Sunday, 16 May 2010



Very exciting and eventful week this week. Lots going on each day, and I feel as though I am 'properly' back into the rotations. Most exciting event this week was getting to scrub in and assist in an emergency ruptured Abdominal Aortic Aneurysm (AAA), which can be beautifully compared to having hours of chat with a particular very sad patient, when I was just meant to be clerking them in. All of this is set on the background of the absolutely abysmal bedside manner the surgeons tend to display, making this one very interesting week!

On with business anyway. Monday was the day, as I mentioned before, that I had been offered the chance to assist during an emergency surgery list. These lists usually involve a lot of diagnostic laparotomies, emergency appendectomies and the such. I was looking forward to this, as after our session on Friday, I was confident suturing and such, so happy I could assist and be helpful. Unfortunately, when myself and my partner got there, there were already 2 medical students in the theatre, meaning we would just crowd the place, or sit at the back and watch. Not much fun. They got their first, they go in - fair enough - so we were planning on going off to a surgical clinic or something, and phoning around using the theatre reception phones to try and find somewhere to go. One of the theatre nurses was helping us for a while, disappeared for a few minutes, then came back just as we were about to leave with the news that a suspected ruptured AAA was on the way in an ambulance, and they were just preparing a theatre to use. Did we want to join in?

Hell yes we did!

Just a side note to explain what this AAA is, for anyone who doesn't know. The Aorta is the main artery in the body. It starts from the heart and travels down to the legs, where it splits in two (one to supply each leg, of course). On its course, it supplies pretty much every organ in the body apart from the lungs, and as such, it is a pretty important vessel. An aneurysm is where it swells up to larger than it should be, due to general rubbish being deposited on the walls (or "A load of shit", as the surgeons call it). This rubbish causes the vessel to get bigger, as it still needs to get the blood through. Picture on the left below (a), seeing the big bulge on the normal aorta!

This aneurysm builds up over years, and is often asymptomatic (people do not know they have one) which is often not too much of a problem. However, in this case the aneurysm had build up and the wall had become weakened, meaning it had torn. This is, as you can imagine, very bad. Suddenly all of this blood which was flowing nicely to your body starts pouring out of the aorta and into the spaces in your body. The AAA is in your abdomen (its in the name) so this blood comes pouring out into this area. This causes plenty of pain, and a massive drop in blood pressure (its not in your vessels any more, its in your belly!). This is bad, and has a mortality (chance of dying) of over 80%. The good news for this patient was that if he got into hospital, the mortality is reduced to 40% - still pretty high though.

We wait around for what seems like ages for the patient to come in and have an emergency CT scan. This is because if the aneurysm is above the level of the renal arteries (the little things which look like arms on the diagram above) the operation is far far harder, and he would usually just be given palliative care because he wouldn't survive the operation. Fortunately, this patient had a suitably placed aneurysm, so was taken through to the theatre. No history had come with the patient other than he had been found collapsed. Does he take any drugs? Does he have any medical conditions? Who knows!

 In theatre, I didn't really know what to do with myself, there were people rushing everywhere, and still no sign of any surgeons. It was the anaesthetist's job first. They had to get some blood to cross match in order to get enough to replace the blood he lost (bags and bags went in through the operation), and they had to put in some cannulas in order to be able to give this blood and monitor his blood pressure properly. Once all this was done, they could give him the general anaesthetic and let the surgeons start the operation. This proved to be a lot harder than I had thought - I saw consultant anaesthetists trying again and again to put a cannula into the patient in the arms, but failing because he had lost so much blood they couldn't get into a vein. Next they tried the arteries. Again, failing on the arms, they had to move up and insert a line into the neck. The more central the vessels, the more likely they are to have blood in them - and the body prioritises the brain over everything, so it will get the best blood flow. All the time this was going on, I had been instructed to talk to the patient, keep him from flinching away from the pain of the repeated needles he was being jabbed with, and keep the anaesthetist informed about his concious level. If he stopped talking, then things were getting worse. He was absolutely out of it - no recordable blood pressure, in hypovolemic shock and in agony, He didn't want to talk, and when I tried to engage him he would mutter something about his walking stick, or about a budgie. All this time, I was aware that, if he died before waking - I would have been the last one to talk to him. What do you say? I didn't know.

Once the patient was anaesthetised, I was given another astonishingly important job. Hold his arm. Wonderful - this operating table only comes with one arm rest now (who knows where the other is) so you need to hold his arm out, full of lines now, whilst holding up the "blood brain barrier" (the shield that separates the the anaesthetists at the head end from the blood and sterile conditions down the other end) and making sure I didn't touch anyone who was scrubbed up. Arms can get pretty heavy after a while, but that's just me being weak. Better that holding up a leg. Finally someone got an arm board from another theatre, and I could set the arm down. At this time, they were just putting in the graft to make the aorta a closed tube again, rather than a torn hose. Similar to the diagram above (c) this is just a section of tube that is put inside the aorta to let the blood flow through that instead, and stitched on at either end. The surgery isn't done like it is in (c) though,  that is a non-emergency aneurysm repair (EVAR) This surgery involved putting a couple of beefy clamps on the aorta either end of the aneurysm and cutting it open to scoop out all that rubbish inside, and put this tube in. obviously whilst doing this you have to avoid all the blood that is already around the aorta from where it is been bleeding from the tear. When I say avoid it, I mean just stick a suction nozzle in it and try and suck it all out of your way so you can get to the aorta.

Once I had put down this arm, I got to scrub in. Excellent - seeing as they had done the hardest part, putting the graft in, the consultant didn't need another highly experienced assistant any more. He could get away with anyone. I went and scrubbed up (basically just washing your hands for ages, and then dressing in a certain way so what you put on is still sterile) and got to get my hands (or should I say gloves) dirty. We just tried to stop any visible vessels bleeding (the incision and surgery is done in a real hurry in order to get to the rupture, that these cannot be sealed as they are cut through) and put the gut back into the body in pretty much the correct order. At the start, all of the gut had been heaved out of the cavity and just put in a plastic bag to keep it wet and warm 'til now. You would then sew the patient up, but there was a substantial delay to this because he wouldn't stop bleeding. This was due to an effect known as consumptive coagulopathy, where the body had used up all of its clotting proteins in trying to stop the ruptured AAA bleeding into the abdomen. Now that that had stopped, the body could no longer clot the blood, and every single capillary that had been cut through was leaking watery red blood. Normally the clotting would shut them off in an instant, but without these fancy factors, the patient would just keep bleeding. Fortunately, the anaesthetists are equipped to deal with this, and after several bags of platelets didn't slow him down, they gave some fancy proteins and drugs which did. About time as well, all this lack of clotting had not just affected the incision in the abdomen. All of the previous attempts at inserting a line in his arms to his neck had started bleeding, and his lips had swollen and bled over his mouth and face, from the pressure that was exerted during intubation. Quite a lot of blood, everywhere. The abdomen was closed and we were free to go off home.

How long did this operation last do you think? About 5 1/2 hours would be a pretty accurate answer. That's a long time with your arms inside someone's belly, but its major surgery. Most patients survive the surgery if they get to hospital, it is the days/weeks later in ITU that pose a problem. It is a lot for your body to recover from. Hoping that the patient would be fine (obviously, no point in wanting anything but that, is there) I went home for a nice shower. You will be pleased to know that he is still alive in ITU!

That is how I can see the appeal in surgery. That was very exciting, and exactly the sort of environment that I would enjoy working in later. I would love to do something that acute and that exciting, where people come in with such extreme problems, and you have to do that work to save them. Awesome.

Over the next week, more things happened, nothing as exciting as Monday, though. On one of the days, I was clerking in a woman who had been admitted from a clinic because of limb ischemia. One of her legs had developed a problem in the artery, and it wasn't getting the blood it needed any more. A simple operation sticking a balloon down the artery and expanding it again, would put her back to normal, otherwise the leg would die and start rotting. Not really a competition. This lady was very unhappy to be in hospital, though, and I started talking about some of her worries whilst examining her. She had lost a number of family members in hospital, including children, one an adolescent. I was just chit chatting with her, really, until I came to feeling her pulse. You should feel both sides, looking for any delay, and as I was feeling on the other arm, it felt all bumpy under my fingers, I turned over her hand, to see what it was, and saw dozens of white scars across her wrist. I didn't change the topic of conversation, I didn't even let on I had noticed, continuing the examination - and I think she bought it, being distracted at the time talking about her pets at the home she lived in by herself. My attitude towards her changed completely, though. I felt I was no longer just clerking in someone who didn't want to be in hospital. I felt I was looking after someone who had been more upset that I could imagine at times in her life. I felt sorry for her. I wanted to help her. But I didn't want to act strangely suddenly. I decided that the best way to do this would be to just talk to her about her worries, her troubles, her past and what she saw in her future. I was there 'til around 8 in the evening (though I hadn't gotten there to clerk her early by any means) and then I visited her the next day, and the day afterwards. There was always a medical reason to lead the visit with. I could be checking on her blood results in order to build a case to present, I could be interested in what the results of the scan were, but I would just end up talking with her. It is sad that, when I am a doctor (sooner rather than later, please), I will not be able to justify doing anything like that. At the moment, it is my time, to spend how I want to learn. If I am being paid to be in the hospital, I will have mounds of work to do, and won't be able to talk to any patients like that. A real shame.

As the week went on, I decided that perhaps I don't want to be a surgeon. Monday was really exciting, but most of their time is spent doing mundane operations again and again. This isn't the main reason, though. Surgeons really do not have any bedside manner at all. Spending time with consultants and registrars in clinics, they would just wander into an examination room, instruct a patient to take off whatever item of clothing was required, wander back in a few minutes later and tell the patient what they were going to do. Then leave.

Surgeon - "I am going to scan your leg"
Patient - "Err, ok - what does that involve?"
"Sit on the couch please" (bear in mind, patient has already taken off trousers from previous 'visit')
"Mmm... ok"
*Surgeon uses duplex scan (ultrasound like device) to assess arterial insufficiency in leg*
Surgeon - "Thank you"- and leaves room
Surgeon - returns 5 minutes later, patient still sitting on couch without trousers on - "You can leave now, we have patient's waiting you know. Your AT has a triphasic response by the way"
Patient - "Psyphasic?"
Surgeon - "We will send you a letter about it in the post, don't worry"

This wasn't just one patient. It happened again and again. Don't get me wrong, surgeons are great fun to hang around, and can be really nice to the patients. It just seems that some of them (don't let me generalise here) don't realise that you should try all the time.

In case you are wondering, a triphasic vascular response is a good thing, and indicates normality. Hopefully the patient will be pleased to find that out!

Have a good week, next week I am doing urology - perhaps not going to be as exciting as this week, but perhaps that is a good thing - I have far too much work I need to be doing!


  1. Awesome post IO, sounds like you had a really good week. You don't think you might like to try and be the surgeon you'd want to see? The one with the awesome bedside manner, or do you think surgery training will beat it out of you and you don't want to lose it? Nice to see you sounding so excited about something :)

  2. Dude! That was brilliant!! You're like a rockstar!! I was on the edge of my seat reading this.. Good job!

  3. i know how it feels like as a clerk. I just finished my clerkship this Feb. We sit around and wait for some real action all med school and we finally get to do something.
    However, my first experience with blood during surgery was not pleasant.
    it was during anesthesia posting, tetrology of fallot case, this kid was around 10 and major surgery was going on when an artery was nicked blood spurted all over my scrubs. thankfully they found it and the operation was successful!

    And about the arm holding thing, i totally know how it feels, making you do meaningless stuff cause your in the bottom of the food chain. really sucks...

    i'm totally bored now ( in psych rotation ), wish i could go back and do my clerkship all over again.

  4. Thanks for the feedback all!

    @hotchocolate, I see where you are coming from, but I think only the exciting side would appeal, doing appendectomy after appendectomy day after day would be very dull! Also, not sure if I want to spend all my time hanging out with surgeons... :P

    @farisazlan, thanks! It was really exciting, but I wasn't sure if I was conveying it.

    @Alujna, blood all over the place? Does sound exciting, bet you were glad it wasn't some IVDU from the street! Psych, was pretty dull, just enjoy the laid-back-ness of it until you lose your life on a more hands on rotation again!