Complications in Surgery. Every surgeon has experienced complications from doing a surgical procedure. Dr. James Hardy even wrote an entire book entitled complications in surgery. The question I want to address today is not a specific complication, but how does a surgeon feel when a complication arises following a surgical procedure which he has performed. Generally, it seems to me that most of us surgeons put on our intellectual hats and recognize that complications do occur. Most often we view it as a continuation of the disease process. However, what about those times when it does not seem related to the disease process. What about when those nagging thoughts of doubt come creaping in "did I do something to permit the complication to happen?" Surgeons are not able to function optimally if constantly confronted by self-doubt. The emotional safety net is to simply acknowledge complications as part of the activity of doing surgery. However, when complications do occur, I believe the usual emotional response is to feel angry. Angry that we are not so much in control as we would like to think and that even with meticulous attempts at hemostasis, hematomas occur; even with careful attention to anastamotic technique, leaks occur, etc. The anger arises out of a sense of helplessness to control the ultimate outcomes of our own physical performances. How great was the insight of Ambrose Pare, the father of modern surgery, who so carefully summed up his surgical endeavors = "I only put on the bandages, God does the healing." So often, we tend to forget that the natural and Divine forces with which we contend far exceed our mortal powers. Looking forward to some responses. JTE.

Work Rules & Ethics. Today's entry has to do with the current work rules and ethics. As everyone knows the State of New York years ago imposed the 80 hour work week for residents in training. This 80 hour work week has now been expanded to the entire country by the ACGME through its power over the RRC's. Anyway, the crux of the matter is that sometimes the question of the letter of the law is sometimes difficult to keep. I had an interesting discussion with a couple of Chief residents who confided in me that they are being as careful as possible to obey the rules but that on occasion they don't; mostly they overstay the limit (particularly on the go home early day) to get to do index cases. Anyway, they are advocating a "don't ask, don't tell" approach. I was never sure where that concept came from when I first heard it with regards to homosexuals in the Armed Forces. I suppose I need to dig a little deeper in to the ethical considerations; however, when I pressed the point, the residents likened it to "a tree falling in the woods". As for my part, since it seems that the system is really like the "honor code" used in college to foster honesty in test taking, I am certainly not going to infringe on the honor of the residents. And since like many trauma attendings my work week almost always execeeds 80 hour, I can not say well follow my example. It will be interesting to see if anyone studys the long term effects of this 80 hour rule. That's all for now. JTE.

Well, today I have decided to enter a post on my teaching experiences with residents in the OR. Today, I had three cases.
The first case was a severe case of infected anal condyloma. I used the CO2 LASER as is my usual custom in such cases. I had the opportunity to explain about the LASER in general and the use of the various power settings in particular. The concept of understanding power settings in Watts and what that means as you use the instrument is not so easy to communicate. My second year resident was able to do some of the case satisfactorily.
The second case was a straightforward case of excision of a sebaceous cyst.
The third case was a very obese man with an umbilical hernia. This case presented an opportunity to teach several important operative techniques. First, the principle of incision design for optimum exposure. Second, the use of well directed blunt dissection to seperate hernia sac from desmoplastic reactive tissue.
Well this concludes my log of teaching entry. JTE.

Hello colleagues, residents, students, friends and guests. Well I guess you are wondering why there has been such a long absence. Well here is the answer. I fell victim to one of the occupational hazards of being a surgeon. I sustained a needle stick in the OR while operating on a patient who was positive for HIV as well as Hepatitis C. I have just recently finished my prophylaxis with the triple drug cocktail for prophylaxis. Let me give you a first hand report. The drug regimen is a real wipe out. What side effects did I suffer = nausea, constant abdominal pain, weakness, tiredness, and headache. So let me remind everyone to always be careful about OR needle safety. The critical opinion question you are all wondering about is when will you know the outcome. Well folks it will be a very long year. However, now that the drug part is over, I am definitely feeling better. So, I shall very soon be back to my regular postings here on the Joy of Surgery. All my best. JTE.