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Hello, everyone. Um Thank you for joining our session tonight. I'm pretty, I'm one of the committee members of the Yorkshire Foundation Trainees Surgical Society. Um So this is our third event in our surgical specialty series. Um So we'll be, we've been hearing about different surgical specialties and in particular from the registrar perspective, what they like, what they don't like and what they think about it. So tonight, we have Mr Mike, use a registrar in emergency general surgery and major trauma in Yorkshire. Um, so he'll be telling us more about those sort of things and if you have any questions, feel free to put them in the chat, um, and we can pick them up at the end and then we're due to have a couple more events as part of this series before wrapping up for the, before the end of the academic year. So just keep an eye out on your emails. So I will hand over to Mike now. Thank you. Hello, Israel. Hello, everyone. Um, so my name's my keys, I'm going to talk you through major trauma and emergency general surgery. My other best specialties and uh due to some slight technical difficulties. We're going to be doing COVID style of next slide. Um So just bear with me when we do that, I'll talk for about 2025 minutes and feel free to interrupt and clarify whenever you want. Um And then happy for any questions at the end. I'll apologize in advance if my Children or anyone else appears at the screen, I'll try it. I'll ask them to go away, but they're not listening to me. Um So let's get on with it next slide, please. Um So, um mine is like you said, um and I'm a surgical resident Yorkshire currently emergency general surgery and major trauma. And I've got a couple of the job roles which I'd like to introduce simply to say that my views don't reflect those are the organizations I work with. So I'm a hems doctor, so an air ambulance doctor um for the Links and Knots are ambulance and that will feature heavily in this tall. I'm also volunteer with the local mountain rescue team as well as previously, but not currently working for York City football club in New York City nights as one of their matchday doctors, but all of the use I'm about to express do not necessarily reflect any of the organizations including the NHS. Um So we'll move on next slide, please. Um So I'm gonna, when we get these talks, we get a slide deck um to kind of what, what we should base our slides on and I've copy and pasted this exactly as it is. So I thought it was quite a lot, a lot to live up to. So what the aim of this talk is, is to, um, ob provide flavor of specialties to make contact, to inspire you, which I might struggle with and educate and then hopefully give you insight into less common or newer surgical specialties and certainly both emergency central surgery and major trauma fall into that newer bracket next night, please. And as part of that, I've been asked to talk about a week in the life of what I do. So as a senior surgical registrar with this emergency, general surgery and major trauma background, uh, there's a nice picture of helicopters. So that's the helicopter. I, I work with the fly with taking off and I thought it was a nice picture. So I put it in and that form is a significant part of my week, but in many ways has no bearing at all on this talk this evening. But it, but it does as well next slide, please. Okay. So hopefully you all, you all decided to be do general surgery. You're going to look like that chap in the top, whether you're male or female and you're ready to go at three o'clock in the morning. Um, and you get a phone call in this instance, you're working in a major trauma center, but you could quite easily be working in a trauma unit for this type of patient who was too sick to get to the trauma centers, pre hospital e and you get told there's a 22 year old male, um or sorry female who's been in a road traffic collision in that car at the bottom, unrestrained and then injected. Um You're told they have multiple injuries, tachycardic hypertensive and as a G C s of six and they'll be with you in 10 minutes. Um, and certainly this is a phone call I've had in major trauma centers and units over the years and there's something that most people have. Well, two reactions to some people will go fantastic. This is brilliant. This is, you know, this is what, what, what my life to be at three o'clock in the morning. Um, and some of those people may want to think about trauma surgery and some people will go, oh my God, this is terrible. You know, this is going to be an absolute disaster. This is my worst nightmare and some of those people are going to do trauma surgery as well, but probably not. And uh I wanted to give you a bit of flavor is where as to where the trauma networks came from as to how this specialty has evolved. Because up until relatively recently, this would be dealt with by you as the surgical registrar on your own. You might get consultant if you're looking and it may be Yorkshire themed, um, Airedale or in Scarborough or in Grimsby, um, or rather Brothers, for example, Chesterfield by yourself because of geography. And we've moved on from that and the specialty is developed to reflect that next slide, please. So back in the bad old days, pre 2007, um, there are a number of reports effectively saying young people were dying from trauma and the demographic is under 40 which I can't see any of your faces. But I imagine that majority of you under that, I'm actually in the 40 don't look at. Um but there were most likely desire from trauma. Um Actually 60% of major trauma patient's were having a below standard of care, which is where major trauma networks came from. And the concept behind that was along with having everything in one place you would have resuscitated surgeons. Um So major trauma surgeons, it's certainly different to the orthopedic surgeons who are primarily there for restoration of function. But resistive surgeons, you can deliver immediate lifesaving interventions and effectively. So stop the bleeding. And that is where the curriculum is developed. And that's what major trauma from a general surgeon perspective is. You're a stop the bleeding surgeon, whether it is in the thoracic cavity, the abdominal totality or pelvis or extremity is your is the job role that's been created next side, please. Um There's now a curriculum although major trauma surgery is read it very much in its infancy in the UK, we only got a curriculum um in 2021 but there is an exam associated with that. Now, when you get to the higher surgical trading levels and there is a specific syllabus about delivering those life saving, primarily hemorrhage control interventions for the major trauma patient's based in the major trauma centers where the majority, not all but the majority of these major trauma patient should go next slide, please. So in practice, what does it mean? Well, before this is a PDF, this is a hilarious slide where I brought more things about, about things that you do while you wait for trauma to happen. But effectively you don't do a lot. You sit around and wait for things to happen, whether that be doing portfolio, looking at comments and tools, looking at rubbish videos and then every now and again, you do a thoracotomy and a lot of the time you go to trauma calls that are non consequential, but actually, it's more than just the operating, it's being able to switch from that benign, not much going on environment and a medical sense of, you know, in a new board kind of sense. Um going to okay. And the next minute I need to get into some lunch chest and delivering intervention and that can be really challenging. And that's what people wants is that is that, you know, that one in 100 opportunities to do that, but I'm afraid it comes with a lot of down time, a lot of thinking about things, a lot of going to a 90 year old who's fallen down one step, which can be very frustrating. Next slide is. So in terms of the actual operating, um, as I've already alluded to general surgery is different to the orthopedic. So the orthopedics, apart from pelvic surgery, operating, um, is primarily about restoration of function, whereas the resistance of surgeon arm, which is generally vascular or general surgery, but other specialties can do it as well and have them is about your hemorrhage control. So your trauma, laparotomy, splenectomy is packing of the liver, getting control of bleeding vessels, including the big, the big vessels. So that your autor your vena cava or any venous bleeding, packing the pelvis and really trying to stop any bleeding as quickly as you can a thought trauma thoracotomy. So, doing the same thing, but in the chest and, and it is within our skill set, certainly in the role and, and actually moving outside the Roland and within the 1st 30 minutes, you should be able to manage that patient regardless whether it's neurosurgery, excluding neurosurgery, where they're, where they're bleeding issue, should be able to get control. And that includes the thoracic cavity, including um dealing with the cardiac dampener, suturing cardiac wounds, managing lung trauma, etcetera, etcetera. And then slightly further down the line. Day three, day five, when they're going back for their re looks actually joining them back together, deciding what to do. Um And sometimes in some centers, so again, I'll quit the role and then they do their own vascular anastomosis to an extent. And then I've already mentioned chest operating, but rib fixations. Well, so moving them along and the key that's all over there is obviously it's great operating because, you know, everyone's stressed, you get people shouting crazy things like the patient's bleeding out and people tried to do CPR on trolleys. But it's all about being that carly influence working and managing a team to deliver really difficult complex interventions in really, really sick patient in a really time critical manner. And certainly in general surgery, it's not many circumstances. I can think of that. You get that, that kind of we need to act and we need to act now, even for your, you know, perforation, a pot Amis, you have to have their anesthetic, they've got time. Whereas with these patient's, you, sometimes they even get pre alert, you walk in, the patient's been driven by the mate and the new Thoracotomy now. And for some people relish out. Some people find that very stressful and that's the appeal for some people for the trauma operating. Uh Next, like please in contrast, emergency general surgery, I haven't got any nice pictures. It's not because I don't like it. It's just because you've all seen power before um is an emerging subspecialty. And I've got this in my conclusion, but I'll say it from the outset as well is um not universally lauded and welcomed because it's seen as registrar work. Um And in terms of the intervention you deliver, you know, appendicectomy is cholecystectomy. Some, a laparotomy is doing the acute and the on core work. But the reason this has become more of a focus in the last couple of years isn't, it's partly lifestyle. So there is a better lifestyle potentially associated with it, but it's primarily driven my outcomes. And actually, if you look at all comers to the surgical department, those that have the worst outcomes of the emergency payment, patient's buy some significant margin. And arguably that's because they're apprentices emergencies, they're more well, but it's probably deeper than that. And actually having a specialist surgeon who can focus on helping these patient's in particular, um similar to a keep medicine has appeared um is can only be beneficial, but it does come with some negatives next slide, please. So this is a concept working week that I drew up and to say that certainly inlayed why in Yorkshire, which is where we're at. This job. Current doesn't exist at consultant level, this emergency general surgery, trauma consulted, major trauma cause it doesn't exist a consultant level in either Sheffield whole or all leads. But this is what we imagine it looks like. Um So a bit of clinic, a bit of telephone triage. Um so trying to reduce the impatient workload trying alternative pathways for patient's, which is better for them, uh better for the hospital. A bit of major trauma working. And I've put some of the operations you'd expect to do a general emergency, general surgery week on call as a consultant. So I think having acted up, uh let me change that phraseology, having worked under remote, distant, remote supervision as a, as a, as a current EKGs registrar. Um This, this is not uncommon. Um But I thought it would be helpful to show you what my actual working week was a few weeks ago. So next slide, please. So this is what I actually did about a month ago now. Um And it was a very unusual week admitted because it was so busy, you get to have a flavor of potentially what it could look like, particularly from a trauma, trauma operating point of view. Um So lots of emergency operating, a good amount of trauma laparotomy is uh uh the code red in the middle. There is a patient who was bleeding to death and he was bleeding to death as opposed to um bleeding but not to death. He needed an immediate surgical intervention. Um Along with my, our ambulance work, which I stuck in there because that, that was what I did in my working week and a bit of sleep and that isn't every week. That's definitely the exception rather than the rule. And the great thing about emergency general surgery. And, or EKGs and trauma, major trauma is a concept is they balance each other out and they can be very complimentary next time, please. So, what was the actual reality of it? Um And why would I say one of the good things of the bad things and I put the next future there. So I think the big appeal for um for E G S at the moment isn't necessarily operating. Um but it's the flexibility, it's the option to have time at home. It's the option to, um, you know, do a few lates or, you know, I have 9 to 5 minutes Friday. So certainly the leads plan at the moment. The leads job plan as a consultant level is Monday to Friday nine till five, no weekends, no night. And that's very appealing, particularly for my life. But contrast that with major trauma, most people don't get stabbed on a Tuesday afternoon, most people get stabbed on a Friday and Saturday night. And so therefore, the operating reflects that and it's completely different with the DS. You've got, it's unpredictable but you have a constant flow. There's always someone who's going to have a diverticulitis and appendicitis, neither gallbladder out. And although what is, it is unpredictable, it is steady. Whereas trauma is very much all or nothing, you're either doing trauma operating or you're not the benefits that is that your patient's either have definitive pathology or they don't, you've either been in a car crash and smash your liver or you haven't, there isn't really any in between. Whereas in EDS, although you do see lots of genuine pathology, you also get the classic update pain query cause. Um they can both be higher stress for different reasons. You're dealing with high acuity, sick patients'. And although the reality of EDS life seems more appealing, um there are lots of cash is with the specialty. Certainly my experience more than one center and, and that can cause additional friction that you might not want in your life if you want to be a cancer surgeon or a sectional surgeon, E G S is not for you. And actually, I think most, most centers are now moving towards taking it out of their job plans if you've got E G S surgeons, um, if you don't really do any big cases, your big cases come from the trauma, although there's always gonna be like watery is that they're doing, um, the MGS can be very life friendly whereas trauma might not be. And a big thing, big thing for some people is private practice and there's no private practice in major trauma operating and there's probably very little in emergency general surgery compared to if you were doing reception or work or, or the, or the type of work. Um, next slide, please. So I thought, well, I say, I thought I was told to give you a higher, low, uh high and low points. And I thought I'd contrast these two young men who I saw one, an 18 year old chap a couple of weeks ago who had been admitted overnight with query appendicitis with white cell count of 23. And the CT had been declined by the radiologist. Um, he looked and well, when I saw him in the morning, he was frankly parasitic, took him straight to theater. He had a perfect perforated Meckel's diverticulum, uh had sepsis 90 day one, but went home seven days later. Um And I genuinely think my timing and my decision making as a senior decision maker pushed him in the right direction, got things sorted quickly and I hope made a small difference to his outcome. Although maybe I'm just kidding myself and he would've been fine anyway because he's young and fit contest that to the 17 year old lad who a few months ago now was there were several patient stabbed. He was one of them. He got stabbed in the leg, ran away and hid behind the bush. And unfortunately because he, he wasn't found by the police immediately. He had gone some distance away from the original seen. He was found by a passer by having bled to death. Uh and he died, he died at the roadside behind that bush where it bled out. But unfortunately, he was pronounced dead in the emergency department. And I think most people think of trauma as being the highest if you know, you do thoracotomy and they survived. But actually, unfortunately, particularly for that intervention, doing outcomes are woeful still and you have a young people killed persistently an emergency. General surgery sounds like a lot of wandering around seeing abdo pain query cause. But you can recommit real difference to these patient's because actually the acute take traditionally has kind of been neglected, left, not pay proper attention to which I wonder is part of why are outcomes have been so bad. You know, the consultants or the team generally focus on the patient's that are well that you've made sick, not the ones that make sick and that's human nature. Whereas having it as a separate specialty mean we can focus on them a bit more. Um Next slide please. And I thought I'd be a bit nostalgic and just talk briefly about my surgical career. I don't know what grade you all are, but the kind of the title of the, of the organizations suggest that you're relatively junior, um reflect on what I've missed by going through surgical training and what I hope, you know, primarily through your actions, generationally, your actions, through the strikes. You, you won't have, you won't have as like I did and perhaps I should have shouted louder when I had the opportunity. But I've missed birthdays. I've missed my kids, walking kids parties. I've missed anniversaries and it's cost me a lot of money and the picture of the corner there in the map. Hopefully you can see it. The red dots are all the places I've worked and you can see, I primarily located in Yorkshire, but, you know, it's a big area, um, as well as having spent some time in northern Ireland than down in London shortly for a fellowship. So, training is a massive burden, not burden. It comes at, it comes at great expense. And I think you need to think really carefully about what specialty you choose as to what the right balance is. And I guess that's my push for emergency general surgery is that things can be better and they should be better, but they can be better now. And they're certainly the model for emergency general surgery primarily for I would hope is to pre pagan outcomes. Actually, you get quite a nice life as well and I think there's a lot to be said for that next slide, please. So, um, that's what I've done. Um And um I have put some out of programs on there to illustrate that you can do with this stuff. It doesn't have to be a massive slog. Uh I've been knocking around a while. I've haven't put my vascular year actually. So after I came back from Northern Ireland, um I did a non training post in vascular surgery as well. Um So a long time in training. So you gotta, gotta be enjoy. It, got to be passionate about it next slide. Please. And I thought again, I'd go down a bit of nostalgia and talk just specifically about trauma for three minutes because you, you could log off if you wanted to. But, um, so I got into trauma when I was a second year medical students and I was driving down the road with my girlfriend, my wife in my hometown of Commentary in the middle of the day between year one and year to, we drove past a guy who was on the side of the road and he didn't look right. So I pulled over, got out of my car, went towards him and found this guy with a significant head injury, blood all over the work, a road and obstructed airway. Uh, he had clearly been hit by a car and smashed his head on the pavement, but I didn't know that at the time. Um, we called 999. I didn't really know it's, there was a first, just 1st, 1st year. Of course, I had a lot of fun in first year, didn't do as much to think as perhaps I should have done. Um, and put him in what I thought was the right position, did what I vaguely remembered was some kind of your thrust. Um, and then the ambulance crew arrived and they were horrible to me. So they told me I did the wrong thing. They told me this guy was just a drunk that I moved in. I'd probably broken his neck, they never walk again. And so I felt pretty terrible. Um, and as I was walking away, I hadn't realized that because of this particular triage category, the air ambulance had been called. So I heard them landing thought, well, I've wasted their time as well. You know what an idiot. When I sat in my car to drive away, police came and got me started to take a statement and then a wonderful woman in orange, an orange jumpsuit came and drive me back and wanted to know what happened. Um They had managed to get CCTV in a few minutes and I've been there and confirmed it been hit by a car, confirmed that he had an obstructed airway. When they arrived at the back of the ambulance, they were going to give him an emergency anesthetic and fly him off the hospital or drive them off. And that really sparked my, we have to do better. And then I started looking into it and that little reference in the corner and that bit of text them is a paper from 1986 which showed that patient's were dying because they were hypoxic because they were bleeding to death. The anti pod report and we talked about showed that patient's were hypoxic patient's were bleeding to death. And I just did a trauma week on call and I can tell you now what patient's are dying from is you guessed it hypoxia bleeding to death and from a trauma perspective, you know, forget everything else. I'm not quite 40. Yeah, I'd quite to live, like to live a bit longer. It's the thing that they like to kill me. We have to do better and so trauma. Although it's been around literally since the dawn of time, people are bashing each other, the heads of falling over stuff. It's still not, I think a specialty that's, that's recognized as much as it should be, has looked after as much it should be and certainly that we can do much better. And that's part of the reason that the ambulance workers because I think we can do better right from the start your disease process starts when you get injured, not when you come into hospital, you're already way down the line. And if you've had no area of being hypoxic for 20 minutes, what we do in hospital is not irrelevant but, but, but the damage has already been done. Um And I would encourage you whatever, especially you get into to have something that pushes you in the dark days when you miss a holiday or you don't get to see X Y Zed, you know, or you're spending five grand on a course and you're trying to claim it back from the dean and it takes uh God knows how long after you fill out the forms, get some drives, you latch onto it because it pushes you through the bad times. Next. Like, uh, so I thought I'd pass on some advice that I got to me. Um, and again, this is advice I was suggested to give you some advice. So the two things I was told about, about getting into surgery was one that you have to live theater and having reflected on that you kind of do have to like it quite a lot because if you don't, it's a difficult specialty and then that's not to say that the specialist are difficult. They absolutely are. But when you've done a 12 hour shift and you think you can get that appendix and if you just stay for another half an hour and then at midnight you're walking out knowing that you're going to be back the next day, you need to have, you need to have some reason for staying. And if you love theater and that doing that appendix was the best part of your day. Bye miles. It's worth doing. Um, and things absolutely do get better. And when you get, when you get to become a consultant, the life that they have is seems to me to be, uh, significantly more conducive to general life in terms of work life balance along with all the other bits that come with being a consultant, um, emergency general surgery. If you're gonna do it there properly up all over the place now, not just in teaching hospitals but in G D H s and I wonder if that's more of the, what I would see is the older MGS type role, which is picking up the slack for the registrars and, and not really dealing with those sick patient as your own, but actually take a lot of the people's work. And I think for it to develop a specialty. The first point of call us on the first, the first recognition has got to be these are sick patients that need their own specialists and then work from there and, and the fact that they've been managed, managed by registrars like me for so long is a bad thing. That's not, that's not positive, that's not a thing. We should continue. It's a bad thing and they should get the same care that are elective, elective patient's do where possible. And if you do major trauma, you've got to accept that it's, you have a bad time and you're gonna get called uh some pretty horrendous times in the morning and then find a good mentor really important. Just someone not, not, let's say someone who can teach you to operate, but someone who can call when things about um when you make a mistake. Um You know, someone who's judgment we trust, who can guide you through. Um and I would encourage everyone to try and match on something like that. Getting the basics right is really important. So doing abscesses again, a general surgery is um can be really irritating, particularly when you just want to do the appendix is happening or you want to jump on with a laparotomy. But if you can handle a life, wealth do an abscess, you can handle it well too. And appendix, well, laparotomy and equally specifically for major trauma. Um, if you could, well, because you've practiced it when you have to do it on a bleeding vessel in the pelvis and the patient has got a systolic of 40 And then the scientists squeezing those are blood, you will get it. Whereas if you haven't got the basics right, you will struggle. And I the first to admit that I did a lot of running before I could walk and regretted that. And I've gone back really focused on the basics and my life is much better. And then finally, if you want to get into a GS or major trauma, you just got to see loads of sick patient's because we put lots of physiological values on them. Uses this the heart races, this the blood pressures this and although there are true truisms in that, if you see 1000 sick patient's, you'll be much better at spotting a sick patient without the physiological values. Then if you haven't seen this patient's so getting that gestalt that feeling that someone is in, well, there's loads of evidence now, particularly prehospital, but a lot in hospital. Well, to show you that that feeling that you develop over time, the more patient's, you see can be incredibly valuable uh next time, please. So my final thoughts are that trauma surgery. It's a brilliant job. It's great. You get great skills but perhaps not the best work life balance and you couldn't do it full time. Partly because of that part because you spent a lot of time sitting around operating. You need some regular operating to keep up your skills. And E G S is a great complimented for that. And actually, it's got the potential to have a good work life balance, have a big change, change in Beijing outcomes. But it does at the moment come with some uh some added uh added issues, but I'm hoping that they will get better as the specialty develops. Uh The last lines, any questions? Thank you very much, Mike for that wonderful talk and share in your insights and your journey with E G s and major trauma. Um If anyone's got any questions, feel free to drop them in the chat. Otherwise, if you can fill out our feedback form, that would be really helpful. Um So yes or any questions for Mike with anything that he's spoken about or anything else related to surgery as well, he might be able to help with. So there's a question here. How would you recommend getting involved in E G S, the air ambulance or sports teams? So I'm going to treat them as two separate questions if that's ok because the stuff is um the air ambulance to the gospel care stuff is slightly separate. So E G S is really easy to get into. All we need to do is expression interest. And uh what I would suggest is if you're really keen is swapping out your elected days for days in acute theaters because you'll get, and I would argue, you'll probably get more operating that way. But that's, um, I know that comes with some contentions but even expressing an interest because, because at the moment, it's not that highly sought after. You wouldn't have a problem with that. Um, in terms of sports teams in our ambulance, so they pre op emergency medicine in general doesn't really fit with surgery unless your orthopedic surgeon. And, and so it can be incredibly difficult to get involved at the moment. My advice for anyone who wants to jump on an air ambulance is unfortunately have to certainly think about emergency medicine or anesthetics and there's no reason you can't do a combined job, but they're hard to come by. Um, sports teams. Um, I would strongly encourage you cover the sport you enjoy because you spend a lot of time watching it and you get to watch free games. So I covered football because I enjoyed it and then offer the rugby as well. Um, actually the most sports teams, particularly, I relatively lower level are desperate for people. So I get emails and phone calls every weekend for, uh, football. Um, not up until championship championship is usually relatively well covered. But league want me to the low lead to get phone calls all the time. And then rugby, rugby league and rugby union, it's saying they're desperate for people. You just need to express an interest, approach. The club spend some time and then work your way up. But it's time that you have to spend. Unfortunately, is there any other like qualifications of things that you need to do if you want to do um work with sports teams or any extra? Yeah, so it's incredibly lucrative. So I was getting paid for your QR non league team or, or a semi longing team. I was getting paid 1000 lb an hour or 2000 lb an hour to basically sit and watch a football game, which is pretty sweet. But they, if they get injured that's their livelihood. So you have to be really careful about what you do. Um There's mrcs in sports medicine and stuff like that, but actually sports medicine is, it seems to be, it's all about who you know. Um So I get a team, um get to know that those, those team people and then yeah, you can do your basic. So, so you should have your A LS or equivalent because one of the big worries as a player, what they wanted for a match days as a player who, who collapses with a cardiac arrhythmia want you to be able to go and jump on the chest. And that's primarily what I'm paid that big money for. And then the, all the orthopedic type stuff has loads of those courses. But I think my colleagues who do it would recommend doing an MSC in sports science because that comes with, that comes with extra stuff. Um And then all the collapse on all the collapse on field stuff. It depends on what sport, urine. So rugby has its own football has its own horse riding, has its own, their motorcycling has it. So they're, they're the events have covered. Um they all passport across the other ones. They pick a sport you enjoy because you're going to spend three days to and of course you may as well do it and do it with sports you enjoy. Wonderful. Thank you. And does anybody else have any other questions? I think we're okay for questions. Thank you, Mike. Cool. Thanks very much. If anyone want to drop me an email, um I'm sure you can ask my email. That's fine. You guys are gonna have any much you say, feel free to send, feel free to send me email. And if you see me about, feel free to say hi. Thanks very much.