Vascular service tips

[3member]

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Incoming PGY1 surgery intern here. Will be starting on Vascular and would genuinely appreciate basic tips and tricks on how to survive/topics to focus on while on this rotation. No vascular exposure during my 3rd or 4th years of med school.

TIA

 

[LucidSplash]

The following list is ideal. But honestly I wouldn’t expect a July intern to know all of this off the bat. But if you do you’ll look like a rockstar.

Dopplerable signals, palpable pulses. Don’t confuse the two. Have a sharpie to mark these on a patient. Dot for a signal, X for a pulse. But we generally only mark the feet, don’t draw all over your patient unless otherwise instructed. A complete peripheral vascular exam includes palpating femoral, popliteal, pedal, brachial, radial. And dopplering where they aren’t palpable. Know what dependent rubor is and how to differentiate it from cellulitis (you will look like a magician to the ED).

Know the basics of what you would expect for symptoms based on ABIs. Know that ABI is falsely elevated in diabetics. Toe pressures needed for healing 30mmHg, but for diabetics 60mmHg. Know what claudication is and what makes it lifestyle limiting, what rest pain is, and take note (and pictures) of any foot wounds.

know what venous insufficiency is, what the CEAP criteria is. What the VCSS is and how to calculate it (hint there are online calculators). Most labs use >500ms for reflux in superficial system, some use 1 sec for deep, some use 500ms, figure out what your lab does

AAA repair at 5.5cm, 5 for women, or otherwise symptomatic. Know the difference between a type A dissection and Type B. Know the treatment for type B uncomplicated vs complicated.

Know the velocity criteria for carotid stenosis by duplex ultrasound. Would be good to know these papers: NASCET, ACAS, CREST, ACST.

Know the rule of 6s for dialysis access, and the KDOKI guidelines. Know the basic types of fistula access. If someone has a pacemaker or ICD (can cause vein stenosis), what patients dominant hand is. Ideally 3mm vein is useful, sometimes will try with 2mm if not on HD yet or patient is younger. Know to start as distal on the arm as possible for HD access assuming will need multiple accesses over the course of life on HD. Know what steal syndrome looks like (and grading system), what banding and a DRIL procedure are. Know what IMN is.

Know the compartments of the leg and the 6 Ps of compartment syndrome. Bonus for knowing thigh, forearm, upper arm compartments.

There’s more but if an intern knew all of this day 1 July I would think they were destined for greatness.

 

[deleted50541]

Outstanding breakdown for the newly minted intern. Definitely knowing how to do a good vascular exam and report accordingly is a key intern skill.

Get familiar with blood thinners, anti-platelet drugs, and fibrinolytics. You'll need to understand what lab values are important to monitoring them, when to hold and start them, transitioning to oral therapy, and interactions. If you think they're supposed to be on one of these medications and they're not, don't hesitate to ask your seniors/attendings. Don't forget all the other meds these folks are usually on, e.g. antihypertensives, diabetic meds, statins, etc.

Also, get ready for A LOT of wound care. Unless you have a dedicated wound care service, you'll be unwrapping, debriding, and redressing wounds everyday. If you've got med students, they'll become walking wound care supply closets. Learn the difference between wet and dry gangrene, what's viable and not, and when the trigger needs to be pulled for surgical debridement/amputation.

Get to know the nephrologists well. You'll interact with them a lot on vascular surgery and they're usually pretty nice folks who love to talk your ear off about the kidney.

Learn to read angiograms and CTAs including what's normal anatomy, what stents and grafts looks like post-op, and what's clearly abnormal.

Get in the OR/angiosuite/hybrid suite whenever you can. Intern year is a lot of scut work, learning the ropes and basic management of surgical patients, but don't forget you're training to be a surgeon.

 

[TypeADissection]

The following list is ideal. But honestly I wouldn’t expect a July intern to know all of this off the bat. But if you do you’ll look like a rockstar.

Dopplerable signals, palpable pulses. Don’t confuse the two. Have a sharpie to mark these on a patient. Dot for a signal, X for a pulse. But we generally only mark the feet, don’t draw all over your patient unless otherwise instructed. A complete peripheral vascular exam includes palpating femoral, popliteal, pedal, brachial, radial. And dopplering where they aren’t palpable. Know what dependent rubor is and how to differentiate it from cellulitis (you will look like a magician to the ED).

Know the basics of what you would expect for symptoms based on ABIs. Know that ABI is falsely elevated in diabetics. Toe pressures needed for healing 30mmHg, but for diabetics 60mmHg. Know what claudication is and what makes it lifestyle limiting, what rest pain is, and take note (and pictures) of any foot wounds.

know what venous insufficiency is, what the CEAP criteria is. What the VCSS is and how to calculate it (hint there are online calculators). Most labs use >500ms for reflux in superficial system, some use 1 sec for deep, some use 500ms, figure out what your lab does

AAA repair at 5.5cm, 5 for women, or otherwise symptomatic. Know the difference between a type A dissection and Type B. Know the treatment for type B uncomplicated vs complicated.

Know the velocity criteria for carotid stenosis by duplex ultrasound. Would be good to know these papers: NASCET, ACAS, CREST, ACST.

Know the rule of 6s for dialysis access, and the KDOKI guidelines. Know the basic types of fistula access. If someone has a pacemaker or ICD (can cause vein stenosis), what patients dominant hand is. Ideally 3mm vein is useful, sometimes will try with 2mm if not on HD yet or patient is younger. Know to start as distal on the arm as possible for HD access assuming will need multiple accesses over the course of life on HD. Know what steal syndrome looks like (and grading system), what banding and a DRIL procedure are. Know what IMN is.

Know the compartments of the leg and the 6 Ps of compartment syndrome. Bonus for knowing thigh, forearm, upper arm compartments.

There’s more but if an intern knew all of this day 1 July I would think they were destined for greatness.

I love it when @LucidSplash talks dirty. But this is absolute gold. Thanks for doing a better write-up than I would have done.

The big thing is to find a way to stay organized. Make check boxes and work through them. The two big meds on vascular are anti-platelets and statins. If they're on anticoagulation, why? If they're on antibiotics, why and how many days? What's the creatinine and what is it compared to baseline? Look at the previous scars for surgical history. There was a resident who once didn't know if a patient had an open AAA repair or EVAR...

Otherwise, it's July. It's going to feel overwhelming. Consults will pour in and learning to triage is important. Always bump things up the chain and don't be afraid to tell nurses that you'll get back to them after talking to your uppers. It's easy to get into work mode and put learning mode to the side, but do your best to not do that and try to pick up little nuggets along the way. Who knows? Maybe you'll realize that after your time on vascular, that it is your destiny. Good luck. Cheers.

 

[HighwayVagabond]

Agree with just generally being organized, knowing the anti-platelets and anti-coagulants, etc. If you know CEAP criteria and don't know some of this basic stuff, I frankly would think you were super book smart and clinically useless, but that's just me. Focus on understanding urgent and emergent things. You have time to look up info on optimal dialysis access if you're consulted for access placement, or carotid stenosis duplex criteria, but other things are more urgent and you want to quickly be able to know what to look for and make a complete assessment. The above is great, but there are a few much more high yield things that I wish my interns knew in the middle of the night that haven't been mentioned:

Understand acute limb ischemia. There is a rutherford classification for this. You will never be the one making the call regarding if the patient needs the OR emergently or the next morning, but knowing the components of that and being able to tell your fellow when you present the patient to them is very important (are they experiencing paresthesias, motor deficiency, or pain only, and what is the duration since symptom onset).

Know if the patient has a contrast allergy. Many patients will require either a CTA or formal angiography and this can mess up the OR schedule if they aren't prepped.

When you're consulted for a wound, in general assess for an arterial or venous component to their pathology. (See pulse exam above. Probably most important thing mentioned). Some wounds are simply secondary to diabetic neuropathy, but others need revascularization prior to amp, and still others are venous and simply need some good compression, elevation, and wound care.

Understand spinal drains. I expect the intern to call me if/when changes to this need to be made, BUT I have had situations where there is a problem with the drain that has gone unnoticed for several hours, so it's critical to have a basic understanding of them. Every institution is different in how they manage them, so I won't go through details here. Also generally understand there is a risk for spinal cord ischemia in patients who have undergone major aortic operations (generally seen with extensive TEVAR coverage or complex endo repairs involving longer lengths of aorta), so if a patient has leg weakness after one of those, even days later, don't mess around with that. Tell someone right away, and know your institution's rescue protocol.

If something is bleeding, don't panic. Place your finger on it. Take a deep breath. Call for help.

Finally, if you want a nice pocket reference manual, stop by a case with a Gore rep and ask if they can get you a copy of the Combat Manual. They will give it to you for free, and it is intended to cover the most commonly encountered scenarios in vascular surgery. I wish I had it as an intern. It is about a decade old now, but it's still pretty relevant.

 

[LucidSplash]

Agree with just generally being organized, knowing the anti-platelets and anti-coagulants, etc. If you know CEAP criteria and don't know some of this basic stuff, I frankly would think you were super book smart and clinically useless, but that's just me. Focus on understanding urgent and emergent things. You have time to look up info on optimal dialysis access if you're consulted for access placement, or carotid stenosis duplex criteria, but other things are more urgent and you want to quickly be able to know what to look for and make a complete assessment. The above is great, but there are a few much more high yield things that I wish my interns knew in the middle of the night that haven't been mentioned:

Understand acute limb ischemia. There is a rutherford classification for this. You will never be the one making the call regarding if the patient needs the OR emergently or the next morning, but knowing the components of that and being able to tell your fellow when you present the patient to them is very important (are they experiencing paresthesias, motor deficiency, or pain only, and what is the duration since symptom onset).

Know if the patient has a contrast allergy. Many patients will require either a CTA or formal angiography and this can mess up the OR schedule if they aren't prepped.

When you're consulted for a wound, in general assess for an arterial or venous component to their pathology. (See pulse exam above. Probably most important thing mentioned). Some wounds are simply secondary to diabetic neuropathy, but others need revascularization prior to amp, and still others are venous and simply need some good compression, elevation, and wound care.

Understand spinal drains. I expect the intern to call me if/when changes to this need to be made, BUT I have had situations where there is a problem with the drain that has gone unnoticed for several hours, so it's critical to have a basic understanding of them. Every institution is different in how they manage them, so I won't go through details here. Also generally understand there is a risk for spinal cord ischemia in patients who have undergone major aortic operations (generally seen with extensive TEVAR coverage or complex endo repairs involving longer lengths of aorta), so if a patient has leg weakness after one of those, even days later, don't mess around with that. Tell someone right away, and know your institution's rescue protocol.

If something is bleeding, don't panic. Place your finger on it. Take a deep breath. Call for help.

Finally, if you want a nice pocket reference manual, stop by a case with a Gore rep and ask if they can get you a copy of the Combat Manual. They will give it to you for free, and it is intended to cover the most commonly encountered scenarios in vascular surgery. I wish I had it as an intern. It is about a decade old now, but it's still pretty relevant.

I think a lot of this is good too.

But as an attending, I kinda expect interns to be book smart and less clinically knowledgeable on July 1. That’s the entire point of residency. In my residency, they were referred to as pointer dogs; they could identify that a problem existed, but then tell you jack all about what to do about it. My list was directed towards basic vascular things an incoming intern could know clinically that would put them above pointer dog status. The OP asked for specific vascular service tips, and staying organized and knowing labs and such is important but not specific to vascular as an inter

I don’t expect interns to manage spinal drains. I consider that advanced and expect the upper level residents and fellows to teach thr interns about them, but to stay on top of these patients themselves between cases.

Some of this is probably institution dependent expectations.

 

[Lem0nz]

I'm going to be a little cynical here but doppler every pedal pulse. Your fingers are not trustable yet. I wouldn't trust them, you shouldn't trust them, a vascular attending definitely won't trust them. If vascular consult, get doppler and doppler pulses. Do this for all of PGY1 year until you trust your fingers. You should have an extremely healthy level of suspicion of your own fingers.

 

[HighwayVagabond]

I think a lot of this is good too.

But as an attending, I kinda expect interns to be book smart and less clinically knowledgeable on July 1. That’s the entire point of residency. In my residency, they were referred to as pointer dogs; they could identify that a problem existed, but then tell you jack all about what to do about it. My list was directed towards basic vascular things an incoming intern could know clinically that would put them above pointer dog status. The OP asked for specific vascular service tips, and staying organized and knowing labs and such is important but not specific to vascular as an inter

I don’t expect interns to manage spinal drains. I consider that advanced and expect the upper level residents and fellows to teach thr interns about them, but to stay on top of these patients themselves between cases.

Some of this is probably institution dependent expectations.

Yeah that's fair. I'm still a fellow, so I'm thinking of things from a different perspective than you (ie, what phone calls do I field from the intern who is at the hospital alone in the middle of the night). And of course residents need to build a foundation of knowledge of disease processes, too. I will say I would rather have a pointer dog any day, though. I can teach someone about a disease process and how to manage it, but I can't necessarily teach someone to recognize when a patient is really sick or a problem is urgent and serious.

And 100% agree with you that spinal drains should be managed by a fellow. That's why I said I don't expect them to make changes, but to understand the basics of when something might be wrong. Like if a drain is dumping 20/hr--call me. This is mainly for night interns. I have woken up to major problems after falling asleep for four hours and finding up to 100mL out of the drain, or a drain that is putting out nothing and no one has confirmed it is patent. Or have seen delays in recognizing SCI that presents later after drains have been removed. Those are the things I'm referring to. Would never expect the intern to manage the level changes, clamping, etc.

 

[mimelim]

I have been doing this for 10 years and I still don't fully trust my fingers. When in doubt, doppler it.

I have no idea why I logged into here instead of continuing to prepare for Grand Rounds tomorrow. But, hello old friends 🙂

 

[longhaul3]

I think a lot of this is good too.

But as an attending, I kinda expect interns to be book smart and less clinically knowledgeable on July 1. That’s the entire point of residency. In my residency, they were referred to as pointer dogs; they could identify that a problem existed, but then tell you jack all about what to do about it. My list was directed towards basic vascular things an incoming intern could know clinically that would put them above pointer dog status. The OP asked for specific vascular service tips, and staying organized and knowing labs and such is important but not specific to vascular as an inter

I don’t expect interns to manage spinal drains. I consider that advanced and expect the upper level residents and fellows to teach thr interns about them, but to stay on top of these patients themselves between cases.

Some of this is probably institution dependent expectations.

Yeah that's fair. I'm still a fellow, so I'm thinking of things from a different perspective than you (ie, what phone calls do I field from the intern who is at the hospital alone in the middle of the night). And of course residents need to build a foundation of knowledge of disease processes, too. I will say I would rather have a pointer dog any day, though. I can teach someone about a disease process and how to manage it, but I can't necessarily teach someone to recognize when a patient is really sick or a problem is urgent and serious.

And 100% agree with you that spinal drains should be managed by a fellow. That's why I said I don't expect them to make changes, but to understand the basics of when something might be wrong. Like if a drain is dumping 20/hr--call me. This is mainly for night interns. I have woken up to major problems after falling asleep for four hours and finding up to 100mL out of the drain, or a drain that is putting out nothing and no one has confirmed it is patent. Or have seen delays in recognizing SCI that presents later after drains have been removed. Those are the things I'm referring to. Would never expect the intern to manage the level changes, clamping, etc.

To what extent do you as vascular surgeons manage these lumbar drains? Do you place them? Troubleshoot them when they stop working? Is neurosurgery always involved in/aware of your drains in case something goes wrong (like the patient blows a pupil)?

LD for a TEVAR is a common intraop consult for me, interested to hear how they're managed at other institutions.

 

[Dr.LeoSpaceman]

Dopplerable signals, palpable pulses. Don’t confuse the two.

We used to have an attending that would beat on people for this. Rightly so.

The point that having non-palpable pulses with signals isn't necessarily "normal" is an important one.

 

[LucidSplash]

To what extent do you as vascular surgeons manage these lumbar drains? Do you place them? Troubleshoot them when they stop working? Is neurosurgery always involved in/aware of your drains in case something goes wrong (like the patient blows a pupil)?

LD for a TEVAR is a common intraop consult for me, interested to hear how they're managed at other institutions.

Institution dependent on who puts them in, anesthesia vs neurosurg, more commonly anesthesia in my experience. There may be some vascular who put their own in but I am not aware of any personally.

Typically vascular knows to check for external issues (kinking/etc) if not working. If all that is verified, whoever put it in (anesthesia) will come check it.

I have never given neurosurg a heads up for it just existing. But I haven’t had a patient with one since fellowship; I now work at an outlier hospital and if I think a patient would need a spinal drain for TEVAR then I send to the mothership. I don’t know that anesthesia would be willing to put one in where I am and I’m positive the ICU nurses wouldn’t have a clue. But I don’t think they tell neurosurg about them at the mothership either.

In fellowship, when I had a patient with a spinal drain and was on homecall and an inhouse intern at night, I would always go over the details of “important spinal drain stuff” with said intern and make them write it down before going home for the night, even if there had been one previously while that intern was on service. There were technically CC doc & NP in house at night and could have managed but the ultimate responsibility was the vascular fellow.

Also I believe in the mantra that the entire hospital is full of otherwise well-meaning assassins who are trying to kill your patients and get your cases for the next day cancelled.

Trust no one.