| |
A
skilled surgeon can make diagnosis appear very easy, almost
intuitive. The process of problem analysis and decision
making may be faster, but it is the same for every practitioner,
whatever his or her experience. It consists of:
| :: |
History |
| :: |
Physical
examination |
| :: |
Differential
diagnosis |
| :: |
Investigations,
if required, to confirm your diagnosis |
| :: |
Treatment |
| :: |
Observation
of the effects of treatment |
| :: |
Re-evaluation
of the situation, the diagnosis and the treatment. |
Skilled
practitioners go through the same process for both a puzzling
case and one that, at the outset, seems to have an obvious
diagnosis. If you make the diagnosis too early, you may miss
the opportunity to collect important information. Do not
jump to conclusions. A diagnostic algorithm can be helpful,
but cannot replace active thinking about the case. Talk to,
examine and think about the patient.
History and physical examination
The patient’s history and physical examination are
key parts of surgical decision making. It is not enough simply
to examine the abdomen when the presentation is abdominal
pain. Examine the whole patient, assess his/her general health,
nutrition and volume status and look for anaemia. Remember
to ask about chronic or intercurrent illnesses.
A full medical history includes the following:
| :: |
Patient
identification: name, sex, address and date of birth |
| :: |
Presenting
complaint |
| :: |
History
of the present symptoms/illness |
| :: |
Past
medical history, especially previous surgery and any
complications, including:
– Allergies
– Medications, including non-prescription and locally obtained drugs
– Immunizations
– Use of tobacco and alcohol |
| :: |
Family
history |
| :: |
Social
history |
| :: |
Functional
inquiry which reviews all systems. |
Investigations: general principles
Use laboratory and diagnostic imaging investigations to confirm
a clinical hypothesis; they will not make the diagnosis in
isolation.
Remember to inform the patient of the results of any tests.
Take time and care if the results are unexpected or are likely
to cause emotional trauma.
Do not delay an urgent procedure if laboratory services or
diagnostic imaging are not available. The decision to operate
must often be made on purely clinical grounds, even though
investigations provide additional information and further support
for the diagnosis and management plan.
Only ask for an investigation if:
| :: |
You
know why you want it and can interpret the result |
| :: |
Your
management plan depends on the result. |
If
the patient’s condition changes, return to the beginning
of the process and re-evaluate everything. Gather information
and communicate the assessment and plan to everyone who
needs to know.
Remember that the surgical practitioner does not exist
in isolation, but is part of an operative team. The surgical
practitioner’s
primary colleagues in the operating room are the anaesthetist
and nurses; communication and coordinated efforts are
essential between these people. Technical staff and porters
are valuable members of the team. The instruments, equipment,
drugs and the operating room itself are also essential components
that require your active attention.
Before undertaking a procedure, contact other members of
the surgical team and enlist their involvement and cooperation.
Assess the surgical and anaesthetic risk and explain it to
the patient (and the patient’s family, if appropriate).
See the sections on consent on pages 1–7 to 1–8
and 13–23.
The ability to provide consistent postoperative care can limit
the surgical capabilities of a hospital. In this situation,
the whole surgical team needs to work together to improve it.
The surgical team is ultimately responsible for all aspects
of surgical care and must be involved in its ongoing evaluation
and development.
Decision making
Your clinical assessment of the patient may indicate that surgery
is required. If so, consider the following important issues.
Can we do the procedure here?
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Is
the operating room safe and fit for use? |
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Are
the necessary equipment and drugs available? |
| :: |
Are
all members of the team available? |
| :: |
Do
I have the knowledge and skill to perform the necessary
procedure? |
Can we manage this patient?
| :: |
Is
there back up or extra support available, if required? |
| :: |
Can
we manage the potential complications if problems arise? |
| :: |
Do
we have nursing facilities for good postoperative care? |
If
the answer to any of these questions is “No”,
it is inadvisable to proceed with surgery. If transfer
is not possible or the patient could not withstand
such a stress, then be aware of, and communicate, the increased
risk of the procedure and proceed with great caution.
Is this patient stable enough to be transferred elsewhere?
At times it will be necessary to transfer an ill patient. Make
contact with the centre to which you wish to send the patient;
make sure they agree to the transfer and are expecting the
patient. If you are finding it difficult to manage a patient
in your hospital, be aware that it will be even more difficult
to manage that patient in transport. Whether transport is by
land, air or water, the environment will be noisier, bumpier
and more crowded than where you are when you make the decision
to transport the patient. Preparation and planning are essential
for a successful transport.
| 1 |
Make
a diagnosis and treatment plan. Do not simply refer the
patient without thinking about what is going on. Manage
and care for the patient while awaiting transfer and
while in transit. |
| 2 |
Do
not refer the patient unless the referral centre can
provide a higher level of expertise and care and the
patient can tolerate the transfer. |
| 3 |
When
possible, talk to the person to whom you are sending
the patient. Make sure they are aware of and willing
to accept the patient. |
| 4 |
Identify
the transportation options that are available and decide
which is best for the patient. |
| 5 |
Stabilize
the patient before transportation; the highest priorities
are airway, breathing and circulation (ABC). Immobilize
fractures, control pain and prevent further injury. Place
a nasogastric tube if gastrointestinal obstruction is
suspected. |
| 6 |
Assess
the need for care and intervention during transport.
Send the patient with the equipment and staffing required. |
| 7 |
Try
to anticipate and prepare for any changes that may occur
on the way. |
| 8 |
Send
a referral or transfer letter with the patient’s
notes and the results of any investigations. The letter
should contain the same information as in the preoperative
note (see below). |
If it is usual for your hospital to transport patients,
make a list of the equipment commonly required, use this
as a checklist and consider having a kit with this equipment,
ready for use. Make it someone’s job to restock the
kit after each use. Devise a sealing system to
ensure that nothing is taken from the kit and that it is possible
to see, simply by looking, that it is stocked and ready
for use.
Preoperative note
The preoperative note should:
| :: |
Document:
– The history and physical examination
– Results of laboratory and other investigations
– Diagnosis
– Proposed surgery |
| :: |
Document
your discussion with the patient and family and their
consent to proceed |
| :: |
Demonstrate:
– The thought process leading to the decision to operate
– That you have considered possible alternatives and the risks and benefits
of each. |
Preparation for surgery
The patient must be seen by the surgical and anaesthetic
practitioners preoperatively. This can range from days or
weeks in advance in the case of an elective procedure to
minutes before in an emergency. If there is a long time between
initial assessment and surgical procedure, it is essential
to ensure that there have been no changes in the patient’s
condition in the intervening period.
The patient’s stay in hospital before an
operation should be as short as possible. Complete
as much preoperative investigation and treatment
as possible on an outpatient basis. Before the
operation, correct gross malnutrition, treat
serious bacterial infection, investigate and
correct gross anaemia, and control diabetes.
On the day of surgery
Always see the patient on the day of surgery. Make sure that
the patient has fasted for an appropriate time before the operation.
It is the surgical practitioner’s responsibility to ensure
that the side to be operated on is clearly marked just before
the operation. Recheck this immediately before the patient
is anaesthetized. The patient’s notes,
laboratory reports and X-rays must accompany
the patient to the operating room.
Intraoperative care
It is the anaesthetic practitioner’s responsibility
to provide safe and effective anaesthesia for
the patient. The anaesthetic of choice for any given procedure
will depend on his or her training and experience, the
range of equipment and drugs available and the clinical
situation. It is important for the surgical and anaesthetic
practitioners to communicate any changes or findings to
one another during the procedure.
The operative note
After an operation, an “operative note” must be
written in the patient’s clinical notes.
It should include at least:
| :: |
Names
of persons in attendance during the procedure |
| :: |
Pre-
and postoperative diagnoses |
| :: |
Procedure
carried out |
| :: |
Findings
and unusual occurrences |
| :: |
Length
of procedure |
| :: |
Estimated
blood loss |
| :: |
Anaesthesia
record (normally a separate sheet) |
| :: |
Fluids
administered (may also be on anaesthesia record) |
| :: |
Specimens
removed or taken |
| :: |
Complications,
including contamination or potential for infection |
| :: |
Method
of closure or other information that will be important
to know before operating again (for example, the type
of incision on the uterus after Caesarean section) |
| :: |
Postoperative
expectations and management plan |
| :: |
Presence
of any tubes or drains. |
Postoperative note and orders
The patient should be discharged to the ward with comprehensive
orders for the following:
| :: |
Vital
signs |
| :: |
Pain
control |
| :: |
Rate
and type of intravenous fluid |
| :: |
Urine
and gastrointestinal fluid output |
| :: |
Other
medications |
| :: |
Laboratory
investigations. |
The
patient’s progress should be monitored and should
include at least:
| :: |
A
comment on medical and nursing observations |
| :: |
A
specific comment on the wound or operation site |
| :: |
Any
complications |
| :: |
Any
changes made in treatment. |
Aftercare
Prevention of complications
| :: |
Encourage
early mobilization
– Deep breathing and coughing
– Active daily exercise
– Joint range of motion
– Muscular strengthening
– Make walking aids such as canes, crutches and walkers available and provide
instructions for their use |
| :: |
Ensure
adequate nutrition |
| :: |
Prevent
skin breakdown and pressure sores
– Turn the patient frequently
– Keep urine and faeces off skin |
| :: |
Provide
adequate pain control. |
Pain management
Pain is often the patient’s presenting symptom. It
can provide useful clinical information
and it is your responsibility to use this information to
help the patient and alleviate suffering. Manage pain wherever
you see patients (emergency, operating room and on
the ward) and anticipate their needs for pain management
after surgery and discharge. Do not unnecessarily delay
the treatment of pain; for example, do not transport a patient
without analgesia simply so that the next practitioner
can appreciate how much pain the person is experiencing.
Pain management is our job.
Discharge note
On discharging the patient from the ward, record in the notes:
| :: |
Diagnosis
on admission and discharge |
| :: |
Summary
of course in hospital |
| :: |
Instructions
about further management, including drugs prescribed. |
Ensure
that a copy of this information is given to the patient,
together with details of any follow-up appointment.
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