“See one, do one, teach one”?

So this morning was a shambles. I have been trying to improve the culture around getting the operating list for the day to start promptly, but it is an uphill battle to say the least. Fundamentally, the issues centre around communication and forward thinking. But there is no point in making myself unpopular over it. I have been slowly chipping away at improving things and we are making some progress. It does mean that we get less done each day than we otherwise could, rarely starting much before 9.30 or 10am. Today however was the ‘icing on the cake’. I had carefully planned the lists this week around the visit of two specialist surgeons, one on Wednesday and one on Friday. I wanted to make sure we had some ‘good’ cases with mesh to make their trips worthwhile as well as perhaps showcasing what we have been doing here.

Today we had two children planned (as both our senior nurse anaesthetists were present) followed by two quick adult cases. Unfortunately, the 8month old had just been breast fed. Hmmm. Then it turned out that the 4 ½ year old had eaten breakfast. HMMMMMM. This meant neither of them could be operated on safely until they had been starved adequately. Practically, that probably meant waiting until another day. After a further short delay I was called into theatres finding not the third case on the list for the day, but the man I was planning to do on Friday! For some reason, they had randomly picked one of the patients from the male ward. At this I was really quite cross and I think for once it showed a little. We were committed now as he had already been given his spinal anaesthetic. He had bilateral inguinal hernias and bilateral hydroceles. A perfect ‘set’ for Friday (normally a day we reserve for emergencies only) and our 2^nd visitor. I had also mentally earmarked this patient for the two local surgeons to operate upon together (relatively straightforward as they become more independent of me). I forced myself to take a deep breath and smiled. I gently aired my frustration but encouraged the two local surgeons to proceed. It was a great case for them and important that they should do it without me. I just knew that it would probably take up most of the rest of our day being essentially four procedures.  I made sure that they were happy and dispelled any air of frustration, encouraging them to take their time and enjoy the case which they did.

I went to the doctor’s room to sit down and settle my thoughts. Part of me was wanting to rage (internally my chimp was agitated and needed to be exercised in some way [for any followers of the ‘Chimp Paradox’]) and I also needed to work out how to re-plan the week. A cup of tea always helps.

The lead nurse anaesthetist came to see me and we discussed the challenges we keep on encountering. What I really wanted was one of the local team to be proactive and take on the task of improving this poorly performing aspect of our practice. After some discussion we agreed that the way the list is presented is unhelpful. It is a scrap of paper, with often illegible names written upon it and only the smallest of scribbles to indicate day and order of surgery. It has long been a bugbear of mine, but with so many other things going on….. Sometimes a catalyst comes along, and today was it. I was delighted when a reworked list was presented to me and I immediately decided to create a quick template (word document table) for future use to emulate how the information was presented. One of the many challenges that places like Muheza has, is very limited or no access to decent IT equipment nor the skills needed to use it. We will have to see if our idea works.

But as they say, ‘every cloud has a silver lining’. For me it was to learn to do a caesarean section. With the two local surgeons beavering away, the news came that two emergency caesarean sections were needed for obstructed labour. Up until now, I had kept my head down in such situations. I had made a conscious decision to avoid being drawn into obstetrics, as the service was pretty well provided and my efforts were definitely best utilised focusing on improving and offering a specialist General Surgery service. I was not needed to ‘prop up’ an obstetric on call rota (the only surgery that really goes on overnight here), but I was very much needed to be available and fresh for ‘specialist surgical’ issues – such as uncontrollable bleeding that has happened a few times. But inspired by listening to BBC Radio 4 – Book of the Week podcast, War Doctor (recently published, recommended by several people and absolutely captivating ‘www.bbc.co.uk/programmes/m0002rjb’) I decided that it was something I wanted to do. For me. And it felt fitting that I should do such a thing.

The staff of course were absolutely delighted including the AMO responsible for O&G. I made a point of telling them that they would be teaching me something. They laughed. Whilst everyone before I left the UK had told me that doing such a procedure would be easy for me, I felt it would be better to assist in my first case and see how I felt about the second. I think I saw a c-section at medical school, but I don’t think I could really say that I could remember how it was done. Messy would be my conclusion from today. Slash, slash, scissors, blood, amniotic fluid, meconium, baby. Then placenta. Lots of bleeding. And efforts to suture everything back together to stop it. Ironically, the bleeding was resistant to being controlled and we had to open the uterus back up. The AMO, clearly a little flustered, ‘phoned a friend’ – the senior O&G surgeon (now ‘retired’ but comes to work every day and gets called quite a lot for such things). This was a little to my bemusement standing across the table (as I get called when he needs help!). I gently suggested that perhaps I could help and as he walked into theatre, I was placing a fairly straightforward haemostatic suture. The bleeding stopped. According to the staff, I was teaching ‘haemostasis’ to the AMO! All very entertaining and genuinely great fun for me.

Yes, I am in the right theatre!

Yes, that is a very gravid belly!

I did the second case. I would love to say that there was a little more finesse to the process, but it really is slash, slash, scissors, blood, amniotic fluid, meconium, baby……. The marvel of delivering a baby was a little lost on me as I focused on controlling what felt like torrential haemorrhage – that much blood is normal for a caesarean, in a general surgical operation it would be very bad indeed! But the patient’s observations barely changed, and everyone was delighted with my performance. Furthermore, my attention to detail in the closure process (I took an anatomical closure approach) was regarded with much appreciation (and perhaps I did teach something with that). So perhaps I have honoured the ‘historical’, albeit legendary, adage ‘see one, do one, teach one’, or perhaps today it was ‘see one, do and teach one’?!

Regardless, although late home, I walked back with a spring in my step (there is always something nice in feeling like you’ve learned something). And I must say I enjoyed my day immensely. One of my messier days here, but fun none the less.