3. The basics
• Fast paced - theatre by 8.30
• Your job is to know your patients as if they’re your
babies.
• Up to date list
• Bloods available. Any recent images loaded.
• Do the basics well and these can be sweet jobs. Theatre
/ clinic / audit / skysports.
4. Surgeons ask for help
• Often frustrating but usually comes from a genuine wish for
the best for their patients (…and they’re
figures/reputation/private work….)
• Rule 1: Every referral (and imaging request) must have a
clinical question. If you don’t know the question don’t start
writing the form. Ask your F2’s, CT’s, we remember!
5. Surgeons ask for help
• Rule 2. Phone referrals – arm
yourself.
Success = Not having to get out of seat.
Fail = Get out of seat on 3 occasions to get
notes, then drug chart, then obs chart…
• Have a plan. SBAR
Situation and what you want / clinical question
Background – have the notes to hand
Assessment – what has changed? Obs, fluid balance, drug chart to hand
Request – restate what you need and offer get started with bloods,
Ix etc before they arrive.
6. You’re on call.
First day. 08:10.
Over to you…
Dear Surgical on call.
Please see Bob Smith (25yrs) who is new to the area. He has a
lot of abdominal pain and I world appreciate your opinion
and further management.
Kind regards
7. Case 1 - Appendicitis
• Nice and easy. Not much for you to do.
• Bloods.
• If young and classical case NO XRAY’s. Any other
imaging?
• In a girl she’s always pregnant until you know otherwise.
• Analgesia. NBM.
• Role for antibiotics?
8. Busy morning. Another waiting
• What do you want to know?
• Differentials?
• Looks rough.
Dear Surgical house officer.
Thanks for seeing Jim (52yrs). He’s not quite right. I think it’s
his belly. He’s in quite often because of the alcohol but
usually pleasant enough.
Kind regards
AAA
Pancreatitis
Biliary disease
Peforated Duodenal Ulcer
9. Busy morning. Another waiting
• What are you going to do?
Dear Surgical house officer.
Thanks for seeing Jim (52yrs). He’s not quite right. I think it’s
his belly. He’s in quite often because of the alcohol but
usually pleasant enough.
Kind regards
ABC’s
Big cannulas – FBC, U&E, LFT’s, CRP, Amylase, G&S/Crossmatch ± ABG
Hartmann’s, O2
Examine
Erect CXR (air under diaphragm) & Abdo XR (obstruction)
Pain relief. Monitor urine output. NBM.
Escalate at any stage if unwell – it’s your first day remember!
10. Case 2 - Outcomes
1. HR126, BP100/50, RR22, T37.6C, XR’s normal, WBC
13.2, ALT70, Bili40, ALP300, Amylase1800
Pancreatitis. These can get nasty. Usually need lots of fluid but
beware ARDS (acute respiratory distress syndrome).
The boss: “How worry should I be”
Any ideas?
1 – Observations & general condition
2 – Severity scoring P a02
A ge
N eutrophils (WBC)
C alcium
R enal (Urea)
E nzymes (LDH)
A lbumin
S ugar
<8
>55
>15
<2
>16
>600
<32
>10
So need to
have had
these
bloods &
ABG
≥3 = Severe
Usually HDU/ITU
11. Case 2 - Outcomes
2. Obs stable, Tender epigastric & RUQ, XR’s normal, WBC
15.0, CRP 130, LFT’s normal, Amylase normal. Old USS showed
gallstones.
Acute cholecystitis
But what’s the difference between biliary colic/acute
cholecystitis/ascending cholangitis?
12. Biliary colic
Pain following impaction of gallstone in
gallbladder neck or cystic duct
Epigastric / RUQ pain
Lasting a few hours & N/V
Preceded by fatty meals
WBC & LFT’s normal
Analgesia, USS abdo
If USS shows gallstones delayed
laparoscopic cholecystectomy
Acute Cholecystitis
Inflammation of the gallblader usually following
obstruction of cystic duct by a gallstone
Epigastric / RUQ pain
Lasting a few hours & N/V
↑WBC, LFT’s may be mildly elevated
Murphy’s positive
Analgesia, IVI, IV antibiotics, USS abdo
If USS shows gallstones usually laparoscopic
cholecystectomy – hot/delayed (72hr)
Ascending Cholangitis
Biliary system infection due to a stone in the common bile duct
Charcot’s triad: Abdo pain (RUQ), Jaundice (↑Bili), Fever
Reynolds’ pentad: Charcot’s + septic shock, confusion
In reality these are not always present but the diagnosis is suspected if biliary type
history & septic.
↑WBC & obstructive LFT’s (↑↑bili & ↑↑ALP, ↑ALT)
Murphy’s negative
SEPSIS 6! Initial ultrasound. If some diagnostic doubt MRCP to assess
for CBD stone, if not proceed to ERCP. Delayed lap chole.
13. You were about to go to lunch….
• He’s all yours…
Dear Surgical team.
Good afternoon. Thanks for reviewing Mr Humphries (78yrs)
who’s noticed he’s been getting up to pass urine requently at
night. I started an anticholinergic but this doesn’t seem to
have helped and he seems to have suprapubic pain this
morning.
I’m out of ideas, Thanks
14. I could bloody well kiss you doc.
• Retention - >500ml
• If you can feel a bladder & they can’t wee – catheterise.
• If you’re not sure it probably is but easy to bladder scan most
places.
• Catheter hints:
o Plenty of instillagel
o Hold penis firmly & stetch – straightens urethra
o Bigger catheters get past big prostates easier – 16Fr
o Elbow (Koude) catheters are a godsend if they’re available
• To make you popular with the urologists as well:
o Document how much has drained in 5mins.
o Document if there is blood initially – decompression haematuria
o Check renal function – high pressure/low pressure
15. Consent – to do or not to do?
• GMC: “It is always best for the person actually treating the
patient to seek the patient’s consent. However, you may seek
consent on behalf of colleagues if you are capable of
performing the procedure in question, or if you have been
specially trained to seek consent for that procedure.
• In reality you shouldn’t be consenting for operations.
• You may however be expected to consent for OGD’s &
colonoscopies / flexible sigmoidoscopies
16. The principles
• Check demographics
• State name of procedure
• Explain briefly what it involves
• General anaesthetic / local anaesthetic / sedation
• Check allergy status & if on anti-coagulants
• Benefits – diagnostic vs therapeutic – upper GI bleed
• Risks
OGD
Bleeding – especially if biopsy
Infection – small risk of pneumonia
Perforation - 1 in 9000
Damage to teeth
Colonoscopy / Flexi Sig
Failure – poor bowel prep / not
tolerated
Bleeding – 1/150
Perforation – 1/1500
17. Summary
• Know your patients and be organised. Anything else is a
bonus.
• Arm yourself and SBAR with referrals.
• Stick to your ABC’s with any unwell patient and escalate
– we all need help with sick patients!
• Familiarise with the ‘first hour plan’ for a few conditions –
that’s all you’re expected to manage!
