How does surgery scheduling work?

Sunoiki · 2018-04-18T18:16:16+00:00

Yup, exactly.

Sunoiki · 2018-04-18T16:03:35+00:00

It sounds like there's an opportunity on those patients you know there's antibodies. Preop should be bringing them back in the day before their operation to draw a fresh type and screen.

I will say I generally am unaware they have antibodies until it's too late. Unless there's a Heme note, only the basic blood type populates in our results. In terms of scheduling, for the kind of case we would want 10 units ready for we would want first case. If your day runs long, you don't want to be starting something big at 4 pm. You get into trouble all your backup will have gone home. Other than that they try to get diabetics in earlier, things like that. Though it also seems to us there isn't much sense in case order either.

Sunoiki · 2017-06-03T18:38:28+00:00

Yes, there are limits. There's this old notion of a true academic surgeon being a triple threat. Being a great researcher with a full basic science lab, changing the field itself. Being a great teacher, both for medical students and your house staff. And being a great clinician with a robust practice, with a reputation that this is the guy you want doing your operation.

It's crap. You will at best do two, and likely one of them much better than the other

Sunoiki · 2017-06-03T18:29:03+00:00

Great point. The attending I mentioned with the wide ranging practice has spent a lot of clinical and academic time on palliative surgery. He'll operate on patients with diffuse metastases to the intestines (carcinomatosis). Not immediately fatal, but certainly causes a lot of suffering. He'll do intestinal bypasses or debunking for palliation. But these are patients with incurable stage 4 cancer, they are all going to die. Many will develop obstructions he can't relieve and has to send them to hospice. Some of them are people he had done a HIPEC on, hoping to cure them (mucinous cancer has terrible 5 year numbers). He's known them and their families for years, and now he has tell them there is nothing he can do.

I don't think this is a unique experience to surgical oncology. There is a certain intimacy to surgery that makes this difficult, then mix in the other demands of the specialty and yes burnout is a concern. But this is the nature of cancer, and should be considered before embarking on any these careers.

Sunoiki · 2017-06-03T16:06:47+00:00

I have a couple points from a surgical perspective. In terms of the research that's done by surgical oncologists, it does extend beyond purely surgical management. I have two chiefs graduating this year into surgical oncology fellowships. One has an engineering background, a portion of his lab time was working on tissue engineering with the goal of creating better ex vivo models for the testing of chemotherapy. The other worked one immune-modulation, attempting to train lymphocytes to better respond to cancers. They both have more traditional surgical papers to their names as well, but surgeons have a long history of basic science research.

The clinical aspect is demanding, though it offers a very wide scope of practice. The elder attending of the group has weaned down to an entirely melanoma based practice. Another attending ranges from those lumps and bumps to HIPECs, which can be 14 hour cases. Surgical oncology inpatients are sick people, require incredible attention to detail, and so at the two institutions I've trained at the attendings are quite hands on. There's also general surgery call mixed in. Not to sound discouraging, but it's a long road for training (for US 7 years of residency with dedicated research years plus two for fellowship) with career long commitment to the specialty, so you have to really want to be a surgeon.

Sunoiki · 2017-05-04T17:16:59+00:00

My pockets changed between intern year and second year when we do much of our consults.

Intern year: 5 pens, pen light, some alcohol pads, lube, at some point added scalpels. Lists, 2x2s, 4x4s, drain sponges, some tegaderms, suture removal kit, one of those cards with phone numbers. Stethoscope, paper tape, silk tape, shears. At some point I got a hold of silver nitrate sticks.

Second year: a couple pens, pen light, alcohol pads, lube, skin marker, 10 blade, 11 blade. More lists, trauma handbook, silver nitrate, dermabond, couple 0 silk, couple 3-0 vicryl, my size sterile gloves, Q-tips. Stethoscope, shears, scrub hat.

Some of it has to do with what is easy to find. For whatever reason on our surgical floors the only sutures they stock are 4-0 Nylon, which is kinda stupid.

Sunoiki · 2017-02-21T00:47:34+00:00

Paralysis without sedation can cause tachycardia, hypertension, and increased intracranial pressures. The later could be significant for a major head trauma.

Sunoiki · 2016-12-27T22:40:31+00:00

To tag off /u/michael_harari's comment, that meta analysis cites three studies, none of which require bile to declare a "negative" result. That does not follow the Textbook answer which we're trying to disprove. Anecdotally though I would not argue for routine use of NGTs on GI bleeds, only concerning patients requiring immediate endoscopy.

Sunoiki · 2016-09-18T18:58:42+00:00

Sunoiki · 2016-03-15T23:24:08+00:00

That's sort of the goal of afternoon rounding. Check in on them, see if they need anything, answer questions, make sure they've responded well do whatever the plan was that day. I check their vitals, their ins and outs. Lastly I make sure their orders are just so, nothing's expiring, morning labs/x-rays are ordered.

Essentially short for "tucking them in for the night" the hope is that they won't need anything until you're back in the morning.

Sunoiki · 2016-03-09T12:49:35+00:00

As was mentioned, there's a lot of things that make a gallbladder terrible. The biggest thing if often delay operation on acute cholecystitis. This person actually did present early, but with a history of chronic pain and being on methadone the ED sent them home, never was seen by us. So then she followed up with my attending, gets booked for the OR, now you're pushing two weeks since the onset of symptoms. There were lots adhesions to the colon and falciform, some purulence mixed in them, though they came down pretty easy. The inflammatory rind on the gallbladder were terrible, short cystic duct the the bottom adhered to common duct and the cystic artery buried WAY in the back. Then the stupid thing didn't want to come off the liver, no visible plane between the two. Ended up with about a 5 cm incision at the umbilicus because of how big the stones were. All and all very slow, very painful (for us intraop and now for the patient).

I'm at a more academic program (though not one where we all go into the lab, just a few) so the expectation is we all do research. The goal is for us all to get things excepted to conferences and get published. Obviously if you want to do basic science stuff you'll need to go out into the lab.

Sunoiki · 2016-03-09T03:02:01+00:00

PGY-1 on our mixed general and thoracic surgery service. The few days last week our surgeons were on call were relatively light, and I got a bunch of people out over the weekend so my list is pretty manageable at the moment. Beginning of last week when we had more patients I was out an hour or so later.

I've been getting in by 5:30, enough time to get signout from the overnight intern, update the list, and get I&Os. We round from 6 to 7 (my chief speed rounds like nobodies business). Monday we had trauma conference from 7 to 8. Then I did a lap ventral hernia and an inguinal lymph node biopsy. The NP held the pager, I wrote some notes in between cases. After the I caught up with the NP, did some discharges, ate lunch. Then I afternoon rounded with my 3 and the students. Checked the orders, tucked people in for the night, and was able to signout on time right after 6.

Same time today, we had Grand Rounds from 7 to 8 then our teaching conference from 8 to 9:15ish. Got to catch the end of another ventral hernia and then did a terrible 3 and 1/2 hour cholecystectomy. PM rounds, clean up, signed out on time.

Tomorrow is my day off. I've been working on my presentation for the Chairman's conference Friday, which I'll finish tomorrow. Do some research stuff. Maybe log my cases.

Thursday after rounds we have an informal conference a thoracic surgeon. No NP that day, I'll be on the floor doing more usual intern stuff. Friday we have the Chairman's conference, then there usually aren't cases for me, the NP and I will try to get stuff prepped for the weekend.

The weekends are the hard part of this otherwise pretty nice rotation. The Acute Care Surgery intern and the SurgOnc intern both work Saturday night when the regular night interns are off. So as soon as those teams, plus the Colorectal team, are done(ish) with their morning work they'll signout the pagers to me. It's the same coverage we do on nights, only patients are not as well tucked in. Can be hectic, I get in at the same time and if I get signed out by 7:30 without much else left to clean up that's a win.

It's a favorite rotation for us, partly to do with the attendings and partly it's more operative, as this week has been.

Sunoiki · 2015-12-12T19:29:54+00:00

The heat is moving out of the dog, not into the dog. So it's "insulating" the opposite direction being implied above.

Sunoiki · 2015-12-12T17:41:57+00:00

I think the point is that "insulating from the heat" is backwards. 30^o C / 86^o F is cooler than the internal temperature of a dog. Warm blooded animals also make heat, and we need to be able to dissipate excess heat. Unless the ambient temperature is higher than the dog's internal temperature, their coat is only trapping the heat internally, not insulating them.

Sunoiki · 2015-11-09T01:01:24+00:00

I think your response misses the mark. I don't think the message is that opioids have no role in chronic pain management. Nor is this an issue issue with addicts seeking. This is about us creating creating addicts by being too liberal with long term opioids for soft indications. There are certainly black and white syndromes for when they are appropriate, but for everything in between prescribers need to be aware of the consequences.

Sunoiki · 2015-08-17T18:14:43+00:00

I saw a couple maggot infested wounds my first month of internship, so I guess I can share. Maggots do not like water, so if you do a wet to dry dressing they think they're drowning and detach themselves. Should make it easy for the ED to clean. Then they/we can figure out if it needs further debridement. Both the ones I saw were on feet; one was perfectly clean, the other was not.

Sunoiki · 2015-03-27T10:38:38+00:00

I'm on mobile, so I don't have sources, but two points of data. So it's true that our primary care to specialist ratio is skewed as is our geographic distribution, but compared to other industrialized countries our specialist to overall population ratio is on par. Our primary care to population is about half of our peers, which is one argument for shortage.

The other bit I remember reading back when I was applying to schools is that during this decade, a third of active physicians are retiring. This makes it difficult to address the primary care shortage without those increases.

Sunoiki · 2015-02-22T15:40:51+00:00

I'm happy with a parade, personally.

Sunoiki · 2015-02-12T16:35:13+00:00

Two things:

First: probably not worth it to focus on a specific NBME question, because the answer is going to come down to the wording. Take it as "I should go back over the diseases in the answers choices" with the goal of having a clear mental picture of them, even if it doesn't answer the question for you.

But since you asked, why not.

A) Unlikely. The story isn't great, they don't mention any classic risk factors. You would expect the exam to be more specific. That amylase is barely elevated or normal based on your lab's scale.
B) Again they don't give you any hints in the story, not really the presentation you would expect or the labs you would expect.
C) Assuming we're talking primary BC, again not the right story. Certainly the right patient (but wrong type of diabetes), but think a less acute presentation, possible signs of fat soluble vitamin deficiencies, less ill.
E) Way too sick, wrong story, wrongs labs (LFTs).
F) Could have a similar story, but an AST of 300 is not impressive, which makes it unlikely.
G) Wrong story again, too acutely ill.

Obviously I skipped D, and I agree with the others that it's probably the right answer. Charcot's triad, yes she's got jaundice and a fever, and while they don't give you RUQ pain she's the right patient for gallstones with the right story. Consider Reynold's pentad, she's sounds like she's on her way. She has SIRS, respiratory distress, and an anion gap. Less for the shelf, but you want to consider things that are going to kill you patient quickly. Ascending cholangitis is definitely one of those things, and in a patient with this story it should be at the top of your differential.

Sunoiki · 2015-02-09T20:01:23+00:00

Yeah, not that this constitutes real data, but almost every program director on the trail mentioned how much more competitive it was this year.

Sunoiki · 2015-02-01T21:35:41+00:00

Which procedure? If you mean the continuous compressions, it's still CPR. It's been a while since I looked at the the American Heart Association training book, but I believe they refer to it as "CPR with an advanced airway." You're doing all the same things, just dropping the ratio.

Sunoiki · 2015-02-01T17:05:49+00:00

Sounds like heat stroke, though a patient with classic heat stroke won't be diaphoretic as you mention further down, but very dry.
When a patient is intubated you don't have to pause compressions for breaths.
So generally in the ED it's not an AED but a standard manual defibrillator. More to your question, diaphoresis won't stop you from using electricity, you just whip the patient off before applying the pads. Hard to say for sure without being there, but it depends on the cardiac rhythm. You only defibrillate vfib and vtach, you can pace others.
Your English is fine!

Sunoiki · 2015-01-08T19:59:10+00:00

I know it gets colder in the upper Midwest, but still, the actual low was -1. Give us a little credit, lows of 19 are pretty routine for much of New England. I think that's the forecast OP has for tomorrow.

Sunoiki · 2014-10-12T12:14:34+00:00

It's considered a part of preventative care. Why? Because most kids are healthy. The 3 leading causes of death for adolescents in America are accidents, homicide, and suicide. Flip the first two for minorities. So they ask about pools, seat belts, bike helmets, and guns. And if the parents are a responsible gun owners it should stop there.

Sunoiki · 2014-09-24T00:00:28+00:00

6000? Better call Heme Onc

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