University of Virginia

Surgical Clerkship
Survival Guide

Damien J. LaPar, MD
 CODES AND NUMBERS
Important Door Codes

Call Room
Supply Room
Scrub Machine
Computer

Important Phone/Pager Numbers

N:___________#:__________ N:___________#:__________
N:___________#:__________ N:___________#:__________
N:___________#:__________ N:___________#:__________
N:___________#:__________ N:___________#:__________
N:___________#:__________ N:___________#:__________

Additional NOTES

Contributions: Eugene McGahren MD, Hillary Sanfey MD, Ramesh Singh MD at University of Virginia
Acknowledgements: The original edition of this manual was developed by the University of Colorado Surgical
Society by Damien LaPar MD, Kenneth Thomas MD, Ryan Koonce MD and Arek Wiktor MD

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 CONTENTS
1. Introduction
a. Hints for EXCELLING in the Rotation ........................................... 4
b. Suggested Texts and Pocket Books ................................................. 4
c. What Should I Carry in My Coat? ................................................... 4
d. Surgical Jeopardy and Oral Exam…………………………………4
2. NOTE TEMPLATES
a. Admission/Consult H&P Note......................................................... 5
b. Pre-Op Note...................................................................................... 6
c. Operative Note ................................................................................. 6
d. Post-Op Note .................................................................................... 7
e. Daily Progress Note ......................................................................... 7
3. Admission to the Surgery Service
a. Admission Orders............................................................................. 8
b. IV Fluids........................................................................................... 8
c. Vascular Access ............................................................................... 8
d. Diet Considerations .......................................................................... 8
4. Pre-Op Care
b. Pre-Op Orders and Considerations ................................................... 9
a. Blood Type and Screen .................................................................... 9
b. Blood Type and Crossmatch ............................................................ 9
c. Blood Products ................................................................................. 9
5. In the OR
a. Suture Materials .............................................................................10
b. Suture Sizes ....................................................................................10
c. Needle Types..................................................................................11
d. Drain Types/Care ...........................................................................11
6. Post-Op Care
a. Post-Op Orders ...............................................................................12
b. Post-Op Fever.................................................................................12
c. DVT Prophylaxis............................................................................12
7. Wound Care/ Discharge
a. Dressing Changes...........................................................................13
b. Suture and Staple Removal ............................................................13
c. Discharge Orders and Considerations............................................13
8. COMMON MEDICATIONS
a. 5 P’s (Pain, Puke, Pus, Poop, Prophylaxis) ...................................14
b. Electrolyte Replacement ................................................................14
c. Fluids ............................................................................................. 14
9. Notes

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 INTRODUCTION
Hints for EXCELLING in the Rotation
1. Check with your chief resident regarding rotation expectations.
2. Be EARLY, be VERY enthusiastic, be confident - NOT ARROGANT.
3. Be eager to take on RESPONSIBILITY.
4. Write all notes (or begin NOTE TEMPLATES) whenever possible.
5. Know your patients better than your intern, and track all data.
6. Deliver concise, informative patient presentations.
7. Read before EVERY case; know ANATOMY and PATHOPHYSIOLOGY.
8. Ask for leftover suture to practice knot tying at home.
9. Always tell the truth, even if it has consequences.
10. Work through assigned Lawrence cases by the end of your rotation.
11. Use The Virtual Patient as a resource for cases.
Suggested Texts, Pocketbooks and Websites
1. Essentials of General Surgery by Peter F. Lawrence
2. Surgical Recall or Advanced Surgical Recall by Lorne H. Blackbourne
3. The Virtual Patient (www.med-ed.virginia.edu/courses/surgery/restricted/utmbcd/)
4. Current Surgical Diagnosis and Treatment by Way and Doherty
5. The Washington Manual of Surgery by Doherty et al.
6. Human Anatomy by Netter
7. Access Surgery (www.accesssugery.com)
What Should I Carry in My Coat?
1. 2 pens
2. Penlight
3. Stethoscope
4. Trauma shears or bandage scissors
5. Tape, 4x4’s, steri-strips, cotton tipped applicators, alcohol swabs
6. Staple removal kit
7. Large note cards to track patient data and take notes
8. Reference book (Surgical Recall)
Surgical Jeopardy and Oral Exam
1. Prepare early and practice with your teammates
2. Take seriously…this is the best prep you will get for the Oral Exam
3. Work with your residents
4. Utilize Surgical Recall and Lawrence as your primary sources of preparation
5. Study each question on your own patient case in The Virtual Patient
6. Relax and have fun…this is your chance to demonstrate to yourself how much
you’ve learned during this rotation!
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 NOTE TEMPLATES

Admission / Consult H&P

Date Surgery MS3 Admission H&P or Surgery MS3 Consult
Time CC:
HPI:
PMH:
PSH:
Meds:
Allergies: PCN? Latex? Betadine? Tape/Dressings? (Document reaction)
FH: Cancer? Heart disease? Diabetes?
SH: Tobacco (current or past)? EtOH? IV drugs? HIV risk factors?
ROS: Respiratory disease? Cardiac symptoms? GI symptoms? Pain? Weight
loss?
Physical Exam (PE):
Vitals: BP, pulse, RR, T-current, O2 sat
Gen: Alert? Oriented x 3? Appears ill?
Neck: LAD? JVD? Supple? Masses? Thyroid?
Heart: Rate? Rhythm? Murmurs? Rubs? Gallops?
Lungs: CTA? Wheezes? Rales? Rhonchi?
Abd: Soft? Rigid? Distended? Bowel sounds? Tender to palp? Where?
GU: Hernia? Inguinal masses? Testicular abnormalities?
Rectal: Tone, mass, tenderness, guiac +/- (mention if control works)
Ext: Movement? Pulses? Tender? Reflexes? Clubbing? Cyanosis?
Edema?
Neuro: Mental status exam, CNs II-XII, sensation, motor, reflexes,
coordination, gait
Labs:
X-rays:
EKG:
Assessment: Age, gender CC consistent with diagnosis.
Plan:
YOUR SIGNATURE, MS3
YOUR NAME PRINTED

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Pre-Op Note – to document that the patient is ready for surgery
Date Surgery MS3 Pre-Op Note
Time Preop Dx:
Planned Procedure:
Labs: Chem 7 results?
CXR: Findings?
Blood: CBC results? Coags?
EKG: Findings?
Anesthesia: General? Local?
Consent: Signed? In chart?
YOUR SIGNATURE, MS3
YOUR NAME PRINTED

Operative Note – written near end or at the end of the case

Date Surgery MS3 Op Note
Time Pre-Op Dx:
Post-Op Dx:
Procedure(s): 1.____________ 2._____________ 3._____________
Surgeon:
Assistants:
Anesthesia: GETA, MAC, Epidural, Spinal
Findings:
IVF: Type (crystalloid/colloid/blood) and amount (get both from anesthesia)
Urine Output: (get from anesthesia)
EBL: In cc’s (get from anesthesia)
Specimens: Type and plan (to pathology?)
Drains: Location of placement and type
Complications: (None)
Plan: PACU? ICU? Floor?
YOUR SIGNATURE, MS3
YOUR NAME PRINTED

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Post-Op Note – within 6 hours of operation/floor arrival
Date Surgery MS3 Post-Op Note
Time Procedure:
S: Neuro status, pain, nausea, vomiting, ambulation, voiding, po intake
O: Vitals
PE:
I’s and O’s Fluid in: crystalloids + colloids + blood + …
Fluid out: drain #1 + drain #2 + urine + tubes + …
Net =
Labs: Post-Op HCT?
A: Age, gender, s/p (operation)…
P: Abx, diet, pain control, etc…
YOUR SIGNATURE, MS3
YOUR NAME PRINTED

Daily Progress Note

Date Surgery MS3 Progress Note
Time S: POD # (from operation)
Abx day #
Complaints? Overnight events? Pain? Flatus? BM? Sleep? Ambulation?
O: Vitals, T-max, T-current, I’s and O’s (Net, UOP/hr, NGT, Drains)
Drains: Location? Output over last shift and 24 hours? Fluid color?
PE: Dressing clean/dry/intact (C/D/I)? Wound inspection? Careful when
palpating fresh wound—it hurts!
A: Age, gender, POD # _ on IV abx day #_of _
P: 1. Diet today
2. Pain control today
3. Ambulation today
4. Can we D/C: Meds? IV fluids? O2? Abx? Foley? Drains?
5. Do we need to change meds?
6. New labs or studies for tomorrow?
7. Consults needed?
8. Dispo plan: Estimate # days? Re-operate?

YOUR SIGNATURE, MS3

YOUR NAME PRINTED
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 ADMISSION TO THE SURGERY SERVICE
Admission Orders “ADC VANDALISM”
Date Admit to: ____________ Attending:_________ Resident: _____ pgr:______
Time Diagnosis:____________ Intern:_______ pgr:______
Condition: Good, Stable, Fair, Critical
Vitals: Per routine, but you can specify (better to specify)
Activity: Bed rest, OOB to chair, OOB ad lib, etc.
Nursing: Strict I/O’s, daily weights, compression stockings, SCDs, etc.
Check with resident on when to call house officer – example:
“Call HO if T>38.5, P>100 or <60, SBP>160 or <110, RR>30, UOP
<30 ml/hr”
Diet: NPO, Sips/Chips, Clears, Regular, Diabetic, NPO after Midnight (MN)
Allergies: NKDA if none
Labs: Specify when you want them – example:
“Now: CBC, Chem 7, UA, LFTs, T-bili, D-bili, PT, PTT
AM labs: CBC, Chem 7”
IVF: Specify type of fluid, initial bolus (if any), and drip rate
example: “D5 ½ NS with 20 mEq KCl/L at 100 cc/hr”
Studies: EKG, radiographic studies
Meds: patient’s pre-admission meds as appropriate, others per specific patient

IV Fluids – Rules of Thumb

1. Maintenance Fluids*: “4/2/1 Rule” = [4 ml/hr for first 10 kg wt] + [2 ml/hr for
next 10 kg] + [1 ml/hr for every 1 kg over 20 kg]
*
Singh’s Short Cut: wt +40, if ≥ 20 kg
2. Trauma: Replace 1 cc of EBL with 3 cc of isotonic IVF
3. Parkland Formula* for burn patients: wt (kg) x TBSA% x 4cc LR over 24 hr
Give ½ first 8 hours, second ½ over next 16 hours.
*
At UVA: (wt) (% TBSA) (3cc LR) over 24 hours

Vascular Access
• Peripheral IV: most common line used
• External jugular: helpful if peripheral line is unobtainable
• Central line: usually into subclavian, IJ or femoral vein
• PICC (peripherally inserted central catheter): great access for chemo, TPN or
long term patient IV use (usually placed in interventional radiology suite)

Diet Considerations
NPO = nothing per oral (nil per os) Diabetic = low sugar
TPN = total parenteral nutrition Cardiac = low sodium and caffeine
Clears = broth, Jell-O, water, etc.
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 PRE-OP CARE
Pre-op Orders and Considerations
1. All patients: NPO p MN
CBC, Chem 7
UA
PT, PTT
2. >40 yo or any risk factors: EKG, CXR
3. Other things to consider:
Consent signed and in chart?
Radiographic studies available and ready to be hung in OR?
Bowel prep needed?
IVF needed now?
Blood type/cross-match/screen or blood products needed for OR?
Antibiotics needed on call to OR (OCTOR)?

Blood Type and Screen

A type and screen should be ordered when there is a reasonable possibility a surgical patient
will require blood but the likelihood of transfusion is too low to justify setting aside
crossmatched units. As a guideline, if a surgical procedure requires transfusion in fewer than
10% of cases, a type and screen request rather than type and crossmatch is appropriate. When
a type and screen is ordered, ABO, Rh and antibody screening tests are performed.

Blood Type and Crossmatch

If the need for transfusion is very likely, request a type and crossmatch for number of units
so that blood will be available in the operating room.

Blood Products
Pre-transfusion medications = acetaminophen and diphenhydramine.
Diuretics between units for volume-up patients.

1. Packed RBCs: 1 unit raises HCT approximately 2-3%. Transfuse 1 unit over 3 –
4 hours. Indications: symptomatic anemia, large blood loss, HCT < 21 to 25%
(highly surgeon dependent).
2. Platelets: 1 unit raises platelet count by 5,000 to 10,000. Usually transfused 6
units at time. Indications: Plt < 20,000, Plt < 50,000 with bleeding and/or planned
surgery, thrombocytopenia.
3. Fresh Frozen Plasma: 1 to 2 units transfused depending on PT and PTT.
Indications: Replacement of clotting factors.
4. Cryoprecipitate: Factor VIII, fibrinogen, and von Willebrand factor. Indications:
Use with deficiency of these specific factors.
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 IN THE OR
Suture Materials
Effective
Wound Complete
Trade Support Absorption Tissue
Material Name (days) (days) Handling Reaction Uses
Poor knot Quick-
Surgical Gut - 4-10 70 security, high High healing
memory mucosa
Poor knot Quick-
Chromic Gut - 10-14 90 security, high Moderate healing
memory mucosa
ABSORBABLE

Mucosa,
Stiff but
sub-cut,
Polyglycolic Acid Dexon 21 90 excellent knot Minimal
vessel
security
ligation
Polyglactic Acid Vicryl 21 90 Excellent Minimal Subcut.
Extended
Polydioxane PDS 60 180 Good Minimal
support
More
Polyglyconate Maxon 60 180 Excellent Minimal supple than
PDS
Poliglecaprone Monocryl 20 28 High memory Minimal Subcut.

Vessel
Silk - - - Excellent High
ligation
NON–ABSORAB ABLE

Vessel
Cotton - - - Excellent High
ligation
Dacron, Good /
Polyester - - Minimal Fascia
Ethibond Excellent
Surgilon, Skin,
Nylon - - Good Minimal
Nurolon fascia
Skin
Prolene, closure,
Polypropylene - - Good Minimal
Surgilene vascular
anast.
Retention
Steel - - - Poor Minimal sutures,
bone
rd
Adapted from Doherty et. Al., The Washington Manual of Surgery, Lippincott Williams & Wilkins, 3 Edition, 2002.

Suture Sizes
Diameter is inversely proportional to the number designation (i.e. 7-0 is smaller than 2-0)
Size Uses
7-0 and smaller Ophthalmology, microsurgery
6-0 Face, blood vessels
5-0 Face, neck, blood vessels
4-0 Mucosa, neck, hands, limbs, tendons, blood vessels
3-0 Limbs, trunk, gut, blood vessels
2-0 Trunk, fascia, viscera, blood vessels
0 and larger Abdominal wall closure, fascia, drain sites, arterial lines, orthopaedic surgery

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Needle Types

1. Taper needles (round): Minimize tissue trauma because they pierce tissue
without cutting it. Used for peritoneum, viscera, dura, vessels - NOT skin!
2. Cutting needles (triangular): The apex forms a cutting surface, which facilitates
penetration of tough tissue. Used for skin.
3. Reverse cutting needles: Designed to pierce tough tissue without
bending/breaking needle. Used for tendon sheaths, periosteum, skin.
4. Blunt-tip needles: Dissect friable tissue without cutting it. Used for liver,
kidney, as well as OB/Gyn procedures for safety.

Drain Types/Care

1. Open Drain = “Penrose”: plain thin rubber tube with one end in the wound and
one end out.
2. Closed Suction Drain =
• Jackson-Pratt (JP): fenestrated tube attached to a suction bulb that looks
like a grenade. Disengage suction before removing from wound.
• Blake Drain: white, radiopaque silicone drain with four channels along the
sides with a solid core center. Can be either flat or round in shape.
• When to remove:
o Drain output ≤ 30 ml/day
o When your chief, fellow or attending tells you to.
3. Chest Tube= flexible tube inserted into the pleural space used to evacuate air
(penumothorax), fluid (hydrothorax), blood (hemothorax), chyle (chylothorax) or
pus (empyema).
• Sizes:
o 16-22 Fr: pneumothorax
o 24-28 Fr: hemo, hydro, chylothorax
o ≥ 28 Fr: hemothorax, empyema
• When to remove:
o After air leak has resolved
o After CT has been to H20 seal for >24 hrs without
pneumothorax or airleak
o Drainage output < 10 ml/hour for 6 hours (ie. ≤200 ml/day)
o When your chief, fellow or attending tells you to

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 POST-OP CARE
Post-Op Orders

Similar to admission orders with modifications specific to surgical procedure. Special

considerations post-op which should be discussed with your resident:

• Pain meds – see back cover

• Antibiotics – see back cover
• Stool softeners (if on opioids) – see back cover
• Advancement of diet - NPO→Sips/Chips→Clears→Soft→Regular
• DVT prophylaxis – Heparin 5000u SC, Enoxaparin, SCDs, early ambulation.
• Ambulation – as tolerated
• Weight bearing status – of extremity (if applicable, check with Ortho)
• Drains/tubes/catheters – JP to suction, Chest tube to suction/seal, Foley to
gravity. NG Tube to low, intermittent suction.
• Incentive spirometry – 10 inspirations/hr, hold inspiration for 1-2 seconds.
• Products/ Fluids
• Neuro/vascular checks – if applicable

Post-Op Fever (> 38.5) - the “5 W's” Mnemonic

• Wind: Atelectasis (MCC of post-op fever in first 24-48 hrs)

• Water: UTI (after POD #3)
• Wound: Infection (usually after POD #5, Grp A Strep→POD 1)
• Walking: DVT (after POD #7-10)
• Wonder drugs: Drug fevers (anytime)

DVT Prophylaxis:

• Unfractionated heparin (UH): either SC or gtt (monitor PTT q6h)

• Low molecular weight heparin (LMWH)
• Aspirin (ASA)
• Anti-platelet agents (Clopidogrel)

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 WOUND CARE/ DISCHARGE
Dressing Changes
POD #1: Do not remove dressing or look at wound unless instructed by chief!
Comment only on status of the dressing (i.e., C/D/I = clean, dry, intact)
POD #2: Only if ok with resident, remove dressing after primary closure and inspect
wound – comment on wound (erythema, induration, drainage, pus, heat?)
• Wet to dry (Wet to moist) - damp gauze covered by dry gauze and tape. Serves
to passively and actively debride wound as gauze dries and is removed
• Supplies - Have ready at bedside prior to team rounds (4x4, ABD’s, bottle of
normal saline, tape, Vaseline gauze, cotton tipped applicators)
• Pain - Consider giving pain meds prior to dressing change
Suture and Staple Removal
Face: 3-4 days
Scalp: 5 days
Trunk: 7 days
Arm or leg: 7-10 days
Foot: 10-14 days
Discharge Orders and Considerations

• Help your intern execute any final orders in preparation for discharge.
• Ensure that the patient is aware of the plan for discharge.
• Always ask first before pulling any IV’s, sutures, staples, drains, or tubes
• Key Considerations:
o Patient tolerating regular diet (no n/v)
o Patient ambulating independently (if applicable)
o Patient having bowel movements
o Pain controlled on oral pain medications
o Social worker involvement (if applicable)
o PT/OT clearance and follow-up (if applicable)
o Does the patient have a ride home?
o Who will care for the patient at home?
o Sutures/staples out (check with resident)
o IV and Foley out (check with resident)
o Tubes and drains out (check with resident)
o Switch antibiotics from IV to PO (check with resident)
o Signed prescriptions: pain meds, stool softeners, abx, DVT meds
o Set up follow-up appointments
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 COMMON MEDICATIONS
5 P’s of Surgery Post-Op Orders:
Pain: Morphine 1-2 mg IV q2 PRN
Vicodin (5/500 mg) 1-2 tabs PO q6 PRN
Percocet (5/325 mg) 1-2 tabs PO q6 PRN
Fentanyl 25-50 mg IV q1-2 PRN

Puke: Phenergan 12.5 – 25 mg IV q6 PRN

Zofran 4 mg IV q6 PRN
Reglan 10 mg PO TID PRN

Pus (Abx): Zosyn 3.375 g IV q6

Timentin 3.1 g IV q6
Levaquin 500 mg IV QD
Flagyl 500 mg IV q8
Clindamycin 900 mg IV q8
Cefoxitin 2 g IV q8
Vancomycin 1 g IV q12

Poop: Colace 100 mg PO BID

Dulcolax 10 mg PO/PR QD
Milk of Magnesia (MOM) 30 ml PO QHS

Prophylaxis: Heparin 5000 U SQ BID

Fragmin 5000 U SQ QD
Ranitidine 100 mg PO BID
Omeprazole 40 mg IV QD
Benadryl 25 – 50 mg PO PRN itch

Electrolyte Replacement:
2-3-4 Rule: Buff to these levels (Mg 2.0, Phos 3.0, K 4.0)
K+ K-Phos: 15 – 30 mmol IV or KCl: 10 – 30 mEq PO/IV
Mg2+ Mag Sulfate: 2 - 4 g IV
Phos4- Na-Phos: 15 – 30 mmol IV (can use K-Phos as well)
Ca2+ Ca-gluconate: 500–1000mg PO/IV or Ca-carbonate 1-2g PO div TID-QID

Fluids: D5 ½ NS with 20 mEq KCl/L at 125 cc/hr*

*
125 cc/hr is an average, dose appropriately based on wt (see IV Fluids, page 8)

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NOTES

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