Due to budget constraints, one of the most efficient public hospital in Victoria is rapidly building up a waiting lists for its local patients to have surgery.
(This hospital is not WIES funded – but bulk funded) The CEO is under pressure from the DHS to balance the budget.
Steps taken:
1. Cut down on theatre days – ie closing longer over Xmas and New Year and also for Easter ie 4-6 weeks closure
2. Reduce operating time for whole day sessions – finishing by 3:30pm instead of 5pm
3. Not allowing patients to be put on standby (even if the list can finish early) – the are often patients who fail to turn up for their schedule surgery
Other steps:
1. Limiting access to surgery to patients from local postcodes
Unfortunately patients in suburds who are just out of the area suffer – longer waiting lists at other hospitals
Patients who have moved out of the area but still see the local GPs are not able to access the hospital
Patients from other areas – will increase the waiting lists of their local hospitals
2. Encouraging patients to use their private insurance and getting surgeons to increase number of private cases in their lists(however this will only be successful if there is a short waiting list …I don’t believe that public patients should be deferred if their case is urgent in order to operate on a private patient in a PUBLIC HOSPITAL)
In the long-term, this will only add to the state wide waiting lists for elective surgery…true every hospital needs to balance the budget. But when the facility is available, the theatre staff are available not using the theatres to its full efficiency is really a waste of resources. Building new hospitals is not the only answer..more importantly theatre services should be fully funded to function at its capacity.
Leave plastic waterproof dressing on for 1 week
If steristrips used – they can be left on for a further week.
If non-dissovable sutures used – they need to be removed usually in 1 weeks time, may be left in longer in certain areas where there is higher risk of the wound pulling apart(eg lower legs, back), can be removed earlier from face(eg 5 days postop)
Answers to FAQ:
1. Showering – you can shower anytime if waterproof dressing is on. If there is no dressing eg sutures on the scalp – best to keep that area dry for 1-2 days.
2. Bleeding – If a cyst/lipoma has been excised, the residual cavity will initially fill with blood-stained fluid(haemoserous fluid – this can have the colour of red wine). This can sometimes leak out from the wound. So be careful if you lie on the wound – it might be a good idea to have a towel under to soak any discharge. If there is a lot of thick red blood or pain from a hard swelling under the wound – you must contact me again.
3. Pain – The wound can be sore eg like any cut. The local anaesthetic usually lasts for a couple of hours. Paracetamol is usually all that is needed after that. If still in pain , consider adding something stronger like Ibuprofen(please from that there is no contraindication). If the pain is severe or the wound becomes painful after a few days (and there is surrounding skin redness) – please contact me
4. Work – most patients can go back to work the next day. But it is important to keep the surgical area clean.
5. Swimming – best not to swim in a public swimming pool until the wound is fully healed. After the sutures are removed, one should wait a few more days until the stitch holes are fully sealed over. (same applies to water sports eg in the Murray – best not to let the unhealed wound get into contact with water)
To prevent wound breaking open/scar getting wider after the sutures have been removed: sometimes it might be neccessary to reinforce the healing scar with Steristrips or even simple Bandaid. Also you should apply more sunscreen to the scar especially in the first 12 months to avoid the scar getting sunburnt.
LP Cheah
Surgeon
MelbourneSurgery.com
Many condition can cause rectal bleeding. It is important that you exclude a serious cause first by speaking to your doctor! Risks symptoms for a more serious cause include having clots, blood being mixed with the stools, having lots of bleeding, bleeding frank blood, passage of mucus, increasing age(the older you are the higher your risk of bowel cancer), presence of anaemia and loss of weight
Causes include:
1. Bowel cancer – in particular a rectal cancer or cancer in the sigmoid colon
2. Polyps in the bowel – especially large ones in the rectum
3. Haemorroids – this is quite common but it is important to speak to your doctor about it and be examined throughly to exclude more serious cause
4. Inflammatory bowel disease eg proctitis, ulcerative colitis, Crohn’s disease
5. Anal fissure – usually there is a lot of pain when or after opening the bowels(but be warned : rectal cancer invading into the anal canal can also be painful)
6. Trauma to the perianal tissue
Lifetime risk of developing bowel cancer in Australia by the age of 85 years old:
1 in 10 men
1 in 14 women
Medial age at diagnosis: 70 years old
Risks in next 5 years:
30 year old person – 1 in 7000(less than the risks from a colonoscopy of perforation and serious bleeding)
40 year old person – 1 in 1200
50 year old person – 1 in 300
60 year old person – 1 in 100
70 year old person – 1in 65
80 year old person – 1 in 50
The risk is also greater for people with a family history of bowel cancer
Eating a healthy diet and having a healthy lifestyle can lower your risk of developing bowel cancer.
Lifestyle steps you can take include;
1. Having a healthy body weight(ie body mass index below 25)
2. Regular exercise 30-60minute a day
3. Limiting alcohol drinks to not more than 2 standard drinks a day for a man(and not more than one standard drinks a day for a woman)
4. Not smoking
Your diet should:
1. Have adequate fibre( 30G/day) – take lots of poorly soluble fibre(eg wheat bran), have at least 5 serves of vegetables a day, have at least 2 fruits a day
2. Take adequate calcium 1-1.2G/day (may need calcium supplements)
3. Restrict daily energy intake to <2500 calories/day for a man and <2000 calories/day for a woman
4. Be low in fat – <25% of total energy intake should be from fat. (eg avoid fried oily food like fish and chips, be aware too that even instant noodles have a lot of fat in them as they are sprayed or fried in fat in their preparation!!)
Symptoms:
Painful lump in natal cleft(groove between the buttocks)
Fever
(this needs to be differentiated from a perianal abscess which is located closer to the anus)
Treatment:
Drainage of abscess, excision of sinus and removal of the nest of hairs – this can be done with small incisions for faster healing.
I am always learning from my patients…just this Friday, after telling the patient the result of his gastroscopy and colonoscopy, my patient told me
” Good..I don’t have Jack the Dancer then”
He promptly explained to me that Jack Dancer means cancer!
Anyway, I did a further search on the web and found this useful link:
http://www.australianhistory.org/australian-slang-etoz.php
This can sometimes be tricky.
Cases I have seen include:
1. Removing a box thorn embedded deep in the tissues
2. Metallic foreign body – located by the use of a magnet; not always possible to remove it – especially if it is deeply located; sometimes one has to use an image intensifier in theatre, this is often an injury from work-related cause(eg miner in Broken Hill, apprentice on first day at work with mechanic; worker in factory)
3. Deeply penetrating large splinter – part of it was initially removed at a major trauma centre, patient was referred to me weeks later as persisting pain and granuloma. On exploration, 4cm remnant of penetrating splinter found and removed
(It is not always possible to remove every single fragment especially if friable object)
4. Spines of fish – this can be very hard to find, sometimes can be radioopaque
5. Broken glass – again also can be hard to find, I would say it is sometimes harder than looking for a needle in a haystack! But is it often satisfactory to be able to find the broken fragment.
6. Splinters, rose thorns etc
Sometimes by the time I am referred, a small abscess has formed around the foreign body – then it is easier to incise over the abscess, drain the abscess and remove the foreign body.
Reminder for residents:
Check tetanus status
Consider oral antibiotics treatment
Xray can be helpful to the surgeon ?radioopaque – some glasses are
Preauricular sinus
What is it?
There is a dimple or pit in the skin in front of the ear. From here a tract heads under the skin. This tract may or may not branch out. Frequently, the tract ends up being infected leading to redness of the overlying skin and a purulent discharge.
Why does it occur?
During foetal development, different parts of the head(called branchial arches) join together. Failure of this may lead to congenital problems such as cleft lip or cleft palate. In a similar fashion, the preauricular tract is due to different parts of the head not fusing together completely during foetal development. Occassionally, there may be other associated anomalies for example in the kidneys.
Treatment
When acutely infected, antibiotics is required. Sometimes if there is an abscess, this requires drainage. If possible, this should be drained by enlarging the pit opening and the tract washed out with Betadiene.
Surgery is the definitive treatment if there has been previous infections. This involves excising the whole tract and is best done in an operating theatre. Often the tract needs to be identified by injecting it with a blue dye. There is significant risk of recurrence with surgery(rates published are as high as 15-40%) – usually this occurs when the tract has branched and the the other tract has not been excised. Sometimes more radical surgery is required to excise out all the tissue in front of the ear to prevent recurrence and this would required a general anaesthesia.
Risks of surgery
Scar
Wound problems – infection, discharge, ooze, redness
Pain
Bleeding, bruising
Nerve damage – the facial nerve lies close
Recurrence
Often in my practice, I am referred patients with chronic warts that have failed other conservative measures.
Examples:
Warts in foot – often because of the long duration, the roots of the warts are digging deep into the sole causing pain on walking
Warts in fingers and palms
Warts on the nostril, around the face
Treatment options
1. Cryotherapy – liquid nitrogen. I often find it useful to consider this option first before considering surgery. For cryotherapy to be effective, the roots of the warts need to be frozen off as well. This requires a more prolonged application of the liquid nitrogen and often several repeat freeze-thaw cycles. The benefit is that it avoids surgery and leaves less scar. Risks with cryotherapy – discomfort and pain on application, blood blister(this can form after but the benefit is that the wart will usually fall off with time). Cryotherapy also needs to be repeated several times for it to work especially in chronic warts with deep roots. Once the warts resolves, the area may be darker or lighter than the surrounding skin.
2. Surgery – excision with scalpel or diathermy. This is more painful and requires either a local anaesthesia or general anaesthesia. Risks – the smoke from the diathermy may contain carcinogens(and be potentially infectious); surgery will cause bleeding and leave a scar.