The First Tracheostomy Assistance

Dr. Dev (fictional name) was posted in the Department of Cardio-Thoracic-Vascular Surgery (CTVS) of AIIMS, New Delhi, during his rotation posting while doing his junior residency in the MS Surgery course. This posting occurred after his Neurosurgery rotation posting. Both the departments were in the same building, CNS Center, but on different sides of the building.

A patient was to undergo an operation for Tracheostomy/Tracheotomy in the CTVS department.

In the Covid-19 era now everyone knows about the tracheal tube inserted from the mouth if a patient is not able to breathe on his own and artificial respiration given by ventilators. If a patient requires a tracheal tube and ventilator support for a long time, then the surgeon makes a direct hole (incision) in the front part of the neck, exposes the trachea (windpipe), and inserts a tube directly in the trachea through it known as tracheostomy or tracheotomy.

In the CTVS department, the assistant professors used to do the operation of tracheostomy with the Mch Senior residents assisting them.  The Mch senior residents were doctors who had completed their MS General Surgery degree course and now have further enrolled in the super-specialist course to become Cardiac surgeons after clearing a tough entrance exam.

Dr. Dev was on evening duty in the CTVS ward that day. The Mch senior resident on duty informed Dr. Dev to report to the CTVS emergency operation theatre to assist the assistant professor in the operation of tracheostomy.

As those of who had read the previous blog post, https://agnipathdoctors.blogspot.com/2021/08/the-first-tracheostomy.html

Dr. Dev had done many tracheostomies independently without any assistance during his neurosurgery posting, yet he was excited to observe firsthand how a faculty member perform the operation so that he can learn some fine points of the operation.

When Dr. Dev reported to the operation theatre, the assistant professor got angry on seeing that a junior resident had been sent to assist him. He angrily phoned and asked the Mch senior resident why had this under-qualified junior resident has been sent to assist me instead of an Mch senior resident. He made his displeasure clear to Dr. Dev who was shocked by his behavior. During the operation, he found fault in Dr. Dev’s assistance multiple times and reprimanded him for it.

Dr. Dev felt angry and sad at the same time. At one point he even felt like saying to the assistant professor, ‘Sir, you stand aside and watch me perform this operation without any assistance better than you’ but kept quiet out of respect for the faculty member.

He pondered on the irony. In the same CNS building, in the Neurosurgery department, Dr. Dev was performing the operation of tracheostomy independently without any supervision, and in the other end of the building in the CTVS department, he was considered not even fit to assist in the same operation.

In the same institution/company/corporation different departments and divisions may have a different policy regarding who is qualified to do some work. We have to mold ourselves and accept accordingly.

Sometimes you may be caught in the crossfire of inter or intra-departmental politics. At that time things were not so cordial between that Assistant Professor and the Head of the Department of CTVS as he was demanding an independent operation theater slot. It is probably because of this a junior resident was sent to assist him instead of a senior resident. Some of the anger of the assistant professor was due to this and not personally directed at Dr. Dev. Well, this is life.

People may form a judgement on your qualities and capability based on your post or background without trying to bother to find out your competence. In this case, the Assistant Professor got angry on learning Dr. Dev’s post as a Junior resident instead of finding out his previous experience. Accept it and take it as a challenge to prove yourself.

Read about the experience of an Mch GI Surgery aspirant when he was judged more on from where he had done his Master of Surgery (MS) degree course rather than his personal ability. https://agnipathdoctors.blogspot.com/2019/02/the-gi-surgery-viva.html

Read about the experience of a faculty member from AIIMS, Delhi, in the UK who was judged more on which country (India) he was from rather than his professional competence. https://agnipathdoctors.blogspot.com/2018/07/the-beginner-eye-surgeon.html

— ND

(Based on allegedly true incident.)

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal, and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board norms. 

 

The First Tracheostomy

 

During their Master of Surgery (MS) in Surgery postgraduate course, the junior residents of the Surgery department of AIIMS, New Delhi are posted for few months in the department of neurosurgery. One of the things which the junior residents used to look forward to during their neurosurgery posting was doing a tracheostomy.

 With the Covid-19 era now everyone knows about the tracheal tube inserted from the mouth if a patient is not able to breathe on his own and artificial respiration given by ventilators. If a patient requires a tracheal tube and ventilator support for a long time, then the surgeon makes a direct hole (incision) in the front part of the neck, exposes the trachea (windpipe), and inserts a tube directly in the trachea through it known as tracheostomy or tracheotomy.

Due to prolonged coma, there used to be many patients in the Neurosurgery department who used to require tracheal tube and ventilator support for a long time. The operation of tracheostomy was usually entrusted to the Neurosurgery Mch senior residents, who in turn used to teach the general surgery junior residents to do it. After some experience, the junior residents starts doing it independently without supervision, so that the senior resident is free to do some other important work. Most general surgery junior residents used to do their first tracheostomy and later gain mastery of the operation in the neurosurgery department.

After few days of posting the senior resident on night duty called Dr. Dev (Fictional Name), who was on rotation posting during his MS (Surgery) course in AIIMS, New Delhi. He told Dr. Dev that the patient in Neurosurgery ICU A on Bed no 2 requires tracheostomy and he will demonstrate to Dr. Dev how to do a tracheostomy. He also told him that they will do the tracheostomy in the ICU itself as the neurosurgery operation theatre reserved for tracheostomy and other infected operations was closed for repair. The senior resident fixed the time at 4.30 am in the morning.

Usually, there are many patients coming to the emergency department till 2 to 3.00 am and the neurosurgery senior resident used to be busy attending to such patients. There were usually no calls between 3 to 5 am so he will be free to teach Dr. Dev to do the procedure. Also by 5.00 am the operation will be over and both of them can start their respective morning routine work after that.

At 4.30 am Dr. Dev was woken up by the pager calling him to the ICU. As Dev had slept at 2.00 am at night due to ward work, groggy with sleep, barely able to keep his eyes open and stay erect on his feet, he reached the ICU. The Neurosurgery senior resident was already there and so was the anesthetist.

It was the anesthetist's duty to remove the tracheal tube via mouth when the tracheostomy is made and monitor the patient's vital signs such as heart rate, breathing rate, and pattern, O2 saturation, etc. during the operation. The operation theatre (OT) nursing staff had also reached the ICU with their instruments.

Just as Dr. Dev and the senior resident after cleaning their hands and downing their sterile gloves and gowns got ready to do the operation that the senior resident received a call to reach urgently the emergency department. Due to the emergency, the senior resident asked Dr. Dev to start the preliminary part of the operation such as cleaning the skin with disinfection solution, laying sterile sheets around the operation site to avoid infection, and giving local anesthesia injection, while he attends the emergency call and comes back swiftly.

With an anxious heart, Dr. Dev started the initial part of the operation. Before this Dr. Dev had never even seen the tracheostomy operation let alone performed one. Remember, this was before the days of YouTube and internet videos. The only good thing was that as he knew that he will get the opportunity to do a tracheostomy during the neurosurgery posting so he had read in detail about the procedures from the books available in the AIIMS library.

The preliminary part of the operation was now complete but yet there was no sign of the senior resident. The anesthetist asked Dr. Dev, ‘Why are you waiting? Complete the operation fast as the patient is not in a good condition.’ The nursing staff also asked Dr. Dev to start as they had to go back to the operation theatre for their other work. With palpitation in his heart, Dr. Dev made the incision (cut in the skin). He asked for the cautery device to further cut the deeper tissues as there was much bleeding.

In their general surgery OT, they had a monopolar type of cautery device. This was a pen-like device. Using electric current the tip of the device gets heated which then cuts the body tissue at the same time stopping minor bleeding due to the heat. The neurosurgery nursing staff handed him a forceps-like instrument. A surprised Dr. Dev asked what this is as he had never seen such a device ever in his life.

The staff nurse informed Dev that this is a bipolar type of cautery forceps and only this was used in neurosurgery OT. Unlike the pen-like direct action of the monopolar device, here you have to cut the tissue first with a surgical knife or scissor, and then to control bleeding you pinch the bleeding site with these forceps then activate the machine to heat the tissues. So now, in addition to doing the operation of the tracheostomy first time alone, without assistance, Dr. Dev had to learn how to use the new gadget on his own.

So the sleepy, tired, Dr. Dev using unfamiliar instruments proceeded in the unfamiliar operation, till he reached the trachea/windpipe. Now there was no turning back. Dr. Dev made the hole in the trachea, asked the anesthetist to quickly remove the tracheal tube from the mouth and he swiftly inserted the direct tracheostomy tube in the new opening. With the crucial part of the operation now over, Dr. Dev found new energy and confidence and rapidly sutured the tissues and skin around the tube, and asked for the dressing to apply around the wound. As he handed over the patient back to the anesthetist and ICU nursing staff for further care, he prayed that the OT nurse and anesthetist had not noticed how tense and apprehensive he was when he started the operation.

Even when you are sure that you will be playing the part of just an assistant or of being guided in some new activity, it is better to be prepared to take over independently if the opportunity presents itself.

One should not assume about the facility or instruments one will be getting in a new place or situation but should find out in detail beforehand. Not just in an operation but even in a simple thing such as lecture or presentation, we see people struggling with an unfamiliar computer system, mike, pointer device, etc. So go beforehand and find out what exact tools or facility you will be getting in a new or unfamiliar setup or place.

— ND

(Based on allegedly true incidents.)

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal, and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal, and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board norms.

The Cheteshwar Pujara Situation

In the previous post, we saw the difficulties faced by Dr. TP and Dr. Robert (both Fictional Names) due to their previous college. Please read it before reading this post at:

https://agnipathdoctors.blogspot.com/2019/02/the-gi-surgery-viva.html

In 2018, before proposed India vs England test series, Cheteshwar Pujara, an Indian cricketer, decided to play in the England county cricket from the Yorkshire team.

This was apparently to get him some experience in playing on England’s cricket pitches and against English Bowlers so that he will be better prepared for proposed India vs England test series. He had a streak of bad luck and had a poor showing while playing for the Yorkshire county team.

When the team for first India vs England test match was announced, Cheteshwar Pujara was not selected in the team. Some experts then commented that if Pujara had not gone and played in the Yorkshire county cricket team, he may have selected for the team based on his performance in the domestic cricket.

His plan of playing in the English county cricket back-fired and what was to be his strong point became the reason for his non-selection.

A similar thing got played out in front of Dr. Dev (Fictional Name) when he was posted in the rotation posting in the AIIMS, New Delhi’s Neurosurgery department.

Dr. Thomas (Fictional Name) got a temporary job as a non-academic senior resident in the Neurosurgery Department. Probably due to a combination of factors, his work was not up to the expectation of the Professor A.K. Mahatma (Fictional Name) who was the unit head.

When the time came to fill the form for the Pre-Mch admission exam for the various colleges, Prof. (Dr.) A.K. Mahatma strictly forbade Dr. Thomas from filling the AIIMS Neurosurgery pre-Mch exams form.

A surprised Dr. Thomas asked the reason for it.

Dr. Mahatama replied, ‘Your work is not found satisfactory by me. Even if you clear the theory part of the exam, I will not select you in the practical part of the exam. I will rather take my chance with a fresh unknown candidate who may turn out be bad resident, than selecting you who I know definitely to be bad.’

So, Dr. Thomas had a better chance of getting selected to AIIMS Neurosurgery department if had taken the temporary job in some other hospital to get experience in Neurosurgery, rather than to take the job in AIIMS itself.

In a temporary job in your dream institution or company, if you are able to impress your superiors by your work and personality, this may open the path to a permanent position there. But if you are found to lacking due to any reason, then this may backfire and your dreams and wishes may not get fulfilled.

So choose wisely even your temporary jobs or position and avoid a 'Cheteshwar Pujara situation'.

(Based on allegedly true incident)

— ND
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 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The GI Surgery Viva Solutions

In the previous post, we saw the difficulties faced by Dr. TP and Dr. Robert (both Fictional Names) due to their previous college. Please read it before reading this post at: 

https://agnipathdoctors.blogspot.com/2019/02/the-gi-surgery-viva.html

We will try to explore some solution to this problem.

One, apply only for the places where there is selection based on only your performance in the written selection exam and there is no interview or viva.

When a despondent Dr. Robert phoned Dr. Dev (Fictional Name) when the AIIMS, New Delhi’s Neurosurgery pre-Mch result was declared and he was not selected, Dr. Dev adviced Dr, Robert to only concentrate on those colleges who have only theory paper for pre-Mch exam and do not have viva or practical exam.

Dr. Robert followed Dr. Dev advice and next time he got selected for Neurosurgery from SGPI, where there was only MCQs based theory exam.

Another solution is to get a temporary job, such as non-academic senior resident in the related field or some prestigious hospital or company.

Dr. TP while continuing his preparation for the next exam got a temporary senior resident job in the GI surgery department of a prestigious hospital so that the stigma of lack of experience in GI surgery was removed. He got selected in Mch in GI Surgery from some other institute in the next attempt.

But while taking a temporary position/job or internship in your dream company or department beware of the ‘Cheteshwar Pujara situation’ which we will discuss in the next blog post.

 (Based on allegedly true incidents)

— ND
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 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The GI Surgery Viva

Dr. TP (Fictional Name) who wanted to do Mch [super-specializing after Master of Surgery (MS) exams] appeared for the AIIMS, New Delhi pre-Mch Gastro-Intestinal (GI) Surgery selection exam.

He was the top scorer in the theory paper and had first rank on the basis of theory marks. He was called for the practical and viva exam which had equal marks as the written exam.

Please note that the number of candidates called for the practical and viva exam is usually three times the seat available. As there was three seats available in the Mch GI Surgery course in AIIMS, New Delhi, at that time, the top nine candidates on the basis of theory marks were called for the practical exams. The final merit list was to be made after combining the marks from the theory and the practical exam and only the top three students were to be selected.

During the viva when the AIIMS, New Delhi’s GI Surgery faculty learned that Dr. TP has done his MS in General Surgery from Khota Medical College (Fictional Name), the atmosphere of the viva changed.

The examiners told him as he had not been exposed to the complex and advanced GI surgeries being performed at AIIMS, New Delhi, during his MS residency, he is not a fit candidate for Mch in their department.

Dr. TP’s effort to convince them that he is a quick learner and he has the requisite theoretical knowledge as he had already topped the theory exam, did not cut the mustard with the examiners. Dr. TP realized what Charles Caleb Colton has so aptly said: 'Examinations are formidable even to the best prepared, for the greatest fool may ask more than the wisest man can answer'.

When the results were declared, as expected Dr. TP was not selected for the Mch course. On the basis of the combined marks in the theory and viva exams, he was ranked fifth in the merit list.

A similar thing happened to Dr. Robert (Fictional Name), who had again done his MS degree in General Surgery from Khota Medical College. He appeared for the AIIMS, New Delhi’s pre-Mch exam for Neurosurgery. He was first in the theory but after the practical and viva when the final results were declared, he was last in merit and therefore rejected.

Where we have studied or worked previously may cast a black shadow on our personal achievements. We may not get our dream job because the examiner or selector is not impressed by our previous college or company. We may not get a chance to show our capabilities closing the door of future growth for us.

The reverse may be also true. Many have reported that undergraduates from AIIMS, New Delhi are preferred candidates in the various medical colleges in the USA as compared to other colleges from India.

We will discuss some solutions to this problem in the next post.

(Based on allegedly true incidents)

— ND
© Author. All rights reserved. 

 

Please Note: Original post was updated/Edited on 7th Dec 2022

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 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Driver Patient

The driver of the District Collector (Head of the Local District Government Administration) got injured and suffered Head Injury. He was taken to the local government hospital, from where he was referred to SMS hospital, Jaipur, as the Neuro-Surgeon was on leave. Rather than risking a transfer to Jaipur via a 4-5 hour journey in the serious condition of the patient, the relatives decided to take the patient to the only private hospital in the city with neurosurgery facitilies.

Dr. Dhramraj Agarwal (Fictional Name) was working selflessly in the city as the lone neuro-surgeon for the last seven years without any recognition from the government. He attended the driver normally as he would attend any other patient and operated him for the head injury of which he made a good recovery.

Sometime later, when the Indian Republic Day (26^th January) came, to his surprise, Dr. Dharamraj Agarwal was honored by the district administration at the district level Republic Day function for his excellent services in the medical field.

The person close to center of power assumes as much importance as the center of power itself. It is like the sun, the moon, and the stars. The stars are actual sun but as they are far away they appear as a pinpoint of lights. The moon without having any light of its own shine brighter than any star as it is near the sun. So, good deed done to patients/persons close to the administration may earn you recognition faster than years of selfless service.

The naïve persons / doctors ignore this fact much to their regret sometimes. They are the people who treat everyone equally. At the other end are the persons who try to ingratiate themselves in the good book of the powerheads to get name and fame.

  

 (Based on true incident)

— ND
© Author. All rights reserved. 

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Poor Prognosis Sign

Please Note: This article is intended only for Doctors and medical undergraduate and post-graduate students. Non-Medicos please do not read this article.

In trauma patients with severe injury where chances of survival are bleak, it is essential to get the fact across to the patient. Since the trauma occurs unexpectedly usually in a fit person, the fact that death can occur sometimes does not register in the shocked mind of relatives.

Even if the treating doctor conveys the fact, if death does occur, the relatives sometimes blame the treating doctor. They allege if the doctors had told them clearly that there was a risk of death in their patient, they would have taken the patient to some other center / hospital for better treatment.

Dr. Dev (Fictional Name) met with his friend, Dr. Dharamraj Agarwal, (Fictional Name) a prominent Neurosurgeon, of the city and asked about this problem as he routinely sees many serious cases of Head Injuries with a high death rate.

Dr. Dharamraj said, “In serious cases, I keep on explaining to the relatives that there is the real risk of their patient dying till I know that they have clearly understood this fact.”

“There lies the problem,” said Dr. Dev. “How do you know that the relatives have clearly understood the risk of dying of their patient?” asked Dr. Dev.

Dr. Dharamraj replied, “I just keep on explaining repeatedly until one or two relatives start crying.” “This is one indicator that the poor prognosis has been clearly understood by the relatives. If the attendants do not exhibit appropriate signs, I keep on hammering the facts till it hit home.”

 (Based on true incident)
— ND
© Author. All rights reserved. 

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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