Most fullfilling patients and cases you get involved with as a General Surgeon

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Kahreek

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Complex or emergent cases are always interesting or at least they are a change of pace and can make a difference. But practice is not just those. What makes you get out of bed and think "i need to see these patients so i can alleviate or cure their condition and be content with the results"
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Kahreek said:
Complex or emergent cases are always interesting or at least they are a change of pace and can make a difference. But practice is not just those. What makes you get out of bed and think "i need to see these patients so i can alleviate or cure their condition and be content with the results"
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Emergency general surgery can be your entire practice, both at trauma and non-trauma centers alike.

General surgery is very broad. What gets you out of bed will vary based on your personal interest. For someone it's their academic (research) activities. For others, it's free or a gunshot wound to the abdomen. For others it's removing someone's early breast/colon/thyroid cancer and curing them OR their pancreas/liver/other bad cancer and giving them a small chance of cure.
 
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lazymed said:
Emergency general surgery can be your entire practice, both at trauma and non-trauma centers alike.

General surgery is very broad. What gets you out of bed will vary based on your personal interest. For someone it's their academic (research) activities. For others, it's free or a gunshot wound to the abdomen. For others it's removing someone's early breast/colon/thyroid cancer and curing them OR their pancreas/liver/other bad cancer and giving them a small chance of cure.
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Let me reprhase my post and just ask what surgeries each of you find more fullfilling
Winged Scapula said:
Oncologic cases are very satisfying.
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Oncologic cases I find them really pleasant, too. Especially colon.
 
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Draining a simple perianal abscess in a average sized American at 2am in the ER
 
bannie22 said:
Draining a simple perianal abscess in a average sized American at 2am in the ER
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ER butt cases are just so cool. "I've been up all night treating butt business"
 
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AdmiralChz said:
Must be nice to have an ED that lets you do that! Ours makes everything come up to the OR... not our favorite.
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What? How can I tell a consultant what to do? Please, tell me more, lol.
 
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Winged Scapula said:
all right Mr. smarty-pants… There IS such a thing as osteosarcoma of the breast but that's not what I was referring to.
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Hey, what's that bone cell doing in there!?

Somehow I misread that other term as DFSP = dermatofibrosarcoma protuberans and started getting all hot for toomas.
 
AdmiralChz said:
Must be nice to have an ED that lets you do that! Ours makes everything come up to the OR... not our favorite.
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how does your ER make you take someone to the OR?
 
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SouthernSurgeon said:
Make a policy that you can't do certain procedures at bedside, or refuse to provide sedation for said procedures.
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A. That is lame
B. I have my own sedation privileges

That said, I ain't getting out of bed for butt pus. That **** can wait till the next day and I will do it in the OR because lighting and positioning is better. Plus if it was my ass I would much rather be out. But I will do foreign body extractions in the ER (usually just let the ER doc sedate them so I don't have to do extra paperwork). I find it shamefully satisfying to succeed where the ER has already failed.
 
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SouthernSurgeon said:
We do it that night b/c we are there anyways. If we waited til the next day ORs would get all jammed up too (University hospital -> constant OR over-utilization).

I agree with you though that most times I prefer to do it in the OR. More comfortable for the patients. If it's a simple gluteal abscess in a diabetic or something like that I will give it a go in the ED. But if it's getting close to the anus they usually hate it too much. Also there's a chance they'll be right back after an inadequate bedside drainage.
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If I was in house might be a different story (though i would still want to do it in the OR if I have the option at night-where I trained we wouldn't call in a team for that sort of stuff since then we would force the home call chief and attending to come in which they wouldn't have to do for a bedside case). But I take home call with no residents and no in house OR at night and the ability to get a case added on during the day fairly easily if you are flexible. So I let us all stay in bed.
 
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SouthernSurgeon said:
Make a policy that you can't do certain procedures at bedside, or refuse to provide sedation for said procedures.
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Yep, this is it. A combination of the ER refusing to provide sedation ("tying up attendings"), infection control forbidding it and the surgeon not having privileges to provide sedation unless it's in the ICU. Thus they all come up to the OR, which is obnoxious.

Worse, in the Peds ED they are trialing a program where our pediatric anesthesiologists come down and provide sedation for procedures like abscess I&D, closed reduction, etc...
 
AdmiralChz said:
Yep, this is it. A combination of the ER refusing to provide sedation ("tying up attendings"), infection control forbidding it and the surgeon not having privileges to provide sedation unless it's in the ICU. Thus they all come up to the OR, which is obnoxious.

Worse, in the Peds ED they are trialing a program where our pediatric anesthesiologists come down and provide sedation for procedures like abscess I&D, closed reduction, etc...
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What about chest tubes? Taken to the OR, do it w/o sedation, or do your ER docs actually put in their own chest tubes?

What about trauma? Do your trauma surgeons do any in-trauma bay sedation?

Just curious. Every place is so different...
 
Haha, so true......of course, with enough local, enough lube, a long enough arm and strong enough restraints there's no need for anesthesiologists period ;-)

I have done most with light sedation, several without sedation but lots of local, and a few emergent ones without anything. If I ever have a 40Fr in my pleural cavity non-emergently but still urgently placed, I would prefer a whiff of versed, please.

Do you do anything with the local besides skin, plenteous in the subq, periosteum, muscle ensuring your area of spreading is covered, lots into the pleura, total usually 20-40cc? Wide but specific local numbing is what I've learned and read about, but don't know if there's a better way.
 
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AdmiralChz said:
Yep, this is it. A combination of the ER refusing to provide sedation ("tying up attendings"), infection control forbidding it and the surgeon not having privileges to provide sedation unless it's in the ICU. Thus they all come up to the OR, which is obnoxious.

Worse, in the Peds ED they are trialing a program where our pediatric anesthesiologists come down and provide sedation for procedures like abscess I&D, closed reduction, etc...
Click to expand...

The trying up attendings is a fair argument. If you're in a busy ED with a full waiting room, it's tough to justify that much time for a procedure that could be done elsewhere.
 
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WinslowPringle said:
Haha, so true......of course, with enough local, enough lube, a long enough arm and strong enough restraints there's no need for anesthesiologists period ;-)

I have done most with light sedation, several without sedation but lots of local, and a few emergent ones without anything. If I ever have a 40Fr in my pleural cavity non-emergently but still urgently placed, I would prefer a whiff of versed, please.

Do you do anything with the local besides skin, plenteous in the subq, periosteum, muscle ensuring your area of spreading is covered, lots into the pleura, total usually 20-40cc? Wide but specific local numbing is what I've learned and read about, but don't know if there's a better way.
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Nothing fancier than that. Also, 40fr? You are just mean. Also, having had a chest tube, the insertion didn't suck so much as the removal and no one ever thinks to medicate extra for that.
 
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TimesNewRoman said:
The trying up attendings is a fair argument. If you're in a busy ED with a full waiting room, it's tough to justify that much time for a procedure that could be done elsewhere.
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I'm not sure why it requires attendings. Have drained a lot of butt puss in the ED and never once has an EM attending been present. Rarely are my own attendings present.
 
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LucidSplash said:
I'm not sure why it requires attendings. Have drained a lot of butt puss in the ED and never once has an EM attending been present. Rarely are my own attendings present.
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If the surgeon wants sedation.
 
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LucidSplash said:
I'm not sure why it requires attendings. Have drained a lot of butt puss in the ED and never once has an EM attending been present. Rarely are my own attendings present.
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Srsly.

In Australia, as a 4th year student in the northern territory doing old school GS, I was allowed to drain pus myself in the OR with just an anesthesiologist present (and the resident or attending doing other things in another room, if I needed them).
 
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I had a 4-5yo kid with like a 2cm eyebrow lac the other day. Community ER nurse said he wasn't comfortable with the patient getting ketamine for sedation despite the EM doc doing it routinely. Nursing supervisor stepped in and they came up with a "compromise": oral Benadryl.

Didn't do anything except make the kid act goofier, and now the kid has to get admitted, go under anesthesia, muck up our full OR schedule, etc all for a lac that would've taken me three minutes to close with procedural sedation in the ER.

Not the most fulfilling case.
 
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VisionaryTics said:
I had a 4-5yo kid with like a 2cm eyebrow lac the other day. Community ER nurse said he wasn't comfortable with the patient getting ketamine for sedation despite the EM doc doing it routinely. Nursing supervisor stepped in and they came up with a "compromise": oral Benadryl.

Didn't do anything except make the kid act goofier, and now the kid has to get admitted, go under anesthesia, muck up our full OR schedule, etc all for a lac that would've taken me three minutes to close with procedural sedation in the ER.

Not the most fulfilling case.
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Next time find the charge nurse or house supervisor and have them find you a nurse who is comfortable.
 
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VisionaryTics said:
I had a 4-5yo kid with like a 2cm eyebrow lac the other day. Community ER nurse said he wasn't comfortable with the patient getting ketamine for sedation despite the EM doc doing it routinely. Nursing supervisor stepped in and they came up with a "compromise": oral Benadryl.

Didn't do anything except make the kid act goofier, and now the kid has to get admitted, go under anesthesia, muck up our full OR schedule, etc all for a lac that would've taken me three minutes to close with procedural sedation in the ER.

Not the most fulfilling case.
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Wait, so the ER doc was comfortable sedating the kid and the RN said no? I'd leave that ED in a heartbeat.....I'd also tell the RN to get the ketamine from the pyxis and tell him/her that he/she is dismissed and that I will do their job since they are unwilling or incapable of doing it....
 
dpmd said:
A. That is lame
B. I have my own sedation privileges

That said, I ain't getting out of bed for butt pus. That **** can wait till the next day and I will do it in the OR because lighting and positioning is better. Plus if it was my ass I would much rather be out. But I will do foreign body extractions in the ER (usually just let the ER doc sedate them so I don't have to do extra paperwork). I find it shamefully satisfying to succeed where the ER has already failed.
Click to expand...

I drain most butt pus in either the office or the ER. I tend to let the residents drain it without my supervision in the ER. It is definitely nice to have the ER doc provide some sedation for the big ones. If they are properly trained, there's no reason that the drainage should be inadequate and require a repeat incision.

In the office I just use 1% lido with epi, and the patients seem to tolerate it well, especially when they can appreciate the difference in the two price tags.

I've found that with the appropriate local analgesia, positioning, and the cadence that comes from doing a lot of these, they tend to go smoothly. The only ones I take to the OR are those with a horseshoe or concern for a necrotizing soft tissue infection.

However, I would never say this is the only way to do it. It's just what works best for me, and it's cheaper, so that's nice.

As far as what cases I find fulfilling, it's a mixed bag. I certainly enjoy cancer surgery, which is a big part of my practice, but I also enjoy anorectal procedures quite a bit, with a lateral internal sphincterotomy perhaps being the most cathartic.

If you cure someone's cancer with a laparoscope or robot, they are thankful, and often think highly of you. However, if you cure their butt pain, you are a god in their eyes.....
 
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SLUser11 said:
I drain most butt pus in either the office or the ER. I tend to let the residents drain it without my supervision in the ER. It is definitely nice to have the ER doc provide some sedation for the big ones. If they are properly trained, there's no reason that the drainage should be inadequate and require a repeat incision.

In the office I just use 1% lido with epi, and the patients seem to tolerate it well, especially when they can appreciate the difference in the two price tags.

I've found that with the appropriate local analgesia, positioning, and the cadence that comes from doing a lot of these, they tend to go smoothly. The only ones I take to the OR are those with a horseshoe or concern for a necrotizing soft tissue infection.

However, I would never say this is the only way to do it. It's just what works best for me, and it's cheaper, so that's nice.

As far as what cases I find fulfilling, it's a mixed bag. I certainly enjoy cancer surgery, which is a big part of my practice, but I also enjoy anorectal procedures quite a bit, with a lateral internal sphincterotomy perhaps being the most cathartic.

If you cure someone's cancer with a laparoscope or robot, they are thankful, and often think highly of you. However, if you cure their butt pain, you are a god in their eyes.....
Click to expand...

I don't even really like colorectal in general but I have to admit that I enjoy doing cut and sew hemorrhoidectomies. One of our CR attendings refers to them as plastic surgery of the anus and I can appreciate that.
 
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SLUser11 said:
I drain most butt pus in either the office or the ER. I tend to let the residents drain it without my supervision in the ER. It is definitely nice to have the ER doc provide some sedation for the big ones. If they are properly trained, there's no reason that the drainage should be inadequate and require a repeat incision.

In the office I just use 1% lido with epi, and the patients seem to tolerate it well, especially when they can appreciate the difference in the two price tags.

I've found that with the appropriate local analgesia, positioning, and the cadence that comes from doing a lot of these, they tend to go smoothly. The only ones I take to the OR are those with a horseshoe or concern for a necrotizing soft tissue infection.
Click to expand...

I do the same. This is probably a product of my training (in residency, we just did them unsupervised in the ER and informed the attendings later) more than anything else. One of my former partners took them to the OR 90% of the time and thought it was cruel and unusual to not do them under anesthesia.
 
Smurfette said:
I do the same. This is probably a product of my training (in residency, we just did them unsupervised in the ER and informed the attendings later) more than anything else. One of my former partners took them to the OR 90% of the time and thought it was cruel and unusual to not do them under anesthesia.
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I do so much in the OR because I personally am a wimp and can't handle putting them through pain if I can help it. The ones I am seeing usually are in so much pain I can't even pull their cheeks apart to get a look so I can't imagine all the local in the world making much of a dent in that (though I never tried so I could be mistaken). I have had just a few abscesses in various body parts come in through clinic most of which take me up on the surgery center offer so they can be sedated. One was a breast abscess that the lady was adamant I drain in clinic. Over my better judgement I complied and despite lots of local she was miserable. Maybe my local technique sucks since I don't test it out too often??? Or is it just that there is still some discomfort and you guys are ok with it because it is over quick?
 
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dpmd said:
I do so much in the OR because I personally am a wimp and can't handle putting them through pain if I can help it. The ones I am seeing usually are in so much pain I can't even pull their cheeks apart to get a look so I can't imagine all the local in the world making much of a dent in that (though I never tried so I could be mistaken). I have had just a few abscesses in various body parts come in through clinic most of which take me up on the surgery center offer so they can be sedated. One was a breast abscess that the lady was adamant I drain in clinic. Over my better judgement I complied and despite lots of local she was miserable. Maybe my local technique sucks since I don't test it out too often??? Or is it just that there is still some discomfort and you guys are ok with it because it is over quick?
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There's still discomfort. I usually warn the patient that it'll sting when I put in the local, but that they won't feel me cut the abscess open. I do tell them it's going to hurt like hell when I make sure any loculations are broken up (since local anesthetic doesn't work in the cavity itself) and pack it, and that they can curse all they want at me for those few minutes if that helps them. The office (and ER) staff is used to helping retract cheeks or whatever parts need to be held out of the way for the fastest procedure. I'm quick once I get started and most are feeling better by the time the dressings are on. I'm pretty clear before we get started that it will hurt but be over fast (no conscious sedation or pain meds available in the office; I will premedicate people in the ER). Most are happy to have instant relief rather than to have to wait hours for a procedure under anesthesia (and they are never NPO, so that's another difficulty depending on the anesthesiologist). Plus they can drive themselves home if I do it in the office. Since the ER or local PCPs often just refer the patients to see a surgeon, we get a fair number of people prepared to have it done in the office anyhow.
 
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Smurfette said:
There's still discomfort. I usually warn the patient that it'll sting when I put in the local, but that they won't feel me cut the abscess open. I do tell them it's going to hurt like hell when I make sure any loculations are broken up (since local anesthetic doesn't work in the cavity itself) and pack it, and that they can curse all they want at me for those few minutes if that helps them. The office (and ER) staff is used to helping retract cheeks or whatever parts need to be held out of the way for the fastest procedure. I'm quick once I get started and most are feeling better by the time the dressings are on. I'm pretty clear before we get started that it will hurt but be over fast (no conscious sedation or pain meds available in the office; I will premedicate people in the ER). Most are happy to have instant relief rather than to have to wait hours for a procedure under anesthesia (and they are never NPO, so that's another difficulty depending on the anesthesiologist). Plus they can drive themselves home if I do it in the office. Since the ER or local PCPs often just refer the patients to see a surgeon, we get a fair number of people prepared to have it done in the office anyhow.
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I do gently look for loculations, but I think sometimes the "loculations" that people fracture with their finger are actually branches of the pudendal nerve, division of which can lead to incontinence. In general, once you give the pus somewhere to go, they will get better.

My technique is left lateral (or prone in office), use tape on the bed to help expose the wound (or just an MA if in the office), sedation from ER doc if available, 1% lido with epi injected very slowly...

Then I make a generous incision (at least 2-3cm) in a radial pattern from the anus (no cruciate). People often drain as far away from the anal verge as possible, but that just makes for a long fistula tract if one develops. I gently probe with my finger to ensure there's no undrained pus, then I pack with nugauze. I remove the gauze on POD #1 and never re-pack, as I've made an incision big enough that packing is unnecessary (and cruel). I tell them to do mandatory TID sitz baths to keep the area clean and help facilitate the removal of pus.

I could talk about butt pus all day!
 
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There's something magical about reducing a "nonreducible" hernia. I like to maintain eye contact with the ED attending throughout.
 
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SLUser11 said:
I do gently look for loculations, but I think sometimes the "loculations" that people fracture with their finger are actually branches of the pudendal nerve, division of which can lead to incontinence. In general, once you give the pus somewhere to go, they will get better.

My technique is left lateral (or prone in office), use tape on the bed to help expose the wound (or just an MA if in the office), sedation from ER doc if available, 1% lido with epi injected very slowly...

Then I make a generous incision (at least 2-3cm) in a radial pattern from the anus (no cruciate). People often drain as far away from the anal verge as possible, but that just makes for a long fistula tract if one develops. I gently probe with my finger to ensure there's no undrained pus, then I pack with nugauze. I remove the gauze on POD #1 and never re-pack, as I've made an incision big enough that packing is unnecessary (and cruel). I tell them to do mandatory TID sitz baths to keep the area clean and help facilitate the removal of pus.

I could talk about butt pus all day!
Click to expand...
What about those of generous size (abscess cavities and patients)? I worry that without an elliptical incision or some packing they will recur (but that might just be from having to take all the failed microstab I+D's the ER doc has done). Sometimes if it is really huge I will make counterincisions and leave a penrose for a week instead of making a gaping hole and when I remove that I never have them pack and the cavity heals just fine. Perhaps I should rethink my strategy. Teach me your butt pus secrets.
 
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WinslowPringle said:
Haha, so true......of course, with enough local, enough lube, a long enough arm and strong enough restraints there's no need for anesthesiologists period ;-)

I have done most with light sedation, several without sedation but lots of local, and a few emergent ones without anything. If I ever have a 40Fr in my pleural cavity non-emergently but still urgently placed, I would prefer a whiff of versed, please.

Do you do anything with the local besides skin, plenteous in the subq, periosteum, muscle ensuring your area of spreading is covered, lots into the pleura, total usually 20-40cc? Wide but specific local numbing is what I've learned and read about, but don't know if there's a better way.
Click to expand...
In all my chest tubes, I've only once given iv sedation that I recall, and that was a redo that someone else messed up and the guy wasn't going to allow it any other way.

And do people really use a 40fr ever? I can't remember the last time I used anything larger than a 28. Maybe a 32 over the summer for trauma, but I think we were using 28fr for those on the regular (my 6 chest tubes in 4 patients over the summer was a fun night...)
 
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thedrjojo said:
In all my chest tubes, I've only once given iv sedation that I recall, and that was a redo that someone else messed up and the guy wasn't going to allow it any other way.

And do people really use a 40fr ever? I can't remember the last time I used anything larger than a 28. Maybe a 32 over the summer for trauma, but I think we were using 28fr for those on the regular (my 6 chest tubes in 4 patients over the summer was a fun night...)
Click to expand...

Really? I sedate practically all of my chest tubes in the ED and ICU.
 
SLUser11 said:
I do gently look for loculations, but I think sometimes the "loculations" that people fracture with their finger are actually branches of the pudendal nerve, division of which can lead to incontinence. In general, once you give the pus somewhere to go, they will get better.

My technique is left lateral (or prone in office), use tape on the bed to help expose the wound (or just an MA if in the office), sedation from ER doc if available, 1% lido with epi injected very slowly...

Then I make a generous incision (at least 2-3cm) in a radial pattern from the anus (no cruciate). People often drain as far away from the anal verge as possible, but that just makes for a long fistula tract if one develops. I gently probe with my finger to ensure there's no undrained pus, then I pack with nugauze. I remove the gauze on POD #1 and never re-pack, as I've made an incision big enough that packing is unnecessary (and cruel). I tell them to do mandatory TID sitz baths to keep the area clean and help facilitate the removal of pus.

I could talk about butt pus all day!
Click to expand...

What would you say is your threshold for "is Ok for the ER doc to try and see me in clinic" vs "must be approached by a surgeon on the first shot?"
 
TimesNewRoman said:
Really? I sedate practically all of my chest tubes in the ED and ICU.
Click to expand...

I think I may have done versed once. Morphine of fentanyl a handful of times. I usually use local and that's it. If they can turn on their side, I do that so it's easier to insert. There are some chest tube that can be done completely Seldinger technique. They make sizes up to 40 I think. I would typically use a 24 or 28, depending if it was a pneumo or fluid. In a trauma situation, I might consider a 32.
 
thedrjojo said:
In all my chest tubes, I've only once given iv sedation that I recall, and that was a redo that someone else messed up and the guy wasn't going to allow it any other way.

And do people really use a 40fr ever? I can't remember the last time I used anything larger than a 28. Maybe a 32 over the summer for trauma, but I think we were using 28fr for those on the regular (my 6 chest tubes in 4 patients over the summer was a fun night...)
Click to expand...
Our trauma attendings insisted that blood cannot possibly drain out of anything smaller than a 36F, so unless you were absolutely certain it was a pure pneumo, they all got 36F. But I also cant think of more than 1 or 2 times I've ever given sedation. Local in the subQ like crazy, cut down to rib, pause, local in the intercostal space and pleura like crazy, and go.
 
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