A simple lesson.

The simplest things can also be the most humbling. In my very first clinical rotation in 4th year, surgery rotation no less, it quickly became obvious how things worked. On the first day, we were heartily chucked into the deep-end and the registrars watched with relish ... who would sink - and who would swim. I swear they took so much joy in watching us suffer. It helped form my subsequent opinion of most surgeons ...
One of my patients was day 1 postop. A young man with stomach outlet obstruction. The prof had operated on him personally. This was mentioned a few times, so I guessed it had to mean something. Sort of like ... no stuff-ups allowed on this patient. Not that stuff-ups were tolerated at all, but we were only human.
It was around midday and we were having lunch in the cafeteria. Yes ... even surgeons must eat. A huge amount of work had been dumped on our clueless heads and we were trying to figure it all out. Suddenly my beeper went off. Nothing serious, but hell of a scary seeing as it was the first time. My patient's drip had tissued, it was my job to issue him with a new one. Ok, I said looking around at my mates. Which of you know how to put up drips? Four very blank faces looked back at me.
Fantastic! First day, prof's pet patient, and already the shit was heading towards the fan.
As I made my way back to the ward, I thought ... how difficult could it be? Find vein, put cannula in , attach fluid. Simple.
Alternatively, find someone who knows how to do it, watch and learn. Simple.
Back in the ward, there was no possible help in sight. Senior students had vanished into thin air, and as for the registrars, God only knew where they were. Not sure I'd have asked them for help anyway.
I refused to get phased about a drip, and secretly I was relieved to be alone. Witnesses were the last thing I needed during Operation Figure It Out. It took me a while to collect everything I thought I'd need. Then I grabbed a chair and sat down next to the patient. He was either heavily drugged, or in a very deep sleep. He just lay there, sweating profusely, totally oblivious to everything around him. At that point it didn't matter why he was not responding to the environment. It was a blessing in disguise cause I was gonna hurt him, a lot , and he was not going to feel it. What a bargain.
Gently I applied the tourniquet and looked for a vein. Honestly, it was my very very first attempt at an IV cannula and I was going to do it blindly. I felt bad about that. How could I touch a patient and not know what I was doing? ( Subsequently I got very well acquainted with that particular emotion). Can't tell you how grateful I was for his semi-comatous state. An experienced person would've put up hundreds of drips in the time I sat there holding the bloke's left arm. In retrospect, I may have been waiting for divine intervention or something.
Finally, I just had to take the plunge. I poked and poked and poked, praying that he wouldn't wake up. Sweating more than he was, I hardened my heart and blocked out everything around me. It helped that he was so out of it. A vein would be found even if it killed me. And even if it took me all afternoon.
As with all procedures, there is of course, a certain way to go about it, ensuring a good success rate. Well ... that left arm resembled an old pin cushion by the time I finally had it figured out.
I was exhausted. My neck and shoulders were stiff and sore. My hands were cold and clammy and there was blood on my shoes.
But the blessed Ringers was pouring into the blessed vein.
Simple was simply not always simple. In those agonizing moments I learnt to have a healthy respect for my job. Even today when drips are our bread and butter and we put them up in mere seconds, you get the odd patient where simple is simply not simple...... You sometimes struggle, and quite simply, it keeps you humble.

The bougie.

What is a bougie? Well, I don't actually know how to describe it, but it's the most insignificant-looking thing ever. It looks useless, but catching it in action reveals its true value. Like most important things in life, it is firm, and slightly pliable. A long tool, of differing widths, made out of some sort of plastic I think. Some are hollow inside (those are the coolest cause you can actually ventilate through them!) and others are not. On the whole, absolutely nothing to write home about at first glance ... but let me tell you, once you experience a bougie, there's absolutely no turning back.

A bougie is a life-saver. It saves yours figuratively, and that of the patient literally. I can personally vouch for that. It can reach those places that few other tools can. I have my own bougie (a top of the range hollow one), in a funky blue colour. I just wish I knew where it was. It was always in my bag, but somewhere between my multiple moves, it got misplaced. Misplaced ... and forgotten ....

So a bougie is used for difficult intubations. The idea is to get it into the trachea, then railroad the endotracheal tube over it. Thus securing a difficult airway. The one thing that consoles me is that everyone has an epiglottis, and everyone's epiglottis lies over their vocal cords. So even if you can't see them - they're there. And somehow, the bougie almost always finds that spot.


The patient had a BMI of 47,9, plus co-morbidities. The procedure was a shoulder replacement. The position was "the beach chair". Intubation was inevitable. I could almost feel the problems around me. On the table I tried to position the patient as best I could. Position is extremely important for a satisfactory intubation especially in huge people. Anyway the painful shoulder kept getting in the way of the perfect position. So we were basically screwed before we even started. The IV was nothing but a stroke of luck. The arterial line proved much more of a challenge, but the cherry on the cake was the intubation. It will most certainly stay with me.

On induction, I could ventilate, but had to use both hands to hold the mask. Not exactly fun, but anyway. I decided to check the airway before relaxing the patient. The mouth opening was really small, with a 2cm overbite, (not good), but I could see the vocal cords. So far so good. Previous neck surgery made me a little wary of fiddling with the neck too much, but hey I could ventilate which (at the expense of my arms) was a huge bonus.
Muscles were relaxed with esmeron, and as I injected it, I wished that I'd had the sense to bring some Bridion ( suggamadex) back with me. Bridion reverses esmeron almost instantly. It's really quite awesome.

So we relaxed and ventilated. First attempt at intubation confirmed all my lingering doubts. I could see the cords but the mouth opening was so small and the ET tube just wouldn't go where I wanted it to. The introducer was too pliable and just kept bending the wrong way. The teeth were in my way and the neck was stiff. What joy... In between, I spent long agonizing moments ventilating. I cursed the patient for being so fat. I cursed the surgeon even more for operating without putting the patient on a diet first. And I cursed my short arms and small hands. After two more tries I asked for the difficult airway trolley and was considering a fast-track LMA, when I spied a bougie!!! Yay a bougie !!!!

Well, what could've been quite a disaster, became a very smooth and sophisticated procedure. The bougie - just pliable enough to bend into the shape I wanted, and firm enough to hold the shape - found its mark with the first try. The tube slid elegantly over it ... and we were in business! I said a mental prayer of thanks for the genius that invented the bougie. Would most willingly have kissed his feet at that moment.

My arms shook for about half an hour after all that, and ached for about three days. There was a damn good reason why I used to carry my own bougie around. How could I have forgotten?

Bad lad ...

There was a surgeon ... let's call him Bad-lad. He was short, balding, and weird, with huge blue eyes magnified by Harry Potter glasses. I tried to believe that his heart was in the right place, but he constantly gave me reason to wonder. He could be quite nasty, and definitely wasn't a team player. Nobody liked him. Everyone complained about him. When Bad-lad was on-call, his surgical colleagues cringed and anaesthetists freaked (to put it mildly). He was the type to spend 15 minutes running around looking for a blanket to cover a P1 patient with, before doing the most necessary stuff like tubing, CVP etc. (Or something along those lines). I often felt a teeny-bit sorry for him, until this particular incident....

I was allocated to anaesthetise for him on this particular day. Did I mention that he was also the slowest, most time-consuming surgeon in the department? In that teaching hospital, the last elective case was put on the table at 3 pm. If you were slow, and didn't finish your list by that time, the case was postponed to the next available list. Unfortunate, yes. Not the best management technique, for sure. But no sister would scrub for an elective case after 3. And well, a scrub sister is an imperative part of any surgical case.

So .... Bad-lad was scratching away at some piles. He'd been at it for ages. The blood loss was almost that of a huge laparotomy. It was 3:15. We still had a hernia on the list. And I was frustrated. Seriously frustrated and extremely irritated. The sister informed her floor-nurses and runners that it was to be the last case of the day. Everyone was aware of how things worked there. Except for Bad-lad of course.

He ordered me, (yes - ordered), to call for the next patient. He had to be joking. I mean a guy who spent two and a half hours on piles for crying out loud, would probably need five hours for a freaking hernia!! I gave a nervous little giggle and before I could help myself, I uttered the three little words that severed our already fragile relationship for ever. "Are you crazy????"

He stopped operating. Threw down his tools. Fixed that magnified icy blue stare on me ... and silence reigned for exactly 5 seconds. Then all hell broke loose. He started screaming, and shaking like a leaf.
I was accused of calling him crazy and he was hurling verbal abuse at the top of his voice. I tried to explain that I hadn't called him crazy as such - I'd simply asked a question. A simple "no" would've been enough of an answer. When the performance showed no signs of abating, my hysterical laughter bubbled to the fore. I laughed uncontrollably till my eyes teared, probably because my nerves were so frayed, and it just infuriated him even more. Fortunately the spinal had long worn off and I'd been forced to convert to a general anaesthetic, so the patient was none the wiser.

Poor guy. I felt like the straw that broke the camel's back. It was not my proudest moment. And although it was never my intention to freak him out, I'd be a liar if I said that some small part of me hadn't thoroughly enjoyed the whole fiasco. That was Bad-lad and me ... finished for good.

Fem pop .....

Fem-pop, fem-flop, fem-chop. The anaesthetists version of the vascular anthem.
Those gangrenous shrivelled up arterially challenged limbs (and their nicotine-drenched owners), present, and the sing-song starts.
First the angiograms, then the never-ending fem-pop-bypass. When I say never-ending, I literally mean it. A couple of days, and the nicely demarcated limb is neatly chopped off. All done, fem-pop, fem-flop, fem-chop. I'm sure it irritates the vascular surgeons, considering the heroically back-breaking efforts they make to save these limbs, but I suspect that deep down they sing the same little tune.
All except the unique vascular specimen I've become a slave to in the last 2 years.
This guy just doesn't give up! Ever. He is difficult (no surprise there) , and he can be painfully stubborn, but yes, I like him.
Early on in our synergy, he asked about the fem-pops I'd been exposed to back home. I nonchalantly sang him the anthem fem-pop, fem-flop, fem-chop, and giggled - just a little bit mind you. It soon became apparent that he didn't share my humour. The daggers in his eyes could've stabbed me in the chest across the blood-brain-barrier and all! Needless to say, the next topic was amputations. When I explained that the local threshold for amputations in the teaching hospitals was quite low, the horrified look on his face was, well, horrific. I explained about how patients presented really late, that most couldn't afford the tediously expensive route of fem-pops and weren't prepared to give up smoking, which ruled them out as surgical candidates. Also that the patient load was so huge they simply couldn't get to everyone, and that ultimately with the festering, non-circulating limbs (sepsis just waiting to happen) out of the way, the patients generally did a lot better, a lot quicker.
He didn't hear a word, just said he didn't operate that way. I soon saw what he meant.
I've already said he never gives up. Drives the entire team to drink, from matron right down to runner. But in his defence, I realised after our most recent fem-pop, that we haven't done a single amputation since I've been here!
All the candidates start with an angiogram. Unfortunately there is no angio suite yet, so the whole affair takes place in a standard theatre using a C-arm for screening with a non-moving bed. I must say I feel a tinge of pity for the poor bloke. These procedures are difficult enough without having the technical stuff against you too. He actually does extremely well under the circumstances.
This particular grandpa's leg looked like death warmed up. The rest of him didn't look too great either, but since when has that bothered a surgeon? The anaesthetist is mos also a magician, we wave our wands and we fix!
I took one look at him (holistically) and thought - amputation for sure. There was just no point in doing anything else. I told the surgeon. He ignored me. We did the initial angiogram. A few days later we spent, oh, just about 12 hours doing our heroic fem-pop bypass. Our vein graft only clotted up about three times intra-op, so to top it all off, a couple of embolectomies and some thrombolysis were thrown into the mix. I was a teeny weeny bit peeved at the end of this procedure. A total waste of time, money and effort. I was even more peeved when he brought the patient back two days later for a repeat angiogram, and spent another 6 hours fiddling with the blessed graft. I actually gave up trying to figure out what he was doing and really felt like sulking.
Then a few more days and gramps came for the amputation! I was revving up for the I-told-you-so speech when I saw it was only a big toe amputation. The big toe was the only clearly demarcated bit! The rest of the leg was pink, warm and pulsing!! What an absolute miracle!! I told the surgeon. He just looked at me with shining eyes. Don't think I've ever seen him so animated.
I watched the patient walk out of the hospital a couple of weeks later. It was an awesome sight, really. I congratulated my colleague on his perseverance and a job well done. His motto it seems, is to always try ... always. Like he says, if you give up, you will never know if it might've worked. And when it does, it just makes it all so worthwhile. He is so right. And here, I would've bagged that leg without a second thought. Just goes to show.

To be, or not to be ...

For as long as I can recall, I've had a goal, ... or two, ... or three. Goals which, against all the odds ( cause it was one hell of an uphill battle in my humble opinion), have actually been achieved.
So the question now is ... why does it feel as though the "project" is done , finished en klaar, (and that it's time for a new one) ??
I'm gatvol, my one-and-only ten-year plan, is beyond it's expiry date, and all the boxes are ticked off. A new plan, with lots of new, empty boxes seems to be in order. (What the heck was I thinking anyway - that it all came to a grinding halt at the ripe old age of thirty something?). Where was my foresight, my vision? The broader view must've been a blur on the horizon, but I wasn't looking. No ... I was too busy mutating. Mutating into one of those not-so-normal-medical-type of creatures. What total rubbish.
Seems I've spent what feels like a lifetime aiming for this exact spot, focused, but with no vision. Plus I've got the hang of the job, and I actually like it too, so why the restlessness? Anyone see the sense in my midlife crisis yet?? If so, for the good of humanity, kindly share.
The next ten-year plan is nowhere near conception ... damn ... and I feel like retiring ...(ha ha ha ha ha!!!).
So, once again .... where to from here? Around the world in eighty days perhaps? Oops, probably not an option if I retire. Or the botox/personal trainer/morning coffee route that's so IN these days? Yip ... what you express derision for always turns around to bite you in the ass later. All those chicks must know something that I don't - they sure as hell look a damn sight better than me, which is just slightly concerning as the big four O slowly creeps closer. And I'll bet they learnt it while I was so busy not paying attention to the more mundane matters. No wait, maybe a kept woman, (aka full-time mom which happens to be bloody hard work), and proudly so?
A combination of all of the above? Who says we can't have it all anyway?
Seriously, is it time to bow out gracefully?
And isn't it awesome how much kak I am able to conjure up so early in the morning?
Now that it's all off my chest, let's see if this day can progress ... in a more positive & constructive way of course. Like going to work.
Man ... I'm actually posting this... (cringe) ... honestly ... have I no pride? ...


























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Freaks of Nature

ICU is unique. So much goes on behind those closed doors. Humanity pushes science to its limits (or vice-versa), knowledge competes with expectation, hope mingles with despair, and basically, life and death are at war.
Mortality strips away pride, and the words humble, and grateful, consistently come to mind. Working in there changes you - for better or for worse - but it changes you.
The scariest thing of all, is experiencing ICU from both sides of the fence. I believe that only a select few medics haven't found themselves in this position. The lines between patient/relative, and medicine, become jagged and blurred. Judgement becomes clouded by emotion, and what you know, clashes with what you want to know. It hurts. And it hurts in a place that most medical personnel prefer to keep under wraps. Simply cause it's easier, and less time-consuming than spilling your guts and analysing the contents. Too busy, too tired, too whatever ... And what poor sod would you empty out your soul's trash onto anyway? But it does teach you something about yourself, and others.

Believers feel the Presence ... non-believers feel the force ... but nobody escapes ICU unscathed no matter what they claim. It is this thought that I try to apply to some ICU personnel. You know, the ones with the compassion of a broken bottle. And trust me, they do exist. I can understand that for reasons of self-preservation one sometimes needs to distance oneself from certain situations. That sheer exhaustion can change the meekest of lambs into a raging bull. And that the stress can get too much. But what I cannot fathom is the power-game some ICU personnel play. I don't want to generalize, but this sometimes takes the form of sister-in-charge, and usually accompanies a transfer.

What is gained by shouting, ranting, raving and merciless bitching? Over a patient on a stretcher nonetheless? No patient is ever transferred without the necessary arrangements, and without dr-to-dr communication. If internal ICU communication systems are not up to scratch, why should the accompanying dr, and most importantly the patient and the relatives take the flack? I was recently subjected to such an abusive situation. Personally I'm long past allowing such crap to affect me (too much that is), but I died a thousand deaths on behalf of the relatives. The patient was old, with no prognosis. and no time, but he was still someone's father, brother and uncle. And all those significant someones, were subjected to the most shrewish, screeching ICU reception, I have ever had the misfortune to experience.

What's happened to professionalism? What's happened to respect ... both self-respect and that of a dying person? What's happened to compassion and common decency? And bloody self-control?

I really don't know. But I do know that I was embarrassed on behalf of certain members of my profession. The ambulance driver put it quite eloquently .... " guess she needs to get laid" ...

It was not quite a good enough excuse for me. The patient died two days later.

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.