STUDY GUIDE

For

FINAL YEAR MEDICAL STUDENTS

THE DEPARTMENT OF SURGERY

College of Medicine

Queen Elizabeth Central Hospital

2017-18 Academic Year

NAME: ____________________________________
Welcome

Welcome to Surgery. You will be with us for 8 weeks. Take the opportunity to clerk and
examine as many patients as possible.

It is essential that a qualified member of staff reviews every patient before he or she is admitted
to the ward.

In this booklet you will find

 A program of teaching including course aims and learning outcomes,
 Weekly departmental timetable
 Ward timetables and allocations
 A log book of practical procedures
 Lecture and on-call schedules.
 Feedback forms

Please read it carefully.

Your mark for this attachment will contribute to your overall end of year examination results.
We expect excellence in clinical ability and note taking. As well as that we are looking for
professional qualities: punctuality, commitment, enthusiasm, a pleasant approach to families
and a caring attitude.
At the end of your attachment there will be an exam.

Good luck, enjoy yourself and work hard!

If you have any problems the senior members of staff in the department will do their best to
help.

Aims of the course

This course will provide you with:

 The knowledge and skills required to make a diagnosis and initiate treatment in patients
with common surgical conditions in Malawi.
 A structured approach to the assessment and initial management of trauma patients
 The opportunity to practise your clinical skills with inpatients and outpatients
 The knowledge of important disease prevention strategies in Malawi
 A facilitation of the progression from undergraduate student to competent, confident
doctor.

2
General objectives of ward /clinic work

 In patients with surgical problems, demonstrate a method of focused evaluation,

including the approach to workup and pre –operative preparation.
 Identify what constitutes appropriate surgical referral by recognition of which problems
are clearly surgical, potentially surgical, and those which do not require surgical
intervention
 Identify the important factors in the diagnosis, workup, and management of specific
surgical problems in the following categories:
o Acute abdomen
o Bowel obstruction
o GI haemorrhage
o Hepato-biliary and pancreatic disease
o Endocrine disease (thyroid, parathyroid, and adrenal)
o Breast disease
o Vascular disease (carotid, aortic, and peripheral vascular)
o Trauma, burns, and surgical critical care
o Paediatric surgery
o Plastic surgery
o Head and Neck
o Orthopaedics

 Perform some basic surgical techniques,

o General wound management
o Urinary bladder catheterization including SPC
o Intercostal chest drain insertion
o Nasogastric tube insertion
o Venepuncture

Students should also have a good working knowledge of:

 Shock
 Peri-operative sepsis and antibiotic prophylaxis
 Deep vein thrombosis and its prevention
 Peri-operative fluid managements and requirements
 Peri-operative nutrition
 The effects of pain, surgery and anaesthesia on respiratory function
 The application of clinical anatomy to all relevant subjects above.

3
Learning outcomes for final year students:

By the end of your attachment in Surgery you should be able to:

1. Carry out a consultation with a patient (a thorough and appropriate history and
examination)

2. Assess clinical presentations, order investigations, make differential diagnoses, and

negotiate a management plan for patients with common surgical problems;

3. Provide immediate care for surgical emergencies, including First Aid and resuscitation

o Provide basic life support

o Provide trauma care according to ATLS guidelines

4. Prescribe drugs

o analgesia

o antibiotics

o IV Fluids

o Blood and blood products

5. Carry out practical procedures

o as described above ( see Logbook)

6. Apply the principles, skills and knowledge of evidence-based medicine, using

information and information technology effectively in a medical context.

7. Apply biomedical scientific principles, methods and knowledge to medical practice and
research

8. Communicate effectively in a medical context

o Establish rapport and communicate effectively

o Take consent

o Be able to break bad news

4
 9. Practice medicine safely, with compassion, within an ethical framework, and according to
the professional expectations and legal requirements of Malawi

o maintain patient confidentiality at all times

o apply ethical principles when considering clinical care

10.Assess psychological and social aspects of a patient's illness

11.Reflect, learn and teach others, and work effectively within a multi-professional team

12.Work effectively in a health care system and engage with population health issues

Each student will be required to:

Attend all the lectures timetabled in this guide. The lectures should be interactive and aim to
reinforce knowledge and explain gaps. They do not aim to cover the entire syllabus in detail.
There is a lecture timetable in your logbook. A signature is required on your timetable to
confirm attendance.
Keep a record of patients and conditions seen, clinics and takes attended, practical procedures
undertaken, core lectures and meetings attended
Clerk, present and follow up patients under the care of the surgical teams to which they are
attached.

Demonstrate competence in history taking and examination at surgical short case presentations
and case-based discussions.

Attend operating theatres when patients, whom they have clerked, undergo surgery.
Understand principles of post-operative pain relief, peri-operative fluid management, antibiotic
prophylaxis for surgery and principles of informed consent for surgery.

In addition students are encouraged to:

Attend, within timetable constraints, other learning opportunities such as ENT, plastic, neuro-
surgery ward activities, theatres, and clinics as well as ICU.

Weekly departmental programme

Handover Meeting 0730 Monday – Friday

5
This is held in the Surgical Annexe with the entire department each morning and is an excellent
learning opportunity. Emergency operated cases, interesting cases and deaths from the
preceding 24 hours are presented and discussed by both general surgical and orthopaedic teams.
Attendance is mandatory and requires a signature in your logbook. You will also be expected to
participate. This is an opportunity to show off your ability to present and interpret X-rays and
also your knowledge of the subjects discussed!
Please sit near the front.

Case Presentations (after Handover meeting) Monday - Friday

Short case presentations occur after the handover formalities Mondays - Friday. Each
presentation should last for no longer than 10 minutes, including differential diagnoses,
appropriate investigations and management steps. Avoid simply paraphrasing the admitting
intern. Think for yourself; approach each case as if you are the admitting physician with full
responsibility for any decisions.

You will be required to assess yourself based on preset criteria. You will also receive a
critique by the consultant who has been allocated to you.

Case Based Discussions

 You must approach your ward consultant who will then allocate you the case and arrange
a time for the presentation during the course of the week.

Other academic meetings of which attendance is compulsory:

.
 Thursdays 8am: Registrar presentation. An interesting case or topic will be discussed
 Friday 8am: Morbidity and mortality audit meeting presented by each departmental
subunit in turn

Daily ward rounds

Attend consultant and registrar ward rounds on the wards you are allocated to. This is a good
opportunity to identify interesting clinical cases for presentation and to elicit clinical signs.
Each student has been assigned a rotation of consecutive two week attachments to: Ward 5A
(Male surgical; including general, urology, neuro, plastics and ENT), Ward 5B (Female surgical
and orthopaedics also including general, urology, neuro, plastics and ENT), 6A and Cure
Hospital (orthopaedic wards), and Paediatric Surgical Wards (inc CN, PN, P Onco, PSCW,
PSW). Ward rounds commence by 9.00am after the handover meeting.

Each student will be assigned a bay of about 8-10 patients. The student will be expected to
present the cases during the ward round and also expected to follow up on the instructions
issued during each ward round.

6
Day Case theatre
While on 5A and 5B take time to attend at least one day case list. These are usually held in ENT
theatres. The 5A team will confirm dates. This is your opportunity to see surgery for hernias
and hydrocoeles etc. Do take as many opportunities as you can to attend theatre.

7
Weekly Ward Timetables:

5A Consultants: Dr Volker/ Dr Noah

Monday Tuesday Wednesday Thursday Friday
AM Clinic Ward/ (Minor) Theatre/ Ward Theatre/ Ward Ward Rounds
theatre
PM Ward Patient Community
Workup medicine
Remember to attend the trainees theatre list

5B Consultants: Dr Chalulu
Plastic Surgery Consultant: Dr Chokotho
1 week Plastics/1 week 5B/trainees theatre list
Plastics MON TUES WED THUR FRI
AM Burns WR Burns clinic Burns ward/ Burns WR Burns ward/
Theatre Theatre
PM Burns ward/ Burns ward/ Burns ward/ Burns ward Burns ward/
Theatre Theatre Theatre Theatre

5B MON TUES WED THUR FRI

AM 5B 5B/Trainees 5B/Trainees 5B/Trainees 5B
list list list
PM 5B 5B 5B 5B 5B

Orthopaedic Consultants: Prof Mkandawire/ Dr Bates/ Dr Mpanga

MON TUES WED THUR FRI
AM Ward Round Ward Round Theatre Ward round/ Ward round/
Theatre Theatre
PM Ward Work Community Fracture Orth Clinic Fracture
Clinic (in OT) Rm 1 Clinic

Paediatric Surgery Consultants: Prof Borgstein/ Dr Thomson/ Dr Kapalamula

MON TUES WED THUR FRI
AM Ward Round/ Ward Round/ Ward Round/ Ward Ward Round
Theatre Theatre Theatre Round/Theatre
PM Clinic Theatre Theatre Wards/Theatre Wards
Paediatric Surgery ward rounds start at 9am on Chatinkha Nursery.

Ward allocations are in the logbook.

Outpatient Clinics
You are required to attend these when you are allocated to them.

Bedside teaching
Bedside teaching will form part of the daily ward rounds.

8
Ward, On Call & Clinic Commitments
These have been allocated. You may swap around if absolutely necessary between yourselves,
but no more than the allocated number may attend each ward/on call at any one time in that
given week (given the need to accommodate clinical officer and nursing students at different
times) and slots should not be left unfilled.
Note that your on call time is a good opportunity to clerk patients for your case presentations.

Failure to attend out patient clinics, ward rounds, handover meetings, lectures or on calls may
result in a fail grade for continuous assessment.

Useful resources

1. The Surgical Hand Book. By EJ van Hasselt (Ed). College of Medicine, Malawi

2. The Burns Manual

3. Common surgical problems (2nd edition)

4. Essential Surgery 3rd edition. HG Burkitt, CRG Quick, Churchill Livingstone, ISBN
0443063753

5. Clinical surgery in General RM Kirk, WJ Ribbons, Churchill Livingstone, ISBN 0443

072620

Assessments/ Ongoing requirements

Case Based Discussions

You are required to complete 1 case based discussion in each 2 week block.
A consultant will mark each CBD. Ideally each case should be presented to a different
consultant. On 5A and 5B please ensure that one of the 2 cases is a non general surgical
case eg ENT, plastic surgery, Neurosurgery
Case Based Discussions

 You must approach the consultant who will then allocate you the case and arrange a
time for the presentation during the course of the week. Most consultants need a few
days notice to arrange a time.
 You will take a history and examine the patient.
 Your presentation should focus on pertinent history; clinical examination findings;
differential diagnosis, relevant investigations, management options and outcomes.
 You should do your own background reading on the subject
 You will present the patient to the consultant in the ward or in the surgical annexe.

9
  You will be required to present the examination findings, interpret investigations and
answer pertinent questions
 All your ward group members should attend your presentation but only the presenting
student will answer questions.
 You should prepare the topic for discussion at the end of your presentation for benefit of
the whole group.

 Each is marked out of 20. The overall mark for CBDs contributes to your continuous
assessment mark which makes up 20% of your overall mark.

Continous Assessment

Your professionalism will be continuously assessed, based on your attendance, performance

and professionalism in each 2 week block. A guide to the standard expected is in the table
below.
The ward consultant for the 2 week block will give you a PASS or FAIL mark. You must pass
this in order to pass the attachment. You should ask for this mark on your last day on the ward.
This WILL NOT be allocated retrospectively.

Attendance Present at all organized

sessions
Apologises in advance for
abscence
Commitment/Motivation Contributes ideas to group
Demonstrates positive
attitudes
towards other professions
Participates enthusiastically in
patient care
‘Goes the extra mile for the
patient’
Reliability/ Personal Good time management
organisation Clear accurate documentation
Passes on information
appropriately
Prepares work in advance
Interpersonal skills Understands role of other staff
Works well with others
Communicates well
Demonstrates respect for
staff/patients
Ethics and probity Respect for persons/dignity
Consent/confidentiality
Honest
Demonstrates tact and
sensitivity
10
Teaching and Learning Accepts constructive feedback
skills and makes changes
Good use of learning
opportunities
Evidence of further reading
Evidence of self directed
learning
Self Care Appropriate appearance,
hygiene, dress
Alert/clear state of mind

Short cases

These are presented soon after the handover at 0815 to an allocated consultant or registrar.
Student on call the previous night will present their short case in the morning. You must
complete a self assessment for each presentation.
You will also be given a pass/fail mark for these. If you fail these you will be required to
present further short cases and pass these.

Procedure Logbook

Your procedure logbook should be completed. Please ask a doctor or clinical officer to
countersign each procedure successfully completed. You are required to complete at least two
thirds of the logbook in order to pass. You will be given a pass/fail mark for this.

End of Rotation Assessment

The assessment for the fifth year Surgery course is as follows:

Marks allocated during your Surgery rotation:

o 45% end-of-rotation written examination MCQ /EMQ/SAQ. This exam will
usually take place at 0930 am on the Thursday of your last week.
o 35% end-of-term OSCE beginning at 0900 am on the last Friday of your
attachment. There will be approximately 10 stations of 10 minutes each. Topics
will be chosen from
 Orthopaedics, general surgery, ICU/intensive care, paediatric surgery,
neurosurgery, burns and plastic surgery and ENT.
 History taking/Data interpretation in any of the topics above
 You must pass at least half of the stations and achieve an overall mark
greater than 50%
o 20% - continuous assessment: logbook + CBD + Short Case+ professionalism
assessment+attendance+10% of this mark is from Community Health.
11
12
 ATLS Admission Notekeeping Example

Clinician: Dr Banda (Surgical intern on Call)

Date: ......
Time: 1530

Hx: 59 year old lady admitted following being hit by minibus at 1430. LOC on the spot.

A – Talking, C-spine immobilized in hard collar, sandbags and tape

B– O2 sats 100% on 15l, RR, Trachea central

Inspection R=L= normal
Perc R=L = res
Good AE bilaterally

C– BP pulse CRT Cool periphs

Abdo soft non tender
Pelvis stable, Femurs NAD
IV access x 2 secured, 1litre normal saline given
FBC, XM, Glucose sent

D– GCS 15/15 PERL Moving all 4 limbs (no lateralizing signs)

Blood sugar…………..

E – 6cm laceration right lateral thigh

Logroll – NAD, PR – normal, no blood on glove

Working Diagnoses
1.

2.

3.

4. ……………………………………………

Plan:
NPO
Chase FBC, XM,
Trauma series
Etc….

13
Writing in ward round notes:

Date WR (name of most senior doctor on round)

Time
Progress
Comments on progress since last review
O/E
Vitals, Temp
Exam findings (ASK the one who had examined if you didn’t do it yourself!)
Plan:

For Example:

12.2.16 WR Prof Borgstein/Dr Kapalamula

0920

Progress
Day 1 post laparotomy for adhesiolysis, Currently in HDU
NGT – minimal green drainage
No vomiting
No BO, No flatus
Catheterised – urine output 3.4 mls/kg/hour
In pain

O/E
HR 130bpm, BP110/60, CRT <2 secs
Temp 37.6

Abdo distended, tender

Wound dry (dressing removed)

Plan
1. Analgesia – Morphine 3mg IV 4-6 hourly max qds
2. Keep NPO
3. Continue IV fluids – RL plus 5%dextrose at 65 mls/hr
4. Remove NGT
5. Continue IV Abx
6. Keep in HDU

Your Signature
YOUR NAME
MBBS 5

14
 Abdominal Examination revision

Wash your hands and introduce yourself to the patient

GENERAL INSPECTION

General (discomfort, distension, colour, muscle wasting, scratch marks, spider naevi, tattoos)
Look around the bed for signs of abdominal pathology (e.g. drains, medications).
Inspect hands. Assess radial pulse for tachycardia and low volume.
Inspect arms for injection marks
Inspect eyes and mouth (with a torch and tongue depressor/spatula)
Inspect chest and axillae

INSPECTION OF ABDOMEN

Inspect for movement, distension, scars, herniae, masses, dilated veins and abnormal pulsations

PALPATION OF ABDOMEN FOR ORGANS AND MASSES

Superficial palpation in each of the 9 regions beginning away from any area of pain
(Palpate for rigidity, tenderness, guarding, rebound and masses whilst observing face)

Deep palpation :
Repeat sequence with deeper palpation throughout the 9 regions and assess any masses felt
If Mass felt, assess and describe
Palpate for liver, spleen, bladder, ballot for enlargement of kidneys and palpate abdominal aorta

PERCUSSION OF ABDOMEN

Percuss for liver

Percuss for enlarged spleen and distended bladder

Percuss flanks for abnormal dullness

(if dull and/or distended demonstrate shifting dullness or fluid thrill)

AUSCULTATION

Auscultate for bowel sounds and abdominal aortic bruit

Auscultate for renal bruits

SIT PATIENT FORWARD

Inspect back
Palpate for renal tenderness
Palpate neck for cervical lymphadenopathy

OTHER AREAS
Inspect and examine groin for hernias and lymphadenopathy.
Examine external genitalia.
Perform digital rectal examination

CONCLUSION

Look at observation charts and test urine with dipstix

Thank patient and wash hands with alcohol gel or water
Summarise and present findings in patient’s notes and orally

15