Friday, June 22, 2007

thinking back

i realized i have gotten over the trauma of studying surgery. sounds melodramatic and it is actually. don't worry, i'm not going to go into some self pity rant about sleepless nights with lives in the balance and personal abu... wait a moment, i'm already doing it.

back to the point. (tangential thought can be such a curse) the other day i was doing a cholecystectomy. the patient presented with obstructive jaundice (went yellow). the sonar revealed stones in the gall bladder as well as in the comon bile duct. what was unusual was dilated extra as well as intra hepatic ducts (stones usually don't give dilated intrahepatic bile ducts). she had hiv so i wondered about some exotic complication. anyway i posted her to pretoria (about 3 hour drive) for an ercp to remove the stones from the duct before i attacked the gallbladder.

the gastro guy phoned after the procedure. he told me there were stones as seen on the sonar which he removed, but there was also a fibrotic stenosis which he dilated with difficulty. this he attributed to chronic infection and inflamation with fibrosis and stenosis (the tube was injured and healed, sort of, with narrowing). he told me a cholecystectomy was indicated (no shit).

so i booked theater (i think in americanese that would be or). i asked my surgical colleague's wife to assist me. (remind me at some point to blog about this guy. we have an amazingly intricate relationship). usually i use very junior doctors as assistants, so it's nice to have an assistant occasionally who really knows how to assist well. i commenced with a laparoscopic cholecystectomy (in private, sid, so i couldn't employ your mini steps. still trying it in state though).

things got pretty ugly pretty quickly. everything was a mass of fibrotic tissue, hard and not allowing dissection in anatomic planes. the cystic duct, hartman's pouch and the common bile duct were all embedded in one mass of scar tissue. no wonder the gastro guy found a fibrotic stricture. surprising that's all he found. i had to convert (change from a laparoscopic procedure to an open one). even open it was a nightmate. i had to do a retrograde and ended up finding the cystic duct by opening the gallbladder (surgical gobbeldygook meaning it was bloody difficult). now the point here is the worst complication a surgeon can get is a bile duct injury. i'm working in hostile territory (we call it lion country, but i don't know what that would be in american. bear country??). i know i have a chance of causing the worst complication known to a general surgeon (except death and such) and i'm merrily operating along. my assistant and i have been exchanging good natured banter throughout. and then it happened.

my assistant randomly mentions something about the old days when her husband wrote intermediates. (we write primaries, then intermediates, then finals to become a surgeon. these are stretched over a 6 year period, post grad of course, while we work as first line surgeons in an academic hospital which is by definition a state hospital). at the mention of those exams and by definition those old days i felt my tension levels shoot up. i got such an adrenal rush i had to take a break from the operation for a moment (almost 2 seconds!!).

and then i had my usual introspective thoughts. here i am in the middle of an extremely challenging operation with the real possibility of permanently screwing up someone's life and i'm totally cool (i would say as a cucumber but what the hell does that actually mean?). then i get reminded of a time and a place i'd rather forget and i almost plutz. it was then that i realised i was no longer used to that feeling that was my constant companion for so long. even a tense operation did not compare.

how sweet. i have healed.


Sid Schwab said...

Ironically, around here I've always referred to it (and heard it referred to) as "tiger country." And whereas I think there hasn't been a tiger around here since before the last ice age, we read of bear encounters not at all rarely...

I've had a few gallbladders like that; not at all pleasant. Nor can I say I always remained cool; cucumber or otherwise.

Bongi said...

ha ha ha. good one. some time i think i might post on the surgical principles of bongi. one of them deals with stressful situations in theater (or)