Surgery

Medical Care Of The Surgical Patient

1. The disease (and its extent) for which the surgery is planned.
2. The condition of the patient and his organ systems.
3. The relative urgency of the surgery.
4. The type of surgery and its alternatives.
5. The relative morbidity and mortality of the disease.
6. The relative morbidity and mortality of the surgical procedure.
   All these factors are interdependent and this assessment is the most fundamental task to be preformed in a surgical patient. The best person to undertake this task is the surgeon himself. Surgeon may, at times, need the help of a physician, cardiologist or anaesthetist, to take the right decision. The preoperative assessment should also include discussion on drugs being taken by the patient & documentation of known allergies.

Informed consent

Informed consent should be taken after a detailed discussion by the surgeon (or his responsible assistant) with the patient and his close relatives, informing them about the nature of the procedure planned, benefits expected, risks involved and possible alternatives, giving full opportunity to them to ask questions and clear doubts.

Preoperative preparation

• Routine investigations Hb, TLC, DLC, CT, BT, urine routine examination, and in patients over 30 years, Chest X-ray and ECG.
• Special and specific investigations depending upon the nature of the procedure planned and the physical condition of the patient for evaluating fitness for surgery.
• Skin preparation as per policy.
• Lipstick, nail polish and other cosmetics which may mask cyanosis and interfere with pulse oximetry should be removed.
• Dentures, spectacles, contact lenses, artificial limbs, artificial eyes, hearing aid and jewellry, cash and mobile phones should be removed before shifting the patient to operation theatre.
• Withholding feeds before surgery depending upon age of the patient and nature of anaesthesia and surgery planned.
• Pre anaesthesia medication as per policy.
• Pre operative treatment.

Drug treatment e.g. prophylactic antibiotics, antihypertensives, IV fluids, anticoagulants, Vitamin K etc. where relevant.
Non drug treatmente.g., rectal washouts, vaginal douches, stomach wash etc. where relevant.

Handling of Medicolegal cases

First aid has to be provided in all cases who report in an emergency state. After stabilizing the patient, patient should be properly guided and helped in shifting to the appropriate centre.

In case that we decide to treat, we must:

• Send an information, in duplicate, to the police.
• Prepare a medico legal report.
• Preserve & seal clothes etc. preserve fluid & stain samples where indicated.
• Respond to information sought by the police.
• Arrange to take dying declaration, where indicated.
• Preserve all X-rays and patient records.
• Respond to court summons.
• In case of death, hand over the body to the police.
• In case of discharge/referral, police needs to be informed.

Care during transfer

This would depend on a number of factors like nature, patient’s condition, reasons for referral, readiness of the referral centre to accept the patient and whether the transfer is an emergency or elective.

Emergency transfer

• Identify the degree of emergency.
• Resuscitative measures to be adopted in serious patients with management of shock, oxygen etc.
• Transfer in an well equipped ambulance to (see relevant section for specific care).
• Transfer to a referral centre with prior intimation and confirmation of the readiness at the referral centre.
• Doctor or paramedical staff to accompany the sick patient.

Referral slip

Should contain information on:

• Condition of the patient when first seen.
• Diagnosis and resuscitative measures taken.
• Reasons for referral.
• Where referred.
• Precautions advised during transportation.
• Any other information (e.g. any staff or equipment sent along with, any communication given to referral centre or specialist concerned).

References

Medical Care of the Surgical Patient. In: Preoperative Medicine, Goldmann DR, Brown FH, Guarnieri DM. (eds), 2nd Edition, 1994, McGraw Hill Company Inc; New York.