Monday, 29 October 2012

Change to surgery


I change rotation this week, and location. I am now back living in my 'own' rented house with my flat mates, rather than the hospital accommodation I have been in for the last 8 weeks, and commuting an hour or so drive to another District General Hospital (DGH) every day. Living back with my friends is lovely, though there are bad aspects too. An hours commute rather than 2 minute walk means really early mornings, and the fact I am now living with my friends, and back in a city where I know lots of people, means that I am not spending much more time socially, and a lot less time doing any work. In summary, the move is good for me, though not good for my work or sleep. 

The new rotation I am on is surgery. This week our team was on take, meaning all surgical patients who came into the hospital (a surprisingly large number) came in under our team, meaning we needed to sort them out and either treat them, or somehow palm them off on a different speciality. Palming people off can be easy (if they have a fracture, orthopaedics love it) but is usually very complex, as many people get stuck in hospital for social or 'unknown' reasons, meaning they cannot be transferred to another ward. While being on take was really interesting for me, and meant I got to do a lot of history taking and so on, it also means I have spent no time in theatre yet, and actually still don't know what speciality within surgery I am placed on.

I was told I was being placed in breast surgery, but one of the junior doctors tells me that that the consultant I have attached myself to is an 'upper GI' surgeon. He spends all his time working away from the ward, and I have seen him for 2-3 minutes this whole week, so I have no idea. It is possible that I have spent a week with the wrong team, but its all learning I suppose!

It was a good week as well. Clerking patients in when they first get to hospital is something that I really enjoy doing. It needs a lot of brain power to work out which questions to ask to exclude the serious causes / cover the common possibilities, then use your information to decide which causes are most likely, and then order investigations (such as blood tests and X-rays) to prove or disprove your 'differential diagnoses', while excluding serious problems (like heart attacks). I really enjoy having to think like this, and it is much better practice for my finals than doing paperwork. I think working in A&E or an acute speciality where this is the norm would be something I would really enjoy.

This week I got to go through this routine with a number of different people, being the first person to see them, taking a history and examination, deciding what bloods to investigate, inserting a cannula to take the bloods and give fluids, taking them to the ward and deciding on the initial management. It was often hours and hours between when I saw them and the first time a doctor saw them, so making the right decisions is very important (or at least not missing something really serious such as a heart attack, or ischemic bowel!) Pretty stressful, but so rewarding.

One of these patients was in acute retention, meaning he hadn't urinated in 4 days. I requested an ultrasound bladder scan to see how much urine he had, and decided that he needed to be catheterised relatively soon, as he had a good few litres in there (as would you if you didn't go to the toilet for 4 days!). I took bloods (looking at kidney function, as this pressure may be damaging them) and decided to call the urology specialist in the hospital to help insert a catheter to relieve the pressure in the bladder. He had had previous surgery to the prostate, and had a stricture - normally catheterising himself but finding it impossible to insert over the last 4 days (hence the massive bladder). I thought that, if he cannot do it, despite having 5 years experience, there is no chance I will be able to! The urologist clearly didn't think so and SHOUTED down the phone at me for a good five minutes about how useless I was, how I was worthless and how dare I waste her time... Completely unnecessary, and time which could have been used catheterising my patient. Instead I had to ask my senior to do it for me, who was just a general surgeon. This went badly, and ended up with continuous bleeding from the penis, and a needle having to be pushed through the abdomen straight into the bladder to relieve the pressure (called a suprapubic catheterisation). It would be a good case for a 'told you so' to the urologist, if I wasn't so scared of her... Fortunately the patient was OK, and was very understanding and lovely about the whole thing. It always seems to be the lovely patients who end up with the raw deal... Since admission I have been to visit him every day, and he always gives me some grapes to eat (reason enough to visit!) and he is recovering well, with surgery planned for the Monday!

Catheterisation on the left, to get urine out of the bladder, and suprapubic catheterisation on the right, bypassing the penis and just putting a tube right through the belly into the bladder.


  1. I know what you mean about the social/work balance; seems I have this in a DPhil too!

    Enjoy reading your blog, nice insight into another course! Good luck!

  2. Wow I didn't realise how much clinical stuff you get to do in placements. With the catheterisation for example, if you are signed off on them does that mean you can just carry them out independently? Is that the case with you?
    Are the decisions you make always watched over by a senior or do they just let you get on with it?

  3. Thanks Joe!

    Snakefisch - you are absolutely right, after I get them signed off I can carry them out on my own, though you need to get many of these skills signed off again during the F1 rotation next year. As for the decisions, here I was making decisions which were then being checked by a senior within a few hours to make sure they were the correct thing to do.

  4. wow that's awesome. I didn't realise you could be that involved. I can't wait!