Never do an elective operation that you don’t expect to work.
Some operations do not work, despite your best efforts (see anastomosis staple prayer) they are in the minority happily but in Vascular Surgery they can feel slightly more frequent. The phrase “more in hope than expectation” applies to many of the patients and operations that the optimistic vascular surgeon does.The typical patient journey of lower limb bypass, followed by failure of the bypass and then amputation is depressing for many surgeons, myself included, but the disease cannot be overcome and surgery is often only palliative in severe peripheral vascular disease. Patients with critical limb ischaemia have a life expectancy of less than 40% at 5 years in comparison to cancer of the colon where an early Dukes’ A cancer has a 90% 5 year survival, polyps of course do not count as cancer as some readers know only too well.
Patients are oddly unaware of the grim future ahead of them when they are faced with critical limb ischaemia. Surgeons don’t spend lots of time holding their hands, there are almost no specialist nurses (in comparison to breast cancer care) there is little information in the public domain and the patients themselves are not informed. As a result, there are very few tears shed and not too much demand on the surgeons to console and comfort. Many of the patients have smoked and have a remarkably stoical approach, almost as though they were expecting the smoking to catch up with them eventually. I find many of my patients admirable, they are fearless, accepting and trusting where I would be distraught, demanding and questioning.
And so to the title of today’s blog, a few weekends ago I was assisting in a bypass operation (fem-pop) that ultimately failed after an attempt at further salvage (flopped) and resulted in a lower limb amputation (the chop). The patient in question wrote me a thank you letter following his discharge from hospital (we keep these letters you know, they mean a lot) and had a very different view from my own about how his care had gone. He was so grateful for how hard we had tried to save his leg, but ultimately he had been sure that he was facing an amputation and was doing well with his new artificial limb. We spent hours and hours trying to save this man’s leg. We tried our absolute best and odds to this attitude of care and concern for the patient with an aggressive and incurable disease were my colleagues in anaesthesia. They love to have a chuckle about how long it takes to do limb saving surgery in contrast to how fast the surgeon can take the leg off when it all goes wrong. It isn’t funny at all for us, it isn’t funny for the patient, it isn’t funny for society due to the financial implications of rehabilitating and caring for an elderly amputee. I wish you’d stop it, I know it rhymes and sounds kind of funny but it isn’t. All of us like to have a laugh at certain aspects of the job, but having spent 10 hours trying to save a leg in the middle of the night only to amputate it 48 hours later is not funny, it is devastating for everyone.
It is of course very unlikely that any anaesthetist anywhere would ever get peripheral vascular disease as much like Sandra Dee in Grease they don’t drink, don’t swear, don’t rat their hair and they get ill from one cigarette.
I’d rather be Rizzo
How I would love to have an email filter that prevented me from sending either drunken emails (I once cc’d an email in error to a very senior colleague, an email full of complaints about how he ran things and swear words that I sent at 2am) or ill thought out emails sent in the heat of the moment.
I recently had the pleasure of smirking at the email a colleague sent which he had signed “yours in anger”. It was really rather a silly way to end what was already rather a silly and too long email. I imagine he regrets sending it as it has not made him look very grown up or clever. Any email has the potential to come back and bite you in the bottom when you least expect it. I think there should be a time delay filter triggered by certain words (which can be set by me) that holds an email in my outbox for a few hours whilst I rethink what I have written.
In Girls, the sweet and heartbroken Charlie invents an app called “forbid” that prevents you contacting by either phone or email anyone you blacklist, you have to pay $10 to unlock their number. Genius plan for messy breakups, but not quite what I need to prevent dodgy emailing.
My opinion is that you shouldn’t put anything in writing that could harm you in any way if it became known to someone or even everyone that you know. The classic case occurring with an email that has “reply all” in the send box and not just your friend.
So, makers of NHS email and iPhone apps, please can you manufacture an app called “facesaver” or something for me that does the above? Cheers.
Charlie from Girls, inventor of the fictional Forbid app.
Are you currently waiting for an outpatient appointment or an operation? Perhaps you are desperate to see your GP? The reason you are waiting is because of the likes of me, yes, part-time women are a burden on the NHS according to Anna Soubry (who? a health minister apparently) and Tory MP Anne McIntosh (another “new to me” person, but then I am a useless part-timer and too busy dossing about to keep up to date). Feel free to read about the whole sorry debate and subsequent furore here, and here and here. It has been somewhat overreacted to by the media.
Anyway, I had the opportunity (due to the fact I work part-time) to listen to Women’s Hour last week and heard Anna Soubry who had supported Anne McIntosh’s frankly mental comment that part time women are a burden and that there are “unintended consequences” of having all these women. Anna Soubry felt it was a “hell of a storm” whipped up by the media and then there was a ridiculous bit of radio when she mentioned how her mum was a radiographer and that she thinks it’s marvellous that women can have babies and work part time….good God woman…it’s 2013. The other medical madame they had invited along was Dr Fiona Cornish the president of the medical women’s federation
(I am not a member) who was so marvellously well spoken she made Jenny Murray sound a bit rough. Most GP’s work less than full time, they don’t do 12 sessions like most of my colleagues do; not one of my friends who is a GP (males and females) is doing the hours hospital doctors put in and this point was well made by Dr Cornish. It was a damp squib of an interview (you can listen too)
though and could have been far more interesting and lively. The Daily Mail
are the voice of unreason as per usual on this, their own Mrs Malaprop Melanie Phillips (who justifies her comments by saying she is a woman who once worked part-time) thinks that the “The dilemma of combining work or a career with motherhood is a difficult one, perhaps even insoluble. But surely it is essential that we should discuss it?” I can assure you Melanie, that we part-time medical women are completely insoluble, unless you try to dissolve us in fits of laughter at the drivel that is published in the Daily Mail.
I have a solution to the problem; stop letting so many hot women into medical school.
Melanie Philips: Unlikely to be chased around the hospital by the few remaining male doctors.
I wouldn’t let her take out my spleen
The test of whether or not you rate a colleague as any good is whether or not you would let them operate on a member of your family. This test is seldom (thankfully) applied but patients in your care sometimes ask if the surgeon who will operate on them is any good and seek your assurance, as a doctor that they know and trust, that this stranger is up to the task. This question is easily answered when it someone you do rate highly as a surgeon and is fraught with problems and stress when it is someone you would not let near your neighbour’s cat. Again, this occurs rarely as most people are good enough at most things that they do. It is good fun in fact to recommend a former boss who you think is great. The pain comes when it’s the opposite. To avoid answering this question directly one could use a generic reply “all the surgeons here are good, I’ve not heard anything to the contrary about Mr Handslikeshovels and I am sure it will go fine” If anyone recommends a colleague this half heartedly they are trying to tell you that they do not hold this person in high esteem.
A similar thing can occur with certain new and novel treatments and certain operations. A friend of mine used to regularly talk patients out of their Whipple’s the night before surgery much to his consultant’s fury. He was firmly in the “get pancreatic cancer and spend your last few months in hedonistic glory” camp, not for him months in hospital with comorbidity and misery. He is a pessimistic kind of guy and I disagree about Whipple’s as it happens and would take my chances with surgery.
The test of a new operation is would you want your family member to have it done the new and novel way if required. Quite frequently the answer is that you wouldn’t. Old ways were of course once new ways but any new technique should be applied with caution and continual audit of personal and unit results. When offered a new operation or a new procedure be sure to obtain the surgeons own results, find out their own experience and what complications they have had. You wouldn’t let just anyone do your garden or your decorating, apply the same prudence in letting someone take a knife to you.
To finish on a happy note a patient I had admitted and looked after was handed over to my colleague, the Prof, for his operation. “Is he any good this chap?” asked my patient. “I’ve known him more than 13 years. He’s the best there is” I said “He is as good as we have got and a really nice guy too”. The patient was out of his bed day 1 walking all around the hospital and was ready for home day 2. He believed the top man had done the operation, and so he had an exceptionally good experience and fast post operative recovery whilst most patients who have this operation stay 3 to 4 days.
You’d be nuts not to like it
Causing a furore this week in the UK is a titillating advert featuring Pamela Anderson and a hot assistant in a boardroom talking to a group of men. One of the men indulges in a spot of fantasising about Pamela and the hot brunette girl dancing in gold bikinis, covered in cream. This advert which is for a company called crazy domains, has been withdrawn following complaints that it is demeaning to women. The Advertising Standards Agency has not held back in their condemnation “we considered that the ad was likely to cause serious offence to some viewers on the basis that it was sexist and degrading to women”. I find the use of “ad” more offensive in any sort of official statement than a bikini clad Pamela dancing in the middle of a cream factory industrial accident.
Can the ASA be serious? Are men the only ones to think about something else during boring meetings? Are men the only ones who would wonder what Pamela looks like naked if she turned up at your place if work? I think it is demeaning to men actually, they look pale and plump and the women are clearly in charge. The man (his advert name is Adam apparently) is the inadequate looking dope who would never get his hands on the great Ms Anderson in a million years and when faced with something as lovely as her in the flesh he can’t keep his mind on the job. It’s men who come off badly in this scenario.
I think some women should stop being so righteous about sex and fun and nudity and also stop confusing them with gender inequality and misogyny. The reason there aren’t women in boardrooms isn’t because all the men in them can’t stop thinking about us naked, if only it was that straight forward. Along similar lines is the campaign to do away with Nuts, Loaded, Zoo and FHM on the grounds that they are pornographic and that handling them as a shop worker constitutes sexual harassment and sexual discrimination under the Equality Act of 2010. It seems unlikely that this law was devised to protect shop workers from looking at Nuts magazine yet Professor Aileen McColgan of Matrix Chambers (legal chambers of Cherie Booth et al) seems to think so. She is welcome to come to a hospital I used to work in and I can fill her in on what sex discrimination means to me and all the other women I know who have had bigger fish to fry than being offended by Nuts magazine.
Robin Thicke ‘Blurred Lines’ (Dirty Version) from OB MANAGEMENT on Vimeo.
And just to show I practice what I preach, check out the video for Blurred Lines, it’s great, the daily mail were remarkably restrained about it, for once. It’s a cracking tune and the girls look lovely, good for them.