On-call surgeon responsibilities need to be clarified

Case summary A comorbid elderly patient presented with haematemesis found to be coming from a proximal gastric source, likely erosions. The patient underwent multiple endoscopies and ultimately died of massive bleeding from the stomach. Case notes A 70-year-old patient presented with haematemesis on a background of multiple medical comorbidities impacting daily function, including recurrent lower respiratory tract infections, bronchiectasis, diffuse scleroderma, osteoarthritis, hypertension, and recent unintentional weight loss. The patient was on multiple medications including mycophenolate, prednisolone, meloxicam, and pantoprazole. The patient’s haemoglobin was 82 g/L on admission and two units of packed red cells were given. The patient underwent two gastroscopies. The first (day one of admission) found a large volume of semisolid blood with poor views. The second gastroscopy, on the following day, demonstrated erosions in the proximal gastric body. An adrenaline injection was placed into a gastro-oesophageal junction lesion and Endoclot was applied to the gastric erosions. There were poor views of the duodenum due to blood. Two days later (day four of admission), a medical emergency team (MET) call occurred at 17:05 for further fresh haematemesis and haemodynamic instability (haemoglobin 48 g/L). The patient was intubated on the ward at 17:30 and transferred to ICU at approximately 17:52. Documentation following this is sparse. There appears to be no running documentation from the medical registrar or the surgical registrar—who was presumably involved to assess and liaise with the surgeon and on-call surgeon. There is only a retrospective note from the reporting surgeon regarding their version of events:

• being contacted during the MET call despite not being on call and being unable to attend expeditiously • suggesting that the on-call surgeon assist in performing an endoscopy and the on-call surgeon not attending to help • discussing with the on-call surgeon in the theatre tea-room prior to the second gastroscopy who should be responsible for the gastroscopy—both feeling that the other should have done the endoscopy. A third gastroscopy was performed at approximately 19:00 by a gastroenterologist who found a large volume of clot in the proximal stomach. The duodenum was visualised and appeared to be normal.

The assessment was a large proximal gastric bleed not amenable to endoscopic intervention due to adherent clot despite extensive wash and repositioning of the patient. A multidisciplinary discussion between the surgeon, the gastroenterologist and the intensivist concluded that intervention with proximal gastric surgery would not be appropriate given the patient’s comorbidities. The patient subsequently died overnight from bleeding. Area of concern The major area of concern is the potential delay to the third endoscopy (approximately one hour) caused by the lack of a clear plan regarding who would perform the gastroscopy. The surgeon who had been involved with the patient’s care felt that the on-call surgeon should have performed the procedure, whereas the on-call surgeon reportedly did not want to be involved because the reporting surgeon had performed the two prior endoscopies. Comments The standard of care before the time of deterioration appeared appropriate. Management of the bleeding medically and endoscopically occurred in a timely fashion. The deterioration was also clearly recognised on day four with another endoscopy required. The issue of concern pertains to who was responsible for performing the procedure and the communication surrounding this. The delay to theatre of approximately one hour may not have made a difference to the outcome in this case—given that the pathology did not appear to be endoscopically manageable—but regardless of the outcome, on-call responsibilities should be clear within the hospital to prevent confusion and delay. When there needs to be handover of care (due to a surgeon no longer being on call), this should be communicated clearly to avoid delays in time-critical interventions such as this. Communication could have been improved in this case.

Professor Guy Maddern Chair, ANZASM

College’s events management system now live

The long-awaited events management solution, which will help us move towards a more streamlined experience for registration and payment of College events is live now. RACS members can search, register, and pay for 2023 events, courses and exams using the Training & Services platform in eHub. At this stage, the platform is open for registration of Skills Training and Professional Development courses and workshops: Generic Surgical Science Examination (GSSE), Clinical Examination (CE), Specialty Specific Examinations (SSE) or Fellowship Examinations (FEX), and some social events and conferences. The solution is built on the existing Microsoft Dynamics365 platform and post Council’s approval of the 2023 fee schedule, the platform is now ready for member registrations. This marks a significant improvement in how you search and register for events, including payments, withdrawals, refunds, and post-event activities—such as downloading invoices and certificates. The platform will be further enhanced to cater for the College’s Trainee Association, RACSTA, Aotearoa New Zealand and Australian state and territory offices, and Trauma and Academic Surgery in the coming months. The Training & Services platform will eventually become the digital one stop for all RACS events and courses, enhancing member experience. Read more: bit.ly/3GHRxO4