surgical principle number 2: fear nothing but fear itself

the gist of this principle i have already covered. it has to do with the patient's best chance. if it's you then it really doesn't help to cower away.

i have seen patients suffering because there is some or other doctor just too scared to have a go at it. twice i have been forced to stand down with thyroid surgeries because the anaesthetist was afraid, even though it meant the one patient would remain intubated for a week and the other would disappear into the system, probably to die of asphixiation somewhere down the line.

yes you need to know your limits, but somehow in surgery you also need to back yourself and go where few dare. it is the nature of the beast.

when i joined the surgery department there had just been an acute shortage of registrars in general surgery. therefore, although i was just a medical officer, i was placed in a registrar position as the head of a firm. i was pathetically ill equipped. my consultant, although he was usually available to come out and help, was not quite so willing. there would also be nights when a private surgeon would be the consultant on call. then there was little chance of getting him to come out. our consultant gave myself and my colleague a crash course in what we were likely to encounter on a call and what to do. i called it the how-to-handle-pretty-much-anything-so-i-don't-have-to-come-out-and-work-once-the-sun-has-set course.
in his opening address he told us about an incident that had happened to him during his registrarship when he called his consultant in the middle of the night to help him with a gunshot tail of pancreas. the consultant irritatedly told him to remove the damaged tail. he had never even seen it being done before. he asked how he was supposed to do that.
"use prolene!" shouted the consultant and hung up the phone in his ear.
"so what did you do?" i asked.
"i used prolene." he replied. i remember thinking i should probably find out what prolene is.

some time ago the state asked me to operate a gunshot chest and abdomen. i naturally responded. the abdominal part went quite well, but it soon became apparent the main source of bleeding was the chest. i phoned the thorax surgeon. he told me a bit about how nice it was to be on holiday and that the sun was shining and he was working on his tan. i considered warning him about the dangers of skin cancer but at that moment it didn't seem to be too pressing an issue. he then helpfully suggested i transfer the patient to pretoria, a good three hour drive. i had a better idea. i opened his chest.

now thoracotomies are not really my thing and i haven't done all that many of them. it is not a general surgeon's usual stomping ground, but that didn't matter at that exact moment. i was not only the patient's best chance, i was his only chance. i swallowed hard and got to work.

so, in surgery it is important to fear nothing but fear itself.

so clever

i'm not the brightest. pregrad took a lot of studying just to scrape by. surgery nearly caused pressure sores on my butt. so i always assumed i was fairly low down on the surgical iq pecking order. we at pretoria knew we could operate better than most of the other universities, but how could we compare to a place like uct (cape town). those guys we knew didn't nearly get our operative exposure. we just assumed they used all that extra time cracking the books.

i remember a registrar's symposium i went to where they presented. at some stage a zim registrar asked a pretty poor question. the uct guys answered, but the zimbo wouldn't accept their answer (mugabe-like???). the uct guy calmly pulled the mike forward and said,
"i suggest you go back to your books!" i was impressed. i knew the zim guy was clueless but i couldn't quote chapter and page to allow me to throw the book at him like that. i really thought that the uct guys were super clever.

a few years later the international surgery conference was held in durban, south africa. we all went. i decided i'd try to get to know the uct guys better. it's always good to make friends. but i also wanted to get a chance to grade them myself.

as could be expected from capetownians, they weren't too keen on this pretoria boy in their presence and they made it pretty hard for me to get to know them. at a stage, as surgeons tend to do, some of them were sharing surgical stories. i noticed they all ended in 'and then i phoned the consultant.' well i had stories and mine didn't end like that. so i told one.

it was a midnight blunt abdominal trauma that ended in a liver resection. (truth be told the impact with the truck out there on the street had pretty much handled the resection. i just needed to tidy up a bit.) they were astounded. no consultant? i did it alone? we do that sort of thing in pretoria? and such questions.
i felt better. even if i wasn't as clever as they were i could at least operate. i had been trained to make the crucial decision at the crucial moment without needing to rely on backup.

a few days later they were once again telling their stories, but this time they had one of their consultants there. it seems one of them opened an abdomen because his junior had put the patient on the list and the diagnosis turned out to be something unexpected. my first thought was that where i come from there is no way the primary surgeon wouldn't have made the decision to operate himself. i admit i felt superior.

the uct registrar described his shock at discovering the actual diagnosis, something that is first approached non-operatively. only when this fails is surgery considered. he phoned his consultant, the guy sitting with us.
the consultant advised closing and reverting to the non-operative management. i piped in.

"but you had the abdomen open. i agree with the non-operative approach, but you're there with the abdomen already open. fix the problem with a knife." they all looked at me. the consultant asked,
"how?" i was a bit surprised. but i told him how. the registrar who was telling the story said that he didn't know how to do what i'd just said. again i was surprised.
"you do know how now. i've just told you how. you just need to do it."

they all shifted uneasily in their chairs. they didn't have the charge-in-where-angels-fear-to-tread attitude that the pretoria guys had. to argue the practicalities of an operation with a pretoria guy was not going to work. it was time for plan b.
"well i've never seen that operation in my books. maybe you should go back to the books." it was the same line that i'd heard them use years before. i was a bit confused because i had read this operation in a book. i'd actually seen it in a few books. but they were uct registrars and i doubted myself suddenly. i knew we could out operate them, but if they said that it was not in the books in the presence of a consultant and he agreed, then maybe i was wrong. i kept quiet.

that night i opened my book, the latest sabiston and sure enough, my operation was there described just as i had said.

i didn't go back to them to point out that i was right. it seemed too petty and vindictive. i just reminded myself that despite the way i felt about my spartan-type training, it was actually good and academically sound. i would never feel inferior to the uct guys again.