Being a Surgeon

Over thirty-seven years ago, I started my career as a surgical intern in a large university teaching hospital in sub-Saharan Africa. There was a perennial shortage of doctors. I was the only intern on a surgical firm. In my first few weeks, I admitted and clerked an elderly African lady with a long-standing, largely asymptomatic multinodular goiter who was planned for thyroidectomy. She had been rendered almost blind (navigational vision) due to smallpox, which had been contracted when she was a teenager. While obtaining her consent for the operation, I reassured her that this was a routine operation that was performed every day, that she would be fine, and that she would be discharged in couple of days. She was a pleasant and calm lady, with a weather-beaten and aged face. She came from a remote village, and despite her blindness, every wrinkle on her face testified that she had seen and endured things beyond my imagination. She assured me by patting my hand. “Daktari, you sound more worried than me,” she said. “I trust you, and you know what you are doing.” Being blind and illiterate, she put her thumb impression where I wanted. I was touched and moved by her personality and her trust. Never had I imagined that her words would haunt me forever and shape my career for life. The next morning in the operating theater, I hesitantly tried to discuss my examination findings of retrosternal extension with the consultant. Radiology then was synonymous with plain X-rays and some contrast studies. He looked at the thoracic-inlet X-ray and said, “It will be all right.” I dared not ask if he meant that it was or wasn’t extending into the chest. Such was the hierarchy and intimidation. The surgery proceeded, and we found a huge goiter with retrosternal extension. No sweat. The consultant surgeon put his index finger on the side of the gland and into the chest. After some struggle and awkward maneuvers, out popped the large retrosternal component. My eyes popped out, too, as the hole in the patient’s chest welled up with blood. Suddenly I felt I was standing on shifting sand. I was scared for my patient and the possibility of an adverse outcome, which I had never considered. Her words echoing in my ears were interrupted by a shout. “Suck and concentrate!” I then saw a large gauze being tightly packed into the hole. We finished the operation and removed the gauze. To my relief, it seemed dry, except for some mild oozing. A drain was left, and the wound was closed. It was the last case on the list. The consultant left, and I stayed with the patient as she was wheeled to the recovery area. I sat on the counter in the recovery bay and started writing operative notes. I was deeply engrossed in documentation when I slowly started to hear some patient snoring in the background. As the snoring became louder, it occurred to me that it was my patient having a stridor. I rushed to her and found that she was barely arousable and had a large and tense neck swelling. It was already lunchtime, and only a skeleton staff was around. My nurse had left me to fetch some drugs. I had read about post thyroidectomy hemorrhage, but I had never seen it.There was no one around to guide me. The traditional and standard kidney dish packed with the necessary instruments for emergency removal of Michel clips and evacuation of a thyroid hematoma was lying at the patient’s bedside. I shouted for my nurse, and in the meantime, I gathered the courage to open the wound and evacuate the hematoma. I did it promptly, with my shaking hands and lot of prayers. Now I was faced with active bleeding, and I started to panic. I did what I had seen in the theater: I packed the wound with sterile gauze and asked the nurse to hold pressure on it while I went to look for help. In the changing room, I found our anesthetist. He rushed over, intubated the patient, and asked me to get my surgeons. The consultant was out of contact on the road somewhere, and there were no cellular phones. Our trainee registrar came in, and we wheeled the patient back into the theater. We explored, but by then the bleeding had stopped. We ligated a few small vessels here and there, but we couldn’t see well enough to identify what was bleeding in the patient’s chest cavity. We left two large bore drains and closed. Now I was permanently stationed in the recovery area. I ran between the patient and the phone, trying to cross match and get more blood and begging someone to cover my urgent ward work. Two hours later the patient was still pouring blood, and I sat beside her, pumping blood and watching it come out of the drains. We finally got hold of the consultant, who came in and decided to pack the cavity, leaving orders to just continue giving blood. By two in the morning, the pack was dripping blood. When we informed the consultant, he told us to call the cardiothoracic team to split the sternum and have a look. We reexplored and split the sternum, and found a buttonhole in the right innominate vein. It would stop bleeding in previous explorations due to the extended neck position of the thyroidectomy. We repaired the hole, but by this time she had received multiple transfusions, developed coagulopathy, and was oozing from everywhere. There were no blood products; if you were lucky, you might get one or two units of fresh blood during the day. Otherwise it was nothing but stored blood and calcium gluconate. We finished the procedure and removed the drapes. Just as I was beginning to hope that the patient would live, she went into cardiac arrest. While I was doing cardiac massage, it seemed that I was the only one who had any conviction in what we were doing. Despite the intubation and despite all the monitors, the drugs, the anesthetist, and the surgeons, the patient could not be revived. At one point I was told to stop the cardiopulmonary resuscitation (CPR). With much reluctance, my cardiac massage became slow and less forceful, and I don’t know when it stopped. She died at six in the morning. Less than twenty-four hours before, this outcome had not been even in my wildest dreams. I was shell-shocked. I kept staring at the patient; she looked younger because her wrinkles were smoothed out due to puffiness. Her lips were pale, and she had a smile on her face. I stood by her like a guilty child—head down, standing still and speechless, waiting for punishment. I held her hand, and with tears in my eyes, I said, “I’m sorry for not knowing enough, sorry for not doing better, sorry for betraying the trust that I was not worthy of, sorry for letting you down so terribly.” Everybody slowly left, and I was assigned to do the paper work and perform the last hospital rites with the nurses—all this when I felt mortally wounded, both physically and emotionally. It was nearly twenty-four hours since I had left the operating theater. I changed and walked listlessly down to my unit, where I bumped into the internship coordinator. He told me that since the previous day, I had to my credit eight serious-incident reports for not being found to cover my duties in different areas of the hospital. This was typical in a large teaching hospital where the right hand doesn’t know what the left is doing. I walked passed him almost in disdain. I was lost in the bigger question: What does it mean to be a surgeon or a doctor? I was not worried at all about my physical endurance, but I was concerned about my shattered dreams and the assault on my values. I had never prepared for such a professional life. Every day I was being left to obtain patient consent for procedures I knew little about. I had to answer every query from worried patients and families without understanding much myself. I was supposed to alleviate suffering, yet I was inflicting more pain by informing patients that they had cancer or that they needed amputation or that their loved one was being abandoned as a futile case. I was fighting death and certifying the dead. It was a nightmare.