The Culture of Surgery Sanjeet Patel, M.D.

Before you start Talk to the student leaving your service Logistics when and where patient list what are the med/surg issues anything interesting during the case Expectations who pimps? what do they pimp about what forms do they use, how do you fill it out what was deemed “helpful” Tips or advice Page the senior resident Time and location for morning rounds

Before you leave the house… Prepare for anything

What to Wear? Professional Attire unless you are IN THE OR Clinics ALL conferences AM rounds Always bring scrubs Clean white coat

What to Wear? Think about how you want to be perceived Medical student vs. physician-in-training

TIP #2: Stethoscope around neck Backpack on rounds Scruff Hats Strong                                      Scruff Hats Strong cologne Long fingernails Long fingernails Strong perfume

Anatomy of a Surgical Service Attending Fellow Senior Resident Junior Resident Intern MS III Each person plays a vital role

TIP #3: FOLLOW THE PERSON ABOVE YOU Watch what the intern does or doesn’t do Organizing information Presenting at rounds Making decisions Talking to patients You will soon be in his or her shoes BUT! do not tell a patient something you dont know; or worse something they didnt know...

Typical Schedule Pre-rounds: 5:30 AM Rounds: 6 – 6:30 / 7AM Preop / Breakfast / Conference 7AM OR 7:30 AM / Clinic 8 AM Afternoon rounds 1 – 6 PM Go home / On-Call

Prerounds Arrive at the hospital early See and examine your patients Check and record vitals & I/Os Look through chart Notes from previous day Orders (overnight events, new meds) Review MAR every day Ask RN or on-call resident about issues

TIP #4: ORGANIZATION IS THE KEY TO SUCCESS Know/record all pertinent information Initial H&P (including PMH, PSH, Meds, etc) Preop and postop course Salient events 5 x 7 index cards (Watch the R3) Printed patient info sheets

Daily information on floor patients

Daily information on ICU patients

Daily Progress Notes SOAP format Concise Try to come up with your own assessment and plan Finish note before you leave for the AM DO NOT keep notes in your pocket Notes must be co-signed by resident

Rounds BE ON TIME! Pay attention to everyone & everything Present your patients Be helpful Change dressings : if rounding either have whats needed in your hand or do it yours Gather charts Be engaged

How to present Patient name HD/POD # for procedure/diagnosis Antibiotic name and day # Diet Overnight events Subjective Objective Assessment and plan

ALWAYS Start With: Name: Post-op day: Procedure/Dx: Antibiotics: Diet: “Mr. Smith is post-op day #1 from sigmoid colectomy for diverticulitis. Cefoxitin day 2. NPO.”

Overnight events MAJOR events only Be concise “The patient had an unwitnessed fall while attempting to get out of bed. He said he fell on his left side. Neurological and musculoskeletal exams have been unchanged from baseline. CT of the head was unremarkable.” “No events overnight.”

Subjective Relevant information or complaints that the patient tells you “The patient’s pain has improved after his PCA was discontinued yesterday. The patient ambulated twice without difficulty. The patient passed flatus, but did not have a bowel movement. He has been nauseated all day but did not vomit.”

Objective: Vitals Temperature “Vitals: Tmax 100.4, Tmax and Tcurrent Blood pressure Range & Current Pulse RR O2 sat Supplemental O2 “Vitals: Tmax 100.4, current 98.6. 120-175/65-95, currently 110/65. 80-115, currently 76. 14-18. O2 sat 94-96% on 2L nasal canula.”

Objective: Vitals Temperature “Vitals: Tmax 100.4, Tmax and Tcurrent Blood pressure Range & Current Pulse RR O2 sat Supplemental O2 “Vitals: Tmax 100.4, 20-175/5-95 10-115. 14-68. “fine.”

Objective: I/Os Total first, “I/Os 2050 in and 1980 out. Ins then breakdown Ins IVF (type & rate) TPN PO Tube feeds (type & rate) Outs Urine BM Drains (amt & kind) NG tube (amt & kind) Chest tube (amt & kind) “I/Os 2050 in and 1980 out. For ins, 1800 was IV fluid (75 cc/hr D5 ½ NS) and 250 was PO. For outs, 1800 was urine. JP #1 put out 75 cc of serosanguinous fluid and JP#2 put out 105 cc of bilious fluid.”

Objective: I/Os Total first, “I/Os 2050 in and 80 out. Ins then breakdown Ins IVF (type & rate) TPN PO Tube feeds (type & rate) Outs Urine BM Drains (amt & kind) NG tube (amt & kind) Chest tube (amt & kind) “I/Os 2050 in and 80 out. For ins, 1800 was IV fluid (75 cc/hr D5 ½ NS) and nothing recorded was PO. For outs, 80 was urine. nothing else was recorded Dr. Hines.”

Objective: Physical Exam Do a full focused physical exam daily Present only pertinent positives & negatives ALWAYS examine the wound carefully Remove post-op dressings on POD #2, then change every day Monitor for erythema, warmth, drainage “Exam was significant for rhonchi throughout both lung fields. Bowel sounds are absent. Abdomen is somewhat distended and tympanic. The wound is clean and dry.”

Objective: Labs & Studies AM labs often not back before rounds Know shorthand for recording labs: Always look at films yourself before you read the radiologists report

Assessment and Plan This is your best opportunity for thinking and learning. Think in terms of systems so you will never forget anything. You can come up with an incorrect assessment and a terrible plan, but you will be a step ahead of the student who can’t come up with one at all.

Assessment and Plan Neuro Cardiovascular Is the patient awake? Is pain controlled? Cardiovascular Is blood pressure controlled? How is the heart rate? Are there preop cardiovascular problems that should be addressed?

Assessment and Plan Pulmonary If the patient is on a ventilator: Can the vent settings be weaned? Can the patient be extubated? If the patient is on supplemental O2: Can this be weaned off? Is the patient using an incentive spirometer, really is the patient using IS?????? Is he/she receiving chest physiotherapy?

Assessment and Plan Renal ID Is the UOP adequate? Has the foley been removed? ID Is the patient febrile? Is the WBC elevated? Are there any culture results back yet? Can any antibiotics be stopped?

TIP #6: WHY MY PATIENT IS FEBRILE Wind, POD1-2, atelectasis*, aspiration, pna Water, POD3-5, UTI Walking, POD4-6, DVT or PE Wound, POD5-7, wound infxn Wonder drugs, drug fever

Assessment and Plan Heme Endocrine Is the hematocrit stable? Are platelets & coags normal? Endocrine Is blood glucose well controlled?

Fluid, Electrolytes, Nutrition Assessment and Plan GI Are the bowels working yet? Can the NGT be removed? Is the patient passing gas or having BMs? Is the diet appropriate? Fluid, Electrolytes, Nutrition Do electrolytes need to be replaced? (Ca, Mag, Phos, K) Can the IV be heplocked? How are the nutritional parameters? (albumin, prealbumin)

Assessment and Plan Activity Prophylaxis Is the patient ambulating? Is PT/OT needed? Prophylaxis GI prophylaxis: H2 blocker or PPI DVT prophylaxis: SCDs or sub-Q lovenox or heparin

TIP #7: TAKE ADVANTAGE OF EVERY LEARNING OPPORTUNITY IV placement/blood draws Nasogastric tube placement Foley Catheter placement Wet-to-dry dressing changes/Wound care Stripping of JP drains Pulling JP drains or chest tubes Suturing (simple interrupted or subcuticular) Knot tying (two handed throws) Incision and drainage of abscess

Preparation for OR Day Before Surgery Find out what cases you will scrub in on Read – Focus on: Indications for surgery Disease process Anatomy Know your patient

Preparation for OR Day of Surgery All patients need pre-op H&P & consent Help the residents with the H&P Introduce yourself to the patient Examine the patient (if appropriate) Record H&P on your patient info sheets – this is now your patient!

Decorum in the OR Introduce yourself to all OR staff, especially the circulating and scrub nurses Pull your own gloves & give to scrub nurse Write your name on the whiteboard Ask questions at APPROPRIATE times Cause as little interruption as possible

Preop Note If H&P is < 30 days but >24 hours old Focus on appropriateness for the OR: What surgery? Appropriate indication? Cardiac/medical workup complete History (CVA,CHF, MI, Valvular), DM, Cr > 2.0 Consents signed & patient understands? Likelihood of blood transfusion? Is there a current type and screen? Is blood ordered and on call to OR? Is blood consent signed?

Preop Note Diagnosis: Planned Procedure: Surgeon: Labs: CXR/Other tests: EKG: Blood: Consent:

Example Preop Note Diagnosis: Acute cholecystitis Planned Procedure: Laparoscopic versus open cholecystectomy Surgeon: Dr. Schmit Labs: LFTs, CBC, Electrolytes CXR/Other tests: Ultrasound results EKG: (If done) Blood: Pt has active type and screen Consent: Procedure and blood consents signed and in chart.

Brief Op Note Pre-Op Diagnosis: Post-Op Diagnosis: Procedure: Attending Surgeon: Assistant Surgeons: Anesthesia: Intravenous Fluids: Estimated Blood Loss: Urine Output: Specimen: Drain: Complications: Condition:

Example Brief Op Note Pre-Op Diagnosis: Right inguinal hernia Post-Op Diagnosis: Direct right inguinal hernia Procedure: Repair of right inguinal hernia with mesh Attending Surgeon: Dr. Charles Chandler Assistant Surgeons: List resident and med student Anesthesia: LMA + local Intravenous Fluids: 500 ml LR Estimated Blood Loss: Minimal Urine Output: None Specimen: Hernia sac Drain: None Complications: None (probably but ask resident) Condition: Stable to PACU

Post Op Check/Post Op Note Usually 3-4 hours after OR Review PACU notes and vitals Review any post-op labs or imaging Like a focused SOAP note: Pain controlled? Vital signs stable? Bleeding or drainage on dressing? Has patient urinated? Drain output and characterization?

Clinics Dress professionally and be on time Go see and examine patients, then present to attending or resident Be efficient Like morning presentations, be concise Try to formulate an assessment & plan Write a note to be cosigned

Afternoon Rounds Follow up on studies and labs Check in with the on-call resident Get vitals and I/Os for the day See your patient before rounds – sometimes they can tell you more information than anything else!

Call Usually once per week Work with the on-call intern/resident Always bring your own work to do No call prior to busy clinic days Excellent opportunity to see consults and learn to make your own decisions

What to Read? For your patients For your exams 1 review book                                                           1 review book 1 textbook For your patients Disease process Treatment Options Surgical Options For your exams Systematic, scheduled topic review

Everyone Can Do It! Don’t disappear Sleeping in the call room doesn’t count as being there Your teammates will quickly tire of having to answer the question, “Where’s <insert name>?” © 2003-2004 Michelle Au http://www.theunderweardrawer.homestead.com

Everyone Can Do It! READ! Every day About your patients About your cases © 2003-2004 Michelle Au http://www.theunderweardrawer.homestead.com

Have Fun and Good Luck!