The Ultimate Examination.

I like to think of myself as a pretty practical person. I also believe that there is always a better, more efficient way of doing things out there ... I just have to find it. Tedious time-consuming tasks drive me crazy. Rules and regulations exhaust me. Boundaries and limits just freak me out. But with advancing age, I slowly seem to understand the logic behind all these things... or so I think ...

In my early registrar years, "the system", drove me insane. I was so sure that it could be done better, faster, and more efficiently. In retrospect, if there was any such possibility, the prof and co, would've implemented it! Ah .... the ignorance of idealistic youth ... But still, I hated the endless waiting and inefficiency, that often ruined my days.

Cutting time was 8 o' clock. Morning meeting was 7 o'clock. In the beginning, I tried my best to miss the morning meetings. They were false and scary, and not the greatest way to ensure good karma for the rest of the day. Plus I could sleep an extra half hour!! In those days it still mattered how much sleep I got. I was young and in pretty good shape, so yes dammit ... sleep was good.

If all calculations were done correctly, I had to be in theatre at the latest 7:30. Had to queue up for my drugs, then prepare for the first case. Didn't take too long if you were the only one in the queue, but by then, the morning meeting was over, and a mad rush for drugs and equipment ensued.

So, I got smart. Instead of queuing for drugs everyday, I queued up once a week. Saved myself hours every month. By drugs I mean schedule 7 stuff like morphine, pethidine and other opioids. Stuff that susceptible individuals could get hooked on. Thank the Lord I never had any such issues. We had special drug sheets where everything we used on patients was written up and checked. The sheets looked so old and forgotten that I often wondered if anyone ever actually checked them.

Got my answer soon enough...

We also had a huge restroom, with 3 beds, an almost fully equipped kitchenette and a TV. When it was quiet we'd all sit around there socialising and drinking coffee. Initially I did a lot of calls and every chance I got I would lie down on one of the beds and try to catch up on some sleep.

A couple of months down the line, I had perfected my own personal little system. Half way through my list that particular day, I got a message. The prof wanted to see me in his office ... STAT.

STAT ... well ... that didn't bode well, but I couldn't for the life of me think of any serious screw-ups I'd made. A senior colleague watched over my case as I walked into the lion's den.

The prof ... and his very clever, and very attractive right-hand consultant. I do believe I have mentioned this guy before. Both looking at me very intently. My drug sheets were spread out on his desk, and suddenly I knew, my little system had been discovered! Phew!! Nothing serious after all, so I promptly relaxed.

Five minutes into the interrogation, and my stomach was in knots. Why, where, how, when, how much, what??????? It felt like I was on some kind of trial! They suspected me of drug abuse!!! Over and over I explained my system, how I tried to save time in the mornings and miss the rush. Nothing. That I was lazy and wanted more sleep. Nothing. Look at the sheets I urged them, I collect just enough for one weeks worth of cases, nothing more. Surely if I was using it myself I would be taking a lot more??? Still nothing. I couldn't believe these guys. I'd thought I was reasonably liked and respected in the department, little did I realise that they had been watching me for all this time. And this was their conclusion!!! Every time I lay down, they thought I was drugged!! It was ridiculous and unthinkable, they really didn't know me at all.

I knew I had nothing to worry about. My sheets were correct and I kept all my anaesthetic charts, so on paper I was clean, but that was part of the problem. Most druggies always were ok on paper, everything always added up ... They would have to do some checks prof said. Ok sure!! Blood tests, urine samples, anything, no problem!!

Well first we need to check for any puncture sites - at least you never wear long sleeves or multiple layers beneath your scrubs. So lets go please ... upper body first, then lower body, including feet.
What like a strip-search??? Here and now??? Basically. Why do both of you need to check??? The prof was old enough to be my dad, but the younger guy, well ....
Witnesses are necessary for the report. Geez, this was getting worse and worse!! Firstly I needed to get practically naked before my boss and his side-kick. Secondly at that specific point I couldn't remember what underwear I was wearing. Thirdly the allegations and reports sounded pretty serious. Fourthly, I was innocent.

I tried for humor. Come now prof, you can't be serious? I'm ok and I don't do this kind of thing, really! A detailed explanation and I knew where I stood. They were the only two in the department who were aware of this issue. They didn't believe that I was guilty, but well one never knows and I had to be checked out. Apparently they'd had two positive cases in the not too distant past. They were just doing their jobs and if I hadn't been trying to cut corners, none of this would be necessary. I had the right to involve someone else if I wanted to, but they could do the examination, clear me of all the nonsense and nobody would be any wiser. At least I was given the choice. This was not a case of the more, the merrier ...

I whipped off the scrubs, turned this way and that way till they were satisfied. My underwear matched, but luckily they didn't seem to notice. It was over pretty quickly and obviously I had passed the test, flawless, unpunctured skin. Thank you Dior. The atmosphere was much friendlier suddenly. Ok, now go lie on the bed in the tearoom, have some coffee, and collect your drugs daily like everyone else.

I learnt a valuable lesson that day, and they were fortunate to be graced with my pre-pregnancy body. Otherwise both parties might have been scarred for life.

Two for the price of one.

It was a midnight c/section. Baby was four weeks early. Mom was HUGE and in labour.
Dad was making jokes....

C/sections have really come a long way in the last couple of years. An elective one can almost be compared with a visit to your favourite spa or salon these days. The appointment is made on a day that suits you, Dad is allowed in, they play music of your choice, it gets videoed & photographed, mom's hair is freshly highlighted, she has a french-manicure, make-up is impeccable etc etc ... and the doctors make jokes. All that's missing is the glass of chilled chardonnay ...

The ambiance of a midnight c/section depends on the collective personalities. The majority of the medical species, suffers from the cinderella syndrome, ie, we lose it after midnight. We do try to cover it up during normal working hours, but one has to bear in mind that we are not exactly normal to begin with.

On this particular night, everyone was pretty jovial and jesty. Dad was exceptionally manic. An extra-ordinarily big guy, he proudly informed us that he himself had weighed in at 5.4kg! (Sadly, his mother didn't have the luxury of a c/section). To give you an idea, I judged him well-over 1.9m and about 120kg. He was rock-solid, but not in the steroid-infused-body-builder kind of way. Obviously a sportsman of some sort. That's why poor Mom looked like a beached whale ... their offspring was genetically enhanced in size. I was grateful on her behalf for the four weeks worth of discount. I eye-balled him, and asked if he was of the fainting sort ... I have always been slightly fascinated by these incredible hulk type of guys, but the thought of this particular one falling on me, was not in the least fascinating. He was offended by my question, but I explained that I routinely asked all dads, and I told him to rather fall to his right, as falling to his left would seriously cramp my style. I didn't need that!


The procedure was going well. When it came to delivering the little mini-me-hulk, the surgeon gave it one shot then reached for the forceps. A reasonable choice considering the prior discussion regarding baby sizes. Well Dad didn't quite agree. One look at the forceps and he started swaying. Now my first priority is Mom, but suddenly I was worried about Dad. In the three seconds it took for me to get to him, he'd totally flaked out. His head hit the ground from a height of about 1.6m ( he was sitting in my chair), in just under three seconds. No serious physics needed to figure that the impact was, sort of impressive. The resounding thud was remarkable, and of course ... he fell to the left.

There were a few technical dilemmas at this stage. One, he was in my way. Two, he was a dead-weight lying at an awkward angle. Three, he was unconscious and bleeding. Four, everyone else was busy, so only I was free to attend to him. Five, I still needed to keep an eye on Mom.

I just about shattered a disc getting him into the rescue position. He was more than double my weight ( using ideal body mass of course). Quick check: he was breathing & had a pulse, but had a serious forehead laceration and his tongue was bleeding. Some suction to clean up his airway, some oxygen for good-will, a pressure dressing for his forehead, and some ice for his tongue. A few slaps on the cheek to help him catch a wake-up ... and voila!! Dad was back!!! A little worse for wear, but nevertheless stable.

He was firmly shooed out of theatre and straight to casualty where he was promptly X-rayed and sutured. At least that was the end of him I thought to myself.

But about ten minutes before the end of the procedure, Mr-not-so-incredible-anymore, was back! Patched-up, and I quote, " good as new". Well by now it was way past midnight, and all fairytales were over, and all gloves were off! The poor guy was ragged senseless, he probably wished that he'd had the sense to just wait outside! I have never seen a guy that size blush. Although it was probably embarrassing for him, to me it was a great improvement on ghastly pale ...

Eventually we took pity on him, advised him to go via admissions next time he felt like some treatment, and congratulated him on his remarkable ability to create a 4kg prem.

My first loss ..

Ten years ago , on May 5, I was a fresh young registrar of 5 months, with a recently acquired Diploma in Anaesthesiology. My confidence was boosted by my success and I was starting to feel as though this weird and wonderful job, could, perhaps, just work for me.

Although I now adore my work, I am the first to admit that I was by no means a natural-born doper. I had no idea what I wanted to specialize in, but knew that a GP practise was out. My initial objective for joining the anaesthetic department was purely personal. For one, I had heard that the hours were not too bad, and most importantly, I needed to overcome my fear of anaesthesia. How ironic is that?? Scared, with a touch of laziness! Anyway, I figured that doing it over and over on a daily basis for a year, with a professor or two breathing down my neck, would do the trick. When I passed the Diploma exams, it just sort of went without saying that the degree would be next.

The day I signed my reg papers the prof pulled me aside, welcomed me to the task force and said, " 5 in 5 years." Needless to say, I misunderstood as per usual...
Well, I do love children, but 5 in 5 years whilst specializing was like begging to be institutionalised, or even worse, pure suicide!!
I was promptly corrected, " 5 DOTT's " .... Death on the table ...

My worst fears were confirmed, this species really was alien, and totally nuts, and I was signing up to join them!!! Was I nuts??? I was expected to kill 5 people in 5 years?? What about that wierdo Hippocrates??? What about my mental health??? What about being able to sleep at night??? What about getting out of this 5- year- stint in the same condition I got into it???

Some of my what about's must have been visible. No good to show a weakness, but hey, I never bragged about any superhuman powers. He explained. The only way to learn how to deal with the inevitable DOTT, was to actually experience it a few times. 5 Times seemed reasonable, it could be more .... but be assured, he said, it would happen.

Well, with the formalities out of the way, I pushed that conversation to the furthest recesses of my mind, and got on with my training. No point in harboring crap thoughts.

Back to 5 May....

I was blessed with the paediatric orthopaedic list. I was excited and ready for it!! All paeds lists were supervised by a consultant, so although I wasn't alone, it was still my list and I was responsible for all the preparations. The first case was a 5 month old baby for bilateral clubfoot manipulation. He weighed 5 kg. Anyone who has ever had a kid could tell you that at 5 months no baby weighed 5 kg unless it was seriously premature at birth. This one wasn't.

The theatre was prepped to perfection. From ambient temperature, to warming mattress, tiny paediatric equipment, all drugs drawn up, diluted to accommodate the child's weight, and clearly marked, warmed bubble-free infusion lines ... everything was exactly right. Even emergency drugs were drawn up and ready for use. I felt proud, and confident that the consultant would be satisfied.

With a skip in my step, I walked over to the mother and took the child from her, assuring her that the procedure wouldn't be long. I put him on the nicely warmed theatre table and he just lay there, looking around, but not moving. No premed had been given. He was soooo comfortable I thought to myself. I had definitely prepared well. Once again, anyone who's had a child knows that no 5 month old lies so utterly still without arms and legs kicking in all directions. Especially having just been taken away from their mother. I didn't have any then, so what did I know? The consultant arrived, and we started the inhalation induction. Unfortunately, in those days, sevoflurane was still scarce and expensive so we made do with halothane. Within minutes the IVI was up and running, then I intubated the little fellow with no difficulty at all. It felt good.

You are not in. No end-tidal CO2. You are definitely not in.

The gas we humans exhale is CO2, and by measuring it after an intubation, we confirm the correct placement of our endotracheal tubes. Because the entrance to the trachea and the entrance to the esophagus are in such close proximity, and even more so in little babies, it is possible for the tube to go down the wrong pipe, thus blowing air into the stomach instead of the lungs. This classifies as an anaesthetic disaster. End-tidal CO2 is also a very sensitive indicator of cardiac output. No cardiac output - no life.

I most definitely WAS in, I saw the tiny vocal cords, there was no way I wasn't in. But now was not the time to argue. I stepped aside for the consultant, a very well-respected and highly intelligent anaesthetist. Within seconds, he re-intubated the child himself. Still no end-tidal CO2. Heart rate was good, ventilation was good, but no end-tidal CO2. The consultant appeared totally calm, but a few beads of sweat had broken out on his brow, something was wrong. Horribly wrong.

Without being told I began administering the emergency drugs, closed the anaesthetic gas, gave 100% oxygen and sent the sister to get help. An intense resuscitation followed, probably the most intense one I have experienced to this day. Theatre 8 exploded with a flurry of activity. When things go wrong, the news spreads faster than the speed of light, and help appears out of nowhere. A reg was appointed to keeping time and recording everything that was being done. Another was appointed to cardiac compressions, another to the airway, another to all IV administrations and a last one was used as a runner. The professor himself, together with the consultant, was in charge. Even the orthopods helped.

One hour and forty five minutes later, the baby was declared dead..... DOTT ......

How could such a perfect day end in such a tragedy?? I was shattered, totally totally shattered. I felt a million things and absolutely nothing all at once. My life flashed before my eyes while I wondered what the hell had gone so wrong. Walking back to that mother, empty-handed, was one of my most horrible experiences. I was sent home that day ...... Sadly the post-mortem yielded no answers, and after expert investigation, the cause of death was given as halothane- induced cardiac suppression.

I still don't know why I didn't quit anaesthetics that day - God knows I wanted to - but the next day I was back at work, and the next, and the next ....
Out of the obligatory big 5 as I later began to call them, that first one was by far the most traumatic. I couldn't look at a baby for months afterwards without feeling ill. I have never used halothane again, no matter how expensive the sevoflurane. I'm particularly sensitive to paediatric cardiac patients whose stories more often than not, don't have happy endings ... and ...
I have not taken a child from it's mother pre-operatively since then.

Double lumen delight.

The correct placement of a double lumen tube brings a level of elation that's difficult to explain. It's not that it's so hard to place, it's just that you have to get it exactly right, or there is no point.

A double lumen tube is basically two endotracheal tubes rolled into one. It is used to ventilate either the left or right lung in isolation, or both lungs independantly of each other.
What could be cooler than that?? I'm sure some would say, small things amuse small minds, but there you have it ... a double lumen tube really excites me!! The down-side is that more often than not, they are accompanied by sick patients, sick lungs and major surgery ... but for now we'll stick to the bright side.

I was fortunate enough to have a very patient and down-to-earth teacher, so where double lumen tubes sometimes strike fear in the strongest hearts, for me they are an absolute thrill. An integral part of placing the thing, is the use of a fibre-optic bronchoscope to confirm correct placement. Luckily, or unluckily, for me, training in deep dark Africa, a back-up plan is always far more important than the gold-standard which is usually not available due to lack of funds, lack of function, or lack of fingers with integrity. So I was taught another, extremely simple, yet well-documented, and basically fool-proof method of confirming tube placement and functionality.


Can't say I was surprised when I learnt that double lumens were not a big part of island- style living, but I was disappointed. Just another skill that would get lost at the expense of greener pastures.

Imagine my surprise when the bane of my existence ( a fellow anaesthetist), called, booking me for a right-sided pneumonectomy ( removal of right lung). I had introduced myself to him about ten months ago. He'd declined to shake my hand, and has never spoken to me.

After the call, I sat back and reflected ... This was good ... and ... this was bad.

Good was the fact that the chance to prove myself had finally come. A successful pneumonectomy, with a thoracic epidural, and lung isolation spoke volumes.
Good was the fact that I'd get to play the double lumen game again.

Bad was the fact that I hadn't done a lung in about three years, and very bad was the fact that I'd be working with an unkown surgeon, without any back-up. Oh, my colleague offered his support and services during his phone call, and I just thought to myself, WTF!!!!!

I sprang into action!! Arranged to meet the surgeon a few days before the case. We had a lovely discussion, familiarised ourselves a bit, and were in full agreement on how to handle the case. Then we spent a significant amount of time examining the patient together, and answering all his questions. I felt confident that things would be ok, and that the surgeon was decent. It does make a difference you know.

The case was booked for 9 am. At 8 am I put up all the IV lines, the arterial line and the thoracic epidural. A 8:50 the patient was induced and I picked up the pre-prepared 39F left-sided double lumen tube. My moment had come!!!!!!

I gently inserted the laryngoscope and started inserting the tube. There is a very specific way of doing this and I was concentrating. Next thing I knew, huge hands were roughly grabbing my tube and twisting it in such a way that my entire placement technique was totally screwed up!! The surgeon had shoved in the tube!!!!! And I didn't know what the position was!! I quickly checked, and of course it was down the right lung instead of the left lung.

I felt personally violated.


Always poised and professional, ( that's my policy) I politely told him to remove himself from the intubation process. He tried to argue. We agreed for me to have a go, and for him to do the cross-check with the option to place it himself if he was in any way dissatisfied.

With an audience made up of my esteemed colleague, the surgeon, the assistant, the referring GP, the scrub sister, all the junior nurses and runners in the complex as well as a fantastic anaesthetic nurse, who was being wasted as a runner, I proceeded to place my tube.
I made a huge show of checking the position and function, all the while praying that everything was as I expected it to be. I showed off my good - old confirmation technique to the full (thank you Sandy!!). Only once I was totally satisfied, did I beckon to the surgeon to perform his check.

Exactly two minutes later I got a wink and a hug. And exactly two days later I was given the option to dope for him on a regular basis.

Seems actions speak louder than words.

Aesthetic anaesthetics

In retrospect, I would have been a damn good beauty therapist. Always had a thing for a pimple. And zero tolerance for a blackhead. Learnt the four basic steps very early ... cleanse, exfoliate, tone, moisturise. And soon after, the fifth very vital step. Sunblock, sunblock, sunblock.

As a kid I would scrutinize my family's faces. Any blemishes were totally unacceptable and all attempts were made for instant eradication. The only problem was that they always bitched and moaned. This would so upset me! I would dream of giving them some potion to get them to zip it and lie still so I could do my thing properly and in peace. Perhaps that was the tiny subconcious seed which led to my walk down anaesthesia lane many years later? Who knows....

I only truly realised the potential of a mute and immobile subject in my second year of medical school. Anatomy dissection. You either willingly donated your body to science, or science claimed your body if nobody else did.

Our cadaver was a middle-aged hobo, found on the streets. It's sad I know, but at least he had company for a whole year. Five of us sat around him for hours everyday, chatting to him and learning from him. We even missed him over weekends.

One such day, we were dissecting the foot. I got bored. Only so many bodies can sit around a foot, so I moved to the head for a break.

I looked down at his yet undissected face and wondered about him ... his life ... the family that hadn't claimed him.... Without even realising what I was doing I ran my gloved fingers over his face. Almost in a formalin-induced trance, I gently began extractions on skin which had never been exposed to the five vital steps....

When I realised the magnitude of the subcutaneous muck, I grew bolder and more determined to give him the best facial ever. After all, he had given us his entire body, it would be the least I could do in return. No-one should ever have to leave this earth without experiencing a decent facial. Plus, and this was a major plus, he didn't complain.

The foot with its tendons, nerves and arteries became a distant haze, as I concentrated on the task at hand. To this day 'tis the body part I know the least about ... the foot ...

I barely registered the horrified reaction from my mates, and when they insisted upon my "getting help", I realised. They just didn't understand, and never would.

I managed to sort of suppress my aesthetic urges for some years, but they surfaced with a vengeance in my second year as an anaesthetic registrar. It was 3am, we had been busy with a vascular case for a number of hours and still had a few hours to go. Some silly teenager had put both his fists through a glass panel and severed just about everything ... tendons, arteries, nerves ... a full house.

He was healthy and cruising, steadily. I was falling asleep.

In an extremely weak moment, I put my head down on the pillow next to his, just for a second mind you ... but that was all it took.

Zits galore!!!!!!

My sleep-fogged mind went on instant alert as I formulated my plan. A pair of sterile gloves, a pack of sterile gauze, some hibitane scrub, followed by hibitane in alcohol, and finally chlorhexidine cream. Perfect!

I surreptitiously got to work. Luckily both the floor nurse and runner were too busy fighting the powers of unconsciousness, to pay any attention to me.

Pop after pop, sleep was forgotten, the length of the operation was forgotten, all that remained was the multitude of zits in differing stages of development, and the sounds from my monitors. Two and a half hours!!! That's how long it took to clean his face! Two and a half hours of intense facial therapy, and absolute BLISS!!! Antibiotics had been topped up intra-operatively so we were covered from that aspect too.

I thought he looked fabulous when I was done. Young, clean, fresh, with a beautifully glowing skin.
All the vital steps had been followed, down to the very last one. Yes, by then I was in the habit of carrying around some sunblock. So Mr Teen, got it all!! For free!! And it looked really good!!

As I was peeling off my gloves, the surgeon drily asked if the patient had signed consent for my procedure. What procedure I thought?? This was a duty to humanity, not a procedure!
Nevertheless, I felt nervous enough to visit the patient the next day. He thought that perhaps anaesthesia must agree with him, cause his skin had so miraculously cleared up. I left it at that.

With no complaints to date, years down the line, I tirelessly continue to fulfill my duty to humanity. And enjoy every second of it!!

Turning Tides

For the past eight months, suffering in silence, is an understatement for what I have been experiencing. Holding my tongue has been difficult, but lashing out at an unknown entity would have been just plain stupid. Also I am the alien amongst the masses, carefully searching for my little spot in the sun, so perhaps it was wise to shut up, and observe. You know ... silence is golden .... and all that, blah blah blah ...

I've become quite the expert at quiet observation I must admit. Hopefully it's a virtue that will serve me well in the future, although I probably come across as a total spineless idiot to all the other drama queens and prima donnas I call colleagues.

Lately, the pieces of the puzzle have been slowly starting to fall into place. I am beginning to understand them. It's exactly the way I felt when I finally grasped the dynamics of Kalafong!! Strange ... ander dam se eende ... but I finally get it, sort of.

They are what they are, and that's it. No more, no less. And quite frankly, I don't give a rat's ass ... anymore.

So it is with this much lighter and much less sensitive heart, that I take myself off to work each day. My neon pink theatre shoes could give vision to the blind they're so bright, and add all the zest my day could possibly need.

Another such day in paradise, and I'm doing premeds. Good thing premeds are done in the mornings, when we still look fresh with freshly applied make-up, shiny lipgloss, and presentable hair! Once that theatre cap goes on, it's tickets for the day's glamour. Not to mention our scrubs, even the crappest fashion house's worst nightmare.

I'm having a conversation with my patient in my much-improved greek. Yep, much-improved. The husband keeps interrupting, answering my questions and generally being an irritation. I so hate it when people do that. I finally decide enough is enough, and look up at him trying to figure out the best way in which to explain that he should butt out, when he takes off his mirror-finished shades.

Ok, I think to myself, here it comes ... and I doubt whether my shiny lipgloss will be of any benefit.
I am a lawyer. Now, in this place a lawyer is something akin to the Father, the Ghost, and the Holy Spirit. Apparently the doctors too ... but I wouldn't know ...

I specifically requested that you be my wife's anaesthetist today.

Get out of here!!!!!!!!!!!!! I almost choke trying not to laugh!!!!!! I am dr anonymous!! Nobody knows of me around here???!!!

How is that I ask?

You come highly recommended by my colleague Georgos. You did him a few weeks ago and he told me to ask for you.

Georgos??? .... Georgos ... ah .... Georgos ... another lawyer ... I thank the Lord for the Omega 3 fish oils and Advanced brain food supplements I've been taking - I actually remember Georgos! The guy that considered me a Romanian. According to his expert knowledge I look and sound Romanian??!! I opted to take his comments as a compliment.

And where did you put in this request? I called the surgeon and told him it was you or no go.

Well, how I wish I could have been privy to that conversation!! Could the tides finally be turning?

I laughed out loud all the way back to theatre. And quietly to myself for the rest of the day!

Decisions decisions...

Huge, round, imploringly innocent, brown eyes turn to mine... Please, please... they beg me silently. Oh man ... the desperation is almost tangible.

A thrombosed haemorrhoid, a warm breezy saturday afternoon, a busy busy stomach happily digesting away at one hour ago's lunch ... a discomforted over weight patient, and a desperate surgeon.

All eyes on me.

As far as I am aware, surgeons encounter the term ASA at some point during their training. Ok, they may not be aware of the full implication of those three letters, but they hopefully get the general idea.

ASA is the American Society of Anaesthesiologists. A bunch of people who spend years and millions doing research, developing protocols and safety guidelines regarding the administration of anaesthesia. Then they are kind enough to print and bind all that excess knowledge, and distribute it world wide. Of course, whether we choose to use the info or not, is totally our prerogative.

The cool thing is, that although the safety of the patient is put above all else, the safety of the anaesthetist somehow gets all tangled up in there too. So ... if the patient is safe - it's almost a given that the doper is safe. If the patient is in trouble, all eyes fall on the anaesthetist first.

Perhaps you can see why we adhere by the ASA guidelines as much as possible. It's in the best interest of everyone involved. Even the surgeons, although they don't always see it that way.

Latest guidelines regarding pre-operative fasting stipulate NPO x 6 hrs for solids, NPO x 2 hours for clear fluids. As always there are stipulations for specific cases, eg certain patients benefit from getting carbohydrates pre-op etc etc. But in general the 6 hrs / 2hrs rule applies.

Also, we are not unreasonable. The problem of theatre time and long lists is fully understood, time is money after all. More often than not, a case is individualized. We even try to find out exactly what was eaten. A clear broth or bowl of jelly for example, may, according to the severity of the case be categorized under the 2 hrs group. In an absolute emergency where time is life, we have our ways and means of doing what we must, without waiting. But it's not ideal.

Allow me to explain the reason for all this paranoia. Chemical pneumonitis is a type of pneumonia one gets when foreign chemical matter (ie food) finds its way into the lungs.
The treatment for this includes a stay in ICU, on a ventilator with a tube down one's throat, amongst other things. It doesn't happen often, but when it does, it can be rather scary.
With induction of anaesthesia, all smooth muscle tone is relaxed, and the patient can easily vomit especially if there is a full stomach on board. Remeber that the patient is asleep and can't spit out his puke. So if we don't suction it out fast enough, it simply flows into the lungs. Yuk!!!!!!!!!!!!!

Back to the saturday afternoon dilemma. A chubby patient, with an extremely sore bum, satisfied himself to his hearts content, then got up from the lunch table and drove himself to hospital. ( Must have been one hell of an uncomfortable ride!)
The surgeon, desperate to get it over with, making bambi-eyes at me and promising the procedure to be 5 minutes only. Just a bit of propofol please???

All eyes on me.

Do we go ahead or don't we??

Let's see ... sore bum plus 5 hour wait, with all our asses covered vs fixed bum plus aspiration and a 5 star ICU retreat.

I know what I chose. What would you choose???

The weakest link.http://www.blogger.com/post-create.g?blogID=2171259283937982137

I have mentioned this woman before ... but this was the last straw.
It's eight months down the line, and well to be honest, I'm feeling more despondent than ever. The more exposure I get to them, the more wary I am of my new colleagues. Often I wonder if they feel the same way...
Making new acquiantances is like a walk in the park for me, making true friends on the other hand takes me years and years. It's how I am, and although it makes a quick settle quite difficult, it's a trait I don't think I could change even if I tried.
So although I walk solo, I still try to do my job to the best of my ability. I often feel as though I'm being "checked out", which makes me even more determined to be the best. I don't lower my standards, or settle for second best, or allow anyone to cloud my judgement. And I can be quite painful about perfection when the need arises.
Yesterday was a public holiday. I was on call. At 9am I got a call for an emergency c/section. By 9:30 I was scrubbed and in the process of doing the spinal, when my mobile rang ... twice in succession I might add.
It's a common occurence in the medical profession to "have your hands full" or your "mind full" for that matter. Thus being unable to answer calls.
I was just pulling off my gloves after settling the patient, probably about 5 minutes after the missed calls, when my phone rang again.
This time, I could answer. An extremely distraught and irrate colleague wanted to know where the hell I was. He had been called by an even more distraught receptionist claiming that the anaesthetist on call had gone AWOL. The best is that she'd even called the "head" anaesthetist, (who had taken a much needed weekend away with her family, and thus been rudely awakened), as well as my home ... only to be told that I was at work. Still no warning bells went off in her empty mind.
Anyone who knows me, knows that I'm never late for work, especially not for emergencies. The fact that there was even the need for me to explain myself out this ludicrous misunderstanding, really pissed me off. When he finally got the message, and realised that I wasn't lazing around, and "frolicking on some beach", but actually at work all along, he calmed down.
But for me, the damage had been done. Everyone had doubted me ... everyone had taken the word of the thickest, most incompetent, receptionist to ever walk the face of the earth. Perhaps for the first time since joining their workforce, I know where I stand.
I'm good enough to work through the night - no complaints. I'm good enough to do all those patients nobody else wants to touch. I'm good enough to dope for all those surgeons that nobody else wants to work with. I'm good enough to help out when others are tired.
I'm also good enough to be judged first, and questioned later.
It's true what they say about the strength of a chain ... one weak link and you're screwed.
Seems it really is each man for himself, after all.

Safety & Security

Something very strange happened last night.
I had to accompany an intubated & ventilated patient being transferred from our hospital, to an ICU in the capital city about 70 km away.

The ambulance was privately owned and state of the art, with all the equipement and gadgets one could ever need. I was at once impressed and relieved, as it would make the journey both interesting and safe.

On arrival, the paramedics threw open the doors, and facilitated the speediest admission I have ever witnessed ( the patient even had a sheet of printed stickers ready when we got to ICU!!). Then they proceeded to lead the way into the hospital.

But, to my utter amazement, they left the ambulance engine running ... with the doors wide open!!! Ok, it made for a very dramatic effect, with the lights glaring and all! There was also, certainly, a sense of urgency about the entire situation, but an extra 2 minutes to switch off the engine and lock the doors surely wouldn't have made that much of a difference? For goodness sakes, there was a lot of expensive stuff in there!!

Not to mention my work bag - in full view of anyone who might have the slightest inclination to look into the vehicle!!! I tend to always carry my bag with me, even for a transfer. It is an absolute work of art!! ( My bag that is). You will find anything and everything in there, from the most basic, to the most advanced, means of survival. I firmly believe that if I were ever stranded in the middle of nowhere, with my McGyver's Bag at my side, I would have nothing to fear. For the first 24 hours at least ...

It is a big hospital, so even at 10 o clock at night, the casualty department was quite busy. There were people milling about everywhere!! I tried to voice my concern to the oh-so -dedicated pair of paramedics now earnestly wheeling the patient towards the elevators, but was promptly reprimanded for worrying about such mundane matters at this crucial stage of the operation. Plenty of time for all those secondary isssues once the patient was safely handed over ....

Yeah right ....

All my life, for as long as I can remember, I have been conditioned to watch my back and lock things up. It is basically second nature to me. This blase attitude towards safety and security grates my nerves. God help them if we got stranded here, or even worse, if my precious bag got stolen ... I simply couldn't help imagining all the variations to the theme ...

Ambulance sans its wheels, (including the steering wheel). Ambulance sans its contents. Ambulance sans my bag. And well ... parking area sans the ambulance... After all, I know a place where, I kid you not, all of the above options are a part of normal, everyday life.

So imagine my surprise at finding everything exactly as we had left it! Even my bag was untouched!! And there were still loads of people all over the place!!

I guess that this is what Safety & Security really means ... even though I still struggle to comprehend it.

Theatre 10

Theatre 10 is ..... just that.

It's the 10th theatre in a complex, of, I forget how many, but lets say 15. It is situated in a corner, directly across from the catheterization lab, and if you are ever priviledged enough to get your hide through its doors, you feel it immediately.... The atmosphere is charged with a million little electrical impulses and there's permanently an excpectant air of anticipation hovering in that tiny space between the conscious and the subconscious.

It's the lions' den, the spider's web, pandora's box, call it what you like ... but the exclusive domain of the cardio-thoracic surgeons is like stepping onto another planet ... there are no rules, and it sure ain't for the faint hearted.

Now in the surgical hierarchy, it is common for the general public to equate a brain surgeon, to a rocket scientist. You know, the guys with an abundant amount of grey matter to spare. But contrary to popular belief, in the medical world, it's the heart surgeons, albeit a little less bright than the brain surgeons, who actually rule. Here, speed and balls, definitely outweigh brains and balance. This is most likely a self-appointed position, sort of like Robert Mugabe. So they blow their own trumpet, assume first place, and who ever doesn't agree ... well doesn't deserve the oxygen he breathes, and is invited to donate his heart to research.

At times, one can almost understand it ... there really is a huge weight on their shoulders. So if believing that they are Hercules makes it easier to carry, so be it. Imagine taking a sick heart into your hands, stopping it, fiddling with it for a couple of hours, putting it back, kick-starting it, and expecting it to take up right where it had left off. Perhaps I too would imagine that I could walk on water! The fact that an entire team is bubbling away beneath the surface to keep their sorry asses from submerging, is totally irrelevant of course.

Be that as it may, oozing confidence can only be a good thing. So ... you either beat them at it (which is virtually impossible), or join them. A sink or swim ... oh sorry, walk on water ... situation.

Even as an anaesthesiologist, the satisfaction gained from a succesfully sorted out stabbed heart, is hard to beat. The speedy preparations, the barely controlled urgency, the joint efforts on numerous levels, take about 5 years off your life, but the thrill ... priceless ...
The cold cases are less exciting for me, I think it's cause I get to look into the patient's eyes for just that fraction too long, and end up pondering the fragility of life for just that bit too much.

Being the adrenaline junky that I am, it pains me to say that I haven't done a heart since completing my training. In my opinion, it's not something to do occasionally. You either do it, and do it properly, or best leave it alone. But the little voice in my head ( and, no I'm not schizophrenic yet), still asks whether I miss the cases, or whether it's the uniquely captivating world of theatre 10, with all its ambivalent extras, not to mention the bunch of over-inflated water- walkers for whom I actually harbour a grudging respect,
(but can never admit it - or they might just believe they can fly next), that has me pining.

Midnight Angels

It was many years ago, but I remember it like yesterday.

I was an eager young registrar, on call for the maternity theatre. No doubt things have changed now, but back then it entailed literally 24 hours of c/sections. On any given day, about 15 howling little miracles could be delivered via the vaginal bypass route.

Most of us dreaded the maternity call ... it was endless ... and extremely painful both literally and figuratively. The gynaes were also in training and usually tended to struggle through the surgery. The patients were usually so exhausted, or so sick, that any form of communication was restricted to the bare necessities. The change over time was way too long. The maternity hospital was situated about 2 km from the main hospital so as an anaesthesiologist you were on your own. Help was at least 5-10 minutes away (and any fresh registrar with half a brain cell knew, that that was way too long ) You knew upfront that you were screwed on that day, but as is the nature of the human race ... against all odds, you still hoped, and hoped, and hoped for some divine intervention and at least an easy night. Or that all your spinals worked perfectly.

Despite all of that, I loved the maternity theatre! I enjoyed the spinals and most of all loved those little babies!! Nothing cuter than a newborn looking around , eyes alert, mere seconds after being delivered, with a know-it-all expression on its little face!! Yep the c/sections were definitely my favourite.

On this particular day it was busy as usual. It was around midnight and the endless stream of pregnant fairies seemed to ease up a little. I was tired, but the current patient was intelligent, friendly and really nice for a
change. I didn't need much convincing to have an enjoyable conversation with her.

Now in those days I used to draw up all the drugs needed for a general anaesthetic (in the event that my spinal didn't work), and have them all ready and labelled. I also had, and still sort of have, this obsessive compulsive notion of always drawing them up in the same way. So I always drew the tracrium up, diluted, in a 10ml syringe and the syntocinon in a 5 ml syringe. Tracrium is a muscle relaxant with a relatively short duration of action, which doesn't need to be reversed. Syntocinon is used to contract the uterus after delivery.

But not on that day .... No, on that day I drew up both the tracrium and the syntocinon in 5 ml syringes. Heaven knows why ... But at least I did have the syringes correctly labelled, although it didn't help me much.

So spinal was working perfectly, the patient was communicating nicely and the baby was out! Time for syntocinon. In our institution we gave 30u in the vaculiter and 10u IVI, so a total of 4ml. ( One ampoule of tracrium was exactly 5ml.)

I warned the lady that the medicine could give her a feeling of pressure on her chest, but reassured her that it would pass quite quickly. Then I took the syringe (labelled and all), wondered for the briefest of seconds why there was 5ml in it and proceeded to add 4mls to the bag of ringers and 1ml slowly IVI.


For a minute or so, all was well. Then it started ... she complained of a heavy feeling on her chest. I told her it was normal. She complained of difficulty to breathe. I started some mental checks. When she broke out in a sweat and started slurring her words, a light flash exploded in my brain! The syringes!!!!! I had mixed them up and instead of giving syntocinon, I had given tracrium!!!! I checked, and low and behold, the synto's was innocently lying on the trolley. No wonder I was perplexed by the 5ml, instead of the usual 4ml!! Faster than the speed of light I ripped off the contaminated vaculiter and replaced it with a clean one. Then I supported the patient with gentle mask ventilation, all the while talking to her softly, telling her not to worry, that all was well and that she was doing fine. Luckily the gynae was quite fresh too so the op took about 20 minutes longer than usual, which was more than enough time for the little bit of muscle relaxant to wear itself off.

Soon she was back to her chatty self as if nothing untoward had taken place, and I was calling myself every kind of fool. How could I make such a mistake?? Why didn't I read the label?? Why did I draw the drugs up differently??

The gynae never noticed and I never mentioned it. I repeatedly asked the patient if she was fine, and when she eventually sighed and said: Ok, if you must know, I am absolutely starving and would love a cup of coffee!! I finally relaxed. Still felt like a dog though ...

When I discussed it with the prof, and told him that perhaps I wasn't cut out for this job, he told me that at some point we all make mistakes but that the important thing was to recognise it quickly, deal with it correctly, and learn something from it. Also, never ever to underestimate the power of the midnight angels watching over us...

The pyjama drill

A loud shrilling noise drags me away from my much-needed slumber... What's going on?? Where am I ... and what on earth is that grating pandemonium?? ...

Ah yes, my phone ... I am on call tonight ...

I answer just in time. A dehydrated two-year old needs an IV infusion and the exhausted ER doctor's numerous attempts were unsuccessful. It's 1am.

Thank God it's not theatre! With a bit of luck, I can be back in bed in about an hour! Reluctance almost kills me as I roll out of bed. I put on my bright pink MAD DOGS tracksuit (which in my opinion is still in a respectable condition), my authentic NIKE's, wash my face and brush my teeth. I barely brush my hair, and don't bother with anything else eg make-up or contact lenses. At this hour it's speed vs elegance!! I do hear my dad's voice echoing around in my head though ... always look good when you leave the house, you never know who you might see .... grab my glasses and go!

My brisk walk across the parking lot towards the ER, is disturbed by loud calls?! It's the security guard!! And he is really upset!! Oh, what now??

Dr, whats wrong?? Are you alright?? Yes, I am fine, what are you making such a racket for??
Dr, how on earth could you came to the hospital in your pyjamas?? He doesn't wait for an answer, just barges on! In your pyjamas, I cannot believe it!! WHY??? What is SOOOOO urgent??
What are you talking about? This is a perfectly respectable tracksuit!! It's Mad dogs!! Do you even know what that is?? It's not exactly cheap you know!! And even if I was wearing pyjamas, what's it to you??

I march on feeling truly offended. It's after one in the morning for crying out loud! What did he want, my sunday best??

At least the parents of the little kid are too distraught to notice my unsuitable attire, and perhaps the sisters know better than to comment cause nobody says a thing. After settling the fiesty little screamer (and indirectly her mom) with some magical Barney juice (a touch of dormicum mixed in a bit of calpol, with the exact same shade of purple as the dinosaur), lady luck smiles my way. Despite what I am wearing .... the IV goes in on the first attempt. As always I say a little mental prayer of thanks, cause these drips have a sure way of keeping you humble at times.

Great, now I can dash off home!! But first I must pass via that security guard once again.... Ah, what the hell, I can do this!!

Hey doc, you can't leave yet, the gynae has just walked in. I told her you were here and it looks like she might need you. Ok, double great.

Back in the ER I notice a man hurriedly filling in an admission, and preop form. Is this for the gynae patient? Yes, she is my wife and it looks like a c/section. From somewhere behind me I hear, Sir, this is our anaesthesiologist. Oh man ...

I cringe a bit inside, (my dad's gonna have a fit if he ever hears about this), but pretend that my now infamous Mad Dogs, is actually Versace or something, and head down to theatre to change.

At least my blessed scrubs lend and air of control and comfort, even if they're a far cry from being elegant or fashionable. In fact they look worse than my pink trascksuit, but just because they are scrubs, that seems to make it ok??!!

Anyway halfway through the c/section the gynae asks if the kiddie is ok. Perplexed I tell her that she is just fine. The security guard told me that you had to get here stat, so you came in your PJ's? Well ... good news sure travels fast!! By tomorrow morning I will most probably have come to work in my underwear !! And I bet that sleaze-bag didn't even mention my state-of the-art NIKE's?? I coolly lift my eyebrow and say, I assume that you're intelligent enough not to fall for that, but rest assured that if the need ever arises, not even my pj's will stop me.....

I am soooooooooooooo going to kill that guy.............

A Medley of Morals

Perhaps it's an arbitrary notion. Perhaps it's due to working in the public sector for too long. Perhaps it's personal hypersensitivity. Perhaps I'm just crazy, I don't know ... but I've always felt that the concept of human rights, is something that doesn't bode well for me. This is a personal view and not intended as a political remark / opinion in any way. It's just that, I have yet to gain an advantage from that little phrase on any level, personal, or professional. It's almost as if I'm always last in line when so-called human rights are being dished out ... and by the time I get to the front of the cue, there is nothing left.

Any professional knows that personal issues and opinions, have no place at work. You do what you are trained to do, to the best of your ability. But where, and how, does one actually draw the line? What happens when your morals clash with that of your patient? When what you're expected to do goes against everything you believe? When your freedom of choice is forfeited for that of another? When someone else's human rights are considered at the expense of yours?

What then?????

I have a problem with abortions. Having witnessed first-hand, both, the double-edged sword of infertility, as well as the divine grace of adoption, it is something that I personally cannot condone. Especially when it is exploited as a form of contraception! And please, I am not generalizing, and I am not judging. All I am saying is that I want no part in it. Perhaps it's a bit cowardly of me, or hypocritical even, I'm not sure. But something dies inside me everytime I contribute to an elective abortion.

In my opinion, no woman ever gets over it anyway. Every single patient I've ever anaesthetized for this, has woken up crying ... barring one. It's something that I've constantly noticed over the years, without fail, and it never seizes to affect me. The reasons why a woman would choose this specific route escape me, yet I fully understand that the decisions are hers to make. She has the right to chose, and she has to live with the consequences of her choices. But, at least her choices are being considered ...

What about mine?

Don't I have the right to protect myself emotionally? Why do colleagues stare at me as if I'm a two-headed, lazy monster when I decline these cases? More often than not, I get bullied into doing them anyway! My professional position supposedly puts me in the upper ranks of the food chain, but what's the point? Even there, my freedom and my rights are at times controlled by others. Add to that the frustration of not being able to discuss the situation openly with the patient ( I refuse to upset any patient before an induction, plus she is basically the gynae's patient, not mine), and I have to ask: Where is the human rights in that??

Medicine ... a mystery ??

It's scary, but it's a fact. The general public has no clue as to what doctors actually do. Add the mysterious element of "going to theatre" and Confusious would be put to shame. I can't figure why anyone in their right mind would consent to anything without understanding exactly whats going on, or at least having some basic idea! I have quit counting how many times patients reply I don't know, when asked what procedure they are having!! This usually as they are being wheeled into theatre! It really disturbs me ...

I get paid to eliminate pain, anxiety and all coherent thought, in as safe a manner as possible. Therefore, I feel it is unethical to unsettle patients pre-operatively. Can't have them all worked up and jumping off the table, so in these situations I basically choke on my tongue. But contrary to popular belief, I too am human, and therefore I sometimes fail.
Didn't you ask the surgeon what he is going to do to you? Yes I did. Did he tell you? Yes he did. Did you understand what he said? Not really. Did you ask him to explain it again? No I didn't. Why ever not??? Don't know ............... Did you sign consent? Yes .... Go figure ..............( of course when the shit goes flying, it's the doctor's fault).
Add to that the audacity to refuse the anaesthetic until they see their doctor, and all I can do is shake my head. I know that people think dopers aren't really doctors, and that we quickly go shopping or something while we wait for the surgeon to finish, but little do they know that the gas fairy is about as much quality control as they're gonna get.

Just the other day we did a total hip replacement. We offered the lady a morphine spinal combined with a GA. The spinal was turned down due to a fear of permanent paralysis, and a general was accepted on condition that her throat not be manipulated in anyway. No pipes please dear... She also requested a 22G paediatric jelco....
After a twenty minute negotiation session, I wrote a report summerising the situation and asked her to sign it. She read it carefully, realised that my ass was neatly covered, and was then ready to hear me out. I once again explained everything ad nauseum. The procedure was successful, but the next day she spoilt it all by asking me why we use the throat pipe ......!!!!!!!!!!!!!!!!!

It's about as bad as the patient that passes his pre-op interview with flying colours. You know the one that has no medical problems? Then you lift his pajama top ... Oh that old scar?? Yes yes, I had a triple bypass a few years ago ... Or, ok now show me your pills, is this not warfarin?? Oh yes, forgot about that, my blood is thick so been taking it for a while ... Or, is this not angised?
Yes I use it about twice per day, but other than that I have no problems ...
It annoys me, but I take full responsibility for these situations. Wish I could get it into my thick skull that, Do you have any medical problems, or anything that I should know about , has a different meaning to me, and a different meaning to the patient. Wish I would remember to always ask all the questions one by one.

Then of course there is the influence from the media.
Today, our patient was having her varicose veins done. In the institution where I earn my living, this is done under mild sedation, using an endovenous laser technique. So I often end up chatting to the patient intermittently.
Today was no different, except that I quickly realised what calibre of patient we were dealing with. (And secretly wished that I could give her a general anaesthetic) Out of habit I confirmed that she was nil per mouth? Her tone was a little condescending as she replied that the LASER was not really an operation. She heard it on TV the other day. Also the doctor told her she was going to be just a little sleepy, so she had breakfast. Okey dokey.
After a few similar questions and answers, I took the cowardly route and pretended to be very busy writing notes. I seriously couldn't handle any further conversation.
Half way through the procedure she asked if haemorrhoids could be done with the laser. I rolled my eyes as the surgeon asked why. Well I'm here now so you can just do the piles too. They really bother me you know. And I really like the laser. Laser, laser, laser!!! The vascular surgeon was a bit offended I believe and told her to see a general surgeon for her secondary problem.
She proceeded to make it very clear that in her opinion all surgeons were equal and that she was very outraged by his rejection.
I thought it wise to administer a touch of propofol at this point ....

Ok so the medical profession needs to revamp its communication skills, but as with everything in life ... it takes two to tango ...

It aint over till the fat lady sings...

Another perk of living on this little rock floating in the mediterranean, is that I've come, up close and personal, with flab ... serious flab ... I'm not judging fat people, in fact with a BMI on the verge of being problematic, I feel real compassion for anyone with a weight issue. But, what I have been experiencing here is not your average, garden variety, fat person. No, it is ... well ... a new, possibly alien-infested, genetically modified, branch of the human species.
We're talking BMI's of 50 plus!!

Bariatric surgery has never been my thing. In fact I truly believed that it is for those lazy, weak, psychologically challenged liars claiming to have tried every possible diet on this planet without success. How on earth did they actually get that big anyway? ( A bit harsh in retrospect ). So , barring your proudly South African mama, presenting for the c/section of her eighth kid, putting the michelin man to shame, and having little inclination to communication, I haven't had much to do with this patient profile until recently.

Two months ... and I realise just how wrong I have been!!

These are tortured souls, completely trapped, beyond escape, by hundreds of kilos of suffocating lard. Their bodies are physical freaks of nature and it doesn't matter how it happened ... the psychological torture is the same ... it's bad , really
bad.
They deserve to have these operations, in fact, they have earned the right to have them.
It's their only chance to have some sort of a normal life. Ok, normal is in the eye of the beholder, but never once being able to wash your own feet ( or any other, more delicate parts of your anatomy,
for that matter ) is abnormal for me. Very abnormal!
My most recent case really opened my eyes. A young mother of three (still trying to figure out by what divine intervention that feat was accomplished ) with a BMI of 57!!
To be visually affronted by the sight of such a quivering mass, stretched out on an operating table, is, to say the least, enough to ensure that no morsel of food ever crosses your lips again! Ever!!!
( Lost 3 kilos since this case...)


Needless to say, there were complications, both surgical and medical. How do you explain to anxious family members that their loved one's disfigured body is the ultimate culprit? That no matter how hard you try, it somehow gets in the way. One can only tape so many interfering rolls out of the way using the elastoplast technique. Nevermind that all that fat is metabolically active. It's a disaster waiting to happen!!

I get to know this young lady very well during her slow and difficult recuperation. I also realise again how wrong I was. She is not lazy, or weak. She is neither a liar, nor psychologically challenged, and she is definitely no fool. She is just a desperate soul severely trapped in a very, very sick body. Now, whatever resulted in this glorious abundance of glyceride esters, is totally irrelevant, because, just as a very, very sick heart needs cardiac surgery ... so too does a very, very sick body need bariatric surgery!!

She is finally being discharged from ICU, minus at least 15kg, and starting to sing - perhaps for the first time in her physically oppressed life - a merry tune!!

The perfect anaesthesia

Strange that after so many years, I only now ask myself, and repeatedly so, exactly what constitutes the perfect anaesthesia. Oh I know all that stuff about amnesia, analgesia, akinesia and altered sympathetic response. Lets face it, every single patient gets that ... I also know that there are anaesthetist factors, patient factors, and drug factors that all have a role in how the anaesthetic is going to play itself out. But what I don't get, is why it sometimes goes really brilliantly, and other times less so. Especially when the basic technique used is the same, with only some minor fine-tuning to accomodate individual needs.

With time one gets a feel for the job. Sort of like baking. Yeah, if you bake the same cake every day, it gets better, easier, and quicker. You also start to get a "gutt feel" for how your cake is going to turn out. And funny enough, even though you use the exact, same , unaltered recipe, the cake is sometimes yummier than other times. Why is that??

What freaks me out even more, is that when a dope feels sort of effortless, if one could call it that, it usually turns out close to perfect. ( I say close to perfect cause I think that absolutely perfect is an illusion ). And when meticulous planning with a lot of extra-careful effort is put in,
things turn out less than satisfying. By that, I mean there is something consciously or subconsciously irritating me.
Coughing, pushing, biting, waking too fast, waking too slow, too much gob, too little gob ...

Am I making any sense here?? I am way too young for a mid-life crisis, and way to old for neon-green-behind-the-ears syndrome. My better half is a pilot and I can't help feeling that some days, although I manage take-off and landing quite safely, it's almost as if I completely miss the runway!! Why, when according to science, everything has been done to ensure the, two-for-the-price-of-one, package-deal of "state-of-the-art snooze plus awake-up", is there no guarantee?
Add to that, the fact that this usually occurs with your least favourite of surgeons ... or when you really don't want it too ... or when you secretly want to show off your cool technique a bit ... or when you really don't expect it too ... and I ask again ... what is that something that I'm sometimes missing?

Every dark cloud has a silver lining.

I am on silent probation (so by some unspoken rule, I get all the kak patients for now), and it's been an exhausting, back-breaking, mind-numbing kind of day.

Not only have I been working since the crack of dawn, which was about 12 hours ago, but my patients have all had some element of risk, resulting in 12 hours of continuos, low-level, stress-hormone release from my poor adrenals. I'm not unable to work for so long, but thanks to "operation relocation", my career-fitness level has taken a bit of a dive...

Also with no real friends around, no coffee-break, no lunch (ag shame), the day somehow feels longer and lonelier. Reminds me of those blokes on the street corner with the cardboard signs around their necks ... You know, from my previous life ...


Anyway the last patient, is a lady that's about 95 in the shade, femur fracture, cardiac disease, cancer, and a fanatical family of ten children. Need I say more... Her induction is shaky, her intubation a nightmare resulting in 2 dislodged front teeth, (an anathema to any anaesthesiologist by the way), and her bloodloss substantial for her age. Other than that, her surgery is successful. Very importantly, the metal is in the bone! We even manage to wire her teeth back into place!! Decent damage-control I'd say!

So off we go to ICU, for some TLC.

It's my virgin flight to ICU, so I haven't met the staff yet, but I expect my reception to be much the same as everywhere else so far.

I hand my notes to a really sweet-looking fellow, do a hand-over in my best, broken greek, help get the old lady settled, and sink down into the nearest chair ... just for a minute or so...

The sweet-looking fellow, with the first, truly friendly, face I 've seen around here, offers me a cup of coffee. He seems shocked to hear that I've survived the day without any form of nourishment whatsoever. ( Secretly, I'm quite surprised too, but hey, they don't need to know that!) Two seconds later, a mug of steaming coffee in my hands, he earnestly explains where all the restrooms / tearooms are situated. Obviously he feels about these places, as an air hostess would about the exits marked in red on board an aircraft.

I don't bother telling him that I'm totally rigting-bef*%. That I would, only with time, find the watering holes myself, but let him ramble on. He definitely doesn't fit into the chauvinistic mould that the majority of males on this island seem to be cast from! I'm really surprised! Pleasantly so!

With every subsequent ICU visit (have I mentioned my probation?), I get to know him better.
Each time over a cup of coffee, that's been made for me exactly the way I like it, nogal by a cypriot male.

I realise that things are really not that bad, as long as I keep an eye out for that silver lining.

The mega colon.

It's freezing out, and I'm on my way to work.
Doing a laparoscopic total colectomy, and expecting a slow and quiet day. Today's surgeon has, in my humble opinion, already got one foot in a retirement village. He seems to know it too cause some hotshot surgeon has been especially imported ... yes from another country, so God help us ... to assist/do the procedure. I have no great expectations for the day and I'm almost sure it's gonna be long, slow and hopefully very boring. Brought my sudoku along just in case ... oh and quitely slipped a mills & boon into my bag when no-one was looking. (Yes, we all have our skeletons ...)
I don't make a habit of "relaxing" in theatre, but on a long 7 hour haul, with proper preparation, the course mapped out on auto-pilot, and everything going smoothly, even a control-freak like myself can relax for about 15 minutes. Bear in mind that I sit in a little spot squashed between the patient and the DATEX, within arms reach of any resuscitation stuff. Super-sensitive ears listening to the blips of the heart from start to finish. My species can detect any changes just by listening ... even in our sleep.

Laparoscopic procedures are minimally invasive to the patient, but usually quite difficult. Imagine removing an entire colon, with minimal bloodloss, using 4 little holes, and your hands never actually inside the abdomen!!! Never seizes to amaze me how these guys seem to know exactly where they are, exactly what they are looking at, and how they manage to orientate themselves. No wonder they sometimes think the sun stops shining when they sit down...

What does all this mean to me??
Well if all goes according to plan and nodody screws up, it means that the fluid-shifts and losses are minimal, which is very good (less calculations for me). Also the postop recovery is much easier and less painful. But intra-op, besides the standard basic anaesthesia rules, lung ventilation is a little more tricky as a whole lot of extra pressures come into play. The patient is put into a head-down position, with her abdomen blown-up by CO2 gas to resemble that of a term pregnant tummy. So the poor little lungs get squashed up nice and tight, and among other things, its my job to ensure normal gas exchange throughout, using a few ventilation tricks and a couple of drugs.

With the milk of amnesia administered, the endotracheal tube secured, and the desired "altitude" attained, we are ready for surgery to begin.

Today I have decided to take the bull by the horns. Time to chuck that bloody chip off my shoulder! Been the new kid on the block for long enough! Time for the old, spunky, me again... and to hell with everyone else.

I boldly introduce myself to the freshly imported, just about shake his arm out of its socket ( I love seeing the shocked look on people's faces when I do that) and act very much in charge. He doesn't look shocked though, but smiles warmly ... WOW... strange surgeon smiling at me ... thats a fresh change from the last 6 months! He instantly gets a new fan.

Surgery is slow, but precise. The guy is brilliant, its obvious that he loves what he does.
On my side we are cruising steadily on auto pilot. No troubles thank God. I quietly pull out my M & B, and enjoy a few pages behind the screen,( with my ears on the monitor of course), when WOW calls my name. Oh shit, within seconds I asses the situation and find nothing amiss ...
Patient is correctly positioned, fully relaxed, vital parameters normal with enough fuel on board, so what's wrong??

Yes?, I ask. He says something in rapid greek. My own language once again makes me look like an idiot. Excuse me but could you repeat that slowly please? Then, in perfect english, comes the sentence that finally knocks all remnants of that chip, forever off my shoulder.

Thank you for the perfect anaesthetic, I am very very happy with your anaesthesia.

Well blow me over!!!!!!!!!! Don't know what I expected, but that was certainly not it! That little sentence, set me free! I finally escape from the cage in which I have both locked myself in, and allowed others to imprison me. Can't explain the soaring feeling....

I wish all God's blessings upon the lady, now minus her megacolon, for facilitating the brief crossing of this man's path with mine. Although I never strictly doubted myself or my capabilities, his words soothed ... no, cured, an injured soul.

Didn't know I was quite so easy to "fix".

My grand reception.

Tuesday evening, 7pm, finds me freshly showered, and frowning at my closet. What to wear? What to wear???
I'm not usually the type of person to disturb my equilibrium over such, semi-mundane matters, especially since my body has long since lost its former glory. (Thanks to a fair number of offspring!). But, damn, why didn't I go on that f%^#&$* diet????

Hospital admin was kind enough to arrange a sort-of, informal, get- to- know- the- new- doper, meeting at 8pm. Must say I felt rather chuffed at the idea of meeting all the surgical colleagues at the same time. I could therefore spare myself the agony of going from doctors rooms to doctors rooms, handing out my snazzy little business cards, and feeling like a glorified call girl/ rep/ idiot.

Eventually, I look at my reflection and think, not bad... not bad at all. I don my killer heels, that don't actually show beneath my pants, but make me feel like some exotic chick with hidden powers, kiss my family goodbye, and present myself to my favourite receptionist (yep the very one I mentioned in a previous post) with 5 minutes to spare.

With a confused, yet sympathetic, "they are not here, but perhaps they are late", she continued whatever she was doing. Should of known then that something was up.

I am strictly punctual, but this is an island ... and apparently you can only call yourself a true islander once you have proudly mastered the art of being late... Very late...

Exactly one and a half hours later, my mood something akin to soured cream, I get a call. "Sorry got caught up with something." No kidding. " It's quite late so maybe you should come to my rooms, just outside the main hospital, to the left." Piss off. By now I just want this joke of a meeting over with so I follow the directions, and come up with... wait for it.... nothing.

Back to the receptionist who explains that said rooms are to the left of the hospital, but that Dr Prick forgot to mention that they were about a kilometer down the road!

My mood now resembling curdled cream, I stomp down the road, expecting at least one hell of a stiff drink for this minor inconvenience, and very worried about my heels. Island pavements seem to be as twisted as island doctors.

At last, Dr Prick in the flesh, lounging against the streetlamp, having a smoke and chatting to Dr X.

"You guys are late and where is everyone else?" I ask. "Two minutes please" is the reply. WTF!!!!!

I'm ashamed to say that I actually granted them their precious two minutes. I was so flabbergasted, that even if I had come up with some acid one-liner to shove them back into the creepy hole they had crawled out of, it would have eluded me at that moment.

What happened afterwards is barely of any consequence, suffice to say that my first impression had been well and truly cemented into my brain. These people sucked!! And I had to work with them!!

Well ... I can always still diet.... doubt whether much can improve for them, poor sods...

The DIRE emergency.

It was my second on-call in greener pastures.... The first one had gone off without a hitch, but yet a mixture of anxiety, fear and excitement was twirling around inside me. What would the day bring my way, and would I cope? Not only was my comfort zone very far away, it was quite frankly, totally shot to hell! Nevertheless I acted as though all was well and butter wouldn't melt in my mouth....

As expected, the inevitable call came. A DIRE emergency!!! Theatre stat!!! Shit!!!

All I could get out of the receptionist (due in part to a language deficiency on my side, and an information deficiency on her side) was... MVA (motor vehicle accident), emergency, get here immediately.

Well that was enough to unleash the formula 1 driver in me. Man it was so cool!! I put on my hazards and made a twenty five minute journey in about eight minutes. They didn't call me Villeneuve back in varsity for nothing!! All the while mentally reciting adrenalin dosages, c-spine considerations, the protocol for low tidal volume ventilation blah, blah, blah.
I screeched to a halt, as only a woman driver can do, and dashed into the hospital, making a beeline for said receptionist...

"So where is he? Still in the ER or in ICU?"

"Oh he is waiting for you up in the ward doctor."

"No not that one, the one you called me about, you know...the DIRE emergency!!! Where is that one?"

"I just told you, he is up in the ward waiting to see you."

Ok I was not getting anywhere with this poppie, and besides she was looking at me like I was half mad and I had just wasted about five minutes! The pixie dust in the golden hour-glass was seriously running out...

I ran up to the ward only to be told that the particular patient was in room 226. Nobody seemed very stressed by the situation and I was getting more and more worried. What the hell was going on here? Surely I was missing some vital part in the equation??

Revved-up and ready for whatever was awaiting me, I entered room 226.

Imagine my surprise when I found an old man, grinning from ear to ear, and hardly able to contain himself as he excitedly relayed the events of a few hours ago leading to his badly fractured humerus. Oh and he reckoned that he was absolutely starving and yes his whole body was sore, and were we going to sort him out now?

Well, I felt myself deflating faster than a pair of silicone boobs on a concorde! For a few blinding seconds the disappointment threatened to overwhelm me... Then I smiled, did the old toppie's premed and continued with the dire emergency, saving my little giggle for later.

Blood-brain-barrier.

One thing that I learnt very early in my training as an anaesthesiologist, and that still baffles me to this day (10 years later!) is the almost irreconcilable differences between us and the surgeons. Allow me to make it very clear from the start, that this is by no means a generelization. All surgeons are gems, but some are certainly more polished than others. It's the unpolished, rough diamonds I wish to get off of my chest today. So all of you brilliant cuts out there, just sit back, relax and let me vent.

We survive in a symbiotic environment whereby surgeon needs anaesthetist and vice-versa. Yet when in close proximity of a "roughy" as I like to call them, one would swear that we and only we, are the parasites! As a registrar I mistakenly believed that this attitude problem was due to the torture the poor surgery registrars had to endure, both physically and emotionally.
Couldn't wait to get into private practise and enjoy decent, fun and equal relationships with the gems ie discussing the patients together, cracking the odd joke in theatre (across the blood-brain-barrier) and most importantly trusting each other.

Luckily or unluckily for me, I am a cross between an idealist and a realist. So everytime my parade gets pissed on, I just clean it up and start again! But sometimes even my mops get saturated and this is where my story actually begins...

I am a recent expat... That in itself is quite a challenge. So here we are... new country, new life, new hospital, new job, new colleagues, but (thank God for small mercies) same DATEX machines. Due to my above-mentioned personality flaw, I really thought that the transition period between "new" colleague and "regular" colleague would be difficult, but manageable.
I was even almost excited (amidst my fear) and couldn't wait to do my beloved job again!


Enter roughy...


"so...you are the new one..." Yes, that would be me, pleased to meet you. "everytime they get a new one, I get stuck with all the problems. I've tried them all around here and not one can give me what I need. Let me tell you that in my long and prestigious career, the 3 sole haematomas I've had where unmistakeably due to the anaesthesia" Really, I'm sorry to hear that. "It's always up to me to tell them what drugs to give, where to position their tubes and even where to stick the tape. What am I going to do with you?" Well you could give me a try and if you find me lacking, no need to use me again, how about that hmm? I actually adore my job, and am quite good at it too, so I might even be okay. What do you think? Should we give it a shot and see what happens?

Exit roughy...

I kid you not, he just looked at me with total contempt, shook his head, turned around and walked off mumbling under his breath. He had never seen me before and this entire session took place in the recovery room in full view and hearing of half the theatre staff.

Out came the mops in full force!! Mop, mop, mop!! Mop, mop, mop!! Mop, mop,mop!

I am a firm believer of the saying, "how someone treats you is their karma, how you react is yours" ,by Dyer. So now I have a bit of a dilemma... Do I lower myself to his unpolished standards? Do I follow my gut feeling and tell him to go get screwed? Bear in mind that he is about my dads age and honestly I still do have respect for my elders! Do I just keep mopping my parade clean and smile? Do I dope for him and prove myself as a worthy anaesthesiologist? Do I swear on my life never to share a theatre with a common little rough pebble like that?

Perhaps I should fall back on the age-old concept of the blood-brain-barrier! Roughy the blood, me the brain and the screen draped over the patient, the barrier...