Sugery cont...

Hello again,
I'm still on lower gastrointestinal surgery, and have been getting stuck in with assisting in operations and helping the house officers on the wards. I've cut and stapled some guts (well, slid a lever across on a gadget that does the cutting and stapling at least!), held plenty of retractors, and helped with a bit of suturing too. One of the best afternoons so far was spent playing anaesthetist - I went to neurosurgery with my anaesthetics tutor and he let me stick big drips in, catheterise, put a line into an artery, inject drugs in, and press the buttons on the machines. Obviously, he was supervising me and making sure I didn't do anything wrong, but he encouraged me to think through the physiology and work out what needed to be done rather than just telling me what to do. The surgery itself wasn't particularly exciting to watch, as it involved poking around in a small incision in someone's neck so there wasn't a lot to see, and apparently the biggest development in anaesthetics in recent years is the su doku (it makes a change form crosswords) but there was plenty to keep me busy. Unfortuntately, I couldn't intubate the patient because the restricted movement of his neck meant that it had to be done with an endoscope to allow the larynx to be seen without tipping his head back, but I'll hopefully have a go at that soon. In the meantime, I've put some laryngeal masks in today, which hold the end of a tube just at the back of the throat during short operations where muscle relaxants aren't used and intubation isn't necessary.
Apart from going into the operating theatres, I've had some teaching on the wards from a junior doctor, and trailed round on some ward rounds (which are much speedier than medical ward rounds!). I've also been to see a stent being put into someone's rectum under X-ray guidance, to prevent a tumour obstructing the bowel, and gallstones being removed via an endoscopic tube through the mouth, also under X-ray guidance. Yesterday I sat in on a surgeon's outpatients clinic, and did a rectal examination on a conscious patient for the first time. And today I was even offered a babysitting job by a surgeon I was watching!
So despite the 7.30 and 8am starts on surgery, it's turning out to be quite fun. And I'm looking forward to moving onto plastics next week!

Surgery

Hi,

I started on surgery yesterday - lower gastrointestinal for the first 2 weeks. The start wasn't actually very promising but it's picked up since. I had an introductory meeting first thing yesterday scheduled at the same time as an appraisal (where you have to answer lots of questions about what you've found challenging and your learning objectives and other not particularly stimulating things like that). Since I had been specifically told that the appraisal was absolutely essential and unmissable, and since I'd already confirmed that I could go before being told about the surgery introductory meeting, I decided to sneak out of the meeting and catch up from other students on any important informtion given out there. I should have realised that was a big mistake when a surgeon who is well known for being horrible to students turned up to take the meeting. He wasn't very pleased at all that I wanted to leave his introduction early and didn't let me go. Fortunately the appraisal people understood and rescheduled that for later in the day!

Having started surgery by being told off, I then tried to find a doctor on my new firm who could tell me what was going on and whether I could do or watch anything. But after bleeping every number I could come up with, the only person I could get hold of was a house officer who had only started on surgery that day and was too worried about what she was meant to be doing to find anything for me to do. I couldn't go to surgery because there were apparently already some students there, although I have no idea where they came from. At a loose end, I went to the endoscopy unit to see whether I could watch them instead, but they told me to come back later. Eventually, around lunchtime, another student on my firm got hold of a registrar who agreed to meet us at 4pm and gave us the names of some patients who we could go and see beforehand. So the afternoon improved with a patient to clerk and hope of some teaching afterwards. I also went back to endoscopy and watched a couple of colonoscopies and saw some polyps being removed before going to meet the registrar. He turned up an hour late, but at least we finally had some contact with a lower GI surgeon, and he listened to us presenting the patients as he went round seeing them. I then dashed off for a college medics' talk and dinner, which was a pleasant end to a fairly frustrating day.

Today has been much more exciting, though. I joined the surgeons for a meeting about imaging techniques, bright and early at 7.30. Following that I went to the operating theatres to see what was going on there. A patient was just about to be anaesthetised for lower GI surgery to remove his rectum and the lower end of his colon, which had a tumour in, so I quickly changed into scrubs (or as quickly as possible with no swipe card access to the changing rooms and having to wait to be let out again by someone with a swipe card afterwards!) and then watched the patient being anaesthetised. Unfortunately, I had to leave almost as soon as the patient had got into the operating theatre because I had an anaesthetics tutorial. However, the tutorial was very useful and when it finished, 2 1/2 hours later, the surgeons were still embolising blood vessels and hadn't started removing the colon yet. The operation took about 6 hours in total, and in the end the whole colon was removed because it was decided that it's blood supply wasn't good enough for a join to heal up. I spent some time playing with the colon after it was removed and had a good feel of the tumour as well as seeing the anatomy of the normal parts of the colon.

I stayed in surgery for the afternoon too, and saw an unusual operation, where a tumour in the rectum was removed from below by cutting out all the tissue around the anus and the cancerous tissue above. I also saw just about every complication of the procedure possible! The bladder and small bowel were both perforated during the operation, and there was plenty of bleeding too. In the end, the hole was just filled with gauze and covered so that the surgeons could return to it in a couple of days and check all the repairs before bringing the end of the bowel out into the body wall as a stoma and closing up the surgical wound.

Assessments and paediatrics abroad.

Hi again,

Just a week left on general medicine now - and at the moment no patients who I haven't already clerked. Apart from checking up on the existing patients and waiting for more to come on Wednesday, when we're on-take again, I've had a lecture on geratology (the study of ageing, used instead of "geriatrics" here) and one on haemorrhagic stroke today. Usually we only have lectures on Friday afternoons, but for some reason we had extra ones today!

I had a cross-firm assessment last week, where a consultant from another firm watched me take a history from , examine and present a patient. I was expecting an elderly person in heart failure, a suspected pulmonary embolism or a pneumonia, because those are the sort of things most of the general medical patients seem to come in with, but I was given a 21 year old with diarrhoea. Despite that little suprise, the assessment went fine, and the examination I was told to perform was an abdominal one, which I think is the easiest! Apart from the case presentation, which I've already done, the only other assessment of this attachment is a report from my consultant (who at least vaguely recognises me from ward rounds!).

Over the weekend, I spent some time writing a CV and applying for placements for my paediatrics attachment in November-December. Because of limited spaces in England, some people (chosen by a ballot) are allowed to go abroad for this attachment. There are approved hospitals in Australia, New Zealand, South Africa and Singapore, or we can find another hospital and ask the medical school for approval to go there. We have access to reports from students who've been to various hospitals abroad in the past, and I thought one in New Zealand looked particularly good so I've emailed them. I've also emailed several others as back-ups. From speaking to older students, it sounds like doing paediatrics abroad is a great opportunity so I hope I have some success with the applications.