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.

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 ...