AN OVERSIGHT IN HEROIC SURGERY

AN OVERSIGHT IN HEROIC SURGERY

It had been a hectic day after going on marathon ward round with my senior register. The round was a tedious one as we had been resuscitating many of our unstable patients. We spent most of our time on a certain lady at the casualty ward who had bilateral pleural effusion secondary to thoracic endometriosis with bilateral chest tubes in-situ draining haemorrhagic effluent. In the course of our physical examination, we discovered that she was in severe respiratory distress with coarse crepitation scattered throughout the lung zones and poor oxygen saturation. In a speed of lightning, we placed her on oxygen via a nasal prong and then commenced intravenous drug administration with the ultimate aim of stabilizing the pleural membrane to avert further rebound pulmonary oedema and to decongest the fluid accumulated within the alveolar space. After a prolonged intensive resuscitation, we left her bedside as the clinical signs and symptoms tremendously abated.
"Keep a close watch on this patient" my senior register instructed me. "Meanwhile, go and transfuse one pint of blood to the patient booked for surgery tomorrow at the female surgical ward". He added.

My senior register was an assiduous young man with a workaholic tendency. He works indefatigably round the clock without seeking an assistance except for a multiple concurrent tasks that demand an urgent attention as was the case at the moment.
He is also a daredevil, adventurous in surgical procedures. He had acquired a good deal of surgical skills during some years of private practice prior to his commencement of residency. He once told us how he would have done a liver transplant for a newly married couple in which the husband was diagnosed of decompensated liver cirrhosis if he had already attained the apex of the medical profession as a consultant.

I wondered how he would be able to do so taking into cognisance of the fact that organ transplant has never been done in our country hitherto. However, the confidence and logical coherence in his description on how to carry out the transplant seemed to have demystified every element of skepticism in my mind against his assertion. He said that the major challenge would be the green-eyed senior colleagues who would be hell-bent in withdrawing his medical license if they overhear such, regardless of how successful the outcome of the surgery might be.

This due to the unhealthy academic system we had been subjected in the country whereby the senior colleagues never believed that anything good could come out from their subordinates. As far as they are concerned, how dare you, a lower rank physician put forward an idea in their midst. Who are you and what do you know!

This is a colossal defect I had earlier noticed in our learning system which I had fervently prayed never to perpetuate during my period of consultancy. In my own thinking, knowledge is a natural process that should be allowed to flow freely. The least among all can raise the most powerful idea and the greatest of all can at times be erroneous. Hence, ideas and suggestions should not be treated based on isolated hierarchical source. Instead, every idea should be sieved in the laboratory of truth and the ones that pass through should be upheld while the residues are discarded. Through this means, medical par excellence and proficiency shall become the order of the day. However, this is not so in our environment. The whole situation negates open mindedness and critical thinking. The house officers and the resident doctors often feel hesitant to make suggestions in the midst of their chiefs (Consultants) for fear of unwarranted overt humiliating opprobrium and derision.

I trudged back to the female surgical ward to carry out the instruction of my senior register. The patient was a middle aged woman of 46 years who was being managed by the general surgery team for advanced metastatic breast malignancy. She had undergone radical mastectomy and thereafter was subjected to radiotherapy to destroy the remaining tumour deposits at the primary site of the tumour. In the course of treatment, she developed extensive anterior chest wall ulcer as a sequela of post radiation mastectomy.

The ulcer seemed to have been deteriorating as it went deeper and deeper involving the second, third, fourth and fifth anterior ribs which had become necrotic. The floor of the ulcer was covered with sloughs and necrotic debris exuding a noisome odour. The treatment of the patient had been essentially palliative as nothing else could be done medically to prolong her life due to the late presentation. She barely had few months to live based on the available prognostic factors.

This time the patient had been scheduled by the plastic surgery team for wound debridement. Our team, the cardiothoracic unit had been invited to assist in the surgery to avert any untoward injury to the major blood vessel based on the anatomical site of the ulcer with close proximity to the patient's heart.

Notwithstanding the assisting position assumed by our team, my senior register in his wonted tendency had proceeded to be at the helm of affairs in the management of the patient. For this reason, I was to transfuse the patient instead of the house officer of the plastic surgery team. I had typed and printed three copies of the elective operation list and submitted same to the perioperative nurses, the anaesthetists and the ward nurses. After transfusing the patient with a pint of blood, I informed her nineteen -year old daughter about the need for two more pints of blood as a prerequisite for the next day's surgery. She rallied around via a telephone call and other logistic manipulations until the two units of blood were secured.
I explained to the patient and her daughter about the surgical procedure she was about to undergo the next day and asked for their consent which was instantly granted. I then opened the folder to convert the abstract verbal agreement into a concrete one as the patient's daughter signed the terms of agreement in black and white.

A moment afterwards, I could see the patient's appearance changed dramatically. Her face was downcast and her head bent in a pensive mood as if she was contemplating on the outcome of the surgery. Moved by my usual humane tenderness and compassion, I drew close to her, not minding the disgusting odour, held her hand tightly and began to speak some encouraging words to her. In a jiffy her spirit was uplifted and she was reassured.

Just before leaving the ward, streams of thought began to flash through my mind. "Will this woman be able to withstand the general anesthesia considering her performance status?" I thought. "What if local anaesthesia is used?" I thought further.

Under the influence of irresistible persuasive force, I was compelled to approach my senior register to share my views and feelings regarding the patient. "I had thought along the same line with you" he said. "All the same ... he continued, let the consultant do whatever they have decided to do. They seem not to regard my opinion."

In the morning of the day of the surgery after the prolonged clinical meeting, we all headed towards the theatre. The patient was wheeled on a gurney by the orderly into the theatre.
We wore our theatre gowns, head ties, foot wears and face masks and then walked majestically into the operating room. The surgeons scrubbed and draped and the surgery began.

The plastic surgeon led the move for the debridement and the cardiothoracic surgeon followed giving the guide on where to cut and where not to cut. The ulcer was sufficiently excised until apparent healthy tissues appeared. The patient was bleeding profusely into the floor of the ulcer. I had collected the two units of blood from the blood bank and the anaesthetist began to transfuse her at a fast rate to avert any form of haemodynamic instability.

After much enthusiastic debridement, the wound was washed with dilute hydrogen peroxide and then irrigated with a copious mixture of normal saline and povidone iodine until every part of the ulcer appeared beef-red and healthy. The wound was then packed with sterile gauze covered with cotton wool and firmly held together with crepe bandages. The surgery was over.
The immediate post operative condition became so unstable that the anaesthetists had to move the patient into the intensive care unit for an urgent post operative resuscitation. Two hours later, I was informed that she had taken a walk to the netherworld. I felt so bad for having been associated with the surgery. I wondered what the daughter of the deceased patient with whom I have had good rapport would say when she sees me. Probably, she would say, "this is one of those that took my mother to the theatre and she never came back". Now, all the effort of the surgeons has ended in smoke. The death which was aimed at being delayed had eventually stretched forth its cold hand so untimely on the innocent victim.
"If the surgery had not been done, the patient would have lived fairly longer". I thought. The bravery behind the surgery seemed to have masked the patient's clinical undertone. It was indeed a heroic surgery on a background of clinical oversight. 

SON OF THE KINGDOM STORY...