Minor surgery in SEhas long been held to be cost-effective and popular with patients. Minor surgical procedures in primary care include:

• Cryotherapy.
• Electrocautery.
• Curettage.
• Therapeutic injections used in a variety of conditions – eg:
  • Injections into joints (steroids but also perhaps viscosupplementation).
  • Aspiration of joints.
  • Injection of tennis and golfer’s elbow, or carpal tunnel injection.
  • Injection of varicose veins and piles.
• Excisions.
• Incisions.
• Other surgical procedures which the practice is deemed competent to carry out – eg, skin biopsy (punch and shave), endometrial sampling, removal of toenails, removal of contraceptive implants, evacuation of perianal haematomas and removal of skin lesions where clinically indicated (see local guidance).

Basic minor surgery

Equipment and accommodation

• Most surgeries have a dedicated treatment room in which such surgical procedures are performed; however, cryotherapy, electrocautery and curettage can be performed in a normal consultation room, provided that there is adequate lighting and space.
• A clean area is not as important as for ‘cutting’ surgery but it is desirable and creates a favourable impression of a professional service.
• Equipment should be appropriate to the job and of adequate specification:
  • A curette can be sharp or blunt. A sharp curette is more frequently employed, although it can cause more damage if used without skill. A range of sizes adds versatility. Disposable instruments are now recommended. A hot water boiler is inadequate and even pressurised autoclaves can no longer be recommended.
  • If there is any uncertainty about the adequacy of equipment, the Clinical Governance team of the local Clinical Commissioning Group (CCG) should be able to give advice.
  • Appropriate infection control measures should be in place. National Institute for Health and Clinical Excellence (NICE) guidance is available^[1] .
  • Electrocautery is provided by a hot wire. This apparatus usually works on about 12 volts. This may be provided by a battery but a transformer plugged into the mains is more usual. There is a button on the handle to switch the current on and off. There may be a number of heads of various shapes and sizes for various jobs. They can be removed to be cleaned and sterilised but letting them glow red will provide a much higher temperature than any autoclave, although not for so long.
  • Cryosurgery requires a cold source and the most common is liquid nitrogen. It can usually be bought by special arrangement from a local hospital or directly from a supplier if a storage vessel is purchased. It is essential to remember that it is exceptionally cold with a boiling point of −196°C and so requires appropriate precautions for use and storage. Thick gloves and goggles must be worn when decanting or transferring liquid nitrogen.

Intensive care units (ICUs)

What is an intensive care unit (ICU)?

Intensive care refers to the specialised treatment given to patients who are acutely unwell and require critical medical care.

An intensive care unit (ICU) provides the critical care and life support for acutely ill and injured patients.

Unless you are an emergency admission, you will need a referral from your doctor or specialist to be admitted to ICU.

Who is cared for in ICU?

Patients may have a planned admission following surgery, an unexpected admission after an accident or be admitted because of a sudden and critical deterioration to their health.

ICU teams are multi-disciplinary, made up of highly skilled intensive care nurses, doctors and specialists trained in providing critical care for patients with a variety of medical, surgical and trauma conditions.

Some hospital ICUs specialise in providing care for particular health conditions or injuries including:

• major trauma
• severe burns
• respiratory failure
• organ transplants
• complex spinal surgery
• cardiothoracic surgery.

What to expect in ICU

ICU is one of the most critically functioning operational environments in a hospital.

Every ICU in a hospital has a different environment that will reflect the specialist medical and surgical procedures they perform.

Most ICUs are fairly large sterile areas with a high concentration of specialised, technical and monitoring equipment needed to care for critically ill patients.

The ICU environment can be confronting for some patients and visitors who may find the activity, sounds, machines, tubes and monitors intimidating.

When you visit someone you care about in ICU it can be an uncomfortable experience –  you may feel helpless, overwhelmed, frustrated and sad. Your feelings and apprehension are understood by the staff that provide support for the people you care about.

Typically ICU also has a higher ratio of doctors and nurses to patients.

ICU equipment

It can be a frightening and uncertain time for you, family and friends to see people you care about being monitored and supported by machines.

In ICU you will see many patients connected to a heart monitor, others will be supported with breathing assistance from artificial ventilators, be on dialysis machines and receiving a variety of intravenous infusions via tubes and drips.

Be prepared to see lots of lines, tubes, wires and monitoring equipment. Almost all ICU equipment uses alarms to let staff know about a change in a patient’s condition. Not all equipment alarms signal an emergency situation.

Visitors

Every ICU has a visitor policy to ensure the wellbeing of their patients. You will need to ask ICU hospital staff about their specific visiting hours and requirements.

Visiting is usually restricted to people the patient considers to be immediate family.

If you are feeling unwell or have an existing health condition you should reconsider visiting ICU or discuss your circumstances with ICU staff before you plan to visit.

Hygiene

As intensive care patients are very vulnerable to infections, it is important that visitors wash their hands before entering ICU to prevent transferring infection.

Mobile phones

Mobile phones should be turned off in ICU as they may interfere with vital electrical equipment supporting patients.

Gifts

Restrictions are in place to allow easy access to vital medical equipment and to patients.

If you are unsure what you can bring with you check with ICU staff before you plan to visit.

Patient and family support services

Counselling

Admission to ICU because of critical illness or accident can have a huge physical and emotional impact on your life and your family.

Some ICUs have a dedicated counsellor to provide support for patients and their families. These counsellors are highly experienced and have a thorough knowledge of ICU procedures.

Hospital counselling support services are also available at all major hospitals.

Pastoral care

For many people, emotional and spiritual thoughts tend to surface when someone they care about is in a critical condition in hospital.

Many hospitals provide chaplaincy and pastoral counselling services for patients, families and staff who need compassionate, professional and spiritual guidance and support.

Some hospitals also have a non-denominational chapel available for times of reflection and prayer.

Interpreter service

An interpreter service is available for patients and families if English is not your first language.

These interpreters are specifically trained to interpret medical terms into other languages. It is important that you use this service if you are having problems understanding doctors explaining information or are being asked to provide consent for medical procedures.

Speak to ICU staff if you would like to use interpreting services.

Overview

An upper endoscopy is a procedure used to visually examine your upper digestive system with a tiny camera on the end of a long, flexible tube. A specialist in diseases of the digestive system (gastroenterologist) uses an endoscopy to diagnose and, sometimes, treat conditions that affect the esophagus, stomach and beginning of the small intestine (duodenum).

The medical term for an upper endoscopy is esophagogastroduodenoscopy. You may have an upper endoscopy done in your doctor’s office, an outpatient surgery center or a hospital.

Why it’s done

An upper endoscopy is used to diagnose and, sometimes, treat conditions that affect the upper part of your digestive system, including the esophagus, stomach and beginning of the small intestine (duodenum).

Your doctor may recommend an endoscopy procedure to:

• Investigate symptoms. An endoscopy may help your doctor determine what’s causing digestive signs and symptoms, such as nausea, vomiting, abdominal pain, difficulty swallowing and gastrointestinal bleeding.
• Diagnose. Your doctor may use an endoscopy to collect tissue samples (biopsy) to test for diseases and conditions, such as anemia, bleeding, inflammation, diarrhea or cancers of the digestive system.
• Treat. Your doctor can pass special tools through the endoscope to treat problems in your digestive system, such as burning a bleeding vessel to stop bleeding, widening a narrow esophagus, clipping off a polyp or removing a foreign object.

An endoscopy is sometimes combined with other procedures, such as an ultrasound. An ultrasound probe may be attached to the endoscope to create specialized images of the wall of your esophagus or stomach. An endoscopic ultrasound may also help your doctor create images of hard-to-reach organs, such as your pancreas. Newer endoscopes use high-definition video to provide clearer images.

Many endoscopes allow your doctor to use technology called narrow band imaging, which uses special light to help better detect precancerous conditions, such as Barrett’s esophagus.

NIV refers to the provision of respiratory support without direct tracheal intubation. As such, it aims to avoid some of the complications inherent with invasive ventilation, such as the need for sedation with risks of hemodynamic instability and subsequent risk of delirium, nosocomial infection, etc.1 In a recent worldwide survey, the use of NIV increased from 4% to 11% of all episodes of mechanical ventilation between 2001 and 2004 respectively, with even higher rates of use in some European countries.2 Indeed, for some situations it is considered the first-choice mode of ventilatory support However, it may not be appropriate for all patients, particularly as it is being used increasingly outside of the traditional critical care setting (Indications/Contraindications for NIV).

Introduction

What is a holter monitor?

A holter monitor is a device that records your heart beats. It contains electrodes, wires and a small machine that attaches to your waistband.

Why do I need a holter monitor?

You may need a holter monitor if your doctor thinks there could be a problem with your heart rate or rhythm. You might have symptoms such as:

• Fainting
• Dizziness
• Shortness of breath
• Chest pain
• Irregular heartbeat

Even if you’ve had an ECG you may still need to wear a holter monitor. ECGs only monitor your heartbeat for a short time – which isn’t always long enough to identify potential problem.

What are the risks of having a holter monitor?

Holter monitoring is a safe and painless test with no significant risks. Some people experience minor skin irritation from the sticky dots (electrodes) used to monitor the heartbeat.

How do I prepare for a holter monitor?

There’s not a lot you need to do to prepare – but you will need to shower. After your holter monitor has been fitted, you can’t get it wet or remove it. The hair on your chest may need to be shaved to help the electrodes stick to your skin.

What happens during a holter monitor?

The holter monitor test is a very straightforward procedure:

• Electrodes are stuck to your chest
• The electrodes are connected to the small holter machine device
• You’ll be shown how to attach the device to your clothes

While the device is fitted, you’ll need to:

• Wear it during your usual activities
• Keep it on at all times, even during sleep
• Never take it off
• Keep a diary of all your daily activities and the time you did them
• Record any specific symptoms you feel (dizziness, light-headedness, chest pain, shortness of breath)

What happens after a holter monitor?

After one or two days, you’ll return to your doctor’s office with your diary. Your doctor will remove the holter monitor, discuss your results and recommend an appropriate treatment plan to help you manage your symptoms moving forward

Overview

An electrocardiogram records the electrical signals in the heart. It’s a common and painless test used to quickly detect heart problems and monitor the heart’s health.

An electrocardiogram — also called ECG or EKG — is often done in a health care provider’s office, a clinic or a hospital room. ECG machines are standard equipment in operating rooms and ambulances. Some personal devices, such as smartwatches, offer ECG monitoring. Ask your health care provider if this is an option for you.

Types

Why it’s done

An electrocardiogram is a painless, noninvasive way to help diagnose many common heart problems. A health care provider might use an electrocardiogram to determine or detect:

• Irregular heart rhythms (arrhythmias)
• If blocked or narrowed arteries in the heart (coronary artery disease) are causing chest pain or a heart attack
• Whether you have had a previous heart attack
• How well certain heart disease treatments, such as a pacemaker, are working

You may need an ECG if you have any of the following signs and symptoms:

• Chest pain
• Dizziness, lightheadedness or confusion
• Heart palpitations
• Rapid pulse
• Shortness of breath
• Weakness, fatigue or a decline in ability to exercise

The American Heart Association doesn’t recommend using electrocardiograms to assess adults at low risk who don’t have symptoms. But if you have a family history of heart disease, your health care provider might suggest an electrocardiogram as a screening test, even if you have no symptoms.

If symptoms tend to come and go, they may not be detected during a standard ECG recording. A health care provider might recommend remote or continuous ECG monitoring. There are several different types.

• Holter monitor. A Holter monitor is a small, wearable device that records a continuous ECG, usually for 24 to 48 hours.
• Event monitor. This portable device is similar to a Holter monitor, but it records only at certain times for a few minutes at a time. You can wear it longer than a Holter monitor, typically 30 days. You generally push a button when you feel symptoms. Some devices automatically record when an irregular rhythm is detected.