How'd you fancy one of these in you're special place?

Well folks, today was the first time I have ever held another man's willy.  It was, of course, not recreational but rather to put one of these in it:

The little balloon at the end is to stop it sliding out of the bladder.  I was, however, unsuccessful.  The gentleman's prostate was enormous and I couldn't get it all the way into the bladder.  Just in case, here's an easy 1-2-3 of male, urinary catheter insertion:

1. Lie the patient supine (on their back)
   
2. Place sterile drapes around the area, cutting a small hole for the penis to fit through
   
3. Using the left hand hold the penis while you use the right hand to clean the glans with irrigation solution
   
4. Holding the penis vertically squeeze 10mL of instillagel (lubricant + anaesthetic) into the urethra
   
5. Wait for 10 seconds
   
6. Take the catheter and slide into the urethra all the way to the port
   
7. Using sterile water inflate the balloon cuff
   
8. Connect urine collection bag
   
9. Clean up
   
10. Ensure the patient is comfortable
    
11. Walk away proud
    

So there you go! You'll never have a problem.  I'll leave you with a true story:  

A medical student was being watched as he was catheterising a female patient for the first time by a senior surgeon.  Whether it was nerves or lack of skill he inadvertently put the catheter in the wrong hole...as it were.  To whicht he surgeon shouted "What's that?! Come on man, I learnt female anatomy aged 15 in the back row of the cinema!"

I Shouldn't Be Here!

Happily walked into a respiratory outpatient's clinic the other day.  The consultant I was with was a bit crazy but they all seem to be in some way.  The Vascular Surgeon I'm going to be with in 4 weeks time will not pay me any attention, in fact he might send me home, if I don't wear a tie!

Back to the clinic.  There were several patients seeing the Consultant for various diseases, Tuberculosis, Chronic Lung Disease, etc.  There were a couple of patients there to receive a confirmation of a diagnosis of lung cancer.  Lung cancer is one of the really bad cancers, they are all bad of course, but many offer good prognoses with current treatment and many people can survive it nowadays.  Lung cancer, however, remains stubbornly resilient to treatment and more importantly early diagnosis.  Early diagnosis is the key to curative treatment in most if not all disease.  Because of this the 5 year survival for lung cancer is around 5% and has been that way for a while.  So most patients will understand that being told they have lung cancer has a major impact on their lives.

So, a patient came in who was wheeled in on her wheelchair by one of her daughters followed swiftly by another daughter wheeling in the patient's husband.  Now the husband had already been diagnosed and treated for terminal prostate cancer.  By some weird trick of fate I ended up sat in the middle of the family, from left to right it went - patient, daughter 1, me, daughter 2, patient's husband.  As the consultation went on the consultant gave the diagnosis and I suddenly felt very aware that I was sat in the middle of all of them!  I have never wanted to run so much in my life!  Partly for me because I was weirded out and felt like a gooseberry but mostly because I felt I shouldn't be allowed to just sit and watch a moment like this, it's too personal!

Truth is though, that I have to be there.  Doctors of every speciality have to be able to break bad news well and sensitively.  It is a learning process and requires a lot of observation of senior colleagues who have done it many times before.  Get it right and you can help people through a very difficult time, get it wrong and you have an already sad patient who is angry and shocked to boot.

Hello again!

Back to abortion later...I'm back on the wards! Hurrah!  It's a brand spanking new hospital and I'm doing Respiratory medicine first then vascular surgery.  I've missed the hospital, lectures are boring and you learn so much interacting with patients.

I was reminded a couple of weeks ago about how weird being a medical student can be.  You don't really know anything and you've not done many procedures but you are referred to as a 'Colleague' by senior consultants and patients seem to trust you implicitly!  Anyway, I had been asked to put a cannula into a patient, should look something like this:

It was all going well, I'd got the flashback of blood which told me that was in the vein (hurrah!) and happily turned my back to get the cap to seal it up when I heard a faint "Blood!" from the patient behind me.  I turned around to find a scene out of The Predator.  The cannula being in vein correctly meant that the blood was free to leave it...and because muggins over here had forgotten to undo the tourniquet the blood was under pressure.  Needless to say I had to spend some time cleaning his arm and wiping some blood off of the floor. Delightful.

Abortion Part 1 - The Law

Well, my friends, it has been a while since I last did a proper post.  I'm not on the wards at the moment so, without any practical examples, I thought we'd all benefit from a bit of theory! Hurrah I hear you cry!  But then...Abortion? Why such a whopper of a subject?  Let me explain.  

I believe, right down in my deepest darkest parts, that ignorance is the scourge of mankind, to quote Derek Bok (former President of Harvard University):

"If you think education is expensive, try ignorance"

and German playwright Goethe:

"There is nothing more frightful than ignorance in action"

Abortion, for reasons that I can't quite explain, is a subject that interests me.  It is the source of so much tension and sadness in the world.  Sadness of those who are personally experiencing it and tension between people who have such passionate views on it.  It is a subject on which I have seen and heard such phenomenal ignorance and this invariably leads to more of that sadness and tension I mentioned.  I have talked about my experience of it in the hospital before but I thought that I might elaborate on more of the technical issues, so that, in my own small and insignificant way, I might erase some of that ignorance.  I am not a lawyer, or a medical ethicist, neither am I an obstetrician or, as you may have noticed, a woman.  However, I do not believe you have to be any of those things to have a sincere and well thought-out position on this issue, and that my friends is the right path to start down.  Because, in the end, knowing more and more about these complex issues is only a means to the end, that end being an opinion.   It is here that I should add a caveat, I am hoping to do a number of posts on different facets of Abortion and in doing so I will try my hardest to remain neutral.  This will be easier with some posts than others!  I do this so as not to cloud the opinion that might be forming in your mind, but also, because I don't believe that in the end my opinion, whatever it is, should make much of a difference.  At the heart of all this is a pregnant woman and a foetus who need kind counsel, patronage and support, neither of which I can see being given adequately with any pre-existing bias.

So, anyway, in my mind I see three posts.  One on the legal side of things, the medical side of things and one going over the main philosophical/sociological side of things.  I don't think they'll be too intense but enough for you to know the key details.  First off...the law.

We must start, as always, with the Offences Against the Person Act of 1861.  This is the definitive law in England, it states that abortion is a crime and punishable by life imprisonment, unless future legislation provides protection against prosecution.

That is what happened in 1967 when the Abortion Act was introduced.  It provided protection from prosecution, not to the mothers, but rather to the doctors carrying out the abortions.  It was later amended by the 1990 Human Fertilisation and Embryology Act.  So, when is it legal to have an abortion?  There are seven conditions under which abortion can be performed, two of which must be in an emergency situation.  Two doctors must agree that one or more of the following options apply:

A - Continuation of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated

B - The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

C - Continuation of the pregnancy would involve risk, greater than if it were terminated, of injury to the physical or mental health of the pregnancy.  As long as the pregnancy has not exceeded 24 weeks

D - Continuation of the pregnancy would involve risk, greater than if it were terminated, of injury to the physical or mental health of any existing children of the pregnant woman

E - There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Or, in an emergency, if one Doctor decides that:

F - The termination is necessary to save the life of the pregnant mother

G - The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant mother

So, there are the conditions under which abortion can be performed legally in the UK. Essentially in the UK when faced with the decision of whether to terminate the pregnancy or not the Doctors must decide whether or not it is safer for the woman than continuing it.  If a woman approaches the doctors before 24 weeks she must demonstrate that continuing with the pregnancy would could cause her more physical or mental damage than if it were terminated. Legally, it doesn't get much more complex than that.  There are different issues with younger women but those are to do with the legal concept of competence.  Where someone who is legally a child (under 18) but is able, or demonstrates that they are able (competent) to make decisions about their own treatment.  You can also see that only options C and D make a statement about a gestational age limit (24 weeks - more about this in the second post), for the other options it is possible to get an abortion right up until birth.

Another important point to remember is that the foetus does not have any legal rights until it has been born.  It does not have the right to be born and it does not have the right not to be born.  The law only recognises the gestational mother only.

It think it would be worthwhile to look at some statistics, all of these are from 2007.

• There were 205,598 abortions (179,746 in 1997 and 133,004 in 1977)
• 89% of these NHS funded and 11% privately
• 98% of abortions were carried out under option C above, less than half a percent of which were due to the risk to the physical health
• 1% were under option D and the rest of the options made up the final 1%
• 90% are performed under 13 weeks gestation, 0.1% were greater than 24 weeks
• Most abortions were carried out on women aged 20-24 yrs, then 15-19 yrs, then 25-29 yrs
• 1,171 abortions were carried out on women under 15 yrs, 163 under 14 yrs
• 81% were carried out on single women
• 32% of women had one or more abortions previously
• 1005 women had had 4 or more abortions previously

Phew, that's a lot of numbers!!  I don't think any of that would be a great surprise to anyone, most abortions are to young, single women who use option C, where the pregnancy would cause greater risk to their mental health than if terminated.  It's staggering to see how young some of these women are and that there are many who have had previous abortions.

Well, I'll leave this post at that point.  I can't tell you how much I want to waffle on about all this but there would be opinions all over the place and we wouldn't want that would we....

Fact me 'till I fart: Part deux

Just in case you weren't feeling special enough, I have some news.  All humans share 99.9% of their genes with each other, all of the variety, all of the differences between humans is down to that remaining 0.1%

Oh, and you're 50% the same, genetically, as a lettuce.

Opt-In or Opt-Out?

Went to an excellent debate today on organ donation, specifically the current debate on whether citizens of the UK should have to choose NOT TO donate their organs following death (Opt-Out) rather than the current system where we choose TO donate our organs (Opt-In).  Representing those against any change was Earl Howe, conservative spokesperson on health and an Intensive Care doctor from Addenbrooke's Hospital in Oxford.  The other side was represented by Dr Evan Davies, Liberal Democrat MP and Veronica English, vice-chairwoman of the BMA Ethics Committee.

There are about 8000 people waiting for a transplant, with about 2300 transplants carried out each year and something like 1000 patients die each year waiting for a new organ.  The UK is waaaaaaaay down the list in terms of donor numbers with ~13 per million population, compared with Italy (21 pmp), France (22 pmp) and Spain (35 pmp).  When a patient dies 40% of patient's families will refuse, but survey's have shown that if the choice is actually put in front of a person an enormous majority (90% I think) would to sign up to the Organ Donor Register.

So, with Opt-Out, you presume consent.  You assume that if the patient were alive and able to give his or her consent, they would choose to allow their organs to be used for transplant.  Is that something you can presume?  Do we, does anyone, have an assumed 'right' to someone's organs?  Would you like to have an organ from a person when you couldn't be sure that the donor wanted their organs to be used?  With there being so many people dying before an organ can be found do we have the luxury of being apathetic to the need to donate organ?

There are so many more questions and I have a lot of opinions, but do you? Have you thought about organ donation?

The View from the Other Side

Well, here they are:

my irritating little buggers of wisdom teeth.  In my first year I spent two weeks with an oral surgery department and saw several patients have their wisdom teeth out under general anaesthetic.  This week it was my turn.  What a weird experience to be on the other side, to be the one led into theatre and asked to lie down on the table.  "Sharp scratch" is what I've heard them say a thousand times when they put the cannula in...not so bad really, "This might feel painful as it goes in" is what they say when they inject the propofol (the white coloured anaesthetic)...and it really does hurt.

Anyway, I'm left doped up on painkillers and getting bored with episodes of ER.  I'd kill to be able to eat Big Mac.