Helpful Tips For Your Surgery Clerkship

Following Patients:

Patient: Know your patients. This includes reading about and

understanding their medical conditions and surgeries. Furthermore, the
medical student should know the active problems with their patients
(infections, post-op complications, etc). along with pertinent labs,
radiology, and procedures being done (and why). Know diets, antibiotics,
cultures and IV fluids.
Patient Load: On the first day of the service the student should pick up
2-3 patients to follow and present on rounds. After this, the student should
follow and present the patients he/she has seen in surgery
AM Rounding: You are responsible for presenting the patients you are
following during rounds. The medical student should plan on arriving with
ample time to see the patients, write down vitals and I/Os, and do a
physical exam. The Surgery Progress Note should be filled out and used
as the general format for presenting. Try to review new labs knowing
trends is important.

General Floor Duties:

Assist the Intern: When you are not in surgery or clinic ask if he/she needs
any help with floor duties. Any help you offer can aid in the more efficient
management of the patients.

Ancillary Duties: Ask the intern about helping with dressing changes,
staple removal, NG tube placement, JP drain removal, etc.

Helpful Hints For Morning Rounds

What to ask and record when interviewing patients on the floor:
Is the patient having bowel movements/stoma output and how
much?
Is the patient passing gas?
What diet is the patient on? And of that diet, what has the patient
actually eaten/drank that day?
o After GI surgery most patients are NPO or on clears. The
diet is advanced based on the patients bowel function and

how they are tolerating the current diet. The patients

currently ordered diet can be found in Powerchart
Is the patient having any nausea/vomiting?
Is the patients pain adequately controlled and what type of pain
management are they on?
Has the patient been getting out of their hospital bed and
ambulating the halls?
Is the patient using their incentive spirometer?
Is the patients Urine output adequate? (>.5ml/kg/hr)
Does the patient have a Nasogastric Tube and how much output is
it producing?
What are the JP drains output? Always check the type of fluid in
these bulbs.
o Most patients have serous or serosanguinous drainage from
their drains
o Bilious drainage would suggest a leak somewhere, so in a
patient with a small bowel resection this would suggest a
leak from their anastomosis.
o Other types of drainage suggesting a potential problem
include stool, frank blood, etc.
Any other medical issues overnight? (Fevers, Hyper/Hypotension,
Tacchycardia, Hyperglycemia, worsening condition, etc)
A very important aspect of the way the chiefs/attendings often think
is related to what is keeping the patient in the hospital. Another
way to think about this is to ask yourself if the patient has improved
enough clinically that their risk is low of going home and having a
serious complication.
o To go home patients need to:
Hydrate themselves orally- they need to be drinking
well and often should be tolerating some regular food
(but drinking fluids is most important)
Have their pain controlled well with oral pills- therefore
know if they are still dependent on the PCA or IV
injections
Be mobile- Are they walking?
Be clinically stable normal vitals, off O2 (unless on
home O2), no fevers

What to observe and elicit during the physical exam:

The most important part of the physical exam after GI surgery
includes the abdominal exam and examination of the incision and
ostomy site (if present). The other parts of the exam are important
and should be taken into the context of the patients history and

current condition, including the Cardiac, Pulmonary, and Extremity

exams. Checking whether the patient is alert and oriented X3 is
important as some patients may have decreased mental status and
possible delirium following a major surgery along with being on
several medications including pain management.
o Abdominal exam The key is to look, listen, and feel. You should be
focusing on whether the persons abdomen is
soft/tense, tender/nontender, and/or distended. Most
of these patients will be tender following surgery so
determining whether a patient is appropriately tender
is important. Because surgery on the bowel causes
inflammation and thus ileus, many of these patients
will not have bowel sounds for the first couple of days
following surgery.
o Ostomy/Incision Exam Examine the bandages first- Look for whether they
are dry, intact, and whether there is any drainage or
not.
Examine the incision sites- Look for drainage from the
incisions along with erythema and pus. Increased
drainage in the days/weeks following surgery may
suggest wound dehiscence. Increased erythema and
tenderness may suggest wound infection.
Examine the ostomy site- You can tell whether the
person is passing gas based on whether the bag is
inflated or not. Furthermore, you can assess whether
the person is producing stool. Lastly, check for the
same physical findings you did with the incision site.

OR
Case BE ON TIME!

Patient- Obviously, know the patient. Grab the OR schedule the night
before and go see the patient that evening. If it is an outpatient case
meet the patient in preop. Know why you are doing the operation.
Disease Process- This is simple; use Lawrence, UpToDate, etc. to better
understand the disease.
Anatomy- Review pertinent anatomy
Surgery- Understand what comprises the surgery being performed; i.e.
whats done in an APR
Introduce yourself to OR staff. Always get your own gloves and gown.

General helpful hints

The more you show yourself to be interested, the more people will involve
you. By asking questions and asking for opportunities to participate, you
show that you are interested in learning. People respond positively to this
and whether intentionally or not, they will end up involving you more.
Ultimately, you are responsible for your learning. You are not given a
detailed syllabus. This does not mean you dont need to read and study.
It simply means you will need to do directed reading. Think about what
you do and dont know well and read to fill in the gaps.
Even if you have no interest in surgery as a career, there is a lot to learn
on your surgery clerkship. Every type of physician will interact with
surgeons in some way. If you have no interest in surgery, figure out what
you need to know about surgery for your career and use this to motivate
and drive your learning during your surgery clerkship. For example, ask
yourself what you need to learn in order to know when to call a surgical
consult. Or, ask yourself what you need to know about pre-operative
clearance of patients for surgery or management of post-operative
surgical complications.
Surgeons work closely with many types of physicians. Your surgery
clerkship may be your only exposure to many of the smaller subspecialty
fields. If you are interested in Pathology or Radiation Oncology or
Interventional Radiology or Anesthesia, look for opportunities where you
can gain exposure to these fields. For example, if your patient is going for
a procedure in Interventional Radiology (VIR), ask if it would be okay if
you go watch the procedure. Or, ask if it would be okay for you to follow
the specimen to Pathology if one is sent for an intraoperative evaluation.
Or, show up early to the case and ask the anesthesia resident or nurse
anesthetist if you can shadow them as they prepare the patient for
surgery. There may be times when the answer is No, you are needed
elsewhere. But, more often than not, the answer will be Sure go ahead.
Ask for feedback on your performance at least once during your rotation.
This is another great way to show you are interested in learning. Dont
accept dont worry about it, youre doing fine as an answer. There are

things that even the best clinicians can do to take their learning to the next
level. Be prepared, though, when you ask for feedback, you may get
some negative feedback. This is not intended to hurt you or put you
down. This is intended to be constructive and to help you find ways to
improve as a clinician and as a team member.
Respect the non-physician staff. The truly successful medical student will
quickly learn that everyone involved in patient care can be a valuable
resource for learning. Often other staff will have more time for teaching
than the physicians. In general, you will find that if you ask, almost
anyone will be happy to teach you.