Surgery Rounds: Formulating a PLAN when

[DarthNevus]

Hey everyone:

On surgery rounds the residents want to know what my PLAN for the patient is. Since I'm not a surgeon and I have virtually '0' experience with care planning where can I find a resource that could outline a simple plan for me to follow regarding my post op patients?

I really only need a plan that is simple -I'm not writing orders for patients and my residents/attendings and they do not expect me to do so but they DO however expect me to formulate a logical plan for AM presentations and my notes.

3rd year review texts don't cover this area of the day-to-day grind and uptodate gives some recommendations but not the general principles I need to fill in the gaps of my knowledge and surgical texts are much too dense.

What do you guys recommend?

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[SouthernSurgeon]

Hey everyone:

On surgery rounds the residents want to know what my PLAN for the patient is. Since I'm not a surgeon and I have virtually '0' experience with care planning where can I find a resource that could outline a simple plan for me to follow regarding my post op patients?

I really only need a plan that is simple -I'm not writing orders for patients and my residents/attendings and they do not expect me to do so but they DO however expect me to formulate a logical plan for AM presentations and my notes.

3rd year review texts don't cover this area of the day-to-day grind and uptodate gives some recommendations but not the general principles I need to fill in the gaps of my knowledge and surgical texts are much too dense.

What do you guys recommend?

surgical texts do cover this. Lawrence's Essentials of General Surgery has a nice chapter on perioperative care/management; I recall NMS having something as well.

You should take some time outside of rounds to get the residents, particularly juniors, to help you go over plans.

For all patients, the goal of the postop plan is basically to "normalize" them over a course of hours/days and get them ready for discharge. For example: if they are NPO, is it safe to advance their diet - if so, do so; if not, why not.

A basic systems based plan never fails.

Example: POD1 patient from a right hemicolectomy for colon cancer

N: Pain control - continue PCA for analgesia; consider increasing demand dose or frequency if pain control inadequate

P: Encourage OOB/Amb and IS to prevent atelectasis

C: If patient is on any home BP/heart meds, consider whether safe to resume (in particular BBs and antiplatelet agents)

GI: Consider advancing to clear liquid diet if pt tolerating. If pt showing signs of postop ileus, continue NPO status; consider abd x-ray and NG tube if vomiting/nauseated

GU/FEN: Monitor urine output, continue replacement IV fluids. Supplement electrolytes prn to reach K > 3.5, MG > 2.0. If urine output stable, consider d/c'ing foley catheter. If urine output low, keep foley

Heme: SQH/Lovenox for DVT prophylaxis

ID: No indication for postop antibiotics. Monitor for fevers, elevated WBC.

Endo: SSI for perioperative glucose control.

Dispo: Pending return of bowel function, tolerance of PO intake, pain control on PO meds

 

[evilbooyaa]

I agree with all of the above (very good list about how to deal with post-op patients), my only question to southernIM (Are you a surgery resident?) is the prevalence of perioperative SSI. We were told that unless the patient had a history of diabetes or blood sugars over 200-250 (especially if reaching 350, the point where apparently WBCs stop working?), there was no role of SSI in post-op patients, as most patients will have some transient spikes in blood glucose because of surgery.

One thing to add in the GI section - Mention if patient has had flatus or a BM. Our hospital required flatus rather than a BM prior to discharge. Other hospitals may have different rules.

Oh never mind, I see it's in the dispo. Can't hurt to put flatus/BM status there as well.

 

[SouthernSurgeon]

I agree with all of the above (very good list about how to deal with post-op patients), my only question to southernIM (Are you a surgery resident?) is the prevalence of perioperative SSI. We were told that unless the patient had a history of diabetes or blood sugars over 200-250 (especially if reaching 350, the point where apparently WBCs stop working?), there was no role of SSI in post-op patients, as most patients will have some transient spikes in blood glucose because of surgery.

One thing to add in the GI section - Mention if patient has had flatus or a BM. Our hospital required flatus rather than a BM prior to discharge. Other hospitals may have different rules.

Oh never mind, I see it's in the dispo. Can't hurt to put flatus/BM status there as well.

Yes I'm a surgery resident.

I don't routinely start an SSI unless there is relevant history of diabetes or hyperglycemia. I just wanted to have something to put in the "endo" section of the plan for my example 😀

There are obviously more nuances that I didn't get into for the purposes of this - should you restart oral diabetic meds such as metformin and when - that come up on a case by case basis.

As for flatus, I would hope the student mentions that in the subjective/objective portion of their presentation. The plan for GI advancement could then be based on that.

 

[evilbooyaa]

Good to hear the endo section wasn't boiler plate for everybody.

Re-start oral metformin in a post-op patient? We almost never did that. Too scared of that lactic acidosis. Only times we would is if the patient was refusing his SSI injections.

 

[secants]

If you read a few surgery notes, you'll get an idea of what they want from almost all their post op patients. Best thing in general is to go over your findings/plan with the intern and then present to the resident/attending because I also had the same problem on almost every rotation since I felt like the stuff I was studying for the shelf wasn't applicable for the day to day assessment and plans we were doing.

 

[mimelim]

8/21/13
0515

CRS PN
NAE, pain well controlled, tol CLD, +F, -BM, -n/v
AF, VSS
NAD
RRR
CTAB
Abd soft NT/ND, incision c/d/i

I/O: XX/YY, UOP: ZZ
(Labs) if any

A/P: POD #3 s/p R hemicolectomy for colon polyp
- D/C PCA, Norco scheduled
- Adv to Reg
- OOB/Ambulate/IS
- Lovenox ppx


My plans really boil down to one thing, how do I get the patient out of the hospital out the front door. They have to be eating, pooping, tolerable pain and able to care for themselves at home. Systems based approach is the way to go while learning, but IS overkill for floor notes. Sometimes I have 15-20 notes to write in the morning. I'm not writing anything more than I have to in order to effectively communicate to anyone reading the chart.

 

[futuredoctor10]

8/21/13
0515

CRS PN
NAE, pain well controlled, tol CLD, +F, -BM, -n/v
AF, VSS
NAD
RRR
CTAB
Abd soft NT/ND, incision c/d/i

I/O: XX/YY, UOP: ZZ
(Labs) if any

A/P: POD #3 s/p R hemicolectomy for colon polyp
- D/C PCA, Norco scheduled
- Adv to Reg
- OOB/Ambulate/IS
- Lovenox ppx


My plans really boil down to one thing, how do I get the patient out of the hospital out the front door. They have to be eating, pooping, tolerable pain and able to care for themselves at home. Systems based approach is the way to go while learning, but IS overkill for floor notes. Sometimes I have 15-20 notes to write in the morning. I'm not writing anything more than I have to in order to effectively communicate to anyone reading the chart.

I agree with the above note especially given that on Surgery, residents want concise notes and presentations. At my institution, the residents told us "we want you to be presenting in maybe 2 minutes" and so southernIM's note if presented would be considered too long. That being said, it is not bad to go through all the systems and think about them (and write them down if time permits).

 

[mimelim]

I agree with the above note especially given that on Surgery, residents want concise notes and presentations. At my institution, the residents told us "we want you to be presenting in maybe 2 minutes" and so southernIM's note if presented would be considered too long. That being said, it is not bad to go through all the systems and think about them (and write them down if time permits).

2 minutes is generous. If you can't tell me about the patient in 30 seconds, you are giving too much information unless there is something actually going on. This is obviously a process that takes a lot of time and practice to hone, but people really like to give extraneous details and it is vexing to no end.

 

[KnuxNole]

For students, it can be a tough transition from a medicine rotation to a surgery rotation. The presentation length is vastly different. Like mimelim mentioned, short and sweet works for surgery, and I would add OB/GYN. A 30 second presentation is unacceptable in a medicine/peds wards presentation. See what the residents in your service are doing and try to tailor to that. It's a good idea to run it through with an intern before rounds in the first few days.

Notes are a different story. Other than the H+P, SOAP notes should be to the point and focused, no matter what service you are on. My inpatient medicine notes are like the ones mimelim has, abbreviations galore. After all, when you have so many things to do, writing a detailed note goes out the window(providing the note is clear to begin with). Getting things ordered/done > writing a pretty novel.

 

[mercaptovizadeh]

2 minutes is generous. If you can't tell me about the patient in 30 seconds, you are giving too much information unless there is something actually going on. This is obviously a process that takes a lot of time and practice to hone, but people really like to give extraneous details and it is vexing to no end.

1.5 minutes beyond your cutoff is "vexing to no end"? And you wonder why surgeons get the reputation they have. Students need to learn...by example and from mistakes. They will become more efficient as they learn what's important and why the rest of the details can be left out.

 

[mercaptovizadeh]

For students, it can be a tough transition from a medicine rotation to a surgery rotation. The presentation length is vastly different. Like mimelim mentioned, short and sweet works for surgery, and I would add OB/GYN. A 30 second presentation is unacceptable in a medicine/peds wards presentation. See what the residents in your service are doing and try to tailor to that. It's a good idea to run it through with an intern before rounds in the first few days.

I would also argue that the generous presentation format on inpatient medicine expected of students is unrealistic and that the detail-orientation of some of the rounds cannot be sustained through internship and residency. It would be better if instead this was left to the written documentation (which is expected to be quite as detailed) and the students were allowed to give condensed oral presentations. Too many people run away from IM, screaming, because of lengthy walk rounds that aren't even particularly educational.

 

[KnuxNole]

I would also argue that the generous presentation format on inpatient medicine expected of students is unrealistic and that the detail-orientation of some of the rounds cannot be sustained through internship and residency. It would be better if instead this was left to the written documentation (which is expected to be quite as detailed) and the students were allowed to give condensed oral presentations. Too many people run away from IM, screaming, because of lengthy walk rounds that aren't even particularly educational.

Oh I agree. 5 hour rounds are crazy(what I experienced as a med student). I'm in the middle of my inpatient month as an intern, and rounds are shorter(1.5 hours max) which has teaching and efficient presentations. That's how rounds should be. Not wasting 40 mins discussing the reasons why Mr. X's Potassium is now 5.5.

 

[SouthernSurgeon]

8/21/13
0515

CRS PN
NAE, pain well controlled, tol CLD, +F, -BM, -n/v
AF, VSS
NAD
RRR
CTAB
Abd soft NT/ND, incision c/d/i

I/O: XX/YY, UOP: ZZ
(Labs) if any

A/P: POD #3 s/p R hemicolectomy for colon polyp
- D/C PCA, Norco scheduled
- Adv to Reg
- OOB/Ambulate/IS
- Lovenox ppx

This is what I would expect my intern's floor note to look like. Not what I'd expect my student's presentation to sound like. For student presentations I want to see that they have a good understanding of the disease process, not that they can mime the lingo we use. They still need to be concise, but I'm going to ask them questions based on what they tell me to assess whether or not they're "getting it" or just reciting.

But it is a good point that everyone's expectations are different, which is why I think talking to the residents about precisely what they want from you is important.

 

[mimelim]

1.5 minutes beyond your cutoff is "vexing to no end"? And you wonder why surgeons get the reputation they have. Students need to learn...by example and from mistakes. They will become more efficient as they learn what's important and why the rest of the details can be left out.

Taking 4 times as long as is necessary because they decided to spend every evening studying for a shelf instead of learning the basics of how to function on the wards, yes it is vexing.

Student's function is to learn. Being an effective communicator is one of those things they need to learn how to do. It isn't just about efficiency. It is about being able to relay information to other people on your service as well as other providers. Our interns are expected to call our consults which 90%+ of the time go to an attending directly. The only way you are able to do that is if you practice. Showing up as an intern without a filter to me at least speaks volumes about one's medical education.

 

[DarthNevus]

That's a good place to start -thanks everyone.

I also like mimelim's advice [paraphrasing]:

Do everything I can to get the patient out the FRONT door.

Got it.