General Notes on Non-Tech Competencies

1. Informed Consent

Duty to disclose material risks.
= a reasonable person (patient or doctor) would view a material risk as being something of significance

Factors to consider are:
- more common and more serious risks must be disclosed
- the nature of the proposed procedure
- respond to patient's desire for more information.
- responsive to the temperament and health of that particular patient.
- circumstances (elective may allow different level of information to emergency)
- explain alternative treatment options

Consider also:
- blood transfusion
- systemic risks
- exacerbation of comorbid conditions
- who is doing the procedure
- pictures to be taken
- right to refuse
- training of surgeons

Must be documented

Booklets are helpful but do not replace discussion with a patient

2. Ethics

Good

i) Beneficence
- do most good, benefiting others
ii) Autonomy
- self governance, own choice and free will
iii) Altruism
- selfless concern for welfare of others
iv) Non-maleficence
- do no harm
v) Justice
- equality of worth, equal rights.

Bad

Futility

Paternalism
- interntionally over-riding a person's decision making based on own judgements and values
- goal to help the person who's will is over-ridden.

Not considering resource allocation

3. Delivering Bad News

SPIKES model

Setting up
- privacy, family, mdt, free of distractions / pagers, phones off
Perception of patient
- assess knowledge, understanding of situation to date
Invite
- ascertain how much they want to know.
Knowledge
- give the news, discuss implications,
Emotions
- observe, empathise
Strategy and Summary
- make plans and discuss options
- offer resources
- make a follow up plan.

4. Stages of Grief

Kubler Ross Model
i) Denial
ii) Anger
iii) Bargaining
iv) Depression
v) Resigned acceptance

5. Sensitivity and Specificity

Sensitivity: proportion of people with the disease who test positive (a/a+c)
Specificity: proportion of people without the disease who test negative (d/d+b)

+ve predictive value: chance that people have the disease if they've tested positive (a/a+b)
-ve predictive value: chance that people do not have the disease if they've tested negative (c/c+d)

 

 

DISEASE

NO DISEASE

 

Test +ve

a

b

      +ve PV

Test –ve

c

d

      -ve PV

 

 

Sensitivity

 

Specificity

 



6. Exposure to Blood-Borne Pathogens in the Operating Room

1. Mainly HBV, HCV, HIV.
-  >1% of general populations have these

2. 100% of surgical trainees will report being stuck by a needle during training.

Post-exposure prophylaxis (PEP):

HIV
No documented case of OR transmission, although >50 seroconversions in other healthcare worker contexts.
- mainly hollow bore needles / punctures.
Transmission via mucous membranes is inefficient; 0.3% of exposures.
Diagnosis first established by ELISA, then confirmed by Western Blot.
When infected risk occurs:
- exposed undergoes baseline testing.
- then, 2 or 3 drug antiretrovial prophylaxis, depending on risk severity.
- start within 72h; window period before onset of systemic infection.

Hep B
DNA virus, highly transmissible by needle stick.
- 30% risk with a hollow needle stick.
Most are vaccinated and no risk if titers sufficient.
- get a booster every 10 y or if titer low.
May show hepatitis with jaundice and fever.
- 5% of acute infected develop chronic disease.
Diagnosis from HBSAg.
PEP is with HBIg and revaccination if risk.

Hep C.
No vaccine, but inefficient transfer; 3% on exposure.
RNA virus, majority infected will get chronic disease but 75% asymptomatic. but slow, predictable march to cirrhosis.
Detection of anti-HCV.
- may follow exposure by months.
Promptly test source and surgeon.
If source positive, test clinician at 3 and 6 months fro anti-HCV and ALT levels.
No prophylaxis currently recommended
25% will clear it spontaneously; 90-98% clearance of rest with interferon at 8 weeks post exposure.

Preventing Sticks
Standard barrier precautions.
Wearing 2 gloves reduces risk of infection following needle-stick by 90%.
Pass sharps in metal trays
Blunt needles

Infection Surgeons
Surgeons should know status and "seek expert advice" for themselves and patients in current guidelines.
Infection is not used in the assessment of suitability to practice.