Getting 'hands on'

Hi,

Last week was relatively quiet again, something I am getting dangerously used to on this rotation. I spend a couple of the days this week in dermatology clinics, where I got to get my hands surprisingly 'dirty' for someone with a week of dermatological experience, and one day in lectures. The other days I mostly had off. Working three and a half to four days out of seven is wonderful, don't get me wrong, but I think it is something I could quickly get used to, all these lovely lie ins and time to spend with friends. I think, after 6 weeks to get used to this, come a harder rotation, or my final year, I could get quite a serious shock to the system!

The clinics that I was placed in this week were both with the same dermatological consultant. They were much more interesting than the theatre list which I was in last week, and I was given a lot more to do.  The idea was that of the patients waiting, myself or the other medical student would pick the next to be seen, and take them from the waiting room to one of the examination/consultation rooms to take their history and examine the problem with their skin. We would then go back to the doctor, present what we had learnt about the patient and give our differential diagnoses for the condition and what we think should be done to manage the condition, then she would go to see the patient. She would look at the problem with the skin, exchange a few words with the patient to confirm the important things we had told her, and then decide on the course of treatment. This could be leaving it, putting a cream on it or cutting out out (which could be done then and there for most of the minor skin problems)

Because we two medical students were seeing different patients and doing much of the time consuming work (the history) this meant that the clinic could take place twice as fast, as she could just review the patients, carry out procedures such as cutting out parts of the skin, and do her paperwork as we talked to the patients. This made me feel useful, and was a great chance for me to practice taking a dermatological history. All aspects of medicine need different questions asked, and dermatology is no different, needing questions asked about things such as sun exposure which wouldn't factor into 'normal' histories. Because of being kept so busy at both of these clinics, the time flew by. This was a very different experience to the times I have spent in clinics in other rotations so far this year. The neurology and oncology clinics were very specialised, so the doctor would lead most of the discussion and I would sit passively in the corner for most of it trying my best to pay attention, learn something and not fall asleep. 

One of the clinics was for people who had been referred to the dermatologist under the two week wait rune, meaning that the GP who had referred them thought that the changes to their skin could have been cancerous, the other was just a general clinic for skin conditions. In both of these clinics I saw some pretty horrific looking skin problems, showing how important a cure is for a lot of these patients. Patients like those with psoriasis (picture below) can have their lives turned around if it is treated properly. Unfortunately the dermatology clinic encourages us not to use gloves unless the wound is obviously infected and oozing, as using gloves gives patients the  impression that they are dirty and unclean, an idea that we are trying to dispel. While this may be good for the patient, it certainly isn't good for the medical student as you try and rummage through peeling skin to look at the sore underneath to see if it has a 'pearly looking edge' to differentiate a basal cell carcinoma from an area of actinic keratosis.

Psoriasis across a ladies back. This is an auto-immune condition where the skin becomes thick, scaly and peels

In summery, while the week was pretty relaxed, the time I did spend in the hospital was very productive. I now feel a lot more confident taking a dermatologically skewed history and examining damaged skin to try and spot cancers. While I still don't think that this is the speciality for me, the fact that I have only seen about 5 conditions so far makes it easy for the medical student to clerk the patient in and guess at the problem. I am enjoying this rotation a lot more than I was last week, and I hope that this continues!

Dermatology

Hi,


This week, seeing as I have finished my neurology rotation, I move onto dermatology. This has never really been a subject that has interested me all that much, and what I have seen so far this week really just re-affirms this  feeling. While dermatology is clearly a valuable subject, with skin conditions being one of the more obvious illnesses, (what with your skin being on the outside of your body, meaning that people can be very upset by such visible problems), it just seems overly complicated to me. Most conditions seem to be treated by either emollients (moisturisers); topical steroids or by cutting bits of skin off. Don't get me wrong, there are other, more complex treatments, but these seem to be in the minority. Dermatologists seem to have made up for this dearth of treatments by creating lots of complicated names for different skin rashes or spots; names which are derived from dead languages. This sounds like I am being scathing of dermatologists, but this isn't the case. Some skin conditions can be very disfiguring, changing peoples lives completely (such as psoriasis), and can be treated effectively, putting peoples lives back to normal. It is a valuable speciality (obviously, just like all the others), but just not a speciality that seems to appeal to me. People don't tend to have emergencies with their skin, meaning you rarely need to treat them immediately for fear of death (quite an exciting idea in medicine for me), though for some people this aspect of dermatology would probably be a real plus (sociable hours!)

All hospital specialities are just as important as one another.

Anyway, perhaps I am judging dermatology too fast, and based on too little information given it is only my first week of the rotation. This week the highlight, if it can be called that, of my time in dermatology was spending a day in the theatre. I went to the dermatology theatres with another medical student, and as there were two lists running we ended up splitting up. One was run by a dermatologist, while the other was being run my a maxillofacial surgeon. Maxfax surgeons need to have both a medical and a dentistry degree (so much time in uni!), and concentrate on the head area of the patient. Neither of us had seen any of this sort of surgery before, whereas we have both seen some dermatology-based-surgery before from placements in first and second years. They only wanted one medical student to be in each theatre, and as surgery and dermatology don't really interest me all that much, I let the other student go in with the Maxfax surgeon, and took the dermatology list.


At the time, this seemed a bit of a mistake, as the dermatologist's list turned out to be super boring. I saw about 8 patients, all of whom had a Basal-cell carcinoma (BCC) or two being removed from their skin. A boring operation, where the cancer is cut out of the skin using an ellipse shape and local anaesthetic, then the skin is stitched up again. BCCs are a common skin cancer, but rarely spread out of the skin, and rarely kill people. It should still be removed though, to stop it growing further, and that was what was being done here. I had already seen this operation in my first year, and all the operations I saw today looked pretty much the same as the operation I saw then. Watching this go on all day was really quite boring, though I am sure that doing the surgeries would be just as boring as well. Another reason not to be a dermatologist! The only real interesting thing which happened during this day of surgeries was meeting a man who used to work in nuclear testing with the British government, and who had kept developing a large number of BCCs all over his body for the last 30 years or so. He had been having 5-10 removed from his body every year for these last 30 years, and it was thought that this was due to the high levels of radiation he may have been exposed to earlier in his life. Developing this large number of BCCs is certainly unusual, and as they are often caused by sun exposure, I don't see why radiation from another source wouldn't cause them as well. Despite this obviously occupational injury, and the inconvenience he has having to go to hospital several times a year to have them cut out, he has no interest in trying to seek compensation at all. He thinks the money is much better off with the government than with him, and he is probably right, though it is a shame more people don't share this sort of mentality. Fortunately (or perhaps, unfortunately) it transpired that the maxfax surgeon's list was exactly the same as the one I sat in on, just removing BCCs from the face, so I didn't really miss anything by my misguided act of kindness.

An image of a basal cell carcinoma from the internet, characterised by its 'pearly coloured' appearance, and raised rounded edges.

Like the previous rotation, dermatology also includes a large number of seminars and lecture-like teaching. More time that I would prefer to spend in clinical teaching, but also more time where I get spoon-fed information, which is always nice. This weeks most notable was a lecture on topical therapies for skin care. The subject material wasn't that exceptional, mostly teaching about emollients and steroid creams, but the nurse leading the seminar had bought along 20-30 different creams for us to try out. Fantastic! I wanted a bit of all of them, so now, if I did actually have any possible infections / autoimmune disorders or any other conceivable dermatological disorder I am now hopefully cured. Cured problems or not, my arms are now certainly highly moisturised! 


I also spent some more time on my GP placement again this week, and saw more adults and children with physical and mental illnesses (GPs do see a wide range of problems!). All the time I have been spending with this GP has attracted me more towards being a GP... It still doesn't appeal that much, and I still think I want to follow a different career path into hospital medicine, but my time with the GP has shown me that it really can be fun as well. Before, I just saw it as time which was spent looking after people with snivels and colds, like I found the outpatient department to be like during my time in Tanzania, but there is so much more to it than that. The GP has to make some quite hard calls without any specialist knowledge. For example, a mother came in to see us concerned about her child, who she didn't bring with her as he was at school. She had been concerned about him for some time, and at 4 he still couldn't pick up things like a pen or a knife and fork, and still had no concept of potty training at all. Despite these problems, he can still talk in huge detail about several of his toys, down to the date that he got it. This lack of fine motor skill and problems in learning what the potty was for had worried the mother slightly, as they were very different to her previous child, but she came to the doctor after the teachers at school had told her that they had noticed obsessive traits in his dealings with other children and toys in the class room. Hopefully this is nothing, but these sort of traits could well be suggestive of a problem such as autism. The GP's problem is what to say to the mum, and what plans to make next. She could tell the mum that is was possible that the child had a learning difficulty, and refer them onto a specialist to help the mum cope and investigate the girls behaviour better. This may help the child get help (which they may need), but would this end up putting a label on a child who could otherwise be fine? Or does the GP leave it, and risk the child falling behind in school because they are finding the work much more difficult than the other children? Being a GP seems to involve a lot of 'grey area' sort of decisions that you need to make on your own in a 5 minute space. In this case the possibility of a condition causing this behaviour was discussed with the woman, which was something she already suspected (hence the attendance at the doctor's) and the GP and mother decided together to leave it for now, and see if the difficulties continued; if they did then they could look into getting some extra help for the child. This was pretty much exactly the outcome we are taught towards in medical school - one that is patient choice directed!

Post Mortems and maggots

Hi,



The most exciting thing that I did this week was visiting a mortuary and observing a number of post mortems. This was quite a graphic experience, and explanations are also graphic, so only read if you are happy with this! Post mortems are carried out on people who have either a suspicious cause of death where someone may be to blame (for example, after a surgery or in a possible murder case) or with an unknown cause of death, such as someone who is found dead at home, having not seen a doctor for some time. The post-mortems I saw varied from someone who has been dead for weeks and has started decomposing (maggots and all) to a patient who died on the operating table and still had all the tubes and devices stuck into his body. Later on in the week, I go on my GP placement again, and see a variety of family-planning-based procedures (my GP's speciality), and chat for an hour and a half with a really nice gent who has prostate cancer.


The mortuary visit happened on Monday, so there were a number of bodies needing a post mortem that had been 'stored up' over the weekend, as post mortems here are not carried out on Saturday or Sunday. The location was an innocent-enough looking building, but once I had gone inside, 'scrubbed up' into my blue scrubs and stepped into the room, it all became very strange. There were four tables with dead people lying on them, completely naked, and the walls and floor looked like a tiled public toilet (as I soon found, to make it easy to have all the blood and mess washed off). I was working with a pathologist, who explained what was going to happen but, to be honest, I wasn't really listening too much. I was overcome by the thick smell in the place, which pervaded wherever you were in the room. This was coming from all of the bodies to a degree, but mainly the partly decomposed body in one corner.

The patients are all identified by a tag, as in the movies, so you know that you are cutting up the right one!

The doctor who was carrying out the post mortems left to read up the case files for the patients we would be dissecting today. Only they are not called patients today, something I found very hard to get used to. They are simply just called 'dead' now, which makes sense seeing as they are no longer being treated. So while she was reading up the case notes for the dead, the mortuary technicians (who are people with nurse training) started to prepare the bodies. The one body which had died on the operating table was left, as it needed to be examined with all the medical devices in situ, but the other bodies were 'opened up' by the mortuary  technicians   for the doctor to examine.


This rather gruesome process involved the head being cut open across the back of the scalp from ear to ear, and the scalp being pealed forwards off of the skull, so ot flapped over the face. This meant that the skull underneath could be cut open with an angle grinder, and the brain removed and put into a bag. The skull was then put back on, leaving the head empty and scalp was re-attached and sewn back, so from the front (if using an open coffin) the person would still appear normal, though their brain had been removed. The chest is then opened up from the top to bottom with one long cut, and all of the organs removed, from the tongue down and put into the bag with the brain. The chest will be closed up at the end with all of the organs (including the brain) packed into it. While in a higgledy piggledy way, this means they look normal, again, so they can have an open coffin.


After these have been removed, the technicians job is done, and the pathologist can take over. The organs are cut apart one by one looking for any abnormalities or injuries which may have occurred to them, leading to the death of the person. The body is examined for any signs or injuries, and the organs are weighed. You can tell a lot of an organ is massively over or underweight, for example, a heart in heart failure could be very heavy compared to a normal heart. This was a great learning chance for me, as previously I have only worked on dissecting bodies in the dissection lab, which have been preserved with formaldehyde to last for a year, and hence have unusual textures and colours. These were (mostly) pretty fresh! I got the chance to help out by cutting some of the organs into slices and helping search for the expected problems with them that would have caused death. Cutting into the bowel and stomach was the worst part. These start decomposing first, because of the acidic conditions and all of the bacteria in them, and still have the remains of the patients last meal in them which need to be drained, along with a lot of gas. Needless to say, the smell, which still hadn't died away like most smells do, was still here in force.


There were a number of patients on who the post mortems were carried out on. There was a gentleman who had died in his sleep, and been found dead by his wife. Because of his history of  heart disease and a triple bypass 10 years ago, it was presumed he had had a heart attack while asleep, and that was the organ that the search was focussed on, though all of the other organs needed to be checked (what if he had had a massive stroke, or had a cancer that hadn't been diagnosed...) This man was difficult, because the previous chest surgery meant that he had lots of adhesions and metal clips in his chest to navigate through, though the heart arteries (even the new ones) were very clogged up, suggesting a cause of death.


It worth saying that, even at this point, this is still really strange for me. I am in a room cutting into organs on a table next to a body which has had all the organs removed and has a big gaping hole in its chest and abdomen. The tongue downwards has been removed to bring the windpipe out, and there is just a huge hole there. Other than this, with the scalp back on (this is for the best, the scalps-peeled-over-face look is really creepy) the person looks as though they are asleep. None of the strange colour or texture of the skin as with dissection, and while you are at this table, there are a number of other naked, opened bodies around the room. It almost feels like a horror film scene. And the smell, pervasive to start with, gets quickly worse after the bowels and bladders are cut into.


I see other patients dissected, including the patient who died during surgery to the heart, who still has all of the tubes and medical devices in situ. The worst patient (no, 'dead', sorry) who I see is a patient who had psychiatric conditions, and just liked to live by himself in what was described as a 'filthy flat' by those who picked him up after he had been certified as dead. After not seeing him for a few weeks his neighbours called the police, who visited and then found him to be dead. He was decomposing, meaning there was little point in taking him to the hospital. The position of the body and state of the flat suggested a fall and a death, but this needed to be confirmed by the post mortem. The less said about this man the better really, as writing about him makes me feel a little queasy. The organs were black and mushy because of the decay, there were maggots all over the place which were eating the flesh, and the smell was awful. I couldn't deal with it and had to stand a few paces back for the second half when the stomach and bowels were opened up. Poor chap.


Despite all of this, I had a great experience in the mortuary, and learnt a lot about different stages of the body after death and lots about organs and how they look and feel when 'natural' (but not from the decomposed person, obviously!) I was told about other students who have thrown up in the post-mortem room, and run out, but this is no surprise after what I saw and smelt! I also heard about some of the more interesting people who have been seen there. The man who died of a perforated peptic ulcer (=hole in stomach) and had his body cavities full of sweetcorn from his last meal, seemingly in places it definitely shouldn't be. There was also the person whose stomach and bowel were full of metal objects, from car keys to cuff links, which they had eaten for some bizarre reason (though perhaps it was because of pica)

A mirena coil, the gynaecologists favourite contraceptive.

As well as this main experience in the mortuary, I did other things in the week (obviously), the main one being the time I spent with the GP on my placement. My GP has a gynae specialism, and so carries out some minor family planning procedures in the surgeries. Today I saw a mirena coil removed from a 30 year old woman so she could have children, and a contraceptive implant removed from a 14 year old girl's arm who was having irregular periods with it and didn't like it. Interestingly, she had come to the GP surgery with her grand mother, as she felt she could share this sort of information a lot more easily with her than with her mum, who she didn't feel happy discussing this with. This is not something that seems rare, from what I have seen, and I wonder if people feel it easier to discuss sex with their less immediate relatives, as they feel they will be treated as less of a child by them as they haven't grown up with them, I don't know... Perhaps this would be an interesting sociological study, as it seems to happen much more commonly than I would have thought.

Ward work and Hitler

Hi,

A relatively calm week, compared to the busy time I had last week with all those early mornings, which is a nice break. I still spend some time on the wards, after I enjoyed it so much last week, as other than a Parkinson's disease clinic I have no time tabled clinical sessions, just lectures. I am not sure about the timetable for this rotation; it seems to vary massively between weeks, sometimes meaning you have plenty of early mornings (last week), other times (like this week) with a few lectures dotted around and little else. I have a presentation to do next week, and other out-of-uni commitments, so it is quite nice for me to have some control over my week and when I can go in and when I don't.

In general, neurology is a very 'post-graduate' type of subject. A lot of the things we are learning or seeing we will not be expected to do (or even necessarily know) as junior doctors, and wouldn't be expected to be doing unless we were specialising in neurology after completing our degree, and working as a doctor. While a lot of neurology is very interesting, with the strange symptoms and signs people can have (the brain is pretty damn complicated), it is also very complex. It does often feel as though a lot of the things we are learning we will never have to apply at all. Will I ever have to interpret an EEG to diagnose absence seizures? I very much doubt it, unless I am a neurologist, and in which case, I will need to be taught again as I will have forgotten by then. I suppose you do learn a lot of things you may never need to know again in medical school - though it is a lot more pronounced in the first few years with all of the microbiology that you learn!


I had a great day on the wards on Tuesday, where I just spent the day with the neurosurgery ward team helping with their ward work. The patient I saw last week who had the cranioplasty (skull reconstruction) is doing very well, and I am told that he could well improve faster now this construction has given his brain more space. I spend a full day examining people before operations, helping out with notes and clerking and other day to day activities. The neurosurgery ward is run by more junior doctors most of the time, as the more experienced registrars and consultants spend their days in surgery instead. I really enjoy working on the wards, which is a fantastic sign, as after I graduate, this is where I will be working for a few years at the very least!


The single timetabled slot I had this week was a Parkinson's clinic, where I was with a specialist nurse seeing patients with Parkinson's disease. I had come across specialist nurses before (for example a heart failure specialist nurse) and had been very impressed with them. This time was no different at all, and he clearly knew exactly what he was talking about. By managing a case load of patients, it means they get better treatment than if the GP was managing their Parkinson's (much more experience), and possibly better treatment than a neurologist because of the specialist knowledge of the nurse, though this is debatable. It is certainly cheaper for the NHS, though, which I am sure factors into it. As well as talking to and examining some lovely people with Parkinson's, I got a good amount of teaching. A lot of it was the pretty standard stuff about the difference between Idiopathic Parkinson's and Vascular Parkinson's, which is fantastic for me to learn, but some of the things I learnt were not entirely medical, but none the less interesting.


For one, I was told about 'Parkinson's trait' where people show traits in life which may make them more likely to get Parkinson's. The nurse was saying that many of the people who come in with Parkinson's have been very obsessive people, who have then developed Parkinson's disease. By obsessive, he means people who tend to focus on one aspect of life obsessively, such as model making or train spotting, and focus on this to the exclusion of other things. While (obviously) most 'obsessive' people do not develop Parkinson's later in life, it is very interesting to see that many of the people who do develop it have this 'personality type'. The nurse said that many of the patients who he sees have had mathsy / physicist / engineer type jobs, where its quite possible that being obsessive about small things can be beneficial. I don't know if it is some kind of genetic defect, predisposing people to Parkinson's later in life and making them obsessive early in life, or if it is the act of thinking about a few things obsessively (or gambling obsessively) which over stimulates neurones and can lead to Parkinson's, but it is a very interesting theory.

A video, watch until about 10 seconds in to see Hitler's Parkinsonian-like tremor in one hand behind his back, perhaps explaining why he usually had this hand behind his back or in a pocket.

The other thing I learnt, which I didn't know but probably should have, was that it is assumed that Hitler was developing Parkinson's towards the end of the war. The video above is 'real' footage of Hitler, and you can see up to about ten seconds in that he has a tremor, like that seen in Parkinson's, in his left hand which he keeps behind his back. Supposedly most of the footage showing these tremors was destroyed by the Germans, but some film (such as this Russian film) remains. Back then he would have been treated with anticholinergics. The nurse was telling me (and I don't know how much truth there is in this) that because of Hitler's Parkinson's disease, and the neurological problems it caused (thus ruining his leadership of the German army and nation) this was a reason that the Allies didn't attempt to assassinate him towards the end of the war, and possibly a reason why the Germans made an attempt on his life. Very interesting stuff, but probably more for historians than medical students! 

Half a head

Hi,


A very productive week this week, spending my time on a neurosurgery placement. I got to see a number of surgeries, which were the highlight of the week really, and spent the rest of the time on the wards and in clinics. A much busier week than many of my previous weeks, which was something I really enjoyed. It reminded me a lot of my third year, with all of the contact time with the patients and doctors, and helping out on the ward, the way I am sure I learn best. The surgeries I saw varied from operations to the spine, to operations on the brain and skull, and lasted for hours and hours each. I was a little disappointed that they were not more complicated, though. I was expecting 'Neurosurgery' to be very complex (everyone assumes it is) but really it just seemed very similar to the rest of the surgeries I have seen. Perhaps rocket science is equally as over-rated.

Before I get into my post, though, I would like to thank the people who run medical-artist.com who, in compiling a list of who they think the top medical student blogs are this year, were kind enough to put mine at the top. I am touched that they thought it was that worthwhile-a-read, and its always good to know what you are writing is appreciated. 


Getting back to my week, saying all I did about neurosurgery not being as complicated as I expected, it doesn't mean that I didn't enjoy the operations, or the time I spent in the theatre. I spent half a day in theatre on Monday and a whole day on Wednesday. When I say I spent a whole day, this means the surgical list running from 9AM to 7PM. While the surgeons may be seen as the 'jocks' of the medical world, they sure do seem to work hard! I was with another medical student for both of these sessions, and we were not allowed to 'scrub in' as we have done for other operations previously, letting us hold things for the surgeon and generally help out. This is probably due to the increased risk of infection, and the fact that most of the operations are done down a sort of microscope, meaning the surgeon could look at the minute anatomy more easily down the eye pieces, but there is no room for medial-student-help. The operations were shown up on a screen, making it easy to see what the surgeon could see, but also giving you the feeling that you could just be watching something similar on youtube at home...


Despite all of the time I spent in surgery, I only saw three and a half operations, as they tend to take a long time. On Monday, there was one operation all day for one complicated case, a patient with a meningioma (a type of brain tumour), which was in the posterior fossa of the brain where the cerebellum sits. A complicated operation where part of the skull needs to be removed, and the tumour searched for in the brain meant that this would take a whole day. Unfortunately I was only scheduled in for the afternoon, having lectures in the morning that I couldn't miss. This did mean that I missed the portion of skull being removed, which could have been interesting, but I did get to see the removal of the tumour and everything being put back on again. Seeing the surgeon search for the cranial nerves so they didn't get accidentally cut reminded me why my anatomy was so important, and I regret the fact that I have forgotten so much of the anatomy I had to learn in my first and second years! Interestingly, if the skull cannot be put back immediately (for example, because they think that there will be inflammation in the brain, which will cause it to swell and they don't want it to swell up inside the closed skull causing injury) the part of the skull cannot be kept and given back to the patient at a later date as it used to be. Because bone is a structural material, they used to be able to remove it, sterilise it and give it back at a later date. Laws relating to the use of human tissues mean that this is no longer possible, and instead the skull always needs to be kept with the patient. This means the portion of the skull is kept inside the abdomen along side your guts, where the patient carries it inside them until it needs to be put back (when the inflammation has gone down). The skull can shrink slightly because of the body's macrophages (immune cells) having a little munch on the edges, meaning if it is left in there for some time it can become too small for the original gap, but this is a very interesting concept! 


As I said before, my part in the neurosurgery involves standing by the edge and watching what happens. On Monday this involved standing up from 12 'il 6.30 straight, which seemed like a long time, but on Wednesday I was standing from 9 'til 7, though I did get small breaks as they switched the patients around. Working for this long means you have to be tough to be a surgeon, but at least they and the anaesthetist get to sit down as they work. I feel sorry for people like the scrub nurse who have to stand for the whole day! On Wednesday the three operations I saw were the changing around of a spinal cord stimulator, the removal of a pituitary tumour via a transsphenoidal route (via the nose) and the replacement of most of someone's skull which had been removed in a traumatic accident. A long day, which I shared with my fellow medical student and an osteopath who was a friend of the surgeon and had come to watch and learn.


The spinal chord stimulator replacement surgery was pretty simple and only took a few hours. Because there was already one in place, this was more about replacement of the unit which had run out of batteries for a new one. This machine is inside the body, and has a small battery with wires in the spine. The patient is given a remote with which they can control how much voltage is put into their spine. Rather than being the terrifyingly painful experience I would imagine it to be, supposedly it is a great pain killer for chronic pain, working by blocking the pain signals going up the spinal chord. 


After this surgery was the surgery for a woman who had been diagnosed with a pituitary tumour. The pituitary gland is a small gland in the brain which controls most of the bodies hormones. Tumours here are usually benign, but they can cause the secretion of many hormones, or interfere with vision as the nerves from the eyes run next to the pituitary gland, and if it gets enlarged it can interfere with these. This surgery is done via the nose, using a similar method to that the Egyptians used to remove the brains from the skull before mummifying their ancestors. This is because the pituitary gland is right behind the nose, and going in this way means you do not need to go through brain, though it does mean that the entire operation is done while looking down one of the nostril! Impressive that this can be done, but it did involve watching a screen for ages as the surgeon fiddled around in the nose. A little more interesting than my experiences of TURPs previously, but only just.

Transsphenoidal surgery route - pretty clever huh! An approach favoured by Harvey Cushing, whose name has become associated with a number of medical syndromes and diseases

The best surgery of the day, and the reason I stayed 'til the end with only a cheese and pickle sandwich keeping me going was the man who had had a serious head injury in April and was having his skull reconstructed. Back in April, he had been hit in the head by a large part of a car while at work, which was travelling at about 70 miles an hour. This had crushed half of his skull, and on admission to hospital he was not expected to survive. Fortunately, with some dramatic surgery, he had recovered and had been living in a rehabilitation home until now. His skull had not been put back on at the time, hough, because of all the inflammation, and because of the large loss of one of his cerebral hemispheres (half of his brain) his head was a very strange shape, missing about a quarter of the top part of his head. It had skin over it, which was growing hair, but he looked distincly different, and wanted to go back to looking more normal, which was the purpose of the operation. A metal plate had been constructed to fit the shape of the skull, and this was going to be screwed in.


I saw him the day before when I was on the ward, to clerk him before the surgery, and was surprised with how well he seemed. Obviously, for someone who was missing half of their brain, he was not perfectly healthy, but other than slow slurred speech, and slight confusion when I asked him to carry out slightly more complex tasks. On physical examination, his body was neurologically normal other than brisk (increased) reflexes across the body. Amazing the sort of injuries the brain can deal with and bounce back - a very plastic organ! Either way, I build up a good rapport with him on this day, and I felt that he really appreciated my presence in the operating theatre before his anaesthetic (he was understandably nervous). As someone who had been a helicopter pilot on the army about a decade ago, this injury had clearly changed his life hugely, but he seemed so determined to do as well as he could. It really puts my problems in perspective! Either way, the surgery went well, the highlight being when the surgeon noticed the surgery lights shining on the plate he was about to insert cast lots of glittery reflections around the walls. He ordered the main lights to be turned off and created a disco... This may seem a little insensitive, but a nice break after hours of painstaking dissection around the edges of the remaining skull. The fact that I really enjoyed talking to the patient about his story (and the theatre-disco) and didn't really care so much about the surgery reiterates to me that I don't think surgery is the sort of speciality for me. It is clever and technical, but so is being a car mechanic.