Is the patient alright?
It was 2am. My usual interrupted sleep cycle had waited a while before starting up its usual charade and that was because I was exhausted ???. I would not have been surprised if I had been snoring sef. I picked up my phone and saw 16 missed calls. Okayyyyy … what’s happening here???? Some of the calls were from my other houseofficer colleagues in general surgery 3 but majority of them were from the medical officer we answered to in the unit. I was afraid, ladies and gentlemen, I won’t even lie. I tried calling the MO back but his number was not going through!
But even as the sleep had cleared from my eyes, I wondered, “So, even if he picks your call, unto what end? Would you actually start going back to work at this time?” He had sent a message at some minutes to 11pm but my tired self had slept since and had plugged in my phone to charge, far from me. The message was to go and review a patient we had earlier admitted that day. I quickly reached out to the houseofficers and they said they were also calling because of this same patient. At this point, I was terrified. What in God’s name could have happened to this patient? What was it that warranted this ungodly summons? I had ensured everything was alright before leaving ó.
So, early in the morning, I was already on my way to work. I really was not settled the rest of that night.
Was the patient okay? Was there something I was supposed to do that I didn’t? Did she go into some kind of shock? Or… wait… was she dead? ??? Oh dear God. That must be it. Or maybe they had to move her to the intensive care unit because all her systems had shut down. Hay God. And she was now attached to several monitors. This is how my temporary license would be revoked ooo. Village people, are you guys happy now? Are you???
The fear with which I entered the emergency treatment room that morning, was enough for my whole surgery posting. My heart was beating so fast, I thought it would burst. Even if she was not dead, what if they all just start shouting at me? I do not like being shouted at. Mummy!!!? I was practically running to the place while my mind was screaming at me to slow down so I would not get the bad news so soon.
At the least, she was still alive!
You can then imagine my relief when I saw the woman alive…like, she was actually still breathing. Wow! And she was not connected to any weird machine. Glory!! And she did not look any worse for the wear, well, apart from a glaring dissatisfied look she had on her face. So, I could tell my heart to stop beating like some Sango masquerade was chasing me and actually breathe properly. I then took her case note to at least know the latest about her. I saw that my MO had come around 12am to review her (I guess after he was not getting across to any of us houseofficers and the nurses on duty were not letting him rest). And what was the patient’s complaint?
She was hungry!?
She wanted to eat.??
Her stomach was protesting.???
This was a woman who came in screaming down the whole ETR due to abdominal pain that was like everywhere and radiating to her back and abdominal swelling, bloating, vomiting, constipation which later became obstipation (that is, she was not even farting) and was being evaluated for possible intestinal obstruction and had been expressly placed on NIL PER ORIS. That is, nothing by mouth. Like, it was written in her case note in capital letters. So, her complaint about hunger was not uncalled for but there was no need for any review because what she wanted was not something we could give her. The nurse calling our MO should have seen the NPO instruction under the plan of management. So, it was either she did not think it the right plan (which I doubt) or she could no longer handle the pressure the patient and her relatives were mounting on her regarding the issue. Apparently, the patient’s brother had started raising a lot of dust and was threatening to wreck some havoc.
Am I a joke to you people?
I first sat down. Looked at the patient. Looked at the nurse. Looked at the documentation again. Were my eyes deceiving me? I did not know whether to laugh or cry. You mean to say the reason why my heart was about to give out was because a grown woman was hungry.
I went to hear from the horse’s mouth and this woman was telling me there was no reason why she should not eat. Why should we be doing that to her? This was a woman whose abdomen was even bigger than what it was when she first came in. I asked if she had passed stool since she was admitted. She said yes, that she did that morning. I asked, ‘’was it well formed?” she said yes. I asked if she was sure and she said yes, and the nurse was also confirming it. I did not believe them. It was possible that she had passed stool but I had a feeling it was spurious diarrhea. This refers to watery stool sometimes passed after a long time of constipation. What happens is that some part of the accumulated feces just above the point of obstruction undergoes breakdown by bacteria and becomes soft enough to seep through the obstruction. It does not mean the obstruction has been relieved kankan.
I documented my findings and part of my plan was to, amongst other things, CONTINUE ON NPO, pass a nasogastric tube to try and decompress the stomach and then keep a monitoring of her abdominal girth. I went ahead to discuss with one of the unit consultants and he agreed with what I wrote and added some more.
Nasty but, necessary!
It was time to pass the nasogastric tube but first, I had to have a heart to heart talk with this woman, because, I doubted she understood the gravity of what was going on. I tried, as patiently as I could, to explain the possible mechanism of what was going on. Whatever was going on was not yet straightforward, but one thing was sure, that abdomen needed to rest. The ultrasound scan she did showed dilated small bowel loops. So, there was definitely something causing an obstruction. She also had had three caesarean sections in the past, so, maybe some adhesions were to blame. But that did not explain why she was having high sugar levels despite not being a previously diabetic. The abdominal x-ray she did was not so helpful.
But, one thing was clear, her tummy was getting bigger and that meant something was still wrong, even her brother confirmed this…well, after he had calmed down enough to understand why his sister could not eat just yet. And he was able to truthfully tell that his sister’s stool that morning was nothing close to well formed. Then, I explained why I needed to pass the nasogastric tube. I have never had this tube thingy passed into my throat and I do not intend to but I have been told it is a nasty experience.
A tube not a rope, don’t pull!
One of the body’s defense mechanism, the gag reflex, is supposed to inhibit any possible intruder that is not saliva, fluid or food or is food but not the safe size or consistency. It is therefore, a big struggle to pass the tube smoothly. Even after all my explanation and pleading with this woman to just cooperate, she still struggled and eventually pulled out the tube just as I was about securing it to her nose. But that was after a copious amount of bilious effluent came out under some pressure.
I think coupled with her earlier hunger games, I was not pleased at all when she removed the tube. I just abandoned the whole thing, documented in her case note and planned to repass the tube when she was ready. By the way, doctors, you really need to learn to document EVERYTHING. Because, with all your explanation, a patient can vehemently deny you. Woh, they can lie that they never even saw your shadow. It is that documentation that will save you ó.
…for a second, I understood surgeons!
Remember how earlier I said in did not like the interactive skills of surgeons? Well. Here I was doing what I thought was the ideal and what did I get in return? This woman was not willing to listen or cooperate. I was trying not to be the typical surgeon but it seemed I was not getting through to her. I was explaining that she might have to be taken in for surgery. My woman was already chanting all the, “God forbid, it isn’t me, God has healed me.”??? mantra typical of religious people. At that point, I think I understood a bit why most surgeons stop bothering. Although, I still do not see it as an excuse for not doing what is right.
He needed to be with family…
One of the rules of resuming general surgery 3 (there are three subunits in general surgery) is to clerk all the patients on admission for the unit before introducing yourself to the consultant and resuming fully. When I was resuming, we had just two patients on the ward. One of them was an elderly man in his 70s who was being managed for a malignancy in his liver that had spread… everywhere. He was swollen all over, worse in his legs, he could not lie comfortably in bed, his breathing was erratic and he was depressed. He was no more eating, no more taking his drugs, no more attending to his visitors and just sat in his chair by the bed, urinating and defecating on himself. It was a sad sight???. He was not willing to answer any of my questions, in fact, when I got to his side and called his name several times with no response, I thought he had gone to the great beyond.
Why was this man on our ward? What were we doing for him? There was no definitive surgery for his case. There was no miracle surgery to get all the cancer lumps all over his body. Even if we took him to theater, the stress was enough to kill him right on the table. This was a man that needed just palliative care. He needed to be with his people, in a familiar environment, waking up and sleeping at his own timing and with little or no pain.
A call to action
One thing we still need to work on, in the medical profession, is knowing when to stop. When to let patients go home to live the rest of their days in peace, away from the motions of the hospital that may no longer be helpful at that time. To know when we have nothing more to offer the patient that cannot be given at home and thus, increase our home based and hospice care services. The hospital environment, in all its help, can be detrimental after a while… especially because no one wants to just lie on an uncomfortable bed and have nothing being done to them. As the relatives are prone to say, “they are not even doing anything for him/her.” No one wants to be subjected to the routines of the ward, which include waking up early, having your bath, eating at the same time, when, “they are not even doing anything for me”. No one wants to be taxed for bed space, hospital utilities and toiletries when, “they are not even doing anything for me”. No one wants to have restrictions placed on visiting time when… you get the drift.
An instance of shifting roles I had in general surgery 3 was after the surgery of an elderly patient; A woman who was surrounded by loving, willing and financially capable children and relatives. The most feared complication after her surgery was lung atelectasis and pain increases the risk. That’s like trying to hold your breath because when you breathe, a truckload of pain hits hard and you feel like you’ll die. Thus, the lungs are not expanding as they should and… some part of the lung more or less collapses and well, that’s a closer bus stop to heaven. So, it was agreed that her post-op pain control must be optimum.
Top up post-op epidural bawo?
Now, let’s backtrack to some hours before her surgery, I was in my scrubs, looking all fine and hot when the consultant anesthetist called me and started asking me questions about my future plans, telling me how it is better to start planning early and determining how much BS from Nigeria I can take and how he has concluded to get his wealth from this country. I was initially hesitant to talk ‘cos I was not ready to be lectured on how Nigeria needs me and how I should be the change the nation needs. But, this man seemed genuinely interested and friendly. Yimu.
So, when the surgery was over and he was telling me and the two other houseofficers that the patient would need proper analgesia, I was just smiling broadly. Until I heard,
“So, the three of you would be alternating to top up the epidural analgesia hourly”. Sir, you say? ??
First off, managing the epidural was the work of anesthetists, that’s how it’s always been. Never have I heard that houseofficers were put in charge of post op epidural. The three of us were just looking lost, like, “how?!?!!” The consultant anesthetists was asking us why we were looking like that, that doesn’t he have the right to instruct us again? That were we about to say no? Lol, who were we biko?? He told us to be on the ward that one of the resident doctors in anesthesia would put us through on how to administer the first epidural so we could carry out the others till 8am the next day. This was around 4pm.
My other two houseofficers told me to go home, get a change of clothing and come back in like 5hours, that they would handle the epidural till I get back. I got back around 8pm to news from one of them that another senior resident doctor in anesthesia said it is not our job as houseofficers to give epidural. I asked him if he was sure and he confirmed it that the regs in anesthesia would handle it. I was like, okay oh???. I had already packed in for the night anyway, so I just stayed in the lounge.
My head almost got bite off
An hour later, my consultant called and all that was left was for him to bite off my head over the phone. That why weren’t we on the ward? What happened to the woman’s epidural? Why were we being insubordinate? That we better drag ourselves to the ward and get it done. He was not even listening to what I was trying to explain. I had barely dropped his call when the consultant anesthetist also called and more or less took over from him to shout my head off. Going on about how he was disappointed in us, and especially in me, after all the chitchat we had earlier and how he had concluded I was responsible. That so he could not trust me to handle the epidural?
Mehn, I was in tears. Did I beg to be called to talk? Did I ask you to talk with me? I was in my space when you brought in this fatherly act and got me talking. So, what’s all this emotional manipulation?
At this point, the other houseofficers had gone home, as we agreed, so, I was the one bearing the brunt of it all. I called the one that told me it was not our job again to relay the turn of events. He was surprised and as shocked as I was. I called the resident doctor he quoted and at first, he confirmed that it was not our job. Then, when he heard what the consultants said, he changed it to,
“I’m not the one on call, maybe you should speak with the reg/SR on call. You know, the consultant’s instruction always supersedes.”
Oh, you did not know that before you told my other HO something else? Cos we thought you guys had settled this issue among yourselves and had concluded to take responsibility for what was… your responsibility? After I had psychologically and physically prepared myself for the task, you gave false hope and then, when the bus came rolling over my head, you remembered you were not the one on call. Wow.??♀️??♀️??♀️
While I was still in shock at the shift, I was prepared to add this to part of the hands-on skills learnt. But, because of some communication gap, I was made to look like I was evading work. This was despite how I had left the hospital at 8pm the day prior, woke up to the 2am 16 missed calls for a hungry patient on NPO, went to the hospital as early as 6am, slept in the hospital till the next day (a public holiday) for this surgery and now had packed my things to stay another night and day (another public holiday) in the hospital. And I was not on call.
The epidural was changed to three hourly and I gave one (the resident doctor on call gave the others but I was with him as an observer). The patient later died … but it was not from pain. It was not from pain. I was pained though. But I did not die. Thank Jesus.
… speed, skills and successful operations.
While in surgery, during theater sessions, I was able to note the different levels of speed, skills and success individual surgeons had. While some were very fast in their operations, some preferred to take their time. And taking their time did not mean they gave the best incisions or finest stitches. And being fast was not a guarantee of successful operations.
But, there was one, a new consultant then. He had the three… speed, skills and successful operations. If you were not careful, you’d miss the whole operation while still trying to settle down. He was that good. And he did his work quietly. I was actually impressed. You see, when you see a man excelling in his element, it makes you feel like following in his footsteps. But knowing my inclination away from surgery, his being in charge of his theater sessions challenged me to be the best of me wherever I find myself in this medicine.
I remember mentioning looking fine in my scrubs. Yeah, that look was hard to get o.
Just as it was hard to get accommodation in this Abeokuta (thanks to God, Ibilola, the Knight and IBK… the best agent you could actually ask for in Abk. You can ask me for her number), it was hard to get a tailor to make me scrubs. I had to go all the way to Ibadan to purchase those readymade ones at ABH ventures. But I was determined not to have to rely on the ones supplied at the theater. Imagine my shookness when a theater nurse told me she would rather I don’t wear my scrubs to theatre, that it is too fine. She does not like it. Eskiss me ma, are you looking at me during theater or you are doing your job? Please pick a struggle. Thanchiuu.
Leave or no leave
Another thing that almost got me scared in this posting was how I almost did not go on leave. Due to the logistics of PSU and being low on houseofficers while I was there, I could not go on leave even though it would have been the best place to go on leave (I spent 5 weeks there). I also could not go on leave in Ortho because I spent 3 weeks and some days there and at some point too, I was the only houseofficer. So, when I got to general surgery where I was to spend 4 weeks and some days, I got scared that they would not allow me go on leave because it was my last posting and I should have taken the leave earlier.
But, thank God with me, I did go on leave. If not, I probably would have keeled over. I needed that break even if the only thing I was going to do was sit on my inflatable bed and stare into space.
Phew!!! And this is the end of my surgery ‘Lamentations’.
Brief of surgery rotation
It sure seems like the whole of surgery was ‘low low’ for me and I wonder if it was just because of the mindset I already had about it or if things were just not aligned right during that time or maybe the place is truly just not safe, well, except for Orthopedics. The high times for me were seeing our PSU ‘Starboy’ do well, start taking direct breast milk, gain weight and get discharged, and getting thanked by my “2am hungry patient” after the surgery and apologizing for those times she was not cooperative and being thanked profusely by her brother who thought his sister was going to die. I later saw this woman during my internal medicine rotation (which we would be going to next) and she looked so beautiful and well.
It’s shout out time!!!
Dr. Adegboyega!!! YOU ARE EXTRAORDINARY. You actually stand out and I wonder how you fit into surgery seeing as you don’t exhibit the ‘typical’ surgeon’s habits. You are diligent and that is highly commendable. Thank you for all the trust, care and jokes. Keep your chin up, Oga, your reward is great.????
Dr. Abdulraheem; I’m glad I spent most of my clinics with you while you consulted. Thank you, sir, for the percussions. You gingered me to go back to read up the cases we attended to in clinic and on the wards. And, thank you for being approachable and down to earth.
Dr. Omotola; Sir, you made orthopedics even sweeter. You are a man of few words but your actions speak louder and speak really well of you. Thank you for inspiring the love for orthopedics in me, and even though I may disappoint you in not toeing that path, I promise to make you proud.
Dr. Sanni; Sir, the triple S of theater belongs to you.?♀️
The End. Now we go to Internal Medicine.