Some thoughts while nymphing Being ruminations on the similarities of the esoteric arts of fly fishing and anaesthesia -- by a practitioner of both | 
MJA 1999; 171: 673-674 |
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This year saw the advent of my second half-century. More than half of
the first has been spent in practice and, worse still, most of that has
been spent in the practice of that most arcane art, anaesthesia.
It seemed time for a review. There is no pastime better suited to rumination than fishing -- and it goes without saying that I mean fly fishing. Norman Maclean hit the nail on the head in the opening to A river runs through it:
In our family, there was no clear line between religion and fly fishing. [Our father, a Presbyterian minister] told us about Christ's disciples being fishermen, and we were left to assume, as my brother and I did, that all first class fishermen on the Sea of Galilee were fly fishermen and that John, the favourite, was a dry fly fisherman.1 Another writer, Zane Grey, described the Tongariro, in New Zealand's North Island, as "Anglers' Paradise".2 Two weeks after celebrating my first half-century, I found myself returning once more to paradise. Contact with a guide (and now close friend) had ascertained that the fishing was "difficult". This is the worst prognosis known to fishing guides. If Mount Ruapehu had erupted and blocked the river at the source, then a term like "pretty good" would have been used. "Difficult" means that no-one had seen a trout for a week or more. I was able to take the news philosophically, however, because actually hooking a fish might well disrupt the Zen-like state induced by standing up to my perineum in snowmelt, enjoying the dissociation brought on by the sheer joy of casting a fly. Catching fish often interferes with fishing. It's not dissimilar to the way surgery disrupts the smooth running of an anaesthetic list. My mind wandered to incidents in theatres over the years and across several continents, from five-star teaching hospitals to tents pitched in the sand; from patients delivered to me by Hercules aircraft to those to whom I was delivered by helicopter. Has there been a common theme to all these times and places? You bet -- surgeons. I've been told "Just make him dizzy with gas, Doc, I'll only be a minute" as a prelude to what turned out to be a four-hour partial hepatectomy. I've had a surgeon, later to head a Royal College, tell me at 11 pm that his patient's appendicectomy had far greater priority than the burrholes we were about to perform, and, when I demurred, retort, "Never mind, we'll do it tomorrow, if that's your attitude." There must be something in their training that teaches them to lie without a qualm. In fact, one of my pastimes over the years has been to watch surgical trainees metamorphose from decent young people into scheming devils filled with the certainty that they are always right, even when the evidence is overwhelmingly to the contrary. Like all anaesthetists I am time-conscious. This is because we are nearly always running late for our next list. (Please note: anaesthetists are "late", surgeons are merely "delayed".) This is usually because the current list is overbooked, as the surgeon genuinely believes he takes 10 minutes per arthroscopy. It's bad enough when a morning list makes you late for the afternoon one, but, on occasion, I have been late for a morning list because the (previous) afternoon one was "a bit of a struggle, laddie". In my first training hospital, in the Royal Air Force, the anaesthetic department had a conversion table for surgical time to real time. This had a factor of two automatically built in, then a personal "handicap" for individual surgeons. Strangely, the surgeons were immensely pleased when we reduced any of their handicaps, and they were equally devastated when episodes of poor judgement (clinical or administrative) increased them. The registrars saw a reducing handicap as a better indication of surgical maturity than passing the College examinations. The same department evolved "Blundell's Rules of Surgical Duration". Blundell had had a scientific education and tried to find formulas to solve the time-truth continuum. He noted that the duration of any procedure was directly related to the number on the suture packet. If the man was using 3/0 then you could probably squeeze in a quick drink in the mess before dinner; 6/0 and dinner was still an outside possibility, but no drink; 8/0 and the dog may as well have your dinner now as wait for it to be cremated. A similar relationship was noted between duration of surgery and the magnification used by the surgeon. The dog ate well when the microscope was called for. To me, one of the many attractive things about fly fishing is that I completely lose track of time. I once gave brief consideration to the possibility that I was seeing a solar eclipse, rather than a perfectly appropriate sunset. I now make a virtue out of necessity and don't wear a watch when fishing. I can only assume that surgeons feel the same way when operating. Fair enough, but why are they late (sorry, delayed) for the start of the morning list? I immediately thought of that branch of surgery (or am I being indecorous here?) that has no understanding of the concept of time whatsoever -- obstetrics. Reluctantly, I concede that here it may (just sometimes) be the fault of the patient, but that doesn't explain the well documented rise in the incidence of caesarean sections on a Friday afternoon, unless, of course, the mothers are anxious to play an undisturbed round of golf over the weekend. It's frustrating for anaesthetists to have to come to terms with the fact that obstetricians know only three procedures and they're all urgent. Fly fishing is a very precise, subtle form of fishing. So too you might think that surgery is precise and subtle. Vascular, plastic, ophthalmology, certainly -- but then there's the orthopods. As a young man, I once saved a life by scrubbing up to remove the K nail that the bone doctor had jammed in the femur, sadly with the extractor eye in the nail inserted first. He was a vegetarian, so his strength quickly faded, and, short of waking the patient up and advising him of uses for 12 cm of titanium steel sticking out of his thigh (clothes horse? television antenna?), I couldn't avoid getting involved. Brute strength (a result of my high-protein diet), a large hammer, and the hospital engineer's multigrips allowed me to remove the jammed nail so that the correct size could be used. Years later, the same surgeon took three hours to get to the stage of calling for the intramedullary femoral nail and discovering that we had ordered the set for the wrong side. Frantic phone calls to the company ensued and a theatre sister came in to announce: "The bad news is that it will take an hour to get the nail here by taxi; the good news is the taxi driver knows how to put it in." While discussing this article with that same theatre sister, who shares my views on surgeons, she pointed out that there was another similarity between those who practise the sport of fly fishing and those who practise the art of anaesthesia (actually she called it "passing gas"). She said that both parties mixed with liars. When I expressed my horror at this she recanted and said that both surgeons and other fishermen (she excluded me, of course) were prone to exaggeration. I suppose I'll just go on with anaesthetics for the next 20-odd years. It's the only thing I know that makes enough money to pay for the fishing. Douglas N Gow
©MJA 1999
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