Surgery at St Francis' - what we do...

Now I have explained how we recruit patients, I've had a look through my logbook for the last three weeks to see what I have actually achieved:

Total - 71 cases (mostly performed, some assisting the Prof or another registrar)
Wound management (burn debridement, skin grafting, snake bite debridement, management of open fractures, wound closure, abscess drainage) - 17
Laparotomy (abdominal sepsis, tumours, bowel obstruction, bowel ischaemia, congenital abdominal wall defects, abdominal pregnancy) - 15
Manipulation of fractures or dislocations - 6
Other orthopaedics (open fracture reduction and fixation, sequestrectomy for chronic osteomyelitis) - 6
Elective hernia (adult and child, including hydrocoeles) - 9
Amputations - 2
The rest included removal of foreign bodies (under the skin or in the nose), biopsy of lymph nodes or tumours, chest drain insertion, caesarean section, one trauma thoracotomy and a urethral dilatation.

Our outcomes are what you would expect given our resources - morbidity and mortality is high following laparotomy or major trauma, although wound infection rates are low considering the environment we work in.

I have this week been able to make some inroads into burns care. It seems that the policy of allowing huge amounts of granulation tissue to form results in a higher than acceptable rate of wound infection, and indeed I think people have been grafting onto granulation tissue and then been surprised when the graft died (granulation tissue makes a poor bed for skin grafts). This week I have successfully operated on several patients with wounds the nurses claimed were infected because of the fluid found in the dressings when they changed them. They all had more than 1cm of granulation tissue, which when removed revealed a really healthy, graftable bed. I also managed to push the theatre team to fully debride an acute full thickness flame burn in a 2 year old (15% to both legs). I overcame the objections, which all cited the degree of blood loss, by operating under tourniquet. Unfortunately my next battle will be to get the ward nurses to appreciate how sick a child with a 15% burn is, and to administer the prescribed IV fluids. The child unfortunately died later in the week. I hope that in a few months, it will be a big deal for a child to die with a 10-15% burn. At the moment, it is just shrugged at.

So, in summary, lots of trauma, some emergency general surgery and a real spread of everything else.