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.

Pranks in a Hospital

Pranks at work take on a whole different level when one works in the health industry. I think I could have made some substantial claims from worker’s compensation as a result of the permanent psychological consequences of all the pranks that I have had to endure during my epic climb from a medical student to a specialist. Some were particularly memorable….

When I was a final year medical student, I was known as the ‘yes’ girl. I was one of those bushy-tailed, bright-eyed eager beaver who would do anything that I was asked to do by the medical team I was attached to. One evening, the senior resident on the team told me to go and check on a patient in Room 14 as the patient has had fainting episodes during the day. I was so chuffed thinking that my team trusted my judgement enough to give me such a responsible task, that I almost skipped down the corridor. I knocked on the door of Room 14, and there was no answer. I pushed the door open quietly and peeked. The room was dark and the patient was asleep. I headed back to the main desk and told the resident that the patient was asleep. He frowned at me and asked if I actually touched or saw the patient, I said no. He then asked me how I could tell the patient was actually alive under the blanket. ‘Go and wake her up so you can examine her.’

I felt so stupid that I hung my head in shame as I walked back down the corridor. I pushed the door open and approached the bed. I didn’t want to wake the patient up rudely by turning on the light, so I gently reached for her shoulder to shake her awake. Her pyjamas felt cool as I touched it and there was no response. So I grabbed the blanket and folded it back to wake her up properly. The minute the blankets were drawn back, the whole person flew/bunced/jumped out of bed and smacked me in the head. Apparently my scream was so loud on the ward, the nurses raced down the corridor with the resuscitation trolley. Not to mention some of the patient also wandered out of their room and followed in curiosity.

When the lights of Room 14 was switched on, there I was, on the ground, frantically batting away at the blow-up doll on top of me. My senior resident was laughing uncontrollably in the corner, and the head nurse stood over the side of the bed, shaking her head. Sniggers and giggles broke out in the crowd that gatherd in the doorway by the time I realised that I was not being attacked by a patient. All I could do, was to put the doll aside, give my senior resident a deathly stare and walk out of the room with whatever dignity I could gather. It was the first and final time I cried from a prank, because after that experience, I learnt that non-malicious pranks were actually a form of endearment bestowed upon favourite junior staff members by some of the senior staff.

However, that particular senior resident was apparently also very popular, because he was found ‘accidentally’ locked in the laundry cabinet three weeks later; it took 2 hours for hospital security to come and break the lock because someone had ‘lost’ the key.

My first job as an intern was on the gastroenterology and renal medicine ward, as part of the kidney/liver transplant team. On my first day, I was super excited because there was a kidney transplant to be done, and I was asked by the professor to help out in the operating theatre as they were short of surgeons.  The morning started with an introduction to all the nursing and allied health staff on the ward, then a ward round was done with the professor so I could get to know the patients. He and the other doctors headed down to start their big case, and I was told to follow once I have finished the paperwork from the round. The head nurse made me a coffee as I sat in the office, and told me that it was a welcome gesture from her and the other nurses. I thought that it was an awesome start to my career – everyone on the ward was friendly, and I was going to assist in a kidney transplant on my first day!

I was wrong. It was the most miserable day of my life. Little did I know that the ‘welcome’ gesture contained more than just Nescafe granules. The nurses added some PicoPrep (the stuff patients have to drink before their colonoscopy so that their bowels can be cleared out). Needless to say, during the kidney transplant two hours later, I had to excuse myself and unscrub 5 time within two hours. I tried so hard to hold it in that I had to change my pants three times because I didn’t make it to the bathoom.

By the end of the day, I was dehydrated, shaking with cold sweats running down my face while painstakingly suturing my first surgical wound. Commando.

Yep, no underwear, just in my scrub gear.

diarrhoea

My second job as an intern was in the Emergency Department. This particular ED I worked in was attached to the State Mortuary. So, one of our jobs a ED doctors, was to check, examine and certify the bodies brought in by the police so that appropriate paperworks can be completed to issue a death certificate before the they take it down to the morgue.  Majority of the time, all that was required was a brief look at the history handed to us by the police, a quick zip open of the bag in the boot of the police van, check of the carotid pulse over pasty-white neck skin and couple of signatures on a clipboard.

One day, there was a lull in the usual steady stream of patients.  Two police officers walked in. The senior doctor waved at them and offered to do the certification. The officers grinned and stopped him from heading out the door. ‘Is it a freshie?’ The doctor asked. They shared a smile. The senior doctor turned to the doctor’s area, ‘Who’s the most junior here?’ I put my hand up. He motioned me over. ‘Can you do me a big favour?’ He lowered his voice to a serious tone, It’s very important.’ I nodded eagerly. He pointed to the officers standing at the door. ‘Follow these two officers, there’s a body in their van that need a certificate.’

I puffed up with self-importance and swaggered outside with the two officers behind me. I should have known even before they opened up the door, but I thought the smell was just the usual bad sewage issues we have always had in the driveway drains. I was even more of an idiot not to stop when a swarm of flies escaped as soon as the van doors were open. Instead of doing what any sensible doctor would do – which is just to open a little bit of the bag, see some evidence of rotting flesh and close the zip quickly – I unzipped the whole bag, and tried to put my hand on the maggot infested neck to check for a pulse. It totally escaped my mind that since the guts were all hanging out in pieces, (obviously exploded from the build up of gas – courtesy of a week’s worth of fermentation), and the eyes were large nests of crawling maggots, not the mention the stench that permeated my whole being which made me want to run as far as I could in the opposite direction, were evidence that the patient is definitely DEAD. Yet I needed to feel his pulse to confirm that he was dead?! The officers were covering their noses with their hands and rolling their eyes at me. Really?? They seemed to say to me, Did you really have to open the whole bag and stick your finger into his neck?  Who found this silly little intern? She ain’t no Sherlock Holmes when it came to dead bodies.

When I grew up to become a surgical trainee, the antics continued in the operating theatres. I never realised how vulnerable a surgeon was when they were scrubbed, until the pranks started. Because the wound and equipment has to be kept sterile, once we are scrubbed, we cannot touch anything that is not sterile. For example, if someone punched me in the face when I  am scrubbed, it’s not like I can just punch them back, since they are not sterile. If I did, I would contaminate my surgical field and will have to take everything off and scrub all over again.

One of the worse things about being scrubbed is not being able to answer the phone. It is very often that our mobile phones go unanswered during surgery. Once in a while, if the nurse or anaesthetist is free and feel kind (as they hate being lowered to the status of the phone-answerer), they will take a message for the surgeon.

Once my senior surgeon was sitting in the operating theatre watching me operate when my phone went off next to him on the bench. He glanced down and said, ‘it’s your husband.’ I shrugged and turned around to say that it’s ok to just leave it unanswered.

But I was too late, my senior surgeon had already answered the call, ‘Hello.’

I called out, ‘just tell him I am scrubbed. I will call him later.’

He ignored me and spoke into the phone. ‘Sorry, she can’t come to the phone at the moment.’  A pause. ‘No, she’s not scrubbed. She’s busy doing a lap dance.’ A dramatic sigh. ‘In my lap, of course. And she’s very good at it too.’ He cleared his throat and held the phone away from his ear when a barrage of words came through the earpiece. ‘Look, why don’t you ring back later when she’s not busy. I can’t concentrate enough to take a message at the moment.’ He promptly hung up.

At my appalled look, he flashed me an evil smile and said, ‘Well, that will keep his mind busy for a while.’  For the rest of my term with him, whenever I saw his phone sitting on the bench next to mine, I considered ringing his wife. Luckily I refrained, because a few months after I moved onto the next team, I found out that he had left his wife for a young physiotherapist whom he was having an affair with.

When I was a surgical trainee, I was an easy target for the anaesthetists, especially the senior ones. They often told me that I was too serious and needed to lighten up. They wanted me to be different to the arrogant surgeons who couldn’t take a joke, or snap at anyone who tried to make fun of them. I worked hard during my training and spent more hours in the operating theatres than any other trainee in my service, so it was no surprise that I became fair game to all my anaesthetic and nursing colleagues.

Once I was performing a traumatic laparotomy, repairing bowel in a penetrating abdominal injury. There were lots of blood and my junior resident and I had our hands full trying to stop intrabdominal bleeding. It was unpleasant as his abdomen was also full of faeces as the bowel was lacerate in several locations. At one stage, some of the wash fluid, blood and poo were spilling over the sides of the operating table and I remember thinking that my surgical boots will definitely need a wash after work. Half way through the operation. I realised that my feet felt rather…. damp. I shuddered as I realised that most likely some of the crap has gotten in from the top of the boots (as I stupidly tucked my pants into them), and that I was probably standing and squelching in blood and poo. I wiggled my toes and felt my soggy socks slosh freely in fluid.

It was then I noticed giggling coming from behind the drapes at the head of the table (where the anaesthetic staff usually hide). I looked up at them suspicious, then I looked down. There in my boots were two intravenous lines, connected to two bags of saline, and there was water spilling over the top edge of my boots.  My feet were drenched in bucket-full boots. Honestly, you guys have the mentality of 5 year-olds, I said in exasperation. They kept laughing, like children laughing at fart jokes.

One night, we were putting some fingers back on. This can take up to 12-18 hours depending on the number of fingers we needed to reattach. Unfortunately I had to reattach four, which meant it was going to be a very long night. The anaeasthetic consultant came up to me and asked me how long it was going to take. I shrugged and said as long as I needed.  He then waited until I was scrubbed and sat myself down at the operating table. He then crouched under the hand table, and attached small neurostimulator pads on my calf. These are often used on patients while they are asleep, a shock is delivered through these pads into the patient, and cause a small electric shock, siginifcant enough to generate muscle contracture directly under the pads. This tests the muscular tension of unconscious patients to determine how relaxed and deep in sleep they are under anaesthesia. Well, In this particular instance, they were not on the patient – I found them on both of my calves instead.

He then retreated back to his position next to the anaesthetic machine and held up the remote control for the neurostimulator. With a slightly evil look on his face, he announced to everyone. ‘I will turn this on once every hour, just so you know how long you are taking.’

Trust me, if anyone was asleep in my operating theatre while I was pulling this all-nighter surgery, they were promptly woken up every hour with loud obscenities. I tend to get lost in time when I operate and the hourly reminder were coming faster than I expected, and each time, I would be caught unaware by the sudden jolt and contraction of my calf muscles.  These episodes were loudly accompanied by a physical jolt, yell of shock and swearing, repeatedly, in that order. It was only 12 hours later, when I finished the surgery that he told me he was actually giving me a shock at random, basically when he got bored.

To top it off, I didn’t realised that he and the nurses were in cahoots with each other. During the surgery, he apparently rang my mobile phone. I forgot to take it out of my pockets in my scrub pants before I scrubbed, so it was ringing away under my gown whilst I was trying to concentrate. The nurse offered to take it out of my pocket to answer it. I turned around in my chair and she fumbled under my sterile gown and shirt to grab my phone. Obviously, it was too late to answer the phone and she told me that it was a silent number, so I left it at that.

What I didn’t realise, was that the whole exercise was so that she could untied my scrub pants. So, as I stood up for the first time after sitting at the table for 12 hours, my pants fell down to my ankles. Lucky I was wearing my undies that day.

Of course, now that I am all grown up as a fully-qualified specialist, I am proof that good students emulate their teachers – and trust me, I learnt from the best. Although in today’s climate of political correctness, some pranks can be taken the wrong way and one must be very careful with the selection of target victim. But I am a true disciple of my forebearers and my pranks are legendary. After all, a sense of humour can be the life-saver in times of desolating fatigue, despair and desperation. I firmly believe that learning to laugh at ourselves is the key for humiliy and perspective. I have learnt, however, that you have to expect to get as good as you give.