Surgical High

I have achieved what I sought out when I first entered O&G and thought, "Since I'm here might as well take as much as I can." I can now perform the lower segment Caesarian section. Yesterday was my tenth solo.

Thank you, Angela for the pic :)

It might not be a big deal to others but it's a personal achievement for myself as it is the first surgery that I was able to perform on my own after tagging and tutoring with my seniors and specialists. It is a procedure that a medical officer is expected to be able to perform in the district. I am not perfect in the art of surgery but I feel that I am improving bit by bit. I started out with a virgin ab and 'presumed' fetal distress (baby came out with APGAR 9 in 1), yesterday was a first advanced labour case which the baby's head was deeply engaged.

I am finding that each C-sec that I perform is always different from the ones I did prior to that and requires different approach, techniques and creativity that I may only be able to gain with time and practice and more learning from others.

I have also realized that we are not just performing surgery. We are not even trying to save lives. We are only helping out. And that comes back to the old medical saying, "Do No Harm." And in surgery its inevitable to do iatrogenic harm. What needs to be done is just damage control and prevent further life threatening harm and in some cases, 'aesthetic' harm.

What frightens me and I am very sure of other surgeons is the possibilities after the abdomen is closed and the skin shut tight. Will healing take its course well? Is there something I missed? A bleeder that may not seal on its own? A viscus I perforated and did not realize? Germs that I accidently left in the tissues that may accumulate and pus? The postoperative complications is what frightens me. I should be afraid as that would and should make me more vigilant. Nobody wants to open up a patient twice.

A successful surgery is not just being able to perform what needs to be done, whether its taking the baby out, taking the appendix out, taking the whole bowels out, fixing bones, amputating. A successful surgery is one that is done so that after the surgery, the patient walks out alive and able to live as near a normal life before she had undergone surgery or before she was sick. It's not about cutting, it's about healing. And not just healing of the body but also of the mind and soul.

As I cut more and more, I also hope to suture also those cut pieces back together. Essentially as I go through more surgeries, I'm also dissecting myself. And I hope I can piece myself together more perfect than before.

Thanks to all whom have brought me this far. Please guide me to bring me further.

Perinatal Mortality Meeting

While I'm glad it was all over, I consider myself fortunate to be part of the team to be presenting on the statistics of labour room for this year. It sort of gave me a few insights as to the importance of data collection and analysis and how we can improve and benefit from statistics and its interpretation.

Perhaps I am an academician at heart.

The meeting was a quarterly effort done with the pediatrics team.

I presented mostly on the number of deliveries and birth rates, including modes of deliveries, number of multiple gestations, preterms, and most importantly in the meeting, stillbirths. The pediatrics team had their own presentation on NICU admissions and mortality rates. Later a few selected cases were brought up for discussions as to how to improve things.

I expected blame games and bashings between department but what I saw was a rather pleasant discussion without too much hostilities.

Some of the data I wished I had included:

1. Rate of success of ECVs

Success of ECVs would reduce CS rates for indication of breech. This would be a big help in preventing maternity risk posed by CS as well as risk to fetus during breech delivery vaginally.

2. Shoulder dystocia

The data would be helpful in seeing what could have been done for prevention and anticipation of similar cases.

3. Cord prolapse

This is potentially preventable. Response time could be assessed and discussed as well.

 4. Outcomes of instrumental deliveries

Success although may not very well indicate justification of the procedure, it may provide insight as to the baby's outcome. Many factors come into play here.

As a person with pediatric surgical interest, my interest in connection to O&G would be antenatal screening of congenital disorders, such as gastrochisis, congenital diaphragmatic hernia, duodenal atresia, and spina bifida. Outcome of baby's are greatly increased with antenatal diagnosis and subsequent deliveries in a equipped tertiary center with pediatric surgeons.

I do intend to do my part to make data collection more bearable and simple. A simple template may help perhaps.



"Those who do not learn from the past are doomed to repeat it"
Winston Churchill

EXIT - Enter O&G

Post housemanship.

I thought I won't see O&G ever again after I finished the posting during my housemanship.

I was SO wrong.

I was placed to O&G, just a stone throw away from the department of my choice, Peds Surgery. What was initial dread, fear of screwing-up, almost alternate tagging calls, incompetencies, morning prayers and high-octane action, turned out it's not too bad at all. For now.

Anyways, we had a first-ever EXIT (EXtrauterine Intrapartum Treatment) done quite recently, organized by the O&G team involving Peds Anesthesiology, Peds medical, Radiology.

It was a case of a baby diagnosed with a huge neck mass antenatally by our fetomaternal medicine specialist. Then he thought, "Hey, why not organize an EXIT for the the baby so he won't come out gasping from airway obstruction?". So he did. And it was a historical success for Hospital Wanita dan Kanak-kanak Sabah.

Pasar di OT

An LSCS was performed only the baby was only delivered halfway. Continuity of the uteroplacental-fetal circulation is the main objective of the procedure. During that time, I was the cameraman for that monumental moment. The O&G team made way for our anesthetist to secure an airway for the child. At first, attempt to intubate the child failed. Only after aspirating the cyst a bit did the anesth team manage to put in the tube. And the baby was delivered and transfer of care to peds medical team was performed.

The kid is still in level 3 while peds surgery team, attempts to shrink or if possible excise the mass so the kid could be weaned off his tube and ventilator.

While in O&G, I am growing in a way. Mistakes happens but that's how we grow. Sure there are ups and there are downs. Alot of downs. But we just have to keep getting up. Because that's the way to proceed.

In O&G I am learning sonography. I am learning surgery. I am learning mother and child. All requirements for Peds Surgery.

I'll stay for awhile to further grow then perhaps... I will become a better Pediatric Surgeon.

Link:
bcdecker.com/SampleOfChapter/550092359.pdf

We Need Guidance, Please

What we don't need are insults. We just need guidance. One of my favourite teacher was Pang Chee Hoong, physician whom took care of male medical acute and HDU 1 during my time there. And that was when I learned how to put in the central lines.

I was in my 5th posting and I still haven't done any central lines yet! But Dr Pang showed me the way and now I'm more confident. I came out of medical with almost 10 central lines and quite a few on my own with assistance from nurses.

Coming to anesthesiology, CVL are mostly done by MOs in the OT. I assume that even they want that bit of practice.

Last night though I had my chance of putting in 2 on my own. But shit did I panic when I realized that I haven't pulled out the guide-wire when I inserted the triple lumen! My heart pounded like hell and I thought I would end up in IJN instead of the poor patient with the thyroid storm.

Fortunately the wire was still there when I pulled out the triple lumen. Booyah! Still a good flow!

Setting up central lines is one of my favourite procedures as a houseman. Haven't tried it on peds yet but would like the experience. Hell I still need the practice to set up regular lines in peds. Still suck at it. Learning from them experienced nurses is not a bad thing. I still have much to learn. As always.

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Tips to CVL insertion:

- Success is assured when patient and your position is correct. Failure is guaranteed when positioning and exposure is sub-optimal.

- Always have help around.

- The hardest part is getting the needle in the vein. Once that's done, the rest is a breeze.

- Know the potential complications.

- I know consent is important in the event of complications, but most of our folks, if we explain to them in details regarding the possible complications of CVLs, they would consult the whole kampung before agreeing. From Dr Pang: Do first, ask later. Save life first. (Up to you which you want to believe).

- Always pull out the guidewire first!!! Having a guidewire in the heart is equivalent to putting in wrong group match to a patient.

Have fun!

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Interlude

I'm writing way too much on O&G!

I promise Pediatric experience next!

(bukan ada orang baca pong)

O&G Revisit: The Bully

I had an MO (name with held but you'd know whom I'm talking about). He was a bully.

He would deliberately find excuse to 'kenakan' new HOs in the department (seriously!). His mood is like a playground see-saw, happy at one spectrum and a nuclear bomb at the other! He even admitted his mood swings and sometimes apologized for it.

My first incident with him was when I had my case note flung to the floor in PAC. I think he was angry with me for not writing well (I don't really remember now).

My second, when I scrubbed up for an emergency C-sec and I couldn't get through to the Peds MO oncall for standby. Baby came out flat, blue alert was called and he was furious with me throughout the whole closing of the patient's ab.

I've seen him calling up HOs for not filling in certain forms or writing in a style he didn't like. There was a time he told us he would find faults in the case note just so that he could find an excuse to scold a HO.

Well that was the worst of him.


On the bright side, after the blue-alert event, he did tell me nicely what I did wrong after I approached him and told him how sorry I am and that it was a mistake. He advised me not to take it personally as he just can't control himself at times and to learn from my mistakes.

He also thought some stuff in the labor room like what to look for in the CTG and during vaginal exams.

During my last few days of O&G, he gave me a chance to do a C-sec with him thus getting a very much needed C-sec performance in my logbook.
 

Much of the scoldings and the bullyings though unwarranted most times do sometimes provide the much needed eye-opener. And bad guys are not always bad (though they may be on the bad side of the spectrum).

He is still in the department and from what I hear from other HOs he is still the time-bomb he was when I was in O&G. But I do hope he does well and cool down a bit.

Well that's life.


Tips: Ambil yang baik, buang yang buruk, bersyukur.

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ps: I am so glad to be out of that department! =)

Final Posting: Anesthesiology

I remembered Prof Arif, my dear, Anesthesiologist lecturer in IIUM telling us how we should advise patient's going for op to pray as when the patient sleeps, it might be his last.

Undergoing anesthesiology rotation, I now can appreciate that anesthesiology is not a department where the anesthetist just 'intubate and extubate' or 'spinal' and just sit around in between.

Putting patient's to death with medications , maintaining airways and heart regulations while the patient is unaware, and reversing them back to life. Ventilator bag and machine replaces the patient's lungs, manipulation of his heart comes as easily with a push of the syringe plunger with the correct drug at the correct dosage.

My first impression of the anesthetist are that they control life itself!

Of course all this requires extensive knowledge on physiology and pharmacology to master this unique discipline. Just into my second month, I see that things do go wrong and shit happens and when it does, the patient's life can just slip from your fingers, and losing a patient on table is a horrible feeling when the patient (and family members) have entrusted you to keep him safe while surgery is on-going.

Things go wrong when you least expect them, ASA I patients, supposedly those undergoing short and routine procedures (I&D, CMR,  D&C).

Being put under is just damn scary. Putting someone under is just as scary. I have done a few successful intubations (20 is still considered few), and each time I still pray and hope that nothing goes wrong while I look for that vocal cords, epiglottis and put the tube in. This is by far the scariest procedures that I have to perform as a house officer.

Going through anesthesiology for 2 weeks in med school and 4 months as a HO is a very big gap. But that 2 weeks thought me a lot. Getting consent, RSI and inductions, MALESSS, holding a face mask properly and assembling the mask-valve-bag. And most important, the need to pray that things do not go wrong and the appreciation that life only belongs to Him and He is the controller of all life.


Lessons and Tips:

* It's OK to not be able to intubate. It's lethal to not being able to VENTILATE.
* MALESSS before intubating. It's a must!
* Label your medications.
* Check and check and check your blood products before giving them.
* Do NOT take things for granted.
* Remember that life is in GOD's hands. You are not god.