It is in the nature of surgery that surgeons will sometimes find themselves in a position to rescue people from certain death. In the developed world this tends not to happen to trainees because there is always a senior to call on for advice and assistance, and as a consequence most surgeons will have reached a degree of competence by the time they have to shoulder the responsibility on their own.
In Papua New Guinea in 1974 it was different. Our hospital was the end of the line, with no onward referral. Our surgeon was on leave, and I was standing in, when a pick-up truck deposited a woman who had been flown out from the remote highlands. As I walked into the cubicle where she was squatting on the bed, my heart sank. A broken spear shaft was sticking out of her back, and the tip was just visible where it had pierced the skin overlying her manubrium sternum. It was immediately obvious that the necessary surgery was way beyond my level of training, and equally obvious that she was doomed unless the spear was removed.
A chest x ray showed no pneumothorax, and, after discussing it with Peter, a nurse anaesthetist trained in Port Moresby, we decided to give it a crack. While preparations were being made in the theatre, a hurried glance through Hamilton Bailey's Emergency Surgery did not reveal any similar case, and Grant's Anatomy was frankly frightening.
With the skill of a master, Peter intubated the patient on her side, because the spear sticking out of her back precluded any other possibility. The spear shaft had been snapped off, presumably in order to fit her into the Missionary Aviation Fellowship plane. What remained was the business end, which was of a hardwood carved in a saw tooth fashion, with barbs that prevented it from being pulled out backwards. I gave it a tentative pull anyway, and to our surprise it dislodged and could be extracted without too much difficulty. The tip, however, was still poking out of the front and would need an anterior approach.
Laying the patient on her back, we prepared the area, and as I cut down I tried to shut out visions of the anatomical structures that the spear must have passed through in order to transfix the manubrium. I freed the tip by nibbling the bone, and then it was loose, so I gently teased it out. A gush of blood followed, but settled with direct pressure, and the job was done. A second x ray showed a haemopneumothorax, for which a chest drain was needed, but the patient went on to make a full recovery.
What did I learn from this? Primarily that when the situation looks hopeless don't be afraid to have a go. But remember, the patient and the surgeon both need luck on their side.
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