Wednesday, April 22, 2009

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.


  1. There is a saying that goes: "Do not trouble trouble until trouble troubles you". It is a sage adage.

    I have found that the loudest way to get your point across, is to drop your tone and speak slowly and quietly. It's often more effective than vast volume. I've certainly seen it stop some people in their tracks ...

  2. Great time to write about tension. Im hoping this is not the last night we all sleep in peace, considering that a certain youth league leader is already crying cheat even before votes are counted. Also doctors are on strike, never would i have thought that would happen in SA.

  3. Post op l slung the artery forceps back at the vet (and hit him with them) He flung them at me as hard as he could in a temper because they were to big for what he wanted.
    He had an entire tray of sizes to choose from right by his hand and l busy was doing the dog's anaesthetic.

    It was an elective op, he had been a vet and operating for over 15years and nothing was going pear shaped. Not that that would excuse his behaviour either. He was/is just a nasty bit of egotism.

    Don't strop at me because l will return the favour. I will give respect but only when it is earned. Abuse or bullying earns nothing but contempt.

  4. what, pray tell, is atchar? Do I want to know?
    Klemmer in German is a clamp...I am cautiously guessing that 'Klem' might be the Afrikaans/Dutch word for clamp. 'Arterie' (spoken ar-ter-EE-ah) in German is an artery--so that's the same, and a 'Pinzette' is German for 'forceps' in English.