Professional Documents
Culture Documents
Always remember...
Dont worry, youre not alone!
You are just an intern. Hierarchy exists for a reason. Call your senior!
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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
Imaging
CXR
Any patient > 60 Anyone with a smoking history Any pulmonary pathology If any question, order it
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
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?
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
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)
Elmhurst consent
VA consent
Pre-op Orders
NPO after midnight
- includes tube feeds - make sure the patient and the nurse know
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
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?
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
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
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
EKG
Compare to old EKGs available in EDR
EKG
Compare to old EKGs available in EDR
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
CT angio
Patient will need an 18-gauge or larger IV (central line too long for rapid flow)
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
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
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
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)
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
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
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
If patient w/ CHF can give 500cc over 1 hour and assess lung exam
Maintenance Solutions:
hypotonic solutions used to replace normal fluid losses in an NPO patient
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
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
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
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.
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
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".