Should you operate?

Although the era of ''furor operandi' has passed, one still has almost daily evidence of the disastrous effects of major surgical procedures, attempted lightly by young, or even inexperienced older surgeons. The author would in no way dampen the ardour of the neophyte, or check his ambition to acquire skill. Still, it is well to suppress the feelings of cocksureness and egotistic pride[...] Max Thorek, Surgical Errors and Safeguards Whether or not you should operate on a given patient will be the most important question you will have to answer. Put yourself in his place. What would you like to happen if you were him? Several factors will influence your decision. We have already discussed one of them[md]can you refer him? On the whole we think that for every doctor who operates when he should not, there are many more who don't operate when they should. So one of our aims has been to get more surgery done[md]on the correct indications!

The mature surgeon is one who knows when not to operate! On the other hand, if you are always too cautious, you will never learn and some of your patients will never benefit.

So beware of Thorek's furor operandi, the furious urge to operate, and ask yourself these questions before you do so.

SHOULD YOU OPERATE? What will happen if you don't operate? If a patient is likely to die or become disabled if he is not operated on quickly, you will have to operate. We have therefore included all the more practical emergency operations, whether difficult or not. For example, you must drill immediately for acute osteomyelitis, but a patient who needs a sequestrectomy for chronic osteomyelitis can wait. If however you cannot refer him, you may have to operate.

How difficult is the operation? At least three factors determine this: (1) Your technical knowledge, (2) your experience, and (3) your skill. We can provide you with the knowledge, and bring you some of the experience of other people, but only practice will improve your manual skill.

How safe is the operation? What disasters might happen? Little can go wrong with draining most abscesses, or manipulating most fractures, but disaster is only too possible if you decide to close an intestinal fistula or do a block dissection of the groin.

Do you have the necessary instruments, materials, and staff? Even if you don't, you may be able to improvise.

Are you yourself inclined to operate too readily, or not readily enough? Cultural attitudes to operating vary. In India or Indonesia, for exampe, the common failing is to be too timid, and not to operate when necessary. The reverse is true in some parts of Africa, where inexperienced operators are much too bold. So be aware of your own personal and cultural bias and try to correct for it.

What is the known or probable HIV status of the patient? See Chapter 28a.

Finally, if you have difficulty deciding what to do and are able to telephone or radio anyone who might know, don't hesitate do so so.

RULES ABOUT DECIDING WHEN TO OPERATE. (1) You must be certain of the indication to operate, even if it is only exploratory. (2) When life is in danger take risks. (3) If an emergency is hopeless be prepared to say: No! (3) Don't do difficult elective surgery, especially if the expected outcome is likely to be of limited value to the patient.

SEVEN RULES WHEN YOU DECIDE TO OPERATE. (1) You must be familiar with the anatomy; if necessary consult an anatomy book during the operation. (2) You must have someone familiar with anaesthesia giving the anaesthetic. If you are giving it yourself, there must be someone who can monitor its progress and the vital signs. (3) There must be a reliable system of sterilization, preferably an autoclave. (4) You must have a good light, preferably adjustable. (5) You must have the necessary equipment and supplies for resuscitation and homoeostasis (infusions, infusion sets, a laryngoscope, tracheal tubes, adrenalin, calcium etc). (6) Have the highest regard for living tissue and be gentle and circumspect. Operate at your own speed. (7) Finally, don't be too elated over your successes, or too despondent over your failures. If you do fail, forgive yourself[md]don't ''give up'! A bad spell during which 2 or 3 patients die may be followed by another in which none of them do. Remember that Brock's first 17 mitral valvotomies all died!

CAUTION ! Remember also that with ''cold operations' disasters are more difficult to justify than with ''hot ones', both to the hospital staff and to the general public, and that accusations that the doctor is experimenting on his patients can do much harm.

If you have not done any surgery before, or only very little, start with the easier operations. You should at least be able to open abscesses (Chapter 5).