Once upon a time when I was a surgical intern (2016) I found myself in an awkward situation. It wasn’t the first or the last but this situation stuck out like a sore thumb. In hindsight it was probably one of the few times I got the opportunity to feel like a real surgeon.
I spent more time in casualties than any other place, it had become a very homely place. I had my food in the fridge in the on-call room, I knew just how many seconds to warm my food up in the communal kitchen microwave, I had speed-showered multiple times in the nurses locker room and I had deodorant and a spare set of clothes on the doctors room couch. I would manage to perform normal human activities in-between clerking and seeing patients and prepping them for theatre.
I was comfortable in my little strange space and had actually come to enjoy it. I would run between theatre and casualties like a yo-yo. In casualties I would interview the patients and get their blood work done and necessary investigations. If it was an emergency surgery, I would then discuss them with the anaethetist who may or may not give me the run-around and more investigations to do, book them on the theatre slate and inform my senior before rolling them up when our name was next on the list. The registrar would operate while I stood and assisted, retracted, held the skin in place, retracted the bladder, milked the bowel, inserted the catheter and nasogastric tube. Assisting in surgery doesn’t involve any glamour. You’re basically the lacky, towel boy and the designated driver. You prepare the patient from scratch, physically wheel them to theatre, do all the manual labour then ring the senior when its time to operate. He waltzes in, scrubs his hands, does the skillful part and then disappears into the distance. you’re left to clean up, move the patient, monitor for any complications like bleeding then counsel the family on the outcome and do the post-op monitoring. So basically, everything besides the actual snip-snip of the surgery.
I didn’t mind the work, it kept me busy and I actually liked interacting with the patients. The prospect of surgery is daunting in any form, so being there to answer questions made me feel useful. It was the actual surgery that scared me. I hated being an accomplice to uncontrolled hemorrhage and perforated bowel and bladder injuries. I disliked looking for the appendix and finding far more complicated things deep in the abdomen. The responsibility fell solely on the chief surgeon operating but I couldn’t walk away feeling guilt-free because I was there too.
This bothered me because as you can imagine, all surgeries bring with it an infinite possibility of complications. Nothing is guaranteed and rarely do things go smoothly. Whether it the surgery itself or the pre-morbid conditions confounding the entire situation or the anesthetic complication, it is a complication nonetheless. And somehow, we always ended up with complications.
It was a Saturday night and I was on-call with a senior registrar so I felt pretty safe. He had enough experience under his belt and was waiting to write his final exams before qualifying as a surgeon. Although I knew that there could be complications in theatre, I knew he would know what to do. This gave me some peace of mind before starting the 30-hour shift.
Casualties called me about a diabetic gentleman with a gangrenous septic foot, nothing new. I put my sandwich down and made my way to casualties. I got a whiff of the smell and I knew it would most likely need butchering. The smell was horrendous but I had become accustomed to bad smells. It helped me recognize the severity of wounds and degree of sepsis. I was just thankful it wasn’t a fourniers gangrene which made me weak in the knees in the complete wrong way. I knew just by smelling it, I would need to prepare him for theatre.
His sugar was 30 (very high), his blood hemoglobin was 8 (very low). I got started with putting up the IV lines, controlling his sugar, ordering blood from the blood bank and booking him for the emergency theatre slate for a below knee amputation. I called my registrar and wheeled him off to theatre.
I met my senior in theatre and he scrubbed up and prepped himself. He winced his nose, commented on the smell and agreed the leg needed to go ASAP. The anaethetist was in a foul mood because we had booked an amputation at ungodly hours of the night. Im not sure if theres some unspoken rule amongst the anaethetists about which surgical cases take preferenceover others. An acute abdomen, a stabbed heart, a stabbed neck, a septic foot.. I didn’t see any difference. All these kill the patient in different ways and need urgent surgical attention, but what do I know anyway.
The anaethetist began the spinal anaesthetic while complaining about the septic smell the entire time. He set his well brewed coffee aside while we began the surgery. We uncovered the wound and the full extent of it hit me like a ton of bricks. The degree of pus, debri, septic matter and malodorous material came pouring out.
We took a second to hold our breath and began the tedious procedure of ligating important blood vessels. It was difficult to find them buried in the ocean of pus. The smell fogged my vision and made my tear ducts work overtime. The registrar was trying t forge ahead but I could see he was also growing more uncomfortable.
The anterior vessels were ligated and we began the posterior vessels. I held up the leg and noticed something move. I stepped back to clear my vision and that’s when I saw it, maggots. A Crawling infestation. The posterior of the wound was infested with maggots feasting on the dead tissue. We peeled them away and drowned them in sterile alcohol solution. The end was near, all that was left was to cut the bone and take care of the stump.
We held the bone saw and moved it from side to side until the shards of bone sprang out foeming a cloud of mist above us. That’s when the trouble began. The registrar became increasingly uncomfortable and I saw him shuffle in his place. I assumed the maggots had reached the floor and he was avoiding them.
He began coughing and choking on the bone dust that rose in the air. He clutched his chest and ripped off his sterile gown, reversing fast. “IM. HAVING. AN ASTHMA ATTACK” he stammered as his nose tip turned blue.
He ran out of theatre leaving us all shocked and worried. There I was, holding a half-sawed off septic pungent leg while the surgeon possibly died outside the theatre room. I had no idea what to do. Do I run after him and leave the patient or do I wait and hope he found his inhaler? I stepped down from the mini stool I stood on and decided on what to do. The anaethetist screamed in my ear. “ DON’T YOU DARE THINK OF LEAVING ME ALONE WITH A PATIENTS HALF-CUT LEG OFF!” I stepped back onto the stool and waited. Surely I couldn’t be expected to complete the amputation alone. Afterall it takes atleast 2 people to handle the bone saw.
The anaethtist looked at me accusingly. He announced that the spinal was about to fade and the patient would gain full sensation in his leg if I didn’t act fast. He also said he was unwilling to convert to a general anaesthetic when the surgeon was no where to be found and unfit to perform the operation. He narrowed down my options pretty quickly and left me with no choice. I had to complete the amputation before the spinal wore off.
Problem was, I hadn’t used a bone saw alone. Infact I hadn’t even paid much attention to it when it was being used. Usually I’d go with the motions and obey the surgeons command zoning out and thinking about unrelated things. I regretted it severely now. I held the bone saw and realized I knew nothing about this instrumentmt. It did look very dangerous. I began sawing the bone with some urgency. The patient twitched. The anesthetic was wearing off. I was panicking.
I sawed the bone as quickly and forcefully as I could. He twitched even more. By now I was sweating. The anaethetist looked at me smugly and without pitty.
Eventually after what felt like a age of sawing, the bone cracked and gave way. The leg slumped off into a septic heap. Success. I dressed the stump as best as I could and got out of there as soon as I could.
I had the honour of writing the notes on the prestigious yellow surgical paper and indicated my name as the surgeon. A first and last time.
I left to check if my registrar was still alive. I found him on the outskirts of casualty reluctantly attached to a nebulizer. He looked relieved to see me.
“So who died first, the patient or the anaethetist” he asked.
“none. But one came very close” I smiled.