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Waiting To Die

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 known to kill most of its victims thirty years younger than him. The chances of him surviving the operation were dismal. I called my senior. Read more »

*This blog post was originally published at other things amanzi*

Drug To Treat Spider Veins: Asclera Now FDA-Approved

The FDA recently (March 2010) approved Asclera (poliocanol) injection for the treatment of small spider veins (tiny varicose veins less than 1 millimeter in diameter) and reticular veins (those that are 1 to 3 millimeters in diameter).

Asclera is a detergent sclerosant and produces endothelial damage through interference with the cell’s surface lipids.and acts by damaging the cell lining of blood vessels. This causes the blood vessel to close, and it is eventually replaced by other types of tissue. Read more »

*This blog post was originally published at Suture for a Living*

Saving Murderers In South Africa

Being South African these days sometimes means we see things in a slightly skewed way. It seems to be the way we have become. I have touched on this before, but there is another story which illustrates the point.

The recent run of hijackings were fresh in all our minds because the perpetrators had shot and killed, execution style, a mother and her three year old child just the previous week. There were reports that one specific gang was working the area and were responsible for most if not all the hijackings and associated killings in the area. So when our patient came in, even before the police told us so, we just assumed he was one of this gang. Read more »

*This blog post was originally published at other things amanzi*

Breaking Bad News To Families Of The Departed

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*

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Latest Book Reviews

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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