The Department of General Surgery comprises 8 Consultant Surgeons and 1 Associate Specialist, split between the Upper GI and Colorectal Teams. They are as follows:

Upper GI Team

Mr Jim Evans – Consultant Upper GI Surgeon & Clinical Lead for Upper GI Surgery

Mr Shopon Saha – Consultant Upper GI Surgeon

Colorectal Team

Mr Mike Johnson – Clinical Lead for Colorectal Surgery & Consultant Colorectal Surgeon.

Mr Dale Vimalachandran – Consultant Colorectal Surgeon.

Ms Nicola Eardley – Consultant Colorectal Surgeon.

Mr Chris Mcfaul – Consultant Colorectal Surgeon.

Mrs Jennie Grainger - Consultant Colerectal Surgeon

Mr Roy Mahapatra – Associate Specialist in Colorectal Surgery.

In addition, the Consultants are supported by a team of Specialist Nurses who assist with MDT, endoscopy and clinics as well as offering a specialist Stoma service providing teaching both in hospital and at home for patients learning to manage a new stoma.

“Take Week”

Each week one consultant acts as the Consultant Surgeon-of-the-Week (CSOW). Beginning midday Friday, the CSOW is responsible for emergency surgery and accepts all emergency patients admitted.

Morning handover takes place at 8am in the general surgery handover/reource room located on the corridor between Wards 44 & 45. The CSOW and On-call Registrar then lead the post-take ward round of all emergency patients. After the ward round, the On-call team’s day is spent clerking in A&E and the Surgical Assessment Unit, or operating in Emergency Theatre (Theatre 5).

As the Upper GI or Colorectal FY1, the Take week can be incredibly busy. The Post-take ward round occurs at a fast pace so that the CSOW and Registrar On-call can then go to theatre. It is important that the FY1 keeps track of management plans for each patient keeping a jobs list. Jobs must be prioritised depending on clinical importance – e.g. reviewing an acutely unwell patient – and those that are time-sensitive e.g. requesting a CT scan or ensuring TTOs have been completed.

Managing the take depends on maintaining & updating the “Take List”. Every patient admitted by the On-call team is entered into the list which is printed at morning and evening handovers. It is the responsibility of the FY1 on the team to update the list throughout the week with up-to-date blood results, imaging and operation dates to ensure handover and PTWR run as effectively as possible. When the CSOWs change over on a Friday a new list is started under the name of the new CSOW.

On-Call Responsibilities

As a Surgical FY1 you will be on-call once a week from 8am-8pm and on-call on a weekend Friday-Sunday 8am-8pm every 7 weeks. The On-call FY1 holds the bleep #3216 and is tasked with clerking patients referred into the Surgical Assessment Unit by the GP (referrals are passed to FY1 via bleep from Bed Bureau). After 5pm the FY1 is then also provides ward cover to the surgical wards.

On a weekend on-call the CSOW conducts an extended PTWR of all General Surgery patients on all wards. The FY1 and SHO on-call then provide ward cover between them in addition to clerking – all patients are seen in A&E on a weekend as SAU is not open.

When admitting patients it is worth considering the following:

• Prescribing:
  • Regular medications are prescribed on EMAR.
  • VTE assessment must be completed and TED stocking & Tinzaparin prescribed as appropriate.
  • Symptomatic medications such as analgesia & anti-emetics should be prescribed
  • Hospital policy mandates that Antibiotics should only be started with the approval of a doctor at CT/ST-2 level or above unless the patient displays features of sepsis in which case an FY1 may start antibiotics. Tazocin is the trust’s 1^st-line antibiotic for intra-abdominal infections.
  • If prescribing IV fluids consider why you are doing so and what best to give:
    • If a patient is NBM pending surgery then IV maintenance fluids are appropriate.
    • If a patient is septic then they may need fluid resuscitation
    • If a patient has presented with bowel obstruction they may need more fluid to replace ongoing losses.
• Investigations:
  • Patients with signs of peritonism should have an erect Chest X-ray.
  • Ultrasound scans can be performed in hours and arranged through SAU.
  • If a patient requires a CT-scan in hours the request should be discussed in person with the ROS in the reporting room. Out-of-hours then discussion with the Radiology Hub by phone is required and should ideally be done by a senior.
• Procedures:
  • Nasogastric tubes: Patients presenting with bowel obstruction or an ileus post-surgery will require a nasogastric tube. On ward 44 this can be done by the nursing staff, however on other wards the FY1/SHO will be contacted to insert an NG tube.
  • Urinary Catheters: can usually be inserted by nursing staff or CSW. If a 3-way catheter is required for haematuria then the FY1/SHO will be required.
  • PICC service: patients requiring long-term antibiotics, TPN, or difficult access will require a PICC line. PICC lines are inserted by the Interventional Radiology department – a request should be submitted through Meditech and then liase with IR. The same applies for IR-guided drainage of a collection.
• Theatre:
  • Patients requiring emergency surgery should be kept NBM, have a VTE completed and TEDs applied if appropriate, be marked & consented.
  • Consent should be performed by an SHO or above.
  • Emergency Theatre should be booked on Meditech (under Emergency Theatre Bookings), the Theatre Coordinator should be bleeped (2570) as well as the 1^st-on Anaesthetist (2605).

When not on-call or managing the take, you will be responsible as the FY1 for the elective patients. Each Consultant usually has 1 all-day list a week in addition to Daycase lists in Jubilee theatre as well as the occasional additional lists.

Patients undergoing a major bowel resection often, depending on the exact operation, require bowel prep or an enema beforehand and this may need to be prescribed.

Post-surgery the majority of patients will follow the Enhanced Recovery Pathway (ERAS) which has been shown to decrease hospital length of stay. There is an ERAS pro forma which will contain the operation note, instruction regarding early mobilisation and management of analgesia postop and leaves space for ward review and blood results to be documented.

It is important that you ensure these patients have bloods taken following surgery and look out for rising inflammatory markers particularly a few days down the line that might suggest potential leak or collection.

When reviewing a post-operative patient it is important to make note of the following to assess their progress:

• Clinical observations
• Fluid Balance
• Nutritional Status
• Analgesia – Rectus sheath/PCA/Oral analgesia
• Drain output
• Appearance of the stoma – has it started to function?
• Wound
• Blood results

In a post-op patient displaying signs of sepsis with rising inflammatory markers it is important to look for the source of infection. Whilst Hospital-acquired Pneumonia and UTIs are common in post-op patients, if there is any concern about the possibility of an intra-abdominal collection or anastomotic leak then a CT scan should be arranged – this should be discussed with the registrar or consultant first.

Patients who have develop an ileus post-surgery may require a nasogastric tube for symptomatic relief and IV fluids to replace ongoing losses. A prolonged ileus may then need consideration for PICC line and TPN particularly if the patient has not been fed for 5 days or more.

Elderly patients who have undergone major surgery will often require input from physios and occupational therapists before they can be discharged, and patients who have had a stoma formed will be taught how to manage their stoma by the specialist stoma nurses and can be followed-up at home.

Not surprisingly TTOs & E-discharges are important tasks that are often left to the FY1. During Take week there is a very high turnover of patients and so it is important to keep track of e-discharges.

When completing a TTO it is worth considering the following:

• Have any regular medications withheld during admission - e.g. Antiplatelets - been restarted?
• If Antibiotics have been started is there an appropriate oral stepdown and stop-date agreed?
• Is the patient to continue on Low-molecular weight Heparin on discharge? Patients undergoing major bowel resections now complete a 28-day course of Tinzaparin post-op.
• If a patient is normally on Warfarin/NOAC has it been restarted and if so do they require follow-up to be arranged with the Anticoagulation Clinic.
• Certain medications prescribed in-hospital do not necessarily need continuing on discharge e.g. Loperamide.
• If the patient has been prescribed electrolyte replacement e.g. Sando K – do they still require it and if so should their electrolytes be checked by the GP.

With regards to e-discharges if the patient was seen and discharged from SAU the same day it is the responsibility of the on-call team who reviewed the patient to complete the discharge summary.

Otherwise when completing an e-discharge it is important to clearly specify the diagnosis, treatment or surgery the patient underwent, and most importantly what follow-up was arranged. This may be in the form of clinic appointment with the Consultant – patients who have undergone bowel resections for malignancy will usually be seen in 2 weeks with histology. Patients with outstanding acute issues may be brought back to SAU for review by the on-call team – this should be included in the e-discharge and a referral should be made to SAU on Meditech.

Note patients with a new diagnosis of GI malignancy must go through the MDT. In the case of HPB malignancy, these patients will also be referred to the MDT at the Royal (Pancreas) or Aintree (Liver & Gallbladder). The MDT discussion may occur whilst the patient is an in-patient but if they have been discharged home prior then it should be documented in the e-discharge that he/she is awaiting MDT discussion.

Education & Training.

There are several opportunities available for education & training whilst working as an FY1 in General Surgery.

MDT takes place on a Monday morning in the Radiology Seminar Room. The Upper GI MDT is from 8am and the Colorectal MDT is from 8.30-10am. FY1s are not required to attend but may benefit from the educational value.

On a Monday lunch-time at 12.30 Department teaching takes place in the Bariatric Seminar Room.

Each week a nominated FY1 and SHO present a short presentation on an agreed topic usually supported a recent case. A registrar or consultant then facilitates a discussion around said topic. The teaching is informal and there is usually a sponsored lunch provided.

Every 6-8 weeks there is a rolling half-day during which the M&Ms are presented. There are also additional M&M meetings in between the Rolling Half Days (dates are posted in the general surgery resource/handover room) It is the responsibilities of the FY1s and SHOs to prepare the M&M presentations which are then discussed. Rolling Half-day also then offers the opportunity for Consultant-led ward based teaching or audit presentations and we have also recently introduced journal club where an SHO or Registrar will critique a paper and present it.

Where possible FY1s are welcome to attend theatre to develop their knowledge and understanding of General Surgery.

For Foundation Doctors interested in a career in General Surgery or simply developing their portfolios the following courses are recommended:

• Basic Surgical Skills Course
  • This 2-day course that is run around the country will teach you the fundamental basic skills and techniques required in theatre – handling instruments, hand-tying, suturing, wound debridement etc.
• Systematic Training in Acute Illness Recognition and Treatment for Surgery
  • This 1-day course at the Royal College of Surgeons in London will advance your skills in managing unwell surgical patients via combination of short lectures, interactive workshops and e-learning.
• Advanced Trauma & Life Support
  • This 3-day course run across the country will teach you the fundamentals in assessing and managing a trauma patient.

Annual Leave

Mr Chris Mcfaul is the appointed Department rota coordinator and as such all annual leave requests should be authorised by him and then submitted to Sophie Davies in Medical Staffing.

As a busy firm sufficient staffing is important and so you must work together with your colleagues to ensure you are all able to take annual leave but at times when there are still enough members of the team available to provide sufficient cover. This is particularly important during the Take week.