Welcome back to The Dogsbody, this is my belated week 3 post! It’s rather late because I spent my weekend at a welfare and ethics conference, so read on to find out how that went down. But let’s start with Monday.
After a painfully dry lecture on pharmacy legislation, followed by two very graphic and exciting lectures on post-mortem technique and incidental findings, I trotted over to the Hospital for Small Animals to meet my group for a “Theatre Practice” practical. With no idea what this would entail, we followed a nurse through the hospital to the surgical department.
She ran through her introductions and Health & Safety spiel before getting down to business, “There are scrubs on the shelves behind me and surgical clogs on the rack to your right. Please find the right size and put them on in the rooms to my left. The changing rooms are rather small and we have lots of ladies so just be careful! There should be nothing under your scrubs so please take your clothes off, just underwear and socks. Then meet us back out here and we’ll split you up.”
I sort of shot a sideways glance at my colleagues, who all appeared to be as surprised as me at the impromptu stripping. I had not prepared my body in any way for public display. Apparently neither had they.
But we had our instructions, and I grabbed my size of everything and squeezed into the changing rooms. She wasn’t kidding about the size of the place. It was like somebody had put all of Africa’s flamingos onto the London underground. We all stood packed together semi-naked and swaying on one leg trying to get our scrubs on. The minute I was dressed I flip-flopped back out into the corridor in my white crocs. To finish off our look, we all put on surgical caps. As I followed my half of the group away, I caught sight of myself in a window, and genuinely couldn’t decide whether I was rocking the surgeon look or just walking about like a dinner lady in pyjamas.
Our nurse took us to a meeting room, where she said we could kick our shoes off if we wanted. I did. She informed us that we would be learning to glove and gown ourselves in a sterile way in preparation for scrubbing in to surgeries on EMS. She explained the difference between ‘open’ and ‘closed’ gloving techniques, and made it quite clear that ‘plunge gloving’ is for fake surgeons on Casualty and that your vet nurse will tell you to “f*ck off” if you ask them to do that for you. Note taken.
She went on to demonstrate the open gloving technique. It sounds obvious, but when you’re dealing with sterility, there are regions of the gloves that you cannot touch even with your sterile hands, and there are regions that cannot touch each other, regions that can touch each other, and regions that can’t touch each other once you’ve touched them, etc., etc. “So you’re going to reach diagonally across and take the inside-out cuff of the right glove with your left hand. Then you introduce your fingers into the glove and begin inserting your hand. As you pull the glove on, you’re going to need to catch the edge of the cuff with the thumb that’s inside the glove to form what we call a ‘thumb capture’. So this glove is sort of only halfway on, but that’s how we want it. Next, reach diagonally across and slide the fingers of your right hand into the inverted left cuff, so that only the two outer surfaces of the gloves are touching. The thumb capture means you can touch the inside of the left cuff with your right thumb even though it’s gloved. Hold that left glove vertically and slide your hand into it, pull the cuff as far back as it will go, and then let it snap back. Finally, reach across and put the fingers of your left glove into the inverted right cuff and pull the cuff as far back as it will go. Just like that.” She waved her gloved hands at us.
Just like that.
I had watched her across the table, so my mind was now trying to rotate this task into my perspective. At least that’s what was going on inside my head. Outside my head, I was just staring at my gloves with my hands in the air. Sensing the universal confusion, she offered to do it again, and suggested we follow as she did it. So she began again, and we mirrored her actions with our own gloves. I watched intently as she performed the first move, and then attempted to copy her. But I was struggling with the thumb capture. My skin was sticking to the gloves so that I couldn’t just “slide” in, and I missed the cuff edge and failed to create the thumb capture. One thing all medical professionals will know is that once you’ve buggered your sterile gloving, you can’t go back. But I thought I could redeem this situation and reverse back to recapture the cuff with my thumb.
And so I stood with my tongue sticking out stretching the glove in all directions, frustrated by the fact that my fingers were completely stuck and all I was producing was squeaking and snapping like a balloon artist at a children’s party. I soon noticed that the nurse had stopped talking, and I looked up to see her and the rest of my group with one glove on, staring at me.
“Sorry, one second.” I hurried to find a solution to my predicament, but now my hands were sweating with the stress. The squeaking and stretching intensified.
Finally the nurse got fed up of waiting, “We’ll just let you play with that. Everyone else, reach across with your right hand and grasp…” I continued in my stretchy endeavour as she pressed on. I did finally get that glove on, and then attempted the second one. With a final satisfying snap, I held up my hands for all to see. Tragically, half the fingers were flopping in various directions, but nevertheless I was proud to have made it.
After numerous more attempts, I was getting the hang of it. Now that we were comfortable with that, she began teaching us to put on a sterile gown. It’s not a particularly difficult thing to do, it’s like putting a dressing gown on backwards. But surgical gowns are quite roomy, and I’d been overly polite when collecting one from the pile so mine was Extra Large.
Rule number one is that your fingers mustn’t peek out the end of the sleeves, you have to keep your hands hidden inside like a five year old child in a huge jumper. Gowns on, it was time to attempt ‘closed’ gloving. I shuffled back over to my gloves, almost killing myself tripping over the gown in the process. Closed gloving is actually supposed to be easier, but I soon discovered that ‘easy’ is a relative term. You have to do the whole thing with your arms inside your sleeves, so I flapped around like a muppet with two sock puppets and a pair of rubber gloves until the damn things were approximately on my hands.
Again, it got easier with practice, but I was so caught up in having fun dressing up as a surgeon that I was fully garbed when it was time to swap with the other group. As my peers were filing out of the room, I was frantically stripping off my gloves and gown and hurrying after them. It was only when I was halfway to theatre that I realised my crocs were still in the meeting room, and so I trotted back barefoot through the hospital to retrieve them. What an embarrassment.
Phase 2 was a tour around the surgical department, where everything could be found, and how they navigate the logistics of such a huge surgical referral centre. There were multiple surgeries ongoing that we peeked at through the theatre door windows. It was state-of-the-art in those theatres. I would have been thoroughly satisfied if I were to go under the knife in there, and so it was almost humorous when the nurse said things like, “This theatre is usually reserved for laser surgeries and neurosurgery but because it has a separate controlled entrance it’s also great for flying patients.”
Like yeah, sure, that’s not bizarre at all.
She then took us to a big row of surgical sinks, where she demonstrated the aggressive and thoroughly thorough technique used to sterilise your hands and arms for surgery. It’s such an awkward and lengthy process, using your elbows to operate taps and soap pumps, keeping your hands above your elbows, remembering which sides of which fingers you’ve done, keeping count of the number of scrubs you’ve done on each side of each finger. I fully understand and appreciate the theory of bacterial spread and asepsis, but as my skin began to scream against the abrasive scrubbing pad I started to wonder if I’d really be sterile with no skin left.
But honestly the thing I hated about it most was the way the soapy water runs down your armpits and into your trousers. There’s something really unpleasant about that. It’s pathetic, I know.
As soon as I’d scrubbed my last scrub and rinsed off my arms, I shook my hands a couple of times and turned around to go and get a paper towel. But the nurse appeared in my face, “Don’t shake your hands! When you shake like that you force water to travel retrograde from your non-sterile skin onto your sterile skin. It transfers bacteria back towards your hands! Don’t do it!”
I hadn’t even realised I’d done it, it was so instinctive. That’s half the problem with sterility. You learn all the techniques and understand all the dangers, and yet you breach asepsis without even knowing you’ve done it. Oops.
After a very long time scrubbing, the nurse introduced us to a new technology that the hospital had agreed to buy into as an attempt to be more environmentally friendly. I assumed it would another laborious and messy affair, but I was pleasantly surprised to see just a wall-mounted dispenser.
“This product requires no water, no scrubbing pad, and only one and a half minutes’ contact time. It’s 80% alcohol, and if you stick to the rubbing instructions, you’ll be completely sterile and ready to perform surgery.” She proceeded to demonstrate the protocol, and after just 90 seconds, she was sterile and surgery-ready. I almost couldn’t believe it. Something in me needed to see aggressive scrubbing to believe that her hands could be sterile, but there they were. Genuinely incredible.
Only four people at a time could stand around the dispenser, so I watched as four colleagues had a go. You have to be very liberal with it, because your hands need to remain covered as you rub, but it evaporates very rapidly. Once they were finished, my group stepped up. The air was thick with the smell of alcohol, and as we stood around dispensing more and more into our hands, it just got worse. Eventually, we were struggling to see the countdown clock for our burning eyes, and I daren’t breathe because I didn’t want to start coughing all over the place. With all my mucous membranes stinging with the alcohol, it was then very easy to imagine that my hands were sterile. I’d be pretty confident about the sterility of my sinuses, too.
I made a joke to a peer about surgeons going into theatre absolutely sloshed from the hand rub, but she didn’t find it very funny.
Tuesday saw some very hard-to-follow lectures about the autonomic nervous system and the drugs you can use to manipulate it, and a terrible circulatory pathology lecture that jumped around crazily from topic to topic. The autonomic lecturer had an infuriating habit of asking us questions that we couldn’t answer, and then getting exasperated and saying, “I’ve literally just taught you this.” Yes you have but wE dON’t undERstAnD.
But the afternoon gave me the chance to have a go at some key skills for extramural placements. The clinical skills lab had been kitted out with dead animals and medical models for us to practice blood draws, setting up drip pumps, catching fractious dogs, calculating and administering vaccinations, and all the other good vetty stuff. There’s something a bit depressing about vaccinating a dead rat though. It’s not gonna do him much good.
Wednesday morning brought a personal highlight: pathology. After attending (and supposedly understanding) lectures on certain pathological processes, you’re supposed to consolidate and apply that knowledge during the practical. The first half was spent looking at microscope images of cases from the hospital and trying to piece together a diagnosis using the histopathology and the clinical presentation. But I’ll let you in on something. All histology looks like this:
IT’S ALL PINK AND PURPLE.
I can just about distinguish what organ I’m looking at if the sample is well-stained and accurately fixed, and the micrograph is of good quality and displaying a typical, normal section of tissue. I have absolutely no hope in hell if what I’m being shown is pathological and abnormal. But I rolled with it in the class so that I at least felt like I was contributing something worthwhile to the discussion.
Then it was on to the post-mortem room, where all sorts of organs were laid out for our inspection. This week’s theme was acute inflammation, fatty change, and necrosis. In other words, every sample had some sort of abscess, pus, or rotting going on. I can’t share photos from the PM room, but I promise you that’s a mercy. There were some extremely severe pathologies going on in there, and some exquisite smells. Half the time I wasn’t exactly sure what organ I was sliding around the table with the end of my pencil, but I could tell it wasn’t good.
Thursday and Friday were another flurry of lectures on client communication skills, anaesthetic breathing systems, more circulatory disturbance, and an introduction to neoplasia. Of course that all added to a growing pile of work I needed to write up, but there was no time for such things that weekend!
Because early (too early) on Saturday morning, Rowena and I took a coach from Summerhall to Easter Bush to attend the Veterinary Ethics & Welfare Conference that we’d so maturely bought tickets to. On arrival we got name badges, a goodie bag, and a buffet breakfast. That morning’s speakers were national experts on a range of topics including clinical ethical dilemmas, the ethics of surgical intervention, and the ethics of breeding based on looks. After a buffet lunch, we attended a workshop that had us discussing different approaches to dealing with mistakes in practice. The afternoon’s speakers talked about the development of animal welfare legislation, the incredibly strong link between animal and child abuse, and ethical issues with working abroad. We were bussed back into the city to a wine reception at Dynamic Earth, and then enjoyed a fantastic three-course evening meal. Wined and dined, we headed home to bed.
Even earlier (groan) on Sunday morning, we travelled back out to the Bush to get breakfast and hear talks on veterinary autonomy, management of animal welfare violations, and compassion fatigue. There were a couple of workshops that got us talking about dealing with situations where what the client wants is at odds with the animal’s welfare, or where financial limitations restrict treatment options, or where you disagree with colleagues over the best course of treatment, and asking just because we can, does that mean we should?
The whole weekend was genuinely riveting. I have never paid attention to a speaker for so long without losing interest. Ethics is a field in which I truly believe veterinary medicine is far more complex than human medicine. There are so many, many more factors at play and such variation in patient, client, and circumstance. The lectures and workshops continuously challenged me. Every time I thought I had my moral footing secure, every time I thought I knew where I drew the line between acceptable and unacceptable, there would arise a new scenario that threw it all up in the air and made me start again. There were very few answers provided to us over those two days, because there are no right answers. But it was a perspective-changing experience that teased out all the different strands of the tapestry for me to see. I’m really, really glad that I went, because for the rest of my career I will be able to stop and consider all angles before continuing. And even if that doesn’t change my course of action, at least I will be sure that I’ve given it thought. And hey, I got all of that for thirty quid – bargain.
This week has provided even more challenges and entertainment, so do join me at the end of it to see what I got up to!