Guilty Little Secret

My other guilty secret

I have a terrible secret that is about to become very apparent to my colleagues. Nothing salacious, but it is something I am a bit embarrassed about nonetheless. My children are all soon going to be in full time education, they wipe their own bottoms and feed themselves etc and for some reason this has shifted something inside my (male) colleagues brains as they think I will now want to work full time. The secret is this, I will just come out with it straight away; I DO NOT WANT TO WORK FULL TIME. I love, love, love my day off and I will possibly love it even more when there are not any children to look after between 9am and 3.30pm. I will go to the gym, I will get my hair done, I will see my relatives, I will have lunch with other happy day off part time mummy friends, I need to tidy and organise my house and the lives of the people in it. The boys at work are all labouring under the misapprehension that I am desperate to come back full time and am counting the days until I can do so.

I do consider myself a feminist and I am deeply indebted to the women who came before me and fought for equality. I have just finished reading Sheryl Sandberg’s book, Lean In, which is interesting and well written but of course is very US orientated. Part time work is nowhere near as common and as easy to access there and presumably the employer provided health insurance system is one reason for this as well as the lack of state funded childcare and maternity pay/benefits. She makes some great points about women in the workplace and it is an easy read. She does not talk about women who feel like me, perhaps because part time work is not an option. I love my job, it is a massive part of my identity and provides intense satisfaction that I do not fully get from the proper care and feeding of children. I love my children, I love being present in their daily lives most of the time and find them just as (actually much more) interesting now that they are getting bigger and I have not picked up any signals that they need me less now they are out of nappies.

I know I am not alone in feeling like this, my best mummy friends (including a few doctors, a judge, a teacher, a lawyer and a policewoman) all have much loved careers but have the same views of the importance of being a mother and a wife. We all want to work, most of us in professional and senior roles and none of us want to compromise too much on our home lives. I know it is a bit off message with feminist thinking that we should all be equal and be treated just like men but I want more than this. I need to be treated differently, I want to work part time because being a mother is a big job. I can outsource the cleaning, the ironing and the shopping can be delivered but nobody else is taking over the mummy role for me. I am proud to be a mother and have a career and deeply grateful that I am able to do both.

Now I just need to come out of the closet and admit that I am not going to be working full time any time soon and shake of the sense of guilt I have about this.

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Mid Staffs on my ward

Here is a real account of an event that happened recently on my ward, it is a bad story.

Mr B is reviewed on the ward round and told the plan for the day, get an endoscopy and a transfusion of blood, standard morning ward round stuff for the admissions unit. As we carry on reviewing the other admissions, he decides to head off to the toilet to open his bowels, he negotiates the obstacle course in front of the loo; linen trolley, dirty linen bins, BP monitors, super sized veterinary style weighing scales and numerous medical students and eventually arrives on the toilet pan. Sadly it is here that he takes suddenly unwell and rings the buzzer for help, a nurse attends and checks his obs (BP, heart rate and O2 saturations). The BP is critically low, 57/40 and he is tachycardic at 125, she calls us to come immediately. In we trot, four of us to see Mr B, who is sitting stark naked on the pan, “right Mr B” says my boss “let’s get you off there into a bed and have a look at you”. Mr B looks at us all, ” no way” he says “One of you will have to wipe my shitty arse first”.

Retreat, retreat, not our department …out we all shuffle “nurse, nurse, Mr B, he needs cleaned up”.

Mr B is naked, he is unwell, he has just passed a bowel movement the smell of which is like nothing on earth (digested blood), he has it all over his legs and his behind, there are 4 doctors standing in the toilet with him sniffing the air and agreeing that this was indeed melaena, all of us desperate to plonk him in his bed and get busy saving him. Also in the toilet, is another person, one who has been there all along, since Mr B first pitched up clutching his stomach and bursting for a crap…..it is the ward cleaner. The cleaner is mopping away, seemingly oblivious to the going’s on around him, mopping the floor and wiping the surfaces.

Bad of us, I am sorry Mr B.

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Garden of Surgery

Imagine that you have a big house with a large and beautiful garden with lawns and flower beds, a water feature and even a vegetable patch and fruit trees.
You have employed a team of gardeners to tend to your garden with the vague instruction to “do the garden”. So the gardeners organise themselves into special interest teams: the rose experts, bush and shrub experts, water feature expert and so on. It becomes apparent that although the special areas are looking good, the rose beds, orchids, fruit trees etcetera there isn’t anyone attending to the weeding or cutting the grass and the garden is in disarray. When you confront the gardeners about this they each cry out “But I am a specialist, not a weeder or a grass cutter”.

Now imagine that you are NHS management and your gardeners are surgeons and your garden is the unwell population that you serve.

Weeding and cutting the grass are the most important jobs in the garden although they are not glamorous or rewarding in terms of impressive results. The NHS needs the rose experts and shrub guys, of course it does, but not at the expense of the grass and weeds. There are too many surgeons fannying about with their roses when they should be getting on with the real work, the acute service and the boring elective work (gallbladders and hernias instead of laparoscopic all singing all dancing extravaganzas). NHS management needs to get control of their surgeons and start telling them what to do and the politicians need to make emergency care the priority and not these stupid and meaningless waiting list times.

I’ve been cutting the grass and weeding for the last month in my job, a 4 week block of on call, and I’ve done more good and helped more of the ill people that I serve than a month of elective work ever does. Not that the politicians care or that management cares; all they give a shit about is the clinics that have been halved in my absence.

A poem for those on night shift

Not one of mine, but one I like a lot. I hate night shift, I dislike sleeping alone and at the opposite time to everyone else, I always feel quite lonely and sorry for myself. I also become lazy and lethargic, hence the stolen poetry.

All you who sleep tonight

Far from the ones you love,

No hand to left or right,

And emptiness above-

Know that you aren’t alone.

The whole world shares your tears,

Some for two nights or one,

And some for all their years.

Vikram Seth

KBW’s guide to an emergency splenectomy

Ensure the team is calm and cool.

Ensure the team is calm and cool.

This post is for my own benefit I am afraid, purely so the next time I am faced with an emergency open splenectomy I can access this handy refresher article and bash on, unhindered by the need to locate a surgical textbook. In this article I am assuming there is no option for any fancy interventional radiology person coming to save the day (ruin my fun) this is old school, spleen out following major trauma.

There is nothing more galling to angry people than the coolness of those on whom they wish to vent their spleen

         The Spleen. You don’t really need it.

The first thing is to calm down, this is a stressful situation but one which if handled correctly (by you) will be life saving. In my hospital and in my experience the patient has suffered some sort of major trauma is usually young, very ill and and there are anxious and terrified relatives all milling about.  Most of the time, A&E have whipped everybody  involved (including themselves) into a sort of frenzy of hysterics and are not headless chickens as such, but there may be stress induced errors; they have forgotten to alert CT that we are en route to them for example or they send the bloods off incorrectly labelled in the rush. Lots of the time (such as in Bighospital) splenic injuries are manageable through interventional radiology and embolization; but that usually takes awhile to arrange and on a number of occasions I have had to reverse that plan and proceed to a laparotomy when the IR guy and his team are taking too long to get themselves in the hospital and ready to go.

You need to pour oil on these troubled waters and exude calm and confidence, even if you don’t feel it, which is easy to do if you are following the KBW plan…

1. Prep the theatre staff on the kit you want: omnitract, 2 suckers with guards, array of sternal and mayo retractors for the omnitract, lots of big abdo packs, a Ligasure, standard major laparotomy tray, cell saver.

2. Prep the assistant (ideally 2 assistants) on the plan, make sure they are clear on it.

The plan: GA on the table, omnitract ready to go, attached to side of table before they are asleep, prep the skin and drape awake, surgeon on patient’s right, assistant on left. As soon as they are asleep open the skin (midline laparotomy) and fascia,then open the peritoneum and the assistant presses down on the LUQ as you unzip the whole abdomen. A big pack in behind the spleen, another pack above the spleen, another pack in left paracolic gutter. Pack over the liver and on top of the liver and you and the assistant get sucking with both suctions.

4. Check the liver, mobilise falciform off abdominal wall if you need to retract left lobe to access spleen. Pack liver if further trauma there. Get the Omnitract set up, sternals and mayos right and left upper half, fish slice on the liver if required.

5. If haemostasis is ok and you have nicely packed the spleen now is the time to do a thorough laparotomy whilst you are waiting for the anaesthetists to get on top of things at their end.

6. The approach to the packed up spleen: Use the ligasure. Enter the lesser sac, you are going to leave the gastroepiploics behind on the stomach and come up the greater curve sticking close to stomach but not taking any of it using the ligasure. Munch, munch all the way up the short gastrics. See the pancreas, see the splenic artery on top of it, take the artery here if you want. Careful as can be with the pancreas, we do not want a fistula. Usually the bleeding is temporarily controlled by the pressure, if it is still hosing out use a pair of scissors and cut it out, deal with any bleeding afterwards.

The way in to the spleen

7. Flip stomach up and out of the way, free the spleen above and medially, be careful up here at the diaphragm, little bites, stay close to the spleen.

8. Fully unpack the spleen if patient stable and have a look at the damage, leave unpacked if bleeding stopped. Come up to the spleen from left paracolic gutter now, it will be attached here, come round to the hilum, now reach round the back and divide the posterior attachments, deliver the spleen up out of the hole and it should now just be attached at the hilum.

9. Ligasure up the medial surface of the spleen, take the vessels and tie them off. Careful, careful, careful that you don’t munch any pancreas here.

10. Spleen out, wash, drain (for panreatic fistula rather than blood) close and go.

Don’t forget to give you may need an NG tube to decompress the stomach. You need to give prophylactic antibiotics, a urinary catheter, consider a post op epidural, check current guidelines on post splenectomy immunisation schedule and antibiotic prophylaxis.

 

Your anaesthetist is crucial in this operation, the fatal triad of hypothermia, acidosis and coagulopathy will be activated and unless your anaesthetist is on the case all your brilliant surgery will be wasted.

(Spleen 1,3,5,7,9,11: The spleen is 1″thick,3″deep, 5″long, it weighs 7oz and lies between ribs 9 and 11. Not that anyone nowadays measures in inches and weighs in oz. If the spleen is enlarged: )