Odysseys of George

From: What an exciting week!

Well, I was on call on Wednesday, it started out like any other morning looking very quiet. As I was doing rounds, we came across a young lady of 16 years old, who had symptoms suggestive of acute appendicitis. Not very convinced, I ordered them to book the case for laparoscopic appendectomy. Two beds later, a young aspiring surgeon now in Masters training, comes up to me and says,” Mr.George, we have a laparotomy. A 72 year old man with possibility of ischaemic bowel. We are waiting for OT(operating theatre) to call!” I smiled. My colleagues smiled back acknowledging my as usual busy and challenging calls.

As I completed my rounds, the anaesthetist decided to call for the laparoscopic appendectomy and my medical officer on call calls me to alert me of an emergency case. Now, everything suddenly appears to be a rush. I sent my junior surgeon to emergency as I rushed to OT to do the laparoscopic appendectomy. As I was doing this, I was contemplating on my decision to proceed with laparoscopic appendectomy or let my medical officer do it the normal way, at least by that I would be free to assess both my ill patients. But, my intuition told me not to change my mind and luckily what we found was a ruptured ovarian cyst with blood in the peritoneum. Great! I spared her needing a 3 to 5cm wound, and left the normal appendix alone.

Relief, I walked out of the OT just to get a call confirming my fears about the emergency case. A young 17 year old boy with internal bleeding from a ruptured spleen. Alerting my anaesthetist who just came back to work from her maternity leave, I rushed to the emergency to evaluate the situation for myself. There on the trolley, is a 17 year old boy very much conscious and alert, complain of difficulty in breathing and pain all over his abdomen. He had other injuries like lung contusion and left kidney contusion. We intubated him and called for an urgent surgery for him. He was bleeding and thus the urgency.

Just I uttered the orders, my junior surgeon interrupted,” George, the patient in the ward collapsed.” We rushed to the ward to find the elderly man with “ischaemic bowel”, pale, breathless, his pulse racing and his pressures had dropped and his abdomen was a mountain high(distended). We intubated him and resuscitated him. I was in trouble!

Trouble? One emergency OT and 2 emergency cases. A 17 year old versus a 72 year old - both bleeding. Dilemma?

I did not have much time to ponder the dilemma as the boy was already on the OT table. So again rush! Chop! Chop! His shattered spleen was out. He was stable. I motioned the anaesthetist to open a second OT for the elderly man as orthopaedics were coming in to fix this boys fractured arms. I was informed that they pushed the elderly man to ICU for stabilization.

I finished closing the boys abdomen and rushed to ICU. My biggest worry was becoming more a reality. This elderly man does not have an ischaemic bowel but a ruptured abdominal aortic aneurysm,AAA( an abnormal balooning of the major vessel in the abdomen). He needed surgery urgently. They managed to arrange a second OT, by which time he was on maximum dose of drugs to support his blood pressure and was in DIVC(a condition which renders the blood inability to clot) His chances were slim but we had to try.

We rushed again. We managed to get control on the vessel and that allowed the anaesthetist to rush in fluids to catch up with the losses. They worked hard and we were drenched in blood and sweat. I could feel the blood permeating through my scrub clothes onto my legs despite me wearing a plastic apron over it. He had lost an estimate 20 litres of blood and we have finished grafting the vessel. But he was deteriorating. His blood was water. He was oozing from every raw surface. We were running out of blood and blood products. It was a losing battle. We tried…… while in our minds the statistics and evidence were glaringly obvious.

Mortality in emergency cases of a ruptured AAA is very high, even at the best of centres. He succumbed. We were tired and sad. Exhausted is more like it. Hungry too. My last meal was the night before. It was already 9pm.

We left the hospital for dinner and returned to do my night rounds reviewing all the new cases and referrals that were awaiting my decision. Luckily, the rest of the night was quiet.

This has been an exciting week! and guess what the week is not over yet!
Well, Monday was interesting as I operated on a gentleman with Rectal Cancer. It was challenging as his pelvis was very narrow. He had completed a course of chemo-radiotheraphy as at presentation the growth was very large. See how well the growth has responded to the chemo-radiotheraphy. The growth has shrunk and makes surgery easier to perform.

Tuesday, was my scope day. Interestingly, there was this patient with this throughout her large intestine(colon). This was depicted once by Bernard in his blog a few months ago. Still remember? This elderly lady also had an added finding. Care to comment?

Wednesday and Thursday, was a totally different story! That in another article!

Answer for the bowel discolouration

Welcome to Grandrounds No.10.

As I,was thinking on how to get around this honour which was set upon me by my buddy and our friends, so this is what I decided to come up with. Well initially, it was suppose to be a sing along to a song and the round had a theme but… next time maybe.

I start this grandrounds with a cheer,to Jimbo and his friend, who won first prize for his poster presentation.

Swee Kheng from Taiping, starts a well written article with “one year on, the pain and hurt has been replaced in its acute form, by a dull and aching sensation, always present in your soul, always present in the things that you do every day.”

As I browsed the blogs, many wrote about work and medicine. You name it had a picture of an abdominal xray which she called coffee-bean, as she continues to examine the elderly lady with a partial? per-rectal examination! I wonder how far her finger would go in a full per-rectal!!

Stormyformydoctors had a stormy locum practice after an intense quiet day but managed to do his bit to make him and all of us proud.

Talking about a stormy day, Sbanboy wrote to us why things ( in his case - bad calls), just don’ change despite changing hospitals. Well, a wise man said, you can never run from fate. Saw Ling adds to this as she describes her tough life in one of her worst days ever. No! I thought I was bad! Three horrors in 2 hours, you beat me to it Saw Ling.

I also realised that Sbanboy was not the only one to have changed hospitals. Shah, also rambled his way to new place but seem to be enjoying himself so much that he forgot to blog for a week!
Hope you are happy,Shah!

Before I leave work in medicine, I thought I would highlight an article where the owl after feeding his nocturnal life decides to advocate research especially among the medical students.

Life treats us in many ways. Shellgal makes an interesting article when she claims love is a paradox just after she realises that working is not about taking instructions blindly. Work is a paradox too sometimes!
Yap in his tent, tried to recall what friendship is all about and what kind of a friend he is. But what attracted me the most is the failure vagus felt as many of us have felt as such one day or another in our own lifetime about life and death.

With that, I end my grandrounds with this :

(Huh! At last got rid of the 404 Error, I hope. Why I don’t know, how also don’t know)

Bernard, tagged me for this meme which looks like it has been going on for a while now. As personal as it is, I definitely will not stop the flow of this! So here it comes! But.. I doubt it would be of any interest! Quite boring actually.

1. I used to play the violin and guitar
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First almost 16 comments were treated as spam and now my article cannot be commented on. Idont seem to know where the problem is!? Help anyone? By the way if this works, you can leave your comments for the meme here!

Well as have been published in the sidebar, yours truly has been nominated for three categories, Best New Medical Weblog, Best Literary Medical Weblog and Best Medical Technologies and Informatics Weblog. Please do click on the trophy in the sidebar which would link you to the polls where you can exercise your voting rights. The closing day for voting is on the 14th January 2007.

Vote for my good buddy Bernard’s Page who was also nominated for the Best New Medical Weblog. Well actually you can cast two votes for this category as there are 2 poll groups.