Looking back, I have already discussed the difficulties I faced dealing with the wide difference between my training in burns care in Chelmsford, textbook care and the reality on the ground here. In fact, we have made big strides, with most patients now being resuscitated better, much faster turnaround and decision making for conservative versus surgical treatment and the consequent reduction in bed time and blood usage. We have however started the more difficult task of modernising the care of patients following major abdominal surgery.
There is now good evidence that feeding people immediately after major surgery reduces the catabolic physiological response to trauma and improves their recovery. The evidence also supports early feeding even when there is a bowel anastomosis, with some exceptions (generally when the patient is critically ill or has been obstructed for a prolonged time). British practice, and my training, has moved away from the previous theory that a patient should not be fed until they open their bowels post-op, to reflect this new evidence. Indeed, I was at a national conference last year where someone suggested it would be negligent not to adhere to enhanced recovery protocols following colorectal surgery, a large part of which centres around early post-op feeding. To this it can be added that the patient population here is already malnourished pre-presentation, and a further week of starvation is a huge physiological challenge on top of a laparotomy.
The current practice at SFH, which has been the international norm for a very long time, is to keep a nasogastric tube in situ and the patient nil by mouth until they open their bowels. This is irrespective of whether they have had an open and shut exploratory laparotomy, a major bowel resection or surgery to another abdominal organ. Three examples from this week best illustrate things:
1. 18 year old boy with traumatic bladder rupture, repaired and catheter left in. Bowel not injured. Should be fed immediately post-op.
2. 56 year old man, HIV positive, small bowel intususseption reduced but not resected at laparotomy (CD4 count unavailable so we were unsure how an anastomosis would fare). Patient had been obstructed for over a week and was left with a bowel full of fluid, so best left with a NG tube, but would rapidly recover and feed on day 1 or 2.
3. 30 year old lady with recurrent sigmoid volvulus, underwent a semi-elective sigmoid colectomy once volvulus reduced. Should be fed immediately post-op.
On each of these patients, we have clearly indicated the feeding instructions on the post-op plan. For each of them, the recovery nurse has (sometimes aggressively) questioned us and told us we were wrong, and the ward nurse has ignored the instructions. I am not being critical - the staff are adhering to the standard of care that is the norm here, and are being true to their training. I also appreciate the need to be sensitive to the fact that we are new faces and are transient members of staff, and so people need time to adjust to us and our ideas. It is however challenging to reconcile that with our desire to provide care that we know to be first rate.
At the moment we are working hard, on a case-by-case basis, to convert nurses and licentiates to our way of thinking. We remove the NG tubes ourselves and directly communicate to the patients and relatives about feeding. We also, every day, discuss the reasons for our approach with the nurses on duty. It is feeling a little easier than with the burns changes, and I suspect that is because I have been around longer, and that the nurses have seen the benefits of my burns changes. We shall have to wait and see how long it takes to make these changes stick!
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