Thursday, September 02, 2010

the master has spoken

i have touched on how to spin the story correctly to your consultant in order to achieve the best possible outcome for all involved. there was another scenario where i worked it to a fine art.

the toughest firm to work in was the boss' firm. i have mentioned this before but it was difficult to avoid his wrath. generally you were placed in charge of his firm only as the most senior registrar in the department. this gave me a good few years to observe how the other guys presented their cases to him in the morning meeting and to learn from their mistakes. one thing about the boss is he was an exception to the general rule of consultants not coming out to help in theater at night. if you called him, he would come. this sounds good, but the down side is that it was not all that much fun to operate with him. he demanded dead silence and always operated himself, seldom letting his junior at the knife which meant he didn't teach too well. i learned a lot from him as far as technique is concerned but it was mostly through observation rather than through tuition. so, in summary, it was not ideal to call him out at night. quite frankly it was a pain in the neck.

but there was another side to phoning the boss at night. as a junior i often observed a hapless registrar presenting a difficult case to the prof the next morning and facing all forms of the proverbial sh!tstorm for not phoning the prof. it didn't matter if he had single handedly raised the patient from the dead or broken down the gates of hades to claim his patient back. if he hadn't called the boss it simply wasn't good enough. and yet, without fail, the registrars endured this tirade rather than endure the prof coming out at night. i wondered if there was a happy middle ground somewhere. it didn't take long for me to find it.

basically the prof was a surgeon and therefore had a very fragile ego. it wasn't that he wanted his sleep to be interrupted to come out in the early hours and operate. he just wanted to be acknowledged as the guy in charge. he didn't want to be surprised the next morning with weird and wonderful stories of heroism, especially when he was not the hero. i understood this and worked with it. in the end it was all about timing.

a good example of how it went when i finally worked it to a fine art is illustrated quite well by a case i still remember.

the patient was the victim of severe blunt abdominal trauma. from the first moment it was clear he was in deep trouble. there was no question about doing a ct scan or not. he was simply too unstable. to go via scan would be to lose precious time which he could ill afford. we had to get him to theater as fast as possible and that is what we did.

after opening the abdomen i was confronted with a massive amount of blood. it was the sort of thing we sometimes do see but it is always a tense situation. i went through the motions and quickly identified the liver as the source of the bleeding. segments six and seven had been totally crushed and had been pretty much ripped off the rest of the liver. being astute as i am i quickly realised this was not good. i must admit there were a few subtle hints like the anaesthetist shouting that the patient was almost in exitus and my house doctor's wide eyes. but the absolute giveaway was when the house doctor spoke.

"aren't you going to call the prof?" he asked.

"do you want the prof here?" i retorted.

"of course not but you know what he is going to say tomorrow morning if you don't call him!" i smiled.

"watch and learn my young paduwan. watch and learn."

i then deftly whipped out the damaged segments of the liver, controlled the bleeding and started rinsing the abdomen. the anaesthetist was looking less tense so i assumed i was on the right track. i then turned to the house doctor.

"it is time." i then turned to the floor nurse. "please get the prof on the phone for me." soon after she was holding the phone to my ear.

"sorry to bother you so late at night prof, but i just wanted to let you know about this patient i'm operating. he had a liver laceration. there wasn't time to call earlier because he was unstable and we were rushing him to theater but i thought i should tell you how it's going. i have the bleeding under control now."

"sounds good. do you need me to come in?"

"not now prof. everything seems ok now, but thank you for offering." the house doctor stared in amazement. i knew the hero worship would come later.

the next morning, in the presence of all the registrars and house doctors i was required to present the night's activities. when i started on the patient in question i could see some of the registrars' ears perk up. i think some of them might even have been delighting in what they saw as my inevitable misery. as i got to the bit about the liver looking like mince soup, the prof intervened.

"yes, bongi phoned me about this case. i advised him how to get the bleeding under control. the patient is fine now. well done bongi." the expression on the face of the house doctor was unmistakable. it was indeed hero worship. who could blame him?


enrico said...

The Force is strong with this one. ;)

rlbates said...

Love it! :)

Anonymous said...

I know a cardiothoracic surgeon who demands absolute quiet. So much so, he even whispers from behind his mask during surgery. Very difficult to hear him with all the environment noise during a CABG/Valve. I felt it could someday compromise things for him -- you DO want your perfusionist to hear you correctly... The day I was invited to observe, I remember being so still watching every move for the entire thing, I was placed so close to the field, that when he suddenly turned his head to ask me in a whisper if I had any questions near the end, I almost jumped out of my scrubs.


Ivy said...

Nice story... so common in medicine. The bosses want to know first hand what happens in THEIR department, not to hear from a well-meaning colleague "Did you hear what happened to that patient who came through YOUR department while you were having your beauty sleep at home?"

stop smoking information said...

I thought pulmonary/icu chiefs were the only ones who tore into young "juniors" for not calling them in the middle of the night.

For some reason, it makes me feel better knowing that surgeons have their master's egos to overcome as well.

Deftly handled!

Thabang said...

Brilliant timing Bongi! And yes, that's the prof... If only that had one in Boksburg at the time I was there ;-)