Saturday, April 11, 2009

surgical principle number 5: it is in fact always the surgeon's fault

one of my professors used to say, in jest i believe, but i'm not sure, that no matter what goes wrong in an operation, it is always the assistant's fault. i used to give the appropriate awkward laugh. it soothes the fragile surgical ego. but my laugh was never more than awkward.

i somehow could not adopt my prof's opinion. the more i thought about it, the more i disagreed. in training, your assistants are almost always students and pretty clueless. as it turns out, you need to direct them to do what you need them to do. you actually have to actively use them as additional instruments in whatever operation you happen to be doing. besides, at the m and m, it will be you and you alone before the prof when he asks the obligatory please explain.

bearing in mind most students have a dread of the surgery and bearing in mind some of the stuff that goes down can rest heavily on the conscience (and therefore your sleep) i'm not sure what advantage there is to let the poor students feel more responsible than they are. in a certain way this principle goes with 4. not only did i try to let my students enjoy surgery, i tried to protect them from some of the trauma which can be inflicted by being so intimately involved with human suffering.

fairly recently my belief in this system was somewhat put to the test. a good friend of mine was assisting me with an appendix. he is destined to become a great internist one day which sort of implies he could sometimes be somewhat absent minded with the physical practicalities of an operation. it didn't bother me. i enjoyed working with him and i reasoned i needed to be fully in control anyway.

with this appendix, every time i asked him to loosen the artery clamp as i tied off the mesoappendis he did some sort of weird hand exchange to be able to loosen the clamp with his right hand. it seems he was not capable of doing it with his left hand. easily solved, i thought. it is true the clamps are all made for right handed people and there was a specific left handed technique needed to loosen the clamp. i decided to teach him this technique. i stopped the operation and asked the sister for an artery clamp.

even though at heart he was an internist, he was a quick learner and quite soon he was easily loosening the demonstration clamp with his left hand. i had a moment of pride in him but it passed soon.

then we got back to work. he grabbed the clamp on the appendix base, the only remaining clamp holding the appendix up to the wound and with a swift smooth movement, released it. the stump slipped easily back into the abdomen. he seemed so proud, i almost didn't want to tell him that usually one ties off the appendix base before the assistant loosens the clamp and allows the appendix to fall neatly into the abdomen. somehow there is less leakage from a closed stump than an open one. but i had to.

we took quite a while longer to retrieve the stump and tie it off and then obviously to do the necessary lavage.

still i had to be true to my principles. yes, even then it was my fault.


rlbates said...

I agree with you, we are always responsible. (except for maybe when the assistant drops the skin graft, etc)

Bongi said...

rlbates funny. reminds me of when the prof of vascular had just nicely prepared the saphenous vein. he gave it to the sister to put in hep-saline. she promptly threw it away. he was not happy.

Jabulani said...

Unlike a relative of mine, I AM amused :)

enrico said...

I am amused too, if only b/c he showed pride at his accomplishment. ;)

I have to believe that instructor was joking--I've never met a surgeon of ANY stripe who didn't think s/he was the "buck stops here" person. The surgeon's the one at the M&M as you said, not the assist/circulator, etc. Ego's fine if there's responsibility behind it, similar to why ppl get chewed out; otherwise, it's just bullshit.

(been longer than usual since I was here--need to look for principles 1-4?)

enrico said...

nevermind last statement, I just didn't register the previous posts as "principles" -- *cowering in shame*

DrB said...

100% responsible. The surgeon will be the one before the jury, if need be, not the assistant.

I guess we all have an 'assistant dropping something important,' 'throwing away a specimen' story. :) Only funny in retrospect, and only if it gets properly resolved.

Dragonfly said...

So true - I once was at an appy that was delayed for 45 minutes searching for a ratek swab that a poor nursing student had thrown in the bin. First time I've seen intestines being "run" like a magician pulling streamers out of a hat.

Jade said...

It's always intresting when a clueless student is the only person available to assist. Once I was asked by a surgeon to come assist for gunshot to the abdo. I tried to explained to him that i was a 4th yr student doing call for int Medicine and had never ever done surgery but he insisted as there wasn't anyone else available. I decided to pass it on to a friend because i was too scared . . . One of my biggest regrets

Bongi said...

jade, don't worry, there will be plenty of opportunity to assist for gunshot abdomen. just next time, remember fear nothing but fear itself. don't ever again pass up such an opportunity because you are afraid.

Beach Bum said...

Funny, in conducting class, our prof told us that when a performance goes horribly wrong "it is always the conductor's fault."

I guess with leadership comes responsibility.

Good post!