The bits I didn’t like

September 23, 2013

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.

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.

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.

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

May 11, 2013

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 puleed 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

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.

Scrubbing up well

March 27, 2013

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.

Sterile_surgical_glovesThen 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.

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