The captain of your ship and a bosun too.

in Medicine/Orthopedics by

The legal, ethical and aged (almost wise, but not quite) captain of the ship medical adage always stand true in any physician led health team. This autocracy is no more apparent anywhere else than that inside a surgical theater orchestrated by a feel god surgeon. I will not contest that Machiavellian theater governance (will write another post for that) but focus instead one ghastly annoyance that hound surgeons both inside and outside the OR once in a while. This:

You are always the captain of your ship but oftentimes, you need to be a bosun too!

I’m not sure if this is unique to any not so lovely practice environment but often something has to be done (short of putting a gun inside your mouth)  un-captainly in order to stop a captain’s sinking vessel.

Take this one anecdote shared by another surgeon in one far flung province here.

It was ten PM then when I receive a hospital call informing me of a VA victim who sustained open injuries to his right lower extremity. Already sleepy and tired from a surgery an hour earlier, I reluctantly hurled my ass to the ER and evaluate the patient around 10minutes after. While our hospital have 24 hour, “resident” staff physicians to attend to these emergencies, I rarely see one who makes an approximate diagnosis and institute an measures expected of a trained physician. So I need to go to the ER as soon as possible, if I need a better assessment of the patients status and institute immediate treatment myself less I get sued for malpractice for someone else’s missed steps.

Anyhow, I came in 10 minutes late and was horrified  that I neither have an x-ray of the patients injured extremity (he has skull, chest and abdominal x-rays that are all significantly insignificant somehow) nor a splint stabilizing his grossly deformed extremity. I asked the nurses (couldn’t find the resident inside the ER) why this procedures wasn’t done earlier (or even prior to calling me up) and they unanimously said none has been ordered at the time patient was brought to the x-ray room. The gaping wound plus the bleeding “fracture” is repulsive prompting them not to do anything but plug the wound with tens of OS and tens more of leukoplast. In the meantime, the patient is wriggling in excruciating pain (an NSAID was already given IM earlier though) as they waited for me to appear in the ER’s doorstep. Not interested in witch hunting at the moment  and keeping my composure “respectable”, I asked for sterile gloves so I can examine the wound, pack the bleeding properly  and then put some form of splint before bringing the patient to the OR. One nurse went scurrying for something immediately, which made me sigh in hope. But this was short lived as I soon discovered, he just actually made a prescription for sterile gloves! I said, “you gotta be kidding me! If this is not for my patient, I (and the patient possibly) could have walked away in sheer disgust over the incredulous situation I am with! But we have no choice but to make sanity out of this proverbial serendipity (composure some more). I took some moment to breathe. I went to the CR and peed while waiting for God to bring in sanity to this ominous chaos.And the sterile gloves.

On my way back to the ER I grabbed one pair of clean gloves and abdominal pack  from the sterilizing room, snatched a wooden handle from broom stick lying around, grabbed a newspaper and went back to the ER to do what I’m supposed to do. Then I waited for two more hours just so the patient can be cleared for OR. And I was ten minutes late?!!!

In the OR theater, the same operational amnesia goes on unabated. No available sutures, inadequate or barely working instruments, robotic assists with pillar like extremity dexterity and blurry dioptic visions. I get lots of stymied fans standing all around me doing everything except being helpful to the ongoing surgical orchestra. I cannot describe how I moved assess and turned OR cabinets to look for this and that but we managed to produced the needed stuff anyway.I bring a back up OR stash anyway for frequent detours like this. It was however, brutally exhausting and tension filled voices and breathing almost always kill the fun inside the OR. Luckily, the patient survived the procedure well and went back to his normal (drunk driving) life again despite the chaotic serendipity. Now, I know some hospitals are ill equipped and manpower deficient most of the time, but occasional like these are totally unacceptable if we want better service for our patients!

The poor surgeon obviously was holding himself in one piece and acted magnificently composed despite his horrific ER/OR encounter. For some, this incident is rather minor and might not constitute an annoying occurrence. Me however, in my zaniest complaining attitude, will whine in sheer frustration. Not this surgeon I guess. He simply went on doing some “extraordinary” stuff to fill in gaps in the proper delivery of health care service. We are abused in our training to do more than being just the surgeon. Who couldn’t forget having to buy sutures for your patients or pleading another patient’s extra OR needs during residency? Un-surgeon-ly? In our day to day encounters as a medical and surgical professional, we might find ourselves in similar situations and do one un-captain-ly act  for patient to recover uneventfully. You might  need to be as a resourceful and quick thinking para medic just so you’ll salvaged a patient. Or your career…

Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is Chief of Clinics at General Santos Medical Center and Medical Specialist II Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (www.remomd.com).