Lesser Surgeons?

I’m amazed at how surgeons in provinces surpass the seemingly insurmountable odds besetting their practice. I’ve heard of horrifying stories regarding provincial practice during my training, that I sometimes wince at the thought that me too shall join their ranks soon when I get back to my hometown.  Then I got the first hand “feel” of what its to be like a surgeon from the provinces.

In my first year of practice I remember managing one patient who sustained multiple closed fractures of the ankle and that of the leg. On treatment appraisal I found out the guy can afford an operative procedure for the (bimalleolar) ankle fracture but not that of the leg fracture. I was in a dilemma at that time since current evidence only supports good overall functional results if both fractures will be treated operatively at the same time. Treating the two fractures differently or separately will result to a less than good outcome the review further noted. I racked my brains out for a middle ground solution. I can find none more than speculative statistics. I presented this dilemma to the patient and let him decide based on the ‘literature” and statistics I was explaining. I was dumbfounded with what he told me after my lengthy explanation. “Do what you think is best doc”.

Not only that.  I  told the patient that because we don’t have intra-op x-rays in that institution, it’s either we risk infection bringing out the patient to the x-ray room during operation to check for fracture reduction or just feel out reduction and accept whatever comes out after surgery. His only answer was “do what you think is best doc”.

Inside OR, there were so many other things that are less than ideal and often “damning’ to surgeons. I’m pushed to use a manual drill because we don’t have a sterilizer fit for my power drill. No pneumatic torniquets. No reduction clamps nor suitable retractors. And did I say before we don’t have a c-arm or an intra-operative xray machine? None of the nurse assists is comfortable with my orthopedic instruments. If this surgery turned horribly wrong, I wouldn’t be surprised. So I made sure the patient knew exactly what are our risk and he too wouldn’t be surprised if this surgery go bonkers.

I don’t know how the patient’s surgery went well despite these never ending list of “have nots. He went through the surgery knowing all of these and it went well, save for the surgeons’ anxiety and stress. I couldn’t sleep before and after the surgery knowing the odds we’re getting through. Frankly, I’m scared more than the patient but choice is something limited for us during those times. The need outweighs the risk.

Nowadays, I stil encounter a few of these have nots in most of my ORs, and I’m just as scared as before. I always talk these oddities to my patients and secure their approval before performing any surgery on them under these situations. This doesn’t lessen my anxiety and stress level though. It just pushes me beyond my comfort zone trying out new things “unorthodox”  that are anchored on a logical framework I’m taught during training. Ultimately, need is such an impetus for innovation.

So I wonder, does these insurmountable odds make us- the”provincial” cutters, less of a surgeon?