I left off telling you guys about my what I perceived to be a disastrous first week of Surgery (come to find out, it really wasn’t disastrous at all). But the one thing that I did point out in the last post is how I observed that first week when I was struggling to find my place and niche on the team. In my last day scrubbing in the OR, one of my fellows mentioned to me that a key thing to being a good surgeon is being able to try something that you’ve only read about in textbooks or seen on a youtube video (or the like). My attending echoed the same sentiment, and obviously that does not mean that surgeons ought to be reckless, but rather that to be a good surgeon and doctor you have to be willing to try something that you have never done before. You should have the mindset to watch and learn and then implement and do. All that to say is that first week, I made sure that I watched and I learned, so even though my confidence level was not ready by the end of that first week to implement my voice to present on rounds, when the time came, I would at least be able to know how to present based on what I had observed.
Things I Did. (Disclaimer: this is what I did during my surgical clerkship and I think it worked for me but this is by no means a “must do” list. Every hospital is different, every resident/fellow/attending has different expectations of their medical students, so please keep that in mind).
First One in: I’ve pretty much been a morning person since I was forced to be one in college being a D1 Rower, so getting up early has not been an issue for me for the last 10+ years. HOWEVER, I am fully aware that I am the exception to the rule. But when I was on Colorectal and General Surg (earliest rounding hours), I wanted to make sure that I had enough time to review everything that happened in the last 24 hours for my patients, see my patients and MAYBE (only applicable to Gen Surg.) write my progress note. I was always the first person in parking lot for those 6 weeks. Of course I would’ve liked to at least get another 30minutes-1hr of sleep (i mean sleeping from 10:00 pm-4:00/4:30 am just isn’t ideal), but I also knew how valuable it could be to have that one lab value or imaging result that my intern or fellow may not have had time to look over. I also found it extremely peaceful to be in the hospital that early.
Presenting: I touched on it before but presenting is different for surgical rounds. Shout out to Surgical Recall for making me sure that I covered all my basis.
Baseline Statement of Health– (Name, Age, the disease/pathology that they are admitted for (not all of the PMH)
Hospital Day/Post Op Day (this is technically in the baseline statement of health as well). The difference between hospital stay and post-op day is pretty basic but let me quickly tell you when to use which.
Hospital Day (HD): Patient admitted to ED for Cholecystitis. Usually before performing a cholecystectomy (or any non-urgent surgery), you want to maximize the patient for surgical success. This includes various basic things like making sure they are hemodynamically stable, labs are stable or trending down (say if their ALP is through the roof), making them NPO, type and screen blood tests, etc. So, usually a patient will be admitted for a few days before their surgery (again NON-URGENT). So, Day of Admission: Day 1. And then next day: HD#2...and so on.
Post Op Day (POD): That patient now has their cholecystectomy. The following Day you now report as POD#1 (not HD# 4 or whatever it is). Now you are like Kare, what happens if they develop an abscess and it has to get drained by IR? You then will report POD#3 Cholecystecomy for Acute Cholecystitis and POD#1 IR Guided Drainage of Gall Bladder Fossa Abscess.
These are pretty straight forward. Check your EHR and review the vitals for the last 24 hours. Mention anything pertinent. It is also good to mention ranges and any outliers. If they were hypertensive and it was treated, mention that. If they weren’t treated and are still hypertensive, mention that in your plan for the day. ALWAYS ALWAYS ALWAYS mention 1) Tachycardia (even if it was just one reading) 2) Temp (100.4+ is febrile). If they were afebrile over the last 24, say that.
Ins and Outs (I/Os)
This was the most foreign thing to me when I started. I had no idea where they were getting these numbers from and what they were even talking about. For Ins, unless you are in the ICU (or if your attending wants you to), no need to go through every fluid they received and how much. Just mention Diet (Just IV Fluids, Full Liquids, GI Soft, etc). OH- but if they were transfused blood or blood products, mention that and how much. BUT Outputs are the name of the game. Remark on 1) Urine Output over the last 24 hrs (and be prepared to comment on it if its low or high) 2) Stoma Output (especially important on Colorectal) 3) Drain output (Specify the type of drain (chest tube, JP, Blake) and location) 4) Bowel Movements (#) and 5) Episodes of Emesis (#, color, consistency). I can’t go into why all of these things are important (that’s what your clerkship is for! But be sure to read the chart and ASK your patient– especially about #4 and #5).
Self Explanatory. Review the labs for the morning or any other pertinent labs that were drawn overnight). Comment on any abnormalities and also comment on trends. You can also comment if they had an electrolyte abnormality the previous day that it was either corrected or not corrected over the past 24 hours.
Check to see if any imaging was done in the last 24 hours and be prepared to give the findings. Most likely, your attending has already seen and reviewed the imaging but it looks good if you were paying attention and comment on it, just saying from previous experience Also, if there was imaging that was supposed to be done but not completed, you can follow-up on that as well.
Review consult notes from the past 24 hours (if any) and just be prepared to share the recommendations.
Your physical Exam findings for that morning.
What your preliminary plan for the day is for your patient
Some services will expect you to write notes. Some services will not. Some services will expect you to only write notes on your specific patients. It all depends. However, I have not yet met a resident or fellow that turned down a progress note that was already written on a patient. It is also good to write it before hand, edit it after rounds with the updated plan and then review it with your resident/fellow to get feedback if possible. As long as your not forbidden to write notes on a service, then write the note. :-)
Always have supplies for rounds
I was fortunate that when I was on my colorectal service they had a tool kit with all of the necessary wound care supplies. But I made it my job to 1) Make sure it was organized and 2) Make sure it was fully stocked daily. If you don’t have the luxury of a set aside wound care kit, just make sure you have all of the necessary wound care supplies with you.
Find the little things to do
My hospital has mobile computing units for walking rounds in the morning and we always started rounds from the same location while on colorectal. So, I always made sure that our two mobile units were ready to go and charged every morning which made it easier for my intern. It was a little thing but it was something less that he had to worry about everyday.
If an elective procedure- Go find your patient in the PACU before surgery and introduce yourself.
Be there to help the nurse and member of the anesthesia team to bring the patient back. Text your fellow/resident when the patient is being brought back (just because it’s nice to do that).
Help in any ways possible prepping the patient. Volunteer to place the foley, help move the patient…whatever…just offer to help.
Make sure you introduce yourself to your OR staff for the day (if they already don’t know you). Get your gown and your gloves for your scrub nurse/tech (and you’ll find that when you’re nice to them and help out– they’ll start getting your stuff for you and make you look good in front of your attending :-).
Following surgery, go with your patient to the post-op handoff.
Lather, rinse and repeat.
This was a lot of information and I think there might be more that I will remember later, but the biggest thing was presenting and knowing the patients on the service. I found that for me, I knew my specific patients inside and out AND I knew at least what happened to the majority of the patients on our service in the last 24 hours, so I didn’t feel lost on the rest of rounds…and I was sometimes able to fill in any gaps that there might have been. My early disclaimer holds true that this is not a must do list, and you if you are fortunate to train at an institution where all of the expectations are crystal clear, than that is amazing but from the conversations that I have had from various colleagues, that is rarely the case. Again, this is what helped me during my surgical rotation so I can never be sure that it will help you but I sure hope so, and although it was a lot of very very very long days, it makes it all worth it when one of your fellows calls you their favorite student and when your patients comment on how thorough you are and that you’re going to be a great doctor. :-)
Any questions or comments, please feel free to post below.