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surgical principle number 8: we do it to impress the chicks

what is the point of even having surgical principles if you can't finish them off with a light hearted one.

general surgery is roughly divided into two categories. ie. blood and guts. the guts side of things involves feces, stomach content, bowel content, bad smells and the like. the blood side of things is often high drama and adrenaline and is the stuff that the medical tv shows are made of. most of the general public don't really want to hear about the time i did a rectal examination and my glove broke or the fact that the smell of a septic abdomen somehow seeps through the gloves and it can't be washed off your hands afterwards leaving a most unpleasant stench. i considered trying to market whatever it is in abdominal puss that causes that stench as a deterrent for fingernail biting, but it seemed too much effort.

but if you talk about someone bleeding to death and you intervene, this causes an entirely different reaction. it makes school children who watch these tv programms think that they would love to become surgeons. i just hope they don't bite their nails. so, bearing in mind we can only really be glamorous in half of our work, it is sometimes nice when one can get a bit of this glory.

it was post intermediates and i tended to stroll around casualties as i have mentioned before. a good friend of mine and i were in the same firm, so the night in question, we were both together checking out what was happening there. we had nothing better to do for a change.
as we casually walked through casualties (why can't more people be casual in casualties i wonder) we heard a bit of commotion in resus. we walked over and glanced in. what a sight.

there was a guy lying on the table. he had a large gash in his chest just left of the sternum. out of this hole bright red blood was gushing out in torrents. there were two casualty officers poking away with artery forceps but in that amount of blood it was clear they were losing the battle badly. the patient was still moving but his movements lacked conviction and were getting weaker as we watched. obviously they had called the thoracic guy but just as obviously, unless he was just around the corner the patient would be dead when he arrived. i thought that the heart was probably lacerated.
i turned to my friend.
"shall we?" i asked.
"why not?" he replied. and we walked in.

the casualty officers acknowledged our presence with nervous smiles. i asked for a knife. there were only loose blades. i took one and extended the wound. the patient didn't flinch. he was on his way out. i shoved a swab in. my friend hooked the edge of the wound with a retractor, but because of the ribs we couldn't really open too wide.
"i see it , i see it!!" he shouted. he reached for an artery clamp and grabbed the upper end of the transected internal thoracic artery (also known as the internal mammary artery, but because this guy was a guy i've decided to go with internal thoracic). immediately the amount of blood was less. i shifted my retractor and quickly identified the lower end of the transected artery. it's a lot easier when you know what you are looking for. i clamped it. soon we were tying the bleeders off.
we spent a bit more time to put up acceptable lines and call theater to book the thoracotomy for when the thoracic guy actually did turn up.

in just moments we had turned a hopeless situation into at least a salvageable one. when the thoracic guy finally did turn up all he had to do was wait for theater and fix up the hole in the guy's chest (which admittedly we were more than partly responsible for).

then my friend turned to me.
"have you seen outside resus?"
"what do you mean?" i asked.
"go look."
i walked outside. there were about five nursing students, all wide eyed and all looking at us as if we were absolute heroes. being a surgeon and already being under the influences of an over active ego, i felt pretty good. i did not want to be the one to tell them we had just been lucky with the injury and that a true stab to the heart would most likely not have turned out quite so rose coloured (except maybe a blood red rose of course).

surgical principle number 7: break the tension, don't add to it

sometimes surgery is routine and mundane. but sometimes it is anything but.

i have assisted enough surgeons who lose their cool at the drop of a hat to be able to see first hand that it doesn't help. however i only formulated this as a principle when something happened while i was operating as a senior registrar.

it was late at night or in the early hours, i can't quite remember. the case was tense enough in that some guy had taken a standard dose of lead through the abdomen. (this is not the best route of administration. it can be messy.) we had gotten him to theater fairly quickly by that hospital's standards and were systematically going through the things you need to systematically go through. my assistant was a junior medical officer. the scrub sister was also quite junior. i was quite at home with this state of affairs. in fact everything was moving along quite smoothly.

then something went wrong. it involved bleeding and the potential of bleeding in great quantities. my mindset changed instantly. i went silent. my assistant, although he was junior, could see this was not a good situation we found ourselves in. the sister was deeply involved in a conversation with the floor nurse. i think it had something to do with a recipe for chicken feet and atchar. i was glad i had something else to concentrate on. (both chicken feet and atchar are disgusting to me and even to be exposed to a conversation about them i find a bit disturbing.)

anyway i asked for artery forceps (i think that is the translation for arterie klem which is actually what i asked for). i needed them at exactly that moment because it was at that split second that i had perfect exposure and could see the source of the bleeding. the sister hadn't yet realised that the operation had just changed into a new gear. there seemed to be some discussion about exactly what type of atchar goes best with chicken feet and she simply was no longer really into the operation. my assistant snapped.
"sister pass the blasted artery forceps right now dammit!!!" he shouted. it was time for a moment.

i shoved a swab into the wound and applied direct pressure. i informed my assistant that he needed to take a moment too. i then turned to the sister and calmly told her that things had gone ever so slightly south and i needed her to leave chicken feet and atchar for later and pay attention for now. and then... then i leaned over and said the first harsh thing i had ever said to anyone in theater. i told my assistant in no uncertain terms that he will never ever raise his voice at anyone while working with me again. in fact i informed him that while working with me he could only speak directly to me from then on. he was surprised seeing that he thought he was trying to help. (only one other time have i raised my voice in theater and that was to blind chicken boy. but that story could be left for another post)

after the moment i got control and finished the operation to almost deafening silence.

later i discussed the situation with him. at that moment there was too much chaos. there were too many variables working against the patient. my complaint with him had to do with that he heightened an already tense situation and only succeeded in showing the sister that he had no control. i explained that he had to transcend the situation and not only take control, but calm the situation. in surgery you don't need to look for trouble or create it. trouble will come of its own accord.

also as a typical surgeon i was not at all impressed that he had attempted to take control during an operation, but that i just kept to myself.

surgical principle number 6: take a moment

you wouldn't think it by reading this blog, but sometimes in surgery things can go wrong. and sometimes they can go severely wrong very quickly. strangely at the moment of disaster it is not always clear if you are facing a problem or a full blown disaster. and thus i learned to take a moment.

the principle of the moment actually took its origins from many years ago when i was still a house doctor. in those days i was already doing certain surgeries which were way above my head. i would always try to get my frame of mind right while scrubbing. i would think about the operation and what i was likely to encounter and just try to focus. yes, in a certain sense i was already taking a moment.

in training when i was a junior i did quite a bit of assisting as can be expected. when things got rough generally the tension was almost too much to bear. and if the lowly assistant didn't hold the deaver retractor just right or for long enough all hell was likely to break loose. let me just use this moment to mention that the deaver was designed by a sadistic internist who now sits in his office chuckling to himself about the hand spasms that his instrument causes to us surgery folk. either that or the devil himself took time off from tormenting the damned to create something that could torment the living too.
anyway, as an assistant during those numerous tense moments my hands often spasmed so badly that it was difficult to open them afterwards. i wondered why the blasted surgeon couldn't just take a moment so the poor assistant could stretch his fingers before the next protracted attempt to get whatever surgical control needed to be gotten. at least then at the crucial moment the assistant would be worth something.

and then there is the small issue of bleeding. yes, boys and girls we have learned that all bleeding stops, but i personally believe it is better to stop the bleeding while there is at least a flicker of life left in the patient. these moments are the true adrenaline moments in our job. during these moments the actions of the surgeon will determine whether the patient lives or dies. you need to be at your best. you need your assistant to be at his best. what an ideal time to take a moment. you can just go through what to do in your mind before the chips really do go down. you can instruct your assistant to relax and prepare to unrelax during what is about to transpire while you settle yourself and concentrate on what you are about to do. (it is important to tell the assistant to take a moment. all but the most useless can feel the tension and will not relax unless they are actually told to.)

but the moment has to do with bleeding too. obviously you can't just step back while some big artery is pumping blood all over the floor (it might annoy the sister). pressure is the key. you put pressure on the bleeder with a swab and then you take your moment. (remember to let your assistant know this is his moment too. he will use it to stretch his fingers and curse the fiend who designed the deaver.) while you are trying to remember the punch line of some weak joke in an attempt to put everyone at ease, your pressure with the swab will help with the bleeding. it is controlling all the venous oozing, leaving only the surgically significant bleeding for you to control. you see in the heat of the moment, with severe bleeding, those worrisome venous oozers sometimes cause just enough trouble to really make control difficult. you are not sure what to tie off and that small amount of ooze obscures the vision just enough to make control difficult.

so in conclusion, at the most critical times during an operation, put time aside to take a moment. it settles your nerves, optimalizes your assistant and helps with bleeding. it also creates the illusion that you are totally in control even if the situation is spiralling downwards towards the creator of the deaver.

surgical principle number 5: it is in fact always the surgeon's fault

one of my professors used to say, in jest i believe, but i'm not sure, that no matter what goes wrong in an operation, it is always the assistant's fault. i used to give the appropriate awkward laugh. it soothes the fragile surgical ego. but my laugh was never more than awkward.

i somehow could not adopt my prof's opinion. the more i thought about it, the more i disagreed. in training, your assistants are almost always students and pretty clueless. as it turns out, you need to direct them to do what you need them to do. you actually have to actively use them as additional instruments in whatever operation you happen to be doing. besides, at the m and m, it will be you and you alone before the prof when he asks the obligatory please explain.

bearing in mind most students have a dread of the surgery and bearing in mind some of the stuff that goes down can rest heavily on the conscience (and therefore your sleep) i'm not sure what advantage there is to let the poor students feel more responsible than they are. in a certain way this principle goes with 4. not only did i try to let my students enjoy surgery, i tried to protect them from some of the trauma which can be inflicted by being so intimately involved with human suffering.

fairly recently my belief in this system was somewhat put to the test. a good friend of mine was assisting me with an appendix. he is destined to become a great internist one day which sort of implies he could sometimes be somewhat absent minded with the physical practicalities of an operation. it didn't bother me. i enjoyed working with him and i reasoned i needed to be fully in control anyway.

with this appendix, every time i asked him to loosen the artery clamp as i tied off the mesoappendis he did some sort of weird hand exchange to be able to loosen the clamp with his right hand. it seems he was not capable of doing it with his left hand. easily solved, i thought. it is true the clamps are all made for right handed people and there was a specific left handed technique needed to loosen the clamp. i decided to teach him this technique. i stopped the operation and asked the sister for an artery clamp.

even though at heart he was an internist, he was a quick learner and quite soon he was easily loosening the demonstration clamp with his left hand. i had a moment of pride in him but it passed soon.

then we got back to work. he grabbed the clamp on the appendix base, the only remaining clamp holding the appendix up to the wound and with a swift smooth movement, released it. the stump slipped easily back into the abdomen. he seemed so proud, i almost didn't want to tell him that usually one ties off the appendix base before the assistant loosens the clamp and allows the appendix to fall neatly into the abdomen. somehow there is less leakage from a closed stump than an open one. but i had to.

we took quite a while longer to retrieve the stump and tie it off and then obviously to do the necessary lavage.

still i had to be true to my principles. yes, even then it was my fault.

surgical principle number 4: enjoy

surgeons are too stuck up. just because you might be saving someone's life and just because blood and guts might be all over the place it doesn't mean you can't take a moment to just enjoy it all. to be honest it might be the one thing that keeps you sane through all the madness.

in our department the prof demanded complete silence during operations. he even used hand signs to ask for instruments so he didn't have to speak. woe to any student who spoke. and if we didn't show due awe at all times he was not impressed. but the problem with spending so much effort working up all that awe all the time was you were often not left with enough energy to just enjoy what was going on. he also had an amazing ability to make students hate their surgery rotations. (how weird is that? it's like hating ice-cream or christmas lunch). i thought another approach would be better.

there is a general shortage of general surgeons in south africa. sure it has a lot to do with the hours and working conditions and all the other well publicised reasons. but it also has to do with a reluctance to go through the old style training. but i don't think all the aspects of the old style training are bad if you want to create surgeons that are worth something in the real world. but at least instill in them an enjoyment in what they do. i mean, let's face it, how cool is it to be a surgeon? we get to cut people open and mess about a bit with their innards. sometimes we might actually make a difference.

so whenever i operated with students one of the things i concentrated on was instilling in them the absolute joy of surgery. i know of three students that decided to study surgery as a direct result of working with me and one student who decided not to quit medicine altogether after having worked with me.

so for all my faithful readers, whenever cutting and dicing, stop and reflect for a moment about how wonderful it is to do what you are doing. don't just enjoy it but instil in those around you more than just a healthy dose of enjoyment.