Transcript The Culture of Surgery - UCLA Department of Surgery

The Culture of Surgery
Sanjeet Patel, M.D.
Before you start
Talk to the student leaving your service
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Logistics
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Expectations
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when and where
patient list
what are the med/surg issues
anything interesting during the case
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
Before you leave the house…
Prepare for anything
What to Wear?
Professional Attire
unless you are IN THE OR
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Clinics
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ALL conferences
AM rounds
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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
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
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Organizing information
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Presenting at rounds
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Making decisions
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Talking to patients
You will soon be in his or her shoes
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BUT! do not tell a patient something you dont
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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
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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
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Initial H&P (including PMH, PSH, Meds, etc)
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Preop and postop course
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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
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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
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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,
current 98.6.
Blood pressure 120-175/65-95, currently
Range & Current
110/65.
Pulse
80-115, currently 76.
Tmax and Tcurrent
Range & Current
RR
14-18.
Range & Current
O2 sat
Range & Current
Supplemental O2
O2 sat 94-96% on 2L nasal
canula.”
Objective: Vitals
Temperature
“Vitals: Tmax 100.4,
Tmax and Tcurrent
Blood pressure 20-175/5-95
Range & Current
Pulse
Range & Current
RR
Range & Current
O2 sat
Range & Current
Supplemental O2
10-115.
14-68.
“fine.”
Objective: I/Os
Total first,
then breakdown
“I/Os 2050 in and 1980 out.
Ins
For ins, 1800 was IV fluid
(75 cc/hr D5 ½ NS) and
250 was PO.
 IVF
(type & rate)
 TPN
 PO
 Tube feeds (type & rate)
Outs
 Urine
 BM
 Drains
For outs, 1800 was urine.
JP #1 put out 75 cc of
serosanguinous fluid and
JP#2 put out 105 cc of
bilious fluid.”
(amt & kind)
 NG tube (amt & kind)
 Chest tube (amt & kind)
Objective: I/Os
Total first,
then breakdown
“I/Os 2050 in and 80 out.
Ins
For ins, 1800 was IV fluid
(75 cc/hr D5 ½ NS) and
nothing recorded was
PO.
 IVF
(type & rate)
 TPN
 PO
 Tube feeds (type & rate)
Outs
 Urine
 BM
 Drains
For outs, 80 was urine.
nothing else was
recorded Dr. Hines.”
(amt & kind)
 NG tube (amt & kind)
 Chest tube (amt & kind)
Objective: Physical Exam
Do a full focused physical exam daily
Present only pertinent positives & negatives
ALWAYS examine the wound carefully
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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
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:
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Can the vent settings be weaned?
Can the patient be extubated?
If the patient is on supplemental O2:
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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
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
Is the hematocrit stable?
Are platelets & coags normal?
Endocrine
Is blood glucose well controlled?
Assessment and Plan
GI
Are the bowels working yet?
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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
Is the patient ambulating?
Is PT/OT needed?
Prophylaxis
GI prophylaxis:
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H2 blocker or PPI
DVT prophylaxis:
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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:
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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:
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What surgery? Appropriate indication?
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Cardiac/medical workup complete
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History (CVA,CHF, MI, Valvular), DM, Cr > 2.0
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Consents signed & patient understands?
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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:
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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?
1 review book
1 textbook
For your patients
For your exams
Disease
Systematic,
scheduled
topic review
process
Treatment
Surgical
Options
Options
Everyone Can Do It!
Don’t disappear
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Sleeping in the call
room doesn’t count
as being there
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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!
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Every day
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About your patients
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About your cases
© 2003-2004 Michelle Au
http://www.theunderweardrawer.homestead.com
Have Fun and Good Luck!