One of my Professors made a statement which rings true to this day, “you can teach a ‘monkey’ how to operate and he will do a fairly good job, but what differentiates a monkey from a trained surgeon is, knowing the indications for operating and post operative care!”
Let me illustrate these points by a few examples, before I had joined MS course I worked as a junior doctor in a rural mission hospital. The hospital was well equipped and run by NGOs. One fine day the orthopaedic surgeon asked me out of the blue, “do you want to do an amputation?” Harbouring dreams of becoming a surgeon, I couldn’t wait to get my hands on a scalpel. I replied in the affirmative, to which he said “Gaekwad will teach you how to do an amputation”.
On the face of it Gaekwad did not seem to have the academic qualifications to be a teacher or for that matter, to operate. He had a high school degree and a certificate for rehabilitation of leprosy patients. But years of assisting various orthopaedic surgeons in the operating theatre had taught him the ropes. He was a patient and ‘respectful’ teacher, very unlike normal teachers who show scant respect to their students. It may have been my superior paper qualifications. So this student teacher relationship was on an unequal footing.
Thus began my first foray into a life with a knife. Though I was the one holding the scalpel, it was Gaekwad who was gently directing me, “Cut here, okay there’s a blood vessel here so tie it and a nerve here so cut it high”. Those were sound principles as if you leave the nerve long it could grow to form a neuroma and give rise to neuralgic pain over the stump.
In a limited field he was good. He may not be competent enough to do a complicated surgery but he was good at fractures and nailing bones, perhaps better than some orthopaedic surgeons. He did everything under the guidance and shadow of an orthopaedic surgeon. But the decision regarding the surgery or which patient would benefit with which surgery he would not be able to decide. In case there were complications following the surgery, he would not be able to handle it. What he was good at is to mechanically do the steps of an operation and with practice he had achieved a degree of perfection.
Fast forward 5 years and I returned to the same hospital with a MS general surgery degree against my name. I did all the general surgery operations leaving the orthopaedic work to the specialist. The orthopaedic surgeon was going on leave for 15 days and he asked me to look after orthopaedics during his absence. I confessed that I’m at sea regarding orthopaedics. His reply was “No problem you have Gaekwad and Titus to help you”. Gaekwad was considered the orthopaedic surgeon and Titus the orthopaedic physician. “If any patient comes with a fracture and only requires close reduction and plaster than the duo will do it. If it’s more complex requiring surgery then explain to the patient that we cannot operate immediately, because there is excessive swelling. He will require elevation of the limb and splinting followed by surgery. I should be back by then”. In this fashion I handled an orthopaedic unit, being the mere face of the unit whereas the grunt work was done by the duo. I looked after the general management of the patient. This is not unique as I have seen many orthopaedic surgeons dependent on technicians for placement of implants.
In this hospital there was a single qualified anaesthetist and two male nurse anaesthetists. These male nurses had done nurse anaesthetist course and were extremely efficient. They could give spinal anaesthesia, epidural anaesthesia, intubate the patient and even do single lung intubation. They managed the patients independently but were under the umbrella of the anaesthetist.
I like to give the analogy of an automobile engineer and your friendly neighbourhood car mechanic. The engineer knows all the theory, that the differential produces so much of torque etc. But he would be lost if you brought your car to him to fix. But the mechanic though may not know the physics behind the car engine design or would be unable to design a new car but by experience and trial and error, he fixes the car. He tightens some screws needs and some part needs to be gissoed (grinding) and will fix your car.
This is also true of a fresh MBBS graduate, who is bursting with knowledge but is at sea as far as the practical application of the knowledge goes. He learns the practical once he becomes an intern and is thrown into the management of patients.
When I joined as a surgical resident in Punjab, on my first call day I went to see a patient in the casualty. I met a ward boy (despite being middle aged, he was still known as a boy) in the casualty. He had been working in there since he was 18 years old and had risen from the rank of sweeper to ward boy. He greeted me warmly and told me that if I needed to do any emergency surgical procedures like tracheotomy (making an alternative breathing site in the neck), chest tube insertion (inserting a tube in chest for a collapsed lung) or venesection (inserting a intravenous line), he could assist/teach me.
He claimed to have a diploma in Ayurvedic medicine from Bihar by paying ₹400/-, which I suspect was fake. He always took the night shift which suited him but was unpopular with others, because he could practice ‘daktari’ during the day. I enquired what this ‘daktari’ entailed? To which he replied that he has his regular clients of rich business men or ‘lalas’, who were suffering from the problems of plenty like obesity, heart condition, hypertension and diabetes. He would administer their insulin shots and check their blood pressure. He also worked as a compounder for another doctor in the city, doing dressing, giving injections and dispensing drugs. He had his own clinic in the slum area where he lived and a devoted following of patients. He was Jodaram to us but his patients referred to him reverentially as ‘Dr. Jodaram’!
Once in a while a patient would stray into the casualty and ask for Dr. Jodaram. They would consult with him, show him a prescription given to them by some other doctor, for his opinion. He would then bring the prescription to me or to any other doctor present and say, “Doctor sahab yeh kya likha hai? Aaj meine chashme nahi laya hoon, padhna mushkil ja raha hai” (Doctor can you tell me what’s written, I have not brought my glasses hence having difficulty reading). Then I realized that he was barely literate, he could just about sign his name. He would ask what the drugs were for and whether they were appropriate and then convey the same to his patient. I wonder what he did for prescribing patients!
Another example in the same hospital was our head of plastic surgery’s assistant Rattan or ‘Rattanji’ as we had to reverentially refer to him. On my first days in plastic surgery posting, the Boss told me, “Rattanji and me are your teachers”. Rattanji was again a high school graduate but had the intelligence and aptitude to pick up things. The Boss used to perform specialized microvascular surgeries like reimplanting amputated limbs and fingers. There was one injury which was unique to Punjab. Since a majority had long hair, on Sundays they would wash their hair in the morning and leave it open to dry. Next they would start their agricultural water pumps to irrigate their fields. Very commonly their loose hair would get entangled in the spinning wheel of the pump pulling the hair and along with it avulsing the scalp from the cranium. Literally getting ‘scalped’. Patients would come to the Casualty with a bandaged head and holding a portion of the scalp with the hair still attached to it.
Another agricultural equipment which was a responsible for giving us patients was the ‘toka machine’. This was used for chopping stalks and chaff into small pieces to make fodder for the cattle. It consisted of a wheel whose spokes were sharp blades. The wheel had to be rotated and the bundle of stalk inserted slowly into wheel. The blades would chop the stalk into small pieces. Two scenarios resulting in accidental amputation of finger were, the person holding the stalk and pushing it into the wheel would accidentally push their finger along with the stalk into the wheel. After use if the wheel was not properly locked, to prevent the wheel from rotating, children playing with toka machine would get a finger amputated. The flip side of a toka machine amputation was that it was a clean slice and was amenable to reimplantation.
Reimplanting scalps is difficult due to the multiple blood vessels, but our boss was very good at it. The only person he trusted to assist him was ‘Rattanji’. He knew the specialised instruments and how to assist. A wise person rightly said “To be a good surgeon you need to be a good assistant”. The assistant should know the steps of the surgery and anticipate what instruments or what retraction the surgeon would require. I sometimes equate it to a waltz where the dancing pair know the steps perfectly, when to sway pirouette and bow. But it should not become a Tango!
Rattanji was the perfect partner in the waltz, anticipating the surgeon’s needs perfectly. When the surgeon extended his hand he would know exactly which instrument he wanted without being told. When we had an exceptionally long list in plastic surgery we used to rope in Rattanji to do some of the minor procedures or suturing. He claimed he could do a cleft lip repair surgery and other plastic surgeries.
I am sure everyone in the medical field may have encountered a version of ‘Dr. Jodarams’ and can recount the case of a paramedical staff who was as good as a doctor in a limited field.
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