Acute upper limb infections in a regional Scottish plastic surgery unit during COVID-19: Lessons learned.

Acute upper limb infections represent a large proportion of on-call referrals and emergency theatre time in plastic surgery. To enable us to maintain effective service provision despite reallocation of hospital resources as a result of COVID-19, and to minimise patient exposure in a hospital setting during the pandemic, we introduced a walk-in clinic and dedicated local anaesthetic (LA) operating theatre for these infections. In this work, we sought to analyse our service changes and resulting patient outcomes. Using electronic records, data from patients presenting with upper extremity infections was collected before the pandemic from 1st January to 30th March 2020, then for a period of three months from 30th March until 30th June 2020, after our changes were implemented. Seventy-two patients were included before 30th March 2020, and 49 patients after. Prior to our changes, most patients underwent surgery (n = 58, 80.6%), requiring overnight admission (n = 64, 88.9%), following mainly general anaesthetic procedures (n = 56, 96.6%). After our service changes, a similar percentage of patients were treated operatively (n = 41, 83.7%), but these procedures mostly utilised LA (n = 37, 90.2%) in the outpatient setting (n = 25, 51.0%). Despite this shift in management approach, no statistically significant difference in readmission rates was calculated between the two groups (p = 0.556) and post-operative complications were fewer in absolute terms. Our results suggest that in many instances, these infections can be managed in an outpatient setting without the need for inpatient care. Selective admission with strict follow-up of patients may be feasible, improving patient experience and reducing resource burden.

Hyperammonaemic encephalopathy following an uncomplicated surgery.

A 59-year-old woman who underwent an uncomplicated exploratory laparotomy, adhesiolysis, small bowel resection and anterolateral thigh flap had a complicated postoperative period characterised by wound dehiscence and poor nutritional intake. 29 days postoperatively, a tremor developed in her upper limbs associated with weakness. Her Glasgow Coma Scale (GCS) fell to 4 and she was transferred to the intensive care unit. The patient was reviewed by multiple specialists and multiple differentials were considered and eliminated. Eventually, investigations revealed hyperammonaemic encephalopathy, being a result of low arginine and potentially small intestinal bacterial overgrowth. Following treatment with sodium benzoate, sodium phenylbutyrate and arginine along with haemodialysis and rifaximin, GCS and hyperammonaemia rapidly improved. She was stepped down to surgical high-dependency unit, continued arginine therapy with total parenteral nutrition and percutaneous endoscopic gastrostomy feeds. She was discharged with regular follow-up from surgeons and biochemistry and continues oral arginine therapy.

Developing non-technical ward-round skills.

BACKGROUND: Conducting clinical 'rounds' is one of the most onerous and important duties that every junior doctor is expected to perform. There is evidence that newly qualified doctors are not adequately prepared by their undergraduate experiences for this task. The aim of this study was to analyse the challenges pertaining to non-technical skills that students would face during ward rounds, and to create a model that facilitates the transition from medical student to doctor. METHODS: A total of 217 final-year medical students completed a simulated ward round. Free-text responses were analysed using template analysis applying an a priori template developed from the literature by the research team. This drew on the generic categories of non-technical skills suggested by Flin et al. RESULTS: Ninety-seven per cent of students agreed or strongly agreed that the simulated ward round improved their insight into the challenges of ward rounds and their perceived ability to work efficiently as an active member of the ward round. The responding students (206) submitted written feedback describing the learning that they planned to use: 800 learning points were recorded, and all could be categorised into one of seven non-technical skills. Conducting clinical 'rounds' is one of the most onerous and important duties that every junior doctor is expected to perform DISCUSSION: We believe that improved task efficiency and insight into the challenges of the ward round gained by medical students will lead to an enhancement in performance during clinical rounds, and will have a positive impact on patient safety. We would suggest that undergraduate medical schools consider this model in the preparation for the clinical practice element of the curriculum.

The use of multiple needle fasciotomy in Dupuytren disease: retrospective observational study of outcome and patient satisfaction.

PURPOSE: The aim of our study was to assess the efficacy, safety, and patient satisfaction of multiple needle fasciotomy for Dupuytren disease. METHODS: During this observational study, patients who underwent the procedure between 2008 and 2010 were followed up, and outcomes, complications, and patient satisfaction were assessed. RESULTS: Satisfaction rate was 75%, with no postoperative complications noted. As predicted, early recurrence rate was the main issue with a rate of 28% at the time of the questionnaire. CONCLUSIONS: Percutaneous needle fasciotomy is a safe and efficient procedure in treating patients with early Dupuytren or those who would not potentially achieve good results with more aggressive surgical intervention.