Finishing Obs and Gynae

My final week in Essex was a short one.  We had the bank holiday on Monday, I went in late on Tuesday and left on Thursday.  I got my logbook (the bane of our lives) “finished” the week before, so all I had to do was a short piece of work commenting on the management of one case according to the literature and I could get signed off.  The rest of the time was for me to do whatever I wanted, and I’m pleased to say I did actually go in.

On Wednesday I got up early for an infertility clinic.  Quite boring, it was a series of couples coming in having failed to make a baby after a year or so of trying.  A few blood tests and fallopian tube check for the woman, a sperm count for the man, and they usually left with a 3 month appointment which would probably end in the woman being told to lose weight again or attempting to get funding for IVF.

For couples who have tried everything properly (weight, diet, enough sex etc.), and have never had a child and can’t conceive, I can understand the value of such a clinic.  But what I couldn’t understand was the obese couples coming in for their 3rd child, complaining that they’ve “tried everything”, and tying up resources.  Call me heartless, but I can’t square it in my mind.

After that clinic thankfully finished I watched a Hycosy procedure to check the patency of a woman’s fallopian tubes.  I didn’t feel particularly welcome by the all-female staff, but the patient didn’t seem to mind.  You’d think I’d get used to the archaic attitudes of some staff members by now, but it just smacks of discrimination to me.  Patients, who are vulnerable, can say no because I’m a man, yes.  Female staff members who disagree with men having anything to do with “women’s bits” cannot.

Later that night I joined the ST7 for her on-call shift in the hopes of maybe scrubbing one last time and seeing some cool stuff.  I was in luck – the umbilical cord had snapped for a Thai lady and she was bleeding steadily.  The midwife hadn’t been able to pull the placenta out and it wasn’t expelling itself, so she was given some syntocinon and the doctor called.  The reg literally just donned a glove and slid her hand up the woman’s vagina.  Her whole hand.  She managed to grab the remainder of the cord and out came a torn placenta and a shitload of blood.  The woman was screaming to high heaven, having only entonox as her analgesia.  Her husband was going quite pale and the baby had been left on the trolley.  I guided the guy to the baby and told him to take his shirt off and hold the screaming baby to his skin.  The midwives loved that.

An hour later and I was scrubbed, only me assisting the registrar repair a really long and 2nd degree tear for a hugely obese woman with the longest pubic hair I’ve ever seen (it was actually braided).  It’s the first time in surgery where I’ve actually felt like I was doing some of the surgery; I was holding back the relevant bits and swabbing as necessary while the surgeon sewed up.  I actually knew what was going on, all of it.  I got alot of teaching and felt great after (thought my back and knees didn’t); she seemed to appreciate the help given that she was the only doctor around and would have struggled without an assistant.

On Thursday I was told the consultant would sign us off.  Sign off means you can go home.  I was told he would be operating so I sought out his patients and took histories.  I followed the first lady to the anesthetics room and chatted to the anaesthetist about helping out.  I did her cannula and watched her drift off to oblivion.  I love that.  The other medical students turned up too but I was the one with the history, which went down well with our consultant.  The woman was having a laparotomy for adhesions and endometriosis.  Turns out she didn’t have endometriosis but her right fallopian tube was stuck to the sides so he took it out.  She was fine after.

The consultant took us to the tea room after and signed us off while simulataneously quizzing us on Obs and Gynae and singing our praises.  When asked what could be improved I told him honestly about the midwives in the first two weeks.  He assured me that things did get better and that he felt exactly the same way when he was in my position and that the situation with medical students and other staff members did annoy him.  Strangely that made me feel alot better.

Surgery; not for everyone, but fantastic with the right people.

Another night of Obs

Last week I tried again for another night, hoping to repeat the “sucess” of the previous one.  A 15 year old girl 34 weeks pregnant comes in with severe abdominal pain.  Her blood pressure is up and the midwives are rushing around.  It’s all very dramatic, and I’m told no about 3 times when I ask to get involved.  The doctors come along and I’m allowed straight in.  Sometimes I think other health professionals really do just get in our way on purpose.  It turns out she’s abrupting – the placenta is coming away from the lining of the uterus; she goes down for a crash c-section.  The surgeon opens up and out comes the baby.  It’s pretty small and they point that out to me as a sign of a pre-eclamptic baby.  The placenta comes away and has a huge clot behind it – where it had abrupted.  I see the baby after in the neonatal unit, looking pretty small and pathetic – I get told he has a big head and tiny bottom half because hes been growth restricted in the womb (IUGR) and his head has been spared at the expense of his body.  I go home, asking for a phone call if anything good should happen.  I get called back at 2:30 to a woman who has had 2 kids already – parity 2, they usually move fast.  I go into the birthing room with the midwife and the woman is in a big bath in her bikini, sucking down entonox.  After all the pleasantries I feel her tummy when she’s in pain and feel the contractions.  Quite amazing.  15 minutes later, and after a lot of bloody and pooey water, it’s all over.   My first natural birth – much better than interventional births.  I won’t be doing obstetrics for a career.

Two nights later I go back. I can deal with nights; there are less people, the atmosphere is better and it’s a good alternative to insomnia. After checking the board and sweet-talking a couple of midwives (very important as a male), I introduce myself to a lady who is 8cm dilated and get permission to come back for the birth. If the midwives really like you, they’ll call your mobile when things start moving so you don’t have to hang about pointlessly. On my way out I hear a scream from a side room and knock on the door (as you do).

The midwife comes to door looking fairly nonchalant and I ask if I can see the birth. I go in and catch the woman screaming again, sucking down entonox big time. Her partner is having his hand crushed, looking a bit pale. When she stops I introduce myself, the husband looks quite relieved to have another male around.

As the babies head starts to push out, the woman screams that she’s going to shit herself. This happens sometimes, and the novelty for me has worn off, so I just take off my jacket and put on a pair of gloves, much to the man’s amusement. Eventually a little face pops out and starts to gasp, the midwives tell the baby to shush and wait until she’s all out, and a minute later she is, squalling in that beautiful, relieving way that only fresh neonates do. I join the student midwife in checking the baby and placenta over after we’ve cleared up a bit. I congratulate the new family and leave to recheck the first lady.

She hasn’t done much, but another lady has just become fully dilated so I go there instead. I say lady; she was 17, her skinny partner looks younger than my youngest brother. They’re both quite pleasant, and she’s has an epidural so isn’t in much discomfort. Father Ted comes on the TV and the baby girl is born to the sound of “my little pony”. Excellent.

The girl tore a second degree on the way out so we set her up for examination and stitching. I stand at the end of the bed watching the midwife work and teach. “Don’t make that face, doctor! You’re putting me off!”, the girl shouts at me, laughing. Apparently I was gaping with mouth open.

I returned to the doctors room after that and have some pizza with the on-cal docs. My first lady still hasn’t shifted, and they go off to forceps deliver a really big baby, very worried about a shoulder distocia. I go home and tell the midwife not to call if the lady gets going. That’s the benefit of being a student; you can go home whenever you want and not worry.

A night of obstetrics

I started my Obs and Gynae placement 2 weeks ago at an outfirm – the hospital is too far away from the uni to commute to, so I have to stay there throughout the week.  My accomodation is nice, but there are only 3 of us on the firm and it does get quite boring and lonely.

My initial enthusiasm for the subject quickly dwindled when the midwives kept coming up with excuses for me not to see births, which is primarily what I’m there for.  All I was doing was attending antenatal and gynae clinics every morning and wasting the rest of the day.  Eventually I complained to the doctors and the consultant, and was pleased when I turned up for a night shift to be greeted warmly and told that I could attend any and all births that were happening.

The night began slowly.  I introduced myself to one lady who was in a great deal of pain with contractions.  She was only about 7cm dilated (you need to get to 10 to be fully), so she wasn’t pushing, and with her being a primip (this was her first baby), I was in for a long wait*.  However, I got talking to the anaesthetist and came with him to put her epidural in.  This wasn’t as bad as I’d been led to believe.  After cleaning the area, he  infiltrated some lignocaine into the skin and then some more into the deeper tissues.  After this he carefully pushed a really long needle between L3 and L4 and used a couple of swanky techniques to check when he was in the epidural space.  The lady didn’t seem to be distressed by this that much, but then she was in enough pain already with her contractions.

After she was sorted I accompanied the doctors upstairs to a PCA setup (patient controlled analgesia) and teaching session with the midwives.  I got a bit bored as it wasn’t too relevant to me, so helped with a cannula and then cuddled a baby that was crying and whose mother needed some sleep.  She must have been about a day old.

When I returned to the labour unit the midwives took the piss out of me for cuddling the baby, until a lady with twins began to get ready for an instrumental delivery.  I snuck in the back and introduced myself to her.  She was shaking so I held her hand and talked to her.  The first baby came out with his arm by his face but he was ok as the paediatrician checked him over.  The fetal heart trace for twin 2 went off and panic erupted.  They tried to deliver him straight away but both his arms were in the way so we all rushed to the theatre for an emergency C-section.  I ran next to the bed with an IV bag attached to the womans hand, desperate for it not to snap.  She was unconscious quickly and the baby was out within a few minutes, blue and floppy, not breathing.

I stood with the paediatrician and the nurse as they ventilated the baby and listened to the heart.  Everything was timed on a very visible clock.  The baby started to pink up and occasionally made a slight gasp, but wasn’t breathing properly.  He had very little tone also, so the cart was whisked to the neonatal unit where he was plopped on an incubator and ventilated more.  Eventually his tone picked up and he started breathing by himself, my relief quite audible.  The father, who had just arrived and was caring for the first twin was ushered in, eyes streaming, to see his other son was OK.  It was quite touching.

I went back to the theatre and helped in there.  One of the student midwives was crying and had been kicked out by the doctors, so I tried to help her for a bit.  I think she appreciated it.  When all the drama was over, I got more thanks than I deserved by the whole team for running paperwork and equipment back and forth during the whole thing.

I returned to the ward just in time as my other lady had reached 10cm and was starting to push.  After an hour of that the doctor deemed an instrumental necessary and an episiotomy was done.  The mother vomitted a few times before the babys head exploded out and blew the episiotomy wide open, almost to the third degree (including the anus).  There was blood everywhere, but this baby started crying immediately, a lovely noise, and the paediatrician checked her over with me and the nurse.  A PPH (post-partum haemorrhage) followed but was controlled by IV oxytocin and the SHO stitched up the tear.

After that I nipped back to the neonatal unit and surgical recovery room to see how the mother and twins were doing.  She and twin 1 were fine, but twin 2 had to stay in the NNU for a while.

When all was done I realised it was 8am, so I thanked everyone, had a laugh and joke with the midwives and made my way home to sleep it all off.  I dreamt of women giving birth in alleys and being unable to help them.  Such is my mind, clearly…

*a cervix dilates at about 1cm per hour, but in primips this can be twice as slow, therefore I was potentially going to wait for 6 hours until things started to move forward.

Orthopaedic surgery

Last week I scrubbed in for surgery with the orthopaedic consultant and his registrars.  It was the first time I’d scrubbed in a long time, and I had a hard time getting into my gown and gloves.  Still, I remained sterile the whole time so it was merely embarrassing.  X-Rays were being done throughout all the procedures, so I had to wear a heavy lead gown and thyroid shield under my scrubs too.  By the end of the morning my back and knees felt ready to snap and I could see myself on the operating table.

The morning list was paediatric cases, which is the first time I’ve ever deal with kids in a clinical setting.  We started by removing K-wires from a 16 year old girls tibia.  Nothing too complicated; just grip them with the pliers and yank them out.  I got to do 3, and have to say I felt a little queasy doing it.  Next up was a boy with some malformation of his left lower leg, the name of which I forget.  The basic idea was that his medial femoral epiphysis (the bit of the bone that does the growing) needed to be held back as he grew to give the lateral side time to ‘catch up’ and correct his valgum deformity (knock-knees).  This was done by screwing an 8 plate, a small plate in the shape of a figure of 8 funnily enough, into the bone above and below the epiphysis so that the bone couldn’t lengthen.

I’ve helpfully drawn a diagram below for your viewing pleasure:

The last case of the day was a boy who’d come in the previous night having been knocked down by a car.  Amazing, his only injury was a transverse compound fracture of his femur.  This would be fixed with elastic wires.  Going into details about this would take too long and probably another diagram (the one above took longer than you think), so it’ll suffice to say that I was allowed to hammer one of the rods into his femur.

The surgeon asked me if I knew what a kitten pawing at a toy looked like.

BnB ICA result

And the results are out…

Just to recap, this ICA covered aspects of neurology, neurosurgery, ophthalmology and psychiatry. I enjoyed it, especially the Psychiatry placements.

Pass in all placements.
ICA result 75.4% (A)

Obviously I’m very pleased with the result, but I don’t think I deserved it given the relatively little amount of revision I did. I found the exam hard but remember being able to answer most things relatively confidently on the second read through.

Next exam in 7 weeks or so. Sigh.

Surgical splatter

Today I made the effort to get in for 8:30am (I know!) to watch some of the neurosurgery I’ve spent the last 2ish weeks harping on about.  I didn’t scrub for anything, though this was hardly surprising.  The other student and I did get some good teaching, however.

The first case was a vetriculoperitoneal shunt placement and 4th ventricle cyst drainage.  It took about an hour and a half.  Essentially the idea is that a thin tube at the base of the brain drains excess CSF away to the peritoneum in the abdomen to be reabsorbed.  It’s about controlling pressure in the fixed-size brain box.  I’m not sure I’ll forget the process of ‘tunnelling’ any time soon; imagine a surgeon pushing with most of his weight on a thick, long metal rod down the patients neck all the way to the abdomen.  Nice.

The second case was a large left frontal meningioma.  It was due to be a long operation so I only stayed until the microscope came out for the debulking.  A large ‘bi-coronal’ incision (ear to ear across the top) was made and the scalp retracted anteriorly and posteriorly.  The temporalis was loosened (I think) and then burr holes were drilled.  The sound is something else.  A cutting tip was then used to join the holes in a semi-circular fashion so that a flap of skull could be cracked off.

After the drilling was done the surgeon took an instrument with a hard flat tip at the end and wedged it under the bone.  He lifted it up and we caught a glimpse of brain and dura.  He then slipped, the flap snapped back down and covered me and the other medical student in bits of blood, bone and God knows what else.

“I didn’t mean it.”, chirped the surgeon.

A chance to shine

“Try not to use the word “damage” when referring to complications of surgery around nerves – if I thought all I did was damage I’d never live with myself.  Better to say “discontinuity.”

And so I finished a teaching session, one to one, with my current consultant.  With most of my stuff signed off and freshly taught about various bits of neurosurgery, I was chuffed.  A session of teaching later that day was cancelled, and so three of us students who had bothered to turn up were taken by the SHO to see a patient awaiting a GON block for scalp pain.

“Right, she’s got good cranial nerve signs.  One of you do the exam and we’ll chat about it after – see if you can figure out what’s wrong.”

All the other students immediately looked at me and volunteered me to take the hit. This seems to happen more often than I’d like, but I rarely have the energy to argue.  I sat down in front of the lady, all the other students silent behind me of course.  A finalist wandered in.  As I spoke to her, gained consent and made an attempt at rapport, I looked at her.  You know, properly looked.  There was something amiss but I didn’t have the experience to say what it was.

And so I began my CNS routine.  She seemed to have a bit of trouble following my finger (CN3,4,6) but I couldn’t pinpoint exactly what that was all about.  Visual fields were fine.  Sensation over the 3 territories of the trigeminal on the right side was subjectively different according to the patient.  When I got to the facial nerve I’d figured out what it was that made think something was up when I was observing – the right side of her face was far weaker than the left.  However, she’d had some operations to rectify this including some tricks to get her blink back, which was why I was unsure what was wrong at first – the textbooks always show you uncompensated patients with facial palsies.

Hearing was absent on the right, too.  In fact she didn’t hear on the left too well either but I could have a conversation with her so she must have had useful hearing.  The rest of the exam was normal.

I stood up, a bit baffled.  The rest of the students looked bemused too, and the SHO came back in.

“So what’s wrong with her?”

One of the students ventured a Bell’s Palsy.  I didn’t think so – this had been there for a while.  I explained my findings, and the SHO rechecked the 3rd nerve which was actually normal.  So that left a 5th, 7th and 8th problem.  The finalist didn’t have a clue.  And suddenly it started to come together but I thought I was probably wrong, “Hmm, can I have another look for scars?”, I asked.  The patient smiled and the SHO looked expectant.  I didn’t find any but decided to go for my best guess anyway, “Did you have a vestibular schwannoma?”.  Blank stares.  ”Er, an acoustic neuroma I mean.  And it’s been removed some time ago.”.  The patient looked very pleased and the SHO congratulated me.  The rest of the students looked stunned.

I didn’t feel the need to mention the fact I’d just had an hour’s teaching on that exact topic from my consultant  I was still quite chuffed with myself though.

Here’s a blog I found about a young woman with AN:

http://buginthebrain.blogspot.com/

Hopefully it’ll give those of you (including me) who are interested some insight into how this condition can affect patients.

T1 MRI of a vestibular schwannoma, on the patients right side (left of the image)

First scrub in

And so, finally, I managed to scrub in for surgery.  Gosh I must have looked all professional.

Monday morning came around and I went in quite early to make up for my recent lax attitude to the firm.  After getting all ready to observe in theatre, I was immediately sent away to run an errand for the FY1 who was scrubbed in.  I wasn’t fussed about doing it – I would only be standing around anyway and this would get me in his good books for teaching later.

I got back to theatre and the lap chole was being converted to an open chole on account of the patient being too fat.  The FY1 was missing.  The surgeon and SHO looked at me and said, “we need help with this, please scrub in”.

After an initial pause of shock, I quickly mumbled out that I didnt know how.  They looked at a nurse standing nearby, but she immediately yelled out “I’m the only one here and far too busy to teach scrub in procedure!”, before storming off.  The surgeons told me to get the FY1 on the phone.  Bugger, my one chance to do something decent here and it was scuppered by an ill-tempered over-worked nurse.

I did as they asked, keeping a fresh face so as not to appear bitter (I was quite annoyed).  The FY1 rolled up just as the assistants finished laying out the open chole kit.  He looked a bit annoyed at having been called back, but went to scrub in.  But the surgeon called over to him, “no, just show him how to scrub and then you can get back to the ward”.

What a result.

After doing all the washes and rinses, I got gowned up and was good to go.  Being scrubbed in is immensely better than observing.  You can see so much more and, if allowed, actually touch things like the liver.  The surgery was hard going and drawn out, and my main job was to hold retractors in certain places throughout.  But I have to say I thoroughly enjoyed it.

That's almost definitely not me on the right.

First week of surgery – gallstones and lap choles

Met3a is a mixed firm of (relevant) surgery and gastroenterology.  Last week was exclusively surgery, but this certainly isn’t to say that I spent 5 days in theatre.  Actually I spent just half of the first day watching a few procedures, not scrubbed in.  My consultant surgeon seems nice enough, as does his reg., and the FY1s are really lovely – all of which is conducive to a good experience, of course.

So last week I started off by watching a laparascopic cholecystectomy (the “lap chole”) which is apparently the most common surgical procedure in the world.

Why do people get gallstones?  High serum cholesterol you say?  Don’t.  Being quizzed by a surgeon is only fun until you get stuff wrong.

1) Supersaturation of bile with cholesterol or another salt
2) Gallbladder dysfunction causing bile stagnation
3) Genetic predisposition

There’s a way to remember which kind of people classically get gallstones called the 5 F’s: Female Fat Forty Fertile and Fair.  Apparently this is a load of nonsense but that’s all the surgeon said on the matter.

Anyway, just briefly – gallstones are only treated if they cause symptoms, which can be acute or chronic.  Pain in the right upper quadrant which is colicky and has shows a positive Murphy’s sign (dependent on stone location) is the classic presentation.  You may also see signs of jaundice if the stone obstructs the common bile duct with a bit of good old pale poo and dark urine.

So apart from that I spent the rest of the week orientating myself in the new hospital and chatting to a few patients.  One lady decided to drop her BP and become unresponsive while I was hanging around – this was very exciting as I got to help out by getting her cannulated, BP taken and ECG’d.  Let’s see what happens next week.

This is pretty much what I was watching during surgery. Notice how the gallbladder isn't green like the textbooks always depict it.