Gravity II

I just finished my first cup of instant coffee in three weeks. I cannot describe how much I enjoyed it. Ramazan has really shown me how important the small luxuries and comforts really are. Last week was pretty insane for me because I had lecture day on Monday, then evening shift that night. I was on call for Tuesday afternoon, then on Wednesday afternoon. This was for the labour ward and it was good. But sleep and normal daily living went out the window.

On Wednesday evening, after assisting the Midwives with two births and breaking my fast with hospital food, I decided along with my colleague, that it was time to go home and study. It is clear that sometimes when we are not useful and also when we're not learning anything, it might be more important to just find a room filled with books and spend hours reading one after another.

So my friend and I left to go back to the accommodation. I was ready to pass out. From the looks of poor G, so was he. Walking home required us to walk past the Operating Theatre entrance. I thought I would just see if there is anything going on in there, but G was smarter than me... he left without stopping.

I asked the reception RN if there was anything on right now.

.....

There's an emergency laparotomy going on. It will be starting in about 15 minutes. Right at that point, the ASU Registrar came out... Dr. FM; one of the most amazing surgeons. I will have to write about him in another entry.

Hi Dr. FM. I heard there's an emergency laparotomy. Can I be of assistance?


Yes. We're down a registrar. Evening handover doesn't start until 1900 and the junior registrar has to see the consultations in emergency. Come and scrub in with me until the consultant arrives.


Sure. I'll go and get changed.


How could I say no? At least I wasn't hungry. I could survive another few hours.

I arrived in OT6 just in time for the patient to go under General Anaesthesia. Dr. FM was looking through the CT scan done in the emergency department.

This patient is a 47-year-old female who presents with abdominal pain, vomiting and offensive vaginal discharge for the past 24 hours. She was discharged from the Gynaecology ward 8 days ago after undergoing Laparoscopic Vaginally Assisted Hysterectomy. On examination she is pyrexic and tachycardic. Full blood count demonstrates leukocytosis of 26,000. This CT scan demonstrates small bowel distension as well as free air under the diaphragm. We are concerned about a small bowel perforation. 


Shit.


It gets worse. Her appendix ruptured at the age of 8 and she developed multiple abdominal adhesions. This probably compounded the risk of perforation. It's going to be a difficult operation. Let's scrub.


Okay I know I'm doing my O&G term and I thought I would deviate into General Surgery for the night.. and I ended up back in Gynaecology land. Well almost. It made me giggle. Lucky I was wearing a mask.

The senior Registrar on the evening shift arrived. Dr. PB was furious - he was also scheduled to be the on-call Neurosurgical Registrar. That baffled me somewhat and then I realised Dr. FM was equally baffled. After a brief introduction, he was dissecting along with Dr. FM while I retracted.

Nothing could be heard in the theatre once we reached the peritoneum. The room stank of faecal matter and our gloves were covered with it. The small bowel was distended to the point of looking obstructed, but it was actually the reaction to sepsis secondary to perforation. There were serosal tears, multiple perforations 3-4 mm apart in the ileum and patches of pus all over the small bowel. The offensive vaginal discharge could now be explained: it was an entero-vaginal fistula.

Dr. FK arrived - the rostered ASU Consultant for the evening. He relieved Dr. FM, who was actually doing Breast & Endocrine this term but scrubbed in as the most senior Registrar. He quickly identified the ileum involved and decided that the only option in this poor lady's situation was small bowel resection & stoma. 8 litres of saline later, the poor patient's abdominal cavity appeared clean. The stoma location was not ideal as it was adjacent to the laparoscopic port scars, which hadn't healed. The laparotomy wound had to be partially closed with a negative pressure dressing; requiring revision every 2 days. All in all, it was a shocker of a case and the patient now needed HDU admission.

Retracting and suction for hours on end can be exhausting. It was now 2230 and Dr. PB was happy for me to leave.

I got dressed and I thought in order to catch up with my sleep patterns, I would take Thursday and Friday off. Thursday was not too bad and I got some work done. Friday I caught up with one of my friends and had a meeting with my research supervisor. I didn't get very much done.

The weekend was really busy with work. Who knew catching up with family was so time consuming? Not that I'm complaining. It's just not helping my stress levels.

So back to today. I left for my hospital from my parent's place and didn't get in until 0900, but the other two students had already reserved time with the OT, where I'm scheduled this week. So it was time for me to finish my ethics essay on Elective Cesaerean Section. Back to the hospital I went for the NICU tutorial in the late afternoon. That didn't happen, so I thought I would go back home to do some work and cook dinner (normally I have canned soup).

But wait... there's more!

I decided to go to OT reception to check the theatre list for O&G tomorrow. I'm scheduled with the Uro-Gynaecologists in the morning, which should be interesting.

The reception RN recognised me from last week. ASU's operating now in OT6 again. Urgent case, if you're interested. 


Right. Do they need help?


Not sure. Give them a buzz.


Okay.


*Rings Theatre 6*

Hello theatre 6. 


Hi. Medical student here. Does the ASU team need assistance?


Well there's only the Consultant here. I'm sure he wouldn't mind your help. I'll just ask him...... Yep. It's fine. Come on in.


Thanks. Now I have no choice.

Dr. HL is the ASU Consultant today. We've seen each other around, but never worked together. He didn't interact much at all other than to introduce me to the case. But most of that I got out of the patient's files.

70-year-old female transferred from BMD Hospital with abdominal pain. CT scan demonstrates an obstructed indirect inguinal hernia. I will be repairing it Laparoscopically.

So I started scrubbing and then the ASU Registrar showed up. At that point I knew I wasn't going to be needed in there, but I scrubbed anyway. As the third wheel, I stood there and watched the screen while the surgeons operated Laparoscopically. The interesting thing was that there were two hernias! The first was the one demonstrated on the CT and the second was a direct inguinal hernia containing what appeared to be a lipoma attached to mesentery. It was interesting to watch how it was repaired with mesh.. both at the same time with a technique known as peritoneal stripping with post-reduction mesh and closure with PDS. I asked to be excused just as the suturing began because I had done nothing the whole time. They were happy to let me go and I was happier to leave.

It was now 1700 and I could break my fast in 40 minutes. As I left the change room, I ran into Dr. HC, one of my friends and a Resident applying for Basic Physician's Training next year. He asked to catch up so I walked him to the Doctor's common room. I saw a few Interns and Residents I met over the year; they were wondering what I was doing on hospital grounds after 1600. Funny if you ask me. At that point, all their pagers went off at the same time: MET Call - Paediatric Ward. We dropped everything and ran, all six of us. We bumped into the ICU Consultant on our way there. At least now we had a leader. Thank God! The room was already packed when we arrived. The ICU Consultant took over care and relieved the six of us.

As we left, I promised Dr. HC that we would catch up again soon and made my way toward the exit. Until... I ran into Dr. BM, the senior Registrar in Geriatrics.

Hey mate how are you?

Good thanks, Dr. BM. How are you? 

Well thanks. I've been asked to speak to a patient's family about end-of-life decisions. Care to join? 


Of course. 


Okay. This is an 89-year-old lady who came in with malaena and a Hb of 61. They transfused her in ED with 3 units of packed cells and went ahead with a CT of the Chest, Abdomen and Pelvis. There appeared to be a deep-seated duodenal ulcer explaining the malena. However, there was also goitre with retrosternal extension, hepatomegaly with multiple lesions enhancing on arterial phase, a soft gallbladder mass and also an irregular lesion in the lower lobe of the right lung. The prognosis is poor. The Gastroenterologists scoped her last night and confirmed the ulcer, injected adrenaline several times but could not reach the base. So the family needs to be informed of what happened last night and also about the CT scan results. 


Shit.

Yes it is.

The patient's two daughters (of eight children), one grandson (of twenty five grandchildren) were present. We arrived to them crying beside the patient, who was asleep at the time. After 45 minutes of explaining the situation, it was about the right time to discuss the NFR (aka DNR) order. They agreed to NFR with the exception of blood transfusion, fluid replenishment, antibiotics and total parenteral nutrition if need be. So many tears. I wish there was more we could do.

It was finally time to go home and break my fast. It was now 1900.

I might stay back and appear to be over-enthusiastic, even obsessed. Yes, it might be that way at times, but more often than not, I am pulled into situations.

That's not to say I'm complaining. There is nothing more satisfying for me to know that I can be of use to someone, somewhere. Nothing makes me happier knowing that my retracting, suctioning or scribing might just decrease morbidity and mortality.

As Sharp Incisions describes in my favourite post: Sometimes Medical Students have an important part to play among all the chaos, particularly in the Emergency setting.