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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Like all days working with the Portland Hotel Society (PHS), I started my day with focused medical learning objectives (I read over all of my extensive notes on how to prepare for and perform the perfect Pap) and came away feeling a mixture of overwhelm, curiosity, and passion to continue to provide care to marginalised people. While running a Pap clinic today (I say that because there was no attending physician present, just me), I learned of one particular woman's history involving significant physical abuse and associated emotional trauma that occurred within the environment surrounding the PHS clinic. I think PHS is amazing in how it brings access to primary care to the people of the Downtown Eastside (DTES), but I hadn't thought about how patients who no longer live and work in the DTES may re-live trauma every time they return to the DTES for ongoing primary care. Needless to say, I was very intentional about obtaining informed consent before the Pap test, with extra sensitivity to explaining why we perform Pap tests, the details of the procedure, and associated risks (physically, potentially a bit of vaginal spotting and pelvic cramping). I also gave her the opportunity to ask any questions, and let her know that if ever during the procedure she was feeling uncomfortable, we could always stop. During the procedure, I kept her informed by explaining what I was doing as I was doing it, and continued to check in to ensure she was comfortable (as comfortable as a Pap test can be, anyhow). The first principle in medicine is First Do No Harm, and in patients with a history of trauma, taking precautions to prevent re-traumatization is an important aspect of providing patient-centered care. After the Pap smear was all done, we discussed the possible transfer of her primary care to another low-barrier clinic situated outside of the DTES, but this was mostly kept as a conversation for another day given the multitude of other things that took precedence at this visit. Recently (aka from 8 am yesterday to almost 4 in the morning - we had a deadline to meet), my resident colleague and I were working on a literature review on the risk factors, protective factors, barriers and facilitators to treatment, and recommendations to promote better care of refugee women with peripartum depression. I was over it when I went to bed in the wee hours last night, but it was at the same time such a good learning experience, and today I was prompted to look to the literature to see what has been published regarding trauma that women have experienced living in the DTES. I found this informative article entitled, "'Like a lots happened with my whole childhood': violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s Downtown Eastside" by Torchalla et al. (2015) as published in the open access Harm Reduction Journal. If you are at all interested in the peripartum experience of marginalised women, I recommend reading it. It also drives home pretty well perfectly the reality of this learning objective and why it matters for primary healthcare providers to understand and critically analyze the environments within which all patients work and live. The social determinants are more powerful than the prescriptions I pen.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
As mentioned in a previous post on routine postoperative care, the following 7 Ps are postoperative complications I explicitly look for when routinely assessing all postoperative patients because they are common and seriously affect patient quality of life and length of hospitalization:
Here I will go over what to do to assess for the specific and common postoperative complications of atelectasis, infections, DVT, and fluid and electrolyte imbalances. I used UpToDate to inform my general approaches to each issue. Atelectasis I assess for atelectasis (i.e., collapsed lung) by asking the postoperative patient if they are experiencing dyspnea, and I also auscultate the lungs to listen for decreased breath sounds and review vital signs to look for evidence of respiratory compromise on examination. Although dyspnea, decreased breath sounds, and decreased oxygen saturation have differential diagnoses and are not specific findings for atelectasis, atelectasis is a common reason for these symptoms/signs in the postoperative period. The impairment from atelectasis tends to peak approximately 2 days postoperatively, but it may be ongoing for up to a week postoperatively. Postoperative deep breathing exercises (ex: incentive spirometry) help to prevent this complication. The approach to treating this complication depends on whether the patient is producing respiratory secretions or not. In the former, a trial of CPAP can be attempted, with close monitoring to intervene with intubation if respiratory status is significantly compromised. On the other hand, if there are significant respiratory secretions, frequent suctioning and chest physiotherapy is first-line. Infections Infection may be signified by localised pain or other symptoms associated with a particular site of infection, or it may be signified by systemic features (ex: fever/chills, altered level of consciousness, leukocytosis). Note that postoperative fever in the immediate postoperative period is not uncommon and by itself is not highly specific for infection, but it is also to do ones due diligence to at least clinically assess and continue to monitor for infection until there are no longer any symptoms or signs that could suggest an ongoing infection. Common postoperative infections include those of the surgical site, pneumonia, urinary tract infection, and intravascular catheter infection. If any source of infection is suspected, starting patients on broad spectrum antibiotics to cover suspected sources of infection is indicated. In the setting of postoperative infection, it is particularly important to start broad spectrum antimicrobials prior to obtaining the results of cultures & sensitivities, as hospital-acquired infections are more likely to be from antimicrobial-resistant pathogens, and that being said, it is best to refer your local institutions antibiogram to select antibiotics taking into account local resistance patterns. If a patient has an invasive line and is febrile, it is best to remove this possible source of contamination if not absolutely necessary. DVT A painful or swollen extremity in a postoperative patient raises the possibility of deep vein thrombosis (DVT). Risk of DVT is usually categorised as low, medium, or high, based on a clinician's gestalt of the individual's patient risk but often also by employing the Well's Criteria as a validated tool for estimating likelihood of DVT in a given patient. Postoperative patients with extremity pain or swelling are automatically high risk per the Well's Criteria, and as such they pretty well always warrant investigation by compression ultrasonography with Doppler. If a patient is indeed found to have a DVT, initiating therapeutic anticoagulation is standard of care unless the individual has a seriously high risk of hemorrhage that may outweigh anticoagulation therapy (in this setting, consider referral to a specialist for alternative therapies such as clot retrieval). While I won't get into the nuances of selecting a specific anticoagulant agent and determining for how long to prescribe it in this blog post, preferred postoperative choices include factor Xa and thrombin inhibitors, depending on patient factors. Anticoagulation therapy is needed for at least 3 months no matter the suspected precipitating factor(s) or lack thereof. Actual duration of anticoagulation past 3 months will be highly dependent on multiple patient factors that I also won't go into here, but the duration can for as brief as 3 months (if the DVT is deemed to be entirely circumstantial) to a prolonged 6 months, 12 months, or indefinitely depending on risk factors for recurrence. Fluid and electrolyte imbalances Depending on a patient's fluid and electrolyte status preoperatively, perioperatively, and in the immediate postoperative period, patients may require rehydration or maintenance fluid therapy. Evidence of dehydration clinically or based on laboratory investigations warrants replacement with small boluses of normal saline (or blood transfusion if indicated) until hypovolemia is corrected. If a patient has ongoing fluid losses without sufficient fluid intake, then a patient also needs to be maintained on maintenance fluid (ex: 20 mEq/L of KCl in D51/2NS, with a rate approximated by the 4:2:1 rule). Any patient receiving intravenous fluids requires monitoring of electrolytes (and some patients who are not receiving IV fluid but who have risk factors for electrolyte disturbance also require daily electrolyte monitoring while in hospital). Correcting for electrolyte abnormalities is important in the postoperative period to avoid complications secondary to electrolyte disturbances (ex: ileum, arrhythmia, seizure). There are a number of different ways to correct for electrolyte derangements depending on the particular electrolyte disturbance(s), and choice will again depend on individual patient factors. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While in clerkship, and so far in residency, I have had the opportunity to perform minor surgical procedures and wound closures on multiple occasions. My reference of choice is Procedures Consult. Abscess Incision & Drainage An abscess is a walled off collection of pus, relatively impenetrable by antibiotics floating in the bloodstream. For this reason, to treat it, it often needs to be incised and drained, to remove the bulk of the gunk and allow the body to heal the remainder. If the abscess is located in the dermis, the layer of the skin just deep to the superficial skin layer (aka epidermis), this is typically an in-office procedure that can be done in any general practitioner's office. In a purulent skin abscess, the causative agent is usually MRSA (methicillin-resistant Staphylococcus aureus), though in patients who are immunocompromised it is possible that there are other microbial culprits. Consider taking a culture of the abscess fluid in unusual circumstances. Equipment:
Procedure:
Postprocedure advice: After the procedure is done, the patient should be advised to watch for, and seek medical attention, if any of the following signs develop:
Wound debridement To debride a wound means to remove dead tissue and foreign material from it. It is an important aspect of proper wound care to prevent infection, restore function, and improve cosmesis. All wounds must be examined for the need for debridement; depending on the history and physical exam, this need can be not at all or extremely compelling, with higher suspicion if wounds have a more traumatic or dirty mechanism of injury. Equipment:
Anatomy: Skin is made up of 3 layers: the epidermis, the dermis, and the subcutaneous tissue. Below the subcutaneous tissue lie the fascia, bones, muscles, tendons, etc. This is a diagram from Procedures Consult showing the different layers of the skin, and a very well clean wound that has either already been debrided or that appears as though it doesn't need any debriding.  Procedure:
Insertion of sutures; simple, mattress, and subcuticular Sutures are the most common way of closing wounds, and the closest I'll ever get to being a good housewife. Before beginning to suture, proper wound debridement needs to be done (as above). We suture skin to restore it's function and improve cosmesis (less scar tissue compared to healing by secondary intent). We do not suture skin closed if there is significant risk for contamination, because this increases the risk of infection, but usually this can be mitigated by good debridement. Equipment:
Anatomy of wound healing, completed quoted here from Procedures Consult because I don't like to make my life harder than it needs to be:
Procedure:
Laceration repair; suture and gluing There are some situations in which a laceration can instead be repaired with a tissue adhesive (aka, skin superglue). When this is a feasible option and there are no contraindications, this can make closing a wound a super easy task, and it also typically means less scar formation. It is also pain-free and super cheap. Pretty much, when it can do the job, it is to everyone's advantage to use it over other methods of wound closure. So, when can we do this already? UpToDate recommends it for lacerations that are clean, that can be well-approximated, that are under low tension, and that are under 4-5 cm in length. It is particularly useful for fragile skin that cannot be sutured easily, common in the elderly patient. In wounds that are under too much tension such that the wound could dehisce using adhesive alone, deep subcutaneous sutures can be employed to relieve tension and allow the adhesive to close the superficial tissue (something to consider in cosmetically important areas). The contraindications, per UpToDate, of using tissue adhesives for laceration repairs are:
Procedure: The basics of the procedure are similar to the above procedures, in that the following elements must be included: consent, personal protection, patient positioning, wound irrigation +/- debridement, neurovascular examination, and documentation. The procedure itself is extremely simple, easily demonstrated with this UpToDate figure:  Aftercare is very simple. The sealed off laceration does not require a dressing, as it serves as its own water-resistant bandage. If glue gets on non-lacerated skin, it can be wiped off rapidly or if on the skin for greater than 10 seconds, it can be removed with the help of petroleum jelly. It usually peels off as the tissue heals over the next 5-10 days. Just like with placement of sutures, patients should return for medical care if any signs of infection develop, or if there is wound dehiscence. Otherwise, no further followup care is needed. Easy peasy lemon squeezy. Skin biopsy; shave, punch, and excisional & Excision of dermal lesions, ex: papilloma, nevus, or cyst Skin biopsy procedures can be useful for for diagnosing and treating various skin lesions. There are various techniques to select from, most commonly being shave, punch, or excisional approaches. The least traumatic method is the shave biopsy, as it only removes tissue protruding above the epidermis, removing epidermis and ideally limited dermis in the process. Naturally, then, this is insufficient for lesions that extend into the dermis, and it is absolutely contraindicated if the lesion being biopsied could possibly by melanoma (in which case the pathologist needs a deep dermal sample). If a shave biopsy won't "cut" it, then there is the option to do a punch biopsy, which is an easy way to gather a deep biopsy/tissue removal. These can remove between 2 and 5 mm in diameter of tissue, based on the size of the punch that is selected. These are great because they are just super easy to perform and if less than 4 mm, and sometimes if less than 5 mm, suturing the site closed is usually unnecessary. If neither of those two options suffices, using a good old-fashioned scalpel to perform an excisional biopsy is always a dependable technique. Equipment (varies depending on the technique):
Procedure (in general, technique varies depending on specific method): Consent, positioning, clean or sterile technique, personal protection, planning biopsy (ex: for an excisional biopsy, plan to excise parallel to lines of minimal skin tension, outline area to be biopsied), anesthesia, remove tissue, control bleeding +/- suture, wound aftercare (as above). *Note that the picture under the "Wound debridement" section above is what an excisional biopsy would look like after the tissue has been removed. Cryotherapy of skin lesions I debated even including this procedure in this section as a minor surgical procedure, but I opted to include it because it's useful to consider as an alternative strategy to surgical lesion removal, if appropriate for the type of lesion. It is much less invasive, almost always pain-free, and convenient to do in the clinic. It is commonly used instead of surgical biopsy for removal of the following sorts of lesions: warts, molluscum contagiosum, skin tags, papular nevi, and seborrheic keratoses. One of the downsides of this technique is that it can leave scars on people if they have darker skin pigment (but not in fair individuals), and you should think twice about doing it in patients who have chronic infection or who are otherwise immunocompromised because they may have more cryoglobulins floating around in their blood, and through some mechanism, this can lead to greater scar formation. You also want to make sure you're not freezing an area with a high degree of cutaneous nerves (may damage the nerves and lead to a permanent loss in sensation) or in which there is not the greatest source of blood supply to promote good healing (ex: lower legs in a patient with long-standing poorly controlled diabetes mellitus). Equipment = freezing agent
Procedure:
*Note that for common warts, the combination of patient-applied salicylic acid and physician-applied cryotherapy is standard practice. While this could also be done for genital warts, generally different strategies are employed. Good first-line options include
Electrocautery of skin lesions Although I've only seen cautery being done in the operating room, this is a modality that can be employed in the office setting. It can be useful to remove moles, with the advantage of better hemostasis and so can be a good option when there is a greater risk of significant bleeding. It is also useful for getting rid of annoying spider veins and telangiectasia. Equipment:
Procedure: Proper technique will depend in part on knowing how to use the device you will work with. Basic settings range from "cutting," "cutting and coagulating" or "cut and coag," and "coagulation." Basically, there is more hemostasis toward the coagulation setting side, but also more scarring (although if too low for the tissue being worked on, this could lead to less smoothness in the cut, and a more unsightly scar). The intensity of the electricity can also be adjusted to modify the power of the instrument, so it can be tuned for the procedure to be effective while also limiting any excess force. This is a procedure that requires proper training and practice. Preparation before and care after the procedure is much the same as for other lump and bump procedures (see above). Skin scraping for fungus determination This wannabe procedure involves a scalpel, so I'd say it "makes the cut." It was also lovely to encounter the description for this simple yet useful procedure in the Canadian Family Physician, the journal I read the most. The article is called, "Microscopic Potassium Hydroxide Preparation" and it was published in 2014 as part of a series called, "The Top Ten Forgotten Diagnostic Procedures," an initiative to teach family medicine residents about useful diagnostic procedures that are on the brink of extinction. Makes sense, I have only seen this procedure being done very rarely despite the multitude of times there's a diagnostic dilemma regarding yeast vs something else. I think the thinking is that empiric treatment with antifungals is of such little harm, it's okay to just give it a go without really knowing. But this can lead to treatment failure, onerous application and cost of antifungal therapies, and a delay in resolving the problem if it is not in fact a fungal infection. Of course, some fungal infections will clinically be very convincing of this, in which case this procedure would not need to be done. But, for those times in which there is diagnostic uncertainty, it makes a lot of sense to me to check a scraping for fungus under the microscope in real-time to inform clinical decision-making. Note that the use of a Wood's lamp is an alternative procedure that can be done before opting to do a scraping. Equipment:
Procedure: As always you start with obtaining consent, and then gather equipment, position and drape the patient, and don personal protection. There is no aftercare needed for this procedure, but if the procedure does not reveal evidence of fungal infection, you should send the scrapings for fungal culture in case the sample collected is just not representative. Here is the meat in the middle:
The article provides this photo of a positive finding under the microscope:  Subungual hematoma release Subungual hematomas aren't a significant concern, at least by themselves, but they can hurt like a B and if large, could suggest a fracture of the underlying bone in the finger or toe. For any significant hematoma, getting an xray before trephination would be the way to go. It's also only really helpful if a patient presents within 48 hours of when it began, as there is no evidence to show that trephination after this time makes a difference at all. Trephination should also not be done by the general practitioner if there are any complicating features, such as signs of infection, extensive nail-bed injury, or evidence of fracture. These patients should extend get a referral to a hand surgeon. Here is an example of a subungual hematoma that could be safely decompressed by the general practitioner, ideally from the distal end of it so as not to risk damage to the lunula (part of the nail bed matrix).  Equipment:
Procedure:
Drainage acute paronychia The information in this post gets credited to a fabulous Emergency Medicine website called Life in the Fast Lane. Some gold nuggets by the Emergency Medicine Nurse who wrote the post:
Equipment: Whatever you need to perform a digital anesthetic block (procedure to be explained, stay tuned), a scalpel, gauze, saline, a syringe and any associated supplies for irrigation, and a bandage +/- antibiotic ointment. Procedure: All the usual, and then following:
Now just imagine this was a patient who came to you, and you can do something to make it better right away! Brilliant.  Partial toenail removal; Wedge excision for ingrown toenail For whatever reason, these are listed as separate procedures under the list of core procedures that I am expected to be able to perform as a family physician, although the latter is really a reason (and probably the most common one) to do a partial toenail removal, so I have lumped them together here. The other common reason would be to clip nails shorter when trying to debride a toenail of onychomycosis (toenail fungus), but in this setting, the procedure is as simple as trimming a nail as short as possible (the part with fungus doesn't have as much sensation, and you basically trim the nail as far back as you can while not causing pain). Another less common reason to trim a nail back is in the setting of trauma and partial traumatic nail avulsion. In this setting, you would want to trim the nail back just until it is not likely to catch (if the nail is oriented in a funny direction). Equipment:
Procedure:
For all the visual learners:  Removal of foreign body, ex: fish hook, splinter, or glass If there's something alien that is penetrating your skin, it's best to eject it from the mothership. Foreign bodies can obviously be painful, but they can also pose a serious risk for infection. Naturally, living in Canada means lots of splinter injuries with all the lumberjacks hard at work (:D), but now that I'm out on the West coast, fish hooks are also a thing (and beware of the ones with barbs on the end, tricky little buggers). Being in the downtown East side means I also need to be on the lookout for shattered glass. Okay I'm being lame, but these are three common types of foreign bodies that can inadvertently get under the skin from trauma. This year, I pulled out a piece of tree from a snowboarder who crashed into the bush while carving his way down Cypress mountain. He came into his family doctor's office for this, not the emergency department, so you just honestly never know what might walk in the door. Really, foreign body removal is part of the process of good wound debridement (see above), so I won't belabour the topic here. It is important to highlight the need to ensure tetanus prophylaxis whenever a wound is penetrated by a foreign object. As well, if a patient complains that a wound feels as though something is in it, heed that sensation; if nothing can be seen, a plain xray can be your friend - even glass is radiopaque as long as the shards are larger than 2 mm. And while xrays are friendly, anesthesia is even friendlier - a digital ring block can make all the difference to ensure proper wound exploration under proper lighting +/- magnification. Irrigating with drinkable tap water is just as good as saline, and better in the possible dirty wound (per the mechanism of injury on history) because the pressure with saline syringe irrigation can further embed foreign material.  ...Sorta worth a splinter or two. Pare skin callus Calluses and corns and common benign skin thickenings on the feet that are physiologic adaptations increased pressure to that region of the body. Often, they arise because or poor-fitting shoes, abnormal gait, or underlying bony problems (commonly neuropathic joints as a complication of long-standing and poorly controlled diabetes). Sometimes corns in particular can be a bit difficult on first glance to differentiate from a wart, but you'll notice that warts obscure the natural skin lines ("toe prints" if you will), while these lines tend to be more pronounced with purely hyperkeratotic skin. After paring them down, you'll also see an absence of the dark specks normally within the central area of a wart (these are punctate capillary thromboses; the wart virus basically causes small clots in the surrounding capillaries). Equipment:
Procedure:
 Infiltration of local anesthetic
Finally, I will now go over the basics of how to provide local anesthesia. The only absolute contraindication to giving a patient local anesthesia is a history of previous allergic reaction to anesthetic, which is extremely rare, but you should always ask, just as when prescribing any other medication. Equipment:
Procedure:
*Although highly unlikely, it may be useful to know that phentolamine is an antidote and can be used to reverse the effects of lidocaine if ischemic complications develop. This would be extremely rare. I have never heard of this being done, and have never even been taught that this is something I should know by any attending physicians with whom I have trained to give local anesthesia. Digital block in finger or toe Performing a digital block is an alternative method of providing local anesthesia when performing procedures on fingers or toes. It is a method of providing sufficient anesthesia to an area that is limited for space to deposit enough anesthetic agent for sufficient freezing. The procedure and equipment needed is much the same as for providing standard local anesthesia. The technique for performing a digital ring block using the two-injection dorsal technique is as follows:
Incise and drain thrombosed external hemorrhoid Left until the "bottom" of this post, this is a variation of the I&D for abscesses, only it is an I&D for a blood clot rather than a collection of pus. Hemorrhoids are common, and thrombosed external hemorrhoids (painful, tender, swollen, bluish lump at the anal orifice) can be a source of significant pain, although are easily "rectified" with an in-office I&D procedure, usually done within 48 hours of onset of pain because after this the pain starts to subside anyway. In the same "vein," perianal skin tags can also be excised, although this is mostly done for cosmetic purposes as they are asymptomatic (on occasion patients may experience pruritus from them). Patients should generally be advised that this procedure, like any, is not without risk, and so is generally not recommended. Equipment:
Procedure:
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Today was the last day of my Obstetrics & Gynecology rotation at St Paul's Hospital, and am I ever glad to be done. It was hard work! I did enjoy it, at least parts of it, but I will not miss waking up at 5 AM every morning to round on the obstetrical ward. My alarm is set for 7:30 tomorrow morning, heaven! At this point in time, I do feel I want to deliver babies (a concept I considered violent and unholy before starting residency), but I have no interest in being a surgical assist (with the exception of assisting with emergency c-sections in women for whom I am providing peripartum care). I can do it, as I did for a vaginal hysterectomy today (after which I was invited back by the surgery to provide further assistance, but was saved by the bell of my pager to asses a woman in labour), or for the laparoscopic hysterectomy and bilateral salpingoopherectomy I assisted with yesterday, but it is not my cup of tea. However, being a medical student means taking part in all aspects of medicine even in areas that are your least favourite, for basic learning and exposure. And if you are a family medicine resident, it pretty much means to do that all over again. Partly it makes some sense, as more exposure to all aspects of medicine help to nurture the well-rounded primary care practitioner. I've made it through my month of obstetrics and gynecology, and now I'll have two weeks of general surgery to conquer, my last 2 weeks of necessary time in an operating room in residency (and possibly ever). It is what it is. On the other hand, while it is my natural inclination to sigh and begrudge the whole process, I want to instead choose to face these next two weeks with an attitude of opportunity. If I use these two weeks strategically, I could really get a lot out of practicing sewing skills in the operating room and managing really sick patients, so I am told by my senior colleagues. In preparation for providing assistance in the OR while in medical school, I encountered this article online that simplified the process. Despite the fact that it was written for medical learners in the UK, and hence has various details that are irrelevant when preparing for nuances of the Canadian OR, the concepts are all very well the same, and I was glad to have encountered it ahead of time. The whole website, Geeky Medics - albeit designed more so for the medical student level - provides great intros to various clinical approaches in medicine. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
The point of preoperative assessment is to look for risk factors that increase a patient’s risk of complications associated with surgery. After assessment, the clinician then attempts to reduce or eliminate, when possible, identified risks. This essentially involves optimising chronic disease management and identifying and mitigating other previously unrecognized risk factors. Along with attempting to reduce risk, it is also important to recognize and convey to patients that no matter how much risk can be reduced prior to surgery, it can never be entirely eliminated. There are always risks associated with surgery, although with comprehensive preoperative care, it is believed that these risks can be significantly reduced. In my last post I outlined a basic approach to preoperative assessment. Here I will review some key perioperative management strategies for common medical problems that may affect surgical care. Cardiorespiratory disease
Diabetes mellitus
Perioperative medication recommendations (general rules of thumbs, always unless otherwise indicated) *See UpToDate article, Perioperative medication management for further details
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While I am currently on my Obstetrics & Gynecology rotation, there isn't often a lot that needs to be done in terms of pre-operative and post-operative medical care. This is because women undergoing OB/GYN surgery are often otherwise healthy young to middle aged women. However, next up will be my General Surgery rotation, so I need to be prepared to assess for and manage perioperative complications in patients who have a bit more going on. Management of surgical patients begins in the preoperative period, ideally well in advance of any surgery they are going to have so as to best optimise their health pre-surgery. Optimising their health means to do 2 things:
It is important to start the pre-operative assessment with complete history. Elements that are particularly important to include in the pre-op history include:
 Credit to the UpToDate article, "Preoperative medical evaluation of the adult healthy patient."
After you've gathered the above history, doing a focused physical exam is next. This includes the following elements:
After the clinical assessment is complete, consider using this nifty risk calculator to stratify the patient's likelihood of having a perioperative complication. After clinical assessment, you can move on to informed investigations based on the assessment. Consider ordering (if you know an indication, not by default) any of the following investigations:
After the full clinical assessment, with the results of any necessary investigations, you can develop your management plan to optimize any medical issues as previously known or as detected based on your pre-operative assessment (ex: getting blood glucose levels better controlled in a patient with diabetes). Next on the to-do list is to communicate any perioperative risk factors to the patient, surgery team, and any other relevant care providers. This will help the patient and care team decide whether or not to proceed with the surgery given the risks, benefits, values, and specific circumstances of the individual patient. If the patient is to proceed with the operation, a detailed care plan will need to be outlined to optimize patient outcomes before and after the surgery. Common issues to work out will be when to stop and start certain medications such as anticoagulants, and what the strategy will be after surgery to try to prevent them from developing a clot (a common post-op complication, we think about this in everyone who undergoes any surgery that keeps them bed-bound for a little while) Post-operatively care consists of monitoring the patient as they recover, checking for any signs of complication, and encouraging a quick return to their usual functioning, because this leads to better outcomes. There is a well-known mnemonic for the medications you want to think about providing to the post-op patient if indicated: the 5 Ps. I've added a couple of extra Ps to include make it a completely useful mnemonic for me to remember not only some basic drugs to think about ordering to improve patients' comfort in the discomfort that is the post-op period, but also to remind myself of the most common concerns I want to check in about as the patient is recovering.
And then, on the surgical ward, they get sent home faster than you can say "no bedside manners." By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 6a: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Recognize the life-threatening situation. Skill: Selectivity Phase: Diagnosis Key Feature 6b: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Make the diagnosis Skill: Clinical Reasoning Phase: Diagnosis Key Feature 6c: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Stabilize the patient Skill: Selectivity, Clinical Reasoning Phase: Treatment Key Feature 6d: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Promptly refer the patient for definitive treatment. Skill: Selectivity Phase: Diagnosis, Referral I have not had the unfortunate experience of ever encountering a patient with an acutely life-threatening cause of abdominal pain. In fact, over the duration of my residency and my only occasional training in critical care/emergency, I may never encounter this. So I don't want to cop out on this, but I also don't want to delve into detail that will probably never be too clinically relevant for me. What I do want to know is what I would need to do to help try to save a patient's life if I am the physician who encounters a patient with an acutely life-threatening cause of abdominal pain. Here is what I feel I need to know to manage such a situation:
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Key Feature 1b: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Generate a complete differential diagnosis (ddx). Skill: Clinical reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4: In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. Skill: Clinical reasoning, Selectivity Phase: Physical, Diagnosis Key Feature 5: In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis A 13 year old female presented to clinic with her mother today concerned about acute abdominal pain. She localised the pain as being midline in the lower abdomen. What is my ddx? Like my previous post regarding the categorisation of acute vs chronic abdominal pain, sometimes (oftentimes) we encounter patients who challenge our clinical ability to categorise symptoms. Certainly this is true with pediatric patients, as their report of symptoms, if they are even old enough to verbally report symptoms, can be challenging to decode. Their inexperience with the pain of a headache may be entirely new, and perhaps associating feeling sick with feeling sick to their stomach, they may point to their tummy when you ask them where there pain is. Or maybe some kiddos actually feel sick to their stomach when they have a headache. The possibilities are endless, and without a reliable way to confidently know where pain or other manifestations of disease is originating from on history, as treating physicians we need to maintain a healthy dose of suspicion in searching for the culprit(s). As their own demographic, children also present with different probabilities of disease, and when it comes to abdominal pain, this is as true as any other undifferentiated symptom. My abbreviated ddx for pediatric abdominal pain (informed by the LMCC learning objectives) depending on the area to which the pain is localised (if they are old enough to be able to localise and communicate this information) is as follows:
Of course, this list is not exhaustive, but it does prompt me to consider some of the most common diagnoses in pediatric patients, as well as important ones not to miss, including the ones that require urgent or emergent surgery. And when I encountered that 13 year old female in clinic today who was able to reliably tell me that she was having midline lower abdominal pain, I was able to use this ddx to inform my clinical data collection, my springboard to collect pertinent negatives to arrive at a working diagnosis (which for this patient was constipation). I don't know that I was correct in reaching this conclusion, or that it was the only thing contributing to the pain, but my attending concurred with this conclusion, and it helped me look for the absence of findings suggesting a worrisome not-to-miss condition. If I cannot feel confident about localisation in a pediatric patient, then I can simply broaden my ddx to include all common and worrisome pediatric diagnoses. And if that still is unsatisfactory, I can consider the more extensive ddx I have for adult abdominal pain (which is still relatively abbreviated, but does take into consideration most bodily systems that may be sources of pain). For completeness, here is my ddx for acute abdominal pain (adult patient, also informed by the LMCC objectives):
And my ddx for chronic abdominal pain (adult patient, also informed by the LMCC objectives):
To elaborate a bit further on inclusion of surgical causes of acute abdominal pain, it is important to know which diagnoses require surgical referral, be it after a bit of a workup to confirm the diagnosis, or more urgent or emergently if the patient is seriously unwell or with signs of peritonitis*. In the pediatric patient, for example, this could mean first doing an ultrasound** to rule out appendicitis if you think it is possible but not highly likely as the cause of the abdominal pain, or it could mean ordering imaging concurrently as you urgently consult general surgery if you think an acute appendicitis is in fact likely to be the underlying etiology for the pain. For any case in which a patient is presenting with peritonitis and a broad working differential for acute abdominal pain, a consult to general surgery is indicated. If the working differential is more focused, given the clinical presentation and patient-specific risk factors, then the surgeon to consult will depend on suspected etiology and local specialist accessibility, and may warrant consultation with general surgery, gynaecology, urology, cardiac surgery, vascular surgery, or otolaryngology. Of course, consultation with a nonsurgical medical specialist may also be warranted given the working diagnosis, such as a gastroenterologist, nephrologist, or infectious disease specialist, among others. The timing of when to involve such specialists must be driven by the urgency of the situation in combination with the working differential, be it to provide diagnostic clarity when there is confusion or to administer therapy that is not in the general practitioner's scope of practice. *In a patient presenting with acute abdominal pain, it is particularly important to examine the patient's abdomen to decide if it is "peritonitic" (otherwise known as a surgical abdomen). Peritonitis is the inflammation of the peritoneum, the sac that encases much of our abdominal organs, and is an ominous finding that suggests surgical intervention is needed. Features most suggestive of peritonitis on physical exam that warrant urgent surgical consultation, in the order in which they would be assessed as per the Inspect-Auscultate-Percuss-Palpate (IAPP) approach to the abdominal exam as is standard medical school teaching, include:
**A tangent on how the management of disease in children differs from adults: A consideration that a physician must have when working up a pediatric concern is how the potential for harm and benefit of various interventions is different from that of an adult or geriatric patient. For example, the potential for harm from repeated CT scans could increase a person's risk of cancer down the road, and having hopefully much more time to live and bear secondary mutations possibly related to effects of radiation, the risk to benefit ratio of performing CT scans in pediatric patients is not the same as in older patients. Although the harm of a single CT scan is not so significant if it means possibly saving a life, it is something to consider if your pre-test probability of ominous disease is low. The converse is also true for the elderly or other patients that have risk factors for true and serious pathology: where the weight balances on the risk vs benefit scale shifts. The same general rationale regarding management decisions applies to considering interventions in pediatric patients as compared to other demographics, and the wise physician will remember to consider that the benefit to harm ratio of anything we choose to do or abstain from doing will differ depending on the individual before us. |
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