It was another night call. I was the senior surgical resident on duty. This meant I held the department in my hand until morning when the rest of residents and consultants would troop in.
This particular call was tough. My first on call (junior resident) and I did not manage even an hour of sleep. We grabbed hot beverages here and there, after the quick early dinner.
It is not unusual to have such calls. We would comfort ourselves with the general surgery trainees’ mantra: “sleep when you can, eat when you can and never mess with the pancreas”.
The shift had begun with phone call after phone call from the emergency department. Then wards. Then theatre. We had split up and I had headed to theatre while my junior patrolled the corridors of the wards and emergency room as need arose. My phone kept buzzing every so often. I would stop midway through surgery and listen as the circulating nurse held the phone to my hear, or sometimes put it on speaker and placed it just within earshot.
It was not that the junior resident could not perform the surgeries independently. We had just opted to share the workload- another strategy often employed during the so called graveyard shift.
I had descended to theatre with my laptop at around 9pm. I had just plugged it to charge and started studying in preparation for the following morning class when the alert came. A couple of injuries in casualty, then an acute abdomen (meaning anything that can go wrong in the abdomen and require emergency surgical intervention).
Acute abdomen in Casualty
I had left my laptop on the couch and stormed out of the operating room lounge. Within two minutes or so, I was in emergency department. Having quickly reviewed the patients and adjudged none to be in grave danger, I had asked the junior resident to stabilize a couple and then team up with me in theatre as I pushed to finish the emergency surgery cases early for us to rest.
I must have jinxed the call by declaring to him that sharing the workload would get us free by midnight to catch some sleep. The torrent began, and my junior colleague never made it to theatre.
‘Diseases come in battalions’ is a mantra in medicine. For this particular week they had presented in the pattern of gunshot injuries. Gangs of robbers were terrorizing the capital from different directions. Earlier that morning we had concluded on surgery for two family members who had sustained varying degrees of gunshot injuries. Three had been admitted- a father and two daughters, I think. One daughter had been discharged with minor injuries. The other and the dad had been scheduled for surgery following each other.
Surgery had not gone so well for the dad. We had lost him moments after surgery. We had to find a way to navigate the daughter coming into theatre to ensure she did not know what had just happened.
Following deliberations with the mum, we had planned to discharge her soonest after surgery so that the whole family would mourn together.
Another interesting fact of surgery is that what looks like a simple straight forward surgery can really take longer than anticipated. The midnight laparotomy (opening of the belly) for the acute abdomen had delayed to start- getting a proper IV, getting the patient to sleep, finding the wide pipe to intubate and all.
Middle-aged Man shot in the abdomen
While I had thought that we had closed that horrible gunshots streak, we were here with another middle-aged man shot in a similar pattern.
“Just keep him hemodynamically stable and wait for my directive”, I could hear the cardiac monitor alarms on the other end of the line.
One way to know that the night is ebbing away is when you encounter janitors pushing trolleys of clean linen while brushing shoulders with the team mopping the hospital corridors.
“Doors closing. Doors opening,” the elevator kept announcing as I turned from one corridor to the other.
I semiautomatically found myself in the emergency room as soon as I was done (not quite) with theatre.
I took a quick look at the gentleman and got a certain spirit of reassurance running through me. He was fully conscious and did not labour to breathe. His blood pressure was normal though his heart rate had climbed to above a hundred. The cause of a racing heart rate in a trauma patient is a popular question for post graduate students. In surgery it is often emphasized that one has to ignore anxiety, pain, medication and all and just imagine that the patient is bleeding.
And that is what I imagined. The next question usually becomes, ‘where is the patient bleeding from’?
I looked at his abdomen. Hairy and obese. It moved with respiration. There was an entry and an exit wound. Anywhere in between those two wounds ‘hurt like hell’ when I touched.
Forensic pathologists will tell you how you can estimate the position of the assailant and that of the victim by tracing the entry and exit wounds. Then they will quickly add that the trajectory of a bullet tract is extremely unpredictable. It can take curves, corners and detours before exiting the body. We should always avoid the temptation to assume a straight or curved line between the entry and exit wounds, however obvious it appears.
I could foresee a popular discussion during the morning meeting:
“Gunshot to the abdomen with tachycardia and tender abdomen, why did you not go to theatre straight?” That school of thought would have a camp of professors and other senior surgeons.
“The blood pressure was normal, meaning the patient was in compensated shock. Why did you not consider a CT scan of the abdomen to offer a road map before surgery?” This other camp would have an equal number of debaters, all of reputable expertise.
It would be a kin to a hung parliament in a democracy.
As the senior resident involved in the case, I would have to take the speaker’s seat and reiterate both observations while at the same time affirming their relevance. I would then have to justify one option. And that option would not fly if it was “ the consultant advised”.
I took my side, and I knew what literature to quote when the debate came. I ordered an urgent CT scan of the abdomen. I needed to see the bullet tract and then imagine the trail of destruction left behind. In case of certain ‘tiger territories’ I would know that an uphill task awaited me in theatre. I would summon senior back up before putting knife to skin.
It was nearing daybreak. Traffic had started building up from the highways you could lay your eyes on from the top floor windows. The matatu hoots would be heard from the adjacent termini.
CT Scan of the abdomen
I passed by theatre lounge to pick my laptop. The screen had gone to sleep after hours of inactivity. ‘EVERY BLEEDING STOPS’, read the screen saver. I flipped it closed, threw it into the rucksack and headed out.
I knew I needed to text a couple of consultants about admissions overnight so that they would be prepared coming in the morning. Otherwise the patients could easily miss a consultant review until later in the evening or the next day.
I finished my texts as I sat in front of the CT scanner, next to the radiology technician. He was a jovial man of short stature. He coincidentally tended to be on night duty with me on many occasions. We both tried to smile early morning greetings but the sleep, hunger and fatigue of walking the corridors all night (and previous day for me) betrayed us. In front of us was the computer connected to the CT scanner. Adjacent to it the voice controls. We were viewieng the patient from the glass screen.
“Breath in and hold”, the scanner speakers ordered the patient as the technician pressed a button. He pressed another button and some contrast chemical was automatically pumped into the patient’s forearm. The scanner slid up and down. The patient held his hands behind his head. Then the first images started rolling on the computer screen in front of us.
I thought the abdomen was ‘clean’. All organs looked normal. No free fluid or air in the abdominal cavity. No blood clot around the solid organs like the liver and the spleen.
The consultant general surgeon on call called my personal number.
“Where are you Stanley?” he enquired for he needed me to show him the newly admitted patients.
I asked him to join me at the radiology suite. He walked in some minutes past 6 o’clock with another chief resident. We breached protocol and started looking at the scans before examining the patient. We even joked how we would be frowned upon were we to be found out by the rest of the team examining CT scan images without first hearing then examining the patient.
“There is no peritoneal breach”, we agreed in unison having peeped at the relation of the bullet tract and the outer apron of the abdomen cavity called the peritoneum. Only the skin and the abdominal wall muscles had been injured.
Good News at the Bedside
We now strolled the corridor to the patient’s bedside to examine him and give him the good news.
The consultant and chief resident exchanged glances with me when they saw the size of the patient’s tummy. It was a luxury we could all afford, given that even the heartrate had ground to normalcy in the intervening hours.
We reassured him that his life was out of danger. We would do some limited surgery around the gunshot wound to wash out any dirt and debris. Then we would monitor him.
When we stepped out of the patient cubicle, I was now the centre of the ridiculous attention.
“Do not always look down on us because of the potbelly bwana”, said the faculty. To which the resident added that had I been the victim (God forbid), the bullet would have stopped at my spinal cord.
In other words, RESPECT THE POTBELLY, I concurred.
And just like that, all those comments of ‘how do you ensure diet discipline?’; which gym do you attend, I would like to recommend my husband?’; ‘we are watching what we eat, unlike you’; were forgotten.
During the morning meeting there were no questions on my decision to send a gunshot patient for abdominal CT scan. It was an exaggerated string of low blow comments on how I should aspire to grow a potbelly. Friendly fire moment, we called it.
Later, the professor teaching the nutrition class summed it up with an off the cuff remark:
“If I am operating on Stanley, he will be started on total parenteral ( IV drip) nutrition from day one. As for X and Y ( well-stocked colleagues whose names will be withheld for the sake of global peace), they can starve for a week for all I care.”