anonymous

13th December 2019

Leader of the Team - 5

Leader of the Team - 5

DR V.N. SHRIKHANDE

A Matter of Conscience

Everybody has heard stories about swabs and instruments being left inside the abdomen. Constant vigilance and accurate swab count should be a mandatory drill in every Operation Theatre. With a left-over swab in the abdomen, the post-operative course turns out to be very stormy with pus inside the abdomen and in the operation wound. Patients have died. I recall an instance in which retention of the swab in the abdomen was corrected, though after some hours in an extraordinary way. It involved a Theatre Superintendent when I was working in England. He came to my quarters on a Sunday morning looking pale and white; he was literally shaking. He refused tea and came to the point directly. He said, "Dr. Shrikhande, I think two swabs have been left inside the patient yesterday morning." I asked him what made him think so. The narration is interesting, informative and educative.

He went home on Saturday evening and a person who had no difficulty in sleeping found sleep eluding him that night. He had never experienced such sleeplessness in all his life. His wife suggested to him to go through the entire days work in detail. He tried to remember everything. When he came to this particular operation he said, "My god, I do not remember if the two swabs have been taken out!" He rushed to the hospital in the middle of the night, went into the O.T. block, collected all the swabs used that day, went through the entire swab count and was convinced that two were missing. He was absolutely sure that they were left behind in the patient's body. I phoned my Chief who explored the patient and the missing swabs were found in the patient's abdomen. The patient had an uneventful recovery.

It is very interesting that only a few days before this episode, the Superintendent took pride in saying that not once in his life time had he left a swab in a patient's abdomen and that should he ever do that, he would resign. Such declarations should be avoided. The great batsman, Bradman, was out for a duck in his last match. Experienced pilots. crashed at the end of their careers. In a biography written by the of one of the outstanding American Surgeons, she had quoted, an instance where her father had cut the bile duct accidentally while doing gallbladder surgery. He was an authority known for repairing the damaged ducts but he himself was to damage the duct, though only once in his lifetime.

I remember a sentence in Godfather that runs like this-Accidents do not occur to those people who consider accidents personal insults.

I have seen tragedies in life. I still remember a youth who had been fatally stabbed in his chest following an argument with a vendor over just two paise. Many thoughts crowded my mind when I examined the dead body only a few minutes earlier he had been full of life. An hour earlier it would not have occurred to him that his most precious possession-life itself—was soon to end. He could not have known when he woke up that day that this would be the last day of his life. I wondered who his parents were, whether he had sisters and brothers, whether he was married and had children. Did the man who knifed him realise what he was doing? It was not a pre-meditated crime. The killing was done on the spur of the moment, in anger. The most difficult thing to control is always one's mind.

In 1955 when I was working in a hospital as a young surgeon, a young man was admitted for acute appendicitis. I advised him operation which he and his relations promptly refused. They told me that for a similar attack of pain in the past he had been cured with injections and intravenous saline! I explained to them that if he had been "cured” the first time, he couldn't be having another attack. I drew a diagram and explained to them what the consequences could be if the appendix ruptures. The nerves that supply our eyes are thicker than those which supply our ears and therefore what we see is more convincing than what we hear. They told me that they will consult the young man's mother who will take the final decision. The mother was summoned and in the corridor of the a hospital meeting was held. It was agreed that the young man could be operated but three conditions where laid down:

• The patient must not die.

• There should not be any recurrence of the same trouble and

• The patient must not suffer from any pain after the operation!

Concerned with the young man's condition, I accepted these conditions but my colleagues and assistants cautioned me because they felt that should anything go wrong, I would surely be in trouble. Their fears we not entirely unfounded. The relatives of the young man looked like bad characters. The usual course in such cases is to leave the decision to the patient and get a signed statement from him that he is willing to undergo surgery. There is a difference between playing safe and being safe. I did the operation. The appendix was about to burst. There was a big crowd waiting outside the Operation Theatre (I often feel that there should be a secret staircase to get away from the crowds in some situations!). I came out. I showed the assembled people the appendix and the pus inside. They were more interested in seeing the patient and not the severed appendix. When they saw him alive, there was a great sense of relief. He showed rapid improvement and now there was nothing but great appreciation and adulation. What impressed me most was that the mother approached me on the 5th day and said that she had another son who was getting stomach aches and that, if I felt it necessary, I could operate on him also! By interacting with the relatives as I did, I had instilled faith in her.

Readers will not believe that when I started my career as a Resident Surgeon 37 years ago, almost 90 per cent of patients would refuse emergency operations unless the need was too clearly perceived to be ignored like an obstructed hernia.

Courage in the face of death is not commonly seen. I remember a young man in England who had advanced cancer of the urinary bladder. His condition was serious and he knew it. When I went near his bed one evening he asked me: "How are you, doc?” He died the same night. I do not think I will have the courage and calmness that he displayed when he knew that death was not far away.

Emergencies can arise during operations. I was one day called when there was dramatic and profuse bleeding during an abdominal operation. The entire atmosphere in the Operation Theatre was one of panic. The surgeon had lost his temper because no sponges were available to pack the region. The Suction apparatus was not working. Phones were out of order and there was an immediate need of blood transfusion, anesthetist looked anxious, the syringes were not working because the plunger did not fit and saline was leaking.

I first washed up, then requested one and all to stop shouting and blaming each other. There was no point in asking for something that was not available and shouting did not improve matters. My philosophical approach helped to soothen nerves and we wriggled out of a bad situation but barely. I called for a large, sterile sheet and used it to control the bleeding. I assured the anaesthetist that no further bleeding would occur, and she could take all the time to resuscitate the patient by doing what was necessary. I called a ward boy by his name and requested him to go personally to the blood bank and get bottles of blood without delay. I had someone mop the floor and had the blood-soaked sponges quickly removed. I did not want the Operation Theatre to look like a battle front.

If a blood vessel is firmly compressed for upto 20 or 30 minutes, the bleeding either stops or the exact site can be seen which can then be sutured. That is what happened in this case. It took the ward boy half an hour to get the bottles of blood, and transfusion was given. By then matters had been brought under control. When the pack was removed only one small tear in a large vein was noticed and this was quickly sutured. The anaesthetist did her job and when I had finally completed the job there was a sense of relief all round. The only individual who had no idea of what had gone wrong was the patient who walked home after ten days!

In 1967, a young engineer consulted me for some difficulty in passing urine. He had developed cancer of the foreskin at the young age of 32. A few years earlier he had been advised by a physician to have the prepuce removed at some convenient time. Convenient or spare-time is something one never really gets. The engineer's wife and child and parents were living about a thousand miles away. Through his friend, I had them quietly summoned to Bombay. The operation was performed but the case was advanced. My patient had recently bought an apartment and was busy decorating it and he was going to invite me for the house-warming party. That was not to be. Within a few months he was dead. I only wish the physician who had first examined him five years earlier had insisted that the operation be gone through with some urgency to prevent the possible development of cancer. Advice should always be specific, and not vague.

The engineer's death was followed in quick succession by the death of both his parents. His brother wrote to give me the information. He added: "My brother's son who is only 30 months old often speaks of Bombay and wants to kill the giant 'Cancer' with his tiny toy pistol! I take this opportunity to tender my respects to you. Excuse me for intruding on your valuable time, but I cannot forget you, a doctor in the truest sense of the term…”


Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar