Baystate Scutpuppy – Guide to Intern Year
TEXAS (To EXcel At Surgery)
Table of Contents
General info
Vascular
Pedi
Trauma
ACS
Colorectal
Blue
Green
SICU – Includes Weaning Parameters and SICU Pearls.
Night Float – includes sign out and how to think through common issues/pages
Pearls for Answering Pages
Surgical Cricothyroidotomy
Leg Compartments
Arm Compartments
Vasoactive Drugs and Receptor Activities for the Treatment of Shock
Clinical Pulmonary Infection Score
Not typical intern services, but ones you may be cross-covering over the weekend:
Thoracic
Transplant
Plastics
Red
Research Fellowship
Surgical Mission Trips (during your vacation)
Textbooks
Recommended Reading for greatness
______
Goals established by the Intern Class of 2011:
1. Maintain firm faith in yourself and your peers
2. Speak kindly
3. Constantly push yourself to improve
4. Aim high
5. Be a team player
Teaching points that will take you far:
1. Hierarchy exists and must be respected at all times
2. Be a team player and help your colleagues out whenever you can
3. Always have each other’s back
4. Don’t complain
5. “Take every opportunity to be excellent.” – Peter Wu, MD (Class of 2013)
"To cure sometimes,
to ameliorate often,
to comfort always."
- Sir William Osler
This is merely a guide to the lands, it is not a textbook. You must still use your clinical judgment and study everyday.
Sources include Parkland Trauma Manual, Top Knife, The Physiologic Basis of Surgery, my notes from throughout the year (lectures, what I was frequently pimped on, etc.), notes from UTSW.
Congratulations, you’re a surgical PGY1!
General Info:
Floor Work
Your floor duties consist of whatever your chief tells you they are. Typically you get sign out in the am from another intern who was on overnight, you prepare the list (post op days, diet, abx, imaging results, consult recs, drain outputs, culture results, etc), and print copies for your team in the am. Present the new patients and overnight events to the team. Round with a “medical student” if you have a dressing-heavy service. (A medical student is a dressing change bag full of dressing supplies). After rounds, you will do chartwork (explained in next section), and you will continue to run around and take care of the floor. As you become more confident/competent, you will be rewarded with more work/responsibilities because you will be trusted more.
You will be responsible for knowing everything about your patients from past medical/surgical history to what meds they take at home to when their last BM was. Work hard, with enthusiasm.
Chart Work (CIS)
Part of your floor work as mentioned above is to write daily notes on your patients. These are similar to the SOAP notes you wrote as a medical student. You are also responsible for entering in orders based on what was discussed on rounds – advancing diets, hep locking IVFs, lab orders, imaging orders, etc. On most large services such as Blue and Green, a COW or WOW (for the weight sensitive patients), work station on wheels instead of computer on wheels, is wheeled around from room to room. The PA or resident manning this COW/WOW will be working on the note as well as putting in orders. Usually in this situation, the list is run after the completion of rounds, and the work is divided up according to what is left.
Of note, orders are more important than paperwork – get your orders in and call your consults etc before you write your notes. Patient care comes before paperwork. It’s best to put in your own orders instead of asking the nurses to do it for you. The order in which you should perform your am work is as follows: Call consults à orders à review and replete labs à paperwork.
As Dr. Nate Conway (class of 2012) once said – “my goal as an intern was to make the PA’s job obsolete.” Our PAs are amazing and we could not survive without them, but you must TRY. Do not depend on the Pas/NPs, you should approach floor work as if you had NO PAs, because sometimes you wont (they might be on vacation or have a day off) and you need to be ready to take care of a large service alone without the help of your senior residents who will usually be in the OR anyway.
Admission H+Ps are also part of chart work. Usually on services likes Vascular, ACS, Pedi, and Trauma, you will have consults to see and admit.
H+Ps include HPI, PMH, PSH, Home meds, Allergies, Social History, Family History, Vitals, PE (this must include if there is hepatosplenomegaly per Dr. Earle), labs, radiologic studies, impression, and plan.
Most services have special admit order sets in CIS which you can use. However, here is the mnemonic: ADC VAN DISMAL
Admit: location (reg bed, tele, intercare, SICU)
Diagnosis: admitting diagnosis
Condition: stable, poor, critical
Vitals: include here how often you’d like the vitals to be checked. This includes weight (the order for weight checks can be every am before breakfast for example)
Activity: ad lib, bathroom privileges, bedrest, non-weight bearing to a particular limb, C-collar precautions, etc.
Nursing Procedures: bed position (ex. HOB 30 degrees), respiratory care, foley, dressing changes
Notify resident if: this is where you put in what you want to be notified for (temp, pulse, RR, SBP, UOP, etc, below or greater than certain values.
Diet: regular, NPO, CLD, renal, cardiac
Ins and Outs: how frequently you want them checked
IVFs: LR, NS, what rate
Studies/Special Orders: EKGs, XRAYs, imaging, etc
Medications: which home meds do you want to continue at this time, and which new meds need to be ordered (Zofran, bowel regimen, pain meds post op)
Allergies: in CIS, list the allergies or mark NKDA
Labs: CBC with diff, BUN, Cr, lytes, divalents, UA, etc. you can also order these to be drawn daily for the next 5 days or so.
Make sure to enter in admitted diagnosis and review home meds under “orders” à “admission”
You will also have to write discharge summaries. It is helpful to start these when the patient is first admitted and just add to the hospital course throughout the admission period. This is easier than having to write a hospital course from scratch upon discharge of a patient’s that’s been in house for 30days. Discharge summaries also include procedures and consults. There is a template that can be filled out in CIS as well as templates for H+Ps, consult notes, progress notes, and procedure notes.
In the discharge summary, you will also include diet, activity restrictions, follow up instructions, wound care instructions, reasons to call the office or return to the ED, where the patient is being discharged to and in what condition, as well as discharge medications – what meds do you want the patient to continue to take. You might want them to take all of their previous home meds, just a few, or start taking the new ones you’ve written scripts for. If you know a patient will be discharged soon, it is useful to have the discharge summary up to date and the scripts in the chart so you can tell your team the patient is “clickable.” This means anyone can click them out just by signing the summary and putting in the discharge order.
When a patient dies, you must also sign your completed discharge summary. Please make sure that there are no statements such as “follow up with PCP” in these death discharge summaries. Attention to detail is key.
Procedure Note – central line, A line, chest tube, wound exploration/debridement, I+D
Procedure:
Indication: (diagnosis)
Position, prep, anesthesia
Materials/equipment, what you did in your procedure, result
Specimens sent and tests ordered
How the patient tolerated the procedure (blood loss, complaints, complications such as pneumothorax)
Again, as mentioned above, there are templates you can easily fill out in CIS for all of these different types of documentation.
Prescriptions
Med: Drug name and concentration
Sig: dosage, method of administration, and how frequently, PRN/or scheduled
Disp: total volume or number to dispense
Refill or no refill
Example:
Benadryl 25mg
1 tablet PO q4-6hrs PRN
Disp: 10 (ten)
Refils: 0
Presenting on Rounds
The only proper way to present is the way the presentee (chief or attending) wants it done. Start with an introductory sentence followed by the diagnosis (I’ve learned the hard way that this is what will capture the listener’s attention). Emphasize the aspects of the history, physical exam, lab values, imaging results, etc that are relevant to the case and will support your argument in what you think is going on and what your plan is. Mention abnormal values and pertinent negatives. You can always discuss your plan and what you think the diagnosis is with an upper-level before you present to your chief or attending. The goal is to be as prepared as possible and to always do what’s best for the patient and demonstrate that you care. The priority is to mention the key facts and be succinct. Don’t try to give too much information, if you leave something out, they will ask you for it, and you better make sure you have the answer at the tip of your tongue. Maintain good eye contact if you’re in person and do the majority of the presentation from memory. If you are talking to them over the phone, have CIS pulled up to the labs, etc.
Example with opening statement: “40yo F with one day history of right upper quadrant pain consistent with acute cholecystitis” à physical exam à labs à ultrasound results à assessment and plan.
“Do not say VSS. There’s nothing more stable than a corpse.” Dr. Earle.
How to look like it’s not your first rodeo in the OR, even if it is:
Prepare before each case. Know the patient, recent lab values, history, indications for the operation, possible obstacles you might encounter or need to watch for based on anatomy/prior operations. Look up imaging prior to the case and see if you can bring up relevant images and leave them up on the OR screens before the case starts.
Practice your skills as much as possible before the case, especially if you’re operating with an attending for the first time. If you demonstrate you have excellent skills, they will trust you and let your do MORE. This means, GO TO SIM LAB as much as you can. Be compliant with your scheduled appointments with Ron Bush and practice like an animal. The OR is NOT the place to practice your skills, this is the place to demonstrate how excellent you are because you have spent so much time outside of the OR practicing. Look up the actual operation before the case as well on the SCORE surgery curriculum website, youtube, or other virtual surgery sites (Websurg.com) so that you know all the steps and could perform it on your own if you needed to. ANTICIPATE! Always be three steps ahead and know what’s going to happen next so you can be ready to assist. By being a helpful assistant you prove that you understand the steps of the operation and can drive it forward. Adjust the lighting, be ready with the suture scissors and always have two instruments in your hand. Do everything you can to prep the patient before the attending gets there – clip the hair, position the patient (although some attendings like to do this themselves), and make sure all the equipment you will need is in the room (it may take time/experience to get this one down). Help move the patient before and after the case.
During the case, ask questions when the time is right, not while there’s audible bleeding. Be confident. Don’t drink coffee before a case where you’ll need your fine motor skills – thyroids, pedi cases, vascular anastomosis cases. It will be helpful to get loupes early in the year. You will use these for pedi, vascular, and thyroids.
OR etiquette – do not finish scrubbing before your chief/attending if yall start at the same time. Allow them to gown and glove first so they can start draping how they wish. Help get everything set up – keeping the cords on the field and passing off the cords that need to be plugged in. Do not speak out of turn. Do not joke around. Control your enthusiasm (learned this the hard way as well). Be as excited as you want after the case, but remain professional around the OR staff and attending. Don’t sing along to the music, as Nate Conway says – “This isn’t karaoke.”
Overall, be as prepared as possible, knowledge wise and skills wise. The more prepared you are, the more you will learn and the more you will be taught. Genuine interest and gentle enthusiasm go a long way.
Getting to actually perform an operation instead of just assisting is a privilege (not a guarantee). This privilege is earned through demonstrating adequate preparation consistently.
My favorite quote and what I repeat to myself when I catch myself trying to hurry (whether it’s in the OR or on the floor) – “Fast is slow. Slow is steady. Steady is fast.” – Navy Seals
The subsequent sections will describe each rotation. All of the attendings are great teachers and a ton of fun to work with. You will really enjoy all of them. They are very interested in you as a person and in your growth and development as a surgeon, physician, and human being.
Some great advice Dr. Ahmad once gave me – “You should see every moment as an opportunity to demonstrate your professionalism.” This is true, especially when you think no one is looking.