End of rotation reflection- NYPQ-Surgery

During 5 weeks rotation of surgery at NYPQ, the most important thing I learned is how to determine whether a patient needs an emergent surgical management or not. Emergency surgery is designed to deal quickly with problems that can be life-threating. It involves resuscitation and stabilization of the patient by a patient management team and preparing the patient for surgery. Upon arriving at the emergency room, the emergency staff will begin to assess the person’s condition. If the patient is critically ill, treatment may begin immediately alongside the intake assessment. If needed, the person may be stabilized with medications, transfusions, intravenous fluids, other types of emergency interventions. Once the physical assessment is done and the patient is as stable as possible, diagnostic tests may be ordered. These tests include X-rays, CT and MRI scans, EKGs and lab work, which are used to see how serious the problem is. For example, a patient has abdominal pain and tenderness, tachycardia, high fever, high WBC with left shift, metabolic acidosis, and CT scan shows incarcerated hernia, and in this case, all findings are strongly suggesting strangulation is present, the patient will need an emergent surgical management. During these 5 weeks, I am engaged in pre-op care, scrub in cases, and also post-op care, and I am able to follow a patient from admission to discharge. The most important thing to know is the patient’s progress, see if the patient is improving with current regimens and care plans, which is the goal to get the patient stabilized.

For H&P, it is a little different from what I learned from internal medicine rotation. In the internal medicine, I learned that it is very important to do an order reconciliation, with home medications, last dose taken, and reconciled with current order, and for plan part, patient’s current acute issues need to be addressed first, including any consults need to be obtained, medication changes or new medications, and monitoring. If there are still multiple differentials in the list, more labs and imaging should also be included in the plan. For surgery, most patient admission usually comes from the emergency room. HPI should include the patient’s history, acute complaints, courses in the ED, lab findings, imaging results, and treatments received in the ED. It is very important to know why the surgery team is consulted, which will determine the next step of management. Because most of the cases belong to general surgery, abdominal examinations are crucial, such as any tenderness, guarding, rebound tenderness, bowel sounds, bowel movements, passing gas, and diet.

Dealing with elderly patients with multiple comorbidities for surgery is not easy. Surgery in this group, however, requires special considerations. One of the residents I followed, he told me his way to manage these patients. He said that a patient’s age should be treated as a scientific fact, not with prejudice, and no particular chronologic age is a contraindication to operation. We should pay attention to preoperative preparation, which is important because, when preparation is suboptimal, the perioperative risk increases. In addition to organs having a steady decline of the functional reserve, the presence of chronic diseases such as hypertension, diabetes, and coronary and cerebrovascular disease are more likely to be present. It is important for patients to understand the preoperative process and ask questions in order to remain informed, understand their risks, and make appropriate decisions that meet their needs and align with their wishes. For pre-op, besides pre-op tastings, patients should be given instructions on their medication schedule for the days prior to the surgery and on the morning of the procedure, and certain types of blood pressure medications such as ACEIs or diuretics, blood thinners or oral diabetes medications are often stopped before surgery.

In this surgery rotation, there is one case that I still remember. The patient is a 44 years old female with a past medical history of diet control hyperlipidemia p/w enlarging left breast mass after routine self-exam x 5 months f/u mammo and core biopsy revealed aggressive invasive breast carcinoma. The patient requires surgical therapy and staging of the left axilla. She is scheduled for a left mastectomy with sentinel node biopsy, lymphoscintigraphy, and possible axillary lymph node dissection, immediate reconstruction breast with a tissue expander, acellular dermal matrix. When we talked in the pre-op room, she told me she is a pathologist, and just moved to New York about 1 year ago. And she did not go to doctors immediately after finding the breast mass, because she thought it is a cyst or a fibroadenoma. After the procedure, the patient is being transferred to PACU and I told her about frozen results. Then the left axillary clavipectoral fascia was identified and divided. With the assistance of the probe, two sentinel lymph nodes were identified. The nodes that were removed were highly radioactive and sent to pathology for the frozen section, and the frozen section of both lymph nodes was negative for carcinoma. I think she is trying to protect herself by refusing to accept the truth about cancer is happening in her life, because with her healthcare background and the breast mass is solid, painless, non-mobile, and large. Refusing to acknowledge that something is wrong is a way of coping with emotional conflict, stress, painful thoughts, threatening information and anxiety. However, denial can be harmful in this case that prevents the patient from consulting doctors.

For my next pediatrics rotation, I will try to practice on foreign body removal from the nose, ear, or other sites, interpret growth curves, interpret immunization schedules, calculate medication dose for kids, calculate IVF bolus and maintenance, form asthma action plan, and interpretation of vital signs. If I have a chance, I also want to practice suturing and splinting in kids. In the surgery rotation, I saw a lot of patients are admitted for surgical procedures, for examples, appendectomy, cholecystectomy, mastectomy, breast lumpectomy, and thyroidectomy. For the following rotation, I will observe how clinicians interact with kids, and patient’s family members in the acute setting, and also in the NICU, how to deal with issues with worsening status, questions from family, and practice on these.

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