Surgical dogma

Some things are the same the world over. I was reminded of this last week in theatres, when I arrived to operate on a burnt child to be told by the anaesthetist and the scrub nurse that I couldn't do the operation the way I had been taught in the UK. Which was also the technique favoured by the Prof. In fact the approach they were insisting upon would be regarded as somewhat substandard in a Western unit. But, there is a technique that has always been followed here and has worked for decades, so why should anyone want to do anything differently?

I suspect the world of surgery is not unique in perpetuating attitudes like this, just the immediacy and pressure of the work focuses it. Performing surgery on someone brings all the concerns, of a whole theatre team, to the fore. This is coupled with the stress of potentially harming a patient through your actions and knowing that you will be held acutely responsible for what you do.

I think it is understandable that an outsider, with different training and attitudes, and indeed a completely different cultural background, should be met with a degree of suspicion. What I found challenging was the obstruction to me even debating the reasons for my course of action, or listening to any attempt to alleviate their concerns. If our roles were reversed however, I can fully understand. A stranger arriving and insisting on doing things completely differently to the norm would be met with suspicion anywhere in the UK.

This brings me back to my original point. Surgery is exactly the setting where we should embrace new ideas and evidence and constantly change what we do. Indeed, it would be criminal to stick with outmoded, inferior techniques. But of course, the temptation to stick with what you know is often over-riding. Even in our surgical mortality meeting this morning, where I was criticising the habit of clinical officers in the hospital to treat everything from haemorrhoids to major burns and bowel obstruction with antibiotics, I met the "we've always done this just in case" attitude. This was despite me and the Professor being very clear on the indication for antibiotics in such cases.

Back to the burnt child. The best I could do was reach a compromise. The concerns from the theatre staff revolved around blood loss and anaesthetic time if I debrided and grafted a large area. I wanted to remove all the dead skin at least, so did so under tourniquets. It took 40 minutes and barely bled, but I couldn't graft. The immediate outcome was a success and I think will have won some support. Unfortunately the child was at the limit of a survivable injury without an intensive care unit and died overnight. Perhaps once I have fought a similar battle over the critical care of these patients on the ward things might change!