Facing daemons.

In contrast to the highs reported yesterday, comes the less pleasant task of living with your failings. Sometimes these are transient, or evident transiently at least. And sometimes they are not. Some you have to face almost every day.

As I walk into theatre to prepare for today’s operating list, I am once again reminded of one of mine. In the coffee room I am greeted by the broad but subtly asymmetric smile and slightly muffled words of the colleague I operated on back in December. You may recount the story described in the posts ‘Childs Play?’ and ‘Two sides to every story’. Unfortunately, the facial palsy following this parotid surgery persists, and I am reminded of this fact on an almost daily basis.

Over the past few months I have from time to time formally assessed the nerve’s function. With a Facial Nerve palsy, all the muscles of facial expression are paralysed leading to a drooping of one side of the face and the inability for that side to smile, raise the eyebrow and close the eye properly. Whilst the asymmetry is thankfully quite subtle to the untrained eye for this individual, it is very obvious when you look for it. Furthermore, formal testing leaves no doubt as to the problem, the now pencil-line scar over the angle of the mandible suggests the cause for those who know to look for it. Early on, there did seem to be some residual function (the eye can close almost normally) and I would be lying to deny that although I knew it unlikely, a part of me deep down was hoping dearly that a dramatic recovery would occur. But as the weeks and now almost 3 months have passed, I have had to accept that it is very unlikely that it ever will.

To say this remains gutting is an understatement. In the first few weeks after they returned to work, it was really quite hard to see such things every time I arrived to undertake another operation. A stark reminder of the stakes I would be facing as I approached the table, picked up the knife and made that first incision. It invoked that feeling of carrying a little daemon on your shoulder, baiting you to make a mistake and fail.

But I have certainly come to terms with it now. I have had to. All surgeons experience complications at one time or another, and no matter how hard it might be, you have to learn to manage your feelings about it. Thankfully, I have had precious few. For me, one of the harder things to come to terms with in this case was the fact that in the UK I would never have been in this situation. I would never be the one to perform such an operation. Yet here I was, having taken on a big parotid tumour, and, quite literally now, staring my failings in the face. In tackling this substantial tumour, it is entirely possible that injury to the nerve was inevitable, no matter whose hands the operation had been in. But such thinking is a dangerous road to pursue. Better to simply accept that it has happened and deal with it. Another patient helped me do that.

Suitable consent received
Sorry if its 'gory' but it
powerfully illustrates a point.

A few weeks ago, I was asked to see the relative of another staff member. When I was told about the problem (a good description of a parotid tumour), I was not sure how I would feel. But of course I agreed to see them. Brought to theatre reception (on a day I was operating), I saw this new patient between cases. As I walked towards them and held out my hand in greeting, their face turned slightly, and the scarf fell away a little from their face. There was no doubt what I was looking at. The huge ulcerated growth over their jaw and in front of their ear was clearly an advanced parotid cancer. It had destroyed many of the structures of the face, including the facial nerve. It was beyond any kind of help and as well as being disfiguring and miserable to live with, I was fairly sure that they would not be alive in three months.

Such things are incredibly sad to see. They once again highlight the healthcare inequality that faces much of the world’s population. There are many cases like this, and they are all equally heart-breaking.

But perhaps operating on my colleague was the right thing after all…..

The rest of the day was slightly odd. For the first time since arriving here, I was the sole provider of the service, something I have tried to avoid (I am very focussed on sustainability and training). However, the senior AMO was still running examinations and the other AMO remains unwell. It was quite fun to be honest. Working with one of the senior theatre nurses, we were able to crack on through the cases at a rate of knots and enjoy my efforts at Swahili ‘small talk’. I’m improving apparently.