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.

Doctors are the worst patients

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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.

Old Shakey

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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.

 

 

Diagnosis: I Don’t Give a S#@% about myself

One of the most frustrating things I encounter at work is trying to help people who doesn’t want to help themselves.

Here are the 10 top clinical signs (for the novice):

1. The beautifully tanned patient who is sunburnt all over, (looking like he/she has just spent their weekend on the beach), and is about to go into the operating theatre to have a melanoma excised.

2. An obsession with blenders. The lap band is tight to maximise weight loss, the patient is supposed to be on a portioned healthy vitamised liquid diet. Instead, he lives on a  ‘vitamised diet’ of Big Mac and French Fries, liquified via a blender. ‘I just don’t understand why I am not losing weight…

3. The dangerous oxygen tank. The patient who just had 1/2 of his right lung removed for cancer – so now he is dependent on oxygen – lighting up a cigarette in the hospital courtyard. Taking a drag on their cigarette in between inhaling a whiff of oxygen from their mask. Honestly – if you want to kill yourself, that’s ok, but to blow up the hospital???

4. An X-ray that shows a new fresh hand fracture through plates and screws over an old fracture. Excuse: ‘Well, punching my fridge is better than punch my Dad in the face, rght?’

5. The MIA patient. The patient was called for the operating room, but he couldn’t be found anywhere. Because he was outside for his ‘last smoke’ before having half f his lip removed for  lip cancer. ‘You only told me that I couldn’t eat or drink before my anaesthetic, you didn’t say I couldn’t smoke.’

6. Patients with bags of ‘unfilled’ medication scripts. One is really unsure as whether these patient don’t take their prescribed medications (for their heart disease, cholesterol, diabetes, infections etc), because they can’t be bothered, they don’t want to or they just ‘don’t believe in taking medications.’

7. DNA’s (did not attend). Patients who have appointments for their cancers to be assessed and removed do not turn up to their appointments despite multiple phone calls, or simply, they have important work-commitments or holidays and need to move their appointment to 6 months later when things are quiet (and the cancer will be inoperable.)

8. The broken plaster on a broken arm. Sometimes, the non-existent plaster on a broken arm. ‘I know my arm is broken, but it got so itchy I had to take the plaster off’.

9. The gigantic fungating cancers. It takes time for cancers to grow. When I see a very very large cancer, I wonder why patients don’t come in when it was the size of a coin. Once I had a patient with a skin cancer on his chest. It was the size of a dinner plate, and it had already eaten into his breast bone. I asked him why he left it until now to come, he said that he only came in because it was growing into his neck and he couldn’t hide it behind his business shirt and tie at work anymore. Did he know it was a cancer? Yes, but he was too busy at work to take time off for an operation.

10. The smoker with a cigarette dangling out of his neck. The throat cancer patient who had his throat removed now has to breathe out of his tracheostomy. He was found lighting up with a cigarette taped to his tracheostomy. A short-cut highway of delivering poisons directly into his lungs. Well, I guess he won’t get oral cancers from smoking this way.

The Differential Diagnoses:
1. I have a severe case of NFI (No F&%$* Idea)
2. I am so f$%#@ scared that I’d rather bury my head in the sand
3. My health is my doctor’s responsibility because that’s their job to fix it

But sometimes we just have to face the harsh diagnosis of: I don’t Give a Shit about Myself.

 

Things you shouldn’t say to your surgeon before your operation

I have had a very long tough day of operating, so please allow me some self-indulgence in writing this blog. I sincerely apologise in advance for the sarcasm and disillusioned humour to follow!

The last thing anyone wants is an annoyed surgeon operating on them. I mean, would you be obnoxious to your chef or the waiter that is serving you? (We all know they will spit in your food) Would you be an ass to your dentist just before he/she picks up the dental drill? So why, oh why, would someone piss their surgeon off just before being wheeled into the operating room?

‘I have been waiting for 2 hours since 8 o’clock.’

My answer: ‘Oh, that’s great, you arrived nice and early so you are now all ready to go in.’

What I really want to say: ‘Sorry, I just finished my 2-hour champagne breakfast, hic.’ or ‘Are you in a rush to go somewhere after your operation?’ or ‘I’d better go faster during your operation then, so you can get home sooner.’

‘Are you sure you have done this before?’

My answer: ‘More times than I can count, you will be ok.’

What I really want to say: ‘No, but there’s always a first.’ or ‘No, but I watched it on You-Tube last night, and I think I got the general idea.’ or ‘Yes, when I was a medical student, on a pig in the lab.’

‘How come this operation costs so much?’

My answer: ‘Because it is a major operation, it takes a lot of time and expertise to do.’

What I really want to say: ‘Because you have come to a surgeon, not the local butcher.’ or ‘You are free to shop around, maybe it will be cheaper if you get it done over the internet.’ or ‘I don’t do surgery because I love helping people, I do it for the money.’

‘Would I have a scar? Will it be ugly?’

My answer: ‘Yes, you will have a scar, just as we discussed before. It will fade.’

What I really want to say: ‘Of course you will have a scar, moron, you are going to be cut open and I may be good, but I can’t perform miracles.’ or ‘No, you won’t have a scar, because I do it all by telepathy.’ or ‘Yes and Yes.’

‘Please do a good job and don’t kill me.’

My answer: ‘Don’t worry, we will do our best to look after you.’

What I really want to say: ‘Ok, for once I won’t make a mess of it, but have you signed a will yet? You know, just in case.’ or ‘Do I get a bonus if you get to live through this?’ or ‘You are expecting too much from me, I don’t think I can handle it.’

‘If the operation doesn’t turn out to be what I wanted, can I get a refund?’

My answer: ‘No, but if that’s the case, I will do my best to give you a result you are after.’

What I really want to say: ‘Sure, if you want a refund, we will have to put the cancer back too.’ or ‘No, because I can’t take the implants out of your boobs when you’ve changed your mind and use it for someone else.’ or ‘No, because I have never learnt how to undo a facelift.’

‘Have you been working all day? Are you too tired to do my operation? Can you please pay attention when you are doing it?’

My answer: ‘This is a normal working day for me, I am fine and you will be fine too.’

What I really want to say: ‘I will be fine. My hands will be steadier once I have had a drink.’ or ‘Don’t worry, watching the tennis on my laptop during your operation will keep me awake.’ or ‘I am fine, my ADHD is under control, I have just had my 6 oclock dexamphetamine.’

‘Do I really need to have this operation?’

My answer: ‘Remember what we talked about before? I would not be recommending an operation unless you need it. You will be ok.’

What I really want to say: ‘Did you hear anything I said last week during your consultation?!?!’ or ‘No, you don’t need this operation, I just like cutting people open for fun.’ or ‘Yes, you really need this operation because I really need to save up for my Ferrrari.’

‘You look too young to be doing this, do you know what you are doing?’

My answer: ‘Oh, that’s so sweet, thank you. I am actually older than I look. I have done this for several years now, so I think both you and I will be ok.’

What I really want to say: ‘If you prefer to go to Old Shakey next door, you are welcome to swap surgeons.’ or ‘I have done heaps of this operation on cadavers during medical school. I graduated with honours last week.’ or ‘I only look young because you are so old.’

 

Ok. That last one was bad. I should stop here. I should go to bed, get some sleep.

Because come tomorrow morning, I have to find my professionalism, tolerance and patience. Again.

The Frustrations of Caring

Sometimes I wish I didn’t care.

I remember when I was an intern, the professor of surgery once said to me, ‘the trick of lasting in this gig, kiddo, is to stop caring so much.’

I thought at the time that he was referring to caring about what other people think.Then I realised he meant caring about patients. I was outraged; absoluately convinced that he was just a cynic.

Now, I think he is actually just a realist. A very experienced one at that.

Caring about patients need to have limits. I have learnt the hard way, that if not, the patient will start pushing boundaries with their expectations, my whole existence becomes one big worry-farm, and then my personal life deterioates.

When I meet my patients for the frst time in a consultation, I take the time and effort to explain everything to them. I care about how much they understood and whether they feel reassured. During surgery, I do my best to be efficient, methodical and meticulous, because I care about the success of their surgery. While my patients are recuperating, I make sure they have all the information and instructions to follow and a contact number to call if they are concerned, because I care about decreasing their distress and anxieties while they are recovering. And at their final followup, I care, in particular, whether they are happy with the result.

This translates to worry. I worry if they have had enough time to digest the information and ask me questons. I worry if I have done my best with their procedure. I worry if they are going to develop a complication after surgery. I worry if they are having problems at home after surgery. I worry if they are dissatisfied with their result and if there is anything further I could do for them.

I worry. And it’s tiresome. But after many years, this constant caring and worrying becomes part of normal living – a bit like the constant background hum one hears in an airconditioned room. Some days the humming is louder, like when I am working over 100 hours a week and I have lost count of the number of patients I have seen. Other days, it’s like a sledgehammer, when I am dealing with problematic patients and complex surgery. Rarely does it becomes silent, even when I am asleep (yes, I do dream of operations and patients), or when I am on holidays (I still receive emails of lab results, letters etc).

Sometimes I resent it. Like when I receive a text message from a patient at 1am with a selfie of their wound or surgical site. I feel like yelling in frustration. But I constantly have to remind myself that it’s not the patient’s fault my life is like this. They are only doing the right thing – contacting me when they feel something is not right. It’s my fault. My fault because I care. I care enough to ring them back and listen to why they can’t sleep, talk about their concerns, and address their anxieties. Then I lie awake worrying. By the time my caring has finished, it is time for me to get up to start my 12-hour day again.

Sometimes my husband resents it. ‘Why do you have to go in to work on Sunday?’ Because I worry that my inpatients may have deterioated overnight, or need an increase in their painkiller prescription. I worry that they are sitting in hospital on a Sunday, feeling abandoned by their doctor (who feels too guilty to have a day off). ‘Why can’t you switch your phone off for dinner?’ Because I worry that my patients may need me and I won’t be there for them. ‘You are thinking about work again and not listening to me.’ I was worrying about what I could have done better in surgery, instead of giving the one most important person in my life the attention he deserves. I worry because I care.

Believe me. I tried. I tried to stop worrying, and erect a wall against caring. I tried to emulate some of my colleagues who has Not-Caring down to an art. But my conscience kept me awake, and my attempt lasted for all of 10 seconds. I know I don’t have to care, I just have to provide a service to my patients. I have seen very capable and successful surgeons who don’t seem to care and still have excellent results. They shrug off complications, they don’t take their patient’s problems home, and they brush off complaints at the office door. They live by the ‘Shit-Happens’ Rule. They don’t ever look worried. Either it is because they aren’t, or they have lived with it for so long, it is unrecognisable.

The problems with caring, is it’s closely associated with feelings and emotions. More and more, I have had to find the strength to put it aside. I have seen that too much caring can cloud one’s judgement, especially if I worry too much about how they might feel. Sometimes, cold clinical judgement to do the right thing, which may not be what the patient want, is the only way to make sure they have the best outcome. The hardest part is stepping away from their expectations, so that the bigger picture can be see in perspective. Thus lies the basis for not
treating our own relatives.

And now I understand that the advice was given to me to prevent ‘Burn-out’. I have learnt that sometimes I am unable to solve all my patient’s problems, and that I am not responsible for all their woes. I have also realised that just because I can’t help them, it doesn’t mean I don’t care. It is often enough for people to know that someone cares.

I have discovered that I need to reserve some ‘caring’- for myself and people who love me. I need to care about my health, that I shouldn’t live on chocolates and coffee. I need to care about my husband, what problems he’s having at work and why he’s wearing a shirt with missing buttons. I need to care about my mother, who still refuses to have her home security installed. I need to care about my 90-year-old neighbour, who still push my bin out every week for the rubbish truck but can barely manage to climb up the stairs of his porch. I need to care about my ever-loyal staff, who stays behind in the office and keeps their family waiting in the evening because I have two extra patients to see.

But how does one measure ‘caring’? And how do you dish it out in equal portions? What is enough and what is too much?

Caring is frustrating. It brings with it tiresome worries, sleepless nights and at times, total helplessness.

If I could talk to Prof now, I would ask him, ‘But, how do you NOT care?’

Two minutes

Mrs Warren* came into my practice yesterday.

Mrs Warren is the mother of Hannah*. Hannah was a 35 year old beautiful young mother of three children, who passed away from metastatic breast cancer two weeks ago. Hannah was my patient three months before she succumbed to her illness.

I heard Mrs Warren’s voice at the front desk reception.

I stayed in my office, consumed by guilt. When Hannah was dying in hospital two weeks ago, one of the nursing staff informed me about her readmission into hospital. ‘Things are not good, I don’t think it will be long.’ 

‘Maybe I should pop by and visit.’ I thought, mentally swiping at the tears that threatened to clog up behind my eyes.

‘I think they will really like that. Hannah loved you. She thought the world of you.’

I started, then realised I had thought out aloud, the nurse was just responding to my comment.

Days, then weeks passed. I couldn’t bring myself to visit her. Several times I walked towards her room – steeling myself to walk in to face her emaciated semi-conscious form on the bed, surrounded by her grieving family – then finding myself turning, striding rapidly away.

Hannah was my age. She was a lawyer, a lawyer who studied hard, worked long hours, made sacrifices and achieved. She once told me that she was the youngest associate ever to be offered partner. She told me how there was no female lawyers in her department at which we both smiled simultaneously in mutual understanding. She said she sees a reflection of herself when she looks at me. As I do, when I see her.  

I never went to see her, I never said goodbye. I never attended the funeral. AFter all, I told myself, she wasn’t a friend. She was a patient. The only thing I did, was to write a card to her family.

Now her mother is standing in my office. And I am kicking myself. I should have made more of an effort. It would have just been ten minutes of my life; After all, my ten minutes would have been nothing compared to ten minutes in her last days. My cowardice overwhelmed me,  I found myself hiding in my office, afraid to move. Or breathe.

‘Hello Mrs Warren, we are so sorry to hear about Hannah.’

‘Thank you.’ I imagined her waving her hand elegantly. Mrs Warren always reminded me of a grand matriach, she moved and spoke with such pride and grace. ‘I just wanted to come in and thank the doctor for her card.’ A sniffle. ‘It was so lovely that I had to read it to Hannah yesterday.’ A brief silence was followed by a sharp snap of a handbag. Must have been a tissue. I could almost see her in my mind, using the task as an oportunity to gather her composure.

‘You know, we had so many people at the funeral last week, the church had to leave the doors open.’ There was less wobble in her voice. ‘We got so many flowers and cards.’

‘She had so many specialists, but doctor was the only one who sent a card. Please thank her for me, we were so pleasantly suprised……’

I shut the door.

Tears were running down my face. I was humbled.

It seems the two minutes it took for me to write a card was enough for them.

 

 *All names have been changed to ensure confidentiality and protect privacy.