suboptimal

recently i did a submandibular gland excision. i always find them challenging. i think i know why though.

i was no longer a junior registrar but i still had a long way to go. i had just been rotated to kalafong and it was my first theater list, a list that had been booked by my predecessor and one i therefore did not know. my consultant knew me from a few years before when i had worked in his firm as a junior registrar. as much as he was able to actually have human feelings, i think he almost liked me.

i assisted the first case with the consultant operating. it annoyed me a bit but i assumed he hadn't worked with me for a while and wanted me to get my eye in before he entrusted the knife to me. when he once again took the prime position in the second operation i started wondering if i was to get any operating time in his firm. what could i do?

after the second operation my boss turned to me.
"just a mastectomy and a submandibular gland excision left. have you ever done a submandibular gland?"
"no." i answered truthfully.
"have you ever seen one done?"
"only once when i was a fifth year medical student, so it hardly counts."
"i'll give you a very good article describing the technique."
and with that he turned and left.

it was kalafong so he returned long before we got the mastectomy patient on the table. he handed me the article, which he had fetched from his study, told me i'd be fine, and left.

great. i had to somehow quickly read the article between the mastectomy and the submandibular gland and then do the operation with only theoretical backing. i tried to swallow hard, but, in sympathy with the patient's soon to be excised salivary gland, my own salivary glands had simply stopped working. my mouth was suddenly very dry.

so i did the only thing i could. i cut out the offending gland, more or less how the article suggested i should. but somehow to this day, whenever i am asked to do a submandibular gland, my adrenal glands tend to contract a little bit when i think back to my first one.

wakeup call

i once heard someone say surgery can be summed up in one sentence. eat when you can, sleep when you can and don't f#@k with the pancreas. this is true. but when you steal a quick shuteye here and there, this dictum doesn't tell you how to wake up on time. (pancreas can wait for later). i discovered a neat trick. actually this is a copyright secret, so everyone who reads this post, please forward money to me. thank you.

i was in vascular. i was doing 15 calls a month. (there were two of us). it was tough. often i would work up to 72 hours with as little as about 4 hour's sleep during that entire time. the operations were long and sometimes in extreme fatigue it was difficult not to resent the drunk with a shot off femoral artery who needed surgery at midnight in order not to lose his leg. the fellow was even more over worked and cantankerous at the best of times. in the immortal words of charles dickens:- "it was the worst of times" (he also prattled on about the best of times but i wasn't listening)

so it happened more than regularly that i would walk out of theater at about 5 in the morning and need to be at work at 7. clearly if i went to sleep i would rise from a comatose state long after i was supposed to be at work, bright eyed and bushy tailed and in deep trouble (or water?).
i was faced with a dilemma. grab a quick nap and be late or somehow fight overwhelming sleep off and be at work on time, but in a zombie state. then i stumbled on a solution.

i got home after not sleeping for who knows how long, with about 2 hours at my disposal before work. bed was not an option. my gcs would drop and someone might try to take my kidneys. so i decided to take a bath and get ready for work early.
i ran a warm bath and sank into it. moments later i was fast asleep. i couldn't help it. i was dead to the world.

and thus i slept soundly. and here lies the secret. the bath water slowly got colder. i was too far gone to notice this though. finally the water was so cold i could no longer stand it and i would wake up. there would be no choice. i would have to get up. it was impossible to warm the water up again (mainly because i couldn't feel my fingers and they wouldn't obey my brain's commands to open the hot tap). only rough actions could be carried out, like to drag myself out of the bath and collapse on the cold tiled floor of the bathroom (which felt comfortingly warm).

this whole process (including fumbling of warm clothes over my body and gradually emerging from hypothermia) took about 2 hours. just enough time to get to work, awake and on time, if somewhat grumpy.

so for those thinking of going into the wonderful career of surgery, spare a thought for your consultant. if he seems cold to you, there might be a reason.

warning, unless you are tall and will therefore not sink below the surface unconscious in a bath, this may not be a good idea.