Never do an elective operation that you don’t expect to work.
Some operations do not work, despite your best efforts (see anastomosis staple prayer) they are in the minority happily but in Vascular Surgery they can feel slightly more frequent. The phrase “more in hope than expectation” applies to many of the patients and operations that the optimistic vascular surgeon does.The typical patient journey of lower limb bypass, followed by failure of the bypass and then amputation is depressing for many surgeons, myself included, but the disease cannot be overcome and surgery is often only palliative in severe peripheral vascular disease. Patients with critical limb ischaemia have a life expectancy of less than 40% at 5 years in comparison to cancer of the colon where an early Dukes’ A cancer has a 90% 5 year survival, polyps of course do not count as cancer as some readers know only too well.
Patients are oddly unaware of the grim future ahead of them when they are faced with critical limb ischaemia. Surgeons don’t spend lots of time holding their hands, there are almost no specialist nurses (in comparison to breast cancer care) there is little information in the public domain and the patients themselves are not informed. As a result, there are very few tears shed and not too much demand on the surgeons to console and comfort. Many of the patients have smoked and have a remarkably stoical approach, almost as though they were expecting the smoking to catch up with them eventually. I find many of my patients admirable, they are fearless, accepting and trusting where I would be distraught, demanding and questioning.
And so to the title of today’s blog, a few weekends ago I was assisting in a bypass operation (fem-pop) that ultimately failed after an attempt at further salvage (flopped) and resulted in a lower limb amputation (the chop). The patient in question wrote me a thank you letter following his discharge from hospital (we keep these letters you know, they mean a lot) and had a very different view from my own about how his care had gone. He was so grateful for how hard we had tried to save his leg, but ultimately he had been sure that he was facing an amputation and was doing well with his new artificial limb. We spent hours and hours trying to save this man’s leg. We tried our absolute best and odds to this attitude of care and concern for the patient with an aggressive and incurable disease were my colleagues in anaesthesia. They love to have a chuckle about how long it takes to do limb saving surgery in contrast to how fast the surgeon can take the leg off when it all goes wrong. It isn’t funny at all for us, it isn’t funny for the patient, it isn’t funny for society due to the financial implications of rehabilitating and caring for an elderly amputee. I wish you’d stop it, I know it rhymes and sounds kind of funny but it isn’t. All of us like to have a laugh at certain aspects of the job, but having spent 10 hours trying to save a leg in the middle of the night only to amputate it 48 hours later is not funny, it is devastating for everyone.
It is of course very unlikely that any anaesthetist anywhere would ever get peripheral vascular disease as much like Sandra Dee in Grease they don’t drink, don’t swear, don’t rat their hair and they get ill from one cigarette.
I’d rather be Rizzo