A bloody complication

Her own emergency surgery will change her practice, writes Beth Crouch

I was handed a plastic cup that contained an innocent looking clear liquid: “Gargle this for as long as you can, then spit it out.” Seconds later blood stained foam started spewing from my mouth onto my face and down my chin. I was back in hospital five days after a tonsillectomy.

My general practitioner had referred me after recurrent tonsillitis. I decided where and when to be treated through the NHS “choose and book” scheme.¹ I wanted the first available appointment, which led to the procedure being carried out at the local private hospital. My room was more luxurious than many hotels I’ve stayed in. Food was served as though it was room service, and my private bathroom was double the size of the one at home. The nurses clerked me in, and I met the surgeon. I was much less anxious once I met the anaesthetist because I had worked with him during one of my clinical rotations.

Family planning

For months my family had been interested in the planning of the operation. It surprised me that aunts and uncles wanted to know where and when I was having the procedure. And as the time approached I realised how upsetting it must be for patients, who have rearranged their lives weeks before the procedure, to find their surgery cancelled. But my tonsillectomy wasn’t cancelled. I spent the evening before with my family and friends.

I tried mentally to approach my tonsillectomy in the same way as we approach surgical rounds: “Just a small operation; 20 minutes long; so straightforward that junior doctors do them.” This approach failed because it was my neck on the block, my throat being cut, my lungs being intubated. I dreaded it. The night before I was so anxious that I slept for only four hours, and I was tired on the morning of my surgery. I promised myself that as a doctor I would check how well patients sleep and empathise about any anxiety.

By the time I put on the theatre gown, with specially chosen knickers for theatre, I was much calmer and ready for the operation. I was taken to theatre and greeted by the anaesthetist. Midazolam was the best part of the whole thing: I was high for two amazing seconds before I went to sleep.

Five days later at home, after lectures all day, I tasted something warm and metallic at the back of my throat. When I spat blood into the kitchen sink I realised that the site of the tonsillectomy was bleeding. It was a surprise, but I had read about this complication in the information leaflet that I’d been given before the operation.² Bleeding is the most common complication after tonsillectomy.

I began to bring up a mouthful of blood every 10 seconds or so. My friends decided that I needed to go to the emergency department straight away. They took me and a salad bowl and tissues for the blood to the car.

It was odd being escorted into the emergency department with my head in a bloody bowl, not being able to see. I was aware of people moving out of the way and staring at us.

The receptionist didn’t bat an eyelid at my blood stained, mascara streaked appearance and barked questions. A man with a sore finger in the waiting area was called before me but kindly let me go first. Triage was brief because I began to cough while spitting blood into the bowl. In what seemed less than 10 seconds the nurse had my history; called a junior ear, nose, and throat doctor; and gave me urgent priority. I was impressed: it takes me 15 minutes to obtain a history.

I lost the concept of time. At first things happened in a blur—I was cannulated, had blood taken, and had vital signs recorded, and the senior registrar gave me hydrogen peroxide. I quietly gargled and foamed while my friends telephoned my family and cleared up the blood stained tissues.

I began to vomit blood, which was horrible. My friends rubbed my back and swapped bowls as fast as they could. They encouraged me and stopped me being so frightened by the vomit.

Testing students

By the time the junior doctor arrived we had all been identified as medical students. My poor friends were quizzed on indication, drugs, and risks of tonsillectomy and how to manage bleeding after operation. This happens to all medical students when they seek health care. The junior doctor applied pressure to the bleeding site with adrenaline swabs. It was unpleasant, and I appreciated my friend holding my hand.

In the initial surgery the cannula was positioned on the back of my hand, and this was much easier to manage as a patient. The flat dorsal surface of the hand is better for fluids to run into because the tube stays patent. This time the cannula was in my antecubital fossa. When I moved, the saline stopped running. It was difficult to keep my arm straight, and the area was painful. I had been taught that the antecubital fossa is for emergencies only, so you could argue that it was appropriate. I went on to develop a 12 x 5 cm bruise. As a doctor I will try to cannulate the back of the hand if possible, for comfort and ease of use.

Somehow two hours had passed and none of the conservative measures had stemmed the bleeding. We developed a routine, in which I spat out several bowls of blood, followed by one or two bowls of vomited blood. I quickly filled the nearest bin and was getting tired. The registrar took one look inside my mouth and told me that I needed to go straight to theatre.

My family is more than 200 miles away from where I study, and it was imperative that I spoke to my fiancé before going for emergency surgery. It made a difference for us to be able to say we loved each other by telephone before the operation.

The thought process while preparing for emergency surgery was much easier than the weeks of anxious anticipation before the planned operation. I recollect thinking, “I hope I survive this” and “I don’t care what you do, just please fix me.” Emergency surgery was more frightening because I knew how seriously ill I was. But I had no doubt about having the operation because it was the only thing that could fix me.

Transfer to the ward

After the operation, once the pain was under control, I was transferred to the surgical admissions ward. My fiancé was allowed to be with me for half an hour despite it being nearly midnight. This made a huge difference.

The dim lighting and gentle continual noise during the night were comforting, perhaps because I have worked in hospitals for years. The care given by the night shift was more personal, and the staff had more time for each patient and seemed less pressured. I imagine this was because the staff didn’t have to do the other things that are done in the day in addition to giving basic nursing care.

A patient sees lots of different staff throughout a day. I had an advantage because I knew the uniforms so I could guess who did what. When a member of staff approached my bed it felt intrusive. Also I felt vulnerable because I was so ill and exhausted. Fewer than half the staff introduced themselves and gave the reason for being there. Those that did made me feel secure, and I trusted them. Those that did not made me feel wary, and I had less confidence in them.

My full name is Elizabeth, but everybody calls me Beth. Before being anaesthetised I told the operating department practitioner my preferred name so that when they were trying to wake me I would respond. My view may be old fashioned, but I refer to patients by surname unless they tell me otherwise. Often patients then ask to be called by a preferred name. This courtesy was not always extended to me, and I found that rude.

I hope that by sharing my experiences medical students who have never been a patient will learn from them.

Competing interests: None declared

Provenance and peer review: Not commissioned, not externally peer reviewed.

Beth Crouch final year medical student Leicester University
crouchbc@yahoo.com
Student BMJ 2008;16:425468-ISSN 0966-6494 | December

National Health Service. Choose and book: patient and public welcome page. 2008. www.chooseandbook.nhs.uk/patients
Nuffield Hospitals. Tonsillectomy: a patient information leaflet. Surbiton: Nuffield, 2005.