COOL NERVES

Despite the absurd, surrealistic dreams I had had the night before, chaotic dreams of disappearing patients and overflowing toilets, I arrived in the hospital with cool nerves and a clear head.

“Dr Spielberg! Welcome back to the phaco suite!” said two nurses as I entered the locker rooms where we change into our operating clothes. Due to a lack of both space and prudishness, the Dutch have unisex changing rooms. I thought back to three years ago, the first time I entered the changing room and saw the same nurses undressing. Being unaware of this Dutch custom, I apologised profusely, closed the door, turned around and bumped right into Niels, my resident buddy and key to all things Dutch. “Dude! Welcome to Holland.”

I had gotten used to it since then. “Who are you operating with today?” asked one of the nurses. “Dr Manzulli already has a resident assisting him. Was there a change of schedule?”

“Nope, I’m on my own today,” I said, as a wave of panic washed away my thin veneer of pride. I tried to keep cool. “Who’s my assistant?”

I changed into my operating scrubs and proceeded to the OR. I hadn’t been in the phaco suite for about a year, so I was no longer familiar with the workflow, with the standard procedures. Who decided when to proceed? Who fetched the patient? Who, I asked myself, was really in charge here?

As though on cue, my question was answered. An OR nurse poked her head through the door and asked: “Doctor, have you had your coffee yet? And if so, would you like us to fetch your first patient from the prep room?”

As a younger resident, I had spent most of my time shadowing the attending surgeon in the OR. The emphasis here is on the word shadow, simply being present and more or less silent in the background. Even when I was operating, the nurses’ attention was focused squarely on the staff surgeon, who was really running the show. A resident is politely tolerated, but is not really listened to.

ALL EYES ON ME

The dynamic is totally different when you’re the primary surgeon, when you’re the one responsible for the successful completion of the procedure. Like the rapper Tupac Shakur said: “All eyes on me.” There was a palpable sense of respect towards me, something that I had rarely experienced.

“Doctor, shall we go ahead and open the material? Doctor, let us know if there’s anything we can do for you.”

This privilege, this respect, comes with the responsibility of getting it done. No one in the room could help out if the operation went awry. I could always call for Dr Manzulli to come assist me, but that would be a last-resort option. As the patient was wheeled into “my” OR, I thought to myself: ‘Am I really ready for this?’

But as I settled into the surgeon’s seat, one usually occupied by my surgical mentors, with the patient before me and an experienced nurse at my side, it all felt right. There was no panic. There was no feeling of an absence of knowledge or skill. Rather, there was an eye to be operated and the instruments to be used. I got right to work.

I thought of what Joyce Jansen, a young vitreoretinal surgeon, had once said to me: “Cataract surgery... so much more stressful than VR surgery... every single step can go fabulously wrong and make the rest of the procedure almost impossible to complete.”

With that in mind, I operated conservatively and took my time with every movement. There was no rush. There was no need to strive for perfection - that eternal enemy of good outcomes - as I had done while my mentors were watching over my shoulders. I completed one step at a time, while always thinking one step ahead.

All the operations went reasonably well, but each procedure had a step or two that made me stop and think. How much do I have to enlarge the primary incision to accommodate the larger cartridge required to insert a 27-dioptre intraocular lens (IOL)? How do I remove the capsulorhexis flap that has somehow gotten stuck to the corneal endothelium? What do I do with this mushy lens that doesn’t have a single properly cracked quadrant?

Each eye introduced an element of complexity and the potential for a complication that I hadn’t really anticipated. But no complications occurred. Each patient left the OR with an intact capsule, an IOL in the bag and, I imagine, a genuine feeling of relief at least as authentic as my own. For the first time in my residency, I had the feeling that all would be well in my career as an ophthalmologist.