10. Trauma and emergency surgery

• Reports continue to highlight the problems which arise with ‘out-of-hours’ surgery.


• Only cases that cannot be delayed for good clinical reasons should be operated on at night e.g. after 21.00.


• One reason for cancellation of elective operations continues to be inadequate provision of theatres and staff during the day for emergency cases.


• Provision of exclusive daytime emergency and trauma lists or an additional third evening session in dedicated, fully-staffed, suitably-equipped and convenientlysituated operating theatres, will enable as many as 80% of all emergencies to be dealt with during the normal working day.


• The benefits of organising emergency work during the day and evening include a reduced requirement to provide resident theatre staffing after the late shift and a reduction in sleep disturbance for on-call anaesthetists and surgeons.


• Emergency lists should be organised and staffed by senior anaesthetists and surgeons working to a fixed sessional pattern with no other commitment to routine work or outpatient clinics; this is pivotal to the success and efficient running of such lists These lists should not normally be used for non-emergency surgery


• 'Consultant anaesthetists, surgeons and hospital managers should together plan the administration and management of emergency admissions and procedures. In order to avoid queuing for theatre space it may be necessary to nominate an arbitrator in theatres who would decide the relative priority of theatre cases '.


• Many patients requiring immediate emergency admission can be scheduled for surgery early on the next day. Less urgent cases can be discharged home with written instructions to return suitably fasted the next morning, possibly to a day unit, for scheduled surgery.


• Good communication enables clinical decisions to be made rapidly, more operations to be carried out safely in a given time, senior presence for the sickest and most complex cases, and a high standard of care.


• The emergency anaesthetist must be given time to assess emergency patients. It may be more efficient for another anaesthetist to see the patients as part of his or her duties and liase with the emergency anaesthetist.


• A full plan of action must be recorded in the patient's records and initiated preoperatively.


• Many elderly patients scheduled for trauma surgery are cancelled at short notice because of inadequate preparation for theatre. Inexperienced surgical trainees often fail to understand the increased challenge to anaesthetists posed by elderly patients, who often have multiple and complex medical problems.


• Pre-operative assessment in the elderly will benefit from a team approach involving cross-specialty advice from anaesthetists, surgeons and physicians