Joel Fish on life as a burn doctor

The Globe and Mail Metro (Ontario Edition) - - OPINION | SESNSES & ABILITIES - Joel Fish is the med­i­cal direc­tor of the burn pro­gram at Toronto’s Hos­pi­tal for Sick Chil­dren.

Joel Fish on how his abil­ity to feel in­forms his work as a burn sur­geon

My hands are not pretty. They could eas­ily be­long to some­one who makes sausages for a liv­ing, or pos­si­bly a con­struc­tion worker. They are thick and short – a bit like sausages, now that I think about it – and have, for the most part, sur­vived rel­a­tively un­scathed de­spite years of mar­tial arts and box­ing. I’ve heard many com­ments about the fact that they don’t look like the hands of a plas­tic sur­geon. I’ve never apol­o­gized for this, and I don’t re­ally care. It’s how I use my hands that mat­ters. They are my tools.

I am a plas­tic sur­geon, and I spe­cial­ize in treat­ing burn pa­tients. I am grate­ful this pro­fes­sion chose me. I am proud of what I do.

My job re­quires an in­nate sense of touch. Ex­am­in­ing the scars or burn wounds of pa­tients is a nec­es­sary part of my work. When I touch a pa­tient, it’s more than just a phys­i­cal eval­u­a­tion. It tells me about who they are. It helps me un­der­stand what it is I’m sup­posed to do. The lay­ing on of hands is very per­sonal for the pa­tient, and a priv­i­lege for the sur­geon. It’s some­thing I do many times each week. If I ever lost my abil­ity to “feel,” I would lose my abil­ity to be a burn sur­geon. If I could not use my hands to feel the stiff sheets of skin, and un­der­stand the power in a tightly-healed scar, I could no longer help the chil­dren in my care. It’s that sim­ple.

I am just one mem­ber of the burn team; to­gether, we treat more than 300 new fam­i­lies a year. A mo­ment in time changes ev­ery­thing for the chil­dren in our care (scald­ing liq­uids is the most com­mon in­jury). We treat the burn wounds and help them heal with spe­cial dress­ings, pain con­trol and – some­times – surgery with skin grafts. We fol­low these chil­dren and their fam­i­lies as they re­turn to school and play.

My love of plas­tic surgery de­vel­oped in the 1980s, when I learned the skill of mi­cro­surgery – re­plant­ing am­pu­tated parts. Later, I moved into burn surgery. If you ever won­der what you are go­ing to be when you grow up, a burn sur­geon is likely not on the list. The job was of­fered to me when I fin­ished my train­ing as a plas­tic sur­geon. I ap­plied for the po­si­tion, but it was of­fered to some­one else; when they didn’t sign the con­tract, it was of­fered to me in­stead. I learned to park my ego and took a job do­ing what few plas­tic sur­geons want to pur­sue. I trav­elled to three of the world’s top burn cen­tres and, un­der the men­tor­ship of a few great burn sur­geons, de­vel­oped my pas­sion for treat­ing burn pa­tients and their fam­i­lies. I did not find this job; it found me.

Un­til re­cently, I had never con­tem­plated what I would do with­out a sense of touch. But then I un­der­went shoul­der surgery – a re­sult of fall­ing off my bi­cy­cle. When I awoke from the surgery I had no sen­sa­tion in my dom­i­nant arm, the re­sult of a blocked nerve for pain con­trol. Even though the nerve block was tem­po­rary, I was scared that my arm was per­ma­nently dam­aged. For a brief pe­riod, I thought my ca­reer might be over. How could I op­er­ate with­out a sense of touch? I am for­tu­nate it was only tem­po­rary.

The op­po­site is true for burn pa­tients; their scars feel “dif­fer­ent.” Pa­tients with deep elec­tri­cal in­juries of­ten de­scribe per­ma­nent, and painful, al­tered sen­sa­tions. Many burn pa­tients are left with skin that is not as sen­si­tive to touch. We know very lit­tle, for in­stance, about how al­tered sen­sa­tion in scarred skin might af­fect a per­son’s sex­u­al­ity. We can never fully com­pre­hend the loss that burn pa­tients might ex­pe­ri­ence. There are no doubt some who are just happy to have sur­vived – de­creased sense of touch or not – but they are a mi­nor­ity.

I re­cently at­tended a con­fer­ence in Hal­i­fax for Cana­dian burn sur­vivors. It un­der­scored the im­por­tance of what we do. I lis­tened to a pa­tient, 50 years af­ter hav­ing suf­fered in­juries, who de­scribed be­ing ex­am­ined by a physi­cian who put his hand on their leg even af­ter be­ing asked not to as it was so painful when touched; they re­called it as if it had just hap­pened last week. An­other pa­tient de­scribed how the soft­ness and warmth of the sur­geon’s hands, af­ter en­dur­ing years of re­con­struc­tive surg­eries, helped with her re­cov­ery. I wish I’d known the im­por­tance of touch when I first started work­ing as a burn sur­geon – I don’t re­call be­ing taught about touch’s ther­a­peu­tic prop­er­ties when I was in med­i­cal school. This is some­thing nurses, who ap­proach pa­tient care more holis­ti­cally than doc­tors, know well. Un­for­tu­nately, I learned this im­por­tant les­son late in my ca­reer.

We re­cently ex­am­ined a small boy’s leg while he was asleep for a laser treat­ment to soften his burn scars. The in­jury and its af­ter­math are per­ma­nent and will be there for­ever. The tight scar around his knee is symp­to­matic and pulls when the leg is straight. He feels this with ev­ery step. His par­ents feel ev­ery step, as well. The scar and the joint were ex­am­ined and the team was able to de­ter­mine the next steps and fu­ture surgery needs for this young boy. It is the sense of touch that guided this de­ci­sion and binds the pa­tients and fam­i­lies to us. Like all senses we are born with, we take them for granted, but mourn their loss.

My job re­quires an in­nate sense of touch. … When I touch a pa­tient, it’s more than just a phys­i­cal eval­u­a­tion. It tells me about who they are.

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