Make A Decision: Surgery

Mark Corrigan, Arnold Hill, Paul Redmond

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9781405196840
• eBook ISBN: 9781118293423
• Edition: 1
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

You're the general surgeon on call. It is you who has to decide every course of action over your shift. Make the right decisions or face the consequences...

Taking a role-playing approach, Make A Decision: Surgery allows you to be the book's main character - Dr A. Simpson - a junior general surgeon on call in a busy teaching hospital. Your decisions and actions determine the clinical outcomes of real patients within a number of scenarios. Each scenario branches out and unfolds as you make more decisions, but choose incorrectly and you may be sent home by your boss! Every decision you make is scored and evidence-based feedback is presented at the end of each scenario together with the correct clinical response and an explanation of what actually happened to the patient.

Blood work and radiological investigations presented in typical clinical formats allow you to practise your data interpretation skills, whilst your skills in clinical communication are tested to the full as you interact with patients and their families as well as co-members of staff.

Based on first-hand experience, the authors have selected real cases that have impacted on their practice and reflect important points of learning, making the book perfect for medical students, junior doctors, and surgery trainees who are looking for a scenario-based, interactive way to learn.

For further information and online interactive medical teaching visit www.pilgrimshospital.com

SECTION 1

What you’re going to learn

After this section you should be able to prioritise surgical patients in the setting of a busy accident and emergency department. Patients should be triaged according to threat to life, limb or organ, with those patients at highest risk treated first.

What you might also learn

Following completion of this section, you will be capable of performing the following in an evidence-based fashion.

• Using analgesia in the acute abdomen.
• Investigating and imaging the acute abdomen.
• Consider the conservative and operative management of the acute
• abdomen, including laparoscopic and open approaches.
• Adapt a sequential approach to trauma.
• Understanding and managing hypovolaemic shock and fluid resuscitation.
• Controlling simple postoperative bleeding.
• Managing superficial tissue infections.

Now, before you start, make sure you have read the background and the instructions.

16.40 SHIFT STARTS

It has been almost 3 months since the job offer arrived. The interview was tough – those old guys know how to hit you with some awkward questions – but you impressed them enough to get your first choice of hospital and your second choice of job. Pilgrims was one of the best surgical hospitals in the country, but recent cutbacks in government spending have hit even the biggest of institutions. You’ve just finished your first year after medical school and now your first rotation on the training scheme is with a busy general surgical firm and you are eager to impress. Your initial excitement was somewhat dampened upon hearing that Winston had received an identical offer. You competed neck and neck with Charles Winston through medical school but he narrowly beat you to first place in your final exams. You had hoped to put his smug face behind you, but now you will both be on the same training scheme, competing neck and neck once again. Only 8 hours into the job, you are faced with your first night on call. Your senior doctor, Ed Cahoon, will be on call with you along with the head surgeon W. Halsted. Cahoon is in theatre with a difficult case that started several hours ago and you will have to face the start of your shift alone. Cahoon has a mean reputation, but nothing is going to dampen your enthusiasm for your first night on the job.

001

It’s 5pm and your bleep goes off. Quickly finishing your dinner, you walk down the narrow corridor, passing the intensive care unit and the theatres and into the emergency department. Outside the main entrance, a stream of people queue to be seen and your heart races. The door to triage opens and you catch the eye of the triage nurse, surrounded by charts. Her face widens, the smile having no warmth. ‘You’re going to be busy tonight,’ she grins. Suddenly that skip in your step disappears and the automatic doors slide open to reveal the chaos behind them. You take a deep breath and roll up your sleeves before reaching for the two charts in the surgical slot.

I. A 14-year-old girl with vomiting and low abdominal pain → 012

II. A 35-year-old man with cellulitis → 092

002

You rightly choose the most potential serious case, add 1 point.

Sharyn Romanowska, a 62-year-old lady with chronic inflammatory bowel disease, cardiac disease and COPD, presents with sudden onset of epigastric pain. In her past surgical history she has had a right hemicolectomy, open cholecystectomy and a small bowel resection for Crohn’s disease more than 10 years ago. Her pulse is 130 and her BP 92/72. Sharyn’s bloods are found in the Investigations at the end of this section. Currently she is sobbing with pain, lying absolutely still on the bed. Her elderly husband stands nervously in the corner of the resus room, insisting to you that it was the chicken she ate last night. ‘I told her not to eat it, I told her’. Do you:

I. Examine her → 038

II. Get more of a history → 033

III. Administer analgesia → 032

IV. Order four units of blood urgently → 105

V. Insert a second IV line → 053

VI. Give more IV fluids → 011

VII. Go to theatre for an exploratory laparotomy → 069

VIII. Group and save her blood type for future possible blood cross-matching → 165

003

You administer the prochlorperazine and within a short while she settles back. She tells you she has only a dull ache around her belly button. She has no urinary or bowel symptoms and this has never happened before.

I. If you want to take a further history → 065

II. If you want to examine her → 008

III. If you want to look at her investigation results → 118

IV. If you want to order radiological tests → 136

004

You administer the cyclizine and within a short while she settles back. She tells you she has only a dull ache around her belly button. She has no urinary or bowel symptoms and this has never happened before.

I. If you want to take a further history → 065

II. If you want to examine her → 008

III. If you want to look at her investigation results → 118

IV. If you want to order radiological tests → 136

005

It’s a good idea to examine the patient where possible, before starting treatment. However, in this case your diagnosis is right. The man’s urine output is reduced, his CVP is down, his urinary specific gravity is increased, his HCT is increased and his urea is increased with a normal creatinine. The picture is that of dehydration. You give him a fluid challenge of 500 ml over 30 minutes and his pulse slows to 88, BP rises to 134/76, urine climbs to 30 ml and CVP rises to 6. Give yourself 1 point. Do you:

I. Recheck in 1 hour → 058

II. Check again in the morning → 120

006

You get to the ward and see a relieved Mia holding the lady’s leg at the end of the bed. Add 1 point. Her pulse is now 78 and her BP is 126/76.

Mia tells you she had stripping of her long saphenous vein earlier today with stab avulsion of her varicosities. She takes her hand away and you see slow ooze from one of the stab avulsion sites on her calf. The staff nurse tells you that they have not needed to change the dressing until now. The dressings appear to have soaked up about 20 ml of blood. Do you:

I. Take over from Mia and ask the nurses to call Cahoon → 084

II. Take over from the intern, raise the leg in the air and apply a compression dressing → 086

III. Get the intern to continue, raise the leg in the air and place a stitch at the avulsion site → 139

IV. Apply a tourniquet proximal to the bleeding point → 148

007

The plain film of the abdomen is normal. Deduct 1 point.

I. If you want a chest x-ray → 036

II. If you want an ultrasound abdomen → 031

III. If you want a CT abdomen → 112

008

You lay the girl down flat for examination.

I. If you want to tell her mother to stay and carry on examining her → 051

II. If you want to tell her mother to leave and then examine her alone → 154

III. If you want to ask her mother to leave and then bring in a nurse chaperone before examining her → 115

009

You try to perform a laparoscopy but there are dense adhesions secondary to her two previous laparotomies and previously active Crohn’s disease. You change to an open laparotomy and discover the bile-stained fluid of a perforated duodenum. You close this with an omental patch and the lady is returned to the ICU. Two days later she is transferred from the ICU to the ward and she eventually makes a full recovery. Well done, add 1 point.

Return to the surgical slot → 067

010

The lady is diffusely tender with generalised guarding and rebound. Bowel sounds are absent and she is clammy to the touch. Her tongue is dry, fissured and cracked. Margaret is standing beside you and can’t believe you’re not going to theatre straight away. Do you next:

I. Get more of a history → 099

II. Administer morphine → 075

III. Get radiology → 060

IV. Go to theatre for an exploratory laparotomy → 069

011

Recognising that the lady is profoundly dehydrated, you administer IV fluids and insert a urinary catheter to monitor her output hourly. Within 30 minutes her pulse has slowed to 96 and her blood pressure has improved to 100/64. Add 1 point. Do you next:

I. Examine her → 010

II. Get more of a history → 099

III. Administer morphine → 075

IV. Get radiology → 060

V. Go to theatre for an exploratory laparotomy → 089

012

You obviously prioritise your patients and she is the more likely to need surgery; add 1 point. You flick quickly through the girl’s chart. Karen Twentyman is a 14-year-old girl with no medical history of note. Three days ago she developed mild suprapubic pain with associated nausea and vomiting. The triage nurse has sent off a urine sample for culture. You pull back the curtain and a stocky girl in a school uniform is vomiting into a kidney dish. Her mother rubs her back and looks up as you enter. Eileen, the nurse looking after her, asks you to prescribe an antiemetic in order to make the girl more comfortable.

I. If you want to give her prochlorperazine → 003

II. If you want to give her cyclizine → 004

III. If you want to give her ondansetron → 079

IV. If you want to hold off the antiemetics and try to elicit a history first → 029

013

She tells you that the patient has deteriorated and needs to be seen. Do you:

I. Tell her you’ll see her after you’re finished with this patient → 028

II. Go and see for yourself → 077

014

The lady is diffusely tender with generalised guarding and rebound. Bowel sounds are absent and she is clammy to touch. Her tongue is dry, fissured and cracked. Do you:

I. Get more of a history → 057

II. Order four units of blood urgently → 105

III. Insert a second IV line → 053

IV. Give more IV fluids → 011

015

Cahoon becomes irritated at the argument. He tells you to take another case and to stop wasting his time. Deduct 1 point.

→ 037

016

Your hospital does not routinely check serum beta HCG and you must wait for another urine sample which takes another 20 minutes. It returns as positive. Add 1 point.

I. If you want to ask Eileen to tell the mother → 061

II. If you want to tell the girl → 062

III. If you want to tell the mother → 019

IV. If you want to ask Eileen to tell the girl → 061

017

The haemat...

Table of contents

• Cover
• Title page
• Copyright
• Dedication
• Acknowledgements
• Introduction
• How to use this book
• Introduction to the staff and nomenclature of Pilgrims Hospital
• SECTION 1
• SECTION 2
• SECTION 3