ROTATION #11: SURGERY

All the PA students take their Surgery rotation in pediatrics general surgery. This is an awesome rotation! The surgeons are great and our team worked well together. This is what a typical day would look like

7:00am – 7:45am – Rounds – these are quick rounds. We looked at vitals, urine output, ins/outs, any issues overnight and any plans for the day. Our service would round on 2 to 15 patients from what I’ve seen.

7:45am – 4:00pm – This can include OR assist or Clinics. Most likely the surgical resident on your team will go to the OR. 

4:00pm – 4:30 pm - Sign over – the team along with the surgeon on call come together and discuss any issues or concerns for overnight.

CLINICS – Most of the patients you see are follow up appointments from a surgical procedure. The important things to ask are pain concerns, changes in appetite and if there are any changes to their urination and bowel movements. It is also important to look at the incision sites and if there are signs of infection. You would use your SOAP note format. For new consults you proceed with your H&P, PMH and exam.

OR ASSIST

You will get to assist the surgeon more likely on your call shift. I was able to assist with the laparoscope while the surgeon performs the surgery. In some cases you can help with suturing. I got to puncture an incision and drainage of an abscess on a babies bum :P

CALL SHIFTS – 24 hours!

Call shifts are my favourite part of pediatric surgery. When you are on call you receive the pages for the new consults in emerge or on the wards. You also get calls from the surgical ward with any concerns that the nurses may have. All new consults you receive you review with the on call surgeon. I recommend the first day you are on service to watch how a new consult is done that way you know where all the paper work is and how to write a proper consult – (I had to figure it out on my on :P). Call was great! You feel a great sense of autonomy since you are on your own overnight. I learned the most on my call shifts. I recommend when you are called for a consult to look it up quickly before you see them. That way you know what to look for in certain cases and prepared to present the pertinent information to the surgeon.

How you feel after a call shift :P

As for how busy you will be is variable. I had nights where I had no calls until 3:00 am :P or I would be up all night with new consults and assisting in the OR.

ADMISSION NOTE AND COMMON MEDICATIONS 

Use the acronym AD DAVID 
A: Admit to ____ (ward) and admitting doctors name
D: Diet orders
A: Activity orders
V: Vital schedule
I: Investigations
D: Drugs 

Example for admission for a 40kg male with appendicitis

GENERAL ORDERS
Admit to surgery ward under Dr. Happy
Diagnosis: Appendicitis
NPO (nothing per oral)
AAT (activity as tolerated)
Vitals as routine

MEDICIATIONS – (remember for peds you dose by weight) 
Bolus now 500cc NS for 1hr
D5NS @80 cc/hr IV (remember the 4-2-1 rule)
Gentamycin 60mg IV q8h (4.5mg/kg/day)
Metronidiazole 400mg IV q8h (10 mg/kg/dose)
Ampicilin 2.0g IV q6h (20mg/kg/day)
Tylenol 650mg q6h prn PO
Morphine 2-4 mg IV q3h PRN
Gravol 20-40 mg IV q4h pRN

I’ll try to get a cheat sheet of medication doses on here once I’m back in Winnipeg (Currently I’m in the Northwest Territories: P)

COMMON CASES

**APPENDICITIS!! – This will be the main consult you will see ** know how to do a proper abdominal exam

Inguinal hernia – key question – is it painful

Umbilical hernia – usually non-surgical. May be done for cosmetic reasons when they are older

Pyloric stenosis – know olive sign

Ingestion of foreign body – usually coins ie. Loonie and penny. These kids are cute/funny. X-ray is important in this one to determine where it is and if a scope is required.

Testicular torsion – important to know time of pain onset

Gastroischesis

Gastric Tube consults and follow up

Reasons for ileostomy and when an ileostomy take down can occur

Traumatic kidney injury (http://radiopaedia.org/articles/renal-trauma-grading)

Traumatic splenic injury

Pectus Excavatum

Pectus Carinatum

 

Unfortunately I came onto the service during the summer so there wasn’t any teaching sessions or grand rounds. Luckily I had the notes of my fellow classmates that came before me and I was able to study on my own. Overall I enjoyed this rotation. Call was definitely the best part.