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.