As an intern, you’re basically the bottom rung of the medical ladder and everyone frequently reminds you of this. Which isn’t really the problem. The right of passage through medicine is an ancient one we have all come to accept. After all, there’s nothing else we could do.
You’re expected to work as if you know everything, but submit, as if you know nothing. You cannot complain because ofcourse, “this is how it is”.
I remember being a student on a firey Sunday night when a stabbed abdomen was wheeled in pouring red cells all over the floor creating an unreal image of blood and gore. He was in florid shock. But not dead yet. He had emptied his blood volume onto the stretcher leaving his blood pressure so low, a pulse was barely palpable. He was in big trouble but if enough could be done, he could be saved. (We were feeling optimistic).
My registrar was a peculiar man who I couldn’t really decipher. But what i knew for sure, he definitely was a Cutter.
You see Doctors in my mind fall into two main categories- cutters and non-cutters, each with their respective personalities.
Cutters are usually outspoken, confident and comfortable with a knife. They arent happy unless they have a ten blade or scalpel in hand. They are seriously methodical and enjoy the instant gratification an incision gives. The fine balancing act of not delving into too much beating-around-the-bush but enough detail to dissect the human body from A-Z. Nothing can’t be solved without a surgery. And ofcourse, if it doesn’t work- cut it off.
Non- cutters are on the opposite end of the spectrum. They require every ounce of detail before making any decision. The urea, creatinine, glomerulofiltration rate, heme panel, tumour markers, lactate dehydrogenase, albumin, troponins, white cell and differential count and a stool culture( just for good measure) Non-cutters need as much information as possible to satiate their curious minds. They make decisions from afar while still reminaing hands on.
The spectrum exists for a good reason. And each person plays a pivotal role in what you may need some day. A cutter will never be happy monitoring the trend of a kidney function test 4 hourly.
And a non- cutter will definitely not appreciate digging into a stabbed neck or a gunshot abdomen.
Each person on the spectrum allows the medical fraternity to exist and function in its entirety. The dynamic facets of each corner is what makes the profession an endlessly exciting one. There’s a place for everyone.
The registrar I was on call with, was a mixture of the two. A rare breed indeed. He had the love for cutting and a quiet appreciation for the finer arts of investigating blood work and monitoring the delicate intricacies that is, the human body. He was a man of a few but meaningful words. He wasn’t for small talk and his calm demeanour was always welcomed. He never raised his voice or showed any agitation. He approached every patient with quiet focus.
When I saw him eyeball the bowel eviscerating from the abdominal wall, the cutter in him ignited and his adrenaline kicked in.
The surgical registrar went into overdrive and announced the orders At once. Still cool and collected. We listened and hoped we heard correctly. Everyone dispersed, slightly confused. No one dared to ask twice, as hearing him raise his voice was not something we heard often.
He said order 4 units of blood, I told myself as I ran uphill to the blood bank, my calves feeling the burn of the building lactic acid.
I flung the door opened and rushed to the counter; no one.
I screamed. 4 units of blood to OT ONE PLEASE! URGENT!
The man on the opposite end chewed his gum and stared at me blankly.
4? As in Four? As in 3 +1?
“YES” FOUR. URGENTLY.
I’m sure i saw his eyes roll back and do a back flip.
He chewed. And stared. And chewed. And stared.
“I can give you 1 unit now and 1 unit if you need it later” he seemed proud of his great compromise. He continued chewing.
“NO. I HAVE TO HAVE 4 NOW. THE SURGEON NEEDS 4 UNITS NOW. HE IS OPERATING ON HIS ABDOMEN. THERES 6 STAB WOUNDS. HE LOST 4L OF BLOOD. THE REG NEEDS 4 UNITS. ELSE HE WILL DIE ON THE TABLE”
The annoyance and fast pace of his chewing was evident. He folded his arms and leaned against the wall.
“Nope. I’ll give you 1 for now. Order more after this unit if you need it”
At this point I couldn’t risk delaying getting the 1 lousy unit of blood which would probably pour out the stab site in 5 minutes flat anyway. I couldn’t argue with him. I couldn’t inject logic into his thinking now. Not while someone is bleeding out before his family’s eyes.
I took the 1 unit of blood and cringed. I’m dead meat. what will i tell the surgeon?
When I approached the patient, he could be written off as a corpse. The one slight sign of life was the gentle heaving of his chest and the stark white sheet like colour of his face under the bright theatre lights. Everyone moved harmoniously prepping him for the surgery. The anaethetist looked at me. She laughed.
“1 unit? He already lost around 3L of blood. He is hypertensive and in shock. What must I do with 1 unit of blood? Empty it on the floor?”
I almost answered by apologising when the reg interrupted calmly.
“Let’s start doping and I’ll speak to the blood bank.” he said, without batting an eyelash. He just barely convinced the anaethetust, which was a rare victory.
I handed the unit of blood over and dialed the blood bank number. I wasn’t surprised when no one answered.
I informed the reg, waiting for a reaction of sorts.
“Moosa Let’s take a quick walk to blood bank while they dope. 5 minutes. It will give them some time to push fluids before we cut”
I watched his body language for any sign of distress or anger. His steps were rushed and his pace was fast, but his expression was still calm.
I was sweating and fuming. My heart rate was 110 and my legs felt heavier by the second. My ears boiled.
We entered the blood bank and rang the cute bell conveniently placed on the desk. The small glass window allowed minimal contract, I imagined because of situations like this.
Ring. We waited. Nothing.
Ring. Ring. Ring.
The gentleman stepped out from the back, still chewing.
“Hi I’m the surgeon on call. I need 4 units of blood to operate a serious stabbed abdomen. Without it, the man will die”.
He peered up from his cell phone. Still chewing.
“Not possible. I only have 3 units of blood left. I have to prioritize in case of other emergencies. ”
That’s when it happened. I saw the reg grasp the counter and lean forward. His pupils dilated. His mouth opened. And I knew, He was about to let loose.
“WHAT KIND OF STUPID LOGIC IS THAT?!?! THERES A MAN DYING ON THE TABLE. HE NEEDS BLOOD NOW!!! YOURE PRIORITIZING FOR OTHER EMERGENCIES THAT DONT EXIST NOW. WHILE THIS MAN DIES ON THE TABLE. GET THE DAMN BLOOD NOW OR I’LL GET IT MYSELF”. His hand rested on the door knob.
The gentleman gulped. He disappeared into the back.
We waited. The reg’s facial expression morphed back into its calm mould. He breathed easy.
He emmerged with 3 brown paper bags filled with 3 fresh units of blood. Success.
In theatre things went as well as could be expected. He had massive lacerations to his small bowel but the large left unscathed. His bowel was pale, only flushed by the units of blood being administered. His blood pressue was being helped up by the adrenaline infusion. His kidneys were failing due to the massive amounts of blood loss. His lungs became difficult to ventilate because of the fluid loss. But All in all, he was doing better than expected(death) after 4 hours of being sliced and diced.
After the surgery, we wheeled him to ICU ourselves where we hoped his body could recover and recuperate.
As we pushed the bed down the quiet hallway, I couldn’t help but wonder, so I asked.
“Doc was that the first time you’ve ever been angry?” I looked at his face.
“Nah.” He kept pushing the bed expressionless.
We pushed the doors of ICU opened and manouvred the patient through.
“Its the third time I’ve been angry in about 5 years”.
The patient survived the next 4 days with no big improvement. He died on the 5th day. I couldn’t help but feel defeated but I knew we had to try. We had to give him the best possible chance to survive. And that’s what we did.
I met the reg during ward rounds the same day and I asked if he had heard. He nodded.
“You win some. You lose many. But the ‘many’ should never stop you from fighting for the ‘some’. ”
I’ll never forget those words. I’ve lived by them ever since.