Rules of Surgery

[Dr Jboo]

So I've just finished all of my 4th year surgical rotations and I was reminiscing on the many "first rule of surgery"s that I have learned from my attendings and residents. Just wondering if y'all had any pearls to add:
1. Trust noone
2. Don't mess with the pancreas
3. Red and blue things bleed
4. Don't cut whatt you can't fix
5. All bleeding stops eventually
6. Everything in the abdomen is the common bile duct or the ureter until proven otherwise
7. Cut well, tie well, sew well, do well
8. Alway read your own films
9. Always touch the patient
10. Eat when you can, pee when you can, sleep when you can

Thats all I can think of at the moment, anyone have any to add?

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[Pilot Doc]

Does surgical recall still have a section on this?

I would amend #1 to

1. Trust no one; expect sabotage

 

[beastmaster]

all students cut sutures too long or too short

 

[opr8n]

1. when a patient tells you one thing in the morning, expect them to tell yuor chief/attending the exact opposite on rounds

2. When you feel like you dont know what yuor doing or you have exhausted your knowledge base, load the boat, call someone else higher than you

3. Most attendings will not get upset at getting called so that you can update them on their patients, but not calling when something goes bad, will not end well for you

 

[San_Juan_Sun]

"I don't know" is always better than a lie.

 

[Blade28]

Assume nothing; trust no one; document everything

 

[Winged Scapula]

If you didn't document it, it didn't happen.

Never say, "Its been a quiet night".

Patients lie.

The enemy of good is better.

# tattoos/pain scale rating will always be less than 1.

 

[SLUser11]

The enemy of good is better.

This is probably the most important surgical one-liner so far.


Otherwise, I typically tend to hate these "rules of surgery" threads. However, I will add my Trauma surgery "rule of 2's" for all of you Meckel's fans:
:
-The patient has had 2 beers

-They were beat up by 2 dudes (never in the history of trauma has a patient lost a 1 on 1 fight).

-Pupils are 2mm and reactive (I had a junior co-resident who always seemed to estimate the pupils at 2mm, as long as the patient wasn't fixed/dilated or uneven.

-Say F@#$ you two times, and you earn the tube.

-Mandatory 2am trauma every night, no matter how quiet it has been.

 

[Apollyon]

SLUser, I was going to say almost the same thing. One other caveat:

Know the "law of inverse value": the less you do for society, the bigger the trauma you can sustain without any sequelae. Drug addict/thief/pimp-prostitute, can fall off one roof to another, then to the ground (4 stories total), and still be able to stand on a garbage pile with a broken beer bottle at the neck, threatening to kill one's self (saw this verbatim in New Jersey) - had 2 burst vertebra (T12 and L1), happened the night before, and was neuro-intact.

Whereas any of us, we slip, bite our tongues, get gangrene, and die horribly and painfully. Or slip in the shower, bonk our heads, and drown.

In other words, if you ever see one of those "two dudes" (or their colleague, "that bitch") as a trauma, look closely and at everything, because they can be severely injured, despite breaking the "law of inverse value".

 

[Fah-Q]

# tattoos/pain scale rating will always be less than 1.

Also, as the tooth/tattoo ratio approaches zero, the chances of the patient having head and neck cancer approaches infinity.

 

[Biscuit799]

The single best predictor of survival is the tattoo:teeth ratio.

 

[LovelyRita]

From the Burn Attending:

What's the last thing a burn victim says before they are burned?


"Here, hold my beer. Watch this."

 

[VincentAdultman]

So I've just finished all of my 4th year surgical rotations and I was reminiscing on the many "first rule of surgery"s that I have learned from my attendings and residents. Just wondering if y'all had any pearls to add:
1. Trust noone
2. Don't mess with the pancreas
3. Red and blue things bleed
4. Don't cut whatt you can't fix
5. All bleeding stops eventually
6. Everything in the abdomen is the common bile duct or the ureter until proven otherwise
7. Cut well, tie well, sew well, do well
8. Alway read your own films
9. Always touch the patient
10. Eat when you can, pee when you can, sleep when you can

Thats all I can think of at the moment, anyone have any to add?

Delegate important tasks to yourself

The sharpest mind is duller than the dullest pencil.

Don't be a douchebag

There are no bull**** consults

Night float will f#@! you over.

 

[Winged Scapula]

Delegate important tasks to yourself

The sharpest mind is duller than the dullest pencil.

Don't be a douchebag

There are no bull**** consults

Night float will f#@! you over.

I've never heard of such a rule.

As a matter of fact, there are a TON of BS consults and even now that I get paid to do them, still consider (and occasionally refuse to see) them BS.

I would rephrase, "As the hour closes in on Friday 5 pm, the number of BS consults increases exponentially."

 

[opr8n]

There are no bull**** consults
.

dude, seriously???

i got called to the ER yesterday by an FMG ER Doc who put in a stat consult for a hernia!
I was thinking incarerated, possibly strangulated, sick pt

I get down there
Its a reducible sliding inguinal hernia with no symptoms???????!!!???
What an idiot
So much for a stat surgery consult

Then the er doc had the nerve to ask me if we were taking him emergently to surgery
Hmm looks like you need to go back to medical school
yikes 😱

 

[Lioness]

dude, seriously???

i got called to the ER yesterday by an FMG ER Doc who put in a stat consult for a hernia!
I was thinking incarerated, possibly strangulated, sick pt

I get down there
Its a reducible sliding inguinal hernia with no symptoms???????!!!???

Dude, I can so beat that.... the "Urgi-Center" (fake ED) at our VA hospital is staffed by all kinds of random docs... GI fellows moonlighting from the U, actual ED docs, and our least favorite, the GP who can't get a job anywhere else. If you dare set foot in there after dark for a real consult they WILL find at least two other people for you to see, no matter what, and when you're the intern on call there's no way to refuse. The favorite threatening line is "Well, you might as well just see them now, so I don't have to call you back in later..." (AKA after any workup is actually done).

Last year one attending used that exact line on me, to "eyeball" a patient he hadn't even EXAMINED yet, for what turned out to be a standard fungal groin rash. He seriously wanted to know if I thought we should take him to the OR for a biopsy.

Argh...

 

[VincentAdultman]

dude, seriously???

i got called to the ER yesterday by an FMG ER Doc who put in a stat consult for a hernia!
I was thinking incarerated, possibly strangulated, sick pt

I get down there
Its a reducible sliding inguinal hernia with no symptoms???????!!!???
What an idiot
So much for a stat surgery consult

Then the er doc had the nerve to ask me if we were taking him emergently to surgery
Hmm looks like you need to go back to medical school
yikes 😱

I've gotten consults that sounded like BS over the phone turn out to be very real surgical problems. I didn't mean that there are literally NO stupid consults. Just that one should not make assumptions.

 

[Pir8DeacDoc]

Also, as the tooth/tattoo ratio approaches zero, the chances of the patient having head and neck cancer approaches infinity.

True true...

 

[deleted89854]

I have, however, responded to consults that I thought were real which turned out to be ******ed.

 

[opr8n]

I've gotten consults that sounded like BS over the phone turn out to be very real surgical problems. I didn't mean that there are literally NO stupid consults. Just that one should not make assumptions.

i agree, im talking about things that sound bogus and are bogus
there are of course timesw where things sound bogus and are certainly not

like . . Hey i have an basceess for you to drain in the ER, from the ER doc, who set up a nice I/D tary at the bedside for me, so that at 3am in the morning i could do his job. Good thing i did, b/c whne i got down there i actually examined the patient and it was not an abscess, it was actually a strangulated ventral hernia. Luckily for the patient, they got a trip to the or to fix their problem with a primary anastomosis vs someone sticking an 11 blade (by the way the er doc put out a 10 blade for me 🙄) into bowel YIKES

so yes, we should see consults and never assume anything, but alot of er docs just dont want to, or more approp, dont know how to do their job properly sometimes

 

[surgeon4ever]

Dude, I can so beat that.... the "Urgi-Center" (fake ED) at our VA hospital is staffed by all kinds of random docs... GI fellows moonlighting from the U, actual ED docs, and our least favorite, the GP who can't get a job anywhere else. If you dare set foot in there after dark for a real consult they WILL find at least two other people for you to see, no matter what, and when you're the intern on call there's no way to refuse. The favorite threatening line is "Well, you might as well just see them now, so I don't have to call you back in later..." (AKA after any workup is actually done).

Last year one attending used that exact line on me, to "eyeball" a patient he hadn't even EXAMINED yet, for what turned out to be a standard fungal groin rash. He seriously wanted to know if I thought we should take him to the OR for a biopsy.

Argh...

I am sure everyone has their own strategies for fighting off the 'add-on' consults. We call it 'hit and run' - spend the minimum required time in the ER and try to be away from the ED resident/attending's visual field during that time. Also - as my chief likes to tell me - everything is either a consult/ or not. Everything needs proper w/up before consulting, unless it is an emergency. There is no eyeballing or 'laying a surgeon's hand' or any such BS.....

 

[durty]

# tattoos/pain scale rating will always be less than 1.

now correct me if I'm wrong, because I had to think long and hard about this.

does that mean on a 1-10 scale if I have 10 tattoos then EVERYTHING that happens puts me at a pain scale rating of above 10?
-durty

 

[Winged Scapula]

now correct me if I'm wrong, because I had to think long and hard about this.

does that mean on a 1-10 scale if I have 10 tattoos then EVERYTHING that happens puts me at a pain scale rating of above 10?
-durty

Pretty much. People with tattoos tend to be the wimpiest.

 

[Smurfette]

And IVDU's are strangely more likely than the average patient to be afraid of needles/blood draws (Haven't figured out that one yet....I'm not talking about the people who have no veins left, either.) and always have pain rated at 100 out of 10 with an otherwise benign exam. Then again, this patient population correlates highly with WS's tattooed population.

 

[Random Anesthesiologist]

Pretty much. People with tattoos tend to be the wimpiest.

Not everyone with tattoos 😉

 

[aphistis]

And IVDU's are strangely more likely than the average patient to be afraid of needles/blood draws (Haven't figured out that one yet....I'm not talking about the people who have no veins left, either.) and always have pain rated at 100 out of 10 with an otherwise benign exam. Then again, this patient population correlates highly with WS's tattooed population.

But on the flip side, I've learned if an IVDU tells you it's not a good vein and you ought to use this one instead, you should take his/her word for it. You'll save yourself a few minutes and an extra angiocath, not to mention the style points lost from missing an IV.

 

[mddo2b]

You can NEVER trust anyone....if someone tells you the consult can wait, the pt is stable, run to see the pt ASAP, because the pt is NOT stable. The opposite can also be true. What can i say, if surgery were easy, medicine weenies would be doing it

 

[pillowhead]

And IVDU's are strangely more likely than the average patient to be afraid of needles/blood draws (Haven't figured out that one yet....I'm not talking about the people who have no veins left, either.) and always have pain rated at 100 out of 10 with an otherwise benign exam. Then again, this patient population correlates highly with WS's tattooed population.

Sooooo true. I had a patient the other day freaking out, crying, nearly jumping off the stretcher because we had to put in an EJ. I'm sure it's not the most pleasant thing in the world, but that's what you get for ripping up your arms for the better part of two decades. She kept calling us barbaric because she would NEVER shoot up in her neck because that just ain't right.

 

[LadyWolverine]

Sooooo true. I had a patient the other day freaking out, crying, nearly jumping off the stretcher because we had to put in an EJ. I'm sure it's not the most pleasant thing in the world, but that's what you get for ripping up your arms for the better part of two decades. She kept calling us barbaric because she would NEVER shoot up in her neck because that just ain't right.

Lol. Do you live in Baltimore, too? My classmate had a patient on our medicine rotation who was admitted from the ED for some vague complaint which happened to include "severe pain" of the something-or-other (h/o multiple admissions for same complaint and then leaving AMA when nothing out-of-sorts was discovered), and demanded that we give him his "usual" cocktail of Dilaudid-plus or he would leave AMA. I went to see him with my attending, who recommended longer-acting methadone instead of Dilaudid for analgesia. The patient promptly began freaking out, carrying on and making a scene about how "only Dilaudid works for me" and that we not give him any methadone because he "didn't want to become an addict." 🙄 He left AMA shortly after arguing with my attending for 15 minutes, but not before asking for a to-go prescription for his favorite drug.

And I thought that the first rule of surgery was "It's never too late to f*^& up."