A cut-and-shut affair

photograph of a surgeon operating

Lanesborough House, the historic St George’s building at Hyde Park Corner, closed suddenly in 1980 when its state of disrepair became a danger to the public. The new hospital was not yet finished, so the consultants had to temporarily occupy Victorian wards in Tooting that were awaiting demolition. I did my surgical house job in the building site where I had been interviewed six years earlier.

It is more than forty years since I was a house surgeon. As I have written about it, I have been surprised by the rawness of my emotions about a distant time in my life. I suppose that time rarely heals humiliations. My post was a cut-and-shut affair, made up of several ill-matched parts. The first three months involved looking after a handful of patients for two consultants whose main activities centred on St James’ Hospital, Balham.

There was a marked, and rather awkward, contrast between the two surgeons I worked for. One was James Gillespie, the charming Scottish laird and vascular surgeon from my first surgical placement as a student. I remember him with considerable warmth. My feelings for the other consultant, on the other hand, are almost entirely negative, because his behaviour was habitually horrible. He died ten years ago, but I am aware that people who cared about him may read this. I really do not want to upset them, so I shall refer to him as MK. Inevitably, it is not difficult to identify him, not least because his conduct made him notorious.

MK specialised in surgery on the bile ducts, which are thin tubes leading to the small intestine, carrying digestive enzymes from the pancreas, and bile from the liver via the gall bladder. MK had qualified as a doctor in 1963, but in 1981 he had only recently been appointed to a consultant post. He had established a reputation for obnoxiousness during his long years as a junior doctor which he continued to nurture in his new role. His “colourful” behaviour was mentioned in indulgent terms in a Royal College of Surgeons obituary. As far as I can see, “colourful” was a euphemism for “inappropriate” in this context. The obituary reports that he was a warm and generous host to those he invited to his home, which casts his behaviour at work in an even worse light. The difference between MK at home and at work suggests that belittling junior staff and students was a knowing choice. Just as the on-calls when you were repeatedly woken were worse than the nights when you never got to bed, so it might have been easier to bear MK’s bullying if James Gillespie had not been so supportive

MK may have had lamentably poor interpersonal skills but his surgical skills were superb. He was by no means the only St George’s surgeon who behaved badly. He was not necessarily the worst. It was well-known at the time that regressive school playground behaviour was tolerated by the dominant medical culture, especially amongst surgeons. Quite possibly, MK had redeeming features that I failed to notice. To be fair, he rarely shouted at the nurses. I never openly objected to his misbehaviour when I worked for him. I acknowledge that calling it out now that he is dead looks suspiciously like cowardice. Habitual bad behaviour is not universal amongst senior doctors, and I have believed throughout my career that it should not be tolerated. I have challenged it within psychiatry. My failure to do so early in my career is understandable, but not necessarily excusable. I took the view at the time that I was working briefly as a surgeon because I had to, not because I wanted to, and that I just had to endure the experience until I could get on with my life. However, looking back, it was wrong to have said nothing. Temper tantrums and unpleasantness were not harmless idiosyncrasies. They had a tangible effect on patient care. They probably still do, because such behaviour has not been eradicated from hospital medicine.

Some people find assisting at operations exciting, but I found it tiresome. It involved standing still for long periods. Dressed in scrubs, gown, cap, gloves and mask, I invariably became over-heated and sweaty. After an hour or so in latex gloves, the skin of my hands would go mushy and a rash would develop. Assisting generally involved pulling on a steel retractor for long periods, unable to see much of the action. These instruments give the surgeon space to operate. The pulling must be done correctly, so as to avoid damaging internal organs. This meant that it was difficult to find a comfortable posture. Operations conducted by MK were protracted affairs, punctuated by irritable outbursts and insults. Occasionally, he would throw a surgical instrument on the floor.

photograph of surgical instruments and tools

Assisting James Gillespie was not so bad. He operated extremely quickly, with a correspondingly low rate of post-operative wound infection. He politely told me what he wanted me to do, and periodically stopped to show me what he had done. His conversation could be very funny. Over one operation, he complained bitterly that the water rates bill for his house was much larger than for his gatehouse, which was rented by a young couple. This was apparently because the gatehouse had one toilet, whereas his main house had six. The difference in the water rate was, he said, a gross injustice. Both properties housed two people, and “physiologically, my wife and I cannot be producing six times as much shit as the tenants”.

One of the commonest emergencies in vascular surgery arises when a major blood vessel becomes blocked. An engineer came to St George’s A&E directly from his workplace with a very sore big toe. He was a smoker in his 40s, and it was evident that he had peripheral vascular disease. The vessels supplying blood to his feet had slowly clogged up due to smoking. Now, a blood clot had suddenly cut off the blood supply to the affected foot. In the aftermath of these events, other blood vessels sometimes open up to provide a collateral blood supply, bypassing the blockage. Over time, the blockage can clear, at least partially. As an engineer, the patient understood the problem very well, and he and  I observed his toe daily. It remained swollen and painful, with an unhealthy dark red-blue colour. He ruefully showed me get-well cards from his colleagues, which included several jokey remarks about not letting the doctors cut his toe off. His friends had no idea that this was no joking matter, as a below-knee amputation was a real possibility.

 Each day I checked for pulses in his foot. There are two major arteries that supply the end of the foot. The posterior tibial artery can be felt behind the outside aspect of the ankle. The dorsalis pedis artery runs a variable course along the top of the foot. If one or other artery regained a pulse, then it would be possible to do a very limited amputation, leaving most of his foot intact. If both remained blocked, there would be insufficient blood supply for the foot to heal, and a below knee amputation was inevitable. On the fateful morning of the decision, Mr Gillespie’s team crowded around his bed. The senior registrar could find no foot pulses, and neither could Mr Gillespie. He started to explain to the patient that a full amputation was necessary. The previous day, I had thought that I could feel a dorsalis pedis pulse, so I quietly felt his foot whilst a difficult discussion proceeded at the other end of the bed.

Sure enough, I could feel the pulse, although it was not located in quite the usual place. I broke into the discussion; “I think you should feel this, Mr Gillespie”. He came and felt where I indicated. “You’re right! There’s a bounding pulse!” He went back to the top of the bed. “Well!” he said “it’s your lucky day! Rob has saved your leg!” Not surprisingly, the patient was rather shaken, and I had to have a long talk with him to help him make sense of what had happened. Minimal surgery was successful and his foot healed without incident. He walked out of the hospital, albeit using crutches.

House jobs were posts that came between the award of a medical degree and full registration as a medical practitioner. There were some compulsory elements, such as on-call, and you had to gain some operating experience. All concerned would have had greater peace of mind if I had never wielded a scalpel, but the General Medical Council insisted. Consequently, one afternoon, Mr Gillespie led me through a straight-forward repair of an inguinal hernia. At one point, his normally indestructible cool was shaken when he told me to put a stitch “there”. Evidently I misunderstood where he meant, because he said “Not there!!” in a tone of voice that could best be described as a strangled scream. He quickly regained his composure and at the end of the operation he said “It’s alright, Rob, I can always do it again in six months’ time”. I think he was joking, but I am not certain. He never suggested that I do another operation.

Once a week, I had an unsupervised minor surgery operating list for “lumps and bumps” in the outpatient department at St James’s Hospital. I spend these afternoons with a very nice Jamaican woman who was a State Enrolled Nurse. We removed small masses from just below the skin of patients whose problem had been assessed as unsightly and/or in need of histological examination. Most of the lumps were either sebaceous cysts or enlarged lymph nodes. The nurse would tactfully steer me through the procedures, and I was pleased to accept her guidance. She was a devout Pentecostalist, and she would quietly chant Bible verses or sing hymns between patients. I chose not to take this personally.

Once you got the hang of it, removing sebaceous cysts was rather satisfying, as they can usually be extracted whole, with little bleeding or bruising. A neat closure of the wound left a pleasing aesthetic improvement for the patient. I felt a bit uneasy about the man who had three sebaceous cysts on his scrotum, which he chose to have removed in one go. When I had finished, he jokingly asked me to count his testicles, which suggested to me that he had accurately appraised my surgical expertise.

Lymph nodes were trickier. No matter how firm and rubbery they were prior to the incision, they had a habit of going missing, which could lead to a lot of unseemly poking about until they were found. This happened one afternoon when I tried to remove a node that was located between the ear and the angle of the jaw of an elderly man. Once I had made the incision, the node was nowhere to be seen, but I was surprised how much fat there was in this rather lean man’s neck. I was removing subcutaneous fat when I had a moment of horrible insight. It was not fat. It was his parotid gland, the largest of the salivary glands. The really important thing for any doctor to know about the parotid is that the seventh cranial nerve runs through it. This controls facial expression, alongside some sensory functions. I went around to stand in front of the patient and asked him to smile. His expression was symmetrical, so I closed the incision and sent the tissue for histology. Sure enough, when the pathology report returned, it was normal salivary tissue.