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How to do well/shine on a vascular surgery sub-i?

D

deleted1038938

Hi everyone - my vascular surgery sub-i at my school starts in two weeks. I wanted to know what I can do to prepare for this rotation. I've only done general surgery, transplant, and plastics rotations so I'm pretty naive about vascular.
 
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OnePunchBiopsy

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Work hard and know your patients. Offer to go see consults. Prepare for cases by reviewing the relevant anatomy.

In clinic, know how to measure an Ankle-Brachial Index (ABI), and doppler arterial signals if necessary.

These factors alone will make you in the top 10%.
 
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Gurby

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I bookmarked this post from a vascular surgeon about how to excel on rotations. There isn't a whole lot that is vascular-specific, and maybe it will be old hat if you've already gone through 3 surgery rotations... But there are definitely some nuggets of wisdom here:

I just did evals for our medical students from February. Supposedly the clerkship director will edit/review them, but I kinda doubt it since what I wrote will be more detailed than he could ever write based on his interaction with them which was minimal.

I will only talk about surgery clerkships since that is what I know. A lot of this will apply to other clerkships that others can adapt. I can give specific examples for every single number below based on last month alone. These are very common issues.

To avoid being a bad student:
1) Show up on time
2) Look professional
3) Be available. You should never disapear and unreachable.
4) If asked to do something, either say, "Yes, I'll do it" or, "I don't feel comfortable with that, do you mind teaching me how to do it so I can do it next time?"
5) Do not ask "Anything that I can do right now?", ask, "How can I help?" or simply offer to do things, I hate scutting stuff to students, but if you offer to drop my notes off for me, or you feel comfortable finishing a dressing change on your own, if you say, "I can handle this" or just "I got this".

To be a good student:
1) Know your patients inside out and backwards. You are carrying less patients than your residents/attendings, you should know the details about your patient, even if they don't. You may not know what it means, but you should have the info available.
2) Always make an assessment, attempt to develop a plan. Start with a wide differential and focus in on the most likely diagnoses.
3) Read. Every night, even if it is for 15 minutes. Read about your patient or the procedure they are about to have or have had.
4) Be helpful. Getting labs, dropping notes in charts etc. Scut sucks, we all have to do it.
5) Tie and suture. I will walk anyone through how to do something, but I expect you to know the basics before showing up in the OR. If I show you how to do something, you should practice it at home and if you don't get it, ask me to show you again when we have down time.

To be a rock star:
1) Know your patients inside and out, but pay attention to what residents and attendings find important. Nobody will fault an MS3 for giving a laundry list of normal physical exam findings/labs, but eventually you have to learn to focus in on the important things so you can effectively communicate with colleagues down the road.
2) Develop skills. You are as useful as the skills that you posess. Things that an MS3 could potentially know how to do solo or with only resident observation:
a) Wet to dry dressings
b) Wound vac exchanges
c) Chest tube placements
d) Chest tube removals
e) Suturing - Simple, horizontal matress, vertical matress, sub Q, deep dermal, running
f) Central line placement
g) Central line removal
h) Fever workup
i) Getting outside hospital records
3) Learn to solve the common problems. Every rotation, go to the charge nurse on your main floor and ask them what the 10 most common intern calls are for. They should sound like this: Pain, fever, nausea, tachycardia, hypertension, electrolyte abnormalities etc. And then the specifics, Vascular: loss of previously dopplerable pulse, Gen Surg: change in abdominal exam findings etc. Then learn how to work up or manage those issues. As an MS4 on sub-I a good student will function like an intern. Those skills don't show up overnight, you have to develop them over time starting as an MS3.
4) Do not stop suturing or knot tieing. If you are interested in surgery, innate ability counts for something, but more important is practice. You should be able to do one handed ties left and right handed with ease. You should be efficient and accurate. When in conference, tie to your scrub bottoms or the chair next to you. If you have down time, have someone check your technique.
5) Think before cutting suture. What kind of suture are you cutting? Where are you cutting it? What is the purpose of this stitch? How many knots were tied? There is a logic behind suture tail length. While you will always have people that do things a particular way "just because", the vast majority will have a method behind their madness.
 
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WinslowPringle

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Surgery sub-i stuff in general:
Show up early, stay late. Know your patients' surgical history, pertinent medical history pertinent labs (Hgb, plt and for vasc this often includes K, Cr - either bc you're going to be doing grafts/fistulas or dialysis catheters or bc you're hitting them with a dye load recent lit on CIN notwithstanding....). Know the relevant anatomy for the case. Know indication for the surgery, potential complications. Write your name on the board, introduce yourself, get your gloves. Don't touch non-sterile things, but if you do just say you did and re-scrub. Don't pimp your residents. If everyone is silent, it's probably not a great time to pipe up with a question.

Vascular topics and patients in specific:
Big topics are going to be PAD, aneurysmal disease, ESRD for dialysis access, and carotid disease/CEA.

PAD
-History: is it acute limb ischemia or chronic limb ischemia? Know how to differentiate the two. Know claudication symptoms (and be able to differentiate from say spinal/neuropathic etc. symptoms). Know signs of acute ischemia. Know the Rutherford classification, particularly IIA, IIB, and III. Are they on meds? Specific meds you will always want to know about are antiplatelets (are they on aspirin? Are they on Plavix? *Ask*) and anticoagulants. Previous interventions? Lots of the chronic limb ischemia patients will have previous bypasses and stents, etc. Look at TASC criteria.
-Exam: When in clinic, consults or rounding you have to be able to do the pertinent exam. I don't trust my fingers and I wouldn't trust yours....you'll need to know where the hand-held dopplers are in clinic/on floors/ED. Check for DP, PT, popliteal, femoral pulses and signal. (You'll need to know the difference between monophasic, biphasic, triphasic signals). Look for signs of acute or chronic ischemia - motor, sensation, dry or wet gangrene, etc. Is there chronic venous stasis? What about their basic cardiac exam - are they in sinus or irregular rhythm, and what is their BP? How functional are they at baseline and if you have to do an amp, how will it affect them?
-Imaging: ABIs, duplex, toe pressures
-Surgery stuff: look at aortoiliac disease vs. runoff. Is it going to be open vs. endovascular? What vessels are you looking at? I would know the difference between wires, stents, sheaths. For doing leg angios, you usually get contralateral access, cross the aorta and shoot the angio down the other leg. Big vessels to identify will be common and superficial femoral artery, profunda, aorta (well, duh), ant and post tib and peroneal.

Aneursymal disease
-Focus on abdominal aortic stuff. You will probably see a lot of EVARs. You may see some TEVARs. Might see some ruptures.
-History: What are their risk factors? Do they smoke?
-Exam: Abdominal exam and pulses.
-Imaging: CTA, abdominal US
-Pimp questions: Know indications for surveillance. Indications for operative intervention. Know your distances for EVAR landing zone, angulation, and iliac size criteria.

ESRD
-History: Are they already on dialysis? What's their K, Cr? Who's their nephrologist and when did they dialyze last? What do they have for access and what other access attempts have they had? Are they in cardiac failure from their fistula? Do they have steal from their fistula
-PE: Check pulses, incisions. You should be able to feel a thrill/hear a bruit if they have a fistula. Is their graft or fistula clotted? If they have a DLDC, is it working? Is it IJ or femoral, tunneled or non? If there's an infection in the catheter is it exit site or blood stream?
-Imaging: duplex US of upper usually if going for fistula/graft. If doing an IJ I always look for prior CXR bc I don't want to be surprised by any fluoro or post procedure findings. Always review any previous CTAs, etc w/ particularly attention to the vessel you're going to be accessing.
Surgery: know size criteria for artery, vein for making a fistula. Have a general idea of when to do a fistula v. graft. Know the steps to do an IJ or femoral -DLDC. Have an idea of how fast your flow rate has to be for dialysis. Basic types of fistulas are: radiocephalic, brachiocephalic, brachiobasilic (this one will have to be 'transposed').

Carotid disease
-History: What are their symptoms? If a stroke - when and really specific symptoms. You need to know motor and side; memory loss; verbal symptoms etc. Loss of vision?
-Imaging: carotid duplex, CTA neck, MRA. Have an idea of which one you would order when. If they've had a stroke, be familiar with their head CT/MRI findings. Know the criteria for PSV/EDV and internal carotid ratios and cut-offs for when you do surgery
-Pimping: attendings like to ask basic questions about NASCET and ACAS trials.
-Surgery: Know cut-offs for stenosis for when you operate on symptomatic and asymptomatic patients. If they've had a stroke or TIA know time-frame of when you operate.
-Anatomy: know branches of external carotid. Know the first branch of internal carotid (hint: intracranial). Know the layers of the artery you remove in a carotid endarterectomy. Know what vein you divide to find the bifurcation. Know what stump pressure would cause you to shunt at. (Some attending shunt everything, some are selective.) Know: marginal mandibular, vagus, recurrent laryngeal, hypoglossal where they are in relation to the surgery and what injury to them does. Know your muscle layers (ie, you divide the platysma and you're operating along the medial border of the SCM).
-Post op: I/we always stay with the patient to make sure they wake up without significant neurodeficit. If they have an on-table or shortly post-op stroke, the board answer is it's a technical issue and you stay/go back to the OR to look for a flap, etc.

Also, I'd know basic MOA of big-time playa anticoagulants and antiplatelets. Know indications for IVC filter. Know basic tx for DVT. Know what HIT is. Mycotic aneurysms aren't fungal aneurysms. Oh, if you have a question about severe abdominal pain after EVAR or open AAA repair - be concerned about ischemic colitis and do a sigmoidoscopy.


Know where the lead is and get comfy, you'll probably be wearing a lot of it. Good luck and have fun!
 
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kb1900

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You will be pimped on the different endoleak types. Doppler for PAD should be treated like a standard part of the pulse exam. Learn to do all the wound care for your service. On rounds you carry the supplies bag and take down dressings for all the patients before we got there and put them back up after.


Review all the topics in the above post to shine. You don’t need to know everything cold necessarily but be familiar at minimum. Anatomy is critical to how much you get out of a case. Definitely do all the standard surgery stuff re knowing your pts, scrubbing, pt transport, prepping the field, post op checks, hawk the most recent labs and vitals


Also, honestly? Just have fun. Some of the procedures you see will be insane and awesomely creative. And when stuff goes wrong, it really goes wrong, especially in thoracic stuff. Expect to get little sleep- my hours were 5am - 8pm with some days going to midnight and a decent amount of o/n call.
 
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D

deleted1038938

Surgery sub-i stuff in general:
Show up early, stay late. Know your patients' surgical history, pertinent medical history pertinent labs (Hgb, plt and for vasc this often includes K, Cr - either bc you're going to be doing grafts/fistulas or dialysis catheters or bc you're hitting them with a dye load recent lit on CIN notwithstanding....). Know the relevant anatomy for the case. Know indication for the surgery, potential complications. Write your name on the board, introduce yourself, get your gloves. Don't touch non-sterile things, but if you do just say you did and re-scrub. Don't pimp your residents. If everyone is silent, it's probably not a great time to pipe up with a question.

Vascular topics and patients in specific:
Big topics are going to be PAD, aneurysmal disease, ESRD for dialysis access, and carotid disease/CEA.

PAD
-History: is it acute limb ischemia or chronic limb ischemia? Know how to differentiate the two. Know claudication symptoms (and be able to differentiate from say spinal/neuropathic etc. symptoms). Know signs of acute ischemia. Know the Rutherford classification, particularly IIA, IIB, and III. Are they on meds? Specific meds you will always want to know about are antiplatelets (are they on aspirin? Are they on Plavix? *Ask*) and anticoagulants. Previous interventions? Lots of the chronic limb ischemia patients will have previous bypasses and stents, etc. Look at TASC criteria.
-Exam: When in clinic, consults or rounding you have to be able to do the pertinent exam. I don't trust my fingers and I wouldn't trust yours....you'll need to know where the hand-held dopplers are in clinic/on floors/ED. Check for DP, PT, popliteal, femoral pulses and signal. (You'll need to know the difference between monophasic, biphasic, triphasic signals). Look for signs of acute or chronic ischemia - motor, sensation, dry or wet gangrene, etc. Is there chronic venous stasis? What about their basic cardiac exam - are they in sinus or irregular rhythm, and what is their BP? How functional are they at baseline and if you have to do an amp, how will it affect them?
-Imaging: ABIs, duplex, toe pressures
-Surgery stuff: look at aortoiliac disease vs. runoff. Is it going to be open vs. endovascular? What vessels are you looking at? I would know the difference between wires, stents, sheaths. For doing leg angios, you usually get contralateral access, cross the aorta and shoot the angio down the other leg. Big vessels to identify will be common and superficial femoral artery, profunda, aorta (well, duh), ant and post tib and peroneal.

Aneursymal disease
-Focus on abdominal aortic stuff. You will probably see a lot of EVARs. You may see some TEVARs. Might see some ruptures.
-History: What are their risk factors? Do they smoke?
-Exam: Abdominal exam and pulses.
-Imaging: CTA, abdominal US
-Pimp questions: Know indications for surveillance. Indications for operative intervention. Know your distances for EVAR landing zone, angulation, and iliac size criteria.

ESRD
-History: Are they already on dialysis? What's their K, Cr? Who's their nephrologist and when did they dialyze last? What do they have for access and what other access attempts have they had? Are they in cardiac failure from their fistula? Do they have steal from their fistula
-PE: Check pulses, incisions. You should be able to feel a thrill/hear a bruit if they have a fistula. Is their graft or fistula clotted? If they have a DLDC, is it working? Is it IJ or femoral, tunneled or non? If there's an infection in the catheter is it exit site or blood stream?
-Imaging: duplex US of upper usually if going for fistula/graft. If doing an IJ I always look for prior CXR bc I don't want to be surprised by any fluoro or post procedure findings. Always review any previous CTAs, etc w/ particularly attention to the vessel you're going to be accessing.
Surgery: know size criteria for artery, vein for making a fistula. Have a general idea of when to do a fistula v. graft. Know the steps to do an IJ or femoral -DLDC. Have an idea of how fast your flow rate has to be for dialysis. Basic types of fistulas are: radiocephalic, brachiocephalic, brachiobasilic (this one will have to be 'transposed').

Carotid disease
-History: What are their symptoms? If a stroke - when and really specific symptoms. You need to know motor and side; memory loss; verbal symptoms etc. Loss of vision?
-Imaging: carotid duplex, CTA neck, MRA. Have an idea of which one you would order when. If they've had a stroke, be familiar with their head CT/MRI findings. Know the criteria for PSV/EDV and internal carotid ratios and cut-offs for when you do surgery
-Pimping: attendings like to ask basic questions about NASCET and ACAS trials.
-Surgery: Know cut-offs for stenosis for when you operate on symptomatic and asymptomatic patients. If they've had a stroke or TIA know time-frame of when you operate.
-Anatomy: know branches of external carotid. Know the first branch of internal carotid (hint: intracranial). Know the layers of the artery you remove in a carotid endarterectomy. Know what vein you divide to find the bifurcation. Know what stump pressure would cause you to shunt at. (Some attending shunt everything, some are selective.) Know: marginal mandibular, vagus, recurrent laryngeal, hypoglossal where they are in relation to the surgery and what injury to them does. Know your muscle layers (ie, you divide the platysma and you're operating along the medial border of the SCM).
-Post op: I/we always stay with the patient to make sure they wake up without significant neurodeficit. If they have an on-table or shortly post-op stroke, the board answer is it's a technical issue and you stay/go back to the OR to look for a flap, etc.

Also, I'd know basic MOA of big-time playa anticoagulants and antiplatelets. Know indications for IVC filter. Know basic tx for DVT. Know what HIT is. Mycotic aneurysms aren't fungal aneurysms. Oh, if you have a question about severe abdominal pain after EVAR or open AAA repair - be concerned about ischemic colitis and do a sigmoidoscopy.


Know where the lead is and get comfy, you'll probably be wearing a lot of it. Good luck and have fun!
Sorry forgot to reply to this last week thank you so much!!! this is incredible. thank you thank you for the most detailed explanation. i appreciate it so much.
 
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D

deleted1038938

You will be pimped on the different endoleak types. Doppler for PAD should be treated like a standard part of the pulse exam. Learn to do all the wound care for your service. On rounds you carry the supplies bag and take down dressings for all the patients before we got there and put them back up after.


Review all the topics in the above post to shine. You don’t need to know everything cold necessarily but be familiar at minimum. Anatomy is critical to how much you get out of a case. Definitely do all the standard surgery stuff re knowing your pts, scrubbing, pt transport, prepping the field, post op checks, hawk the most recent labs and vitals


Also, honestly? Just have fun. Some of the procedures you see will be insane and awesomely creative. And when stuff goes wrong, it really goes wrong, especially in thoracic stuff. Expect to get little sleep- my hours were 5am - 8pm with some days going to midnight and a decent amount of o/n call.
Thank you! :) i appreciate it.
 
A

AnatomyGrey12

Great thread.
I bookmarked this post from a vascular surgeon about how to excel on rotations. There isn't a whole lot that is vascular-specific, and maybe it will be old hat if you've already gone through 3 surgery rotations... But there are definitely some nuggets of wisdom here:
YES. I was looking for this post the other day and couldn't find it. Thank you.
 
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theonlytycrane

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Bless all of you going into vascular. Srsly the coolest specialty (open f*cking AAA omg). I just couldn't do the hours. But sewing on the aorta and femoral artery was the coolest thing I did in med school. And making my resident and attending laugh when I couldn't click softly enough to lock the castros
 
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Lawpy

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Surgery sub-i stuff in general:
Show up early, stay late. Know your patients' surgical history, pertinent medical history pertinent labs (Hgb, plt and for vasc this often includes K, Cr - either bc you're going to be doing grafts/fistulas or dialysis catheters or bc you're hitting them with a dye load recent lit on CIN notwithstanding....). Know the relevant anatomy for the case. Know indication for the surgery, potential complications. Write your name on the board, introduce yourself, get your gloves. Don't touch non-sterile things, but if you do just say you did and re-scrub. Don't pimp your residents. If everyone is silent, it's probably not a great time to pipe up with a question.

Vascular topics and patients in specific:
Big topics are going to be PAD, aneurysmal disease, ESRD for dialysis access, and carotid disease/CEA.

PAD
-History: is it acute limb ischemia or chronic limb ischemia? Know how to differentiate the two. Know claudication symptoms (and be able to differentiate from say spinal/neuropathic etc. symptoms). Know signs of acute ischemia. Know the Rutherford classification, particularly IIA, IIB, and III. Are they on meds? Specific meds you will always want to know about are antiplatelets (are they on aspirin? Are they on Plavix? *Ask*) and anticoagulants. Previous interventions? Lots of the chronic limb ischemia patients will have previous bypasses and stents, etc. Look at TASC criteria.
-Exam: When in clinic, consults or rounding you have to be able to do the pertinent exam. I don't trust my fingers and I wouldn't trust yours....you'll need to know where the hand-held dopplers are in clinic/on floors/ED. Check for DP, PT, popliteal, femoral pulses and signal. (You'll need to know the difference between monophasic, biphasic, triphasic signals). Look for signs of acute or chronic ischemia - motor, sensation, dry or wet gangrene, etc. Is there chronic venous stasis? What about their basic cardiac exam - are they in sinus or irregular rhythm, and what is their BP? How functional are they at baseline and if you have to do an amp, how will it affect them?
-Imaging: ABIs, duplex, toe pressures
-Surgery stuff: look at aortoiliac disease vs. runoff. Is it going to be open vs. endovascular? What vessels are you looking at? I would know the difference between wires, stents, sheaths. For doing leg angios, you usually get contralateral access, cross the aorta and shoot the angio down the other leg. Big vessels to identify will be common and superficial femoral artery, profunda, aorta (well, duh), ant and post tib and peroneal.

Aneursymal disease
-Focus on abdominal aortic stuff. You will probably see a lot of EVARs. You may see some TEVARs. Might see some ruptures.
-History: What are their risk factors? Do they smoke?
-Exam: Abdominal exam and pulses.
-Imaging: CTA, abdominal US
-Pimp questions: Know indications for surveillance. Indications for operative intervention. Know your distances for EVAR landing zone, angulation, and iliac size criteria.

ESRD
-History: Are they already on dialysis? What's their K, Cr? Who's their nephrologist and when did they dialyze last? What do they have for access and what other access attempts have they had? Are they in cardiac failure from their fistula? Do they have steal from their fistula
-PE: Check pulses, incisions. You should be able to feel a thrill/hear a bruit if they have a fistula. Is their graft or fistula clotted? If they have a DLDC, is it working? Is it IJ or femoral, tunneled or non? If there's an infection in the catheter is it exit site or blood stream?
-Imaging: duplex US of upper usually if going for fistula/graft. If doing an IJ I always look for prior CXR bc I don't want to be surprised by any fluoro or post procedure findings. Always review any previous CTAs, etc w/ particularly attention to the vessel you're going to be accessing.
Surgery: know size criteria for artery, vein for making a fistula. Have a general idea of when to do a fistula v. graft. Know the steps to do an IJ or femoral -DLDC. Have an idea of how fast your flow rate has to be for dialysis. Basic types of fistulas are: radiocephalic, brachiocephalic, brachiobasilic (this one will have to be 'transposed').

Carotid disease
-History: What are their symptoms? If a stroke - when and really specific symptoms. You need to know motor and side; memory loss; verbal symptoms etc. Loss of vision?
-Imaging: carotid duplex, CTA neck, MRA. Have an idea of which one you would order when. If they've had a stroke, be familiar with their head CT/MRI findings. Know the criteria for PSV/EDV and internal carotid ratios and cut-offs for when you do surgery
-Pimping: attendings like to ask basic questions about NASCET and ACAS trials.
-Surgery: Know cut-offs for stenosis for when you operate on symptomatic and asymptomatic patients. If they've had a stroke or TIA know time-frame of when you operate.
-Anatomy: know branches of external carotid. Know the first branch of internal carotid (hint: intracranial). Know the layers of the artery you remove in a carotid endarterectomy. Know what vein you divide to find the bifurcation. Know what stump pressure would cause you to shunt at. (Some attending shunt everything, some are selective.) Know: marginal mandibular, vagus, recurrent laryngeal, hypoglossal where they are in relation to the surgery and what injury to them does. Know your muscle layers (ie, you divide the platysma and you're operating along the medial border of the SCM).
-Post op: I/we always stay with the patient to make sure they wake up without significant neurodeficit. If they have an on-table or shortly post-op stroke, the board answer is it's a technical issue and you stay/go back to the OR to look for a flap, etc.

Also, I'd know basic MOA of big-time playa anticoagulants and antiplatelets. Know indications for IVC filter. Know basic tx for DVT. Know what HIT is. Mycotic aneurysms aren't fungal aneurysms. Oh, if you have a question about severe abdominal pain after EVAR or open AAA repair - be concerned about ischemic colitis and do a sigmoidoscopy.


Know where the lead is and get comfy, you'll probably be wearing a lot of it. Good luck and have fun!

Def listing this in the directory. Awesome stuff
 
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