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THE CLINIC AT SIR PATRICK DUN'S HOSPITAL
A clinic devoted entirely to the diagnosis and treatment of varicose veins is essential if full advantage is to be taken of the technique of compression sclerotherapy. At Sir Patrick Dun's Hospital two clinics for new patients, six for the current patients, one consultation clinic and one discharge clinic are held each week.
The clinics for new patients
One 2-hour clinic for new female patients and one 1-hour clinic for new male patients are held each week. At these clinics about 20 patients per hour are examined, diagnosed and given their first treatment. Each clinic is attended by four doctors and conducted on an assembly line system (see diagram). The clinic consists of (a) one large waiting room, (b) an office with three secretaries, (c) and (d) two small waiting rooms, (e) a large room containing four couches in which diagnosis and treatment takes place, and (f) a room where the patients are supplied and fitted with elastic stockings.
In the office each patient is given a punch card. The name, address and age of the patient are filled in by the secretary. The patients then go into the first small waiting room. This room contains seating accommodation for twelve patients. Here each patient is weighed and a specimen of blood is taken for haemoglobin, white cell count and E.S.R. estimations. Blood is also taken for W.R. and Kahn. The patients then go into the second small waiting room in which there are six chairs separated by portable screens. Here they take off their stockings. At the male clinic the men remove their trousers. From this room, each patient in turn goes into the treatment room, where he is seen by one of four doctors, who is assisted by a nurse. Relevant history is taken, and the answers are recorded on a punch card by a secretary. One secretary is sufficient. Patients are examined, diagnosed and treated. When their legs have been bandaged, the patients walk to the fitting room, where they are seen by a fitter who supplies them with elastic stockings. Each patient is given an appointment to attend the clinic for return patients in two to three weeks time.
Return clinics
Six return clinics are held each week: four 2-hour clinics for women, two 1-hour clinics for men. Each clinic is run by doctors, who see between them about 30 patients per hour. Whereas, at the clinic for new patients, the doctor himself bandages the legs he has injected, at the return clinics two nurses skilled in bandaging assist the doctors and complete the bandaging of the legs. One of the doctors who attends the return clinics is a general practitioner who works on a sessional basis, the other is a hospital staff member of the Venous Insufficiency Unit.
Consultation clinic
A consultation clinic is held each week and lasts two hours. It is attended by a member of the staff with considerable experience in the technique of compression sclerotherapy. Patients may be referred to the consultation clinic if the doctor treating them thinks they are not responding adequately to treatment, or if he wants the advice of a more experienced colleague. An example of this is where a patient has an ulcer where malignant change is suspected. Patients who have attended the return clinics on more than seven occasions are automatically referred to the consultation clinic.
Discharge clinic
The discharge clinic is also attended by one of the more experienced doctors. Patients who have completed their course of treatment are seen there, and if considered to have responded satisfactorily, they are discharged. They are given an appointment to be seen again after three months. If they are not satisfactory they are referred back to the return clinic. Particularly difficult cases are referred to the consultation clinic.
Material required for the clinic
There must be adequate room and light for each doctor to diagnose and treat patients. The doctor must be able to stand on either side of the couch so these should not be placed too close to the wall. Good ventilation is essential since the patients are forbidden to was their legs after treatment of varicose veins commences. In addition some patients may have infected ulcers.
Couches. Couches used at the clinic in Sir Patrick Dun's Hospital are 30 in. high, 6 ft. long and 21 in. wide. The head of the couch can be elevated. Trays containing bandages and rubber pads are attached in such a way that they can be swung beneath the couches.
Syringes. All-glass 2 ml. syringes, filled with 1 ml. of sodium tetradecyl are used. Each new patient receives an average of 3.5 injections, thus 175 syringes per 50 patients are required. At the return clinics each patient receives an average of 1.5 injections, thus 75 syringes per 50 patients are required. A supply of syringes is kept in a metal tray which is placed on a trolley beside the head of each couch.
Needles. Very sharp needles are essential. They are 1/2 in. in length. Disposable No. 20 needles are used at the clinic in Sir Patrick Dun's Hospital.
Bandages. An average of three 3 in. crepe bandages per leg per patient are required. Thus at the new clinic 150 bandages are necessary for 50 patients. At the return clinic an extra supply of bandages will be necessary because some of the patients will be having both legs treated at the same time.
Rubber pads. These pads are individually cut, shaped by scissors from sheets of 9 ft. by 3 ft. by 1 in. thick Dunlopillo foam rubber. Various sizes of pads are used: 2 in. by 2 in., 3 in. by 3 in., 2 in. by 5 in. and 2 in. by 7 in. The smaller pads are used near the ankle and the largest ones on the thigh. The 3 in. by 3 in. and the 2 in. by 5 in. pads are used on the back of the calf and on the inner and outer aspects of the leg. It is usual to place a pad 3 in. by 3 in. in size behind the knee when the bandages extend above the knee. A rubber pad should be incorporated in the bandages so that it protrudes above the highest bandage. About 225 pads are required in the treatment of 50 new patients and about 125 for the treatment of 50 old patients if one leg only is being injected.
Strapping. Three-inch strips of 1 in. strapping are used to secure the bandages. These are prepared before the clinic and are attached to the side of the trolley on which the syringes are placed so that they are easily accessible.
Lint. A supply of lint should be available for use in dressing varicose ulcers. The bandages, rubber pads and lint are kept in trays supported by brackets which can be swung out from beneath the couches.
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