The organisation of a surgical department can at its most simplistic be described as the recruitment of patients needing surgery then operating on them. This is at times challenging in the UK, where everyone has a phone and postal address, and GPs have referral pathways to outpatients, or emergency departments for more urgent cases. Here, it is somewhat more tricky!
Communication with patients in the community is unheard-of. Communication with referring centres (ranging from the local government hospital to rural health centres) is in the form of a letter brought by a patient when they arrive at St Francis'.
So during the working day, new patients arriving are directed to St Luke's, which is the outpatient department. This applies to all patients, regardless of whether you have an in growing toenail or major trauma. They then wait in a line, which is often out the door and down the path, to see a clinical officer (they have some medical training but are not doctors). From here they are triaged to another outpatient clinic (general, surgical, gynae, HIV, TB) or admitted to a ward with a basic plan. I say basic, because it seems like for all surgical patients it consists of fluids, antibiotics and review by a surgeon (which only happens at about 5pm, as we are not told they have been admitted). This is fine for wound infections, but less so for the patients I found last week late in the evening, both of whom had waited 8 hours to be seen, one with a tension pneumothorax and one with an incarcerated hernia.
The patients we see in OPD fall into four categories:
1. No surgical problem - return to general OPD
2. Elective surgery required - give a date for surgery and ask to return the day before
3. Emergency surgery required - admit and operate as soon as needed
4. Follow up patients (often post op or fracture healing reviews)
Our full OPD days are Tuesday and Thursday, although someone is always available when we are operating Monday/Wednesday/Friday. We then operate as soon as we have a slot. Given all the trauma we have had recently (see the next post) we have struggled to keep up with elective work, and often do 25-30 cases in two operating theatres every day.
Around this, we do our ward rounds. On operating days, this normally means seeing 40 patients in half an hour, while on non-operating days things are a little more leisurely. Within this, we do all the complicated dressings ourselves (dressings aren't complicated, they are all moistened gauze, but the wounds often are) and have to communicate through translators, although the nurses do all the phlebotomy and cannula insertion.
The working day therefore runs from 0730 to 1800 most days, often with little rest! It is hard work, but very rewarding and great fun.
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