Service Unit

CPMC Medical Students

Each student is assigned to a team. At the Milstein Hospital Building, there are: Hepatobiliary/Endocrine Surgery Service, Acute Care Service, Vascular Service, Colorectal, and at the Allen Pavilion, the ALLEN team. The team is composed of chief, senior and junior residents. Your intern and resident will orient you to the daily routine. You will generally spend your day with your team, except when you are in one of the student didactic or preceptor sessions.

Lockers (CPMC medical students only)

We will supply you with lockers, during your surgery rotation. Due to the locker shortage, please double up. They are located on Milstein Hospital 7-109 HS. The locks and all your belongings must be removed the last day of your rotation.

DAILY DUTIES AND RESPONSIBILITIES

Much like the Medicine rotation, students act as part of a specific team, usually consisting of one Chief Resident, one Senior Resident, and one or two Interns. The hierarchy is that the chief resident operates all the time but still is ultimately responsible for the patients on his or her service, the senior resident also operates all day but conducts morning and afternoon rounds with the team, and the interns only operate on minor cases and spend most of the time on the floor managing the patients. So, on rounds, you are reporting to the senior resident and the interns. Each team has a separate focus.

You will be assigned 2-4 patients of your own. Every morning, beginning no earlier than 5:30AMpre-round on your patients (check vitals, perform a focused physical, change dressings as needed, devise a daily plan) and write a "SOAP" note (overnight events reported by surgical or nursing staff; subjective report from patient including any symptoms of pain or nausea;objective data including vitals, inputs and outputs including those for IV fluids, urine, and drains over the last 12 and 24 hours, physical exam, and any notable labs or study results; your assessment of the patient's condition and progress, and a proposed management plan including the major patient care goals for the day) for each. Include in the first section of the note the number of days post-op and the names of any antibiotics the patient is taking, along with the number of days they have been on each. SOAP notes in Surgery should be concise and less than one page. Otherwise Surgery notes are similar to SOAP notes in Medicine and other rotations. Early in the year, allow approximately 25-30 minutes per patient to pre-round. Later in the year, when you become more efficient, 15 minutes per patient is usually adequate.

On work rounds (~6AM-7:30AM), you will report to the team on the status of each patient, including changes on physical exam, results of new labs or studies, and plan for the day. Your most important responsibility is to help the team stay abreast of the patient's progress. You will be expected to know the history, current physical, what the consults' notes say, and lab values for their patients at all times. Remember that your patients also have interns assigned to them so it is important to share with the intern covering your patients what is going on with them. Most likely the intern may already know about major events or results, but you may catch other important details or physical exam findings that could end up being critical to your patient's course in the hospital. Most of these studies and events happen between 10AM and 3PM, so make it a habit to check Eclipsys (and check on your patients!) between cases, so that you can inform your intern right away and be prepared to give updates to the rest of the team on evening rounds (brief, usually occurring between 3PM and 6PM; you may miss these rounds if you have a scheduled preceptor or didactic session). In contrast to other rotations, you are considered a vital part of the team in surgery. Your chance to shine is by presenting your patients in a concise accurate manner (no more than 5 minutes per patient) and having a good plan in the notes. Try to rehearse your presentations and as a rule, memorize all but the most trivial information so that you don't have to refer to your paper while presenting—especially for the attendings.

A major part of every day in surgery, beginning at 7:30AM, is spent in the operating room. You should attend any operative procedures on your patients, as well as see procedures on other teams in order to get a good feel for the various types of operations done by general surgeons. If you are very motivated, and if there are not competing responsibilities to your patients or your team, you should seek out other operations, such as cardiothoracic, vascular and transplant procedures. After the second week you should be spending at least part of your time seeing new things. At least one student is expected to be present and scrubbed from the start of every operation. After the surgery is over, the student who assisted is expected to help the residents undrape the patient, and go with them to the Recovery Room, and write operative notes and orders. If you are still in the hospital three to six hours after your patient leaves the operating room, make sure to stop by and write a "post-operative note" detailing subjective and objective events in the first—and often most critical—hours after their procedure.

Whenever possible, prepare for each case by reviewing the operation to be performed, the relevant anatomy, and the indications for the procedure. In addition, a review of each patient's chart before the start of the procedure is important, as an attending will often ask questions specific to that patient's history. It is also good practice to introduce yourself to the patient before the operation. The student's role during procedures depends on the attending and the procedure. Students are routinely asked to cut sutures and hold retractors. On some occasions students are allowed to make incisions, sew, and even do some small amounts of dissection. It is important to remember that surgery is a hands-on field, so standing back and watching is not very beneficial; on the other hand, recognize and appreciate that it is a privilege to learn on the body of another person. When possible, make it a point to palpate masses, explore abnormal anatomy, etc. during surgery. As a matter of safety and etiquette, it is important to ask permission from the attending before touching anything on the operative field including instruments and the patient; however, most surgeons will not only allow exploration in the OR, but will encourage it.