Kate’s Surgical Rotation Survival Guide

Katherine Donches

Lewis Katz School of Medicine, Class of 2018

Keep in Your White Coat:

  1. Something to read
  2. Sterile gauze (have at least 4)
  3. ABDs (abdominal pads)
  4. Tegaderm
  5. At least 1 suture removal kit
    1. Nonsterile scissors if you’re feeling fancy but you can just use the ones in the suture kit
  6. Tape
    1. Do not carry this on your stethoscope you look stupid and they judge you
  7. 3+ pens (keep a couple you don’t care about – your attending will borrow them and not give them back)
  8. At least 1 granola bar and I highly recommend almonds (Paige’s anti-pass-out trick of salt intake + long lasting energy!)

*a copy of your patient list in the back pocket of your scrubs so that you’ll have it right before and right after you leave the OR.

Things you don’t need: reflex hammer, penlight, your stethoscope after morning rounds unless you’re in clinic.

 

Anticipating:

  • in the OR
    • if they grab the razor to shave the patient, you grab the tape to remove the shaved hair
    • if they grab suture, you grab the suture scissors
      • do not use mets to cut suture – they will yell at you because it makes them dull
      • pull the finger holes of the scissors in opposite directions (up and down) to make a clean cut
        • leave long tails if: fishing wire-esque suture (plasticky), if it’s inside the body; if it’s on a biopsy specimen, if placing a JP drain
        • leave short fails if: silk ties, anything that is sutured in the epidermis
          • slide scissors down until you feel knot, then turn them and cut
        • if they grab a retractor, you grab the end and wait for them to let go cause they will not warn you and expect you to be holding tension already
      • on the floor
        • if anyone on your service needs a dressing change, figure out EXACTLY how it was done and have it changed before the residents round on that patient. Also remove all sterile dressings on post op day 2 (makes you look great it you do this before anyone asks you to)
          • If you’re not sure how it was done, ask. They get more pissed if you do it wrong than if you’re not sure and double check
        • If they’re waiting for lab values or CT results, compulsively check EPIC for them. If you’re the first one to notice, you get major points
        • If your patient went to get imaging done, be the one who knows when they get back to their room AND what the imaging study said.
          • Side note: when you write your SOAP note in the morning, include impression of any imaging studies taken since the previous night’s note was written. Your interpretation doesn’t have to be correct if the official read hasn’t come back yet, but it gets you points for trying.

 

Random Tips

  • When entering the OR area, you have to be wearing scrubs and a scrub cap (aka shower cap thing), and you cannot be wearing your white coat or a stethoscope. You don’t need to wear a face mask until you’re actually in one of the ORs, and you don’t need eye protection until you are starting to scrub into the case. Make sure you put your eye protection on and that your mask is comfortable before you scrub because once you do you are stuck like that for the rest of the surgery.
  • Med student jobs in the OR before and after surgery
    • Get your residents gloves. Learn their glove size and what order they like their gloves in, and have them ready
    • Offer to get the scrub nurse an extra gown because a lot of the time they won’t know a med student is coming in and it saves them from leaving the OR to get it, and they will love you
    • Wheel the patient’s bed in and out of the room quickly. Wheel it out as soon at the patient is seat belted onto the OR table, wheel it in as soon as everyone has unscrubbed (urges anesthesia to hurry the F up and wake the patient)
    • Write you and your residents names and years (we’re MS3, they’re PGY_) on the board
    • Do NOT back into the sterile table or you will literally get murdered by the scrub nurse. If you’re not sure how to unwrap the gloves and gowns in a sterile way, ask. It’s actually more complicated then you’d think.
  • During surgery
    • Be the first to scrub because:  1) Then your attending won’t yell at the way you are scrubbing, 2) It’ll take you longer to do everything and then you won’t be in the way when the scrub nurse has more important things to do then get you dressed, 3) You get to look a little less derpy
      • Alternatively, while your attending/residents are scrubbing is a great time to mysteriously disappear to go the bathroom/eat before the case starts
    • NEVER touch the mayo table (the little table the scrub nurses have all the crap on that hovers over the patient’s feet). Even if your attending has asked 6 times for something that is inches away from your hand, don’t get it for them. Don’t. Resist the urge.
    • Keep instruments and sponges from falling off the field. This includes: the bovie, the suction, lap pads and retractors. Everything else is the surgeons fault, but these things have long tubes or tend to get left on the patient’s feet and slip off
    • If you’re retracting, hold the retractor EXACTLY as it was handed to you. This means the same tension (don’t pull any harder than you have to), angle (‘toe in’ means pull the bottom of the retractor towards you to move a deep structure out of the way), and position (don’t let it slide along the incision site). Hold that thing until you are told not to, never relax without being asked to first.
      • caveat: some attendings will say ‘relax when I relax,’ but most do not feel that way
    • If they are boving up a storm and there is smoke everywhere, use the suction to suck it up by holding the suction tip close to the bovie without getting in the way.
    • If there isn’t a dry lap pad on the field at all times (exception: laproscopic surgery), feel free to ask for one nicely and when the scrub nurse isn’t already busy. It will be asked for eventually.
    • Ask questions, but only if the surgery is going well and isn’t at a stressful point. Never ask a question while an anastomosis is being made (these are stressful, someone will yell at you).
  • On the floor
    • If someone has a JP drain or an NG tube, make sure you look at the output. They will invariably ask the quantity of the output and what it looked like.
    • ASK EVERYONE AND THEIR MOTHER ABOUT FARTING AND POOPING. That is the most important question you can ask your patients – everyone is worried about small bowel obstructions and post-op ileus, and until they fart they can’t go home.
    • Know everyone’s post op day – if they have multiple surgeries (ie you took them for a colectomy but had to go back 2 days later for an ostomy revision), write both procedures’ post op days in your note
    • Talk to the nurses about overnight events – they will tell you things nobody else can, the residents often don’t bother to ask, and you look like a genius.
    • Offer to get people pillows and blankets to make them more comfortable. Never say ‘is there anything I can do for you to make you more comfortable’ because they invariably respond with: 1. I want water or 2. I want food because basically everyone is NPO.
    • Know what meds someone was on when they were at home – a lot of the time, the home meds don’t get restarted post-op, and you can have someone who looks like they have a PE, but you just forgot to restart their anxiety meds, or someone who’s tachycardic because they haven’t taken their beta blocker. Makes a HUGE difference in how spastic the team becomes in response to tachypnea and tachycardia
    • Each morning, check for any consults that saw your patient overnight, and be prepared to tell your resident what their recommendations are. If you can’t read it because their handwriting sucks, take a picture of the consult sheet and then when they’re like ‘how could you not read it’ you can show them.
  • Always eat, pee and take 2 advil before surgery. You have no idea when you will be able to sit down, pee or eat next.

 

Physical Exam Maneuvers

  • Cardio: listen to their heart
  • Respiratory: listen to their lungs
  • Abdominal: double check that they haven’t farted or pooped (ask the nurse cause senile patients will straight up lie to your face). Actually percuss (tympani in these people is insanely noticeable if they are obstructed), palpate and ask the patient if they feel bloated (distention is hard to tell between patients sometimes)
    • Listen for bowel sounds, but the surgeons really don’t care about them. Farting/pooping is more important
  • Check JP drain/ostomy bag output
    • If there is a tiny bit of clear-ish fluid in the ostomy bag, this is bowel sweat (yes that’s a real thing) and does not count as output
  • Check all incision sites. If everything looks great, write c/d/I (clean, dry, intact). Note any erythema, increased tenderness or warmth
  • Look for pitting edema on the lower extremities

 

Lab Values

Make sure you trend hemoglobin and potassium every day. They don’t really care about anything else.

They do not care about blood glucose. At all. Ever. It could be 260 and they wouldn’t care.

 

Frequently Asked Pimp Questions

  • Stages of shock (there are 4. Know them well)
  • SIRS/sepsis criteria
  • I had 3 different attendings ask me who Bovie and DeBakey were. Also randomly I was asked by 3 different (non-transplant) surgeons about who did the first kidney transplant (correct answer: a plastic surgeon)
  • Causes of small bowel obstruction in order of frequency (#1 adhesions, #2 hernia, #3 cancer)
  • 5Ws of post op fever
    • wind, water, wound, walking, whatever else = atelectasis/pneumonia, UTI, wound infection, DVT, a whole mess of random stuff
  • FRIENDS mnemonic for reasons a fistula won’t heal
    • Foreign body, radiation, infection/inflammation/IBD, epitheliazation, neoplasm, distal obstruction (high flow through fistula), steroids
  • Hinchey classification for diverticular disease – problem is that the list the residents learn is different from what the textbooks say. This is what the residents want to hear:
    • Purulent 2. Feculent 3. Mass near colon 4. Mass far from colon
  • Charcot triad, Beck triad
  • Everything about gallbladder disease – especially know when emergency surgery is needed, what kind of imaging to get and in what order, when you should put a percutaneous drain in, etc.
  • Know that primary survey for trauma (ABCDE)
  • Anything about pneumothorax/hemothorax (know everything about chest tube placement), pericardial tamponade (do an ultrasound as study of choice) and penetrating abdominal trauma (DPL/FAST exam, when to do an exlap, etc).
    • Massive hemothorax means chest tube drains 150 mL immediately or 100 mL/hour
  • For laproscopic surgeries, they infalte the abdomen with CO2
  • The cremaster muscle comes from the internal oblique, the nerves we are trying to avoid are the ilioinguinal, iliohypogastric and genitofemoral (favorite questions during hernia repairs)
  • “what was the patient’s pre-op hemoglobin?”
  • know the 421 rule for IV fluids, and what the difference between maintenance and resuscitation fluids are
  • if you’re in a breast surgery, know the boundaries of the breast and the blood supply
    • boundaries: lat dorsi, clavicle, sternum, inframammary fold
    • blood: thoracoacromial, lateral thoracic, intercostal, medial thoracic aka intramammary
  • treatment for hyperkalemia: C BIG K. I was asked this at least 6 times
    • calcium gluconate (fastest fix- stabilizes cell membranes), b agonists, insulin, glucose, kayexalate (chelates calcium in gut)
  • 4 mediastinal masses (4Ts: terartoma, thymoma, thyroid adenoma, terrible lymphoma)
  • common bile duct diameter normally is 4-6 mm
  • what is it called if you have a large stone in the gallbladder that intermittently obstructs the cycstic duct? Mirizzi syndrome
  • what is the first thing you do in someone with a suspected GI bleed? Place an NG tube.

 

Hope this helps!

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