Lesson Of the Day

Lesson Of the Day

I have added one new rule to my surgical pearl necklace. If you try and be helpful and take a case from someone else’s theatre, be prepared for trouble

Today we took two cases from other theatre lists as our list had, in Bighospital terminology, fallen apart. This was partly thanks to me, who feeling cocky and egged on by the anaesthetist, took the decision to cancel a case yesterday. 

Today in Bighospitalburgh the sun was shining, it was warm and the theatre staff were moaning that we were looking for extra work. Every single sign and person was pointing to “get out of here and enjoy an early finish for once.”

Reader, you know that I did not do that. The Daily Mail can relax that a theatre list did not go under-utilised whilst I watered my courgettes.

Fast forward to midday and we have identified no less than 2 patients who we could operate on, taken from other  overbooked lists. 

We went to see both patients and introduced ourselves as the new team, checked the notes and confirmed the consent. 

The first patient woke up after her small procedure complaining loudly that the wrong surgeon had done her operation and that is why she was so sore. She caused a huge fuss in recovery and had to be talked down: lesson number 1 of the day, re-consent everyone yourself to ensure they are adequately prepared. 

The second case was not as advertised. A simple operation (a gallbladder became a nightmare. Lesson number 2: don’t take gallbladders as favours. 

This is not the first time i have been burned by a hot gallbladder parcelled up like a biliary colic when you are trying to be helpful. The last time, my name became linked to someone who was in ICU for months, but that’s a story for another day, the moral being always check an amylase. 

So after a fight with a massive beast of a gallbladder with abnormal anatomy that involved 6 surgeons.

Closest I’ll ever get to a Ted talk:

I got into the car finally at 7pm and raced home to relieve the nanny of my children (arriving late) and did not stop to buy milk, fruit and post a letter as I had planned. Being helpful does not pay! 

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SBAR headache

SBAR headache

Almost every phone call I receive when on call that comes from a junior I don’t know follows the infuriating “sbar” mnemonic. They give me the situation, then the background, their assessment and then we come to an agreed recommendation. You can read about it here

This is a real conversation with minimal changes made to protect confidentiality.

“Hi I have a 76 year old lady here with diarrhoea and abdominal pain. She came into the hospital, ummmm, 7 weeks ago with a fractured neck of femur and that was fixed, I think but then she was diagnosed with some sort of cancer, ummm, she’s quite unwell,  I think it is a lymphoma and she had chemo I think and an operation on her groin maybe and then she seems to have been well. But then she got a DVT, which she needed a filter for, and then she had a chest infection, she’s in a lot of pain….”l

This woman was unwell with ischaemic gut, she had a low blood pressure and was in a bad way. 

Nowhere in the SBAR is there scope to override the endless and irrelevant to drivel, which is not relevant in deciding whether or not I am coming to see her. 

Too much Background and not enough Assessment, cut to “Hi we have a really unwell woman here and you need to come and see her now”.

I’m old fashioned, I see everyone that is referred to me, unlike the new younger trainees who like to give telephone advice based on the SBAR. My advice is don’t ever do that, it’s shoddy medicine and indefensible medico legally as there is often no record in the notes of what they said to you and what you said. 

I let this person ramble on with the tedious SBAR story, we still hadn’t reached the point of the story about the hypotension. I interrupted them “listen, you sound worried about this lady, do you want me to come now?”. The poor junior on the other end of the phone was delighted “oh yes please, she’s not well, do you want her 10 digits?”. 

The ability to give a concise and relevant history is a skill that comes with time and practice and watching others. Most newly qualified doctors don’t have it, those who do tend to lose the ability under pressure. 

Hospitals have changed and we have more and more out of hours care delivered by people who don’t know the patients they are covering. We need to instil confidence in juniors to phone up a registrar or consultant and say “I need you to come now. This person is really sick”, not give them stupid protocols for referring things, SBAR has a place but it is not in the referral of the critically ill.