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.

vascular cuts

anyone who knows me knows i hate vascular surgery. it is hard work with little reward. scratch that. when you actually get i nice pulsating distal artery the next day you almost think the night's hour upon hour of work may be almost worthwhile... almost. but all too often vascular operations were one small step along the road to disaster.

i suppose one of the reasons i dislike vascular so much has to do with my exposure to vascular during my registrarship. we had a very good department and there was always a vascular fellow who was not only interested in vascular but competed actively to do as many operations as possible. this meant us mere registrars didn't do too many worthwhile cases. we assisted and we did the grunt work in the wards. vascular was also amazingly busy and very demanding. these things all conspired together to leave in me an enduring dislike for the discipline.

i also don't think i was the only one who felt this way. most of us disliked and even dreaded our vascular rotation. that didn't mean we couldn't have the occasional laugh at some of the things that went on. for instance we used to have a saying about the femoro-popliteal bypass operation (to place a bypass from the femoral artery in the groin to the popliteal artery just below the knee.) you see this is generally done on people that have been smoking their whole lives as a last ditch effort to prevent amputation. the patients were usually wreaks. the smoking didn't just destroy that single artery but it destroyed all the arteries to a greater or lesser degree. at best the bypass would improve the blood supply, but not always sufficiently. all too often after hour upon hour of tedious labour, the leg would remain threatened and often an amputation would be carried out a day or two down the line. we jokingly referred to these patients as fem-pop, fem-flop, fem-chop patients. the fellow tended to get a bit annoyed about this. he took his fem pops very seriously and any suggestion that it was a small step towards the inevitable below knee amputation was met with open hostility from him. we knew not to say this in front of him.

but the one time i remember not being able to hold back my laugh even as the fellow's face became red with rage and his knuckles turned white as he grasped his dissection scissors deserves mention.

we were doing a fem-pop bypass. now part of this operation is to remove the superficial vein in the leg (the saphenous magna) and to use it as the bypass for the artery. the result is that it is necessary to make a long meandering incision from the groin all the way down to below the knee. so although the artery is only exposed where the proximal anastomosis and distal anastomosis are made, the incision runs for the entire length of the bypass. the fellow was delving into the groin looking for the artery while i dissected out the vein. there was the usual theater small talk. then one of the junior general surgery consultants trotted in. he immediately saw what operation we were busy with (there are not exactly many operations that require this length of a cut down the leg). i think i might have seen an evil grin on his face. he turned to the fellow.

"hi. my but that's a big incision just for a below knee amputation." i fell about laughing.

lights, knife, action

i was reading a post by a really good medblogger i follow. it reminded me of an incident years ago when i was rotating through neurosurgery.

now neurosurgery lends itself to tracheostomies (long intubations in people who tend to not want to breathe on their own). i soon became pretty good at an icu unassisted trache (that was the way we did them then). then the new guy arrived.

the new guy was a rotating orthopod. the neurosurgeons knew i would be leaving soon and their reprise from doing all their own traches would come to a sudden end. when the orthopod expressed interest in learning the procedure they saw an opportunity and quickly appointed me his teacher. as usual there were a couple to do that day. i'd do the first and he'd do the second. then he would be on his own.

the demonstration trache went well. i tried to point out all the tricks i'd learned with the thirty or so tracheostomies i'd done. he watched in silence, occasionally nodding his head in acknowledgement. and then it was his turn.

we walked together to the outlying icu where our next patient was. there were quite a few icu units in that hospital. when the neurosurgical icu was full any new neurosurgery patients could find themselves landing in one of any number of outlying icu units. generally these weren't quite as geared for neurosurgical patients but they were good enough.

finally my young apprentice put steel to skin. immediately i realised this guy had a natural acumen for surgery. he seemed to intrinsically know what to do. his movements were precise and achieved exactly what was intended. he definitely didn't need any advice from me. there was only one thing not right.
"sister, please call the anaesthetist on call." the orthopod stopped dead in his tracks. his head shot around to look at the monitor. as soon as he confirmed the patient was stable his head swivelled back to stare at me almost accusingly. then he got back to work. he knew there was basically no way an anaesthetist in that hospital would actually come out of theater, much less to make the long trek up to this out of the way icu. and if he did come all the way, it better be to miraculously raise someone from the dead. anything less would be beneath the gas monkeys of that hospital.
"sister, please call the anaesthetist on call!" i repeated. she also could not believe me, but dutifully moved towards the phone.
"why?" she asked as she lifted the receiver.
"the lights are not right. tell him to come and position them for us please."

again the orthopod stopped operating, but this time it was because his body was convulsing with waves of laughter.