Charlotte has had to entertain herself for a few days - I have been rather busy! Monday was my first on call, arranged so I would cover surgery and an obstetrician was covering his side of things, but would call me in to help and teach me the ropes. We had an epic operating day, including two laparotomies, two open fractures for external fixation, some hernias and biopsies.
At the end of the list, I then popped onto the ward to see the new admissions.
There is no emergency department here. During the day, all new arrivals are seen by the clinical officers in the outpatients department. If we have a surgical outpatients clinic happening, surgical patients get sent to see us. If not, they just get sent to the ward. We then pick them up at the end of the day. At night, the same thing happens with the coverage nurse assessing the patient and calling us if they have concerns.
So, at 6pm on Monday (or 18 hours, as it is known here) I discovered a chap who had sat on the ward all day with a tension pneumothorax. With a beautiful X-ray showing it. In the UK, it is said you should never see a tension pneumothorax on chest X-ray, as it is an emergency, is diagnosed clinically and should be drained sooner than you can do the X-ray. On ER, it is what they are talking about when they shout "TENSION. Chest drain stat!" Anyway, I quickly got him to theatre and drained it and was feeling suitably pleased with myself to drop by the labour ward on the way home to make sure everything was OK.
This yielded an emergency Caesarean section, who turned out to have undiagnosed twins - all very exciting!
This then left only five patients to be seen on the surgical wards. Four were straightforward, the fifth being a 3 day old baby admitted with bilateral cleft lip and palate, for our attention! These are all dealt with by the plastic surgeon, who comes up every three months - his next clinic is in November. It was however obvious this child was a little more complicated - high fevers, and clearly a very peculiar syndrome, causing the cleft, exophthalmos and a plagiocephaly [essentially he had a very abnormally shaped skull]. Indeed, I wonder if he has a cloverleaf skull. Anyway, I called the paediatrics on call to come and sort him out, was marching out the door, when I hear "there's one more doc...."
She was an old lady with an incarcerated femoral hernia and obvious small bowel obstruction who wasn't looking too rosy. She had been admitted at noon, but no one had informed us! So I called the theatre team in, nipped home for a spot of dinner while they prepared, then operated on her. She had necrotic bowel, and needed a laparotomy, so I had to call the Professor in as well. We ended up resecting two segments of dead bowel. She unfortunately died the next morning - I suspect electrolyte disturbances, but our lab does not test for them, so we can never know!
By the end of all the operating, it was 0230 and I had been operating nearly constantly for 18 hours! The obstetrician was however just arriving for another section - he suggested I went to bed, so I left him to it.
I have today spoken to the anaesthetic licentiates about our pulse oximeters from Lifebox - they were very excited by the prospect. Currently, there is minimal monitoring of anaesthetised patients - they only knew one of my laparotomies on Monday was hypoxic because the blood coming out was too dark. I hope we can get to a point where there is a pulse oximeter not only in every theatre (which will happen from Friday), but also several in recovery. This is currently a minimally observed corridor, where anything could happen and no one know. I think there is a big difference that can be made in perioperative monitoring and care, with really very little effort.
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