behind closed doors

most non medical people have little idea what a general surgeon does on a day to day basis (unless, of course, they read this blog). few can imagine us elbow deep in blood and guts in an eternal battle against the angel of death. this is partly due to the fact that what we do borders upon the unimaginable, but it is also due to the rigid controls about who is allowed into the holy realm of the theater. understandably, not just anyone can be present at that most sacred of moments when the knife slides through the skin, opening that which is not meant to be opened. the average lay person will tend to simplify the whole process in their minds. the doctor has operated, so now what could possibly go wrong? i know what could possibly go wrong and sometimes it fills me with dread.

but at the moment when it is all happening, when the family are waiting outside, barred from the hallowed events performed within by a surgeon overcome with dread, it is all in the hands of that surgeon. then the family can only wait. as they wait they don't even know what they are waiting for. i understand it engulfs them in a feeling of immense helplessness. i also understand people don't like to be helpless.

it was a bad injury. the bullet hit him on the lower edge his left chest anterior and exited through his back about 5 cm below this level. the medical officer called me to see the patient in casualties at about 9 o' clock in the morning. 

"who gets shot at 9 in the morning?" i joked over the phone, but there was something in his voice that told me i'd better get there fast. maybe it was that he wasn't laughing at my joke.

i walked into casualties. the patient was pale and confused. he turned to me and tried to focus, but i realised he wasn't seeing me. it was as if he was looking straight through me, possibly at some distant object only visible to him. i quickly evaluated him. hemodynamically he was not in a good way. clearly there was some serious bleeding happening somewhere. equally as clearly we would need to operate him fast if he was to have any chance at all. i barked commands.

"you, five units packed cells and six plasma. i want them in theater immediately. go!" i went on. "you, go to theater and tell them we are going to be there in 10 minutes. i want a theater ready now. go!  you," i looked at my medical officer, "i have nothing for you to do. help me get this guy to theater. don't go!"

"uum, doctor." he replied, "i'll take the patient to theater but i need you to speak to the family. his parents are outside and they are very worried. i'll get everything ready in theater so long, but please don't make me speak to them?" hmmm, not the best time to mentally gear down enough to calmly reassure family members that i had things under control, especially when i didn't even know what things would need controlling yet.

"sure!" i said, remembering it's always important to look in control in front of the medical officers. moments later he was wheeling the patient to theater and i was introducing myself to the parents.

"doctor, i feel terrible!" was there something i didn't know? could it be that this guy's mother had shot him? just as i was trying to picture this frail old woman as a ruthless killer, she went on. "you know, doctor he was fetching his daughter from our house to take her to school. he is a night shift worker and we look after our grand daughter when he is at work. he got hijacked outside our house and that's where he was shot. i actually heard the shot doctor." she started crying. "i looked out the window, but when i didn't see his car...the hijacker had already driven off... i locked the door and stayed inside because i was afraid. only after ten minutes did i go outside to find my son lying in a puddle of his own blood. doctor, if he dies it will be my fault!" i felt for her.

"i'll do my best." it is difficult, really to say anything meaningful at such a junction in life. especially when my best may not be good enough. i said it anyway. no matter how inadequate it was, there didn't seem to be anything else to say.

soon thereafter i was in theater, just about to scrub up.

"doctor, the mother is outside. she wants to speak to you again." this was a bit ridiculous. her son was literally bleeding to death and the only thing that could save him was a very prompt operation, which we were about to embark on and here the mother wanted to use up some valuable time with a bit of chit chat? i was not impressed. yet i probably could spare about 30 seconds or so, i thought. after all it is important to maintain a certain rapport with family members, especially if there is a very real chance that the patient may not survive the operation. if the last emotion of the family towards the doctor before an operation is one of animosity, if the patient dies, that animosity will continue and may manifest afterwards, potentially even in accusations and court cases. i decided 30 seconds may just be worth the effort. i ran out.

"doctor," she grabbed my hands, "while you are operating, i just want you to know that we will be holding you up in prayer." i tried to pull my hands gently free. after all the 30 seconds i had allotted myself were almost up. she continued, "we will be praying that god will guide your hands and be in control of your every move. ok?" i had nothing to say to that, even though it seemed to be a question, so that is exactly what i said, nothing. i understood her. it was her way of not feeling totally helpless during the operation when she would be barred from her son in the most critical moment of his life. she already felt responsible for leaving him shot and bleeding outside her house for ten minutes before she went to him. if he died on my theater table she would live with guilt forever because she had not been with him at that moment. she was essentially telling me that she was not leaving him alone as he went into the restricted area of theater to face his tribulations. she was going to go with him by sitting outside and praying for my hands not to mess up. i smiled.

"ok, but i must go. time is of the essence here." i managed to work my hands from her grip, the same hands that would later be covered in the spilled blood of her son while i fought for his life.

the bullet had done its job. there was quite a mess inside, but the major injury was a transection of the splenic artery about 2cm from its origin. the open ends were pissing blood all over the place creating more than just a small challenge to get under control.

once the operation was over i was exhausted. the weight of being the only thing standing in the way of a human being and his demise drains one. also the emotional gymnastics involved in moving from the human interactions with the family and the patient to the simple mechanics of working with the blood and guts of a lump of meat on the theater table and then back to the raw hopes of the family directly after the operation can often be almost more than one can bear.

"we did what we could. he's going to icu where we will continue to do whatever we can to keep him alive, but we'll have to see how things go."

"doctor, we know god's hands, and not yours, were over him in there. we have faith." i wondered then why i felt so tired, if, as it turns out, i had apparently done nothing. i was too tired to bother about that then.

once the patient finally left the hospital alive i was so proud of all our efforts to pull him through. the patient and the family never said thank you. yes, normal people have little to no idea what happens behind the closed theater doors or in the minds and hearts of the surgeon, fighting on their behalf.