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.

the best

when i was a registrar i used to tell my students that all surgeons believe they are the best surgeon there is. with only limited logic one can clearly see this is obviously a load of rubbish. how can every single surgeon be the best there is...when i am the best!! for some reason they always laughed.

there has to be a certain self confidence in a surgeon's work. and yes sometimes it does flow over into arrogance. i knew this before i really knew this. i was still in my community service year and had only just decided to do surgery. one of my old friends was a medical officer in the surgery program at tukkies so i went to pretoria to discuss it with him. to be honest he spent most of the time just speaking about the primaries he had just passed and was of little help to me. then he told a story.

he was in paediatric surgery at kalafong. a patient came in with a condition which was on the outer limits of his abilities. it was actually just on the other side of his limits. he felt totally out of his depths, but what could he do? there was no one else. he sucked it up and did what was needed. i found the story frightening and told him so. then he shared some hard wisdom. he was not the best surgeon there was for that child, but he was the only one available at the time. so for that patient at that moment, he was the best there was.

recently i was required to open a chest in the state for a gunshot wound that just kept pumping bright red blood (the best type of blood to have inside the vasculature but the worst type to have outside). i phoned the thorax guy who informed me he was on leave and far away. he then helpfully suggested i refer the patient to pretoria. i mentioned that a ten minute trip for this guy was pushing it and there was no way he'd see the other end of a three hour trip. then i did what i needed to do even though i am not overly comfortable on the inside of a chest. what choice was there?

i try to refer away whatever i feel is not in my scope but once the knife goes through the skin you become suddenly very alone. it is too late to think there is someone else who can do the job better than you. you must be the best for that patient at that moment. this becomes more acutely true when something goes wrong and you have to dig yourself out of a difficult situation. the thing about difficult situations in my line of work is if you handle them not too well someone may just end up dead. somehow to believe you are the best does seem to give just that little more of an edge.

i am not justifying surgeon's arrogance and i hope never to be arrogant. but i can't imagine being able to do what i do without just a little more than the normal amount of self confidence.

old school

sometimes old school surgeons are interesting to watch. one of my 'mentors' was a real study. he came across as hard and even cruel. and yet there was no one who truly cared for his patients as much as this man. you had to know him quite well to be aware of the fact that he cared so much. he usually hid it well.

the patient had stomach outlet obstruction due to benign stricture. the consultant in question decided that a dilatation would be a better option for the patient as he could therefore avoid an operation with all its associated morbidities. he told me to get it done.

the gastro unit at that hospital was not fully functional so it came as no surprise to me that they said they didn't have the necessary equipment to dilate a pylorus. i knew my consultant was not the type of guy to let trivialities like lack of equipment get in the way of what he perceived as a good idea so i phoned the parent hospital.

the gastro unit at the parent hospital assured me they had the necessary dilatation balloon but unfortunately it was broken at the time. i could see my consultant going mad at this news so i insisted they tell me exactly when they would have everything working properly. they told me to phone back in two days time.

on the rounds i had to break this news to the consultant. he was not happy. he wanted to take this ineptitude to the highest court in the land. he wanted someone to fix it now. it took me quite a lot of convincing to calm him down, telling him that the gastro unit would be able to help us in two days time. finally he relaxed.

when i phoned the gastro unit again, as could be expected, they still were not able to help. once again i asked when we could expect satisfaction and once again i was told to call back in two days time. this i knew would not go down well with my consultant. i decided to attempt another tactic in the delivery of this information.

my basic plan was to express as much or more dismay and indignation at the pathetic gastro unit than my consultant. thereby his attack wouldn't be focused on me but he would rather see me as a fellow crusader for all things good.
"can you believe it, doctor!" i almost shouted, "and i suppose when i phone again in two days time they are going to tell me to phone back in another two days!" i could see the frustration on his face. his plan to save the patient the morbidity of a laparotomy was not working out. now because i had come out in agression against the evils of the gastro department he couldn't even take his rage out on me. after all, i was now on his side. i went for the master stroke.
"maybe we should just operate him and be done with. otherwise we're going to wait forever in two day increments until the patient wastes away from malnutrition!" i piped up.

it seemed to hit a nerve. he started pacing. i could see his mind working, looking for release for all its pent up rage at the broken system. despite his best efforts the patient was going to get operated and there was nothing he could do about it. and he couldn't even take it out on me. finally he snapped. he charged towards the patient and shouted:-

"ons gaan jou oop sny van bo tot onder en ons gaan jou slukderm vasmaak aan jou kakderm sodat as jy ietsie eet sal jy dit onmiddelik net so uitkak!" (a paraphrase is roughly, 'we're going to open you fairly widely and do a bypass that will cause a noticeable decrease in transit time') i confess i laughed, but not in front of the patient.

fortunately, just like most of my readers the patient didn't understand afrikaans.

surgical ego

i don't know why surgeons have such inflated egos. maybe it's that the type of person that decides to do surgery is arrogant to start with. or maybe constantly being in a position where someone's life may hang in the balance based on your decision cultures a confidence which flows over into arrogance. whatever the reason i learned to read the ego of fellow colleagues and sometimes even swing things in my favour.

i was always short of money during training. towards the end this became much worse. i used to work in casualty units (er doctor) but when my prof found out that i was moonlighting he threatened to fire me. this door was closed and double bolted. he would only permit us to do private assistances.

so when one of the junior consultants asked me to assist him with a few private cases after a 36 hour shift with no sleep, i jumped at it. sleep be dammed. i needed the money. besides, assisting is a darn site better than casualty work.

the cases went well and i felt that i should be able to make ends meet with the amount of work i would get from assisting this surgeon. i was quite excited about it. but then, as life would have it, i got no more calls from him. once again my situation became tenuous.

then, out of the blue, he called me again. it seems his regular assistant was on call. it was my moment. but this time i knew i had to impress.

we started the operation. i did the usual things an assistant needs to do, but i watched every move he made carefully. i was looking for a way to get at his ego. then he did something that was ever so slightly better than mediocre. it was my chance.

"that was beautifully done! it is so great to assist you! i learn so much doing these assistances!" cheesy i know but i was desperate. besides it was also an interesting test to see if my theories about surgeons' egos were true. i was willing to be cheesy in the name of science. it was but a small sacrifice that i willingly made for the progress of knowledge.

and sure enough it worked. just a few choice words here and there so that the surgeon felt he was brilliant and i quickly became preferred assistant. i relied on that extra income and it made a great difference.

p.s although i had also done some great research, i unfortunately never published. somehow i just never got around to it.