Obedience to seniors
Monday, July 29, 2013
Julius Caesar, Neurosurgeon?
As a neurosurgeon and a self proclaimed expert on Julius Caesar, I feel it in my bones to write this new blog post about my favourite hero. I always feel that neurosurgeons have adopted many key qualities from Julius Caesar into our working lives. But there is still more to learn from that giant of a man. I present some glimpses from the life of Caesar and ask you whether he would make a skilled neurosurgeon. These are my views and I have stated Yay or Nay, for each quality. But feel free to disagree and add your comments. Any more comparisons are welcome, especially from writers, readers and fellow neurosurgeons, and in one case, anaesthetists.
Team work and camaraderie
For a neurosurgeon to survive a regular 10-12 hour work day, one has to have a highly refined sense of organization. Bustling in and out of the wards, clinic, operating room and intensive care, several times a day and yet delivering immaculate standard of care to patients, is a herculean effort. Years of rigorous training go into making a skilled neurosurgeon. Even so, the best of neurosurgeons can not function at this pace if left entirely on their own. A dedicated team of nurses, technicians and sacrificial lambs (neurosurgical trainees/ residents) play an ever important role in getting things done, on time and with pristine efficiency. This team work is paramount in delivering the quality of care that the neurosurgeon ultimately takes the credit for. The great Roman general, Julius Caesar, was but one man. But the training he gave to his legions was, well, legendary. The Romans were skilled in fighting their foes in formations, in which one legionary protected the one on his left. These formations had names like ‘Pig’s head’ and ‘Turtle’; each devised for a specific battle strategy. These formations were the bane of the Gallic and Germanic hordes, who were vanquished mainly because of their primitive philosophy of ‘each man for himself’. No other general exemplified the importance of team work as Julius Caesar did.
My verdict: Yay for Julius!
Attention to detail
From the very first day of residency (neurosurgical training) we were burdened with a mountain load of work. No mercy was shown if the work was not completed in a timely manner and punishments were very severe. Not only was the amount of work unbearable, but we had to deliver it with due diligence shown in every teeny tiny detail. The reprimand, “No attention to detail, ah!” was a commonly heard one during daily rounds. Nevertheless, after the initial wave of torture passed (for me it took a good 6 months), we stopped feeling sorry for ourselves, and smartened up. But we were never smart enough for our seniors, who could still find mistakes in our long hours of work, within mere seconds. And that’s what Julius taught his legions. Not only did they gain advanced combat skills, they practiced relentlessly to gain perfection in each and every skill, and its subtle nuances and modifications. These legionaries stopped being individuals, instead became a giant organism which moved, and thought and slayed, as one. And for 80 men in a century to think and move like one organism, attention to detail was crucial, not only for victory, but for their survival.
My verdict: Yay for Julius!
Conquering new territories
As a young neurosurgical resident, I was very eager to get inside the operating room and, well, ‘become a neurosurgeon’. After all, operating on the brain is the fun part of neurosurgery. This myth was cruelly shattered, when for the first couple of years, we toiled and slaved in the wards, and emergency, and intensive care learning how to take detailed histories, examined patients, presented cases to staff and senior residents, learned how to interpret CT scans and MRIs, intubated and ventilated patients, typed discharge summaries; essentially do ward work – not at all what I had hoped for. Only after those years moved past at an agonizing slow pace were surgical responsibilities heaped upon us. Now we entered the holy grail of neurosurgery – the operating room. Overjoyed that those slavish years were over, we got another rude shock when we realized that we were still the junior most in the operating room and had the menial job of holding a retractor or passing instruments to the operating surgeon. Some of us even learnt to sleep while standing and holding on to instruments. Not me though. Finally when we got our hands on the brain we were halfway through residency. We were tasked with learning very basic surgeries like those for head injuries and gliomas (brain tumor). Only when we had mastered them did we move on to more complex ones like skull base surgery, complex spine surgery and vascular neurosurgery. We moved from skill to skill in a step-wise manner, mastering each as we went along, seeking the best technique, and then refining it, learning, making mistakes, learning from mistakes, stumbling, falling, GET UP AMITABH, always moving towards more complex and daunting surgeries. This dogged determination towards perfection was demonstrated by Julius Caesar. While training his legionaries, he ensured that every single one of them mastered the technique he set out to train them in. He believed that the strength of a chain lies in its weakest link. He trained his men so that the weakest legionary (weakest link in the chain) was stronger than the strongest of foes. From one simple technique to complex ones and then more complex ones did he train them, till they could do it in their sleep. No wonder the Gauls, the Germanic tribes, the Celts and the Brits, each more ferocious than the ones before them fell under the onslaught of the well orchestrated Roman legions.
My verdict: Yay for Julius!
Obedience to seniors
As residents (neurosurgical trainees), obedience to seniors was absolute. Although we were tortured with the amount and intensity of work, but never complained. We could not show our weakness or pain. An order given was carried out immediately and to perfection. One chief resident instructed us that he wanted to discuss new patients’ case histories (usually done in the evenings at 9pm) only after midnight. All junior residents reported to the ward for case discussions every night at midnight; no questions asked, no opposition. We did that for months, irrespective of whether we were on-call or not. So absolute was the power of someone just a couple of years senior. In this era of democracy, my dear reader, slavery is still present in its most brutal form. There was so much pain and misery that we forced ourselves to become immune to it. Survival instincts. We started enjoying the pain, we played with it and we flirted with misery. We were no longer humans, but automatons, born to obey and to serve. Till those 6 years of self-inflicted imprisonment in a Nazi concentration camp (the residency programme) ended, there was no escape. With the eye on the prize, we trudged on, some walking, some stumbling, but no one could run till the finish line. Contrary to our plight, Julius Caesar had had enough of the Senate, who governed Rome. After spending years conquering Gaul and Britain, the Senate started growing wary of Julius’ rising power. Scared that he might attack Rome and send them all packing, they issued a decree that Julius should disband his legion. Insulted at not being hailed a hero and rewarded, Julius crossed the river Rubicon and attacked Rome. Months later, he had either killed or driven out all his foes in the Senate and became Dictator of Rome. So much for obedience to seniors. Unfortunately,…
My verdict: Nay for Julius!
Ability to face hardships
“You can not sleep. You can not eat. Work has to be complete,” a senior resident told me, once. I had laughed inwardly on hearing this; till the moment of truth arrived. My personal record for facing hardships (read as 'abuse'): no sleep for 4 days & 3 nights at a stretch (wow, that’s almost 90 hours; when I was the single first call during a bleak spell); no food, not even coffee for 24 hours (I remember drinking water from the sink in the operating room in between operating on patients; we had to operate on so many head injured patients that day). But I could never feel sorry for myself; I was the perfect slave. Human rights violations, you might say, but I beg to differ. Human rights are for humans, and we were not humans. So strict was the code of conduct that a resident showing physical or emotional weakness was not considered fit to become a neurosurgeon. Julius drilled the legions mercilessly. They could not sleep till they had finished that task; he did not allow them to eat. The work has to be complete. The foe had to be vanquished. And he set an example by going without food and sleep himself. He inflicted those hardships for a cause – to produce the perfect soldier- unyielding and unbreakable. That’s why the Romans ruled the world. Only in death did they accept defeat.
My verdict: Yay for Julius!
Improvise, and fast
The year is 2007 AD. Julius Caesar has been dead for over 2000 years. I have finally become a neurosurgeon. Thank you Julius, your principles have guided me through my journey, to victory. It is a regular day. I am operating on a high grade glioma (brain tumor). These beauties are soft and suckable and usually one can breeze through such surgeries without batting an eyelid. Suddenly, as if it had a mind of its own, the brain starts swelling rapidly. My vision blurs. A gush of blood pools into the previously quiet operative field. I can not see the tumor anymore. I hear the anaesthetist shout, “BP is crashing. Stop operating, Amitabh”. In my mind’s eye I know that about 25% of the tumor is still left behind; the imperfect, leaky blood vessels within it are bleeding profusely, causing this mess. If I stop operating, the patient will die. If I keep operating, the patient may still die. “Arrange for 2 pints of blood,” I whisper to the resident assisting me. The only way to stop the bleeding is to remove the remaining tumor. Swish, swish, swish dances my suction at a ferocious pace. Coagulating this vessel and then the next at break neck pace. I can not see the tumor; too much blood is pooling in the brain. The anaesthetist is shouting her frustration at me but I can not understand the words; just incomprehensible sounds now. My entire world exists under the operating microscope. I do not hear anyone or smell anything. Vision and touch sensations are heightened. “Keep at it,” a voice in my head. It’s a hallucination, my rationale mind tells me. But the voice is real for me, during those frantic seconds. I can not hear the anesthetist anymore, though I am sure she is very close by, still shouting, probably about to faint. Hopefully, there is someone around to resuscitate her. Swish, swish, buzz, flash my instruments within the brain cavity in a space less then 2 cm; more from instinct and experience, rather than by vision anymore. I still can not see the tumor … too much blood. And then the heavens part. There is a lull in the bleeding. I can see the operative field more clearly. I suck the blood out in a controlled manner. Ah I see it now. The offending tumor, sitting pretty, tucked in a little fold of brain. You gray, jelly-like nubbin, still oozing blood, come to Daddy. Swish, swish, swish! Fifteen seconds later and the pest has been conquered. The BP is stabilizing, the brain is relaxing slowly. I can hear the anesthetist now. She wants to kill me. This drama lasted for less than a minute. Such exhilarating experiences happen more often than one may imagine in the neurosurgery operating room. It becomes second nature for neurosurgeons to back off from the original plan and adapt a diametrically opposite one according to the need of the hour, or in this case, according to the need of seconds. The game plan changes within seconds, and the neurosurgeon who can not improvise, and fast, sends his patient to an as-yet-undug grave. This ability separates the men from the boys. Julius Caesar recruited boys, farm lads mere fifteen year olds, and churned them into men. Many times during a melee, the Gauls arranged ambushes for Julius’ men. They would attack from the sides, when least expected, while Julius was concentrating his forces straight ahead. A bugle alerted the legions of the surprise attack from the sides. One command from Julius, and the legion divided into three, under separate commanders, to face the wily Gauls. No unnecessary words spoken - no anaesthetists on the battle field, apparently - (any anaesthetists reading this blog, please forgive me), no confusion, within seconds the legion had adapted to the new battle plan. One organism had split into three. Each ready to kill, as a separate entity, and yet as one.
My verdict: Yay for Julius!
I feel Julius Caesar would have made a terrific neurosurgeon. Don’t you?
~ A David Singh