Blue Service (Colorectal Surgery)
Rotation Director Charlie Friel MD
Attendings: Traci L. Hedrick, MD
Upon Completion of this rotation the medical students should be able to
1. Preoperatively evaluate patients and appropriately select surgical intervention for the following conditions:
- Colorectal cancer
- Inflammatory bowel disease
- Benign anorectal disease (hemorrhoids, fistulas, fissures, perirectal abscess) and other benign colorectal disease (diverticulitis, rectal prolapse, volvulus)
2. Describe the following operations:
- Intestinal resections:
- Small bowel resection
- Low anterior resection
- Abdominal perineal resection
- Intestinal Stomas
- Anorectal operations:
- LASER ablations
3. Describe the postoperative care to patients undergoing these procedures and be able to recognize and treat postoperative complications.
4. Perform a focused history and examination
5. Develop a plan of care for all in-house surgical patients with whom they come in contact. This includes data collection, ordering and interpreting appropriate diagnostic tests, and working to provide a patient centered plan consistent with the resident's level of training
6. Evaluate and develop a plan for patients seen in consultation in the emergency room or inpatient service
7. Recognize significant changes in patient status.
8. Participate in the above operations.
The responsibilities of the 3rd year medical student while on the
Service at UVA include:
1. Floor duties
2. OR duties
3. Clinic duties
- Patient: Know your patients. This includes reading about and understanding their medical conditions and surgeries. Furthermore, the medical student should know the active problems with their patients (infections, post-op complications, etc). along with pertinent labs, radiology, and procedures being done (and why).
- Patient Load: The medical student should generally carry around 4-6 patients. On the first day of the service the student should pick up 2-3 patients to follow and present on rounds. After this, the student should follow and present the patients he/she has seen in surgery
- AM Rounding: Morning rounds take place between 5-6am. Ask the intern or chief resident the night before to determine the exact time. You are responsible for presenting the patients you are following during rounds. The medical student should plan on arriving with ample time before morning rounds to see the patients, write down vitals and I/O's, and do a physical exam. The Surgery Progress Note should be filled out and used as the general format for presenting.
- PM Rounding: Afternoon rounds are variable in when they take place. Because the student is in clinic or the OR he/she generally does not present in the afternoon. However, you should attend if you are out of surgery or the clinic before afternoon rounds begin. The attendings often round in the afternoon as well and this is a good time to learn more about the management of the patients on the floor.
General Floor Duties:
- Assist the Intern: When you are not in surgery or clinic ask if he/she needs any help with floor duties. Any help you offer can aid in the more efficient management of the patients on this busy service.
- Labs/Chart Notes: Following morning rounds and morning report, the medical student should put the morning labs for all the Blue Service Patients on their respective progress notes. Ask the intern for his/her progress notes once they are completed so you can do this. The labs are available on Carecast or MIS. Finish filling out the surgery progress notes for the patients you are following as well. Ask the intern to sign all progress notes and subsequently file these notes in the appropriate chart on 5-Central. Attempt to have this completed by 10am. Some mornings, surgery or clinic will take precedent over this activity. In this case, the intern will handle it.
- Pre-Write Notes: At the end of the day, pre-write the subjective portion of the Surgery Progress Note for all the patients for the next day. This includes Brief HPI, Date, Post-Op Day with surgery or condition, and attending's name. These notes can be found on 5-Central. Printing out the Intern's patient list on MIS at the end of the day is a good way to know all the patients that are currently on the floor.
- Ancillary Duties: Ask the intern about helping with dressing changes, staple removal, NG tube placement, JP drain removal, etc.
Helpful Hints For Morning Rounds
What to ask and record when interviewing patients on the floor:
- Is the patient having bowel movements/stoma output and how much?
- Is the patient passing gas?
- What diet is the patient on? And of that diet, what has the patient actually eaten/drank that day?
- o Most patients on the service start on NPO following surgery, move to sips of clears (following passing of gas, stool, etc), move to clears, then to transitional diet, and finally to regular diet. All of these changes are made based on the patient's bowel function and how they are tolerating the current diet. The patient's currently ordered diet can be found on the rounds reports printed off MIS.
- Is the patient having any nausea/vomiting?
- Is the patient's pain adequately controlled and what type of pain management are they on?
- Has the patient been getting out of their hospital bed and ambulating the halls?
- Is the patient using their incentive spirometer?
- Is the patient's Urine output adequate? (>.5ml/kg/hr)
- Does the patient have a Nasogastric Tube and how much output is it producing?
- What are the JP drain's output? Always check the type of fluid in these bulbs.
- o Most patients have serous or serosanguinous drainage from their drains
- o Bilious drainage would suggest a leak somewhere, so in a patient with a small bowel resection this would suggest a leak from their anastomosis.
- o Other types of drainage suggesting a potential problem include stool, frank blood, etc.
- Any other medical issues overnight? (Fevers, Hyper/Hypotension, Tacchycardia, Hyperglycemia, worsening condition, etc)
- A very important aspect of the way the chiefs/attendings often think is related to what is keeping the patient in the hospital. Another way to think about this is to ask yourself if the patient has improved enough clinically that their risk is low of going home and having a serious complication.
- To go home patients need to:
- Hydrate themselves orally- they need to be drinking well and often should be tolerating some regular food (but drinking fluids is most important)
- Have their pain controlled well with oral pills- therefore know if they are still dependent on the PCA or IV injections
- Be mobile- Are they walking?
- Be clinically stable - normal vitals, off O2 (unless on home O2), no fevers
What to observe and elicit during the physical exam:
- Because this is the colorectal surgical service, the two most important parts of the physical exam include the abdominal exam and examination of the incision and ostomy site. The other parts of the exam are important and should be taken into the context of the patient's history and current condition, including the Cardiac, Pulmonary, and Extremity exams. Checking whether the patient is alert and oriented X3 is important as some patients may have decreased mental status and possible delirium following a major surgery along with being on several medications including pain management. Still, the focus should be on the abdomen and incision/ostomy site.
- Abdominal exam:
- The key is to look, listen, and feel. You should be focusing on whether the person's abdomen is soft/tense, tender/nontender, and/or distended. Most of these patient's will be tender following surgery so determining whether a patient is appropriately tender is important. Because surgery on the bowel causes inflammation and thus ileus, many of these patients will not have bowel sounds for the first couple of days following surgery. Other pieces of the physical exam include hearing high-pitched bowel sounds in patients with obstruction and eliciting rebound tenderness in those with peritonitis, among many others.
- Ostomy/Incision Exam:
- Examine the bandages first- Look for whether they are dry, intact, and whether there is any drainage or not.
- Examine the incision sites- Look for drainage from the incisions along with erythema and pus. Increased drainage in the days/weeks following surgery may suggest wound dehiscence. Increased erythema and tenderness may suggest wound infection.
- Examine the ostomy site- You can tell whether the person is passing gas based on whether the bag is inflated or not. Furthermore, you can assess whether the person is producing stool. Lastly, check for the same physical findings you did with the incision site.
- Patient- Obviously, know the patient. Grab the OR schedule the night before (2nd floor, OR Control Desk-copies are sitting out) and go see the patient that evening. If the patient isn't in the hospital, look through Carecast-you can see medical history and the last clinic note.
- Disease Process- This is simple; use Lawrence, UpToDate, etc. to better understand the disease.
- Anatomy- Review pertinent anatomy
- Surgery- Understand what comprises the surgery being performed; i.e. what's done in an APR
- Patient Transport- Always assist anesthesia with bringing the patient to the OR and back to PACU. This is another good time to meet the patient if you weren't able to the night before.
- General- You can also help with moving the patient from bed to OR table, grabbing warm blankets (ask nurse where to find these), cleaning after case, etc.
- Post Op Note- Pull the Post-Op note from the patients chart after the case has finished and fill it out. Ask the anesthesiologist for information such as IVF's, Urine Output, Estimated Blood Loss, etc.
- Laparoscopy Cases- Always go to the Laparoscopy cases because you will be controlling the camera which allows the attending and resident to work the case together.
- Introductions- ALWAYS introduce yourself to the scrub nurse and circulator. Offer to grab your gloves and gown. Ask them if you can be of assistance in any way. These people can make or break your OR experience so stay on their good side.
- Purpose- you are in the OR to learn, and we are there to facilitate the learning process. Use judgment to ask questions at appropriate times.
- Be the 1st to clinic. Avoid strolling in after a social breakfast in the cafeteria.
- Introduce yourself to Linda, she manages the clinic and knows everything- she's invaluable.
- If clinic is extremely behind, use your judgment about questions, etc. (same idea as the OR).
Mechanics of Clinic
- Chart on the door = patient to be seen.
- H&P vs. SOAP note: An initial visit usually requires an H&P as does a pre-op visit. Additionally, if a surgery is planned, bring a consent form (you can't consent the patient, but can make clinic flow smoother if you have the consent form ‘handy'). The surgery H&P and consent forms can be found in clinic-ask anyone to show you. A post-op check or general f/u requires a brief SOAP note. The SOAPs are for dictation purposes so write them as such: dense in information, short in length. If you're unsure whether a visit requires a SOAP or H&P, ask Linda.
- Be aggressive. This is not a "shadowing" opportunity; it's a chance to hone your H&P skills, efficiency, and presentations. You'll get from clinic exactly what you've put in; so take every opportunity to be proactive about seeing patients all day and the chiefs, residents, and/or attending will take the time to teach.
General Schedule (subject to change)
- Morning rounds- every day between 5-6am
- Morning report- every day 6:30am, except Wednesdays at 6am, Saturdays/Sundays at 7am
- Afternoon rounds- variable
- Friel Clinic- Wednesday, after Surgery Lecture (Come dressed professionally)
- Surgery in Main OR- Tuesday & Friday
- VASI cases and add on surgeries in the Main OR- Thursday
- Grand Rounds- Wednesday, following morning report
- Blue Team Meeting/Teaching Session- Thursday, 8:30-10am, meet in OR classroom
- GI Conference- Wednesday at 5pm, in Moss Auditorium
Teaching Rounds- Monday after Foley Clinic, meet on 5-Ce