I have always taken the view that one is better operating in a familiar environment, with scrub-nurses and anaesthetists that one knows, to say nothing of the equipment required and, most importantly ensuring the most appropriate pre- and postoperative care of the patient. London is easy to reach and we have had a constant stream of fellows and observers either on an individual basis or as part of our regular surgical courses.
Consequently, I have consistently politely declined the many invitations to strut my surgical stuff in foreign parts of the world, usually as part of an academic teaching event or congress. I and my local colleagues undertook the ‘live’ surgery on our own course and I only asked one other surgeon to operate under these circumstances – my French friend. And we know how well that turned out (see last edition of ENT & Audiology News)!
Perhaps it is easier for a woman to say ‘no’ whereas many of my male colleagues have been inveigled into performing elsewhere, though many give up the practice after a ‘bad’ experience. The drapes may ignite from the heat of an inadvertently placed endoscopic light cable whilst the surgeon is distracted, or the rhinoplasty chisel may go through the skin as the foreign assistant misunderstands the instruction to ‘tap, tap’ and instead gives it their full welly. More often, the patient has already had 23 unsuccessful endoscopic procedures or has a condition no one locally feels able to manage, and also happens to be the hospital administrator’s mother. Meanwhile, the nurses and anaesthetists speak a different language from you, and no one can find the instruments you need. But in the spirit of gladiatorial combat, the surgeon reluctantly proceeds so as not to disappoint the audience. Reeling from just such an experience, one of the world’s most elegant rhinologic surgeons was made to look incompetent during a meeting in France. I mentioned to him that I would not be taking part in the live surgery as I never operated abroad. “You are a very intelligent woman,” he muttered despondently.
"More often, the patient is someone who has had 23 previously unsuccessful endoscopic procedures or has a condition that no one locally feels able to deal with"
Of course, even without an audience, things can turn out badly. Swiss ENT surgeons will sometimes discreetly whisper ‘Remember the King of Morocco’ in this context. Some many years ago, I was told that a famous Swiss surgeon was invited to Morocco to examine the then King who had a blocked nose*. The inevitable diagnosis of a deviated nasal septum was made and a surgical correction offered, to be performed back at the surgeon’s bright and shiny clinic in the Swiss Alps. This was declined by the king who, fearful of insurrection, asserted that it must be done not only in Morocco but actually in the palace and under a local anaesthetic. Assured that it would be worth his while, the surgeon agreed, creating a mini-operating theatre in the palace and, with the help of a local nurse, embarked on the procedure.
On injecting the local anaesthetic, the surgeon was appalled to see that the king suddenly stopped breathing and died. Without any appropriate resuscitation equipment, the situation was hopeless and things seemed to be going from bad to worse when military police swiftly arrived to escort the surgeon from the room and likely to prison or worse. Instead, and to his great surprise and relief, they handed him a briefcase full of cash, put him on a plane and waved goodbye. It seems likely that the whole thing was a set-up, the local anaesthetic which had been drawn up by persons unknown and not checked by the trusting surgeon, had possibly not been local anaesthetic ,and he was lucky to get out of the country. What made the episode even worse is that, in a subsequent questionnaire organised by the Swiss ENT Society on complications of local anaesthesia and presented at their national meeting, it came to light that this surgeon had claimed never to have experienced any such problems during his career! There is much to learn from this story, not least of which is to think twice before rushing to operate abroad but, if you do, always ‘Remember the King of Morocco’.
"Reeling from just such an experience, one of the world’s most elegant rhinologic surgeons was made to look incompetent during a meeting in France"
I don’t know of any other colleagues in ENT who had such an extreme experience, but a good friend was once asked to go to India to examine and treat a guru who had a voice problem. He demurred on the grounds that he was a nose specialist, but the more he refused, the more money they offered.
“I will only come if I can fly British Airways.”
“Of course.”
“I will only come if I can bring my own anaesthetist.”
“Not a problem.”
“I will only come if both I and my anaesthetist can fly first class.”
“Naturally!”
Having run out of excuses and demands, he felt obliged to go and flew to India with his nasendoscope and his anaesthetist, a cantankerous and obsessional individual who complained throughout the flight. They were then driven by jeep into the mountains to the ashram where they were taken to an unlit cave and instructed to meditate before examining the patient, a lady whose hoarseness was due to a small vocal cord polyp. The guru insisted that an immediate solution was forthcoming but refused to go to a local private clinic, let alone London. “It must be sorted out here in this cave,” she decreed.
They were then prevailed upon to make a list of all the necessary equipment in order to perform a microlaryngoscopy, with electricity provided by a generator in the cave. The kit duly arrived and the procedure was undertaken in the cave to the amazement of the guru’s many acolytes. Postoperatively, my friend mischievously insisted that she must have absolute voice rest for at least 21 days, somewhat longer than was strictly necessary, wondering how she would run the ashram during this period of enforced silence. Easy! The entire ashram community was also commanded to observe a vow silence for unspecified lapses in their devotions until she had recovered.
*King Mohammed V died in 1961 during an ENT operation, details of which vary in the press.
This series of stories is dedicated to those of you with whom some of these moments were shared (or endured) and, above all, to my amazing and long-suffering husband, David Howard. Most of you know him as an exceptional head and neck surgeon but, since Covid, he has been involved in a large multi-speciality international charitable project reintroducing negative pressure non-invasive breathing support which could transform the management of respiratory disease all round the world. If you are interested, please visit www.exovent.org for further information and, if you enjoy the stories, please consider donating to the charity through the Exovent website (Click DONATE on the home page drop down menu).
