Handbook of General Surgical Emergencies

Sam Mehta, Andrew Hindmarsh, Leila Rees

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315342474
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This is a quick and easy portal of vital information for medical students and clinicians working in accident and emergency departments and surgical admissions units. It is also recommended as a revision aid for surgical exams. Written in an engaging, no-fuss style with helpful overviews and tips, Handbook of General Surgical Emergencies covers the most important of potential problems, including management of the acute surgical patient.

Chapter 1
Surviving ‘on take’

Surviving ‘on take’

Different hospitals adopt different policies with regard to who carries the on-call bleep, from the consultant to the most junior member of the team. Remember to be courteous and helpful to all general practitioners (GPs) who refer patients. Being rude on the phone not only wastes time and energy but may lead to negative feedback being relayed to your consultant.

GP admissions should be seen as soon as they arrive. This is important because you may receive a patient later who is critically unwell, and requires a great deal of time and investment. Keep a list that includes details of the expected patients, provisional diagnoses, any outstanding investigations and management plans. This will be particularly useful at handover times.

Working with the nursing staff

A positive relationship between surgeons and nurses is vital when looking after patients. Nurses can make your life much easier, so co-operate with them.

The respective roles of doctors and nurses have changed substantially in the last few years. Some nurses are now more specialised in certain areas, and increasingly take on some traditional ‘doctor’ roles.

Remember that nurses may have far more experience in dealing with patients from a practical viewpoint than you do. Therefore if you aren’t sure ask for their help. In addition remember that many of the nurses may know about particular consultants’ traits and behaviours.

Always communicate and liaise with whoever is looking after the patient, so that they have a clear idea of the diagnosis and plan of action. Many patients may feel more comfortable discussing their anxieties and questions with the nursing staff rather than clinicians.

One of the critical points of concern in the doctor/nurse relationship is time. Remember that everyone is under pressure. The nurse in question may be too busy to carry out everything you ask. Try and help out as much as possible. When you are similarly busy these same nurses will help you.

Working with the casualty department

It is important to establish a good relationship with the casualty department: they will be the source of many of your referrals and if you are polite and attend promptly they will be more likely to help you in return.

Remember:

● accident and emergency (A&E) staff are often busier than you and have different priorities. Their aim is to diagnose, stabilise and refer appropriately, and so they may not have requested all the specialist investigations you require

● when taking a referral establish who you are speaking to. The A&E doctor may not have as much experience in dealing with general surgical problems as you. However, never assume you know more than them

● if you are in doubt about the appropriateness of a referral try speaking to senior A&E staff. They will be able to tell you which specialties are available to deal with patients who have a particular diagnosis at your hospital. It is often quicker and easier for you to go and see the patient yourself if the diagnosis is unclear

● A&E departments often have protocols to follow – find out what they are

● waiting time restrictions are imposed on the A&E department and can be frustrating for them as well as you. Consequently, you may have to be flexible with regard to where you see the patient, and this can result in having to admit patients for a short period of time to complete your assessment.

Working with the radiology department

Plain radiographs should be organised as and when necessary. Abdominal X-rays are still over-ordered and generally have a low diagnostic yield. Indiscriminate ordering of X-rays wastes time and may be harmful to the patient.¹ It must be clear on the request card why you are ordering an X-ray. More importantly somebody should look at the film(s) as soon as they arrive back on the ward. A recent study has shown that most chest X-rays on acute medical admissions are not looked at until the following post-take ward round.² This is unacceptable in surgery.

Radiological workload has increased substantially over the last few years with advancing technology. There are more computerised tomography (CT) and magnetic resonance imaging (MRI) requests, and the field of interventional radiology is expanding. The on-call radiologist will be very busy, so ensure that all specialist investigations are justified, and discuss with your seniors before requesting them. If possible go and discuss the reasons for the request face-to-face rather than by telephone. They may be able to answer the same clinical question using a quicker, simpler or more accurate test.

The following information should be imparted to the radiologist:

● patient details with the appropriate form filled in

● why the patient needs the imaging, and in particular how the results may alter management. Give as much clinical information as possible

● who sanctioned the request

● how urgent the request is (i.e. immediately or later that day).

Radiologists may say ‘no’ if they are not convinced that the investigation is required or that it will alter management. In this case talk to your immediate senior and let him/her take things further.

Types of investigations

The following three investigations are commonly requested in acute general surgery.

Ultrasound

Ultrasound is useful in evaluating and diagnosing hepatobiliary, pancreatic, vascular and gynaecological pathology. It is an operator-dependent investigation. There is evidence that abdominal ultrasound may be a useful tool in the hands of surgeons with appropriate training. However this practice has not become commonplace in the UK.

Computerised tomography (CT)

Early abdominal CT in patients presenting with an acute abdomen has been shown to reduce hospital stay and perhaps mortality.³ Disadvantages of CT include lack of resources and radiation dosage. When ordering a CT, ensure that the radiologist understands what you are looking for, since the type of scan is tailored to provide the best sensitivity and specificity. This may involve oral or intravenous (i.v.) contrast.

Contrast examinations

●Enteral contrast may be given orally for a swallow or follow-through, or rectally. It may be barium or gastrograffin. Gastrograffin is used in the acute setting because it is water soluble and does not preclude subsequent surgery

●Intravenous contrast may be used for CT sca...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• Glossary
• 1 Surviving ‘on take’
• 2 Assessment of the general surgical patient
• 3 Critical care
• 4 Trauma
• 5 Hernias
• 6 Breast disorders
• 7 Abdominal emergencies
• 8 Anorectal emergencies
• 9 Vascular emergencies
• 10 Urological emergencies
• 11 Important paediatric surgical emergencies
• Appendix 1 Common reference intervals
• Appendix 2 In-hospital resuscitation and Advanced life support
• Index