Thursday, June 26, 2014
Last Minute Decisions and Iffy Results
So this morning I made an error. I call it an error, say of judgment, rather than a mistake, because split semantics aside, it came off a gamble I took which didn’t pay off as it should have because of unexpected circumstances beyond my anticipation. There was this case we had posted for surgery a week (10days?) ago and back then we had reviewed the case and had decided to go for a full thickness (epithelium+ connective tissue+ periosteum) flap. But today when the patient turned up for surgery and was prepped, anaesthetized and ready to be operated on, I took a long, long look at the operating site and my surgical judgment (my intuition?) telling me that with a split thickness flap (a half-way flap) will give better results and also help in preserving the donor site from where I was going to harvest the graft and then stitch it to the new (deficient site), I made the split-second decision to go for the tougher to do split thickness flap instead of the agreed on protocol and proceeded to raise a beautiful split flap. And then came the anti-climax.
The theatre staff handed me 3-0 sutures which is what they had ready for a full flap while I prefer to use a 5-0 suture (thinner one) to stitch a thinner split flap. Although the theatre IS supposed to have all sizes of sutures at all times (for all surgeries) somehow they did not have what I wanted right then and I had to make do with the had – a 3-0 size only which dint really fit the thin flap I had taken. So I wasn’t really satisfied with the end result of my surgery and will eagerly wait for next week when the sutures come off to see the result – fingers crossed.
The thing is I am still in a dilemma about whether I should have stuck to my original surgical plan frozen a week ago or should I have made the call to change the design at the moment of surgery. Do good intentions excuse an error of judgment? What if the gamble had paid off, as it would have if the nurses had properly stocked the operating theatre? There are so many “IF’s” but no clear cut answers. The only thing of certainty is I took a risk and it didn’t come off as it should have – maybe a 70% success rate only- which may be good enough for the patient but still is kinda hurting to my ego. So was I justified in giving precedence to my surgical skill over the team decisions by invoking my privilege as the operating surgeon? The jury’s out till the sutures come of…and till then feel free to pop in with your views on what I should or should not have done.
Thursday, June 19, 2014
No Shame In Saying I Don’t Know, Is There?
So they called me today all of a sudden in the middle of my canteen break (for those of my readers from countries which were never under the shadow of the British Empire – a canteen break is a midmorning visit to the in-house cafeteria – say around 11am- for a coffee/tea) with an emergency call and unlooked for appearance of a postgraduate student standing beside my cafeteria table, staring morosely down at my tea before saying “they want you back at the department sir, something not right with the laser”.
So I leave my half drunk tea on the canteen table with a look of longing and hurry back to the surgery room screaming “What? What? What? What happened?” to find the two guilty persons who tried to use the laser unit in my absence (temporary/tea break) adopting an unconcerned “we are not responsible” look. Seems they had tried to do a case (a surgery) all by themselves and the laser had malfunctioned and they tried to lay the blame solely on me saying that “you were the last person to use it” to which I replied irritably “yeah and I left it in good working condition just a few minutes ago”. For I knew they were trying to pin the blame of the malfunctioning unit on me and try to appropriate my next month’s salary towards repairs for the at-fault laser unit- on the principle that the last person gets blamed and foots the bill.
So I went up to the unit and checked it and found it was working fine. Surprised I asked them to demo to me what they were doing with the laser. So they sat there the two of them and applied the laser to the anesthetized patient and waited for it to start cutting and then after a few minutes they turned towards me and said “See, its not cutting”. Whereupon I asked one of them to vacate the seat and sat down took the laser in my hand put it near the surgical site, operated the foot switch, cut the tissue and showed them “see, it works now, by magic”. The poor fools had not realized that the laser operated with a foot switch which they had comfortably left all alone between the two of them and neither of them operating it and they had thought that you just need to point a laser at something for it to start working. And of course they had thought they could do it in my absence in the mistaken belief that what he does we can do too- without learning at least the basic functions of the machine.
Which shows once again that people would pretend anything except to accept their ignorance of something. I hope they all realize soon that it’s never too late or too much to ask for help and its definitely no shame to say those three magic words “I don’t know”.
Tuesday, June 17, 2014
Lasers Vs Conventional Surgeries
For those who ask me why lasers, well I got a one word answer for you (well, actually two words) – no sutures. Remember those sharp curved long needle things with threads attached to them which doctors poke into your body umpteen times and use weird contortionist positions to tie them into knots (knot after knot after knot?) well those stitches or sutures are “gone with the wind” baby when it comes to laser surgeries. Now coming to the other side of the argument that lasers are expensive to use and why surgeons are pushing lasers more than scalpel surgeries all the time and is it because it’s convenient for them and not for the patient. Well, I agree that surgeons more and more prefer to use lasers nowadays for even the simplest and shortest of surgeries. But it’s not only because of its convenience given that a laser surgery is done in a clean and bloodless field for laser automatically coagulates (clots) the blood vessels- thereby preventing bleeding and thereby allowing the surgeon to see what actually he is doing with sharp instruments and voila you get great results, which is what you want right?. And because the surgeon can work calmly with no blood and clear vision of the operating site – even in extremely bleeding sites like, for example, the tongue which is notorious for its rich blood supply and for bleeding excessively even for minor injuries and hence tongue injuries are a real bitch to treat (sample case below of a tongue tie patient -with a pronounced lisp- being treated by me with a laser during a tongue release surgery). And of course the USP of lasers – no stitches. Now tell me isn’t a laser worth the price?
|The Tongue-tied patient|
|Me using the Laser to cut|
|Pulling back the tongue with a temporary stay suture to expose the undersurface|
|The End. Finis. Bye-bubyee|
Sunday, June 1, 2014
So the last time I blogged which was about a month ago was when I cribbed about having to move against my will to one of the largest hospitals in the country, far away from my hometown and to abandon my old department which to tell the truth was my own personal piece of heaven based on my vision of how medicine should be practiced as I had over the years molded it with my sweat as a top-class surgery department beyond its financial limitations. The change was painful as everyone knows and not least because it was all so unexpected. And so after a month or so of working at my new department and facing the ragging every newbie gets from entrenched old fossils who have spent all their time polishing chairs with their backsides I am now in a better frame of mind to start blogging again.
Firstly the positives, I get to treat a lot more patients than I did at my old workplace. The fact that my new hospital is the only large hospital for quite a few districts around town means we get a lot of referral patients from everywhere around a 200km range. And other patients do drop in off their own volition as the reputation of the hospital is such that they believe miracles from the doctors here. Which is a bit surprising considering that the majority of the doctors here are tenured people and like typical tenure track professors – once they have got a guaranteed job till retirement they don’t give a damn about patients are anyone else. The bulk of the work of course falls on the various students here, of whom there are masses and masses doing every kind of course-degrees and diplomas and to tell the truth the students are more than upto it as they realize that this is the only place they can get hands on training and experience which can stand them in good stead throughout their lives and they will be thankful for when they are practicing alone in some little town by themselves. As a corollary I get to guide and discuss and treat all these patients with interesting complaints that the students bring to me for help. Which acts a rapid review refresher course for me as I am now getting to treat a lot of weird disease which defy diagnosis at first glance. Of course, I miss dealing with the kids as I used to do in my old hospital. But still its far easier to treat adults who know what they have and when they got it- no more working my guess-work and intuition and hoping for the best.
My work day starts at 7Am and goes on till 4PM most days of the week. And to top it off the old fogies who don’t like enthusiastic youngsters like me crashing their relaxation spots have managed to fob off all sorts of extra duties on me citing my most junior status. So every Wednesday I am on EC duty- emergency duty/casualty duty (what the Americans call ER) where I check in at 7AM on Wednesday morning and get to leave by 2PM on Thursday afternoon- a total working period of 24hours+7hours. Talk about a new test of endurance- I now get to work 24+7 once every week which come to think of it is still a lot less than people who work 24/7hours all days of the week. So I guess I am better off than them, right? Besides I get to take the whole day off on Friday as a Post-duty off day. And then come back to work only on Saturday. Of course I also have been posted on Sunday duty for this month- which means that I check in on Sunday morning at 7AM and then leave on Monday by 2PM which means I get Tuesday’s off duty as a weekly-off. So all in all it’s a pretty weird work week for me- when I am on, I am on for a long time and then I get to sleep for a long time in compensation.
The days I am on emergency duty are some of the toughest I have had since my PG days – an unending stream of cranky patients who demand instant treatment for the mildest of conditions and wasting the doctors time, energy and concentration which would be better spent on patients with real emergencies. But what can we do? It’s a rule of every government hospital to treat the hypochondriacs and time wasters with the same standard of care reserved for genuine life and death cases. So the ones with hangovers and tension headaches who turn up at 3AM or 4Am suck up what little energy I retain after working all day and well into the night. What this does to my alertness and concentration and general capacity for thinking on my feet and managing complicated patients I leave to your imagination. All I say is if ever you are intending to get into a big mash-up and end up in the emergency room, please don’t do it on a Wednesday night and for god’s sake don’t do it on early morning Thursday- you will get a zombie doctor on the verge of collapse from exhaustion to manage your complaints, ok?
So all this nonstop work has had a big beneficial effect on me and I have lost, wait-for-it, 4 kilos over the last month despite my sedentary lifestyle- sitting down in one place and writing prescriptions all day. Guess its all the late nights and stress of dealing with snarky and sneaky colleagues. So alls well that ends well right? If I keep on losing weight at the rate of 3-4kilos a month then by 6 months time I would end up a slim and svelte figure, wont i? cheers to my newest weight loss program- work, work and more work and throw in a little mental torture from time to time. Well, I got to push off now- cant keep postponing the mountain of test reports I have to read and sign before tomorrow morning. More next time when I get the time to blog again.