Surgery

Acute Care Surgery Service

SITE

Columbia

DURATION

4 weeks

MEETING PLACE

• You will take signout every morning in the surgery lounge (7HN-114) at 6 AM. The code for the door is 314. After sign out, you will usually have an hour or so to go over data. Review each patient’s vitals, ins and outs, medications, plans, etc. Morning Report will be a daily clinical teaching conference held in Dr. Arnell’s office (7GS-313), usually between 7:30 and 8 AM, depending on which attending is on that day, followed by rounds. The post-call PGY-V will oversee the post-call PGY-II’s presentation of all new patients/consults and their pertinent radiographic and diagnostic findings, as well as the status of old consults and ICU patients. You are not expected to see the patients prior to rounding with the entire team, but you do need to have their vitals/I&Os/data.
• Incoming interns should contact off-going interns on the weekend prior to switching to familiarize themselves with the service and current patients.
• A Surgery Intern Survival Guide is available in the Surgery Housestaff Office (7GS across from the nursing station). The guide contains useful information, which will help optimize your experience and performance on the Service.
• A Surgery Important Numbers card is also available in the Surgery Housestaff Office. All of the important consult and resident pager numbers are listed.

CALL SCHEDULE

• EM interns cover the rainbow pager two weekends out of every month. During these rainbow weekends, the EM intern may take additional sign outs from services other than ACS list at 6 AM and round on those services. Consult the schedule to know what particular services you are responsible for.
• After rounds, the EM intern will take sign out on the HPB, laparoscopic, plastics, and breast services and cover all 6 pagers until 6am the following morning. You are expected to round on the ACS that morning before signing out ACS to the new rainbow intern.

ED SICK CALL RESPONSIBILITY

None

DAILY SCHEDULE

After signout and prior to morning report, handoff sheets should be printed, vitals should be collected and patient plans reviewed. It is not necessary to pre-round on patients. After morning report, formal rounds will be conducted. The medical students will write the progress notes on their patients, other patients are the intern’s responsibility. You should proofread and edit the med student notes as necessary. The rest of the day will be occupied with patient care and disposition and going to the operating room with the team as necessary or as desired. The day will end at 6 PM with signout to the overnight intern/resident. Signout is at 6 PM during the week..

EM WEDNESDAY

CONFERENCE

Expected when conference is on the Columbia Campus. You will go after rounds are done, typically at 10 am.

SURGERY CONFERENCE

Rotators are welcome at all conferences, but these are not mandatory for the EM resident. Weekday lunchtime conferences are optional as well but provide lunch for the residents. Asterisked conferences are mandatory as long as they do not conflict with ED conference.

EM ROTATOR PAGER

Personal EM Pager

CONTACTS

Surgery Chief Residents:

John Trahanas, MD jmt2171@cumc.columbia.edu

Surgery Consult p88882

Please contact the Surgery Chief Residents or visit the NYP EM Teamsite a copy of the Surgery Intern Survival Guide.

Description of Rotation: The Acute Care Surgery Service treats trauma and non-vascular pathology suspected to require an emergent/urgent operation or emergent/urgent surgical expertise. Conditions include trauma, SBO, acute abdomen of unclear etiology, appendicitis, cholecystitis, pressure ulcer, abscess, and incarcerated hernias. In addition, elective general surgery cases, feeding tube access and tracheostomies are performed. This is a great rotation for the ED rotator because it will involve the medical and operative management of urgent/emergent general surgery cases that you evaluate in the ED, therefore providing a greater perspective on how these patients progress through their care. In addition, the ED rotator will likely be the only intern, so there will be greater cooperation with the surgery residents. The intern will learn important topics in General Surgery through direct patient care as well as didactic sessions. The intern will be expected to participate in all surgical procedures occurring during their shift, as long as there is no conflict with floor patient care. Interns are responsible for completing all discharge summaries within 24 hours of each patient’s discharge. You will need to check with medical record a few times after you leave the service to ensure that all your summaries have been completed.

Team: Two PGY-V/PGY-II teams alternate 24 hour shifts, addressing all new consults, while also caring for the Service’s floor and old consult patients. The PGY-I is an ED rotator, responsible for taking care of floor patient, in coordination with the surgical PAs. The surgical PAs have a very structured system, so the EM rotator should work and communicate closely with them to ensure the service runs smoothly.

Educational Objectives:

- Develop the ability to evaluate, stabilize and treat the surgical patient based on sound judgment, available evidence, and patient preference (PC, MK, PBL)

- Begin to recognize potential serious surgical problems and to begin to participate as a member of the resuscitation team (MK, PC, ICS)

- Demonstrate a basic understanding of the pre-operative evaluation of patients admitted to the surgical service and to assist in the operative and peri-operative care of those patients (PC, MK)

- Demonstrate the rational use of laboratory, radiographic, and other diagnostic tests in the care of the surgical patient based on available evidence and cost effectiveness (PC, MK, PBL, SBP)

- Become familiar with the physiology of the critically ill surgical patient and to develop an understanding of the role of invasive hemodynamic monitoring (PC, MK)

- Acquire proficiency in the technical/procedural skills needed for the emergency management of the acutely ill or injured child (PC).

- Become familiar with the indications, contraindications, and dosage for the commonly used medications on the surgical service (PC, MK)

- Demonstrate an understanding of catastrophic surgical problems and how to rapidly recognize and begin treatment specifically as it relates to the Emergency Department (PC, MK)

- Demonstrate an understanding of the appropriate use of consultants in the care of the surgical patient (PC, ICS, SBP)

- Demonstrate an understanding of the ethical and legal principles applicable to the care of the surgical patient (PC, ICS, SBP)

- Demonstrate effective use of informational resources, scientific studies and technology to enhance patient care and pursue self improvement and self education (PBL, SBP)

- Demonstrate good interpersonal skills among patients, families and professional colleagues (PC, ICS, P)

- Always demonstrate respect, compassion, integrity and honesty (P)

- Always advocate for quality patient care (P)

KEY: PC – Patient Care; MK – Medical Knowledge; PBL – Practice-Based Learning; ICS – Interpersonal & Communication Skills; P – Professionalism; SBP – System-Based Practice. Please refer to Section VI of this manual for a full description of ACGME’s Core and General Competencies.

Evaluation:

The resident will receive a core competency-based evaluation by the supervising attending following his/her 4-week rotation on the Surgical Service. The review will be forwarded to the resident and will become part of the formal semi-annual resident evaluation process. Immediate problems or areas of concern will be discussed as necessary on a case by case by case basis. The resident will evaluate the rotation via the web-based system. This evaluation will become part of the annual review of the program, which will be reviewed by the Program Director.

Survival Tips:

• On the night before Day #1, contact the person who was on before you and get a general sign out of who the patients are and what to expect.
• On day #1, take the elevator to the 7^th floor and head to 7 Hudson North, Rm 114 where you will get signout from the overnight intern. (Door code 314). This is usually where signout is and where you can leave your stuff.
• Page 85936 at 6:00AM for signout if you can’t find the night intern. You can signout anytime up until 7:00AM but signout MUST be done by 7:00AM. Signout the pager (dial 0, give them your pager number).
• Rounds
  • Rounds are in the surgery office. If Dr. Arnell is on (and she usually is on Mondays) they start anywhere from 7:45-8:00 AM. Get there EARLY. Usually scans are reviewed and any new consults are presented. You are responsible for any consults that are admitted to ACS floors. Note SICU patients will get transferred to ACS floors so it pays to be aware of who is in the ICU.
  • Your job is to lead rounds—the first day usually the PA’s will help you. If anyone is on the 7^th floor this is where they start, with the HIGHEST room number first working their way back. You must present every patient that is not covered by the medical student on rounds.
  • Always give POD # XX followed by the surgery, active issues, and overnight events. Vitals do not need to be read in detail unless abnormal. Always give pertinent I’s & O’s, especially if the patient has drains. Usually the 7pm-7am overnight number is helpful with the 24 hour overall total as well.
  • Dr. Arnell likes to hear a solid plan. “Patient is a XX year old XX, POD # XX s/p lap chole now with ileus. Our plan is” – even if you are not sure, just state your plan.
  • During rounds the PA’s will usually carry an IPAD and put in orders as you round. However it is your job to follow-up all orders and make sure they are correct. Certain orders that are more time consuming (such as CT-scans, diet changes, and those requiring ID approval will be done after)
• New Admissions: The surgery PGY2s do all of the ED admissions and consults. However, we are responsible for any admissions if they are transfers from outside hospitals or admissions from clinic. This involves a full admission note and medication reconciliation. There are no caps like there are on medicine services and you can get an admission at any time until you sign out to the night intern, including on your rainbow call days.
• Rainbow Call Days: On weekend rainbow call days, you need to do a progress note for all the ACS patients as well as any additional service you are scheduled to cover. Consult the schedule to know what you are responsible for.. Sometimes the attending may do progress notes (Arnell) in which case you do not need to.
• OR Cases: For OR cases that finish during the day, remember to complete a post-op check (POC) and write a note 4 hours after the case has finished. The POC note is basically just a progress note.
• Running the List: Always know which OR your team is in. You MUST run the list with your senior before you sign out. You can look at the OR schedule to see which room Dr. Arnell or Dr. Simone is on and you can call down to see if they would be okay to run the list with you. This can occur between 4:00pm-6:00pm. Make sure you personally round on the service in the afternoon so you can give the senior updates.
• Labs: After AM labdraw, you MUST draw the labs yourself if you want them done quickly. If it is not emergent, they will eventually get to it.
• Weekend Signout: The interns change for the weekend so make sure you have a good signout prepared for the new night intern. They will be covering your service for the first time. I suggest making a word document with important information regarding your patients and what to do for them. Make sure all discharges are put in as a “Hold” discharge order. Make sure all prescriptions are in the chart and ready if a patient is expected to be sent home over the weekend.
• Discharges: How to write a D/C summary
  • You may shower. Do not bathe, swim, or immerse yourself in water for 3 weeks. No heavy lifting >30lbs for 3 weeks. The bandages may come off 2 days after surgery. Leave the steri strips intact. Please contact your physician immediately or come to the ER should you experience redness or pus from the wounds, severe abdominal pain, fever >101, inability to tolerate oral intake or any other concerns.
  • You may follow-up with ACS clinic in XX weeks. Please call 212-342-1734 for an appointment.
  • Uncomplicated appy, chole, perforated appy: 4 weeks
  • Open wound: 1-2 weeks
  • SBO: do not follow-up
• Social work: when you are sending someone home with wound care services (if they have an open wound or a vac) there is a “pink form” that needs to be filled out. Each floor has their own social worker and you can find them on the floor. Make sure these are filled out prior to discharge so the patient will be set up with home nursing services when they leave. Start ALL social work requiring discharges early (nursing home, LTAC’s, etc).

Readings:

Principles of Surgery, Schwartz 7th Edition, McGraw Hill.

Emergency Medicine Concepts and Clinical Practice, Rosen 5th Edition, Mosby.

Emergency Medicine: A Comprehensive Study Guide, Tintinalli 5th Edition, McGraw Hill.