July 24th, 2009 by Bongi in True Stories
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I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.
It was the time of the taxi wars. Now taxis in our country are nothing like you might be thinking. They are fleets of mini-buses, quite often owned by people of questionable legal character. Occasionally rival groups try to take each other out (I mentioned this before here). But roughly at the turn of the millennium there was outright war. When the war came to Pretoria we saw quite a few of the victims, but neurosurgery got the most. A friend of mine was rotating through neurosurgery and this story came from him.
There had been a contact between two different taxi organisations. The casualties were streaming in. The neurosurgeon and my friend, his trusty lackey, were overworked and I think it had affected their sense of humour. So while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. When the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. And this is what they did.
The neurosurgeon looked at each patient in turn. The first three he told them to send into casualties for his attention. But the fourth…he took one look at the fourth and exclaimed;
“Vat hom weg! hierdie een is gefok!*”
My colleague laughed the next day when the newspapers reported: “On arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty.” Fortunately they did not quote him verbatim.
*take him away! this one is f#@ked!
*This blog post was originally published at other things amanzi*
July 12th, 2009 by Bongi in Better Health Network, True Stories
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Sometimes before you are even called the sh!t has already hit the fan. The mopping up is not fun.
I was on call. As usual I was hanging around in the radiology suite (I spend a lot of my free time there sharpening up my CT scan reading skills. The radiologists even think I’m a frustrated radiologist, poor fools). The urologist phoned me. He had a nervous laugh. Most types of laughs of urologists I quite enjoy. But the nervous laugh I do not. He then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. I quickly called the scan up on the monitor and sure enough there it was. The patient was mine.
There was an 8cm aneurysm. But just anterior to this there were signs of recent retroperitoneal bleeding. This was not good. The guy was just one step away from a fatal rupture. I phoned my vascular colleague in Pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. Then another call came through.
“Doctor, the urologist says I must call you about his patient. He says it is now your patient. Something has happened.”
I knew I needed to run.
“I’m on my way!”
As I rushed through the ward I saw what must have been the family. They were all looking anxious and some had tears in their eyes. I rushed on. I needed to focus.
In the patient’s room it looked like well orchestrated chaos. Lying on the floor was a massive man who was as pale as a sheet. The casualty officer was intubating. A sister was doing CPR. The urologist looked up.
“Glad to see you! well then I am no longer needed. See you around.” And with that he walked out. Someone was trying to place a drip with little to no success. A large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. I needed to take control. Only thing is I had seen the scan and I knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).
I told the nurse to stop CPR long enough for me to check for signs of life. There were none. She continued. I then did some basic tests to gauge brain stem function. There was no detectable brain stem function. I called it right there.
After a dramatic unsuccessful resus there is usually an eery silence in the room. Maybe it is a sort of respect for the departed or maybe it has to do with confronting one’s own mortality. I think it has a lot to do with thinking who is going to say what to the family.
“Are you going to speak to the family?” I asked the casualty doctor. I had to try.
“No! you are!”
“Great!” I thought. “I walk in on the closing act and I’m left with the hot potato.”
I took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. Then I went quiet. I needed to focus.
The family had been taken into the sisters’ tea room. They then sent me in. The mopping up had begun.
I have spoken before about breaking bad news. Fact is, it is never easy and I’m not sure there is any easy way to do it. I try not to leave the family in the dark too long. Once they know I try to be as supportive as possible and to answer their questions as best as can. Usually I am struck by the human tragedy and I allow it to affect me as it should. Sometimes when I have been overcome by the relentless nature of my work I must stand back and observe. This was one of those times.
*This blog post was originally published at other things amanzi*
June 28th, 2009 by Bongi in Better Health Network, True Stories
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In the old days sometimes confrontation was the only way to get things done. But sometimes anger lead one into useless and unnecessary confrontation. I recently spent some time with my old friend, swimmer’s chest and a story came to mind when that swimmer’s chest saved me from my own anger.
We were on call together. Quite early in the day the chemotherapist called me. He had apparently put a patient on the emergency list the previous day for a portacath and the case didn’t get done. This was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. Something like a portacath would tend to get shifted down the list and may even stand over to the next day. This is what had happened here. He now wanted me to do the case.
“Sure I’ll do it” I said. “As long as it’s on the list as soon as it comes up I’ll be there.”
“I want it done now!” he retorted. I was not impressed.
“Well phone the anaesthetist on call and motivate for him to move it up the list.” I said helpfully.
“That is not my job! You will do that!”
It was clear we had a communication problem. Whenever I had a telephonic communication problem I would put down the phone and take the effort to go to the relevant person to sort it out face to face. Not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). This is what I did here. I turned to swimmer’s chest and told him to accompany me. Off we set at speed.
We walked into the chemotherapy ward and asked to see the relevant doctor. Soon he was there in front of me. swimmer’s chest hung back. I introduced myself and explained that I was more than willing to do the surgery but I had no control over the order of the list. That was entirely in the hands of the anaesthetists. If he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.
“You will phone the anaesthetist yourself and you will do this case right now!” he said.
I could feel my anger slowly turning into fury.
“No! you will!” as I said it I clenched my fists and took a step towards him. Swimmer’s chest realised things were on the verge of going south. He later told me he thought I was going to punch the guy. I denied this, but the thought was going through my mind at the time, I confess.
So my good friend stepped in front of me with his broad chest and nudged me backwards. He then started speaking to the chemo doc in a calm diplomatic voice. He also subtly and slowly (almost so one didn’t notice) ushered the guy further and further away from me. By the end of it we left with the chemo guy feeling that we were there for him and would do all we could. I don’t think he even had an idea of how enraged he had made me.
Walking away swimmer’s chest asked me if I was mad. I had only a few month’s of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.
Those times in the end brought out the worst in me. By the end of my studies I knew I needed to get away from it all. I had very nearly become something I did not like. After leaving pretoria I gradually rediscovered the true me again. It was still there to my relief.
*This blog post was originally published at other things amanzi*
June 18th, 2009 by Bongi in Better Health Network, True Stories
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In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
The guy had apparently fallen asleep next to his fire. When he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. Someone found him and brought him in late that night.
When I walked into casualties I could smell him. You can almost always smell the burn patients. I took a look. The one leg actually wasn’t too bad. It had an area of third degree wounds but they weren’t circumferential. I could deal with that later. The other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. This could not wait for later.
In third degree circumferential burns, the damaged skin becomes very tight. Constricting is actually a better description because unless it is released the taught skin will so constrict the leg’s bloodflow that if left untreated the patient’s leg will die. It is like a compartment syndrome only the entire leg is the compartment. Interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. That means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. You just cut the skin and as soon as you hit an area that the patient feels you’ve gone too far. If you do it right they will feel nothing. The longer you wait the higher the chance that he will lose his leg. I knew what I needed to do. I also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.
I asked for a blade and gathered my students around me. I sunk the knife through the dead skin and ran it down the length of the leg. The wound burst open as the pressure was released. The patient didn’t flinch. Quite a number of the students did. One excused herself and ran out. I think she might have been crying. Despite me telling them that it wasn’t painful and it was in the best interests of the patient to actually see it was more than most normal people could take.
When I wrote my last post and expressed a form of traumatic stress I found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. I was ok doing what that one student obviously thought was gruesome and bizarre because I was convinced it was in the best interests of the patient. When I did this procedure which, on the face of it, is so much more brutal than taking someone to shower, I was ok, but the shower incident was terrible for me. I ended up hoping the student didn’t see me as quite that monsterous. I also hoped she would get over the trauma I had inadvertently caused her.
June 12th, 2009 by Bongi in Better Health Network, True Stories
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Leaking
People are basically sacks full of water. The skin keeps the water inside. Trust me when I say you want to keep your water inside.
The second post I ever wrote had to do with watching someone with burn wounds fade slowly away. In the end it had more to do with my own mortality. When I read it recently I was reminded of quite a few poignant stories. This is one.
Usually things happen in groups and, it seems, burn wounds are no exception. On two successive nights two severely burned patients came in. I got the first. My colleague got the second. My patient had 98% burn wounds (Usual story of being doused in petrol and being set on fire. Someone didn’t seem to like him). Only where his hair had been was he not burned. That means that 98% of the sack that is supposed to keep the water in was leaking.
Let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. This patient was as good as dead, so whatever we were going to do would only partly help. The outcome could not be changed.
The immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. The amount of fluid one gives is proportional to the surface area burned or the surface area leaking. In 98% that turns out to be quite an amazing amount of fluid. And that is what we did. I worked out the fluid needed, put up a good central line and started running it in. The next day he was still alive.
The next day was when the second burn wound patient came in. He had 95% burns and therefore was leaking pretty much the same amount as my patient. My colleague admitted him, but he treated him differently. My colleague knew that the end of the road was predetermined and didn’t see the point in prolonging the inevitable. He only gave him normal maintenance fluid which a normal person would require. He considered more as treatment and didn’t see the point in treating something that could not be treated. I considered that he may have a point. I went to see his patient.
His patient was not doing well. The loss of fluid had pushed him into a stuporous state. He didn’t seem to have long to go. I left. He died soon after.
My patient remained alive through that day too. Because of his wounds he could not lie in bed without extreme discomfort. But the soles of his feet had no skin so he could not stand either. The skin of his hands had all peeled off and they had swollen into useless immovable paws.
The head of the firm then decided we should take him into a shower and remove all remaining loose skin. I got the feeling he was trying to teach us some sort of lesson. The only thing I learned is that it is brutal to try to remove loose skin, even gently from such a patient. The patient was not having fun at all. I kept thinking why are we making the last days of his life any more miserable than they already are? The head then decreed that we would repeat this process in two days time. I felt sick at the thought. The wisdom of my colleague not treating his patient seemed much clearer to me then.
The next day when I arrived at work I was relieved to discover my patient had finally succumbed to the inevitable. It would not befall us to have to torture him the next day in order that we learned some mysterious lesson.
I noticed my use of the phrase ‘call it’ a few times recently. It is something I saw on American TV and not at all something that is common in my neck of the woods. The sort of scene that you would get in gray’s when the junior doctor is pumping the chest shouting ‘I will not let you die, dammit!’ while the senior doctors stand one side and instruct him to ‘call it!’ is pretty foreign to our way of doing things. I even got ragged a bit for using the phrase at all. I thought I’d relate a story from days gone by that illustrates this point.
