Scalpel's Edge

A surgeon's notes

Cowboys and Heros

2015 07 05 10 58 02

I missed sharing my Friday’s list last week, because I really didn’t feel like it.  It was a rough day.  I had another rough day today.

Many times here, we are trying to solve a surgical or diagnostic problem that I have never seen before.  At home, I would call for help, refer, or even just discuss the case with a senior colleague.  But here my surgical colleagues and I are all within a few years of experience. We have no senior surgeon as such.

Part of the difficulty is dealing with only half the information, or half the treatment options. For example, we have no access to radiotherapy, and chemotherapy is often too expensive for most patients.  It is exceptionally hard to access evidence on the best surgical treatment for a cancer, if you have no access to any adjuvant therapy.  The evidence really doesn’t exist.  These situations happened 50 years ago, and everyone sort of did what they were taught and didn’t study pros and cons.  So its all about asking people’s opinion and making a best guess.

At 5am today we had a patient with presumed abdominal infection deteriorate.  He arrived at hospital after our radiographer had gone home, so we didn’t even have plain xrays of his abdomen.  He was dehydrated and in early kidney failure, and we decided to proceed to an operation as he was deteriorating.  But to the me from six months ago it sounds absurd – no CT and not even plain X-rays, no previous medical history and no clear diagnosis and a decision to do a laparotomy in the middle of the night.  

So the case goes badly and the patient requires CPR and resuscitation.  At this stage we still don’t know the diagnosis.  So myself and my resident, the anaesthetist and the nurse anaesthetist bounce ideas around.  The senior medical staff (trained as GPs, but working as hospital physicians) come into theatre and join in the discussion.  We have to decide whether to proceed, whether we want to operate on a patient who may die, given that the family will incur the financial insult.  We have to figure out his likely mortality. We have to decide whether the patient deserves ventilation for twenty-four hours – expensive, and standard practise in the expensive world, but a big choice here.

Any time I talk about choices like this, my friends and colleagues can respond in many different ways.  A lot are supportive, and amazed. Colleagues here in Tansen are universally supportive – they have all experienced the same. But some home colleagues  imply we are cowboys, being unsafe and flying by the seat of our pants.  Which is true.  It feels ridiculously unsafe to be looking up textbooks in the tea room in the middle of an operation.  I feel like a cowboy doing a pure diagnostic laparotomy.  I am perpetually scared of doing an operation on someone who actually has pneumonia or a heart attack, or something completely unrelated.

Rough days usually coincide with tired days.  Difficult, sick patients are harder to come to terms with. On tired days, I don’t feel like a conquering hero, but a dangerous cowboy.  Difficult operations make me question my experience, my right to step up to the table for these crazy cases, out of my wheelhouse.  Tiredness makes those accusing voices harder to ignore, louder in my ears.

Last Friday was a tired day – laparotomy at 2am for crazy pathology I had never seen before. Then a full day of operating, with difficult cases that made me feel I am helping no one.  A more experienced colleague told me that some days you feel like a hero and some days you feel like you are making things worse for everyone. Friday was not a hero day. Here’s crossing fingers for the rest of the week.

Photo note: Monsoon season has been much less wet than it should have been, but the rain has been much appreciated by our crazy kids when it has arrived.

One response to “Cowboys and Heros”

  1. nick bauman says:

    Hi Chris,

    I was given your blog link from Debbie Dornon, as I’m a general surgeon contemplating following in the footsteps of your family…

    I’ve been enjoying your blog entries – thank-you for taking the time to do that.

    Athough I haven’t experienced this situation that much we have travelled and done some work in africa, and sympathize with these ‘rough cowboy’ days…

    Keep up the good work, and thanks for your writing.

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