Friday, March 19, 2010

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.

Wednesday, March 17, 2010

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...

Tuesday, March 16, 2010

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.............

Sunday, March 7, 2010

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??

Wednesday, March 3, 2010

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 ...