Monday, 23 September 2013

Smack in the Head

Fourth year eases you in gently with a Special Study Unit.  In this case, it's a three week block spent in one department, assessed by an essay to be handed in the following week.  The rest of my SSU's this year are all longitudinal ones, so I get the odd week on them here and there, but mostly we work on them in our own time to produce the assessed work required.  As they repeated like a broken record at the induction, this is to test our organisational and time management skills.

The SSU I have just finished was three weeks in the maxillofacial department.  Now I did pick it but it wasn't what I was hoping for from the list I submitted to the medical school.  The blurb was written very cleverly.  It sounded like a trauma SSU, as you can see from the title "A smack in the head" and glossed over the fact it was maxfax.  I think that's probably why it was a 'red spot', which means it's a hot favourite that lots of people pick so there's a lot of competition for it.

Despite being somewhat disappointed by the fact I wouldn't be spending three weeks in the Emergency Department and that our facilitator would be on holiday for the first of our three weeks, it was actually really good.  It soon became apparent that we have had no maxfax exposure in our course.  I had no idea where to start when it came to teeth.  Maxfax deals with dentistry, facial trauma, neck lumps, skull fractures and orbital pathology.  A lot of the clinics we saw were mainly painful wisdom teeth, temporalmandibular joint (TMJ) dysfunction (clicking, locking and pain of the joint where the jaw meets the skull by the ear) and teeth abscesses.

The head and neck MDT and cancer clinics on a Thursday were good although very harrowing.  I was moved to tears several times by some of the stories, as head and neck cancers only have a 50:50 survival rate at 5 years.  Some of the people coming to clinic seemed far too young to be getting that news, it wasn't fair.  I'm getting better with the tears though.  I shall have to really, I have a whole 9 week block in oncology and palliative care coming up this year.  If I don't improve, I'm going to dissolve!

We got to scrub into surgeries helping to remove teeth.  Teeth come out a lot easier than I thought they would.  I didn't get to pull any, and to be fair I really didn't want to, but I did get to inject some of the local anaesthetics to help make the patient more comfortable when they came around from the general anaesthetic.  We also saw some noses being straightened after trauma, and a couple of washout surgeries to flush out the contents of the TMJ.  By far the most impressive surgery however, was a 10 hour all day orbital exenteration.  The patient had cancer extending into the orbit and around the back of the eyeball, so the surgeon removed the eyeball and some of the surrounding tissues, packing the area with grafts from the skull, muscle from further down the face and skin from the thigh.  Because the surgery was so long, they were able to get frozen sections looked at by the histopathology lab to ensure they had clear margins and had removed all the cancer while the patient was still on the table.

I thought I would be quite squeamish, as the only other time I've nearly fainted in surgery was removing a tumour from a lady's face under local anaesthetic in dermatology.  I find it a lot easier to cope with when the patient is all covered up, it's harder to reconcile the reality of what you are doing to a real person.  With this one however, obviously the face wasn't covered up, but it just felt like we were performing surgery on a cadaver.  It didn't seem possible that you could do such drastic and brutal things to a person and for them to be alive.  I was pleasantly surprised with myself for not freaking out like I was expecting.  Once the cavity has healed, further down the line the patient will have a prosthetic eye area made for them, complete with eyelashes, eye brows and wrinkles.  The examples we saw were incredibly realistic, it was amazing.  The eye won't blink, but the passer by in the street won't be able to tell it's not real.

The consultant surgeon had a nice addition to the WHO surgical checklist where everyone introduces themselves at the start of the theatre list and the cases are discussed to keep everyone up to speed.  He gets everyone to rate themselves out of 10, so others are aware that maybe their colleague isn't on top form and needs a little looking out for.  We do a similar thing in our small group sessions, where we have a 'baggage check', so you can say if something has interfered with your work in the last week like illness or computer problems.  I thought this was a nice, elegant way that helps you tell people you're not 100% but means you don't have to discuss it if you don't want to.

No comments: