Trust, but verify. A surgeon tells stark stories from his clinical experience to make a point
In 1966, the Royal College of Surgeons of England and that of Edinburgh awarded me their Fellowships after rigorous examinations. The examiners at that point of time, I am still proud to say, were doyens in surgery like Late Professor Norman Dot and Late Sir Russell Brock.
The clinical examination was tough and searching. My task was to observe a lady for a couple of minutes and report my findings. I was flabbergasted but kept my cool. The lady was middle-aged, well-built and well-covered. Her facial features were ironed out. A prominent collar scar ran right across her midline neck swelling. When I reported my findings, Prof. Dot asked me if I was curious to know anything more about the patient. In fact I was. I was itching to know if her voice was affected by her disease process or by the surgical intervention. Humour prevailed. I asked the lady for her name and found that her voice was hoarse.
Discussion of the case followed. The provisional diagnosis was malignancy of the thyroid gland. She had surgery. Recurrent laryngeal nerve was damaged in the bargain and she developed hypothyroidism too.
The purpose of this narration is to illustrate how in the span of a couple of minutes by keen observation (the proper use of sense organs) and common sense one could gather enough information, to come to a provisional diagnosis.
The supreme duty of a surgeon is to save life when threatened by injury or disease. Keen and astute observation is vital and goes a long way. But that is not enough. It should be followed by prompt and decisive action if you want to succeed.
In 1974, I was in charge of a surgical unit in the District Hospital in Cannanore, today called Kannur. Around 5 p.m. one day, when I was getting into my car to go home I was stopped to see a patient in casualty. The patient had sustained a penknife stab on the left side of his chest. He was cyanosed. There was no palpable pulse. The limbs were flaccid. He had a sighing respiration. The diagnosis was written on the face. The patient had cardiac tamponade (the pericardial chamber within which the heart is located was compressed by some collection so that the heart was prevented from filling and pumping) and cardiac arrest was imminent.
I told the patient’s brother, himself a physician, about the critical situation and that the only thing I could possibly offer was to open his chest and pericardium and relieve the tamponade then and there. I warned him that the patient might not make it, or worse still, he might end up as a vegetable. He orally agreed. And in less than 10 minutes I could relieve the tamponade.
As soon as the blood clot popped out of the pericardium, the heart chambers filled up and started pumping and blood spurt out through a small rent in his left ventricle (caused by the stab) and hit the ceiling. The hefty man, who hitherto lay as a dead log, started to struggle aggressively to get out of the trolley. I leave it to your imagination to visualise the panic that ensued and the struggle we mounted to keep him down while we sutured the rent in his left ventricle with ordinary catgut that was available in the casualty and also closed his chest wound.
As luck wound have it, all ended well. He had no post-operative complications whatsoever and was discharged after 12 days. Of course his ECG showed some evidence of a partial left bundle branch block.
Indeed, inappropriate speed and lack of alertness can lead to disaster. Recall an episode in the Ramayana. Desharadhan, archer par excellence, was hunting. A gurgling sound from a pond alerted him. He guessed that the sound was produced by an elephant drinking water.
He shot at the imaginary elephant, and proceeded to see his trophy. But his victim was a teenager struck by his arrow in the chest. At the youngster’s request Desharadhan collected a pot of water from the pond and delivered it to his blind parents who lived nearby.
What was Desharadhan’s error, nay crime? It was negligence. He was proud of his auditory acumen. He did not care to use the precious gift, God had granted him, vision. The tragedy could have been averted, had Desharadhan verified his finding by visual examination.