A surgeon is an altricial animal

A surgeon is an altricial animal

When I was a very young medical student (just 18 when I began medical school and 22 when I finished- it’s not postgraduate in the UK) I was a rather altricial sort of a creature. I was a product of a state education, from a family where although we were not poor I was first person to go to university. I was unsure of so much, how to behave, how to get my point across and yet also full of passion and enthusiasm for my chosen career. It has taken a lot of years for me to become the sort of woman who doesn’t mess up the dress code, never rips her tights, doesn’t forget things, doesn’t get drunk at a drug rep dinner and never falls over on too high heels.

Some people are more precocious than me, they are fully hatched at birth and function like mini consultants from the minute they get in to medical school. Much like it’s hard to imagine William Hague as a teenager, these people have some sort of inner mini consultant.

The thing about these annoying people who act like they are the “big I am” from the minute they arrive on a ward, is that they don’t learn or develop very much. One of my colleagues is this sort of a guy.

Like a newborn foal stumbling to his feet within minutes of birth, he has adopted the authority and gravitas of a professor of surgery. All of this would be great if he was any good, if he made good decisions and was in fact ready to be the boss, but he’s an idiot. He has no insight whatsoever into his many mistakes and massive cockups. I am partly fascinated and partly appalled by him.

The good thing about Bighospital, which makes it rather unusual in many ways, is that nobody gives a shit if you have a PhD, 25 publications, and are an expert on something (beware anyone who calls himself as expert) if you can’t do a difficult hernia or a Hartmanns’ operation on your own.

That’s not to say that we don’t expect the PhD and publications, we just judge you by how you do the job, as many people have discovered and then been sent away somewhere else to opine on radio 4 Women’s Hour and focus on academia.

The newly arrived smart arse has had to call for help in theatre during a not even very difficult hernia. Along came one of our very dry and clever consultants who took one look at the unshaved groin and the rather messy situation and headed off to wash his hands. Smart arse started gibbering trying to justify his inability to deal with it all.

The boss asked him just two questions whilst he did the operation; “Do you like blood?” when he first arrived at the table surveying the horrific scene. And the second as they finished the operation and began to close the skin, the full extent of his inadequate preoperative preparation was revealed and he asked him “Do you like pubes?”.

Hahaha. Take that new boy, don’t talk the talk until you can walk the walk.

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Desert island essential..

Desert island essential..

You know how beauty editors are always writing or commissioning articles about the 5 things you shouldn’t leave home without and then go on to name 5 obscure products that clearly you could manage fine without, like Chanel anti-shine papers or an eyebrow brush. This is not like that.

I often struggled with those tricky quizzes in magazines for teenaged girls (which now don’t exist anymore as they all just tweet and follow people) about which single make up item I would take on a desert island.

Just Seventeen magazine assured me that my choice of lipstick meant I was “organised and didn’t like kissing” or some other shite. I read this rubbish for a few years and then moved onto “more” magazine which featured a ridiculous feature called position of the fortnight and was mostly read by 14 year olds who thought using tampons meant you weren’t a virgin anymore. Kids nowadays don’t know what they are missing!

I have now discovered which item I cannot live without. We have been away on holiday for half term and I brought all the usual stuff with me, but I failed to bring my tweezers. No amount of touché éclat and bronzer can compete with the humble tweezer.

I have discovered that no woman the wrong side of 35 should be without her tweezers for 7 days. Last night at 11pm I stood, starkly illuminated plucking out the weird and stray eyebrow and chin hairs (chin hairs-what the fuck???!!) that had sprung up like bloody toadstools all over my face. Never again, I am going nowhere without them.

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Chewing Gum is excellent

Chewing Gum is excellent

I was in the top set for maths at school, which the teacher who had us didn’t like at all. At report card time I got a 4 for effort, usually a 3 for behaviour and had some of the best marks so she couldn’t get rid of me (a 4 was the worst). This really pissed off Mrs Mitchell, who gave me endless punishment exercises.

I must not eat in class. 100 times.
I must not talk constantly in class. 100 times.
Chewing gum is a disgusting habit. 100 times.

This month’s British Journal of Surgery suggests otherwise, although why we are still calling it that I don’t know as almost every article this month is from the Netherlands. Lots of smart people over there obviously, with nice workloads that give them time for this sort of stuff. (See van der Heijkant et al. Randomized clinical trial of the effect of chewing gum on postoperative ileus and inflammation in colorectal surgery. British Journal of Surgery 2015;102:202-211)

Back to the chewing gum, this has long been one part of the ERAS program (you can read my thoughts on that here) and had previously been shown to be effective in reducing post operative ileus. This group have gone one step further and evaluated the effect on the inflammatory processes post operatively. They have looked only at elective colorectal surgery, including all sorts of colonic and rectal resections.

What is so very interesting about this study is that the mean length of stay was 9 days in one arm and 14 in the other (a non-significant difference when they used a Kaplan-Meier) so they decided to use the wrong analytical tool, a two sample T test (which they admit that they should not have used as the data wasn’t normally distributed but they adjusted that to make it fit) which is significant yet utterly irrelevant as it was the wrong test? There’s something that doesn’t quite seem right about this but my stats are not up to scratch to say what that is; it does seem odd that a 5 day difference is non-significant.

A mean 14 day stay…in the fast tracking, ERAS loving, cycling to hospital and home again land of miracles? It’s all rather different to the home on day 4 following anterior resection shite that gets banded about by the Dutch informing us how stupid we are to not give everyone steak and chips on day 2 and get a nurse to ring them at home the next day to check they aren’t dead.

Also thrown in as an almost aside is that they have a 50% colostomy rate, that’s pretty high for a mixed group of resections. They have faffed about with a lot of extraneous experiments (someone’s PhD obviously, see should I do a higher degree?) that are not particularly interesting and I won’t bore you with here.

What is most important in this paper is that chewing gum post operatively makes you better quicker, passing wind and stool quicker, home sooner and much less likely to have to go back to theatre (5% versus 18%). There were the same amount of little complications (Clavien-Dindo 1’s, like wound a bit red) and massive ones (Clavien-Dindo 4 and 5’s, life threatening or death).

Back to theatre complications (Clavien-Dindo 3) are the ones we really hate, the patient hates, the anaesthetist hates and really sets patients back and makes them feel dissatisfied. Complications are my life’s obsession and if a drug existed that could have an effect as fantastic as chewing gum does, it would make someone a millionaire.

Nobody has looked at the use of chewing gum in emergency surgery as yet, but I would assume the results are the same. I may have to look into this if I can motivate myself to investigate it, I need a student who wants a project..

In the meantime, if you’re having an operation then bring a few packets of chewing gum with you.

Space Cadet; anaesthetic view of why complications happen

Space Cadet; anaesthetic view of why complications happen

I don’t know much about anaesthetics; they give the white stuff followed by the gas stuff followed by the paralysing stuff and then sit on their backsides and play on their iPads for the rest of the day. Pausing only to go and get more coffee and tutting loudly as it approaches 1630 and we aren’t close to closing up.

What I do know about it is that much like airplane travel, very little goes wrong and they have few complications. Which is good and correct and very clever of them.

Operating on the citizens of Bighospitalburgh is different to giving them a cocktail of drugs and then reversing them. Let’s take the operation of a very low anterior resection (coloanal anastomosis). This carries a leak rate of up to 20%. 1 in 5 will have a leak. That’s all comers of course, if you look at obese smokers with diabetes you will have half of them getting a leak.

If someone suffers a complication during an anaesthetic it is usually because they have failed to rescue a deteriorating patient. If my 72 year old, BMI of 36, smoking, alcohol abusing locally advanced rectal cancer man leaks it is because he was always going to.

It gives me one view of complications: some are inevitable, can be impossible to prevent and are not related to bad surgery that is at odds with how anaesthetists see them: someone’s fault.

One anaesthetic colleague of mine is quick to point the finger of blame every time we have someone unwell with some entirely predictable and expected post operative complication. This person does not understand that cutting people open, removing parts, rejoining them and closing up again is not without its risks.

This attitude of “you incompetent bozos have half killed someone else” radiates from him. A few months ago I was performing a potentially life saving and completely necessary operation on a pregnant women. The operation lasted about an hour longer than we had predicted but it went well.

This anaesthetist went on and on about how the baby was going to die, which I found rather distracting actually and quite unhelpful. Would he have preferred that I let her die of appendicitis and lose the baby in the process because of massive intra-abdominal sepsis? Does he think that we are psychotic murderers who randomly haul people off the street to remove body parts from for our own gratification?

I operate and as a consequence, unfortunately some people have a less than perfect outcome. I deal with that awful responsibility by walking away from the operating table knowing that even if they experience a post/operative complication, there isn’t a single stitch or clip that I would want to change given the opportunity to do so.

You cannot lie awake wishing you had left a drain/de functioned them/transfixed instead of tying a vessel or wondering if you tied that stay suture….That is how to make yourself a stressed out nut case.

Patients will get complications, we go to great lengths to minimise the risks, we prepare the patient properly and we proactively hunt for them before they make you really sick. But they happen and they happen to everyone.

To continue the airline analogy, which for some reason the anaesthetists like, they are just like airline pilots and we, the surgeons, are like astronauts. There is the constant risk of it all going tits up.

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Astronaut with the constant risk of death, disaster, flying bits of space rock, aliens, shuttle exploding, breaking up on re-entry, engine failure…and some happy laughing Easyjet pilots with a 1 in 47 million chance of it all going horribly wrong.

Pics from http://www.lovethesepics.com and http://www.plane-mad.com.

Outside the grass was raging

Outside the grass was raging

Ageing is inevitable we hope, good health and a long life is one of the most universal of wishes. Some are not so lucky, they find themselves with a long life and poor health, they may even lose themselves in the process and are left in distress and decay as their physiology keeps them alive when they have long since departed.

At school we studied the poem Old Woman by Ian Crichton Smith. The words are forever ingrained in my mind as when we learnt it I was “volunteering” in a nursing home (as prospective medical students are prone to do to demonstrate their commitment to being a doctor- a frankly ridiculous idea perpetuated by mediocre state schools) and the horrors and indignities that I saw in there whilst simultaneously studying the poem cemented his words.

I hated those Wednesday mornings, I hated the nasty, fat old bags who worked in the nursing home who could see my obvious dislike for my task. They all used to ask me why I didn’t want to be a nurse, as though what we were surrounded by was something that many straight A students aspired to.

They didn’t like my ambition, my confidence that I would not be wiping arses in a nursing home and that I would be a doctor. The city I grew up in is at times the kind of city where people are encouraged to stay in their place, to dream small and not get ideas above their station, and more than 20 years ago that certainly applied to uppity 16 year old girls. I hated what they made me do: feed old people Nice biscuits and thickened tea. It used to make me retch, what a wicked little cow I was. I hated it with a passion and would retch and gag all the way back to school when I smelled Nice biscuits and tea on my fingers and hands.

I have a patient just now who makes me think of this poem. He is paralysed from a massive stroke and keeps blowing up his colon to enormous dimensions necessitating a trip to the endoscopy department every few days to suck shit and gas out of his backside. He eats his water, coffee and tea, he cannot drink it; he has thick and easy (the name is the source of lots of amusement in hospitals) added to every fluid so he doesn’t choke on it. He is fed it on a spoon. He cannot speak, he communicates by raising his eyebrows and looking distressed.

I am not imprisoned in pity and shame like ICS is in his poem, although I have found myself wishing to be away. I am too used to decrepitude to still feel shocked by it. I just feel so helpless; he’s too frail to have his colon removed or fixed and yet he keeps volving and requiring decompression.

I see the students faces sometimes when we are confronted with the naked vulnerability of patients, I see them hesitate to help lift someone’s legs, or wipe the spit from their cheeks or the faeces from their legs or a bit of sick from their hair. You see them visibly recoil from the ugly reality of the provision of care.

Maybe they should all be forced into nursing homes as school pupils. Maybe it does teach them something, because I see the same look on some of my colleagues faces as well as they wait for a nurse to come and wipe or lift or care.

Old Woman by Ian Crichton Smith.

And she being old fed from a mashed plate,
As an old mare might drop across a fence
To the dull pastures of its ignorance.
Her husband held her upright as he prayed

To God who is all forgiving to send down
Some angel somewhere who might land perhaps
In his foreign wings among the gradual crops
She munched, half dead, blindly searching the spoon.

Outside the grass was raging. There I sat
Imprisoned in my pity and my shame
That men and women having suffered time
Should sit in such a place in such a state

And wished to be away, yes to be far away
With athletes, heroes, Greeks or Roman men
Who pushed their bitter spears into a vein
And would not spend an hour with such decay.

“Pray God” he said “we ask you God” he said
The bowed head was quiet, I saw the teeth
Tighten their grip around a delicate death.
And nothing moved within the knotted head

But only a few poor veins as one might see
Vague wishless seaweed floating on a tide
Of all the salty waters where had died
Too may waves to mark two more or three.

Make up that lasts all day

Make up that lasts all day

This is a seriously girlie post and I apologise for those who are not interested in make up; you may wish to stop here. I am interested in make up, like most women are and I love pottering through duty free and department stores.

Surgical make up has specific requirements (as opposed to mummy make up/weekend make up and special occasion makeup which involves significantly more stuff and effort);

1.It needs to be applied at 6.30am and look exactly the same at 8.30pm without any touch-ups or ever even looking in a mirror during that time.

2. It has to be hard wearing, we sweat, we wear a mask all day, we get hit in the face sometimes with fluids of varying degrees of horribleness.

3. Mascara can’t flake, there is nothing worse than catching sight of yourself in the middle of a ward round looking like a panda eyed drug addict.

4. Lipstick must last all day, must not bleed, must not transfer onto your mask, must not leave stains on coffee cups and must not leave you with that awful look of lip stick round the outside of your lips and nothing in the middle. It should not ever get on your teeth!

5. Don’t ever get caught doing your make up. This is my own insane rule, because I imagine how the nasty nurses (a tiny minority) would just love to catch me preening in the mirror putting on lipstick. I show no weakness in this regard.

6. Night shift makeup. Concealer. Vaseline. That is it. Anything else looks insane at 3am when you’ve been woken from sleep with mascara on your cheeks.

7. Sparkle is a no-no. Surgeons should not shimmer or sparkle at work.

Handily, due to me being at this game for a very long time now I have whittled my make up bag down to the barest of surgical essentials.

These are:

not just for men, for me.

Not just for men, perfect for me.

Skin: I avoid foundation for work as I can’t be bothered with it. However I am a fan in the summer of matching my white SPF protected face to the rest of me and if my arms are brown as they usually are, then I like this stuff. It looks like black slime but a little bit of this blended with moisturiser makes you golden brown all day and doesn’t fade until you wash it off. It’s in the Clinique for men range, it is no nonsense stuff. Unscented and sparkle free.

benetint

Glow in a jar

Cheeks: benetint it’s amazing. It gives you a just jumped off your bike glow that lasts all day.

even in bright, slutty red this stuff lasts all day

Even in bright, slutty red this stuff lasts all day

Lips: max factor lipfinity. It really does last until you take it off, which requires a heavy duty remover (Clinique lips and eyes does the job nicely).

the best mascara ever

The best mascara ever, fact.

Mascara: benefit again, “they’re real” mascara. It’s Britain’s best seller for a reason, even on your bottom lashes it lasts all day.

expensive but worth it. Use it to hide bags, redness, darkness, spots, sunburn, contouring...

Expensive but worth it. Use it to hide bags, redness, darkness, spots, sunburn, contouring…

Concealer, for me it will always be Touché Eclat by YSL. There is nothing comes close, shade 2 in pale and interesting winter and shade 3 in the summer. I could not live without it.

So, Clinique, MaxFactor, Benefit..if you’re thinking of a new advertising campaign featuring a real person putting your stuff through it’s paces…I am available!