ORGANIZATION OF SURGICAL SERVICE

The course of general surgery begins with the study of the surgical departments work organization and care of patients. Why are the 1st year students involved in patients observation today and is sanitary practice introduced after the end of the ІІ year of study?

Sanitary practice and care of patients are included into the educational process of medical schools in order to help students mastering all knowledge necessary for hospital attendants and nurses. The majority of students consider that they enter the institute to be a doctor, but a doctor should know all of the work habits of hospital attendants and nurses and be able to carry them out better than his subordinates, and doing like this he will be a good doctor.

The modern idea of surgery considerably differs from the former one. If surgery was considered to be a medical specialty before, for the last 100 years it had such radical changes, so today it is possible to reckon it as one of the youngest and quickest developing part of medicine. If before only people with various pathological processes, which had external signs of illness, went to surgeons, today the concept of “general surgery” is getting narrower.

Due to the development of anatomy and physiology, the introduction of anaesthesia and preventive measures of surgical infection, haemotransfusion, surgery obtained quick development, which led to appearing independent disciplines: traumatology and orthopaedics, obstetrics and gynaecology, oncology and urology, skin and eye diseases, otorhinolaringology, etc. The specialization is on even nowadays. The departments of cardiovascular surgery, toracic department, esophagus department, microsurgery, proctology, etc. are open. Specialization, certainly, is a positive thing. It gives an opportunity for highly skilled treatment, but it has its disadvantages. In fact, before the beginning of treatment in such a department, one of the doctors should first make a diagnosis. So, doctors, in particular section doctors, should have full knowledge of all diseases. Therefore the university studying is carried out in such great volume for students of all faculties.

The organization of surgical care during the period of existence of surgery as specialty, had essential changes: from barber, chiropodist, and medical hospitals — to modern structure. The modern surgical service is a component of the medical network. It contains medical and preventive establishments, polyclinics — state, jointstock and private.

Institutions of motherhood and childhood care (maternity hospitals and female consultations, children’s houses, boarding schools, etc.) are somewhat separated in our country.

All medical institutions work according to a territorial principle — they serve the inhabitants of a certain area. In big factories there are polyclinics, medical-sanitary parts, which serve the staff of this factory.

The basic medical institution is an ambulance station (from the word ambular — walk slowly on foot). 80% of the population begin and finish treatment in out-patient establishments and only 20% are hospitalized.

The greatest importance in organisation of medical care for the rural population, which lives in rural medical territory, have the medical assistant-obstetrics stations (MAOS). They are necessary for a small population in the country; the settlements are 3–5 km from local hospitals. There there should be two medical workers: the medical assistant and midwife. The primary goal of MAOS is rendering urgent aid in an ambulance station or house, and revealing infectious diseases. The medical assistant keeps in close touch with the local hospital, refers patients who demand medical assistance and consultation to it, consult them with the doctor during consultation at the MAOS.

MAOS takes part in prophylactic medical examination of the population and reveals early forms of diseases and carries out sanitary-educational work.

The rural medical ambulance station settles in the country, its task — to render the first medical aid to the rural population, manage the MAOS, and carrying out preventive means.

The polyclinic is a many-profile out-patient medical institution, which is a part of the incorporated hospital. Its staff consists of: therapeutists, surgeons, traumatologists, stomatologists, ophthalmologists, otorhinolaringologists and doctors of other specialties. Depending on the amount of attendance they are divided into 3 categories. In case of more than 1,000 attendances the polyclinic belongs to the 1st category. The local doctor carries out reception in turn: either in the morning, or in the evening. Recently, the family doctor, who carries out treatment of patients of a certain region and involves in consultations different experts, was introduced into practice.

Enlargement of polyclinics became the important step, which gives the opportunity to equip them by diagnostic facilities and make more convenient for population.

The main task of a polyclinic is diagnostic, treatment, preventive measures of diseases and expertise work capacity. For expertise of work capacity in a polyclinic medical control commition (MCC) and medical expert commission (MEC) exist. If the patient is not able to work more than 4 months, he is appointed a physical inability group. The polyclinic and local doctors provide medical service not only in the polyclinic but at houses, such a polyclinic doctor is called a family doctor. The family doctor comes to the patient on a call or visits him without invitation.

The medical center of health care is treatment-prophylactic establishment at the enterprise or collective farms. Depending on the amount of workers or collective farmers, they can be doctors’ or medical assistants’. At big factories the center of public health services were turned into medical and sanitary posts (MSP). The open MSP carried out treatment-prophylactic measures in nearby territory, i.e. among the inhabitants of a given area, the closed ones serve only the workers of the enterprises. The task of the MSP is similar to the center of public health services’. The MSP doctor is the basic workshop therapeutist. He carries out dispanserization and preventive surveys, early revealing diseases, preventive measures of professional diseases.

Since the 40s, prophylactic centers have appeared in our country. Preventive measures of diseases and sanitary-educational work with healthy people are mainly carried out in clinics. There are such clinics: narcological; tuberculosis prophylactic centre; oncological; dermatovenerological; psychiatrical, etc. Children’s polyclinics and female consultations belong to clinical methods of service. Workers of the clinics take part in carrying out prophylactic medical examination. In clinics, certainly, there is a hospital, where patients are treated. After recovery, patients are on the books for a long time.

Thus, it is possible to draw a conclusion that rendering medical surgical aid in the country side and in the city is not identical. In the country side the first medical service takes place at the MAOS, then at the rural medical ambulance station, local hospital, and district and regional hospitals. In the city first aid, as usually doctors’, is emergency care, then at once the patient is delivered to a specialized hospital.

Today the medical stations and hospitals of urgent aid are created in all big cities and settlements of our country. The Odessa firstaid station was one of the first in Europe. It was initiated under direct participation and the means of a count N. N. Tolstoi. It was created because of an accident happened to his daughter, who swallowed a fish bone in the evening. The count Tolstoi sent for many doctors, but nobody came; the doctor arrived only in the morning and removed the bone from her throat. After that Tolstoi sent a messenger into many countries of Europe to find out whether there were any medical establishments there providing emergency aid. Such medical establishments in Europe were not found. Then the station, which had some carriages and medium-level medical personnel, was created.

Now in Odessa, substations of emergency aid and specialized brigades have been organised. If earlier the emergency aid served for quick deliver of the patient to a medical hospital, today its doctors can render highly skilled medical aid.

The surgical aid is given in the district, city and regional hospitals. On this level depending on the equipment and qualification the specialized aid is provided. The management of the hospitals is carried out by republican scientific institutes and centers. So, in Kiev, there is the Scientific Institute of Clinical and Experimental Surgery, and in Kharkov — the Institute of Urgent Surgery. The basis of them is made by the surgical department (hospital).

For successful treatment of surgical patients it is necessary to develop and equip the surgical department. The department should answer the volume of the carried out work according to its purpose and specialization. Peculiarity of surgical patients treatment consists in creation of special conditions which provide, first of all, preventive maintenance of wound infections. The following one belongs to the surgical department: acceptance chamber, wound area (clean and purulent), operation, dressing, manipulation, and also bathrooms, bathing, dining room, buffet, chief of the department office and doctors’ office, X-ray cabinet, laboratory and other rooms. The chambers should have 1–2 beds. The area — 7.5–9 m2 for each bed. If there is an opportunity, clean and purulent departments should be allocated. If it is not possible, clean and purulent chambers.

Medical Staff

The head nurse and the head scrub nurse are by one in each department. For each operational table there are 2 scrub nurses. One dressing nurse for the dressing room. For every 10 beds there can be one ward nurse in the postoperative wards and one — for 15 beds in preoperative wards.

Junior Medical Staff

The amount of ward aid-women are according to the amount of medical nurses. Two aid-women should be at the operational room. One aid-woman is in the acceptance chamber, barmaid, door-keeper — 1 post for the department.

Wards and their Equipment

The ward should be for 1–2 patients. Furniture should be convenient and smooth, easy-to-wash. There should be nothing superfluous. The beds shoud be specialized, functional, bedside-table, chair-stool, above-the-bed demountable table for feeding the seriously ill patients (one for every 5 persons); supports for haemotransfusion and solutions (one for every 10 beds), stretcher-wheelchair or a wheelchair (one for every 10 beds), a vessel and urine dispenser in a sufficient amount. Buffet and dining room should be provided with enough utensils.

Operating Block

It should be isolated from other wards. Windows should be opposite to the north for reduction of solar beam reflection from nickelized tools on the operating field. In the summer, through wrong orientation of windows, the temperature of the air in the operating room increases, which complicates the surgeons work. The operating block consists of a lot of rooms connected to themselves: operating, preoperating, autoclave (operating, instrumental), etc.

In the instrumental room the tools are kept. The surgeon before an operation selects the necessary tools, which are sterilized by the scrub nurse. In general, there are certain sets of instruments, which are sterilized during an operation by the scrub nurse, according to the operation list, which is sent to the operating room in advance.

In the autoclave, as a rule, are dry-heat case and autoclaves.

Preoperative room is the room where the surgeon washes his hands and puts on sterile clothes. The preoperative room can be adjoined with a changing room where the surgeon changes clothes. In some surgical departments surgeons dress in sterile linen, but nowadays the single-use surgical garb has been applied. Equipment at the preoperative room: sand-glass, three washstands, disinfectant solutions, steam sterilizer with sterile lab coats, masks and other linen.

The operating room is the basic room of the operational block. Equipment: operating tables (minimum two, but no more), shadowless lamp, little tables for the scrub nurse, a table for instruments, support for basins, fitted with oilcloth, so that not to create noise from the instruments, which supports the haemotransfusions, narcotic solution devices of different marks, a little table for the anesthetist, device for mechanical ventilation of the lungs, defibrillator, diathermocoagulator, electric pump and other equipment depending on the kind of operation.

Functional Duties of the Surgeon

Examination, making the diagnosis, surgical interventions performing, postoperative care of the patient and medicaments prescription and functional treatment, meals, regimen of movement.

Performing morning and evening rounds; supervising bandages,dressings, haemotransfusion.

Talk and meeting with the patient’s relatives (for this purposespecial time should be determined in surgical departments).

Guidance and control of the work of the medical nurse, hospital attendant.

Functional Duties of the Medical Nurse at the Surgical Department

Medical nurses of the surgical department are on duty without the right to sleep. Care during an operation (bandage, drainage) enters the duties of medical nurses of the surgical department. The nurse also watches over urination, intestinal evacuations and reports to the doctor on duty or treating doctor. Until the patient finally wakes up after narcosis, a nurse-anesthesist should constantly be near him after that she pass the patient to the nurse on duty. During the duty the nurse follows the doctor’s indications, takes body temperature, gathers patient’s excretions for analyses (urine analysis, faeces, phlegm etc.). The nurse prepares the patient for operation. Over the night and in the evening she gives clyster, processes the skin, carries out preventive measures against bedsore, fills in the medical documentation, pastes analyses in the case report at night, writes down passport data. The nurse is the first assistant to the doctor, particularly the scrub nurse.

Scrub Nurse

Her functional tasks differ from the duties of an on-duty nurse. First of all, it is preparation of the instruments, suturing and dressing material for the operation. It is necessary to strictly adhere to sterility during the operation. A scrub nurse is personally responsible for asepsis violations during the operation and for the different complications in the postoperative period, such as suppuration of operational wounds, etc. The scrub nurse organizes over the work of the operating room and supervises their current, scheduled and general cleaning, dresses the surgeon sterile clothes, gives the instruments during the operation. She is the first assistant of the operating surgeon, and a good nurse should know the course of a majority of operations and understand the surgeon without words. Sending operational material for histological exam is the scrub nurse’s duty.

Functional Duties of Aid Woman

An operating aid woman conducts a damp cleaning of the operating room during the operation and at the end of the operation list, takes part at general cleanings of the operating room no less than once a week, brings patients to the operating room and transports back to his ward, brings dressings, linen and medicines from autoclave and drugstores, washes used surgical instruments.

Functional duties of a ward aid woman: replacement of bed linens and underwear, washing and cleaning the patients at the ward, feeding the patients at the ward (in general the nurse can carry out the same work), cleaning the wards and manipulation rooms, halls, corridors and places of general purpose, giving urinals, urine and faeces analyses transport to the laboratory, the dead — to the mortuary.

Admission Office

The admission office of the hospital is intended for reception, registration, examination and sanitary-hygienic processing of patients, who are brought to the hospital. Patients can enter the hospital by polyclinics referral. Patients can be brought to the hospital by an ambulance car. In some cases patients can turn to the hospital without an appointment card. Patients (up to 15%) can be directed by the professor managing the department (thematic patients) to the department on the basis of which clinics (departments) are.

The admission office can be centralized and decentralized, because there is an opportunity of examination with experts of different profiles (surgeon, urologist, traumatologist, gynaecologist, etc.). The reception department consists of a lobby, registry, examination rooms and sanitary controls. In some reception departments, there are beds for temporary patient supervision and isolators for infectious patients. In those hospitals and departments which carry out emergency care for the surgical and traumatologic patients, there is a X-ray cabinet, laboratory, operating, dressing room (clean and purulent), reanimation. Each patient at the admission office should feel the sensitive attitude of the medical staff.

MEDICAL DOCUMENTATION

Medical surgical documentation has big organizational, practical, legal and research values. A list of documents, which should be made, is precisely determined in definite cases. Official documents, which are prepared during the primary and following examinations, should be complete and written on-time by the doctor-surgeon or nurse.

Medical work at the city polyclinic department is recorded in the medical card of the outpatient. Passport data are filled in on the title page of this card. On the first page of an outpatient’s card there are final diagnoses with an indicated number, date of definition. On the following page the anamnesis, the objective data and the intended treatment are described. Lower marks are made about the sick-lists and vaccinations. The results of additional investigations (gastrofibroscopy, X-ray, ultrasound, etc.), medical report after treatment at the hospital are pasted in to the outpatient’s card. At a polyclinic there is a book of sick-lists giving. If it is necessary to direct a patient to the medical expert comission (MEC), separate coupon of reference to the sheet of MEC increases, which comes back from MEC to the medical consulting commission (MCC). For registration of students, pupils of technical schools, schools disability the special form is approved: certificate of temporary disability of students, pupils of technical and secondary schools.

For direction of patients to sanatoriums and rest homes the sanatorium-resort card is filled out at the polyclinic.

After visiting patients at home by call a book of emergency calls is filled in.

At the hospital, in the reception of the surgical department there must be a journal of the reception of patients and hospitalization refusals, outpatient journal, inpatient journal, journal of people who had traumas, log-book for taking analyses of blood for alcohol test, rabies journal, etc. The case history is the main document at the hospital. This document has a big legal meaning. Each doctor should know this well. The passport part of the case history is filled by the nurse on duty. Diagnoses at the patient’s admission and the clinical diagnosis are written and signed by the doctor. All other records in the case history are done by the ward doctor or the doctor in charge, the chief of the department certifies it and the head doctor of the hospital checks it.

The registration of work of the operating room of the surgical department is carried out at the operational journal. The following is marked in it: last, first, patronymic name of the patient, date and time of operation, diagnosis before the operation and after it, type of anaesthesia, amount of anesthetizing substance, name of surgion, course of operation, all complications occurred during the operation, data from the biopsy or histological analysis of the removed material, end of the operation, healing of the operation wound, if the patient died — specify the reason of death, with signature of the operating surgeon.

At the surgical department blood is transfused frequently. Therefore there should be a book of blood and plasma transfusion, and also a book of blood substitutes transfusion registration. Accordingly, at the case history the report of haemotransfusion is recorded.

Students fill in these documents during practical classes on haemotransfusion. During operation the surgeon removes a part of an organ, sometimes the whole organ, which should be sent for histological analysis. For this purpose, there is a special form, which is filled in by the operating surgeon — an appointment card for pathological anatomy research of the removed tissue.

At the surgical hospitals, the medical death certificate, which is then fixed in a registry office, is given to the relatives. At the hospital, there is a registration journal of preserving and delivery of poisoning, strong, and scarce medicines.

The list of prescriptions is filled in every day by the treating doctor. The diet, regime, drug treatment, physiotherapeutic procedures are marked in it. The nurse, after performing these assignments makes a mark in it.

The doctor’s on duty journal is filled by every doctor on duty. Data about patients’ transfer, admission, discharge, severely ill patients, all the operated the day before patients and those who have a fever are noted in it.

The diagnosis, kind of operation, diagnostic studies (blood and urine analyses, blood group, Rh-factor, X-ray examination, etc.), and recommendations concerning the out-patient and sanatorium treatment, type of sanatorium and its specificity, list of medical treatment, which was carried out, must be written down to the medical report.

The nurse handing over the watching fills in the journal of the watch transmission. The amount of inventory, syringes, hot-water bottles, catheters, probes, thermometers, drugs, in particular strong drugs, and narcotics is marked there.

In connection with the beginning of clinical training, it is necessary to pay attention to the value of medical deontology and medical ethics, which students learn during all their term of studying, but elements which are necessary to know in the 2nd year.

The term “deontology” (from Greek deon — proper, logos — study) was introduced at the beginning of the XІX century by an English philosopher Bentham as the name of the science about professional behavior of a person. Deontology is closely intewoven with ethics, which is the doctrine of morals, principles. So, medical ethics and deontology means a set of behavioral norms and morals of medical workers.

Medical deontology is not only rules of doctor’s behavior, relations of the doctor with patients, other people and all medical staff but also preparation of doctors for the profession, their aspiration for self-improvement.

The emblem of the International Society of Surgeons declares: “Surgery gives life”.

We should never forget the ancient precepts: “Do not harm first of all”.

While working at the medical institution the doctor, nurse and aid women should use words very cautiously. Eastern wisdom says: “The wound done by a knife can be cured, but the wound done by the tongue never heals”. In connection with this we should underline the importance of observing medical secrecy. What is the “medical secrecy”? These are data received by the doctor from the patient during a conversation or examination and treatment, which should not be provided in society or among relative and close friends, and data which the doctor should not inform the patient, as it can serve as a reason for mental trauma (bad diagnosis, bad prognosis, etc.). However, it is important to understand that medical secrecy should not become a conflict to the public. Medical secrets should always exist untill they violate the interests of society (hiding a criminal, concealing information of infectious diseases, etc.).

Naturally, there are a number of serious questions before young men and women who decided to devote themself to medicine, namely: what should a doctor of our time be like, what qualities should he aquire during the years of university studying in order to bring maximum benefit to people and society.

Its a good luck if a person finds his vocation, which is a big creative successes. The formation of a doctor is a difficult and temporary process. If we look at the past, it is necessary to determine the decisive motives for the senior generation of the best representatives of medicine? Sometimes, like Mykola Ivanovych Pyrogov’s example testifies the motives like that occur as if subconsciously, in the early childhood. Meditating on his life way, the ingenious surgeon came to a conclusion that two insignificant cases in his childhood played a certain role in the formation of his moral representations and future aspirations. The first one happened while the small Pyrogov was walking with his favorite old nurse by a bank of the small river Jauza. A desperate squeal got their attention. It appeared that near water two boys were playing with a dog, one tried to drown it and another one tried to interfere. The nurse praised the boy for displaying regret to the poor animal. These words, in particular, somehow were marked in M. I. Pyrogov’s memory. The second case is connected to the famous professor Ye. O. Mukhin who attended the house; he was invited to a serious patient with acute articulate rheumatism, who was the elder brother of Nikolai Ivanovich. The atmosphere of respectful expectation of the well-known doctor, his solemn arrival in a carriage, imposing appearance, process of examination of the patient, as well as the fact that Ye. O. Mukhin’s recommendations made a positive effect (the patient quickly recovered), — all of this impressed the boy very much. For a long time his favorite hobby was a home “doctor” game. He admired this game like a student-physician of the first year, and truthfully, he was not even 15 years old there.

At the same age an outstanding surgeon, founder of the first surgical magazine “Bulletin of surgery”, professor of the military medical college, Nikolai Aleksandrovich Velyaminov disregarded his aristocratic family to enter the medical faculty.

The founder of antiseptics Joseph Lister, who inspired to “work for the welfare of neighbours”, from the age of 17, began preparing for the doctor’s activity.

The famous therapeutist Sergei Pavlovich Botkin at young age dreamed of the mathematic faculty, but he became a physician rather unexpectedly. The first acquaintance with medicine radically changed his intentions.

A professor Theodore Billroth from Vienna, who had a remarkable talent for music, was going to devote his life to art and only after his mother insisting he received medical education. Not long after he became one of the leading feagures of medical science.

What qualities make up a doctor? I. P. Pavlov considers that a doctor should be able to analyze the facts, but mainly, synthesize them, he should be able to collect the facts offered to him by nature. Experience takes from nature everything he wants, “the facts is the air of the scientist”.

Veresayev in his “Notes of the doctor” proves how the diagnosis is established with the help of synthesis and analysis, collecting facts, supervision, revealing fine symptoms and the correct interpretation. He was impressed by the discussion of the patient’s condition made by the professor: “Eventually the professor started making conclusions. He went to them slowly like a blind along a steep mountain path: any smallest sign was not omitted but attentively discussed in order to explain any unuseful symptom on which I did not pay attention to, he turned upside down a store of anatomy, physiology and pathology, he faced all the contradictions and ambiguities and left them only after full explanation… The complicated and unclear picture which, in my opinion, was impossible to understand, turned out to be absolutely lucid and understandable, and it was considered on the basis of such insignificant data which were ridiculous to think”.

The difficulty of the profession is that patients are not alike and need an individual care.

In one of his letters A. P. Tchekhov noted: “sometimes doctors have very bad days and hours. God forbid”. Such days and hours like that are inevitable doctor’s concomitants. Only he knows sleepless nights “with fixed thoughts about the destiny of severely ill patients”.

A remarkable doctor S. S. Yudin after the death of a 30-year old woman-agronomist accused himself till the end of life when he did not detected intestinal obstruction and prescribed laxatives. And an outstanding diagnostician S. P. Botkin could not forgive himself for the lack of any objective data, did not believe the complaints of a strong headache of a young medical assistant, who arrived at the clinic again after recovery from abdominal typhus. The young man was discharged from the clinic with a mark as a “melingerer”, and the next day he died. Autopsy showed abscess of the brain.

An operation, as V. I. Rozhanovsky marks, is a huge responsible act which should be taken seriously, with responsibility. There are cases in the history of national medicine when serious emotional experiences caused by sharp feeling of medical responsibility for a mistake or failure had tragic consequences. So, prof. S. P. Kolomnin (1866) committed suicide after the death of a patient operated on by him with the usage of a new method of anaesthesia (cocaine).

In 1928 a popular doctor-gynaecologist Z. V. Vasilyeva from Saratov began to use morphine, being unable to endure the death of her friend, a talented surgeon N. V. Almazova, whom she operated. These cases are exclusive but they prove how difficult is sometimes responsibility of a doctor and how much power and self-possession are needed so that not to be bent under its weight.

Hence comes conclusion that doctors should take care of one another, protect from worries and emotional anxieties, which our difficult profession is rich in. The example of such attitude to profession at the end of his life is the life of the Leningrad professor P. A. Kupriyanov, an outstanding doctor for his scientific merits and sincere nobleness. He was seriously ill, and it was time for serious surgical intervention. When the head of the department addressed to him with the request to designate the surgeon who would operate him, P. A. Kupriyanov looked at him amazed and said: “I understand my condition and I know that it is a punishment to operate me. Don’t you think that I could severely punish anybody of my friends?” There are a number of examples like that.

Prof. V. R. Rozhanovsky says that some doctors and students are notable for great indiscretion. They are ready to inform patients of the necessary and unnecessary. There was such a case: one known pathologist was operated on at the clinic of a well known Moscow surgeon concerning polyposis of the stomach. He told that before the operation a young assistant who carried out curation, wishing to strike with erudition, for a long time and in details told him (the patient) about the outcomes of operation in cases of polyposis of the stomach, the mortality percentage and malignant transformation of polyps, etc. Imagine, that the patient — an outstanding pathologist who many times carried out post-mortem examination of people who died after such operations, having a number of works concerning this question, was so traumatized by the conversation with his “doctor” that for a long time after the operation was thinking with fear about the impression made by this conversation.

It is difficult to be a doctor, but to be a good doctor is much more difficult because it needs permanent skills training.