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...