surgical principle number 8: we do it to impress the chicks

what is the point of even having surgical principles if you can't finish them off with a light hearted one.

general surgery is roughly divided into two categories. ie. blood and guts. the guts side of things involves feces, stomach content, bowel content, bad smells and the like. the blood side of things is often high drama and adrenaline and is the stuff that the medical tv shows are made of. most of the general public don't really want to hear about the time i did a rectal examination and my glove broke or the fact that the smell of a septic abdomen somehow seeps through the gloves and it can't be washed off your hands afterwards leaving a most unpleasant stench. i considered trying to market whatever it is in abdominal puss that causes that stench as a deterrent for fingernail biting, but it seemed too much effort.

but if you talk about someone bleeding to death and you intervene, this causes an entirely different reaction. it makes school children who watch these tv programms think that they would love to become surgeons. i just hope they don't bite their nails. so, bearing in mind we can only really be glamorous in half of our work, it is sometimes nice when one can get a bit of this glory.

it was post intermediates and i tended to stroll around casualties as i have mentioned before. a good friend of mine and i were in the same firm, so the night in question, we were both together checking out what was happening there. we had nothing better to do for a change.
as we casually walked through casualties (why can't more people be casual in casualties i wonder) we heard a bit of commotion in resus. we walked over and glanced in. what a sight.

there was a guy lying on the table. he had a large gash in his chest just left of the sternum. out of this hole bright red blood was gushing out in torrents. there were two casualty officers poking away with artery forceps but in that amount of blood it was clear they were losing the battle badly. the patient was still moving but his movements lacked conviction and were getting weaker as we watched. obviously they had called the thoracic guy but just as obviously, unless he was just around the corner the patient would be dead when he arrived. i thought that the heart was probably lacerated.
i turned to my friend.
"shall we?" i asked.
"why not?" he replied. and we walked in.

the casualty officers acknowledged our presence with nervous smiles. i asked for a knife. there were only loose blades. i took one and extended the wound. the patient didn't flinch. he was on his way out. i shoved a swab in. my friend hooked the edge of the wound with a retractor, but because of the ribs we couldn't really open too wide.
"i see it , i see it!!" he shouted. he reached for an artery clamp and grabbed the upper end of the transected internal thoracic artery (also known as the internal mammary artery, but because this guy was a guy i've decided to go with internal thoracic). immediately the amount of blood was less. i shifted my retractor and quickly identified the lower end of the transected artery. it's a lot easier when you know what you are looking for. i clamped it. soon we were tying the bleeders off.
we spent a bit more time to put up acceptable lines and call theater to book the thoracotomy for when the thoracic guy actually did turn up.

in just moments we had turned a hopeless situation into at least a salvageable one. when the thoracic guy finally did turn up all he had to do was wait for theater and fix up the hole in the guy's chest (which admittedly we were more than partly responsible for).

then my friend turned to me.
"have you seen outside resus?"
"what do you mean?" i asked.
"go look."
i walked outside. there were about five nursing students, all wide eyed and all looking at us as if we were absolute heroes. being a surgeon and already being under the influences of an over active ego, i felt pretty good. i did not want to be the one to tell them we had just been lucky with the injury and that a true stab to the heart would most likely not have turned out quite so rose coloured (except maybe a blood red rose of course).

surgical principle number 7: break the tension, don't add to it

sometimes surgery is routine and mundane. but sometimes it is anything but.

i have assisted enough surgeons who lose their cool at the drop of a hat to be able to see first hand that it doesn't help. however i only formulated this as a principle when something happened while i was operating as a senior registrar.

it was late at night or in the early hours, i can't quite remember. the case was tense enough in that some guy had taken a standard dose of lead through the abdomen. (this is not the best route of administration. it can be messy.) we had gotten him to theater fairly quickly by that hospital's standards and were systematically going through the things you need to systematically go through. my assistant was a junior medical officer. the scrub sister was also quite junior. i was quite at home with this state of affairs. in fact everything was moving along quite smoothly.

then something went wrong. it involved bleeding and the potential of bleeding in great quantities. my mindset changed instantly. i went silent. my assistant, although he was junior, could see this was not a good situation we found ourselves in. the sister was deeply involved in a conversation with the floor nurse. i think it had something to do with a recipe for chicken feet and atchar. i was glad i had something else to concentrate on. (both chicken feet and atchar are disgusting to me and even to be exposed to a conversation about them i find a bit disturbing.)

anyway i asked for artery forceps (i think that is the translation for arterie klem which is actually what i asked for). i needed them at exactly that moment because it was at that split second that i had perfect exposure and could see the source of the bleeding. the sister hadn't yet realised that the operation had just changed into a new gear. there seemed to be some discussion about exactly what type of atchar goes best with chicken feet and she simply was no longer really into the operation. my assistant snapped.
"sister pass the blasted artery forceps right now dammit!!!" he shouted. it was time for a moment.

i shoved a swab into the wound and applied direct pressure. i informed my assistant that he needed to take a moment too. i then turned to the sister and calmly told her that things had gone ever so slightly south and i needed her to leave chicken feet and atchar for later and pay attention for now. and then... then i leaned over and said the first harsh thing i had ever said to anyone in theater. i told my assistant in no uncertain terms that he will never ever raise his voice at anyone while working with me again. in fact i informed him that while working with me he could only speak directly to me from then on. he was surprised seeing that he thought he was trying to help. (only one other time have i raised my voice in theater and that was to blind chicken boy. but that story could be left for another post)

after the moment i got control and finished the operation to almost deafening silence.

later i discussed the situation with him. at that moment there was too much chaos. there were too many variables working against the patient. my complaint with him had to do with that he heightened an already tense situation and only succeeded in showing the sister that he had no control. i explained that he had to transcend the situation and not only take control, but calm the situation. in surgery you don't need to look for trouble or create it. trouble will come of its own accord.

also as a typical surgeon i was not at all impressed that he had attempted to take control during an operation, but that i just kept to myself.

surgical principle number 6: take a moment

you wouldn't think it by reading this blog, but sometimes in surgery things can go wrong. and sometimes they can go severely wrong very quickly. strangely at the moment of disaster it is not always clear if you are facing a problem or a full blown disaster. and thus i learned to take a moment.

the principle of the moment actually took its origins from many years ago when i was still a house doctor. in those days i was already doing certain surgeries which were way above my head. i would always try to get my frame of mind right while scrubbing. i would think about the operation and what i was likely to encounter and just try to focus. yes, in a certain sense i was already taking a moment.

in training when i was a junior i did quite a bit of assisting as can be expected. when things got rough generally the tension was almost too much to bear. and if the lowly assistant didn't hold the deaver retractor just right or for long enough all hell was likely to break loose. let me just use this moment to mention that the deaver was designed by a sadistic internist who now sits in his office chuckling to himself about the hand spasms that his instrument causes to us surgery folk. either that or the devil himself took time off from tormenting the damned to create something that could torment the living too.
anyway, as an assistant during those numerous tense moments my hands often spasmed so badly that it was difficult to open them afterwards. i wondered why the blasted surgeon couldn't just take a moment so the poor assistant could stretch his fingers before the next protracted attempt to get whatever surgical control needed to be gotten. at least then at the crucial moment the assistant would be worth something.

and then there is the small issue of bleeding. yes, boys and girls we have learned that all bleeding stops, but i personally believe it is better to stop the bleeding while there is at least a flicker of life left in the patient. these moments are the true adrenaline moments in our job. during these moments the actions of the surgeon will determine whether the patient lives or dies. you need to be at your best. you need your assistant to be at his best. what an ideal time to take a moment. you can just go through what to do in your mind before the chips really do go down. you can instruct your assistant to relax and prepare to unrelax during what is about to transpire while you settle yourself and concentrate on what you are about to do. (it is important to tell the assistant to take a moment. all but the most useless can feel the tension and will not relax unless they are actually told to.)

but the moment has to do with bleeding too. obviously you can't just step back while some big artery is pumping blood all over the floor (it might annoy the sister). pressure is the key. you put pressure on the bleeder with a swab and then you take your moment. (remember to let your assistant know this is his moment too. he will use it to stretch his fingers and curse the fiend who designed the deaver.) while you are trying to remember the punch line of some weak joke in an attempt to put everyone at ease, your pressure with the swab will help with the bleeding. it is controlling all the venous oozing, leaving only the surgically significant bleeding for you to control. you see in the heat of the moment, with severe bleeding, those worrisome venous oozers sometimes cause just enough trouble to really make control difficult. you are not sure what to tie off and that small amount of ooze obscures the vision just enough to make control difficult.

so in conclusion, at the most critical times during an operation, put time aside to take a moment. it settles your nerves, optimalizes your assistant and helps with bleeding. it also creates the illusion that you are totally in control even if the situation is spiralling downwards towards the creator of the deaver.

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.

surgical principle number 4: enjoy

surgeons are too stuck up. just because you might be saving someone's life and just because blood and guts might be all over the place it doesn't mean you can't take a moment to just enjoy it all. to be honest it might be the one thing that keeps you sane through all the madness.

in our department the prof demanded complete silence during operations. he even used hand signs to ask for instruments so he didn't have to speak. woe to any student who spoke. and if we didn't show due awe at all times he was not impressed. but the problem with spending so much effort working up all that awe all the time was you were often not left with enough energy to just enjoy what was going on. he also had an amazing ability to make students hate their surgery rotations. (how weird is that? it's like hating ice-cream or christmas lunch). i thought another approach would be better.

there is a general shortage of general surgeons in south africa. sure it has a lot to do with the hours and working conditions and all the other well publicised reasons. but it also has to do with a reluctance to go through the old style training. but i don't think all the aspects of the old style training are bad if you want to create surgeons that are worth something in the real world. but at least instill in them an enjoyment in what they do. i mean, let's face it, how cool is it to be a surgeon? we get to cut people open and mess about a bit with their innards. sometimes we might actually make a difference.

so whenever i operated with students one of the things i concentrated on was instilling in them the absolute joy of surgery. i know of three students that decided to study surgery as a direct result of working with me and one student who decided not to quit medicine altogether after having worked with me.

so for all my faithful readers, whenever cutting and dicing, stop and reflect for a moment about how wonderful it is to do what you are doing. don't just enjoy it but instil in those around you more than just a healthy dose of enjoyment.

surgical principle number 3: all bleeding stops

this is not originally my principle, but it is so true that it somehow found its way into the surgical principles of bongi.

i first saw this principle in action many years ago when i was a community service doctor in qwaqwa. i was doing a call in casualties. actually, the way it worked there meant i was doing more than just a casualties call. i was also the anaesthetist on call and the overall backup for the two interns. for any big surgery we'd call the cuban surgeon out. otherwise we were it. the interns would do the caesarian sections. i would dope the patients and resuscitate the baby if needed. the interns would also do the debridements and ectopics. here i would dope and give useful advice about what to cut off and out and how. anyway i digress.

one of the hospitals that referred to us phoned. the guy had a stab wound neck. he told me it was bleeding profusely and he wanted to send it for surgery. i naturally accepted the patient. but i told him to somehow apply pressure to the wound to control the bleeding for the trip (his hospital was about 40 minutes away). i actually suggested he send someone with a bit of savvy who could put their finger in the wound to directly stop the bleeding.

once i had gotten off the phone i got casualties ready for a big resus. in qwaqwa this took some doing. the charge sister had to unlock the cupboard where the drip needles were kept (they tended to go missing leaving the hospital with no means to put up a line). i checked the intubation equipment and discovered the batteries in the laryngoscope were not working. this resulted in a protracted search through the hospital for either batteries or another laryngoscope. finally we found a working one. i soon gave up on getting a working defibrillator, although some nurses said they heard there was one somewhere on the second floor. i then phoned the surgeon to give him a heads up. he told me to phone back once the patient arrived. then we waited.

about an hour after the initial call, an ambulance came tearing in. the paramedics jumped out and came rushing in with a patient on a stretcher. the patient was tubed. one paramedic was bagging him. another was giving chest compressions. but there were two other things i noticed right away.

the first was that the neck wound was open with no clear signs of any attempt made to stop the bleeding. the second was that the patient was not bleeding.
"when you left the other hospital, was the patient bleeding?" i asked.
"yes!" replied the guy pumping the ambubag. "he was bleeding like crazy!" he seemed to be the one in charge.
"and when did he stop bleeding?"
"about five minutes after we loaded him."

i called it right there, thereby saving everyone a whole lot of paperwork.

and thus i learned that all bleeding stops....eventually.

surgical principle number 2: fear nothing but fear itself

the gist of this principle i have already covered. it has to do with the patient's best chance. if it's you then it really doesn't help to cower away.

i have seen patients suffering because there is some or other doctor just too scared to have a go at it. twice i have been forced to stand down with thyroid surgeries because the anaesthetist was afraid, even though it meant the one patient would remain intubated for a week and the other would disappear into the system, probably to die of asphixiation somewhere down the line.

yes you need to know your limits, but somehow in surgery you also need to back yourself and go where few dare. it is the nature of the beast.

when i joined the surgery department there had just been an acute shortage of registrars in general surgery. therefore, although i was just a medical officer, i was placed in a registrar position as the head of a firm. i was pathetically ill equipped. my consultant, although he was usually available to come out and help, was not quite so willing. there would also be nights when a private surgeon would be the consultant on call. then there was little chance of getting him to come out. our consultant gave myself and my colleague a crash course in what we were likely to encounter on a call and what to do. i called it the how-to-handle-pretty-much-anything-so-i-don't-have-to-come-out-and-work-once-the-sun-has-set course.
in his opening address he told us about an incident that had happened to him during his registrarship when he called his consultant in the middle of the night to help him with a gunshot tail of pancreas. the consultant irritatedly told him to remove the damaged tail. he had never even seen it being done before. he asked how he was supposed to do that.
"use prolene!" shouted the consultant and hung up the phone in his ear.
"so what did you do?" i asked.
"i used prolene." he replied. i remember thinking i should probably find out what prolene is.

some time ago the state asked me to operate a gunshot chest and abdomen. i naturally responded. the abdominal part went quite well, but it soon became apparent the main source of bleeding was the chest. i phoned the thorax surgeon. he told me a bit about how nice it was to be on holiday and that the sun was shining and he was working on his tan. i considered warning him about the dangers of skin cancer but at that moment it didn't seem to be too pressing an issue. he then helpfully suggested i transfer the patient to pretoria, a good three hour drive. i had a better idea. i opened his chest.

now thoracotomies are not really my thing and i haven't done all that many of them. it is not a general surgeon's usual stomping ground, but that didn't matter at that exact moment. i was not only the patient's best chance, i was his only chance. i swallowed hard and got to work.

so, in surgery it is important to fear nothing but fear itself.

surgical principle number 1: to swear does in fact help

don't get me wrong, i don't swear at people (except when they really deserve it). but sometimes in that critical moment in an operation it does tend to dissipate some of the tension if you let off a bit of steam. i first realised this as a medical officer working in the transplant firm.

it was late at night. we had just procured a kidney and had our recipient all prepped for theater. the only problem was we were having trouble finding someone to do the actual transplant. the guy whose name was on the call list for transplants, a private surgeon who had a session post, flatly refused. in the end i had to call the prof.

the head of the transplant unit was the best prof in the department. he was a gentleman( unusual for a surgeon). he always taught the students on rounds with patience and respect. he was an all round nice guy. but he did suffer from a fairly severe form of theater rage (somewhat like road rage but experienced behind the knife rather than behind the wheel). when i called him, despite not being impressed that he had to step into the breech left by the private surgeon, he immediately came out. and so we got to work just after midnight with a tired and somewhat cranky prof.

the mobilization went well but i could see the prof becoming more irritable with every passing minute. even the anastomoses went acceptably well. however the prof started showing signs that his blood nicotine levels were dropping. most of us also believed the prof and his prostate no longer had an amicable relationship, which meant that he did not enjoy long operations. by the time he got to the reimplantation of the ureter into the bladder he had been reduced to a tired irritable old man with a bladder of his own that was no longer going to stand for it. up to that moment, being junior and working with the best prof, i had been nervous that i would do something wrong. but with the laws of nature and old age conspiring against the poor man his hands became progressively more unsure. each movement needed to be repeated a number of times before it was done. this delay further infuriated his bladder which in turn put pressure on the prof to work faster. the faster he tried to work, the slower he got. the true gentleman that he was, he never swore at anyone in the theater (except himself, now that i think about it). but he did swear and quite a bit. ironically i started to relax. behind my mask i actually found myself laughing. i mean what else can you do when the prof starts addressing the patient's bladder (possibly in proxy for his own bladder whom he felt a certain loyalty to and couldn't directly swear at) as a separate troublesome person with sentences like.
"f#@k you bladder!" and
"you're not going to f#@k us around any more, you bastard!"
sometimes i must admit i did wonder which bladder he was speaking to, especially when just after letting the patient's bladder know who is boss the next few stitches would be disasterous and would need to be done all over again. maybe at least his bladder was no longer f#@king us around.

and thus i learned that a well timed harsh word can actually lighten the mood, if only sometimes for the assistant.

yes i swear during surgery, but not ever at anyone and actually never in anger. it is just a sort of valve to deal with what can sometimes be a loaded situation.

surgical principles of bongi

i've always maintained that you should not be allowed to qualify as a doctor without reading the house of god by samuel shem. but that is not what this post is about.

for those of you who have read the masterpiece, you will be familiar with the rules of the house of god as espoused by the fat man. well i sort of developed the surgical principles of bongi, also all anecdotal and not tested by the rigorous requirements of science, but somehow of value, at least to me.

i have decided to embark on a series of posts based on the surgical principles of bongi. to be honest i have been playing with the idea for some time, but have always wondered if these sorts of series may be a precursor to the natural death of a blog (like the great surgeonsblog) and have therefore resisted the urge.

and so without further ado. the principles are:-

1)to swear does in fact help.

2)fear nothing but fear itself.

3)all bleeding stops.

4)enjoy.

5)it is in fact always the surgeon's fault.

6)take a moment.

7)break the tension, don't add to it.

8)we do it to impress the chicks.