Surgery Guide for Interns

A simple guide to your term in general surgery

Some preferences and mistakes I’ve made that might make a general surgery term easier. It is not complete and there are exceptions it’s just a starting point.

Admissions:
Good to see patients before registrar, there is no better way to learn, esp acute problems in ED

Analgesia
Panadol: strict
Tramadol: good drug but idiosyncratic. Often blamed for nausea unnecessarily. Generally avoid in the really old, as can accumulate and cause delirium.
Endone: use instead of codeine. Oxycontin for pain expected to last for some time.
Codeine: only in kids. A percentage of Caucasians cannot break down to active metabolite.
Panadeine/Panadeine forte: NEVER. Unless specifically attempting to constipate…
NSAIDS: Great and underused, esp in young. Long term C/I are different than short term! Give strictly where possible. Avoid in over 80’s and all the other usual reasons

Anitemetics:
No maxolon in mechanical bowel obstruction. The treatment for N+V in mechanical obstruction is a nasogastric

Bloods:
Sparing, but a daily UEC in patients on IV fluids is a good idea. If K is low its because you’re not prescribing it!!!. Coags pre-intervention in jaundice, with Vitamin K 5mg at some stage.

Charge nurses:
Know way more than you. They are generally in charge for a reason. The best port of call for advice, especially discharge planning, wounds etc. Be respectful. Always let them know the changes made on the ward round.

Consents:
Be practical. You’re not expected to know about the Karydakis procedure but the best approach is complete the form so the wheels keep turning, then let the reg or consultant know and we will speak to the patient. Lots of time is lost on this issue…Just be honest wtih the patient and reassure them the reg or consultant will speak to them (and we will).

Contacting registrar: try mobile first
Ring theatre or better still come in and talk directly. We like knowing what is going on in the ward, but can’t answer pagers when scrubbed. If not in theatre we will be in ED. If you are paging, put identifiers on your page so we know it’s you. Theatre nurses don’t answer pagers. Mobile is a good place to start looking. Then look in OT, ED, Surg office, reso’s (hopefully)…

Diabetics: Generally stop usual regime and convert to sliding scale unless you want a smoking pager. Patients fasting and on a hospital diet often become hypoglycaemic. Endo referrals are generally not required as this can waste plenty of bed days. Once they are over the surgical problem, we can flag the issue on the discharge summary for the GP or outpatient endo to follow up. We must keep the surgical wheels turning…. Stop metformin peri-operatively and if Cr >0.15 to prevent acidosis.

Diarrhoea:
Always check Cl.diff toxin as this is common and often fatal, yet treatable. It can happen weeks after a single shot of abx. Never prescribe Lomotil.

Discharge summaries:
Brief and succinct! A 2 minute phone call to the GP is infinitely better, especially in complex patients and will often prevent bounces.
Doing something you don’t agree with, or think you know better:
This is a common chestnut. Whilst the current UpToDate may not recommend leeches on wounds, remember there are plenty of different ways of doing things. Often these are no more than fashions; one as good as another .You need to be sure you know more than a consultant with 20 years experience because if you get it wrong you’ll be on your own. Discussion and questioning is good, ignoring a specific request from a boss is not.

Dressings:
Leave in tact unless heavily soiled

Gentamicin:
Time for 10pm or so if possible to enable level to be done on morning bloods. Gent levels do not need to be done where we are giving it only for a short time, (i.e 5 days or less) and if not, we will change to another agent, ie gent levels are over ordered.

IV Cannulae:
Thrombophlebitis is depressing. Remove at earliest convenience, or leave no longer than 72 hours. A PICC line is easy; consider where access is needed for > 5-7 days. Just like a big IV really. A good chance to learn this procedure and your patients will thank you no end.

IV fluids:
Hartmans or saline in first 24 hrs.
Following that patients need only 140mmol Na per day and at least 60mmol of K. Avoid continuous saline, the elderly cannot shift all the salt and you’ll end up with low sats/fat legs = can’t discharge. 4%D 1/5 NS or two 5%D and one NS are fine with K in two of the bags.
If Nasogastric then continuous saline with potassium in every bag: they will get hypokalaemic quickly
Hypokalaemia is an iatrogenic problem. In a patient with normal kidneys you will never treat hyperkalaemia, so don’t be shy with potassium if the patient is making urine.
On the ward round, always write up the fluids for the next 24 hours.

Medically inclined residents:
You are a bonus! The surgical wards are full of diabetes, CCF, AMI’s etc. Get involved with these problems, its OK to avoid theatre, but not OK to sit in the reso’s with ‘nothing to do’ if there is a BSL over 10.1 on the ward somewhere.

Notes:
Write in notes every day, even if only who was present on the ward round and what decisions were made. The SOAP format is good. No need to write things that nursing notes will provide eg temperature, more about what we thought it meant. Interns can get sued too.

Postoperative problems:
Are bleeding until proven otherwise. If you are giving lasix for oliguria, think carefully, discuss with registrar. Generally filling is the best option initially.

Tests:
Order radiology at the start of the day. All results must be chased before 5pm. Films are infinitely better than a report, especially if you can deliver to theatre. Tell the registrar about important abnormal results. It will be assumed residents are checking blood results etc.

Theatre:
Come often, learn how to sew even if you hate surgery. No need to ask about scrubbing in, just let the theatre nurse know your glove size and ask for a gown. Most tedious ward stuff can be done from theatre, eg discharge summaries at time of surgery, bloods for the following day if needed, IV fluids for 24 hours. It’s a good time to sort out follow up appointments with consultants etc for routine procedures. Often the only time you will see a consultant: they will remember who was in theatre at the time of assessment writing.

Thromboprophylaxis:
Heparin in every patient is the default option. TEDS will decrease DVT by HALF. Easy but easy to forget. Clexane for cancer, major pelvic or lower limb fractures.
Urinary retention post op:
An in/out catheter is best except for the over 70 male with prostatism… Use your judgement, but in 90% you will fix the problem with an in/out (and patients will thank you: catheters are irritating)

Ward rounds:
Should be short. Why stand around while a consultant or reg is crapping on when you could be on to the next task i.e finding the next patient notes etc. If two residents, one should write up fluids for 24 hrs, check TEDS, Heparin, Meds are correct, write in notes (i.e routine stuff to set and forget). The other should examine the patient, discuss and check the management plan for the day . Only 1 resident is needed for a round, the other can order tests, make referrals. It is easier to order 6 CT’s at once than page the radiol reg 6 times…

Warfarin/Anticoagulants:
2nd daily INR enough unless very high. Beware overdosing patients who have been fasting.
Alert surgeon/registrar to clopidogrel/ antiplatelet drugs. Stop 10 days before surgery. Beware stopping clopidogrel if the patient has a drug eluting coronary stent.

General:
We’re aiming for a low stress unit. You will be everyone’s dog’s body so when you’re overwhelmed, remember the following priority list, it will help you no end:

First comes patients. Then when they’re as buffed as possible:
Look after consultants. Then:
Registrar. Then:
Charge nurse
GP’s
Families
Yourself
Notice that med admin dont rate a mention. They can generate a lot of stress, time, paperwork, but there is little gain in spending time pleasing them.

If someone is not on the above list and asks you to do something…think again.
We’re aiming to have enough time free to learn procedures, see new patients with acute conditions, drink coffee etc. Regard all patients as your own, and a consultant as just that: someone to ask for advice. There is no-one else is around to worry about them!

Things that make me slightly shirty
· coming out of theatre at 7pm, then having to search for films not chased before 5pm. (Everone has gone home!) A note in theatre or a quick word before you leave is good.
· Hypokalaemia
· Staying late
· Too much paperwork
· Pagers especially when they go off
· Panadeine forte
· Long stayers
· No TEDS, doing the ward round by myself, PE’s, unhappy residents, unhappy charge nurses, I could go on….
Things that make me happy
· Residents in theatre
· A quick handover before you go home esp face to face