It matters a lot to us who is at the “head end” of the patient as our anaesthetist (anaesthesiologist) and recently I have been thinking on just how much this matters. I’ve moaned a little bit about anaesthetists on this blog, and I do think that they are for the most part not funny, but much like a decent sports bra or proper toilet paper, you only really appreciate them when made to do without. There are lots of jokes about us and them and we like to pretend that their job is easy (inject the white stuff, breathe the gassy stuff, inject the paralysis stuff, done) and they think we are stupid for an example see this youtube video of the Orthopaedic registrar talking to the on call Anaesthetic registrar.
During a nice straight forward gallbladder list I was left to do last week (with the consultant available if I needed him obviously) I had an unknown anaesthetist whose affect and manner seemed at odds to the usual capable and competent anaesthetists that I am used to. Five minutes into the case and she was flapping, something about the pressures somewhere being too high. I was mid dissection of the fat (this case was a BMI 40 gallbladder) that was sticking the duodenum onto the gallbladder and this, although straight forward, requires attention that you don’t burn the duodenum or make anything bleed. I clearly asked her “do you need me to stop and let the gas out?”. “I don’t know” she said “I’m not sure what’s wrong.” So I stopped and we let the gas out and waited for her to get control and I felt anxiety wash over me as I watched her flap and panic.
The anaesthetic nurse wisely exited the room at this point to call for the anaesthetic consultant who had popped down to the coffee room for lunch. He arrived (he is the coolest and best anaesthetist we have as it happens) immediately realised that the tube was in too far as the lady had a short trachea, pulled it back a bit and we carried on. It was all pretty straightforward apparently and Dr Cool said he wouldn’t have interrupted the operation and that Dr Panic Merchant was new and inexperienced.
As the surgeon operating you carry the responsibility, it’s your patient, you know them and their husband, that they have a wedding to go to in March and are going to Spain in 4 weeks, they know and trust you. The deep fear that this event put in me that something was going to happen to my lady and that I couldn’t control any of it was terrifying. The next 2 cases were similar with repeated flapping from the top end and the nurse having to reassure me that it was all ok as she dealt with the minor problems this new girl could not resolve. I was nervous by the end of the list, I didn’t trust the local anaesthetic dose she she’d given me, I didn’t trust the antibiotic dose (yes, yes smarty pants readers I made a hole in one and spilt a tiny bit of bile) that she gave and was stressed out for the whole list.
Usually I am blissfully unaware of problems unless I need to be made aware and the communications between us and them are smooth and calm. Problems a good anaesthetist tells you about are: to stop operating as the patient needs chest compressions (happens during ruptured AAA’s etc) or that they need you to stop so they can catch up on blood loss and clotting products, if the BP drops suddenly they will ask if you are squashing something important (IVC, heart, liver), to ask if you have just had a big bleed (usually we will have told them already) and to ask how is it going.
In turn, when we ask how it is going and there are concerns they use some sort of ambiguous answer that will reassure us, it is not like lying but avoids telling us the full extent of the bad news until we have finished. For example “good, she’s making urine and her haemoglobin is ok”. The truth is she has a pH of 7.15 and has received 3 units of blood to make her haemoglobin ok but there isn’t much point in telling me that when I am elbow deep in a narrow pelvis and can’t do much about it. It just makes us worry, distracts us and that is bad for operating. The fact I am asking how it is going, is an indicator that I know it is not going well at the physiological end. A friend of mine who anaesthetises for big cases tells me that a huge part of her job is to keep the surgeon happy and focused and unaware of problems unless they need to know or until the case is done.
So following last weeks nonsense with the new girl, I am full of love for our usual anaesthetists. I am grateful and impressed with their smooth and easy anaesthetics (they could be a bit quicker in the anaesthetic room though) and have a new understanding of the relationship. Many of my bosses have great anaesthetists, one or two have less great ones, it’s impossible to influence who you end up with but I hope when I grow up I get one of the greats.
KBW’s Need to Know for medical students
(not a how to do it and not comprehensive by any means)
I do like to harp on about Whipple’s operation, it is a lengthy and difficult procedure and even in the best hands and best centres (Bighospital is once such place) has a high rate of complications and death. Even if you survive the operation the outlook can remain poor as the type of cancers that require a Whipple’s are aggressive and deadly (pancreatic cancers, cholangiocarcinoma).
What is a Whipple’s operation?
Professor Allen Whipple was an American (born in Iran) who described the operation of pancreaticoduodenectomy, more widely known by it’s eponymous name and also described Whipple’s triad. He is not the same Whipple as Whipple’s disease but apparently the two were great friends. He modified the operation from his original two stage procedure into the classic operation that we now perform.
The aim of this operation is to remove en bloc the head of pancreas, the duodenum, with attached first part of jejunum and the distal portion of stomach, the common bile duct the surrounding nodes and vessels that are attached and as a separate specimen the gallbladder and cystic duct. Continuity of the bowel and biliary system is then restored via a series of joins called anastomoses. The cut body of pancreas is sutured onto the small intestines (the panreaticojejunostomy) and the top end of resected common bile duct is sutured onto the small intestine (the hepaticojejunostomy) a bit further down stream to restore the flow of bile and pancreatic juices into the gut. Then the stomach is joined onto the small intestines (gastrojejunostomy) to allow food to pass in and finally there is a join between the small intestinal loops (enteroenterostomy) to prevent biliary reflux up into the stomach.
This operation takes about 6hours (on a good day) so make sure you have had your breakfast and make sure you have had a look at your anatomy books.
First off you have to get down to the retroperitoneum where the pancreas lies hidden and innocuous looking like cooked cod roe under a layer of fat and peritoneum. To do this you need to make a rooftop incision and then move the right colon away (just like you do for a right hemicolectomy). Then you have to come from the superficial, main abdominal compartment down into the lesser sac onto the pancreas snuggled in the c of the duodenum. The duodenum is freed from the fixed position all plastered down and flipped over (kocherised) to lift all the business up.
Then we need to come under the pancreas, we define the vascular anatomy; firstly you find the SMV (superior mesenteric vein). Then the most complex area, a little cube of clockwork known as the porta hepatis. Find the common hepatic and then the GDA (gastroduodenal artery) the right hepatic artery, cystic artery and gallbladder (it is removed). We like to sling the vessels such as the GDA prior to division and also the common bile duct. It should all look rather beautiful and like an anatomy prosection at this point. Then, in order to get on with things you start by dividing the stomach proximal to the pylorus and dividing the jejunum, then you separate the pancreas from its vascular supply (nasty little veins that bleed like stink and you fear for the SMV and the portal vein) you then divide it and remove the specimen with all the lymph nodes and fat.
This area of the body has the most complex and difficult anatomy to get your head around, there are also annoyingly, lots of variations of normal. There is no easy way to fix this in your head, it takes lots of study, plenty of time in theatre, time looking at scans and I also think the passage of years to fully grasp. I have not grasped it fully yet and have seen it a fair bit.
This series of intraoperative photographs is fantastic and shows beautifully the operative view that you will see.
After removal of the specimen you join it all back up. Pancreas to jejunum, common bile duct to jejunum, stomach to jejunum and then jejunum to jejunum. We are not routine Roux loopers in Bighospital. Some of the joins can be stapled or hand sewn, it is down to surgeon preference. Every student should watch a Whipple’s as it is truly amazing and inspirational even if you are a career immunologist, just make sure you eat a big breakfast and read your anatomy before hand. I am repeating myself because this part is important, read and eat students, read and eat.
You will not be able to get it all correct here, if you know all this you will please even the most fussy of HPB surgeons; and my god, are they ever fussy.
Shoes and I have a long and happy relationship; I am never too fat to buy shoes, heels make me feel taller, they make me look thinner, shoes make me feel better, shoes are pretty, shoes can be fun, shoes are much better than a diamond seeing as sparkly rings are not allowed at work.
Had I been wearing some decent shoes and not my theatre clogs I may have handled a recent row with a radiologist slightly better, seeing as I would have been a taller and more cocky version of me. Sadly I instead ran off near crying with frustration after a run in with the evil little doctor of darkness.
Confidence in my ability to manage my job and the endless decisions I take used to vary in a sine curve fashion, moving around the midline as I made alternating good and bad decisions. Recently in spite of no real fuck up’s (tempting fate here I know) my confidence has been stuck at the bottom of the curve and doesn’t seem to be moving from there. I’m not sure why this is, normally it makes me feel quite down for a week and then the feeling usually passes with a good operation done well. I don’t feel too unhappy despite this current crisis of confidence but the mood isn’t lifting. I’ve had a lucky amount of time off this Christmas and hope that the break will have resulted in a new found surge of confidence, we will see.
I discussed with a more senior female colleague the worries I have about complications and dealing with the range of emotions you experience when an operation goes wrong and even more so when someone dies. She nearly wrestled me to the floor and told me to shut up, lest a man overheard us. She said I should never feel like this, that the boys don’t feel like that and I couldn’t and shouldn’t doubt myself.
I’ve progressed from 12 years ago when I used to lie awake imagining the vessel I had tied off was spurting arterial blood and the patient was exsanguinating as I snored. I’ve progressed from 7 years ago when I used to hover over patient’s beds and check on them repeatedly throughout the day. Now I check for readmissions on the computer of people I may be worried about, operations that were difficult to perform or people that have high risk factors for complications. The relief when the names aren’t there is comforting to me.
So what I think I need, what surely will give me the balls I am currently lacking is some serious kick ass shoes, shoes that say “fucking right I am the surgeon on call, now do what I say and be quick about it”. One of my very junior colleagues has this attitude in spades, she has next to no experience and can’t tell her APER* from an EVAR** but my goodness, she is confidence personified.
Red soles are called for, I feel strongly that red soled shoes were surely made for surgeons and that 120mm is in order. They have beautiful brown suede ones on net-a-porter I keep peeking at, how completely impractical for January in the UK but they somehow say authority and confidence, and I know they’ll fit despite the “mince pie half a stone” I need to lose.
*abdominoperineal excision of rectum
** endovascular aneurysm repair.
My 6 year old has been told by his teacher today that he has to make a new year resolution. I have suggested a long list; eat your vegetables, don’t leave clothes on the floor, wash your bike after you’ve been out playing, tidy up the Lego before I have to shout, try something new once a week (vegetables)…unsurprisingly he isn’t keen on any of my suggestions. We have spent the last 40 minutes doing his homework (he has forgotten how to do homework it would seem in the holidays and what usually takes 20 minutes dragged on and on today) so he has now concluded that his resolution is to play more. Good for him, clever little man, he does swimming and tennis lessons and school but otherwise will spend all his time playing, I don’t think that this is what his teacher wants to hear so perhaps we will have to discuss things again tomorrow morning.
I was one of those little girls who couldn’t wait to grow up, I was always desperate to be older than I was and was rushed through my childhood as though it was something inconvenient. At 10 I had numerous household chores and responsibilities, mainly helping my mother prepare and clear up meals, at 12 I had an egg round (I made 1p per egg) and at 14 was out waitressing and washing dishes for £2.50 an hour. I am not yet sure if I will make my own children do so much around the house or indeed let them have a job whilst still at school. Mr KBW did not have the same experience as a child and he is appalled at the idea of 10 year olds clearing and setting tables and cleaning the bathroom. He feels they should be engaged in worthwhile activities and not be tasked with responsibilities like this at home or allowed to earn their own money out in the real world.
I don’t really do resolutions and the calendar new year never seems particularly new and fresh to me, instead the start of the academic year always marks the beginning of a year in my mind. However to all those turning over a new leaf in 2014 good luck and best wishes, I don’t think you’ll find an easier resolution to follow than my son’s, we should all play more.
There is no task worse than doing the rota. It is painful and annoying and the only advantage is the ability to accommodate all my own plans and those of my family. Otherwise it is purgatory.
I’ve done the rota for the next 6 months and now the moaners are starting up. There must be a formula for working out the number of complaints and swaps that my colleagues make.
Generally the moaniest moaner is a postgraduate doctor (those who didn’t get in to med school straight after school) newly qualified, who has a boy or girlfriend who is a doctor and a parent who is a doctor. They moan like fuck.
The least moaniest are the oldest doctors, who are married with school age kids, and care about the service and their training.
Sweeping generalisations? Yes. Feel free to moan. Don’t expect me to care.