diaphragm

in the old days, before i would operate, i used to get a bit worked up. i used to have an adrenal rush at the sheer prospect of cutting a fellow human being open and fixing something. these days...not so much. most of it has become a bit mundane. but there are exceptions. traumatic diaphragm rupture is right up there and for the flimsiest of reasons.

it was my first month in a general surgery firm. my registrar was one month away from his finals so he tended to keep his head down. this meant he stayed at home with his nose in the books while i handled the calls. once the patient was on the table i would call him to come in and operate. he would swoop down like batman, fix what needed to be fixed and fly off into the night. it seemed pretty cool to me.

yet, despite my admiration of him, i had only been in the department for one month and in a general firm for a few days. i really had no clue about how things really worked. i sort of assumed one called a real surgeon when the sh!t really hit the fan.

it was a blunt abdominal trauma case. the patient was the passenger in the car when it plowed head on into a tree. the driver said the tree ran across the road, but his blood alcohol level was doing most of the talking at the time. the patient had an acute abdomen. there was clearly something wrong inside. even a clueless medical officer like me could see that. i knew nearly nothing, but i did know what needed to happen. i called my senior.

"i have this patient with an acute abdomen." he was pre final exams and tended to be cranky.

"what does the ct scan say?"

"the patient is a bit too unstable for a ct scan." i could hear the irritation in his voice. he obviously hadn't read all he intended to read that night.

"well then he needs an operation!" the implication was that i was a fool. "get him to theater as soon as possible! then you can call me."

"uum, the patient is on the table already and the anesthetist is about to put him to sleep. i'll open so long, but i'd appreciate it if you could start heading this way in the mean time." there was little more i could do other than open so i was hoping he would read quite a bit into the use of the word 'appreciate'. there was a longish silence.

"good. i'm on my way." i knew i had impressed him.

fortunately he arrived just after i'd made the skin incision. he was keen to get back to his books so there was absolutely no hope of him tutoring me though the operation. i understood this even though i didn't like it. i had to accept the role of assistant.

my senior had the abdomen wide open very quickly and soon we had our arms elbow deep in bowel. surprisingly things didn't look too bad. in fact i was wondering if i had made the right judgement by taking him to theater before doing any further investigations. but yet i knew what i had felt clinically and i remained silent, as did my registrar. he systematically went through all the small bowel and colon. other than a bit of blood there was no real damage. then he moved towards the stomach, or where the stomach should have been. there was a tear in the left diaphragm and most of the stomach had been pulled up and was in the chest, pushing the left lung flat. it was something i had never seen before. i felt a rush of panic. surely this was a severe injury far above the operative levels of a mere registrar. surely he would need to call the prof to come out and help him.

"wow, what an injury!" i said. then i added, somewhat injudiciously, "i assume you want me to call the prof quickly?" he stopped operating and looked at me. he seemed to be looking for some signs in my facial expression that i may have been joking.

"no. why?"

"are you going to fix this on your own? do you know how?" despite the absolute lack of signs in my face he started laughing. he was laughing at me, maybe not so much because i hadn't had the confidence in him to be able to handle such a thing on his own, but more because i had been in the department for such a short time that i hadn't yet learned the sink or swim approach that was used in our training. of course he could handle this. he could and had handled much worse in his time as a registrar. besides he was so nearly finished he was as good as a fully qualified surgeon when it came to wielding a knife. i thought back to what a friend had once told me about surgery and his training even before i had joined the department and it all fell into place.

i was not yet capable of handling a ruptured diaphragm, but that was because i had hardly even begun with my training. in the end it had more to do with the confidence to go ahead and do what needed to be done than the actual skills to do it. my registrar had no lack of confidence and self belief and had not even considered the possibility that he couldn't do it and would need to call the prof. the thought that had stuck in my mind and then escaped through my lips had not even crossed his mind at all. but that was because he was essentially a trained surgeon and i was a mere medical officer. he seemed so cool and in control. these concept crystallized instantly in my mind. then i had another thought. this time i kept my mouth shut.

one day, i thought to myself, when i am all grown up and a surgeon, i too will be able to fix ruptured diaphragms with such a calm and confident demeanor. i too will be this cool in the face of what then seemed to me to be a major disaster.

the first time i did a ruptured diaphragm repair i was so excited that i had finally arrived and was acting like a real surgeon that i could hardly keep my hand steady as i placed the stitches. and all these years later, every time i am faced with another one, i still get a jolt of the old adrenal glands and an excitement totally out of proportion to the operation. i am now as cool as my registrar was then.