Cervical Spine Injuries

Introduction

  • Common cause of disability 
  • Most common causes:–  RTA, Fall, Penetrating trauma, Sports 
  • Highly prone to traumatic injury:
  • Mobile, relatively unprotected, and its high position 
  • 60% of all spinal injuries occur in the cervical spine 
  • Subaxial cervical spine injuries include:
    • 2/3rd of all cervical fractures
    • 75% of all cervical dislocations 
  • One third of injuries occur at the level of C2, and one half of injuries occur at the level of C6 or C7.

Epidemiology

  • Bimodal Peak
  • Adolescents and Young Adults
  • Middle Aged Individuals (55 years)
  • Males accounts for 80% of injuries 

I have always enjoyed interacting with surgical residents and one of the first questions the young resident who enters surgery asks me is “ How do I study during residency?” Studying during a tough surgery residency is not easy at all. The biggest hurdle will be your seniors and colleagues who will discourage you from picking your books. The long hours, lack of sleep and abusive seniors  just compound things. But one fact we forget is - studying in residency is not a privilege, it's a duty. Acquiring knowledge so that you can treat your patients appropriately is a fundamental duty. 

This article will be a continuation to Part I of being an amazing surgical resident. 


 





HOW TO STUDY DURING PG LIFE?


IN THE WARD: 

The best surgical atlas an Indian resident can have is the patient himself. The good caseload in most Indian centres means that there is no dearth of surgical material. The optimal way to start studying is to read about the cases in the ward everyday.     The moment a case is admitted in the ward, pick up your Washington Manual of Surgery and start reading about it. The Washington Manual can be used as an e-book on your phone or tab. The Washington Manual of surgery is a small and concise handbook that doesn’t delve too much into theoretical aspects of surgery but merely lists out the concepts, diagnosis and management of a particular problem. Residents who can afford to shell out significant chunks of money can also spend on UptoDate. UpToDate is one of the best resources a resident can subscribe to. 



Keep in touch with recent research. Just type in the keywords on NCBI/Pubmed website and checkout the most appropriate research paper. Even if time doesn’t permit you the read the entire paper, read the abstract and try to understand it. 



IN THE OPERATING THEATRE:

The operating theatre can be quite intimidating as a first year resident. One of the best ways to come out unscathed out of the OR is to read well before surgery. Use Farquharson's Textbook of Operative General Surgery to read upon on the operating steps. If you have time to read the previous night, use Fischer's Mastery of Surgery 7th edition. Fischer’s is a fantastic resource which explains the anatomy and the surgery in detail. For a first year resident, it might seem like a humongous task to go through it. But the effort you put into understanding the concepts in Fischer’s will reflect on your operating table. 



For understanding the basic principles of surgery use Kirk’s Basic Surgical Techniques 6th edition . This book will teach you the methods of knot tying, suturing, fixing a drain and inserting a chest tube. 


However the best resource for operative surgery is YOUTUBE. The absolute wealth if content YouTube offers you is unsurpassed and the only hurdle will be in dis time ting between good quality content and useless videos. 


The NCCN guidelines are the most important resource a resident can use before treating a patient with a malignant condition 


YOUTUBE CHANNELS TO FOLLOW:


https://www.youtube.com/channel/UCVpqNpkdJtxqSDw8C2Lw4XA - The official channel for Learning General Surgery. The ultimate resource on surgical knowledge especially after the lockdown lecture series. LGS videos are extremely well curated

by Dr GD Sharma and Dr Patta Radhakrishna




https://www.youtube.com/c/SurgicalEducator - Basics of surgery - essential for every resident 


https://www.youtube.com/c/Surgery101 - Surgery basics explained in simple terms 


https://www.youtube.com/c/SAGESVideo - SAGES channel. Follow for high quality laparoscopy training 


https://www.youtube.com/channel/UCTOg68oXp2S-yIPz0tkTewA - Operative surgical oncology by Dr Marimuthu of Thanjavur, Tamil Nadu


https://www.youtube.com/user/surgyserg - Follow the Ukrainian maestro Dr Baydo for daredevil laparoscopy 


https://www.youtube.com/channel/UCVpqNpkdJtxqSDw8C2Lw4XA - Dr Omedary teaches us how to tie surgical knots 


https://www.youtube.com/channel/UCE1sLGb-8COMdl0_xkdxD3w - Dr Ashwin’s laproscopic Hernia videos are a must watch


I can keep talking about wonderful surgeons on YouTube. Really soon we will do a separate exhaustive post on YouTube channels for surgery residents. 



BOOKS YOU SHOULD BUY 


Bailey and Love Short Practice of Surgery, 27th edition - Read basic aspects of surgery and urology from bailey. You need nothing more for final exams and also NEET SS




Sabiston Textbook of Surgery, 20th edition - GI Surgery is best read from Sabiston,. It is quite exhaustive and an absolute deligh to read. Residents interested in GI surgery should never complete residency without reading  Sabiston. 




Schwartz Principles of Surgery, 11th edition - Breast and Thyroid chapters are extremely detailed and thorough in this masterpiece. A definite must-read. 


                                                          

 

Clinical Surgery Pearls 3rd edition by Dr Dayananda Babu   This book is the living soul of every resident preparing for final year exams. For clinical surgery, this is no-brainer. You should definitely purchase the hard copy. 



Bedside Clinics in Surgery 3rd edition by Dr Makhan Lal Saha - This beauty of a book is a lifesaver in final year examinations. Certain chapters like abdomen examination are never omitted. 




A Manual On Clinical Surgery by S.Das 14th edition. This book is now in its 14th edition but shall never go out of favour. You would be committing a sin if you don't read ulcer and swellings from this evergreen book. Note: Even if you possess an older edition, it doesn’t matter - Nothing ever changes in successive editions. 


Separate posts will cover books that GI surgery, Onco surgery, Neurosurgery and Plastic aspirants should buy.


APPs 


I used to read Bailey during my PG days and would always wish that I has an application on which I could solve MCQs so that I could simultaneously prepare for NEET SS. There were a couple of web based options but none were good for daily use in the ward. I ended up developing the SURGTEST app with a group of friends so that residents could use a handy app that would work even at low internet speeds in dimly lit, dungeon-like wards with a whole host of network issues. The general surgery question bank with more than a thousand questions based on Bailey and Love 27th edition are exhaustive and a must-have for every first year surgery resident. The questions are arranged topic wise and will help you revise core topics at ease. The Onco surgery question bank based on MD Anderson Surgical Oncology Handbook 6th edition and NCCN guidelines should be on the wish list of every resident aspiring to be an hot shot onco-surgeon. The GI surgery package is about to be released soon. There are also extensive video lectures on GI surgery which would be an invaluable resource on GI surgery for residents. Residents can contact the team for discounts. 


                                                              


I have covered a few aspects of studying during residency. In future chapters, I will cover research during residency, negotiations seniors and diplomacy while a resident and a few other topics. Since it is an extensive topic, I have not covered MRCS preparation. MRCS preparation is definitely possible even while you are a resident and I am gonna tell you how to crack both parts of MRCS even before you finish MS/DNB.


There is nothing more satisfying than treating the patient the right way. The patient puts his/her full trust on you. It is extremely essential that we understand this. It is a huge privilege to be a surgeon. That privilege comes with a huge responsibility. One major aspect of that responsibility is acquiring knowledge.


Learn well. Treat well.


Vinayak Rengan is a General surgeon from Chennai who completed his Surgical residency at Madras Medical College. He is a compulsive news junkie who regularly writes for print media and runs a blog The Stonebench where he writes on technology, public health and politics . He is the co-founder of Surgtest - a surgical education platform which helps surgeons prepare for NEET SS and MRCS.


#neetss #surgery #residency #indiaPG #Generalsurgery





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Here is a review of various pathways for specializing after completing MS General Surgery. In the part 1 of this post I will be reviewing Urology, Surgical Oncology, Surgical Gastroenterology and Neurosurgery.

Contents


NEET SS Best Specialties after General Surgery

Urology MCh/ DNB - Pros and Cons

  • Less emergencies
  • Peace of mind as most patient do not require ICU support
  • High demand high volume
  • Average Per procedure fee for routine procedures low
  • Possibility for starting basic individual practice with low investment
  • Minor surgeries to oncosurgery, laparoscopic, endoscopic, robotic surgery and transplantation
  • Can also do individual practice and do basic procedures

Surgical Oncology MCh/ DNB- - Pros and Cons

  • Large variety of cancers can be operated
  • Good demand in corporate setups
  • Competition with general surgery is there
  • One of the highly sought branches
  • Depends largely on a institutional model of practice, individual practice difficult

Surgical Gastro MCh/ DNB - Pros and Cons 

  • Fierce competition with General surgeons and FNB/ MCh Minimal Access Surgery  
  • You need to further specialize in hepatobiliary, liver transplantation, bariatric, colorectal surgery
  • Value only in big cities  
  • High patient load
  • Can do both individual and institutional practice

Neurosurgery MCh/ DNB - Pros and Cons

  • High in demand
  • High stress
  • High patient load
  • High complications and mortality rates
  • Easy to get jobs both in metro cities and tier B cities
  • Good remuneration (One of the top most)
  • Challenging in terms of hours and techniques involved
  • Has a variety of procedures including Neuroncology, Brain Trauma Surgery, Endoscopic Surgery, Neurovascular Surgery, Spine surgery, Peripheral Nerve Surgery
  • Evolving fast with many new breakthroughs
  • Can also do individual practice and do basic procedures


Keywords: Best Specialties after MS General Surgery, MCh/ DNB Superspeciality, Which super speciality to choose, Urology, Neurosurgery, Surgical Gastroenterology, Surgical Oncology, Review, Surgery NEET SS

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PROS AND CONS OF JOINING DNB: DR DEEPAK SHETTY




Also check out these links for more details:



It was 2014. After wasting an year in post internship syndrome,the world seemed to stand still. With whopping 5 digit numbers in All India and State Entrances, I had started questioning my inner self if I was an apt fit to this profession. Should I sit back and prepare again or should I get a job and start making a living, such questions used to continuously hover on my mind, making things restless.

Should I sit back and prepare again or should I get a job and start making a living, such questions used to continuously hover on my mind

Preparation for an entrance are one of the most dreadful periods in a medicos life. You can't eat more as you might start feeling sleepy after it, you can't go out for that starts making you feel guilty, you can't attend family functions for you are bombarded with what are you doing currently questions which if explained no one understands. Preparing? Achha uske liye bhi padhna hota hai kya?
Such questions used to boggle my mind off.

Battling all these self doubts and guilt in my mind, I decided to give it one more shot.
"The next 9 month,either this side or that side" I mumbled in my mind. Say it my luck or my room mates bad luck, he was stuck at a borderline rank. He couldn't dare to take it neither leave it.
We both decided to change our study place in hope that will change our fortunes. This friend of mine was my MBBS batch mate. The last year we had shifted together and started preparing. But just in 3 months I lost way and left him. Anyways,this time with rock solid determination in the scorching sun of April we decided to find a place in the medical hub of Delhi, Gautam Nagar.

Anyways,this time with rock solid determination in the scorching sun of April we decided to find a place in the medical hub of Delhi, Gautam Nagar.

This place was true for a doctor what was true for an engineer in Bangalore. Even the barber knew the difference between a PG aspirant and a FMGE here. Surprisingly the landlord's were more welcoming to a foreign graduate than to a Indian one. The reason which I came to know later on was not surprising.

So finally we found a place for us which by God's grace had a balcony and a view. One of the rare things you would find in Gautam nagar,where people make 4 walls covered with a tin shed and call that a room. Thanking our starts enough,we immediately finalized and paid advance.

Now the next target was to find a library where one could immerse in the world of mcqs with many others who were one of the best brains of the country. In Gautam Nagar one would find libraries in every corner and streets. We finalized one which had the best record in past years plus which was no girls allowed library. We were so focused for a PG seat this time that we were trying to avoid all the possible urvasis around us, not that we were surrounded by any of them before.

Back then there were 3 types of coaching available. The tablet apps were still in their dormancy. One had to select between regular classes, test and discussion or test series. Being done with regular classes and tasting every inch of their business, I didn't want to go for any further coachings wasting lakhs of rupees. Firmly, I decided to go for a test series,which would be light on my pocket and keep my preparation in check.

Every step in this place was competitive. From grabbing a seat in library to finding a place to eat,there was a que everywhere. Any place you could see up to you would find a qualified MBBS doctor in his bermudas looking as helpless as you . This was the place you would hear more MCQs than prayers.

With all the determination I started preparing. There was a provision for seating 2 people on a single table which would make you immovable. Things were tough here as I said. So I started with the weekly test series of a coaching institute. We would read up a subject in a week and give its test on Sunday. We had to make sure the subject got over in those 7 days itself. A single day here and there and the left over were left forever,so was the crunch of time.

We would read up a subject in a week and give its test on Sunday. We had to make sure the subject got over in those 7 days itself. 

As the time passed and a few tests were done, we had started gaining some confidence. Then came may AIIMS exam. For which we never did any special preparation. For someone having 5 digit rank in NEET PG a few months back, aiming AIIMS was out of question where only a few seats were to be competed for. Anyways, with whatsoever preparation we did,we appeared for the exam and then totally forgot about it. When the results were out, I got a rank of 361. It was a major morale booster. Never in my life I had imagined of being so close to what I had been aiming for. Within a few minutes of results being announced I became famous in the library. People had started congratulating and asking tips on how to read as if I had topped the exam. But then,who doesn't likes fame. Now I was more confident than ever. I started writing a small diary where I would jot down all the emotions I felt. Be it personal, professional, parents, love life etc. I used to appreciate myself whenever I did good and scold as well when I became overconfident. This diary was my mentor. I would often go through it and check my emotions.

Then came the mid year DNB exams and we both did extremely well that would fetch us clinical seat in the branch we wished. But now we were determined to take our fight to the NEET PG exam which was the landmark exam of PG entrances. With same enthusiasm we continued preparing. 12 hours a day, no booze, no girls, no outings, no parties, burning our ass to the every core possible. We often tried to escape from our other friends who were in jobs that time so as to save a few minutes. I often felt guilty of such behaviour but now when I am through it I feel it was necessary.

12 hours a day, no booze, no girls, no outings, no parties, burning our ass to the every core possible

At an age when everyone is earning we were still drawing cash from our parents,who did not asked a single question on what we were doing. Every rupee we spent was with caution. PG preparation is not only a tough time physically and mentally but financially as well. We would regularly pump each other. There were times when we felt low,not able to think what would happen if we were not able to crack.

The situation in library was becoming tensed with every passing day. It was November and all were adrenaline charged . Even the noise of sipping tea was not tolerable. Being all men library,often brawls would surge up. The only thing now important was to hold the nerves and revise. Deep inside we knew that we had read everything possible and  now only need good revisions.

Finally the d day arrived. And we attempted it with all the might we had gathered all year long.
As soon as the exam got over I ran away from all the books and immersed myself into the world of beer. I just wanted to forget all the questions and relax a bit. Now I wanted to use this time rejuvenate myself for all that was lost this year.

The results were out in a month time and I had finally cracked one of the toughest exams in India admitting myself to a government medical college learning the art of surgery. I was content and satisfied with what I had achieved. The dreadful phase was over.  Not knowing what future was waiting with, I moved steps towards the next title. My designation had changed, PG aspirant to a would be surgeon.

The results were out in a month time and I had finally cracked one of the toughest exams in India admitting myself to a government medical college learning the art of surgery.


About the Author 

Dr Vinay Kumar Rai is currently pursuing his DNB Urology at Max Hospital, Saket. He finished his M S General surgery in 2018 from Bikaner. He is interested in scalpel, sports and students. 




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Quick Publish your articles on World Surgery Forum
There are about 3000 young minds entering surgery residency in India this year. Most of them have waited for months and years to be a surgeon. During their internship as they assisted their PGs in a hernia and while suturing broken foreheads - all they wanted to be was “a surgeon”. It indeed is a proud moment for them and their families, I want to start by congratulating them for their phenomenal achievement. 

However the path ahead is fraught with challenges and struggles. Surgery residency in India is one of the toughest and most brutal periods of a medical student's life. Some residents have a good life where they are treated with dignity. Others are treated as lowly slaves and drivers. You might learn a lot under a fantastic teacher or you might not be allowed to operate even a hernia all your residency. In the short term, these are extremely important. However in the longer run, these factors does not matter at all. One of the first things you must remember is that training doesn’t not end with residency. There is an option of doing senior residency is top institutes after your surgery residency where you will get exposed to best practices in the field. So never despair. One of the finest GI surgeons I know was allowed to operate on only 2 appendectomies throughout his residency. This did not stop him from being a maestro in GI surgery. One of the finest laparoscopic hernioplasties I have ever seen was performed by a surgeon who did his DNB in a corporate hospital well known in surgical circles for not allowing residents to even scrub up for cases. However both these surgeons had one thing in common: an intense desire to succeed. 

amazing first year PG in surgery



How to be a good resident?


One of the most important qualities you need is compassion. Good residents are usually the most compassionate people you can ever meet. They work hard because they know that the effort they put translates into quality care for their patients.

A good resident also is a knowledgable resident. When you work in a high volume centre, you will be expected to take decisions that impact your patient’s care. Good decisions can be made only if the resident is reasonably knowledgable. 

Residency involves a lot of effort and stamina. Investing in your health is extremely important. There are hardworking residents who tend to fall sick often. They miss out on learning and operating chance simply because their health doesn’t permit them. 

Diplomacy is one of the most important aspects of residency. Indian surgery training is brutally hierarchical and negotiating through the complex maze of surgical heirarchy is not a simple task. 

We shall analyse each parameter in detail.

COMPASSIONATE RESIDENT 


It is a very tough task to be polite when there are 300 patients waiting in the OPD, especially when you haven’t slept for the past 36 hours. The surgical training programs in high volume centres are designed to be efficient, not patient friendly. However it is essential that you maintain your goodness and compassion even during residency. There will always be that one resident who doesn’t shout at patients and juniors. Invariably he/she is the one who evinces maximum respect from staff and doctors. That resident should be your example. 

There are good selfish reasons to be compassionate. A small smile at the boy who pushes the stretcher goes a long way. When I was a resident at Madras Medical College not long ago, I would ensure that the OT boys had food before dinner time ends. I would also make sure that I learnt the names of every staff and worker who worked with me. Addressing everyone by their names shows that you respect them and have made the effort to learn their names. These small gestures go a long way. The OT boys would make sure that my case was wheeled in even before the brutes from orthopaedics rushed in to occupy the lone table in the emergency OT. On a particular summer post admission day morning when I almost collapsed due to dehydration, one of the senior staff nurses fed me with her own hands. These are moments which shall remain etched in my memory for long. 

Compassion towards your patients is a must even before you enter residnecy. If you feel, you dont give a damn about your patients - surgery is not the place to be. Treat your patients as human beings, not as operating opportunities. If you feel that a T4 lesion in the breast needs chemotherapy before surgery, dont push for surgery just because it is your chance. If a patient with rectal CA needs neoadjuvant RT before surgery, it is important that you ensure that the right treatment is ensured. 

Be an advocate for your patients. Fight alongside them for their rights. Most of the patients in government hospitals have come here because they have nowhere else to go. It is matter of huge privilege that you are given the opportunity to treat them. For you it might be just an emergency splenectomy. For the mother, it is her 24 year old son who has had a major accident and is battling for his life with a shattered spleen. A patient is not just a case. When a patient or an attender has a query, take time to explain to them the situation. If you dont have the time, apologise and promise them that your intern will answer the query or you will come back later. Do remember to keep your promise. It is quite easy for me to type these things but your small gesture will be remembered for a long time. 

At the end of the day, be the resident you want to be treated by.

In the next part, I will discuss on strategies to study during residency. 

Recommended reading material about surgery residency


These 2 books about a surgery resident’s life also talk about the human aspects of residency. A lot of young Indian residents  will able to relate to Heart,Guts & Steel which is about residency in a Bombay Hospital by the ever brilliant Dr Sivasubramanian. 




Vinayak Rengan is a General surgeon from Chennai who completed his Surgical residency at Madras Medical College. He is a compulsive news junkie who regularly writes for print media and runs a blog The Stonebench where he writes on technology, public health and politics . He is the co-founder of Surgtest - a surgical education platform which helps surgeons prepare for NEET SS and MRCS.

#neetss #surgery #residency #indiaPG #Generalsurgery



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https://www.worldsurgeryforum.net/2018/06/what-all-to-study-in-first-year-of.html


BEST MCQ BOOKS FOR GENERAL SURGERY FOR INDIAN PG AND SUPER SPECIALITY EXAMS

https://www.worldsurgeryforum.net/2018/03/best-mcq-books-for-general-surgery.html


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Phyllodes Tumor
Phyllodes Tumor
  • The term Phyllodes originates from Greek word "phullon" which means a leaf.
  • It is also called as Cystosarcoma phyllodes.
  • Here is a picture of a Phyllodes tumor recently operated by us. 
  • The patient was a 38 year old female with complaints of swelling in Left breast of 6 months duration which was fast growing in size.
  • The tumor was excised through a submammary incision
  • Phyllodes tumors are a fibroepithelial tumor composed of an epithelial and a cellular stromal component. 
  • They may be considered benign, borderline, or malignant depending on histologic features including stromal cellularity, infiltration at the tumor's edge, and mitotic activity
  • Predominantly a tumor of adult women
  • Very fast-growing, and can increase in size in just a few weeks
  • 10% of patients with phyllodes tumours can develop distant metastases 
  • Commonest sites for distant metastases are the lung, bone, and abdominal viscera.
  • Treatment : Wide Local Excision