awkward

recently i attended the association of south african surgeons congress. it's always strange and maybe fun for me to interact with surgeons. they are extremely interesting to me. i feel that i'm a bit of an outsider in the sense that i don't view myself as a typical surgeon, so i can sit back and observe, fooling myself that they are not looking at me in exactly the same way.

but one thing about these congresses is that you get to see and rub shoulders with the heavyweights of the profession. it took me back many years to another congress that i attended when i was still a mere mortal registrar and truly was not yet one of them.

the congress in question was in durban. at that stage i pretty much kept away from all the big names. it seemed the safer thing to do. however, one of my fellow registrars and a good friend of mine was quite friendly with the vascular prof, a greater than life man and a true legend in his own time in south africa. in fact my friend went on to specialize in vascular and is now himself a well known vascular surgeon in one of the big centers. so when my friend invited me to the vascular dinner the one night, i should have just said no. i didn't.

the vascular dinner, as i was to discover, was a fairly exclusive affair. it was sponsored by one of the companies that supplied prosthetic grafts, mainly used for the repair of abdominal aorta aneurysms. all the big names were there, including our massive prof and the vascular prof from wits, who at the time was also head of the department of surgery there as well as the president of the vascular society of south africa. in fact the only two non entities were myself and my friend. bearing in mind the entire vascular fraternity knew my friend would one day be one of them, in all reality, i was the single individual there who deserved and got sideways glances. my usual tactic of keeping my head down wasn't going to work; it stuck out like a blushing throbbing aneurysm and there was little i could do about it.

the function was advertised as a dinner on a boat that was supposed to cruise around the durban harbour, all very fancy. but, as it turned out, the weather was a bit too bad and the owner of the boat, which was a bit more like a large raft, all fitted out with tables and chairs and, of course, a bar, decided it wouldn't be safe to take the entire vascular complement of the country on a cruise where the boat had a good chance of sinking and rendering vascular surgeons in our country even more scarce than they already were. i was fine with this. besides the chance of dying, i felt it might be a bit awkward stuck with such eminent beings far from shore and no place to hide. but the sponsors of the event felt let down. they wanted to show off a bit i think and a boat safely anchored in the harbour just wasn't going to cut it. they felt they needed to make a plan, so a plan they made.

after the snacks and a fair amount of dutch courage had been consumed the plan became apparent. suddenly next to our safely moored raft appeared the biggest baddest speed boat i had ever seen. it looked like the type of thing you see on national geographic deep sea fishing specials. i wondered if we would limit ourselves to just the harbour cruise or would we venture into the big blue.

quite soon all the big names had made their way onto the boat. i, being the most junior person there, waited until last to see if there was enough space. as it turned out, it was a very big boat and there was plenty of space, so, somewhat reluctantly i followed my friend aboard. there were three areas where the vascular passengers could sit. one was the main area downstairs which was full. the next was the front portion of the boat which was fulling up quickly and seemed like not the greatest place to sit, just in case we did venture beyond the protection of the harbour. the third was a fairly quaint upstairs area. it seemed like the only real option. my friend and i climbed the ladder.

the upstairs area was the smallest of the three areas and was not yet totally crammed with vascular academia, but there was a reason for this. you see when the profs had gone aboard, they had all gone upstairs. the mere mortals, not wanting to seem forward, had decided to rather remain below. my friend and i didn't know this because we had waited until the last moment before we came aboard so when we got to the upstairs area, i was quite perturbed to see all the great profs sitting there. it was too late to go back down. for one thing, there was no space downstairs and for another all the eyes of all these great and intimidating men were staring at us as if we had just walked in on an awkward conversation. there was nothing for it but to stay there. i immediately decided i would stand as far away from everyone as possible. if there was a corner there i was determined to find it.

the president of the south african vascular society and great and mighty head of the department of surgery at our neighboring university, and more than likely someone i would be meeting soon in my final exams, looked at me and, gently tapping the seat next to him, spake he.

"come sit here next to me." he said with a wry smile.

" no thank you, prof, i'm fine here." i replied. he seemed persistent. again, almost stroking the seat next to him, he repeated his invitation.

"ag, come on, bongi, come sit here next to me." occasionally in life, you are presented with a situation where you really can say the wrong thing, and at the last minute, better judgement prevails. that day it seems i had no judgement at all. the words just seemed to roll out of my mouth, which I confess, stayed open in absolute shock at what had just escaped.

"no thank you prof, i'm not that type of boy."

the vascular prof from our university at least got a good laugh out of it.

covert operations

the consultants didn't always need to know what was happening on the floor. but sometimes keeping things away from them became downright clandestine.

i was a senior registrar at kalafong (hell). an old friend of mine had just taken up a post as consultant in the department of internal medicine. one day he approached me.

"bongi, what are the chances you can do the occasional open lung biopsy for me?" now there was no thoracic department in kalafong so it seemed to me to be a reasonable request. in fact i was quite excited. it would give me a chance to do a few thoracotomies, something us general surgeons don't do all that regularly.

"sure! anytime. just let me know and i'll book them on my list."

"uhmmm, there is just one small problem," he continued, "i've already asked your consultant when the previous registrar was here and he bluntly refused, so i suppose you would need to convince him." this was no small problem. my consultant tended to be a bit hard headed and i knew if he had already decided, then there would be no convincing him. if i were to ask his permission he would refuse and that would be the end of it. if i just went ahead at least i could claim ignorance, that is until he catches me out. there was only one thing for it.

"ok, i'll do it on one condition. at no point must you discuss the matter again with my consultant. everything must go through me." and so it was arranged.

a short while later the internist approached me with the first patient he wanted a piece of lung from. i took her name down and booked her on the back of my list. i then re-wrote the list, carefully omitting her name and took it to my consultant. we went through the somewhat abbreviated list together. he was happy. i didn't want to be the one to erode that fragile joy.

halfway through the theater list, as was his habit, my consultant asked me if i'd be able to handle the rest and went back to his office. i assured him i had everything under control and sent him on his way.

the thoracotomy went well and the hiding of the patient from the consultant in the ward for the next few days also went well. i was feeling good. i suppose i knew it couldn't last.

two more thoracotomies were pulled off in similar fashion. and then we prepared for the whole charade for the next one. again i put the patient on the list and again i discussed the abbreviated list with my consultant the day before. again everything looked good. i went home, looking forward to a great list culminating in a nice thoracotomy to obtain a piece of lung for my internist friend. but this time something went wrong.

how was i to know that my consultant decided to pass by theater that evening before he went home to check something on the list? how was i to know that he discovered my thoracotomy that until then he knew nothing about? how was i to know that when i walked into the morning meeting i was walking into a fire fight?

the consultant was clearly angry. before the meeting he called me over and asked me why there was a thoracotomy on the list that he knew nothing about. i told him the internist had asked for a lung biopsy and i had added the patient because we had some extra time on the list. he went mad (or slightly more mad). leaving no room for any misunderstanding he informed me, with much frothing at the mouth, that there would be no thoracotomies on his list....not now....not ever. i apologized. i thought that was the end of it. i was wrong.

after the meeting the prof asked if there were any announcements. my consultant raised his hand. it was so unusual for him to say anything during the morning meeting because of a certain amount of animosity between him and the prof that everyone sat up and paid attention. he then moved to the front of the room.

"it has come to my attention that bongi has been doing thoracotomies on my lists." he started. "now if this ever happens again i give you my word that i will personally see to it that the guilty party is put up against the wall in front of a firing squad and he will be executed! we will reinstate public executions here in kalafong. we will make it compulsory for all the registrars to attend so they can see what will happen to them if they step out of line. if he wants he can have a blindfold, or he can go without, but he will be executed. the registrars watching will not be permitted to use blindfolds."

i considered the question of the blindfold, but in the end i decided to rather stop doing the thoracotomies.

the graveyard

this is a difficult story to tell but if i am to be true to the complete experience of a surgeon, i do need to tell it.

one of my seniors used to say that every surgeon has a graveyard hidden away somewhere in the dark recesses of his mind. he went on to say it was unfortunately normal, so long as you remember all the names engraved on the tombstones. at the time i thought he was being a bit melodramatic, especially seeing as though i could barely remember the names of any of my living patients. somewhat like one of our consultants i used to refer to them as the guy with the pancreatitis or the lady with the bleeding peptic ulcer. unfortunately i learned what he meant.

it was a tough call so when my pager went off at five in the morning i was not delighted to hear there was a gunshot abdomen in casualties. bearing in mind i had been on the go solidly for about 23 hours and i had a full day ahead of me, including an afternoon theater list, it was going to be tricky to juggle things. i charged down to casualties to evaluate the patient.

gunshot abdomens are slam dunks. you operate them. there are only two exceptions which you seldom see, one of them being a bullet that only passes through the abdominal wall and doesn't actually penetrate the abdominal cavity. this guy had a tangential wound passing through the left flank. his abdomen was completely soft and asymptomatic. i was amazed at my luck. he actually didn't need to be operated. the statistics said i had a 97,5% chance of being right and if we checked him out in a few hours that statistic was supposed to approach 100%. i was quite relieved. it would definitely make the day more manageable.

in the morning meeting the professor in whose firm i was working (who was chairing the meeting on behalf of the boss who was away that day) listened to me present the cases. when i got to the gunshot abdomen that was not a gunshot abdomen, he expressed extreme cynicism. he knew the statistics too but what i was describing was just not seen all that often. he, however, knew we would be doing rounds with him in about two hour's time so he told me he would check the patient out himself. i was fine with that. i knew what i had felt and the worst that could happen was that he could tell me to operate the guy.

on the rounds the prof took his time with gunshot guy. he examined him. he then examined him again. he went over the vitals and then he went through everything again. finally he turned to us all and informed the students that i was right and the patient indeed did not need to be operated. he even suggested i discharge the guy which i respectfully refused to do. i told him i'd be a bit more comfortable to observe him for one more day.

the day went on as days tend to do. just before i went to theater i briefly layed my hand on the patient's abdomen once again. all seemed well and off i went.

theater dragged on a bit and finally at about 7o'clock pm i emerged. by that time i was pretty tired and i shuffled off home, somewhat in a fatigue-induced daze. only when i was in bed in a near comatose state did i remember i hadn't checked the gunshot guy before going home. moments later i was asleep.

the next morning in the handover meeting my friend and colleague who had been on call approached me.

"your patient was a bit dizzy last night, but don't worry. i checked him out and his abdomen is fine." i just gave him a bolus of ringers and he's fine. my spine went cold. i thanked him and smiled but my face belied what was going on in my mind. the same words went through my mind over and over again. young men don't get dizzy unless there is something wrong. young men don't get dizzy unless there is something wrong.

i ran down to theater and booked him on the emergency list for a laparotomy. then i went to the ward again. still his abdomen was completely asymptomatic, but his pulse rate had risen slightly. that was enough for me. i told him we wanted to operate and he consented. thereafter i went to negotiate with the anaesthetist to try and push for the earliest possible gap. he assured me he would help directly after a caesarian section that was about to be done.

it was too late. the patient crashed just before he was supposed to go to theater. there was a massive resuscitation followed by an operation. at operation the bullet had traversed his abdomen for only about 2cm, but that was enough. there was a small hole in the bowel which had been leaking all night. but despite this the operation went well and we delivered him to icu in a fairly good state.

as sometimes happens to good people and seems never to happen to bad people, the patient then plunged into a full blown sirs response. thereafter it was a two day downward spiral before the patient passed away. there was just nothing we could do. i felt terrible.

i knew i was the one who had made the initial call not to operate. it didn't help that a prof and a senior registrar had separately evaluated him and agreed with me. i also knew i had not reevaluated him that fateful night when i had wandered home in a barely conscious state. i had also not emerged from my bed to find my way back to the hospital once i had realized my oversight. also soon after his death i was to learn that he was making a massive difference in the lives of the youth in his community and steering them away from lives of crime. all in all he was a very good man and we were all poorer for him no longer being alive.

i suddenly knew what my friend meant when he had spoken about the graveyard in the most secret corners of our minds. i knew i had someone whom i was going to bury in mine. i also knew i would never forget him and i would never get over it.

engraved on the tombstone i still clearly see his name. his name was prince.

pink and purple

recently i discovered the blog of a good friend. only problem is that he is a pathologist. i understand nothing of it, just like in the old days.

in the old days when i was still a registrar we had a joint meeting with the pathologists once every three months. if you ask me it was way too much. you see surgeons and pathologists are poles apart. for one thing, they are quite clever. for another their patients are all stable so there is never any urgency with them. i've heard they have to deal with bleeding a lot less too. but i suppose the clever bit got to me the most.

the way the meeting went was based on patient presentations. we would get a list of the cases they wanted to discuss. the surgeon involved in the case would then be required to present the case in front of everyone. he would talk about the clinical presentation, the findings an then the operation. it would usually end in a description of some or other thing that was cut out and sent to the pathologists. we would then hand over to them. i remember how their eyes would light up when we got to the bit about the thing we'd cut out. you see when they were handed the whatever it was we had removed or excised they got to work turning it into shades of pink and purple.

no matter what it was we presented them with, they would cut it into fine strips, put it on slides, colour it different shades of pink and purple and get very excited. at these meetings they would show us these slides. the thrill of it could often be detected in their voices as they spoke and could always be seen on their faces. they would wax lyrical as they increased the magnification, showing us the pink and purple ever closer. we would look, probably with visible expressions of increasing bewilderment with each new magnification, and nod knowingly. it probably didn't fool them. but the thing that irritated me the most was their standard opening line before they interpreted these pink and purple patterns to the room full of either excited or bewildered nodding faces. they always said the same thing. i think they might have been taunting us.

"as you can see..."

the sentinel

anyone who follows this blog will know i have a tenuous relationship with the ivc (here and here). it is something i've seen only too often and each time it has me on edge. somehow i just can't get used to being up close and personal with an ivc that seems to want to bleed. but even i can laugh at some of our interactions.

i was the senior registrar so when the bone doctors decided to do a spinal fusion at the 4th and 5th lumbar vertebra and they wanted someone to expose the spine for them from the front, i was their go to guy. only problem is i didn't know how to do it. having been in surgery for long enough, it came naturally to me to show no weakness. i couldn't tell them this. i reasoned to myself i'd discuss it with the prof and if he felt i needed assistance then he could offer to help. looking back it wasn't the best thought out plan, all things considered.

the operation was booked for two days time, so the next morning i went to the prof's office and told him that i had been asked to help with exposure for a spinal fusion at level l4-5. he seemed almost not to hear me.

"good." he said as he continued with his work.

"only thing is, prof, i've never done it before." i considered telling him i'd never even seen it before but that was implied in the first statement, i thought. "should i go transperitoneally?"

"do what you are more comfortable with." great help, i thought. well transperitoneally (through the abdominal cavity) it would be then. the abdomen was after all my stomping ground.

the orthopaedic consultant who was going to do the operation was a bit of a legend. he was this super genius whiz kid that everyone doing intermediates was afraid of. he pretty much knew everything about everything and would always be able to dig out a question that you couldn't answer if he wanted to. luckily intermediates were way behind me so i didn't need to worry about offending him too much, but still it was a bit intimidating being asked to get exposure for an academic giant such as this man.

i entered theater at the predetermined time. there were about 3 orthopaedic registrars getting the patient ready. immediately when they saw me they asked how i wanted the patient to lie.

"put him on his back, " i said, oozing confidence, "i'm going through the abdomen." they nodded. and did so. once everything was ready we all started scrubbing and the sister started draping the patient. i tried to envisage what i would be doing in a while. i decided that i'd reflect the right colon up and pull the ivc out of the way, rather than reflecting the left colon up, which would mean i'd have more to do with the aorta. my reason had little to do with the blood vessels but rather had to do with the fact that the right colon can be reflected right out of the way whereas the left colon can't because it continues down to the rectum which is pretty much fixed. truth be told, the aorta is easier to work with than the ivc, but i just felt i'd get more exposure on the right. in my mind i was just trying to convince myself that it was going to be fine when the great orthopaedic consultant entered. he greeted us all and thanked me for my help before quickly going into the theater to make sure everything was in place. moments later he was back.

"the patient is on his back. are you going transperitoneally?" he asked. there was something in his question that bothered me, but this was not the time to seem unsure.

"yes, transperitoneally it is."

"for l4-5 fusion?" he asked it in such a way that the implied answer was that transperitoneally was not a good idea for l4-5 fusion. i thought back to the useful advice of my prof that i should use whatever approach i was more comfortable with. it occurred to me that this was an operation the prof possibly had never done before. besides if this legendary orthopod sounded like he knew something that neither i nor my prof knew, it was probably because he did know something that we didn't know. i felt my heart rate rise. but it was too late. i had no backup (the prof hadn't offered to help) and i would have to stand with my decisions.

"yes. we will be going transperitoneally."

"are you sure." i wasn't.

"of course i'm sure."

"well if you say so, but you are a braver man than me." he replied with a laugh. i felt my heart sink into my shoes. i just smiled.

i went through the abdomen. i flipped up the colon and exposed the ivc. i then mobilised it enough to pull it gently away from the spine....and discovered why transperitoneal approach is not good for l4-5. the ivc splits into two veins which drain the legs at roughly this level. the left one (left common iliac vein) crosses over the spine and when you try to ease the ivc away from the spine it gets pulled so tight it looks like it wants to tear off. but still i mobilised everything enough that their target area was nicely at least visible.

"there you are." i said with an air of i-told-you-so. "enjoy the rest of the operation. i'm outta here.

"what do you mean you're going?" said the giant. "you stay right where you are. it's your job to keep the ivc out of my way. you just stay there and stand guard over your ivc." this was starting to sound familiar and i was no longer happy to be part of it. but anyway, it wasn't as if i had a choice. besides, how bad could it get?

it could get pretty bad. i stood there with a retractor carefully in position putting just enough traction on my precious ivc without tearing the left iliac vein while the orthopod took the biggest badest instruments i have ever seen and ripped one entire vertebral body out bit by bit. now a vertebral body is somewhat tougher than an ivc and he used amazing amounts of power. i swear there were times he picked the patient off the theater table by his vertebra until a chunk was ripped off and the patient came crashing down again, all the while with me trying with all my might to not pull on the ivc with all my might and yet still keep it out of the way of that ferocious instrument the orthopod was wielding. in my mind he looked like a medieval barbarian with some sort of overly vicious weapon swinging around with just too much force. there were times when i thought he was going to pull the patient right off the table with me and the ivc being dragged down with him. i didn't only fear for that poor ivc but there were times i actually feared for myself.

after a while he got that condemned vertebral body out and replaced it with some sort of metal device. once that was in the ivc was allowed to return to its normal position. thereafter my frayed nerves also started recovering. once again had i stared into the dark eyes of the ivc and lived to talk about it.

p.s the patient survived too.

a close shave?

some versions of history claim that surgeons and barbers stem from a common pool. that is apparently the reason the british still refer to their surgeons as mister rather than doctor. i personally even used to believe this, but then something interesting happened which changed my mind forever.

sometimes a theater list can fall apart. sometimes some patients just neglect to turn up, sometimes anaesthetists cancel patients and sometimes the blood results preclude theater as an option. it is seldom that the powers that be conspire together for a total collapse of the list but it did once happen. when we got to theater we discovered that every single patient had fallen from the list for one reason or the other. the anaesthetist looked delighted. we were not. and yet it put us in the interesting situation of having the morning off. we weren't sure what one did with a morning off. i had been thinking about a haircut for a while and suggested we head down the road to a nearby barber. i remember my good friend and medical officer (whom we affectionately thought of as the ninja because of his amazing martial arts ability) suggesting that we go to a modern hairdresser, but i would have none of it. i told him i wasn't the type to fork out a whole wad of cash for a fancy haircut when someone who historically was linked to our noble profession could do it at a fraction of the price. the ninja looked at me as if i was mad. then he remembered i was and offered to come with me.

quite soon we were parking the car outside the barber shop. it was so early in the morning that they had just opened their doors and didn't have any customers yet. truth be told, i had often driven past them and i had never seen a customer there. it seemed to me such a pity that our brothers, the barber-surgeons were being driven out of their profession by fancy hair dressers and i for one was proud to support them.

the doors stood wide open so we walked in. there was no one there. we sort of stood around for a while but still no one came to our aid. the ninja was looking at me with this i-told-you-so smile which just made me all the more determined to stick it out. then i saw a bell on the counter. i picked it up with maybe too much of a show and rang it in ninja's face. he scowled but remained silent.

the bell had its desired effect. from an almost hidden door at the back someone entered. immediately the ninja's scowl turned to a broad smile. in fact i think it was a chuckle. the man who had entered was one of the oldest men i had ever seen. he moved slowly with a shuffling motion towards us and asked in a thin voice if he could be of assistance. he also spoke with a strange accent. the only thing fast about him was the noticeable tremor of his hands. they seemed to shake so much i couldn't imagine him picking up a pair of scissors, let alone working with them. i turned to leave but i walked right into the beaming face of the ninja.

"what are you waiting for, bongi?" he grinned. "you are the one who insisted on coming here, what, with stories of the common bond we share with grandpa here. lets see you go through with your convictions now." i was stuck. i considered fighting my way past him, but he was not the ninja for nothing. i was done for.

what could i do? i sat down in the chair. i think i more crumpled up into the chair in a defeated heap but i tried to make it look like i was sitting down. the old man threw a towel around my shoulders. it only took him five attempts to get it right. he then fixed the clasp securely around my neck. it felt like jail bars closing in on me. i was truly stuck. in the mirror i could see the ninja now openly laughing. i wished i could wipe that smug smile off his face, but i was using all my energy to try to prevent an expression of terror creeping across my own face.

the old man then shuffled off towards the door from which he had emerged. he shouted to the back. for a moment i felt a sense of relief. he was calling for someone else to take up the tools of our mutual trade. i was going to be ok and the laugh would be on the ninja for doubting his all knowing senior.

i was just practising my smug smile to use on the ninja when the person the old man was calling finally emerged from the doorway. imagine my shock and horror when i looked upon the face of what had to be the old man's grandfather.

dogma

surgeons are creatures of habit. they also tend to be somewhat dogmatic. when things change they often become edgy or annoyed. however, this little fact made for a funny story once.

i was a lowly medical officer working with a senior registrar. it was a good time. i had senior cover which in those days was quite rare. also my senior was a really great guy, even though he was a surgeon. as it turned out when the time came to be rotated the prof moved us both to a new firm together. he must have assumed we didn't like each other, such was the prof's usual logic.

the new firm promised to be fun. the consultant was an old prof who no longer operated but enjoyed teaching. we would be left to do the operations without too much interference and we would get good academic input. life was sweet. we just needed to make sure we didn't annoy the old respected man. with this in mind we asked the prof's previous registrar if there was anything we needed to know about the prof in order to do everything right. he assured us there were only two things that should be dogmatically stuck to and all would be well.

firstly the prof was always exactly on time and accepted no excuses for his underlings being late. if he said rounds were to be at 07h30, then you had dam well better be there waiting for him at exactly that time. if you were busy with a resus then you should have thought of that before you allowed the patient to crash before the prof's rounds. he would not be impressed by such trivialities over his rounds. no excuse would suffice.

the next thing his registrar told us was that, after his so called grand rounds on a wednesday he would dismiss the students and invite the doctors to enjoy a cup of tea and biscuits with him. we were to supply abovementioned tea and biscuits. and, the registrar sternly warned us, the only biscuits we were permitted to supply were romany creams. apparently nothing else was good enough for the important palate of the old bull.

i was quite happy. these were easy things to do and the rotation should be a breeze. i was right. it was.

then many years later when i was the senior registrar, once again my turn came to rotate through the old prof's firm. once again i approached the incumbent registrar and once again he told me that if i'm on time and i supply romany creams for the prof's tea on a wednesday, all would go well. i was always on time and i kept a few emergency packets of romany creams ready in my locker just in case. the rotation was fabulous. the prof never said a bad word about me.

as with all good things my time with the prof soon came to an end. i was rotated into another firm and replaced by my friend and colleague. as was the habit of all of us my friend approached me to get the low down on how to stay on the prof's good side. it was obvious throughout the department that the prof was actually fond of me (well as fond as a surgical prof can be). i told him the secret. it was so simple, be on time and supply romany creams. my colleague should do well too, i thought.

about a week later, during the prof's post grand round tea party, i wandered in to the tea room. i was astounded to see an assortment of biscuits on the table. i was even more amazed to see that none of them were romany creams. had my friend lost his mind? had he decided to ignore my advice? was he tired of life? i didn't know. i left in possibly too much of a hurry.

the next day i went to my friend and asked what the hell was going on? why had he totally disregarded my advice that i knew had been passed down faithfully from registrar to registrar at least since five years previously and probably even longer? he told me.

"well, bongi, on day one i told the prof that i was told he like romany creams so much and i asked him why. he replied that he actually didn't like them at all and had been wondering for some time why his registrars always gave them to him. it didn't bother him too much so he just left it."

i couldn't help laughing. this piece of erroneous information had been passed down faithfully over possibly eons from one registrar to the next without anyone ever bothering to check with the prof to find out if it was in fact so. i could just imagine how it had all started in times gone by, maybe just after the mesolithic era. the prof had casually taken a bite out of a romany cream and made a comment that it wasn't half bad or something equally moderate. the registrar of the day probably looked up from his stone surgical tool and remarked "uhgh!" as he made a mental note to remember what he assumed was the prof's favorite biscuit. and thus he started possibly the single longest untested erroneous surgical fact of all time.

p.s it is true that you must be on time though.

suboptimal

recently i did a submandibular gland excision. i always find them challenging. i think i know why though.

i was no longer a junior registrar but i still had a long way to go. i had just been rotated to kalafong and it was my first theater list, a list that had been booked by my predecessor and one i therefore did not know. my consultant knew me from a few years before when i had worked in his firm as a junior registrar. as much as he was able to actually have human feelings, i think he almost liked me.

i assisted the first case with the consultant operating. it annoyed me a bit but i assumed he hadn't worked with me for a while and wanted me to get my eye in before he entrusted the knife to me. when he once again took the prime position in the second operation i started wondering if i was to get any operating time in his firm. what could i do?

after the second operation my boss turned to me.
"just a mastectomy and a submandibular gland excision left. have you ever done a submandibular gland?"
"no." i answered truthfully.
"have you ever seen one done?"
"only once when i was a fifth year medical student, so it hardly counts."
"i'll give you a very good article describing the technique."
and with that he turned and left.

it was kalafong so he returned long before we got the mastectomy patient on the table. he handed me the article, which he had fetched from his study, told me i'd be fine, and left.

great. i had to somehow quickly read the article between the mastectomy and the submandibular gland and then do the operation with only theoretical backing. i tried to swallow hard, but, in sympathy with the patient's soon to be excised salivary gland, my own salivary glands had simply stopped working. my mouth was suddenly very dry.

so i did the only thing i could. i cut out the offending gland, more or less how the article suggested i should. but somehow to this day, whenever i am asked to do a submandibular gland, my adrenal glands tend to contract a little bit when i think back to my first one.