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Well, helloooooo Strangers.
It has been over two and half years since I last posted and it has taken me a long time to finally decide to knock on this door again.
When I first started blogging, I wanted to write about everything that mattered to me, in an honest and truthful way. In a world of political correctness and judgmental self-proclaimed ‘experts’, not to mention medico-legal confidentiality issues, it was difficult to for me to blog without anonymity. I did my best to be non-specific about my identity, so that I could stay true to my blog (i.e. to be honest about how I felt and to be able to write about real events without violating confidentiality). The medical fraternity is a very small world, especially in my specialty which is predominately male. It became increasing difficult to field specific comments and personal emails without being deliberate dishonest or misleading in an attempt to hide my identity. I was not prepared at all for the onslaught of people who were not just happy to read my blogs for what they are (a female surgeon’s perception of the world, or just a story); there were those who wanted to ‘expose’ me in my personal and professional life, some well-meaning, but majority of the time not necessarily in a positive way.
I did not start my blog to ‘advertise’ my business. I did not write my posts to ‘seek attention’. I joined WordPress because I love telling stories, and I love writing. I have been told by non-medical people that I have a knack for making Medicine easy to understand and humorous at the same time, and I just wanted to refine my ability to do so because it is something I enjoy immensely: to let everyone see the health profession in a positive light. At the time I found a perfect outlet in blogging, because it was the ideal way for me to explore different writing styles, to expressed the ‘wanna-be-writer’ in me, and respond to the variety of reactions my posts have evoked in people. Not to mention, I have ‘met’ some pretty awesome fellow bloggers and made great friends in the process. Many of whom I was so happy to find are still blogging.
A few months ago, I was truly honest with myself and asked the hard question: What was it that made me feel uncomfortable when people started confronting me about my true identity? I knew it was because once I have lost my anonymity, I felt uncomfortable to put down in writing on how I really felt about things. Then I snickered at myself as a voice within me sneered, ‘did you just hear yourself?’ What I was really saying was that I was afraid of what others would think of me and I was ashamed of my opinions. So, it was self-preservation that kicked in two and half years ago and stopped me from writing.
I never took myself as a coward.
That’s when I gave myself a hard mental slap in the face. Why should I be ashamed? And why should I be afraid? I should be proud of who I am and where I am in life. I don’t claim to be an expert in everything, even in the area I have been trained. I don’t push my opinions onto others, or tell people what to do. I simply tell a story the way I see it, or voice an opinion formed by my experiences.
I am dedicating my first ‘return’ post to all my friends on WordPress. I sat down to write today because I have just spent the weekend reading all the comments you have posted on my past blogs. I could still feel the positive vibes and the encouragement each one of you have put on my page. But more importantly, I realised that it was not just blogging that I have missed but also all of you with your warm funny comments that I used to read with my morning coffee. You are the reason I wrote today.
So here I am, standing on the threshold.
*Warning: this post contains graphic descriptions not suitable for the squeamish
Christmas Eve (nearly 10 years ago)
Hand trauma call on Christmas Eve was always busy. Typical presentations included people who cut their hands with Stanley knives wrapping or making presents, housewives with stab wounds in the left palm, mostly from the knives slipping whilst they were trying to wedge an avocado seed out (use a spoon, ladies!), or clueless men who cut their fingers trying to open a can without a can-opener. Work was steady, I had been running between admitting patients in ED (Emergency Department) and operating in theatres all day. I was a junior registrar, only nearing the end of my second year training in plastic surgery. There was not a lot a second-year was supposed to do without senior supervision, however, I had been on this hand surgery team for nearly 12 months now, so I was accustomed to performing routine hand trauma surgery such as infections, lacerations, tendon repairs and simple fractures without calling my senior registrar in.
Our on call had two tiers – if I was out of my depth, I was to call the senior registrar (a final year trainee), who usually came in to give me a hand. If he/she needed help, then the consultant plastic surgeon on duty was called for either over-the-phone advice or had to physically turn up at the hospital. The nurses and other doctors could also bypass the junior registrar to call either the senior registrar or consultant if they felt that the junior was out of his/her depth, or doing something that may have not been in the best interest of the patient. Rarely, the consultants were required to be on site, apart from major complex hand trauma cases, which luckily were far and few in between. This was because our country had very strict firearm laws, motorcyclists also had to wear protective gloves by law and it was illegal to buy fireworks and firecrackers without a licence.
The senior registrar I was on call with was two weeks short of becoming a consultant. He had just passed his specialist exams and was finishing off his final rotation. Throughout the year I had been on call with Peter several times, and I knew he did not like to operate late at night. I had learnt to book all the more complex cases in the mornings and avoided doing procedures I was not comfortable with at night in case I needed him. As for the consultant who was on call over the Christmas weekend, Dr H, he lived by the motto: ‘Don’t be afraid to cope’. His phone was only to be used for nothing short of life and death. He never came in on call, unless the patient had private health insurance and was willing to pay for their surgery. It was unheard of for a junior registrar to call him directly, we valued our lives too much.
Back to my Christmas Eve, the day was progressing smoothly – at one stage, it looked as if I may even get home for Christmas Eve dinner. As I was writing up the last operating notes for the day, my pager went off. The tone indicated that it was a trauma call from ED. Probably another car accident. Guilt flooded me, but I couldn’t help smiling. This meant that no other cases could proceed unless it was life-threatening, and most likely this particular trauma case, if it made it to the operating theatre, will keep the emergency theatre occupied until early hours of the morning – therefore I could not do anymore hand cases tonight, even if they started piling up in Emergency. A trauma call at 7pm not only meant that I could go home for dinner, but that I may also get to sleep through the night! My steps lightened as I headed towards the ward to see my postop patients before heading home.
As I was about to finish the evening round, my pager went off again. This time with a phone extension from ED. I shrugged, whatever they were holding down there will have to wait until the morning when the trauma case is over. I headed to the desk and punched the numbers into the phone. ‘Tiff here, what you got?’
‘Oh, Tiff,’ it was the trauma reg on call. ‘Hey, I am so sorry mate, but I think this one is going to be all yours. You are going to love it, consider it my Christmas present to you.’ An evil chuckle followed.
I raised an eyebrow. We rarely get involved in trauma calls. Even if the patient had concurrent hand injuries, we only ever get the call a few days later when their main injuries have been taken care of.
I sighed, ‘I am on my way.’ With heavy footsteps and visualising all my evening plans disappear above my head in an imaginary puff of smoke, I headed to the elevator.
My colleague was not wrong. The patient was cleared of any serious injuries. The only trauma he suffered was that to his right hand. Mr D was a 65 year old right handed, retired lawyer. He was finishing off a rocking horse he made for his 6 year old grandson. He found the handle a little loose, so decided to re-fashion the rounded piece. However, when he was trimming it with a bench-top mounted circular saw, the wooden rod slipped and he ended up putting all four fingers through the saw instead. They were all taken off at base and was handed over to me unceremoniously by the nurse in a plastic bag.
After meeting the fingers, I went in to introduce myself to Mr D, noting that his injured hand was wrapped up firmly like a boxing glove to try and stem any bleeding. I looked at his x-rays of both the hand stump as well as amputated parts to assess both the level of amputation and the metal work that may be required to reattach the digits. After having had a serious chat with Mr D, I took the bag into another room and laid all four amputated fingers on the bench top. Then I took a marker and printed on each finger which ones they were. I checked the amputated ends and silently offered a prayer of thanks that the saw was high speed and sharp, as all four fingers showed clean guillotine-type amputation rather than avulsion-type injuries associated with slow oscillating saws. The latter usually involved more extensive injuries to tendons, nerves and vessels which often make replantation difficult with very poor outcomes. Even though the prognosis was looking good for Mr D, my heart sank. Replant surgery took hours to perform; one finger alone could take up to 4 hours, and I was looking at 4 fingers. There was no contraindication for me not to replant any of the fingers, as all of them looked clean-cut and despite his age, Mr D was otherwise fit and healthy, thus suitable for a long anaesthetic.
I checked Mr D’s details and smiled when I realised that he had private health insurance. Dr H would love this case, it was well known that replantation of a finger was well-paid by insurance companies. Remuneration for four fingers would be equivalent to almost a whole year’s private school fee for one child. I picked up the phone and rang Peter. He was also glad to hear that the patient had private health insurance, and promptly asked me to ring Dr H. I protested, as it wasn’t appropriate for me to contact the consultant directly. Peter said that since Dr H will have to come in to do the surgery anyway, there was no point for him to see the patient, and if he hadn’t seen the patient, he didn’t know enough details to talk to Dr H. He told me that Dr H would be pleased to hear from me.
I was naïve and believed him.
So I rang Dr H. At 8pm Christmas Eve.
To say that the conversation was unpleasant would have been an understatement. Dr H was livid that I had contacted him. He told me that he was having Christmas Eve dinner with his family and had no interest whatsoever spending the night operating. He was not interested in the patient’s insurance cover, and if the patient had presented at a public hospital, then he was to be treated as a public patient by training registrars regardless of his insurance status. Dr H then told me that under no circumstances was I to call him again directly, especially about this case. I could almost hear the phone being slammed down when the disconnection clicked in my ears.
I called Peter, as this is going to be a major complex case, so he had to come in. There was no way I was expected to carry out this surgery on my own even though I have read this procedure in detail and knew the basic principles. In practical terms, however, I had only seen two similar cases performed before and assisted in one. This was definitely not an operation that followed the rule of surgical training of ‘see one, do one, teach one’. Only the most senior of trainees were allowed to perform it unsupervised.
When I told Peter about my conversation with Dr H, he swore and made disparaging comments about lazy consultants. He then told me that he was having Christmas Eve dinner and he couldn’t possibly get away, so I would just have attempt the surgery on my own. I almost dropped the phone in shock, and protested that I was too junior to take on such a case. He told me that he is more than happy to talk me through it and give me advice on the phone, but he could not physically come into the hospital. I glanced at the clock as we were talking and realised that it was nearly 8.30pm. This meant that warm ischemic time for the fingers was over 2 hours now (as his injury was around 6.30pm). Warm ischemic time referred to the amount of time the fingers had been without blood supply while it was not on ice. If the fingers were to have the best chance of survival, they needed to be reattached within 6-8 hours of warm ischaemic time. Whereas cold ischaemic time could be extended to 24 hours. However, there had always been controversy associated with reperfusion injury and poor nerve regeneration with prolonged cold ischaemia.
I knew that staying on the phone arguing with Peter was delaying Mr D’s treatment, so I finally acquiesced to Peter’s request (much to his relief), and finished the phone call. I quickly documented both phone calls in Mr D’s chart and then rang theatres to let them know that he was coming up for a very long surgical procedure. While the transfer was taking place, I went to the office and pulled the hand surgery books off the shelf (this was before Google days). I quickly familiarised myself with the chapter of replantation again. Then I took the bag of fingers with me to the operating theatre. The nurses were still preparing equipment and the anaesthetist was just starting to put Mr D to sleep, so I set up an operating table in the corner, cleaned and tagged all the nerves and vessels at the amputated end with micro-sutures under the microscope, to save me time later on looking for them.
I knew I only had 4-6 hours to re-establish blood flow into these fingers. I also knew that if I did not plan this well, it would be at least 12-16 hours before I could get them all perfused, as normally it would take around 4 hours just to complete a one-finger replantation. So I devised a strategy in my head, part of which included planning ahead. Firstly I made sure all the equipment I required were ready to go, then I got a bucket of ice and put the fingers (wrapped in plastic) in it. I was trying to buy an extra hour or two by swapping warm ischaemic for cold ischaemic time.
As soon as the patient was asleep, I inflated the tourniquet on the patient’s arm, to stop any blood flow into the hand so that I could work in a bloodless field (and see what I was doing more clearly). I prepared the stumps on the hand and again tagged all structures under the microscope ready to be joined to the other end. Then, under x-ray guidance, I reattached all of the fingers with wires to realign the bones. This was achieved within 2 hours. Then I had to let the tourniquet off, as stopping blood flow to the arm for more than two hours could cause muscle damage in the arm and hand. Often if we needed to have the tourniquet on for more than 2 hours, we allowed blood reflow for 15 minutes between each tourniquet period; this was sufficient to minimise any lasting damaging. So I wrapped the hand tightly in a bandage to prevent excessive blood loss and un-scrubbed for quick coffee break while the tourniquet was down. I knew that for me to work efficiently, I needed to be alert at each stages of surgery, so I deliberately planned to use these reflow times as my breaks.
After 15 minutes, I spent the next 2 hours of tourniquet time repairing the tendons. There were two tendons in each finger, so that meant repairing 8 tendons altogether. Unfortunately when the tendons were cut under tension (as it was when one’s hand was gripping an object), the tendons retracted into the palm. Luckily I had thought of this during my stump preparation earlier on (while the fingers were on ice), thus I had already dissected out each tendon and pulled them back out, ready to be reattached.
At this point, I am sure most of you would be wondering why I didn’t join up the blood vessels first – if re-establishing blood flow into the fingers was so important to be done in a timely manner. Well, the reason was that both the bony and tendon work required a lot of retraction and manipulation of the fingers. If I had rejoined the blood vessels first (which were around 1-2mm in diameter and the threads we used to sew them together were thinner than human hair), then any traction or movement would have easily disrupted the repair. The repairs were also too frail to hold together unless there was some form of structural stabilisation of the fingers. The easiest way to explain it would be to equate it to constructing a building; one wouldn’t put the plumbing in place until the walls, beams, struts and foundations have been established.
Once all eight tendons were adequately joined, it was time to let the tourniquet down again. This was perfectly in plan with joining up the arteries (which brought blood flow into the fingers). Each of the fingers had two of everything, two arteries, two veins (vessels which allowed blood to flow out of the fingers), and two nerves. Arteries were best joined when the tourniquet was off, as blood flow often dilated these tiny vessels, thus made it easier to identify and place the stitches. I worked furiously under the microscope, with the aim to connect up only one artery in each finger as quickly as I could, thus to re-established blood flow into them within 8 hours of total ischaemic time. I breathed a sigh of relief when all four finger became pink on the table. I looked up and it was just before 2am. Then, at a less pressured pace, over the next 4 hours while the fingers were happily alive, I connected up the rest of the arteries, veins and nerves.
Unbeknownst to me, during those 10 hours as I was working quietly away, phone calls were being made outside. The nurses and anaesthetic staff were aghast that a second year trainee was attempting this procedure alone. The operating theatre nurse manager called Dr H and told him that I was performing the case on my own. Dr H told her that it was Peter she needed to ring. Peter was rung, and he told them that I had said I was happy to do the case alone and did not need him. He reassured her that he would have come in if I was having trouble. The nurse manager did at one stage poke her head in and asked if I was ok, and I just assumed it was a courtesy visit so I told her I was fine. Peter then rang the operating theatre about midnight to ask how I was going, he spoke to the nurse who picked up the phone. The nurse offered to put me on to speak to him directly, he declined. Apparently he didn’t want to speak to me and just wanted her to pass on a message. The message was that he was about to go to bed and if I was struggling, or feeling tired, I was to put whichever fingers I hadn’t attached back in the fridge on ice and rebook the patient for surgery tomorrow so that he could reattach the remainder fingers in morning. I snorted at the message in a very unladylike manner (much to everyone’s amusement as it matched their sentiments exactly) and kept going. No one made another phone call after that.
So the fingers lived. Mr D had the full hand of fingers to compliment his uninjured thumb when he left hospital 5 days later. He had a long road of rehabilitation ahead of him, but he was thankful that we managed to save all of them. I got called into the office by the Head of Department (HOD) on that same day as Mr D was discharged. The HOD had received an incident report from the Nurse Manager about how inappropriate it was for such a major complex case to be done by a junior doctor alone. I received a thirty minute lecture about biting off more than I could chew as a junior trainee, followed by another fifteen minutes on learning to know my limitations and recognising the need to ask for assistance.
A few days later, at the end of my last clinic with the team, I saw both Dr H and Peter being pulled into the office with the HOD. I asked the nurses what was going on and they told me that the HOD saw Mr D’s chart in clinic and asked them why this patient was in a public clinic when he was privately insured. All the nurses avoided giving him an answer so he flipped through the admission notes himself.
The following week, I had already moved onto another rotation at a different plastic surgery unit when I received my assessment report. I read, with surprise, what the HOD had written:
Tiffany improved well above her training level as a second year trainee during the last 12 months. She showed initiative in difficult situations and exhibited good insight in her abilities. She demonstrated natural aptitude in microsurgery. I would strongly recommend her for ongoing training with any plastic surgery unit.
Peter became a consultant and moved in with Dr H as his partner in private practice.
After three flights in 30 hours, and a 2-hour drive at manic speed across the Austrian border, we have finally arrived home for Christmas. When I say home, I mean hubby’s family home in Eastern Europe. Although this is definitely not the first time I have spent Christmas with the in-laws, this place is a vast contrast to our home in Australia so I still need to switch on my adjust button whenever I come here.
On arrival, Mamka would laugh in genuine delight at the sight of her first born, one that she has not seen for far too long. Amongst the excitement, 87-year-old Babka would lift herself out of the chair, making sure no one notices her difficulty. The traditional three kisses on the cheeks are exchanged all round, and as usual, my cheeks are patted by weathered hands for good measure. A rowdy exchange occurs between the two brothers; they slap each other’s backs amongst verbal insults. M and I take off the layers of our winter gear, while his brother mumbles at the weight of our luggage as he drags them across the threshold.
M’s mother, grandmother (or Babka as she’s fondly known), and 34-year-old brother live in an apartment in the town centre. This is a 2-bedroom apartment that has not been touched since the 1960’s, the whole floor plan would fit easily into our lounge room. It would be unheard of for us to stay elsewhere when we visit, even though his brother has to move out of the second bedroom onto the lounge room sofa to accommodate us. The décor of the apartment has not changed since M’s parents have gotten married and moved in in the early 70’s. Old cupboards in orange pine lacquer line the walls, each with scratches and peeling edges. The shelves are bent in the middle under the weight of timeworn books, vintage ornaments and items of all sorts for the last 50 years. Childish stickers adorn the glass panels of these cupboards; old photos, trophies and toys line the benches, all live documentations of his childhood.
The apartment is in desperate need of renovation. The toilet flushes but does not rest evenly on the floor, thus it rocks if one sits down on it with full weight. The small balcony off the kitchen French doors shows cracks in its concrete floor, barely strong enough to hold any human weight but serves as a perfect spare fridge/freezer in the cold winter months when the outside temperature is barely above 5 degrees Celsius. The bathroom holds a bathtub that is as old as the apartment itself where one still has to shower the old fashion way – sitting, soaping one handed whilst wrestling a shower head with the other hand. The stove and oven is one that is only seen in a museum nowadays with iron holders and old racks. The sink is barely large enough to fit a soup pot; old plastic drying racks rests on top of a laminated bench. What dishwasher? I would have gladly purchased one for them, but not only is there no space for such a luxury, but they do not actually have the appropriate plumbing to fit one.
The ‘second’ bedroom really is the front sitting room and part of a passageway into the main bedroom (which is shared by mum and grandma), thus there is no privacy to speak of. Babka lies in her bed most of the day, watching soap operas with the volume dialled up, as she is not one to admit to the need for a hearing aid. Occasionally she ventures out of bed for the essentials, one of which includes a cigarette and a glass of beer every couple of hours. It is a regime which prevents pressure sores and satisfies her curiosity as to what everyone else was up to. She never goes outside the apartment anymore; the osteoarthritis in her knees prevents her from walking more than a few steps at a time. A cane sits stubbornly ignored by the door and whenever her knee is mentioned, she would hold onto the cupboard and do a little jig just to prove that it is all a figment of our imagination.
Everyone smokes continuously in this household, everyone, that is, except us. This is irony at its best considering M is a heart and lung surgeon. Cigarette smoke constantly permeates the whole apartment, which then infiltrates into everything in our luggage, a reminder of our visit when we move onto the next European destination. Opening windows to air the apartment is never an option, as the bitter cold of European winters, when permitted to slip inside, renders the heating systems ineffective.
It is not uncommon for us to escape the apartment with long walks, the biting wind and icy footpaths a better alternative to the indoor haze. Once rugged up, with gloves and a rubber soled boots over wool-covered feet, we would tackle the local hill up to the township castle, or trudge by the icy river at the base of the retaining walls. Two hours of fresh air not only flush out our smoke-ridden lungs, but also brings sanity back after being stuck in a small shared space. Hubby is often silent on these long trips, as he takes a rest from being bombarded, not only with the latest local gossip, but also with questions about the latest developments in his life from his mother and grandmother. This is also a time when he enjoys a reprieve from being the translator between the three women in his life. It is a concept that the older women do not seem to understand as they continually talk while he tries to translate to me, until he gives up – usually by the end of the first day of our visit, at which time they berate him for not involving me in their conversations.
Breakfast is not for the faint-hearted here. Mamka would get up around 7.30am. She sits down at the vinyl covered dining table, leisurely enjoys her first cigarette before her preparations. An hour later, we would wonder in, with hubby being in charge of the coffee and I, in charge of toasting sliced bread. Once everything is placed on the small dining table tucked in the corner of the closet kitchen, Babka shuffles in on her slippers and in her pyjama dress. The first meal of the day starts with a shot of Vodka or Cognac, of which she knocks down in one toss with a big satisfied sigh. A black coffee is then savoured with toast and homemade spread. The spread alternates between the fishy one (a blend of sardines, mackerel, mayonnaise, butter, and mustard), or the cheesy one (a beaten mix of blue cheese, beer, butter and seasoning). This is accompanied by freshly sliced brown onion, radish and strips of paprika. Often with a look of disdain from Babka, I stick to my jam or marmalade on toast. As I daintily chew through my breakfast and sip my coffee, I would recognise the word ‘princess’ in conjunction with my name as she comments on how I eat ‘like a sparrow’. Once breakfast has been consumed, a cigarette is then lit, accompanied by a shared bottle of beer. As an excuse to get away from the fumes, I would volunteer to do the dishes. In reality, it is not the meal which bothers me. No, it is the burp that comes out of hubby about two hours later when we are on our walk, when he decides to steal a kiss, at which time a rumble starts in his stomach and releases as one toxic explosion in my face. One might think I am swooning at his kiss, but I can assure you that it is no other than the stench which permeates my nose for the rest of the day.
Christmas here is celebrated on the 24th, at four o’clock in the afternoon, as the winter sun descends rapidly behind the hill, we head to the town cemetery, armed with bags of candles, matches and fresh greenery. The place is full of people and constant traffic passes by the gate. It is an exercise that may take time depending on how many friends and acquaintances Mamka runs into. At every visit, we hear the story of whom each graves belong to, and stories of the deceased. Candles are lit, the marble headstones are cleaned, and the greenery is laid on each family grave. She mumbles a prayer quietly and we move on. The walk home is usually filled with peace, places of interest are usually pointed out. This is where M went to high school; that way is where Mamka used to work, and this is the road that leads up to Babka’s old house.
Dinner is usually served around seven, in the small lounge room that barely fits a sofa, two lounge chairs and a rectangular glass coffee table. His brother is made to remove his pillows and blankets, and he is in charge on turning the lights on the Christmas tree. The smell of fresh pine leaves from the tree cuts through an odd mixture of stale cigarette smoke and evaporated oil of deep-fried carp in the lounge room. Family crystals, silverware and porcelain are laid out on Christmas-themed table clothe. A round of Vodka or Cognac is shared as a toast to health before the meal starts. Grace is spoken, with blessings bestowed on all at the table, where Mamka paints a cross is on everyone’s forehead with a honey-soaked garlic clove. This is rather troublesome for one who sports a fringe such as myself – for the rest of the evening, I have to try and ignore the discomfort of having my dark locks plastered to my forehead, not to mention the slow descent of excess honey into my eye lashes and my nasal tip as we work through the courses.
Entrée consists of poppy seed pudding with poppy seed coated prunes. Once we are floating on poppy-induced Christmas cheer, the fish is served with a potato salad. Beer is consumed like water, and one is never allowed to rest on an empty glass. As we munch through our meals (eating carp is never a graceful affair), we again listen to both older women tell the story of how each dish came to be part of the Christmas tradition. It was an eclectic mix of the two families. Your father’s family didn’t like fish, so they always had cabbage soup. We never had the prunes coated in poppy seeds, that’s something your father’s mother brought into the house.
An apple is cut by grandma after the mains, and if a star is found when sliced in half, it bodes good luck and prosperity for the new year. It therefore doesn’t take a genius to figure that the apple need to be cut perpendicular to its core, although it can be nail-biting in case worms are found in a rotten fruit, disrupting a perfect star-shaped core. Dessert is a self-serve affair, consisting of chocolates hanging from the Christmas tree. Sometimes this could be a little sparse when the sweets mysteriously vanish from the branches during the days before Christmas Eve. Mamka however always have a spare stash for such an emergency, of which she hides in the TV cabinet next to a large collection of DVD’s until required.
Presents are given and opened before the stroke of midnight. Each person is given the attention and time to open their presents and thank the giver. By now if the poppy-seed doesn’t make one happy, the beer would make one exuberant about any present, no matter what it may be. Without doubt, Babka would run a dry commentary on each present revealed whilst happily nursing her umpteenth glass of beer in the large lounge chair.
This is Christmas. A tradition that my husband has shared with his family since he was born. A tradition that makes me grateful to be a part of when I am here, as a member of this small loving family.
Vesele Vianoce to you all.
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Some days I am a little sick of the stereotyping inflicted on me as a Plastic Surgeon, so I am here to put all the urban legends to rest. There are plenty of myths about plastic surgery from both public ignorance and misconceptions established by shows such as ‘Nip Tuck’.
Myth #1 We use plastic.
Once I had a young tradesman whose face was smashed up by the windscreen in a truck rollover. Just before he was put to sleep (and this is after I have spent an hour explaining to him how I was going to put his face back together), he asked me, ‘So doc, where do you put the plastic?’
*Insert eyeroll*
I have lost count the number of times I have been asked that question. Plastic surgery doesn’t mean we play with plastic or put plastic in people. In fact, if we were to use any form of prosthetic device, it is usually silicone. The ‘plastic’ in plastic surgery is derived from the Greek word plastikos. It means to change shape, or to mould. The aim of plastic surgery is to change the shape of any part of your body, for cosmetic or functional reasons.
So, sorry folks, we don’t shove blocks of plastic into people.
Myth #2 We can perform surgery without leaving a scar or we can remove scars
Here’s a couple of frustrating conversations I have regularly with patients every week.
Scenario one:
Me: We have to make a cut around the skin cancer on your face to remove it. Once we stitch it up, it will leave a straight line scar.
Patient 1 (outraged) : A scar? But you are a plastic surgeon; I have come to you to have this done so there will be no scars.
Scenario two:
Me: I hope you have recovered from your fall last month. Your cut lip has healed really well since the stitches came out, it looks great.
Patient 2: I hate it. I can’t believe you put a scar on my lip; I want you to remove it.
Ok people, I know plastic surgeons are incredibly good, but we can’t perform miracles. Where there is a cut, there will be a scar. We can’t remove scars either. If you want scarless surgery, you should have had your surgery done when you were a foetus – that is the only way to perform surgery without leaving a scar. And if you want us to stitch up your injuries, it was not me who had created those scars; it was your stupidity in falling into a window whilst you were pissed.
So what makes us better than others in scarring? We stitch differently to other surgeons, we use finer sutures, we know how to hide and minimise scars. We have techniques which can camouflage or improve scars. We have the knowledge and means to treat bad scars.
So, apart from making people look hot, we can make your scar look sensational too. But unlike God, we cannot remove history which has been carved onto your body.
Myth #3 All we do are boob jobs, facelifts and buttock enhancements
‘I don’t understand why I have to come to see a plastic surgeon to have my skin cancer cut out, it’s not like I want a facelift or something,’ said the man sitting in front of me with a fungating growth coming out of his nostril. Unfortunately, I was the one who had to break the bad news to him, that the cancer in his nose was so big that we would have to amputate his nose. Any surgeon would be able to remove his cancer, but he would be left with a hole in the middle of his face. The reason he needed a plastic surgeon was because we can remove the cancer and reconstruct his nose.
The acronym for our specialty is actually PRS – it stands for Plastic and Reconstructive Surgery. There are two components to our work:
Reconstructive surgery: which is surgery to improve and restore function, to minimize disfigurement and reconstruct structure which was lost due to trauma, disease, cancer or birth defect. Basically, our job is to fill up a hole anywhere on the body. Sometimes we excise tumours ourselves, but often we work in tandem with other oncological surgeons such as orthopaedic surgeons who resect bone and soft tissue tumours, ear nose and throat surgeons who resects tongue, nose, throat cancers, as well as breast surgeons who perform breast cancer surgery. The way I see it is that my oncology colleagues are the ‘destructive’ surgeons and I am the ‘constructive’ surgeon. I remember when I first started training I was hesitant as to how much margin to take around a tumour. My supervising surgeon took me aside and said, ‘Just remember, Tiff, the reason you are going to be a plastic surgeon is because you are not afraid to make a big hole. Unlike other surgeons, you can fix holes.’
Aesthetic or cosmetic surgery: which is surgery to enhance, or to rejuvenate a specific body part, it is designed to improve a person’s appearance by reshaping facial or bodily features. So yes, we get a chance to make people beautiful. We make boobs bigger, smaller, perkier or firmer. We lift up butts, thighs, arms and faces (not specifically in that order). We inject, insert, eliminate and suck to enhance contours. There has not been a single part of the human body that a plastic surgeon has not attempted to alter, although I gladly admit that I have had no training or experience in anal bleaching – nor am I interested in expanding my field into that area.
Myth #4 Our work is frivolous and we perform non-essential surgery.
As my husband (who is a heart and lung surgeon) sums it up succinctly, ‘Honey, I save lives, you just make the world beautiful.’
Even though spoken in jest, unfortunately it is a view held by many, including hospital administrators, insurance companies and sadly, our colleagues in other specialties. I have had medical students who did not attend their plastic surgery sessions with me at the clinic because they feel that it is not something they need to learn about. I was once told by a second year student that plastic surgeons are not real surgeons who practice ‘true medicine’.
People seem to forget that plastic surgery is not just about cosmetic surgery, but that the most important aspect of our role is to improve a person’s self esteem. No matter how much the self-help books may claim about not placing too much importance on one’s appearance, and to stop using your looks to determine your self-worth, the reality of life is simply – people do judge you by the way you look. And that includes yourself.
It is amazing the difference we sometimes see in our patients. Like the 12-year-old boy who was constantly teased at school for his bat ears – he got it fixed before he started high school. He became a completely different person; he happily went to the barber to have him shaggy long hair removed, started going out with his friends and strutted into my office at 8 weeks postop as if he owned the world like a typical 12-year-old boy. My favourite last month was a 30-year-old mother who had a nasty burn scar over her neck and chest from a childhood hot-water scald. The scars stopped her breasts from developing properly and distorted whatever little breast tissue that did develop. After surgery to correct the deformity and implants to provide shape, she swapped her oversized jumpers for tailored dresses, and started becoming more involved in mother’s groups. She wore a pink singlet with a pearl pendant dangling in her new cleavage when she came to her appointment, despite the visible old burn scars which covered her neck.
Surprising it may be, we do perform surgery that saves lives and limbs. We are often called upon to join small blood vessels under the microscope for organ transplantation in children. We reconstruct the neck after throat cancer, so that the patient can still eat, drink and breathe. We put fingers back on after they have been accidentally severed, and we transplant soft tissues into smashed up legs that otherwise would have had to be amputated.
Unfortunately our work often goes unrecognised, as throughout history, we have had to repeatedly fight for our patients’ right to access plastic surgery. When hospitals have budget cuts, our operating lists are often the first to be cut. Breast reconstruction after cancer was the last one they slashed from our hospital, because once the cancer has been removed, it is no longer considered life-saving surgery. Health insurance companies which exclude plastic surgery cover leave their members with a policy which pays for the cancer removed, but not the plastic surgical procedure to reconstruct or repair the hole.
Admittedly I sound like I am trying to justify our existence, but I truly believe that even though we are not saving lives every day, our work makes a siginificant difference in people’s lives.
Myth #5 We date our patients
There seems to be a misconception that we fall in love with our creations. I explored this particular issue with my male colleagues. The answer was a categorical no, although they have had plenty of invitations from patients to cross that line. Not only is it ethically wrong and fraught with medicolegal implications, it is also rather disturbing that someone would fall in love with an image they have created, which may have nothing to do with the actual person underneath.
Myth #6 We make lots of money because we charge ridiculous amount of money
I am not blind to the fact that as a plastic surgeon, I am often the target of many sarcastic jokes about money. This not only comes from patients, the general public, but sometimes our own colleagues in the medical fraternity. When I was sitting my specialist board exam, one of the candidates for general surgery taunted me, ‘I think your essay question would be on whether a Maserati is better than a Lamborghini.’ I was not shy to show him the finger as I sweetly replied, ‘well, I do hope you know the answer to your essay questions, which hole to put your finger up.’
Once I was leaving work, and one of my patients walked past me as I was putting my bag into the boot of the car. He took one look at my ten year old Toyota Corolla and shook his head. ‘Oh, doc, you need to get a new car, people would think you are not very good if they see you driving that car.’ I just shrugged and said, ‘Don’t worry Mr B, I leave my Ferrari in the garage for weekends.’ At his stunned look, I had to tell him I was joking.
It is not uncommon sometimes for our patients to comment on the cost of surgery, especially if it involves cancer surgery. For some reason people seem to think that we should do their surgery out of the goodness of our hearts if they have cancer….. but that’s another story altogether. One of the reasons that plastic surgery costs a lot more money than most other surgery is the rebate from health funds are low (because our procedures are not deemed to be a necessity), but also our practice has a lot of overheads, especially with wound care, garments, implants and dressings. We also employ a greater number of staff than other specialties, because there is a lot more patient contact time pre and post operatively. Plastic surgery patients and procedures are more complex to organise, and often requires various number of phone calls and coordination. Not to mention, our patients are usually high maintenance and requires constant reassurance.
Yes, some of us drive Aston Martins, stay at 6 star hotels, wear Gucci and walk in Louis Vuitton, but we work hard for it, and our responsibilities may not be life and death, but there is still a lot of stress involved in our surgery because we know the end result will have a life-long impact on our patients’ life.
Myth #7 We drive fast cars, hang out with celebrities, party like animals, snort cocaine and have the most glamorous life of any doctors
This is simple. We drive fast cars, because we have very busy lives and have places to get to. That’s my excuse and I am sticking to it. And trust me, my Corolla is pretty fast.
The only celebrities we hang out with are those that come for treatment. As I don’t perform a lot of cosmetic procedure, most of the celebrities I have contact with are those who have injured themselves or need reconstruction for cancers. They don’t usually act anything like celebrities when they are in my office and the last thing they need is for me to ask them for a selfie.
We try to party like animals, but often our job stops us. We are notorious for pulling out of social commitments at the last minute. One of the worst thing about being a reconstructive surgeon, is that our colleagues take all day to remove the cancers, and we have to sit around waiting for them to finish (or we may have to watch them so they don’t destroy our reconstructive options whilst cutting out the cancer). Once they are done, they piss off to enjoy their evening, while we start our work, usually at the unsociable hour of 4-5pm, working well into the night to patch up the ‘mess’ they have left behind.
What glamorous night life?
As for cocaine, yeah, I know colleagues who do it at parties, but honestly, it usually doesn’t take long for the Board to find them. It is rare that a plastic surgeon is stupid enough to risk their career and reputation to develop such an expensive habit.
Myth #8 We all have had some ‘work’ done on us
I would not deny that some plastic surgeons have had work done, but not all. Although I can’t say the same for the wives or staff! Personally, I don’t trust anyone enough to have plastic surgery done on myself and it is a little difficult perform a facelift on yourself when you should really be asleep throughout the procedure. I know colleagues who inject themselves in the mirror, but I have this unusual need to close my eyes when I see needles coming towards my face, so the results would be rather questionable if I went down that path.
Most of my staff have injections, not because I force them, but it is something I offer them if they want it. And who could say no to free Botox? Because I am very conservative in my treatments, my staff are actually free advertisements of my work. When one of my staff admits to having treatment, the patients are reassured that they won’t look like Jocelyn Wildenstein when they leave my practice.
But, truthfully, the greatest benefit in giving my staff Botox is its efficiency in stopping my practice manager frowning at me and my receptionist frowning at my patients.
Myth #9 Our practice staff are picked for their looks
So, supposedly, this means that our staff should be beautiful young girls with faces full of injectables and look-at-me enhanced breasts. I mean, it is free advertising after all, and who would’t want to be surrounded by luscious females?
Truth number 1 – Most surgeon’s practices are run by their wives. So, which wife would be stupid enough to surround her husband with gorgeous young things?
Truth number 2 – Young girls who are obsessed with their looks don’t usually have the right personality nor the prioritisation skills to run a business well.
Truth number 3 – Experience comes with age. So unless you want to be surrounded by rookies who have no idea what they are doing, you would pick more ‘mature’ staff members to make your own life easier.
Truth number 4 – Patients and clients sometimes find perfection intimidating. They are more comfortable talking about their inadequacies to someone who has flaws as they feel that someone would understand what it is like to be ‘ugly’.
Myth #10 We can make Queen Latifah look like Heidi Klum and vice versa
This is the ultimate myth. I always know it is going to be a difficult consultation when a 5’3, 200+lb person walks in and slaps a picture of Gisele Bundchen on my desk.
So here’s my spill:
So, we may be Plastic Fantastic, but we are really just like any other regular surgeons. We cannot perform miracles, and we cannot change who you are. You need to speak to either God or a Shrink about that one.
One morning I found a note on my desk from my secretary. It said:
The Medical Director at St X would like an appointment with you to check that everything is going well for you at St X.
It wasn’t unusual to get a ‘summon’ from the Medical Director of these private hospitals. Usually, it is a low-key chat to make sure that the private surgeons working there are not having issues with the operating theatre equipment or staff, and that they have no complaints about ward care of their patients. It was just over 2 years since I have started bringing patients into St X for my surgical lists so I was expecting an invitation from the MD sooner or later.
I asked my secretary to shorten my next St X operating list, and arrange an appointment with the MD afterwards around 5pm for me.
This was the conversation:
MD: Hi Dr T, thanks for taking the time to see us. So, how’s everything going?
Me: Great. I have had no problems, the theatres are great, the nurses on the ward are helpful, my patients have had no complaints. They are liking the private rooms and….
MD: (Nodding vigorously and leaning forward to cut me off). Well, I want to talk to you about Mrs Y.
Me: Oh? Is she causing problems with the staff?
Mrs Y was a patient of mine on the surgical ward whom I had just admitted two weeks ago. She was a teacher in her late 50’s who sustained severe spinal injuries when she was a teenager and is now wheelchair bound. Mrs Y was also a long term insulin dependent diabetic who unfortunately had severe ketoacidosis last year and ended up in ICU, ventilated for 2 months. During her illness, they didn’t look after her pressure areas so she ended up with severe grade IV pressure sores over both the ischium and sacrum by the time she was transferred out of ICU. She was then discharged from hospital with this problem as no one wanted to deal with it whilst she was an inpatient. Mrs Y went back to teaching, and spent hours every day in her chair. When her blood sugars started to deteriorate and her family doctor noticed an unpleasant smell during one of her visits, it led to the discovery of her persistent pressure sores. By the time she came into my office, she was hyperglycaemic, septic with infection as both pressure sores were wide and deep enough for me to put two fists in each. I could see her ischial bone at the base of one, and the rectum at the base of the other, and because she was incontinent from her spinal injury, the wounds were severely contaminated with faeces as she sat in the wheelchair in her soiled diapers. Understandably, both her and her husband were by now, agitated and frustrated with unhelpful medical staff and hospitals.
I admitted her into St X, because it was a large tertiary private hospital with all specialties on hand. She required an urgent endocrinology review, infectious disease input, a general surgical procedure to divert her faecal output via a temporary colostomy, dressings and pressure care. Needless to say, she started to improve within 7 days. She required intensive nursing care with four times a day dressing change (to prevent accumulation of pus that was continually exudating from the wound) and two hourly turns to prevent development of new pressure sores while she was bed bound.
Mrs Y, at the beginning of the week, cranky from feeling ill and hating being bed bound, was not the best compliant patient. She was a teacher after all and did not like being told what to do. She was also a little distrustful of the nursing staff as it was poor nursing care in ICU which resulted in her current problems. However, after seeing herself improve over a week, she became the most pleasant and grateful patient on the ward. She helped the staff by setting an alarm clock and turning herself so that all the nurses had to do was to pop their heads into her room and check that she was in a different position. She also changed her own colostomy bags so that the staff didn’t have to deal with this particularly unpleasant job. The nurses told me that they enjoyed looking after Mrs Y.
I was rather surprised that the MD had brought her up in our meeting.
MD: No no, nothing like that at all. (He cleared his throat awkwardly). Patients like Mrs Y, well, we find it hard to accommodate them in this hospital.
Me: I know, I know, spinal patients should really be in dedicated spinal units, but there are no private spinal facilities for these patients. Mrs Y has been paying her private health insurance for over 30 years, so she didn’t want to go to a public hospital; she wanted to be looked after in a private hospital.
MD: We understand that, but private health funds in general don’t pay us very much for looking after patients like her. She requires intensive nursing care so we actually don’t get any profit for such a heavy nursing load.
Me: (Speechless for a second) So, let me get this right. You don’t want patients like Mrs Y because her admission doesn’t generate enough profit for the hospital?
MD: I just wanted to make you aware of this, so that you will remember in the future not to bring patients like her into our hospital. We would prefer day surgery patients, but if you feel strongly about keeping them overnight, we are more than happy to accommodate that. As for Mrs Y, I believe you are planning to keep her in hospital for a while?
Me: Yes. At least 3 months.
Both Mrs Y and I had a long discussion about this. She had agreed to take a whole semester out of teaching and come into hospital to have her sores treated properly. This meant bed rest with appropriate pressure care, no sitting in her wheelchair and regular dressings. I had explained to her in depth that if we could make her overall health better, these sores may heal without intervention. If not, they may need an operation. However, even with an operation, she will need to be off the surgical wounds for 6 weeks before she could sit on them. She knew she was in for the long haul, because she didn’t just bring her suitcase when she checked into the hospital, she also brought her Nespresso machine. According to Mrs Y, 3 months was a long time to go without good coffee.
I watched the MD’s face cringe.
Me: I can’t rush the healing process, and I have to wait for the infection to settle.
MD: Maybe you can find a little operation for her so that we can get a little more money out of her health fund during her stay?
Me: But she doesn’t need an operation. She just needs dressings.
MD: We are probably going to lose money if she stays that long.
Me: Would you like me to transfer her to the public hospital? (The MD looked up at me with surprise and a glint of hope in his eyes). I could just say to Mrs Y that St X doesn’t want you here because they are unable to make a profit out of your stay. They think you should really be in a public hospital despite the fact you have paid your private health premiums for the last 30 years…..
MD: No, no. (He started to clear his throat again). There is no need for that. I suppose since we are a hospital affiliated with the church, we can show charity by letting her stay her for a while.
Me: Righto. Is that all? (I started to get up to leave).
MD: But, (he stopped me turning towards the door), if you do a few more of your cosmetic cases here at St X’s, it may compensate for her stay.
He stood up and reached out to shake my hand.
Me: Well, I cancelled two breast augmentations this afternoon because of this meeting. I have transferred them to my lists at another hospital tomorrow.
I ignored his hand, turned to open the door, and walked out of his office without a backward glance.
Mrs Y stayed for the full 3 months and went back to teaching full time, sitting in her wheelchair with a beautifully healed bottom.
When I was reading about the Ebola outbreak last night, I thought of my time in Taiwan during the SARS epidemic. So I went back to the diaries I kept during this time and found couple of interesting entries. I was there as a Fellow in one of the world famous plastic surgery units during 2003. A Fellow is a young doctor who travels to another hospital unit to train for a specified period as a ‘trainee’ doctor, usually to learn from a specific doctor or a particular procedure/technique.
I have left this entry unedited, as it is a true perspective of an Australian living in Taiwan during the SARS epidemic, both as a doctor and local resident.
25th Aug 2003
It’s been more than two months already since the first wave hit Taipei. I still remember the panic that hit the city during that first week; it was when they closed down Ho-Ping Hospital in central Taipei, with all its patients and staff isolated within the hospital. It was constantly being aired on the news and the hospital exterior was being videoed 24 hours a day, a bit like reality TV. There were scenes of flying badmington cocks over the railings of the balcony, and I remembered the presenter reporting that it was great to see that the occupants of the hospitals keeping up their spirits, and exercising to keep fit. The comments from my male colleagues in the TV room at the time were less than polite. I think something was mentioned about there are better things to do when you are couped up with a whole bunch of young nurses. *eye roll*
Then there were news of individuals who were to be isolated at their own homes because they’ve been in contact with SARS suffers. After which, news of non-compliant isolated individuals venturing out of their homes were reported with the police were called to herd them back home. They have now posted guards around quarantined buildings to stop residents from ‘escaping’. Cases were on the rise, another hospital got shut down, and the mortality is starting adding up.
I have missed my chance to go home. Four weeks ago our department director gathered all the overseas Fellows in his office to let us know that if we wanted to go home and leave the country, he would still be happy to write us a certificate for our fellowship and recommend us for jobs back home. There were 7 of us, two from Harvard in the US, 2 from Italy, 1 from UK and another from Ukraine. The Ukrainian and I stayed. It was really a blessing in disguise, because now, instead of elbowing other Fellows out of the way for an opportunity to do cases, we are both operating more than 12 hours a day. I joked to my concerned parents back home that I spend so much time in the operating theatre with its filtered and uni-direction airflow, I am probably at the lowest risk of getting any respiratory virus. They weren’t amused. Wherease my boyfriend just said that if I got SARS, he wasn’t coming to visit. I’d like to believe that’s anger and frustration talking. I can understand why he’s so pissed at me. I think I would be too if our positions were reversed.
The one thing I have discovered about living in this SARS epidemic is that there seem to be more pregnant women than usual at the moment. One nurse mentioned to me that since we have to take our temperatures every day as required for all hospital staff, she has finally managed to get pregnant during her last cycle as she knew her exact ovulation date. A fellow colleague also mentioned that you can pick the pregnant nurses during this epidemic, as they are usually the ones wearing an N95-grade mask. These are heavy duck-billed masks which have viral filters and are very hot and uncomfortable. Most staff members such as myself (who want to breathe and admittedly am a bit blasé about the whole thing) just wear the regular light ones.
Oh well. You’ve gotta learn to see the bright side of life when living in an Epidemic.
Administration has been harping on about wearing the right masks, but I seriously believe that if I wash my hands (which are raw from scrubbing all day), and keep away from sniffling, slobbering people, I’ll be fine. I have been avoiding public transport as much as possible. I have blistered on my feet because it takes me one hour each way, walking to and from work. After 8pm, I just sleep in one of the spare beds in the Burns Unit. I suppose I am like every other deluded doctor at the moment, we think we are being ‘adequately’ careful and probably invincible.
A thought just occurred to me. If I die in this epidemic, I won’t be able to hear ‘I told you so.’
Well, I guess if I am not back tomorrow, you know I am being ventilated in ICU with SARS.
The Holistic Wayfarer from A Holistic Journey has lined up a series of stories about money from a selection of guest bloggers. It was a great honour to be invited to be part of this series, writing amongst some of the most interesting bloggers around!
Surgery at Tiffany's 