The Life Raft for surgery

July 9, 2008 at 9:59 pm (Life Raft)

I wanted to kick off this series by discussing surgery. Few rotations are as anxiety-provoking as this one. You can expect to be at the hospital by 5:00 a.m. every morning with plans that you’ll stay put for the next 12-14 hours. You’ll have to come in almost every day on your rotation, and that includes weekends. Expect to spend 80 hours a week in the hospital. You should kiss your loved ones goodbye because as far as they’re concerned, you’re going to be gone for the next eight weeks.

To excel on surgery the first thing you need to do is become very familiar with the reasoning behind the procedures. Attendings don’t care if you know how to remove a gallbladder. They will, however, expect you to know what are the indications for taking one out. If a patient has right upper quadrant pain, what’s the differential diagnosis? How would you know that someone has cholecystitis versus pancreatitis? What do you look for on ultrasound? What are the findings on the physical exam? What labs should you order, if any? How urgent is this procedure? Are there any alternatives to this procedure, including medical ones? What are the risks to a cholecystectomy? If the resident in the case prematurely cuts the bile ducts, what do you do then? What’s some of the relevant anatomy in that area? That is, what do you have to watch out for during surgery? Once the gallbladder is removed, is there any chance for recurrence of disease?

Those are just some of the questions you should be able to answer any time you go into an operation. And if you’re dealing with cancer, you should know all of the relevant tumor markers as well as their half-lives. The half-life is important to know because it gives us an indication of how long to wait before retesting the patient.

The second expectation that attendings will have is that you can manage hospitalized patients. You should do some reading on fluids and electrolytes because those issues become very important once a patient comes out of surgery and cannot eat for several days. You should also be aware of your patients’ conditions at all time, including urine output, feedings, any fevers, relevant labs, ambulatory status, and pain level, just to name a few. Some attendings are also very big on wound care—so you should always carry gauze, tape, suture removal kits, staple removal kits, and a pair of scissors.

In addition to the general etiquette that was discussed earlier, there are several new behaviors you will have to acquire on this rotation. First, you should address everyone as “ma’am” or “sir.” That includes the nurses, the techs, and all of the residents and attendings. For some reason, surgeons believe that medicine should be run like the military. Granted, none of them had ever served in the armed forces, but I certainly heard a lot of attendings say, “This is just like the military.”

Second, do not speak unless spoken to. If you have a question, you should keep it to yourself and look up the answer later. I cannot stress this point enough. Do not ask your attendings any questions regarding any disease is that you may encounter. You’re attending will very likely turn the question around and either pimp you or force the resident to answer. Then you’re going to be stuck with the resident that dislikes you and a comment on your evaluation that says “The student needs to read more.”

Finally, you’ll have to start introducing yourself to everyone in the OR. Whenever you head into a case, immediately let the circulator know who you are. You should also introduce yourself to the scrub tech, as he/she will be passing you instruments throughout the operation.

As I mentioned earlier, the attendings aren’t looking for you to learn surgical technique. Very likely your experience in the OR will consist of holding retractors and cutting suture lines. If the surgeons take a liking to you, they might let you place the closing stiches. In that case, it pays to be knowledgeable in advance on how to tie knots. Hop on over to YouTube and watch a few videos on the subject. You can then practice at home using old suture line obtained from the scrub nurse.

In addition to all the amount of time you’re going to spend in the hospital, you should devote about 10-20 hours a week for reading. The most popular textbook for a surgery clerkship is Lawrence. However, I found the book very difficult to get through. Students generally like Surgical Recall because it preps them for all the pimping that they’ll inevitably receive in the OR. Unfortunately, there’s not a whole on out there that does a good job of preparing you for the Shelf. This exam is very difficult because it covers a wide range of topics on everything from breast cancer to skin cancer to electrolyte management to ethics. The good news is that there is no anatomy on the Shelf.

Here are some of my previous posts about surgery:
First Impressions
Letters
Lighting Rounds
1-800-IDEA-MAN: Camel packs for surgeons
Interview with the dean
Second impressions