Routine Preop Knee Orders: Fill & Download for Free

Q. What is the daily itinerary of a surgical resident?A2A. I cannot answer as I have never been a surgical resident. Interesting reads from a surgical resident in a large community hospital program affiliated with the University of Massachusetts Medical School (Baystate Medical Center), a chief resident in a major academic center (Baylor COM) and a neurosurgery intern (most impressive of all.) They do more by 9 am than most people do all day.Day in the Life of a Surgery Resident4:45 amMy alarm goes off and I hop out of bed. I have 30 minutes to get ready and get my things together. I grab my iPad and the journal articles I am reading for the upcoming cases I have later this week.5:30 amI drop my bag off in my locker and put on my white coat. I find a computer, log my pager in, and take a quick glance at our list and patients in our EHR system. Looks like we have 3 new patients. I will hear more about them from the PGY-1 when we run the list. I should check the OR schedule as well to see if there are any changes such as added or cancelled cases, especially for the case to which I am assigned. Looks like there is a laparoscopic cholecystectomy added to the schedule. Ready to head upstairs to meet the team!5:45 amI meet up with the team and the PGY-1, who gives us a list with details such as diet, antibiotics, and special medications. She leads off the morning review of our patients with the overnight events on our patients and tells us about new patients. The Chief of the service gives the team a summary of the changes to the OR case assignments and who will be going to office today. Looks like I am going get to do the laparoscopic cholecystectomy in addition to my other case, which is a melanoma excision with sentinel lymph node biopsy.We see our patients, take down dressings, examine wounds, and review the daily plans with each one. We have a team of residents on the Surgical Oncology service and a PA, so we try to get some of our electronic progress notes started on rounds. Rounds are done in about an hour and we have time to sit down together for breakfast and to “run the list.” This is where we recap the plan on each patient.7:00 amIt’s Thursday, so we have our weekly M&M conference at 7 AM. We know the topic ahead of time so we all have studied up. Following this is our 8 AM Surgical Grand Rounds. These are always interesting since we get a lot of visiting speakers. At 9 AM we have surgical education time where we have ABSITE question review this week. Last week we had journal club.(Our daily conference schedule)10:00 amWe quickly reconvene as a team and check in on any events on our patients while we were in conference. The PA and junior residents divide up the remaining progress notes and floor work. The Chief and I make our way down to the OR to meet our patients in the preop area. The two medical students on our service will be participating in our cases. I am doing the laparoscopic cholecystectomy first. I discuss a few key points to the operation with the medical student and then we head back to the OR.(Message from our Chief Resident)10:20 amIn the OR, I hand off my gloves to the scrub tech, put my name on the whiteboard, and log into the EHR system. I pull up the imaging from our patient and review her labs. The attending comes in and we discuss the patients she has in-house. I fill the team in on the updated plans before the case starts.The attending, medical student, and I discuss the case we are about to do, review the imaging together, and talk through the steps of the operation. In this patient, we are going to be doing an intraoperative cholangiogram. All three of us go scrub and get gowned and gloved for the operation. The patient was prepped by the circulating nurse, so we drape the abdomen, set up our laparoscopic equipment, and prepare for the time-out. We all introduce ourselves and start the operation. We discuss whether to place our umbilical port supraumbilical or infraumbilical. Supraumbilical it is. We start the case and we are done about an hour and half later.12:30 pmDone with the cholecystectomy and orders are in. I page the team to check-in and get updates. My melanoma excision is going in about 45 minutes. I am going to meet her in Preop and get some lunch quickly. I should have time to go check on the patient who got a CT-guided drainage of a fluid collection earlier this morning. The medical student and I take some time to discuss the case we just did while walking up to the cafeteria and over lunch. Maybe we can head down the skills labs together later this week to work on suturing!5:00 pmCases are done for the day and we have all been getting piecemeal updates on patients over the day. It is now time for us to sit down together and review all the events and plans for overnight with the Chief. We prepare a list with details for the resident who will be covering our service overnight.6:00 pmTime to head out. The PGY-1 signs out our service to the overnight resident and we plan to start rounds at 5:45 again tomorrow morning. I give my husband a call on my way out of the hospital to see what he would like to have for dinner.7:30 pmAfter dinner, I watch some TV to unwind. Then I get in 30 to 45 minutes of reading and ABSITE prep questions.9:30 pmLights out. It is really important that I get my sleep. Before I know it, my alarm will be going off again for another day!Day in the Life of a Chief ResidentCaleb Campbell, M.D.Ben Taub Hospital:The day begins before dawn at 4:48 a.m. My alarm goes off, and I begrudgingly roll out of bed. It is important as a chief resident to set an example, and arriving at the hospital before the other members of your team is never a bad idea. Upon arrival, I peruse the admissions and various disasters from the night before, so that I can mentally begin planning the alterations to the daily OR schedule that are sure to follow. Administrative duties are numerous as a chief resident at the county hospital: the order of cases, position of patient, implants needed, outpatient surgical scheduling, outpatient phone calls/questions and all manner of necessary tasks all fall under the purview of the chief resident. I mentally begin formulating a plan of attack to accomplish these tasks as the other team members filter in. At 6:00 a.m. sharp, morning report begins. Every consult from the previous 24 hours is reviewed to ensure it was triaged or treated appropriately. Preliminary surgical plans are formulated in conjunction with staff present. Junior residents are frequently the target of focused questions regarding management as a part of their ongoing education.Ben Taub HospitalOnce morning report has concluded, every patient that has been admitted is seen by me with the junior resident who admitted the patient. Once every injury has been examined and the diagnoses confirmed, paperwork awaits. I fill out the necessary forms to post the next day’s cases and verify the surgical plans with the attendings of record. Next, every implant representative must be contacted to ensure that the mandatory equipment will be available on the morrow. It is now time for a second cup of coffee, and the McDonald’s in the Ben Taub basement happily obliges.The remainder of the day is spent primarily between two activities: teaching in the OR by performing various cases with the operative third and fourth year residents and oversight of the clinic. Due to the fact that only two community hospitals serve the underprivileged in a community of over 3 million people in Houston, all manners of complex and complicated cases meander into clinic in various stages of repair. Many have already undergone definitive or temporizing surgical treatment at outside hospitals and then told to follow up at Ben Taub. As you may imagine, this requires a tremendous amount of mental gymnastics to determine the best course of action for these patients. Along with our various attending physicians, I, as chief resident, will come to a coordinated plan for operative and non-operative management of these problems in a timely fashion. I am also constantly talking to family members of inpatients and the patients themselves. This is usually due to various surgical delays required by the frequent stream of urgent cases that flows inexorably into the ER at all hours of day and night. In order to alleviate the aforementioned scheduling difficulties, I am also constantly lobbying the surgical front desk for more OR time and more ORs. It is nothing short of a pride-swallowing siege.Baylor/St. Luke’s HospitalAs the day winds down, clinic will generally finish between 5 and 6 p.m., [with] over 100 patients usually having been seen. The ORs (if there were ever more than one) dwindle to a single operative suite. As chief resident, I am constantly changing the schedule as needed to accommodate any urgent cases that arrive during daylight hours. This, of course, requires dialogue with various attendings and implant representatives, as well as the circulating nurses, to ensure that every case proceeds as smoothly as possible. Before the day concludes, I contact the upper level resident on call, and a frank dialogue regarding the evening cases and their surgical plans is undertaken. Additionally, I locate the day-time call resident and a review of the day’s consults and admissions is completed. This process is generally ongoing during most of the day at various intervals determined by the influx of new admissions. At last, the sun has set, and I walk to the parking garage, keys in hand. If I am the chief on call during the night, I can generally expect one to two phone calls regarding possible transfers from outside hospitals. I make sure to have my pager at the bedside in anticipation of these 2 a.m. surprises.Baylor COM Surgical facultyMichael E. DeBakey Veterans Affairs Medical Center:The day begins in a more leisurely fashion. My alarm goes off at 6:15 a.m., and I rise with the sun. Upon arrival to the hospital, the first orders of business is to determine if there were any admissions from the night before, and ensure that all of the patients currently admitted are in good health, or as good as can be expected. This is accomplished by locating the junior resident on service and going over the list of patients to review any complications from the inpatients overnight and any new admissions. If an admission needs surgical treatment in an urgent fashion, the OR schedule is altered by talking to the anesthesia service and the front desk of the OR. If a new patient needs surgery in a non-urgent fashion, the schedule is altered in accordance with the best timing for the patient.I now make sure that all of the patients for surgery are marked and all of their questions are answered. Surgery then ensues, which is usually a combination of total knee arthroplasty and total hip arthroplasty. Between three and eight arthroplasty cases are accomplished per day, except on Tuesdays, which is an all-day clinic. Variations to this theme include two to four arthroscopic rotator cuff repairs per week, the occasional ACL reconstruction, and, of course, the fixation of all manner of hip fractures.Baylor VAOnce the OR is complete, I proceed to clinic. The junior resident on service and several physician assistants have generally seen most or all of the patients in clinic. Any complicated post-op or new patients are then reviewed with the staff and the junior resident. As would be expected, the attendings and I formulate the appropriate plans of treatment, and the various tasks for the execution of these plans are delegated to the appropriate members of the team.As chief resident at the MEDVAMC, management of the OR schedule is my responsibility. The schedule is reviewed several times per week, and the cases are posted in an en bloc fashion, usually a week in advance. As with Ben Taub, the implant representatives are contacted in a timely fashion so that the necessary equipment is available and the cases are appropriately templated.The day usually concludes around 5 p.m. Generally, there is no evening or night-time cases with which to be concerned. However, the junior resident is located and all issues, both inpatient and new consults, are reviewed in their entirety.A neurosurgical resident's typical dayCOLIN SON, MD | EDUCATION | DECEMBER 1, 2010I’ve made some fairly outrageous claims about the workload of a neurosurgical resident recently. Seems like a reasonable time to lay out exactly what a day on call can be like for me and my fellow residents.To be fair an average experience may be hard to articulate. Different rotations and different days yield different … adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.7 a.m I meet with the post call junior resident and the chief at the county hospital. We table round, looking at images from last night and going over any new consults. The list has 60 patients on it. And that truly is a conservative number. Approximately half of them are our primary and half we are consults on.8 a.m. The chief and post call resident run up to round on the unit and the approximate 5 primary patients up there and the 15 consults (let’s make the ICU players add up to 20 for simplicity, which is reasonable for our list).I run down to see the 40 patients on multiple floors. I start at the top and work my way down.9 a.m. My partner in crime is done rounding with the chief and is putting in basic orders and notes, without plans, on the patients in the ICU. I’m still seeing patients on the floor.10 a.m. Our T9 fracture we added on for today gets an OR room. We were supposed to get to him on Friday, but couldn’t. Luckily I’ve seen everyone on the floor, unfortunately there are three people waiting to get out of the hospital as I run down to the OR. My fellow junior resident manages to discharge two of the people.11 a.m. I’m in the OR. My fellow resident is getting some of my floor work done but none of my notes.12 p.m. In the OR I get a consult for a hypertensive bleed with intraventricular extension. I scrub out and run down and see her. My fellow junior resident meets me and checks out. The ICU attending wasn’t going to be available to round until the afternoon and so that task falls to me.I run back upstairs and let my chief know I think this head bleed needs an external ventricular drain (EVD). I scrub back in and we close quickly.1 p.m. While we’re putting in the EVD the intensivist calls me to see if I’m available to round.2 p.m. I run upstairs and round with the ICU attending for 2 hours. Luckily I’m able to put in orders as we go on a computer on wheels. To give an issue of how many times I’m getting interrupted by other providers in the hospital my beeper goes off 15 times in those 2 hours including another consult for a C2 lateral mass fracture down in the ER.I manage to put in admission orders for the head bleed downstairs on the computer on wheels while I’m rounding with the attending.3 p.m. Still rounding in the ICU.4 p.m. I run downstairs to see the cervical fracture. While I’m down there they have another consult with a small volume traumatic subarachnoid bleed. I see him as well.5 p.m. Then I run upstairs to see the post op on the floor and the EVD we placed, she has made it to the ICU. I sit down (it’s the first time I’ve sat down since 8 this morning) to add my last discharge and then write my consult notes and add the plans to the notes for the ICU patients. I follow up on a stat head CT the ICU attending had wanted while rounding, I call him with the results.6 p.m. While starting my notes for the floor patients I get called about a patient in the ICU whose EVD has stopped working. I go downstairs and indeed it doesn’t flush or withdraw and the patient needs the ventric. I call my chief and prepare to replace the EVD.7 p.m. EVD is in and go and see a guy I got called on with multiple parenchymal melanoma mets. I go upstairs and write that consult note, my procedure notes, dictate the op report from earlier in the day and then start on my notes for the floor patients.8 p.m. I’m still writing my forty floor notes. I get called on a patient with some desaturations on a floor patient. I go and see him, check the CXR, see the atelectasis and with him doing okay go back to writing floor notes.9 p.m. Still writing floor notes. Done I go downstairs and grab some chicken strips for dinner. I go upstairs and walk the ICU.10 p.m. Another consult from the ER. A gentleman who fell from standing on Coumadin. There is 2 cm of shift from the subdural. His INR is supratheraputic. I call my chief, who calls my attending. They call me back and I call the OR. I order mannitol and more fresh frozen plasma. I go and talk to the family at length and consent for the procedure. I have to physically run and get the FFP myself.11 p.m. I scrub into the decompressive crani.12 a.m. Still in the crani and closing I get called about a teenager with some subarachnoid and an apparent giant basilar aneurysm on an outside CT-angiogram (CTA).1 a.m. I write my consult note on this emergency craniotomy and dictate the operative report and put in admission orders. I run up the PICU where this new consult has already been admitted. I try to track down the outside CTA; this will be an adventure.2 a.m. I finally get the CTA and indeed even I can identify the aneurysm. I call my vascular attending and email him some of the pictures from the CTA. I then go down and consent the family for a potential angio later that day.3 a.m. As I’m writing my consult note I get a call about one of our ICU consults, actually on the trauma service, having a seizure. I go up there just to see if the trauma guys need anything. I then go back to writing my consult note on the pedi patient with the aneurysm.4 a.m. I get called on a thoracic burst fracture down in the ED on some gentleman who jumped from a 2nd story window likely related to a positive drugs of abuse screen. I go downstairs and see him and as he’s intact I’ll just keep him in bed. I write my note.5 a.m. I head back upstairs and start working on the list for the morning. Moving people around, taking the discharges off, adding the new patients and getting the labs for all the new patients and the 20 guys in the unit. I run and make copies for the chief and the junior resident coming on.6 a.m. I pull up all the images from overnight on all the consults and on anyone who got uprights or repeat head CTs or MRIs.7 a.m. The junior coming on and the chief show up. We table round going over all the images and everyone on the list. I’ll see the ICU patients today.8 a.m. Me and the chief resident go up to the unit and round on the ICU patients including the consults up there. Let’s say we signed off on some of the consults yesterday and so even with the new admissions I still only have 20 ICU patients. There are the daily little things to do like drawing CSF.9 a.m. I start writing my ICU notes.10 a.m. The ICU attending wants to phone round today and so I take his call and run all the patients with him. It’s a little bit shorter over the phone. I’m able to sit at a computer and put in orders while we’re talking.11 a.m. I finish up my notes in the ICU.12 p.m. I check to see if my fellow resident needs any help and I get out with an hour to spare.As with any service I’m taking numerous pages and answering questions and doing the basics for my patients, 20+ on the floor and 5+ in the ICU, during this whole time. I’m also constantly reviewing results such as sodiums for hypertonic therapy and repeat head CTs at 6 and 24 hour intervals for head bleeds.I’ve written more than 60 notes, rounded on 80 patients, done 2 EVDs, scrubbed 2 operations, seen 5 consults in 29 hours. Often fun and always rewarding hopefully but like any training program difficult at times. Even with the work hours.Colin Son is a neurosurgical intern who blogs at Residency Notes.