September 6th, 2009 by Dr. Val Jones in Health Tips, True Stories
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Today an elderly physician friend of mine woke up with some very mild abdominal pain. He is a stoic man, and never complains about anything – not even the pain associated with a dislocated/shattered hip and multiple bone fractures from a car accident (he was very nonchalant about that event 2 years ago).
So when I heard that he was going to see a doctor about his belly pain – I knew that something serious was afoot. His doctor ordered an abdominal x-ray series, noted a tumor, and sent him to the O.R. within the hour.
In the O.R. the surgeons found a perforated colon (it must have ruptured minutes to an hour or two prior) without signs of peritonitis. There was a cancerous mass (without metastases) that they were able to remove completely. They washed his peritoneal cavity extensively to remove all fecal matter and potential cancer cells and transferred him to the ICU for observation overnight and IV antibiotics.
So far it seems that my friend will make a full recovery – and there is no evidence of remaining cancer, though we’ll need to be vigilant with follow up.
I can’t get over how lucky he was to have discovered the perforated colon within hours of it occurring, that the surgeons took care of him immediately, and that the cancer seems to have been contained and removed. I don’t know if his “luck” was partially due to his physician’s intuition about his own body, professional courtesy extended to him by peers, or that the Canadian healthcare system is not as burdened in his part of the country (Nova Scotia) as it is in others where there may be longer wait times.
All I can say is that my friend is one lucky Canadian!
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 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 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 15th, 2009 by KevinMD in Better Health Network
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A 90-year old man with a pancreatic mass, almost definitely pancreatic cancer, was admitted to a hospital.
Surgeon Jeffrey Parks does the initial surgery consult on this terminal case, and recommends hospice care.
The next evening, he’s shocked by the “astounding amount of medicine [that] had been practiced” during the day:
Consults had gone out to GI, oncology, and nephrology. The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.
It’s often said that we spend the most money in the world on futile care, often with little benefit to the patient. The preceding account was that phenomenon in action, replicated thousands of times on a daily basis.
A microcosm of what’s wrong with American medicine indeed.
*This blog post was originally published at KevinMD.com*
