Pediatric surgery

[johnny_blaze]

I’m gonna be working in peds surg for the next couple of months. I’m not really sure what to expect. Anybody want to give me some useful advice based on their experience working in this specialty? -general, clincial, or operative

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[maxheadroom]

Stay away from the NICU. Don't approach the NICU babies, they can smell your fear. As soon as you open the Isolette, they'll desat, turn blue, drop their pressure, and crap all over everything. They're hateful, evil creatures who live to destroy you.

Oh the painful memories . . .

;-)

 

[Scrubbed In]

Small patients mean small operative fields. Keep your hands as far back as possible on the instruments (retractors, bovie, even needle drivers) to not obscure the field.

Also, be the one to place baby back into the crib from the operating table...the female nurses will be putty.

 

[Winged Scapula]

Present urine output in cc/kg/hr rather than total cc/shift or day.

Know your pediatric medication conversions/usual dosages. Same goes for IV fluids.

Small operative fields mean that big moves (especially with laparoscopy) will often overshoot the field and the area of interest. Loupes are often necessary.

DON'T WAKE THE BABIES...get used to this cry from the nurses. You will hear it often in the NICU as you arrive.

Use Dermabond, Collodium, etc. rather than traditional bandages if allowed by the attending.

Know: hypertrophic pyloric stenosis (esp. the common electrolyte disorders), management of perforated appendicitis, gastrochisis/omphalocele, pediatric hernias (when do you fix, how do you fix?), TE fistula, congenital diaphragmatic hernia, NEC, small bowel atresias, Hirschsprung's and Cystic Fibrosis, esophageal foreign bodies, refeeding syndrome, pectus excavatum (mostly) etc.

You may get pediatric trauma - if so, again know the fluids, how to assess for non-accidental injury and work it up (usual xrays, ophtho exam, skeletal survey, notify CPS). PICU team may do critical care management rather than surgery.

If your service places ports for kids on med onc, know which kind of port they want (single or double lumen, completely tunneled vs external [ie, Groshong, Hickman]).

All the usual stuff with Peds applies - you often have to treat the parents rather than the child, the kids aren't always cute and its hard when they cry because of something you did to them.

Have Fun!

 

[johnny_blaze]

the kids aren't always cute

Don't tell me I'm gonna have to treat ugly kids as well?! haha thanx for the advice

 

[Winged Scapula]

Don't tell me I'm gonna have to treat ugly kids as well?! haha thanx for the advice

Well, I meant they aren't cute acting, but yeah, there are some FLKs on peds surgery as well!

 

[tussy]

Be prepared for lots of passive-aggressive personality disorder types; they seem to gravitate towards the pediatric world for some strange reason!

 

[Winged Scapula]

Be prepared for lots of passive-aggressive personality disorder types; they seem to gravitate towards the pediatric world for some strange reason!

Whoa boy, are you right there!

It was the worst rotation in terms of getting our own attendings to stand up for us; their passive acceptance of abuse from other services (ie, 2 am calls from the med onc intern about needing a central line first thing in the am because they forgot to tell us days ago) while griping about it in private used to drive me nuts.

 

[maxheadroom]

True-dat!! The pedi-folks do seem to be the most passive-aggressive types that I've seen. PAINFUL!!

 

[SocialistMD]

It was the worst rotation in terms of getting our own attendings to stand up for us; their passive acceptance of abuse from other services (ie, 2 am calls from the med onc intern about needing a central line first thing in the am because they forgot to tell us days ago) while griping about it in private used to drive me nuts.

I think it has to do with clout more than anything else; at adult hospitals the medicine:surgeon ratio is lower than at a pediatric hospital, and it is just easier to deal with the stupidity than have the political battle or complain. They have less administration time to put up with the battles it would take to argue about inappropriate(ly timed) consults. I imagine at programs with a strong surgical representation this is less common (i.e. CHoP, TCH, UCin, Boston). Still, I agree the griping and yelling that should be directed at the other services, yet finds its way to us, is very disappointing.

I always tried to "educate" the pediatricians about the timing/etiquette of their consults (read: don't call and tell me "you need to do a fundoplication on this kiddo"). We also require a peds PGY-2 to rotate on our service so s/he can feel the pain in hopes it changes the way s/he consults us. It is amazing how it doesn't seem to accomplish that goal, though...

 

[Winged Scapula]

I think it has to do with clout more than anything else; at adult hospitals the medicine:surgeon ratio is lower than at a pediatric hospital, and it is just easier to deal with the stupidity than have the political battle or complain. They have less administration time to put up with the battles it would take to argue about inappropriate(ly timed) consults. I imagine at programs with a strong surgical representation this is less common (i.e. CHoP, TCH, UCin, Boston). Still, I agree the griping and yelling that should be directed at the other services, yet finds its way to us, is very disappointing.

I always tried to "educate" the pediatricians about the timing/etiquette of their consults (read: don't call and tell me "you need to do a fundoplication on this kiddo"). We also require a peds PGY-2 to rotate on our service so s/he can feel the pain in hopes it changes the way s/he consults us. It is amazing how it doesn't seem to accomplish that goal, though...

I appreciate your theory on the power balance and I'm sure its true; in my case however, I was talking about a Children's hospital, albeit not one as "powerful" as those you list. I honestly think it was our Peds Surg attendings who had little interest in protecting or teaching the residents on their service. God forbit if they actually told the Onc attendings that it wasn't appropriate to call for a line at 2 am - I mean, where else are those kids going to get their lines - IR doesn't like to do them in kiddos. Of course all that PC behavior from those guys has paid off, one is in line to be named Department Chair.

We also have a Peds intern (usually) rotate on the service, but since they don't take call and leave for lectures often, they seemed a bit oblivious to the 2 am consults from their colleagues telling us what we HAD to do. Love those consults that tell us what to do...I would like to think that although I may realize that I need a Heme consult, I would never deign to tell the consultant what they were supposed to do.

Then again, after umpteen consults from medicine for R/O pSBO only to find the patient eating, with no NGT or acute abdominal series done, I don't know why I would think anyone except surgeons would actually try and remember the basics of management of a problem outside of their usual scope of practice. Why bother when someone else can do the work for you?

 

[SocialistMD]

We also have a Peds intern (usually) rotate on the service, but since they don't take call and leave for lectures often, they seemed a bit oblivious to the 2 am consults from their colleagues telling us what we HAD to do.

We make them do a week of night float call so we can ensure they at least experience it. However, like I said, it seems not to do the trick, as we still get those same consults over and over and over.

 

[Winged Scapula]

We make them do a week of night float call so we can ensure they at least experience it. However, like I said, it seems not to do the trick, as we still get those same consults over and over and over.

I would worry that they would horribly mess up surgical patients...or at least that was the mindset of my program. They refused to also let the EM residents take Trauma call because we had a serious mismanagement a couple of times.

But if they were to take call in house with a senior and run most things by them, that might be feasible...although as you say, it appears not to work.

 

[johnny_blaze]

Wow… a barrage of ridiculous consults and no teaching… I can’t wait! Thanx guys.. .u could have at least lied to me and told me the next few months of my life would be great

 

[Winged Scapula]

The next few months of your life will be great.

Honestly, you may have a wonderful rotation; every department is a bit different and your attendings may be great teachers who take an interest in your education. I learned a great deal on my Peds Surg rotations.

However, I do think that pediatric surgeons, in general, tend to be very overprotective of their patients (which can translate into residents not doing very much in the OR) and to be passive-aggressive in their approach to colleagues, consultants and parents. Like pediatricians, they often relate better to the children than adults. This can be a bit frustrating when you are trying to have a normal adult conversation with one of them. Fortunately, they aren't as bad as pediatricians, IMHO. Sometimes you don't notice the behavior until you're a more senior resident (and out of the fog that covers internship)...so thank us for giving you the "inside scoop".