surgeon superhero

this is a post i wrote as a guest post for another blog a few years ago. since then that blog has been retired, so i decided to import the post back here.


yes i have an alter ego. yes, i dress in funny clothes with a cap covering my head and a mask covering my face. and yes, dressed as such i try to fight the powers of evil (mainly sepsis and bleeding and cancer and the like). i am ... a superhero. but there is often little understanding for what goes on under the paper thin masks and baggy gowns we wear. certain …um…occurrences, well, occur with us just as much as with other people.

a common cold behind a theatre mask is no small thing. remember you can’t blow your nose. sniffing loudly only works for a while and attracts all sorts of strange stares. just leaving it is really the only option. the positive side of this is you suffer less from the mild dehydration that accompanies massive loss of …mucus. there is, after all, fluid replacement (it is a very short trip from your nostrils to your mouth over your upper lip). ‘nuf sed. somehow this never appealed to me though. so, for all you budding surgeons out there, when you have a cold, plug your nostrils with tissue before scrubbing up. once you’re scrubbed, it is too late. The side effects are only a slight change in voice which is a small price to pay to avoid the constant lip licking and salty taste throughout the operation.

then there is a running stomach. this may be one reason to excuse yourself, handle the situation and rescrub. however, there is the real problem of dehydration, confounded by long hours of standing and concentration. here may i suggest a drip. the gas monkey (anaesthetist) can quite easily give a quick bolus or change the vaculiter when needed. (quick note, i’m not pulling this out of my thumb. i have actually seen this). stay at home, i hear you say? somehow that just doesn’t work with us doctors. i’m not sure why, but it is very rare that a doctor will stay at home merely because he is sick. what sort of a superhero would that be.

the last problem that can be encountered is best explained by thinking back to my registrarship. i was assisting the prof with some or other laparotomy. my stomach had been giving me trouble for some time. up until just before scrubbing up with the prof i had found it necessary to quietly leave polite conversation to allow the release of colonic gas quite a number of times. but once scrubbed up, this avenue was no longer open to me. what could i do? i simply puckered up and held it all in. this worked well, but became progressively difficult. we were approaching the end of the operation, but i could pucker no more. finally i reached a point where i had no choice. i needed release. i decided to quietly let one slip as to not attract too much attention with loud noises. so, as the professor started to close the sheath, i did just that. i was just inwardly congratulating myself for the stealth with which the…um…operation had been executed when the professor stopped closing and dived back into the abdomen. in a dry voice he quietly says, “someone cut the colon.” as he started carefully moving bowel out of the way to better examine the colon. now imagine my embarrassment when i was forced to say’...

“colon? yes. cut? no”

bedside manner

if nothing else, this previous post illustrates that surgeons are not that great with the whole bedside manner thing. i would like to think i'm an exception...but i still am a surgeon.

i make a point of communication with my patient. obviously if he is a child, i use the same measure of effort in communicating with the parents. but few things irritate me more than some or other family member that insists on forcing their way into the fairly personal interaction between patient and the guy that in all likelihood is going to carve him up in the very near future. i refer to the person who insists on answering my questions directed at the patient as if they know better. i mean if i ask what the pain is like and, before the poor patient can express himself, his well meaning irritating wife or mother begins to describe to me what he is feeling as if she is feeling it too. i often want to tell them to get sick themselves before i give a dam what they feel or think. i'm usually at least slightly more diplomatic.

i was a senior registrar. a private consultant friend of mine asked me if i could look after his patients while he was on leave for two weeks. apparently he did not trust the other private surgeon working in that hospital. to be frank neither did i (but we'll keep that story for another post, shall we). we went on a sort of handover round together and i got a feel for what was going on. after rounds he mentioned to me that there was still one more patient coming in from a general practitioner that apparently had a bowel obstruction due to a previous operation as a child. the patient was apparently going to be admitted via x-rays. i could evaluate him and operate if i felt it was indicated. all seemed well. he would be my first ever private patient.

the patient arrived and i was called to evaluate him. i walked into the room and took in the scene before me. the patient, a young man that i estimated must be about 26 years old, was lying in bed and what had to be his father was standing next to him. i greeted them both and introduced myself. i then turned to the patient.

"what seems to be the problem?" i asked, looking at him. the father answered before the patient even had a chance to open his mouth.

"well doctor, he started with..." i cut him short right there.

"uhmm, excuse me, but i did not ask you. i asked him." i said. then turning towards the patient with possibly too much of an ostentatious flick of my head i started again.

"what seems to be the problem?" the moment the patient opened his mouth was the moment i became acutely aware that he was mentally retarded. he very nearly could not string a sentence together and certainly couldn't express himself in terms above that of about a five year old boy. i felt like a total idiot and could feel my cheeks flush in embarrassment, but what could i do? i just had to soldier on. i mean i could hardly now turn to the father and admit that after careful consideration i did want to hear from him what sort of pain the patient was experiencing, especially seeing that i had just brushed him aside rather unceremoniously.

the entire interview and examination was painful (i think the patient also experienced a bit of pain) but i just kept on slugging through it. i then looked at the x-rays. it was a clear case and i knew i needed to operate. for the consent i fortunately could turn to the father. it was clear the patient didn't have the mental faculties to sign his own consent, if he even could write at all.

fortunately the operation and the post operative phase went well and quite soon i discharged the patient into the care of his parents.

just over a week later i followed the patient up. luckily everything was in order and i informed him and his father that all was well and they could go in peace. they left the consultation rooms, but then the father turned back to me. i had been expecting something like this from the first moment i had realized the patient was mentally retarded. i was just surprised it had taken so long in coming.

"doctor, i'd just like to have a word with you in private." oh, well, i thought. it's not as if i don't deserve some backlash for my unintentional indiscretion at our first meeting. i braced myself for the worst.

"doctor, at our first meeting, from that first moment when you refused to hear from me what was wrong with my son, but instead insisted on speaking only to him," i cringed. "well from that moment i knew we were with the right doctor. thank you so much for all you have done for him and for the respect you showed him. we as a family will forever remember everything you have done."

i didn't see that coming. i decided to just keep quiet about the fact that i hadn't realized the child was mentally retarded. we all went our separate ways, me with my pride and hide intact and the family chuffed at how i had treated them. i was relieved.

you've got to hand it to him

some students refused to listen to good practical advice. sometimes it hurt us all, but sometimes it was good for a laugh.

general surgeons have a reputation amongst doctors. they are viewed as crude, arrogant and even aggressive. this might be because they are often crude, arrogant and aggressive. but yet they are simple folk and can easily be pacified.

he was a private consultant. he was a typical surgeon but he was also a great teacher, if you could look past his rough mannerisms. he only came in one day a week and did a sort of a ward round. but in all reality it wasn't a ward round at all. he would ask us to show him some interesting patients and then he would teach us all about the condition of the first patient we showed him. he never addressed the patient. he never examined the patient. it was more coincidental that we would be standing next to the bed of a wide eyed patient while we listened to his tutorial. he taught us so much, including what a bedside manner should not be. he was also a great example of how not to present a patient to the professors.

"when you present a patient to doctor l," i would coach the students before the time, "do not go into all the detail!! he doesn't care. simply point at the patient and in a loud clear voice shout the diagnosis. then have a piece of paper and a pen ready. every word you hear after that is worth its weight in gold for your exams, so take notes." they all nodded, but i somehow knew they thought i was exaggerating.

the allotted time of the allotted day arrived and we all stood around waiting for the consultant. true to form he was exactly on time. he ignored the students as was his habit and only acknowledged me with an almost imperceptible nod of the head. i greeted him curtly and headed off in the direction of our first patient, which i had specifically chosen because i felt he had the condition the students most needed to brush up on.

we arrived at the patient and the consultant turned to the students. normal human interaction always seemed to be an effort for him. more looking at his own feet as anyone in particular he asked;

"right, whose patient is this?" the student stepped forward.

"mine!" he whimpered.

"well? what are you waiting for? present!" i had trained them well how to present to this consultant and yet i somehow knew what was going to happen.

"uhmm, the patient is a 25 year old black male..." the consultant lifted his head. his eyes were suddenly ablaze with what seemed like years of pent up frustration and anger. he cut the student short.

"do you think i am a blerrie idiot?? i can see the patient is male. i can see he is black. i can see he is about 25 years old! next thing you are going to tell me he is the third child in a broken home? i don't care about all of this. and if you even try to tell me he lives in a house with running water or no running water or whatever i think i'll kill you!! just tell me what is wrong with him!!!" i managed not to laugh, but as the student looked to me in supplication i confess a smile darted across my face. i had warned him. he shrugged his shoulders, pointed at the patient and in a clear voice shouted;

"alcoholic pancreatitis."

the consultant grumbled under his breath and extended his hand to the side, in the true fashion of a surgeon in theater. i was ready with the pen and slapped it sharply into his waiting hand. as if by magic, a sheet of paper appeared before the consultant. i remember thinking that they were at last listening to my practical advice.

thereafter the students (and patient if he was paying attention) got the best tutorial on alcoholic pancreatitis that they would ever be exposed to. i confess i didn't pay too much attention. i was otherwise occupied trying to suppress a laugh.

christmas meal

often on christmas i think back to a story from long ago that was based on a christmas meal but had nothing to do with a christmas meal. the man in question was unique to say the least.

it was about february. we were on one of the painful yet entertaining rounds with our eccentric consultant. up to that stage he had actually been so contained that some of us could even have been described as being bored.he just didn't seem to be ranting as much as he usually did. he was also not spewing forth his particular brand of black humour.

then we got to a new admission from the previous night. the patient was a middle aged female with cellulitis, but the thing that struck us all the most was that she was morbidly obese. she must have weighed in at 220kg. obviously we displayed the necessary tact and didn't make a big fat deal of it. the consultant, however had no such scruples.

"you are the fattest person i have ever seen in all my life and let me tell you, i have seen fat people in my many years in this hospital." we all looked around awkwardly, hoping his verbal indiscretion would end. those that knew him well had little illusion that this would be the case. he then turned to the student nearest him;

"you! go and get me a carrot!" the student looked on incredulously. "you heard me!" he bellowed, "fetch me a carrot! and when you bring it give it to her to eat!" we still didn't quite understand what new madness had taken over the faculties of our master. we mutely looked on.

"and then on christmas day give her a second carrot to eat!" he then turned to her. "christmas!" for that is the name he bestowed upon her and indeed the name he used to address her every day until she was discharged, "you are about to make history. you are going to take part in the biggest diet in the history of medicine!"

no winning

another story of the futility of trying to get it right in kalafong happend to a friend of mine.

the patient was stabbed just outside the hospital at the taxi rank. his friends immediately carried him into casualties. my friend and colleague happened to be there at the time. he immediately saw that the stab was probably to the heart and the patient was in trouble.

my friend grabbed the gurney and charged off to theater. amazingly enough he got the patient onto the table almost immediately (very nearly unheard of in kalafong). similar to my previous story, by the time he put knife to skin, the patient was in exitus.

the surgeon ripped his sternum open at double quick time. the pericard was a large sack of blood. the heart just couldn't compete against this and had stopped beating (this is not good). the surgeon opened the pericard and drained the blood. this allowed the heart to start beating again. unfortunately with the first contraction a stream of blood shot out of the left ventricle.

a steady hand and a few stitches later and the heart was no longer leaking. all that was left was to close.

the next morning, when i heard the story i was pretty impressed. a general surgeon had moved into a domain that he was not fully comfortable with and managed to pull a patient through that had actually been stabbed in the heart and that in the left ventricle. when he presented the next morning, once again the professor ripped into him.

it seems, according to the professor that the correct entry should have been a thoracotomy (between the ribs) rather than a sternotomy (through the middle chest bone). the small matter of getting the patient on the table literally about 10 minutes after the incident and pulling a guy through that had received an essentially fatal wound seemed of little concern. at a stage the prof even attacked my bewildered friend personally. as usually we all sat in silence. it was not the first time and it would not be the last time that this happened. we had all at some or other stage experienced the wrath from on high and it was just his turn.

at a stage my friend rose from his seat in a seething rage. he stood for a moment. he then seemed to realise that the safest move for his career would be to just sit down again. this he then did, but i'm sure i saw steam rising from his head.

after this fiasco, i went to him and said that despite what anyone says i thought he had pulled off something amazing. i even wrote a message on the tea room notice board saying that he was the man. he laughed at this and all seemed better.

too little too late

when i was working at witbank hospital i had financial problems based on not being paid. i touched on it in a very early post. as part of the solution i approached a private surgeon working in the private hospital. i asked if there was any possibility that i could do after hours work there to augment my salary. the guy was overjoyed and even delt me into the calls of the next month. he, however, said that i'd need to chat to the other two private surgeons to get their blessing.so i made appointments with them and both said that it sounded good.

i then approached the administration. they too were overjoyed. they even took me on an orientation through the hospital. i looked forward to at last getting some money.

about a week later the administration called me back for a meeting. they informed me that two of the surgeons had held a meeting with them (the last two that i met with). they had basically said that if the administration permitted me to do any work there whatsoever, they would withdraw from calls. this caused the first guy to also lose enthusiasm for the plan. he was hoping to do one in four calls instead of one in three. if the other two withdrew he would have to do one in two, which didn't appeal to him.

the administration assured me they wanted me to stay in witbank and would approach the delinquent surgeons to see if they could sway them. i said i'd approach the other guy and ask his advice. the administration then assured me they would get back to me. until such time, i was not to do any work in the private hospital.

i went to the first surgeon. he told me he really wanted me to be involved but was not willing to sacrifice his relationship with the other two guys to help me. i was on my own.

i left and waited for the call. it never came. in fact part of the reason that i went to nelspruit was the promise of being able to do after hours work in their private hospital.

but strangely enough, today i got a call from witbank private hospital administration. it seems there is too much work there now for the surgeons working there and they are desperately looking for another guy to help with the load. it also seems that the instigator of their initial resistance to me is becoming less willing to do after hours work. in short, they are in a difficult situation.

i thanked them for the call (i didn't mention that it was about a year and a half too late), but i politely declined. they asked me if i knew of anyone who would be willing to go there. i considered reminding them that, due to the many coal burning power stations in the area, the pollution was quite bad and no one in their right mind would take a job there if there was absolutely any other option. i also mentioned to them that there is an overall deficit of general surgeons in the country and they would struggle to find someone. i wanted to say that they should have invested in me when they had the chance and when i really needed a financial boost, but i also kept that inside of me. to be honest i did have a malicious thought aimed at the surgeons there (two of them at least) hoping that they suffer under their loads.

in the end i thought about the beautiful place i live in now and the fact that if i had established myself there i may never have moved here. so in the end i have no real bad feelings to them.