1. The Culture of Surgery
Sanjeet Patel, M.D.

2. 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

3. Before you leave the house…
Prepare for anything

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

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

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

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

8. 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...

9. 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

10. 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

11. 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

12. Daily information on floor patients

13. Daily information on ICU patients

14. 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

15. 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

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

17. 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.”

18. 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.”

19. 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.”

20. 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.
/65-95, currently
110/65.
80-115, currently 76.
14-18.
O2 sat 94-96% on 2L nasal
canula.”

21. 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
14-68.
“fine.”

22. 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.”

23. 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.”

24. 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.”

25. 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

26. 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.

27. 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?

28. 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?

29. 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?

30. 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

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

32. 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)

33. 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

34. 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

35. 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

36. 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!

37. 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

38. 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?

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

40. 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.

41. 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:

42. 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

43. 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?

44. 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

45. 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!

46. 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

47. 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

48. 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>?”
© Michelle Au

49. Everyone Can Do It! READ! Every day About your patients
About your cases
© Michelle Au

50. Have Fun and Good Luck!