CHAPTER 1
Wisdom Begins in Wonder
Wisdom begins in wonder.
— Socrates
Reflections on the Past
Over thirty-seven years ago, I started my career as a surgical intern in a large teaching hospital in sub-Saharan Africa. There was a perennial shortage of doctors. I was the only intern in one of the surgical firms, and I worked with two trainee surgical registrars and four consultants. I soon realized that I was the workhorse of the department, and I made the unit my permanent abode.
In my first few weeks, I admitted and clerked an elderly African lady with a long-standing, largely asymptomatic multinodular goiter who was planned for a thyroidectomy. She had been rendered almost blind (navigational vision) due to smallpox, which had been contracted when she was a teenager. While obtaining her consent for the operation, I reassured her that this was a routine operation performed every day, that she would be fine, and that she would be discharged in a couple of days. She was a pleasant and calm lady with a weather-beaten and aged face. She came from a remote village, and despite her blindness, every wrinkle on her face testified that she had seen and endured things beyond my imagination.
She assured me by patting my hand. "Daktari, you sound more worried than me," she said. "I trust you, and you know what you are doing." Being blind and illiterate, she put her thumb impression where I wanted. I was touched and moved by her personality and her trust. Never had I imagined that her words would haunt me forever and shape my career for life.
The next morning in the operating room, I hesitantly tried to discuss my examination findings of retrosternal extension with the consultant. Radiology then was synonymous with plain X-rays and some contrast studies. He looked at the thoracic-inlet X-ray and said, "It will be all right." I dared not ask if he meant that it was or wasn't extending into the chest. Such was the hierarchy and intimidation.
The surgery proceeded, and we found a huge goiter with retrosternal extension. No sweat. The consultant surgeon put his index finger on the side of the gland and into the chest. After some struggle and awkward maneuvers, out popped the large retrosternal component. My eyes popped out, too, as the hole in the patient's chest welled up with blood. Suddenly, I felt I was standing on shifting sand. I was scared for my patient and the possibility of an adverse outcome, which I had never considered. Her words echoing in my ears were interrupted by a shout. "Suck and concentrate!" I then saw a large gauze being tightly packed into the hole. We finished the operation and removed the gauze. To my relief, it seemed dry except for some mild oozing. A drain was left, and the wound was closed.
It was the last case on the list. The consultant left, and I stayed with the patient as she was wheeled to the recovery area. I sat on the counter in the recovery bay and started writing operative notes. I was deeply engrossed in documentation when I slowly started to hear some patient snoring in the background. As the snoring became louder, it occurred to me that it was my patient having a stridor. I rushed to her and found that she was barely arousable and had a large and tense neck swelling. It was already lunchtime, and only a skeleton staff was around. My nurse had left me to fetch some drugs. I had read about a post-thyroidectomy hemorrhage, but I had never seen it.
There was no one around to guide me. The traditional and standard kidney dish packed with the necessary instruments for the emergency removal of Michel clips and the evacuation of a thyroid hematoma was lying at the patient's bedside. I shouted for my nurse, and in the meantime, I gathered the courage to open the wound and evacuate the hematoma. I did it promptly with my shaking hands and lot of prayers. Now I was faced with active bleeding, and I started to panic. I did what I had seen in the operating room: I packed the wound with sterile gauze and asked the nurse to hold pressure on it while I went to look for help. In the changing room, I found our anesthetist. He rushed over, intubated the patient, and asked me to get my surgeons.
The consultant was out of contact on the road somewhere, and there were no cellular phones. Our trainee registrar came in, and we wheeled the patient back into the operating room. We explored, but by then, the bleeding had stopped. We ligated a few small vessels here and there, but we couldn't see well enough to identify what was bleeding in the patient's chest cavity. We left two large bore drains and closed the wound. Now I was permanently stationed in the recovery area. I ran between the patient and the phone, trying to cross-match and get more blood and begging someone to cover my urgent ward work. Two hours later, the patient was still pouring blood, and I sat beside her, pumping blood and watching it come out of the drains.
We finally got hold of the consultant, who came in and decided to pack the cavity, leaving orders to just continue giving blood. By two in the morning, the pack was dripping blood. When we informed the consultant, he told us to call the cardiothoracic team to split the sternum and have a look. We reexplored and split the sternum and found a buttonhole in the right innominate vein. It would stop bleeding in previous explorations due to the extended neck position of the thyroidectomy. We repaired the hole, but by this time, she had received multiple transfusions, developed coagulopathy, and was oozing from everywhere. There were no blood products; if you were lucky, you might get one or two units of fresh blood during the day. Otherwise, it was nothing but stored blood and calcium gluconate. We finished the procedure and removed the drapes.
Just as I was beginning to hope that the patient would live, she went into cardiac arrest. While I was doing a cardiac massage, it seemed that I was the only one who had any conviction in what we were doing. Despite the intubation and despite all the monitors, the drugs, the anesthetist, and the surgeons, the patient could not be revived. At one point, I was told to stop the cardiopulmonary resuscitation (CPR). With much reluctance, my cardiac massage became slow and less forceful, and I don't know when it stopped. She died at six in the morning.
Less than twenty-four hours before, this outcome had not even been in my wildest dreams. I was shell-shocked. I kept staring at the patient; she looked younger because her wrinkles were smoothed out due to puffiness. Her lips were pale, and she had a smile on her face. I stood by her like a guilty child — head down, standing still and speechless, waiting for punishment. I held her hand, and with tears in my eyes, I said, "I'm sorry for not knowing enough, sorry for not doing better, sorry for betraying the trust that I was not worthy of, sorry for letting you down so terribly."
Everybody slowly left, and I was assigned to do the paperwork and perform the last hospital rites with the nurses — all this when I felt mortally wounded, both physically and emotionally. It was nearly twenty-four hours since I had left the operating rooms. I changed and walked listlessly to my unit, where I bumped into the internship coordinator. He told me that since the previous day, I had, to my credit, eight serious-incident reports for not being found to cover my duties in diff erent areas of the hospital. This was typical in a large teaching hospital where the right hand doesn't know what the left is doing. I walked past him almost in disdain. I was lost in the bigger question: What does it mean to be a surgeon or a doctor?
I was not worried at all about my physical endurance, but I was concerned about my shattered dreams and the assault on my values. I had never prepared for such a professional life. Every day, I was being left to obtain patient consent for procedures I knew little about. I had to answer every query from worried patients and families without understanding much myself. I was supposed to alleviate suffering, yet I was inflicting more pain by informing patients that they had cancer or that they needed amputation or that their loved one was being abandoned as a futile case. I was fighting death and certifying the dead. It was a nightmare.
In the early days of my career in the United Kingdom, we received a nineteen-year-old girl. She was a pillion passenger on a motorbike en route to her university in the morning when an oncoming car hit her. She had a bad degloving injury to her right groin — which exposed and damaged her external iliac and femoral vessels — and an associated hip fracture. I called the vascular surgeons.
It was daytime, so their whole team responded with their consultant. They decided that because it was a dirty and exposed wound, any vascular graft repair would have no cover and would get infected. Therefore, they suggested a hip-disarticulating amputation of the leg. I was the first-year resident (SHO or senior house officer) on this orthopedic unit, and she was my patient. I felt the decision was insane, and I could not resist speaking. I politely asked, "Is there any harm in trying? Amputation will always be an option. This way, we are just condemning a nineteen-year-old to a disabled life without even giving her a chance."
The senior surgeons were visibly red. There was a hush of silence and obvious disdain; my comments were perceived as emotional and irrational. The consultant turned around and stared at me over the crowd. After a mortifying pause, he looked over his half-rimmed spectacles and asked, "How long have you been a doctor?" I told him it had been less than eighteen months. He said, "No wonder." I showed no remorse and said no more. They left me standing by the patient as I thought, Surely, this is not what it means to be a surgeon.
Later, my own consultant told me that I was reported to him for challenging their decision and being disrespectful. He patted my back and said that he was happy I had questioned their decision. I told him that I was still disturbed with the decision and that it was not about scoring points. I genuinely felt that we should have tried even if there was only half a chance. I thought they should come and see the poor girl's pain now. She was devastated, totally withdrawn, and always in tears. Why was it so hard to think from the perspective of a nineteen-year-old? I thought that being a surgeon was all about trying and fighting; some, we may win, and some, we may lose, but not for want of trying.
The reality was sinking in that caring for human lives and dealing with human beings was not going to be easy. As I was grappling with these new realities, another incident occurred that rocked me to the core. I was halfway through my first six-month training rotation in the United Kingdom in accident and emergency (A&E). One Sunday morning, there were only two of us covering the usually quiet morning shift. This was often a period of lull after the overnight storm of Saturday night. We were alerted by ambulance control that they were bringing in a child who had been in a road-traffic accident. The nurse in charge (sister) and another nurse started organizing the resuscitation room to receive a pediatric trauma patient.
I heard the ambulance sirens and approached the resuscitation room. I saw a stable-looking five- to six-year-old child sitting on the stretcher trolley and being wheeled into the room. A third person walked in with two members of the ambulance crew. He was the child's father. The sister asked him and the crew to make room for the doctor to come in. They turned around and saw me coming toward the room. The father immediately shouted across the room, "I don't want any colored doctor to touch my child!"
I was stunned and froze in my stride. I couldn't decide to go in or to go out. I took a deep breath, composed myself, slowly approached the father, and reassured him that I would send my colleague to see the child. Even before I finished, the sister immediately told the father, "The child will be seen by this doctor and nobody else."
I told her that we should sort out the child and respect the wishes of the father and that I had absolutely no issues with that. "But I have issues. The child is fine, and I am not tolerating any of this nonsense," she angrily snapped.
My colleague, who was listening to the commotion, rushed in and simply refused to see the child. I did not even notice until I heard his voice from behind me, saying, "It's this doctor or nobody, and before he sees your child now, you must apologize to him. You have shamed us all by your racial slur against our very decent and highly competent colleague." I still remember his red face full of anger. There was now an apparent standoff with the father.
By then, I was shaking but overwhelmed by the outpouring of support and solidarity from my colleagues. I was the team leader of the shift, and by now, I could barely speak. But I managed to tell my colleague, "Please see the child; there is no cause worthy of compromising patient care. I am sorry that I am not in a position anymore to see the child."
I walked out to the office. I had put on a brave face. But I was very young and inexperienced, and I felt very low and dishonored. It was the first time in my life I had experienced such a thing. I realized how it felt being considered a lesser human being due to the color of my skin. As I sat there — many thoughts running through my mind and struggling to get my composure back — there was a knock on the door. The father walked in, followed by the sister. He said that his son was all right, and he had come to apologize for his behavior. He explained that he was just stressed out and sincerely regretted his remarks. I thanked him wholeheartedly and explained how important his apology was to me. I reassured him that I had no hard feelings and escorted him back to see his son.
Reflecting back on the early years of my career, I wonder why I was faced with such an impasse. It is difficult to pinpoint one particular reason. However, you could certainly place a sizable portion of the blame on the type of training that we received. There was every emphasis on teaching and evaluating clinical knowledge and skills, but there was little emphasis on human interactions and conflict. Even after entering practical life, there were few resources to help one's moral distress and emotional suffering. This was compounded by the fact that there was neither time to stop and reflect nor anybody to provide counsel. I felt I was made to act like a zombie, and all my compassion, altruism, empathy, and dreams of being a healer were being systematically beaten out of me.
Advocacy
Today, the inadequacies of surgical education and moral development are being exposed. The surgical profession exposes you at a very young and tender age to the day-to-day heartrending realities of human suffering, pain, sickness, and death. The bioethics education you receive these days prepares you to solve some complex ethical dilemmas. But it does not address the everyday moral conflicts that surround caring for one's patients, making difficult and morally disturbing choices, making observations of differential care, practicing surgery under the cover of anesthesia or behind drapes, and living with conflicts of interest. As trainees, living with all these challenges and moral distresses is not easy, but we must never become indifferent. We must always take the moral high ground and make prudent choices, all while keeping our souls as sensitive and human as ever.
Surgical culture is still very hierarchical and parochial in many places around the world. Superiors tend to reign supreme, and there are always attempts to suppress moral indignation. This is inherently unethical. Even if you are right, there must be a humble respect toward others' perspectives. The only thing certain about surgery is uncertainty. We must acknowledge these uncertainties and our own fallible positions.
Trainers must understand the potential to harness the enthusiasm, compassion, and moral instincts of their trainees. First, you must be conscious of the ever-present moral conflicts in the sensitive minds of trainees. You must always be able to read the invisible writing in every wrinkle on their foreheads that reads, "Fragile — handle with care." Never trivialize or stifle them, even if their issues sound insignificant. There are no foolish questions but many intolerant answers. Create a culture of support. They must feel confident enough to externalize their moral conflicts, self-doubts, disillusionments, and despair. Encourage them to open up, ideally by describing your own moral conflicts to receive their advice and opinions. There is nothing more reassuring than exposing your own vulnerabilities as a human being. Harness the inherent desire of the trainees to help the suffering, and go beyond.
The environment you need to foster is not meant to harden and cultivate indifference but to keep trainees soft, enthusiastic, and sensitive. They are looking for that help and support in making the transition to being virtuous surgeons.
