10 August 2007

Surgical Clerkship 101 (Part 1)

I thought I would take this opportunity to spend some time listing some helpful hints to moving through your surgical clerkship seamlessly. Surgery is one the the third-year “required” clerkships during medical school. It doesn’t matter if you are interested in surgery or not, you still need to master this important portion of your medical school training. Many student look at surgery as something to be dreaded but this approach will not serve you well in surgery (or any class or clerkship). It is most useful to go into this clerkship with an open mind and a willingness to learn and master what you need from this required clerkship to become an excellent physician.

As a third-year surgical student, you will be required to keep honing and using your Physical Diagnosis skills. Your acumen with the abdominal history and physical exam will be sharpened. In addition, you can pick up some valuable procedures and skills that will serve you well on any rotation regardless of specialty such as scrubbing and interaction with a sterile field, central venous access, suturing and simple skin closure. As a third-year surgical student, you ARE part of the team and you can either “carry your weight” or “drop the ball” but 95% of what you get out of this and any clinical rotation will be directly related to your attitude. In short, open your mind (and your ears) so that you get the most for your experience and money.

Surgical patients may present at any time of the day and from various sources such as the clinic, the emergency department or from your preceptor’s private office. In general, you will be assigned to a team (trauma, general surgical, surgical specialty) where you can expect patients from the above sources. You will be expected to take overnight “call” along with the interns and residents since many surgical patients will present in the middle of the night with emergencies. Your surgical clerkship is a very nice opportunity to interact with the “late-shift” personnel in various departments such as radiology, lab and nursing so that you can learn who to see when you need to get something done or when you need information.

The intern (PGY-1) is your first point person. Try to learn the scope of their role on the surgical team and how you can assist this person. The intern will usually be the busiest person but remember, that regardless of specialty, in two years, you will be in their position. Watch how the intern performs their job and learn how to function as an intern. During your fourth year “acting” internships or (AIs), you will want to have mastered time management and multi-tasking. It is great to have a good relationship with your intern and learn as much as possible and become as helpful as possible.

Being helpful does not mean that you become the person to “go fetch” coffee, radiographs and laundry but it does mean that you know more about your assigned patients than anyone on the team. You will pick up three to four patients on each rotation (more if you are efficient) that you will follow through their hospital course. It is your responsibility to follow-up on all orders, consults, labs and studies on your patient. The intern on your service will be covering every patient on the service so the more closely you can work with your intern the better. This means reading in your surgical text about your patients’ pathology and the surgical treatment of that pathology. This means reviewing and following up on every order, medication, dressing change and complication.

Typically, you will enter the hospital early in the morning to pre-round. In some cases, pre-rounding means heading over to a computer to gather any laboratory work, checking in with the overnight (post-call team) and reading any nurses notes/checking with the nurses who have been on duty overnight. Armed with this information, you should quickly check the previous 24 hours of vitals, intake and output. Finally (if this is allowed), you should do a quick (no more than 5-10-minute) focused physical exam on your patient. Armed with this information you can prepare your AM presentation which should make up the bulk of your AM progress note. If you encounter any problems, discuss these with your intern and be prepared to present this patient to the AM rounding team.

On AM rounds, the chief (or most senior resident) will listen to your report presentation. If you are not ready, the intern will present the patient but you should step up and have your presentation ready. Other good things to do will be to be at the bedside with things like extra bandages, scissors and tape if needed for your patient. I learned very early, how to “peek” under a dressing without removing it. In general, dressings may be removed at 48 hours but never remove a dressing unless you have cleared it with your intern. You can peek and examine the wound to figure out if it is intact. Also, be sure to note any dressing drainage (dry or fresh) and note if nursing has been reinforcing the dressing overnight (or since surgery). If you are on the vascular service, one of your tasks will be to “take down” your patient’s dressing so that the team may examine the wounds on rounds. You may be asked to replace the dressing (great skill to learn) by your resident. Get help from the intern (or nursing) if you have difficulty or questions with this.

If you have read about your patients’ pathology and surgical treatment, you should know (or learn) what complications to look for and how to monitor your patient. For example, you should know what to do if your patient develops a post-op fever at 8 hours, 24 hours, 36 hours or 72 hours. You should have a differential of things to check and monitor. You should know what to do if your patient has an extreme amount of pain that is unrelieved by their current analgesic regimen. You should know how to monitor electrolytes and when to replace them. You should keep your intern informed of the results of all consultants and any studies that have been ordered. In short, you micromanage the patient and you keep on top of things.

Another wonderful experience of your surgical clerkship is assisting in the operating room. I am going to devote an entire essay to this very important task. You will be performing tasks such as retracting tissue, driving camera (on laparoscopic cases) and closing skin. Do not underestimate the importance of these duties and do not underestimate the importance of thoroughly mastering the surgical anatomy of the cases that you scrub. Here again, is a great opportunity for you to show what you know and hone what you learned in Gross Anatomy and physiology. During many of your cases, you are going to be questioned by the senior resident/attending surgeon about the anatomy, physiology or procedure on which you are assisting. I will give you some tips to make you shine and guide you through this process.
Textbooks for your surgical clerkship: The big “three” texts for General Surgery are Greenfield’s, Sabiston’s and Schwartz. You need not purchase these texts (even if you are going into surgery) as they are readily available in your library (medical school or hospital) for research and consultation for presentations and projects. My favorite clerkship text is the Lawrence text for both General Surgery and the text for the Surgical Specialties. This book (or one like it) should constitute the bulk of your reading on this clerkship. In addition, you may want to invest in a smaller “pocket-type” book such as Surgical Recall that you can keep in your pocket for downtime during cases. Other good books in addition to your main clerkship text (Lawrence or something else) are NMS Surgery and NMS Surgery Casebook which contain excellent and compact information.

With Lawrence, NMS and the NMS Casebook, I cut the bindings off [FedEx/Kinko’s] and placed these in binders. I could then take pages with me and keep up with my reading between cases. The pages were held together by a ring and would fit in my jacket pocket or back pocket of my scrubs. I always had something to read with me be it Surgical Recall or my pages. This was the easiest way to keep reading and prepare for your surgical shelf exam. Surgical Recall was great for pointing out the surgical anatomy, surgical instrumentation and other answers to “pimp” questions for a particular procedure or pathology.

In my next essay, I will review scrubbing and assisting in the OR. In addition, I will comment on being a great third-year on call and keeping yourself “in the game” when you are exhausted and ready to “give up”. In my last essay on the Surgical Clerkship, I will point out some strategies for when things go wrong and how to prevent getting into situations where things can go wrong.

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