starting with surgery

[PTOSIS]

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hey peeps,
well now that boards are over, i ma starting 3rd year w/surgery. it occurs to me that i know almost nothing that i will need. don't know how to draw blood,start IV's, do rectals, etc. i have been taught how to do a history and a physical exam, but it seems those were geared more for medicine. anyway, i am kinda scared and would appreciate some words of wisdom. i bought surgery recall, maxwells,pharm guide, plus some stuff for the PDA. should i read anything before i start? thanx, ptosis

 

[klubguts]

Don't be too nervous about your lack of experience with procedures (we've all been there). Things i did during my 3rd year surgery clerkship included H & Ps (yup, it's true), daily progress notes, dressing changes, some suturing, scrubbing cases, ABGs, etc. No one expects you to be a wiz at blood draws or any other procedures, and you will probably be taught these things during the rotation by your residents. Early useful reading over things like fluid and electrolytes, trauma, pre- and postop care, etc may be helpful....check out those early chapters in recall just to become familar with some of the jargon and basic concepts. Work hard and enjoy your rotation, it's fun (i liked it anyway, now a surg intern). Good luck!

 

[Pox in a box]

What should we be reading before the rotation begins and during the first week or two? Assume no clinical experience beforehand.

 

[klubguts]

What should we be reading before the rotation begins and during the first week or two? Assume no clinical experience beforehand.

I would recommend reading about basic surgical issues and common disorders---fluid and electrolytes (very important in surgery), wound healing, nutrition, tubes/drains, shock, postop care (fever, etc), hernias, and biliary disease (the ol' gallbag) for starters. I don't know how your school does it's rotation, but you can focus your reading once you know what service you are going to be on. Read about the diseases your patients have and that are seen on your service...surg onc, colorectal, vascular, peds, endocrine, trauma, etc...Once your cases are assigned, you can flip thru surgery recall and get an idea of the most common "OR pimp questions". There are many sources for you to use...some people like NMS surgery, recall, Lawrence, Sabistons essentials of surgery, etc. I'm sure you guys are nervous (i was..and started with medicine), but no one expects you to know everything (or anything, for that matter). Your residents will help you out and hopefully offer you some teaching. Best of luck and enjoy!!

 

[SlowToLearn]

Other bits of advice...

Surgery techs...you are their bitch...whether you like it or not. I'd say the majority are there to help you, but others are just downright mean. Grow some thick skin pretty quickly as you'll be gettin' crap all directions...attending, maybe your resident, circulating nurse, and the scrub tech. Always pull your gloves before hand, avoid quick sudden movements as you are gowning up or you're more likely to contaminate yourself (or the scrub tech). Like everyone else has stated, read the cases in advance...surgical recall is good for pimp questions.

I also concur with other basic topics to brush up on...fluids/electrolytes, nutrition, wound healing...very important. Don't be afraid to tell the anesthesiologist to raise the table when you're about to close...attendings hate it when you're bent over their patient as you're closing skin. Also, if there's one thing you wanna have your residents teach you early on, it's writing orders...i didn't learn how to write orders until these last two months (which just happened to be my surgery months).

Hope my random thoughts are useful,

-Slow
MCW Class of '06

 

[Pox in a box]

Surgery techs...you are their bitch...

Why??? Do they not realize we'll be able to return the favor within a few years?

 

[DrMom]

I encoiuntered one bitchy surg tech, but the others were incredibly helpful and patient with me.

From my experience, you need to be ready to do good H&Ps quickly (I sometimes had to do 5+ before 9am) and the same for daily progress notes. We were expected to finish our progress notes by 7am so that we could be scrubbed into the first surgery in time. Depending on our patient load, this could be challenging.

Surgery Recall & Maxwells are excellent, btw.

 

[PTOSIS]

thanx everyone! is the maxwells that people talk about just one reference or is it rotation specific? alsom, is reading fluids and electrolytes made rid simple overkill?

 

[Rudy Guliani]

dude, no one expects you to be able to do any kind of procedures, especially not first rotation, especially not on surgery...the most they are hoping for is that you don't blow your lunch during a case. there's no way in hell they would be having you do blood draws or anything like that...****, half the time the nurses don't even do that, they have dedicated IV nurses who do that stuff. the only time you would have to do more than a simple dressing change is if you asked to do something. otherwise just stay humble and act like you are trying to learn, and try to help out in the small ways that you are capable of. otherwise, just try to stay out of everybodies' way.

 

[Smurfette]

Why??? Do they not realize we'll be able to return the favor within a few years?

The techs run the OR, so until you are an attending, the techs can do whatever they want with you. If the tech says you're contaminated, you are contaminated. They don't have to be helpful to you or anything. This is why it is important to be nice and to do what they ask you to do---otherwise they can embarass or humiliate you in front of your attending.

There's always some surgical techs who are on power trips or just out to get students. The best way to deal with it is to not give them a reason to be hating on you. Most don't stay nasty to you if you are respectful of them and do as you're told after a few cases with them.

 

[NateatUC]

dude, no one expects you to be able to do any kind of procedures, especially not first rotation, especially not on surgery...the most they are hoping for is that you don't blow your lunch during a case. there's no way in hell they would be having you do blood draws or anything like that...****, half the time the nurses don't even do that, they have dedicated IV nurses who do that stuff. the only time you would have to do more than a simple dressing change is if you asked to do something. otherwise just stay humble and act like you are trying to learn, and try to help out in the small ways that you are capable of. otherwise, just try to stay out of everybodies' way.

I disagree with this somewhat. Surgery is a specialty that DOES things. As such, expect to be asked to do things like change dressings. Its not really that hard. Just observe what is there as the dressing comes off, and put it back the same way.

Also, expect to be taught how to do things like sew up wounds in the ER (if you're on trauma), place Foleys in the OR, and yes, draw blood and start IV's. You may even be walked through an intubation (ask the anesthesiology folks to show you) ABG, central line, arterial line, or chest tube. Once you've been taught some med-student level procedures (dressing changes, suturing, Foleys, blood draws, IV's), expect do be asked to do them when needed. Also, in the OR, expect to help close the subcutaneous layers and skin (either with staples or sutures), then help move the pt off the table and to the PACU. And if someone asks you to do something you don't know how to do, ask them to teach you!

Another piece of advice I can give: observe your team on rounds the first couple days and try and anticipate what they're going to need. If you know dressings are going to be changed, have the stuff already in the room or on you. It makes rounds go faster, and you look good. Remember, you have to get through rounds by the time the OR cases start, which can be tough when you have a bunch of pts to see. Show initiative, enthusiasm, and a desire to learn, and you will be rewarded with teaching and maybe the opportunity to do some pretty cool real surgeon stuff.

 

[Espion]

dude, no one expects you to be able to do any kind of procedures, especially not first rotation, especially not on surgery...the most they are hoping for is that you don't blow your lunch during a case. there's no way in hell they would be having you do blood draws or anything like that...****, half the time the nurses don't even do that, they have dedicated IV nurses who do that stuff. the only time you would have to do more than a simple dressing change is if you asked to do something. otherwise just stay humble and act like you are trying to learn, and try to help out in the small ways that you are capable of. otherwise, just try to stay out of everybodies' way.

No offense, but where on earth did you do your surgery rotation?


H&Ps are not just an "internal medicine" thing. They are a surgery thing, a pediatrics thing, an OB-GYN thing...you get my point. One of the best things you can do this year is learn to take a good H&P. Its not as easy as you think it is, and it takes practice to attain the kind of efficiency you will need later.

Having stuff ready for dressing changes is a very good idea. Always have some tape and scissors on ya. It helps out a lot.

Always read about your cases before you go to the OR.

If you are in a trauma, you might not be allowed much involvement, but actively watch. Think about what you would do in each situation. Think about what could go wrong, and what you would do in those situations. It can make for interesting conversation later and you can get some great teaching points from your observations.

Never stop reading.

And finally, they're going to realize that it is your first rotation and that you probably have not started any IVs, venipuncture, etc. So ASK. Go pre-op with the anesthesiologists and learn to start IVs and intubate. Go to triage in the ER and get more IVs than you could shake a stick at. Go to the ICU and get nasogastric tubes, central lines, chest tubes. There are not many residents that are going to hold your hand and drag you into procedures. So, you have to ASK. Before you know it, you'll be putting in A-lines with ease.

 

[Rudy Guliani]

No offense, but I'd have to say the last two posters are insane. Starting with surgery, no one is going to want or expect you to do anything aside from changing dressings. As I said in my previous post if anyone cared to read it, the only time you'll do more than that is if you ask to do something, which of course you can. As I also said, be prepared to help out in the small ways you can at this point, such as by helping to take the patient off the table, walking them back to recovery, retracting, inserting a Foley, etc. No one is going to tell you to go start an IV or get an ABG. Take it from me, I started with surgery as well, I was in your shoes. My intern told me that my chief resident expected absolutely nothing out of me and the other students with me on the rotation, and was impressed that we just worked hard, showed up on time, were enthusiastic, and were prepared.

 

[ears]

hey peeps,
well now that boards are over, i ma starting 3rd year w/surgery. it occurs to me that i know almost nothing that i will need.

Possibly helpful hints for starting with surgery:

• If you want to read something ahead of time, reading Lawrence's Essentials of General Surgery is pretty good. Reasonably well-written, and covers the stuff med students are supposed to know. Plus, the shelf exam is almost written to this text.
• If there's something you don't know how to do (ABG, blood draw, etc.), just ask someone to show you how when it needs to be done. The next time, ask if you can do it. You can fake your way without doing many, many of these things, but mostly people are happy to teach you about them. (This is true of many, many procedures; you have to ask to be taught, but when you do, people are mostly delighted to show you, if there's time.)
• Go out of your way to be respectful and polite with the surgery techs. Go to the OR early. Introduce yourself. Make sure the circulating nurse (the one not scrubbed in) has the spelling of your name. Ask them if there's anything you can do to help them. Try hard to stay out of their way (mostly, they have an important, patient-oriented job to do, while you don't). Basically, just smile and be as pleasant and accomodating as you know how to be. Being in the scrub tech and circulator's good graces is like gold in the OR. I've had them put the instrument I didn't even know I needed in my hand, or tell me the pimp question the attending likes to ask, or go out of their way to bring me a stool so I could see better. (Yes, of course, some are obnoxious no matter how nice you are to them. But many, many of them will work hard to help you if they like you, and it's not that hard to get them to like you.)
• On rounds, try to ask youself, "How can we, the med students, move things along more efficiently?" The wrong way for things to be is for everyone to be standing around waiting for someone to get something, or (possibly worse) the med students standing around while the chief resident gets stuff him/herself. Different chiefs will have different rules for rounds (about how much you can be running off making stuff happen while other patients are being presented), but the better you prevent standing around on rounds, the happier everyone is.
• No whining. Yes, getting up really early sucks. Yes, the hours can be brutal. Yes, rounds on 35 floor patients and 6 unit players before a 5-hour laparoscopic gastric bypass is an awfully long time on your feet. Yes, people will be rude to you. But you will only make things worse by complaining about it. (And this is more true on surgery than anywhere else.) Find a close friend you can bitch to about how awful surgery is, but when you're actually in the hospital, smile, smile, smile 'til it hurts.

I am not going to be a surgeon, but I had a great time on my surgery rotation. I hope you do, too.

 

[Espion]

No offense, but I'd have to say the last two posters are insane. Starting with surgery, no one is going to want or expect you to do anything aside from changing dressings. As I said in my previous post if anyone cared to read it, the only time you'll do more than that is if you ask to do something, which of course you can. If you had read my post, you'd see that I said this as well. As I also said, be prepared to help out in the small ways you can at this point, such as by helping to take the patient off the table, walking them back to recovery, retracting, inserting a Foley, etc. No one is going to tell you to go start an IV or get an ABG. Take it from me, I started with surgery as well, I was in your shoes. My intern told me that my chief resident expected absolutely nothing out of me and the other students with me on the rotation, and was impressed that we just worked hard, showed up on time, were enthusiastic, and were prepared.

What did you work hard on if all you did was change dressings?

If you had read my post, you would see that I do agree with you in that no one is going to give you procedures...you're going to have to be proactive and ask. What I do have a problem with, is that you are insinuating that being proactive in your first rotation is a worthless endeavor because, apparently, first rotations must be "freebies".

Surgery was my first rotation as well. "My first rotation ever" is a pretty sorry excuse to be content in the background with a roll of gauze and tape.

I'm really sorry your residents expected nothing from you. I could think of no worse way to spend an entire rotation.

If you have no desire to do surgery, you could probably get away with his advice. I, on the other hand, do want to do surgery, so I probably tend to be a little more gung ho about it.

Which brings up another point for anyone who is looking for advice on this forum...take it with a grain of salt. We're all coming from a completely different places. Ask your own 4th years as well, they'll be some of your best resources.


Edit: Let me edit this, because no one likes to read.

 

[Smurfette]

What did you work hard on if all you did was change dressings?

If you had read my post, you would see that I do agree with you in that no one is going to give you procedures...you're going to have to be proactive and ask. What I do have a problem with, is that you are insinuating that being proactive in your first rotation is a worthless endeavor because, apparently, first rotations must be "freebies".

Surgery was my first rotation as well. "My first rotation ever" is a pretty sorry excuse to be content in the background with a roll of gauze and tape.

I'm really sorry your residents expected nothing from you. I could think of no worse way to spend an entire rotation.

If you have no desire to do surgery, you could probably get away with his advice. I, on the other hand, do want to do surgery, so I probably tend to be a little more gung ho about it.

Which brings up another point for anyone who is looking for advice on this forum...take it with a grain of salt. We're all coming from a completely different places. Ask your own 4th years as well, they'll be some of your best resources.

Before people get their undies in a bundle, remember every hospital is different. At my med school hospital, our ancillary staff was so good I never even heard of a resident or med student starting an IV or drawing blood until I was on the interview trail. No, I'm not kidding. Nurses always did that (except in the OR where anesthesia did it), and that applies to each of the six hospitals I've rotated thru to this date. It's highly variable depending on the ancillary staff as to how much scut you have to do. I am aggressive about doing procedures, and I did whatever I could get my hands on and wasn't afraid to ask. And, I've never seen an ABG, let alone done one, and I've graduated from a top 25 med school, rotated on a trauma service and am going into surgery (I should mention that all my patients who got ABGs had a-lines, so the nurses could draw them, or it was already done in the ER before my team was paged).

Stuff I did do on surgery rotations as a med student: pulled lines, pulled drains, dressing changes, suturing, foleys, rectals, NGs, etc. Other than for a rectal, residents will either show you or walk you thru anything the first time or two they expect you to do it---because to assume that you can do these things without supervision can endanger the patient, and they are ultimately responsible for anything you as a student screw up. If you don't know how to do something, ask. I've seen med students lie and say they knew how to do something, only to cause major complications and emergency surgeries on their patients.

 

[Espion]

My last post sounds way harsher than I intended. I'm not personally attacking anyone (you know what they say about fighting on the internet). I guess I'm lucky. I've done ABGs, central lines, IVs, venipuncture, etc. And not really because I had to, but because I asked.

All I'm saying, is that if you *want* to do something...ask.

That's it, bottom line. You can ignore everything else I have said, if you'd like.

 

[mark146914]

Don't they teach you how to start IVs and draw blood in med school?

 

[greets fr. nyc]

Possibly helpful hints for starting with surgery:

... 6 unit players before a 5-hour laparoscopic gastric bypass is an awfully long time on your feet...
I am not going to be a surgeon, but I had a great time on my surgery rotation. I hope you do, too.

6 unit players?!! Luv the term...! for some reason i imagine bed-ridden violinists stringing songs of love and devotion up on the 10th floor SICU.

Great post, btw.
Lots of pearls, and brought back memories too.

😉

 

[Smurfette]

Don't they teach you how to start IVs and draw blood in med school?

It depends on the school. My school had us practice drawing blood on each other before clinical rotations. IVs they taught on surgery or anesthesia rotations. However, I got very little experience with either during med school---it was not something residents or students did themselves (exception: anesthesia).