January 2022
35
Only for one stitch Anupama Barua FRCS (C-Th)
I
t is a snapshot of trainee’s life. The characters are drawn from my own experiences and observations but are amalgamations. Dr Ali is a composite of dominating males in a discriminating society, of a type that can be seen everywhere including cardiac surgery in the UK.
Nirmala wants to be a surgeon – how dare she! She was our classmate, a dark skinned, slim-built Bengali girl, five feet three inches tall. We named her “Conscience” after the character in medieval Bengali theatre who would appear between acts to tell the moral of the story to the audience. Nirmala was much too ethical and principled to ask anyone to answer the attendance call on her behalf, and would refuse to sign the attendance sheet for others. During our internship, she showed her interest in surgery. One of the senior students, Nasrin, asked her, “Why do you want to do surgery? You are like a dwarf trying to touch the moon.” Nirmala replied, “Surgery is not only for giant men, a little dwarf like me can also work in the surgical ward.” Nasrin advised, “You can earn more money by palpating a uterus externally during pregnancy and internally during caesarean section.” Nirmala answered, “I don’t just work for money.” Nasrin emphasised, “In surgery, you cannot build up a good practice and no patient will trust you.” Nirmala hesitantly replied, “Trust should be made by rapport, not by physical phenomena.” The surgical registrar, Dr Ali, was not entirely happy to see her on the induction day. Usually the female interns came into surgery for two reasons: to avoid a heavy workload in the gynaecology and obstetrics ward and to avoid night duties. Typically, female internees do this placement before leaving for the United States. In the long run, they will be very unlikely to pursue a career in surgery. Nirmala broke the rules again. She approached Dr Ali, “I would like to do night duties.”
Dr Ali said, “Why do you need to do nights? You have to cover male and female wards. It is not safe to work at night in the surgical ward with a male ward boy and male patients.” Nirmala said, “If you think that a female is at risk working at night in the top medical college hospital, where can she be safe?” Dr Ali answered after a pause, “You need to do male catheterisations at night with a ward boy or a nurse.” Nirmala answered,“I do not think catheterisations or examinations change after daylight.” Dr Ali was not happy but agreed, thinking that Nirmala would give up after working two or three weeks. Nirmala did not follow the general rules. She worked hard, day and night. During their six months’ internship, every intern should do at least one appendectomy. During the first month, Nirmala spent days in wards and clinics. Her friend Jahangir had already done an appendectomy. She could not even scrub for one single day. Dr Ali said, “Nirmala, you should not scrub during this month, as there’s no water supply, we have to use collected water.” Two months later, Nirmala was ready to scrub. Dr Ali said, “Nirmala, you should not scrub today as there is shortage of sterile gowns.” During the third month, Dr Ali said, “Nirmala, I cannot allow you to do any cases because the patient couldn’t buy enough suture material. We cannot waste this precious stuff for your log book.” Next weekend, during our weekly shopping trip, Nirmala bought two sutures: one prolene and one silk, from the nearby pharmacy. She wished she could buy water and sterile gowns! On the fourth month, Nirmala was allowed to scrub for a duodenal perforation. Dr Ali requested, “Nirmala, come to the surgeon’s side and hold the retractor. I cannot see anything, every thing is so deep and the patient has only fat.” Nirmala was standing on tiptoes and holding the retractor with all her energy and sweating. Dr Ali was yelling,“Oh no, we need
one more prolene stitch but the patient didn’t buy enough.” Nirmala replied promptly, “Don’t worry, I have bought a prolene stitch and it is in the pocket of my apron.” Nirmala asked the nurse to open the packet of prolene. Dr Ali was in a rush, “I can’t give you the stitches to do, the perforation is deep down and difficult to tie.” Dr Ali used that suture to close the duodenum. It was her last day on the surgical ward, Nirmala was not allowed to do a skin closure, let alone an appendectomy. Dr Ali said, “Today is the last day for your surgical placement. I shall give you an appendectomy.” Nirmala replied with hope and pleasure, “Yes, I admitted two appendicitis patients.” During the operation, Dr Ali yelled, “Sh*t, inflamed appendix, I have to ligate and dissect out the appendix.” Nirmala answered without hesitation, “It should be inflamed, we are not here to dissect the healthy appendix.” Dr Ali reassured, “Do not worry, Nirmala, you can close the wound.” Not surprisingly, the patient had not bought any silk. Dr Ali said, “We can use leftover silk from the sterile pot.” The so-called sterile pot was filled with Savlon and leftover threads which were kept for emergency use. Nirmala told Dr Ali, “I do not want to use those threads. I bought silk with a handheld needle.” When the suture was opened on the table, Dr Ali’s eyes sparkled. He said, “My God, Nirmala, you bought this expensive stitch for this poor patient. I have never used hand-held stitches. The three-centimetre wound needs three stitches. I will do the two corners. You can do the middle one.” Nirmala did the one stitch in the middle, at 3:00am with tearful eyes. Nirmala still wants to be a surgeon, of course cardiac surgeon, but can see how many hurdles she needs to overcome, and how many sacrifices she needs to make, to reach her goal. n
