The bits I didn’t like

The only bits of medicine I didn’t like, and in fact was quite squeamish about, was eyes. There were things I didn’t enjoy as much as others, like filing, but eyes did my head in. There was a girl at school who could put her finger under her eyelid and basically wipe her eyeball with her finger. Used to make me feel physically sick.  And as a doctor it’s pretty tricky to just say “Yeuk, no don’t show me that stye/conjunctivitis/contact lens!” so I had to brace myself and swallow hard when I did anything involving eyes. Funnily enough I rather enjoyed incising and draining Meibomian cysts which are little cysts in the eyelid and you have a special circular little clamp to use once you have flicked the eyelid inside out. Sounds gross but actually rather fun.  But that’s about the only time I haven’t minded eyes.

The worst time was when I was covering Accident and Emergency and two men came in having been involved in a stabbing. The guy I was resuscitating had been stabbed in the chest,the neck and the face. The knife in the chest had pierced his ventricle – the pumping chamber of the heart. The neck one had missed the major artery but looked like it had pierced the top of the lung. The one in the face was through the cheek bone and up through the bottom of his left eye. His eye was pushed forward out of its socket and resting on his cheek.

As the anaesthetist my job was to secure his airway so that air could come in and out. Basically to keep him alive whilst the rest of trauma team worked on him. He had arrested and had no signs of life so I needed to put a tube down in to his trachea (windpipe) so I could help him breathe and some lines in to give him fluids and drugs. Someone else was on his chest doing compressions whilst trying not to squirt all the blood out of the hole in his chest and heart itself.

The cardiac surgeons arrived. We are still in casualty but they decide they need to open him up and sew up the hole in his heart.  This meant getting all the sterile drapes on and making sure the field they were going to operate in was clear of any of my unsterile equipment. No tubes or bits and bobs in the way that they might accidentally touch once they had scrubbed up.

So I had to wrap his head in a sterile green drape to keep all my tubes and stuff  well clear of the surgical area as all my equipment is not sterile. But obviously I still have to be able to access them all and check he is still breathing OK and still unconscious. Wouldn’t want him to wake up and start coughing or pulling at his tubes.

Thus I have a green drape about a metre square and I lift his head up to shuffle the drape underneath. I then take the corners furthest away from me (I am standing behind his head) and pull them up and across his face, trying to ensure I capture all the tubing. (It’s a bit like putting a towel turban on after you’ve washed your hair except I’m wrapping his face in it too). And as i bring my hand up my finger catches his eyeball resting on his cheek. I am nearly physically sick as it blobs around. I have to clip the drape with forceps to hold it in place and I am terrified I will accidentally puncture the offending eyeball but I don’t.

It’s fairly crammed in the resus room in A and E but it’s all we can do and the surgeons have split his sternum (breast bone) open and have rib spreaders in place to hold the rib cage apart whilst they sew up the ventricle. They have managed to restart his heart and they put in a chest drain to reinflate the lung that has been punctured. It’s all going on and I am keeping him alive whilst they build him back together. I’ve had to be very mindful of this eye that is now hidden under the green drapes as it is not uncommon to rest ones hands on top of them, or a piece of equipment if it were light and obviously I can’t do that as I might damage it.

And soon the cardiac surgeons leave – all flying surgical gowns and blood stained boots. And I am left with this poor guy. And his eye. It is still there staring at me from under the drape that I have now loosened but not revealed the offending globe.

We are waiting for the ophthalmic consult. The eye guys have been called but obviously couldn’t do anything whilst the cardio-thoracics are ongoing. So I wait for them. They have been called from the specialist eye hospital Moorfields which is not far away in the City.  I am dreading the eye surgeons wanting to take him to theatre and then I will have to  anaesthetise him for that and sit through the whole gruesome procedure. And eyes are so close the head where I sit, I can’t get away with not looking.

And then the door opens and two guys sweep in. In shades and black crombie coats. As cool as fuck. Seriously it was like Men In Black but 20 years before it. I removed the drape. They took one look and said “He’ll have to come back with us.” What a result. The surgery was too complex for them to do at our hospital, They wanted to take him back to the highly specialised theatre in Moorfields.

“So how did it happen?” asked one of them. “It was an argument about a parking space outside a curry house.” I said. We all looked around the room at the aftermath of a senseless altercation over something as trivial as a parking space. He was lucky to be alive and may well have lost the sight in one eye. The other guy had been whisked away to theatre with an abdominal stab wound. At various points there had probably been in excess of seven or eight people working on each victim, numerous pieces of equipment, drugs, and blood being used, It will have cost the NHS thousands and thousands. All for a sodding parking space.

When bottling it took on a whole new meaning

I loved working in accident and emergency, or casualty as we called it. The terms are interchangeable but A and E is probably more modern. You really have no idea what is going to roll in. Sometimes literally as drink is a major player. Of course when I was working in them Casualties were often very busy, but we didn’t seem to be troubled by the shit minor stuff that comes in nowadays. Stuff that should be sorted out by a wash and a plaster, or perhaps a visit to a chemist shop. Or a visit to the GP on Monday. I mean there were time wasters, but nowhere near the level there are today. People seem to have lost the ability to sort themselves out and will call out an ambulance because they have a splinter in their thumb.

But I digress. The first time I was attached to Casualty was as a student, and I blogged here about the Hoover Dustette incident and here about the fireworks. But there were plenty of other stories. It really is a place to see all of life and we did. Sometimes in eye-watering ways.

And so it was that I was asked to see a young woman who had “Got something stuck”. I think we all know where this is going. And sure enough behind the curtain was a fairly dishevelled looking girl of about 19. Looking a bit embarrassed but more worried than anything else. I asked her what the problem seemed to be and she told me she’d got a Coca Cola bottle stuck up inside her. And sure enough, when she lay down I could clearly see the bottom of one of those nice shaped glass Coca Cola bottles between her legs. “How did it happen?” I asked, waiting for the “I was walking nude around the house and tripped over and it just went up there,” usual guff  But no. She was unperturbed to tell me she’d been masturbating frantically with the Coke bottle and suddenly she’d been unable to pull it out altogether. She’d no idea why not. She’d been pulling and pulling but it just wouldn’t come. (no pun intended).

I examined her more closely and could see that her vaginal wall had been sucked inside the coke bottle and was now swollen and unable to come back out of the top of the bottle. It was well and truly plugged in. I thought I’d better call the Gynae Reg to come and see her. This was their department after all. But of course in the mean time I was discussing her with other colleagues on the floor. I mean, these kind of cases brighten the day and raise a smile. So often we are dealing with tragedy and loss it is fun when something like this comes in. And during the conversations someone came up with the obvious solution which I hadn’t thought of. The frantic up and down, in and out motion had created a vaccuum and sucked the vaginal wall inside the bottle so all that was needed was to break the vaccuum and it would release the pressure. Brilliant.

So now we had to work out how to break the bottle without injuring her further. The colleague who’d thought of the answer came over and we thought about wrapping the bottle and hammering it but there wasn’t actually much bottle protruding so it was pretty impossible to get enough leeway to try to smash it without also risking crunching her pelvis instead. In the end we got an orthopaedic drill and drilled a hole in the bottom of the bottle and hey presto the vaginal wall was gradually and gently released and although a bit sore and swollen, she was able to go home even before the Gynae Reg had made it down to see her.

She was in and out in no time.

The first time I had to break bad news

Breaking bad news is never easy. And comes in many guises. It’s not just about death or diagnosing a fatal disease. I gradually realised that many things qualify as ‘bad news’ to others which to me seemed relatively minor. As a student  I hadn’t understood the likely impact of my words or the preconceived ideas patients would have which meant they would interpret my breezy announcement about their condition in a way I did not predict. I would say “Mr Jones it looks like you have a condition called diverticulitis which has been causing this bleeding from your bottom” and I would expect him to be as relieved as me that it wasn’t cancer. But sometimes Mr Jones would appear to be as devastated as if I had told him he had a month to live. Because of course I stupidly didn’t realise he would have no idea what a diagnosis of diverticulitis would actually mean.  Because I hadn’t told him.

So I quickly learnt that what seemed to work for me was to be explicit upfront about the diagnosis NOT being cancer. It surprised me how many patients default to imagining they do have cancer or a serious fatal illness whatever their symptoms. Not everyone obviously, but lots of people. So I would always ask people what they thought it might be so I could be explicit and clear in my reassurance if we were able to exclude that particular problem.  It made it easier for me too as it somehow gave it a platform of being not the worst news even if it wasn’t good news. A perspective of relativity perhaps.
We had classes on giving people terminal diagnoses. What to tell them. How to tell them. How to listen. How to ask. How to remember the patient when all the family are insisting on a particular course of action.  It would often be more stressful battling with the family to treat their loved one as an intelligent adult than talking to the patient themselves. They often seemed to insist that their parent or partner would not be able to take it if they were told their diagnosis. But I had no right to withhold that information if the patient was of sound mind. And I found that patients do tend to give you pretty clear signs how much they want to know if you ask them.

As a student I had been with doctors when they were delivering bad news to patients, but there comes a time when you are the one to have to do it, not be the sympathetic bystander. Unlike nowadays, we did not have roleplays to practice our technique and responses but if I am honest I am not sure how useful roleplays are unless they use real patients who have been through it. Actors, no matter how good, are not real patients and come with their own  ideas of how they would react which is not necessarily the same as seeing it in real life.

But anyway, I’d seen it in real life before I did my first. In fact, unlike the usual medical adage of see one, do one, teach one I had seen it a few times before I was left to do it myself. I had really enjoyed my stint on the Oncology ward as I blogged here, and had seen an inspirational Consultant talk to his patients about death and dying. The best possible training. Except that this wasn’t really the same scenario…

I think it only fell to me this particular time because it was at the weekend and an emergency so the more senior doctor who had been with me trying to save the patient’s life had been called away to another patient. And the living take priority. So I was left to tell the parents and boyfriend of a seventeen year old girl that we had been unable to save her from the anaphylactic reaction she had had. Because they needed to know. They had a right to know. We couldn’t let them just wait until my more senior colleague was finished. That could have been hours. They would already have been waiting for over an hour wondering how she was doing since she’d been brought in semi-conscious. And so with pounding heart I went to find them in a small side room in Casualty.

A nurse came with me and we walked in to the room. They all instinctively stood up and looked at me expectantly.  And then the boyfriend started crying when he looked at my face. It was so hard. I had been the one who had taken the history from him to find out what had happened as by the time she arrived she was losing consciousness so couldn’t speak. Her parents didn’t arrive until later. So I already had a relationship with him. And I expect he saw it in my eyes that it was the worst news possible.

I don’t remember where the nurse was, but we all sat down. I drew my chair up so close my knees were touching the mother’s. And then I told them. I tried not to use euphemisms and said that we had done everything we could but she had died. I remember thinking I shouldn’t say things like “She’s gone” in case they might think I meant she’d gone to another hospital or just out of the building. And the father appeared stoic and supported his wife who looked shell shocked. I asked them if they had any questions and did my best to answer them. But it is often too early to have questions when you have been hit by the ten ton truck of sudden death. So in fact there were few, mostly about what she would or wouldn’t have been aware of. And whether she would have been in pain.

And they were very gracious and grateful and thanked me for all our efforts. And I felt terrible. And their niceness made me well up even more. I was trying to stay professional but I could feel the tears. The throat closing in. I wanted to leave before I crumbled completely but felt I couldn’t just get up and go abruptly. We sat and I held the mother’s hands. “I’m really sorry,” I said as I got up. The father shook my hand. The boyfriend was still as a statue looking at the floor. I touched his shoulder as I left the room. The nurse stayed to talk to them about what happens next.

And I really was sorry. This wasn’t just a trite saying. Sorry for their loss of course, But the overwhelming feeling was guilt that we had failed. Sorry we hadn’t been able to save her. And I went over and over it in my mind. Could we have done something differently? Had I done something wrong?  We are trained to save lives and make things better and it is hard to come to terms with failure, even if you have done everything possible. It was awful.

They do say relatives often remember this kind of conversation with incredible accuracy and replay it in their minds. I hope to fuck that I didn’t make things any worse for them than it already was by the way I handled it. But I’ll never know.

When people talk about stress in their work I am minded to shout that they’ve got no fucking idea what work related stress is. But I don’t of course.

What made me apply to be a doctor

I had been at a pedestrian comprehensive where  the vast majority of people left as soon as they could. Some would go to tech, but very few aspired to University. My sister had been one of only three people in the upper sixth, so you can see there was not a huge stimulating debate to be had in the common room.

I had enjoyed school – cruising along doing very little and spending most evenings and weekends doing paid work in shops, hotels and bars. Played hockey, learnt some instruments, did some acting and messed about with boys. That was about the sum of it.  I wanted to leave school at 16 and either do hotel and catering or act.
My parents (particularly mother) were not keen. They had both been to University and expected me to go too. But I couldn’t think of anything I wanted to study. And anyway, I wanted to leave school.
However, that changed after spending a couple of months in hospital during the fifth form (year 11). I had to have lots of physiotherapy and I thought that looked quite a fun job and it might keep mother off my back about going to University. Unfortunately it meant staying on to get A levels but I kind of resigned myself to that.
I don’t remember being keen to go away to sixth form college, but the initial application process meant a day off school so what’s not to like? I turned up for interview with the Director of Education along with about ten other hopefuls. We were being given a preliminary interview to see if the county would fund one of us to go to an international sixth form college which at the time cost about £10,000 a year.

The other applicants were all in their prissy school unforms and eager to please. I, on the otherhand, was wearing a midi length flared brown skirt with button pockets, a brown and cream striped, ribbed V-neck jumper from Van Allan, a brown fake sude jacket with faux fur collar, huge brown platform shoes from Lilly and Skinner and black painted nails. I used to love that outfit, disgusting as it sounds.

I got in to the sixth form college and from there it became an assumption that I would go to university. Much to my parent’s relief. But still I thought I might do Physio or Drama. Until my mother had a long talk with me. Firstly, you can do acting as a hobby and if you really like it, do it after University. Secondly, although physiotherapy is a great profession, she felt I had the brains to be a doctor. The academic requirements were higher for doctors than physios, so if I were able enough I should apply for medicine because otherwise I would be taking a physio place that someone else could have had. And the chances are that the person whose place I had taken would have been someone whose dream it was to be a physio, who had worked hard and strived to get the neccessary A levels, but because I didn’t feel like pushing myself I had stolen their dreams when I could easily do something else. Something that lots of other people couldn’t do. I had to aim higher or it wouldn’t be fair.

She appealed to the altruism of a sixteen year old – and it worked.
It was very clever of her. I didn’t realise she had done it till much later. It never occurred to me to say “But I WANT to do physio, or I WANT to act.” And I don’t hold it against her. I had a great time doing my degree and have enjoyed my career ever since.
And there’s still time to take up acting………………… 🙂

A bit of a bum job

Don’t ask how my husband and I started discussing this topic, but I am so old now that the treatments we recommended for certain conditions are no longer used. Superceded by “evidence based medicine”. In the old old days a treatment or procedure might be thought to be a jolly good idea in theory and so, hey ho, it would be tried out, written up and before you know it, it would be routine. Before you had to do clincial trials and stuff and actually find objective evidence that the treatment worked better than doing nothing.
The procedure I remember in particular is known’s as Lord’s procedure. I did it as a House Surgeon and also had to keep people asleep who were having it done when I was an anaesthetist. The latter role was much much harder because the procedure was intensely, agonisingly painful and would cause people’s hearts to go in to weird rhythms, threatening to stop, so you had to make sure they were really deeply unconscious before the surgeon started.
Because the procedure was one to alleviate piles and/or fissures (splits). It was really barbaric. The patient would be in the lithotomy position – on their back with their legs up in stirrups (like in the old days birthing mothers were made to be). The surgeon would then get ready to manually dilate the anus. The aim was to insert four fingers of each hand in to the anus, with the hands being turned back to back not in the praying, palms-together position. Then you would stretch as hard as you could – pulling your hands apart at each side of the anus – so like ripping the bum cheeks apart. You only ever pulled in that direction not up and down. And basically over 3 or 4 minutes, you would stretch this poor soul’s bum until you thought you’d done enough. It was during the stretching that the heart rate would go all over the place. And I think we can all see why.
The procedure (named after the doctor who dreamt it up, not after the House of Lords routine entertainment of each other) was used for years until eventually somebody did do more robust research and found that although it appeared pretty effective straight away, 20 years on people actually had trouble not dribbling shit so perhaps knackering their sphincter maybe wasn’t the best thing to be doing.

Working out

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?

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.

Scrubbing up well

As a medical student you have to learn lots of procedures. I already blogged about learning to take blood. But even preparing to do a procedure requires training and practice. I am taking about aseptic technique. Where putting on a pair of surgical gloves is an art as much as a neccessity.

Aseptic tecnique is when you have to do everything under sterile conditions. Usually it means you are about to do something that could potentially introduce an infection in to the patient if you don’t make sure everything you use is sterile. So listening to a chest is not going to put the patient at risk of an infection so you don’t need to do that under aseptic technique, but doing a lumbar puncture possibly could so you do. Depending exactly what you are doing and the level of risk of infection (and mess)  will determine whether you just ‘glove up’ or ‘gown up’. If you are going to theatre to do something you will completely ‘scrub up’ to do things in a sterile (not just aseptic or clean ) way. The principle is to ensure that everything that touches the patient is sterile. Your hands, you clothing at the front, the instruments. Once you are ‘gowned up’ you can’t use anything sterile to touch anything non-sterile. So you can’t use your gloved hand to scratch your nose. Or tuck your hair back in to your cap. Or wipe your nose. Someone else who is non-sterile has to do that for you. Similarly if you are in theatre but not scrubbed up and therefore not sterile, you must only touch the things that are non-sterile.  It becomes second nature after you have done it a few times, but it is nerve wracking at first. Terrified to touch the wrong thing and cost the NHS time and money and potentially put the patient at risk.

So the first thing you have to determine is your glove size. They need to fit snugly so there aren’t flapping finger ends that mean you can’t manipulate your tools easily. or so tight that the circulation is cut off to your fingers. They come in various sizes and half sizes and I am a 71/2. But it took trying on a number of different ones and trying them out to work that out.

So when you are going to assist or carry out an operation in theatre, you will be dressed in your scrubs and have your surgical hat and clogs or wellies on and you will go to the scrub room just next to theatre. There you have to  wash your hands (scrub up) and put your sterile clothing on (‘gown up’).

Not as simple as it sounds when you are actually scrubbing them to try to remove any traces of bacteria lingering on your skin. So you start off  by ensuring you have no jewellery on and your arms are clear to your elbows. Turn the taps on to a comfortable temperature. Taps in operating theatres have long handles so you can operate them with your elbows once you’ve started because you musn’t touch anything that isn’t sterile once you start or you go back to the beginning aagin. So you press the pump-operated disinfecting scrub  – often chlorhexidine- based – with your elbow and wash and wash. You will have a sterile scrubbing brush to use that you need to get in every nook and cranny, always holding your hands up as if praying so that the water runs downwards, away from the fingertips. Scrubbing up takes a good few minutes, and your skin can feel sore and raw.  Once everything is rinsed off you need to dry your hands on the paper towels that have come in the pack with the sterile gown you are about to put on. If you are sensible you will have opened this before you start as the outer packaging is not sterile so you can’t touch it once you have scrubbed. If you’ve forgotten, a friendly nurse or ODA might help you if you ask nicely. if you are senior enough they will do it for you automatically.

So you dry your hands with the sterile towels and the next thing you do is put on the sterile gown. You unfold it and feed your arms in to the sleeves but do not touch the outside of the gown with your bare hands or you will make it unsterile and have to start again. Someone else will do it up behind you.

Then come the gloves. There  are various ways to get them on, but this particular technique was the one first taught to me. Someone will open the pack for you and there will be each hand laid out like two pages of a book. The cuffs of the gloves are turned up so that about three inches overlaps. You must not touch the outside of the gloves with your bare hands so you must pick up the first glove by the cuff and wiggle your hand in and esure the glove goes over the sleeve of your gown. . If you haven’t dried it properly this will not be easy. There is a packet of  sterile starch (like snooker players use) if you want to rub your hands in that to make sure they are dry and slippery.

Then, once you have got the first glove on comes the second.  You musn’t let your gloved hand touch the bare skin of your other hand or arm or you’ll go back to the beginning again. So you slide your gloved hand inside the turned over cuff and pick the glove up so the fingers are pointing down the back of your gloved hand towards your wrist. And you slide your second hand in, making sure no skin touches the outside of the glove, or you know what will happen.

Then once the gloves are on you have to get any trapped air out of them and bang them down in between your fingers and make sure your cuffs of the gown are tucked well inside the cuffs of the gloves. No gaps.  meanwhile someone will tie up your mask .

And then once you’ve done all that you need to walk in to theatre itself, always keeping your hands up in the praying position to minimise the risk of you accidentally touching something unsterile and having to start all over again.This usually involves going through double swing doors which you need to reverse in to to make sure you don’t desterilise the front of your gown or your hands by touching the door with them.

So, the first time I was assisting in theatre after spending ten or fifteen minutes laboriously scrubbing and gowning up, no one  was happy when I simply pushed the door with my hand. I was banished back to the scrub room and they did the operation without me. I never made the same mistake again.

Christmas on the wards

When I was a hospital doctor I always worked over Christmas. Not out of choice, but because I didn’t have children so priority was always given to those who had. The first time it happened I was in North Yorkshire and Christmas Day fell over the weekend. Saturday if I remember correctly. So I was rota- ed to work that whole weekend. So that would mean working the normal week and then when I came to work Friday morning I would be continuously on call until the Monday morning.
Most people left the hospital on Friday lunchtime. The few of us that were left on call covered for our colleagues so they could get away early to start celebrating with their families.
The nursing staff were happy to be working on Christmas Day and wondered why I wasn’t so enthused, but they seemed to forget the substantial difference between their working and mine was that theirs was a shift that ended and allowed them to go home to their families whereas mine meant I couldn’t leave the hospital for 72 hours.
So Christmas morning arrived and I went to the wards. We had tried to let everyone go home that could, even if only for the day, so those left on the wards really had to be there. I realised I was lucky in that I was healthy so it was beholden on us to try to give the patients a good time. And the wards were probably less than two thirds full so it wasn’t busy.
I wouldn’t normally have helped with breakfast on the wards, but today was Christmas so I donned my tinsel headband and went to wish everyone merry christmas. Obviously I had to do all the work one routinely does at weekends, putting up drips, writing up drugs, sorting out folk who take a turn for the worse and admitting people through casualty.
But come lunchtime the Consultant surgeon on call came in with his family and toured the wards like a celebrity. The patients really seemed to enjoy seeing the human side of him and his small offspring. And he loved playing the Patron.
And there was wine and beer with the full Christmas lunch which we all served to the patients. And of course we were not holding back on the wine and the sherry for ourselves!
Those that could sit were put at a table in the middle of the ward, those bed ridden had us feed them. Probably not as good as a nurse doing it, but at least we were trying. There were crackers and all the trimmings. The NHS pulled out all the stops. We even gave every patient a present. And of course there were shed loads of Quality Street that relatives had kindly donated and we scoffed non stop.
We were keen to try and make it as good for the patients as possible and sang carols and played games until their visitors started to arrive mid afternoon.
And that had been fun and nice. But it wasn’t my usual family Christmas. And the mid afternoon lull when I went back to the Doctors’ Mess, was awful. Acutely lonely knowing, or at least feeling, that everyone else was with their family. Even the patients had their families visit. The nurses would be going home to their families. The doctors who lived locally would have their families. It was only the few on call medical staff that were really on their own. I hated it.
There was TV to watch. Well, the basic three channels so not much. No computers. No videos. Books didn’t hold an attraction. I went back to the wards just to be with people. Because that’s what Christmas is all about isn’t it?

Rifling through my drawers

My parents’ death has meant we had to clear out their house. In fact my father’s papers were very much in order -and he had even sorted out photos in to brown envelopes that were labelled with various categories. It has meant our house has got rather more furniture and ‘stuff’ in it now than it is used to, so I thought I’d start to clear out my own drawers in an effort to make way for it all.

And I came across one of my postgraduate exams. Brought me out in a cold sweat just seeing it. What a stress they are. You’ve qualified in medicine but that’s not enough, you have to take further exams over the next few years whilst you are also working full time. God knows how people do it once they have children. And as a rule of thumb its a 50% pass rate so you often may have to retake one or two of them. Stress central. Anyway I’d also kept the list of candidates names and the timeslots for their vivas (the gruelling, humiliating oral part of the exams where you are put on the spot and can dig yourself in to a hole so deep only a submarine would find you.) Unlike the joy of written exams, you can’t go back and cross it out. Once you’ve said it, the examiner has heard it, logged it and thinks you’re a twat. It then takes a Herculean effort to bring them round again.

I was doing some practice vivas at work a week or so ago as now I get to be the examiner. And it is really surprising how people perform under pressure. I am not always good at predicting who will do well and who will flounder. But it is so much better being my side of the table than theirs.

Some patients I never forget

As a medical student one has little actual responsibility for the care of the patients one sees as obviously qualified doctors are overseeing everything. We are superfluous to requirements and there to learn rather than contribute. On the whole most patients were generous enough to let me study them. In fact, I don’t remember anyone ever refusing. Perhaps they were worried the doctors wouldn’t treat them as well if they did. I hope not. It isn’t the case.

My favourite firm as a medical student was Oncology. The cancer ward. I had already done Cardiology and Metabolic Unit, and hated the latter. It was run by two dry Consultants; one an academic expert in these rare diseases we were seeing and the other old and boring. The juniors called him ‘Shifting Dullness’  – a medical term relating to fluid in the abdomen but one which perfectly described his ward rounds.

Oncology on the other hand was brilliant. The consultant was fantastic. Inspiring. And the patients were incredible. Two I remember in particular. One of our jobs as students attached to oncology was that we had to administer all the intravenous chemotherapy . Nowadays one gets gloved up and puts safety googles on to handle these toxic chemicals, but we were just sent off to the treatment room to try to work out what to do by ourselves. Some of these medicines would cost hundreds of pounds  a vial. Even then.  Nobody taught us how to draw up intravenous drugs so we didn’t realise they were vacuum packed. What that means in practical terms is that if you stick your syringe in to the bottle to try to draw up the liquid you can’t pull the plunger back as the vacuum is fighting against you. What you have to do is inject air in to the bottle to break the vacuum and then withdraw the same amount of drug as you have just injected in air. If you don’t do this correctly the whole thing can explode and spray toxic chemicals all over the room. Yes, guess who managed to do that….
So we would spend quite a bit of time on the wards with the patients and get to know them well. And of course in the oncology ward, many of them had life-threatening diseases.

The first patient to make a fundamental impression on me was a man in his 80s. I can’t tell you his name although I’d like to so that he would get the recognition he deserves. But confidentiality extends post mortem so I can’t. I can see him now. Sitting up in his bed, leaning forward trying to catch his breath. He had lung cancer and at that time there were no successful treatments for the type he had. I was assigned him and had to take his history and examine him.

He had various scars and so I had to ask him what they were from. It turns out he had fought in the First World War. He was in the battle of the Somme. He watched thousands of men be killed or mortally wounded. He was in the medical corps. He was stationed at a kind of triage post where the casualties would come or be brought and he would decide whether to send them on to get proper treatment, giving them basic first aid as needed or if there was no point sending them on, then just making them comfortable. He had administered to thousands of young men and they still haunted him. He had tears in his eyes as he talked about the horrors of war.

The more he told me the about the awful the things he had witnessed, I was amazed he had managed to come out of it, get married, have a family and a normal life. The huge burden of trauma he was still processing sixty years later was humbling. He had never talked about it to anyone, not even his wife, but now he was dying and I had started asking questions, he wanted to let people know how awful it had been. I wish I’d known more history to be able to ask more pertinent questions, but it seemed he would just talk about it without much prompting.

I only saw him a couple of times as he died within days of our starting on the ward. Much more quickly than I had anticipated. I was surprised how sad I felt, as if he were a close relative or friend. He had reminded me of something that I already knew but the arrogance of my youth had decided to forget; these ‘old people’ I was seeing were much more than simply a sum of their current symptoms and signs. They were living history and had experiences and feeling that could not be guessed at by looking at their frail frames.

The other patient from that firm (as we called our time on a given unit) who stays in my head was a 26 year old with leukemia. She was amazing. Life affirming. Positive. Wasn’t taking this lying down. Shaved her head and sometimes dyed it bright punkish colours. Had to undergo horrendous chemotherapy which I would administer in to her bloodstream and she would feel atrocious for days. She was an inpatient for a long time and as she had no working immune system one had to get gowned up to go in to her side ward to try to minimise the risk of her getting an infection. So she didn’t have lots of people popping in to see her. But she was always great. I loved going to see her as it was like seeing a mate. We would chat about all sorts; men mostly. She was always smiling and laughing but she knew she was very ill. She wasn’t in denial, but coping incredibly well. Except very occasionally she would let the mask slip. I was probably too inexperienced to be any help to her, whereas she was able to help me understand the feelings she was wrestling with. And there would be tears.

After I finished the oncology rotation I still popped up to the wards to see if she was around and have a chat. Sometimes she would be well enough to go home, which was great for her, but I would be disappointed not to be able to chat to her. She died about eighteen months later. I hadn’t known she’d been admitted and had been on a rotation up in Bedfordshire so hadn’t been in for a couple of months. I was gutted. I felt guilty I hadn’t seen her during her final days and weeks. She had been a similar age to me, a fighter, had the best possible care and yet she had been taken. It was so bloody unfair.

I realised it was nothing more than luck that I was on this earth and she was not.

It was an accident. Honest.

The training to become an anaesthetist is second to none. Expert one on one tuition from more experienced doctors. You start with simple cases and work up to more complex.

Open heart surgery is ‘more complex’ and the first time I was assisting the more senior anaesthetist, one of the very very senior surgeons was operating. Very old school. No real banter or craic with this guy, he was serious.

I would be the person in blue on far left – this side of the barrier at the head end of the patient

It’s the kind of operation where the patient is put on the bypass machine at various points so that the blood doesn’t circulate through the heart, but is pumped by an external machine (the bypass machine). It’s all very hitech and serious stuff. The patient has lots of different drips and lines in, and throughout the operation I would be putting up new lines and replacing bags. You’ll all know you have to get the air bubbles out of any tubing before it gets to the patient – don’t want an airbubble in the bloodstream. And a standard way of getting rid of them in tubing is to tap the tubing with side of a pen and the bubble will rise upwards until it gets to a chamber where it can stay.

Exactly like this

I had a classic clear Bic biro. We had to fill in charts throughout the operation to monitor the patient’s vital signs and record what we had done.  I was standing behind the green sheet that we make as a barrier bewteen us (at the anaesthetic, non-sterile, head end of the table) and the surgeon, who works in a sterile environment. Informally it was known as the Blood Brain Barrier, dividing the surgeons (with the blood) and us (with the brains).

The operation was progressing. The sternum had been sawn open and the rib spreaders put in place to hold the chest cage open. The heart was pumping away.

One of the intravenous lines had a bubble in it. I held the line straight with one hand and  tapped it sharply with my pen. The bubble didn’t shift. I tapped again, harder this time.

Whereupon the pen top flew off, over the green barrier and straight in to the gaping chest wound. A perfect hit. I couldn’t have done it if I’d tried.

But this was awful. A chewed pen top is about as far from sterile as you can get. Dropping it in to the operating field was an error so gross I can hardly bear to think about it. I was in serious shit and I knew it. I was going to get torn off a strip for this, and rightly so. I had put the patient at risk of an infection by being so careless.

The whole theatre had gone silent. My senior anaesthetic colleague muttered something like “Oh God, you’ve done it now”. The surgeon is staring at the pen top, bobbing on the beating heart. My own heart is hammering in my chest. Theatre sister is staring at me in incredulity.

I did the only thing that came naturally to me.

I peered over the top of my green barrier, put my hand straight up in the air and, in my best imitation of a child, asked, “Please Sir, can I have my pen top back?”

Luckily for me the place erupted in laughter. Well, nervous sniggers really, but it broke the ice and we were able to get on with the operation. It also averted the full on, public dressing down that had no doubt  been coming way way. The surgeon removed the pen top, irrigated the area and I stayed well away from the drip lines for the rest of the operation .

I did check on the patient a few days later and no infection had developed so I’d got away with it this time. But lesson learnt. I went out and bought a papermate pen that had a button to press on the top so that never again would I need to use a pen with a detachable top.

Road trip!

Yesterday facebook prompted me that it was someone’s birthday. A friend I was at sixth form college with and appears in the great naked men shot.  Anyway, it reminded me of a story of when I  visited him when we were both medical students.

A  friend and I went to Amsterdam for a long weekend. We travelled by train and boat and arrived at this wonderful city full of excitement. We were staying  with a friend of mine from Atlantic College – what a luxury it is to know people from all over the world and be able to sleep on their floor!

And he lived in the heart of the red light district in a student house so we had a ball. He showed us round and took us out to the seaside in his old 2CV. And he even let us borrow the car for a day trip to the Hague. I’m not sure either of us were insured or even thought about it. But somehow I drove and Jane navigated. Micon had given us a map. I had never driven a 2CV before and was amazed at its lack of power. I would be on the motorway trying to overtake a lorry and get two thirds of the way past when the slipstream would push me backwards and I would have to drop behind again.

great little car

Anyway, we got there and had a lovely day sightseeing. And so we set off back towards Amsterdam. The Hague was very busy with lots of traffic and we seemed to be driving for ages getting nowhere. We would follow signs that said Amsterdam, but they would disappear and we we had ended up in side streets. No mobile phones of course, no sat nav to help us out.

So we decided simply to pick another town, any town to get out of the Hague . We’d get to that town, find it on the map and then work out how to get back to Amsterdam from there So we picked Omtrek.

At last we were getting somewhere. The signs were clear and continued to be marked. Keep left for Omtrek. After about half an hour of this we both had a realisation that we had been here before. We had definitely seen that building, that row of shops etc.  We were not out of the Hague city and nowhere nearer to Amsterdam.

We were now getting desperate and  randomly chose a road to turn in to and drive. We thought we would eventually get out of this nightmare city and ask someone how to get to Amsterdam. But in fact we didn’t need to as by complete fluke a sign for Amsterdam straight ahead appeared before us. The relief in the car was palpable.

So we got back much much later than planned, and told our host about our calamitous trip. “Which town did you choose to follow signs for?” he asked. Omtrek we told him. “That’s like ‘ring road’ in English ” .

No wonder we felt we were going round in circles. We bloody well were!

Fine anatomical specimens. It may have inspired my choice of degree.This is just an excuse to post it agian!

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Whistle while you work

One of the great joys of anaesthesia is that the majority of the time patients are unconscious. You hope. It is, after all, your job to make sure they can’t hear or feel anything unless they are having just a local anaesthetic, or are meant to be waking up.  Or not yet asleep. You get the drift.

And many operations can take a number of hours so the healthcare professionals can talk openly and in a relaxed fashion if they want to. What they did at the weekend. How their lovelife is going. How the wedding plans are going.  Jokes. Banter. The craic in theatre is like no other.

It very much depends on who the individuals are and how they like to work. Because everyone is working non stop, and no one forgets what the purpose of being there is, but with experience lots of operations are routine, and everyone can join in the chit chat. Whilst in training in anaesthetics you are hand held initially, which basically means you have someone senior with you nearly all of the time. This also has its advantages in that you can take it in turns to pop off for a coffee. Obviously you can’t drink or eat whilst in an operating theatre, so it is a welcome and joyous perk of anaesthetics to be able to pop out to the coffee room every few hours. Surgeons can’t do that mid-op as they would have to re-scrub up and that is a mightly pain. However they do it between patients when anesthetists are tied up taking one patient to recovery and anesthetising the next patient on the list to try to minimise theatre down time. A smooth succession of patient out patient in.

The other entertainment that was not infequent in operating theatres was music. Seemingly always the surgeon’s choice, never the anaesthetist’s or nurse’s or ODA’s. The prima donna got to choose. And some surgeon’s were prima donnas; others couldn’t have been lovelier. In general the urologists were good fun – anyone who makes their life’s work staring down men’s willies has to have a sense of humour, and the orthopaedic surgeons the builders. Often rugby players. Handy with a black and decker. Those doing neuro (brain surgery) were so patient, detailed and skilled it was awesome. But their operations go on. And on. And on.

And the music they would choose would be as diverse as them. Some loved classical or opera, others heavy metal, some a light and fluffy pop. A standard time filler would be to play games like ” Top ten tunes to operate by”(not!)  and we would all chip in with our hilarious ideas………….Under pressure,  Tears are not enough,  Help me make it through the night, You ain’t seen nothing yet, Comfortably numb, Another One Bites the Dust, Killing me softly…..

If you are going in to have an operation soon let me reassure you that there have been studies showing that surgeons are happier and less stressed when they are listening to their music. Even if it’s Metallica. So when you hear their  “For whom the bell tolls” or Iron Maiden’s “Dance of Death”  booming out as you are drifting off don’t worry – it’s a sign of a happy cutter.

Choosing anaesthetics

Wish I’d had one of these all those years ago

Choosing careers must be difficult. At least having studied medicine you kind of don’t have to think about it for a while as you are on a pre-trodden treadmill  But you do have to choose which branch of medicine to specialise in.

After my Houseman year I opted to for Anaesthetics. It is by far the best specialty. Perhaps Emergency Medicine runs a close second. Basically it is really practical, immediate, covers every type of patient and disease, includes Intensive Care and lots of  life and death  stuff. You have shedloads of individual responsibility – no need to consult with others about what you are doing, but work in a group environment so get the banter and human contact.

And it is incredibly well taught. That last one makes it fundamentally different from so many other specialties which tend to leave one to get on with it and learn by osmosis and experience. Anaesthetics on the other hand is very much direct Consultant and other seniors teaching juniors on a one to one basis. After all, you can’t risk a patient’s life by leaving them in completely untrained hands. And anaesthetics is all about life and death. Putting people to slepp, paralysing them so they can’t breathe, making their blood pressure drop. All good fun and physiological games. For a purpose of course.

I did my training back in London. I’d had my year out and loved it, but pined for the city on two counts. One is snobbery – as a London graduate I believed I would get better training in a London teaching hospital, and the other is just London itself.

And so it was I rolled up to The London Hospital in Whitechapel, the East End of London. It’s so long ago it wasn’t even Royal at that time. And I  joined the large Anaesthetics department, along with a number of other new SHOs (Senior House Officers). They say starting Anaesthetics is 99% terror and 1% boredom. And that by the time you are a Consultant it is 99% boredom and 1% terror. I disagree with the high boredom factor, but the terror part is certainly true at the beginning. But that’s where the fantastic training comes in. Plus an entire new breed of people who I had never really noticed as a medical student – the ODAs. Operating Department Assistants. I think they are now called Practitioners or some other arse wank title, but to me they are ODAs. Bloody fantastic. They are practical help in theatre, and can assist the anaesthetist, the surgeon or in recovery. They will prepare the room, lay out the drugs, clean the equipment and all that kind of stuff. Obviously as the anaesthetist you are ultimately responsible for  what happens to the patient, but it is wonderful to have someone you can trust to physically move machinery, get the ECG leads out, do lots of the basic tasks. And even more important they have usually got years of experience and can really help when you are doing stuff on your own and things don’t go quite according to plan.

A good ODA will prepare a patient in the anaesthetic room, putting them at ease and chatting whilst you are finishing off the previous patient. Not literally finishing off (fingers crossed), but taking them to recovery or whatever. They will draw up the drugs, label them and pass them to you as you need them, and pass the correct equipment at the right time. They might even put a needle in ready for the drugs to be injected.

It was routine to put a tube in to the trachea (windpipe) when operating for a long time or on the abdomen (because you need to paralyse all the muscles so the abdomen will relax and allow the surgeon easy access, but it also means paralysing the respiratory muscles) and usually it is very straightforward once you have the knack. But very occasionally it isn’t straightforward and a good ODA will be worth their weight in gold as they get you different equipment and suggest new strategies you might not have thought of if you are relatively new.  They will also go get help when they think you need it!

Anaesthetics is not dissimilar to cookery – there are a thousand different recipes for the cocktails to put you to sleep and every anaesthetist has their favourite ways of anaesthetising for certain operations. Different operations require different cocktails and different patients require different cocktails within that so there are plenty of permutations to consider. And the human is a living organ (we hope) and things change as the operation progresses. And the anaesthetist is responsible for keeping that person alive and giving the surgeon optimal operating conditions. So the patient doesn’t move when the scalpel goes in for example. Or their blood pressure doesn’t shoot up and make them bleed excessively. And they wake up without pain when the operation is over. And ideally without feeling sick too.  It’s all a balancing act – too much anaesthetic and you might not wake up, not enough and you might feel it or remember it.

And we also got to do Intensive Care too – another critical care area full of practical procedures, challenging problems and very sick people.

One of the many pluses of doing anaesthetics is you get to wear scrubs the whole time so you don’t have to worry about work clothes. The hospital supplies you with standard cotton (usually blue or green) trousers and a top. Or a dress.  I always wore trousers, even with a dress. And lovely white clogs or wellington boots. Topped off with a hat and mask and you are good to go. On the wards you might add a white coat, but basically you wander round in jim jams all day. Then throw them in the laundry basket on your way out of work. Result.

The other big plus is that other doctors are nearly always pleased and relieved to see you because you are usually only called in when they need your immediate help – getting a line in when everyone else has tried and failed, resuscitating when the shit has hit the fan, taking charge of the very very sick and unconscious patient. Oh yes, anaesthetics is one of the coolest specialties.  And I had never been cool in my entire life. Until now. And I loved it.

Jim jams for work. What’s not to love?

“You’ll like this one”

When I was a junior anaesthetist in the dim and distant past, there was no European Working Time Directive or any shit like that. We worked for as long as we were needed. My rota was technically a one in three, but it always works out a bit worse than that becuase you have to cover each others holiday and study leave.

So one in three means that you work every day Monday to Friday as normal – technically described as 8 hours a day but for anaesthetics morning lists usually start at 830 so you would have to be in setting up by 810. Assuming you had managed to see all your patients for today’s list last night. If not, then you’d need another hour or so to check them out before coming to theatre and preparing for your day ahead. Afternoon lists finish around 5 usually, but obviously this can vary enormously depending how things go. And you can’t just ‘clock off’ and leave your patient unattended.

After the surgeon has finished though, you can’t waltz off as you have to take the patient to recovery and wait for them to be well enough to go back to the ward before you can scoot. And then you have to go see the patients for the next day’s list. So that’s routine Monday to Friday. On top of that, for a one in three you work every third night (all night) and every third weekend. So if you were working Tuesday night you’d come in to work Tuesday morning say 730, work all day, work all evening, work all night. Hope to snatch a few hours sleep but no guarantees. Then straight to work Wednesday morning and afternoon until home time hopefully about 6 pm. Depending how busy you’d been overnight it could be OK or complete shit.

But it was the weekends that got me. You’ve worked all week (including Tuesday night), and then Friday 6pm everyone else buggers off home except for those of you on call. And you will be there working or waiting to be called to work, until Monday evening. Friday morning straight through till Monday evening, snatching sleep where you can. In crappy little on call rooms.

Saturday nights would usually be livened up with car crashes, drunken fights and emergency stuff like that which would be interesting and  challenging. At some point there would be Emergency Caesarian sections. Or epidurals if you were covering labour ward. Sunday afternoons often quiet. Desperate times in soulless hospital messes with no sky TV or DVDs or computers to while away the hours. And often I’d be studying for postgraduate exams so time would be spent poring over textbooks if not actually anaesthetising.  The anaesthetic co-ordinator would try to make sure Sunday evening/night was quiet – trying to defer cases if at all possible until the follwing day. But sometimes of course things just can’t wait.

As was the case this particular sunday night where I had had one hell of a weekend. Stabbings a go-go and lots of other operations. But I had gone to bed about 1 am. Shattered. When the co-ordinator  rang at 3 am I took a while to stir out of my coma. I was near to tears with fatigue. “No Sarah, you’ll like this one I promise you”. I had no idea what he meant but got back in my scrubs and went to theatre. To be met by the ODA (brilliant folk who help in theatre) smiling at me whilst he checked the details of the male patient lying on the trolley between us.

As it happens I remember the patient’s name as it is a diminutive for penis so I also thought it was funny. Anyway, I picked up the notes and started talking to the patient when I heard a noise. A faint buzzing sound. “What’s that noise Mark?” I asked the ODA. He choked, unable to speak and turned away.

And then I opened the notes and saw the consent form “Removal of vibrator”.

“Do you want to tell me what happened?” I asked. Apparently this was his best dildo and he was having such a good time he simply let go and then couldn’t get it back. His friend had tried too but no luck. Then a doctor in casualty had tried to no avail. So here he was, waiting for a surgeon to try.

I put him to sleep and as he drifted off he frantically asked “You will let me have it back won’t you?”

I pulled back the covers and there he was. Looking like nothing was wrong.  Lovely flat tummy.But then when you looked closely, you could see his tummy wall was vibrating as the vibrator  pushed it’s way further up the colon. The surgeon tried initially with long forceps but couldn’t get a decent grip so he ended up opening his tummy and squeezing it down and out through the anus. It was fucking enormous. At least a foot long. Even the Duracells had given up by the time it was removed.  But it stood up proud on its end -pale pink and glorious as I took him in to recovery.

The co-odinator was right. Of all the cases to have to get up for at 3 am on a Sunday, that was one I did like. It had been fun. But probably not as much fun as the guy had had who got us there.

Plastic surgeons and me just don’t mix

Obviously I havem’t had any ‘work’ done. I wouldn’t look like this if I had. And no one can make me three inches taller, so I’m not likely to either. But when Natalie  made me a sandwich and accidentally got a bit of anchovy on it, the immediate trout pout it produced was surprisingly attractive. Only lasted a couple of hours though, so I’d have to have a handy anchovy lip balm to keep re-applying.

Anyway, the combination of writing about my student days and watching the Olympics closing ceremony reminded me of an episode as a student in St Pancras Hospital. It is an episode of its time and thankfully I feel sure it wouldn’t happen now. But you never know.

I was doing Plastic Surgery for 2 months and the one of the Consultants I was “attached” to was the ultimate stereotype. He was suave, sophisticated, had  chiselled cheekbones and was dripping with money. He drove an incredibly flash car, waltzed in to the wards wafting expensive aftershave in his wake. He wore bespoke, understated Savile Row suits and was neat as a pin.

I, on the other hand was in a phase of wearing cornflower blue tights and a mish mash of brightly coloured things I had bought from a market stall off the Walworth Road or the army surplus store Laurence Corner. And the white coat on top. I would like to point out that my clothes were clean and didn’t have holes in or anything, but were fairly full on. The Consultant only appeared on the wards two mornings a week. Plus he had an operating list on another day. The rest of the time he was in Private Practice.
The nurses worshipped him. Or were afraid of him. I’m not sure which. A bit of both really. They thought he was marvellous, and were more than happy to have everything just the way he liked it. They didn’t think he’d like my dress sense. Those coloured tights. The purple skirt. The black and yellow top. The pearlised blue flat doll shoes.  There was no ‘uniform’ for medical students apart from being clean and tidy. I was both. But loud as well. Their concern  just fuelled the fact that I hated everything he stood for. Pompous twat. I was completely anti private practice at the time ( although happy to use it now in my mature and mellow state).

So I continued to wear what I pleased and the days passed uneventfully. He didn’t comment on my sartorial choices. Until I changed my style and went went in wearing mens trousers, a white  shirt, a tie and my white coat. Fairly sober in comparison to how I had been dressing if I’m honest.

The plastic surgeon went ballistic. Absolutely mental. Apparently I was completely unprofessional, would never make a doctor, and he did not appreciate my insubordination. What’s more I was breaking the rules. I was to get off his wards and never come back.

And what exactly was he outraged about?

The fact I was wearing trousers. No female medical student was going to get away with that whilst he was in charge.

I left the ward and never went back when he was there. But he couldn’t stem the tide of two-tone outfits and baggy trousers that took over my wardrobe. Madness had gotten under my skin and I loved them.

Loved em. Still do. And how great to see them in the closing ceremony. National Treasures now.

Jargon Jargon

I know I posted here about people not saying what they mean in the corporate world but it kind of reminded me of those halcyon days when I was working in hospitals and no one thought that patients would ever see their notes. Using abbreviations starts as a medical student – usually to help you learn various bits of the anatomy off by heart. Funnily enough I can remember the mnemonics as they are known, but not always what they stood for.

Classics are Oh Oh Oh To Touch And Feel A Girl’s Vagina And Hymen for all the cranial nerves. Two Zulus Buggered My Cat for branches of the facial nerve and Lazy French Tarts Sit Naked Inviting Anal Sex was for things that pass through the supraorbital fissure. That was about the level of them. Then there were rhymes like ‘S2,3,4 keeps the anus off the floor’ to help one remember which nerves serve which areas.

‘L1,L2 keeps the bollocks off the shoe’  reminds poor medical students which nerves are responsible for the joyous ripple known as the cremasteric reflex. Stroke a man’s inner thigh and watch carefully. Then stroke the other leg.

Progressing through Medical School gave us a template of how to take a history and do an examination and write up the notes accordingly. It meant we had to memorise the causes of various signs and symptoms, so handy reminders like the Five Fs would help us work out what was making an abdomen swollen – Fat, Fluid, Faeces, Flatus or Fetus……

I would come across letters between doctors which would be blunt in the extreme, and various acronyms in the notes. There are medically accepted acronyms (SOB means short of breath for example) but on the whole they are best avoided as they can be misinterpreted. Anyway, thought I would relate dubious ones that I remember seeing. Obviously never ever used them myself!

LOLOL Little Old Lady Off Legs

NFN -Normal for Norfolk

FLK Funny looking kid

FLK JLD – Funny Looking Kid.  Just Like Dad.

P-FO Pissed, fell over

TTFO – Told to Fuck Off

TTFOIAV – Told to Fuck off, it’s a virus

And the actual letters to and from GPs and the hospitals were so much franker – and possibly libellous – than they are now. With Drs happily writing things like ‘Thank you for asking me to see this tedious 42 year old…. “, or ” Thank you for referring this thoroughly unpleasant individual”, or “I don’t know why you referred this patient as his dick looks as normal as mine does”. Got to say they are fun to look back on, but not what you want a patient to read.

Or notes relating to a person repeatedly admitted for having overdosed;  “Mr Smith is in yet again on the overdose ticket. At first he seemed to be unaware what a loser he is in the overdose stakes. However, on direct questioning he admitted that jumping from a bridge holds out more hope in future.” Unsurprisingly, nowadays no one would dare write something like that. And the exasperation from the Consultant back to the GP after repeated tests have failed to find any abnormality “I am discharging her back to your care, she has made up her mind what is the problem and no amount of truth is going to deter her.”

jumping jack firework

One of the more interesting  discharge letters I had to write was for a man who was admitted through casualty  in absolute agony. Very very unwell as his colon had ruptured so he had peritonitis and needed urgent surgery. How on earth had this happened? He had no previous history of any bowel problems. But it transpired he was at home with his wife and he had a jumping jack fire cracker.  Also known as bangers. These were common fireworks back in the day –  about the size of an iPod shuffle. You lit them and they jumped around and went bang lots of times. The wife apparently said to him ‘I bet you wouldn’t stick that up your arse and light it’. So he bloody did.  And blew apart his insides. Because his wife bet him he wouldn’t. Lifelong colostomy and lucky not to have died. Amazing how incredibly stupid people can be.

And suddenly I am a doctor

Father’s banner for my passing Finals

When it came to finding out the results of my Finals I bottled it and asked a friend to read the list for me. Results were posted on the notice board by the refectory and you had to check your name wasn’t on there. Luckily for me medicine was a pass/ fail degree, no firsts, two ones and the like. Just yes or no you’ve made it.

She rang me at the flat where I was living in Peckham. The twelfth floor of a council tower block. The lifts would hardly ever work and stank of urine anyway. But carrying the groceries up twelve floors was tough even in my early twenties. The young black lads on the estate would play street hockey in the corridors and the noise as the ball banged in to the metal front doors or lifts was deafening. Towering over me with their rollerblades on and their hockey sticks flying fast and loose I should have been nervous of them but I wasn’t. They never bothered me apart from the noise on the doors and they had nowhere else to play. At least they were getting some exercise.

And so, on about this day thirty years ago, I waited for the call from Jane . The phone rang. And she said ” Can I speak to Dr Morgan?” and we both screamed.

On the radio was Captain Sensible singing Happy Talk. I completely love that song because it reminds me of that moment. It transports me back to that sitting room with the green corduroy foam bed settee and the dawning realisation I had done it. I had actually managed to qualify in medicine. Hoo-fucking-ray! Go me!!

Pretty fucking pleased with myself at passing

I already knew where my first job was. I had applied to move out of London to try to see more common conditions rather than all the exotic stuff that gets referred to London when the provinces were stumped. I chose a non teaching hospital so I wouldn’t be contending with students and others to do the procedures. So I was going to be a surgical houseman in Northallerton, North Yorkshire.

In those days all new housemen , as they were called, started work on August 1st.  The year I qualified that happened to be a Sunday. So I thought I’d get up there for the Saturday evening ready to start work the next day. I had bought a car from my uncle. An old maroon Peugeot estate with cream leather seats. I don’t remember how I actually got it as my uncle lived in Bristol. I think perhaps he drove it up to London for me. My memory is of my first trip in it being all the way from London to Yorkshire.

I set off and about a hundred miles later broke down. I called the RAC having been banned from The AA after my Avenger broke down so many times they refused to renew my membership. (I only had the car a year and gave it to the Salvation Army after the prop shaft sheared off on the M2 . They said they had mechanics who could fix it and it would be great for visiting all the homeless people they helped).

Anyway, I had to wait about six hours altogether for them to turn up. They hadn’t been able to find me and of course there were no mobile phones in those days so I was sitting on the side of the A1 and had to walk miles to a phone box every time I contacted them. And no sat nav to tell them exactly where I was, just the location inside the phone box and where I thought I was on the map. Then all the way back to the car to sit and wait. And it got dark and I was still waiting. Eventually they turned up and repaired it and off I went, only to break down again about 20 miles later. I wasn’t phased at this point. I just rang them again and at least they knew roughly where I was And they came within an hour or so. But by now it was late. And midnight by the time the car was hitched up to the rescue lorry and we were ready to go.

I arrived at the Friarage Hospital Northallerton with the yellow light of the tow truck flashing. We stopped at the main entrance and I asked the porter where the Doctors’ Mess was. I would be ‘living in’ for the following year. “They were looking for you earlier” he told me helpfully and handed me an envelope with my room details and key and gave me my pager. The wards would ring switchboard and then switchboard would ‘page’ the appropriate doctor who would then ring back to the ward that wanted them. It was 4 am and I just wanted to go to bed. I would be starting my first day on the wards in a few hours. He pointed me in the direction of the Mess and I unloaded my bags and let the driver take my car to a local garage for repair.

I went up to my room and found a note stuck to my door: August 1st started at midnight. You are late.

Of course it had. I hadn’t thought about the realities of hospital medicine. That someone would have to be on call from midnight onwards. The previous incumbent would have another job to go to. Also potentially starting at midnight. And even if he or she wasn’t starting at midnight ( not everyone has to be on call at the same time- its done on a rota basis) , he or she would have to get to their new hospital in time to settle in and start Monday morning.

I felt terrible. I had planned on arriving early evening so in fact if it had gone to plan I would have been able to be on call from midnight. As it was,someone else must have had to do it for me. I was already owing and I hadn’t even started.

I unlocked my room and rang switchboard. “Do you know if the surgical houseman is on the wards?” I asked.  ” Hang on  I’ll ask the Night Sister.”  I was feeling slightly sick with the tension of it all. “No, it’s all quiet at the moment. Are you the one who arrived in the breakdown truck? ” Word obviously travelled fast. “Yes” I said. “You were meant to be on call. It’s Mr Whittaker’s take and you’re working for him on my list here” ” I don’t know” I said. I hadn’t read the letter yet that was on my bed, along with two highly starched and beautifully folded long white coats. ” Well I’ll tell the wards to call you now if they need anything shall I ?”  ” Yes please” I said, but wanted to say no thanks.

I slept fitfully until I was woken up a couple of hours later by the phone ringing. Could I come to ward 4 and write up some painkillers for one of the patients and re-site a drip. Oh my God. This was it. I really was going to start practising medicine.

The Anatomy Dissection Room

In our first year at Medical School we only studied three basic subjects; Anatomy, Physiology and Biochemistry. We would sit in lectures – I think there were about 120 of us in a year – taking notes, we’d have tutorials in small groups,  have practicals in the labs, and  weekly biochemistry tests. I found physiology easy – how the body works is fairly interesting and lots of it I’d covered in Biology already. Biochemistry on the other hand was shite. I’d not even got chemistry O level so understanding chemical reactions and molecular structure  was a bit out of my league. But I muddled through (just).

Of the three basic subjects, anatomy was the one virtually unique to medicine. To be allowed the privilege of dissecting a human being who had left their body so generously to science to help us understand the three dimensional nature of our wonderful machine.

We were not taken to the Anatomy Dissection room in the first week. We were built up to it, to ensure we understood the gravity and the respect we must show. It was also true that most folk are very wary of walking in to a room full of dead bodies. Most people have not seen one dead body let alone a roomful.

And so it was we had to turn up with our white coats and dissection kits – all mine had was a scalpel, forceps and a pair of scissors. Others had been bought more deluxe versions with other instruments in which never got used. we were also advised to buy a skeleton from a second year. Mine came in a lovely wooden box

Just irresistible. Have to play with a skull

.

We were taken to the basement towards the Dissection room. There were double doors in to a vestibule area, and more double doors in to the dissection room itself. As soon as you got near the dissection room the smell was apparent. It is the most distinctive smell. Inescapable. Unforgettable.  Formaldehyde. And if ever I get a whiff of it anywhere else it immediately transports me back to that room.  I was nervous in the vestibule. Not sure how I would react. I had seen my grand mother immediately before and after she died, but that was a very different prospect to that which faced me now.  We were told if any of us felt ill, or that we were going to faint to simply get yourself out of there and come back when you are ready. I didn’t feel like I would faint, I was just nervous.

The double doors were opened and we stepped in to a cavernous room with bodies laid out in rows.  A  few couldn’t hack it and left the room straight away. Others felt ill a bit later and disappeared too. But most of us kept our nerve.

There were probably about 25 bodies in the room, and about 5 of us were assigned to an individual body that would be ‘ours’ for the next twelve months as we slowly dissected every part of them.

The initial view was not as shocking as it sounds, as for our initiation, our medical school had made sure the bodies were covered apart from the area where we were going to start dissecting. This maintained some dignity and modesty for the bodies, albeit they were unaware, and critically this meant the hands, feet and face were covered. These are particularly human features that are most likely to be upsetting to brand new students, not yet able to detach themsleves from the fact that this is a dead person.

They had also done the first incision for us, in to the chest, as cutting through skin for the first time is incredibly emotional.

So our practical dissection started by peeling back the chest wall skin to reveal the fat then muscles and ribs beneath. Fat looked like scrambled egg. I hadn’t expected that.  And human muscles look just like any other red  meat. I was glad I was a vegetarian. Although  I did have a recurring nightmare of bending down and eating the meat off our body. I can still visualise it now.

In the dissection room is the lecturer –  often a Professor –  and various surgical trainees. They are qualified doctors now having opted to become surgeons and obviously they need an incredible knowledge of anatomy so come back to medical school for a few months and work in the dissection room whilst they study anatomy in far greater depth than us. They help us work out what is what and how to dissect without simply cutting through everything you are trying to find. We only dissect the area that the Professor sets for us, and the sessions are all morning.

Qccasionally throughout the year we get live anatomical models to help us understand the workings and attachments of the various muscles. These were very well defined lads in nothing but tiny trunks. They would tense and relax various muscle groups on demand and allow themselves to be drawn  (and fawned) over as we worked out what attached where.

Plus there are the Mortuary Assistants. A separate breed entirely. They are the ones who do all the cleaning and preparing of the bodies -so that we can dissect without blood clots everywhere and the organs are preserved for us to study. They do this by  injecting formaldehyde . Which has the distinctive smell. They also control the saws and drills that are needed to cut through various parts.

And the first day we need them to open the sternum (breastbone) for us so we can get right inside the chest and take out the heart and lungs.  Our guy appears to have been a smoker and have had lung cancer.  They love being so at ease with the bodies and knowing a shedload more about them than we do. At this point we know virtually nothing, but have given our body a name. We called him Elvis.

After we leave the dissection room the Mortuary assistants clean up after us, finish off what we haven’t managed to complete and set the bodies for the next session. It does not take much time for us to be used to this scene, and be relaxed chatting around the body, peering in, poking and cutting. Learning, learning learning. Getting involved in minutiae.  Sometimes people get too relaxed, forgetting where they were, laughing or dropping ash from their cigarette on the bandaged head,  and we have to be reminded to give these bodies the unreserved respect they deserve. And we do.

We look at other people’s dissections if there is a particularly good example of something, or when we need to do female reproductive organs we have to swap with a table that needs to see male ones. But basically we work our way through Elvis over weeks and months. When his hands were unwrapped, it was a stark reminder that this had been a vibrant human being. Hands that would have reached out and held another’s.

The final dissection was the head. The mortuary technicians helped us remove the bandages and there he was. His face now uncovered. A man. But not just any man. Incredibly it was someone we recognised. Not Elvis admittedly, but a film and TV star who had died the year previously.

It was rather odd peeling off the face of a person you kind of felt you knew.

So here was someone who had entertained in his lifetime and was now educating from beyond the grave. What gifts he gave to humanity.

Patients are called that for a reason

We didn’t wear gloves when I was a student

My medical training was traditional. None of this modern PBL (problem based learning) for us. No integration of pre-clinical and clinical. . Rote learning for two years then on to the wards to try to make sense of it all. It was a shock to the system to go from standard student life (albeit highly timetabled compared to todays lazy arse Arts students) to the clinical years where we had only four weeks holiday a year. We still got Wednesday afternoons off for sport, but basically we were on the wards before patients’ breakfast to take bloods and would be there till routine ward business finished around 5 or 6 ish. It was one of the student duties to do all the blood taking.

So before we were let loose on the patients we had a session being taught how to take blood. As with all medical training it was a case of ” see one, do one, teach one.”. We all watched the doctor quickly and easily extract about 10ml of blood from one of my fellow students.  It was over in a flash. We all then had to do it to each other. It was hardly brain surgery, but surprising how much of a performance it became. Working in pairs we are all looking over our shoulders seeing what others are doing. Are we doing it in the right order? Is that a vein? How do I know it’s not an artery? How do I open the needle to attach it to the syringe? How tight do I make the tourniquet? (Tight enough to stop the flow of venous blood, but not so tight it stops arterial – that way the  veins below the tourniquet will get full of blood as the tourniquet stops it going any further – a bit like a dam) . Questions questions. We are asking each other and ourselves, not the doctor of course. That would be cheating. And it’s only each other we are stabbing repeatedly, unable to find the enormous veins that inhabit the antecubital fossa (elbow). Of course we eventually all do take a sample successfully and the next day are let loose on patients.

This of course is an entirely different kettle of fish. We turn up on the wards and the Houseman (most junior doctor, just qualified) gives us a huge wad of forms. “You need to get these done” he says.”And there’s another load in the nurses station .” We divvy them up between us and set off to find the equipment we need from the treatment room. Each different blood test requires a specific bottle for the blood to go in. It is critical to get the right bottles for the right tests. Some bottles have special anti-clotting agents in, others have chelating agents and all are different colours to ensure easy identification, and different sizes as they require differing amounts of blood. Each bottle has to be labelled with the patient’s name, number date of birth, ward etc. If you are lucky there will be stickers with this info on in the notes. Otherwise it means writing them all by hand.

Approaching the first patient I was incredibly nervous. I had my bottles, syringe, needle, swab and cotton wool ball in a small tray and my tourniquet in my pocket.  I had worked out how many ml of blood I was going to need to do all the tests and was praying it was going to be OK. The patient  was a lovely old man who was wearing  pastel striped pyjamas. I remember his thin wrists were poking out.

I pulled up his sleeve and put the tourniquet on. He had blood vessels like ropes along his arms. My heart was hammering as I tore open the alcohol swab and cleaned the skin. I opened the needle  and attached it to the 20ml syringe. I felt his arm and found the brachial artery easily. I needed to avoid that. Next to it I could feel the fullness of a decent sized vein. With shaking hands I held his arm flat with my left hand and inserted the needle at about a 30′ angle to the skin. His skin was paper thin and there was no resistance. I pulled back the plunger on the syringe and hey presto blood appeared in the barrel. Phew!

I then had to continue to pull the plunger back and keep the needle in the vein. It’s not as easy as it sounds or looks. Especially if your hands are shaking. I had got about 5 ml of blood in when I inadvertently pulled the needle out of the vein. Blood oozed out of the hole. I couldn’t simply stick my needle back in because I couldn’t see where to put it. The blood was coming out at a fair lick. I didn’t know what to do so tried using the cotton wool ball to press on it. It soaked through the ball in no time. I asked the patient to press the sodden ball to try to stem the bleeding whilst I went to get some swabs or anything that would soak up the blood.

I came back and the blood was streaming down his arm. He was unperterbed and so nice to me. I got a handful of swabs and pressed as hard as I could. I got him to bend his arm up in an effort to stem the flow. After a couple of minutes I unbent his arm only for the blood to start pouring again. “I’m so sorry” I kept saying, having no real idea what to do next. I thought perhaps he had a clotting disorder and I should have read up about him in the notes before I started.

Just then one of my fellow students walked past and I beckoned her over with a scared rabbit expression. “He won’t stop bleeding” I hissed. She came closer. “Perhaps you should take the touniquet off ?”.

Poor man. I took it off and of course the blood was able to flow back to the heart instead of building up an increasing  head of pressure with its only release being to pour out of him, and so the bleeding stopped within a minute or so. And like so many patients he was so utterly charming and forgiving he let me attack his other arm as I hadn’t even managed to get the blood we needed for his tests.