When do you get to perform your very first surgery?

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This might be a crazy question but when do surgical residents get to perform there first sole surgery. With a superior watching just in case anything was to go wrong.
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I did an AKA skin-to-skin as a med student with the attending walking me through the case.

First case in residency solo (attending not scrubbed in) was a port-a-cath removal (teensy case) on my first day of intern year.
 
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I'm fairly sure I did a trach with the chief resident as teaching assistant during my M4 ENT sub-I.

As an intern, I did some lumps and bumps excisions on day 1 of my internship with a PGY2 resident as teaching assist.

First time doing a case entirely by myself was probably an ear tube or tonsillectomy sometime during my PGY2 year.
 
southernIM said:
Lol I did my first port removal at the bedside under local (with the trauma chief available for consultation) intern year.

First truly solo surgery was an appy in first month of PGY2 - a level one trauma came in just as we had made incision so attending left to attend to the trauma while I did the appy
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It was under local in the procedure room.

First ENT case as resident surgeon was a Gilles approach to a zygomatic arch fracture. Pretty damn satisfying to see the guy go from a one finger to 3.5 finger oral opening immediately.
 
You have to realize that surgery is usually a two person sport. At most academic hospitals, there are no surgical assists for routine cases that residents are scrubbing. Thus, many resident-lead operations are either with a senior residents and junior resident, or a resident with an attending where the attending acts like an assistant (the latter being a not truly solo).

As a third year resident I did plenty of cases without an attending scrubbing. Usually appy's, but a couple of ex laps also.
 
VisionaryTics said:
I did an AKA skin-to-skin as a med student with the attending walking me through the case.
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Yikes. I mean, AKAs don't look difficult... More like medical school anatomy. But I don't see how someone can solo that. Clamping vessels, tying...lifting the damn leg. And approximating the edges when you close. I guess it's feasible... But I'd be exhausted.
 
Kaustikos said:
Yikes. I mean, AKAs don't look difficult... More like medical school anatomy. But I don't see how someone can solo that. Clamping vessels, tying...lifting the damn leg. And approximating the edges when you close. I guess it's feasible... But I'd be exhausted.
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I didn't interpret VT's AKA post as VT was the only one touching the patient. I assume the attending was walking him through it AND assisting.
 
Also I think my first "solo" cases were as an MS4 on a medical missions trip. They set the two MS4s up with our own area for procedures under local. An attending took us through a couple lipoma removals and then we must have done another 10-15 with just the two of us and an experienced scrub tech in the room and an attending or fellow popping in on us every so often.
 
LucidSplash said:
I didn't interpret VT's AKA post as VT was the only one touching the patient. I assume the attending was walking him through it AND assisting.
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It doesn't count unless you're doing it solo with one hand holding it and the other cutting through. Bonus points if you can bovi through the bone.
 
From what I can remember...

MS3 on vascular - OR debridement of dead foot, attending watched while I went at it. Ended up doing the BKA with him a week later, but such is life on Vascular.

PGY1 - removal of porta-cath, central lines (I stopped logging them after the first two months), numerous washouts
PGY2 - Aortagram, Fistulagram + PTA, AKA (did alone with a GS PGY2), a bunch of ray amps, through knee amp (attending and PGY1 did one side, I did the other with the med student)
 
mimelim said:
From what I can remember...

MS3 on vascular - OR debridement of dead foot, attending watched while I went at it. Ended up doing the BKA with him a week later, but such is life on Vascular.

PGY1 - removal of porta-cath, central lines (I stopped logging them after the first two months), numerous washouts
PGY2 - Aortagram, Fistulagram + PTA, AKA (did alone with a GS PGY2), a bunch of ray amps, through knee amp (attending and PGY1 did one side, I did the other with the med student)
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Yeah, I've been fortunate in vascular so far. Considering I didn't have loops, I didn't think they'd let me do as much. But I think part of it was showing by example I could be a team player and help with the most miniscule task without bitching. One point I was cleaning the instruments for the scrub tech... I asked the nurse if they were hiring. The attending chuckled and remarked "250k education to become a scrub tech."
 
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I did about 15 Power Port insertions as a MS4 on a sub-I. The last 5 or so the attending didn't scrub. He was in the room for the blind subclavian stick and the fluoro to make sure the wire crossed the midline. After that he just chilled while I did the rest of the case. Pretty satisfying to say the least. He then had me dictate the note and discharge the patient.

I've done amputations with an attending assisting now as an intern, a few ray amps, some stump wound debridements, etc. Small lump and bump cases, bedside procedures, and so forth are usually with an upper level resident, but sometimes solo depending upon their comfort level with you.
 
PB n J said:
I did about 15 Power Port insertions as a MS4 on a sub-I. The last 5 or so the attending didn't scrub. He was in the room for the blind subclavian stick and the fluoro to make sure the wire crossed the midline. After that he just chilled while I did the rest of the case. Pretty satisfying to say the least. He then had me dictate the note and discharge the patient.

I've done amputations with an attending assisting now as an intern, a few ray amps, some stump wound debridements, etc. Small lump and bump cases, bedside procedures, and so forth are usually with an upper level resident, but sometimes solo depending upon their comfort level with you.
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Port function is extremely important to patients undergoing chemotherapy, and simple rookie mistakes (e.g. fractures or kinking in the catheter) can have long-lasting implications. Subclavian lines are also arguably a more dangerous approach than IJ since it's "blind," and I can't imagine a medical student having enough sticks to be competent to do it alone. It is also my opinion that the dilator/sheath combo is more dangerous than the tools used for an non-tunneled line, and venous injury is possible.

To top that off, most people getting ports are mildly sedated, so they would be at least partially aware that a medical student is doing the port without the attending scrubbed....

I guess my point is that it's neat that you were allowed to do that, but probably inappropriate, and I would guess the surgeon doesn't have to compete with anyone else for those ports, or he would want a more active role in their placement. Still, more power to you, although I caution readers that this experience is very uncommon in 2014.

On a side note, I've always used the subclavian vein for non-tunneled lines due to the infectious advantage, ease of care, and when I did trauma, it did not disrupt c-spine precautions. However, whenever I do tunneled lines, the infectious advantage is lost, and I go to the right IJ as I believe it to be the safest, and burns less bridges for the future.
 
SLUser11 said:
Port function is extremely important to patients undergoing chemotherapy, and simple rookie mistakes (e.g. fractures or kinking in the catheter) can have long-lasting implications. Subclavian lines are also arguably a more dangerous approach than IJ since it's "blind," and I can't imagine a medical student having enough sticks to be competent to do it alone. It is also my opinion that the dilator/sheath combo is more dangerous than the tools used for an non-tunneled line, and venous injury is possible.

To top that off, most people getting ports are mildly sedated, so they would be at least partially aware that a medical student is doing the port without the attending scrubbed....

I guess my point is that it's neat that you were allowed to do that, but probably inappropriate, and I would guess the surgeon doesn't have to compete with anyone else for those ports, or he would want a more active role in their placement. Still, more power to you, although I caution readers that this experience is very uncommon in 2014.

On a side note, I've always used the subclavian vein for non-tunneled lines due to the infectious advantage, ease of care, and when I did trauma, it did not disrupt c-spine precautions. However, whenever I do tunneled lines, the infectious advantage is lost, and I go to the right IJ as I believe it to be the safest, and burns less bridges for the future.
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My sentiments exactly.

I was a bit shocked to read that a medical student was placing ports autonomously. After all, in my lower risk specialty, port placement is one of the riskier procedures.
 
SLUser11 said:
Port function is extremely important to patients undergoing chemotherapy, and simple rookie mistakes (e.g. fractures or kinking in the catheter) can have long-lasting implications. Subclavian lines are also arguably a more dangerous approach than IJ since it's "blind," and I can't imagine a medical student having enough sticks to be competent to do it alone. It is also my opinion that the dilator/sheath combo is more dangerous than the tools used for an non-tunneled line, and venous injury is possible.

To top that off, most people getting ports are mildly sedated, so they would be at least partially aware that a medical student is doing the port without the attending scrubbed....

I guess my point is that it's neat that you were allowed to do that, but probably inappropriate, and I would guess the surgeon doesn't have to compete with anyone else for those ports, or he would want a more active role in their placement. Still, more power to you, although I caution readers that this experience is very uncommon in 2014.

On a side note, I've always used the subclavian vein for non-tunneled lines due to the infectious advantage, ease of care, and when I did trauma, it did not disrupt c-spine precautions. However, whenever I do tunneled lines, the infectious advantage is lost, and I go to the right IJ as I believe it to be the safest, and burns less bridges for the future.
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Agree.

I almost exclusively place subclavian lines for the above reasons. The dressing lays better. It's cleaner (CDC recommended central line). Patients tolerate it better. It's also faster, so in a crashing patient, you can reduce the "time to central access" as it were or, in some cases, time to any access at all.

Placing IJs under ultrasound guidance is probably safe enough for a resident or attending to guide a medical student through if the supervising person is very comfortable with scanning with the probe to track the exact tip of the needle and experienced enough to set it up nicely. I prefer to take the interns and 2nd years through subclavians only after they have already gotten a couple IJs under their belts and thus have a feel for the steps and how to stick a vein.
 
SLUser11 said:
On a side note, I've always used the subclavian vein for non-tunneled lines due to the infectious advantage, ease of care, and when I did trauma, it did not disrupt c-spine precautions. However, whenever I do tunneled lines, the infectious advantage is lost, and I go to the right IJ as I believe it to be the safest, and burns less bridges for the future.
Click to expand...

Same on preferring the subclavian for routine central access. At this point, I refuse to place an IJ without an ultrasound. Not because I don't feel comfortable, but because in 2014 I don't think you could ever justify not using one if it's available. So not only is the subclavian better for the above reasons, it's also just less painful than going to find the ultrasound.

I also agree that it's much easier to get a poorly functioning port when going for the subclavian. The mistake I've seen is people treating it like any other subclavian and going in too close to the clavicle. That not only can cause a port that works poorly from the start, but is also when you get the catheters that fracture over time from rubbing on the clavicle.
 
I did 50+ burn cases as an intern and first month of PGY-2 without attending in the room. I will let 4th year students going into surgery do IJ lines and interns under me only do those unless we're in the ICU and I am there. I only do subclavians unless it's for temporary access while needing fluids and the patient is wide awake. Numbing up a "large" person at bedside for subclavian can be painful for all involved. But for someone who is in the ICU, asleep, or in the trauma bay I always do subclavian.
 
SLUser11 said:
Port function is extremely important to patients undergoing chemotherapy, and simple rookie mistakes (e.g. fractures or kinking in the catheter) can have long-lasting implications. Subclavian lines are also arguably a more dangerous approach than IJ since it's "blind," and I can't imagine a medical student having enough sticks to be competent to do it alone. It is also my opinion that the dilator/sheath combo is more dangerous than the tools used for an non-tunneled line, and venous injury is possible.

To top that off, most people getting ports are mildly sedated, so they would be at least partially aware that a medical student is doing the port without the attending scrubbed....

I guess my point is that it's neat that you were allowed to do that, but probably inappropriate, and I would guess the surgeon doesn't have to compete with anyone else for those ports, or he would want a more active role in their placement. Still, more power to you, although I caution readers that this experience is very uncommon in 2014.

On a side note, I've always used the subclavian vein for non-tunneled lines due to the infectious advantage, ease of care, and when I did trauma, it did not disrupt c-spine precautions. However, whenever I do tunneled lines, the infectious advantage is lost, and I go to the right IJ as I believe it to be the safest, and burns less bridges for the future.
Click to expand...

I definitely see where you're coming from. The attending was always in the room but didn't always scrub. And you're also correct that there was no competition for these cases. I was well-educated on the complications associated with their placement as well as the implications of such "rookie" mistakes as catheter kinks and, God forbid, and unnoticed catheter stick while suturing the small incision where the initial stick occured.

I was also made aware of the dangers of inserting the dilator/sheath combo, which is without a doubt the most dangerous portion of the procedure. The 15 procedures was with this single attending, there were probably 10 more with a separate attending and 5 more with yet another. The dilator/sheath combo was always seen as the most important portion of the case.

And I agree that this experience is not routine or normal for this day in age. I am, however, happy to have had it as it makes me more comfortable with lines than my intern counterparts and personally I think it speaks to the level of autonomy I was given during my medical school (whether or not any of you feel this was appropriate). Just remember, significantly more autonomy was given to medical students not that many years ago. That said, I do not expect to have that same experience replicated during my intern year.
 
Lap chole as an intern with the chief resident assisting
 
Some port packaging even says "not recommended for subclavian placement". It's the most complicated "simple case" there is and as one attending liked to say, "it has to be right". I disagree a little with access in a crashing patient. As long as not a pelvic fx, I place groin lines- easiest, quickest and less likely to cause a confounding problem 5 or 10 minutes afterwards- "is their deterioration from their crashing or my tension ptx?" Plus easier to place with compressions happening. Change it when they are alive.

Case 1- tracheostomy with thoracic attending.
 
JayDoc06 said:
I disagree a little with access in a crashing patient. As long as not a pelvic fx, I place groin lines.
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I think most of us agree that the groin line is the most appropriate in emergency situations. I don't see above where anyone suggested another route for crashing patients.
 
JayDoc06 said:
Some port packaging even says "not recommended for subclavian placement". It's the most complicated "simple case" there is and as one attending liked to say, "it has to be right". I disagree a little with access in a crashing patient. As long as not a pelvic fx, I place groin lines- easiest, quickest and less likely to cause a confounding problem 5 or 10 minutes afterwards- "is their deterioration from their crashing or my tension ptx?" Plus easier to place with compressions happening. Change it when they are alive.

Case 1- tracheostomy with thoracic attending.
Click to expand...

SLUser11 said:
I think most of us agree that the groin line is the most appropriate in emergency situations. I don't see above where anyone suggested another route for crashing patients.
Click to expand...

Crashing patient vs. emergency. The wording is pretty broad, and I don't think we are on the same page. If a patient is in VT storm and requires access while you are getting things together, but isn't actively getting compressions, I think a subclavian is totally appropriate. Similarly, if a patient is doing poorly and you suspect that you will need to float a Swan-Ganz catheter soon either for hemodynamics or to pace, then a subclavian is infinitely preferable to a groin line. This includes patients who will need to go to the OR soon, e.g. Type A dissection, acute MR due to papillary muscle rupture. Those patients need the groins available for balloon pump placement, peripheral cannulation for CPB, or ECMO, and the anesthesiologists prefer having the lines be a little bit more accessible.

Even for large surface area burn that rolls in and there is still epidermis on the chest, I have done subclavians for the initial resuscitation in spite of the fact that they are teetering. These patients have limited real estate for lines that will have to stay for awhile.

If it is a multitrauma that comes in and you have someone intubating while another person performs the resuscitative thoracotomy, then a subclavian is less appropriate. Same for patients actively receiving compressions.
 
BKA as an third year student with attending first assisting
 
Oh, I see it now.

I agree with JayDoc. Groin lines for crashing patients (trauma bay, codes, etc) most of the time. Less likely to stick yourself or someone else during a hectic mess, and the line won't be too sterile anyway, ultimately requiring replacement in the near future. Also, all the movement and chaos makes PTX more likely. I also would do a groin line for most people with REVERSIBLE coagulopathy.

But, if by "crashing" you just mean doing poorly in the ICU, then that's most of the lines that will be placed anymore, and subclavian is fine.
 
flying in academic setting with a attending as co-pilot is a breeze (from what i've seen) as long as you can stand some mild verbal abuse and you are coolz with him/her.
 
oldman said:
First case was inguinal hernia on day 3 of residency at the VA. Attending handed me the knife and said, let's see what you can do. I couldn't do too much. ha
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lol
arent hernia repairs supposed to be tricky. how did it end.
 
SLUser11 said:
I think most of us agree that the groin line is the most appropriate in emergency situations. I don't see above where anyone suggested another route for crashing patients.
Click to expand...

I will always go for the femorals in an emergency/trauma if it isn't contraindicated (pelvic smash or whatever). But, UT's standard go-to line is a subclavian. I got in trouble for throwing a femoral line when given the option between the two.
 
Did pegs and trachs on my ICU rotation in med school, as well as the approach for a forearm fracture (placed some screws too, but I wouldn't call that doing the case) and most of an amputation. Can't remember what my first case in residency was, but it was first day of intern year that we started getting walked through cases (with the subtle "attending finger" speeding things along at certain points so that I thought I was doing the whole thing myself until I learned more later). Funny that hernias were considered intern level, but then again it wasn't like they just handed us a scalpel and told us to go for it.
 
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