Procedure notebook during residency

[st0w]

I've had several residents recommend upon starting internship that it would be wise to keep a procedure notebook. Not an ACGME-type case log, but a notebook that is procedure-centered, and can include different variations that are attending specific. Most residents here do it, and I wanted to see what kinds of things people found useful/useless to track.

One of the residents gave me a sample template that he uses:

Appendectomy

• Indications
• Important anatomic landmarks
• Important possible anatomic complications
• Patient position
• Antibiotics
• DVT Prophy
• Incision
• Exposure
• Steps

This seems reasonable and comprehensive to me, but I know enough to know I don't know anything at this point.

Are there additional things any of you would recommend keeping notes on? Did this kind of system work for you, or did you do something else?

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[Textbookversion]

Sooo I glanced at your blog. How does surgery work as someone who uses a wheelchair?

 

[Smurfette]

Actually, in residency, it was helpful to keep track of attending quirks/OR set ups.

i.e. Attending A likes using x, y, z and positions with arms tucked and suction and bovie placed from foot end. Attending B uses x and z and leaves arms out, suction and bovie from the head end. Attending C hates medication A and always wants a foley in every laparoscopic case no matter what, etc. etc.

 

[survivordo]

It certainly can get confusing with each attendings likes and dislikes. Instead of creating an individual notebook why not create a google doc that everyone from your program can add to and utilize?

Survivor DO

 

[st0w]

Sooo I glanced at your blog. How does surgery work as someone who uses a wheelchair?

There's some information in https://sci.chrismcculloh.com/2012/02/06/a-gift/ and https://sci.chrismcculloh.com/2008/05/03/my-inspiration/. I'm also working on getting a video online at some point soon. I'd be happy to answer other questions, but please either create a separate thread or PM me - I'd like to keep this thread on topic.

Actually, in residency, it was helpful to keep track of attending quirks/OR set ups.

Instead of creating an individual notebook why not create a google doc that everyone from your program can add to and utilize?

Both great ideas! Actually Survivor DO, that's the general direction that I'm headed with this - something electronic that can be shared amongst several people. Figured I'd start by seeing what kind of information other people found useful.

 

[cpants]

Anyone else hate this crap? I just hate when you are chastised and made to feel like you did something wrong or hurt the patient because you applied the steri strips the "wrong" way, closed with 4-0 instead of 5-0, used toradol, or violated some other inane superstition of the attending. While I understand the temptation to accumulate a list of the attendings' quirks in this manner, I do kind of feel that it is stupid and a waste of time, enables bad behavior by attendings, and possibly instills bad habits into trainees.

 

[dpmd]

Anyone else hate this crap? I just hate when you are chastised and made to feel like you did something wrong or hurt the patient because you applied the steri strips the "wrong" way, closed with 4-0 instead of 5-0, used toradol, or violated some other inane superstition of the attending. While I understand the temptation to accumulate a list of the attendings' quirks in this manner, I do kind of feel that it is stupid and a waste of time, enables bad behavior by attendings, and possibly instills bad habits into trainees.

I went to a small program so there wasn't that much attending specific stuff to figure out, and I felt they weren't as bad with their superstitious stuff as at some places. Most of the time they would either give a reminder about some detail they felt strongly about, or it would be on the preference card. Otherwise, if you were doing or ordering something that wasn't part of their routine they would either ask you to stop/get rid of it without getting mad and give a reason even if the reason was just that they are used to XY or Z or they would let you be and see how things went. Some of them would even say stuff like I would try ABC here but you can do what you want. If you kept doing what you were doing and it worked out there was no problem, if you struggled for a while and eventually took their advice they would just crack a joke about it.

Now that I am the attending I like to be up front about the things I like done that have no real reason behind it besides the fact that I am used to them. I also ask the resident how they want to do certain procedures and if they have a plan that sounds like it will work I will let them try it. If they don't (like when I am doing something with an intern where I don't expect them to have a preference for something that has multiple appropriate ways to do like an umbilical hernia or something) I show them my way and let them know what I like about it so that when they do it a different way with someone else they can better decide what way they will want to do it the next time they have a choice. My only voodoo thing that I always make them do has to do with a post op pain regimen that has no scientific evidence for it but that almost always seems to work.

 

[mimelim]

...

You sound like most of the attendings I have. At level cases, I get the patient prepped and draped and when they walk in I start. I talk through outloud things that I'm going to do before/as I do them. If I get stuck or struggle they tell me what they would do and we do it. For cases beyond my level, the first case is usually a first assist. Second case, I'm walking through the case with a narration from the attending on the next step and what I need to focus on or be aware of. Third case, things turn more into the 'at level' case.

 

[Buzz Me]

I have notes on each attending's preferences for the major cases, down to the little details (positioning, suture preference - including NEEDLE TYPE! - and post-op preferences). Really helps when you're in the OR by yourself, or don't want to get yelled at during rounds.

 

[docisin]

Would you all recommend a procedure notebook for someone who is applying to a surgical tech 1 year program? The reason I am doing this is because I want to apply to a PA program soon and I need HCE and I thought this would be perfect, also perhaps a plan B G-D forbid if I can not get in the first time around.

 

[dpmd]

Most places have preference cards for what instruments and suture a particular attending wants. I wonder how often the really picky people make sure they are correct though. Perhaps they like bitching about things not being the way they want them? For a tech, I would think that most surgeons want the same kinds of things-make sure you listen to what is said so if you hear that some special instrument or suture will be needed soon that you have it ready, hand the instruments over in a way that we don't have to look and it is in the proper orientation for use, don't give us broken instruments (and if we say something needs fixing make sure it gets tagged and done instead of just getting put back into rotation). Anticipating out needs and handing us what we need (sometimes instead of what we ask for ) is a plus, but that just comes with experience I think and only a jerk will hold it against you if you don't.