Saturday, November 05, 2011


i am somewhat known for not knowing when to keep my mouth shut. but, fortunately for me i once managed to put a watch in front of my mouth, but only just in time.

i was on rotation just before intermediate exams. this was a difficult time when generally you had to make sure you didn't make enemies in other departments. you always ran the risk that the guys you irritated would be in the exam or write a scathing report to your own prof. then, no matter how well you knew your work, you would not get through. it's just the way things were.

interestingly enough the obstetric and gynaecology department stood apart from all other surgical disciplines. for many years they had not done the rotation and therefore did not write the intermediate exams common to all the rest of us. other than the fact that this meant that they didn't share with us the burden of running the icu department (which they did use, however) it also meant that they could be very narrow minded. they didn't have an overall knowledge of physiology and the management of acutely sick patients. to them a patient was simply a vagina and a uterus of varying size, with or without a bun in the oven. in short, the rest of us thought of them as lazy and stupid.

i was on call in the icu at kalafong (hell). the way things worked there is we all knew all the patients in the finest detail. on a call day that knowledge was absolute. we could recite the finest details of any patient under our care in an instant. so late that afternoon when i walked into icu and saw the prof of obstetrics standing at the bed of one of my patients who we were treating with severe pre-eclampsia and hellp syndrome with his entire entourage i immediately walked towards them to answer any questions they might have.

as i approached i remembered that prof from my pre-grad days. we used to call him red beard which was some sort of a reference to a scary pirate, but more a comment on his interesting choice of facial hair. he always seemed to try to intimidate and to be honest i think we were all scared of him. looking at him now i couldn't understand that anyone could be scared of an obstetric prof. thinking back it seemed to me that his so called intimidation tactics were no more than posturing. he must have been trying to hide something. i walked up the the group of gynaecologists milling around my patient.

"hello prof." i greeted.

"oh, are you in charge here?" he asked looking up at me. i could see his underlings shifting uneasily. maybe he still had the power to intimidate them.

"yes prof, i am." i smiled in what i thought was a friendly, disarming way. i readied myself to help them with any and all questions they might have. after all there was absolutely nothing about the patient that was not at the tip of my fingers.

"good, because we are trying to make head or tail of what is going on here." simultaneously a few things happened. firstly i realized he was not going to lower himself to the point of actually asking me anything in front of his hordes. secondly, right there i decided that i would not be intimidated by what i now saw as the posturings of an old sad man. i stepped, back and folded my arms. secretly i enjoyed watching him struggle and flounder as he went through the patient notes. lastly the perfect sentence popped into my mind. by some miracle i actually kept my mouth shut and did not actually say.

"of course you are prof. after all the only thing more stupid than a gynaecologist is an obstetrician."

Tuesday, November 01, 2011

senior assistant

a good surgeon does not imply a good assistant. i personally don't like my assistant to be equally qualified with me. more qualified assistants can sometimes be a nightmare.

one of my role models in the department of surgery was my registrar when i started there. he was just a very nice guy. he was in fact such a decent guy most people wondered what the hell he was doing studying surgery at all. he just didn't seem like the type. but no matter how good an individual he was, he still had to learn how to operate.

the boss believed in teaching us to remove gallbladders the old fashioned way. therefore in his firm there was no such thing as a laparoscopic cholecystectomy. this was good in the sense that we all ended up being very comfortable with open cholecystectomies. however it was bad in the sense that you didn't get that much opportunity to learn the laparoscopic procedure, which is the standard modern procedure throughout the world. so when we moved together to the firm of the older semi-retired prof, ironically my senior would get to do some laparoscopic cholecystectomies. i remember when we got the first one on the list.

"doctor, this patient needs a laparoscopic cholecystectomy and you are going to do it." i watched my senior's face. i knew he had never done one alone before, but i also knew he would not pass up this opportunity.

"thank you prof." he looked a bit worried but he seemed determined not to let the prof know.

"and i will assist you." announced the prof with a broad smile which i'm sure he meant to be reassuring. now my senior looked very worried indeed. the prof was old and hadn't operated for years. in fact i had never seen him scrub into a case at all. i wasn't even sure he could operate any more. the problem was that with the prof there if there was any trouble it was unlikely the prof could help and his presence meant we would not be able to call anyone else that could. we'd just have to soldier through.

the operation started well enough although slowly. even the dissection of the artery and the duct progressed acceptably well. but it was here that the prof's assistance skills started to interfere. i personally suspected that the poor old man was nodding off intermittently. the reason was that every now and then the camera would wander away from the operation field. my poor colleague would be just about to apply a clip to the cystic duct when we would suddenly be given a wonderful view of the stomach or the abdominal wall or some other random organ. obviously everything would come to a grinding halt, with both of us trying to decide how best to tell the mighty prof that he needs to keep the camera on where the surgeon is trying to operate. in the end, neither one of us was brave enough to chastise the prof and we ended up just waiting for him to realise his mistake and return the camera to the correct position. i thought it was comical, mainly because i wasn't operating. i'm sure my poor colleague didn't quite appreciate the humour in it at the time, though.

finally the awkward pause was too long as we admired a pristine view of the colon. my colleague had to say something.

"um, prof, could i ask you to move the camera slightly." slightly wasn't going to be enough, i mused, but i was not about to say anything. if someone was to face the wrath of the prof, it sure as hell wasn't going to be me. yet somehow this request seemed to do the trick. maybe the prof realized his camera work had been suboptimal and he decided to try harder. i suspect that he had had his nap and was no longer tired. whatever the reason the camera settled on the cystic duct and did not move. at last the registrar could clip and cut the duct unimpeded. at last the operation was proceeding at what i considered a reasonable pace. quite soon the registrar was carefully dissecting the gallbladder out of where it was embedded in the liver. but then gradually i realized there was another possible dilemma on the brew.

you see, although the camera position was perfect for the cystic duct, as my colleague dissected the gallbladder loose i realized that the prof was not following his progress with the camera. the dissection progressed across the screen of the monitor and finally moved right out of sight. the dissection progressed beyond the limits of what the prof was looking at and finally it came to a grinding blind halt. again we sat in an awkward silence. it just could not go on like this. maybe bolstered by the success of his last request to the prof to drive the camera better my colleague decided to address the prof again. but this time the prof was awake.

"sorry prof but ..." the prof cut him short.

"doctor you must operate in the middle of the screen, not on the side!"

more and more i came to appreciate the real reason we wore theater masks while operating. they were to hide the fact that we were laughing so often.