The graveyard hidden in a surgeon’s mind

This is a difficult story to tell but if I am to be true to the complete experience of a surgeon, I do need to tell it.

One of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. He went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. At the time I thought he was being a bit melodramatic, especially seeing as though I could barely remember the names of any of my living patients. Somewhat like one of our consultants I used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. Unfortunately I learned what he meant.

It was a tough call so when my pager went off at five in the morning I was not delighted to hear there was a gunshot abdomen in casualties. Bearing in mind I had been on the go solidly for about 23 hours and I had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. I charged down to casualties to evaluate the patient.

Gunshot abdomens are slam dunks. You operate them. There are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn’t actually penetrate the abdominal cavity. This guy had a tangential wound passing through the left flank. His abdomen was completely soft and asymptomatic. I was amazed at my luck. he actually didn’t need to be operated. The statistics said I had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. I was quite relieved. It would definitely make the day more manageable.

In the morning meeting the professor in whose firm I was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. When I got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. He knew the statistics too but what I was describing was just not seen all that often. He, however, knew we would be doing rounds with him in about two hour’s time so he told me he would check the patient out himself. I was fine with that. I knew what I had felt and the worst that could happen was that he could tell me to operate the guy.

On the rounds the prof took his time with gunshot guy. He examined him. He then examined him again. He went over the vitals and then he went through everything again. Finally he turned to us all and informed the students that I was right and the patient indeed did not need to be operated. He even suggested I discharge the guy which I respectfully refused to do. I told him I’d be a bit more comfortable to observe him for one more day.

The day went on as days tend to do. Just before I went to theater I briefly layed my hand on the patient’s abdomen once again. All seemed well and off I went.

Theater dragged on a bit and finally at about 7 o’clock pm I emerged. By that time I was pretty tired and I shuffled off home, somewhat in a fatigue-induced daze. Only when I was in bed in a near comatose state did I remember I hadn’t checked the gunshot guy before going home. Moments later I was asleep.

The next morning in the handover meeting my friend and colleague who had been on call approached me.

“Your patient was a bit dizzy last night, but don’t worry. i checked him out and his abdomen is fine.” i just gave him a bolus of ringers and he’s fine. my spine went cold. I thanked him and smiled but my face belied what was going on in my mind. The same words went through my mind over and over again. Young men don’t get dizzy unless there is something wrong. Young men don’t get dizzy unless there is something wrong.

I ran down to theater and booked him on the emergency list for a laparotomy. Then i went to the ward again. Still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. That was enough for me. I told him we wanted to operate and he consented.Tthereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. He assured me he would help directly after a caesarian section that was about to be done.

It was too late. The patient crashed just before he was supposed to go to theater. There was a massive resuscitation followed by an operation. At operation the bullet had traversed his abdomen for only about 2cm, but that was enough. There was a small hole in the bowel which had been leaking all night. But despite this the operation went well and we delivered him to ICU in a fairly good state.

As sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown SIRS response. Thereafter it was a two day downward spiral before the patient passed away. There was just nothing we could do. I felt terrible.

I knew I was the one who had made the initial call not to operate. It didn’t help that a prof and a senior registrar had separately evaluated him and agreed with me. I also knew I had not reevaluated him that fateful night when I had wandered home in a barely conscious state. I had also not emerged from my bed to find my way back to the hospital once I had realized my oversight. Also soon after his death I was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. All in all he was a very good man and we were all poorer for him no longer being alive.

I suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. I knew I had someone whom I was going to bury in mine. I also knew I would never forget him and I would never get over it.

Engraved on the tombstone I still clearly see his name. His name was Prince.

“bongi” is a general surgeon in South Africa who blogs at other things amanzi.

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