banter

of all the specialities, i like the anesthetists the most. some of them are even my friends. this doesn't mean there isn't some degree of niggling that goes on between us.

during anesthetics there are two crucial times when things can go horribly wrong. the first is when the patient is put to sleep and the second is when the patient is woken up. during most operations the time between can be quite routine and even mundane. the patient can almost be put on autopilot and the anesthetist has very little to do except maybe catch up on a bit of reading (there are exceptions). yet strangely enough the one quality gas monkeys appreciate above all else in a surgeon is speed. somehow they seem to want to get through the stress free stage of the operation (for them at least) and move on to the part where things could potentially go frighteningly wrong. maybe they get bored, i don't know.

so the anesthetist thinks the surgeon is great if he gets the operation done fast and he also takes a certain amount of pride in waking the patient up moments after the operation is finished. this way the surgeon, who usually does not appreciate waiting around for anything, doesn't end op waiting around for changeover time. i suppose you could say we work fast to impress them so that they will work fast to get the one patient awake and the next one on the bed as fast as possible and thereby impress us. yet in my opinion there are things worse than waiting a minute or two longer between cases. i don't like working on awake patients. also for some reason that i can't fully explain if you finish the operation before the gas monkey is completely ready to wake the patient up, they tend to get the impression you are super fast.

then of course you get the two basic types of anesthetists. the first type shows an interest in the operation and knows when to start decreasing the gas. the second type has little interest in the operation and is possibly more dedicated solely to his craft. he will often ask for a heads up when the operation is nearing its conclusion (i once wrote about such an anesthetist)

if you put all this together, due to the fact that i can't always predict how far i am from the end of an operation and that i've had a previous nasty experience with patients moving while i'm trying to place the last stitches i tend to wait a while before i warn the gas monkey (that's if he asks) that things are coming to an end. so a typical conversation with a good gas monkey friend of mine would typically go like this.

"bongi, give me a warning five minutes before you've finished."

"sure." i'd answer, wondering how exactly i would know when five minuted before the end would be. then i'd go on merrily, secretly keeping one eye on my sandman friend to see if he was following the operation. if he was not i'd pretty much wait until i had only one more stitch to place. i'd then glance up and announce;

"five minutes to go." i would then bow my head and carefully place the last stitch. once i was happy with that stitch, i'd look up.

"finished."

i'd be lying if i said i didn't enjoy the reaction this usually elicits from my friend. he tends to go on about now having to wait for the patient to wake up, something i'm not overly worried by as i have said. i also enjoy the illusion it creates with him that i operate fast.

it is all done in a very good nature and our friendship is not at all affected by my possibly juvenile behaviour (i hope).

friends?

there is a sort of love/hate relationship between the surgeons and the anesthetists. neither one can survive without the other. we supply them with work and they get the work to lie still while we cut and dice. yet their job is to keep the patient alive while we challenge their ability to stay alive. at the moment of surgery they play good cop and we play bad cop. of course after surgery the good cop is suddenly the surgeon through and through. but that is another story.

i really appreciate a good anesthetist (i've had bad ones) and to tell the truth these days i'm spoiled by the quality of the gas monkeys that i work with. however many years ago i remember a case where the anesthetist and i had a misunderstanding about time frame.

i was doing a laparotomy in kalafong. the gas monkey was a long term medical officer. he had attempted to specialize in anesthetics but simply had not been able to pass. in the end he found himself stuck in a senior medical officer job with no way of advancing himself. he was a bitter little man and it was easy for him to take his bitterness out on surgeons.

towards the end of the operation when i started closing the sheath the patient's abdominal muscles were so stiff that he was pushing all his intestines through the wound. this did not mean the patient was awake. it simply meant that his muscle relaxant had worn off. it was a tricky time. i needed the patient to be at least partly relaxed, but if the gas monkey fully relaxed the patient he would not be able to wake the patient directly after the operation, thereby wasting all of our time. a good gas monkey will find a compromise between these two extremes. i did not have a good anesthetist. he was also more stuck on the hate side of the relationship between our two disciplines.

"the patient is pushing a bit." i hinted.

"the operation is almost over," he snapped, "i'm not going to relax him any more. otherwise he'll still be asleep half an hour from now". i was annoyed to say the least, but i knew it was a fight i couldn't win. it seemed so important to him to get this patient off the table in half an hour. i smiled. i could close this abdomen with the patient pushing against me, but i couldn't do it in half an hour. it would take longer. i decided not to share this information with my touchy friend. i buckled down and got to work.

it turned out more difficult than i initially thought it would be. each stitch was an effort and my assistant ended up straining against the patient to keep the tension on the suture. the gas monkey started becoming edgy, but i ignored him. if anything i slowed down my pace, making sure that, despite his best efforts, i closed the sheath properly.

about an hour later when i finally had it closed the qwasi-gas monkey was so irritated that he couldn't sit still. i was smiling behind my theater mask. i knew i had closed the sheath properly despite his inadvertent attempt at sabotage. and maybe next time he would pay slightly more attention to my seemingly ridiculous demands.

abroad

i'm of the opinion south africans have a good sense of humour in general. you have to be able to laugh at the absurd with a government like ours. and yet i do think we need to be a bit cautious about how we express that sense of humour while in the presence on non south africans. in general when you are working overseas in a foreign culture, you might want to be careful in the expression of your sense of humour.

like many south african doctors he had gone overseas to make a bit of money faster than it is possible on our shores. soon he was raking in money presiding over the sleeping while foreign surgeons plied their trade. yes, he was an anaesthetist.

now quite often the relationship between anaesthetists and surgeons can be strained. i can only assume it is worse when a language and cultural barrier are added. then there is the question of being in unfamiliar surroundings where more likely than not, things are done differently to what you are used to. it is probably best to keep a low profile and to not stand on anyone's toes. this anaesthetist did not believe on standing on toes. he went straight for stomping on their feet.

it was a neurosurgery case. the anaesthetist was of the opinion it was a non-starter and i suppose that's where it all began. there was tension between the neurosurgeon and the gas monkey right from the word go. but what could the south african giver of gas do? he had to dope the patient.

the operation got underway. quite soon the anaesthetist realized it wasn't going well. he couldn't understand a word of what the neurosurgeon, his assistant and the sister were discussing, so it wasn't really something that was said that cottoned him onto the fact that things were heading south. it was more the amount of brain tissue the neurosurgeon was suctioning out of the patient's skull that the gas monkey viewed as suboptimal. and as the operation progressed he passed through being perturbed and went right on to being amazed. it seemed there was no end to the stream of brain tissue that made its way through the suction tubing into the suction container.

after a while, once the anaesthetist was sure all the maths and science had been suctioned out, he took a more philosophical approach. it seemed to him there was little he could do to make the situation any worse so he just sat back and waited for the suction crazed surgeon to stop. and finally the surgeon did stop. he then got to the work of closing up, which in neurosurgery takes quite a while in itself. then he turned to the anaesthetist and for the first time spoke in a language he could understand.

"ok, you can wake the patient up now." the anaesthetist initially thought he must be joking, but there was nothing but an earnest expression on his face. he stared at the neurosurgeon in disbelief. the neurosurgeon stared back. "i said you can wake him up now!"

the anaesthetist shrugged his shoulders, strolled over to the suction container where it stood on the floor with its grizzly content. he then crouched down and started knocking on the side of the container.

"sir, you can wake up now!" he shouted.

reserved judgement

recently in the newspapers there have been a flurry of articles about a general surgeon who was found guilty of certain surgical misadventures by the council. truth be told i actually feel sorry for the guy. but i must add that i have felt the repercussions of this man. you see he worked in the town i call home until a year or two before i arrived there. the memory of him still hung heavilly in the air while i was trying to get up and going. there was a general mistrust of surgeons that lingered long after he left. right at the beginning i was confronted by this even before i knew it existed.

it was my first day in the new hospital. no one knew me and i knew them all just as well. i was also a bit nervous about working in a private hospital which i had hardly done at all up to that point. despite this i had no doubts about my abilities as a surgeon. it didn't even occur to me that i was the only one that felt this way.

the second case i saw was a young boy that had stuck his arm through a window. there was a deep laceration in the medial aspect of his upper arm, but the absolute absence of pulses distal to the injury was the thing that bothered me. i knew what to do. i trundled him off to theater and proceeded to repair the brachial artery which had been completely severed. although idon't particularly like vascular, these trauma cases in young people are much more rewarding than the standard vascular cases on old worn out people completely saturated with nicotine whose vessels are pretty much all totally destroyed. i even settled down and started to enjoy it.

the anaesthetist hovered just over my left shoulder. he seemed to be watching my every move, which i thought was great. after all in my mind my every move was nothing short of a work of art. i was quite happy that the gas monkey was paying so much attention to the surgery and not just watching his machine as it perpetually went ping. i started thinking i was going to enjoy working here.

the operation ran it's course. once the artery had been repaired and was merrily pumping blood back to the hand, i looked up at the anaesthetist again. he was still standing behind me watching. i was impressed with the bounding pulse i had just restored to the arm and smiled. he must be impressed too, i thought. it was impressive after all.

a few days later the chemotherapist phoned me. he had a patient with a perforated peptic ulcer that he wanted me to fix. he assured me that, although his patient did have cancer, he was not yet terminal and still had a good few years of life left in him. that didn't really matter actually, because to die with a stomach perforation is a pretty nasty way to go. i would have operated even if the case was solely palliative. i evaluated the patient and soon had his name on the emergency list.

moments later i got a call from the anaesthetist on duty that night.

"hello, i'm doctor w. i take it you're the new surgeon. i see you've put a patient on the list for a stomach perforation." i was quite impressed that he was phoning me. i really began thinking that working here was going to be great. the anaesthetists really were actively interested in the cases and the surgeon. "tell me more about the patient."

i told him all i knew about the patient in question. i mentioned that he was a cancer patient but his chemotherapist felt we should go all out as the patient wasn't terminal.

"well, you know chemotherapists," he said "they would send a corpse to theater and expect me to wake it up after surgery." this was a bit surprising, i thought. however i knew my reasons were sound.

"but this patient is still relatively well. besides even if he was for palliative treatment i'd still think we should operate, if for nothing else besides pain control."

"i'll be the one that decides if he goes to theater or not. i'll go and see him and get back to you." i was stunned. never before had an anaesthetist so blatantly questioned my decision to operate a patient. i was in fact stunned to silence. before i could reply, the anaesthetist had put the phone down. well, i thought, i am the new kid on the block so maybe discretion is the better part of valour here. maybe i should wait until he has seen the patient and then we can discuss the issue together if need be. i left it at that. but i would be delving into the realm of untruths if i were to say i was not annoyed.

some time passed and finally dr w phoned back. this time i was ready. i wouldn't be caught unaware again. i was ready to fight for my patient's right to get his deserved operation. but it seemed to be a different dr w on the other end of the line. he was friendly and even jovial. he told me that we would be operating my patient next.

"so you saw him and agree he needs an operation?" i asked.

"no i didn't," replied dr w. "i spoke to dr s who doped a patient for you last night, a boy with a vascular injury. he says you know what you are about and that's all i need to know." then it all fell into place.

i had heard stories of this other surgeon who had left the hospital about a year before under a cloud of controversy. the stories were often horrific and had left quite a few people quite skeptical about the insight of general surgeons. the anaesthetists, the people that were often called upon to dope the patients he seemingly foolishly took to theater were more than a little jaded. so on that first night when the anaesthetist seemed so interested in my work he was not interested in my work at all. he was checking out my abilities to see if i was another dud like the previous guy. and apparently judgement had been passed and it was in my favour. i was happy. not only had one of the senior gas monkeys seen that i know what i'm doing but another senior one was just about to see me in action with a fairly tricky case. i didn't feel any need to defend myself. once i was scrubbed up i would let my work speak for me.

p.s dr w and myself soon became great friends after that first rocky meeting.

the silent treatment

misunderstandings are bound to happen. sometimes i just wish i could understand the misunderstandings

i generally got on well with the anaesthetists and this one was no exception, despite a slightly rocky beginning. in fact after that i actually looked forward to working with her. the atmosphere in theater would be light and jovial and we would exchange jokes and laughs. then a time passed when we just ended up not working together. the lists just happened to be dealt in that way. so when i saw her in the theater complex after this time i thought i should say hello. it seemed to polite thing to do.

she was chatting with one of her colleagues. i walked up and waited for a lull in their conversation. her colleague, also someone i knew well, turned to me and greeted me with a broad smile. we shook hands. then i turned to her to greet her. she turned around and walked away. i was quite surprised, but assumed she had something on her mind and let it slide.

the next time i saw her, once again i approached to greet her, but as soon as she saw me she made a speedy exit. i realised there was some or other problem that she had with me, but i didn't know what it could be. after that there were a few more similar incidents that left me in no doubt she didn't want to speak to me at all.

then we were allocated to each other for a list. she could not run from me. yet somehow she managed to avoid all human interaction with me for the duration of the list. she did her work and pretty much ignored me totally. by this time the situation was no more than an irritation to me. my feeling was that if she had something against me she should discuss it with me and if she didn't want to then i pretty much couldn't be bothered with her childish behaviour. i ended up ignoring her in equal measure.

then one of those cases that age both the surgeon and the anaesthetist came in. i was the surgeon on call and she was the anaesthetist on call. once again we were thrown together. but during these cases there has to be at least a little bit of contact between the cutter and the gasser, yet she still absolutely avoided speaking to me. while we were busy we were both so involved in our relevant roles in trying to keep the patient alive that the silence between us was at least not awkward. as it became clear that we were at least going to get the patient off the table and into icu i asked her a few questions pertaining to the stability of the patient, but i made sure i kept it business-like. she answered only as much as she was required to. it didn't bother me. the life of the patient was more important than whatever the misunderstanding she had with me.

when a patient is taken to icu while still ventilated, both the surgeon and the anaesthetist would accompany the patient together and this was no exception. and so it transpired that we ended up in the lift together with the patient. i looked at the anaesthetist. i could see her nerves were frayed. the case had been a nightmare and she had done well to keep the guy alive while i did my best to patch him up. i reflected that her efforts to ignore me must have made the whole experience even worse. i felt for her.

"well done. i really couldn't have done this without you excellent handling of the anaesthetic. thank you" i really meant it. despite whatever her problem with me was, she deserved a compliment for a job well done and i was not about to withhold it from her. that, to me, would be worse than what she was doing by ignoring me the way she was. i could see her shoulders drop as the pent up tension seeped out. she even smiled a bit, but still said nothing. it was ok. i didn't need her to.

some time after that we did a list together again and she started speaking to me. i involved myself in whatever conversation she initiated, but i remained cautious. after all i still had no idea what the episode of silence had been about and our relationship was pretty much destroyed, so i kept things fairly superficial. but i must admit i was glad that she had finally started getting over her offence. things went on pretty much like this for a while. we were civil with each other but we were not close by any stretch of the imagination.

then about a week later we ended up in theater together again. i was chatting merrily away with my assistant as is my habit during surgery and occasionally the anaesthetist would join in the conversation. things were almost back to normal. then i made one of my standard fairly weak bongi jokes. i can't seem to help myself. she turned to me.

"careful what you say, bongi, i have only just started speaking to you again after nearly a year. you don't want to mess it up." this was the first time she had acknowledged any such thing which could be seen as a breakthrough i suppose, but i was immediately annoyed. i felt that she shouldn't think her opinion of me would in any way affect who i was and how i interacted with people, especially when she thought she was punishing me with her silence. i was not impressed.

"yes i noticed something like that." i replied. "i still have no idea what all that was about."

"you know exactly what it was about." she said, almost accusingly.

"sorry to burst your pretty little bubble, but i have no idea what it was that you took offence at and quite frankly i don't really want to know."

fortunately after that she finished her specialisation and went on her way. i knew we would never work together again and, all things considered, it was probably for the best.

orchestrator

team work in an operation is essential. usually i can just get on with my job and trust the anaesthetist to keep the patient going (alive). i don't have to worry too much about him. however in state sometimes i need to orchestrate everything.

the case was unusual. blunt trauma to the abdomen often causes the left diaphragm to burst, causing the intestines to migrate into the chest. this time the trauma was to the chest. the diaphragm burst from above. the x-ray picture was the same with the stomach in the left chest, but at operation it looked quite different.

they had apparently already done a full resus in casualties before even getting the patient to theater, so the patient wasn't in the best of shape.

the anaesthetist was a doctor from some outlying peripheral hospital that usually didn't do more than very simple cases and didn't even have a diploma in anaesthetics. he was doing his best and at least trying to meet a need in our local state facility. i opened in the midline. i found it a tad disturbing to find the heart free in the abdomen, just above the liver. i considered saying,
"i don't think this is supposed to be here!" but i thought better of it.

the diaphragm was destroyed. the pericard was destroyed. the heart had wondered off to the left and the lung had shrivelled up to hide somewhere out of sight. it didn't take a genius to realise this was not good. i realised this was not good.

i started the repair. then the heart stopped. it was easy to diagnose. i could clearly see the heart in front of me. i informed the gas monkey (anaesthetist). he looked at me. i put my hand around the heart and started to squeeze. the gas monkey looked at me. i realised he simply didn't have the beginning of an idea what to do. i realised this was not a team work situation. i needed to take control of everything. i was the gas monkey consultant suddenly. i took control. i orchestrated what needed to be orchestrated.

"you!" to the gas monkey, "give adrenaline now! you" to house doctor floating around like an unwanted fart on the wind, " draw up x ampoules of adrenaline and put it into y ml saline!" all the time i compressed the heart. now i have occasionally compressed a heart against the sternum from inside the abdomen, but seldom have i stood with the heart completely in my hand. i quickly adjusted to the correct amount of pressure to apply directly to a naked heart. it is quite a bit less than one on the other side of a diaphragm and decidedly less than one hiding behind a sternum. soon i was applying compressions with thumb and two fingers. that was all the pressure that was needed.

the adrenaline did the work and the patient came back. we went on. then things went south again. this time i put my hand around the heart and clearly felt the gentle vibrations of ventricular fibrillation.
"you!" to the wide eyed floor nurse "get the defibrillator now! you!" to the surgical medical officer, "get ready to shock and give me ample bloody warning because if you shock me i will not be happy!" all the time the heart was cradled in my hand with my three fingers doing the necessary.

we defibbed once and the patient came back.

the patient crashed twice more and i orchestrated the relevant resus. i then sent the house doctor to icu to ensure they prepared an adrenaline infusion and started closing. the patient had had better days but she was alive. i closed, gave the last necessary instructions and left.

when working with true gas monkeys we work as a team. but it is times like these when i work with junior doctors who find themselves in deep water that i remember what a priveledge it is to have well trained colleagues.

old rural surgery

one of my friends was sent to a homeland hospital when he did his military service (the old regime bolstered the homeland hospitals with whatever doctors they had at their disposal, which somehow makes the present government's totally disasterous management of the department of health seem so much more ironic). anyway, having spoken about war doctors, albeit in a different context, and also about my anesthetic escapades, i thought i would relay this typically south african story. (to be honest, eish reminded me of it with his last post too.)

the hospital was in the middle of nowhere (ok it was slightly to the left of the middle of nowhere, but you get the idea). when he arrived for his first day he was surprised to find that almost everyone was still on leave. only the superintendent was still there. the next surprise was that he was on call that first night. i suppose, looking at the facts, that wasn't really too surprising.

anyway, there was a caesarian section that needed to be done. the super gave my friend the option of either doping or cutting. my friend chose to cut. and soon they were working.

quite soon my friend noticed the blood was looking quite dark. he mentioned this to the super. the super snapped at him, saying he knew and was trying to fix the problem. it seemed the boyles machine (anesthetic machine that delivers a mixture of oxygenand anesthetic gasses to the patient) was broken and there was no air delivery to the patient. he decided to switch to manual mode where he would have to pump air in with a hand held bag. but, lo and behold, the bag had a hole in it. he sent the floor nurse to get another one. meanwhile he had to do something to give the patient oxygen. he resorted to blowing directly into the endotracheal tube with his mouth. desperate times call for desperate measures. at this point let me once again assure you this happened, many years ago, but still. finally, just as the patient was starting to become fairly light due to not getting enough inhalation anesthetic, they got another bag, connected it up and got things back on track. then...

the lights in theater went out. suddenly everything was pitch black. fortunately the floor nurse was a smoker and had a lighter. with this she illuminated the field while someone else rushed off to get a torch. and thus the operation was concluded by torchlight.

apparently after that nothing else that happened in his time there could phase him at all.

cyanosis

it has been a very long time since i gave my last anesthetic, but i still don't think blue is a good colour. i was reminded of this recently when one of my gastroscopy patients developed laryngospasm. he turned out fine but blue patients tend to age me quite a bit.

when i was a student i found anesthetics boring. that is because i didn't really know what was going on. when i was a comm serve i started off in anesthetics and was soon the number three in the department in our small hospital. in fact for that entire year i was considered an astute giver of gas to my great dismay. i was on the wrong side of the action on all calls.

i had been in anesthetics for not too long, but long enough to develop adrenal hyperplasia. i was on call and had to dope for a common or garden caesarian section, obviously late at night. i injected the contents of the big syringe followed by that of the small syringe and tubed without any difficulty. the gynae started.

almost immediately i realised there was a problem. the patient's chest was not moving with the ventilator, not a good thing. quite quickly the saturation monitor dropped its tone from its usual comforting high pitched beep to a very disconcerting low pitched boop. i started sweating. at about this stage the gynae calmly in a helpful voice said.
"the blood is looking very dark." i wanted to say something like i know the blood is f#@king dark and i don't know why. you just keep yourself busy with what you are doing and leave me the f#@k alone but all i said was
"i know. i'm on top of it." i flushed the system with oxygen and pumped. the chest lifted but soon the pressures dropped again. there was a leak somewhere and i had no idea where. i told the floor nurse to phone the cuban anesthetist, my mentor. she left to make the call. he lived on the hospital grounds and, even though it was very late at night he would be able to get there quite quickly. but quickly would not be soon enough. the fact of the situation was that when he arrived the problem would be over or the patient would be dead.

i flushed the system with oxygen again and managed to at least get a bit of air into the lungs. but it wasn't enough. i flushed again, but this time i put my ear close to the boyles machine and listened for a leak. i heard it. one of the pipes had a hole in it. i quickly made the necessary replacements and all was well.

about ten minutes later the cuban anesthetist charged in, completely out of breath from his run up to the hospital. i was probably blue myself at that stage but at least the patient was pink again. i still nearly hugged him.

nearly a year later on my last call as a comm serve just after an anesthetic the patient developed laryngospasm and also turned blue. i very casually drew up scoline. i injected it an tubed him. during the whole time i just kept saying to myself
"never again will i give anesthetics. never again." i felt good.

anesthetics

without anesthetists, we couldn't do our work. but sometimes the relationship between surgeon and anesthetist may be quite odd.

having worked for some time in government hospitals where the anesthetic is seldom, if ever, given by a consultant i was not entirely used to the privilege of consultant anesthetists doping for me. in private it is always a consultant. this obviously means there is a difference in quality of anesthetics.
probably the least important of these differences has to do with changeover time between cases. but, having said that, anyone who has worked as a surgeon for the state in this country most appreciates this difference. in the state changeover time can easily be up to one hour. it is not unusual to only do three cases on a list because of this. in the typical efficiency of the state, the rest of the list is then canceled, leaving the surgeon to 'please explain' to his patients why their operations are being postponed. in private, the list can't be canceled, so it is in everyone's interest to get the one patient off the bed and the next one on as fast as possible.

with this as a backdrop, a good private anesthetist can time his doping to coincide exactly with the end of an operation. as you down tools, the patient wakes up. i think it is quite an art. in the state, when you down tools, you wait with a mixture of boredom and irritation for the patient to slowly come around before he can be bustled off to recovery.

once there was an exception to this fairly general rule. i was a house doctor, the most junior of all doctors. i was working in a fairly remote part of the country. there, the caesarian sections were done by the most junior doctors (me mainly).
so i'm cutting another baby out of one more of the continuous string of pregnant women. the anesthetist is a medical officer from pakistan. finally i get the baby out and start closing. the anesthetist was trying to perfect the art of waking the patient up as the operation ended, but hadn't quite perfected it yet.
half way through closing the skin, the patient starts moving. i mention to the gas guy that the patient is moving. he tells me he knows, but he does nothing. being very junior and not exactly full of confidence, i keep quiet. i think i sort of assumed he knew what he was doing.

as i placed the next stitch, the patient almost sat up and tried to grab my hand. i stopped dead in my tracks and once again brought the patient's near fully awake state to his attention. i expected him to crank up the gas or to inject the patient with something or both. he did neither.
instead he moved casually towards the patient's feet. i waited to see what he was going to do. maybe he is going to get some drug from somewhere, i thought. how wrong i was.
suddenly he grabbed the patient's legs and held her down. 'quickly finish!' he yelled at me. i was shocked. i swear the blood drained out of my head (not quite like later in my career, though). i didn't quite know what to do. it was a very surreal moment for me. being very junior (or did i already mention that) i listened to him. with shaking hands i placed the last stitches. (the memory has been somewhat blocked out because of the trauma of the whole event but i suspect the patient actually helped me to cut the last suture she was so awake).

so these days, when i'm working in private i take time to appreciate the speed with which the consultant anesthetist wakes the patient up after the procedure and when i'm working in the state i am only too grateful when the medical officer struggles to wake the patient up long after i've finished.