Being a surgical house officer

Consultant anaesthetist Leyla Sanai shares her experience of working with surgical house officers

Prioritise

As a house officer you will be faced with many different tasks at the same time. Learn to prioritise. Patients who have just had an operation should be reviewed before carrying out routine tasks, such as filing, and urgent investigations for sick patients should be organised before less pressing ones. Don't be hassled into just working through your list of tasks without giving them some thought--a minute or two spent organising which are urgent and which are not is time well spent.

Communicate

You are working as part of a team, and your job will be more effective and satisfying if you communicate with others, both in your surgical team and in other specialties. It also makes for much safer patient management. If you are unsure of something, ask. No one wants you to be a hero, and your seniors will not thank you for struggling on alone if the patient has been mismanaged. If you asked to organise urgent investigations on a sick patient do not just drop the request card into the tray for the porters to pick up--it may languish in the internal mail for days. Telephone the relevant person and discuss the patient.

Always keep the patients fully informed of the investigations they are going to have and when, and ensure that you or a more senior member of the team discusses the results with them. It is amazing how many patients are trundled off for tests without having been told that they are having them. Many are also not told of the results, with the junior house officer assuming that a normal test means that it can be ignored. If you were wheeled off for an ultrasound scan you would want to know why you were having it and what it showed.

Preoperative preparation

Anaesthetists are not ogres, but many will get miffed if they arrive on the ward to review their patients the evening before surgery and basic blood tests have not been done. Find out the protocol in your particular hospital for what investigations are done routinely for various different operations and patient age groups. Testing urea and electrolytes and full blood counts are fairly standard for all but the very young and fit.

Use your initiative--don't send fit, healthy 20 year olds for routine chest x ray examinations. On the other hand, if one of your patients has a chronic respiratory illness, contact the anaesthetist well in advance and ask if he or she would like pulmonary function tests. Do not forget essentials like cross matching and blood group.

Make sure that blood results are written in the notes for when the anaesthetist arrives and ensure that electrocardiographs are not strewn haphazardly about the ward but are in the patients' notes.

Cross match with neurotic caution

Never take more than one cross match sample without first filling out both form and bottle label. This may sound over cautious but mix ups happen very easily and have potentially disastrous consequences.

Postoperative complications

Always assess patients after they have returned from anything other than the most minor surgery, and make sure that they are cardiovascularly stable, passing adequate amounts of urine, and are pain free, warm, and have adequate fluids prescribed as well as deep vein thrombosis prophylaxis if appropriate. When complications develop, remain calm and assess the patient logically, in terms of systems--cardiovascular (heart rate, blood pressure, peripheral perfusion, heart sounds, jugular vein pulse, presence or absence of lung crepitations or ankle oedema), respiratory (presence or absence of central cyanosis, respiratory rate, use of accessory muscles, breath sounds, added sounds), etc. Do not forget urine volume--this should be at least 1 ml per kg per hour. If a 60 kg woman is passing less than 60 ml per hour start wondering why.

Think of reasons for physiological abnormalities rather than just trying to ablate them--for example, do not reach for the beta blockers if a patient is tachycardic, but ask yourself why the heart rate is racing, and whether it is a sinus tachycardia or an abnormal rhythm. (Possible reasons for a tachycardia include pain, dehydration, heart failure, dysrhythmias). Do not delay treatment while you carry out investigations--for example, if the patient is severely compromised call your senior or the medical registrar while waiting for the electrocardiogram to be done, not two hours afterwards.

Oxygen

Medical schools place a disproportionate emphasis on patients with type 2 respiratory failure, for whom high oxygen levels can be harmful as they rely on a hypoxic respiratory drive because of chronic hypercapnoea. These patients are rare. Do not assume that all patients are in this group. For the vast majority of patients, hypoxia is extremely harmful. Giving a hypoxic patient 24% oxygen is next to useless. Hypoxia kills far, far more patients than too much oxygen does. If you really suspect a patient may rely on a hypoxic drive check their blood gases to see if their CO₂ is high to start with. Even if it is, it may just be because the patient is exhausted (in which case, the patient needs a review from the intensive care unit). Check blood gases on incrementally higher levels of oxygen and see if the respiratory drive really does decrease with higher levels (as evidenced by steadily increasing CO₂ levels). Ask a senior anaesthetist for advice if in doubt.

Contact the intensive care unit early

Many patients are referred to the intensive care unit (ICU) far too late. Those critical early hours are crucial--if resuscitation can be instituted early the chances of recovery are far higher. No one in the ICU will think less of you if you ask the staff to review a patient before he or she becomes moribund. The ICU registrar can return and review the patient later if he or she deteriorates. Fighting a losing battle all night on your own, out of your depth, while a patient goes down the tubes, does not make the nurses gaze swooningly on you as a macho god; it makes them moan to your seniors about how you do not know your limitations.

Check electrolytes before prescribing fluids

Testing urea and electrolytes is done for a reason--look at the results. After their operations many patients are prescribed inappropriate fluids. Elderly patients prescribed litres and litres of dextrose can rapidly develop hyponatraemia. In severe cases, this may lead to confusion and even permanent neurological damage. Similarly, look at the potassium result before automatically scribbling your standard 20mmol in every other bag.

Check postoperative full blood count

Again, the postoperative full blood count is often treated as a chore which is taken but not examined. If elderly people are severely anaemic the oxygen delivery to their tissues may be compromised to the extent that they develop end organ ischaemia, such as angina. Discuss the need for transfusion with a senior member of your team. Do not try to run blood through a weedy pink venflon that was inserted four days ago, put in a new one. Venflons are painful--ask an anaesthetist to show you how to use a blip of lignocaine before inserting anything larger than 18 g.

When giving blood, assess the patient's fluid state before reverting to the standard junior house officer recipe of frusemide cover. If they are as dry and creased as a piece of ancient parchment you may need to omit the frusemide, especially if the blood is running slowly and the patient is not taking any other fluids.

Investigate suspected infection

When a patient displays evidence of infection after an operation (raised white count, pyrexia, signs or symptoms of infection in the relevant system) it is often necessary to start antibiotics on a best guess basis to try and tackle the problem before it becomes clinically severe.

Discuss the choice of antibiotic with a bacteriologist. Taking blood cultures is a pain but do not slope off home without doing it. If the patient deteriorates there will be no record of the causative bugs.

Do not be slapdash about it either, or the sample will grow staphylococcus, and no one will know if it is a skin contaminant. Set up a trolley with a sterile pack, sterile gloves, betadine, etc. Do not assume that the nurses will send sputum or urine for culture without being asked. Ask them to do so and give them completed bacteriology forms for the samples.

Surgical patients may have medical conditions

Just because a patient is on a surgical ward, it does not mean that you can ignore their pre-existing medical conditions. Find out the ward protocols for the perioperative treatment of diseases such as diabetes.

Give the results of tests some thought: if a blood sugar comes back as 30 mmol/litre, do not just record it faithfully in the notes while prescribing another bag of dextrose. Call a medical registrar, investigate for suspected diabetic ketoacidosis or non-ketotic hyperosmolar coma, and start treatment urgently.

Basic protocols

The emergency treatment of many conditions is actually very logical. There are many easy ways of jogging your memory for basic protocols. Investigation and treatment of diabetic ketoacidosis, for instance, can be remembered by thinking FISHCAKE:

F fluids (saline)

I insulin

S seek cause (blood, urine, sputum cultures, chest x ray examination, electrocardiogram)

H hydrogen ions (check acidotic status); hypotension (check cardiovascular state)

C central venous pressure/catheter

A arterial blood gases/antibiotics

K K+ (watch potassium)

E electrolytes (watch sodium, chloride, etc)

Be kind to patients

Patients coming in for surgery will almost all be anxious. However busy you are, remember to treat them as you would want to be treated--be kind and courteous, and ask them if they have any questions.

Patients are humans

Do not discuss patients as if they were pieces of meat. The "gallbladder in bed two" is actually an individual with feelings and a family. Do not throw technical jargon around when discussing patients within earshot without explaining things to them--it is intimidating and arrogant. Ensure that a patient has been told of a result before announcing it loudly to the entourage circled around his or her bed on the ward round: finding out that you have disseminated cancer is not something that you would want to hear first in front of 20 people.

Remember your position

Never be afraid to ask, be it for advice, help, or for a senior colleague to review a patient. You are a junior house officer, not a singlehanded surgical team.