Can a GP preform emergency surgery?

Original post by Jatyization

Okay this question has been on my mind through sheer curiosity. pretend there is this scenario: Your friend is a GP and you live alone in an isolated environment hours away from any hospital. Your GP friend is visiting at your house and you suddenly need emergency heart surgery, miraculously the GP has all the required surgical instruments to hand. Will they be able to perform open heart surgery? Pretend in this fantasy land that there is no bacteria to cause any infection and the GP has surgical machines/equipment. Sorry about the terrible story

My other Question is: If you intensely train a normal person to perform open heart surgery for 7 days, will they be able to perform open heart surgery? Considering a surgeons training is 7 years...

Yes i am quiet curious! :biggrin:

GP would not be able to - open heart surgery needs at least 2 anaesthetists and an assistant. GP would have no idea how to do it, and would only ensure your death. The only thing they could do, would be a clamshell thoracotomy in some situations.

Normal person would not be able to, registrars performing simple hernia repairs after years of training are often stopped by the consultant surgeon to take over. They would have no contemplation of how to deal with variable anatomy, would not be competent with basic surgical skills, would not be able to deal with complciations, would not be able to recognise if they had done anything correctly... etcetcetc

Reply 2

TSR George

OP

17

Original post by hslt

GP would not be able to - open heart surgery needs at least 2 anaesthetists and an assistant. GP would have no idea how to do it, and would only ensure your death. The only thing they could do, would be a clamshell thoracotomy in some situations.

Normal person would not be able to, registrars performing simple hernia repairs after years of training are often stopped by the consultant surgeon to take over. They would have no contemplation of how to deal with variable anatomy, would not be competent with basic surgical skills, would not be able to deal with complciations, would not be able to recognise if they had done anything correctly... etcetcetc

Oh wow! That is surprising, i would think that the GP may have some general knowledge on heart surgery and what it involves. But do you think a normal person will really struggle so much, i mean what if in this one week they had seen the same procedure done multiple times, seen videos, did some surgery under the guidance of cardiothoracic surgeon... i reckon they may be able to pull a procedure off alone providing there was no complications. This is so interesting aha!

Reply 3

Original post by Jatyization

Oh wow! That is surprising, i would think that the GP may have some general knowledge on heart surgery and what it involves. But do you think a normal person will really struggle so much, i mean what if in this one week they had seen the same procedure done multiple times, seen videos, did some surgery under the guidance of cardiothoracic surgeon... i reckon they may be able to pull a procedure off alone providing there was no complications. This is so interesting aha!

Absolutely no chance.

There is no way they could do it accurately enough enough to not CAUSE complications. And once they have, they would have no ability to stop them.

Plus, cardiac surgery takes an expert hours - you think in a week you can see enough of these operations that you would even remember all the stages? You think you could do it quickly enough for the person not to bleed to death on the operating table?

Put it this way, the most failed station at my clinical school in our practical osce was putting 2 sutures in a fake pad in 10mins. This is after 3 years of practicing suturing etc. Then next most failed station was putting in a cannula - this is after 4-5 years of putting in cannulas. To complete cardiac surgery you're going to have to be competent in skills far more difficult than this. If you think that any old Jo can, in a week, learn to suture a new valve in place, or learn to strip and implant a vessel and suture something delicate and precise in place, you are off your rocker. I wouldn't even trust them to close the skin at the end after a week of constant practice.

If it was as easy as you make out, there wouldn't be cardiothoracic surgeons. Why bother if it's so easy, just get the general surgeons to do it. Nope, I'm afraid its a complex area of surgery, and, like I said, when a 5th year registrar is rarely able to complete an operation without assistance from the consultant after years and years of doing these operations, and with very good general clinical/surgical skills, I don't think anyone else has a chance in hell.

(edited 9 years ago)

Reply 4

Helenia

Original post by Jatyization

Oh wow! That is surprising, i would think that the GP may have some general knowledge on heart surgery and what it involves. But do you think a normal person will really struggle so much, i mean what if in this one week they had seen the same procedure done multiple times, seen videos, did some surgery under the guidance of cardiothoracic surgeon... i reckon they may be able to pull a procedure off alone providing there was no complications. This is so interesting aha!

Most GPs will have spent a couple of weeks at medical school learning about cardiac surgery - and that may have been 20+ years ago. So while they may technically know which bit needs to be connected to which other bit, they will have minimal idea about how to get to that point, what instruments to use and how to work them, what equipment is needed, how to keep the patient asleep and alive... It would be vastly negligent for any doctor to attempt surgery on this scale when they have minimal knowledge and no support.

I spend a large portion of my life in theatres watching operations (I'm an anaesthetist). I have seen some procedures done hundreds of times, but I can only think of a handful of really minor ones which I think I would have a chance of doing decently without a risk of causing damage to the patient (likewise, most surgeons wouldn't really know how to do what I do). And even then it would be negligent of me to try, most of the time.

Reply 5

squeakysquirrel

Original post by Jatyization

Oh wow! That is surprising, i would think that the GP may have some general knowledge on heart surgery and what it involves. But do you think a normal person will really struggle so much, i mean what if in this one week they had seen the same procedure done multiple times, seen videos, did some surgery under the guidance of cardiothoracic surgeon... i reckon they may be able to pull a procedure off alone providing there was no complications. This is so interesting aha!

I think to be honest you are better off being alone with a paramedic - they are brilliant. Many many years ago I saw a guy with a crush injury to his chest which had ripped his chest right open and he was in complete cardiac arrest His luck was having a paramedic walking past - who reached in an massaged his heart until the ambulance arrived. The man lived. ( I was a student nurse at the time standing by watching in awe)

Reply 6

HCubed

13

Original post by Jatyization

Okay this question has been on my mind through sheer curiosity. pretend there is this scenario: Your friend is a GP and you live alone in an isolated environment hours away from any hospital. Your GP friend is visiting at your house and you suddenly need emergency heart surgery, miraculously the GP has all the required surgical instruments to hand. Will they be able to perform open heart surgery? Pretend in this fantasy land that there is no bacteria to cause any infection and the GP has surgical machines/equipment. Sorry about the terrible story

My other Question is: If you intensely train a normal person to perform open heart surgery for 7 days, will they be able to perform open heart surgery? Considering a surgeons training is 7 years...

Yes i am quiet curious! :biggrin:

Absolutely - and why they waste all that time training neurosurgeons when I reckon an amateur could do it with a few videos and a good pep talk, I have simply no idea. I think you're on to something, and I pray you talk about it in your PS and interview, because this is just the sort of out of the box thinking that is so impressive to selectors. They love it when candidates have such a thorough understanding and respect for what they do.

Edited to add: Just checking that in your hypothetical the GP has at least 8 arms, right?

(edited 9 years ago)

Reply 7

nexttime

22

The situation is silly - you've picked a very hard operation and provided no assistance to the poor GP. It would be crazy to try anything.

However.

Most surgery is not as difficult as is being made out here. Something like a laproscopic cholecystectomy (keyhole surgery taking out gallbladder) can be done by junior surgeons after a month or two of training. I reckon I could give that a decent stab myself ('stab' perhaps being the operative word - perhaps a 10-20% chance of me messing up the patient in some way?). In some countries, all doctors including GPs need to be able to perform appendectomies, C-sections and amputations for the exact scenario you describe - the isolated emergency. Some countries can't afford to train lots of doctors so use 'doctor's assistants' instead, who learn all of medicine and how to do general surgery (laparotomies etc) in 3 years then work unsupported (You'd still need an anaesthetist, though you can also train a nurse to do that or even do it yourself at a pinch). Do patients occasionally die as a result of their lack of training? Absolutely. In the situation you describe - where the patient is critically unwell and you're sure he will die anyway - does that matter? Possibly not. Surgery only takes a lot of training in the UK because success rates of 95% are not acceptable here - we want 99%+.

Such a situation is very unlikely in this country though, of course. Even the remotest areas are not that far away by air ambulance.

(edited 9 years ago)

Reply 8

TSR George

OP

17

Thanks everyone for your input. This turned out to be really interesting as well as informative!

Reply 9

Original post by nexttime

The situation is silly - you've picked a very hard operation and provided no assistance to the poor GP. It would be crazy to try anything.

However.

Most surgery is not as difficult as is being made out here. Something like a laproscopic cholecystectomy (keyhole surgery taking out gallbladder) can be done by junior surgeons after a month or two of training. I reckon I could give that a decent stab myself ('stab' perhaps being the operative word - perhaps a 10-20% chance of me messing up the patient in some way?). In some countries, all doctors including GPs need to be able to perform appendectomies, C-sections and amputations for the exact scenario you describe - the isolated emergency. Some countries can't afford to train lots of doctors so use 'doctor's assistants' instead, who learn all of medicine and how to do general surgery (laparotomies etc) in 3 years then work unsupported (You'd still need an anaesthetist, though you can also train a nurse to do that or even do it yourself at a pinch). Do patients occasionally die as a result of their lack of training? Absolutely. In the situation you describe - where the patient is critically unwell and you're sure he will die anyway - does that matter? Possibly not. Surgery only takes a lot of training in the UK because success rates of 95% are not acceptable here - we want 99%+.

Such a situation is very unlikely in this country though, of course. Even the remotest areas are not that far away by air ambulance.

Assuming you're a med student/junior doctor without surgical skills training, then you would have a chance of doing it correctly, but there is no way we'd be talking a 10% chance of getting it wrong, even in an abdomen with standard biliary anatomy (which remember is incredibly variable) and absolutely no adhesions going on. 50-60-70-80-90-100% is far more realistic.

Maybe just maybe if you had a surgeon leaning over your shoulder telling you every time you were about to go wrong you might do the operation correctly, without any subsequent biliary leaks and without clamping the hepatic artery. I'd give most med students a 50% chance of complications on insertion of the first trocar.

I'd give you a lower chance of serious complications performing open surgery - much easier to know where to make the cut, to identify anatomy, and to suture/clip.

Reply 10

username1236842

8

Surgical training is now extremely specialised and now no-one but an experienced heart surgeon would be able to do heart surgery. Major heart surgery requires heart bypass equipment plus an anaesthetist, assistants etc. I can't see a cardiothoracic consultant deciding to hack open someone's chest in the middle of nowhere with just a few instruments. The whole scenario is mad. The patient would instantly die of blood loss.

Reply 11

username113840

Original post by Helenia

I spend a large portion of my life in theatres watching operations (I'm an anaesthetist). I have seen some procedures done hundreds of times, but I can only think of a handful of really minor ones which I think I would have a chance of doing decently without a risk of causing damage to the patient (likewise, most surgeons wouldn't really know how to do what I do). And even then it would be negligent of me to try, most of the time.

In context, I know of maybe 3 doctors with London HEMS who aren't anaesthetists (but have had significant anaesthetics training).

If we're talking about emergency thoracotomies at the road side etc (to clamp the aorta or whatever), it's only really indicated in a handful of situations (which are only really major trauma) and usually aren't performed very often. With London HEMS now doing REBOA at the roadside, those numbers will probably drop in future too.

Bare in mind, they're designed and taught to be quick a dirty as emergency procedures (and would be thoroughly washed out in theatres later), with possibly limited kit and equipment, as pretty much a last resort resuscitation. The suture needles in the thoracotomy kits I've seen are huge (the curved needle is around the size of my palm) to quickly throw in stitches without forceps.

Also, most emergency surgeries like emergency airways, thoracotomies etc won't be done start to finish by the same person - the air ambulance, ED or anaesthetics/ITU doctor may do it first, but the handed over to or transferred to a facility which can accommodate patients for trauma, cardiothoracics, maxfax/ENT, vascular, complex pelvic surgery etc. to finish and close.

Reply 12

nexttime

22

Original post by hslt

I'd give you a lower chance of serious complications performing open surgery - much easier to know where to make the cut, to identify anatomy, and to suture/clip.

Easier to identify anatomy in an open procedure? Really?

Yeah I'm a student - have seen about 5 lap cholies and held the camera once. You probably have more experience than I but i do still disagree with those numbers. I think a student would be incredibly hesitant and take an age to do it, but would be pretty unlikely to, say, nail the aorta with the trocar. In fact, i think a trained surgeon might be more likely to do that - the student would just be too cautious. Mal-placement of the clips is probably a big risk though yeah.

Admittedly I am backing myself more than i would the average student as, frankly, some people have the manual dexterity of a JCB, but yeah I stick by 20% chance of major complication as my estimate.

Reply 13

Original post by nexttime

Easier to identify anatomy in an open procedure? Really?

Yeah I'm a student - have seen about 5 lap cholies and held the camera once. You probably have more experience than I but i do still disagree with those numbers. I think a student would be incredibly hesitant and take an age to do it, but would be pretty unlikely to, say, nail the aorta with the trocar. In fact, i think a trained surgeon might be more likely to do that - the student would just be too cautious. Mal-placement of the clips is probably a big risk though yeah.

Admittedly I am backing myself more than i would the average student as, frankly, some people have the manual dexterity of a JCB, but yeah I stick by 20% chance of major complication as my estimate.

Open surgery much easier to identify anatomy because you can far more easily identify, in 3d, the relative positions of things, and you have tactile feedback. You can grab the gall bladder and slide your hands down the cystic duct. Can't do that in a lap chole, hence much easier to mis-indentify structures.

Reply 14

Helenia

Original post by nexttime

Easier to identify anatomy in an open procedure? Really?

Yeah I'm a student - have seen about 5 lap cholies and held the camera once. You probably have more experience than I but i do still disagree with those numbers. I think a student would be incredibly hesitant and take an age to do it, but would be pretty unlikely to, say, nail the aorta with the trocar. In fact, i think a trained surgeon might be more likely to do that - the student would just be too cautious. Mal-placement of the clips is probably a big risk though yeah.

Admittedly I am backing myself more than i would the average student as, frankly, some people have the manual dexterity of a JCB, but yeah I stick by 20% chance of major complication as my estimate.

Chances of getting murdered by the anaesthetist for dicking about and taking too long close to 100% though :p:

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Reply 15

345rty

Define open heart surgery. I've certainly heard of a GP decompress pericardial tamponade twice in a career, once successfully (in south africa), but again there its do or die and die doesn't matter. Here its wait for the helicopter with a prehospital physician who does it reasonably often.

If you mean cabbage or the like then its not going to work. Anything involving properly opening the chest is then going to need positive pressure ventilation which at the very least means more people required if you are going to accept mouth to mouth as a functional minimal until proper kit arrives.

Reply 16

junior.doctor

18

I am UK-trained but live and work in rural Africa. Here, generalists train 'on the job' to be able to perform basic and life-saving surgery, and as others have said, the expectation here in such a rural environment as ours, is that general doctors can also perform some basic surgery. Often when we say 'life saving surgery' then people tend to think heart surgery, but by life-saving, I mean things like Caesarean section - by far the most common life-saving operation that we do here. Then basic laparotomy for ectopic pregnancy, appendicectomy, typhoid perforation... moving up to more complex things like managing bowel obstruction and strangulated hernias. Then simple routine operations such as basic hernia repairs, hydrocoele repairs... I have personally chosen to steer well clear of operating, as I think it is one thing to be able to perform a procedure under supervision with someone who can help you sort out your complications, but it's entirely different to learn it to the degree that you can dig yourself out of your complications as well. And we don't have anaesthetists here, so you also need to learn how to do spinal anaesthesia or give ketamine. I have done one Caesarean before here without another surgeon, in life-or-death extremis (having also done the spinal anaesthetic) - but I had a very experienced theatre assistant, who had spent the last 10 years learning on the job and assisting with similar surgery and could probably have done it himself. And I certainly couldn;t have done it completely solo without his help. But even out here in our field hospital in rural Africa - we have a simple operating theatre, the appropriate sterile equipment, assistants, the kit and basic monitoring to administer simple safe anaesthesia. And we would never do 'heart surgery', however you define it, as we don't have any of the monitoring etc that you would need during / after.

And as I said before, out here in Africa, and probably in many places, knowing how to do an emergency Caesarean saves many more lives than knowing anything about cardiac surgery.

Reply 17

HCubed

13

Original post by junior.doctor

I am UK-trained but live and work in rural Africa. Here, generalists train 'on the job' to be able to perform basic and life-saving surgery, and as others have said, the expectation here in such a rural environment as ours, is that general doctors can also perform some basic surgery. Often when we say 'life saving surgery' then people tend to think heart surgery, but by life-saving, I mean things like Caesarean section - by far the most common life-saving operation that we do here. Then basic laparotomy for ectopic pregnancy, appendicectomy, typhoid perforation... moving up to more complex things like managing bowel obstruction and strangulated hernias. Then simple routine operations such as basic hernia repairs, hydrocoele repairs... I have personally chosen to steer well clear of operating, as I think it is one thing to be able to perform a procedure under supervision with someone who can help you sort out your complications, but it's entirely different to learn it to the degree that you can dig yourself out of your complications as well. And we don't have anaesthetists here, so you also need to learn how to do spinal anaesthesia or give ketamine. I have done one Caesarean before here without another surgeon, in life-or-death extremis (having also done the spinal anaesthetic) - but I had a very experienced theatre assistant, who had spent the last 10 years learning on the job and assisting with similar surgery and could probably have done it himself. And I certainly couldn;t have done it completely solo without his help. But even out here in our field hospital in rural Africa - we have a simple operating theatre, the appropriate sterile equipment, assistants, the kit and basic monitoring to administer simple safe anaesthesia. And we would never do 'heart surgery', however you define it, as we don't have any of the monitoring etc that you would need during / after.

And as I said before, out here in Africa, and probably in many places, knowing how to do an emergency Caesarean saves many more lives than knowing anything about cardiac surgery.

Wow - how did you come to be working in Africa and is this a placement or a permanent career for you?

Reply 18

junior.doctor

18

Original post by HCubed

Wow - how did you come to be working in Africa and is this a placement or a permanent career for you?

It's for 3 years - I am coming back to the UK shortly to start specialty training. It's a voluntary position in a rural mission hospital - it's something I've always wanted to do, and I've loved every minute of it. I will most probably end up doing something like this in the long term.

Reply 19

Helenia