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The Primary Duty Of A Surgeon Question: Discuss about the Primary Duty Of A Surgeon.     Answer: Paediatric Preoperative Care: The primary duty of a surgeon after entering the Operation Theatre or OT, is studying the patient and their clinical account. The initial patient observation is based on visual perception; this helps us gather general overview about the patient’s health such as state of consciousness, breathing pattern, pigmentation, and body temperature (Yentis et al. 2009).  More importantly, post-operative survival rate depends on the initial assessment of the distressed patients before operation (McFadyen et al. 2012). If this issue arises, the change of pigmentation and body temperature of the affected area will signify blockage of blood circulation to the limb, as a result, the patient’s pulse could be checked accordingly. The Royal College of Nursing RCN recommends that, OT surgeons and nursing staffs should be skilled enough to recognise the ailing patient (Royal College of Nursing RCN 2013). The College of Operation Department Practitioners CODP states that surgeons play an important role in analyzing, devising and delivering the services required in an OT. Observation of a recognizable bruise on the head of a patient should be considered as a possible brain injury from trauma and the patient should be subjected to CT scan immediately. The recommendation provided by National Institute for Health and Care Excellence (NICE 2014) states that it is the duty of the OT surgeon to make sure that the scan is thoroughly completed and make further observation to check for abnormalities like; dizziness, memory-loss, spasm to detect any potential head injury or major/minor skull rupture, and report immediately. The TBI patient should be subjected to clinical observation for at least 2 days post damage and monitoring for blood and intracranial pressure is important.   Association of Paediatric Anaesthetists of Great Britain and Ireland recommends that if the pre-operational vaccine was not activated the surgery should be postponed for 48 hours after the administration of the vaccine, for which it is essential to check the immunisation history (APAGBI 2007). The British Medical Association (BMA) suggests that the consent form is to be passed on to only the person who signed the form in the reception desk (BMA 2000). Adolescent and underage patients who are unable to sign the consent form should be accompanied by a parent or guardian who can responsibly sign on behalf of them, as recommended by the National Health Services (NHS). In case of separated parents, the custodial parent or the parent with a legal permission or either parent’s legal partner may have the ability to sign the consent form on behalf of the minor, according to the norms of the Department of Health (DH 2006). The patient if in case is a minor, using the Gillick competency assessment can be analyzed whether he is consciously mature enough to understand the severity of his condition and consequences of the surgery (Griffith 2013).  In the given case the patient seems to be in distress and indifferent to the surrounding and succumbed to crying which may oppose the Gillick competency. Fasting time before the surgery is an important issue in emergency cases which is to be taken seriously and reviewed with the respondent nurse in the respective department.  This step is important to avoid the ascending of digestive materials during anaesthetic conditions. (Maltby 2006). It is recommended by the Association of Anaesthetists of Great Britain and Ireland AAGBI (2010) the individual healthcare facilities should have their own policies regarding Fasting time. According to RCN, medications prior to operation do not react with the fasting recommendations. Even in cases with children with supra-condylar fracture issues are recommended fasting (RCN 2005). A survey on 399 children with supra-condylar fracture surgery was studied and found that delay in surgery due to fasting did not complicate the outcome of the surgery in any way (Larson et al. 2013). Nevertheless, the research team suggests more in depth study that will establish the beneficial effects of intervention during supra-condylar fracture surgery. A different controlled study performed by Kronner and his has reflected postponement of supra-condylar fracture surgery in minors did not affect the outcome of the procedure (Kronner et al. 2013). Nowadays, practitioners administer fasting time, approximately 18 hours before the surgery (Absug and Herman 2012).   Engagement with patient and their family is essential after the patient is checked into the OT. Self introduction is important to ensure effective communication with the patient party (Health and Care Professions Council HCPC 2012).  Decreasing the preoperative nervousness of minor patients is important and surgeons should effectively communicate to ensure that (Murphy and Taylor 1999). Parents of the minor undergoing surgery should be informed about the surgery, the type of anaesthesia administered and the post operational pain treatment that will be commenced. Some minors show high levels anxiety and demoralised condition before surgery (Li and Lopez 2006). Details of the anaesthetic procedure, pain of the surgery should be kept from the minor as they show signs of anxiety and the family will be in distress (Smith and Callery 2005). Attractive informative flyers can be handed out to them. In the given case, since the minor is under stress, sympathetic engagement is important to assess his condition. Effective communication engagement is an important skill possessed by nurses and practitioners to make sure that patient and his family does not succumb to pain and address any issue immediately (RCN 2012). The biological parents were absent in case of the minor’s surgery, the severity of the child’s outcome could not be foretold. Support from the parents or guardians during surgery should always be encouraged. If such situation is faced where the parents are unavailable, a staff should be assigned to the minor at all times to distract the child from anxiety or meet their needs (RCN 2011). The minor is this case, as directed by the mother’s partner had fallen from a slide, showed multiple bruises and scars apart from his injury, which raises suspicion of physical abuse. Professional and moral duties of the surgeon prohibit them to take legal actions in these cases (HCPC 2012), but the assigned doctor can express concern or query if deemed necessary and a team of doctors can be consulted for this case and a vigilant nursing staff should be assigned to the minor to ensure child protection by the Royal College of Paediatric and Child Health (RCPH 2008). Local authorities can be informed so that evaluation of the child’s suspected abuse can be done and commence legal action under the child protection act (Working Together to Safeguard Children 2010). Protection of the welfare and health of the possibly abused minor is recommended by the Royal College of Anaesthetists (RCOA) and Anaesthetists of Great Britain and Ireland (APAGBI) in 2010.   Intra-Operational Paediatric Care: The injury treatment procedure of supra-condylar fracture in case of trauma care patient is important segments to be considered, starting from anaesthesia, pain managing, homeostatic stability, and breathing control for minors (McFadyen et al. 2012). All required equipments should be made ready before the administration of anaesthesia to the minor (Gwinnutt 2008). Patient safety can be ensured by controlling the breathing of the minor during anaesthesia (Benumof and Klock 2007). Depending on the anatomy of the minor the surgeon should prepare various breathing device to avoid troubles during intubation (Finucane et al. 2011). The most common breathing device used for minors are Non-cuffed Endotracheal Tubes (ETT). Emergency drugs like atropine or succinyl-choline should be kept ready beforehand. In case, the child shows reluctant intravascular access, the anaesthesia can be administered through inhalation. Short trachea in children may hinder auscultation, which is why checking the position of the ETT is important (Hagberg et al. 2007). Accidental displacement of the ETT can be avoided by immobilising the tube (Hagberg et al. 2007). A newer approach to breathing management is rapid sequence intubation (RSI), utilizing a step by step approach to preparation, sedation, and paralysis which substantially minimizes patients consciousness ( 2014). There are three steps involved in Pain management: pre, intra, and post operative methods. Using pain management and assessing tools is important to evaluate the severity of the pain (APAGBI 2012). Lowering of the anxiousness and inhibiting the health deterioration of the minor is important in managing pain. Immobilizing or relaxing the minor can be effective in pain managing service. The response towards pain varies with every child, which makes it difficult to evaluate. The different tools for Pain assessment are implemented, like Face, Legs, Activity, cry, and Consolability (FLACC) used for children under 7 and above 2 years (McFadyen et al. 2012). Preoperative pain scales are also used in cases where the minor is unable to express the severity of the pain. This form of patient service is offered at the emergency unit by distracting the child with playing materials and non-clinical techniques, like showing an animated movie. Administration of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) reduce chances of opioid based medicines (APAGBI 2012). Blocking the peripheral nerves is an effective method to reduce pain. Marinating the homeostatic stability of the minor is essential and can be administered by controlling the fluid intake and temperature control in OT (Vincent et al. 2011). Loss of blood from the injured area can be inhibited to ensure blood volume of the patient is up to threshold limit. Recommendations from APAGBI show that hypotonic fluids prepared with 4% dextrose and 0.18% salt is effective in such conditions (APAGBI 2007). The preferred solutions for intra operative fluid administration are isotonic solutions and Ringer’s Lactate (Vincent et al. 2011). Observations should be made if patient seems dehydrated and the issue is solved by checking vital signs (APAGBI 2010). Thermal regulations and management policies are provided to healthcare facilities which can be addressed in these cases to maintain the temperature (Bernardo et al. 1999). Administrator of anaesthesia should skilled enough to understand the clinical symptoms the minor may exude. The assigned nurse or doctor should be prepared to administer thermal heating tools, fluid and blood channelling conditions. If any such situation arises, pair-huggers, warming mattresses should be provided to avoid hypothermic conditions.     Pain Management: According to the Guidelines of RCN, scheduled check-ups should contain a separate pain assessing segment to ensure that the child is properly diagnosed. The “faces scale” technique can be utilised to evaluate the pain of a child less than 7 years of age in the room where they recover (RCN 2009). A recent practice common amongst paediatric practitioners is using the cream for anaesthesia, like EMLA before administering intravenous cannula (Debeer and Lockie 2008). Analgesic medicines should be kept close in case of emergency during surgical procedure (Howard 2008). Generally, using opioid and NSAID based pain relief medicines are administered after the completion of the surgery (Howard 2008). A brachial plexus block method can be implemented to lower the pain levels and stress after surgery (Fiadjoe et al. 2013). A secondary, intraclavicular instead of supraclavicular block can be carried out (Marhofer et al. 2008).  Children with a case of nerve blocks in the periphery, ultrasound guidance shloud be implemented so that post operative complication are lowered and patient safety is ensured (Fiadjoe et al. 2013). The Psychosocial Care Of Children In Hospital: Separate setting for adults and children is recommended by the Royal College of Surgeons of England (RCSE 2007). It is important to set up the care facility and provide services, both according to the need of the child as well as their family (Department of Health 2003). The NHS has framed a set of guidelines to follow during such situations. Interdepartmental as well as inter agency connection is important to maintain the working flow of the care facility, if such issue arises where the child may need help from social work organizations. The child health unit of the care facility is expected to have the best possible service (RCSE 2007), where presence of minimum one assigned nursing staff at all times. Since I am an OPD myself, my paediatric training is limited to a certain extent, but fluency of information among the patient, assigned doctors, nurses and their family is very important to avoid confusion and child harming. Children are better provided age appropriate information for protection (Cunnington 2008). Parents or guardians are allowed to stay with the minor patient in the anaesthesia and recovery room (RCSE 2007). Studies have shown many psychological recompense when a parent or guardian is allowed to reside with the child patient instead of allowing them to visit at scheduled timings (Priddis and Shields 2011). Children have shown symptoms of anxiety and distress in absence of their closed ones with regards to the Attachment theory. Presence of a figure that the children are attached to makes them feel safe, this practice should be allowed (Priddis and Shields 2011). If the mother is unavailable, then the person who is second closest to the child should be allowed.   Analysis of various research articles have shown the different psychological responses a child exudes after admission into the hospital are segregated in two three broad categories: ecological (family and hospital atmosphere), biological (sex, personality, clinical symptoms) and lastly development and cognitive functions (brain development, previous incident and coping mechanism). Studies have shown the importance of survival mechanism and plan of action that children utilize in the daily life to deal with stress is correlated with the genetic traits that define a child’s character, like “vigilant-active” or “avoidant-reactive” (Vessey 2003). Similar survival instincts are seen when a child is ill and ailing (Ryan and Wenger 1996). Therefore, it is essential to gather knowledge about the child’s survival instincts from previous experiences.   Legal And Ethical Issues: The case study provided is an example of typical injury occurring from falling down from a height in children (Kemp et al. 2008). The problem is that the child has visible bruises and scars that are a result of possible physical maltreatment. In terms of ethics, beyond medical qualification, the safety of a child overrides, professional boundaries (RCPCH 2007). It the responsibility of the assigned healthcare staff to ensure that the child is safeguarded in the hospital premises (RCPCH 2010). In case of the given case study it is advised to contact a local child protection or social working organization , who may be able to provide the child proper protection they require (NHS 2012). The intercollegiate safeguard guidelines, state that assigned nurses and doctors are expected to provide “level 2” competence (RCPCH 2010). These guidelines included state, recognition of signs of child abuse and reporting that incident to a higher authority and keeping written account of the incident to help with potential police investigative procedure. Clear distinction between assumption and clinical proof is important in this case. Intuitive conclusions should be taken without any proof of the incidence and every person should be held accountable without guilt during investigative procedure. A senior with “level 3 expertise should be contacted for advice regarding the matter (RCA 2012). Proof of hypothesis should be investigated without relying on visual observations and the child can be questioned to make a statement regarding the truth of the issue. In case the child needs to make a statement, the responsible parent of guardian must be informed to gather their consent. The case can be taken to the local police station or court depending on the child’s statement to take legal action (RCPCH 2007). Consent of the parent should always be collected in both cases on emergency and non-emergency (Department of Health Social Services and Public Safety 2003). If the above mentioned Gillick competence method fails to prove the child’s mental maturity, the child cannot provide consent for themselves (Department of Health Social Services and Public Safety 2003). In case of absence of biologiocal parents of the child, the legal partner cannot provide consent on behalf of the child without legal permission; in this case, the biological mother’s partner. In case where the delay in operation is predicted either of the biological parents needs to be contacted as soon as possible. Protection of privacy and confidentiality is a duty of the assigned medical practitioner and information should be withheld from unknown parties, unless a case demands legal action or investigation with respect to the child’s safety and well being (RCPCH 2007).

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