The Appendix Question

I had a great time on the Basic Surgical Skills Course - all docs should do it!

It has been a while since I last wrote and my time here in Plymouth seems to be flying by. Us BASMU docs are still feeling privileged to have the opportunity to refresh our medical knowledge in a whole range of specialities, and have been introduced to new skills too.
‘So you’ve be learning how to take someone’s appendix out then?’...

You may have read the recent BBC article about the ‘man who cut out his own appendix’ - Russian surgeon Leonid Rogozov who was stationed in Antarctica in the 1960s.  If you haven't, I'd recommend you have a read at the above link.  The article was taken from the always interesting BBC World Service programme Witness (one of my regular podcast listens), which spoke to his son here.  (For those with access, the same son wrote a BMJ article in 2009 outlining the operation.  I can email a copy of the article to those without access if you want!)

Appendicitis remains a common surgical emergency in the general population, and that risk is still there in Antarctica.  Some Antarctic missions actually mandate that the doctor has their appendix taken out before they go!  An operation to remove the appendix (appendicectomy) as soon as possible after diagnosis remains the gold standard of treatment for appendicitis.  

So it may surprise some people that I am not going to be taught to whip out an appendix..

It is actually quite difficult now to get taught how to do a traditional appendicectomy (the type which would be done in Antarctica).  Not that long ago, a sizeable proportion of fairly junior doctors would be expected to do this operation, and were doing so regularly.  It is after all, surgically, often a very straightforward procedure.

However nowadays most appendicectomies are done laparoscopically (key hole surgery) rather than open (traditional with an incision), and only by doctors who are on a surgical training pathway rather than the junior surgical houseman. This is much better for patients, but means that the training opportunities for us BASMU doctors to learn the open operation are very scarce.  

Team BASMU built an igloo laparoscopically on the surgical skills course

So in 2015, it is unrealistic to expect us as lone practitioners to administer and maintain safe anaesthesia whilst concurrently carrying out an operation we have limited experience in. 

So what will we do if we get a patient with appendicitis?  Well interestingly, whilst operative intervention remains the gold standard in hospitals, there is increasing evidence that treating appendicitis conservatively (without an operation) may be a safe option in remote environments.  A 2011 Cochrane Review cautiously concluded that “antibiotic treatment might be used as an alternative treatment in a good quality RCT or in specific patients or conditions were surgery is contraindicated”.  A subsequent UK based RCT concluded that “initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis” 

Knowing that treating first line with antibiotics is a safe option when evacuation is not possible is incredibly valuable (for those medically minded with access, a good evidence summary of the role of non-operative management of appendicitis can be found on UpToDate).  I think it is important to note here that I will not be making these these treatment decisions alone when I am South.  BASMU is very much a team sport and I'll have 24hr telephone support from our BASMU Emergency Medicine consultants.  In fact we have consultant level telemedicine support from specialities across the whole of Plymouth NHS Trust. 

So if I haven't been busy butchering the residents of Plymouth, what have I been up to?!

Tooth extraction and socket suture

Temporary Splint for fractured tooth

Dentistry! 

We've been learning all sorts of dental first aid.  We even gave local anaesthetic injections to each other (top tip: when at the dentist ask for numbing gel first!).

Aside from the Basic Surgical Skills course and refreshing ALS and ATLS, I've had sessions with physiotherapy, ENT, plastics, ophthalmology, anaesthetics, and have sessions coming up with blood bank, radiology, GUM, hyperbaric centre as well as general ED sessions.

And that is just the medicine side of things....Well this blog is long enough, so I'll leave it there for now.  I'm still tweaking the blog design, so do let me know via facebook/twitter or email if you have any gripes.