A) Introduction and Professional Behaviour

Introduction
Surgical patient care

Introduction

These guidelines are intended to provide new surgical staff, particularly interns, medical officers and registrars employed in the various hospitals of the Cape Town Metro West with a simple source of information regarding common, every day general surgery conditions they may encounter in the wards, emergency room and outpatients.

It is not a comprehensive document, and it is not meant to replace the many very good surgical textbooks available.

Surgical patient care

Be a professional. Be proud of your work. Take on responsibilities and complete the tasks assigned to you, to the best of your capabilities. Consult your senior colleagues and ask for advice at all times.

Ensure that your behaviour and appearance is of a professional standard. Wear appropriate clinical attire (scrubs or a white coat) and ID badge to allow patients and staff to identify you as a doctor. Patients prefer their doctor to be well groomed and respectable. Be polite and courteous at all times. Remember to introduce yourself to patients prior to examining them or performing procedures. Our patients do not have a choice in who their doctor is, be respectful of this lack of choice by being professional and doing your best at all times.

If you are an intern, your main responsibility is the day to day care of the surgical patients. You are expected to be particularly meticulous about the clinical note keeping of the patients. Keep the folders up to date, discard all useless paper and clutter, and focus on keeping the core information tidy, clear and accessible. Be proactive, arrange investigations in advance, do not duplicate others’ work but rather complement it. Arrange patients’ discharges timeously, and attempt to do as much work as practical during the rounds, to avoid idle hanging around. Keep good relations with the ward clerk and nursing staff, it will save you hours of needless frustration.

When doing an elective admission, send the required bloods and request for other investigations, including any referrals (to Surgical ICU or Department of Anaesthesiology) before starting the actual clerking of the patient.  Results will then be ready by the afternoon.  Please remember it is your responsibility to make sure that blood specimens and requests for other investigations reach their destinations. Try to obtain the results of the investigations the day they are done to expedite further management decisions.  If the result of a test is abnormal, please deal with it immediately.  This will ensure that patient management is promptly modified.

Intern Cross-cover: When a colleague from another firm/ discipline is looking after your patients after hours and during the night, inform him or her about the condition of your patients in detail.  This should preferably be in the form of a list of patients with the diagnoses.  This list should be made at the time of afternoon round.  Also speak personally to the intern on call about the sicker and complicated patients and advise him / her about the expected problems and their management.  

Remember the cross cover intern may not know your patients well, so he should have the list of patients and knowledge of any expected problems during the night.  It is not the duty of the cross cover intern to take bloods and organise investigations that have been finalised at the afternoon round. He should however check any outstanding blood results and act upon them if necessary.  

Do not leave ‘tissued’ IV’s for the cross cover intern to do; do them yourself before going home. It is especially important to inform him / her of any patients who will be coming to the ward late, after surgery or other radiological interventional procedures, so that they can be seen once they arrive in the ward. 

Before going to bed while on call in the hospital, do an evening ward round focusing on postoperative and recently admitted patients.  Check their Hb, blood pressure, pulse, urine output, pain control, breathing (remember morphine overdose) and make sure there is no abnormal bleeding (look at the drains if there are any) and that IVs are running.  This will ensure better care for patients on day one after the operation.

When going to your rest room, give the staff in the ward your phone extension number/ cell phone number/ speed dial so that they can call you if necessary.  Ensure that you are contactable before going to bed.

Nursing staff, especially the senior sisters in the ward and ward secretary are an invaluable source of help.  They often know more than doctors about the dynamics involved in daily running of the ward.  They are always ready to help, liaise with them in a friendly and collegial manner. Be respectful of their opinion. If they are concerned about a patient’s condition, take the issue VERY seriously.

Update patients and their families fully about their condition, the progress in the diagnostic work-up, and inform them in advance of any planned surgery and the nature of the surgery.  Where malignant diseases are concerned, use your judgement about how much to tell the patient. This is usually determined by how much patient wants to know. Be meticulous in ensuring that you know all the facts before discussing the diagnosis with a patient, and make sure that there is absolute proof (i.e. a histology report) of the diagnosis.  Avoid giving them survival in months unless a patient specifically asks for it.  In cases of malignancy, you should disclose the diagnosis, discuss with the patient his disease stage, and options for management and also answer any queries. When the diagnosis is communicated to a patient with malignant disease, this should be recorded in patient’s notes.

Breaking bad news is the one of the most delicate tasks in the overall care of a terminal patient.  Do not generally give the family the news on the telephone.  Rather ask them to come to the hospital, sit with them and then tell them about the death of their loved one.  Please convey your regret to the family at the death of one of their members.  Make sure this is done in a private, comfortable environment in a professional manner.  Gently explain to the family the circumstances surrounding the death of a patient, especially if they would like to know in detail.

Palliative care and end of life decisions: discuss this eventuality with all your patients and their relatives. Document decisions not to pursue invasive life support measures and decisions to withdraw treatment in a clear and obvious way. Avoid futile interventions and resuscitation, unless there is an expectation of a good outcome. Patients have a right to a dignified death. Be respectful of patients’ wishes to seek alternative care, within their cultural paradigm.

If a patient dies in the ward after any medical or surgical intervention, an autopsy is required (medico-legal or pathological).  Before completing a death certificate, confirm if an autopsy is required.  If no autopsy is required, complete the death certificate promptly.  Unnecessary delay in this regard is a source of immense frustration for the grieving family.