"Sir, Please operate me" - We operated and then...

          
         Last time I mentioned about a young lady who desperately wanted to get operated. Our senior consultant was withholding the surgery in view that her imaging findings were too trivial to cause such severe pain, and we calculated that the dearth of surgery would be more painful than what she is suffering from now. Any way she was persistent and finally got operated.

          What we removed was a capsulated collection of thick paste like a dermoid, of size of a thumb attached along the chest wall, we also had to remove a small piece of rib to allow proper access to chest cavity. It was also noted that it was attached to a thin cord like structure, doubtful whether an entrapped nerve or just a thickened parietal pleura.

         The bottom line is she is happy now. Every day we ask her one question, "how is your pain?" and she says, she does not feel that kind of pain she suffered earlier, but just the pain of surgery. She seems very reasonable and she says she can feel difference between both kind of pain.

         It is difficult to generalise, but sometimes patient is the guide, and one has to believe blindly and hope for the best. I remember my zoology professor who used to instil in our mind that biology is the science where 'there is an exception for everything' is the rule.

Sir, Please operate me !!

 
    It is said that in the first ten years of surgical training one learn to operate, in next ten years become an expert to decide when to operate a patient, and by the end of next decade one will be able to decide when not to operate. That is why older people get a second opinion from a senior doctor before making a decision whether to undergo a surgery. No surgery is without risk. All of our senior consultants have stories of their own patients who went through serious complications following procedures which are considered to be simple.

   So advising a person to undergo a surgery is an important part of the surgeons job. Indications for surgery varies. In a case of malignancy at an operable state, or a gangrenous limb, there is no doubt in taking decision. But in a patient with a small hernia or lipoma, the surgery can wait. But there are some other situations where, even if there is a pathology, the surgery may be of  no use, than aggravating the symptoms. And for a similar complaint, it will be logical to operate on a person, while it may be better to avoid operation in another.

    Any way the reason I wanted to talk about this is that, some times patient insist on the surgeon to operate for a complaint, which cannot be addressed adequately by surgery. For example we warn all the patients who come for gall bladder stone surgery with history of central abdominal pain or pain at left costal margin that, the pain may persist even after the surgery because these are not the typical sites where a gall stone disease cause pain. Many a times the intense search for the cause of an intermittent atypical pain ends in finding a trivial pathology in that body area. An experienced surgeon defers the surgery. But the patient compulsion, may be so severe that surgeon is left with no choice.

    Now there is a young lady admitted with complaints of pain at the right side of chest. Her chief complaint is pain which is not severe and breathlessness on exertion. Except for a small lesion extending between a single rib space on right side which looks like a collected empyema or soft tissue mass, all her cardio- pulmonary evaluation reports are normal. The lesion has been there and of the same size in her chest X ray 8 years back. She came to us one year back for the first time, That time she was evaluated in detail and surgery was deferred because that small lesion was unlikely to be the cause for symptoms.Thoracic surgery is one area were chronic post operative pain, and paresthesias are common.
     
       She came back now, to a different consultant of our own unit and insisted on getting operated. She also underwent a psychiatric evaluation. Although psychiatrist know nothing of chest surgery, since there is a demonstrable pathology and localised pain symptom, they think she is fit for surgery in their view.

      So finally she has been posted for surgery. Let us wait and see.......

 

Excuse me, Sir....

     Recently I came across some funny excuses given to the professor for not doing their work. These instances are very common. But this one is note worthy. We have an afternoon clinic in which we see patients who have undergone surgery. Every one in the unit has to be there by two o clock in the afternoon. My senior did not show up in the clinic. The Professor asked one of us to call him to clinic. Within few minutes he rushed in to the clinic a bit weary. The Professor asked him what was he doing.
        
       He replied " Sorry Sir, I felt asleep after the lunch and I was having this dream that I came to the clinic and examining patients along with you. Then suddenly I got this phone call and I woke up!"

      This is the most ridiculous excuse I have heard till now. Any way the Professor was a jovial person, and took it lightly.

 

Teaching is not easy as it seems

    
      Doctor- Itself means 'to teach'. Now a days I am beginning to understand what it takes to be a good teacher. It requires so many qualities which has to be acquired and earned. Some people have these skills inherent in them. Unlike the school teaching and college teaching, this is a profession where one train the junior to become like him. The junior is going to enjoy the same level of respect and expected to give the same services as given by the teacher. In a fact it can give a competition too.

      There are things which we do due to fear of authority and some other things which we do due to the passion for it. The most important influencing factor for the teacher to teach, is the passion of the student for the subject. In medical profession the student has to take an extra effort to get useful information out of his teacher. Nothing comes for free. The student who take everything for granted is an irritating character for the teacher.

        Another important factor is that the seniors always want their juniors to earn the knowledge. They want them to go through the same striving they went and learn things the hard way. Because early imparting of wisdom does not feel natural and right. But todays generation has got more easier ways of access to knowledge via media and internet. Even then the passion is required.
  
     Although I feel that if someone has worked under me for a considerable time, and he does not know what he is supposed to know, that is my failure. At some point, someone has to strike a balance. A least responsible student with least passion for the subject and patient care can be a headache to the medical teacher. No one can blame him if he do not acquire what he needed to by the end of the course.

     After all, the best compliment one can get in a profession, is when some one good in his field tells that he has been trained by you. So the bottom line is teaching is a good rewarding profession.
 

Surgeon's OCD

    St Luke is considered as the patron of physicians and surgeons by catholic church. But some behaviour peculiar to surgeons make me think we are followers of Apostle Thomas. We don't believe unless we feel it ourselves. This is a job induced obsession.

    Every time when someone comes with a deep wound, the surgeon is restless until he could put the finger inside, rotate and feel the depth and floor of it. It is a part of medical examination, and it has to be done. But even if one doctor in a group feel it and explain, others wont be satisfied until they have their own personal experience.

    There was one patient who came with a 'T tube'. It was time to be removed. Normally it would come out easily on a gentle tug. So the junior most resident tried, it didn't come out, then the next senior guy tried, then my colleague tried, but it didn't come out. Then a weight was attached to it and the patient was asked to move around. Even after the description how tight it was, I could feel my inner urge to try myself. I couldn't resist it. I also gave a try only to find that it was abnormally tight as they described.

     But a many a times, this obsession can save the patient from catastrophes. Counter checking the clinical findings by a senior resident, going through the lab results from original reports and confirming the biopsy results have saved lives and decreased unwanted morbidity.

     

Problem solving is the answer for problem solving

         Two and a quarter year has passed since I joined for post graduate training in general surgery. Although I know the limitations of my knowledge, I notice some development in my problem solving skills. An acquired way of thinking and analysing the data so as to reach a decision or a plan of action. I realised this when, one of my freshly joined junior asked me about a surgical consultation call he got from another department. I asked him whether he assessed the patient. He gave me a look "what am I going to do...I don't know what to do.." I too used to give the same reply till recently. But this made me think what is that thing that caused the change in the attitude.

              It is the basics of science. The algorithm of working out problems. The first step is to talk with the patient and identify the complaint. Most of the time, the complaint conveyed by the nursing staff will be different. Then quantify the complaint. Check for the vitals , objective measurements of well being. Then segregate the abnormal values. This will give us the clue or lead point to the underlying problem. Many a time, it can be found after quantification that the problem is trivial or the surgical solution for that problem might be more weary than the problem itself.
         
               Knowledge about the disease, the treatment the patient is on and the possible complications can give light to what the patient is complaining of. Consulting with the senior person about the problem which not clearly understood helps in creating management strategy for future. That's how the experience matters in medical field. Because every person is different, and no text book can give you ultimate answer for any question. The bottom line is, the more one try to involve in solving patient problems, the more chance that the problem could be solved. So do not try to avoid complaints, but take challenges, enjoy the doctor job.
 

Medical translation: the art of medical communication

                        Although the term hemothorax and rib resection seems nothing unusual to me, a normal person who has left his connection with the subject of biology after schooldays might not understand it even after hours of explanation. That is just with medical terms, but that is the least difficult part. To understand how the operative procedure going to affect the daily routine of the patient is much more complicated. Even three years of residency is little time for the surgeon to assimilate it. But as a surgeon I cannot give the Maingot's book of surgery to the patient and ask them to read and understand about the surgery themselves. There should be an effective way of translating medical definitions and procedures to layman's language.

                     Here I would like to share some of the examples, my professor elaborates to explain things to patients and even the non surgical medical personnel. At this point I have to mention that a surgeon is very different from a physician. A doctor who has never seen or done any surgery after medical school training cannot understand or explain how real life situations are different from text book descriptions.

                   Crossing the road situation 

               A surgery with a described low risk is like crossing a road on a fine sunny day. What are the chances of getting hit by a vehicle or slipping down?

            
 Now for a surgery with a described high risk, it is like crossing the road during a stormy rainy night. The chances of getting injured is high.

             




 



 Ascending the stairs situation

                See...,  undergoing a surgery is like ascending the stairs till the third floor. I will have to do it, the patient have to do it, the attendant has to do it, the child has to do it, the eighty year old grandpa has to do it. You know, the child will run and climb, the grandpa might get breathless by the first floor. This is a simple example to show how the age can be a factor for surgical outcome.

             




    Making Rotti and curry situation

              If the attendant is a person who cooks, this is a helpful example to relate how much athey can rely on experience of surgeon.  " You must have made atleast ten thousand rottis (bread) or around five thousand dishes in life till now. But can you guarantee that the taste of the dish you are going to make will exactly be same as the taste of previous one? "
            That's the same with surgery, the surgeon might have successfully done the same surgical procedure five hundred times.But, the outcome of next surgery cannot be predicted as same as the  previous one.