Surgical Algorithms

1. Surgical Algorithms Session # 1

2. Surgical Algorithms • Consults • Patient Transport • Rounding • Turnover/Sign-out • Stress • Integrity

4. Consults

5. Consults“The Question” • Has the question been clearly communicated / documented? • Does it appear in the consultation request, progress notes? • It should be re-stated in the consultation with the accompanying answer.

6. Consults

7. Consults“Urgent/Emergent” • Acute abdomen • Acute abdomen with shock • Pneumothorax • Tension pneumothorax • Peripheral vascular disease with rest pain • Peripheral vascular disease with thromobosis ***Remember your ABC’s!!!

8. Consults

9. Consults“Elective” • Central line placement for hyperalimentation • Hernia evaluation (not incarcerated or strangulated) • Long term intubation for tracheostomy • Asymptomatic carotid artery disease • Cholelithiasis

10. Consults

11. Consults

12. Consults“Look for yourself” • Interview and examine the patient directly yourself • Repeat essential tests and studies as felt essential to making the correct diagnosis for the delivery of the correct/appropriate care • Obtain additional studies and tests as indicated

13. Consults

14. Consults“Be brief” • Be careful not to simply regurgitate all of what is in the patient’s chart

15. Consults

16. Consults“Be specific” • A goal - oriented consult that specifically answers the question at hand will most often be helpful • If posing differing diagnoses, be concise

17. Consults

18. Consults“Contingency plan” • There will almost always be therapeutic options and alternatives • It may be appropriate to state such in the consultation or, • Discuss these options directly with the requesting team/physician

19. Consults

20. Consults“Teach” • Remember that a consult is almost always a learning / teaching opportunity • One may include a pertinent citing of a reference that is pertinent and current • Don’t be condescending • Be tactful

21. Consults

22. Consults“Don’t assume primary care” • Remain mindful that you are not the patient’s primary physician • Remember your place in your interactions with the patient • Keep the primary physician in the loop and • ****The university setting may often be the exception to this rule

23. Consults

24. Consults“Discuss” • Talk is cheap andeffective • Direct contact with the requesting physician or team will help to alleviate tensions, explain clarify and eliminate controversial matters • You may talk about what may not be written in the chart that may create liability for the primary care physician

25. Consults

26. Consults“Follow-up” • A great opportunity to learn • To determine whether important recommendations were acted upon • May often fall into the background and follow “peripherally” • Surgical intervention may of necessity occur during this period

27. Transport

30. Transport

31. Transport“Urgent/Emergent” • Acute abdomen with shock • Pneumothorax • Tension pneumothorax • Peripheral vascular disease with rest pain • Peripheral vascular disease with thromobosis ***Remember your ABC’s!!!

32. Transport

33. Transport

34. Transport

35. Transport“Urgent/Emergent-unstable” • Hypotension with/without pressors (shock) • Hypoxic • Tachypnea in the non-ventilator patient • High airway pressures ( super-peep) • Abdominal compartment syndrome • The unstable head injured patient!!!! ***Remember your ABC’s!!!

36. Transport“Pre-flight checklist” • Senior clinician patient evaluation • Equipment check • Ventilator, pumps • Medication check • Sedation, analgesia • Travel plan and route • Notification of personnel at destination • Transport method • Informed consent • ** Is this trip necessary????

37. Transport

38. Transport“Elective” • Patient area • Regular inpatient “vs” PCU • Do physical exam • Review chart • Is the patient at risk for instability? • Does the patient need a physician escort

40. Transport“Elective” • Patient area • Regular inpatient “vs” PCU • Do physical exam • Review chart • Is the patient at risk for instability? • Does the patient need a physician escort • Is the journey / trip necessary??

42. RoundingGeneral Considerations • Integral to the process of medicine/surgery • When effective and efficient, can be an invaluable asset to patient care • Fundamental teaching tool

43. RoundingResident Considerations • Punctual • Enthusiastic • Proper attire • Alert • Communicative • Initiative

44. RoundingPresenting • State patient name • Disease process • POD # (If post-op) • Vital signs and I/O • Pertinent exam • Critical values and study results • Discussion???…….Plan!!!! * Be organized and thorough!!!

45. RoundingDisposition • Discussion occurs outside of the patient’s room (special issues beyond earshot) • Most senior personnel addresses the patient • Additional information will be solicited as indicated • Wound care is variable

47. TurnoverGeneral considerations • Highly variable • Shared responsibility • As work hours • Turnovers

48. TurnoverPhysical setting • Private (relatively speaking) • Quiet • Good lighting • Limited interruptions

49. TurnoverSocial setting • Mutually acceptable • Conducive to exchange

50. TurnoverLanguage barrier • Diversity among medical professionals • Avoid colloquialisms • Use linguistic checks and balances • Review critical points