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*
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*
July 27th, 2009 by DrWes in Better Health Network, Health Policy, News
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Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.
I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it’s more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.
So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technology cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deleterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multi-center trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won’t be, will it?
Probably.
But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?
Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.
Now that might make for some really interesting reading.
*This blog post was originally published at Dr. Wes*
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!!!
