The Culture of SurgeryThe Culture of Surgery

Sanjeet Patel, M.D.Sanjeet Patel, M.D.

Before you startBefore you startTalk to the student leaving your serviceTalk to the student leaving your service LogisticsLogistics

when and wherewhen and where patient listpatient list what are the med/surg issueswhat are the med/surg issues anything interesting during the caseanything interesting during the case

ExpectationsExpectations who pimps?who pimps? what do they pimp aboutwhat do they pimp about what forms do they use, how do you fill it outwhat forms do they use, how do you fill it out what was deemed “helpful”what was deemed “helpful”

Tips or adviceTips or advice

Page the senior residentPage the senior resident Time and location for morning roundsTime and location for morning rounds ExpectationsExpectations

Before you leave the house…Before you leave the house…

Prepare for anythingPrepare for anything

Professional Attire Professional Attire unless you are IN THE ORunless you are IN THE OR ClinicsClinics ALL conferencesALL conferences AM roundsAM rounds

Always bring scrubsAlways bring scrubs

Clean white coatClean white coat

What to Wear?What to Wear?

What to Wear?What to Wear?

Think about how you want to be perceivedThink about how you want to be perceived

Medical student vs. physician-in-trainingMedical student vs. physician-in-training

Stethoscope around neckStethoscope around neck

Backpack on roundsBackpack on rounds                                    

ScruffScruff

HatsHats

StrongStrongcolognecologneLongLongfingernailsfingernails

LongLongfingernailsfingernails

Strong Strong perfumeperfume

TIP #2:TIP #2:

Anatomy of a Surgical ServiceAnatomy of a Surgical Service

MS III

Intern

Junior Resident

Senior Resident

AttendingFellow

Each person plays a vital roleEach person plays a vital role

TIP #3: FOLLOW THE PERSON TIP #3: FOLLOW THE PERSON ABOVE YOUABOVE YOU

Watch what the intern does or doesnWatch what the intern does or doesn’’t dot do Organizing informationOrganizing information Presenting at roundsPresenting at rounds Making decisionsMaking decisions Talking to patientsTalking to patients

You will soon be in his or her shoesYou will soon be in his or her shoes

BUT! do not tell a patient something you dontBUT! do not tell a patient something you dont

know; or worse something they didnt know...know; or worse something they didnt know...

Typical ScheduleTypical Schedule

Pre-rounds: 5:30 AMPre-rounds: 5:30 AM

Rounds: 6 – 6:30 / 7AMRounds: 6 – 6:30 / 7AM

Preop / Breakfast / Conference 7AMPreop / Breakfast / Conference 7AM

OR 7:30 AM / Clinic 8 AMOR 7:30 AM / Clinic 8 AM

Afternoon rounds 1 – 6 PM Afternoon rounds 1 – 6 PM

Go home / On-CallGo home / On-Call

PreroundsPreroundsArrive at the hospital earlyArrive at the hospital early

See and examine your patientsSee and examine your patients

Check and record vitals & I/OsCheck and record vitals & I/Os

Look through chartLook through chart Notes from previous dayNotes from previous day Orders (overnight events, new meds)Orders (overnight events, new meds) Review MAR every dayReview MAR every day

Ask RN or on-call resident about issuesAsk RN or on-call resident about issues

TIP #4: ORGANIZATION IS TIP #4: ORGANIZATION IS THE KEY TO SUCCESSTHE KEY TO SUCCESS

Know/record all pertinent informationKnow/record all pertinent information Initial H&P (including PMH, PSH, Meds, etc)Initial H&P (including PMH, PSH, Meds, etc) Preop and postop coursePreop and postop course Salient events Salient events

5 x 7 index cards (Watch the R3)5 x 7 index cards (Watch the R3)

Printed patient info sheetsPrinted patient info sheets

Daily information on floor patientsDaily information on floor patients

Daily information on ICU patientsDaily information on ICU patients

Daily Progress NotesDaily Progress Notes

SOAP formatSOAP format

ConciseConcise

Try to come up with your ownTry to come up with your ownassessment and planassessment and plan

Finish note before you leave for the AM Finish note before you leave for the AM

DO NOT keep notes in your pocket DO NOT keep notes in your pocket Notes must be co-signed by residentNotes must be co-signed by resident

RoundsRounds

BE ON TIME!BE ON TIME!

Pay attention to everyone & everythingPay attention to everyone & everything

Present your patientsPresent your patients

Be helpful Be helpful Change dressings : if rounding either haveChange dressings : if rounding either have whats needed in your hand or do it yourswhats needed in your hand or do it yours Gather chartsGather charts

Be engagedBe engaged

How to presentHow to present

Patient namePatient name

HD/POD # for procedure/diagnosisHD/POD # for procedure/diagnosis

Antibiotic name and day #Antibiotic name and day #

DietDiet

Overnight eventsOvernight events

SubjectiveSubjective

ObjectiveObjective

Assessment and planAssessment and plan

ALWAYS Start With:ALWAYS Start With:

Name:Name:

Post-op day:Post-op day:

Procedure/Dx:Procedure/Dx:

Antibiotics:Antibiotics:Diet:Diet:

““Mr. Smith is Mr. Smith is

post-op day #1 frompost-op day #1 from

sigmoid colectomy for sigmoid colectomy for diverticulitis.diverticulitis.

Cefoxitin day 2.Cefoxitin day 2.

NPO.NPO.””

Overnight eventsOvernight events

MAJOR events onlyMAJOR events only

Be conciseBe concise

““The patient had an unwitnessed fall while The patient had an unwitnessed fall while attempting to get out of bed. He said he fell on attempting to get out of bed. He said he fell on his left side. Neurological and musculoskeletal his left side. Neurological and musculoskeletal exams have been unchanged from baseline. CT exams have been unchanged from baseline. CT of the head was unremarkable.of the head was unremarkable.””

““No events overnight.No events overnight.””

SubjectiveSubjective

Relevant information or complaints thatRelevant information or complaints thatthe patient tells youthe patient tells you

““The patientThe patient’’s pain has improved after his s pain has improved after his PCA was discontinued yesterday. The PCA was discontinued yesterday. The patient ambulated twice without difficulty. patient ambulated twice without difficulty. The patient passed flatus, but did not The patient passed flatus, but did not have a bowel movement. He has been have a bowel movement. He has been nauseated all day but did not vomit.nauseated all day but did not vomit.””

Objective: VitalsObjective: Vitals

TemperatureTemperatureTTmaxmax and T and Tcurrentcurrent

Blood pressureBlood pressureRange & CurrentRange & Current

PulsePulseRange & CurrentRange & Current

RRRRRange & CurrentRange & Current

O2 satO2 satRange & CurrentRange & CurrentSupplemental O2Supplemental O2

““Vitals: Tmax 100.4,Vitals: Tmax 100.4,current 98.6. current 98.6.

120-175/65-95, currently120-175/65-95, currently110/65. 110/65.

80-115, currently 76. 80-115, currently 76.

14-18. 14-18.

O2 sat 94-96% on 2L nasalO2 sat 94-96% on 2L nasalcanula.canula.””

Objective: VitalsObjective: Vitals

TemperatureTemperatureTTmaxmax and T and Tcurrentcurrent

Blood pressureBlood pressureRange & CurrentRange & Current

PulsePulseRange & CurrentRange & Current

RRRRRange & CurrentRange & Current

O2 satO2 satRange & CurrentRange & CurrentSupplemental O2Supplemental O2

““Vitals: Tmax 100.4,Vitals: Tmax 100.4,

20-175/5-9520-175/5-95

10-115. 10-115.

14-68. 14-68.

““fine.fine.””

Objective: I/OsObjective: I/Os

Total first, Total first, then breakdownthen breakdown

InsIns IVF (type & rate)IVF (type & rate) TPNTPN POPO Tube feeds (type & rate)Tube feeds (type & rate)

OutsOuts UrineUrine BMBM Drains (amt & kind)Drains (amt & kind) NG tube (amt & kind)NG tube (amt & kind) Chest tube (amt & kind)Chest tube (amt & kind)

““I/Os 2050 in and 1980 out.I/Os 2050 in and 1980 out.

For ins, 1800 was IV fluid For ins, 1800 was IV fluid (75 cc/hr D5 ½ NS) and (75 cc/hr D5 ½ NS) and 250 was PO.250 was PO.

For outs, 1800 was urine. For outs, 1800 was urine. JP #1 put out 75 cc of JP #1 put out 75 cc of serosanguinous fluid and serosanguinous fluid and JP#2 put out 105 cc of JP#2 put out 105 cc of bilious fluid.bilious fluid.””

Objective: I/OsObjective: I/Os

Total first, Total first, then breakdownthen breakdown

InsIns IVF (type & rate)IVF (type & rate) TPNTPN POPO Tube feeds (type & rate)Tube feeds (type & rate)

OutsOuts UrineUrine BMBM Drains (amt & kind)Drains (amt & kind) NG tube (amt & kind)NG tube (amt & kind) Chest tube (amt & kind)Chest tube (amt & kind)

““I/Os 2050 in and 80 out.I/Os 2050 in and 80 out.

For ins, 1800 was IV fluid For ins, 1800 was IV fluid (75 cc/hr D5 ½ NS) and (75 cc/hr D5 ½ NS) and nothing recorded was nothing recorded was PO.PO.

For outs, 80 was urine. For outs, 80 was urine. nothing else was nothing else was recorded Dr. Hines.recorded Dr. Hines.””

Objective: Physical Exam Objective: Physical Exam

Do a full focused physical exam dailyDo a full focused physical exam daily

Present only pertinent positives & negativesPresent only pertinent positives & negatives

ALWAYS examine the wound carefullyALWAYS examine the wound carefully Remove post-op dressings on POD #2, Remove post-op dressings on POD #2,

then change every daythen change every day Monitor for erythema, warmth, drainageMonitor for erythema, warmth, drainage

““Exam was significant for rhonchi throughout Exam was significant for rhonchi throughout both lung fields. both lung fields. Bowel sounds are absent. Bowel sounds are absent. Abdomen is somewhat distended and tympanic. Abdomen is somewhat distended and tympanic. The wound is clean and dry.The wound is clean and dry.””

Objective: Labs & StudiesObjective: Labs & Studies

AM labs often not back before roundsAM labs often not back before rounds

Know shorthand for recording labs:Know shorthand for recording labs:

Always look at films yourself Always look at films yourself beforebefore you youread the radiologists reportread the radiologists report

Assessment and PlanAssessment and Plan

This is your best opportunity forThis is your best opportunity forthinking and learning.thinking and learning.

Think in terms of systems so you willThink in terms of systems so you willnever forget anything. never forget anything.

You can come up with an incorrectYou can come up with an incorrectassessment and a terrible plan, assessment and a terrible plan, but you will be a step ahead of the studentbut you will be a step ahead of the studentwho canwho can’’t come up with one at all.t come up with one at all.

Assessment and Plan Assessment and Plan

NeuroNeuro

CardiovascularCardiovascular

Is the patient awake?Is the patient awake?

Is pain controlled?Is pain controlled?

Is blood pressure controlled?Is blood pressure controlled?

How is the heart rate?How is the heart rate?

Are there preop cardiovascular problemsAre there preop cardiovascular problemsthat should be addressed?that should be addressed?

Assessment and Plan Assessment and Plan

PulmonaryPulmonaryIf the patient is on a ventilator:If the patient is on a ventilator: Can the vent settings be weaned?Can the vent settings be weaned? Can the patient be extubated?Can the patient be extubated?

If the patient is on supplemental O2:If the patient is on supplemental O2: Can this be weaned off?Can this be weaned off?

Is the patient using an incentive spirometer, Is the patient using an incentive spirometer,

really is the patient using IS??????really is the patient using IS??????

Is he/she receiving chest physiotherapy?Is he/she receiving chest physiotherapy?

Assessment and Plan Assessment and Plan

RenalRenal

IDID

Is the UOP adequate?Is the UOP adequate?

Has the foley been removed?Has the foley been removed?

Is the patient febrile? Is the patient febrile?

Is the WBC elevated?Is the WBC elevated?

Are there any culture results back Are there any culture results back yetyet??

Can any Can any antibioticsantibiotics be stopped? be stopped?

TIP #6: WHY MY PATIENT IS TIP #6: WHY MY PATIENT IS FEBRILEFEBRILE

Wind, POD1-2, atelectasis*, aspiration, pnaWind, POD1-2, atelectasis*, aspiration, pna

Water, POD3-5, UTIWater, POD3-5, UTI

Walking, POD4-6, DVT or PEWalking, POD4-6, DVT or PE

Wound, POD5-7, wound infxnWound, POD5-7, wound infxn

Wonder drugs, drug feverWonder drugs, drug fever

Assessment and Plan Assessment and Plan

HemeHeme

EndocrineEndocrine

Is the hematocrit stable?Is the hematocrit stable?

Are platelets & coags normal?Are platelets & coags normal?

Is blood glucose well controlled?Is blood glucose well controlled?

Assessment and Plan Assessment and Plan GIGI

Fluid, Electrolytes, NutritionFluid, Electrolytes, Nutrition

Are the bowels working yet?Are the bowels working yet? Can the NGT be removed?Can the NGT be removed? Is the patient passing gas or having BMs?Is the patient passing gas or having BMs?

Is the diet appropriate?Is the diet appropriate?

Do electrolytes need to be replaced?Do electrolytes need to be replaced?(Ca, Mag, Phos, K)(Ca, Mag, Phos, K)

Can the IV be heplocked?Can the IV be heplocked?

How are the nutritional parameters?How are the nutritional parameters?(albumin, prealbumin)(albumin, prealbumin)

Assessment and Plan Assessment and Plan

ActivityActivity

ProphylaxisProphylaxis

Is the patient ambulating? Is the patient ambulating?

Is PT/OT needed?Is PT/OT needed?

GI prophylaxis: GI prophylaxis: H2 blocker or PPIH2 blocker or PPI

DVT prophylaxis: DVT prophylaxis: SCDs or sub-Q lovenox or heparinSCDs or sub-Q lovenox or heparin

TIP #7: TAKE ADVANTAGE OF TIP #7: TAKE ADVANTAGE OF EVERY LEARNING EVERY LEARNING

OPPORTUNITYOPPORTUNITYIV placement/blood drawsIV placement/blood draws

Nasogastric tube placementNasogastric tube placement

Foley Catheter placementFoley Catheter placement

Wet-to-dry dressing changes/Wound careWet-to-dry dressing changes/Wound care

Stripping of JP drainsStripping of JP drains

Pulling JP drains or chest tubesPulling JP drains or chest tubes

Suturing (simple interrupted or subcuticular)Suturing (simple interrupted or subcuticular)

Knot tying (two handed throws)Knot tying (two handed throws)

Incision and drainage of abscessIncision and drainage of abscess

Preparation for OR Preparation for OR

Day Before SurgeryDay Before SurgeryFind out what cases you will scrub in onFind out what cases you will scrub in on

ReadRead – Focus on: – Focus on: Indications for surgeryIndications for surgery Disease processDisease process AnatomyAnatomy

Know your patientKnow your patient

Preparation for OR Preparation for OR

Day of SurgeryDay of Surgery

All patients need pre-op H&P & consentAll patients need pre-op H&P & consent

Help the residents with the H&PHelp the residents with the H&P

Introduce yourself to the patientIntroduce yourself to the patient

Examine the patient (if appropriate)Examine the patient (if appropriate)

Record H&P on your patient info sheets – Record H&P on your patient info sheets – this is now your patient!this is now your patient!

Decorum in the ORDecorum in the OR

• Introduce yourself to all OR staff,Introduce yourself to all OR staff,especially the circulating and scrub nursesespecially the circulating and scrub nurses

• Pull your own gloves & give to scrub nursePull your own gloves & give to scrub nurse

• Write your name on the whiteboardWrite your name on the whiteboard

• Ask questions at APPROPRIATE timesAsk questions at APPROPRIATE times

• Cause as little interruption as possibleCause as little interruption as possible

Preop NotePreop Note• If H&P is < 30 days but >24 hours oldIf H&P is < 30 days but >24 hours old

• Focus on appropriateness for the OR:Focus on appropriateness for the OR: What surgery? Appropriate indication?What surgery? Appropriate indication? Cardiac/medical workup completeCardiac/medical workup complete

History (CVA,CHF, MI, Valvular), DM, Cr > 2.0History (CVA,CHF, MI, Valvular), DM, Cr > 2.0

Consents signed & patient understands?Consents signed & patient understands? Likelihood of blood transfusion? Likelihood of blood transfusion?

Is there a current type and screen?Is there a current type and screen?Is blood ordered and on call to OR?Is blood ordered and on call to OR?Is blood consent signed?Is blood consent signed?

Preop NotePreop Note

• Diagnosis:Diagnosis:

• Planned Procedure:Planned Procedure:

• Surgeon:Surgeon:

• Labs:Labs:

• CXR/Other tests:CXR/Other tests:

• EKG:EKG:

• Blood: Blood:

• Consent:Consent:

Example Preop NoteExample Preop Note• Diagnosis: Diagnosis: Acute cholecystitisAcute cholecystitis• Planned Procedure: Planned Procedure: Laparoscopic Laparoscopic

versus open cholecystectomyversus open cholecystectomy• Surgeon: Surgeon: Dr. SchmitDr. Schmit• Labs: Labs: LFTs, CBC, ElectrolytesLFTs, CBC, Electrolytes• CXR/Other tests: CXR/Other tests: Ultrasound resultsUltrasound results• EKG: EKG: (If done)(If done)• Blood: Blood: Pt has active type and screenPt has active type and screen• Consent: Consent: Procedure and blood consents Procedure and blood consents

signed and in chart.signed and in chart.

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

Example Brief Op NoteExample Brief Op Note• Pre-Op Diagnosis: Pre-Op Diagnosis: Right inguinal herniaRight inguinal hernia• Post-Op Diagnosis: Post-Op Diagnosis: Direct right inguinal herniaDirect right inguinal hernia• Procedure: Procedure: Repair of right inguinal hernia with meshRepair of right inguinal hernia with mesh• Attending Surgeon: Attending Surgeon: Dr. Charles ChandlerDr. Charles Chandler• Assistant Surgeons: Assistant Surgeons: List resident and med studentList resident and med student• Anesthesia: Anesthesia: LMA + localLMA + local• Intravenous Fluids: Intravenous Fluids: 500 ml LR500 ml LR• Estimated Blood Loss: Estimated Blood Loss: MinimalMinimal• Urine Output: Urine Output: NoneNone• Specimen: Specimen: Hernia sacHernia sac• Drain: Drain: NoneNone• Complications: Complications: None (probably but ask resident)None (probably but ask resident)• Condition: Condition: Stable to PACUStable to PACU

Post Op Check/Post Op NotePost Op Check/Post Op Note

• Usually 3-4 hours after ORUsually 3-4 hours after OR

• Review PACU notes and vitalsReview PACU notes and vitals

• Review any post-op labs or imagingReview any post-op labs or imaging

• Like a focused SOAP note:Like a focused SOAP note: Pain controlled?Pain controlled? Vital signs stable?Vital signs stable? Bleeding or drainage on dressing?Bleeding or drainage on dressing? Has patient urinated?Has patient urinated? Drain output and characterization?Drain output and characterization?

ClinicsClinics• Dress professionally and be on timeDress professionally and be on time

• Go see and examine patients, Go see and examine patients, then present to attending or residentthen present to attending or resident

• Be efficientBe efficient

• Like morning presentations, be conciseLike morning presentations, be concise

• Try to formulate an assessment & planTry to formulate an assessment & plan

• Write a note to be cosignedWrite a note to be cosigned

Afternoon RoundsAfternoon Rounds

• Follow up on studies and labsFollow up on studies and labs

• Check in with the on-call residentCheck in with the on-call resident

• Get vitals and I/Os for the dayGet vitals and I/Os for the day

• See your patient before rounds –See your patient before rounds –sometimes they can tell you moresometimes they can tell you moreinformation than anything else!information than anything else!

CallCall

• Usually once per weekUsually once per week

• Work with the on-call intern/residentWork with the on-call intern/resident

• Always bring your own work to doAlways bring your own work to do

• No call prior to busy clinic daysNo call prior to busy clinic days

• Excellent opportunity to see consultsExcellent opportunity to see consultsand learn to make your own decisionsand learn to make your own decisions

What to Read?What to Read?

      

                      

1 textbook1 textbook1 review book1 review book

      

                      

For your examsFor your examsSystematic,Systematic,scheduled scheduled topic reviewtopic review

For your patientsFor your patients

Disease processDisease process

Treatment OptionsTreatment Options

Surgical OptionsSurgical Options

Everyone Can Do It!Everyone Can Do It!

• DonDon’’t disappeart disappear Sleeping in the call Sleeping in the call

room doesnroom doesn’’t count t count as being thereas being there

Your teammates will Your teammates will quickly tire of having quickly tire of having to answer the to answer the question, question, ““WhereWhere’’s s <insert name>?<insert name>?””

© 2003-2004 Michelle Auhttp://www.theunderweardrawer.homestead.com

Everyone Can Do It!Everyone Can Do It!

• READ!READ! Every dayEvery day About your patientsAbout your patients About your casesAbout your cases

© 2003-2004 Michelle Auhttp://www.theunderweardrawer.homestead.com

Have Fun and Good Luck!Have Fun and Good Luck!