Emergency Abdominal Surgery in the Elderly: Can We Predict Mortality?

BACKGROUND: The United Kingdom population is ageing. Half of patients requiring an emergency laparotomy are aged over 70, 20 % die within 30 days, and less than half receive good care. Frailty and delay in management are associated with poor surgical outcomes. P-POSSUM risk scoring is widely accepted, but its validity in patients aged over 70 undergoing emergency laparotomy is unclear. AIMS: To assess if P-POSSUM risk stratification reliably predicts inpatient mortality in this group and establish whether those who died within 30 days received delayed care. METHODS: Observational study of consecutive patients aged 70 and over fulfilling the National Emergency Laparotomy Audit criteria from a tertiary hospital. The predictive value of pre-operative P-POSSUM, ASA, lactate and other routine variables was assessed. Surgical review, decision to operate, consultant surgical review, antibiotic prescription, laparotomy and discharge or death time points were assessed by 30-day survival. RESULTS: One hundred and ninety-three patients were included. This represented 46.28 % of those undergoing an emergency laparotomy in our centre. Pre-operative P-POSSUM scoring, ASA grade and lactate were moderate predictors of mortality (AUC 0.784 and 0.771, respectively, lactate AUC 0.705, all p ≤ 0.001). No correlation existed between pre-operative P-POSSUM and days to death (p = 0.209), nor were there delays in key management timings in those who died in 30 days. CONCLUSIONS: P-POSSUM scoring may predict inpatient mortality with moderate discrimination. Addition of frailty scoring in this high-risk group might better identify those with a high risk of mortality after emergency laparotomy and would be a fertile area for further research.

A qualification in medical education--a luxury or a necessity?

As doctors, in all spheres of medical practice, we have a responsibility to contribute to the education and training of other doctors, medical students and non-medical healthcare professionals. This is particularly pertinent in the Royal Naval Medical Service where effective education and training of medical teams is extremely important, particularly when preparing for the operational environment. However, it is not unusual to reach a fairly senior stage of a medical career without ever receiving any formal instruction in methods of teaching. So, it is not surprising that most people can recall being on the receiving end of a bad teaching experience; few doctors have escaped the familiar scenario of being taught by humiliation on a ward round. Accepting that good teaching abilities are not innate, I would suggest that we all have a professional obligation to develop and maintain our skills in the field of medical education. The Royal College of Anaesthetists have formalised this obligation by including the subject of medical education in the curriculum for Specialist Registrar training. There is a wealth of courses, which are easily accessed and which offer a broad introduction to generic teaching methods. In addition, many universities now offer part-time and distance-learning courses that lead to a qualification in education, specific to medical practice. Hopefully, this account has given an overview of the available resources and has provided food for thought for anyone wishing to develop an interest in medical education.