"Are you sure"

     This happened yesterday. Our professor who has an experience of more than 25 years in surgical practice was doing a laparoscopic cholecystectomy. As I have mentioned so many times before he is a very friendly person and easily approachable for residents. Now my Junior who is in his second year of residency recently did a laparoscopic training course. There they taught him basic laparoscopy techniques and cholecystectomy on porcine specimens. Our professor dissected the Calot's triangle and clipped the cystic duct. Unlike we usually do he was in a little hurry and didn't mind to explain each step. Then my junior who was really enthusiastic after all that one week training   questioned him, 'Are you sure?!!' (that you are clipping the cystic duct and not the common bile duct!!). Professor started laughing. Even I, who was holding the scope, could not prevent myself shaking the scope due to laughter.

          Surgery and any other medical professions has got this peculiarity. Once we pass the degree, we are legally equal to our teachers. Now this is a reality, but it depends on individuals how he or she assimilates that fact. Even though senior resident has the same educational qualification as the professor, his clinical examination and treatment modality may not be the one the Professor wish. In this profession the thing that matters most is experience. Allthough it may considered class 3 or C evidence in context of evidence based medicine, it is the most important factor.

         It is also another effect of this profession. You are at a position with ten years of experience and then a youngster who just passed out, come and question your decisions. Often you may not have an evidence based explanation for what you do, but based on a 'gut' feeling. Most of the time the youngster believes what he learned in books, but each patient is different and each one needs treatment or surgery, tailored to his or her need which an experienced practitioner can understand.

Robotic surgery and some thoughts

             Robotic cholecystectomy was going on. Surgeon was uncomfortable because he was not able to use the Maryland dissector the way he wanted to. Using the Bipolar cautery he was not able to adequately separate the tissue. My junior scrubbed and assisting by the patient side suggested that we should use scissors to cut the tissue. Then the Urology professor watching the procedure replied, “we can, but we will have to open a new instrument and that will add cost to the surgery”. We were doing robotic cholecystectomy as a part of getting used to the robot before going on to do major surgeries.

              Definitely robotic cholecystectomy does not offer any advantage over laparoscopic surgery. But in fact, add cost and effort. The machine itself costs hefty and the accessories also come at a high cost. Each surgery needs costly drapes and the instruments get auto-locked after ten uses. The Da Vinci system has got the monopoly over robotic surgery all over the world. 

             The day before the surgery I went to the patient to take consent for the surgery. Earlier she was posted for Laparoscopic cholecystectomy, but the surgery was cancelled since the previous cases on the list got delayed and the OT time was over. I explained to her that we were planning for a robotic surgery and if there was any problem, we will convert it into a normal laparoscopic procedure and again if we find difficulty, we may have to convert it to an open surgery. The poor patient coming from a village hundreds of kilometers away nodded her head for what ever I explained to her. Finally her only question was “Do I have to stay fasting (NPO), tomorrow also?”

Amputation

            Nobody wants to live with an incomplete body. When it comes to amputation of a body part, every one is equally worried. Even I have imagined so many times what will happen if some mishap occurs and I have to get my finger, hand or any other appendage amputated. Amputation of upper limbs can result in end of my career, while amputation of the lower limbs can cause me life style problems. 

            There are situations in which there is no way other than cutting the diseased part. The classical textbook description of amputation includes ‘dead, deadly and dead loss’. It is difficult for a surgeon to decide on major thing like amputation. Even with the same patient, 5 surgeons will have five different opinions on management. Each one forms their decision from their clinical experience and judgment.

           There is a patient currently admitted in our ward with a large wound on right lower limb. It started as a necrotizing fasciitis and underwent multiple debridements. He is not a diabetic, but had jaundice, probable as a result of sepsis. His septic symptoms started resolving after the first debridement. Almost two months have passed and there are no signs of granulation of the wound. Amputation of the limb was advised, but the patient and relatives were not willing. Today one of our consultants commented that, there is still hope and debriding with dressing should help in healing of that wound. The senior consultant replied ‘I can give in writing, that wound is not going to heal and the patient is not going to get a functional limb back even if you wait for long.’

      

           There was a patient post renal transplant, a chronic diabetic and near blind as a squeal of diabetic retinopathy, presented to Out patient department with a small foci of infection at 2^nd space of right foot. There was no underlying bone infection and he was treated with incision drainage and antibiotics according to culture reports. The lesion never healed well, it remained dormant. After 2-3 months, he presented with infection involving forefoot. At that stage it warranted a forefoot amputation. On imaging the blood flow to the limb was present although decreased. The patient was a well-educated man, with an equally educated wife. It was difficult convincing them for a below knee amputation at the first instance. The same time it was not possible to substantiate on the available reports that, there was no chance of healing. The treating doctor did not want to put pressure on the patient or relatives and the patient and relatives did not want to give up hope. The wound was treated with serial debridement and dressing for a period of two months. Finally he started having fever and increasing pain, the decision was made and he underwent a below knee amputation. Even after that it took around 4 weeks for the stump to heal properly.

          There was another patient I met in Trauma Center. He was a young man recently married and had a small child. He had polio during child hood and had left lower limb residual paralysis. He was travelling on a scooter and got hit by a car, resulting in an open fracture of the paralyzed lower limb. There was a major tissue loss, and the fracture was fixed with external fixators. I did his wound dressing. There was little muscle tissue on that limb. Most of the muscles were atrophied and replaced by fat as a result of the paralysis. But the interesting thing was that the patient looked extremely sad and irritated. He wanted to have that limb amputated. He had even requested the surgeon in charge to amputate that limb. He said ‘All the life, I was carrying this limb like a burden, It was of no use and now I am in hospital just because I have a wound on this limb which is giving me pain. Even if the fracture and wound heal, I am not going to get any advantage of it. Why can’t you just amputate it? I will be happy with prosthesis.’ Well, the surgeons point was that, the limb was salvageable according to the grade of injury and we should do whatever that takes to save that limb.

            It is not just about the limbs, breast is another important organ, which needs to be removed as a part of cancer treatment. In India for the less educated population coming from rural area, their only condition is to get the whole disease removed. They are not worried about cosmetic outcome. They often express a feeling as if some dangerous animal or thing is attached to their body and they want to get rid of it. They come to surgeon just because they cannot remove if by themselves. On the other hand the educated, urban ladies often want to do a procedure that retains the breast.

              Many breast conservation surgeries are done now days. But radiotherapy is an inevitable part when you do breast conservation surgery. Often the radiotherapy leaves persistent skin color changes, thickening of skin, and local reaction. I cannot think from a female point of view, but I often feel, removing the whole breast and going for a reconstruction gives a better cosmetic outcome than the ‘different’ looking deformed residual breast.

        One has to take in account of everything before deciding on amputation. The decision for amputation will be painful for the patient and family. The patient and family will always turn their head to the side where they see some hope. Medicine is a subject where no one can give hundred percent guarantee on anything. But once the decision is made, it is better to stay with it than giving multiple options and adding confusion to the already perplexed patient.

The story of Prometheus

        Prometheus was a hero in the greek mythology, who got punished for helping humans. Zeus chained him to a rock where he was daily tormented by an eagle. Later Hercules rescues him.

It just stroke me how I met Prometheus in my books at two different times in two different ways. It gave me an insight how one can interpret the same thing in two different ways.

         It was the seventh or eighth grade language textbook where I met Prometheus for the first time. It was an emotional description of the human nature of Prometheus and how much he loved humanity. It was a poetic description of his kindness, goodness and his sufferings and sacrifice for the humanity. It detailed the pain he was imposed upon by the eagle and how his immortality became a curse for him. His virtue of immortality prevented him from dying and he had no way but to endure the never-ending torture by Zeus. For a short time I was also touched by his story.

           

         Recently I met him for the second time in the opening pages of Blumgarts’ textbook of Hepatobiliary surgery. This time his picture was depicted as an example of the regenerative capacity of liver. The surgeon, who works on logical explanation and scientific methods, found that the regenerative capacity (may be a little more than natural human being in this case) of the liver was what prevented Prometheus from dying. I don’t know whether the eagle did it on purpose or chose to devour on liver just because it was tasty!

         

        This is how one can see the same thing from different views. The people who tried to think and acquire knowledge from the sufferings and diseases, which crippled other people, are the ones who have contributed to basis of medicine. Most of the scientific persons described in the textbooks are people who had empathy for the patient while there were also other people in the dark pages of history who studied people without any empathy. Like, Joseph Mengel, the notorious Nazi doctor and the Japanese doctors of WW II who run similar concentration camps in the East. A surgeon has to have the heart of a soldier, he should be ready to think and act logically and swiftly in situations, which normal persons usually try to avoid.

First response

      Hearing complaints is a chief part of the job profile of a Doctor, be it a physician or surgeon. We are here to solve the complaints of patients or persons (because many of the people coming to OPD are do not have adequate suffering to qualify as a 'patient'). Even from medical school we are taught to write a case sheet starting with the chief complaints of the patient. Especially on Out patient days, we will be tired conversing with the patient.

        Once the threshold has reached or even otherwise, some persons come with such stupid doubts for which threshold is zero, 'first response' starts flowing in.
For example patient: 'Sir, I have leg pain while smoking'. Reply : 'Stop smoking'

Patient:' I have back ache while walking fast or bending down'.
Reply:' Stop bending down and avoid walking fast'

Patient:' I have stomach trouble on taking spicy food'
Reply:'Stop taking spicy food!'

Patient:' I am worried, I am masturbating too much?'
Reply:'Stop masturbating!'

Now these are reasonable replies. But as threshold goes down

Patient:' I have pain on passing stools'
Reply:' Stop passing stools'

Patient:' I cannot eat solid food'
Reply:' Stop eating!'

           Although all these first responses come like a passive reflex, we know that hearing complaints it is a part of profession. No person with sound mind will take the hardship of waiting long hours in queue to get an appointment and later to see the doctor unless he/she is really worried. A word of reassurance or a "doctor restriction" of diet or excersise   is effective most of the time.

Patient is not an MCQ.

      Everything in medicine or surgery is not clear. Actually it is not possible to explain every patient problem on a scientific basis. Now this is going to make the life of surgeon more difficult because the first requisite for surgeon's treatment criteria is a logical connection of the pathology and patient symptom. A surgeon with clear mind cannot put his scalpel on his patient without assuring himself first that his intervention is going to give some benefit. 'First no harm' and no surgery is without risk.

      Here come our patient, who presented to nephrology for abdominal pain and dysphagia. He was worked up for dysphagia and found to have Gastroesophageal reflux disease and hiatal hernia. He underwent Nissen Fundoplication and was relieved of symptoms for one year. Unfortunately a year later he presented with severe abdominal pain and on investigation it was found that he had migration of wrap. He had a revision surgery (which included unwrapping of the migrated wrap, collis gastroplasty, mesh hiatoplasty and a new fundoplication). Following surgery he was relieved of symptoms.

      About one and half year passed and then he started complaining of abdominal pain, mainly around umbilicus. Given the history of the patient, the surgeon was naturally worried whether there was a recurrence of disease. Many investigations were done including an Endoscopy, Barium swallow, Ultrasonography, CT scan of abdomen and blood tests. All the imaging and lab tests were within perfect normal range. Now as a resident I was in charge of this patient and he used to call me whenever he had pain. I prescribed him PPIs, antispasmodics, analgesics. But according to the patient none seemed to give an effective pain relief. Later I was getting restless seeing his messages, because it was like treating blindly. On requesting multiple times , the patient came to emergency room. He was kept in observation for 24 hours. Inspite of complaining pain, he did not have any tachycardia, seemed to be comfortable and his abdomen was soft. His imagings were rediscussed with the most senior faculty and nothing wrong could be found.

     I don't know what exactly worked, but after some counselling by senior surgeon, that we cannot find any serous problem with him after all the elaborate tests, he said there is some decrease in the pain. He was discharged.

     Now what i want to share is that moment in each surgeons' clinic life, when they find nothing can logically explain the patient problem and no medication relieve patient problem. Attributing the problem to the patient psychology is a diagnosis of exclusion. Once a surgeon operates on a person they develop an unwritten responsibility for any complaint related to that body part. And this often puts them in difficult situation. Solving a patient problem is not easy as answering an MCQ. Checking 'none of the above' is not going to solve a real life situation.

     This is another reason, why our senior professors always advice. Take a good history and confirm that   the patient has significant symptoms and those symptoms are related to the pathology which you are going to operate for. 

"Let the nature take care...."

      A patient who had developed a bilious fistula after a major hepatobiliary surgery came to the follow up clinic. He was alright except for the small out put fistula which was gradually decreasing in output. He was worried about the fistula and asked the doctor what is the plan for that fistula. He said "Let the nature take care of it". 

          We were doing closure of flaps following a mastectomy surgery. As soon as the consultant de-scrubbed, the anaesthetist started putting pressure on us to complete the closure fast. As we were trying to close in a hurry, overlapping of edges occurred at some areas. Then the consultant came back and watched our suturing. Then he made the comment " Don't let it for the nature to take care! "

         Time and Nature are the best healers in the world. Give some time and the natural physiology of the human body will modify itself and find a way to heal itself. Surgeons role is to realign things in a manner so that the healing process can be faster. Like Ambroise Pare, who is considered as the father of surgery commented "I treat, God cures".