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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