If you don’t put your finger it..

…you put your foot in it. So goes the old surgical adage.

There is a piece of kit available to every doctor that is unbelievably sensitive, flexible, reusable and cheap and is woefully underused, the index finger.

I have strong views on pr examinations, this is because I think that if it is indicated it should be done at the time of the initial examination as part of the physical assessment and clerk in. What I hate, and sadly all too often happens, is that I come and do a ward round and find someone who should have been examined per rectum and has not been.

Picture the scene, there are 10 of us at the end of a bed, some junior is presenting their findings to the team and the error of omission is revealed; all of us look to the presenting doctor and then the patient. The spotty wee junior doctor gulps “the thing is. I didn’t think a rectal was indicated in this person who has presented with rectal bleeding”.

The patient now looks to me, like I am some deranged anal pervert who thinks that he does need a finger shoved up his bum when the nice young doctor has said it “wasn’t indicated”. Not one to be upstaged or undermined by some little shit bag 6 weeks out of medical school with little or no understanding of anything, I deal with this swiftly by asking the nice young doctor what he would consider an indication for a pr, this baffles them.

The junior doctor is excused from the round and they are sent back to the patient to do the examination.

It’s SO aggravating, it makes a big deal of something that isn’t a big deal. They should do it at the time of initial examination and spare the patient this awkward interaction on the ward round. It’s even worse because the rest of the bay knows exactly what is happening because they have overheard it all and then see curtains drawn and a flying visit for a pr. It’s humiliating for the patient.

Some patients decline to be examined pr and I probably would too. It is now standard practice to have a chaperone for this examination and this is always documented in the notes. As a screening tool for colorectal cancer the finger is not much use and the old school mandatory pr for the whole ward has been dropped.

It is still useful in assessing a patient, especially in cases of constipation and faecal impaction, change in bowel habit, assessing the prostate, in all cases of pr bleeding and for neurological problems but I have never diagnosed appendicitis based on pr alone and it often doesn’t alter my management much as it is usually normal.

That aside, it is still indicated a lot of the time and as it is an intimate and sometimes uncomfortable procedure it should be done with care and consideration.

The medical school spend a lot of time teaching them how to do it on a big fake dummy bottom that they talk to like it’s real, it is painful to be involved in. I had the bad luck of being the examiner for this in a recent exam. The only amusing part was when one student referred to the KY Jelly as “lube” which suggested a degree of pre-existing familiarity with the procedure.

I think the part the medical school miss out, which is unlike them in the current touchy feely curriculum climate, is that the timing of this examination makes all the difference.



Medical students: how to survive a surgical attachment

Right, you little munchkins, I’ve had enough of your disinterested and sullen faces slumped over coffee at tutorials, my clinic, theatre exit rooms, etc. If you want to get anything out of general surgery, by which I mean get anything out of us, you have to engage our interest.

I can’t say this to you in the hospital as I would be done for bullying or some other crap (like my colleague in ortho, accused of being a chauvinist for some minor joke in a lecture) so I’m not going to hold back here.

The first thing we will ask you is if you want to be a surgeon, now, we know you don’t, if you did you would have already told us. Surgical med students are practically jizzing in their pants to speak to us and come to theatre.

When we ask you though, don’t say “I hate surgery”, “anything but surgery”, “I can’t tie my shoe laces and am very clumsy”. Even if you want to be a palliative care physician or a telemedicine community psychiatrist somehow or other put a spin on why surgery is interesting and relevant to you. The fact that the university is going to give you 2 degrees, one of which is a bachelor of surgery seems lost on you all and I think you should just be given an MB not MBChB.. Sorry I am off on a pet rant of mine.

Somehow or other fake some enthusiasm for surgery. At some point in your life you may be required to lance an abscess or amputate a limb to save a life. Who knows how or what or why, but you have the letters after and the title before to suggest that you have some basic competence at this sort of thing.

Pre theatre dinner.

You must, must, must have a pre theatre dinner. By which I mean get your tea in early and then open some books. Anatomy textbook, followed by surgical text books (note plural), followed by YouTube or websurg to watch a heavily edited operation. Then if you are genuinely interested you can look at some guidelines for management.

Anatomy obsessives

We are crazy about anatomy. DO NOT say to me that you can’t remember any anatomy because it was a long time ago. It was not a long time ago, 20 years ago is a long time, 2012 was very recently. You don’t remember it because it was badly taught, you weren’t interested, it meant nothing to you at the time and you didn’t bother learning it.

The anaesthetist

The anaesthetists are not better teachers, they don’t like you more than me, they are so bored that they teach you. They have done their bit, now they’re cruising at 32000ft and want a distraction, meanwhile I’m in an abdomen which has been unzipped for the fifth time, dealing with adhesions from hell and an unexpected amount of bleeding..I’m not talking to you because I am busy. So don’t put it in your feedback form that we didn’t speak to you much during operations!

We are predictable creatures

I ask the same stuff over and over and much like the professor of infectious diseases asks you all what bugs cause pneumonia and where the likely sources of E. coli bacteraemia are, my colleagues and I are similarly predictable.

Causes of pancreatitis, symptoms of colonic and rectal cancer, gall stone disease, causes of jaundice, small bowel obstruction, stomas… All of which is very standard general surgical fare, we aren’t looking for anything weird in the differential diagnosis of a profusely vomiting patient, I want the common stuff.

Little black book

In the olden days, before Tinder and mobile phones and Facebook, people kept their friends contact details in an address book. “A little black book” usually contained numbers of members of the opposite sex and was closely guarded. You need to get a little book, not a bit of paper, and you are going to write down all the things you encounter in a day that you don’t know. Take an ERCP- today on the round we spoke to a patient who was going for one- then we moved on to the next patient. I asked the four students what an ERCP was as we left the bay, none of them knew. Nobody had asked or written it down to ask later. You must do this, write it in your book and consolidate your learning at home with a textbook afterwards. This is the whole point of these (stupid) self directed teaching methods that they are so keen on these days. It doesn’t work if you are not paying attention to what is going on.

Try and enjoy your time with us, if you give it some effort we will too. Read the books, some students last year told me that they don’t have a surgical textbook as they don’t need one; you do. You must have one and you need to read it throughout the attachment.

We love having motivated and interested students around. Ask lots of questions, ask to scrub in as much as you can, follow the people that seem to like teaching you and are good at it. Stay away from those who ignore you or are mean. If you are able and keen, do a night shift or a weekend shift, you will get one to one teaching and get to do a lot more in theatre as we need the extra pair of hands.

NHS Health and Safety for Surgeons (Part 2)

NHS Health and Safety for Surgeons (Part 2)

Health and Safety again, don’t say I don’t care about you…

You really should wear eye protection when operating, this is a much flouted rule by my colleagues and one of the few rules that I insist medical students scrubbed in with me adhere to. I don’t really care if you have small earrings in and I can just about tolerate false eyelashes if they are properly attached. What I am not prepared to accept responsibility for is giving you an eyeful of potentially infected blood and causing you harm. When we know a patient has a blood borne virus like Hepatitis C or HIV we are all protected to the maximum and take great care during the procedure but these standards are erroneously relaxed for low risk cases.

Below is a picture of my visor following a laparotomy today, in a low risk patient. I am not normally quite this messy but you get the idea.

Glasses are not adequate eye protection despite what many people believe and you really should wear a visor of some sort. I haven’t always been so proper I have to admit and I only started wearing a mask with a visor when I was pregnant with my first baby as suddenly I was protecting someone else instead of myself. I struggled for the first few times with feeling hot and bothered but I soon got used to it.

Some people like to use their own judgement about whether or not a patient looks high risk or not. This is ridiculous and naive, even the nicest and most demure lady can be married to a man who has a taste for high risk activities.

A lovely colleague of mine has hepatitis C, contracted via a needle stick injury. He is on anti-retro virals and is jaundiced, stressed out and exhausted. He has a nap after lunch every day and cannot operate or even do simple procedures like take blood. He has the added stress of a wife and children to protect from his virus. He is going through a nightmare situation that nobody would wish on their worst enemy.

Public health England estimate (2012 figures) that there are 98,400 people with HIV in the UK with 21,000 of then being unaware of the diagnosis. There are 216,000 people with hepatitis C. It’s not a huge number but why take any chances? You wouldn’t have share body fluids with a stranger in any other situation so why do so at work?

Frequent fliers

Frequent fliers

If you come into hospital it’s probably because you are ill, are in pain, or at least someone thinks you are ill and has arranged for you to be admitted. There is a subclass of patients that are not ill, at least not like the other people in the bay, that frequently come in to hospital and are known by us as frequent fliers (with a roll of the eyes, muttering fuck sake fuck sake).

General surgery in Bighospital have a number of them, they tend to go through a period of intense activity with a year or two of very frequent admissions and either they get bored of us and start having different symptoms necessitating admission somewhere else or they get better and stop coming in to hospital. Most of the time they are down in Urology with loin pain or getting CT’s of their head with imagined arm weakness and headaches.

Let’s take the example of Mrs Rotten Teeth, she appears every month with a story of small bowel obstruction, she has a personality disorder and a stoma and I imagine has a fairly miserable life. She is usually dirty and unkempt and has poor hygiene. She has never had a small bowel obstruction, her stoma works instantly on arrival in the hospital and she does not vomit. She usually stays 2 days, gets fed and washed and then sent away again.

Then there is Mr Stoma Sex, he wants a stoma, desperately and has tried to get all of us at one point or another to give him one for no real reason whatsoever. He turns up at all new consultants clinics claiming anal pain, rectal spasms, bleeding etc, hoping someone will give him a stoma. Bighospital legend has it that he wants to have sex facing his partner and believes a stoma would facilitate this, which seems faintly hard to believe to me and somewhat homophobic, but that is the legend.

There are plenty of seemingly normal people who have this sort of behaviour; there are the young women with right iliac fossa pain, they come in and out during periods of acute stress in their life with textbook symptoms of appendicitis but none of the signs. Some of my colleagues take their appendixes out so we don’t have to see them again, which is somewhat unethical.

It may be hard to believe that some people actively seek hospital admission for attention but I am afraid that they do. Münchausen syndrome is the real name of this chronic and debilitating condition. It is commonest in women aged 20 to 40, especially those with some sort of healthcare background and in unmarried, socially isolated males aged 30 to 50. In my experience these people start off being genuinely ill in some way and get stuck in their illness behaviours.

Many people with mental illness turn up as well of course, I see lots of women with eating disorders who claw stool out of their rectums and want “cleared out” for imagined constipation. Also there are the self harmers, usually young women who stick knives or needles into their abdomens, rectums and vaginas.

The set up of an acute surgical receiving ward is so woefully inadequate to even attempt to deal with these people. We lack the time, the resources, the skills and we also don’t care enough (consultant on call is on a 1 in 8 and the chances of them belonging to you more than once a year are slim). Similarly, general practice has changed so much over the past 10 years that out of hours care is provided by locum GP’s who don’t know the patient and are admitting these people willy nilly, as they have to believe them. I saw three frequent fliers in my last week on call, they are all quite nice, they aren’t much bother and they go home within 72 hours but what a waste of resources, of their own time and cost to the economy and society.

The saddest thing about frequent fliers is that nobody ever phones or comes to visit them, which suggests it’s not just us who find them annoying. These are challenging patients who do not get what they need from us or from general practice. I don’t have the skills or the time to gently explore if just maybe they are fabricating this for attention, what I need is a liaison duty psychiatrist to come and see them and that is for some reason totally impossible in Bighospital.