anonymous

13th October 2018

THE PASSAGE OF THE DENTURES - 7

THE PASSAGE OF THE DENTURES - 7

DR H.L. CHULANI

 In the hierarchy of the operation theatre staff, the top rung is occupied by the chief surgeon, the anaesthesiologist followed by the assistant surgeon, chief theatre sister, the senior resident, the junior resident (the latter often vies with the theatre sister for the fourth rung), the circulating nurse (so-called because she moves around and provides the missing items), the junior nurse and finally the theatre attendant. I remember my days as a junior resident when the dirty work had to be done by me (when I say "dirty” , it does not imply unclean work, but what would be considered as menial in surgical parlance). This would involve changing of dressings of wounds, putting or changing plaster of paris of fractures and the many bric-a-brac associated with surgical work. Three incidents remain vividly in my mind though more than 25 years have elapsed since I was a junior resident.

The first incident occurred after the completion of a hydrocele operation and the assistant surgeon asked me to complete the dressing. A hydrocele is a disease where fluid collects in one or both scrotal sacs which normally house the testes. After the operation, a firm dressing is given to prevent blood from collecting in the loose tissue of the scortum. Today, ready suspensory supports are available for this surgery. But in the district hospital where I worked, this was not available and one had to do with the ordinary bandages. I attempted to do this only to see the bandage coming loose. I tried again and again and to my mortification saw the bandage in a bizarre shape on the scrotum. On seeing my discomfiture, the theatre attendant who, as I have already mentioned occupies the lowest rung in the hierarchy, came to my rescue, saying: "Saheb, can I help?". And what followed was a lesson to me. He did the bandaging so beautifully that not a thread was out of place. He taught me the various tricks of this difficult bandage and I still can do it perfectly, though I have changed my speciality.

The second incident occurred when a patient was brought to the casualty with a history of a jam bottle (whether it was Rex or Kissan, I do not recollect!) having slipped into the rectum. The patient suffered from a condition called a rectal prolapse and each time the rectum came out, after he had a bowel movement, he would sit on the upturned jam bottle and help the rectum inside. This time the jar entered the rectum along with the prolapse and there was no way the patient could pass it out. He was taken to the operation theatre. In such a situation one has to decide whether to remove the object from the natural passage, the anus, or by opening the abdominal cavity and then making an incision in the rectum and delivering the object from above. Now making an incision into the rectum from above involves certain hazards and can lead to complications. But we were in a quandary as to how to remove the bottle from below. The idea of using obstetric forceps (the ones used to deliver difficult babies) was given up since it could lead to breaking the jam bottle and damaging the rectum. It was then that the theatre attendant again came to our rescue. He suggested that since the open end of the jar was facing downwards, we could fill the jar with bandages treated with plaster of paris, allow it to harden and then pull down the bottle. This is exactly what we did and thanks to the ingenuity of the attendant, were able to extricate the jam bottle without any injury to the rectum and without having to open the abdomen. The theatre attendant in both the incidents described had been working in the theatre for nearly 30 years. This only proves that mere learning from books is not enough and experience goes a long way in treating patients. Every surgeon during his training days learns a lot from experienced theatre attendants.

The third incident involved a case where an incorrect diagnosis by me led to the removal of the rectum for what was thought to be a rectum. I was an intern (a period immediately after pass M.B.B.S.) and a middle aged man came complaining of pass his stools. On finger examination, I felt an ulcer which I diagnosed as malignant ulcer and showed the case to the chief surgeon who, after examination, confirmed my diagnosis.

Normally, after the examination, one takes a tiny bit from the suspicious area and sends it for histologic examination and the confirms the same after studying the tissue under the microscope. We did not do this since we were in a district hospital and this facility was not available to us. The tissue had to be sent to Bombay and there about three to four weeks. The senior surgeon undertook the operar removed the rectum and constructed an artificial opening in the abdominal wall for the passage of stools. The patient developed serious infection the post-operative period and as an intern I would do his dressing daily, each dressing taking upto an hour. He recovered. The rectum which had been removed was sent for confirming the diagnosis. The report when we received it about five weeks later, said that there was no cancer and is was then that we realised to our horror that the rectum had been removed for an entirely benign condition. The patient having recovered, was grateful for the cure and before going home brought some fresh vegetables from his farm as a gift to us. Can you imagine the paradox? Here were doctors who, because of their stupidity, had removed the rectum for a noncancerous disease and were being given gifts for their ignorance!