Surgery

While medical and technical expertise are what might be described as core business for a surgical college, the question of who is to assume responsibility for teaching other, non-technical competencies remains. So far only the colleges have stepped forward, though often in tandem with other stakeholders.

Michael J Hollands MB BS, FRACS

Recent changes in perioperative patient management — including well integrated pre-admission clinics, the “bundle of care” initiative and clinical handover using electronic medical records — mean that surgical patients should have a smooth perioperative journey.

Bruce P Waxman FRACS, FRCS, FACS

To the Editor: Reducing the time from presentation to cholecystectomy in patients with acute cholecystitis has been shown to benefit patients (eg, by reducing the duration of patient discomfort before surgery) and to be cost-effective.1-3 Benefits have also been shown for performing cholecystectomy during the index admission for gallstone pancreatitis.4 Geelong Hospital (in regional Victoria) introduced daily general surgery emergency theatre sessions in February 2011. We ...

Daniel P McGlade · David A Watters · Douglas A Stupart

To the Editor: Surfboard riding is an iconic pastime in Australia. Injuries to the head and face constitute a considerable proportion of surfing injuries;1-5 26% of acute surfing injuries are to the head and face, and these make up 42% of emergency department presentations by surfers.3 We conducted a retrospective review at our tertiary referral hospital of patients who underwent medical imaging for injuries sustained to ...

Simon J Dimmick · Patrick V Sheehan · Mark Gillett · Suzanne E Anderson

A survey of Royal Australasian College of Surgeons trainees suggests that although many trainees are interested in pursuing part-time surgical training, very few have obtained accredited positions to do so. In a related commentary, the RACS censor-in-chief acknowledges the desire of trainees for flexible training, and describes what the College is doing to help meet this need.

Rachel E McDonald BSc · Amy E Jeeves MB BS, BMedSci(Hons), FRACS(Plast) · Carolyn E Vasey MB BS, BMedSci · Deborah M Wright BMedSc, MB ChB · Gregory O’Grady BHB, MB ChB, PhD

Establishing part-time surgical training posts may be difficult, but evidence suggests it is possible and increasingly necessaryThe study by McDonald and colleagues confirms previous reports in Australia and elsewhere that there is a significant difference between the number of trainees who are undertaking some of their surgical training part-time and those who would be interested in doing so.1 It cannot be denied that doctors entering a ...

Simon A Williams MB BS, FRACS, FAOrthA

To the Editor: Weisbrot and Breen’s proposal1 for a no-fault compensation system for medical injuries should extend to all injuries in Australia, including those from motor vehicle accidents and in the workplace. It should also apply to recreational injuries that may lead to common law compensation cases. After 40 years of clinical experience in the rehabilitation of patients with severe neurological injury, I argue that such ...

David C Burke

A reflection on surgical life in a public hospitalThe fluorescent tubes in the corridor shine with a watery blue light, casting dappled shadows from the newly hung Christmas decorations. The surgeon opens the door to the operating theatre, but it catches on the tinsel, unsticking it from the ceiling. 8 am. Already the day is in chaos: no breakfast, delayed clinic, unhappy administrators, and now this ...

Rosalind L Jeffree MB BS, MSc

Changing clinician beliefs and behaviour in response to credible evidence of lack of treatment efficacy remains highly challengingArthroscopy is commonly used to treat people with knee pain due to osteoarthritis. However, data collected from randomised controlled trials over the past two decades have provided compelling evidence that, in general, arthroscopic treatment comprising debridement and lavage is no more effective than placebo surgery or non-operative alternatives,1,2 ...

Rachelle Buchbinder MB BS(Hons), MSc, PhD · Ian A Harris MB BS, MMed(Clin Epi), PhD

To the Editor: Adrenaline is often added to local anaesthetic for injection because the vasoconstrictive effect of the catecholamine counteracts the dilative effect of the local anaesthetic, decreasing systemic absorption and prolonging its action.1 Traditionally, the use of this drug combination has been discouraged in structures supplied by end arteries — most notably the digits, but also the nose, ears and penis — on the ...

Christopher J D Barlow

Objective: To determine the risk and timing of a broad range of infective outcomes and mortality after splenectomy.Design, setting and participants: Analysis of a non-identifiable linked hospital discharge administrative dataset for splenectomy cases between July 1998 and December 2006 in Victoria, Australia.Main outcome measures: Age, sex, indication for splenectomy, infectious events ...

Claire Dendle MB BS, FRACP, GCHPE · Vijaya Sundararajan MD, MPH, FACP · Tim Spelman MB BS, BSc, GradCert(Stats) · Damien Jolley MSv(Epi), MSc(Stats) · Ian Woolley MB BS, FRACP, DTMH

Closing a regulatory gap to ensure patient safety in all surgical proceduresHealth services are delivered in a variety of settings, including public and private hospitals, day surgeries and practitioner offices. Office-based surgery has been practised safely in the United States for many years,1 and has been embraced by surgical specialties such as otolaryngology,2 vascular surgery,3 ...

F A Hugh Bartholomeusz OAM, MB BS, FRACS

Objective: To determine whether the introduction of an acute surgical unit (ASU) resulted in a greater proportion of patients with acute cholecystitis receiving definitive surgery on index admission with no adverse change in surgical outcomes.Design, setting and participants: A retrospective study of medical records for patients presenting to Nepean Hospital with ...

Lester Pepingco BMedSc, MB BS(Hons) · Guy D Eslick PhD, FACE, FFPH · Michael R Cox MB BS, FRACS, MS

Objective: To describe the management and outcomes of a population-based cohort of patients with pancreatic cancer in Victoria, Australia.Design, setting and patients: Retrospective study based on questionnaires completed from medical histories of patients diagnosed with pancreatic cancer during 2002–2003 in Victoria who were identified from the Victorian Cancer Registry and followed up ...

Antony G Speer BE, MB BS, FRACP · Vicky J Thursfield BSc, GradDip(ApplStats) · Yvonne Torn-Broers BA(Hons) · Michael Jefford MB BS, PhD, FRACP

Robert MacMahon AM, MB BS, MS, FRCS, although publicly renowned as a paediatric surgeon, was far more — teacher, innovator, a family man with a delightful sense of humour, and founding governor of the Make-A-Wish Foundation Bob was born in the Sydney suburb of Eastwood on 22 April 1931. He studied medicine at the University of Sydney, graduating in 1954. He undertook 4 years of training at the Royal Newcastle Hospital, and spent his spare time in the surf and on the rugby field for the Newcastle Wanderers. He then studied in the United Kingdom, where he decided to become a paediatric surgeon. After obtaining a Master of Science from the University of Colorado Denver, he returned to Sydney in 1965, to become the first James Fairfax Surgical Research Fellow at the Children’s Medical Research Foundation. In 1967, he was appointed inaugural Head of the Department of Paediatric Surgery at the Queen Victoria Medical Centre (later Monash Medical Centre), Melbourne. In 1970, he became Associate Professor of Paediatric Surgery at Monash University. At Monash, he developed his interest in the nutrition of premature infants, running a research program in amino acid and mineral metabolism. Between 1970 and 1975, through intravenous feeding, he increased premature infant survival from 18% to 71%. In 1974, Bob founded the Australasian Society for Parenteral and Enteral Nutrition and was its inaugural President. He served on the Monash University Human Research Ethics Committee for 40 years, and was its Chair from 1999 to 2009. He was President of the Australian and New Zealand Association of Paediatric Surgeons from 1991 to 1993. He performed the first human fetal operation in Australia and the first in-utero repair of a diaphragmatic hernia. He also pioneered in-utero laser vesicostomy and helped create the Fetal Diagnostic Unit at Monash Medical Centre. Throughout his career, Bob contributed to 10 textbooks and authored more than 60 research articles. In 2010, he was made a Member of the Order of Australia. After he retired from medicine, he enjoyed camping in the bush, surfing and golf. Bob died on 1 April 2011 from prostate cancer, and is survived by his wife Bessie and four daughters. He will be remembered for his personal integrity, enthusiasm, achievements, intellect and judgement, and his wonderful sense of humour.

Robert J Stunden

The well publicised difficulties encountered in managing the recently exposed failure of breast implants manufactured by Poly Implant Prothèse (PIP) have pushed the issue of device regulation into the spotlight. In this issue of the Journal, we address the issue of device regulation and the role and performance ...

Annette Katelaris

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This is a compelling read. Dr Jayant Patel arrived at Queensland’s Bundaberg Hospital on April Fools’ Day 2003 and, in the words of former Federal Health Minister Michael Wooldridge, “walked into an environment tailor-made for disaster to occur”. In June 2010, he was sentenced to seven years’ imprisonment for manslaughter and grievous bodily harm involving four patients operated on in Bundaberg. An appeal was dismissed. The authors of this well documented account are eminently qualified to tell the tale — Professor Dunbar teaches clinical governance and risk management at Flinders University in Adelaide, Professor Reddy is a health and organisational psychologist at Flinders and Stephen May is a former psychologist and journalist. As they explain, Patel was far from being the only one at fault. The authors carefully examine the bureaucratic structures and attitudes in existence in Queensland Health, and the personal and professional failings of particular administrative staff at the Queensland Medical Board and the hospital that led to Patel — whose registration as a specialist surgeon was restricted in two US states — being appointed as director of surgery at Bundaberg. They find that the hospital was “fiscally driven”, and Patel’s ability to perform large numbers of operations benefited the budget and completely overrode concerns about patient outcomes. The gulf between management and clinicians is neatly encapsulated in the story of an administrator telling a senior Bundaberg clinician concerned about Patel’s activities: “You have to understand that this is a business.” To which the doctor replied: “That’s where the problem is, you see. I think it’s a hospital.” The efforts of this clinician and many other staff, patients and relatives to achieve justice are well described, as are the findings of the numerous formal inquiries and the details of Patel’s trial. Patel’s earlier life and medical training have been meticulously researched and the authors have attempted to give a balanced view, pointing out that many of the 1000 patients he operated on at Bundaberg benefited from his surgery. Had the proper checks and balances been in place, the negative outcomes might never have occurred. Has the Queensland public health system learnt from the Patel case? Sadly, the authors conclude that it has not — their final sentence warns that a case like Patel’s “could be happening right now in your own modern overburdened healthcare system”.

Caroline M de Costa

Teaching children how to behave around dogs can reduce the incidence Dogs never bite me. Just humans. Marilyn Monroe (1926–1962) Dogs have been companions of humans for over 12 000 years and have become an inseparable part of rural and urban life. Many breeds continue to do valuable work — managing livestock on farms, guiding the visually impaired, sniffing out contraband, and as guard dogs. Most of the 3.4 million dogs in Australia are family pets, with 36% of households owning a dog.1 Unfortunately, as a result of this close relationship, dog bites are common. Statistics on dog bites often seem alarming, but most bite injuries are relatively minor, not requiring hospital admission.2 In 2008 and 2009, 928 children aged 0–14 years attended accident and emergency departments in Queensland with dog bites, equating to nine bites per week (Access Information Service, Queensland Health). The Queensland Trauma Registry (QTR) contains data on 186 children (aged 0–14 years; mean age, 5.5 years) who were admitted to Queensland hospitals for more than 24 hours in 2003–2009, equating to one such hospitalisation for a dog bite injury every 2 weeks (own unpublished data). No children died from dog bites in this period. Of the dog bite injuries recorded in the QTR, 88% occurred in the home environment, and almost all (98%) required at least one operation under general anaesthetic. In 2003, the Royal Children’s Hospital conducted a telephone survey on 45 consecutive children who were admitted with serious dog bites during 1997–2002. This survey showed that the child had physically interacted with the dog immediately before the attack in 63% of cases. Most attacks (92%) occurred in a setting familiar to the child, usually the family house or garden, or that of a relative or friend. Most bites were to the head and neck region (72%) and most children (93%) were left with permanent cosmetic scarring (own unpublished data). These results are consistent with those of other Australian studies.2,3 While most dog bite reports attempt to identify the breed, this information is commonly not documented in the patient record and, when stated, relies on correct identification by the family. No one breed stands out, but breeds commonly mentioned in Australian articles include Rottweilers, German Shepherds, Cattle Dogs and the Bull Terrier group.2,3 Data on an array of other breeds and cross-breeds provide evidence that any dog is capable of biting. An American study examined 238 dog-bite-related deaths over 20 years to 1998, and identified at least 25 different breeds.4 Breed identification may not be accurate. For example, the general public might have difficulty differentiating between several breeds in the Bull Terrier group. Staffordshire Bull Terriers, American Staffordshire Terriers and American Pit Bull Terriers all appear very similar. To add further confusion, a recent Queensland Supreme Court ruling stated that there was no distinction between the American Staffordshire Terrier and the American Pit Bull Terrier. Dogs are highly regulated in Australia with mandatory registration laws. It is now prohibited to import certain breeds, including American Pit Bull Terriers, Japanese Tosa, Dogo Argentino and Fila Brasiliero. State laws on the ownership of such breeds vary, but generally require desexing (unless registered for breeding), microchipping, the use of a leash and muzzle in public places and a locked enclosure at home with a warning sign. The laws are based not so much on evidence that these breeds are inherently dangerous, but rather that they are breeds which have been traditionally used for dog fighting. Much debate continues whether this is good and fair legislation, as studies have failed to show improvement in the incidence of bites after the legislation was passed.5 Breed-specific legislation fails to take into account that any breed of dog can be dangerous in the hands of an irresponsible owner who fails to provide good and early training. Further, these restrictions may create the risk of higher numbers of unregistered animals or irresponsible owners simply turning to other breeds. It is clear that all breeds bite, and that the severity and commonality is related to the size of the dog and how many of a particular breed exist.6 In the Netherlands, where good data on breeds and bites exist, breed-specific legislation was repealed because they found no one breed more dangerous than any other. They recommended there be a focus on owners of dogs in cases where the people bitten did not interact with the dog that bit them.6 Training for dogs and education for dog owners and children can reduce the incidence of dog bites. A recent United States study reported that knowledge about dog bite prevention among young, school-aged children is poor.7 However, education programs in the primary school setting have been shown to alter a child’s interaction with dogs.8 In general, children should be taught: to ask permission from the owner before slowly approaching an unfamiliar dog; never to run from a dog or scream; to stand still if approached by a strange dog and, if knocked over, roll into a ball and lie still; to avoid eye contact with the dog by looking at their own feet; not to disturb a dog that is sleeping, eating, or caring for puppies; and not to pat a dog without supervision or without allowing it to see and sniff them first.9 Furthermore, dog owners should take their dogs to obedience classes, and dogs should be taught to obey commands from all family members. Dogs used for hunting or as guard dogs should not be allowed to mix with children.9

Roy M Kimble MD, FRCS, FRACS · Natalie Dallow · Richard Franklin PhD · Belinda Wallis BBEnv(Dist)