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May 5, 2013

When I was a junior hospital doctor, my first job was as a surgical houseman in a busy local hospital in North Yorkshire. Back in the day when nurses did nursing and were routinely referred to as Angels by the patients they cared for. What I hadn’t  really anticipated was the physicality of the job I was about to undertake. Not just the walking around the wards and across the road (about a mile) to the geriatric hospital that we also covered. But the hard work in theatre itself.

Like all exercise, it becomes easier with practice. But the first time I had to hold a liver retractor I thought I was going to pass out. As the ‘assistant’ in theatre you are there to keep the operating field clear for the surgeon. So you have to hold organs out of the way and keep the area free of blood so the surgeon can see what they are doing. Often this is fairly simple and not too onerous. In fact surgeons often do it all without an assistant apart from the scrub nurse who has to pass the appropriate instruments when directed. But if it’s a simple enough operation, then the scrub nurse doubles as the assistant – and no doubt does a far better job than the newly qualified houseman.
But a huge part of medical life is training to be able to undertake the tasks that your more senior colleagues are doing. And the best way to do that is to be right in there and helping. In medical training the adage is “See one, do one, teach one.” And that is often literally what happens. You watch a more experienced person do something, you then have a go yourself whilst being supervised and then before you know it you are the one teaching others how to do it. I can tell you it concentrates the mind when you realise you’ll have to do it yourself. However obviously this doesn’t hold true for doing an appendicectomy. I must have seen about three or four before I was actually allowed to do one myself – and even then under very tight supervision.
But straightforward minor procedures like taking blood, putting up a drip, putting in a catheter, removal of a sebacous cyst, were basically shown to us once and then we had to get on with it. Most often with a doctor watching first time, and then you hoped a friendly nurse might come and assist. They’ve seen it all before even if they haven’t done the procedure themselves. And seemingly straightforward things like taping a drip down so it doesn’t fall out are actually trickier than they look. There is a way to do it that makes it simple, but it’s a matter of working out exactly how the doctor supervising you did it. A friendly nurse will be a godsend of knowledge on these things. And also reassure the patient that everything’s fine, even when the doctor appears to be shaking like a leaf.
I loved my ‘minor ops’ list that I did one afternoon a week. It was all kinds of things but mostly removal of harmless but unsightly lumps and bumps, ingrowing toenails, abscess drainage and stuff like that. All very satisfying. For both the patient and me. And no operation lasting more than about half an hour. And that’s a long one.
Unlike major surgery which can mean eight hours standing in theatre, pulling and heaving and sweating under the lights. Until you get used to it. But even so, I found as an anaesthetist my right arm and hand became an iron grip from holding a mask on the face and the jaw at a particular angle. Usually if you knew the operation was going to take a while you would put a tube down the throat and in to the lungs so that you could attach the gases straight to it and not need to hold a mask on. But sometimes surgeons were slow, or hit a problem and then you’d be stuck with the mask and fingers cramping, and the whole arm aching. And you can’t just leave the mask off for a few minutes while you get the life back in to your hands because it is those gases that are keeping the patient asleep. So you swap hands and become ambidextrous and your endurance improves with practice and soon it is second nature.

 I'm the guy straight on. See how his hand is clamped round the mask and his biceps is tensed?

I’m the guy straight on. See how his hand is clamped round the mask and his biceps is tensed?


So much so that in fact one Monday afternoon I was doing a list after having been on call all weekend. I had managed to snatch only a few hours sleep since Friday morning when I had come in – it may even have been the infamous weekend that involved the stuck vibrator – and I was very tired. As the anaesthetist I would sit or stand at the head end of the patient; they are lying on the operating table and I am sitting at their head end, with my hand firmly clamped holding their jaw in place and the black mask on, watching the bag inflate and deflate. their chest go up and down and my finger on the pulse just in front of the tragus of the ear so I can feel the steady beat of their heart and know all is well with them. One of the issues of using a hand held mask to keep someone asleep is that tiny amounts of the gases escape if the seal around the mask edge isn’t absolutely perfect. It doesn’t usually matter. But on this Monday I was sitting down not standing because I was already exhausted. So I was even closer to the edge of the mask if any gas did escape as I relaxed my grip or readjusted the mask for any reason. The operation continued. All was going well. It was very very straightforward. The patient’s pillow was crisp and white and I thought I’d just rest my head on it whilst continuing to hold the mask, watch the bag, feel the pulse and I lay my hand on his chest so I could feel it move gently up and down. All was calm. The rhythmical breathing, the steady pulse, the warmth of the operating theatre…….
The next thing I know is that one of the Operating Department Assistants is tapping me on the shoulder and telling me one of my Senior Registrars is asking if I’d like a coffee break. It was one of the courtesies anaesthetists afforded each other; if you are working alone (as I was) another anaesthetist (who was working with a colleague) would come and offer you a break otherwise you’d never get one. I have never been as grateful to anyone for their timing. I may have only drifted off for a moment. Or it could have been minutes, I really don’t know. But thank God anaesthetists are civilised human beings who look after each other as otherwise both the patient and I could have been in deep shit.

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