gatekeeper

i am somewhat known for not knowing when to keep my mouth shut. but, fortunately for me i once managed to put a watch in front of my mouth, but only just in time.

i was on rotation just before intermediate exams. this was a difficult time when generally you had to make sure you didn't make enemies in other departments. you always ran the risk that the guys you irritated would be in the exam or write a scathing report to your own prof. then, no matter how well you knew your work, you would not get through. it's just the way things were.

interestingly enough the obstetric and gynaecology department stood apart from all other surgical disciplines. for many years they had not done the rotation and therefore did not write the intermediate exams common to all the rest of us. other than the fact that this meant that they didn't share with us the burden of running the icu department (which they did use, however) it also meant that they could be very narrow minded. they didn't have an overall knowledge of physiology and the management of acutely sick patients. to them a patient was simply a vagina and a uterus of varying size, with or without a bun in the oven. in short, the rest of us thought of them as lazy and stupid.

i was on call in the icu at kalafong (hell). the way things worked there is we all knew all the patients in the finest detail. on a call day that knowledge was absolute. we could recite the finest details of any patient under our care in an instant. so late that afternoon when i walked into icu and saw the prof of obstetrics standing at the bed of one of my patients who we were treating with severe pre-eclampsia and hellp syndrome with his entire entourage i immediately walked towards them to answer any questions they might have.

as i approached i remembered that prof from my pre-grad days. we used to call him red beard which was some sort of a reference to a scary pirate, but more a comment on his interesting choice of facial hair. he always seemed to try to intimidate and to be honest i think we were all scared of him. looking at him now i couldn't understand that anyone could be scared of an obstetric prof. thinking back it seemed to me that his so called intimidation tactics were no more than posturing. he must have been trying to hide something. i walked up the the group of gynaecologists milling around my patient.

"hello prof." i greeted.

"oh, are you in charge here?" he asked looking up at me. i could see his underlings shifting uneasily. maybe he still had the power to intimidate them.

"yes prof, i am." i smiled in what i thought was a friendly, disarming way. i readied myself to help them with any and all questions they might have. after all there was absolutely nothing about the patient that was not at the tip of my fingers.

"good, because we are trying to make head or tail of what is going on here." simultaneously a few things happened. firstly i realized he was not going to lower himself to the point of actually asking me anything in front of his hordes. secondly, right there i decided that i would not be intimidated by what i now saw as the posturings of an old sad man. i stepped, back and folded my arms. secretly i enjoyed watching him struggle and flounder as he went through the patient notes. lastly the perfect sentence popped into my mind. by some miracle i actually kept my mouth shut and did not actually say.

"of course you are prof. after all the only thing more stupid than a gynaecologist is an obstetrician."

senior assistant

a good surgeon does not imply a good assistant. i personally don't like my assistant to be equally qualified with me. more qualified assistants can sometimes be a nightmare.

one of my role models in the department of surgery was my registrar when i started there. he was just a very nice guy. he was in fact such a decent guy most people wondered what the hell he was doing studying surgery at all. he just didn't seem like the type. but no matter how good an individual he was, he still had to learn how to operate.

the boss believed in teaching us to remove gallbladders the old fashioned way. therefore in his firm there was no such thing as a laparoscopic cholecystectomy. this was good in the sense that we all ended up being very comfortable with open cholecystectomies. however it was bad in the sense that you didn't get that much opportunity to learn the laparoscopic procedure, which is the standard modern procedure throughout the world. so when we moved together to the firm of the older semi-retired prof, ironically my senior would get to do some laparoscopic cholecystectomies. i remember when we got the first one on the list.

"doctor, this patient needs a laparoscopic cholecystectomy and you are going to do it." i watched my senior's face. i knew he had never done one alone before, but i also knew he would not pass up this opportunity.

"thank you prof." he looked a bit worried but he seemed determined not to let the prof know.

"and i will assist you." announced the prof with a broad smile which i'm sure he meant to be reassuring. now my senior looked very worried indeed. the prof was old and hadn't operated for years. in fact i had never seen him scrub into a case at all. i wasn't even sure he could operate any more. the problem was that with the prof there if there was any trouble it was unlikely the prof could help and his presence meant we would not be able to call anyone else that could. we'd just have to soldier through.

the operation started well enough although slowly. even the dissection of the artery and the duct progressed acceptably well. but it was here that the prof's assistance skills started to interfere. i personally suspected that the poor old man was nodding off intermittently. the reason was that every now and then the camera would wander away from the operation field. my poor colleague would be just about to apply a clip to the cystic duct when we would suddenly be given a wonderful view of the stomach or the abdominal wall or some other random organ. obviously everything would come to a grinding halt, with both of us trying to decide how best to tell the mighty prof that he needs to keep the camera on where the surgeon is trying to operate. in the end, neither one of us was brave enough to chastise the prof and we ended up just waiting for him to realise his mistake and return the camera to the correct position. i thought it was comical, mainly because i wasn't operating. i'm sure my poor colleague didn't quite appreciate the humour in it at the time, though.

finally the awkward pause was too long as we admired a pristine view of the colon. my colleague had to say something.

"um, prof, could i ask you to move the camera slightly." slightly wasn't going to be enough, i mused, but i was not about to say anything. if someone was to face the wrath of the prof, it sure as hell wasn't going to be me. yet somehow this request seemed to do the trick. maybe the prof realized his camera work had been suboptimal and he decided to try harder. i suspect that he had had his nap and was no longer tired. whatever the reason the camera settled on the cystic duct and did not move. at last the registrar could clip and cut the duct unimpeded. at last the operation was proceeding at what i considered a reasonable pace. quite soon the registrar was carefully dissecting the gallbladder out of where it was embedded in the liver. but then gradually i realized there was another possible dilemma on the brew.

you see, although the camera position was perfect for the cystic duct, as my colleague dissected the gallbladder loose i realized that the prof was not following his progress with the camera. the dissection progressed across the screen of the monitor and finally moved right out of sight. the dissection progressed beyond the limits of what the prof was looking at and finally it came to a grinding blind halt. again we sat in an awkward silence. it just could not go on like this. maybe bolstered by the success of his last request to the prof to drive the camera better my colleague decided to address the prof again. but this time the prof was awake.

"sorry prof but ..." the prof cut him short.

"doctor you must operate in the middle of the screen, not on the side!"

more and more i came to appreciate the real reason we wore theater masks while operating. they were to hide the fact that we were laughing so often.

six degrees of separation

i try to treat all my patients equally. sometimes i don't get it right i suppose, but i still think i do better than most.

i was as junior as one can get. but as i have touched on before, when i started studying surgery there was a general shortage of staff in the department. this meant i was running a surgical firm long before i was actually capable of doing so. this happened in my first week of running a firm.

a general practitioner phoned about an appendix he wanted to send to us. he spent a bit too much time explaining that they had no money and he had seen the girl as a favour. he threw in that he had managed to have blood tests done at a nearby state facility under the table. with a bit more experience i would have known there was trouble brewing. i did not have that experience.

the patient arrived a few hours later, as the sun was setting. she was a 16 year old girl that looked like she should have had medical aid and therefore not be with us but rather be at some fancy private hospital. i checked her out and went over the blood results that she had been so kind to bring along. to me it looked like she had a clear cut appendicitis and she needed a clear cut to solve her problem. i organised the admission and booked her on the theater list. all i needed to do was run it by the parents who were required to sign the consent and all would be set. there was of course the small matter of never having done an appendisectomy before, but that was a bridge i was going to jump off when i got to it.

i found the mother in the waiting room. i quickly ran through my findings with her and told her that i thought an operation was in order. once again with a bit more experience i think i would have been prepared for her blatant and open aggression. i wasn't.

"and how did you come to this opinion?" she demanded with an accusing look. i was shaken, but i recovered. i went through my clinical findings and threw the blood results they had brought in themselves. then just for good measure i claimed that we were even then sending her for a sonar just to make sure. i also made a mental note to tell a student to rush her off the sonar as soon as i got clear of the mother.

"ok, but i'm not just going to take your word for it. i'll first speak to my husband and i'll get back to you."

"fine, but i'm going to book her on the list so long. we can always cancel later if needed." with that i left (after telling the student to rush the patient off to sonar of course). after that i just got on with the work of the night. we admitted a few more cases, at least one of which i would be required to call my consultant out to operate because of my total lack of experience.

about ten o'clock that night i quickly shot through theater to put yet another patient on the emergency list. the anaesthetist on call stopped me. she also stopped me in my tracks.

"bongi, why is your prof stalking the corridors at this hour?" i may not have had all that much experience but i did know the prof actually being in the hospital so late at night was one of the signs of the apocalypse. i was worried. i felt even worse when i was informed the prof had pushed that 16 year old appendix patient up the list, as high as he ethically could. i was then informed he was preparing to spend the night in the anaesthetic consultants' room. things were looking dismal. i knew i either needed to find him and find out what the hell was going on or i needed to avoid him altogether. avoiding him was not really an option because i would be required to present my call to him the next morning. if he knew that i didn't have complete control of the call, even if it was because he usurped me, it would spell disaster for me. however in the back of my mind was the nagging fact that i had never done an appendisectomy before. maybe he could do this one and i could assist. the next one which was already on the list would be left to me. hopefully watching the prof do an appendisectomy would be all the training i needed.

the anaesthetist also told me why the prof felt it important to do a procedure that was usually far below his great and mighty status. it seemed the patient was a vip. as it turned out, the patient's mother's neighbour's daughter's boyfriend was the prof's son. clearly the prof held his son in such esteem that his son's girlfriend's mother's neighbour's daughter needed his immediate attention. who says six degrees of separation doesn't come in use every now and again?

then, while i was searching the hospital for the prof, he once again snuck into theater where he was informed my consultant would be required to be called out to do one of the other operations on the list. he informed the anaesthetist to inform me that my consultant and not myself should do the appendisectomy. he then left.

telling my consultant that he was required to do the appendix just because of the long and convoluted connection between the prof and the patient was a bit awkward. at least the consultant had a sense of humour and simply accepted his fate.

finally when the patient got to theater we got ready to go. the consultant handed me the knife.

"i think the prof said you were to do the operation." i ventured helpfully.

"the prof isn't here now. i won't tell if you don't tell. cut."

and with that i started my first appendisectomy on a very special patient (or at least her mother's neighbour's daughter's boyfriend's father was important in his own eyes)

as can be expected with a first, i struggled through the operation. the fact that the appendix was very inflamed and adhered to a whole bunch of things in the abdomen didn't make it easier. however, even when i asked the consultant to take over, he refused. he told me that a surgeon can't just back off halfway through an operation and i must finish what i had started. i considered saying i had not wanted to start it, seeing that the prof had pretty much forbidden me from doing the operation and i had only raised the knife at the insistence of the consultant, but i knew what he would say. i soldiered on quietly and finally had the last stitch in.

the next day, on post operative rounds, the consultant asked the patient how she was feeling.

"much better, thank you." said the vip.

"good, "replied my consultant, "we were worried we had done the wrong operation on you."

gee thanks, i thought. imagine what the prof is going to say when he hears from his son who heard from his girlfriend who heard from her mother who heard from her neighbour who heard from our patient what the consultant said.

looking good

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.

anger

in the old days sometimes confrontation was the only way to get things done. but sometimes anger lead one into useless and unnecessary confrontation. i recently spent some time with my old friend, swimmer's chest and a story came to mind when that swimmer's chest saved me from my own anger.

we were on call together. quite early in the day the chemotherapist called me. he had apparently put a patient on the emergency list the previous day for a portacath and the case didn't get done. this was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. something like a portacath would tend to get shifted down the list and may even stand over to the next day. this is what had happened here. he now wanted me to do the case.

"sure i'll do it" i said. "as long as it's on the list as soon as it comes up i'll be there."
"i want it done now!" he retorted. i was not impressed.
"well phone the anaesthetist on call and motivate for him to move it up the list." i said helpfully.
"that is not my job! you will do that!"

it was clear we had a communication problem. whenever i had a telephonic communication problem i would put down the phone and take the effort to go to the relevant person to sort it out face to face. not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). this is what i did here. i turned to swimmer's chest and told him to accompany me. off we set at speed.

we walked into the chemotherapy ward and asked to see the relevant doctor. soon he was there in front of me. swimmer's chest hung back. i introduced myself and explained that i was more than willing to do the surgery but i had no control over the order of the list. that was entirely in the hands of the anaesthetists. if he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.

"you will phone the anaesthetist yourself and you will do this case right now!" he said.
i could feel my anger slowly turning into fury.
"no! you will!" as i said it i clenched my fists and took a step towards him. swimmer's chest realised things were on the verge of going south. he later told me he thought i was going to punch the guy. i denied this, but the thought was going through my mind at the time, i confess.

so my good friend stepped in front of me with his broad chest and nudged me backwards. he then started speaking to the chemo doc in a calm diplomatic voice. he also subtly and slowly (almost so one didn't notice) ushered the guy further and further away from me. by the end of it we left with the chemo guy feeling that we were there for him and would do all we could. i don't think he even had an idea of how enraged he had made me.

walking away swimmer's chest asked me if i was mad. i had only a few month's of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.

those times in the end brought out the worst in me. by the end of my studies i knew i needed to get away from it all. i had very nearly become something i did not like. after leaving pretoria i gradually rediscovered the true me again. it was still there to my relief.

master and apprentice

surgical training is very hierarchical. everyone knows where they fit on the pecking order and everyone stays pretty much in their place. a basic team consists of the consultant, (or the boss), the registrar, (the guy who runs the show), the medical officer (his second in command), the house doctor (the skiv), and an assortment of students. but the registrar and the medical officer are actually the functional unit, the master and the apprentice. it is a sacred relationship. only once were those lines blurred.

a friend of mine was a phenomenal doctor and a most capable operator. he was medical officer to the senior registrar and quickly learned how to do pretty much everything. soon his senior was doing his calls from home (an almost unheard of state of affairs reserved only for those working with exceptional medical officers) where he could hit the books for his up coming finals. at the same time another medical officer was biding his time in 1military hospital. the work load between the two hospitals was incomparable. the academic hospital was always at full capacity and a call generally delivered much and severe pathology. the military hospital was very quiet and to even do a laparotomy on call was most unusual. although of the same station, the two medical officers were very different in experience and ability.

when it came time for them to write primaries, for some reason my capable friend passed up the opportunity due to a few peripheral problems in his life at the time. however, because of this, when the next year came around, he was not promoted to registrar, but remained a medical officer. as life would have it the boss put him together with the most junior registrar, the guy from the military hospital.

i was rotating through urology. the surgeons phoned us to join them in theater for a gunshot abdomen with an injury to the ureter. they would open and get the life threatening stuff sorted out. we would then be required to fix the ureter and they would handle the rest. (ahh the cushy life of a urologist.) we walked into theater just as they were about to open. i saw my friend, the medical officer, and we exchanged a quick friendly smile. he looked a bit sheepish only assisting on a type of operation which he would have been doing himself only a few short months previously.

the registrar opened. there was blood in the abdomen, pretty much the normal amount for a common or garden gunshot wound. right away i could see the registrar was out of his depth. he sort of patted the blood with a swab, lifted the swab to see how much blood was on it and patted some more. he didn't seem to even have an idea how to explore a simple abdomen, let alone one with a smidgen of blood from a bit of acute lead poisoning. i considered offering to help. after all i was a general surgeon registrar, even though i was rotating through urology and i was the most senior generalist there. i decided to wait.

my urology senior leaned across and asked;
"what do you think is hit to cause that much blood in the abdomen?"
"that is not all that much bleeding," i replied, "the patient is still stable and there is no increase in the amount of blood. this is mostly old blood."

again i considered volunteering my immense experience and skill, but i knew that this situation was well within my friend, the medical officer's abilities. i held my tongue.

"what do you think is hit?" my urology senior asked the registrar. still softly and ineffectually dabbing the blood with swabs, the registrar replied, probably more with his adrenals than his brain,
"i think the ivc is hit." i'm a bit ashamed to say i laughed, but i did. i thought he should know that if i thought there was any real danger i would have already been in there. i looked at my friend, the medical officer. i could see the frustration in his eyes. the situation was not dire enough for him to undermine his senior's authority and take control and yet nothing was happening!

he then humbly suggested he help a bit. within moments he had exposed all relevant injuries and shown them for what they were. the registrar looked in control again. we, the urologists got stuck in and fixed the bloody ureter. then we left.

that day there was a master and there was an apprentice, but which was which?