Urgent Surgical Care Service
Goals and Objectives for Senior Residents
1.0 Medical Expert/Clinical Decision-Maker
General Requirements
The senior general surgery resident should have the diagnostic and therapeutic skills for ethical
and effective management of patients with emergency and urgent general surgical diseases and be
able to access and apply relevant information to the care of these patients.
Specific Requirements
Whenever possible, all decisions should be made adhering to the principles of evidenced-based
medicine.
1.1 Peri-operative management of the emergency surgical patient
1.1.1
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Shock
Recognize varying degrees of compensated and uncompensated shock
Choose appropriate resuscitation fluids based on current best evidence
Asses adequacy of resuscitation using valid end-points
Understand the pathophysiology and management of ischemia and reperfusion injury
Appropriately use inotropic, chronotropic and vasoactive medications
1.1.2
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Sepsis
Recognize sepsis, severe sepsis and septic shock
Choose appropriate resuscitation fluids based on current best evidence
Asses adequacy of resuscitation using valid end-points
Recognize the urgency of starting antibiotic therapy and use empiric antibiotics appropriately
Understand the use of new therapies such as recombinant activated protein C and steroids
1.1.3
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Critical Care
Identify patients with multi-organ failure, acute respiratory distress syndrome and other conditions
requiring admission to the intensive care unit (ICU) and make appropriate referrals to the ICU
Recognize priorities in the ongoing postoperative management of acute surgical patients in the
ICU
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1.1.4
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Blood transfusion medicine
Recognize the need for blood and blood products and transfuse them appropriately
Understand the use of new therapies such as activated factor VII
1.1.5
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Diagnostic testing
Use laboratory investigations appropriately
Interpret arterial blood gases
Obtain appropriate microbiology cultures and interpret results
Understand the indications for, limitations of, and be able to perform basic interpretation of
diagnostic imaging including: plain x-rays, CT scans, upper and lower GI contrast studies, HIDA
scans, MRCP and MRI.
Identify indications for complementary use of interventional radiology procedures in the
management of acute surgical conditions and their complications
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1.1.6
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Fluids, electrolytes and surgical nutrition
Understand and correct fluid and electrolyte imbalances
Understand the pathophysiology of acute renal failure
Understand the nutritional needs of surgical patients based on their degree of physiologic stress
and influence of medical co-morbidities
Understand rationale, indications and delivery of enteral and total parenteral nutrition
1.1.7
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Co-morbidities
Recognize the impact of patients’ co-morbidities on their clinical course
Perform pre-operative risk assessment and optimize overall medical condition when possible
1.1.8
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Post-operative complications
Understand the appropriate use of prophylactic antibiotics to prevent surgical site infections (SSI)
Recognize and treat SSI
Understand the indications for DVT and stress ulcer prophylaxis and appropriately prescribe DVT
and stress ulcer prophylaxis
Develop an approach to and be able to manage post-operative fever, low urine out-put, ileus, chest
pain and respiratory decompensation
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1.1.9
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Specific disease entities
The senior resident should understand the anatomy, physiology and pathophysiology relevant to
the following diseases. The resident should also be able to effectively take a history, perform a
physical exam, order diagnostic tests, interpret basic diagnostic test and develop management
strategies (including operative and non-operative strategies) for the following emergency and
urgent general surgical diseases:
Acute appendicitis
Acute cholecystitis
Acute cholangitis
Obstructive jaundice
Acute pancreatitis
Acute diverticulitits
Perforated viscus (gastric, duodenal, small intestine, colonic or rectal)
Upper gastrointestinal bleed
Lower gastrointestinal bleed
Mesenteric ischemia
Ischemic colitis
Small bowel obstruction
Large bowel obstruction
Incarerated hernia
Perirectal and anal abscess, perianal fistulas
Soft tissue infections
Surgical site infections
Abdominal wall fistulas
1.2: Operative management principles and technical skills
The senior general surgery resident should demonstrate careful handling of tissues, in-depth
knowledge of appropriate use of surgical instruments and staplers including laparoscopic instruments, and
advanced suturing and knot tying skills. The senior general surgery resident should assume a leadership
role in the operating room and should oversee patient preparation and operating room set up for open and
laparoscopic procedures. The senior general surgery resident should display good surgical assist skills.
When acting as primary operator, the senior general surgery resident should demonstrate the ability to
direct his or her surgical assistants, display safe operating techniques, anticipate and mitigate technical
difficulties, and demonstrate sound judgment in intra-operative decision-making.
1.2.1: Resuscitation
 Placement of central venous catheters: seldinger and cut-down techniques, use of ultrasoud
 Placement of arterial catheters
1.2.2: Airway
 Tracheostomy
1.2.3: Chest
 Diagnostic thoracentesis
 Exposure and definitive management of non- esophageal injuries and perforations
1.2.4: Biliary tract
 Laparoscopic and open cholecystectomy
 Open common bile duct exploration
 Laparoscopic and open intra-operative cholangiogram
 Exposure and management of complicated pancreatitis
1.2.5: Upper gastrointestinal tract
 Gastrostomy (PEG/laparoscopic/open)
 Jejunostomy
 Exposure and management of gastric and duodenal perforation, bleeding and obstruction
1.2.6: Lower gastrointestinal tract
 Laparoscopic and open appendectomy
 Exposure and management of small intestine, colonic and rectal perforation, bleeding and
obstruction
 Management of perirectal and perianal infections (abscess, fistulas)
 Management of acute mesenteric ischemia
1.2.7: Abdominal compartment and wall
 Management of abdominal compartment syndrome
 Incarcerated hernia
 Management of the open abdomen and definitive closure of the difficult abdomen
 Management of abdominal wall fistulas
1.2.1: Other
 Manage surgical site infections
 Manage soft-tissue infections
2.0 Communicator
General Requirements
The senior general surgery resident should be able to communicate clearly, systematically and
thoroughly with members of a multidisciplinary team, patients and patients’ families. Effective
communication is paramount in this new acute care paradigm as it takes well-integrated teams of
many providers to care for complex patients who often have multisystem diseases around the
clock.
Specific Requirements
The senior general surgery resident should demonstrate effective communication with patients,
families, and all members of the health care team in the following ways:
2.1: House Staff
 Effective handover to house staff during morning and evening rounds
 Updates house staff about new or acute issues as they arise throughout the day and maintains
accurate patient lists
 Gives clear instructions to house staff regarding duties that need to be performed on the wards, in
the emergency department and in the operating room
2.2: Staff Surgeons
 Notifies staff surgeons of new or acute issues in a timely fashion
 Keeps staff surgeons informed and up-to-date regarding active patient issues
2.3: Multidisciplinary Team
 Clearly communicates patients’ care plans with all necessary team members at appropriate times
 Listens respectfully and thoughtfully to input from all team members at appropriate times
2.4: Patients and Patients’ families
 Establishes good rapport with patients and their families even in acute situations
 Delivers difficult news to patients and their families in a respectful manner
 Helps patients and their families understand patients’ overall care plans, why care providers may
change during their hospital stay and the roles that different health care professionals play
2.5: Documentation
 Completes clear written documentation on charts in a regular and timely fashion and clearly
indicates in the orders and progress notes who the most responsible physician is
 Completes clear, concise and timely dictations
 Maintains accurate patient lists
3.0 Collaborator
The senior general surgery resident must be able to optimize working relationships with other
physicians and health care professionals in all settings to adequately care for complex patients in
this new acute care paradigm. The general surgery resident must demonstrate good working
relationships with dieticians, social workers, occupational therapists (OT), physiotherapists (PT),
rehabilitation therapist (RAT), nursing staff, ICU staff, and other consulting services.
4.0 Manager
The senior general surgery resident should demonstrate the following:
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Develops effective personal organizational habits and time management skills
Uses health care resources appropriately in a cost-effective manner
Learns how health resource issues are addressed in the hospital/community/region
Takes responsibility and delegates responsibility appropriately
Supervises more junior residents and medical students
Monitors and review all complications and deaths occurring on the service and presents summary
data at mortality and morbidity rounds
Participates with attending surgeons in evaluating other residents and students
Appropriately incorporates input from all members of the health care team (dieticians, social
workers, OT, PT, RAT, nursing staff, ICU staff, and other consulting services) into patients’ care
plans and the overall organization and running of the service
5.0 Health Advocate
The senior general surgery resident should demonstrate the following:
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Recognizes determinants of health as they apply to individual patients and populations
Understands the role of the general surgeon to intervene on behalf of patients with respect to
biological, social and economic factors that may impact on surgical disease, disease prevention
and outcome
6.0 Scholar
The senior general surgery resident should demonstrate the following:
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Development of effective habits for personal learning
Teaches students, residents and other health professionals during working activities
Coordinates informal teaching activities so that core topics are completed in 1 month cycles
Actively participates in formal rounds
Demonstrates an interest in issues in acute care surgery research issues
7.0 Professional
The senior general surgery resident should demonstrate the following:
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Incorporates high ethical and moral standards into daily working and learning activities
Is punctual and prepared for clinical and academic activities
Reliably follows up, especially in rapidly changing clinical situations
Recognizes his or her own limitations and seeks advice or assistance when necessary
Accepts advice and respond appropriately