Post on-call for the second in a row (last Friday and now Monday). In all fairness this rarely happens as we share an on-call service with the colorectal team and they have twice more consultants than the UGI team.

When arriving on Monday morning and looking at the lists to combine them we have 30 odd patients around the hospital. Ok, combine the list and head down to the surgical admission ward and see what is listed for the CEPOD list. The word CEPOD comes from Confidential Enquiries into PeriOperative Deaths (CEPOD). It usually means the surgical emergency theatre (or OR list) which is a dedicated theatre for the surgical on-call team to deal with cases which need intervention.

From a general surgical point of view there was just an Appendix at the time however we’ve had 2-3 patients which might head this way as well.

Post on-call consists usually of the post on-call F1, the UGI F1 and myself to collect the ward jobs during the ward round , divide them between us and do the jobs in addition to the pager triggering every 5 minutes. If any problem come up I tend to ring the consultant of find one of the registrars who are usually operating on the elective list.

Luckily the ward round was relatively quick and we’ve been around the wards by around 10am. During the post ward round chat we handed some patients over to the incoming on-call team (like the appendix) as they are performing the potential surgery.

Two of our patients were quite poorly and they needed sorting out more or less straight away: A young pregnant lady with either cholecystitis or Appendicitis. The abdominal ultrasound was inconclusive which make additional imaging difficult (like CT scan) due to fetus. An MRI scan was requested which then showed appendicitis with the appendix in the RUQ (Right Upper Quadrant of the abdomen) instead of the RIF (Right iliac fossa).

She then ended up in theatres later that day and during surgery not only did she had appendicitis but also a hole in her caecum which needed to be dealt with as well. Despite the findings the surgery went without a hitch and she was doing fine post surgically( so did the other appendicitis patient who went home the same day).

The other poorly patient on that day was a patient with adhesional small bowel obstruction (SBO). The bowel often forms scar tissue (called adhesions) after being handled during surgery. The more abdominal surgeries a patient has the more scares are likely to be formed which means that bowel can get trapped in that. These patients present with abdominal pain and emesis (vomiting). These patients need intestinal decompression which means they need a nasogastric tube (NGT) inserted and siphon off gastric content which can go down stream due to a constriction of the adhesions.

A CT scan usually give us an idea what is going on, where the obstruction is and if there is anything else to be seen on the CT.

The initial management of SBO therefore is IV fluids, bloods (checking renal function and electrolytes), NGT insertion and antiemetics. When things are not settling we usually give gastrografin a go. Gastrografin is an X-ray contrast which also is hypertonic. This means it’ll draw out fluids from the bowl wall into the lumen and will therefore reduce the bowel size and sort of kickstart peristalsis and the bowel starts working again.

Unfortunately in case of the patient above this did not work and surgery was not an option either. His kidneys started to deteriorate and AKI 3 showed up on the blood tests. To make matters worse the patient then went into SVT (Supraventricular tachycardia) and we needed to give adenosine to slow the heart rate down which then gave the patient atrial flutter which means the upper chamber of the heart (atria) is beating to fast. Digoxin was given for that.

A review by the anesthetic team and the renal team revealed that options of surgery and/or dialysis would be in vain.

We then had a tough talk ahead of us with the patient and the family and explained that the our options are limited and that neither surgery and/or dialysis are an option and that the patient is reaching the end of life.

This is obviously a shock to patients and family and once we answered all their questions we left them to think about what we just explained to them. Later that afternoon I was paged and together with one of my consultants we went back and the patient together with the family decided that we should palliate and stop active treatment.

The heart monitor was stopped and the Just in Case (JiC) medication were prescribed following a discussion with the palliative team. The reason for the discussion was predominantly due to the AKI 3 and ensuring that the right dosages are prescribed.

This sums up only 3/4 of my two days!!!!! 😦