Maiden flight into a patient’s chest

I hope that I don’t send my readers in a tizzy, if I let them into a secret.

This is that every surgeon is very occasionally forced into performing a surgical operation, which he has not assisted at, perhaps not even seen.

This is because the surgical domain is vast and growing in leaps and bounds.

In spite of specialisation which restricts our scope, we cannot possibly capture the whole paranoma of surgical techniques in a three or four year training, which we undergo before qualifying as a fully fledged surgeon and let loose on the unsuspecting public!

Nobody in that period can claim to have mastered all surgical procedures in his specialty. Occasions do arise when the surgeon has to walk a path not trodden by him before and sometimes do so without a roadmap.

As a comforting reassurance, let me add, however, that the surgeon’s basic training does prepare him adequately to deal with such contingencies, without exposing his patients to any risk.

To give an example, in every surgeon’s professional life, especially in our setting, situations do arise when he is the only one available and hence has no choice but to take the plunge and a calculated risk.

The only other option is to be a coward and leave the patient untreated. Now surgeons have many faults but shying away from a challenge – head on – is not one of them.

I must confess to be in such tight spots a few times and every time I rose to the challenge. I will relate one which is a sharp reminder of the time when I had to refer to the text book of operative surgery and rehearse the procedure in my mind.

I then took courage in both my hands and proceeded to do the best I could.

Mental trauma

As they say, sometimes our best is not good enough. To relieve my readers of a painful suspense, let me announce at the outset that there was a happy ending for the patient and, though it might not have been my best, it was good enough to save my patient’s life.

The only one who suffered mental trauma was the poor surgeon who, because of the stress, must have formed a large plaque on his coronaries!

The saga started with a phone call from the Accident & Emergency department. ‘‘We have a bus conductor here who got into an argument with a passenger over the fare in Eastleigh and was stabbed in his left chest,’’ Dr Karanja informed me. ‘‘He is bleeding badly from his wound and is breathless!’’

Those two pieces of information left no time to discuss the matter further on the phone and I dashed to the Emergency section.

On arrival there, I was handed the file of Mr Ogutu by the Sister. The large padded dressing on the patient’s chest was soaked with blood and the excess blood was dripping on the floor from the couch.

As I did a quick examination, Dr Karanja informed me: ‘‘I have ordered four units of blood and the radiographer has just taken a portable X-ray.’’

‘‘Good,’’ I said looking at the glucose running into Ogutu’s vein. On finishing auscultating the patient’s chest, I realised that we were dealing with a stabbed lung from which air and blood had escaped and were pressing on the lung.

As if to endorse my clinical diagnosis, the radiographer arrived in a timely manner and put the chest X-ray on the viewing box.

‘‘You can see the dark shadow caused by air and blood,’’ I instantly started my tutorial, reading the X-ray to the junior staff around me.

‘‘There is the lung in the corner, collapsed by pressure from the surrounding air and blood,’’ I continued pointing at what looked like a squeezed sponge.

I had just finished describing the X-ray findings when the Sister showed us the pulse, respiration and blood pressure chart of the patient.

The triad of fast pulse and breathing and falling blood pressure left no option but to open Ogutu’s chest without any further delay, stitch his stabbed lung and stop the copious haemorrhage which would soon turn fatal.

‘‘Ring Dr Robertson Glasgow,’’ I said to Dr Karanja. ‘‘And tell the theatre to prepare for a thoracotomy.’’ Dr Mary Robertson Glasgow was the anaesthetist and thoracotomy meant opening the chest.

What I did not disclose to any one was my own dilemma. The strictly compartmentalised surgical training I had received in England had scarcely prepared me for chest surgery.

I knew my way around the abdomen but opening the chest and skull was treading on unfamiliar ground. While Dr Karanja went about his task, I rushed to the hospital library.

There were five dusty volumes of illustrated operative surgery lying on the top shelf. I knew that the series consisted of 16 volumes and, seeing only five, I hoped that the one on chest surgery had not been poached by my predecessors!

I was in luck and quickly looked at the diagrammatic rendering of opening and closing the chest and repairing an injured lung.

I read and reread the detailed description, illustrated in colour and then walked with slow deliberate steps to the operating theatre.

There was no chest surgeon in the vicinity to turn to; indeed there was not one in the country. General surgeons like me had to treat the whole body from top to toe.

My spirits were not particularly raised when I met Dr Robertson Glasgow outside the surgeon’s changing room. ‘‘Are you sure you need me?’’ she asked.

‘‘Of course I do. Why do you ask?’’ I was surprised.

‘‘I have just seen the patient,’’ she replied, ‘‘and it looks that you might find an undertaker more useful than an anaesthetist.’’

Though I agreed with her assessment, I was not amused. I was also surprised because it was not like her to speak like that.

‘‘There is a tap running inside the chest of this man,’’ I replied, ‘‘and I have to stop it to save his life.’’ My voice was strong but I could hear the palpitations in my chest. I was wondering if I was equal to the task.

‘‘I might as well tell you that I haven’t done many open chest anaesthetics,’’ Dr Robertson Glasgow declared.

This announcement dismayed me further but explained why she was talking as she did. My photographic memory helped me as I made a curved incision on Ogutu’s left chest and removed a rib to give me access into his chest cavity.

‘‘God must have done this to Adam to create Eve,’’ I said to Dr Karanja. Obviously, nervousness prompts some unusual remarks and I was suffering from the same disease that my anaesthetist was ailing from.

As we entered the cavity, we were faced with a sea of blood, bright red, fluid and clots – and lots of it. Dr Karanja sucked the blood and I just picked up the large clots with my hands.

I put these in a receiver the Sister was holding. ‘‘There is the culprit,’’ I said looking at the tear in the lung with an artery furiously spurting blood with each heartbeat.

I put a special clamp on the lacerated lung to stop the bleeding while I stitched the torn lung. There was an eerie suspense as I did the intricate procedure.

Silently, I thanked Charles Rob and Rodney Smith, co-authors of the 16 volume illustrated operative surgery series.

After reading their treatise, the procedure seemed so easy. My confidence was further bolstered when Dr Robertson Glasgow quite casually remarked:

‘‘Chap seems to be picking up.’’ ‘‘The blood pressure is up and the pulse rate is down,’’ she said.

‘‘Home and dry,’’ I said when I finished and we had waited a couple of minutes to see that there was no renewed bleeding.

‘‘Can I expand the lung?’’ my anaesthetist asked.

‘‘Sure,’’ I said as she pumped air through the tube she had inserted in the patient’s wind pipe and I saw the lung slowly expand like a balloon and fill the chest cavity.

It was past midnight when I reached home. I slept fitfully wondering what the morning held for me. I need not have worried because sitting in his bed, Ogutu was enjoying his breakfast of bacon, eggs and sausages.

I had just managed a cup of tea! I looked at the bottle connected to the patient’s chest, a routine post-operative requirement after chest surgery. The fluid level in the bottle was rising with every inhalation and dipping as he exhaled.

Three days later, a routine chest X-ray showed that the lung had remained expanded and Ogutu’s chest tube was removed. A week later he went home.

I took Marie out to dinner to celebrate my solo maiden flight into my patient’s chest, hitherto on uncharted sea for me. A month later, Ogutu came for his routine check-up.

‘‘You know, doctor,’’ he said to me. ‘‘I was too ill to mention it but you looked very ill at ease when you saw me.’’

I thought I might as well come out clean. ‘‘It was a combination of nervousness and stress.’’ As Ogutu continued staring at my face, I added: ‘‘Because I had never opened a chest before.’’

‘‘That makes two of us,’’ Ogutu, looking at me with kindly eyes, replied. ‘‘In my 22 years’ service with Kenya Bus, I have never been stabbed before!’’