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See one, do one, teach one
Moments in surgery Many of our readers are the guardians of lore, amusing or illuminating, about our surgical heritage. This oral history will be lost unless it is captured now. The Editors invite you to submit anecdotes, vignettes, stories of your mentors (great and small), or simply the tall tales you tell your residents about the way it once was.
See one, do one, teach one Moshe Schein, MD, Brooklyn, NY
From the Department of Surgery, Weill Medical College of Cornell University, New York, NY
MOST RESIDENTS ARE NOT INTERESTED in tall tales from the past: Anything that does not belong to the present or the future is water over the dam. Those who deign to listen may find some of those old stories hard to believe. How can they who train under today’s tightly supervised residencies imagine a surgical program guided by the principle of “see one, do one, teach one,” sometimes skipping the first step? “In this Department, my dear boy, you’ll learn how to cut, and cut...,” the soft-spoken Chairman of Surgery at Baragwanath Hospital, Johannesburg, South Africa, muttered to me on my first day of residency in 1981. The Professor’s Department was composed of 5 units, each treating up to 100 cases at one time—probably the largest academic general Surgical Department in the world. The Professor allocated me to the Surgical Unit led by the notorious “Bokkie”—whose other nickname was “the cowboy” because of his athletic frame, the white-starched safari suit he always wore, his military bearing, and, above all, the huge handgun bulging under his pants. When I arrived in Bokkie Unit’s Male Ward—an army barracks-
Accepted for publication May 12, 2000. Reprint requests: Moshe Schein, MD, Department of Surgery, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 112159008. Surgery 2000;128:868-9. Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0 doi:10.1067/msy.2000.108615
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like structure containing not less than 80 beds—I found Bokkie inspecting his troops (doctors). I immediately received his standard welcome speech, which included his gospel on surgery, consisting of pearls such as: “You should open the abdomen with a blade in one stroke...” or “In my unit, there is no place for closed cardiac massage, I want you to crack open all chests.” At the end of his tirade, Bokkie—“the cowboy”—poked me on the chest and admonished, “Hey Schein, just remember, I won’t tolerate any cowboy in my unit. Understand?” At 10 o’clock sharp, after morning rounds, the entire unit went for the ritual tea, which was served together with cute little sandwiches of anchovy paste. During tea, while Bokkie lectured the team on politics, surgery, and guns, I read a reprint of a paper. Bokkie swallowed another little anchovy sandwich and eyed me. “Show me what you’re reading.” He looked at the paper with disgust. “Pericardiocentesis in penetrating heart injury? American Journal of Surgery. Tell me, what the hell do Americans understand about stabbed hearts?” He threw the paper on the floor with contempt. “I don’t want you to read this crap while in my unit. No one can teach us how to treat cardiac injuries— we teach the world. Pericardiocentesis, what fools...” So began my short but memorable stint in Bokkie’s Unit. Baragwanath Hospital is located at the heart of Soweto, a multi-million crowded township. It was an urban battle zone. The great “wars” regularly erupted on Friday, payday. With fresh cash in their pockets, the locals became either victims of violent
Surgery Volume 128, Number 5
crime or its perpetrators, promoted by cheap wine or home-brewed ale. The feast of fury, persisting through the weekend, overwhelmed Baragwanath’s surgeons with a tide of horrendous injuries. The surgical receiving area, locally called “the pit,” resembled a dressing station in Stalingrad: patients on stretchers, on chairs, on the floor, crushed skulls, stabbed chests, shot abdomens, and mangled vessels. Those surviving the triage and the resuscitation room were wheeled to the nearby operating rooms, which worked nonstop day and night. The volume of severe injuries was unbelievable: a single night with 7 laparotomies, 4 explorations of the neck, 2 shot subclavian arteries, 3 stabbed hearts, 3 peripheral vascular injuries, along with all the bread-and-butter emergency general surgery. In the midst of this controlled chaos, we trainees “enjoyed” absolute surgical independence. During the day, academic professors taught us surgery, but then they departed leaving us the kings of the stormy nights. I saw a number of stab wounds of the heart during my first month in Bokkie’s Unit and even operated on one under the supervision of my senior resident, now a leading trauma surgeon in California. A week or so later, at dawn, when I was dozing with a few interns in the pit, my opportunity arrived to “do one.” The young lady was wheeled in, drenched in sweat and already defecating. Her pulse was barely palpable and a large stab wound was present to the left of the sternum, the product of a drunken jealous lover. “Let’s go,” I hissed to the interns. We wheeled her to the OR shouting “stab heart,” a local battle cry that instantly woke up anesthesia and the nursing team. Lubscke knife to the sternum, the pericardium opened, a finger onto the ventricular wound, a few sutures of silk. A few days later the patient was exercising on the grass, outside our ward, together with the regular battalion of chest tube-carrying patients. A week later I had another chance to prove my surgical skills, again in the early hours of the morning, when a young man arrived with a gunshot wound to his abdomen. “Selective conservatism” was, and still is, Baragwanath’s rule in such patients, but as the abdomen was diffusely tender, I and an intern took him for a laparotomy, during which we found multiple holes in the terminal ileum. I had never been taught how to do a bowel resection and anastomosis. The memories of the few cases I assisted on during internship were clouded in my mind and so were the drawings from texts of operative surgery I used to look at from
Schein 869
time to time. So with the assistance of the sleepy intern I constructed a 2-layered chromic and silk anastomosis, the outdated practice of those times. The end result looked awful and distorted, but I closed the abdomen and went for breakfast. During the following 5 days, I was convinced that the anastomosis would leak. I simply could not believe that my suture line had any chance for holding. I was sick with anxiety, a feeling the patient did not share; he recovered promptly and started to eat on postoperative day 5. Consequently, my surgical self-confidence grew exponentially. I was ready to tackle anything, even bypassing the stage of “see one.” One of the following nights, I took to theater (an OR in English) another multiple abdominal gunshot wound, this one unstable. Knowing by then the rule that any organ has a potential entry and exit wound, I repaired the anterior and posterior wounds of the stomach, the 4th part of the duodenum and transverse colon. The body of the pancreas appeared bruised so I left a large sump in the lesser sac. For the patient, the operation was a great success, but for his surgeon it brought only misery. I did not know that one of Bokkie’s golden rules was always to use a flat rubber, corrugated drain. Bokkie abhorred roundtube drains. The next morning I found myself in the Professor’s office, listening to Bokkie’s demands to throw me out of the residency. Luckily, the Professor transferred me to his unit “on probation” thus saving my mediocre surgical career. During the remaining months of my Baragwanath year I did a lot of additional “do one” operations. I even did “teach one” procedures with “junior residents,” those poor souls who joined the unit a few months after me. I saved many lives, but lost a few as well. On the day when I left Baragwanath to continue the residency in an affiliated hospital, I felt like an accomplished surgeon, but really it was the day when my proper training started, as I was forced also to “see one.” A note: What took place 20 years ago at Baragwanath is history, and history should not be judged solely through today’s perspective. We must not forget that the contemporary modes of teaching and patient care in certain American inner city hospitals were not dissimilar. Whatever critics may say now, the trauma care provided to the mass casualties in Baragwanath Hospital in those days was worthy of pride. I am indebted to Paul Rogers, FRCS, of Glasgow, Scotland, for his invaluable criticism.
See one, do one, teach one Moshe Schein, MD, Brooklyn, NY
From the Department of Surgery, Weill Medical College of Cornell University, New York, NY
MOST RESIDENTS ARE NOT INTERESTED in tall tales from the past: Anything that does not belong to the present or the future is water over the dam. Those who deign to listen may find some of those old stories hard to believe. How can they who train under today’s tightly supervised residencies imagine a surgical program guided by the principle of “see one, do one, teach one,” sometimes skipping the first step? “In this Department, my dear boy, you’ll learn how to cut, and cut...,” the soft-spoken Chairman of Surgery at Baragwanath Hospital, Johannesburg, South Africa, muttered to me on my first day of residency in 1981. The Professor’s Department was composed of 5 units, each treating up to 100 cases at one time—probably the largest academic general Surgical Department in the world. The Professor allocated me to the Surgical Unit led by the notorious “Bokkie”—whose other nickname was “the cowboy” because of his athletic frame, the white-starched safari suit he always wore, his military bearing, and, above all, the huge handgun bulging under his pants. When I arrived in Bokkie Unit’s Male Ward—an army barracks-
Accepted for publication May 12, 2000. Reprint requests: Moshe Schein, MD, Department of Surgery, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 112159008. Surgery 2000;128:868-9. Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0 doi:10.1067/msy.2000.108615
868 SURGERY
11/60/108615
like structure containing not less than 80 beds—I found Bokkie inspecting his troops (doctors). I immediately received his standard welcome speech, which included his gospel on surgery, consisting of pearls such as: “You should open the abdomen with a blade in one stroke...” or “In my unit, there is no place for closed cardiac massage, I want you to crack open all chests.” At the end of his tirade, Bokkie—“the cowboy”—poked me on the chest and admonished, “Hey Schein, just remember, I won’t tolerate any cowboy in my unit. Understand?” At 10 o’clock sharp, after morning rounds, the entire unit went for the ritual tea, which was served together with cute little sandwiches of anchovy paste. During tea, while Bokkie lectured the team on politics, surgery, and guns, I read a reprint of a paper. Bokkie swallowed another little anchovy sandwich and eyed me. “Show me what you’re reading.” He looked at the paper with disgust. “Pericardiocentesis in penetrating heart injury? American Journal of Surgery. Tell me, what the hell do Americans understand about stabbed hearts?” He threw the paper on the floor with contempt. “I don’t want you to read this crap while in my unit. No one can teach us how to treat cardiac injuries— we teach the world. Pericardiocentesis, what fools...” So began my short but memorable stint in Bokkie’s Unit. Baragwanath Hospital is located at the heart of Soweto, a multi-million crowded township. It was an urban battle zone. The great “wars” regularly erupted on Friday, payday. With fresh cash in their pockets, the locals became either victims of violent
Surgery Volume 128, Number 5
crime or its perpetrators, promoted by cheap wine or home-brewed ale. The feast of fury, persisting through the weekend, overwhelmed Baragwanath’s surgeons with a tide of horrendous injuries. The surgical receiving area, locally called “the pit,” resembled a dressing station in Stalingrad: patients on stretchers, on chairs, on the floor, crushed skulls, stabbed chests, shot abdomens, and mangled vessels. Those surviving the triage and the resuscitation room were wheeled to the nearby operating rooms, which worked nonstop day and night. The volume of severe injuries was unbelievable: a single night with 7 laparotomies, 4 explorations of the neck, 2 shot subclavian arteries, 3 stabbed hearts, 3 peripheral vascular injuries, along with all the bread-and-butter emergency general surgery. In the midst of this controlled chaos, we trainees “enjoyed” absolute surgical independence. During the day, academic professors taught us surgery, but then they departed leaving us the kings of the stormy nights. I saw a number of stab wounds of the heart during my first month in Bokkie’s Unit and even operated on one under the supervision of my senior resident, now a leading trauma surgeon in California. A week or so later, at dawn, when I was dozing with a few interns in the pit, my opportunity arrived to “do one.” The young lady was wheeled in, drenched in sweat and already defecating. Her pulse was barely palpable and a large stab wound was present to the left of the sternum, the product of a drunken jealous lover. “Let’s go,” I hissed to the interns. We wheeled her to the OR shouting “stab heart,” a local battle cry that instantly woke up anesthesia and the nursing team. Lubscke knife to the sternum, the pericardium opened, a finger onto the ventricular wound, a few sutures of silk. A few days later the patient was exercising on the grass, outside our ward, together with the regular battalion of chest tube-carrying patients. A week later I had another chance to prove my surgical skills, again in the early hours of the morning, when a young man arrived with a gunshot wound to his abdomen. “Selective conservatism” was, and still is, Baragwanath’s rule in such patients, but as the abdomen was diffusely tender, I and an intern took him for a laparotomy, during which we found multiple holes in the terminal ileum. I had never been taught how to do a bowel resection and anastomosis. The memories of the few cases I assisted on during internship were clouded in my mind and so were the drawings from texts of operative surgery I used to look at from
Schein 869
time to time. So with the assistance of the sleepy intern I constructed a 2-layered chromic and silk anastomosis, the outdated practice of those times. The end result looked awful and distorted, but I closed the abdomen and went for breakfast. During the following 5 days, I was convinced that the anastomosis would leak. I simply could not believe that my suture line had any chance for holding. I was sick with anxiety, a feeling the patient did not share; he recovered promptly and started to eat on postoperative day 5. Consequently, my surgical self-confidence grew exponentially. I was ready to tackle anything, even bypassing the stage of “see one.” One of the following nights, I took to theater (an OR in English) another multiple abdominal gunshot wound, this one unstable. Knowing by then the rule that any organ has a potential entry and exit wound, I repaired the anterior and posterior wounds of the stomach, the 4th part of the duodenum and transverse colon. The body of the pancreas appeared bruised so I left a large sump in the lesser sac. For the patient, the operation was a great success, but for his surgeon it brought only misery. I did not know that one of Bokkie’s golden rules was always to use a flat rubber, corrugated drain. Bokkie abhorred roundtube drains. The next morning I found myself in the Professor’s office, listening to Bokkie’s demands to throw me out of the residency. Luckily, the Professor transferred me to his unit “on probation” thus saving my mediocre surgical career. During the remaining months of my Baragwanath year I did a lot of additional “do one” operations. I even did “teach one” procedures with “junior residents,” those poor souls who joined the unit a few months after me. I saved many lives, but lost a few as well. On the day when I left Baragwanath to continue the residency in an affiliated hospital, I felt like an accomplished surgeon, but really it was the day when my proper training started, as I was forced also to “see one.” A note: What took place 20 years ago at Baragwanath is history, and history should not be judged solely through today’s perspective. We must not forget that the contemporary modes of teaching and patient care in certain American inner city hospitals were not dissimilar. Whatever critics may say now, the trauma care provided to the mass casualties in Baragwanath Hospital in those days was worthy of pride. I am indebted to Paul Rogers, FRCS, of Glasgow, Scotland, for his invaluable criticism.