< Back Colorectal Disease UpToDate Patient Education Patient education: Diverticular disease (Beyond the Basics) . Also known as diverticulosis. If associated with an acute episode of infection, this is reference to as diverticulitis. Patient education: Constipation in adults (Beyond the Basics) Patient education: High-fiber diet (Beyond the Basics) Patient education: Colonoscopy (Beyond the Basics) Patient Information from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Colonoscopy American College of Surgeons: Division of Education Colonoscopy Prep Form Golytely®, Colyte®, Nulytely®, Trilyte® Source: UpToDate Images: Colon and Rectum Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

< Back Who Is Our Patient Population? We take care of critically ill and injured patients. Here are just a few examples of the different patient scenarios we manage. We are available 24 hours a day, 7 days a week. Therefore, we often receive consults for various other surgical disease processes outside of what is listed here. Trauma Penetrating wounds from gunshot wounds, stabs, or assaults from any material that breaks the skin and causes bleeding or significant tissue damage Blunt injuries from falls (roof, ladders, etc.), motor vehicle accidents, bicycle accidents, pedestrians struck by vehicles. Non-accidental injuries (abuse, inter-personal violence) Surgical Critical Care Critically ill trauma or emergency general surgery patients. Patients undergoing complex or high-risk surgical procedures or requiring intensive care unit (ICU) admission. Complications from procedural interventions. Intra-abdominal catastrophes. Airway emergencies- patients who are unable to be intubated and require a surgical airway. Emergency General Surgery Appendicitis, Cholecystitis, Diverticulitis. Bowel ischemia or bowel obstruction. Soft tissue infection- necrotizing soft tissue infection. Surgical airway or enteral access- tracheostomy for ventilator dependency and percutaneous endoscopic gastrostomy (PEG). Previous Next

< Back Vent Mgmt #4: All Together Choosing a mode Controlled- patients who aren't generating breaths. PC, VC. Most common mode at initiation of MV. SIMV- patient generating some breaths, but still needs significant mechanical support. Spontaneous- not frequently used at initiation, but can be used for patients with airway obstruction and preserved lung function. How to set initial parameters TV (6-8 mL/ kg predicted body weight) [lung protective ventilation] RR 10-14 FiO2 often start at 100%, but quickly weaned unless severely hypoxic Inspiratory:expiratory ratio typically 1:2 Flow- typically set @ 60L/min, can increase if the patient is in distress or has a high minute ventilation How to adjust parameters based on arterial blood gas results Low PaO2 (low arterial oxygen content)- increase FiO2, increase mean airway pressure Markedly elevated PaO2 (hyperoxia)- decrease FiO2 Low PaCO2 (low arterial carbon dioxide concentration)- decrease TV or RR High PaCO2 (high arterial carbon dioxide concentration)- increase TV or RR *For more details, check out these resources: Lectures: Critical Care: Respiratory Failure Lectures: Critical Care: Vents Other principles of mechanical ventilation VAP bundle- elevated head of bed, oral care Daily awakening and spontaneous breathing trials Previous Next

< Back Chicken Enchiladas in Sour Cream Sauce Ingredients 10 small soft flour tortillas 3 Tbsp flour 2 c chicken broth 1 c sour cream 2.5 c shredded cooked chicken 3 c shredded Monterey Jack cheese 3 Tbsp butter 4 oz can diced green chillies Instructions 1. Preheat oven to 350 degrees 2. Combine shredded chicken and 1 cup of cheese. Fill tortillas with the mixture above and roll each one then place in a greased 9x13 pan. 3. Melt butter in a pan over medium heat. Stir flour into butter and whisk for 1 minute over heat. 4. Add broth and whisk together. Cook over heat until it's thick and bubbles up 5. Take off heat and add in sour cream and chilies. Be careful it's not too hot or the sour cream will curdle. 6. Pour mixture over enchiladas and add remaining cheese to top. 7. Bake in oven for 20-23 minutes then you will want to broil for 3 minutes to brown the cheese. The roux, with sour cream and green chilies added Previous Enchiladas covered with sauce Cooked and broiled to brown the cheese Next

< Back Mangled Extremity- Keep or Cut? A 42-year-old male was struck by a vehicle as he was crossing the street. He was brought in by EMS. He had a depressed GCS and unequal pupils, and he was intubated for concern for airway compromise. He had a significant injury to the right lower extremity with diffuse bleeding, but no active arterial bleeding. Compressive dressings were applied. He had fluid in the LUQ window of his FAST. He was hemodynamically unstable. Initial evaluation and management? Imaging? Poly-trauma patients demand prioritization and quick decision making, and the simple step-wise algorithms designed for each injury in isolation are less helpful. Patients with blunt abdominal trauma and hemodynamic instability require emergent operative intervention. Patients with a depressed GCS and an abnormal pupil exam require emergent CT imaging to define the severity of their head injury and consultation with neurosurgery. Patients with a mangled extremity require a CT scan to define the vascular injury. In the setting of blunt abdominal trauma, a positive FAST and hemodynamic instability, he was transported to the OR emergently. If there was an option for a rapid CT en route to define his TBI, that would have been ideal. But hypotension is associated with worse outcomes for TBI patients, so the priority is stopping the bleeding. We performed a midline laparotomy, splenectomy, and repaired a diaphragm injury. We placed a temporary abdominal closure. Intraoperative Image What do we do about his mangled lower extremity? Consult vascular or ortho? Ex-fix? Amputate? There are several important tasks. Assessment of injury to neuromuscular structures is vital. If possible, rapid restoration of arterial blood flow is beneficial. However, it is vital to evaluate the need for amputation. This decision requires consideration of current physiologic status, co-morbidities, and baseline functional status. It's sometimes a question of life versus limb. Orthopedic and vascular specialists can be consulted, but it is important not to lose sight of the patient's overall clinical status. A brief temporizing procedure to restore blood flow with a shunt, stabilize bony structures, and preserve any remaining soft tissue may be appropriate, but a lengthy vascular repair and bony fixation are likely not ideal. The patient's baseline functional status, social support, and co-morbidities were unknown. Based on the severity of his extremity injury, high injury burden, and need for urgent head CT, my recommendation was for immediate amputation. This decision requires weighing the risks/ benefits of limb salvage (prolonged time in the operating room for stabilization, risk of ongoing tissue ischemia leading to systemic complications) vs amputation (limb loss). Our orthopedic specialists felt they could salvage his limb, and give him a chance to be an active participant in the decision-making. We agreed to a time limit to minimize operative time, so the limb was stabilized temporarily with a plan for ongoing evaluation of the limb viability. Managment of the Mangled Extremity WTA Algorithm Management of patients with mangled extremities remains controversial. Severe scoring systems have been created, with variable success in predicting who requires amputation. In the acute setting, the trauma surgeon must weigh the risks and benefits of limb salvage versus immediate amputation. If the limb injury is devastating (perhaps only hanging on by a small skin bridge), and the patient has other injuries that require immediate intervention, rapid amputation can be life-saving. If the decision to amputate is less clear, a second opinion from a colleague and orthopedics should be elicited. There have been remarkable advances in the ability to restore function to mangled extremities, and discussion with specialties can be very helpful. "Therapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury." Loja, Melissa N et al. “The mangled extremity score and amputation: Time for a revision.” J Trauma Acute Care Surg. 2017;82(3):518-523 The trauma surgeon must maintain perspective on the whole patient- spending hours doing meticulous vascular or nerve dissection/ repair or extensive orthopedic manipulation can be an intolerable burden on a patient with multiple other injuries. 1. Control active hemorrhage. 2. Restore anatomic limb alignment. 3. Assess distal arterial flow→ evidence of vascular injury→ CTA to characterize injury. 4. Assess neurologic function. Unable to control active hemorrhage or there is hemodynamic instability→ proceed to OR. Assess for the need for immediate amputation. Factors to consider: Complex, segmental, severely comminuted fracture. Large circumferential soft tissue loss or massive soft tissue necrosis. Compartment syndrome with myonecrosis. Nerve disruption. Massive contamination. Prolonged warm ischemia >6 hours. Poor distal anastomosis options. No immediate amputation→ intraluminal shunt to re-establish perfusion. Then assess bony and nerve injury. Evaluate risks/ benefits of limb-preservation. Previous Next

< Back Studying Tips Study Techniques Reading and re-reading textbooks/ notes. Pros- simple. Cons- passive. Easy to not absorb information as your eyes pass over the same text. Reading and highlighting textbooks/ notes. Pros- simple. More interactive than merely reading. Cons- similar to re-reading- still relatively passive. Risk of highlighting everything and not focusing on key points. Reading and handwriting notes in your own handwriting. Pros- active engagement in learning, reframe the information in your own style. You can color-code, reorganize, personalize it. Cons- takes more time. When to study There are two key circadian rhythm patterns. In his book When: The Scientific Secrets of Perfect Timing ," Daniel H Pink refers to these as "chronotypes." There are three chronotypes (larks, owls, and third birds), but the differences between them are largely inconsequential, so they are simplified to two different groups, classically known as early bird and night owl. If you haven't identified your chronotype, you can do a few relatively straightforward steps to determine your pattern. Identifying your chronotype will give you a framework to plan your peak time for analytical tasks, such as studying. If you have any control over your daily schedule, even if it's just weekends, take advantage of your inherent pattern to optimize your studying. Early morning studying before class/ clinical rotations might be optimal for some, while others are more conducive to evening learning. What has worked for me? I used to be a read and re-read type. I'm a fast reader, so it worked to get through high school and medical school. During surgery residency, I used iAnnotate PDF, which allows me to highlight and make notes. When I was entering fellowship, I renovated my style. First, I wrote notes for the handful of critical care texts that I read (Fink and Marino) and the trauma text (Mattox). During the summer before my ACS fellowship, I typed notes while reading Fink and Marino. I used iAnnotate PDF because it allows me to highlight and make notes. I did switch to a hard copy of Civetta because I needed a new format to re-ignite my focus. I used old fashioned lined paper and pencil and then rewrote them into a notebook. After I got burnt out on textbooks, I made the leap to reading journal articles. Switching to primary literature was a monumental change in my studying. I always marvel at attendings who can quote journal articles with ease. It always strikes me that their memory is so crisp...I've never had that gift. When I started reading articles, I developed a system for finding, reading, and then recording the salient findings. How I built my literature database for Acute Care Surgery There are several ways to find articles. Surgical Clinics (previously known as Surgical Clinics of North America) is one of my favorite journals for reviewing broad topics. Every article is evidence-based, with abundant references. The most current journals will be a treasure trove of high-yield references. The open journals and published guidelines (read: free!) are another excellent resource. The references in reviews and guidelines are the basis of evidence-based medicine. Read! You don't have to read every word, and as you read more articles, you will develop a sense of which papers can be perused and which deserve a more diligent review, such as landmark articles (see suggested articles). Highlight, make notes and ask yourself, "how will this change my practice". Previous Next

2 Range Why Generalists Triumph in a Specialized World - Early expertise and overspecialization do not equate to success. Having a breadth of knowledge is key to solving issues that cross different disciplines. - An extensive explanation of the benefit of the breadth of knowledge and the risks of super sub-specialization. Loss of cross-communication between silos of isolated components. - Wicked problems- issues that require outside-the-box thinking, can't be solved by relying on specialization but needs interaction between various contexts. - Capitalize on the varied backgrounds when trying to solve a problem. Gathering 10 specialists who all share the same knowledge and experience to focus on one issue can easily lead to a dead-end- without the benefit of new and fresh ideas, the team ends up in a loop. Diversity can exponentially increase problem-solving by drawing from different perspectives, viewpoints, and thought processes. - Contrasts to the 10,000-hour rule, which asserts the benefits of focused training and specialization. Previous Next

5 Team of Teams New Rules of Engagement for a Complex World - From retired General Stanley McChrystal. Guidance on developing an adaptable, agile, and unified organization. - Changes in the nature of war necessarily lead to changes in leadership and team dynamics. - Given the dynamic nature of current combat, the prevalence of unknown unknowns, and the rapid pace of information dispersion, it is unreasonable for every leadership level to approve every maneuver. - Teams need to be competent and well-trained. But in this current environment, it would be prohibitively cumbersome to require the commander's involvement in every decision while remaining agile and quickly responding to constant changes. In contrast, developing a strong team and providing a common goal, an overarching mission, allows teams to execute, react, and adjust to shifting battlefields. The end state serves as a guide, and the group draws from their training to accomplish the mission. Previous Next

< Back Mentorship What is mentorship? Mentorship is a partnership between a more experienced and knowledgeable individual (mentor) and a less experienced individual (mentee) seeking to learn, develop skills, and advance their career in the healthcare profession. The mentor is typically someone who has achieved a level of success that the mentee aspires to reach. Through this relationship, the mentee, who could be a medical student, trainee (resident or fellow), or junior staff member, can benefit from the mentor's expertise and past experiences, gaining valuable insights into the healthcare profession. The mentor can serve as an advisor, consultant, or coach depending on the mentor's expertise and the mentee's needs. For example, a mentorship relationship can be designed to help the mentee improve clinical skills, navigate the job search process, or advance research endeavors. It's common to have different mentors for different purposes, as each mentor may have different strengths. Mentorship also provides networking opportunities, as the mentor can facilitate connections between the mentee and other professionals in the field. In summary, mentorship is a valuable tool for professional development in healthcare, offering guidance, support, and connections that can help mentees achieve their goals. Do I really need a mentor? Throughout medical school and residency, I didn't have any formal mentors, but I did actively seek the opinions, advice, and feedback of several surgeons I respected. As a young staff surgeon, I still didn't actively pursue mentorship, though I now recognize that it could have been highly beneficial. My first formal mentorship relationship was late in my training, when I was an Acute Care Surgery fellow and I was required to choose a staff member as a mentor. It's not uncommon for trainees to lack mentors, and one possible explanation resonates with me. "Many young people today who end up in residency…have been on a fast track. They’re essentially high-achieving, highly driven professional students who have been on a fairly regimented pathway…and they haven’t reached a point where there are multiple pathways they could take."(1) As someone who has been on a straight path since high school, progressing from high school to medical school to residency to being a junior faculty, I potentially missed out on a valuable asset. It's important to note that having a mentor is not a requirement, but developing a strong relationship with a mentor can positively influence one's success. It's highly recommended that individuals consider formal mentorship, but it's equally important to recognize that they have the ability to end relationships that are toxic or not a good fit. How do I find a mentor? Mentorship relationships can be an essential aspect of professional growth for medical trainees. These relationships can develop organically or be assigned by program directors in residency or fellowship programs. If you are assigned a mentor, it can be a great experience, but it is also possible that you may not mesh well if the assignment was not carefully considered. It's essential to recognize that if you find yourself in a mentor-mentee relationship that is not productive, amicable, or beneficial, it's okay to end the relationship and seek out another mentor. On the other hand, organic mentorship relationships can also be incredibly fruitful. As you work with various individuals in different settings, such as the operating room, during rounds, or while discussing consults, you will begin to form opinions and may find that you gravitate towards a particular person. If you respect and trust them and they demonstrate skills or expertise that you want to learn from, they might be a viable option as a mentor. The process of finding a mentor can be as simple as asking the person you would like to work with if they would be willing to mentor you. Remember, the worst they can do is say no, so it's worth taking the risk to ask. If they don't have the time to commit to being a mentor, they may be able to connect you with someone else who could be a good fit. It's important to recognize that mentorship relationships require effort from both the mentor and the mentee. While your mentor can offer guidance, support, and feedback, it's ultimately up to you to take ownership of your own professional development. Be clear about your goals, seek out feedback, and be receptive to constructive criticism. By putting in the work, you can make the most of your mentorship relationship and set yourself up for success in your career. Finding a mentor can be a great way to help you achieve your personal and professional goals, but it's important to have a plan in place to make the most of the relationship. Here are some steps you can take after finding a mentor to ensure that you get the most out of the relationship: 1. Set specific goals: Take some time to think about what you hope to gain from your mentorship. Are you looking to improve your skills in a particular area? Do you want help navigating a career transition? By setting specific goals, you can make sure that you and your mentor are on the same page and working towards the same objectives. 2. Establish communication: Once you've set your goals, it's important to establish how you will communicate with your mentor and how frequently you will meet. This can be done through formal meetings, phone calls, or casual chats over coffee. Make sure that both you and your mentor are comfortable with the frequency and type of communication. 3. Complete assignments or tasks: Your mentor may assign you tasks or provide you with guidance on specific projects. It's important to take these assignments seriously and complete them as directed. This could be anything from revising your CV to drafting a study protocol. By following through on these tasks, you can demonstrate your commitment to the mentorship and make progress towards your goals. 4. Reassess and refine: As you work with your mentor, it's important to regularly reassess your progress and refine your goals. This may involve checking off completed tasks, adding new objectives, or removing items that are no longer a priority. By keeping your goals current and relevant, you can make sure that you are making the most of the mentorship. Overall, finding a mentor can be an incredibly valuable experience. By taking the time to set goals, establish communication, complete assignments, and reassess your progress, you can make sure that you get the most out of the relationship and achieve your personal and professional objectives. 1. Darves B. Physician Mentorship: Why It’s Important, and How to Find and Sustain Relationships. NEJM Career Center. 2018 Feb. Previous Next

< Back Diverticulitis...pending A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable. A CT of the abdomen/ pelvis with oral and IV contrast was obtained. CT Scan of Diverticulitis There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics. Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home. What is the next step? Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis. The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis. Management of Diverticulitis Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2] Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy. Indications for Surgery Emergent surgery- acute episode with perforation or peritonitis. Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics). Elective colectomy - Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction. - Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc). For More Information on the Management of Diverticulitis ASCRS Patient Information: Diverticular Disease AVOD Trial. Chabok A et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539 . Diabolo Trial. Daniels L et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104:52–61. Previous Next

Resolving Patient Concerns Who's my doctor? < Back Resolving Patient Concerns During the course of a day, numerous people walk into a patient's room- nurses, case managers, physicians, APPs, trainees, respiratory therapists, physical therapists, just to name a few. It is easy to see how a patient can lose track of who's who. There are multiple providers on a typical inpatient service, including students, residents, APPs, and an attending physician. Although it's not impossible, it would be a rare occasion for a patient to not be seen by a physician or APP at least once a day (usually more). But multiple times, patients ask their nurse or directly ask their provider why they haven't seen a doctor yet. They may also ask why they hear different plans from different people, or why no one has told them a plan. At first glance, these comments might seem as an indicator that the team caring for the patient isn’t being attentive, isn’t knowledgeable about the patient's current condition or plan, or isn’t a united front. And it's understandable why this would be disconcerting to a patient. So why does it happen and how can you handle it? Some of these comments reveal a misperception (who is my doctor, why does no one come to see me, why is nothing happening), while other comments reveal true instances of confusion or breakdown in communication or that could be avoided (multiple consultants, waiting to talk to the attending, change in plan). Patients can be upset about any of a wide variety of things- untreated pain, prolonged NPO status (nil per os, meaning they can't eat), frustration about prolonged illness or another complication, or restricted activity (patients at risk for falling have to ask for assistance to get out of bed). Patients can also display anger when they are scared. For all of these issues, make sure the patient has the opportunity to verbalize their thoughts and concerns- their initial question may not actually be their real issue. Question #1 Why haven’t I seen my doctor today? When am I going to see the person in charge? A. Background. Patients expect their doctor to be involved in their care. They expect their doctor to examine them, ask them questions, and provide a diagnosis and a plan. They also expect to be able to ask questions and voice concerns to their doctor. B. Why/ how does it happen? Given the wide variety of people who pass through patient rooms, it can be difficult for a patient to identify who their physician is. If the patient feels that nothing is happening or they're still in pain or they haven't had their questions answered, it's natural to ask who the boss is. C. How to respond? Identify your role with the team- whether you're the chief resident, the attending, or even a student or young resident. If you aren't a senior team member, ensure the patient that you will bring their concerns to the attending- and make sure you follow through. If you're the attending or senior resident, your response should be tailored to the patient's demeanor. - If the patient is angry, give them time to express their feelings. - If it's a matter of confusion, it's helpful to take a moment to explain the team structure- the other team members who they see throughout the day are direct extensions of the attending on the service. - If there is a real medical issue that hasn't been resolved, none of the explanations about team structure matter. If you're the attending, convey this to the patient, and make it clear that you will work with them to solve the problem. Question #2 Why does no one know what's going on? Why are you telling me something different than what the other doctor said? A. Background. Patients expect their doctors and nurses to take the best possible care of them, which includes having one unified plan. It would be easy to understand why a patient would be distressed or anxious when they hear conflicting plans or recommendations. B. Why/ how does it happen? Plans are not set in stone in the dynamic field of surgery. - Patients with non-elective surgical issues are at risk of having changes in their plan. New fevers, changes in pain, new laboratory values, or radiographic findings can all lead to an urgent need for intervention, either surgery, a minimally invasive procedure, placing tubes, etc. This doesn't mean that the teammates who spoke to them earlier were wrong- it just means there has been a change. - Patients are often seen by residents, both from the primary team as well as consultant teams. Residents, especially more junior residents, don't have the same authority to tell the patient a definitive plan as the chief resident or attending. They might propose some possibilities, and then tell the patient they'll be back with their boss (common language to refer to their chief resident or attending). Sometimes patients hear one thing and don't understand that it's not the final plan. - In addition, when patients are first seen by the resident, there is often a time delay between the initial patient evaluation and discussion with the attending physician. It can appear that nothing is happening or that the team doesn't know what to do. C. How to respond? - Explaining the team structure and reassuring the patient that they will be updated as soon as possible can alleviate some of the anxiety/ frustration. Explaining a change in plan can be tricky. It's important not to undermine other team members. It's a learning process for trainees- you don't have to make excuses. As the attending, you can reassure that patient that the team members discuss their plans with you and you have the final say in their care. Question #3 Why was my surgery canceled? A. Background. When a patient needs surgery, the operating team makes a plan for their operative day. The patient is made NPO, meaning they can't eat or drink before surgery. They may have their family or friend scheduled to come to be with them on that day. So it's understandable for a patient to be frustrated or angry when they are told their surgery is canceled. B. Why/ how does it happen? Operative cases can get rescheduled or delayed with minimal notice. Even when cases are scheduled, there is always the possibility of another patient needing a more urgent operation. This applies to cases done by the trauma team, as well as cases with subspecialists. The orthopedics team is busier when trauma volume increases, so this puts further strain on OR availability. C. How to respond? The frustration is understandable, so it is helpful to explain why their surgery date has been pushed back (or hasn't been set yet). It's important to NOT "throw them under the bus"- in other words, don't speak ill of other teams. You don't have to go into a big explanation, but it's helpful for the patient to understand because this can alleviate some of their displeasure with the teams, including the consultant teams. It's not a matter of the teams not thinking the patient is important- it's simply triage. Also, try to get a plan as early in the day as possible, so the patient can be allowed to eat if their surgery is postponed. Question #4 Why is nothing happening? A. Background. Patients expect things to happen in a hospital to make them better. B. Why/ how does it happen? A lot of patient care happens away from the patient's bedside. Reviewing labs, imaging, discussing with consultants, performing procedures, phone conversations with nursing and case managers, just to name a few things that happen outside of the patient's room. However, this complaint can be a little more nuanced- sometimes the patient is trying to say they're frustrated by prolonged hospitalization, or they're scared about a complication, or they're worried they won't get back to their life as they had before their injury. C. How to respond? Again, if this is an issue of confusion, sometimes a brief explanation is enough. If there are specific consultant recommendations or a specific test result that is pending, attempting to contact the consultant team or expedite a radiology study in front of the patient is a small way to show the patient that things are happening behind the scenes. But if the patient is frustrated with being hospitalized or scared about surgery or a complication, those explanations won't address their concerns. Those issues require a more tailored response. Question #5 Why can’t I eat? A. Background. Sometimes patients in the hospital are feeling ill enough that they have no interest in eating. But if they still have an appetite, there are sometimes when it’s not safe to eat. B. Why/ how does it happen? Patients can't eat before surgery- specifically, it's dangerous to have food or thick liquids in their stomach when they have sedation medication or paralytics, because there is a risk of the stomach contents coming up into the throat and then going into the airway. So while a patient is awaiting procedural intervention (surgery, minimally invasive procedure that requires sedation), they can't eat. When we are awaiting the recommendations and plan of care from a consultant, we don't allow the patient to eat until we know they don't need a procedure. Besides procedures, patients may have to abstain from eating if they have a problem with their intestines, such as an obstruction or a fistula (abnormal connection from the bowel to the skin). C. How to respond? Apologize, basically. There's not much else to do. Previous Next

< Back A Day in the Life of an Acute Care Surgeon This is a general outline of the daily routine of an Acute Care Surgeon- it does not represent a universal experience, because every facility and every team is unique. Daily schedules vary between the different services. Some facilities have a small enough volume that all three aspects are covered by one surgeon. However, for busy facilities, there can be up to 5-6 surgeons covering the different services. There can be multiple ICU teams to manage, each requiring a surgeon. In-coming trauma might require the full attention of one surgeon, while another surgeon takes care of inpatients and scheduled cases. This is not a guide for how to set up a department- it's just a peek into what we do during the day. The day typically starts with morning report, where overnight events are discussed. This can include trauma and ICU admissions, as well as operative cases. Other significant events such as patients who required transfer to a higher level of care are also discussed. Following morning report, the different services diverge to meet with their teams, either in the OR, in the ICU, or on the inpatient wards. Trauma Service Rounds [the process of evaluating and examining patients currently in the hospital] - Residents typically see the patients first, review their blood work and their x-rays, examine them and ask them pertinent questions to report to their chief resident/ attending. The attending and the chief resident/ senior resident discuss the patients and visit patients in person. There are different practice patterns, and flexibility is required. If the same team is also covering new trauma consults from the emergency department (ED), rounds might be staggered or split based on staffing and patient volume. - Patient evaluation focuses on monitoring patients in the postoperative period, including assessment of bowel function (have you passed gas or had a bowel movement?), nutrition and oral intake (hungry, eating 1/2 of meals, nauseated), pulmonary function (performing breathing exercises), pain control, activity (working with physical therapy, walking laps, breathing exercises), examining wounds, and ruling out surgical complications. Care for patients recovering from trauma also entails communication with subspecialists, such as orthopedics or neurosurgery. Procedures - Emergent operations on new admissions- exploratory laparotomy for intra-abdominal injuries (bowel injury, severe bleeding), thoracotomy for intra-thoracic injuries (severe bleeding, wound to the heart), repair of vascular injuries (bleeding from a blood vessel). - Scheduled operations for patients on the trauma service. Consultations and New Admissions - The majority of patient consults for trauma originate in the ED. Rarely, a patient who is currently admitted to the hospital may be diagnosed with an occult injury (meaning it wasn't found on initial assessment) or a patient may sustain an injury while in the hospital. Surgical Critical Care Rounds - See “What happens during Surgical Critical Care (SICU) Rounds? for details. Procedures - Tracheostomy- creation of a connection directly through the neck to the trachea (airway) to allow removal of the endotracheal tube (breathing tube) from the mouth. - Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose. - Bronchoscopy- use of a small camera (think of a really skinny colonoscopy) to examine the airways of the lungs, take a specimen for culture or remove obstruction. - Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications. - Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status Consultations and New Admissions - Scheduled or semi-scheduled surgical cases such as complex vascular procedures (aortic surgery, carotid surgery), transplant surgery (patients receive a new liver or kidney), resection of head and neck cancer with a need for management of tracheostomy, and monitoring of muscle flap. - Emergent surgical cases such as a ruptured abdominal aortic aneurysm (thinning of the wall with eventual rupture with bleeding), bowel perforation (hole in the intestine), or any of a variety of surgical catastrophes. - Severely injured trauma patients, including patients who require close monitoring of hemodynamics (low blood pressure, high heart rate) or pulmonary status (ability to take deep breaths with severe trauma to the chest), or patients with head injuries requiring intubation. - Non-ICU patients in lower acuity units that require ICU admission for deterioration in clinical status (respiratory distress, altered mental status, hemodynamic instability). Emergency General Surgery Rounds - Similar to trauma patients as above. For patients who haven’t had surgery (uncomplicated diverticulitis or small bowel obstructions secondary to adhesive disease), close monitoring for changes in clinical status is vital. Procedures - Emergent operations on new admissions- laparotomy for bowel ischemia/ perforation (decreased blood flow to the bowel or a hole in the bowel). - Scheduled operations for patients on the emergency general surgery service, for example, reversal of an ostomy. Patients who undergo emergent surgery for trauma or bowel ischemia/ perforation sometimes require creation of an opening on the skin to allow stool to pass outside into a bag. These can be “reversed”, meaning the bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed. Consultations and New Admissions - Patient consults typically originate in the ED. Everything from abdominal pain to rectal pain to massive intestinal bleeding can prompt a phone call/ page/ text message to the Emergency General Surgery service. - Patients admitted for non-surgical diseases can develop a surgical emergency during their hospital admission. This includes diagnoses that typically prompt a visit to the ED (appendicitis, cholecystitis), but there are a host of other diagnoses that are more frequent in the hospital setting, such as C. difficle colitis. In addition to daily responsibilities, there are weekly or monthly department-wide events. - Staff Meetings - Trauma Morbidity and Mortality- discuss outcomes from trauma cases. - General Surgery Morbidity and Mortality- discuss outcomes from general surgery cases. - Grand Rounds- lectures from subject matter experts on various surgical topics. Previous Next