The Life Raft for surgery 2

July 26, 2008 at 5:02 pm (Life Raft)

Looking over my previous post about how to conduct yourself on surgery, I realized that I left out an important point about pre-rounding and presentation on rounds. Part of your job as a medical student will be to wake up all of the patients first thing in the morning so you can ask them about their pain level, bowel habits, and any overnight events. You will also conduct a very short physical exam. Depending on which service you’re on, you might have as many as six patients that you have to see and write notes on in one hour. Since timing is so important, I used the following lines of questioning with every patient:

How did you sleep last night?
How’s your pain right now? Can you rate it on a scale from 1-10? Where is it located?
Any nausea, vomiting, or diarrhea? Have you passed gas?
How’s your appetite?
Did you get out of this bed yesterday to walk around?
Are you using the incentive spirometer? (You should have the patient demonstrate that he knows how to use the spirometer.)

Next, listen to the patient’s heart, lungs, and abdomen. You’re looking for any chance of atelectasis, new murmurs, and bowel sounds. If the patient is on the first postoperative day and had abdominal surgery, you may very well not hear any bowel sounds—hence why it’s so important to ask if the patient has passed gas since the operation. And make sure to do a real physical exam. That means that you will have to set the patient up in bed, if possible, to do a proper lung exam. I’ve seen many residents claim that the patient is healthy when they’ve only listened to the anterior chest. They later get burned when they discover that the patient has a lower lobe pneumonia. Don’t let that happen to you. Getting an immobilized patient to sit up—or even roll over—takes only a few extra seconds.

Finally, check to see what the patient is getting via IV. While the orders may say that the patient is to receive 100 mL per hour of 1/2 normal saline, you might be very surprised to see that he is now receiving 150 mL per hour of 0.9 normal saline. Also make a note of the color of the urine in the Foley bag—whether or not it has any blood, as well as look at any drains. The color of the fluid in the JP drain should be either clear, pink, or green if you are expecting bile. The output in a drain should never contain frank blood, but a serosanguinous fluid is acceptable. I also knew a few attendings that wanted us to change the patients’ dressing before rounds each day. Check with former students to learn the attending’s preferences.

Whenever I’m pre-rounding on a patient, I usually try to find the nurse who took care of him the night before to ask about any overnight events. While your patient might tell you that he slept well throughout the evening, your nurse may tell you that he was up vomiting all night. If the nurse is unavailable, then try to find her notes.

You should be able to complete all of the above steps in less than three minutes.

Now you need to look up all of the patient’s overnight lab work, including any new imaging studies. You should write your note by detailing what the postoperative day is, what was the surgery, all the information that you gathered earlier, and what day of antibiotic treatment the patient is on. Leave out any past medical history. An example note looks like this:

S) Mrs. Smith is a 67-year-old female who is postoperative day number three for a gastrojejeunostomy. There were no acute events overnight. The patient states that she currently has a 2/10 pain level and is well controlled by current medications. Clear liquid diet is well tolerated. No N/V/D. Patient is ambulatory.

O) List your physical exam findings as well as any new labs.

A/P) Give a very short assessment and plan, but focus more on the plan. Examples might be “Advance to soft diet” or “Chest x-ray to rule out pneumonia.”

When you give your presentation on rounds, recite the information from the subjective part, list the vitals, mention only pertinent findings from physical exam—otherwise just say, “heart and lungs sound normal”—and then give your plan for the day.

Rounds stop being nerve-racking around week two.

Addenum: Someone pointed me to the surgical review by Pestana. It looks good, but given that I don’t know the copyright status of the outline, I’m hesitant to post it here. You’ll have to do a search for it.

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2 Comments

  1. MG said,

    Great advice, thank you. I learned most of this last week during the first few days of my OB/Gyn rotation and it’s just as you describe. Just discovered your blog today and look forward to reading more.

  2. bebe said,

    good stuff

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