Surgical Intern Survival Guide by guy25

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									Surgical Intern Survival Guide


        Brought to you by,
           The Chiefs
Who do you want to be?
 Always remember...

Don’t worry, you’re not alone!

   You are just an intern.

Hierarchy exists for a reason.

      Call your senior!
                       Outline
1)   “I wrote the note - so the pre-op’s done, right?”
                         Outline
1)   “I wrote the note - so the pre-op’s done, right?”
2)   “The operation is finished - do we still have to
     see the patient?”
                         Outline
1)   “I wrote the note - so the pre-op’s done, right?”
2)   “The operation is finished - do we still have to
     see the patient?”
3)   “Is now a good time to call the chief?”
                         Outline
1)   “I wrote the note - so the pre-op’s done, right?”
2)   “The operation is finished - do we still have to
     see the patient?”
3)   “Is now a good time to call the chief?”
4)   “What is that thing hanging out of the patient?
                         Outline
1)   “I wrote the note - so the pre-op’s done, right?”
2)   “The operation is finished - do we still have to
     see the patient?”
3)   “Is now a good time to call the chief?”
4)   “What is that thing hanging out of the patient?”
5)   “What does D5 stand for anyway? (a.k.a Is it OK
     to replace Phos?)”
              “I wrote the note –
        so the pre-op’s done, right?”
         (a.k.a. How to do a pre-op)
• Plan ahead

• Check OR schedule frequently during the day

• Order the necessary labs and films early, so that
  they can be getting done as you work on other
  tasks during the day
          Pre-Op ingredients
•   Labs (CBC, Chem 7, Coags, hCG)
•   Blood products/Type and screen
•   Imaging
•   Bowel prep
•   Review of current medications
•   Clearance
•   Consent
•   Note
•   Orders
                  Pre-op labs
• CBC
  - How low can you go with Hct or Plts?
  - Is the WBC count high for an elective case?

• Chem-7
  - If any electrolytes need to be replaced, make sure you have
    a repeat chemistry afterwards showing the new normal value
  - Chasing a low K+ can keep you up all night, so start early
  - Be especially careful with dialysis patients

• PT/PTT
  - If INR is >1.3 you might need Vit K or FFP, check w/ chief
              Blood products

• Type and screen
  - Call the blood bank to confirm that it’s active
  - Typically active for 72 hours after the draw

• Hold what you (and your chief/attending)
  think is necessary
  - 2U PRBC for typical abdominal case
  - Is the patient on Coumadin or in liver failure?
  - Will you need FFP or other products?
                    Imaging

• CXR
  •   Any patient > 60
  •   Anyone with a smoking history
  •   Any pulmonary pathology
  •   If any question, order it


• Have CTs, MRIs, angiograms available if
  requested by attendings or chiefs
             Bowel preparation

• Is it even necessary?

• Typically used for all colorectal cases

• Attending preference

• Bowel prep = mechanical prep + chemical prep
                  Mechanical
• Sodium Phosphate (Fleets)
  - Two doses of 45 ml given 3-6 hours apart
  - May cause electrolyte abnormalities
  - Avoid in renal failure, cirrhosis, ascites, CHF, elderly


• Polyethylene Glycol (GoLYTELY)
  - 4L solution over 4-6 hours
  - Large volume, salty taste, bloating / cramping
  - Fewer water and electrolyte abnormalities

• Tap water enemas
                   Chemical
• Neomycin 1 gm + Erythromycin 1gm
  - Each given for a total of three doses 3-4
    hours apart

• Alternatives include Cipro + Flagyl

• Intravenous antibiotics are also given in the OR
  – recommended to be given 30 minutes before
  incision
             Pre-Op medications

Review all medications (home and hospital)
  •   Cardiac
  •   Anticoagulants
  •   Anti-platelet therapy
  •   Antibiotics
  •   Insulin
            Cardiac medications

• Continue all cardiac medications perioperatively
  - Especially beta-blockers
  - Post-op orders should include hold parameters


• Exception is diuretics
  - Post-op patients tend to third space, don’t want to
    further deplete intravascular volume with diuretics
  - Hold AM dose on day of surgery
  - Resume once taking adequate PO
Chronic anticoagulation
What to do?
     Antiplatelet therapy (Aspirin/Plavix)
• No increase in bleeding complications in patients
  taking aspirin preoperatively undergoing emergent
  surgical procedures (Ferraris et al. Surgery, Gynecology, and Obstetircs 1983)

• Cardiac surgery patients on aspirin have been noted
  to have increased transfusion requirements and
  rates of reoperation but no differences in mortality
   (Sethi et al. JACC 1990, Goldman et al. Circulation 1998)



• No consensus recommendations
   In practice, patients should have any anti-
   platelet therapy stopped 7 days prior to elective
   surgery
                  DM medications
• Long-acting insulin (e.g., ultralente, glargine) should be
  discontinued 1-2 days before surgery
• Glucose levels should be stabilized with a regimen of
  intermediate insulin (e.g., NPH, lente) mixed with short-
  acting insulin (e.g., regular, lispro, or aspart) twice daily
  or short-acting insulin before every meal
• Standing insulin should be halved or dc’ed the morning
  of surgery

• Oral agents are discontinued before surgery
   - Long-acting sulfonylureas (e.g., chlorpropamide) are stopped 2-3
     days before surgery
   - Short-acting sulfonylureas, other insulin secretagogues can be
     withheld the night before surgery
              DM medications

• Make sure every diabetic has a regular insulin
  sliding scale


• Fingersticks should be performed q4 hr or
  before each meal and in the evening


• Patients should receive dextrose-containing
  solutions to avoid hypoglycemia
                     Clearance

• Medicine, cardiology, neurology, nephrology,
  psychiatry, neurosurgery…
  • call consults early, don’t wait for the last minute


• Need for clearance should be discussed with
  chief, attending, and anesthesia

• Prepare what is necessary for your consultants
  (most patients will require at least an EKG)
             Operative consent
• Think about this early!
• Does the patient have capacity?
• Who is the health care proxy or the next of kin?
• Discuss risks, benefits, alternatives (ask seniors
  or chiefs if unclear)
• Telephone consent requires the telephone
  operator/administrator to record the
  conversation - must record name of operator on
  the consent form (each hospital has a different
  way of doing this)
Mount Sinai consent
Elmhurst consent
VA consent
                  Pre-op Orders

• NPO after midnight
  - includes tube feeds
  - make sure the patient and the nurse know


• IVFs to start at midnight (usually D5 ½ NS with
  20 mEq KCl @ 100-125cc/hr)
  • no potassium if it is a dialysis patient


• Medication changes

• Medications necessary on call to OR
               Pre-op Note
More a formality, but it helps you and others
review the status, should include:
 • Procedure
 • Labs
 • T&S and blood availability
 • EKG reading
 • CXR reading
 • NPO status / IVFs
 • Consent status
 • Medication changes
 Additional pre-operative concerns

• ESRD patient
  -   When did the patient last have dialysis?
  -   When do they need it next?
  -   Minimal IVFs when NPO (0-30cc/hr, no KCl)
  -   Do they need blood before the OR?

• If a patient is on another service (including
  the SICU), always discuss pre-op status
  with the primary team
         “The operation is finished,
     do we still have to see the patient?”
               Post-Op Checks
•   Should be done 4-6 hrs after the end of surgery
•   Check vitals – look at trends
•   Check urine output – minimum of 0.5cc/kg/hr
•   Check drain (JPs, NGT, G-tube, etc.) outputs
    - Quantity/quality
    - Can send fluid for hematocrit or creatinine if
      concerned
    - Are tubes connected properly and working?
• Examine the patient
    - Attention to the dressing
                 Post-Op Checks
• Labs – check post-op labs and order new ones if
  necessary – trend significant labs

• Vascular: check pulses (usually marked postop in OR),
  watch PTT in pts on heparin, check for bleeding

• Assure that the patient has venodynes and an incentive
  spirometer and an understanding of how to use both

• Is pain adequately controlled and pt is not too lethargic?

• Note – record all of the above with a legible, dated/timed
  note
           DVT Prophylaxis
   All post op pts get venodyne boots unless
    contraindicated
   Sub Q heparin: all pts unless told
    otherwise by chief/attending (5000Units
    unfractionated heparin subQ q8 hrs)
                       Diets
   Clear liquids – anything you can see thru, Jello
   Fulls – all liquids, including dairy
   GI soft/low residue: regular food but no hard to
    digest fiber/veggies/nuts/seeds – for anyone
    with GI anastomosis/resection/stoma
   Heart healthy: low fat, low cholesterol
   1800Kcal ADA: for diabetics, low sugar
   Special diets: Bariatric Stage I and II, dysphagia
    diets, renal/dialysis diet, enteral feeds, etc
        “Is now a good time to call the
                   chief?”
   YES
   Remember – you are not alone
   There is ALWAYS a senior resident you can call
    in- house with any problems or questions with
    patient management
       You can also call the chief or attending with any
        questions or change in patient’s condition
              On-call problems

Most surgical emergencies evolve over hours, not minutes,
  take the time to think!
   • Fever
   • Chest pain
   • Hypoxia
   • Hypertension
   • Hypotension
   • Oliguria
   • Pain
   • Mental status changes
   • The clogged/dislodged NG tube
“Doctor, the patient doesn’t “look
    good”. Can you come?”
   Ask the nurse to get a set of vitals
     If patient is hypotensive, ask for a 1L bolus
     If the patient is hypoxic, ask for oxygen

   What medical problems does this patient have?
   Start treating the problem right away (even
    before you have arrived) and GO see the
    patient!
   Don’t forget, there is always help available
        On-call problems – Fever
• Fever = T > 38.2°C
• Examine patient with attention to wound and
  lungs
• Fever work-up required if >48 hours postop or
  clinical condition is not as expected
• CXR – make sure it gets done, and f/u result
• CBC
• U/A, UCx, BCx w/ gram stain (both central and
  peripheral)– order, draw if necessary, and f/u
• Tylenol
• ? Empiric antibiotics – check with chief
    On-call problems – Chest pain
• H&P
      • Is this cardiac? Pulmonary?
      • Quality/duration of pain, previous episodes
• EKG
      • Compare to old EKGs available in EDR
• Basic labs w/ attention to Hct & electrolytes
• Cardiac enzymes q8 x 3
      • CK, CK-MB, Troponin (at Mt.Sinai, Troponin must
        be ordered separately)
• Pulse oximetry
• Chest x-ray
    On-call problems – Chest pain
• H&P
      • Is this cardiac? Pulmonary?
      • Quality/duration of pain, previous episodes
• EKG
      • Compare to old EKGs available in EDR
• Basic labs w/ attention to Hct & electrolytes
• Cardiac enzymes q8 x 3
      • CK, CK-MB, Troponin (at Mt.Sinai, Troponin must
        be ordered separately)
• Pulse oximetry
• Chest x-ray
     On-call problems – Tachycardia

   Hypovolemia- Is it fluid losses, inadequate resuscitation. Is
    the patient bleeding?
      Check the blood pressure and urine output

   Hypoxia- Is it fluid overload, aspiration, PE
      Check the pulse ox, CXR

   Cardiac- Arrythmia, MI
      ECG

   Medication withdrawal
      Was the patient on Beta blockers

   Pain, Anxiety
     On-call problems – Hypoxia

• H&P
• Repeat pulse oximetry
    • Assure there is a good waveform
• Chest x-ray
• ABG
    • Radial a., Femoral a., Dorsalis Pedis a.
    • Avoid brachial a.
• CT angio
    • Patient will need an 18-gauge or larger IV (central
      line too long for rapid flow)
  On-call problems – Hypertension
• Examine patient
     • Any associated symptoms, end-organ signs (blurry vision,
       headache, etc)?
• Repeat vitals
     • Check BP on both arms using appropriately sized cuff
     • Treat trends, not single values
• Review meds
     • Did the pt skip his/her AM meds?
• Beta-blockers
     • Best first-line agents if no contraindications
     • e.g. Metoprolol 5mg IV q 6 hrs
• Avoid long-acting agents and diuretics
               On-call problems –
              Hypotension/Oliguria
• Examine patient
     •   Evidence of bleeding?
     -   Check foley: irrigate or replace if necessary
     -   Palpate bladder, assess skin turgor, mucous membranes
     -   Is the patient thirsty?
• Review fluid requirements and losses
• Review medication list, hold BP meds, hold
  epidural and narcotics
• This is surgery - think about bleeding!!
• Everyone can tolerate some fluid - start w/ a bolus
• Consider steroid withdrawal
         On-call problems – Pain
• Examine patient
     • Is the pain appropriate for the procedure performed?
• Review vitals –tachycardia, hypertension
• Review preoperative narcotic use and OR
  requirements
• PCA
• Toradol
     • Useful synergistic medication
     • Avoid in patients with high bleeding risk or renal insufficiency
• Consider pain service consult
 On-call problems – Mental status changes
• Think about why
     • Hypoxia, sepsis, hypovolemia, hypoglycemia, medications, etc.
• Examine patient, get vitals + O2 sat
     • ABG
     • Ask family, nurses re: baseline
• Check a finger-stick glucose level
• Review medications
     • Hold narcotics, H-2 blockers, psychotropic meds
     • Is this narcotic overdose? Check pupils, give Narcan.
• Avoid sedatives
• Physical restraints
     • Acceptable, especially if patient is at danger to self or others
 On-call problems – The dislodged NGT
• Examine patient

• Why was it placed initially?

• If clogged, gentle flushing with NS often works
  • Flush air into blue port in Salem sumps


• Is there a danger in replacing the tube?
  - Do not replace an NGT if placed intraoperatively
    during upper GI surgery
  - Same for rectal tubes and lower GI surgery
         On-call problems – Codes
• You MUST go to a code if your team has a
  patient on that floor

• Even if you have no idea what you’re doing, you
  can start by:
  - Call for “Team 7000”, (“700” at Elmhurst)
  - Get the crash cart into the room
  - Start with your ABCs
  - Get the EKG monitor / defibrillator paddles on the
    patient to check the rhythm
  - Help is on the way!
        On Call Problems – special cases

   Bariatric patients
       Often, tachycardia or other very non-specific
        complaint heralds very bad things (ie: leak, bleeding)
   Kidney donors
       Special population – any concerns need to taken
        seriously
   ANY concerns -> call the senior/chief/attending
    especially with the donor patients
“What’s that thing hanging out of the patient?”
           Lines, drains, and tubes

• Post-op check
  - CXR to check position and r/o pneumothorax
  - Look at the site (esp. in a febrile pt)


• Record what date catheters are placed
             Triple lumen catheter
Short-term central venous catheter typically placed for TPN or Abx
   or simply for access in patients with poor peripheral veins
                 Hickman/Broviac
Long-term tunneled central venous catheter typically placed for TPN
 or Abx or simply for access in patients with poor peripheral veins
                 Shiley catheter
• Short-term large bore dialysis/apheresis catheter
• Needs to be flushed with heparin 1:100 U solution using
  exact volume labeled on catheter
                     Permcath
• Long-term tunneled dialysis / apheresis access catheter
• Needs to be flushed with heparin 1:100 U solution using
  exact volume of catheter
    PICC – Peripherally inserted central
                 catheter
• Long-term catheter placed typically for TPN or Abx
• Really not for blood draws (clogs easily)
• Flush well if used
                     Portacath
Central venous access with subcutaneous reservoir typically
placed for chemotherapy or in patients with poor peripheral
  access who require other IV medications or transfusions
Don’t forget about me….
the external jugular vein
                ….or me
             the arterial line
• Excellent source for blood draws in
  patients with poor venous access
          Other tubes / drains

•   Jackson Pratt
•   Penrose
•   Hemovac
•   NGT / Salem
•   Gastrostomy and jejunostomy tubes
•   Rectal tubes
           Jackson-Pratt drain
• Always check to make sure suction is working
• “Strip” on daily AM rounds
Penrose drain
Hemovac drain
                    Nasogastric tube
• Salem sump should be placed to low continuous suction with the blue
  port open to air
• Clear port should be flushed q8 hr with 20 cc NS while the blue port
  should be flushed q 8 hr with air
• Single-lumen tubes should be placed on low-intermittent suction
• Never ever use an NGT for feeding unless you’ve checked an x-ray
Gastrostomy and Jejunostomy tubes
    “What does D5 stand for anyway?
            IVFs & Electrolytes
Replacement Solutions: isotonic solutions used to
   replace volume for pts who are hypovolemic
   from dehydration or bleeding

•   Normal Saline (NS): just 0.9% NaCl
•   Lactated Ringers (LR): glucose, Na, Cl, K, Ca,
    Lactate (converted to HCO3 by liver)
•   Plasma-Lyte: Na, K, Cl, Mg, Acetate
              IVFs & Electrolytes
Replacement solutions are
    typically given in 1L
    boluses

Patients w/ sepsis, DKA,
     burns, trauma,
     pancreatitis may need
     many liters

If patient w/ CHF can give
     500cc over 1 hour and
     assess lung exam
                 IVFs & Electrolytes

•       Maintenance Solutions:
    •     hypotonic solutions used to replace normal fluid
          losses in an NPO patient


•       Typically “D5 ½ normal w/ 20 of K”:
        5% Dextrose, 0.45% NaCl, and 20mEq of KCl
            IVFs & Electrolytes

Notes:
• For NPO ESRD patients, run fluids at 30-
   50cc/hr
• For pts w/ CRI or ESRD don’t add K+ to
   maintenance fluids and don’t replace K+ if
   mildly low (remember, it’s going to rise by itself
   until dialysis)
• Never bolus a patient w/ D5 or K+
• If replacing GI losses, use a comparable fluid
• Diabetics need sugar too (OK to use D5 ½)
            IVFs & Electrolytes

Parenteral Nutrition

•   TPN: via central line or PICC (dedicated line)
•   PPN: via peripheral line
•   Should taper at ½ rate for an hour before
    stopping TPN because it may contain insulin
•   If need to D/C, run D10
                   IVFs & Electrolytes

Potassium

•       If pt is taking PO, give oral replacement
    -      If Cr normal, can give lots PO safely


•       Runs of IV if NPO
    -      Risk of arrhythmia - can only run 10 mEq of KCl per hour
    -      20 mEq / hr in a monitored setting like ICU
    -      run at slower rate if causing burning sensation in patient’s arm


•       Actual deficit is larger than you might think
    -      eg. for K=3.2 will likely need 10mEq IV x 4 or 40mEq PO x 2
            IVFs & Electrolytes

Calcium

•   If calcium is low, first adjust for albumin
•   Can also check an ionized calcium instead
•   If mild, give PO calcium carbonate (TUMS)
•   If symptomatic, give calcium gluconate IV
•   If head/neck surgery, may have inadvertently
    injured the parathyroids? Need to check Ca
    level postop
            IVFs & Electrolytes

Phosphate
• Often see drop in patients undergoing major
   hepatic resection
• Replace w/ PO NeutraPhos or IV K-Phos

Magnesium
• Important to check Mg level if K is low

Be cautious repleting electrolytes on ESRD pts –
   don’t do it without checking with chief/senior
            IVFs & Electrolytes

Glucose

•   If blood sugar is ~50-80 can just give patient
    some juice and observe

•   If <50, or if patient is symptomatic (altered
    mental status, diaphoretic) push an ampule of
    D50 x 1 stat
                   Discharge planning
• Think about early and discuss with team

• Involve Social Work (SW) and Physical Therapy early when
  necessary- remember daily SW rounds!

• Enter IDP (implement discharge plan) in TDS when discharge is
  planned in the next 24 hours

• Enter discharge order after morning rounds

• Write prescriptions clearly and legibly in a timely fashion – don’t
  forget to include DEA on narcotics, License number.
   • Mount Sinai institutional DEA# AM9707805- your suffix

• Complete discharge summaries before the chart disappears – can
  be done in SignOut on computer
                    Pager Etiquette

   Tag your pages or use text-page system when paging
    other members of team
   Text paging (www.archwireless.com or
    intranet1.mounsinai.org/surgery)
   Don’t page people who may not be inhouse to 3-xxxx
    numbers
   When scrubbed, give pager to other intern. At Sinai, you
    can forward your pager by calling 41200 and follow
    prompts
   If you have a question regarding patient care- Go to the
    OR to find your chief. Don’t page because they are
    scrubbed and may not be able to call back.
•   ER 4-6639                   • 11W 4-5826
•   Blue slip 877.337.4624      • 10E 4-3595
•   Main Pharmacy 4-7714        • 9E 4-7935
•   ID drug approval p9407      • 9C 4-7944
•   Main Labs 4-LABS            • 8E 4-7939
•   Stat Lab 4-3895             • 7W 4-7929
•   Blood Bank 4-6101           • SICU (6E) 4-5111
•   Pathology 4-7373            • MICU (5W) 4-5721
•   Main Radiology 4-7401       • Radiology on call p1490
•   Ultrasound 4-7431           • Surgical clinics 824-7606
•   CT 4-7412                   • ME’s Office 212-447-2030
•   Special Procedures 4-7409   • Sinai Surgery Office 4-5871
•   DAS 4-7778                  • Elmhurst Surgery Office
•   Bed Board 4-7461                  718-334-2475
•   Main OR desk 4-1990         • Englewood Surgery Office
•   PACU 4-1992                       201-894-3141
•   Dictation line 8-9889       • Bronx VA Operator
•   Line service p1872, 37393         718-584-9000
                Useful Websites

   www.amion.com (login mssurg)
   www.mssurg.net (links to all sorts of useful stuff)
   www.acgme.org (don’t forget to log cases!)
   intranet1.mountsinai.org/surgery
   www.archwireless.com
   www.mssm.edu/library
                         Elmhurst Shuttle
  Mt. Sinai 99th St. &     Elmhurst Bus Stop
Madison Ave. (Weekdays                          Subway Directions
         Only)
                                               -6 train to 51st
       6:00 A.M.               6:25 A.M.       -Transfer   to E to Queens
       7:10 A.M.               7:45 A.M.
                                               -Get off at Roosevelt Ave
       8:40 A.M.               10:15 A.M.
                                               -Walk on Broadway past
      11:50 A.M.               12:30 P.M.
                                               “Pacific Supermarket” 4
       2:15 P.M.               3:20 P.M.       blocks to hospital, on your
                                               left
       4:05 P.M.               4:35 P.M.

       5:40 P.M.               6:30 P.M.

       7:00 P.M.               7:30 P.M.       -alternatives – R, V, or 7
                                               trains all go to Roosevelt
                                               ave.
                  Bronx VA Shuttle
   Mt. Sinai          VA
 98th/Madison
(Weekdays Only)
                                   Subway Directions
   6:30 A.M.       7:00 A.M.           4 to Bronx
   7:30 A.M.       8:15 A.M.
                                       Get off at Kingsbridge
   9:15 A.M.      10:00 A.M.            Rd
   10:45 A.M.     11:30 A.M.
                                       Walk on Kingsbridge
   12:00 P.M.      12:30 P.M.
                                        past large abandoned
   1:15 P.M.       2:45 P.M.            Armory building
   3:30 P.M.       4:35 P.M.            approx 5 blocks
   5:15 P.M.       5:50 P.M.           Hospital parking lot on
   6:30 P.M.       7:15 P.M.            your left across street
    Englewood Shuttle
Weekday Schedule Leaving   Weekday Schedule Leaving
      Englewood              Mt. Sinai (Aron Hall)

        5:15 A.M.                  6:00 A.M.

        6:30 A.M.                  7:00 A.M.

        8:15 A.M.                  9:00 A.M.

       12:00 P.M.                 12:45 P.M.

        5:00 P.M.                  5:30 P.M.

        6:30 P.M.                  7:00 P.M.

   Weekend Schedule           Weekend Schedule

        8:00 A.M.                  8:30 A.M.

        9:45 A.M.                 10:15 A.M.
            Call Schedule Requests

   If you have a request for the next month, find out early
    who is making the schedule and contact them.
   Requests have to be in by the 10th of the previous
    month, so do this EARLY
   Understand that it is not always possible to get what you
    want and be nice to the person making the schedule –
    they have a tough job
   If you will be postcall on the 1st day of the month, let your
    future chief know ahead of time
Some last words of advice…
•   Always leave a dated / timed note for every encounter

•   Trust no one! (always repeat the exam yourself,
    always re-check important labs, etc)

•   Be meticulous and organized– you cannot remember
    everything, make detailed lists, cross off items as you
    go

•   NEVER LIE. The chief would much rather hear "I don't
    know for sure" rather than passing on incorrect
    information. You will find that admitting what you don't
    know is a very important part of "first do no harm".
      Some last words of advice…




   Always call for help when you are not
    sure…
Some last words of advice…




• … and eat lunch!

								
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