When I Really Needed a Hand

*Warning: this post contains graphic descriptions not suitable for the squeamish

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Christmas Eve (nearly 10 years ago)

Hand trauma call on Christmas Eve was always busy. Typical presentations included people who cut their hands with Stanley knives wrapping or making presents, housewives with stab wounds in the left palm, mostly from the knives slipping whilst they were trying to wedge an avocado seed out (use a spoon, ladies!), or clueless men who cut their fingers trying to open a can without a can-opener. Work was steady, I had been running between admitting patients in ED (Emergency Department) and operating in theatres all day. I was a junior registrar, only nearing the end of my second year training in plastic surgery. There was not a lot a second-year was supposed to do without senior supervision, however, I had been on this hand surgery team for nearly 12 months now, so I was accustomed to performing routine hand trauma surgery such as infections, lacerations, tendon repairs and simple fractures without calling my senior registrar in.

Our on call had two tiers – if I was out of my depth, I was to call the senior registrar (a final year trainee), who usually came in to give me a hand. If he/she needed help, then the consultant plastic surgeon on duty was called for either over-the-phone advice or had to physically turn up at the hospital. The nurses and other doctors could also bypass the junior registrar to call either the senior registrar or consultant if they felt that the junior was out of his/her depth, or doing something that may have not been in the best interest of the patient. Rarely, the consultants were required to be on site, apart from major complex hand trauma cases, which luckily were far and few in between. This was because our country had very strict firearm laws, motorcyclists also had to wear protective gloves by law and it was illegal to buy fireworks and firecrackers without a licence.

The senior registrar I was on call with was two weeks short of becoming a consultant. He had just passed his specialist exams and was finishing off his final rotation. Throughout the year I had been on call with Peter several times, and I knew he did not like to operate late at night. I had learnt to book all the more complex cases in the mornings and avoided doing procedures I was not comfortable with at night in case I needed him. As for the consultant who was on call over the Christmas weekend, Dr H, he lived by the motto: ‘Don’t be afraid to cope’. His phone was only to be used for nothing short of life and death. He never came in on call, unless the patient had private health insurance and was willing to pay for their surgery. It was unheard of for a junior registrar to call him directly, we valued our lives too much.

Back to my Christmas Eve, the day was progressing smoothly – at one stage, it looked as if I may even get home for Christmas Eve dinner. As I was writing up the last operating notes for the day, my pager went off. The tone indicated that it was a trauma call from ED. Probably another car accident. Guilt flooded me, but I couldn’t help smiling. This meant that no other cases could proceed unless it was life-threatening, and most likely this particular trauma case, if it made it to the operating theatre, will keep the emergency theatre occupied until early hours of the morning – therefore I could not do anymore hand cases tonight, even if they started piling up in Emergency. A trauma call at 7pm not only meant that I could go home for dinner, but that I may also get to sleep through the night! My steps lightened as I headed towards the ward to see my postop patients before heading home.

As I was about to finish the evening round, my pager went off again. This time with a phone extension from ED. I shrugged, whatever they were holding down there will have to wait until the morning when the trauma case is over. I headed to the desk and punched the numbers into the phone. ‘Tiff here, what you got?’

‘Oh, Tiff,’ it was the trauma reg on call. ‘Hey, I am so sorry mate, but I think this one is going to be all yours. You are going to love it, consider it my Christmas present to you.’ An evil chuckle followed.

I raised an eyebrow. We rarely get involved in trauma calls. Even if the patient had concurrent hand injuries, we only ever get the call a few days later when their main injuries have been taken care of.

I sighed, ‘I am on my way.’ With heavy footsteps and visualising all my evening plans disappear above my head in an imaginary puff of smoke, I headed to the elevator.

My colleague was not wrong. The patient was cleared of any serious injuries. The only trauma he suffered was that to his right hand. Mr D was a 65 year old right handed, retired lawyer. He was finishing off a rocking horse he made for his 6 year old grandson. He found the handle a little loose, so decided to re-fashion the rounded piece. However, when he was trimming it with a bench-top mounted circular saw, the wooden rod slipped and he ended up putting all four fingers through the saw instead. They were all taken off at base and was handed over to me unceremoniously by the nurse in a plastic bag.

After meeting the fingers, I went in to introduce myself to Mr D, noting that his injured hand was wrapped up firmly like a boxing glove to try and stem any bleeding. I looked at his x-rays of both the hand stump as well as amputated parts to assess both the level of amputation and the metal work that may be required to reattach the digits. After having had a serious chat with Mr D, I took the bag into another room and laid all four amputated fingers on the bench top. Then I took a marker and printed on each finger which ones they were. I checked the amputated ends and silently offered a prayer of thanks that the saw was high speed and sharp, as all four fingers showed clean guillotine-type amputation rather than avulsion-type injuries associated with slow oscillating saws. The latter usually involved more extensive injuries to tendons, nerves and vessels which often make replantation difficult with very poor outcomes. Even though the prognosis was looking good for Mr D, my heart sank. Replant surgery took hours to perform; one finger alone could take up to 4 hours, and I was looking at 4 fingers. There was no contraindication for me not to replant any of the fingers, as all of them looked clean-cut and despite his age, Mr D was otherwise fit and healthy, thus suitable for a long anaesthetic.

I checked Mr D’s details and smiled when I realised that he had private health insurance. Dr H would love this case, it was well known that replantation of a finger was well-paid by insurance companies. Remuneration for four fingers would be equivalent to almost a whole year’s private school fee for one child. I picked up the phone and rang Peter. He was also glad to hear that the patient had private health insurance, and promptly asked me to ring Dr H. I protested, as it wasn’t appropriate for me to contact the consultant directly. Peter said that since Dr H will have to come in to do the surgery anyway, there was no point for him to see the patient, and if he hadn’t seen the patient, he didn’t know enough details to talk to Dr H. He told me that Dr H would be pleased to hear from me.

I was naïve and believed him.

So I rang Dr H. At 8pm Christmas Eve.

To say that the conversation was unpleasant would have been an understatement. Dr H was livid that I had contacted him. He told me that he was having Christmas Eve dinner with his family and had no interest whatsoever spending the night operating. He was not interested in the patient’s insurance cover, and if the patient had presented at a public hospital, then he was to be treated as a public patient by training registrars regardless of his insurance status. Dr H then told me that under no circumstances was I to call him again directly, especially about this case. I could almost hear the phone being slammed down when the disconnection clicked in my ears.

I called Peter, as this is going to be a major complex case, so he had to come in. There was no way I was expected to carry out this surgery on my own even though I have read this procedure in detail and knew the basic principles. In practical terms, however, I had only seen two similar cases performed before and assisted in one. This was definitely not an operation that followed the rule of surgical training of ‘see one, do one, teach one’. Only the most senior of trainees were allowed to perform it unsupervised.

When I told Peter about my conversation with Dr H, he swore and made disparaging comments about lazy consultants. He then told me that he was having Christmas Eve dinner and he couldn’t possibly get away, so I would just have attempt the surgery on my own. I almost dropped the phone in shock, and protested that I was too junior to take on such a case. He told me that he is more than happy to talk me through it and give me advice on the phone, but he could not physically come into the hospital. I glanced at the clock as we were talking and realised that it was nearly 8.30pm. This meant that warm ischemic time for the fingers was over 2 hours now (as his injury was around 6.30pm). Warm ischemic time referred to the amount of time the fingers had been without blood supply while it was not on ice. If the fingers were to have the best chance of survival, they needed to be reattached within 6-8 hours of warm ischaemic time. Whereas cold ischaemic time could be extended to 24 hours. However, there had always been controversy associated with reperfusion injury and poor nerve regeneration with prolonged cold ischaemia.

I knew that staying on the phone arguing with Peter was delaying Mr D’s treatment, so I finally acquiesced to Peter’s request (much to his relief), and finished the phone call. I quickly documented both phone calls in Mr D’s chart and then rang theatres to let them know that he was coming up for a very long surgical procedure. While the transfer was taking place, I went to the office and pulled the hand surgery books off the shelf (this was before Google days). I quickly familiarised myself with the chapter of replantation again. Then I took the bag of fingers with me to the operating theatre. The nurses were still preparing equipment and the anaesthetist was just starting to put Mr D to sleep, so I set up an operating table in the corner, cleaned and tagged all the nerves and vessels at the amputated end with micro-sutures under the microscope, to save me time later on looking for them.

I knew I only had 4-6 hours to re-establish blood flow into these fingers. I also knew that if I did not plan this well, it would be at least 12-16 hours before I could get them all perfused, as normally it would take around 4 hours just to complete a one-finger replantation. So I devised a strategy in my head, part of which included planning ahead. Firstly I made sure all the equipment I required were ready to go, then I got a bucket of ice and put the fingers (wrapped in plastic) in it. I was trying to buy an extra hour or two by swapping warm ischaemic for cold ischaemic time.

As soon as the patient was asleep, I inflated the tourniquet on the patient’s arm, to stop any blood flow into the hand so that I could work in a bloodless field (and see what I was doing more clearly). I prepared the stumps on the hand and again tagged all structures under the microscope ready to be joined to the other end. Then, under x-ray guidance, I reattached all of the fingers with wires to realign the bones. This was achieved within 2 hours. Then I had to let the tourniquet off, as stopping blood flow to the arm for more than two hours could cause muscle damage in the arm and hand. Often if we needed to have the tourniquet on for more than 2 hours, we allowed blood reflow for 15 minutes between each tourniquet period; this was sufficient to minimise any lasting damaging. So I wrapped the hand tightly in a bandage to prevent excessive blood loss and un-scrubbed for quick coffee break while the tourniquet was down. I knew that for me to work efficiently, I needed to be alert at each stages of surgery, so I deliberately planned to use these reflow times as my breaks.

After 15 minutes, I spent the next 2 hours of tourniquet time repairing the tendons. There were two tendons in each finger, so that meant repairing 8 tendons altogether. Unfortunately when the tendons were cut under tension (as it was when one’s hand was gripping an object), the tendons retracted into the palm. Luckily I had thought of this during my stump preparation earlier on (while the fingers were on ice), thus I had already dissected out each tendon and pulled them back out, ready to be reattached.

At this point, I am sure most of you would be wondering why I didn’t join up the blood vessels first – if re-establishing blood flow into the fingers was so important to be done in a timely manner. Well, the reason was that both the bony and tendon work required a lot of retraction and manipulation of the fingers. If I had rejoined the blood vessels first (which were around 1-2mm in diameter and the threads we used to sew them together were thinner than human hair), then any traction or movement would have easily disrupted the repair. The repairs were also too frail to hold together unless there was some form of structural stabilisation of the fingers. The easiest way to explain it would be to equate it to constructing a building; one wouldn’t put the plumbing in place until the walls, beams, struts and foundations have been established.

Once all eight tendons were adequately joined, it was time to let the tourniquet down again. This was perfectly in plan with joining up the arteries (which brought blood flow into the fingers). Each of the fingers had two of everything, two arteries, two veins (vessels which allowed blood to flow out of the fingers), and two nerves. Arteries were best joined when the tourniquet was off, as blood flow often dilated these tiny vessels, thus made it easier to identify and place the stitches. I worked furiously under the microscope, with the aim to connect up only one artery in each finger as quickly as I could, thus to re-established blood flow into them within 8 hours of total ischaemic time. I breathed a sigh of relief when all four finger became pink on the table. I looked up and it was just before 2am. Then, at a less pressured pace, over the next 4 hours while the fingers were happily alive, I connected up the rest of the arteries, veins and nerves.

Unbeknownst to me, during those 10 hours as I was working quietly away, phone calls were being made outside. The nurses and anaesthetic staff were aghast that a second year trainee was attempting this procedure alone. The operating theatre nurse manager called Dr H and told him that I was performing the case on my own. Dr H told her that it was Peter she needed to ring. Peter was rung, and he told them that I had said I was happy to do the case alone and did not need him. He reassured her that he would have come in if I was having trouble. The nurse manager did at one stage poke her head in and asked if I was ok, and I just assumed it was a courtesy visit so I told her I was fine. Peter then rang the operating theatre about midnight to ask how I was going, he spoke to the nurse who picked up the phone. The nurse offered to put me on to speak to him directly, he declined. Apparently he didn’t want to speak to me and just wanted her to pass on a message. The message was that he was about to go to bed and if I was struggling, or feeling tired, I was to put whichever fingers I hadn’t attached back in the fridge on ice and rebook the patient for surgery tomorrow so that he could reattach the remainder fingers in morning. I snorted at the message in a very unladylike manner (much to everyone’s amusement as it matched their sentiments exactly) and kept going. No one made another phone call after that.

So the fingers lived. Mr D had the full hand of fingers to compliment his uninjured thumb when he left hospital 5 days later. He had a long road of rehabilitation ahead of him, but he was thankful that we managed to save all of them. I got called into the office by the Head of Department (HOD) on that same day as Mr D was discharged. The HOD had received an incident report from the Nurse Manager about how inappropriate it was for such a major complex case to be done by a junior doctor alone. I received a thirty minute lecture about biting off more than I could chew as a junior trainee, followed by another fifteen minutes on learning to know my limitations and recognising the need to ask for assistance.

A few days later, at the end of my last clinic with the team, I saw both Dr H and Peter being pulled into the office with the HOD. I asked the nurses what was going on and they told me that the HOD saw Mr D’s chart in clinic and asked them why this patient was in a public clinic when he was privately insured. All the nurses avoided giving him an answer so he flipped through the admission notes himself.

The following week, I had already moved onto another rotation at a different plastic surgery unit when I received my assessment report. I read, with surprise, what the HOD had written:

Tiffany improved well above her training level as a second year trainee during the last 12 months. She showed initiative in difficult situations and exhibited good insight in her abilities. She demonstrated natural aptitude in microsurgery. I would strongly recommend her for ongoing training with any plastic surgery unit.

Peter became a consultant and moved in with Dr H as his partner in private practice.

The Myth of being Plastic Fantastic

Some days I am a little sick of the stereotyping inflicted on me as a Plastic Surgeon, so I am here to put all the urban legends  to rest. There are plenty of myths about plastic surgery from both public ignorance and misconceptions established by shows such as ‘Nip Tuck’.
Myth #1 We use plastic.

Once I had a young tradesman whose face was smashed up by the windscreen in a truck rollover. Just before he was put to sleep (and this is after I have spent an hour explaining to him how I was going to put his face back together), he asked me, ‘So doc, where do you put the plastic?’

*Insert eyeroll*

I have lost count the number of times I have been asked that question. Plastic surgery doesn’t mean we play with plastic or put plastic in people. In fact, if we were to use any form of prosthetic device, it is usually silicone. The ‘plastic’ in plastic surgery is derived from the Greek word plastikos. It means to change shape, or to mould. The aim of plastic surgery is to change the shape of any part of your body, for cosmetic or functional reasons.

So, sorry folks, we don’t shove blocks of plastic into people.

Myth #2 We can perform surgery without leaving a scar or we can remove scars

Here’s a couple of frustrating conversations I have regularly with patients every week.

Scenario one:

Me: We have to make a cut around the skin cancer on your face to remove it. Once we stitch it up, it will leave a straight line scar.

Patient 1 (outraged) : A scar? But you are a plastic surgeon; I have come to you to have this done so there will be no scars.

Scenario two:

Me: I hope you have recovered from your fall last month. Your cut lip has healed really well since the stitches came out, it looks great.

Patient 2: I hate it. I can’t believe you put a scar on my lip; I want you to remove it.

Ok people, I know plastic surgeons are incredibly good, but we can’t perform miracles. Where there is a cut, there will be a scar. We can’t remove scars either. If you want scarless surgery, you should have had your surgery done when you were a foetus – that is the only way to perform surgery without leaving a scar. And if you want us to stitch up your injuries, it was not me who had created those scars; it was your stupidity in falling into a window whilst you were pissed.

So what makes us better than others in scarring? We stitch differently to other surgeons, we use finer sutures, we know how to hide and minimise scars. We have techniques which can camouflage or improve scars. We have the knowledge and means to treat bad scars.

So, apart from making people look hot, we can make your scar look sensational too. But unlike God, we cannot remove history which has been carved onto your body.

Myth #3 All we do are boob jobs, facelifts and buttock enhancements

‘I don’t understand why I have to come to see a plastic surgeon to have my skin cancer cut out, it’s not like I want a facelift or something,’ said the man sitting in front of me with a fungating growth coming out of his nostril. Unfortunately, I was the one who had to break the bad news to him, that the cancer in his nose was so big that we would have to amputate his nose. Any surgeon would be able to remove his cancer, but he would be left with a hole in the middle of his face. The reason he needed a plastic surgeon was because we can remove the cancer and reconstruct his nose.

The acronym for our specialty is actually PRS – it stands for Plastic and Reconstructive Surgery. There are two components to our work:

Reconstructive surgery: which is surgery to improve and restore function, to minimize disfigurement and reconstruct structure which was lost due to trauma, disease, cancer or birth defect. Basically, our job is to fill up a hole anywhere on the body. Sometimes we excise tumours ourselves, but often we work in tandem with other oncological surgeons such as orthopaedic surgeons who resect bone and soft tissue tumours, ear nose and throat surgeons who resects tongue, nose, throat cancers, as well as breast surgeons who perform breast cancer surgery. The way I see it is that my oncology colleagues are the ‘destructive’ surgeons and I am the ‘constructive’ surgeon. I remember when I first started training I was hesitant as to how much margin to take around a tumour. My supervising surgeon took me aside and said, ‘Just remember, Tiff, the reason you are going to be a plastic surgeon is because you are not afraid to make a big hole. Unlike other surgeons, you can fix holes.’

Aesthetic or cosmetic surgery: which is surgery to enhance, or to rejuvenate a specific body part, it is designed to improve a person’s appearance by reshaping facial or bodily features. So yes, we get a chance to make people beautiful. We make boobs bigger, smaller, perkier or firmer. We lift up butts, thighs, arms and faces (not specifically in that order). We inject, insert, eliminate and suck to enhance contours. There has not been a single part of the human body that a plastic surgeon has not attempted to alter, although I gladly admit that I have had no training or experience in anal bleaching – nor am I interested in expanding my field into that area.

Myth #4 Our work is frivolous and we perform non-essential surgery.

As my husband (who is a heart and lung surgeon) sums it up succinctly, ‘Honey, I save lives, you just make the world beautiful.’

Even though spoken in jest, unfortunately it is a view held by many, including hospital administrators, insurance companies and sadly, our colleagues in other specialties. I have had medical students who did not attend their plastic surgery sessions with me at the clinic because they feel that it is not something they need to learn about. I was once told by a second year student that plastic surgeons are not real surgeons who practice ‘true medicine’.

People seem to forget that plastic surgery is not just about cosmetic surgery, but that the most important aspect of our role is to improve a person’s self esteem. No matter how much the self-help books may claim about not placing too much importance on one’s appearance, and to stop using your looks to determine your self-worth, the reality of life is simply – people do judge you by the way you look. And that includes yourself.

It is amazing the difference we sometimes see in our patients. Like the 12-year-old boy who was constantly teased at school for his bat ears – he got it fixed before he started high school. He became a completely different person; he happily went to the barber to have him shaggy long hair removed, started going out with his friends and strutted into my office at 8 weeks postop as if he owned the world like a typical 12-year-old boy. My favourite last month was a 30-year-old mother who had a nasty burn scar over her neck and chest from a childhood hot-water scald. The scars stopped her breasts from developing properly and distorted whatever little breast tissue that did develop. After surgery to correct the deformity and implants to provide shape, she swapped her oversized jumpers for tailored dresses, and started becoming more involved in mother’s groups. She wore a pink singlet with a pearl pendant dangling in her new cleavage when she came to her appointment, despite the visible old burn scars which covered her neck.

Surprising it may be, we do perform surgery that saves lives and limbs. We are often called upon to join small blood vessels under the microscope for organ transplantation in children. We reconstruct the neck after throat cancer, so that the patient can still eat, drink and breathe. We put fingers back on after they have been accidentally severed, and we transplant soft tissues into smashed up legs that otherwise would have had to be amputated.

Unfortunately our work often goes unrecognised, as throughout history, we have had to repeatedly fight for our patients’ right to access plastic surgery. When hospitals have budget cuts, our operating lists are often the first to be cut. Breast reconstruction after cancer was the last one they slashed from our hospital, because once the cancer has been removed, it is no longer considered life-saving surgery. Health insurance companies which exclude plastic surgery cover leave their members with a policy which pays for the cancer removed, but not the plastic surgical procedure to reconstruct or repair the hole.

Admittedly I sound like I am trying to justify our existence, but I truly believe that even though we are not saving lives every day, our work makes a siginificant difference in people’s lives.

Myth #5 We date our patients

There seems to be a misconception that we fall in love with our creations. I explored this particular issue with my male colleagues. The answer was a categorical no, although they have had plenty of invitations from patients to cross that line. Not only is it ethically wrong and fraught with medicolegal implications, it is also rather disturbing that someone would fall in love with an image they have created, which may have nothing to do with the actual person underneath.

Myth #6 We make lots of money because we charge ridiculous amount of money

I am not blind to the fact that as a plastic surgeon, I am often the target of many sarcastic jokes about money. This not only comes from patients, the general public, but sometimes our own colleagues in the medical fraternity. When I was sitting my specialist board exam, one of the candidates for general surgery taunted me, ‘I think your essay question would be on whether a Maserati is better than a Lamborghini.’ I was not shy to show him the finger as I sweetly replied, ‘well, I do hope you know the answer to your essay questions, which hole to put your finger up.’

Once I was leaving work, and one of my patients walked past me as I was putting my bag into the boot of the car. He took one look at my ten year old Toyota Corolla and shook his head. ‘Oh, doc, you need to get a new car, people would think you are not very good if they see you driving that car.’ I just shrugged and said, ‘Don’t worry Mr B, I leave my Ferrari in the garage for weekends.’ At his stunned look, I had to tell him I was joking.

It is not uncommon sometimes for our patients to comment on the cost of surgery, especially if it involves cancer surgery. For some reason people seem to think that we should do their surgery out of the goodness of our hearts if they have cancer….. but that’s another story altogether. One of the reasons that plastic surgery costs a lot more money than most other surgery is the rebate from health funds are low (because our procedures are not deemed to be a necessity), but also our practice has a lot of overheads, especially with wound care, garments, implants and dressings. We also employ a greater number of staff than other specialties, because there is a lot more patient contact time pre and post operatively. Plastic surgery patients and procedures are more complex to organise, and often requires various number of phone calls and coordination. Not to mention, our patients are usually high maintenance and requires constant reassurance.

Yes, some of us drive Aston Martins, stay at 6 star hotels, wear Gucci and walk in Louis Vuitton, but we work hard for it, and our responsibilities may not be life and death, but there is still a lot of stress involved in our surgery because we know the end result will have a life-long impact on our patients’ life.

Myth #7 We drive fast cars, hang out with celebrities, party like animals, snort cocaine and have the most glamorous life of any doctors

This is simple. We drive fast cars, because we have very busy lives and have places to get to. That’s my excuse and I am sticking to it. And trust me, my Corolla is pretty fast.

The only celebrities we hang out with are those that come for treatment. As I don’t perform a lot of cosmetic procedure, most of the celebrities I have contact with are those who have injured themselves or need reconstruction for cancers. They don’t usually act anything like celebrities when they are in my office and the last thing they need is for me to ask them for a selfie.

We try to party like animals, but often our job stops us. We are notorious for pulling out of social commitments at the last minute. One of the worst thing about being a reconstructive surgeon, is that our colleagues take all day to remove the cancers, and we have to sit around waiting for them to finish (or we may have to watch them so they don’t destroy our reconstructive options whilst cutting out the cancer). Once they are done, they piss off to enjoy their evening, while we start our work, usually at the unsociable hour of 4-5pm, working well into the night to patch up the ‘mess’ they have left behind.

What glamorous night life?

As for cocaine, yeah, I know colleagues who do it at parties, but honestly, it usually doesn’t take long for the Board to find them. It is rare that a plastic surgeon is stupid enough to risk their career and reputation to develop such an expensive habit.

Myth #8 We all have had some ‘work’ done on us

I would not deny that some plastic surgeons have had work done, but not all. Although I can’t say the same for the wives or staff! Personally, I don’t trust anyone enough to have plastic surgery done on myself and it is a little difficult perform a facelift on yourself when you should really be asleep throughout the procedure. I know colleagues who inject themselves in the mirror, but I have this unusual need to close my eyes when I see needles coming towards my face, so the results would be rather questionable if I went down that path.

Most of my staff have injections, not because I force them, but it is something I offer them if they want it. And who could say no to free Botox? Because I am very conservative in my treatments, my staff are actually free advertisements of my work. When one of my staff admits to having treatment, the patients are reassured that they won’t look like Jocelyn Wildenstein when they leave my practice.

But, truthfully, the greatest benefit in giving my staff Botox is its efficiency in stopping my practice manager frowning at me and my receptionist frowning at my patients.

Myth #9 Our practice staff are picked for their looks

So, supposedly, this means that our staff should be beautiful young girls with faces full of injectables and look-at-me enhanced breasts. I mean, it is free advertising after all, and who would’t want to be surrounded by luscious females?

Truth number 1 – Most surgeon’s practices are run by their wives. So, which wife would be stupid enough to surround her husband with gorgeous young things?

Truth number 2 – Young girls who are obsessed with their looks don’t usually have the right personality nor the prioritisation skills to run a business well.

Truth number 3 – Experience comes with age. So unless you want to be surrounded by rookies who have no idea what they are doing, you would pick more ‘mature’ staff members to make your own life easier.

Truth number 4 – Patients and clients sometimes find perfection intimidating. They are more comfortable talking about their inadequacies to someone who has flaws as they feel that someone would understand what it is like to be ‘ugly’.

Myth #10 We can make Queen Latifah look like Heidi Klum and vice versa

This is the ultimate myth. I always know it is going to be a difficult consultation when a 5’3, 200+lb person walks in and slaps a picture of Gisele Bundchen on my desk.

So here’s my spill:

  1. I cannot make you taller – go see an orthopaedic surgeon or stick to your heels
  2. I cannot make you a natural blonde – you need a hairdresser or a beautician
  3. Neither can I change the colour of your skin – that’s a disease called vitiligo
  4. Lipsouction is not a form of weight loss – get a personal trainer and stop eating junk
  5. A tummy tuck will not give you six-pack if you haven’t got one to start with
  6. I cannot turn back time to make you look 40 years younger, maybe 10, without the pimples
  7. I cannot make your woo-hoo look perfect nor make you a virgin again (yep, this is a genuine request, apparently Dr Google says it is a great anniversary present for your husband, or wedding present if you are marrying a younger man.)
  8. I cannot reverse gravity with a cream, it is called surgery
  9. And of course, I cannot perform scarless surgery
  10. Oh, and I cannot execute plastic surgery which will make your husband stop sleeping with his 20-year-old secretary, unless you want me to ask my Urology colleague to do a quick operation on your husband.

So, we may be Plastic Fantastic, but we are really just like any other regular surgeons. We cannot perform miracles, and we cannot change who you are. You need to speak to either God or a Shrink about that one.

 

 

Not a Saint Hospital

One morning I found a note on my desk from my secretary. It said:

The Medical Director at St X would like an appointment with you to check that everything is going well for you at St X.

It wasn’t unusual to get a ‘summon’ from the Medical Director of these private hospitals. Usually, it is a low-key chat to make sure that the private surgeons working there are not having issues with the operating theatre equipment or staff, and that they have no complaints about ward care of their patients. It was just over 2 years since I have started bringing patients into St X for my surgical lists so I was expecting an invitation from the MD sooner or later.

I asked my secretary to shorten my next St X operating list, and arrange an appointment with the MD afterwards around 5pm for me.

This was the conversation:

MD: Hi Dr T, thanks for taking the time to see us. So, how’s everything going?

Me: Great. I have had no problems, the theatres are great, the nurses on the ward are helpful, my patients have had no complaints. They are liking the private rooms and….

MD: (Nodding vigorously and leaning forward to cut me off). Well, I want to talk to you about Mrs Y.

Me: Oh? Is she causing problems with the staff?

Mrs Y was a patient of mine on the surgical ward whom I had just admitted two weeks ago. She was a teacher in her late 50’s who sustained severe spinal injuries when she was a teenager and is now wheelchair bound. Mrs Y was also a long term insulin dependent diabetic who unfortunately had severe ketoacidosis last year and ended up in ICU, ventilated for 2 months. During her illness, they didn’t look after her pressure areas so she ended up with severe grade IV pressure sores over both the ischium and sacrum by the time she was transferred out of ICU. She was then discharged from hospital with this problem as no one wanted to deal with it whilst she was an inpatient. Mrs Y went back to teaching, and spent hours every day in her chair. When her blood sugars started to deteriorate and her family doctor noticed an unpleasant smell during one of her visits, it led to the discovery of her persistent pressure sores. By the time she came into my office, she was hyperglycaemic, septic with infection as both pressure sores were wide and deep enough for me to put two fists in each. I could see her ischial bone at the base of one, and the rectum at the base of the other, and because she was incontinent from her spinal injury, the wounds were severely contaminated with faeces as she sat in the wheelchair in her soiled diapers. Understandably, both her and her husband were by now, agitated and frustrated with unhelpful medical staff and hospitals.

I admitted her into St X, because it was a large tertiary private hospital with all specialties on hand. She required an urgent endocrinology review, infectious disease input, a general surgical procedure to divert her faecal output via a temporary colostomy, dressings and pressure care. Needless to say, she started to improve within 7 days. She required intensive nursing care with four times a day dressing change (to prevent accumulation of pus that was continually exudating from the wound) and two hourly turns to prevent development of new pressure sores while she was bed bound.

Mrs Y, at the beginning of the week, cranky from feeling ill and hating being bed bound, was not the best compliant patient. She was a teacher after all and did not like being told what to do. She was also a little distrustful of the nursing staff as it was poor nursing care in ICU which resulted in her current problems. However, after seeing herself improve over a week, she became the most pleasant and grateful patient on the ward. She helped the staff by setting an alarm clock and turning herself so that all the nurses had to do was to pop their heads into her room and check that she was in a different position. She also changed her own colostomy bags so that the staff didn’t have to deal with this particularly unpleasant job. The nurses told me that they enjoyed looking after Mrs Y.

I was rather surprised that the MD had brought her up in our meeting.

MD: No no, nothing like that at all. (He cleared his throat awkwardly). Patients like Mrs Y, well, we find it hard to accommodate them in this hospital.

Me: I know, I know, spinal patients should really be in dedicated spinal units, but there are no private spinal facilities for these patients. Mrs Y has been paying her private health insurance for over 30 years, so she didn’t want to go to a public hospital; she wanted to be looked after in a private hospital.

MD: We understand that, but private health funds in general don’t pay us very much for looking after patients like her. She requires intensive nursing care so we actually don’t get any profit for such a heavy nursing load.

Me: (Speechless for a second) So, let me get this right. You don’t want patients like Mrs Y because her admission doesn’t generate enough profit for the hospital?

MD: I just wanted to make you aware of this, so that you will remember in the future not to bring patients like her into our hospital. We would prefer day surgery patients, but if you feel strongly about keeping them overnight, we are more than happy to accommodate that. As for Mrs Y, I believe you are planning to keep her in hospital for a while?

Me: Yes. At least 3 months.

Both Mrs Y and I had a long discussion about this. She had agreed to take a whole semester out of teaching and come into hospital to have her sores treated properly. This meant bed rest with appropriate pressure care, no sitting in her wheelchair and regular dressings. I had explained to her in depth that if we could make her overall health better, these sores may heal without intervention. If not, they may need an operation. However, even with an operation, she will need to be off the surgical wounds for 6 weeks before she could sit on them. She knew she was in for the long haul, because she didn’t just bring her suitcase when she checked into the hospital, she also brought her Nespresso machine. According to Mrs Y, 3 months was a long time to go without good coffee.

I watched the MD’s face cringe.

Me: I can’t rush the healing process, and I have to wait for the infection to settle.

MD: Maybe you can find a little operation for her so that we can get a little more money out of her health fund during her stay?

Me: But she doesn’t need an operation. She just needs dressings.

MD: We are probably going to lose money if she stays that long.

Me: Would you like me to transfer her to the public hospital? (The MD looked up at me with surprise and a glint of hope in his eyes). I could just say to Mrs Y that St X doesn’t want you here because they are unable to make a profit out of your stay. They think you should really be in a public hospital despite the fact you have paid your private health premiums for the last 30 years…..

MD: No, no. (He started to clear his throat again). There is no need for that. I suppose since we are a hospital affiliated with the church, we can show charity by letting her stay her for a while.

Me: Righto. Is that all? (I started to get up to leave).

MD: But, (he stopped me turning towards the door), if you do a few more of your cosmetic cases here at St X’s, it may compensate for her stay.

He stood up and reached out to shake my hand.

Me: Well, I cancelled two breast augmentations this afternoon because of this meeting. I have transferred them to my lists at another hospital tomorrow.

I ignored his hand, turned to open the door, and walked out of his office without a backward glance.

Mrs Y stayed for the full 3 months and went back to teaching full time, sitting in her wheelchair with a beautifully healed bottom.

 

Living in an Epidemic

When I was reading about the Ebola outbreak last night, I thought of my time in Taiwan during the SARS epidemic. So I went back to the diaries I kept during this time and found couple of interesting entries. I was there as a Fellow in one of the world famous plastic surgery units during 2003. A Fellow is a young doctor who travels to another hospital unit to train for a specified period as a ‘trainee’ doctor, usually to learn from a specific doctor or a particular procedure/technique.

I have left this entry unedited, as it is a true perspective of an Australian living in Taiwan during the SARS epidemic, both as a doctor and local resident.

25th Aug 2003

It’s been more than two months already since the first wave hit Taipei. I still remember the panic that hit the city during that first week; it was when they closed down Ho-Ping Hospital in central Taipei, with all its patients and staff isolated within the hospital. It was constantly being aired on the news and the hospital exterior was being videoed 24 hours a day, a bit like reality TV. There were scenes of flying badmington cocks over the railings of the balcony, and I remembered the presenter reporting that it was great to see that the occupants of the hospitals keeping up their spirits, and exercising to keep fit. The comments from my male colleagues in the TV room at the time were less than polite. I think something was mentioned about there are better things to do when you are couped up with a whole bunch of young nurses. *eye roll*

Then there were news of individuals who were to be isolated at their own homes because they’ve been in contact with SARS suffers. After which, news of non-compliant isolated individuals venturing out of their homes were reported with the police were called to herd them back home. They have now posted guards around quarantined buildings to stop residents from ‘escaping’. Cases were on the rise, another hospital got shut down, and the mortality is starting adding up.

I have missed my chance to go home. Four weeks ago our department director gathered all the overseas Fellows in his office to let us know that if we wanted to go home and leave the country, he would still be happy to write us a certificate for our fellowship and recommend us for jobs back home. There were 7 of us, two from Harvard in the US, 2 from Italy, 1 from UK and another from Ukraine. The Ukrainian and I stayed. It was really a blessing in disguise, because now, instead of elbowing other Fellows out of the way for an opportunity to do cases, we are both operating more than 12 hours a day. I joked to my concerned parents back home that I spend so much time in the operating theatre with its filtered and uni-direction airflow, I am probably at the lowest risk of getting any respiratory virus. They weren’t amused. Wherease my boyfriend just said that if I got SARS, he wasn’t coming to visit. I’d like to believe that’s anger and frustration talking. I can understand why he’s so pissed at me. I think I would be too if our positions were reversed.

The one thing I have discovered about living in this SARS epidemic is that there seem to be more pregnant women than usual at the moment. One nurse mentioned to me that since we have to take our temperatures every day as required for all hospital staff, she has finally managed to get pregnant during her last cycle as she knew her exact ovulation date. A fellow colleague also mentioned that you can pick the pregnant nurses during this epidemic, as they are usually the ones wearing an N95-grade mask. These are heavy duck-billed masks which have viral filters and are very hot and uncomfortable. Most staff members such as myself (who want to breathe and admittedly am a bit blasé about the whole thing) just wear the regular light ones.

Oh well. You’ve gotta learn to see the bright side of life when living in an Epidemic.

Administration has been harping on about wearing the right masks, but I seriously believe that if I wash my hands (which are raw from scrubbing all day), and keep away from sniffling, slobbering people, I’ll be fine. I have been avoiding public transport as much as possible. I have blistered on my feet because it takes me one hour each way, walking to and from work. After 8pm, I just sleep in one of the spare beds in the Burns Unit. I suppose I am like every other deluded doctor at the moment, we think we are being ‘adequately’ careful and probably invincible.

A thought just occurred to me. If I die in this epidemic, I won’t be able to hear ‘I told you so.’

Well, I guess if I am not back tomorrow, you know I am being ventilated in ICU with SARS.

 

 

Doctors are the worst patients

chestxrayphotobomb

There are plenty of reasons why doctors shouldn’t get sick. The best one being – we make the worst patients. I, of course, am no exception. Despite having had plenty of practice in the past of being a patient, somehow, I just don’t seem to learn. Every time I get sick, I am always a doctor, trying to be a patient.

So why are we such bad patients? Because we think we know better. We are the one saving lives, and sometimes we refuse to admit that we are the ones that need saving.

6 weeks ago, I caught a viral infection, not hard when you work with sick people all the time. I kept working, because as far as I was concerned, if I wasn’t intubated on a ventilator in intensive care, or in a casket, I was not sick enough to stop working.

Reason #1: We don’t realise how crap we really feel until we stop worrying about how crap everyone else feels. When you are deeply buried amongst blood and gore during an operation, you concentrate on what’s in front of you, rather than the tightness and clogging in your own lungs.

Two weeks later, instead of improving, I developed a hacking cough which sounded like I was trying to expel my lungs in piecemeal. As I was struggling for breath whilst talking to patients in my clinic, one of my colleagues suggested that I go and have a chest x-ray done. I did. I looked at it with my colleagues (bear in mind we are both plastic surgeons who rarely ever have to look at chest x-rays), we decided that my lungs looked normal, that I would live and carry on. However, just to be on the safe side, I texted a photo of my x-ray to my husband, who is a lung surgeon, and looks at chest x-rays every day.

Reason #2: For every doctor who self-diagnoses, there is an idiot patient.

I received a text from the husband. Go and see a real doctor. I shrugged it off, he was obviously happy to look at everyone else’s x-rays, but couldn’t spare two minutes looking at his own wife’s x-ray.

Reason #3: Sympathy is sparse when you are married to a fellow medico (and surrounded by friends who are doctors). You have to be showing signs of multi-organ failure before you get breakfast in bed.

I carried on with my afternoon operating list, during which, couple of times I had to sit down because I felt light headed from being short of breath. I felt tired, and was taking more care than normal, but the list went on smoothly without a hitch.

Reason #4: It takes a sledgehammer to slow  down a surgeon. Because we are so focused on our work, we often don’t realise we are pushing our bodies to the limit until we collapse in a heap.

I got home late that evening, at which point my husband looked at my bluish lips, my ashen complexion and yelled, ‘What the F$#@ are you doing at home? You should be in hospital.’ He pulled up the x-ray photo I texted him and shoved it into my face, ‘you have right upper and middle lobe pneumonia.’

Reason #5: When we self-diagnose, we either completely miss the obvious, or become total hypochondriacs with the worst over-diagnoses. In my case, it was the former. Also, note to self- I obviously am not qualified to read a chest x-ray.

I climbed into bed in my work clothes. I couldn’t think of anything more mortifying than going into hospital for a cold and cough. There was no way I was going into hospital for this. So exhausted was I that I fell asleep within 10 seconds.

Reason #6: We never think we are sick enough to seek medical attention.

The next day, as I was doing an early morning ward round, I ran into a friend/colleague who is a general physician. He took one look at me, frowned at the sound of my wheezing and coughing, and promptly declared that I needed to be admitted to hospital for treatment. I told him that I had a full clinic, and will have to check into hospital later that evening. He suggested that I get myself into hospital as soon as possible; I told him that I couldn’t cancel all my appointments and let my patients down at such short notice.

Reason #7: We think that the Earth would stop spinning without us, and that our patients couldn’t possibly survive without us.

The day was particularly long – like a train in slow motion. Several patients looked at me in concern and told me I didn’t look well. I asked my secretary to shift all my appointments and operating lists for the next few days, so I could be admitted into the hospital. Some patients were angry and upset, some complained that they are busy people and already had arrangements in place for their booked surgery. Apparently my illness was going to interfere with their plans. Some were worried that their treatment were delayed and felt that I was neglecting them.

Reason #8: Some of our patients think they couldn’t possibly survive without us.

So I checked myself into hospital that evening. I was put on oxygen, given nebulisers, antibiotics and tucked into bed to rest. It was only when I was forced to do nothing that I suddenly realised how terrible I felt. My chest felt tight, my ribs ached, and my body gave in to the continuous coughing that rattled my bones. My limbs were like jelly and my muscles barely contracted, behaving like useless slabs of soft meat patties. I couldn’t sleep as the call bells pealed throughout the night, sounds of doors opening and closing interrupted my light slumber, and occasional moans and yells from other patients made me toss and turn. The next morning, the physiotherapist spent half an hour bashing on my chest to clear up the clogging in my lungs. We then decided to venture out of the room for a walk, and that is when I saw one of my own patients walking down the corridor on her zimmer frame with her physiotherapist. I looked down at my pyjamas in shame and high-tailed it back into my room. I started thinking about leaving the hospital.

Reason #9: Even though as doctors, we spend the majority of our lives in a hospital, we actually really hate staying in one.

When my physician came to see me, I spoke to him about the possibility of having my treatment at home. He was able to adjust my antibiotics and decided that I could be discharged as a ‘hospital-in-the-home’ patient, where I will be going home with my IV cannula in place, and just come back to day hospital for my IV antibiotics, physio and nebulisers once a day.

Reason #10: A colleague will always assume that as doctors, we would be trust-worthy, compliant, sensible patients. WRONG.

As soon as I arrived at home, I headed to the study and switched on my laptop. I reviewed all my dictation and letters, chased up lab results of my patients and caught up on some bookkeeping for my practice. The day after I was discharged, I had a case which could not be cancelled, so I asked my anaesthetic colleague to remove my IV cannula so that I could scrub for surgery, then to replace it after surgery before I headed back into hospital for my treatment.

Reason #11: We know how the system works and we have connections. Doctors will always find a way to circumvent treatment regimes to suit their activities.

But as I sat there at the end of the day, with the IV antibiotics dripping into my veins, and the nebuliser oxygen mask on my face, I suddenly felt so tired. So tired of it all, of putting on a brave face, of carrying on as if nothing is wrong when I felt so unwell, of worrying about my patients when I should be concerned for my own health, and most of all, I was just simply tired. My bones ached from exhaustion, and my mind was so worn out, it was completely devoid of any emotions.

Mentally, I was waving a white flag. My body was shutting down because it had reached its limits, and it was time I surrendered to the consequences.

Reason #12: It is terrifying for doctors to admit that we, despite our abilities to help people and save lives, are just like everyone else, mere mortals, in bodies that have limits.

After four frustrating, agonising weeks, I am finally on the slow road to recovery. It is only now that I have started to contemplate changes in my life, ways of improving my health, and strategies of looking after myself. In a moment of déjà vu, I felt that I may have been down this path before. Regardless, I was, at last, being a sensible patient.

That is, until next time.

Stalker #2

stalker 2

It was the summer of 2008. I was driving to work one day, and my mobile phone rang. I answered it on my hands-free, thinking it was because I was running a little late for the ward round, and the nurses were being impatient. However, the sharp retort froze on my tongue when the caller introduced himself.

‘Hi Doc, it’s Bruce, I am the head of security at the hospital.’

Oh crap. They found out it was me who has been parking in the Director of Surgery’s spot on weekend call.

‘Could you give me call on this number when you arrive at the car park?’

Great, now they are going to make sure I don’t use anyone else’s reserved spots.

‘We need to escort you to and from the car park from now on. We have had to take out a restraining order against a patient of yours, and we have been assigned to ensure your safety.’

WTF?!?!

During my final rotation as the senior registrar in plastic surgery, I was often entrusted with difficult cases, or difficult patients. My boss at the time was the HOD (head of department). He was referred a patient from the cardiac surgery unit. It was an elderly 70-yar-old lady who had bypass surgery which unfortunately went pear shaped. She ended up in intensive care for a month with complication after complication. One of the consequences of her general comorbidities was break-down of her lower leg wound from where they harvested her veins for the bypass grafts. There was no sign of healing due to her poor general health.

When I saw her wound, I told the HOD that there was no way a skin graft would take. It was slimy with a biofilm of bacterial colonisation. The bed of the wound was completely white and scarred with no healing granulation tissue. It would be like laying turf on concrete. The HOD told me to take her to theatre and just lay a graft on it. He could tell that I didn’t agree by the silence that ensued.

‘I know the graft won’t take, Tiff, but we need to graft her. Her son is being difficult and demanding.’ At my raised eyebrow, he sighed. ‘I know, I know, it’s the wrong reason to operate, but he is making life hell for the cardiac team.’

I shrugged, documented his decision in the chart, spoke to the patient and booked her for theatre. 10 days after her surgery, the graft became sloughy, and the wound went yellow. Surprise, surprise, I thought, but I spoke to patient, explained why the graft didn’t take and she agreed that it was a long shot, but was very grateful I tried. We both agreed that more dressings were required. I didn’t give it any further thought.

Couple of days after that, I was caught up in an 8-hour case in the operating theatre, during which my pager kept going off. When I un-scrubbed from surgery, I noted that they were outside calls. I rang the switchboard, and they told me that there was a man who was very insistent on talking to me. I asked them if they knew who he was, they said he wouldn’t say. It was well past 7pm, so there was not much I could do, so I put it to the back of my mind and headed home. Then, my mobile phone rang whilst I was driving home that night, I thought about not answering it as I was about to enter the under-river tunnel, where I would lose mobile phone signal. However, the number showed that it was the hospital, so I picked it up.

‘Hi Doctor, I have one of your friends on the line looking for you.’

I rolled my eyes, must be one of my colleagues who wanted me to pick them up for work tomorrow. ‘Sure, put them through.’

‘Hello?’

‘Are you Doctor Tiffany?’

Something in his voice got my attention. It was not a voice I recognised. ‘Yes, it’s me. Who am I speaking to?’

‘You did an operation on my mother couple of weeks ago, and it was a complete failure. Now she has an infection in her leg, what did you do to her?’ He was yelling down the phone.

Initially, I was too shocked to reply. I remember vividly listening to the agitated heavy breathing that reverberated over the phone during the silence.

‘I am sorry, I am not sure who you are referring to, could you tell me who you are and your mother’s name please?’

Unfortunately that just earned me another blasting. ‘How can you not remember who you’ve operated on? What kind of doctor are you? My mother is…… you….. not good…… bad….find you…..’

There was no point. I was now in the tunnel and the signal was cutting in and out, which eventually cut off completely. I sighed. That was probably going to make matters worse now because he would probably think I had hung up on him.

When I exited the tunnel, I rang the hospital and spoke to the switchboard lady that connected me before. I asked her who he was, and whether there was any way I could get in contact with him, the switchboard lady sounded surprised and said, ‘but doctor, he said he was one of your really good friends and wanted to be put through to your mobile immediately because he was running late for a dinner you were both going to.’ I had to tell her that it wasn’t a friend but a patient’s relative. She apologised profusely. I had to point out to her the fact that if he really was my friend whom I was meeting for dinner, he would have had my number without having to go through her.

There was nothing I could do, and he never rung back.

It was two days after that, when I got the phone call from security. So I dutifully called them when I arrived at the car park. Within seconds, as if they were already waiting for me there, two men in uniform materialised around my car and walked me to ward. They reminded me to call security when I leave for the day.

When I arrived on the ward, sudden silence ensued. My residents looked at me with fear, and the nurses were whispering. I was just about to ask them what was going on when the HOD came out of his office. A look of relief passed his face when he saw me.

‘Tiff,’ he smile. Now, that was something rare, my HOD did not have ‘smiling’ as one of his usual repertoire of facial expressions. The look on my face must have been one of complete confusion, because he took my arm and literally dragged me along with him. At 5’3 to his 6’2, I had to run to keep up with him. ‘We are going down to see the Head of Security.’

So, at 7.30am, I found myself sitting in a small room in the hospital basement, opposite a large bald man in security uniform. He was leaning on his desk which appeared tiny under his bulging biceps. Loose paper littered the surface of the desk, some of which overspilled onto the floor around his chair.

Bruce the Biceps nodded at my HOD as if to ask him to start. I turned and looked at him. He cleared his throat and uncrossed his legs. ‘You remember Mrs Y?’ I nodded, he was referring to the lady from Cardiac Surgery whom I grafted nearly two weeks ago. ‘You remember how I told you his son was being difficult?’ I frowned, because I only very vaguely remembered anything other than clinical stuff from our conversation. ‘Well, apparently, he was told by his mother that the graft didn’t take, and then the nursing staff got her mixed up with another patient, and told him that the leg was badly infected.’ He paused. ‘Apparently he created a scene on the ward couple of days ago, and demanded to see the surgeon. The nurses told him that it was not possible as the surgeon was operating. During lunch break, he snuck behind the nursing station and was caught reading her chart by one of the nursing staff. He got your name from the operating notes. ‘

Mr Biceps nodded ‘he then pestered the switchboard all day to be put through to you, but they said that they could only page you. None of those pages were answered.’

I sat up, ‘But I was….’

‘Operating, I know.’ Mr Biceps reached over the table and patted my shoulder, ‘Switchboard also told me that he managed to get through to you on mobile phone late that night?’

I nodded and told him my story. He grimaced. ‘I really should re-do that protocol on phone safety.’

‘Anyway,’ my HOD said, obviously uncomfortable with the whole situation, ‘Apparently yesterday, he turned up on the ward again, demanding to see you. The nurses told him that you weren’t in the hospital for the day, he left the ward.’ He threw his hands in the air in frustration, as we both knew I was at work yesterday, ‘I don’t know, maybe they were trying to get rid of him. He then rung switchboard and asked which hospital you were working at. Switchboard was reading off the old roster and told him that you were at St M’s.’

‘But that was my last rotation,’ I said.

‘Yes,’ Mr Biceps nodded, ‘but he was just following the information he was given, so he drove over to St M’s, went to their front desk and demanded to know where you were. Their receptionist told him that you didn’t work there anymore and has been transferred here.’

‘Geez,’ I rolled my eyes, ‘the guy must have thought he was given the run around. The phone calls, then the hospitals…..’ I grimaced, ‘if he wasn’t pissed off before all this, he would have been livid by now.’

‘Uh, huh.’ Mr Biceps agreed, ‘and that’s when he lost his sh…. marbles. He accused everyone of trying to protect you, and that you were hiding from him because you were guilty of trying to kill his mother. He then threatened to shoot you.’

That got my attention. ‘He what?!?’

‘That’s when the front desk at St M’s called security,’ he heaved a sigh, ‘They should have held him, instead, the num nuts over at St M’s told him to leave and not come back. They didn’t even get his name. Then they called me.’ Mr Biceps shook his head. ‘It took me a whole day to work out who he was; I had to make phone calls to the ward, to switchboard and to your boss here.’

He looked at me sternly, ‘I don’t take death threats to our staff here lightly, so I called the police.’

‘So they have arrested him?’

‘Hush,’ my HOD patted my arm, ‘listen to him, there’s more.’

‘The police looked him up on their system, and realised that he had a gun licence.’ He and I both knew that gun licenses were hard to get in Australia, but it didn’t necessarily mean the person owned any firearms. He took a deep breath, ‘and he had half a dozen firearms registered under his licence.’

  1. Now not only did I have a loony after me, but a loony with guns.

‘But the law states that if anyone with a licence or firearms threatens anyone with witnesses, they can confiscate his licence and firearms,’ I said. My boss looked at me in surprise, he didn’t realise I taught Gun Safety courses.

He nodded. ‘Yes, so the police went to his house, cancelled his gun licence and confiscated his firearms,’ he paused, ‘but they also found a few extra unregistered firearms in the same cabinet.’ He then looked at me with a concerned expression, ‘Because they didn’t have a search warrant, they couldn’t look for any others.’

‘Wow, this is getting better and better,’ I said. My boss winced at my sacarsm.

‘They arrested him, but couldn’t hold him. They could only slap him with a fine for the unregistered firearms.’ Mr Biceps scratched his bald head in frustration. ‘So I asked them what they were going to do about your safety, since he may have other firearms which we don’t know about. They have applied for a search warrant and we have applied for a restraining order against him. I was told both of these should come through today.’

‘So,’ my HOD said, ‘he will not be allowed within 200m of the hospital. I don’t want you to go anywhere near that ward she’s on, I will assign another registrar to look after those patients.’

‘And you must be accompanied to and from the car park every day,’ Mr Biceps added. ‘We can’t afford to have any safety issues here at the hospital.’

‘That’s all great,’ I said, ‘but what happens when I am not at work?’

They looked at each other blankly.

My HOD recovered first, ‘he won’t be allowed within 200m of you either.’

Which was all sweet, but I wondered how either of us would know if we were within 200m of each other, since we had never met, and had no idea what the other looked like.

Lucky for me I never found out, because four days later, he was caught sneaking into the ward to see his mother and punched a staff member when he was being forcibly removed. They found a shotgun in his utility truck parked in the hospital car-park. He was arrested and kept in custody without bail. His mother was then discharged from hospital a week after that.

And I thought the highest rate of homicides for plastic surgeons are male patients unhappy with their nose-jobs. Funny how they have stats on that.

 

To Read about Stalker #1, click here.

Old Shakey

Doogie Howser2

People write passionately about discrimination in Medicine: sexism, racism and even fattism (yes, there is such a word, I checked). Today, I want to talk about Ageism.

Ageism = Prejudice or discrimination on the grounds of a person’s age. (Oxford Dictionary)

Like all forms of discrimination, it goes both ways. There is ageism from the doctors to the patient, and then there is ageism from the patient to the doctors. The latter is the cause of my ongoing angst.

When am I going to see the real doctor?

This is actually something I get on a regular basis, usually after spending 45 minutes with them, taking a history, examining, diagnosing and explaining their treatment options. I suppose I should really consider it as a compliment. I do know I look young for my age. I know I don’t look like I am about to turn 40 (*sigh*). This can be attributed to both my ethnic background, but also to the fact that I don’t smoker nor spend much time in the sun (I do, however, sport a very unattractive sallow chronic ‘fluorescent tan’.) Yes, I do look after myself, but despite being a plastic surgeon, I have yet found a colleague trusty-worthy enough to stick needles or scalpels in me, and I am definitely too chicken to do it to myself in front of the mirror (unlike some of my colleagues – *winkwink nudgenudge*). So, no, my youthful appearance is not chemically or surgically enhanced, all I can blame it on is my genes.

So, why, you ask, am I complaining about looking young? Well, here’s a list of reasons why my age-inappropriate appearance doesn’t exactly make my job easier.

I don’t mind having someone young for the cough and colds, but can I please have someone older for the serious stuff?

I am not having someone fresh out of medical school operating on me.

You are too young to understand my problems

I need someone who are older and know what they are doing.

You look younger than my granddaughter, how old are you?

I am not being judgemental, but you are too young, I want someone who’s competent.

I have a very complex problem, I need someone with a little bit more experience.

The standards for the young graduates nowadays are not like the good old days, I want an older doctor who has been through the real training.

I want a doctor who is at least my age.

Now, what in the world makes you think you have the right to ask for my age? You are saying it isn’t being judgemental. But it is. You are judging my capabilities as a doctor by my age.

These patients feel that because of my age, I lack experience and should only treat the ‘easy’ stuff. There are two incorrect assumptions here. Firstly, the inferred ‘lack of experience’ by my age. Most people don’t realise that to become surgeon, one has to finish medical school, gain basic medical experience working as a junior doctor before being selected via a rigorous process to become a trainee in surgery. The surgical training program can range from 3 to 7 years, depending on the actual specialty, any sub-specialisation training within that specialty, and any additional overseas training to gain a wider perspective. At the end of which, one has to go through a series of very stringent assessments before a specialist qualification can be granted. I was at least 10 years out of medical school before I became a fully-qualified specialist surgeon. All I can say is, if 10 years of working and training (and not forgetting the 6 years of medical school before that) doesn’t constitute ‘enough experience’, and my qualification ain’t worth shit to you, then go ahead and set your own definition of ‘experience’.

Secondly, the patient’s assumption what ailments are ‘easy’ to treat and what aren’t, may not exactly correlate to true clinical relevance. A cough and cold may be easy to treat, but it may also be a manifestation of something more sinister. I would never presume a cough and cold as exactly that – I am a plastic surgeon after all – I always refer the patient back to their Family Doctor, as that is something those doctors would have more knowledge of. Patients who infer that they know what is ‘easy’ and what is not, show not only a total lack of awareness for the complexity of medicine, but also their disrespect for their doctor’s judgement. What may appear to be ‘easy’ may just be a harbinger for an underlying problem which is very difficult to treat, or it may just be the tip of the iceberg where surgical complexity is concerned. One of the most critical aspect during our training is to be able to recognise when we are out of our depth. If your doctor admits to needing a second opinion or assistance of another specialist, you should be grateful that you have found someone who will not take risks with your health.

People think that lack of ‘life-experience’ due to age is a deterrent to being a good doctor who could understand the issues of the ‘older’ population. This myth is easily busted when I look around at my colleagues. Which one of us isn’t jaded by what we have seen during our careers? We have seen it all. Birth, Life, Death, Disability, Misfortune, Pain, Suffering, Drug Use, Crimes, Abuse, Deviants, Perverts, the Insane, Murderers, Liars, Malingerers, Sadness, Grief, Anger, the list goes on. Some of the things we see and the frequency in which we see them, gives us multiple life-times of the so-called ‘life-experiences’. Sure, we may not have experienced any of these ourselves personally, but sometimes watching somebody we care for going through it and feeling utterly helpless can be just as real to us as the person who is experiencing it. Many of us view some of our patient’s misfortune as personal failures, and they take their toll on our own mentality.

Each specialty also has their demographic of patients; to assume that we have no inkling to a patient’s particular age-related issues is really quite ignorant. Most of my patients with skin cancers are elderly; I understand they may have issues getting to and from hospitals, care at home and simple matters such as attending appointments for dressings. We organise nursing home-visits for their dressings, and sometimes, arrange suitable surgery dates so that their family can take time off work to care for them. Most of my breast cancer patients have young children. We fit their appointments around school pick-ups and their surgeries out of school holidays so they can spend as much with their children as possible. Doctors are not unaware of our patient’s personal situations; we are not blind to possible social issues surrounding health problems. We, ourselves, have elderly parents, young nieces and nephews, friends outside of medicine and older/younger siblings. Often when we meet new patients, if they are not of similar age or demographics as ourselves, we can still relate them as one of our own relatives or friends.

So you think we don’t have enough ‘life-experiences’? Well, tell me, have you ever had to listen to a mother’s heart-breaking sobs in the middle of the night while she is sitting next to her dying 3-year-old baby? Have you ever had to spend two hours stitching up a battered wife’s mangled face and then watch her leave with her husband because she refused to report him despite your best efforts in counselling her? Have you ever stood in a room, watching a whole family saying goodbye to a man dying, while you are busily pumping him full of morphine because you know there’s nothing else you could do for him? Have you carefully removed a brain tumour from a patient who only hours before, had a psychotic episode and scratched, punched and spat at you? I could go on, but did you just say you were abused as a child? I have lost count of the number of child-abuse victims I have seen, but I understand everyone’s story is different. A different variation of the same……

Education has changed dramatically over the years, and this has definitely influenced Medical Schools. Standards are different, and they are different for a reason. The emphasis in medical training has changed, from purely scientific rote-learning to a more holistic clinical approach. Yes, I may have bitched and moaned about some of these changes as a teacher, but I can see why these changes needed to happen. To be honest, I don’t envy the students and trainees nowadays, an explosion in medical knowledge and technology over the last two decades has added a phenomenal amount into their core curriculum. Some of which I have yet to catch up with because it bears no relevance to my current sub-specialty. When I attended medical school, notes were written on paper, lab results were given over dial phones (yep, I am that ancient), X-rays were on films and put up on light-boxes, blood pressures were taken manually, pulses were counted with a pocket watch, surgical drills and saws were hand driven (not powered by electricity or gas). Back then, the list of diseases I needed to exclude for any presentation could be written on half a page, the number of tests I needed to do could be counted one hand and the number of ways I could treat it could barely fill a chapter in a textbook. Things are so different now, possibilities in Medicine are endless. Medical education nowadays place importance on basic core knowledge so that a graduate is not expected to know everything, but rather, to be able to pick out and apply relevant components of their knowledge to clinical situations. Most importantly, they need to know how to approach the problems and where to source the information they require. The point of today’s schooling is to generate a doctor that thinks, rather than one that relies on a checklist. So give your young doctor a chance, you might be surprised, he/she may think of another approach to your chronic problem. Something that is different to the same old thing which hasn’t been working for you.

We all know that we are getting old when we think everyone else is looking younger, especially when we see our pilots boarding the same plane we are travelling on. Commercial pilots start their careers in their late 20’s and to a lot of us think they are just kids, really. They are responsible for hundreds of lives for hours, but their age does not reflect their capabilities in getting all of us to the correct destination, safely. Why? Because of their qualifications. No airline would put a pilot at the helm of a plane unless he/she has passed all the requirements and assessments, whether they are young or old. In fact, once the pilots have reached a certain age, they have to be re-assessed for their ‘fitness’ to fly.

Some patients actually admitted to coming to me because their previous surgeon was getting old and I looked young (if only they knew!). Some do so in the hope that I have more up-to-date knowledge on new techniques, new technology or new approaches to their chronic problem. Some change surgeons because they have become concerned as their previous surgeons are deemed to be ‘too old’ to still be operating (ageism in the opposite spectrum), whilst some disliked the more paternalistic approach and ‘old-school’ attitude of their previous older surgeons.

Some older surgeons nearing their retirement have insight into their decreasing capabilities. Their eyes aren’t as sharp anymore, their hands have started to tremor, or they are now on several heart medications and struggle to cope with long cases. They cut down on the number of cases they take on as well as limit the type of operations they do. Many become surgical assistants to their younger counterparts. When I first started, I had one of the retiring Professors of Surgery as my regular assistant. It took a long time for me to adjust to giving him orders and correcting him when he is not doing something right. The nursing staff used to giggle when I would say, ‘Would you mind sewing that drain in for me, Sir?’ But it was a very happy arrangement. Prof could still get his hands dirty without the stresses and responsibilities of a surgeon, at the same time, I had instant access to any advice I needed. Not to mention the stories he used to tell as we were operating, those were gems to learn from. He would always tell me that he was not there to judge my competence, but to be my assistant for procedures I was more than capable of doing on my own.

So next time you meet a young doctor, don’t ask them how old they are, ask them what their qualifications are. And if they are just learning, give them the benefit of the doubt, because you could contribute so much to their education and experience by sharing yours with them. You never know, when your doctor retires, and when you are much older, they will be the ones in their prime, in charge of your health.

So you still want a doctor who is at least your age? Ok then, why don’t you go down the corridor and see Old Shakey next door?
Doogie Howser

* Disclaimer: Please do not take this blog as a disrespectful post to generations of surgeons before myself; I fully acknowledge the fact that their expertise could not be surpassed by myself. I am deeply appreciative of their willingness to share with me all that they know, as well as their unfailing support to me as a fellow surgeon, despite my age.