady with heart disease or whatever who is forced to succumb to the dark inevitable is the point. It is the person, the individual. the one like me. and maybe like you.
I was just left with a sense of how difficult it is to stand back and let someone die when you know what that means. It, I assume, is much easier for the powers that be, snug in their artificial real worlds.
*This blog post was originally published at other things amanzi*
August 9th, 2009 by Bongi in Better Health Network, True Stories
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Recently I spoke a bit about interaction with foreigners. The impression I left would have been strained to say the least. But as with all things there must be balance.
They were tourists (aren’t they all?) when in the Kruger she developed severe abdominal pain. Her son brought her to hospital.
When they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were American and that her son, the one who brought her in, was a physician. Let me take a moment here just to mention a language difference between English and Americaneese. In South African English, a physician is a specialist in internal medicine. In American, it seems, a physician is simply a doctor. At that time I did not know this. None of us did. So when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety MD.
I mentally prepared myself for a confrontational family. Usually with non medical first worlders they question you at every turn. A physician (South African definition) traditionally is sceptical of the knife-happy surgeon. I couldn’t help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. All I could hope for was a benign abdominal cramp which would soon pass.
The patient was in pain. She associated her discomfort with some or other something she had eaten the previous day in the Kruger. But it just seemed too severe. Besides, could anything bad actually come out of the Kruger? She had none of the signs which indicated that she needed immediate surgery. But the pain really bothered me. It nibbled away at the back of my mind. Then came the x-rays. They were worrying. I was looking at a partial obstruction, but the bowel was just too distended. One more thing to quietly eat away at my mind.
Then suddenly the son appeared as if out of nowhere. He greeted me in a friendly manner. I introduced myself as the surgeon. Even after hearing who or rather what I was, he remained friendly. I remained guarded. Afterall I was under the impression I had to do with a physician (when in actual fact I later found out he was only a doctor).
I showed him the x-rays. He could see they were not good. I then went on to tell him I was worried and I felt an operation was in order. At this stage let me mention that a partial bowel obstruction does not need to be operated immediately. It can be left for the next day. But in this case there were just a few too many things eating away quietly at my mind. I had a pretty good idea what this meant. He surprised me. He said that I should do whatever I thought was needed. I did.
The operation went as I expected. I expected necrotic bowel. I resected what was needed and did all the other things that us surgeons do in these circumstances. But when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. This was no exception. We were worried about here generally and her hemodynamics and kidney function specifically. We were worried enough to send her to ICU. The gas monkey even felt the need to leave her intubated. I concurred.
After I had tucked her into bed in ICU I wondered where her son was. It was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. But I just felt I’d better check in the ward where his mother would have gone to if she hadn’t ended up in ICU. He was a colleague and besides, he might expect the worst if he found his mother in ICU intubated unexpectedly. I took a stroll to the relevant ward.
I found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. I smiled. I was starting to like them.
I greeted them warmly. I didn’t want them to expect the worst. I then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to ICU. I reassured them that she was well and we expected no further unforeseen problems. I warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. He was pretty ok with everything but I could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to ICU.
He put a strong face on it. He asked me a few questions and I did my best to reassure him on each point. Then he asked a question I was afraid I would not be able to reassure him on.
“And when we go down to ICU, will we be able to speak to the intensivist?”
“Umm…errr….that would be me.” After all, this was a peripheral town in South Africa. In fact there is no real intensivist in our entire province. Suddenly I felt sorry for these Americans. They were far from home, their mother was very sick and the best they had to look after her in ICU was a mere surgeon. There must have been at least some inkling of a misgiving in their minds. But he didn’t show it. He smiled at me and simply said;
“Ok. Well we’ll see you tomorrow morning then?” I was impressed.
The next morning I did not see them. They must have still been asleep after such a late night, I assumed. However the following few days their involvement really did leave an impression on me. It was also about this time that I realised he was not in fact a physician as I understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).
Anyway the patient did well. She had the setback of a bit of wound sepsis which, considering everything, I could live with (although I have heard that some people in America want to put it onto a never event list?????). That was soon sorted out and after not too much time she was sent on her merry way.
This case also caused me to be contacted from the States. The patient herself sent a thank-you letter as soon as she got home, as did her son. She then sent a further thank you letter a year later and the year after that.
So, if I left the impression that I have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.
*This blog post was originally published at other things amanzi*
July 28th, 2009 by Bongi in Better Health Network, True Stories
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Ask almost any surgeon and he will tell you your chances of surviving a catastrophe are inversely proportional to your usefulness to society. This sentiment is expressed in different ways by different surgeons but the basic message is the same. If two people come in with exactly the same injuries and one is a teacher who spends his extra time in community upliftment projects and the other is an armed robber, the armed robber will sail through treatment and be back on the streets in no time, but the teacher will slowly waste away in ICU and finally die. Unfortunately it seems to be true.
There was a super clever cardiologist friend of mine who speculated as to why this was the case. He basically divided people into two groups, those with over active immune systems and those with just the basic immune system. The first group would tend to be allergic to everything and be over protected by their mothers. They would tend to grow up in a protected environment devoting their time to inside activities (safe from the dangers of the outside world, including grass and pollen and dog hairs and the like) reading and bettering themselves. The latter group would be immunologically free to run around like wild things doing whatever they liked.
He then extrapolated this to the likelihood that the first group possibly had a higher chance of developing SIRS (systemic inflammatory response syndrome) after major trauma and it was in fact their own immunity’s overreaction that finally brought them down. Amazingly enough this theory is based on logical scientific thought.
Like all surgeons I too tend to think that the good guy will probably die and the bad guy will survive. I have seen it too often. But unlike my boffin cardiology friend I think it is just some sort of evil cosmic reverse karma that is out to destroy all good people in this world. This makes much more sense to me than actually trying to understand immunology. And that is why I try to do at least one bad thing a day so that if something does befall me I at least have a chance of surviving. But there are always limits.
A few years ago our hospital organised a weekend away for all the doctors and their families. It was at a really nice lodge here in the Lowveld and truth be told, it was great. The days were pretty much spent lounging around the pool. That is of course if you didn’t play golf. I don’t play golf.
Anyway, there I was producing vitamin D for all I was worth when I glanced over at the pool. One of the other doctors had a small boy of about 4 years old that had been running around all day like a mad thing. But at that moment, as I looked at him leaning over the edge of the pool he toppled in. I was about 10 meters away so I first looked to see who was closer that would respond. No one moved. No one had seen him fall in except me.
Then everything went into slow motion. I could see that he could clearly not swim. His eyes were wide open as his arms an legs flayed about helplessly not bringing his head any closer to the surface. He was clearly in trouble. Then a strange thought went through my mind based on my above mentioned philosophy.
“If I leave him, that is bad enough that I will probably live forever.”
Who actually wants to live forever?
So I rushed over and pulled the kid out.
His mother seemed pleased.
*This blog post was originally published at other things amanzi*
Occasionally I post something that scores high on my weird sh!tometer (here, here and here). It seems this is such an occasion.
