The (Fastest) Ward Round You Will Ever Do:

Surgical ward rounds can usually be completed quicker than it takes a computer on wheels (COW) to start working. As an intern, it is important to be prepared for this ward round. You’re aim is not to have pretty, beautiful, detailed notes. You’re aim is to GET THE PLAN for each patient. Everything else can be filled in at a leisurely place once you are in the safe confines of the doctors office. As an intern, try and work out the most efficient method of documentation that suits you and your team. It might be prepping everyone’s ward round note before the round starts and typing in the plan as you go. It might be looking at all the patient’s observations and overnight notes in the doctor’s office pre-ward round and writing down all the plans on a piece of paper instead. Have a discussion with the other residents and the registrar on your team and see what works best. Remember, the aim is to be efficient, so nothing gets missed. Also, just because the ward round is super speedy, doesn’t mean patient’s should be left confused or in the dark about their management plan. If you notice that they are confused or have lots of questions on the ward round, offer to come and speak to them later. Just be a good doctor and human.

Ward Jobs:

At the end of the ward round, sit down with the other residents and do a paper round. A paper round is where you sit down (+/- coffee) and talk through all the patients and their plans. You determine what ward jobs need to be done and divide them up amongst the team.

For pre-operative patients, common ward jobs include:

• Booking patients for theatre: this usually involves filling out a paper form and delivering it to the theatre reception. You will also need to call the Theatre Co-ordinator (TC) and Anaesthetist and telling them about the patient and the operation your team is planning on doing. The Anaesthetist will be interested in the patient’s BMI, co-morbidities and any prior issues with general anaesthetics (GA’s).
• Consenting patients for theatre: Strictly speaking, the operating surgeon must consent all patients. Realistically speaking, this never happens. It usually falls to the most junior member of the team (aka the intern) to ensure all the paperwork is complete. Read the consent documentation before discussing it with the patient. This will give you an idea of what risks to discuss (and how common they are). Do your best to explain the surgery and its risks to the patient. If the patient has any further questions that you do not feel are within your scope to answer, ask your registrar. When consenting for more complex surgeries with high risk (e.g. upper GI surgeries, hepatobiliary surgeries), ask for the registrar’s help.
• Ensuring the patient is NBM: Patients need to be fasted prior to surgery to reduce the risk of aspiration (and aspiration pneumonias). Make sure that the nursing staff looking after the patient also knows that the patient is awaiting theatre and will need to be kept NBM.
• Charting IV fluids: Patients usually receive IV fluids pre-procedure. The type of fluid (common options include sodium chloride 0.9% and Hartmann’s) will depend on the surgical department. Ask the registrar or resident what patients are usually given.
• Pre-Operative Medications: Chart the patient’s regular medications. Look out for anticoagulation medication (warfarin, apixaban, rivaroxaban) and ensure these are ceased in an appropriate time frame prior to surgery. Once again, I would ask the registrar or pharmacist, what the usual protocol in the department is. Also keep an eye out for any diabetic medications (insulin, metformin, dapa/empagliflozin) as these will need to be adjusted or ceased prior to surgery.
• Bloods: Ensure that a patient has a valid group and hold (in case they need blood products peri-operatively). Also, ensure that there is a baseline set of blood tests available prior to surgery (FBC, Chem20, Coagulation profile).

For post-operative patients, common ward jobs include:

• Charting appropriate analgesia: Ensure a patient has simple analgesia as well as stronger analgesia charted (usually small doses of opioids) to control their pain post-operatively.
• More IV fluids: Depending on when the patient is feeling ready to eat again, they may require IV fluids post-operatively.
• Requesting Bowel Charts: It’s all about those bowel motions. Ensure a patient is at least ‘passing wind’ post-operatively to rule out the presence of an ileus or bowel obstruction. Bowel charts are a great way to keep a daily monitor on this.
• Allied Health Input: Post-operatively, surgical patients will be encouraged to mobilise as early as possible. This can not only aid in their recover but result in a speedier discharge from hospital. It’s important to alert the physiotherapist about these patients. Liaise with speech pathology about potential swallow issues. Talk to the dietician about patients with poor nutritional status. Discuss with social work (early!) if you feel there may be social barriers to discharge.
• Discharge scripts: Usually this will be for a stronger opioid (in limited quantity) and an antiemetic (if the patient is still nauseous). Prioritise discharge scripts as it facilitates speedier discharge and keeps the nursing staff happy.
• Follow up arrangements: Always discuss follow up arrangements with the patient on discharge. Ask them to see the GP for any removal of sutures or repeat pathology. Book them in for a clinic appointment to assess their post-operative progress. Always give representation advice.