Surgical Algorithms
-
Upload
buckminster-haney -
Category
Documents
-
view
28 -
download
0
description
Transcript of Surgical Algorithms
![Page 1: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/1.jpg)
Surgical Algorithms
![Page 2: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/2.jpg)
Surgical Algorithms
• Consults
• Patient Transport
• Rounding
• Turnover/Sign-out
• Stress
• Integrity
![Page 3: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/3.jpg)
![Page 4: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/4.jpg)
Consults
?
Urgent/Emergent Elective
![Page 5: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/5.jpg)
Consults“The Question”
• Has the question been clearly communicated/documented?
• Does it appear in the consultation request, progress notes?
• It should be re-stated in the consultation with the accompanying answer.
![Page 6: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/6.jpg)
Consults
?
Urgent/Emergent Elective
![Page 7: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/7.jpg)
Consults“Urgent/Emergent”
• Acute abdomen• Acute abdomen with shock• Pneumothorax• Tension pneumothorax• Peripheral vascular disease with rest pain• Peripheral vascular disease with thromobosis
***Remember your ABC’s!!!
![Page 8: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/8.jpg)
Consults
?
Urgent/Emergent Elective
![Page 9: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/9.jpg)
Consults“Elective”
• Central line placement for hyperalimentation• Hernia evaluation (not incarcerated or
stragulated)• Long term intubation for tracheostomy• Asympomatic carotid artery disease• Cholelithiasis
![Page 10: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/10.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 11: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/11.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 12: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/12.jpg)
Consults“Look for yourself”
• Interview and examine the patient directly yourself
• Repeat essential tests and studies as felt essential to making the correct diagnosis for the delivery of the correct/appropriate care
• Obtain additional studies and tests as indicated
![Page 13: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/13.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 14: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/14.jpg)
Consults“Be brief”
• Be careful not to simply regurgitate all of what is in the patient’s chart
![Page 15: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/15.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 16: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/16.jpg)
Consults“Be specific”
• A goal - oriented consult that specifically answers the question at hand will most often be helpful
• If posing differing diagnoses, be concise
![Page 17: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/17.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 18: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/18.jpg)
Consults“Contingency plan”
• There will almost always be therapeutic options and alternatives
• It may be appropriate to state such in the consultation or,
• Discuss these options directly with the requesting team/physician
![Page 19: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/19.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 20: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/20.jpg)
Consults“Teach”
• Remember that a consult is almost always a learning/teaching opportunity
• One may include a pertinent citing of a reference that is pertinent and current
• Don’t be condescending• Be tactful
![Page 21: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/21.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 22: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/22.jpg)
Consults“Don’t assume primary care”
• Remain mindful that you are not the patient’s primary physician
• Remember your place in your interactions with the patient
• Keep the primary physician in the loop and• ****The university setting may often be the
exception to this rule
![Page 23: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/23.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 24: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/24.jpg)
Consults“Discuss”
• Talk is cheap and effective• Direct contact with the requesting physician or
team will help to alleviate tensions, explain clarify and eliminate controversial matters
• You may talk about what may not be written in the chart that may create liability for the primary care physician
![Page 25: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/25.jpg)
Consults
Process
look for yourself
be brief
be specific
contingencyplan teach
do not assume
carediscuss
followup
![Page 26: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/26.jpg)
Consults“Follow-up”
• A great opportunity to learn• To determine whether important
recommendations were acted upon• May often fall into the background and follow
“peripherally”• Surgical intervention may of necessity occur
during this period
![Page 27: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/27.jpg)
Transport
?
Urgent/Emergent Elective
![Page 28: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/28.jpg)
![Page 29: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/29.jpg)
![Page 30: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/30.jpg)
Transport
?
Urgent/Emergent Elective
![Page 31: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/31.jpg)
Transport“Urgent/Emergent”
• Acute abdomen with shock• Pneumothorax• Tension pneumothorax• Peripheral vascular disease with rest pain• Peripheral vascular disease with thromobosis
***Remember your ABC’s!!!
![Page 32: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/32.jpg)
Transport
?
Urgent/Emergent Elective
Stable Unstable
![Page 33: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/33.jpg)
Transport
?
Urgent/Emergent Elective
Stable Unstable
Will the examalter therapy?
![Page 34: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/34.jpg)
Transport
?
Urgent/Emergent Elective
Stable Unstable
Cause of instability?
![Page 35: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/35.jpg)
Transport“Urgent/Emergent-unstable”
• Hypotension with/without pressors (shock)• Hypoxic• Tachypnea in the non-ventilator patient• High airway pressures ( super-peep)• Abdominal compartment syndrome• The unstable head injured patient!!!!
***Remember your ABC’s!!!
![Page 36: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/36.jpg)
Transport“Pre-flight checklist”
• Senior clinician patient evaluation• Equipment check
– Ventilator, pumps• Medication check
– Sedation, analgesia• Travel plan and route• Notification of personnel at destination• Transport method• Informed consent
• ** Is this trip necessary????
![Page 37: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/37.jpg)
Transport
?
Urgent/Emergent Elective
Implies stability
![Page 38: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/38.jpg)
Transport“Elective”
• Patient area– Regular inpatient “vs” PCU
• Do physical exam
• Review chart
• Is the patient at risk for instability?
• Does the patient need a physician escort
![Page 39: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/39.jpg)
![Page 40: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/40.jpg)
Transport“Elective”
• Patient area– Regular inpatient “vs” PCU
• Do physical exam
• Review chart
• Is the patient at risk for instability?
• Does the patient need a physician escort
• Is the journey/trip necessary??
![Page 41: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/41.jpg)
![Page 42: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/42.jpg)
RoundingGeneral Considerations
• Integral to the process of medicine/surgery
• When effective and efficient, can be an invaluable asset to patient care
• Fundamental teaching tool
![Page 43: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/43.jpg)
RoundingResident Considerations
• Punctual
• Enthusiastic
• Proper attire
• Alert
• Communicative
• Initiative
![Page 44: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/44.jpg)
RoundingPresenting
• State patient name• Disease process• POD # (If post-op)• Vital signs and I/O• Pertinent exam • Critical values and study results• Discussion???…….Plan!!!!
* Be organized and thorough!!!
![Page 45: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/45.jpg)
RoundingDisposition
• Discussion occurs outside of the patient’s room (special issues beyond earshot)
• Most senior personnel addresses the patient
• Additional information will be solicited as indicated
• Wound care is variable
![Page 46: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/46.jpg)
![Page 47: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/47.jpg)
TurnoverGeneral considerations
• Highly variable
• Shared responsibility
• As work hours
• Turnovers
![Page 48: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/48.jpg)
TurnoverPhysical setting
• Private (relatively speaking)
• Quiet
• Good lighting
• Limited interruptions
![Page 49: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/49.jpg)
TurnoverSocial setting
• Mutually acceptable
• Conducive to exchange
![Page 50: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/50.jpg)
TurnoverLanguage barrier
• Diversity among medical professionals
• Avoid colloquialisms
• Use linguistic checks and balances
• Review critical points
![Page 51: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/51.jpg)
TurnoverCommunication barrier
• Direct
• Face to face
• Maximizes information channels – Expression– Posture– Eye contact– Verbal cues
![Page 52: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/52.jpg)
TurnoverPatient information
• Identification information, location, etc…• Current medical issues• Pending tests to follow• Potential problems (family interface)• Severity of illness rating• Code status as indicated• Overall concerns • Chain of command (Attending involvement)
![Page 53: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/53.jpg)
![Page 54: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/54.jpg)
![Page 55: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/55.jpg)
Fatigue
Inexperience
Fear of Failure
UnknownTime
Stress
![Page 56: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/56.jpg)
Integrity
Thoughts/Values Actions/Behavior
![Page 57: Surgical Algorithms](https://reader036.fdocuments.in/reader036/viewer/2022062422/56812eed550346895d948901/html5/thumbnails/57.jpg)