Surgical Clerking and Making a Plan

Introduction

As an SHO, you will be expected to make an initial management plan for patients you have clerked. This can feel like a step up from simply carrying out plans dictated by your senior colleagues as an FY1. This article will outline elements to include in your management plan and an approach to seeking senior advice, particularly overnight.

Irrespective of the diagnosis, immediate interventions for surgical patients are similar and are a good starting point for any management plan. As you gain experience, you will become familiar with the next steps in the investigation and/or management of specific presentations.

Immediate interventions for surgical patients may include:

• Analgesia
• Antibiotics
• Intravenous fluids
• Oral intake and nil-by-mouth
• Imaging
• Thromboprophylaxis
• Surgery

As well as documenting your plan in the notes, it is important that you physically enact it and inform relevant team members. For example, if you want a patient to have antibiotics – document the plan for antibiotics, prescribe the correct antibiotics and inform the nurse looking after the patient so they can give the antibiotics.

Don’t expect something to be actioned simply because you have documented or prescribed it!

Admit or discharge

Often, after seeing a patient, the first decision is whether or not they need admission. This must be documented clearly to enable the emergency department (ED) to manage patient flow accordingly.

Have a lower threshold for keeping elderly, more vulnerable patients in hospital and if you have any doubts, discuss the patient with your senior or admit them. You will likely face pressure regarding the scarcity of beds, but patient safety should always be your primary concern.

Generally, there are three options:

1. Admit to hospital
2. Discharge with follow-up: many surgical units will have a ‘HOT clinic’ that patients can be booked into for review and imaging e.g. outpatient ultrasound scan, clinic review for repeat blood tests. Find out what your local system is and how to book appointments
3. Discharge with no follow-up: make sure to discuss these patients with your senior before discharge

Analgesia

Many surgical patients will present with abdominal pain, and making them comfortable is important. The type (opioid versus non-opioid) and dose of analgesia required to make a patient comfortable is often a good indicator of the severity of their pathology.

It is good practice to prescribe analgesia according to the WHO analgesic ladder:

1. Mild pain: non-opioid analgesics such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
2. Moderate pain: weak opioids such as codeine
3. Severe and persistent pain: strong opioids such as morphine and oxycodone

Generally, every patient can be prescribed regular IV/oral paracetamol, as required (PRN) codeine and a PRN anti-emetic. Stronger opioids, such as oral morphine and oxycodone, can be added if the pain is severe. Rectal (PR) diclofenac is frequently used in patients with pain from renal colic and is particularly effective. Avoid NSAIDs in elderly or high-risk patients.

Antibiotics

Antibiotics are indicated in most surgical pathologies and should be prescribed according to local antimicrobial guidelines, considering patient allergies. Some antibiotics, like gentamicin, require monitoring, so ensure you know how to prescribe these correctly.

There are a few scenarios where the prescribing of antibiotics is more nuanced:

Appendicitis

Patients referred to the surgical team with right iliac fossa pain and clinical suspicion of appendicitis (i.e. not confirmed with imaging) generally fall into one of three categories:

1. Clear history and decision taken for surgery – give antibiotics
2. Unclear history, but decision taken for surgery – give antibiotics
3. Unclear history (inconclusive blood results and examination findings) and not for surgery – do not give antibiotics. These patients are clinically well and may be admitted for observation, to identify any deterioration on serial examinations and blood tests, and/or for imaging. Antibiotics will non-specifically treat any source of inflammation, so they will cloud decision-making

Patients with imaging-proven appendicitis, either ultrasound or CT, should be prescribed antibiotics.

Diverticulitis

Acute diverticulitis can be classified according to the Hinchey classification. Broadly, it is uncomplicated (i.e. localised diverticular inflammation with no abscess or perforation) or complicated (i.e. associated with abscess, perforation or peritonitis).

In cases of uncomplicated diverticulitis, antibiotics are generally not recommended unless the patient has systemic signs of inflammation or is high-risk (e.g. immunocompromised, elderly, multiple co-morbidities). However, department practice will vary, so follow your local guidelines.

Pancreatitis

Although patients with pancreatitis will typically present with a systemic inflammatory response, acute pancreatitis is usually non-infected, so antibiotics are not recommended.

Intravenous fluids

Similarly to antibiotics, if you want to give IV fluids, ensure that you physically prescribe them and inform the nursing team looking after the patient.

Specific fluid regimes will vary depending on your patient’s clinical status and pathology. A dedicated guide to prescribing IV fluids can be found here.

Oral intake and/or nasogastric tube

If in doubt, make the patient nil-by-mouth until the surgical registrar sees them. Ensure to inform the nurse looking after them so they are not given food or drink while waiting in ED. Most patients who are nil-by-mouth can still take oral medications with a sip of water.

If you are concerned about persistent vomiting and the risk of aspiration, the patient requires a nasogastric tube (NGT), also known as a Ryle’s tube. Most nurses in ED or surgical wards will be able to place an NGT, but you should also be able to do so yourself if required.

Imaging

CT of the abdomen & pelvis with IV contrast is the imaging of choice in unwell patients or those with concerning blood results or examination findings. As the SHO on-call, you can request and vet a CT scan if you believe it is indicated. If you are on-call overnight, this may involve contacting an external teleradiology service (via switchboard) to vet the scan.

If a patient is clinically stable, alternative first-line imaging may be more appropriate.

Table 1. Preferred imaging modality according to suspected diagnosis.

Ultrasounds will not happen overnight, but you can still request them as part of your plan.

There is a higher threshold for performing a CT scan in younger, particularly female, patients so it is often best to discuss these cases with your senior.

Thromboprophylaxis

Every patient admitted to hospital requires thromboprophylaxis of some sort, and most hospitals will have specific venous thromboembolism (VTE) documentation that needs to be completed on admission.

If indicated, the choice of low molecular weight heparin varies according to hospital and is dosed according to weight.

Surgery 

When pathology is confirmed and requires surgical treatment, inform your registrar and prep the patient for theatre:

• Make nil-by-mouth (NBM) and document when they last ate or drank
• Ensure 2 valid group & save samples are available
• Book onto the emergency operating/CEPOD list
• Inform the on-call anaesthetic team
• If appropriate, consent for the procedure
• Inform the ward and/or nurses looking after the patient

Overnight, suitable cases will be postponed until daytime when more staff are available, and operating conditions are safer. However, this is a senior decision considering the entire clinical picture, so cases should always be discussed with your senior.

If a case is for the next day and you have time, you can still prep the patient similarly and make them NBM from 2 am.

Seeking senior advice

If you are worried about a patient or unsure what action to take, promptly escalate your concerns to your senior colleague or involve appropriate additional support (e.g. medical registrar, critical care outreach team).

Asking for senior input only to be reassured may feel embarrassing, but it is much better than doing nothing and simply hoping the situation improves. Patient safety is your priority and early intervention during the initial stages of clinical deterioration is key to improving survival.

If it is overnight, you may have to wake your senior colleague up. This can feel particularly daunting but, again, patient safety is the priority and your senior is on-call for this exact reason.

Gather your thoughts before making the phone call – you need to paint a clear, logical picture of the clinical situation to allow your senior to give appropriate advice, and it makes a much better impression if you are prepared. Give a summary of the patient’s presentation, your assessment and what has been done so far (bloods, imaging, medications).

Example template

Start the conversation by saying who you are and giving them time to wake up rather than launching into your patient’s history – “Hi this is X, I am the surgical SHO on call tonight at X hospital. It is 3 am”.

State whether you want over-the-phone advice or whether you think they need to come into hospital. This will give them a chance to start getting up and dressed while listening to the history – “I don’t think you need to come in, but I wanted to discuss a patient with you” versus “I’m concerned about a patient and would like you to come in to review them”.

Give a brief summary starting with demographics – “This a 34-year-old woman with no past medical history presenting with X” or “This is a 79-year-old man with a background of type-2 diabetes, hypertension and previous laparotomy”.

Then, proceed with the rest of your history, assessment, and what has been done. It is a good idea to have the patient’s notes open for review in case they have additional questions.