the theater cap

"bongi, i have a patient who came in last night with appendicitis. can you operate him for me?"

my colleague was known to load shed and mostly i didn't really mind. that day, however, i just didn't feel like any extra work, so it took a bit of effort to fake enthusiasm.

"sure! any time." i lied. "anything special or straight appendicitis?"
"well, i saw him two days ago, but he refused operation, so he might be a bit sick." i knew what that meant. a bit sick was surgical talk for 'good luck pulling this one through'. oh well, a challenge at least.

the patient was a young man of about 27 years old. despite the fact that he was clearly in pain he still was a striking individual. he was alert and interested in my analysis of the situation. his questions were to the point and demonstrated deep contemplation about his situation. his eyes sparkled with life and potential. he touched a chord in me and i felt for him, despite the fact that he had refused an operation a day or two ago that was clearly necessary. when i examined him it was clear that he needed surgical intervention, but his pain was no longer located just in the area of the appendix, but it had spread more diffusely through the abdomen. i decided that a lower abdominal incision would be better to fully address all potential problems.

"doc, i like your cap." we were pushing him towards theater. i was wearing one of my genuine sutured for a living caps that i always wear when i'm in theater. i smiled. this sort of small talk i took to mean that he had resigned himself to the operation and was simply trying to distract himself.

"thanks." what more was there to say?

"i would love a cap like that." there didn't really seem to be anything to say to that, so i just kept quiet.

quite soon the patient was asleep and we got to work. when i opened up the lower abdomen, a thick, suppurating appendix protruded through the wound in an apparent attempt to escape from the septic abdomen that it had actually been the cause of. it had clearly burst. i smiled to my assistant.

"looks like this is going to be easy. whip out the appendix, rinse the abdomen and home free." sometimes i wish i would learn not to tempt fate with idle talk. i mobilized the caecum. and that's when i realized something was wrong. it was an appendicitis, but it wasn't caused by a stone in the appendix lumen or thickening of the lymphoid tissue in the wall. there was an obstruction in the base of the appendix but it took the form of a hard mass that had broken through the caecum and infiltrated the abdominal wall. what we actually were dealing with was a colon cancer that had incidentally caused an appendicitis. to remove the appendix simply would not suffice. i had to be aggressive.

i removed the right side of the colon with its blood supply and lymph nodes, taking a sliver of the abdominal wall along in the specimen. yet i already knew that the cancer had probably spread throughout the abdomen along with all the inflammation when the appendix burst. that would by necessity be something for the chemotherapists later. right now my priority was to do the best i could and get him healthy enough to withstand the onslaught of the chemo drugs.

the rest of the operation went as can be expected. i stuck the necessary pieces of intestine together, rinsed, placed drains and closed. the patient did well post operatively too. of course i still had to tell him that he had a cancer and not a simple appendicitis. that was not fun. i also involved the chemotherapist as soon as the histology confirmed what i already knew. finally i discharged him and left the rest to the chemotherapist.

many months later as i was walking down the corridors i happened to run into that same chemotherapist. i hadn't heard anything about the patient so i decided to ask how it was going with him.

"well, bongi, despite my advice, he refused chemotherapy and jetted himself off to china for some sort of experimental therapy where they place radioactive beads in the bed of where the cancer was. i wish him all the best but i don't think he is going to get all the best." i was upset. in a sense it wasn't actually too surprising. after all he had initially refused surgery by my colleague. he did seem to be a bit of a free thinker, even to his detriment. maybe this stupid stubbornness was one of the things about him that made me like him on some level. still i knew he had decreased his odds dramatically and it did upset me. i felt like a young promising mind was about to be cut down and there was nothing i could do. it was as it was.

i had just about managed to nearly forget the man when, once again, walking down the main passage of the hospital, as my chemo peddler walked past he gave me some news.

"guess who i admitted last night with a malignant obstruction?"

"an obstruction? do you need me to operate?" it was grasping at straws and i knew it, but i had to ask.

"bongi, the scan shows masses throughout the abdomen and almost his entire liver is just one large metastasis. i think we are deep into the palliative stage of his treatment. an operation might actually be a form of active euthanasia." and then the words dried up. it was pointless telling each other how tragic it was that such a young man was doomed. it wouldn't help to wonder how the course could have been different if he had taken the chemotherapy when there was still a chance. it was even more futile to wonder what would have happened if he had been operated earlier or, better yet, presented earlier somehow. in the end we just walked away from each other. no words would suffice.

yet, although i could walk away from my colleague, i felt i could not just walk away from the patient. i couldn't help him as a surgeon, that i knew, but maybe i could do something else.

when i walked into his room carrying one of my very precious rlbates theater caps and presented it to him as a gift, there was surprise in his eyes. but there was something more there too. his eyes still sparkled, but most of the life had already been drained from them. his body was just the frame of what it once had been but in his eyes i could see gratitude. when i left, there was a smile on his face. i hid my face from everyone as i walked out of the ward.

two days later he passed away. it was a small gift but, maybe in that stage of the battle we call life, the gift of a smile is really not that small after all.

in the dead of night

after having spoken about when you seem to know more than your consultant, i was reminded of another incident from my internship year where a colleague of mine taught me that sometimes it is best to do certain things under cover of darkness.

the patient (a sangoma) turned up at the surgery clinic one day. my colleague asked her what the problem was. without uttering a word she lifted up her shirt to expose her breasts. the left one had a massive tumour that had fungated through the skin probably some time ago. there was a large stinking cauliflower-like mass with central ulceration that caused a fist sized cavity right up to the chest wall. the smell was also remarkable. we couldn't help asking why the patient hadn't sought help earlier, especially seeing that she was supposed to be a so called traditional healer. i mean you didn't have to be a rocket scientist to know that that stinking monstrosity growing right through the chest was not supposed to be there. she simply said that it hadn't been painful, but now she had a cough.

my colleague knew what to do. she would refer the patient to the academic center in bloemfontein in the morning, probably for palliative radiotherapy. to make sure everything was up to date, she took a chest x-ray. it was so impressive she showed it to me. the breast cancer had grown right through the chest wall and had infiltrated the lung below. that is what caused the cough. it was a truly amazing case of neglected breast cancer.

then the cuban surgeon strolled in. this was the sort of thing you just didn't see in cuba. their health system is just too good for something like this to slip through. i suspect they don't have the sangoma problem we are burdened with so on the whole there will be less late stage sicknesses presenting. he was clearly astounded. then he said something that confused both my colleague and myself.

"put her on tomorrow morning's list for me to do a debridement." we looked at him in amazement. my colleague whipped out the x-ray, assuming that after seeing it no sane person would want to put a knife to that thing. i mean where would you stop cutting? in the lung? he looked at the x-ray casually but said nothing.

"you still want me to put her on your list tomorrow?" asked my colleague with more than just a hint of sarcasm in her voice.

"yes." we glanced at each other. maybe there was something we were missing. my colleague entered into a lively debate with him about the rationality of what he was demanding. anyway it was not my patient and i had other things to do so i left as the level of their discussion escalated. i did not envy her position in that she was being asked to do something she knew was not a good idea by any stretch of the imagination.

the next morning i ran into my colleague. she had a broad smile on her face and a somewhat mischievous glint in her eye. obviously the resolution of the matter had been to her liking.

"so," i asked, "did he finally see the light and drop his mad idea?"

"no." she said. the smile didn't falter.

"then what happened?"

"well i was on call last night. so as soon as the sun set and our illustrious consultant went home i bundled the patient into an ambulance and sent her off to the academic hospital. when he got to work this morning the patient was gone. there was nothing he could do." the smile took on an almost sinister look. i was impressed.

years later i employed a similar strategy, but maybe that is better left for another post?

the last goodbye

this is a story i considered not telling. somehow it comes too close to how we deal with the constant tragedy of life we are exposed to, both positively and negatively. then a post by buckeye reminded me of it.

the rotation through the military hospital was interesting in that the slog work was done by relatively junior doctors. that night one of them admitted a patient with abdominal pain. to be honest i didn't pay too much attention in the handover because he was admitted to another firm and that consultant would surely handle whatever the problem was.

late that afternoon, when the relevant consultant was no longer available, the medical officer of his firm asked me to evaluate the patient. the first thing that struck me was that the patient was in excruciating pain, yet his abdomen was soft. his face bore the deep grooves acquired from years of diligent smoking. his kidneys were going into shutdown and he was severely acidotic. i didn't even bother to check his phosphate levels. i had a good idea what was wrong. i called theater. i also let my consultant know i was going to do a laparotomy and asked him to hang around a bit before he went home...just in case. he was one of the few that was both a brilliant surgeon and a brilliant person. i knew i could rely on him.

as i started the laparotomy i spoke to my intern about necrotic bowel. i even went into detail about the thrombotic type, the emolic type and the low flow type. then i still remembered all that detail. sure enough, as we opened, loops of dark blue to black bowel came bursting out of the abdomen. the situation was dire. we all went silent. the bowel was dead from the duodenum to the transverse colon. a resection seemed pointless. i went through the bowel again, more to give myself time to think. but the mesentry was also dead and the slightest touch tore it. soon i found myself trying to control a persistant slow bleed from the base of the mesentry, but every time i placed a stitch it tore through the very friable tissue. i started becoming nervous. i called for my consultant. it was after hours but i knew he wouldn't have gone home. he would be waiting to hear how the operation went. he was just that type of man.

sure enough, moments later he burst through the theater doors. he looked into the abdomen. i explained the situation of the bleed that i just couldn't seem to control. in the knowledge that he would soon take over from me, i felt much reassured. i continued to work at getting control.

after a while i wondered why he was taking so long. i looked up to see what the delay was. the consultant was helping the anaesthetist adjust his suction which seemed not to be working. i was shocked and amazed. but i did not dare say anything. i just thought that that wouldn't take too long, so i would just need to be patient. it did take long.

after what seemed like ages the anaethetists suction was finally fixed. i relaxed again. but once again i looked up to see the consultant not scrubbing! he was wondering around theater, not really doing anything. occasinally he would chat to the floor nurse or the anaesthetist or just check all sorts of irrelevant fixtures in the theater.
'why is he not scrubbing to help me?' i thought! and then it struck me. he knew there was nothing that could be done. he wasn't going to tell me what to do, but, instead was patiently waiting for me to make the call.

"there is nothing to do here, colonel" i said. i think the corner of his mouth lifted in an almost smile.
"yes, bongi, there is nothing to do."
"should we stop now or close and send him to icu to die?" i asked. we did have a bed in icu organised.
"i think you can stop, but it is up to you." said the colonel.
"his family didn't get to say goodbye," i said, "so i'm going to close and see if we can get him to icu alive."
"ok." and then he left.

we got him to icu on high doses of adrenaline. the anaesthetist was annoyed with me. he felt it was a waste of time and resources. in a sense it was, but i felt it was the right thing to do.

once we had settled him, i went through to the waiting room to speak to his wife and son. i explained the situation. the wife asked me what his chances were. i told them he had no chance and would probably not see the next day. the son then asked me why, if it was pointless, had we closed and taken him to icu rather than just let him die in theater. i explained, as honestly as possible, that it had been my call so that they would at least have a moment with him to say goodbye before he died. the son was furious. i actually thought he was going to physically attack me. he did verbally abuse me quite a bit. i wonder what his reaction would have been if i left his father to die in theater.

after all the drama had subsided the doctors involved took a few moments to unwind over a cup of coffee. i remember a dentistry student who was doing her anaesthetic rotation. it was her first night with any form of clinical exposure. i wonder if she needed therapy afterwards.