ASGBI Guide to who is who

ASGBI Guide to who is who

This post was published in 2014 and I have updated it for ASGBI 2017. 

This week it is ASGBI and just about everyone who thinks that they are anyone in general surgery in the UK is there.

Here is my guide to some of the types of people you get at ASGBI:

The reps
The reps have a secret agenda, the chances are that you aren’t it, nonetheless they have to be polite and humour your enquiries and idiotic questioning undertaken to fulfil your agenda; trying to see down her low cut top and check out her impressive tits. 
I have an ASGBI shopping list, pens, a novelty USB drive, mints, a rucksack and something childishly smutty, like anal dilators.

The newly appointed consultant
This guy is cock of the walk, he wants to show his colleagues just what a great decision they made appointing him. He will have 3 videos, 2 talks and a few posters. He will ask lots of questions, slag off other people’s work and will be wearing a suit.

The bonkers staff grade
Bonkers staff grade does a nice wee job in a district general hospital and does nothing but hernias, haemorrhoids and gall bladders. Inexplicably they will be at a practical session about trans anal microsurgery and a talk on the new Reboa balloon in major trauma, where they will ask questions like “usually in trauma we do a diagnostic peritoneal lavage”. No, we don’t.

Party boy
Party boy is on a mission, a mission to get trashed like it is 1996 and throw up during the plenary lecture and not recall anything about the presentation he gives because he was still drunk. Woo hoo!!

The post-CCT registrar
This guy will hopefully be a newly appointed consultant next year but right now he is sweating and stressed. He is looking for a job, he has to ditch party boy and bonkers staff grade who are both making him look bad (really bad) and start speaking to people and making a good impression. He has 4 posters (disaster) and the medical student he supervised has been given an oral presentation, the little bastard.
He is getting a lot of love from the reps, not as much as new consultant but enough to make him feel important.

Good Guy Professor
Good guy is loved by everyone, he knows everyone and keeps his team (including party boy, bonkers staff grade and all the registrars) on speed dial and firmly on his radar. He manages to look after everyone and deliver a superb plenary talk. The team would walk over coals for him, they all want to sit beside him in the pub. He buys all the wine and has never tried to shag his trainees, well at least none of the current ones. 

The Sex Pest
This man is easy to spot, he’s staring at every female (10% female delegates) like he wants to lick her. He has delivered a few talks, but is feeling inadequate because his old SHO has somehow become a Professor and has a hot second wife and an A merit award and he is feeling hard done to. It would help if he could have sex with someone, anyone. He sits with his legs open looking at his crotch and licking his lips when a woman is presenting and smiling at her, like a wolf. He will try to grope a ripe young medical student if he gets within feeling distance.

The wanker
Wanker is a junior registrar in a suit. He has his name badge proudly on display and has been up to every important person and introduced himself. He goes to every session from 8am to 6pm and all the lunch sessions too. He makes notes and takes photos of himself with notable professors from around the world that he puts on Facebook. His colleagues hate him, he eats lunch alone because he makes eating noises and talks shop.

The Specialist Surgeon 

Fuck knows why he has come to Glasgow. All he talks about is how he has three presentations at his specialty meeting. He asks stupid questions that begin “this is more of an observation..”. He hates general surgery and only knows about polyps of the anterior rectum that are more than 2cm and less than 4cm. He doesn’t do other operations or any scopes or any general surgery like hernias and gallbags (please, I’m special) or on call (yuck!) because he is so special. 

I have a military style attitude to this meeting; get in and get out. Arrive late and leave early. Bring a faithful wingman if possible and avoid all of the above apart from Good Guy Professor.

Margarets and Lindas 

Margarets and Lindas 

At a recent leadership course, my classmates and I were discussing how to inspire hard work and provide good leadership in our organisation, it wasn’t as bad as it sounds, honestly. I quite enjoyed the course, it was far more relevant to healthcare than the last time I had to do something like this. 

There were many people there in quite different medical and surgical specialties than the wonderful world of General Surgery and it was interesting to hear their gripes and problems and find the common themes. 

One of the exercises involved thinking of ways in which you can inspire others as a leader. A general surgical colleague suggested that knowing the names of the team members was a good idea. A hush fell across the room, all eyes turned to him as though he had suggested something illegal. A palliative care doctor eyed him suspiciously, “know your teams names?” she queried aghast that not knowing their names was even an option. 

I leapt to my colleagues defence and explained that actually a great many surgeons have no clue what half of the nurses are called and that although I don’t fall into this group (being an eager to please female with a pathological need to be liked) many surgeons do. The silence and raised eyebrows persisted and my surgeon friend decided to speak up. “What I do” he said “is I call them either Margaret or Linda and that usually is correct.”  

He looked pleased with himself, like a dog with a dead baby rabbit, he was unaware of what it seemed like to everyone else. Happily he wasn’t dragged off into a dark room and beaten with a heavy textbook and we moved on. 

It’s easy to say “the nurse” and not take time to know someone’s name and you may be respected anyway and function as an average leader even if you don’t bother with this stuff. In order to be truly effective and negotiate the politics of a hospital it helps considerably if you know the name of the woman who empties your bin as well as the chief executive. 

In my job, getting things done well and efficiently makes for better patient care and knowing the team makes that happen much quicker. I’m proud to be someone who makes the effort to know everyone’s names and as a result my life is easier for it. The theatre porter will possibly delay his break and get my patient for me if I personally tell him “Please Jim I really need this man down here now….”

Again, more stuff that seems obvious if you are a human but nobody tells you about it. 

Is it better to be lucky or good?

  

Some surgeons believe that it is better to be lucky rather than good. Personally I opt for both when possible but would opt for good over lucky. 

Luck comes in to surgery quite a lot. Everyone knows a colleague who is the renowned shit magnet when on call. As soon as you comment that “it’s quite quiet” you can guarantee that a person will suddenly start bleeding, perforating or infarcting some part of their GI tract and be heading in to you. 

Patients wish to be lucky, when you tell your old, elective, cancer patient that they have an 8% predicted mortality (I love this website for risk in surgery predictions it’s by Paris Tekkis) they hope that it doesn’t happen to them. Patients need all the luck they can get. 

I try to be good, I try very hard to do a nice operation. My perfectionism is occasionally a hinderance and endlessly washing until it’s crystal clear goes against any belief in the magic God of luck, who one of my Great Leaders swears will take care of anything I haven’t sucked away or a tiny bleeder I’ve failed to frazzle. 

I’m a red cell chaser, I like it all to look like an anatomy book. 

Having surgical OCD kicks in even worse when I am doing the operating alone, with nobody surgically minded assisting me. My need for just one more look, one more stitch, one more wash and then I will be happy is quite bad. I’m a mother hen fussing about, indecisive and back and forth peeking at the bit in question. I also talk to myself, which is bat shit crazy, but I imagine that I’m talking to someone who actually knows and understands surgery and is not the medical student or junior doctor hauled off the ward to assist me. 

Talking aloud and agreeing with yourself is obviously madness but quite often my opinion is the only one I have available  during an operation. I also think that my operating table chatter is a deliberate way of controlling the noise level in the room as at least if I keep talking everyone else stays quiet. An as yet unemployed tactic suggested to me by a friend is to declare “right, everyone shut the fuck up unless you are me”. 

Luck is something that you can’t control, sometimes you will have some bad luck and other times it will be good luck. You can control being a good surgeon, doing good operations and making good decisions and quite often your good decisions can compensate for any bad luck. 

Theatre 

Theatre is so called for a reason (I know in the US they call it the Operating Room or OR but we call it theatre) that reason being it is a show featuring numerous performers on a sort of stage. You would be wrong to assume that the patient is the star of the show, they are asleep, covered up from head to toe apart from the gaping naked maw of their abdomen. 

The stars of the show are the surgeons, obviously! We are centre stage, illuminated from above and all activity happens around us and because of us. I love being in theatre, it is my natural habitat if you like. Scrubbed and gowned, masked and hatted, removed from the normal obligations to look a particular way, even the rules of personal space are gone and we touch hands and hips with each other as we work. 

Watching two surgeons operate together who know what they are doing is truly beautiful. It is like watching a dance, hands come together and apart, instruments come in and out, pink viscera are pulled apart and rejoined wordlessly. Operating with someone whose mind you can either read or predict is a joy. I have the pleasure of that just now working with my current boss. 

I love the feeling of the warm theatre lights, the rituals of scrubbing and gowning, prepping the skin and the traditional “is it ok to start?” to the anaesthetic team. If someone told me that I could never operate again I would be devastated. I can’t see why anyone wouldn’t want to do surgery. Washing my hands to start a case takes me away from the ward, from all the annoying admin crap, from the endless ward reviews and A&E consults of the mad, the fabricating, the distress and all the unfixables and unhelpables are temporarily gone. 

I love that I am reduced in theatre to a pair of hands and a brain. It is the only time that what I do is not influenced by what I look like, what I wear, that I am a woman, that I am tall or short or fat or thin. I am also unreachable by the outside world thanks to the sterility and being scrubbed at the table. I’m a pair of hands and a brain doing what they have been trained to do. 

It has taken me a long time to see that perhaps one of the reasons I so like surgery is because being good at it is independent from both appearance and personality and purely on whether or not you are any good. It helps make my job pleasant and easy when patients and nurses like me of course. I am pathetically desperate to be popular and liked, so I am told.  I enjoy immensely that the one part that really matters is down to me as a surgeon. 

I have become quite vain this year about how I do an operation, always making it look good, minimising the movements, being on top of the kit I need next. This is new for me as previously I only cared about the end result, now I am obsessed with the process. I am rather enjoying this vanity, it being a welcome relief from my usual concerns over my appearance and weight. 

There can be so much drama in theatre; bleeding, rivers of bile, holes in great veins sucking air into the circulation, dead and dying intestines, dead and dying patients, grunting and struggling surgeons. It is an ensemble performance, a complex cast of people make it happen and everyone on the team matters. 

The only slightly depressing thing is how do we motivate everyone on the team to feel the same? How can I make the 50 or so people also involved in my patients care feel that they should be doing their best efforts? I do my best because I am personally responsible for what I do to them and have to face them before and after and deal with the complications. 

If it was a movie production and we were all actors how could the supporting extras be convinced that the success of the show depends on them? I don’t know, but I thank everyone in theatre and appreciate their work and have no problem doing that at all. The patient thanks me after all and so I pass that gratitude on to the team. 

The drama. The fun. The challenge. It’s great. Happy new year readers. 

  

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.