Surgical Algorithms

Surgical Algorithms

• Consults

• Patient Transport

• Rounding

• Turnover/Sign-out

• Stress

• Integrity

Consults

?

Urgent/Emergent Elective

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.

Consults

?

Urgent/Emergent Elective

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!!!

Consults

?

Urgent/Emergent Elective

Consults“Elective”

• Central line placement for hyperalimentation• Hernia evaluation (not incarcerated or

stragulated)• Long term intubation for tracheostomy• Asympomatic carotid artery disease• Cholelithiasis

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

Consults“Be brief”

• Be careful not to simply regurgitate all of what is in the patient’s chart

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

Consults“Discuss”

• Talk is cheap and effective• 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

Consults

Process

look for yourself

be brief

be specific

contingencyplan teach

do not assume

carediscuss

followup

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

Transport

?

Urgent/Emergent Elective

Transport

?

Urgent/Emergent Elective

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!!!

Transport

?

Urgent/Emergent Elective

Stable Unstable

Transport

?

Urgent/Emergent Elective

Stable Unstable

Will the examalter therapy?

Transport

?

Urgent/Emergent Elective

Stable Unstable

Cause of instability?

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!!!

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????

Transport

?

Urgent/Emergent Elective

Implies stability

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

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??

RoundingGeneral Considerations

• Integral to the process of medicine/surgery

• When effective and efficient, can be an invaluable asset to patient care

• Fundamental teaching tool

RoundingResident Considerations

• Punctual

• Enthusiastic

• Proper attire

• Alert

• Communicative

• Initiative

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!!!

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

TurnoverGeneral considerations

• Highly variable

• Shared responsibility

• As work hours

• Turnovers

TurnoverPhysical setting

• Private (relatively speaking)

• Quiet

• Good lighting

• Limited interruptions

TurnoverSocial setting

• Mutually acceptable

• Conducive to exchange

TurnoverLanguage barrier

• Diversity among medical professionals

• Avoid colloquialisms

• Use linguistic checks and balances

• Review critical points

TurnoverCommunication barrier

• Direct

• Face to face

• Maximizes information channels – Expression– Posture– Eye contact– Verbal cues

TurnoverPatient information

• Identification information, location, etc…• Current medical issues• Pending tests to follow• Potential problems (family interface)• Severity of illness rating• Code status as indicated• Overall concerns • Chain of command (Attending involvement)

Fatigue

Inexperience

Fear of Failure

UnknownTime

Stress

Integrity

Thoughts/Values Actions/Behavior