Always see the patient, take a history and examine them and record your findings in the patient record – More mistakes are made in medicine by not looking than by not knowing. Avoid phone orders without reviewing the patient. The clinical assessment of the patient should be the baseline against which all other information, including investigations and results, is assimilated.
If a test is worth ordering, the result is equally important to ascertain.
Always follow-up a patient with a definite Outpatient appointment and always check the pathology at each and every visit in Outpatients.
Always consider bleeding as a cause of post-operative hypotension.
Communicate, Consult and Escalate. Continuity with handover is extremely important – You can never over-communicate.
Severe abdominal pain of greater than four hours duration with requirement for repeat doses of narcotics is highly significant and should be actively managed, rather than observed or given increased doses of opiates.
Beware of a bowel obstruction in a virgin abdomen.
Any deviation from a normal post-operative course after a laparoscopic cholecystectomy should flag the possibility of a biliary leak, until proven otherwise.
Acute appendicitis is a very common cause of right iliac fossa pain and if neglected, may cause significant morbidity and even mortality.
DVT and PE are common – Consider prophylaxis and always consider the diagnosis of PE.
In a patient with general deterioration after abdominal surgery, always consider the possibility of a leaking bowel anastomosis.
For the work-up of any lump in general terms, consider; 1. Clinical assessment, 2. Imaging, and 3. Biopsy to establish the diagnosis.
Prior to every operation, always re-check the patient’s clinical notes and investigation results.
Never walk away from the peritoneal cavity or any operation dissatisfied or concerned.
Handover at the bedside can be invaluable.
The anastomosis that is not made cannot leak.
If the face is blue, the brain is too – always consider the importance of hypoxia.
Always consider fine needle aspiration cytology on a lymph node before excisional biopsy.
Always discuss a problem with a colleague. This will help crystallise the issues in your mind and often provide a solution.
If clinical deterioration is noted, it must be acted on and escalated – not just recorded. Delay in recognising and dealing with complications increases their significance and morbidity.
Nasogastric tube decompression in a bowel obstruction is important to treat the condition and to reduce the risk of vomiting and aspirating.
If a patient presents again to the hospital, always inform the treating surgeon.