Complications

Apologies to Dr Gawande for stealing the title of his book for this post on complications, all medical students read this at some point I think and rightfully so, it is a jolly good book.

dehiscence

I have had a bit of a crisis of career choice recently and have wobbled a bit within my chosen area of surgery with which subspecialty to choose. I have had years to decide on this but I am torn between the exciting and dramatic with often devastating complications and the solid and dependable with less life destroying complications A surgeon is a different sort of doctor, we pick up a knife and cut into a live person, ostensibly to help and to cure and at least to alleviate suffering but there is short term pain in this act and a risk of serious disaster caused by our operation. Lay people are frequently interested to know what it is like to wield a knife and I never quite know what to say. What is it like to be a pilot and fly hundreds of people up to 36000 feet, or to be a stripper and hold the attention and the desire of every man in the room? The answer I feel like giving is that it is brilliant fun and a great privilege to do this job and I think I am seriously lucky. That’s not what they mean though, they want to know about cutting through virgin flesh and having a life literally in your hand. Not many surgeons think about that day to day, there are moments when you do have that those thoughts but they are rare. The first time I took a small, sick child that only I had seen to theatre, I had a sense of apprehension as I made the incision that if I was wrong and she didn’t have a belly full of pus I would feel wretched. The first and only time I took a clamp off a ruptured and irreparable aorta (that we had taken to theatre thinking it may be fixable) and let the patient bleed out on the table I felt the weight of the knowledge I had essentially just ended a life.

 

I have been responsible for my share of complications over the years, as we who cut people all have been unfortunately, it is a surety that at some point someone will be harmed by an operation regardless of surgical skill and clinical decision making.  One of my bosses, for whom I have the utmost respect and hold in high regard, has a good theory on dealing with this problem. He says that we should walk away from an operation with no regrets, that we should not want to replace a single tie, or check the haemostasis, or wash some more etc. The test of this is that if the patient then goes on to develop a complication you don’t berate yourself, as you know it was as good an operation as could have been done and you have no wish to do it differently.

Still though, complications are hard to deal with and I recall my first solo appendicectomy who took a whole week to finally get better. I felt I had done a good operation and took it rather personally that the man did not feel immediately better and went on to stay in hospital for a week.  I came to dread coming to see him on the ward round as both of us had not had our expectations met, I had not adequately prepared him and had told him he would soon be much better and get home in 24 to 48 hours.

Nowadays I know that this is not abnormal after a bad appendicitis and I don’t have such high and unrealistic expectations of outcomes in the immediate post operative period.  I have a colleague who consents people with every possible worse case scenario and tells them at length, sometimes with the aid of a textbook, just what he is going to do and how hard it all is.  The result of this is that his patients think he is a hero when things go well and nobody is surprised when they go badly. I don’t recommend his technique.

In settling on a subspecialty I have thought long and hard about what sort of complications I want to deal with, and in the end I have wimped out of the big stuff, not for lifestyle reasons, not because I can’t be bothered with ten hour cases but because I simply can’t bear the big complications.

Have your cake and eat it

I love baking, I love cakes and when I am trying not to eat too much cake myself I bake for others, sometimes I bring in homemade cakes for my colleagues at work. One of my dearest friends bakes a lot for her male colleagues too and her husband has expressed disapproval of our baking for work. He thinks  it is a waste of money and of time and that it is rather unprofessional. Leaving aside the issues of time and money, I think this is an outdated view along the same lines as to be taken seriously women should avoid wearing makeup, skirts and heels.

My friend and I have discussed at length the reasons for this. Initially we wondered if it was because the  cake maker gets to be the centre of attention for a while and receives thanks and compliments. We have concluded that it is a lot more complex than that; baking cakes is an almost exclusively female pursuit, to bring in a cake highlights the bakers femaleness within the (male) working environment. And so  if a man is busy thinking what great cakes someone has made, it isn’t much of a mental leap to realise that the baker is a woman and to start wondering what she looks like naked, hence husbandly disapproval.

I make a cake for work about eight times a year, certainly not enough to make me the office feeder. Office feeders are a different sort of phenomenon, usually they are females trying to make other females fat to justify their own munching or by not eating the cake they want to highlight their own self control where others can’t resist.  We have a sort of feeder who supplies chocolate biscuits quite unnecessarily to a weekly meeting. The tin is produced with much glee and we are shown what treats she’s purchased this week and then we are all asked to financially contribute, which I resent as I never have taken one of her biscuits.

I like that every once in a while I can do something nice for the ward nurses or the clinic nurses or the secretaries. We frequently miss out lunch and dinner in our job and so the odd cake hanging about theatre does improve the collective mood. I don’t think it makes me less of a doctor, I don’t do it because I am seeking approval or trying to curry favour and I certainly don’t mind if not everyone wants a piece of it.

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Jiggleburn

In the late nineties I was a huge fan of sex and the city and whilst in some minor ways my life at that time was like those of the fabulous four, it was never quite as Manolotastic as theirs. I could never decide if I was Carrie or Samantha, I didn’t have the clothes or the disposable income to be any of them of course but one of my flat mates was all Charlotte and it was left to me and the other non-Charlotte to fight it out for the top Carrie spot. Other non-Charlotte flatmate had sort of curly hair and was skinnier than me so maybe I was really Miranda.

SATC was always a bit fake though, unlike the marvellous Girls by Lena Dunham. Many of her escapades remind me of the mad and bad things my friends and I got up to and I love it but for different reasons to SATC, I wanted to be Carrie; I am glad I have left my Hannah and Alison days behind. It is painful viewing at times, and worth watching for the good writing and dark humour and not just the way she uses her body, which is like nothing else on TV, she is always unkindly lit, she wears revolting underwear and never holds anything in.  Anyway, much like Hannah in Girls, who believes that she has invented the term “sexit” (a hasty exit after sex) I think I too have a new term for a most unpleasant sensation. Jiggleburn: noun. The pain experienced in wobbly parts which jiggle when running, especially on a cold day.

Not as good as omnishambles from the thick of it, but not a bad word I think and unlike sexit, it is not in the urban dictionary.

Exhibit A

Exhibit A

Exhibit B. Somehow lovelier because it is real.

Exhibit B. Somehow lovelier because it is real.

The death of the white coat: any sightings in Mid Staffs?

If you want to be rebellious, to mark yourself as someone really important, to show that you give not a hoot to whatever management may say in our hospital  then there is no finer way to do all these things than by wearing a white coat. Preferably a vintage white coat which bears your name, a long lost relic from the good old days. Since 2008  the white coat has been outlawed and we now have a uniform policy of “smart attire” and the faintly smutty sounding “bare below the elbows”. We are also not allowed to have our hair down or wear rings other than a plain wedding band and other dull rules and regulations relating to closed toe footwear and not having ones tits or tatts out. Clearly there is some wisdom in this, no rings at all would be better, no watches makes sense, sleeves rolled up ready for work and rigorous hand washing all seems clear enough to me.

Two of my great leaders frequently flaunt the laws of the NHS that dictate thou must not wear a white coat. A number of not so great leaders also try this tactic in a bid to make themselves seem more senior but they always look nervous about it, this other pair can do what they like whilst the rest of us admire their audacity. I must admit that I have on occasion worn one at night, when the infection control police are in bed and it’s freezing and I am under cover of darkness but it’s just like a cardigan really, I wash it after every wear. I have been around long enough not to be accosted about this and not to care if I am.

David Cameron was recently in trouble whilst visiting a hospital, he was tieless, had his sleeves up and was adhering to policy for the public yet his cameraman was not. A wonderfully brave surgeon stormed into his ward and interrupted the interview, he booted out the team flaunting the rules. A video of it here shows Dave flapping and faffing and realising his faux pas.

A white coat was a joyous and wondrous piece of clothing, it carried all your shit, it made you look thinner, it hid sweaty armpit marks post cardiac arrest, it made you look like a doctor, it made you feel like a doctor, it was warm over scrubs and it even played a part in on call room sexual antics.  Not many people dry clean their clothes or even wash their clothes after every wear, especially not surgeons who spend most of the working day in scrubs and so I wonder if we are really less infectious in our own clothes.

NHS management have many stupid ideas, they frequently don’t get what is really going on and are whipped by their political masters who are even more removed from patient care. I was rather impressed with Gary Walker, ex NHS chief executive of a trust in England who was interviewed on the Today program on BBC Radio 4 on Thursday, he seemed to have more of a clue than most and was commenting that we must be able to speak out publicly about patient safety. The Francis report into the Mid Staffs scandal is according to the BMA “essential reading for all doctors” but with 290 recommendations who can really find the time. Handily they can be distilled into 18 key points and can be summed up by saying that patient care should come first and that we must be accountable and transparent. The full report is two volumes long and makes grim reading, account after account of poor care, poor communication and poor hospitals. It is terrible, but sadly not unimaginable to those of us who are in this system, the huge volume is dispiriting.

This is just one of the witness statements:

“After a five-hour wait and pressure from his son, who worked as a doctor
in another hospital, the patient who had been admitted to Stafford
Hospital with pneumonia was assessed. He was treated on a general
ward where his family found mouldy sandwiches in the bedside cabinet
and needles and syringes being kept in an open box on the windowsill.
On one occasion, the patient found the lavatory covered in blood, which
he cleaned himself. When the patient was transferred staff asked his wife,
who suffered with back problems, to push her husband’s bedside cabinet
to the new ward. When the patient was discharged he was made to wait
in the ambulance area wearing only pyjamas until his wife arrived to
collect him. Some months later at an outpatient appointment it was found he had been suffering from Legionnaires’ disease and not pneumonia.”

As yet we haven’t been subjected to a uniform, but no doubt we will be at some point. As you can see they have already designed some lovely ones for the professions allied to medicine. In the light of the Francis report though, one has to wonder if we haven’t got our priorities a little mixed up.

What can you say? They are roomy for post prandial mac cheese and chips bloating.

NHS Uniforms. Safe to assume that Armani weren’t invited to tender for the contract

Good enough to eat

Many of my friends are mothers and wives as well as still trying to be themselves, succeed in demanding careers, be a good daughter, sister, friend, a contributing member of the community, to keep up with all the things we must keep up with, to look good, to feel good, to have nice clothes, have great weekends, to drink nice wine but never too much, to eat local and in season food, have a clean and comfortable home…..no wonder we are so bad tempered. Standing today in our local gym, for what is known to one of my friends (3 kids, full time job) as “the hour of hell” we were drinking coffee whilst our respective offspring were either at tennis lessons, gymnastics, karate or in the case of the youngest ones, playing beside us in the “softplay” area. There were lots of mothers there, all of us doing much the same thing, and none of us eating anything, skinny latte, skinny flat white, skinny capuccino with an extra shot and a green tea (skinniest friend) were duly ordered and of course, nothing at all to eat. Between the 4 of us, 3 have had breast implants and 1 has had an abdominoplasty, the fattest of us (me) is a UK 8 to 10 (US size 4 to 6). All of us were hungry, all of us have had a busy week, all of us could have done with a cake or a bar of chocolate. We all looked on totally miserably at the snacks our children were eating, I stole a raisin from one of the kids and then felt ashamed. Why are we so hard on ourselves? Every pub across the land on a Friday evening is host to lots of men drinking pints and eating crisps, nuts, whatever they want. We stand sipping fat free, huge volumes of caffeine steadfastly resisting the raisins and anxiously looking at our thighs comparing them to the skinnier ones next to us. Despite our efforts to look good, none of us think we look good enough to eat. Madness.

I'll have a super skinny with an extra shot of self denial

I’ll have a super skinny decaf with an extra shot of self denial and secret sweets on the way home