Doctors Guide of Clinical Surgery

Interoduction to Surgical Diagnosis


The Phrase diagnosis in surgery should refer to the process of investigation necessary to discover the nature of disease or injury.
However in practice the phrase is also used to finally label the condition so discovered with a name or description.

To archive a proper diagnosis in surgery one should:
1. Collect the facts(information)
2. Correctly interpret the facts (information)


1. Collection of Facts (Information)
The Three time honoured methods for the collection of facts are those obtained by
1.1 Inquiry from the Patient (History)
1.2 Examination of the patient (Clinical examination)
1.3 Special methods of investigation such as examination of body fluids (Urine and blood), Dianostic imaging, endoscopy or aspiration and biopsy.

There are two important considerations that should be remembered in search for accumulation of facts. Firstly the facts falling under one of one the categories 1.1, 1.2 and 1.3 may out weight all others and there is a natural tendency to neglect the completeness of the process in other directions.
Let me illustrate these with clinical examples. A patient's description of bleeding per rectum from haemorrhoids may be  so typical as to suggest that detailed examination is not necessary.

The 'No-lose' philosophy in surgery

Pascal's 'no-lose' philosophy relates to belief in god. If god does exist and we live our lives believing in him then everything is gained when we die, If god does not exist then at least nothing is lost.
Clinical implications





The 'no-lose' philosophy is occasionally applied in pratice but in a different context. When faced with a problem the outcome of which is doutful, a doctor may erron the side of 'no-lose' in giving the prognosos to relatives. If the patient dies then the prediction was correct, if the patient lives then everything is won. in either even the doctor does not lose.

Dangers of 'no-lose'
Application of the philosophy to all areas of medical practice carries considerable risks especially when investgating patents(in order not to lose, the diagnosis must be made) This may be illustrated by a case report.
A patient recovers well after oversewing of a perforated  duodenal ulcer, but on checking his blood an elevated serum calcium is noted. After further investigation for a possible parathyroid adenmoa, selctive venous cannulation of the neck veins was carried out.
No tumour was demonstratedd but the patient developed infective complications from which he died. At post-mortem no parathyroid tumour was found.


Advice for surgeons






* Prevent  iatrogenic disease. Beware of invasive investigations which may be expensive, dangerous, or unnecessary. Is the risk of the procedure worth taking? Would you carry out the same investigation on your self?
* How important is it to make the diagnosis? If it is academic do not cause your patients anxiety or discomfort, or expose them to risk.
* Avoid the attitude: "At least this won't cause any harm even if it does no good" When prescrbing drugs, treatment, or investigation. If it does no good, why do it at all?
* When discussing the prognosis with the patients or relatives be as honest as possible. Base your statements on your own experience, that of your seniors, and the relevant literature.
The "no-lose" philosophy has considerable potential for loss. Further, it may adversely influence decision-making and prevent the solution of clinical and ethical problems.

"The 'no-lose' philosophy in medicine."

REASSURANCE

Reassurance is commonly referred to in medical and surgical practice. It is believed to relieve anxiety and to improve the patient's physical condition. It is good practice to give reassurance.

Implications of indiscriminate reassurance
'Normal' people as well as obsessional patients have intrusive thoughts from time to time which are disturbing. For example, the patient who presents with nausea mayinterpret the symptom as being due to gastric cancer instead of alcohol-induced gastritis due to his regular drinking. He needs reassurance that cancer is not the cause of his problem,
And that the symptoms are due to excessive alcohol intake. The necessary investigations are carried out and are negative. The doctor then reassures the patient that all is well , That cancer plays not part . At first the patient is relieved  but  then sets about seekingg further reassurance, 'why did you do the investigations if you did not suspect cancer?" What if you have missed something?" 'I never thought i had cancer. Why did you mention it?" This response can lead to recurrent outpatient attendances, further investigations, further reassurance, and further anxiety. The vivious circles so set up has been described as the 'fear syndrome'.

Guidelines for dealing with 'fear syndrome'

* Identify why the patient has come for help. listen and decide the role anxiety plays in the presentation.
* Remember that 'malingeres' get mailgancies too.Carry out an unbiased thorough assesment. Further investigations may not be needed.
* Anxious patients make anxious doctors. Make your judgements independently, irrespective of how anxious the patient appears to be.
* Do not feed doubts by providing irrelevant information.
* Speak clearly so that the patient understands.
* Show awareness that anxiety and symptoms are part of any clinical problem.
* Give the patient a chance to ask questions after imparting information.
* Be sure that the  patient has understood. The presence of a less anxious relative maybe helpful in the SOPD.


Ethics and the Surgeon

Duties of Surgeons to patients.
A surgeon must maintain the highest professional standards and  practise his profession without a profit motive.
He must:
* Be obligated to preserve human life
* Be loyal to his patients
* Summon a second opinion if a certain type of treatment is outwith his ability
* Maintain confidentiality on his knowledge of patients
* Give emergency care where indicated as a duty unless others are able and willing to administer such care.





Duties of Surgeons to one another.
Surgeons must:
* Behave respectfully and professionally towards colleagues
* Not attempt to or succeed in enticing patients from surgical colleagues.

Unethical practices
* Self-advertisement
* Collaboration in medical practice where clinical insependence is not maintained
* Reciving monies, other than proper professional fees
* Acts or advice which could weaken the mental or physical status of a person and which could result in profit of some kind  for the Surgeon.

Caveats
* Beware of  new discoveries and techniques unless they are properly tried and tested.
* Give certification or testify only to that which you can personally verify.



Communication with Patients

Communication is the act of imparting (knowledge or) exchanging (thoughts, feelings,or ideas)by speech, writing, or gestures. Doctors must be able to communicate successfully with patients, colleagues, nursing staff, and administrators.


Five areas of communication
What to tell the truth if at all possible. Establish the diagnosis by histology. (Eg-malignant disease) Or over whelming radio logical or bio chemical evidance. Use clear non-esoteric language.
Tell the truth calmly. Sit at the same level as the person to whom you are sepaking. Discuss treatment options.

When to tell when all relevant results are available, a full diagnosis with implications of treatment and prognosis can be given. It may be easier to give the diagnosis in stages: a clinical impression in the SOPD, the results of relevant investigations or histology in SPOD on the ward, and the operative findings once the patients has recovered sufficiently to understand(usually the first postoperative day.) Try to tell the patient and relatives as soon as possible.

Whom to tell Tell the patient. USe Disccretion when the prognosis is very poor. permit the patient to ask questions. He has a right to know what is happening to him. Discuss the clinical implications of the diagnosis with the closest relatives. Reassure them that a truthful approach will permit maxmium cooperation from the patient and also  justyfy future admissions, treatments, or continued follow-up at hospital, etc.

Where to tell  Speak to patient or his relatives in privacy not in the corridor. If in the open ward, draw the screens and ask the nurse allocated to the patient's care to accompany you.

Who tells? Jounior hospital doctors, consultants, staff nurses, or sisters. Establish the ward and the consultant's policy. Nurses are often asked the diagonosis or result of an operation during the delivery of care . They are frequently better at speaking to patients than doctors are, and should be involved. After telling the patient be prepared to talk to him again. When the initial shock has passed there may be many questions. Others maybe  relieved to have a diagnosis for their trouble some symptoms. Some may accept the situation without further disussion.



Negligence
Insure yourself against professional negligence and ensure that  your subcription is up to date.
Common surgical reasons for allegations of negligence
Amputation of the wrong digit or or limb/operating on the wrong side. This is virtually indefensible and is due to carelessness in the patient/doctor relationship. If you are operating, speak to the patient on the per-operative ward round and identify  the side.

Record in it the notes. Mark side/digit with a waterproof marker pen yourself. Speak to the patient again in the anaesthetic room and repeat the process. Do not permit the indution of anae sthesia until you are certain.

Leaving Swabs or instruments in the patient. It is the total responsibility of the operating  surgeon to ensure that nothing is left in the patient. Satisfy yourself that the swab count, etc. is correct. If in doubt X-ray the patient on the operating table.

Removing the wrong organ/removing a solitary organ. When one of paired organs is diseased, ensure that it is the diseased organ which is removed. When there is a diseased or damaged organ of a pair ensure that its mirror imgae is present and functional.

If the operation is vital for the well-being of the patient then his consent  should be obtained. Under exceptional circumstances it may not be possible to obtain consent.

Ligating ducts/ureters/arteries,etc. Be aware of the peri-operative. Risks of each producer you carry out, eg- biliary surgery is  fraught with the danger to the bile ducts; colonic surgery may lead to damage to the ureters or duodenum; laparoscopic sterilization may lead to small intestinal injury with subsequent pelvic absccess or peritonitis.
If your patient is not recovering as predicted, carry out further investigations to ascertain why. Laparotomy maybe necessary. It maybe accidental to cause damage to a structure during surgery, But it is negligent to cause damage to a structure during surgery, But it is  negligent not to act if the patient has signs which suggest such damage.

Operating on the Wrong Patient This  results from breakdown of patient identification. Check that  each patient  corresponds wich the list both numerically and for the surgical producer.
Risks are reduced if you recognize your own indelible marker. Check the notes and patient identification in the anaesthetic room before anaethesia is induced(see above)

Failing to X-ray fractures/applying splints too tightly/applying plaster casts too tightly. Look for the clinical signs of fractures. 
X-ray if suspicious. Beware the quiet fractures-scaphoid(may not show radiologically for 10-14 days), C   / C     fractures (X-ray in 
                                                              7     8
"Swimming" Potion. Ask for  C   / C    / T   views.)
                                                   7     8       1
Check splints and plasters after 24 hours. Give the Patient a warning card to return if there is pain, Discomfort , or numbness.

Wrong transfusion/ Wrong drugs/ Wrong dose. Transfusion mistakes can be avoided by checking carefully that the name, hospital number, and date of birth correspond to  the label on the blood bag. Blood samples for cross-matching should be accurately labelled immediately the blood is taken. 
Drugs and dosages should be clearly legible on the kardex. If in doubt, check with your senior or consultant.