Good Practice: Confessions of a Physician Associate Student

Chapter 1 Cutting Edge

The room was bright and white, with an atmosphere so tranquil, you could almost hear the drops of blood as, one by one, they hit the smooth vinyl floor. I considered how long it would be before the single drops merged and turned into a puddle, and the puddle into a problem.

Under normal circumstances, I would have busied myself in trying to be as helpful as possible, cleaning up the growing mess, but this was not just any mess. Bodily fluids came with different rules – rules I had not yet learned. There was lots that I had not yet learned.

This was only my first day, after all.

It was not the blood itself that was unsettling. I was used to blood by now. It was more the dynamics of the scene before my eyes that disturbed me ever so slightly. Her, as she lay unconscious on the bed, with spotlights shining down and her blood decorating the floor below. Us, responsible, standing around the bed where she lay, watching, observing. It all reminded me somewhat of the type of film where the victim, helpless, lies in wait for a superhero to swoop in and save them. I had not considered before that sometimes, it is the good guys who leave behind the trail of blood.

From where he stood opposite me on the other side of the bed, the surgeon caught me staring, my eyes fixed on the crimson blood on the floor, my mind lost in reflection. I cared about what he thought of me. It mattered that he considered me up to the task, whether I was or not. It all mattered, everything counted.

‘Don’t worry about the blood,’ he said casually, as if referring to something much less important, before turning back to the crimson canvas of his artistry. ‘Sometimes in this job, things get a bit messy. Like life.’

‘OK, great,’ I replied, sounding calm and relaxed, though inside I was anything but.

She was a middle-aged woman of average height and build, neatly fitting into the surgical hospital bed on which she lay with her eyes closed and her breath soft and rhythmic. The room that we were in was large, despite us only taking up a small area of it, perfectly centred in the middle of the floor. A couple of members of clinical staff hovered around the foot of the patient’s bed, head to toe in personal protective equipment (PPE) like us, repositioning medical implements on a silver trolley clean enough to be used as a mirror. There was another clinician at the head of the bed whose only interest was the bleeping machine that the patient was hooked up to, showing various numbers and shapes in different patterns.

I wondered what the patient was dreaming about, and whether people even had dreams under general anaesthetic. Would she be happy with the outcome, feel this procedure had been worth it? Despite wearing a hospital gown tied tightly at the back of her neck, she was covered from beneath her chin all the way down to her feet in a large, disposable green sheet. All apart from her left leg, which was exposed from the groin of her thigh to the tips of her toes.

That reminded me of how I slept on a sweltering summer night, reluctant to surrender the comfort of my duvet, but allowing a single limb to peek out from underneath and experience all the cool air that it could. Although it would not be long before I no longer felt comfortable sacrificing it to the terrors lying in wait in the darkness surrounding my bed, and I would bring it back under the protection of my covers.

Concentrating my mind once more on the here and now, I contemplated how she had come to be here, unconscious and bleeding. There are two main routes into having a surgical procedure: elective surgery, planned between the surgeon and the patient, and emergency surgery, which is self-explanatory. Varicose vein stripping is an example of elective surgery and is as ruthless as it sounds. It was also one of the first procedures that I observed when I started my placement. It was fair to say that I was thrown in at the deep end.

Varicose veins are quite common, typically occurring at the back of the leg when the vein becomes swollen and starts to protrude through the skin. In a healthy leg vein, valves inside it work together to keep the blood circulating around the body and push it back up towards the heart, but sometimes the valves become weakened or damaged, meaning that they are no longer able to operate properly. The blood then pools in the veins, making them swell.

Apart from being unsightly, varicose veins do not generally cause any medical problems. On occasion, however, they can become painful, and can even affect the patient’s skin. If pressure stockings do not help manage the symptoms, the only other solution is to remove the problematic vein entirely. Which was what was happening right now, in this patient’s case.

I watched as the surgeon made small incisions with a steady hand-held scalpel into the patient’s exposed left groin and at different points along her leg. Each careful incision opened the bloody pink flesh with wounds no longer than a couple of centimetres. He then inserted a fine piece of flexible wire into the first incision at the groin, feeding it along the thigh beneath the skin until it reached the last incision below the patient’s calf.

Like he was performing a magic trick, he gently removed the entire length of the wire through the lowest incision at the calf, pulling it out of the body. Attached to the wire was the rubbery blue varicose vein.

After being pulled out, the vein was tied off like a shoelace to reduce bleeding, though there still seemed to be a lot of blood everywhere. The once clean forest-green sheet covering the patient had been painted a deep red, making its purpose clear to me now. Whilst covering her, the sheet did not sit flat, but instead created a groove, channelling the blood to run off it like a small river and drip onto the floor.

I had not had any prior surgical experience, not personally. TV programmes and films did not help me quite as much as I had hoped. Most of the information that I had to go on before starting my first day of clinical placements was hearsay from other students.

Not the students from my course as we, overall, had limited, if any, personal experience about each clinical specialty before we arrived. I mean from the other medical students around the university who were always keen to impart advice and wisdom to us. We represented the shiny new profession that the students around the university were still learning about.

Listening to the medical students, I was interested to notice that all clinical specialties seemed to have been awarded unique stereotypes, as if the specialty itself produced certain characteristics and personality traits within its staff. In the communal area outside the library, a couple of keen informants cornered me one day and told me that the doctors who worked in paediatrics were, by nature, soft and gentle people. I hoped that this would be true. Surgeons, on the other hand, tended to be ‘quite cold and abrupt’ and ‘impatient’. I wondered whether this stereotype had come about because of surgeons’ unmatched skills in cutting people open. Or had my informants briefly mistaken these medical professionals for Marvel supervillains? I was not sure. More concerning, – from my perspective, anyway – was their insistence that surgeons tended to be ‘not good with students’.

Surgeons, unlike those in other medical specialties, do not refer to themselves as Dr, but instead as Mr or Ms, a tradition dating back to the 1800s. Around this time, surgeons were not required to have official medical training and could, in essence, just start cutting people open. It was the introduction of the Royal College of Surgeons that deemed it necessary for practitioners to attend medical school before picking up a scalpel.

Thankfully!

The negativity I had heard ahead of starting my clinical placement in general surgery did leave me slightly nervous. However, the team I was placed with at Purple Hospital, a single bus ride from where I lived – could not have been further from the stereotype I had been led to believe. I should have realised that the pieces of ‘information’ imparted by eager gossips would hold no more truth than Chinese whispers.

My clinical supervisor during my time on my surgical placement was a softly spoken yet confident consultant, extremely friendly with a passion for teaching and demonstrating to his students what life in the department entailed. He was very tall, which meant that for three weeks, I would have to be beady eyed to spot the standing stool placed in each of the operating theatres. After discreetly positioning and stepping onto it, I would get a clear view of what was happening on the operating table, as if I had just had a rapid growth spurt.

I have been told on various mandatory health and safety training days the importance of protecting your back, and surgeons are no exception. The patient’s bed would be adjusted to a comfortable eye level for the surgeon, which in my clinical supervisor’s case meant raising it significantly. With at least a foot of height difference between us, it was safe to say that our eye levels were not the same, but an intricate surgical procedure could take much longer than anticipated, so it was essential that the surgeon was comfortable from the very start.

So that was where I found myself on my first day in placement, perched on a stool above a growing pool of blood, watching a troublesome vein being removed. When the procedure was complete, the patient’s entire leg was tightly bandaged, allowing for pressure to aid healing. And if all went to plan, by the time the bandages were removed and replaced by support stockings the following day, the patient would have varicose veins no more.

At one point during the procedure, the surgeon, with the help of his clinical team, had to raise the patient’s left leg as high as his tall shoulders to more easily, access and remove the parts of varicose vein remaining below the skin surface, using a sharp, thin tweezer-type instrument to fish around the open wounds, pulling out fragments of vein one at a time. When he eventually lowered the leg back to the bed, he informed me proudly that he had ‘got them all’.

I decided to supress a smile. He reminded me of Ash searching for Pokémon.

Although general surgery as a specialty covers the entire body, most of the procedures that I observed on my clinical placement tended to involve the abdomen. The reason for this is likely that the abdomen contains so many different organs and structures. The appendix the gallbladder, the stomach itself all occasionally require surgical intervention.

I had assumed, however, that during my time in general surgery, I would be seeing a wider variety of intricate procedures. One day, I would be observing complex brain surgery, the next day the heart, but it didn’t work that way.

The abdominal wall reminds me of strong brickwork. It helps to keep skin and fat on one side, vital organs on the other side. However, if there is a weakness, the bigger and heavier structures poke through like a tree root through a patch of worn masonry, producing a protrusion. This protrusion is called a hernia.

Hernias can happen at different sites in the abdomen and the groin, and for different reasons. Anything that increases the pressure inside the abdominal wall can cause a hernia, including pregnancy, weightlifting, chronic constipation, even just growing older, as we all do.

A few days into my general surgery placement, I spoke to a patient who had come in for his preoperative assessment, prior to his routine hernia operation the following week. During this assessment, nurses would carry out the necessary physical examinations before his consultation with the surgeon. The patient was a short man in his late 60s, smiley to the point where I wondered whether his cheeks permanently ached.

The preoperative ward was small, with a handful of hospital beds dotted around the periphery of the room, all of which were empty, giving the nurses plenty of room to work. Whilst cheerfully discussing the previous night’s episode of The Great British Bake Off with the patient, the nurses were doing things like checking his blood pressure, pulse, weight, and height and asking relevant questions about his current lifestyle, all to make sure that he remained fit and well for his upcoming procedure. The patient seemed altogether unfazed by the thought of being cut open by the surgeon’s scalpel, his demeanour more that of someone who had popped to a café for a relaxing cup of tea[KR1] .

Once the nurses had finished documenting their clinical findings onto the clipboards, they then began unclipping and detaching the patient from various pieces of medical equipment as he sat in a chair next to one of the ward’s perfectly made-up beds. At this point, I asked him if I might talk to him about the progression of his medical problem – this is called ‘taking a history’ – whilst he waited for the consultant to arrive. The patient seemed pleased for the opportunity to have a chat and jumped straight into the story of how he had noticed the lump in his stomach, which had continued to grow and grow despite his best efforts to slow it down by keeping his hand firmly pressed on the area for as long as he could throughout the day. When he realised that functioning with only one free hand was much more difficult than seeking professional medical attention beyond the internet forums where his advice had been coming from, he finally made an appointment to see his doctor. The conversation was all very much what I had expected… until it wasn’t.

Midway through our chat, the penny dropped. There had been clues, questions such as how long did I typically take for a hernia procedure and how many times had I carried it out, but the defining moment was when he remarked, ‘You look so young to be a surgeon.’

Now, many people told me I still looked like an early teen, despite the fact I was by this time 21. But my age wasn’t the real issue here; that was the big, clanging misunderstanding going on. The patient was under the impression that he was speaking not to a student physician associate, and a very inexperienced one at that, but to the consultant who would be performing his operation. Upon realising the error, I quickly and earnestly reassured him that I was not a surgeon and wouldn’t be carrying out his procedure the following week. I would merely be standing on a stool, observing whilst the operation took place, and only if he consented to me doing so.

I did attend the surgery the following week as planned, though it was very strange seeing this chatty, bubbly patient lying unconscious on the bed, no longer smiling, his face neutral, neither happy nor sad, eyes closed in his anaesthetic-induced sleep. The abdominal wall had been neatly cut open at the site where the hernia was and the intestines – looking like links of raw sausages, fresh from the butcher – were visible through the deep incision. A fine metal mesh was put in through the open wound and sewed into the abdominal wall, adding strength where there was previously weakness.

Part of me regretted having talked to this patient during his preoperative assessment. Our laughter at the case of mistaken identity sprang to mind; I recalled his infectious chuckle and the way his warm eyes sparkled with the pleasure of our shared misunderstanding. With every surgical incision, I found myself wincing as if I was somehow betraying him, causing him pain and distress, even though I knew that he was looking forward to the containment of the egg-shaped lump that popped out every time he laughed, sneezed or coughed. It would have been easier to see a faceless, nameless man in such a vulnerable position, rather than someone with whom I had built up such a rapport.

Before the surgeon started to stitch up the patient’s abdomen, two of the team inside the operating theatre, clad head to toe in PPE, began counting pieces of equipment out loud and annotating a piece of A4 paper attached to a clipboard. Nobody seemed perplexed by this, apart from me. Whispering, I asked the consultant why they were doing this, knowing he was eager for me to learn and had reminded me often to ask as many questions as I wanted.

He explained that everything used during the surgical procedure, such as pieces of cotton gauze, sponges, needles, clips, tweezers, forceps, had been itemised beforehand. Now, each item needed to be accounted for before the patient was stitched back up, to make sure that nothing had been left where it shouldn’t have been. The last thing the patient needed was to swap a hernia for a surgical scalpel.

I accepted this answer, even though I quietly thought that it seemed a little over the top. When I got home that evening, I decided to see whether the internet could provide me with any more clarity. Was this counting ritual well known and practised by many? Or was it just my surgical team being over cautious?

To my surprise, Google returned countless reports of what is called ‘retained foreign objects post procedure’, with general surgery having the highest incident rate. Cotton swabs and surgical instruments were the most common offenders, left inside of the patient after their procedure had been completed and their wounds stitched back up. The retained foreign objects often resulted in significant pain and discomfort for the patient, and sometimes injuries, secondary surgery, lawsuits and even death.