Part 1: Baptism of fire: My first ENT operation

Jayantha Premachandra recounts his disastrous first day as a student ENT SHO in General Hospital Colombo.

Photo Credit: The Execution of Maximilian by Edouard Manet, 1867-8, Oil on canvas | The National Gallery

I finished medical school as a fairly invisible student. I scraped through my exams unnoticed by any of the teachers, and took up a DMO post in Dankotuwa in 1976. My 4 years in Dankotuwa were some of the most enjoyable times of my life. I made friends for life, passed my Primary FRCS and returned to Colombo in 1979, a lot wiser and ready to start a career in Ear Nose and Throat surgery.


ENT was not my first choice, it was all that was left after others had picked up the more glamorous specialities like General surgery and Orthopaedics. In some ways I become an accidental ENT surgeon and I am still a little envious of colleagues who decided they wanted to become ENT surgeons while in medical school. This is the story of one of my first ENT operations ... a baptism of fire!


Colombo 1979: I was placed under the guidance of Dr Ananda Soysa, a dapper surgeon who wore a real bow tie and tailored suit. He had impeccable manners, polite to the core but with occasional temper tantrums. As you all know it is the norm for brilliant surgeons to have a short temper during that time of our evolution. He was thrilled to meet me as I may have been his first ever houseman who had the qualification of primary FRCS.


The most challenging thing that an ENT SHO has to do is an emergency tracheostomy under local anaesthesia on patients who present with Stridor. I was in total admiration of my co SHO who had only a few months of ENT experience but who could do a tracheostomy at a drop of a hat ... or so he said.


It was the end of the first day of my SHO job when my senior colleague called me to assist him with a tracheostomy and to learn the ropes. I couldn’t believe my luck, although I was dead tired I felt a sudden rush of adrenaline with the excitement of it all, which also made me feel very confident.


It was to be an emergency tracheostomy at the neurology unit on a patient who was suffering from ascending paralysis. I knew I could learn this difficult and challenging task from my trusted friend and senior co SHO. Within a few minutes we found ourselves at the neurology unit with all the instruments ready for the tracheostomy. The sister in charged barked at us saying there was no scrub nurse available, but she could spare us a young student nurse. My senior colleague was not in the least bit fazed by this and was confident we could even do it without a nurse.


When I palpated the neck of the patient (our poor victim) I realised she had a goitre. I could remember during our operative surgery lectures, Dr Dayasiri Fernando firmly telling us that on no account should one attempt to perform a tracheostomy if the patient has a goitre. I mentioned this to my colleague and he brushed me aside saying "all the women in this country at this age have goitres and one can push a goitre of this size to the side of the trachea. There was no problem finding the trachea! it being the largest midline structure, it is very easy to find it." I did not want to lose this vital opportunity to learn a life saving operation and i felt there was no reason for me to object, i told myself "Well I must be brave to be a surgeon! if i was a coward i would have become a dermatologist"


My confidence bolstered, I assisted my colleague with great enthusiasm, attentively learning all the knife strokes ... to find we encountered rather a lot blue blood obscuring our view of the operation field. In fact, the student nurse pointed out to us that until that day she thought blood was in fact red ...? At this stage all we saw was a blue lake of blood but no structures. The artery clips we inserted resulted in even more blood - a fountain of blood! Almost a suitable water feature for Sigiriya's famed water gardens.


By now my guru was sweating profusely, the thick glasses he wore were covered in blood. I can remember the nurse wiping the blood from his glasses and also the sweat from his face so that he could see better. This is exactly the way Elvis Presley was treated by his adoring female fans when they saw him sweating on the stage. I thought how fantastic to be a surgeon! Ah hah! hah!!


Next, I heard a terrible thud and found our student nurse unconscious, lying supine, legs akimbo, the poor woman had probably seen more blood in the last 5 minutes than she’d ever seen in her life. The sound of the fall was so loud the sister in charge peeped into our cubicle and realised what a mess we were both in: Both surgeons bathed in blood and a nurse lying on the floor unconscious. At this stage I thought not only was I in trouble, but this may be the first operation in the history of surgery with a mortality of 200%. I was heading for the Guinness Book of records!

Thankfully, the sister in the neurology unit saved the life of the patient by informing Dr Benjamin. The next thing we knew he was instructing us, in calming tones, to stop further digging and place a large swab on the wound, to press hard to arrest bleeding so that he could come and take over the operation. Later the patient was taken to the main theatres and a formal thyroidectomy was done before tracheostomy performed. The sense of relief I had when i heard that her life was saved was immense.


The following morning I sheepishly walked passed the ward several times to see whether the student nurse had survived! Seeing her alive was also a great relief! This lasted until the morning ward round where everybody gave me a rather cold reception. Only then I realised the value of public relations, as somehow they had all been given the impression that I had tried to do the tracheostomy without listening to my experienced colleague!

In part two, I have invited my guru and co SHO to write a small blog in response to this account. You can read it here.


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