eager

i hated vascular surgery. part of the problem was that it was so busy and we were ridiculously understaffed (except for a short while). but i also simply didn't like it. then there was the small issue of incredibly long and taxing operations. i found them long and taxing. so one day when a junior showed unbridled enthusiasm for a vascular case, i didn't have the heart to tell him he was in for severe disillusionment.

the medical officer called me late one evening. he was so excited he could hardly speak. i knew he had a particular interest in surgery and had even mentioned to me he was considering specialising one day. his present excitement was related to a gunshot wound patient he had just seen in casualties. finally he calmed down enough to tell me what it was all about.

"bongi, the bullet went straight through his knee. there is a massive hematoma behind his knee and there are no distal pulses. and that's not all!" he saved the best for last. "the hematoma is pulsating!!"

he was excited because he was going to be seeing his first vascular repair of a popliteal artery. if he had ever seen one before, let me assure you, he wouldn't be excited at all. he would be dreading what was to come. i didn't have the heart to disillusion him. i simply told him to get the patient to theater as fast as possible and call me as soon as he was ready. i then considered crying. vascular cases took forever and it was already almost midnight. i wouldn't be sleeping at all that night.

i walked into theater. the medical officer was bouncing off the walls, poor guy. he just didn't have an idea. he informed me he had never seen a gunshot of an artery before. i wanted to say that that was bleedingly obvious, but the pun would be wasted on him in his state. i just smiled sympathetically. after this night i suspected he'd be a broken man.

we started the operation. now when doing a repair of an artery that has been shot to pieces, the first part of the operation has all the glamour and glory of any number of television medical dramas. there is blood and gore and bucket loads of adrenaline. as i struggled to get the artery under control i could see through the corner of my eye that the medical officer could almost not contain his excitement. i chuckled a bit to myself. i did it quietly and behind my mask so as not to break his spirit any more than the operation was about to. you see the first part takes mere minutes and then it is down to the long slog of replacing the damaged piece of artery with an appropriately prepared piece of vein harvested from the other leg. this part of the operation takes hours and is tedious, especially if your sole duty is to hold the wound open so the surgeon can see.

"hold the wound open better! i can't see!" i shouted. poor guy. for me to access the popliteal artery i was sitting on a chair working from an angle up into the area behind the knee. the medical officer was standing on the other side and literally leaning back on the retractors. every time he tried to peek into the operative field he inadvertently let slip with the retractors and the entire wound closed. only one of us could see at a time. seeing that i was doing the operation, i thought it best that that person be me. he somehow didn't like this idea.

and so the operation progressed through the night until the poor medical officer was totally disillusioned. when we finally walked out of theater to greet the rising sun i felt somehow i should encourage him, but what could i say? he had tasted vascular and just as it had done with me many many times, it had left a bad taste in his mouth. as i looked at his downcast face i could almost hear what he was thinking.

'dermatology seems like a good idea.'

late night surgery

sometimes when people hear how little sleep a surgeon sometimes functions on they tend to be surprised. actually it is not a problem if you are operating. during an operation all your faculties are at their sharpest. there is no chance of dropping off, as it were, into an open abdomen. to assist is an altogether different story.

by the time you actually get to operating yourself you would have put in quite a number of hours assisting. the difference between operating and assisting is vast. as i've said during an operation you are totally alert, no matter how little sleep you have had. while assisting, you could easily become distracted and may tend to doze off if you are not fully rested. i have spent many long hours late at night or in the ungodly early morning hours holding some retractor in an abdomen while my senior sewed up what seemed to me to be vast tracts of bowel and i have often heard his irritated voice telling me to retract correctly moments before i probably would have fallen unconscious into the open abdomen. basically put, i know what it is like to assist at these hours and just because i'm fully into the operation does not mean i don't have sympathy with my poor assistants.

however there was one unique assistant. i was still junior but i remember him well. he was not a surgeon at heart so he didn't even have the exhilaration of experiencing open surgery to keep him awake, despite his physiology crying out for sleep. he quickly nodded off with the slightest quiet moaning of his physiology. but he had a unique talent.

this house doctor (that is what he was), while assisting, would push his feet up against the table, lock his knees, hook the retractors into the wound, throw his head back and go to sleep. the weight of his torso pulling indirectly on the retractors gave better exposure than he was ever capable of doing awake.

yes there were times when theater was eerily silent in the wee hours in the fear that the assistant would be woken up, making the operation so much more difficult.

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.

assistants

assisting isn't rocket science. it's not difficult. you basically need to give the surgeon exposure. if you can't do this, then just do what he tells you. that's all.

having said this, to work with a good assistant is amazing. a good assistant can predict what is going to happen next and get everything lined up so it all just goes that much easier.

as a student i assisted quite a bit. as a junior doctor i assisted a fair amount. as a registrar i assisted after hours for extra money. i can assist and therefore i can direct and teach a poor assistant. in fact, for me the ideal assistant is an inexperienced one that i can train and develop to my specifications. but i also use young doctors because they are the ones that need the money. they are the ones that work for the state and are underpaid. i remember how i needed money in those days and therefore i usually use these doctors. the practice that i work for has occasionally basically requested that i use the older gps but i feel a certain obligation to the state doctors.

but, especially when i am trying to favour those who need the money, nothing irritates me more than having to phone a whole bunch of people before i get an assistant. i mean when someone says they are on call or out of town, then i have no problem, but when they say they are tired or have a headache or need their beauty sleep or whatever they tend to fall to the bottom of the list of people i call. i recently was told by one of my assistants that another guy was wondering why i phone him so seldom. i didn't say anything, but i thought of all the times i did call him and he wasn't available because of 'social obligations'. it's at times like this that i realize i can be a typical surgeon. i don't want to know about inconvenience and the like. i just want an available assistant at midnight when i have a gunshot abdomen who is decompensating.

i recently lost two great assistants (they moved to canada where they are presently freezing). so now i am trying to reestablish an assistant base.

but it can be difficult to assist (unless it is your passion). no matter the time of day or night and no matter how little sleep you've had in the last week, when you are operating, all your senses are sharp. you are fully alert. you are fully alive. but to simply hang on a retractor at 3 in the morning while the surgeon works his magic can be mind numbing. and mind numbing when fatigued means sleep and sleep means poor assisting.

except the exceptions. many years ago while i was a medical officer in surgery (before i officially started specializing) we had a house doctor who had a special talent. awake he wasn't a particularly good assistant but in the early hours, he would hook the morris into the wound, push his feet up against the table, throw his head back and fall asleep. in this position he gave such good exposure the surgeon would demand total silence just in case someone woke him up.