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Surgery 350

Surgery will probably be the most physically demanding rotation during the third year.  The hours are long and the pay is non-existent but you get to cut people open and put them back together.  It is quite cool.

Surgery now includes 6 weeks of general surgery and two 3-week blocks of surgical subspecialties.  Your final grade will combine clerkship evaluations from all three sections of the rotation.

During general surgery, you will work very hard.  During your six weeks of subspecialties, you will have much more free time – use it to study (and relax)!

General Surgery

At Jefferson, the rotation is divided into two three-week blocks of General Surgery, Transplant, Vascular, Colorectal, Plastics, Breast, Trauma, Cardiac, or Thoracic. At the affiliates, there is typically no set division for the rotation. However, the affiliates are usually more flexible if you want to bounce around a few different ORs.  Try to be prepared for cases ahead of time.  If you know that you are scrubbing in on a particular case for the next day, go home and read up on the surgery.

You will work hard during this rotation and you will learn a great deal. A typical day might extend from 5 a.m. to 7 p.m. and even longer if your attending rounds later. It is recommended that you get in early enough to write notes on your patients before attending morning conferences. On the first day of the rotation, you will be given some handouts on pre-op and post-op care and on some common procedures. These are very helpful, so read them as soon as possible.

Lectures

Lectures for surgery are held once a week on a morning, sometimes on Saturday mornings, beginning between 6:00 - 8:00 AM.  Attendance is mandatory. Some affiliates have additional lectures for the students rotating there.

Books

  • Surgical Recall is a popular pocket book.  It is designed with a question-answer format and presents the most frequently asked 'pimp' questions. Recall is a good resource for reading about cases before you step in the OR.  Highly recommended.
  • Essentials of General Surgery (Peter Lawrence) is easy to read with excellent pictures and diagrams but it is long. If you put in a few hours a night reading (between working 15 hour days, eating and sleeping) you’ll be in good shape.
  • Surgery (NMS) is the "red book" written by Jefferson Faculty. Full of information in outline format. Good if you want an outline format.
  • Cope's Early Diagnosis of the Acute Abdomen is not a book that is necessary to purchase, but it is a great educational book for one of the most ambiguous presentations in surgery.
  • Library Texts. There are several large textbooks of surgery in the library (or on JEFFLINE) for additional reading if you have the time. In addition, the Gross conference room in the Department of Surgery (605 College) has copies of surgery textbooks for you to use.
  • The Mont Reid Surgical Handbook is by no means exhaustive, but it is a good supplement for the initial management of common surgical conditions. This is not necessarily the easiest book to carry around throughout the day, but it is fairly good for quick look-up topics.

Exams

There is a clinical OSCE exam at the end of the six weeks of general surgery in which students encounter common clinical scenarios and are expected to perform basic procedures, such as suturing, starting an IV, and inserting a Foley catheter. Standardized patients with models are used in most rooms. Students are expected to demonstrate a basic ability to conduct a patient interview and perform common procedures related to surgery. Standardized patients grade students using a predefined checklist.

The written exam is the NBME surgery shelf exam.  This will be taken at the end of the twelve week rotation.  Similar to other shelf exams, the test is 100 questions over 2 hours and 10 minutes.  Pre-Test, Appleton & Lange, Case Files and/or Kaplan QBook are recommended question books for preparation.

Call

Call is every fourth night and alternates between floor call and emergency admissions (first and second call) at Jefferson.  The affiliates' call varies but, in general, it is every fourth to fifth night and involves floor and emergency admissions as well. At the beginning of the rotation, you may have to make up your own call schedule so try to note days you have prior obligations.  Most students learn a lot on call.  Most residents are more inclined to teach while on call, so take advantage of this opportunity.

The Operating Room & Scrubbing

Most third year students are a little nervous about entering the OR for the first time. You will be instructed on scrubbing procedures early in the rotation. Here’s a brief tutorial:

Be sure to get a mask with an eye guard (or goggles) and hair cap before beginning your scrub.  Also, it’s a good idea to go into the OR before you sterilize your hands to let the scrub nurse know you will be scrubbing and get your gown and gloves to him/her ahead of time.  Glove sizes generally vary from 6 to 8.5.  You’ll just have to try on a few pairs before you find the size that’s right for you.  You want them tight so you have good tactile sensation but not so tight that your fingers turn blue.  Once you’ve ensured the nurse has your gloves and gown, head out to the sink.  Turn on the water with the foot or elbow pedal and break open a back of scrub soap.  Use the finger nail digger first and then start the scrub.  Use a lot of soap, it’s said that the soap more than the actual scrubbing is what sterilizes your hands.  Start with the fingers and scrub up to your elbow (push the dirt away from the hands) on both sides.  Once you’ve done this for 2-5 minutes with special attention to the hands and between the digits, wash off in the same manner – fingers to elbow.  Now that your hands are sterile, walk into the OR back first (be sure not to touch the dirty door with your hands).  Walk over to the scrub nurse and put a needy look on your face.  She’ll hand you a sterile towel (usually green or blue).  Take the towel and dry one hand followed by the other; try to use half of the towel for each hand.  Again, dry off starting with the fingers and moving toward the elbow.  Drop the towel in the laundry bin and look longingly at the scrub nurse again.   She’ll unfold a surgical gown for you.  Step into the gown with your hands straight out in front of you. The scrub nurse will then help you glove while the circulating nurse ties up the back of your gown.

It is important to be aware of where your body is at all times with respect to the sterile field. The student's role in the O.R. is essentially to help out with whatever needs to be done. Usually this means holding retractors so the surgeon can see what needs to be seen. If you are lucky and if you show interest, you may get to close the incision. Many attendings like to ask questions (aka "pimping") during the procedure, so stay alert. Mentally, review the important structures and vessels in the region so you can shine when asked questions. Although reading about the surgical procedure is a definite plus, most attendings tend to pimp you on things that were learned in the first two years (e.g. anatomy and physiology).

Notes

Surgical progress notes tend to be shorter than notes on other rotations:

POD# (post-op day number)
S: No c/o, +flatus, fever/chills?
O: Vitals: T, Tmax, BP, HR, RR, Pulse ox, I/O's, drain outputs, etc.
      CV: RRR, no m/g/r
      PULM: CTA BL, no w/c/r
      AB: +BS, soft, NT/ND, +/- guarding, +/- rebound
      INCISION: c/d/i (clean/dry/intact)
A/P: POD # s/p (status post) lap chole (laparoscopic cholecystectomy)
Will advance diet to house as tolerated
CBC in a.m.
IS q1h wa (incentive spirometry every hour while awake)
D/C (discontinue) Foley in a.m.

Operative note:

Pre-Op DX: Cholecystitis
Post-Op DX: Same, common bile duct stricture
Procedure: Lap chole, intraop cholangiogram
Surgeon: Dr. Gross
Assistant: Resident, MSIII
Anesthesia: GET (general endotracheal)
Specimen: Gallbladder, bile duct stone
Drains: Foley to gravity, NGT
Fluids: 1500 cc crystalloid, 500 cc Hespan
EBL (estimated blood loss): 300 cc
Complications: None
Findings: Enlarged gallbladder with stones, common bile duct stricture
Disposition: Patient tolerated the procedure well. Patient stable, extubated and sent to PACU.

Surgical Subspecialties

Anesthesiology

Anesthesiology is pharmacology and physiology in action. There is not much patient care during this rotation, but you will get to practice IV/A-line placement and intubation. You are given freedom to see, do and attend as much or as little as you want. There is plenty of downtime during this rotation. Students typically arrive around 7 a.m. and stay as long as their residents request.

Grade based on:

  1. Thee evaluations distributed to people with whom you have spent significant time (50%)
  2. Final exam (50%)

The exam is approximately 50 questions. Most questions are based on the handout they give you at the beginning of the course and you can pass just by knowing this handout.

Required text: None. The department provides a syllabus that some students find helpful. The lecture on the first day is also very useful for exam purposes. The exam is difficult, but with the aid of the syllabus and the first lecture, you should not have a problem. Doing well is not difficult, so enjoy the free time.

Ophthalmology

Ophthalmology is a chance to get exposed to life at Wills Eye Hospital, one of the country's best eye hospitals. A typical day runs from 8 a.m. to 5 p.m., but often the day is over earlier. There are lectures every morning for students given by a resident from 8 to 9am. You are assigned to a different clinic or private doctor's office each half-day; some are required (see below). Students get to learn how to use the direct ophthalmoscope, indirect ophthalmoscope, slit-lamp, and refraction techniques. Three nights of call are required in the ER from 5-9 p.m. during the rotation. Students are usually sent home earlier than 9 p.m. unless they express an interest in ophthalmology.

Grade based on:

  1. Fundus drawing on 1st day
  2. Attendance at CPEC*, ER, private doctor's offices, lectures, chiefs' rounds (required)
    * Wills hires an attending to teach you during CPEC (Cataract & Primary Eye Care service)
  3. Take-home exam

The exam is actually quite difficult, necessitating the use of outside ophthalmology textbooks (one is available on MDConsult), the Internet, and morning lectures. The exam is given to you on the first day of the rotation so you have 3 weeks to complete the exam. The questions vary from block to block but each exam is 15 questions long. Answers are short answer/essay limited to <250 words per response.

Required Text: Basic Ophthalmology (Bradford 1999) will be supplied by the rotation for free. Morning lectures are based from this textbook. A Near Vision card will also be provided to you.

Orthopedics

This rotation is designed to give you a taste of different areas of orthopaedics. As students, you spend significant time in the OR where you will be asked to retract, especially on joint cases. Occasionally you will also get to suture, hammer, and, if you are lucky, use the saw. Students also spend time in the outpatient offices of different attending physicians and attend radiology rounds and morning report (site dependent). Topics highlighted on this rotation include: indications for surgery, anatomy, post-operative care, surgical technique, and common orthopaedic injuries. Those interested in orthopaedics as a career need not be concerned if they do not get Jefferson as their site for the IDEPT 410. This course is only an introduction and most of the affiliate sites have Jefferson orthopaedic residents and Jefferson affiliated attendings that love to teach.

Grade based on:

Grades are largely based on resident feedback. To qualify for high honors, in addition to receiving honors on resident feedback, the student must show interest and involvement in orthopaedics by achieving one of the following:

  1. Take 5 evening calls over the course of the three week rotation.
  2. Work with a resident or fellow on a research project and present their work at the end of the rotation during a research meeting.
  3. Exam? No

Required text: There is no required text for this rotation. Dr. Hilibrand has mentioned two books that would be helpful in preparation for the rotation: Physical Exam for the Spine and Extremities by Hoppenfeld, and Musculoskeletal Medicine by Bernstein. These two books are suggested though not necessary for the rotation. Any student planning on rotating in orthopaedics should have an anatomy atlas. Netter's Concise Orthopaedic Anatomy is a great reference text and can fit in your white coat.

Otolaryngology

This rotation gets your feet wet in the world of ENT. If you are interested in pediatrics, this is the only IDEPT 410 rotation offered at duPont. Students often go on AM rounds starting at 6:45 a.m. with the residents and then spend the majority of their time in the OR from 7:30 a.m. on. Most students say this rotation is what you make of it. If you want to work like a sub-intern, you can. If you want to work like a third-year student not interested in ENT, you can do that too.

Grade based on:

  1. Clinical evaluations.
  2. Attendance at office hours one time during rotation.
  3. An optional 10-20 minute presentation may get you honors depending on the site.
  4. Exam? No

Required text: Primary Care Otolaryngology is given to the students for free. With no exam, this book is a good keepsake for the future and has some helpful pictures and techniques. A packet of articles is also given at some sites, which the students are free to keep.

Urology

This rotation allows the student to learn about the field of urology and spend a lot of time in the OR. Students typically arrive around 7:30 a.m. for OR cases and are done by 5 p.m. at the latest, often much earlier. There is also an opportunity to attend office hours.

Grade based on:

  1. Required presentation at the end of the rotation given to Jefferson residents and attendings.
  2. Clinical evaluations.
  3. Exam? No

Required text:  The Urology department may have textbooks to loan to students during the rotation.  This is not required but may help prepare for the presentation and OR time.

Neurosurgery

This rotation allows students to learn about the fields of neurosurgery and interventional neuroradiology.  Students typically arrive around 6 a.m. for morning rounds and then scrub in on OR cases for the remainder of the day.  The surgical procedures are often longer than those encountered during a general surgery rotation, but the cases are often spectacular.

Grade based on:

  1. Daily attendance at morning rounds and in the OR.
  2. A 10-15 minute optional presentation to residents and attendings may earn you a grade of honors.
  3. Exam? No

Required text: Greenberg’s Handbook of Neurosurgery is loaned to students during the three-week rotation for use as a reference text.