physician, heal thyself

even doctors get sick, but there is often a difference.

i was rotating through orthopaedics and was on call that night. they tended to relegate us mere general surgeons to casualties during the calls so i was quite excited to get some theater time that afternoon, even if it was for a simple wound inspection and secondary closure and even if it meant there would be a backlog of patients in casualties for me to see afterwards. once i had finished operating i rushed through the change rooms to get back to casualties. while i was changing i heard the unmistakable sounds of someone throwing up in the toilet cubicle. quite soon the door opened and out came the orthopaedic registrar who was on call that night with me. he did not look good. he glanced at me but didn't seem to see me. his face was pale, verging on grey and there were fine droplets of sweat on his brow. he was staggering slightly as he made his way to the basin to throw water over his face. i greeted him but the only reply he gave was a sort of grunt.

much later that night i had to take some x-rays to theater for the senior to see. to my surprise the registrar was still there. he hadn't swapped his call out. i assume no one wanted to help so he had no choice, he had to work. however, he had come up with a practical solution. he was scrubbed up busy operating, but i noticed two drips hanging from the drip stand next to the anaesthetist. the one drip went to the patient, but the other went under the orthopod's gown and was replacing the orthopod's fluid loss that his severe case of vomiting had caused. the anaesthetist was actually maintaining hemostasis in both the patient and the surgeon simultaneously. i was quite impressed.

a few years later when i was the senior registrar in general surgery i too came down with some or other virus and i too was on call that day. in our department no weakness was tolerated and i knew it would not be a wise move to let the prof know i was ill. i just had to suck it up and go on.

the call was busy and being a bit sick i was struggling. there were too many things happening at the same time and it was becoming increasingly difficult to get to everything, but i kept on going to the best of my abilities. quite soon i found myself in theater operating. and there i stayed, doing case after case in quick succession and rushing down to casualties between cases to sort out the continuous stream of patients that were still coming in. and thus the call grinded on.

sometime in the early morning hours standing over yet one more open abdomen in theater i started to feel light headed. with the immense workload i realised i had not taken any time at all to have anything to eat or drink. this, combined with my illness had finally caught up with me. i was on the verge of passing out. fortunately i had more or less completed the operation and my medical officer was a capable guy. i turned to him.

"ninja, i need to take a seat. do you think you can close?" as i said it i staggered back. the world seemed to be moving beneath my feet. i leaned against the wall and slumped down. the ninja was saying something but his voice was far off and incoherent to me. the next moment i was aware of the house doctor leading me to the surgery tea room where i collapsed on the bed. i looked up in a haze. she was preparing a drip. i considered refusing but the words just wouldn't come out. besides i realised that fluid was exactly what i needed.

"put glucose in that drip too!" i finally managed to say.

quite soon the drip was up and the house doctor left. i reached up opened the drip to run in as fast as possible. then sleep came.

some time later i heard the house doctor return. she seemed surprised to find the drip sack empty, but changed it anyway. as soon as she was gone, once again i opened the drip to run full speed. the first liter had made a difference and i didn't want to waste any time, just in case i was needed during the call.

the next memory i had was the ninja shaking me awake.

"bongi, there is a gunshot abdomen. i've sorted everything and he's on the table. are you ok to operate or should i call the prof?" the ninja too knew that to let the prof know i had collapsed could potentially be disastrous for me.

"no. i'm ok now. get started so long and i'll be there in ten minutes."

later when i examined the timeline of events i had only been out of action for about an hour and a half. except for the people involved in the incident, no one ever found out. and, most important of all, the prof was none the wiser.

sucker

as a registrar i made sure there was no one in my firm who worked harder than me. i would arrive early and leave late and would generally see everyone myself, not leaving it to the house doctor or students. that way when they complained about how hard you had to work in surgery i could justifiably tell them to suck it up and get on with the job. i say generally because there was one glaring and even shocking exception to this rule.

the vascular rotation was the busiest, bar none. there were two of us in the firm so we ended up on call every second night and the calls could get quite tough. one single vascular emergency could destroy your circadian rhythm. yet if there was only one we would boast about the three hours sleep we had managed to get. in that time we considered that more rest than we knew what to do with. the other problem was we had no house doctor so our days tended to get quite busy with all the administrative tasks that were needed to get things running smoothly. so after being there for a few months my enthusiasm for long hours had somewhat diminished.

then suddenly there was an extra house doctor in the department and in a moment of weakness the boss allocated him to vascular (he would often rather put two house doctors in his own firm than send one to vascular). we were ecstatic, especially after the first day when it became obvious the guy was not afraid of work and he also clearly knew what he was doing. we had been given a gem. on his second day on the job he asked us about how the calls worked and what his after hours duties would be. i was just about to tell him that his calls were going to be quite light because we handled pretty much everything, but my colleague spoke first.

"well, you are the only house doctor, so you'll have to handle all the stuff primarily and call us if there is a problem or if someone needs to go to theater." it was so clearly a joke i thought at any moment one of them was going to start laughing. then we would send him home to his new wife and we would continue to slave through the night. but they both nodded. the house doctor seemed to accept this as simply one of the hardships associated with where he had been allocated in surgery. it was my colleague's call that night so once the day's activities had ended i made my way home.

the next morning my colleague told me he had had a great call. the amazingly competent house doctor had handled everything and he had spent the night at home. i was intrigued. i wondered what it was like to spend a vascular call at home. i decided not to tell the house doctor yet that the story of him being on call every night was just ridiculous and let him do another call. the next day he would probably complain so much we would have to inform him that it was just a joke and then life would settle back into its usual rhythm.

my call was wonderful. unlike my colleague i did come out to operate, but all the other peripheral irritations were completely handled by the house doctor. the guy was good. and still he hadn't complained. i spent post call in theater and went home well after the sun had set. i didn't see the house doctor that day and just assumed he was also at home. yet the next morning i discovered he had done another call and once again my colleague had spent the night at home. i started wondering how much of this the house doctor could take. it was clear he was tough, but the question was how tough was he.

and so we sort of never really told him that it had been a bit of a joke and he just kept on working, day and night and night and day. i think we also fell into the luxury of not doing the hard yards during a call and we got used to it. also we knew he was only going to be with us for three weeks and then we would be alone again so i suppose we saw it as a rest in the eye of the storm before the reality of vascular returned in full force.

after nearly two weeks of being on call every single night the house doctor started to hint that he might need a break. they were just hints so we did what any normal male does with hints. we ignored them and hoped they would go away. they didn't. after another few nights he told us he needed to speak to us about the call situation. by this time he was looking a bit worse for wear. who could blame him? he had done a solid two weeks of call on the trot and that in vascular. that was enough to break most people, but he seemed to be at least partially alive still. we agreed to discuss it.

the house doctor explained that he had done more than his fair share and had in fact done much more than the other house doctors in surgery who were doing about one call a week. he went on to say that it wasn't that he was lazy but he just needed a break. he also told us that he was fairly recently married and although his wife was understanding there was only so much a young wife could take of this sort of lifestyle. he told us that he needed to give some attention to his marriage too and couldn't just work constantly. we knew he had a point. he had proven himself beyond our wildest expectations and he did need a break. also secretly we knew that we had expected him to do far more than what was actually required of him. he was well within his rights. we had to relent.

we gave him one night off and told him to be back at work the next day, ready for another weeks call.

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.