surgical principle number 3: all bleeding stops

this is not originally my principle, but it is so true that it somehow found its way into the surgical principles of bongi.

i first saw this principle in action many years ago when i was a community service doctor in qwaqwa. i was doing a call in casualties. actually, the way it worked there meant i was doing more than just a casualties call. i was also the anaesthetist on call and the overall backup for the two interns. for any big surgery we'd call the cuban surgeon out. otherwise we were it. the interns would do the caesarian sections. i would dope the patients and resuscitate the baby if needed. the interns would also do the debridements and ectopics. here i would dope and give useful advice about what to cut off and out and how. anyway i digress.

one of the hospitals that referred to us phoned. the guy had a stab wound neck. he told me it was bleeding profusely and he wanted to send it for surgery. i naturally accepted the patient. but i told him to somehow apply pressure to the wound to control the bleeding for the trip (his hospital was about 40 minutes away). i actually suggested he send someone with a bit of savvy who could put their finger in the wound to directly stop the bleeding.

once i had gotten off the phone i got casualties ready for a big resus. in qwaqwa this took some doing. the charge sister had to unlock the cupboard where the drip needles were kept (they tended to go missing leaving the hospital with no means to put up a line). i checked the intubation equipment and discovered the batteries in the laryngoscope were not working. this resulted in a protracted search through the hospital for either batteries or another laryngoscope. finally we found a working one. i soon gave up on getting a working defibrillator, although some nurses said they heard there was one somewhere on the second floor. i then phoned the surgeon to give him a heads up. he told me to phone back once the patient arrived. then we waited.

about an hour after the initial call, an ambulance came tearing in. the paramedics jumped out and came rushing in with a patient on a stretcher. the patient was tubed. one paramedic was bagging him. another was giving chest compressions. but there were two other things i noticed right away.

the first was that the neck wound was open with no clear signs of any attempt made to stop the bleeding. the second was that the patient was not bleeding.
"when you left the other hospital, was the patient bleeding?" i asked.
"yes!" replied the guy pumping the ambubag. "he was bleeding like crazy!" he seemed to be the one in charge.
"and when did he stop bleeding?"
"about five minutes after we loaded him."

i called it right there, thereby saving everyone a whole lot of paperwork.

and thus i learned that all bleeding stops....eventually.

surgical principle number 2: fear nothing but fear itself

the gist of this principle i have already covered. it has to do with the patient's best chance. if it's you then it really doesn't help to cower away.

i have seen patients suffering because there is some or other doctor just too scared to have a go at it. twice i have been forced to stand down with thyroid surgeries because the anaesthetist was afraid, even though it meant the one patient would remain intubated for a week and the other would disappear into the system, probably to die of asphixiation somewhere down the line.

yes you need to know your limits, but somehow in surgery you also need to back yourself and go where few dare. it is the nature of the beast.

when i joined the surgery department there had just been an acute shortage of registrars in general surgery. therefore, although i was just a medical officer, i was placed in a registrar position as the head of a firm. i was pathetically ill equipped. my consultant, although he was usually available to come out and help, was not quite so willing. there would also be nights when a private surgeon would be the consultant on call. then there was little chance of getting him to come out. our consultant gave myself and my colleague a crash course in what we were likely to encounter on a call and what to do. i called it the how-to-handle-pretty-much-anything-so-i-don't-have-to-come-out-and-work-once-the-sun-has-set course.
in his opening address he told us about an incident that had happened to him during his registrarship when he called his consultant in the middle of the night to help him with a gunshot tail of pancreas. the consultant irritatedly told him to remove the damaged tail. he had never even seen it being done before. he asked how he was supposed to do that.
"use prolene!" shouted the consultant and hung up the phone in his ear.
"so what did you do?" i asked.
"i used prolene." he replied. i remember thinking i should probably find out what prolene is.

some time ago the state asked me to operate a gunshot chest and abdomen. i naturally responded. the abdominal part went quite well, but it soon became apparent the main source of bleeding was the chest. i phoned the thorax surgeon. he told me a bit about how nice it was to be on holiday and that the sun was shining and he was working on his tan. i considered warning him about the dangers of skin cancer but at that moment it didn't seem to be too pressing an issue. he then helpfully suggested i transfer the patient to pretoria, a good three hour drive. i had a better idea. i opened his chest.

now thoracotomies are not really my thing and i haven't done all that many of them. it is not a general surgeon's usual stomping ground, but that didn't matter at that exact moment. i was not only the patient's best chance, i was his only chance. i swallowed hard and got to work.

so, in surgery it is important to fear nothing but fear itself.

surgical principle number 1: to swear does in fact help

don't get me wrong, i don't swear at people (except when they really deserve it). but sometimes in that critical moment in an operation it does tend to dissipate some of the tension if you let off a bit of steam. i first realised this as a medical officer working in the transplant firm.

it was late at night. we had just procured a kidney and had our recipient all prepped for theater. the only problem was we were having trouble finding someone to do the actual transplant. the guy whose name was on the call list for transplants, a private surgeon who had a session post, flatly refused. in the end i had to call the prof.

the head of the transplant unit was the best prof in the department. he was a gentleman( unusual for a surgeon). he always taught the students on rounds with patience and respect. he was an all round nice guy. but he did suffer from a fairly severe form of theater rage (somewhat like road rage but experienced behind the knife rather than behind the wheel). when i called him, despite not being impressed that he had to step into the breech left by the private surgeon, he immediately came out. and so we got to work just after midnight with a tired and somewhat cranky prof.

the mobilization went well but i could see the prof becoming more irritable with every passing minute. even the anastomoses went acceptably well. however the prof started showing signs that his blood nicotine levels were dropping. most of us also believed the prof and his prostate no longer had an amicable relationship, which meant that he did not enjoy long operations. by the time he got to the reimplantation of the ureter into the bladder he had been reduced to a tired irritable old man with a bladder of his own that was no longer going to stand for it. up to that moment, being junior and working with the best prof, i had been nervous that i would do something wrong. but with the laws of nature and old age conspiring against the poor man his hands became progressively more unsure. each movement needed to be repeated a number of times before it was done. this delay further infuriated his bladder which in turn put pressure on the prof to work faster. the faster he tried to work, the slower he got. the true gentleman that he was, he never swore at anyone in the theater (except himself, now that i think about it). but he did swear and quite a bit. ironically i started to relax. behind my mask i actually found myself laughing. i mean what else can you do when the prof starts addressing the patient's bladder (possibly in proxy for his own bladder whom he felt a certain loyalty to and couldn't directly swear at) as a separate troublesome person with sentences like.
"f#@k you bladder!" and
"you're not going to f#@k us around any more, you bastard!"
sometimes i must admit i did wonder which bladder he was speaking to, especially when just after letting the patient's bladder know who is boss the next few stitches would be disasterous and would need to be done all over again. maybe at least his bladder was no longer f#@king us around.

and thus i learned that a well timed harsh word can actually lighten the mood, if only sometimes for the assistant.

yes i swear during surgery, but not ever at anyone and actually never in anger. it is just a sort of valve to deal with what can sometimes be a loaded situation.

surgical principles of bongi

i've always maintained that you should not be allowed to qualify as a doctor without reading the house of god by samuel shem. but that is not what this post is about.

for those of you who have read the masterpiece, you will be familiar with the rules of the house of god as espoused by the fat man. well i sort of developed the surgical principles of bongi, also all anecdotal and not tested by the rigorous requirements of science, but somehow of value, at least to me.

i have decided to embark on a series of posts based on the surgical principles of bongi. to be honest i have been playing with the idea for some time, but have always wondered if these sorts of series may be a precursor to the natural death of a blog (like the great surgeonsblog) and have therefore resisted the urge.

and so without further ado. the principles are:-

1)to swear does in fact help.

2)fear nothing but fear itself.

3)all bleeding stops.

4)enjoy.

5)it is in fact always the surgeon's fault.

6)take a moment.

7)break the tension, don't add to it.

8)we do it to impress the chicks.

shut up fool

some of my colleagues used to tell me i needed to learn how to keep my mouth shut. sometimes i just couldn't resist saying something choice. often this didn't go down well with the old style surgical profs. there were exceptions.

every thursday afternoon we had a gastroenterology meeting. only the surgeons, the gastro fellow and the head of gastro, who were both internists, attended. for reasons i don't know the internal department as a whole didn't feel the need to be there. so generally speaking there were far more surgeons than any other type of doctor.

that day we had already worked through a few scans and had academic discussions about diagnosis and treatment options. we were approaching the end of the meeting. the prof asked if there were any more patients to be presented. the gastro fellow moved forward with a ct scan in his hand.

"i have a patient." he smiled. "i'd like to hear what the surgical registrars have to say about him."
i was in no mood for an internist to try to catch me out in front of my profs. i remember being a bit annoyed. he started presenting. he gave the history of the patient and the clinical findings. as i listened i felt sure the conclusion of the story was going to be that the patient was referred to one of us for a laparotomy.

"i have the ct scan here." he announced proudly, "but before we look at it i have a question for the senior surgical registrars. who can tell me why i requested a scan of this patient's abdomen."
i couldn't stop myself.
"because you can't operate!" i piped up.

everyone except the fellow fell about laughing. that was the only time i remember when the profs laughed at my often injudicious comments. it brought the meeting to an end. the internist was outnumbered. sure enough, the patient had been operated and the profs cut to the chase and asked the relevant surgical registrar what he had found.

late night surgery

sometimes when people hear how little sleep a surgeon sometimes functions on they tend to be surprised. actually it is not a problem if you are operating. during an operation all your faculties are at their sharpest. there is no chance of dropping off, as it were, into an open abdomen. to assist is an altogether different story.

by the time you actually get to operating yourself you would have put in quite a number of hours assisting. the difference between operating and assisting is vast. as i've said during an operation you are totally alert, no matter how little sleep you have had. while assisting, you could easily become distracted and may tend to doze off if you are not fully rested. i have spent many long hours late at night or in the ungodly early morning hours holding some retractor in an abdomen while my senior sewed up what seemed to me to be vast tracts of bowel and i have often heard his irritated voice telling me to retract correctly moments before i probably would have fallen unconscious into the open abdomen. basically put, i know what it is like to assist at these hours and just because i'm fully into the operation does not mean i don't have sympathy with my poor assistants.

however there was one unique assistant. i was still junior but i remember him well. he was not a surgeon at heart so he didn't even have the exhilaration of experiencing open surgery to keep him awake, despite his physiology crying out for sleep. he quickly nodded off with the slightest quiet moaning of his physiology. but he had a unique talent.

this house doctor (that is what he was), while assisting, would push his feet up against the table, lock his knees, hook the retractors into the wound, throw his head back and go to sleep. the weight of his torso pulling indirectly on the retractors gave better exposure than he was ever capable of doing awake.

yes there were times when theater was eerily silent in the wee hours in the fear that the assistant would be woken up, making the operation so much more difficult.