Job Reviews: General Surgery as a Foundation Doctor

Ward round 

The first thing I do in the mornings is prep the notes. Ward rounds can happen very quickly, so I find it helpful to have notes prepped to keep up as you go around the patients.

As there are many surgical specialities and medical patients, several different ward rounds happen each day. Each ward round can turn up at any time in the morning, and sometimes all happen at once. 

Example of Jobs after ward rounds

Once ward rounds have finished, I make a jobs list of everything that needs doing throughout the day. At this point, I prioritise urgent jobs. For example, ordering an urgent CT abdomen would need to be done before ordering a routine OP echo. Some of the jobs that I do include:

• Ordering investigations is something I do every day. If it is an urgent request, I will always ring and get it vetted. Sometimes this can prove difficult, and I can find myself spending a significant amount of time on the phone with the radiologist trying to persuade them to do the scan. Once the request has been approved, I will do another job on my list to chase and action the result accordingly. 
  
• There is quite a high turnover of patients on the surgical wards, so there will often be several discharge summaries and TTOs to prep. It is important to try and get the TTO’s done earlier in the day so that they can be processed by the pharmacy to allow the patient to go home that day.
• Microbiology discussions are another thing that I do during the week. These can be for various reasons, including needing an appropriate oral antibiotic switch, a positive blood culture or wound swab, raising inflammatory markers and temperature spikes despite treatment with antibiotics. I have found it is important to have all the information about the patient prior to speaking to the microbiologists – it will make the conversation run much more smoothly.
  
  
• Referrals – often, patients will need input from other specialities for various reasons, so they will need a referral to request input from that speciality. They may also need input from specialist nurses – e.g. diabetes specialist nurses, tissue viability nurses.
  
  
• Family updates – usually the nurses will kindly update families; however, sometimes, the family will specifically request an update from a doctor. These can be quick, pleasant conversations or can be lengthy, difficult conversations.
  
  
• I will usually chase bloods in the mid-afternoon. This can often generate more jobs; for example, patients may have deranged electrolytes that need treating and require an ECG. At the end of every day, I will also print blood for every patient that needs blood the next day for the phlebotomist to do, ensuring this is done can save a lot of time during the following day.
  
  
• Sometimes a patient will need bloods, cannulas or an ABG for various reasons. On my ward, the nurses are excellent and will always try to do the bloods and cannulas; I will usually only have to do it if they have poor access or if something needs doing urgently.
  
  
• Occasionally I have had been able to learn a new procedure. I have had the opportunity to perform an ascitic tap and a lumbar puncture on my general surgery job. If people need these things done, it is always a good experience to watch them be performed to learn how they are done and then have the opportunity to do one yourself with supervision. 
  
  

The unwell patient

The nurses will often find me and ask me to review an unwell patient. I find that this can be the most challenging and time-consuming part of the day. The days I leave late are when I have had several sick patients. 

I am asked to see unwell patients for various reasons including a high NEW’s score (the most common), chest pain, PR bleed, and new oxygen requirement. I will assess the patient using an A-E assessment, ensure that the immediate treatment that is required is given (oxygen, pain relief etc..) and then escalate as appropriate. Other things that I often have to review are a rash, an open wound, low urine output, a mass, confusion/agitation and constipation. 

Pre-operative and post-operative-patients 

When I know a patient is going to surgery, I have to ensure everything is prepared for them to go to surgery. This will include ensuring they have a clotting screen, group and screen, an ECG and ensuring the LMWH is held the night before the surgery/procedure. There have been times when all of these things are not in place, and the procedure/surgery has been delayed or cancelled. 

When patients return to the ward, I will look at the operation note and ensure that the post-op plan is implemented. I try to ensure they have VTE prophylaxis prescribed if needed, ensure that they have adequate pain relief, antiemetic and fluids prescribed, and have the appropriate antibiotic prescribed if required.
 

Handover 

Any scans that have not been reported yet or bloods that are not back, I will hand over to the evening team to chase. If there have been any sick patients during that day, I will hand this over to the evening team to ensure they are aware of them and the plan. 

On-call shifts 

Once a week, I have a long day, this will consist of a normal day and then in the evening, I will be on call and will usually cover three wards. I take handovers from the doctors covering those wards in the day and go and review any sick patients on the wards and do any jobs that arise from 16:00-20:30 and then hand over to the night team.