Sunday, February 14, 2010

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
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!!

Wednesday, February 10, 2010

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?

Monday, February 8, 2010

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.

Wednesday, February 3, 2010

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".