The Surgical Reg

The hospital in which I currently work is unfortunately not a Major Trauma Centre, although the head of Emergency General Surgery tells me that the Big Wigs have aspirations to make it one in the next 10 years - so long as Neurosurgeons can be persuaded to work here. Nonetheless, in a typical on-call week you can currently only be expected to be dragged down to A&E once or twice for a trauma call and consequently trauma laparotomies are vanishingly rare! Last weekend however, my Sunday afternoon got a bit exciting! The Consultant was being supportive and hanging around unscrubbed in theatre whilst I attempted a somewhat troublesome Hartmann's for perforated diverticular disease that had been brewing on the ward for a little while before deteriorating that morning. As I was firing the Contour stapler to divide the rectum, the trauma bleep went off, so we sent the SHO off to investigate and the Consultant scrubbed in to help me. Not long afterwards, the SHO called back to excited

The question of how to choose a subspecialty is an anxiety that has insidiously been creeping into the periphery of my consciousness over the past few months. I am now midway through my ST5 training year, and thoroughly comfortable with my identity as a surgical registrar. Unfortunately, my levels of self-regard have clearly not yet reached sufficiently lofty levels, and I am still utterly unable to imagine myself as a consultant. I am therefore at rather a loss as to how to answer my TPD’s recent enquiries as to my thoughts regarding a subspecialty, and have ignominiously left that particular e-mail unanswered for an unacceptably long time. But this is a big decision! Training feels preposterously long and arduous; but is actually only a trivial 8 years compared to potentially 30 to 40 years of sub-specialist consultant practice! Nonetheless, before the end of training, a declaration must be made as to which of the five sub-specialties is preferred; the major sub-specialties being Bre

Why does it take so long to train a surgeon? The typical trainee will not finish training until the age of 35-40 years old. I am currently 34, and still have years of moving around the region, jumping through hoops and fighting to get operating time and sign-offs to look forward to. Surgical training is not a comfortable place, and I have not met a single trainee who is content with year after year of no fixed routine, no certainty, constantly moving around, no time for friends and family, difficulties setting up a home, financial worries and concerns about the future. Furthermore, new consultants are now very much  not  expected to be the finished product, and it is anticipated that they will still be learning how to operate and function as a senior surgeon for some time after completion of training! Elsewhere in the world however, surgical training is often much quicker than our minimum of 8 years of surgical training. The Americans for example, despite all of their advanced technolo

The papers are screaming vociferously about the current crisis in the NHS. People are dying in the back of ambulances whilst stuck in a queue to get inside the hospital, and still more patients are dying on trolleys or chairs in corridors once they get in through the front doors. As a Guardian-reading lefty, I have subsequently been subject to a smorgasbord of sensationalist statistics over the last couple of months. For example, in September 5,025 patients waited for more than 12 hours to be admitted to hospital in England[1]. The figure for October was 7,059 people – the highest number on record apparently[4]! The target that 95% of patients attending A&E should be seen within four hours has also apparently gone out of the window, as they are currently only hitting an unseemly 62%[3]. Furthermore, an estimated 6,097 people in the UK died in 2020-2021 due to the roadblock of A&E delaying their care[4]. The Association of Ambulance Chief Executives also recently weighed in to g

Necrotising fasciitis! Two words that instantly twist the guts of any surgeon with an icy squeeze.  It’s bad enough when the back of your mind whisperingly flirts with the possibility of this dreaded diagnosis whilst reviewing a patient with a perfectly innocent, garden-variety cellulitis in the light of day. It’s a little more troubling when, later that night at 3am, you suddenly sit bolt upright clutching at the damp bedsheets, utterly convinced that somehow you missed the first subtle signs. It is of course worse by far to peek under the bedsheets and instantly just know. For a disease that is supposedly vanishingly rare according to the textbooks, I feel that in my short career I have already encountered more than my fair share. Four cases of barbaric, destructive, ruthless dissection are seared into my memory. The overpowering smell. The sensation of human flesh liquified to a grey soup. The putrefaction of normal anatomy to the point where a deluge of stinking liquid leaks out of

Squeezing impatiently through the waddling crowd of the unhealthy and the overweight in a hospital's corridors and stairways (and the world in general), it is astounding to remember that that the lifetime prevalence of gallstone disease is actually only about 10% to 20%. It's even more difficult to keep this at the forefront of your mind in a General Surgery outpatient clinic or On-Call, when there is barely a patient who doesn't have abdominal pain that they attribute to their inevitable gallstones! Nonetheless, I assumed that the decision making was a foregone conclusion in these patients who present with typical biliary colic and have proven stones or sludge - of course we should just whip their gallbladder out! Whilst this bit is easy, the practical business of listing a patient for cholecystectomy is a little harder - particularly with the decimation wrought by the COVID-19 pandemic on waiting list times. Patients with uncomplicated biliary colic are extraordinarily fo

This may come as a surprise to those who bemoan the stress, unpredictability and long hours, but it was refreshingly great to be on-call last week! Predictably there were frustrations, as I found myself frequently lost in this new hospital, constantly ignorant of how the system works and rather peeved at being left high and dry by a rota gap for the on-call SHO on two days. But in general it was good to be back on the horse, attempting to sift through and make sense of huge numbers of patients with belly pain, vomiting and bleeding that were coming at me from all directions, and trying to determine who needed an operation and in what order. One of the highlights, having just unscrubbed after finishing a particularly horrendous appendix, was a call from obstetric theatres, asking to attend for a woman having a c-section. Scrubbing in, the Consultant Obstetrician had already got into the peritoneal cavity, and was concerned about a small bowel injury. The patient had had previous c-secti

Since rotating onto this current placement on the first Wednesday in October, I have been rotated only to normal working days. Gone is the previous Rota Master's fickle torture regime of a single night shift followed by a day shift, followed by a night shift madness. Instead, the new Controller of Spreadsheets appears to group on-calls together in a big lump! It all kicks off next week, when I have a week of long days on-calls, followed by a week of nights on-call, followed by weekend of nights, finishing up with a weekend of days on-call!  I have surprised myself with the realisation that I am wholeheartedly looking forward to receiving the bleep on Monday morning?!? Despite the higher possibility of getting a lunch break, the feasibility of using the bathroom when you need to, and the ability to get a decent amount of sleep at night that comes with elective work, I find that I do get tiresomely fatigued with day after day of Multi Disciplinary Team Meetings, ward rounds, outpatie

The first Wednesday in October. All Change! Change of course, being the one constant in Surgical Training. On this occasion however, on stepping off the merry-go-round, I was most surprised and relieved to discover that I was not to be starting with a night shift in the hospital that I'd never worked in before - miracles never cease to exist!  The HR Department however, held little else back in the way of surprises - it was all very much in line with their usual tried and tested protocol. The On-Call rota of nights and weekends had been sent 2 weeks prior to starting, and was obviously incorrect almost every regard. Having finished work in one NHS hospital just 14 hours earlier, and now a continuous full time NHS employee of 8 years vintage, Occupational Health had now suddenly decided to play their usual charade of finding a reason that I was not fit to work in a hospital somewhere on the exhaustive health questionnaire that they had received 2 months previously. Not to be outdone

As a surgical trainee, there is always a constant, nagging pressure for numbers, numbers, numbers! Looming ever-present in our subconsciousness is the next stony-faced ARCP panel member peering over the top of their glasses and demanding an explanation for exactly why our numbers are so disappointing. Unfortunately, this pressure can on occasion lead to the rather undignified business of sharking - ie getting involved in an operation that another surgeon feels should be 'theirs' by virtue of the rota, groundwork with the patient or relationship with the consultant. Yesterday I found myself at somewhat of a loose end (not counting my overflowing in-tray of admin paperwork). Thankfully, just as I was about to grudgingly settle in for a session with the dictaphone, I got a call from one of the consultant to say that a cholecystitis patient on the ward was getting a little septic, and he needed someone to book her onto the emergency list for a cholecystectomy. I dropped my paperwo

I have been on-call this weekend. For the most part, it has been a dreary affair, with the ward round of the 40-odd surgical patients interspersed only with popping an abscess or two, and trudging to A&E to see the next non-specific abdominal pain that they're not sure what to do with. Fortunately however, the next phone call was a referral for a  74 year old gentleman presenting with abdominal pain, distention and vomiting. The CT demonstrated a closed loop small bowel obstruction, with venous congestion of the affected loop. I got on the phone to the anaesthetist and theatre co-ordinator to give them the good news. As it was Sunday, and my consultant had only popped in to be briefly acquainted with the new admissions so as not to fall foul of Trust Policy, I let him know what I was up to when the ODP was on their way to retrieve the patient from A&E. Once the anaesthetist had done their bit, I carefully examined the relaxed virgin belly, attempting to palpate anything tha