HEART BEAT:There's only so much we can learn from tests and teaching, writes MAURICE NELIGAN
ROGER BACON aka “Doctor Mirabilis” told us: “There are two means of acquiring knowledge, namely by reasoning and experience”. By and large, this holds true if you regard the written word and teaching as the distillation of the reasoning and experience of others.
Not all surgical experiences have happy endings as any practitioner will tell you, if they are being honest. However, I know some who claim never to have made a mistake, at least one they can remember. Their juniors often take a contrary view. “Remember old Mr Blank, he couldn’t cut his way out of a paper bag”, and similar uncharitable comments or judgments are often heard in the later less-inhibited part of surgical reunions.
Everything is logical and reasonable in surgical texts and teaching. Generations of surgical gods laid the foundations of procedure. Pitfalls were identified and rare complications were discussed and dealt with, outcomes were satisfactory and we all lived happily ever after – most of us anyway.
It wasn’t really like that. The surgeon’s capabilities, reasoning powers and skills varied widely. Nor were patients uniform. “It was only a routine coronary bypass operation. How could that go wrong?” It might not be mentioned that the patient was a 24-stone, smoking diabetic with varicose veins. The operating surgeon needed every ounce of skill and accumulated experience to pull the patient through.
Surgeons are taught, they pass exams and they are mentored and monitored throughout their training. There comes a day when they must fly solo, all supports withdrawn. The patient choosing that particular time to ask the question, “How many of these operations have you done, doctor?”, is unlikely to be reassured by a truthful answer. That’s the start of personal experience for the surgeon. The learning from such experience brings reasoning and skill into play, and hopefully brings the humility and strength to deal with failure.
Easter Saturday, many moons ago, and I am on call in the Queen Elizabeth Hospital in Birmingham. On the long weekend, it is quiet. I do ward rounds and as I am leaving the hospital I am paged. I am told that a patient is being sent in from Hereford with a dental plate lodged in his oesophagus (gullet), since the previous day, Good Friday. The local ear, nose and throat surgeon had tried to remove it through a scope but had failed and felt it should be referred to a thoracic surgical centre. I tell the senior house officer to arrange the transfer and investigations, and to let me know when the patient arrives.
Hours pass. Eventually, I get the call and return to hospital. The referral letter tells the story of unsuccessful attempts at removal. It does not tell us that the patient is an 18-stone fellow countryman of mine, working on the buildings. I noticed teeth in both jaws and no sign of dental plate placement. Upon inquiring he tells me he had borrowed his mate’s plate because the meat was tough. I choked back the uncharitable impulse to tell him that it served him right for eating steak on Good Friday.
A grumpy anaesthetist arrived and we explained to the patient that we would repeat the procedure attempted in Hereford (code for, we were much better). He told us that the surgeon had tried long and hard to retrieve the plate. I told him that in the unlikely event of our failure, we might have to open his chest to retrieve the plate.
I passed the scope. I couldn’t even see the plate because the lining of the oesophagus was red and inflamed from the event and its attempted solution. Plan B was instituted and it proved to be a long evening. I opened the chest and there looking at me was a black tooth with strands of disintegrating meat. I removed the plate and the debris, sewed the leak and the surgical incision, cleaned out the chest cavity and placed the requisite chest drains.
Ward rounds the following Tuesday showed our patient propped up with a prominent “nil by mouth” notice on the bed. He was not happy and complained about the loss of his friend’s dental plate. On the rest of the ward round there was a discussion about the quaint mores of we Irish who borrowed each other’s teeth to eat the dinner.
I have a 100 per cent success rate in removing dental plates from the gullets of fat men. That’s experience.