Surgery Books Student Recommendations: The shelf has focuses on medical management of surgical patients, and thus resembles the Medicine shelf (but you can still do well even if you haven’t done IM yet). There is very little, if anything, on surgical techniques. Make sure to read general notes, like Kaplan or a textbook to cover the management of patients on the floor. Most recommend: Review Source +Case Files +Questions What Students Said... Textbooks - Essentials of Surgery (Lawrence) Review Books Surgical Recall - Kaplan Surgery Notes/Vignettes Case Books - Case Files for Surgery Question Books - Pretest for Surgery - USMLE World Fill Your Pockets… - Maxwell’s - Surgical Recall - Mini Spiral Notebook Easy to follow and organized well, but lengthy. Use to review difficult topics. Read first chapter weekend before rotation. It describes the names of all the tools, what you should do in the OR, etc. Great to have in your pocket for the floors, but not sufficient for the shelf (see “Fill Your Pockets” section). A good reference/overview for the SHELF, but not sufficient alone. The vignettes (which reiterate the notes but in a Q and A form) are especially high yield. Great review of important topics, but should supplement other material (not enough details). Try to read twice with rapid read through second time 2 days before test. Felt like questions were similar to SHELF. Questions were useful, but there’s usually only about 200 Surgery questions. There were also more ortho questions than on the actual exam. Lab values, helpful equations, and templates for notes. Great to read before going into a case, as you will likely be pimped on some of the questions listed. Also, a good quick overview before lectures. Though it will help you on the floors, it is not sufficient for the shelf. Jot down pearls of wisdom and notes from the day. You can also write down assignments/tasks and stay organized. - Scissors, tape, gauze, etc. Pay attention to what your team may be looking for during rounds (ex. dressing changes materials, suture removal materials, etc.). It just helps make rounds more efficient for your team rather than always having to scramble to find materials. What to Do the Weekend Before/First Few Days Review GI chapter in an Internal Medicine book (such as Step Up to Medicine). Focus on the work-up and management , and review relevant anatomy. Make sure you know your ABCs (Airway, Breathing, Circulation), and try to quickly review a trauma chapter.. Read first chapter of Surgical Recall, which lists the instruments they will be using in the OR and what you should be doing. It is also helpful to review causes of post-operative fever, infections. Cardiovascular and Pulmonary chapters along w/EKGs and CXRs are also useful if you have time. What to Do on the Floors You will pre-round (depending on the hospital and the service, this could be anywhere from 4AM to 6AM), then you will do quick rounds with the rest of your team. Surgeons love efficiency and so how you write your notes and present your patients should reflect this (only the most important details; physical exam should always include at least heart, lungs, abdomen; always write down vitals and labs and make sure they are from the correct day). During rounds, pay attention to what may be needed to care for a patient and offer to go to the supply room and get the appropriate materials (ex. gauze, tape, etc.). Offer to look up patient labs/information if a question comes up during rounds. Listen to the management plans for each patient, even if you are not following them, because this is what you will be tested on for the SHELF. You may or may not have time to grab a quick breakfast before heading up to OR. You can begin taking patients into the OR at 7:30AM, and you need to make sure you have done all the appropriate notes before then (see Maxwell’s yellow section for template for pre-operative note; make sure consent is signed, that all of the relevant paperwork is present). If you try to write pre-op notes at 7:15 AM, you may not get the opportunity to talk to the patient (Anesthesia and RNs also talking to patients at this time). Try and do the pre-op note for your first case during pre-rounds. Also, always introduce yourself to the patient before going to the OR. You usually have about 20 minutes between cases if they are scheduled back to back. During this time, finish writing your notes on the patient you just operated on (operative and post-op notes), and do your pre-op note for your next patient. This is also a good time to eat. For the most part, people will not tell you to eat during surgery, and you have to remember to do so! If you don’t have lunchtime lectures, you may not get the opportunity to eat during the day. You should always keep food and money in your pockets, and eat between cases (could be a complicated case that lasts for 5 hours). Nobody will tell you when they are getting ready to take a patient from the pre-op room to the OR, so you have to watch the time, and make sure you are near the patient. Make sure you have reviewed the indications for the surgery and the relevant embryology, anatomy, pathophysiology, and management before you go into any case. If you have extra time, read about the steps of the procedure, which will help you predict the surgeon’s moves—this allows you to provide better visualization of the field. Ask thoughtful questions in the OR, especially questions about technique. Never ask questions during a critical part of the case, or if things are going poorly. Ask to be taught to suture, etc. Keep bandage scissors, needle drivers, and sutures with you for practice when you’re tired of reading.Surgery is all about style. Palm your needle driver. Suture like you’ve been doing it for years. Being vocal, confident, and hardworking is especially important in surgery. On a busy service, it can be easy to disappear, especially on call. Residents will notice, so make sure you are always available in the OR and the ER. Also, always be nice to the scrub nurses!! You can usually scrub into any interesting cases, but if you are going in during the middle of a case, put a mask on, go into the OR and ask the attending if it is okay, and then grab and open your gloves (scrub nurse will tell you where) before you scrub in. Rules in surgery: do NOT go into the OR hallways w/o covering your hair (usually red lines on the floor indicate where these start). Never go into an OR w/o a mask. You must always scrub in if you are going to be involved in the case (you will be shown how). Before you scrub in, always pull your gloves and gown for the scrub nurse (again , ask how). When you are scrubbed in, try not to contaminate yourself or anyone else. If you are planning on operating on a patient, accompany them from the pre-operative room to the OR (if you ask, they will let you put in Foleys, etc in the OR). After a case, always accompany the patient to the recovery room. Preparing for the Surgery OSCE & SHELF OSCE: Prepare the cases provided during orientation throughout the 2 months. This will help you become more comfortable with the responses rather than cramming the information last minute. The cases also help you prepare for the SHELF exam too so really any time you spend prepping the cases will help you for the exam. Also on this CD is a document called ‘Surgery Cases’ which is a review sheet compiled by students that summarizes the cases. Use this with caution and make sure you check the accuracy of responses! SHELF: The unique aspect of the surgery rotation is that you spend most of your day in the OR, yet the SHELF has few, if any questions about how to do a particular surgery. The exam is more like the Internal Medicine SHELF in that you need to know how to manage patients and know the appropriate initial measures to do so. This just means that you need to make sure you put aside time to read everyday, which can be difficult because you can be very busy both months. Even if you have not had IM before Surgery, you can still do well on the test if you manage your time appropriately. Given your time crunch, lectures are a great time to learn/consolidate information. Since there is a good chance you will be pimped during these lectures anyways, try and read for lectures and pay attention. This will go a long way, as will being prepared for your cases. The majority of the exam will focus on general surgery. There may be a few questions on subspecialties, but they are not the main focus of the test. Surgery Site-Specific Advice Site DRH/Harper Children’s Oakwood/VA HFHS Beaumont What Students Said… Learned a lot and got to do a lot as well. This hospital specializes in trauma care and call nights were always very exciting albeit hectic. The attending or chiefs usually ask you questions that are already listed in Surgical Recall – read it before scrubbing into a procedure. Keep up with your reading, which might be hard considering that your entire 2 months are pre-call, call, and post-call. Make sure you go to all lectures, especially the fluids & burns ones. Very busy schedule with little time to study. Try to study any moment you have while you are at DRH. Make sure you study as much as you can the month you are at Oakwood. Oakwood is somewhat laid back, so if you have it first, make sure you do not take it easy when you get the VA. You can’t be so laid back when you get to the VA, it may reflect poorly. VA also very busy service. Great site with great teaching. Residents and attending are friendly. Do not take shortcuts or get out of things. Most students will have a few weeks of trauma (blue or red team) and a few weeks of general surgery (specific teams you will be assigned to include transplant, bariatrics, vascular, colorectal). 2 students/rotation will be assigned to the Green/White team (hepatobiliary and parathyroid) instead. Everyone will end with about 1.5 weeks of a speciality service (ENT, plastics, anesthesia, ortho, urology), though you can request to do trauma or to be assigned to a general surgery team as well. Lectures are really great, but be prepared for lots of pimping. Busy service w/majority of the day spent in the OR (not much floor time except when on call) with a good deal of variety. You get a lot of O.R. time because you can St. John’s Providence scrub into any surgery you want (not just surgeries with your team). Great teaching from both residents and attendings, especially if you show interest. They have a surgical learning center with workshops to teach students tying and stitching etc. Your hours are from 5:30ish am to 5-6 pm. You are on call every 4 nights for the first 5 weeks, with 8 calls total. You will likely see a wide variety of trauma on call. Final 2 weeks of rotation consist of electives. Thoracic, plastics and ENT are great services with lots of teaching, but long hours. Peds surgery is great too. Moderately busy service w/a good amount of floor time. Residents very friendly, and free food. Hours some of the best. However, it may not be completely representative of a true Surgery residency, so for people who are interested in Surgery I would suggest doing a SubI or elective downtown to get the true experience as far as hours and call, etc. For everyone not interested in surgery, it was great. Hours were 6am – 5:30 pm (no earlier, no later). No weekends, unless on call. Call was once a week, overnight. It's kind of hectic at first b/c you're not on call with your team, so you have to contact the residents on call to give them your pager for any consults. Do NOT try and skip out of call; the residents will notice even though it seems like they don't. You respond to all of the traumas overnight. We rotated through 4 areas: 2 weeks service 1 (general surgery), 2 weeks service 2 (general surgery, but mostly laparoscopy), 2 weeks vascular, 2 weeks of subspecialties (where you just show up and go to whatever surgery sounds interesting on the board). We got meal cards (which were technically supposed to be used just for call, but worked all the time; although, I hear they're going to be more strict about it this year). There are 2 students per team. The services were pretty busy, but there usually was time to study in the afternoon between consults. St. John has some wonderful WSUSOM alumni that are excellent to work with in the OR. Dr. Mittal and Dr. McKendrick will be doing your evaluation, even if they have talked to you for less than 5 minutes for the duration of the 2 months. Become friends with whoever has access to the dissecting lab (it may be the ortho residents). Get in the dissecting lab so that you look good in the OR. Keep bandage scissors, needle drivers, and sutures with you for practice when you’re tired of reading. On Wednesday mornings the residents are in conference. This offers direct access to attending surgeons. Useful Formulas See Orange Section of Maxwell’s: -Anion gap: Na-(Cl+HCO3) -Fractional Na Excretion: (urine Na x serum Cr)/(serum Na x urine Cr) -Maintenance Fluids: 4mL for each kg 1-10 + 2 mL for each kg 11-30 + 1mL for each kg>30 -Corrected Na: Na +[ (glucose-100) x .016] -Aa Gradient: [713xFIO2)-(PaCO2/0.8)]-PaO2 -ABG Rule: change in 10mmHg PaCO2 = change of 0.08pH -Osmolality: 2 x Na +glucose/18 +BUN/2.8 -Body Water Deficit (liters): [0.6 x wt (kg) x (patient Na-normal Na)]/ (normal Na) -Creatinine Clearance (GRS estimation): [urine Cr x urine volume (mL)]/[serum Cr x time (min)] [(140-age) x wt (kg)(x0.85 for females)]/[72 x serum Cr (mg/dL)] -Corrected total calcium: [0.8x (normal albumin-patient albumin)] + Ca -Mean Arterial Pressure: diastolic BP + [(systolic BP-diastolic bp)/3] Useful Note Templates 1) Maxwell’s: Admit/Transfer, Pre-op, Operative, Post-Op and Discharge notes. 2) Medfools.com (under download section) has templates you can use as well (especially to manage multiple patients).
