Surgical Intern Survival Guide

Brought to you by, The Chiefs

Who do you want to be?

Always remember...
Dont worry, youre not alone!
You are just an intern. Hierarchy exists for a reason. Call your senior!

Outline
1)

I wrote the note - so the pre-ops done, right?

Outline
1)

I wrote the note - so the pre-ops done, right?

2)

The operation is finished - do we still have to

see the patient?

Outline
1)

I wrote the note - so the pre-ops done, right?

2)

The operation is finished - do we still have to

see the patient? Is now a good time to call the chief?

3)

Outline
1)

I wrote the note - so the pre-ops done, right?

2)

The operation is finished - do we still have to

see the patient? Is now a good time to call the chief? What is that thing hanging out of the patient?

3) 4)

Outline
1)

I wrote the note - so the pre-ops done, right?

2)

The operation is finished - do we still have to

see the patient? Is now a good time to call the chief? What is that thing hanging out of the patient? What does D5 stand for anyway? (a.k.a Is it OK to replace Phos?)

3) 4) 5)

I wrote the note so the pre-ops done, right? (a.k.a. How to do a pre-op)
Plan ahead Check OR schedule frequently during the day Order the necessary labs and films early, so that they can be getting done as you work on other tasks during the day

Pre-Op ingredients
Labs (CBC, Chem 7, Coags, hCG) Blood products/Type and screen Imaging Bowel prep Review of current medications Clearance Consent Note Orders

Pre-op labs
CBC
- How low can you go with Hct or Plts? - Is the WBC count high for an elective case?

Chem-7
- If any electrolytes need to be replaced, make sure you have a repeat chemistry afterwards showing the new normal value - Chasing a low K+ can keep you up all night, so start early - Be especially careful with dialysis patients

PT/PTT
- If INR is >1.3 you might need Vit K or FFP, check w/ chief

Blood products
Type and screen
- Call the blood bank to confirm that its active - Typically active for 72 hours after the draw

Hold what you (and your chief/attending) think is necessary

- 2U PRBC for typical abdominal case - Is the patient on Coumadin or in liver failure? - Will you need FFP or other products?

Imaging
CXR
Any patient > 60 Anyone with a smoking history Any pulmonary pathology If any question, order it

Have CTs, MRIs, angiograms available if requested by attendings or chiefs

Bowel preparation
Is it even necessary?
Typically used for all colorectal cases

Attending preference
Bowel prep = mechanical prep + chemical prep

Mechanical
Sodium Phosphate (Fleets)
- Two doses of 45 ml given 3-6 hours apart - May cause electrolyte abnormalities - Avoid in renal failure, cirrhosis, ascites, CHF, elderly

Polyethylene Glycol (GoLYTELY)

- 4L solution over 4-6 hours - Large volume, salty taste, bloating / cramping - Fewer water and electrolyte abnormalities

Tap water enemas

Chemical
Neomycin 1 gm + Erythromycin 1gm - Each given for a total of three doses 3-4 hours apart Alternatives include Cipro + Flagyl Intravenous antibiotics are also given in the OR recommended to be given 30 minutes before incision

Pre-Op medications
Review all medications (home and hospital)
Cardiac Anticoagulants Anti-platelet therapy Antibiotics Insulin

Cardiac medications
Continue all cardiac medications perioperatively
- Especially beta-blockers - Post-op orders should include hold parameters

Exception is diuretics
- Post-op patients tend to third space, dont want to further deplete intravascular volume with diuretics - Hold AM dose on day of surgery - Resume once taking adequate PO

Chronic anticoagulation

What to do?

Antiplatelet therapy (Aspirin/Plavix)

No increase in bleeding complications in patients taking aspirin preoperatively undergoing emergent surgical procedures (Ferraris et al. Surgery, Gynecology, and Obstetircs 1983) Cardiac surgery patients on aspirin have been noted to have increased transfusion requirements and rates of reoperation but no differences in mortality
(Sethi et al. JACC 1990, Goldman et al. Circulation 1998)

No consensus recommendations

In practice, patients should have any antiplatelet therapy stopped 7 days prior to elective surgery

DM medications
Long-acting insulin (e.g., ultralente, glargine) should be discontinued 1-2 days before surgery Glucose levels should be stabilized with a regimen of intermediate insulin (e.g., NPH, lente) mixed with shortacting insulin (e.g., regular, lispro, or aspart) twice daily or short-acting insulin before every meal Standing insulin should be halved or dced the morning of surgery Oral agents are discontinued before surgery
- Long-acting sulfonylureas (e.g., chlorpropamide) are stopped 2-3 days before surgery - Short-acting sulfonylureas, other insulin secretagogues can be withheld the night before surgery

DM medications
Make sure every diabetic has a regular insulin sliding scale Fingersticks should be performed q4 hr or before each meal and in the evening

Patients should receive dextrose-containing solutions to avoid hypoglycemia

Clearance
Medicine, cardiology, neurology, nephrology, psychiatry, neurosurgery
call consults early, dont wait for the last minute

Need for clearance should be discussed with chief, attending, and anesthesia Prepare what is necessary for your consultants (most patients will require at least an EKG)

Operative consent
Think about this early! Does the patient have capacity? Who is the health care proxy or the next of kin? Discuss risks, benefits, alternatives (ask seniors or chiefs if unclear) Telephone consent requires the telephone operator/administrator to record the conversation - must record name of operator on the consent form (each hospital has a different way of doing this)

Mount Sinai consent

Elmhurst consent

VA consent

Pre-op Orders
NPO after midnight
- includes tube feeds - make sure the patient and the nurse know

IVFs to start at midnight (usually D5 NS with 20 mEq KCl @ 100-125cc/hr)

no potassium if it is a dialysis patient

Medication changes
Medications necessary on call to OR

Pre-op Note
More a formality, but it helps you and others review the status, should include: Procedure Labs T&S and blood availability EKG reading CXR reading NPO status / IVFs Consent status Medication changes

Additional pre-operative concerns

ESRD patient
When did the patient last have dialysis? When do they need it next? Minimal IVFs when NPO (0-30cc/hr, no KCl) Do they need blood before the OR?

If a patient is on another service (including the SICU), always discuss pre-op status with the primary team

The operation is finished, do we still have to see the patient? Post-Op Checks
Should be done 4-6 hrs after the end of surgery Check vitals look at trends Check urine output minimum of 0.5cc/kg/hr Check drain (JPs, NGT, G-tube, etc.) outputs
- Quantity/quality - Can send fluid for hematocrit or creatinine if concerned - Are tubes connected properly and working?

Examine the patient

- Attention to the dressing

Post-Op Checks
Labs check post-op labs and order new ones if necessary trend significant labs Vascular: check pulses (usually marked postop in OR), watch PTT in pts on heparin, check for bleeding Assure that the patient has venodynes and an incentive spirometer and an understanding of how to use both Is pain adequately controlled and pt is not too lethargic? Note record all of the above with a legible, dated/timed note

DVT Prophylaxis

All post op pts get venodyne boots unless contraindicated Sub Q heparin: all pts unless told otherwise by chief/attending (5000Units unfractionated heparin subQ q8 hrs)

Diets

Clear liquids anything you can see thru, Jello Fulls all liquids, including dairy GI soft/low residue: regular food but no hard to digest fiber/veggies/nuts/seeds for anyone with GI anastomosis/resection/stoma Heart healthy: low fat, low cholesterol 1800Kcal ADA: for diabetics, low sugar Special diets: Bariatric Stage I and II, dysphagia diets, renal/dialysis diet, enteral feeds, etc

Is now a good time to call the chief?

YES Remember you are not alone There is ALWAYS a senior resident you can call in- house with any problems or questions with patient management

You can also call the chief or attending with any questions or change in patients condition

On-call problems
Most surgical emergencies evolve over hours, not minutes, take the time to think! Fever Chest pain Hypoxia Hypertension Hypotension Oliguria Pain Mental status changes The clogged/dislodged NG tube

Doctor, the patient doesnt look good. Can you come?

Ask the nurse to get a set of vitals

If patient is hypotensive, ask for a 1L bolus If the patient is hypoxic, ask for oxygen

What medical problems does this patient have? Start treating the problem right away (even before you have arrived) and GO see the patient! Dont forget, there is always help available

On-call problems Fever

Fever = T > 38.2C Examine patient with attention to wound and lungs Fever work-up required if >48 hours postop or clinical condition is not as expected CXR make sure it gets done, and f/u result CBC U/A, UCx, BCx w/ gram stain (both central and peripheral) order, draw if necessary, and f/u Tylenol ? Empiric antibiotics check with chief

On-call problems Chest pain

H&P
Is this cardiac? Pulmonary? Quality/duration of pain, previous episodes

EKG
Compare to old EKGs available in EDR

Basic labs w/ attention to Hct & electrolytes Cardiac enzymes q8 x 3

CK, CK-MB, Troponin (at Mt.Sinai, Troponin must be ordered separately)

Pulse oximetry Chest x-ray

On-call problems Chest pain

H&P
Is this cardiac? Pulmonary? Quality/duration of pain, previous episodes

EKG
Compare to old EKGs available in EDR

Basic labs w/ attention to Hct & electrolytes Cardiac enzymes q8 x 3

CK, CK-MB, Troponin (at Mt.Sinai, Troponin must be ordered separately)

Pulse oximetry Chest x-ray

On-call problems Tachycardia

Hypovolemia- Is it fluid losses, inadequate resuscitation. Is the patient bleeding? Check the blood pressure and urine output Hypoxia- Is it fluid overload, aspiration, PE Check the pulse ox, CXR Cardiac- Arrythmia, MI ECG Medication withdrawal Was the patient on Beta blockers Pain, Anxiety

On-call problems Hypoxia

H&P Repeat pulse oximetry
Assure there is a good waveform

Chest x-ray ABG

Radial a., Femoral a., Dorsalis Pedis a. Avoid brachial a.

CT angio
Patient will need an 18-gauge or larger IV (central line too long for rapid flow)

On-call problems Hypertension

Examine patient
Any associated symptoms, end-organ signs (blurry vision, headache, etc)?

Repeat vitals
Check BP on both arms using appropriately sized cuff Treat trends, not single values

Review meds
Did the pt skip his/her AM meds?

Beta-blockers
Best first-line agents if no contraindications e.g. Metoprolol 5mg IV q 6 hrs

Avoid long-acting agents and diuretics

On-call problems Hypotension/Oliguria

Examine patient
Evidence of bleeding? Check foley: irrigate or replace if necessary Palpate bladder, assess skin turgor, mucous membranes Is the patient thirsty?

Review fluid requirements and losses Review medication list, hold BP meds, hold epidural and narcotics This is surgery - think about bleeding!! Everyone can tolerate some fluid - start w/ a bolus Consider steroid withdrawal

On-call problems Pain

Examine patient
Is the pain appropriate for the procedure performed?

Review vitals tachycardia, hypertension Review preoperative narcotic use and OR requirements PCA Toradol
Useful synergistic medication Avoid in patients with high bleeding risk or renal insufficiency

Consider pain service consult

On-call problems Mental status changes

Think about why
Hypoxia, sepsis, hypovolemia, hypoglycemia, medications, etc.

Examine patient, get vitals + O2 sat

ABG Ask family, nurses re: baseline

Check a finger-stick glucose level Review medications

Hold narcotics, H-2 blockers, psychotropic meds Is this narcotic overdose? Check pupils, give Narcan.

Avoid sedatives Physical restraints

Acceptable, especially if patient is at danger to self or others

On-call problems The dislodged NGT

Examine patient Why was it placed initially? If clogged, gentle flushing with NS often works
Flush air into blue port in Salem sumps

Is there a danger in replacing the tube?

- Do not replace an NGT if placed intraoperatively during upper GI surgery - Same for rectal tubes and lower GI surgery

On-call problems Codes

You MUST go to a code if your team has a patient on that floor Even if you have no idea what youre doing, you can start by:
Call for Team 7000, (700 at Elmhurst) Get the crash cart into the room Start with your ABCs Get the EKG monitor / defibrillator paddles on the patient to check the rhythm - Help is on the way! -

On Call Problems special cases

Bariatric patients

Often, tachycardia or other very non-specific complaint heralds very bad things (ie: leak, bleeding) Special population any concerns need to taken seriously

Kidney donors

ANY concerns -> call the senior/chief/attending especially with the donor patients

Whats that thing hanging out of the patient? Lines, drains, and tubes

Post-op check
- CXR to check position and r/o pneumothorax - Look at the site (esp. in a febrile pt)

Record what date catheters are placed

Triple lumen catheter

Short-term central venous catheter typically placed for TPN or Abx or simply for access in patients with poor peripheral veins

Hickman/Broviac
Long-term tunneled central venous catheter typically placed for TPN or Abx or simply for access in patients with poor peripheral veins

Shiley catheter
Short-term large bore dialysis/apheresis catheter Needs to be flushed with heparin 1:100 U solution using exact volume labeled on catheter

Permcath
Long-term tunneled dialysis / apheresis access catheter Needs to be flushed with heparin 1:100 U solution using exact volume of catheter

PICC Peripherally inserted central catheter

Long-term catheter placed typically for TPN or Abx Really not for blood draws (clogs easily) Flush well if used

Portacath
Central venous access with subcutaneous reservoir typically placed for chemotherapy or in patients with poor peripheral access who require other IV medications or transfusions

Dont forget about me. the external jugular vein

.or me the arterial line

Excellent source for blood draws in patients with poor venous access

Other tubes / drains

Jackson Pratt Penrose Hemovac NGT / Salem Gastrostomy and jejunostomy tubes Rectal tubes

Jackson-Pratt drain
Always check to make sure suction is working Strip on daily AM rounds

Penrose drain

Hemovac drain

Nasogastric tube
Salem sump should be placed to low continuous suction with the blue port open to air Clear port should be flushed q8 hr with 20 cc NS while the blue port should be flushed q 8 hr with air Single-lumen tubes should be placed on low-intermittent suction Never ever use an NGT for feeding unless youve checked an x-ray

Gastrostomy and Jejunostomy tubes

What does D5 stand for anyway? IVFs & Electrolytes

Replacement Solutions: isotonic solutions used to replace volume for pts who are hypovolemic from dehydration or bleeding Normal Saline (NS): just 0.9% NaCl Lactated Ringers (LR): glucose, Na, Cl, K, Ca, Lactate (converted to HCO3 by liver) Plasma-Lyte: Na, K, Cl, Mg, Acetate

IVFs & Electrolytes

Replacement solutions are typically given in 1L boluses Patients w/ sepsis, DKA, burns, trauma, pancreatitis may need many liters

If patient w/ CHF can give 500cc over 1 hour and assess lung exam

IVFs & Electrolytes

Maintenance Solutions:
hypotonic solutions used to replace normal fluid losses in an NPO patient

Typically D5 normal w/ 20 of K: 5% Dextrose, 0.45% NaCl, and 20mEq of KCl

IVFs & Electrolytes

Notes: For NPO ESRD patients, run fluids at 3050cc/hr For pts w/ CRI or ESRD dont add K+ to maintenance fluids and dont replace K+ if mildly low (remember, its going to rise by itself until dialysis) Never bolus a patient w/ D5 or K+ If replacing GI losses, use a comparable fluid Diabetics need sugar too (OK to use D5 )

IVFs & Electrolytes

Parenteral Nutrition TPN: via central line or PICC (dedicated line) PPN: via peripheral line Should taper at rate for an hour before stopping TPN because it may contain insulin If need to D/C, run D10

IVFs & Electrolytes

Potassium

If pt is taking PO, give oral replacement

If Cr normal, can give lots PO safely

Runs of IV if NPO
Risk of arrhythmia - can only run 10 mEq of KCl per hour 20 mEq / hr in a monitored setting like ICU run at slower rate if causing burning sensation in patients arm

Actual deficit is larger than you might think

eg. for K=3.2 will likely need 10mEq IV x 4 or 40mEq PO x 2

IVFs & Electrolytes

Calcium
If calcium is low, first adjust for albumin Can also check an ionized calcium instead If mild, give PO calcium carbonate (TUMS) If symptomatic, give calcium gluconate IV If head/neck surgery, may have inadvertently injured the parathyroids? Need to check Ca level postop

IVFs & Electrolytes

Phosphate Often see drop in patients undergoing major hepatic resection Replace w/ PO NeutraPhos or IV K-Phos Magnesium Important to check Mg level if K is low Be cautious repleting electrolytes on ESRD pts dont do it without checking with chief/senior

IVFs & Electrolytes

Glucose If blood sugar is ~50-80 can just give patient some juice and observe If <50, or if patient is symptomatic (altered mental status, diaphoretic) push an ampule of D50 x 1 stat

Discharge planning
Think about early and discuss with team Involve Social Work (SW) and Physical Therapy early when necessary- remember daily SW rounds! Enter IDP (implement discharge plan) in TDS when discharge is planned in the next 24 hours

Enter discharge order after morning rounds

Write prescriptions clearly and legibly in a timely fashion dont forget to include DEA on narcotics, License number. Mount Sinai institutional DEA# AM9707805- your suffix Complete discharge summaries before the chart disappears can be done in SignOut on computer

Pager Etiquette

Tag your pages or use text-page system when paging other members of team Text paging (www.archwireless.com or intranet1.mounsinai.org/surgery) Dont page people who may not be inhouse to 3-xxxx numbers When scrubbed, give pager to other intern. At Sinai, you can forward your pager by calling 41200 and follow prompts If you have a question regarding patient care- Go to the OR to find your chief. Dont page because they are scrubbed and may not be able to call back.

ER 4-6639 Blue slip 877.337.4624 Main Pharmacy 4-7714 ID drug approval p9407 Main Labs 4-LABS Stat Lab 4-3895 Blood Bank 4-6101 Pathology 4-7373 Main Radiology 4-7401 Ultrasound 4-7431 CT 4-7412 Special Procedures 4-7409 DAS 4-7778 Bed Board 4-7461 Main OR desk 4-1990 PACU 4-1992 Dictation line 8-9889 Line service p1872, 37393

11W 4-5826 10E 4-3595 9E 4-7935 9C 4-7944 8E 4-7939 7W 4-7929 SICU (6E) 4-5111 MICU (5W) 4-5721 Radiology on call p1490 Surgical clinics 824-7606 MEs Office 212-447-2030 Sinai Surgery Office 4-5871 Elmhurst Surgery Office 718-334-2475 Englewood Surgery Office 201-894-3141 Bronx VA Operator 718-584-9000

Useful Websites

www.amion.com (login mssurg) www.mssurg.net (links to all sorts of useful stuff) www.acgme.org (dont forget to log cases!) intranet1.mountsinai.org/surgery www.archwireless.com www.mssm.edu/library

Elmhurst Shuttle
Mt. Sinai 99th St. & Madison Ave. (Weekdays Only) 6:00 A.M. 7:10 A.M. 8:40 A.M. 11:50 A.M. 2:15 P.M. 4:05 P.M. 5:40 P.M. 7:00 P.M. Elmhurst Bus Stop

Subway Directions
-6 train to 51st
-Transfer

6:25 A.M. 7:45 A.M. 10:15 A.M. 12:30 P.M. 3:20 P.M. 4:35 P.M. 6:30 P.M. 7:30 P.M.

to E to Queens

-Get off at Roosevelt Ave -Walk on Broadway past Pacific Supermarket 4 blocks to hospital, on your left

-alternatives R, V, or 7 trains all go to Roosevelt ave.

Bronx VA Shuttle
Mt. Sinai 98th/Madison (Weekdays Only) 6:30 A.M. 7:30 A.M. 9:15 A.M. VA 7:00 A.M. 8:15 A.M. 10:00 A.M.

Subway Directions

10:45 A.M.
12:00 P.M. 1:15 P.M. 3:30 P.M. 5:15 P.M. 6:30 P.M.

11:30 A.M.
12:30 P.M. 2:45 P.M. 4:35 P.M. 5:50 P.M. 7:15 P.M.

4 to Bronx Get off at Kingsbridge Rd Walk on Kingsbridge past large abandoned Armory building approx 5 blocks Hospital parking lot on your left across street

Englewood Shuttle
Weekday Schedule Leaving Englewood 5:15 A.M. 6:30 A.M. 8:15 A.M. 12:00 P.M. 5:00 P.M. 6:30 P.M. Weekend Schedule 8:00 A.M. 9:45 A.M. Weekday Schedule Leaving Mt. Sinai (Aron Hall) 6:00 A.M. 7:00 A.M. 9:00 A.M. 12:45 P.M. 5:30 P.M. 7:00 P.M. Weekend Schedule 8:30 A.M. 10:15 A.M.

Call Schedule Requests

If you have a request for the next month, find out early who is making the schedule and contact them. Requests have to be in by the 10th of the previous month, so do this EARLY Understand that it is not always possible to get what you want and be nice to the person making the schedule they have a tough job If you will be postcall on the 1st day of the month, let your future chief know ahead of time

Some last words of advice

Always leave a dated / timed note for every encounter Trust no one! (always repeat the exam yourself, always re-check important labs, etc)

Be meticulous and organized you cannot remember everything, make detailed lists, cross off items as you go NEVER LIE. The chief would much rather hear "I don't know for sure" rather than passing on incorrect information. You will find that admitting what you don't know is a very important part of "first do no harm".

Some last words of advice

Always call for help when you are not sure

Some last words of advice

and eat lunch!