Saturday, November 03, 2007


you agree to do a favour for a friend. it is sealed with a handshake. sounds so innocent, but in surgery this spells disaster.

i thought of this when i read about surgical superstitions on a blog i frequent. but can you call it superstition when experience confirms it to be true?

she had clear cut cholecystitis. but she had no medical aid, so she couldn't afford the private hospital. she knew someone at the state hospital. this someone knew me. he asked me if i would do the operation. at that time i was operating at the state hospital every tuesday, so it wasn't a problem. i said if she got into the system, when she turned up on the list on whichever tuesday, i'd do the operation. he organised it.

then politically all hell broke loose. i was officially banned from the state hospital because i was supplying a service that they couldn't take credit for. the administration ensured that i was no longer available at the state hospital. there was no one there able to do a cholecystectomy (true story). so the patient went without the needed surgery. she just accepted intermittent severe pain with each worsening attack.

finally it became too much. she came to me in private. but the private hospital fees were too much for her. her friend at the state hospital had moved up the ranks during this time. she phoned him. he phoned me. he was in a position to grant me temporary permission to do the operation there if i consented. he was a friend and i decided to do him the favour he'd asked for.

it is not often these days that i get to do an open cholecystectomy (in private it is, of course laparoscopic), so i don't often get to try out sid's mini chole. in the state hospital, there is no laparoscopic equipment, so the decision to do the procedure open is quite easy. i went for the mini chole. i made a 5cm incision. but i don't have the benefit of a clip applicator as described in the steps. i clamped the artery and duct with a roberts. the galbladder was out. i tied the duct without too much hassle. then came the artery.

when tying the artery, the suture slipped. for the non surgeons out there, to tie an artery way below the liver through a 5cm incision can be a spot difficult. when the suture has slipped off, the artery bleeds as arteries tend to do. blood obscures vision. there is an urgency to get the bleeding under control, but with active bleeding it is difficult to see what to do. there can be a bit of tension in the air (and in the surgeon).
i couldn't help thinking that i do a favour for a guy and the patient bleeds to death during a routine operation. i wonder how that would look on my resume.

also mental note, again, to do no favours for anyone. ever....

p.s, i extended the incision to 7cm, got the bloody bleeder under control and closed.


make mine trauma said...

In real estate, the mantra is "Location, location, location."
In surgery I always think to myself that the mantra is "Exposure, exposure, exposure."
Must be awfully hard to tie so deep in a 5cm incision.
(No clip appliers!? No one able to do a chole!? We sure take a lot for granted here).
She is probably soooo grateful to you-imagine having to suffer with symptoms-that any length incision would be fine by her.
Besides, what's a little arterial spray among friends?

P.S. Thanks for the link (and the videos) ;}

rlbates said...

So very true. I almost hate it when friends send friends to me, for the same reasons. Is it experience or superstitions? I'm not sure, but it always makes me nervous.

Greg P said...

I have a lot of patients coming in and saying, "My doctor says you're the best."

I don't know if the doc really did say it, if he did whether he meant it, and don't know what the patient expects by saying it.

Makes me uncomfortable, sometimes very much so, especially when I later get a sense of how horrendously complicated this person's situation is. Somehow you have to mentally brush it all aside and be attentive, be careful -- very careful.

Elaine said...

A watchword through all this sort of thing is "Let the dog see the rabbit"

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Anonymous said...

I think it is disgusting that laparoscopic equipment is not available in your hospital. Against the backdrop of the wastage that occurs in state hospitals due to incompetence as well as just plain theft from ridiculous salaries for no work to opportunist pilfering, placing a cost effective laparoscopic stack and instruments in the hospital is not going to break any budgets. but of course it has to go to tender and who could be bothered with putting together a tender when they don't know the difference between a laparoscopic monitor and an insufflator?