Although not a Country Music fanatic, I would like to acknowledge the contribution that Kenny Rogers, elder statesman of the genre, has made to the practice of modern surgery. I refer to his insightful song, and subsequent film, The Gambler. For the uninitiated, the song describes a chance meeting between a world-weary professional card player and an aspiring young gambler. The older man gifts the younger with pearls of wisdom on winning at cards, culminating in a chorus stating that a player needs to “know when to hold ‘em, know when to fold ‘em, know when to walk away, know when to run”. I am not for a minute condoning the practice of surgeons literally running away from their patients, however strong the urge, but I do think some of the other sentiments are instructional in our practice.
The revelation came to me as a student, staying in the hospital late with the senior surgical trainee on call, hoping for something exciting to come through the door. Late that night, a very elderly, frail woman arrived shocked, in agony, confused, combative, and in multi-organ failure. The CT showed a significant portion of her small bowel was ischaemic. The trainee drilled me on management options; thrombolysis or endovascular techniques were impractical here, leaving only extensive resection; anastomosis with proximal diversion. Of course this would be a high-output stoma with associated high loss of fluid and electrolytes, difficult to manage, she would be a poor candidate for elective reversal… It did occur to me that this was going to be tough on the poor lady, and probably even futile, but a student can’t say “let’s just keep her comfortable” on a surgical rotation. The trainee had the experience and humility to suggest it himself. He confirmed my predictions of failed extubation, a prolonged ICU admission with worsening multi-organ failure, debates about whether to dialyse, increasing vasopressor and inotrope support, undying hope from the family that she would “turn the corner”, until finally a wrecked shell of a human being would succumb to an unavoidable complication of her treatment. “Sometimes, you’ve got to know when to call it quits”. This inspired me. “You’ve got to know when to hold ‘em, know when to fold ‘em?”. “Exactly”, he replied, and Kenny Rogers’ Law was born.
A mentor of mine once said, “there is no medical condition that can not be made worse with a poorly conceived operation”. This is the doctrine I cling to when feeling pressured to “push the envelope”, or attempt “heroic surgery” in the face of good sense. The most important factor influencing surgical outcomes is patient selection. Poor substrate results in poor results. The problem is that complex surgical problems often come wrapped in the most sympathetic, heart-breaking packaging. The delightful lady with a neurological disorder who is really fed up with the urinary diversion she had twenty years ago. The poor old fellow who can’t bear his nephrostomy. The tearful wife who asks if there is anything, ANYTHING you can do for him? At a departmental meeting it might be easy to assess these cases in a cold academic light, and rightly recommend against intervention. But then you don’t have to face the desperate human face of suffering at the meeting.
A surgeon I know who has a million useful platitudes once told me that if I was planning to do a surgery, but was not sure of the wisdom of it, to say out loud what I was going to do in the past tense with the preface, “well, Your Honour…” If you have never done this, I recommend it. “Well, Your Honour, I know she was morbidly obese and had had multiple laparotomies in the past with significant adhesion disease, and was admitted to the ICU with profound sepsis each time, but even though her dexterity is too poor for her to effectively self-catheterise, I thought it would be worth trying to reverse her ileal conduit and perform a clam cystoplasty. She was really sick of her conduit.”
As doctors, rather than just surgeons, sometimes our role is to convince a patient that however bad they think things are, we could certainly make things worse for them. Undoing an operation and its complications is usually not easy, and often impossible. Better to know when to fold ‘em.