General Surgery Clerkship Guide

General Surgery is typically structured as a 4 to 6 week rotation, with 4 weeks spent in General Surgery. This rotation is a notoriously intense rotation, but is a great opportunity for clinical clerks to gain exposure to working a surgery environment.

There is additional two weeks spent in a Selective where you can spend in a surgical specialty (e.g. Cardiac, Thoracic, Neurosurgery, Paediatric Surgery, ENT, Urology, Plastic Surgery, Orthopaedic Surgery, Vascular Surgery etc.). Each school will have their rotation setup differently.

Here we’ll cover:

1. What is General Surgery: Definition of the specialty, common conditions seen in General Surgery and practice settings.

2. Typical schedule: See an example of a typical daily and weekly schedule in General Surgery

3. Clerkship responsibilities in General Surgery : How to get started in your orientation, what you’ll do in General Surgery (expectations and responsibilities of clerks), opportunities for learning

4. What to Bring: Dress code, essential medical equipment and optional items.

5. Documenting Patient Encounters: Tips, and types of medical documentation in General Surgery

6. How to Study during your General Surgery rotation: How to review materials, background reading before the rotation, setting aside time to study, and reading around cases.

7. Favourite Resources in General Surgery: Recommended Apps, Books and Online Resources

I. What is General Surgery?

Definition of General Surgery

General Surgery is a surgical specialty that focuses on the management of a broad range of surgical conditions, including diseases of the gastrointestinal tract, endocrine system, breast, skin and soft tissue, trauma, and critical care. General surgeons are trained to diagnose, treat, and manage surgical problems using a variety of surgical techniques, including minimally invasive and robotic surgery.

Common Conditions in General Surgery

• Obesity (management with bariatric surgery)

• Pancreas: Pancreatitis, Pancreatic Cancer

• Perforated Viscus

• Managing Post-Operative Wound Complications: wound dehiscence, delayed healing, wound evisceration, incision hernia, wound infection, ulcers, post-op fever

• Hernias: hiatial, ventral/adbominal, and inguinal hernias

• Thyroid: Nodules

• Trauma: Non-Orthopaedic trauma

  • Blunt Force trauma (MVA, fall, crush injuries),

  • Penetrative Trauma (stabbing, gunshot wound)

  • Chest trauma (rib fracture, pneumothorax, hemothorax, cardiac tamponade, myocardial contusion, traumatic aortic rupture, traumatic tracheal/bronchus rupture)

  • Head and Neck trauma

• Evaluation of undifferentiated conditions: Abdominal Pain, Abdominal Distension Abdominal Mass, Abdominal Injury, Anorectal Pain, Breast Masses, GI Bleeding (e.g. Upper GI vs. Lower GI blled) and Neck Mass,

• Acute Abdomen

• Appendicitis (acute and chronic)

• Breast Cancer

• Bowel Obstruction (Small - SBO and Large Bowel)

• Colorectal Cancer (CRC)

• Diverticulitis

• Esophageal perforation

• Gallbladder Disease: Biliary Colic, Cholecystitis, Cholangitis

• Hemorhhoids

• Ileus: paralytic ileus, ogilvie syndrome

• Inflammatory Bowel Disease

• Ischemic Bowel: e.g. mesenteric ischemia, venous thrombosis, vs. atherosclerotic disease

Common Surgical Procedures

• Appendectomy

• Bariatric Surgery: Roux-en-Y gastric bypass

• Chest tube insertion

• Cholecystectomy

• Colectomy

• Lumpectomy

• Mastectomy

• Inguina Hernia repair

• Whipple Procedure: complex GI reconstruction

General Surgery Subspecialties

General Surgery is a broad field that encompasses a variety of subspecialties. General surgeons often undergo additional training to subspecialties in these areas. Some of the common subspecialties in General Surgery include:

1. Colorectal Surgery: Colorectal Surgeons specialize in the diagnosis and treatment of conditions affecting the colon, rectum, and anus. They commonly perform procedures such as colectomies, rectal resections, and anal fistula repair.

2. Endocrine Surgery: Endocrine Surgeons focus on the surgical management of endocrine disorders, such as thyroid and parathyroid disease, adrenal tumors, and pancreatic neuroendocrine tumors.

3. Pediatric Surgery: Pediatric Surgeons specialize in the surgical care of infants, children, and adolescents. They commonly perform procedures such as hernia repairs, appendectomies, and corrective surgery for congenital anomalies.

4. Trauma Surgery: Trauma Surgeons are specialized in the management of traumatic injuries, including those from accidents, falls, and violent acts (e.g. blunt trauma, penetrating injuries, abdominal injuries)). They often work in trauma centers and emergency departments, where they provide critical care for patients with life-threatening injuries.

5. Transplant Surgery: Transplant Surgeons specialize in the surgical management of organ transplantation, including kidney, liver, and heart transplants. They work closely with transplant teams to evaluate potential donors and recipients, perform transplant surgeries, and provide ongoing care to transplant recipients.

6. Vascular Surgery: Vascular Surgeons specialize in the diagnosis and treatment of conditions affecting the blood vessels, such as aneurysms, arterial occlusions, and varicose veins. They commonly perform procedures such as endarterectomy, angioplasty, and bypass surgery.

II. Typical Schedule in General Surgery

Daily Schedule

A day in the life of a General Surgery clerk is usually long and demanding, but also rewarding. Here’s what you can expect in a sample schedule (which will vary depending on institution!):

• 5 or 6 AM: Patient Handover and Clinical Clerk Pre-rounding: Patient handover from previous night, and pre-rounding on your patients: You will typically start your day early, around 5 or 6 am, to pre-round on your patients and gather information about their progress overnight

• 7 am: Patient rounds: After pre-rounding, you will attend morning rounds with the surgical team, where you will present your patients, discuss their care plans, and receive feedback from attending surgeons and residents.

• 8 am: Clinic or Operating Room:

  • Assist in the Operating Room: Once rounds are finished, you will spend most of the day in the operating room, observing and assisting in surgical procedures, and learning from the surgical team.

  • Attending Clinic: Here you’ll see, assess and manage patients in a surgery clnic. Here patients usually receive outpatient care for surgical procedures that do not require an overnight stay in the hospital. The clinic may offer consultations, diagnostic tests, preoperative evaluation, and postoperative follow-up care.

Other Daily Activities

• Occasional Teaching: In the afternoon, you may have time to attend lectures, grand rounds, or case presentations, depending on the schedule of your institution.

• Completion of Documentation: After finishing your clinical duties, you will need to complete your documentation, which may include writing SOAP notes, operative notes, post-op notes, and inpatient round notes.

• Responding to calls from the ward: Clinical clerks may also be expected to respond to pages from the ward during the day (outside of overnight call). Responding to issues on the ward refers to the daily care and management of patients who are admitted to the surgery ward. If there are missing medication orders, requirement for consults, changes in patient’s status (on exam, on labs, etc.). This allows for prompt prevention and response to complications from surgery or medical conditions that surgery patients may develop during their hospital stay.

III. Clerkship responsibilities in General Surgery

Getting started in General Surgery

Starting your General Surgery rotation can be an exciting but daunting experience. On your first day/week, you can expect to receive an orientation that will help familiarize you with the environment, schedule and expectations of the rotation. This orientation can include a tour of the hospital, an overview of the schedule including start and end times, and an introduction to the surgical team.

Here are a few additional tips to help you get started on your General Surgery rotation:

• Introduce yourself to the surgical team: Make a good first impression by introducing yourself to the surgical team, including the attending physician, resident, nurses and other staff members. Be polite, respectful, and professional, and take the time to learn everyone’s name and role in the surgical team.

• Understand the flow and expectations of the rotation: Each General Surgery rotation can have its own unique flow and expectations. Be sure to clarify what is expected of you as a clinical clerk, whether you will be observing/assisting in surgeries, participating in rounds, seeing patients, or performing procedures.

• Get familiar with the Electronic Medical Records System (EMR): General Surgery rotations will likely use an EMR system to document patient information. Be sure to familiarize yourself with the EMR system that is used in the hospital or clinic where you will be working. This can include systems like EPIC and Meditech. This can include learning how to input orders, document patient encounters, and access radiology reports (e.g. through Coral)

What you’ll get to do in General Surgery

• See and assess patients: General Surgery clerkship is not just about observing other providers providing care. You should be seeing and assessing patients daily with hands-on experience, under the guidance of a preceptor.

• Patient History Taking: Taking a comprehensive or focused history with patients is essential in General Surgery. You will learn how to ask the right questions to obtain pertinent information about a patient's medical history, family history, and current condition. This skill will help you to identify potential complications and develop a treatment plan.

• Physical Examinations: You will learn how to perform comprehensive physical exams, including focused exams for specific conditions (e.g. acute abdomen, abdominal exam, pelvic exam for women and testicular exam for men). This will help you to identify potential complications and develop a treatment plan.

• Order and interpret investigations: You will learn how to order and interpret a variety of investigations specific to surgery, including labs, imaging, and diagnostic tests (abdomen x-ray, CT, etc.).

• Management of General Surgery patients - pre-operatively, intra-operatively and post-operatively: You will learn how to manage a variety presentations that General Surgery patients present with before, during and after surgery. Management can be on the ward, managing drains, managing post-operative complications (e.g. fever, shortness of breath, pain management after surgery). You will also learn how to educate patients on healthy lifestyle changes and refer them to appropriate resources within the community.

• Case Presentations: You will be expected to present cases to your preceptor. This will help you to develop your clinical reasoning and decision-making skills.

• Medical Documentation: You will learn how to write progress notes on your patient encounters using the SOAP note method for progress notes, writing surgery admission orders, discharge orders and consults.

• Medication review/reconciliation: You will learn how to review patients' medications, compare past and current regimens, ensure correct doses, and rule out potential interactions that can cause adverse side effects. Antibiotic stewardship can play a role too.

• Observing or assisting in the operating room: Under surgeon physician, you may assist in the operating room during surgical procedures. This includes retracting tissues, suctioning fluids, cauterizing bleedin vessels, helping to close the incision (see tips below on learning to suture/stitch), wound dressing, placement os drains and transfer to the recovery room.

• Rounding on patients

  • Pre-rounding on patients and gathering information about their progress overnight

  • Attending morning rounds and presenting your patients to the surgical team

• Performing On-Call Duties: You may hold the pager once every 4-6 shifts overnight to perform on-call duties for the General Surgery service. This is usually done in conjunction with a resident, fellow and on-call staff surgeon. See below for tips!

On-Call

When “On-Call” the General Surgery service is available to provide urgent medical care and surgical interventions. This can include being on call during the day, evenings, overnight or on weekends.

As a clinical clerk, when you hold the pager, you will be responsible for evaluating patients who present with acute surgical conditions, such as trauma, acute abdominal pain, or acute infections. The patients that you evaluate may eventually require performing urgent surgeries or procedures, such as emergency appendectomies, wound debridement, or bowel resections.

In addition to emergency interventions, being on-call may also involve providing consultation and advice to other healthcare providers (e.g. radiologists or intensivists) on the management of complex surgical cases to coordinate care for critically ill patients.

On-Call Issues addressed on the Ward

Here is a checklist of different potential ward issues you may be called for when on-call:

• Insomnia

• Leg Pain

• Mental status changes

• nausea and vomiting

• pain management

• Post-operative bleeding

• Seizures

• Shortness of Breath

• Syncope

• Tubes and Drains

• Urine output changes

• Wound complications: dehiscence, evisceration, stitch abscess

• Abdominal Pain

• Constipation

• Diarrhea

• Drug Reactions/Withdrawal

• Dysrhythmias

• Falls

• Fever

• Fluids, Electrolytes, and Acid-Base Balance

• GI bleeding

• Glucose management

• Headache

• Hypertension

• Hypotension and Shock

Recommended Book for On-Call!

Our favourite reference to respond to on-call issues you may receive on the ward including is On-Call: Surgery by Adams.

Opportunities for Learning in General Surgery

As a clinical clerk in general surgery, you will be expected to expand your medical knowledge related to the field of surgery.

This will involve learning about the common surgical procedures, the indications for surgery, the pre-operative and post-operative management of patients, and the potential complications associated with different surgical procedures. You will be expected to participate in rounds, attend teaching sessions, and read relevant textbooks and journals to enhance your understanding of surgical principles and practices.

To help you in this process, you can use your academic half day each week to read around cases, review common presentations in surgery, and learn about the latest advancements in the field. This will not only be helpful on your End of Rotation exam (EOR), but also when you practice it the future, knowing when to refer patients to this service and specialty clinics.

You can also:

• Participating in patient care conferences and case discussions

• Attending lectures, grand rounds, and seminars related to General Surgery

• Reading up on the relevant literature and discussing cases with your team

• Participating in research projects and quality improvement initiatives

A note on “pimping”

In medical education, "pimping" is a teaching technique where a senior physician, often the attending or chief resident, asks rapid-fire, pointed questions to a medical learner, such as a PA/medical student or resident, to test their knowledge and understanding of a particular topic.

Example “pimping questions” that can be asked in General Surgery:

• What are the 9 layers to the abdominal wall?

• What are the potential side effects of ERCP?

• What are the three branches of the celiac artery?

• What is the most common cause of small bowel obstruction?

• How do you diagnose a patient with acute appendicitis?

• What are the indications for a laparoscopic versus an open cholecystectomy?

• What is the difference between an ileostomy and a colostomy?

The term "pimping" has a negative connotation and can be stressful for the learner, as they may feel embarrassed or intimidated if they do not know the answer to a question.

However, the intent of pimping is to teach and reinforce important concepts, and it can be an effective way for medical learners to solidify their understanding and improve their performance.

Tips on How to Approach a Pimping Question

• Stay calm: It's natural to feel nervous when you're being questioned, but try to stay calm and composed. Remember that the person asking the question is trying to help you learn.

• Listen carefully: Listen carefully to the question being asked. Make sure you understand what is being asked before you start answering.

• Be concise: Answer the question in a clear and concise manner. Avoid giving extraneous information that is not relevant to the question.

• Don't be afraid to say "I don't know": If you don't know the answer to a question, don't try to guess. Instead, say "I don't know" and ask for clarification or for the answer.

• Show your thought process: Even if you don't know the exact answer, try to show your thought process. Explain how you would approach the question and what factors you would consider.

• Be respectful: Remember to be respectful and professional when answering pimping questions. Even if you feel like you are being put on the spot, maintain a positive attitude and treat the person asking the question with respect.

• Remember the answer - sometimes the preceptor will ask you the question again in the future!

IV. Structure of General Surgery

General Surgery encompasses a broad range of clinical areas, each with its own unique set of responsibilities and challenges. Some of the common clinical areas that clinical clerks may encounter during their General Surgery clerkship include:

1. Operating Room (OR): In the OR, General Surgeons perform a wide range of procedures, from minor outpatient surgeries to complex, life-saving operations. As a clinical clerk, you may have the opportunity to observe surgeries, assist with procedures, and learn about surgical techniques and instruments.

2. Inpatient Rounds: General Surgeons typically make daily rounds on their hospitalized/post-op patients to assess their progress, adjust their treatment plans, and communicate with the healthcare team.

3. Outpatient Clinics: General Surgeons also see patients in their outpatient clinics to diagnose and manage a wide range of surgical conditions, such as hernias, gallbladder disease, and skin lesions. During your clerkship, you may have the opportunity to observe clinic visits, take patient histories, and assist with minor procedures.

4. Consults in Emergency Department (ED): The General Surgery service also responds to request for consults from the ED, and often respond to emergency situation, such as acute abdominal pain, trauma, or bleeding.

5. On-Call: General Surgeons are frequently on-call, meaning they must be available to respond to urgent or emergent surgical needs at any time, day or night. During your clerkship, you may have the opportunity to accompany the surgeon on-call, observe the management of acute surgical cases, and learn about the principles of trauma management and critical care.

V. What to Bring

Dress code

General Surgery is a professional environment, and as such, you should dress professionally. This means wearing scrubs or business attire with or without white coat, depending on the expectations of your institution.

Essential medical equipment

You should also come prepared with the appropriate medical equipment, including a stethoscope.

Optional Items

• Pocket-sized notepad and pen to take notes and jot down reminders

• Pocket reference books or electronic resources (mobile apps, online references) related to General Surgery (see favourite resources below!)

• Suture Practice Kit with suturing tools, silicone suture pad and suture thread and needles

VI. Surgery Documentation

Here we share a basic outline/template of different types of orders and documentation you may see on the General Surgery service.

You can use the examples shown here as reference, however, it’s best to see what the standard for documentation is at your particular hospital/service and use that format.

Typical Surgery Documentation

• Consult note/Pre-Op Assessment: This is a standardized form that is completed prior to the surgery, usually during the patient's pre-operative visit. It includes a comprehensive medical history, physical examination, and relevant investigations. The purpose of this documentation is to ensure that the patient is medically optimized for the surgery and to identify any potential risk factors.

• Operative Note Template: This is a documentation of the surgery that was performed, which includes details about the procedure, any complications encountered during surgery, and any other relevant information

• Post-Operative Note: This is a documentation of the patient's post-operative course, which includes information about the patient's pain management, vital signs, any complications that may have arisen during surgery, and the patient's overall condition.

• Surgery Progress Note: A brief note that uses the SOAP format to track the progress of the patient while in hospital post-operatively.

• Discharge Summary: This is a documentation that summarizes the patient's hospitalization, including the reason for admission, the course of treatment, and any significant events that occurred during the hospital stay. It also includes information about any medications prescribed at discharge, follow-up appointments, and any recommendations for ongoing care.

See below for templates and examples of surgery documentation.

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Pre-Operative Note

• Pre-Op Diagnosis:

• Procedure Planned:

• Staff Surgeon:

• Pre-Op Exam:

• Pre-Op Labs:

• Home Medications:

• Bowel Preparation (if applicable)

• Antibiotic Prophylaxis:

• VTE Prophylaxis

• Surgical Consent Statement

Example of Surgical Consent Statement

Patient consented for cholecystitis surgery. Risks, benefits, complications and post-operative recovery were discussed in detail. Questions were answered to patient’s satisfaction and patient has elected to proceed as planned. Consent has been signed, and patient has been placed on list for surgery.

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Brief Operative Note

• Pre-Op Diagnosis: Provide the diagnosis recorded prior to surgery taking place.

• Post-Op Diagnosis: Document any changes to the diagnosis after surgery

• Procedure: Include the name of the procedure performed

• Surgeon: Name of the surgeon who performed the procedure

• Assists: List the names of any surgical assistants who were involved in the procedure (include name and designations)

• Anesthesia: Name of anesthesiologist/anesthesia assistant (AA) and type of anesthesia used (e.g. General, Regional)

• Blood Loss: Estimated Blood Loss during surgery, usually the circulating nurse will announce this (e.g. minimal or 125 cc EBL).

• Complications: Include any complications or issues that arose during or after the surgery.

• Drains: List the drains

• Plan/Post-Procedure Care:

  • Disposition : Document where the patient will be transferred to after the surgery (e.g. PACU to the floor or PACU to day surgery unit)

  • Orders for PACU: Include any orders for fluids, pain medications, or other treatments that are required for the patient's immediate post-operative care in the PACU

Example Post-Op Note for Cholecystectomy Patient

GENERAL SURGERY OPERATIVE NOTE

• Pre-Op Diagnosis: Acute Cholecystitis

• Post-Op Diagnosis: Acute Cholecystitis

• Procedure: Laparoscopic Cholecystectomy

• Surgeon: Dr. ____

• Assists:

  • Jane Langhorn, PA-S2

  • John Doe, PGY3.

• Anesthesia: Dr. Y, General Anesthesia

• Estimated Blood Loss (EBL): Minimal

• Complications: None

• Drains: None

• Plan:

  • In PACU:

  • Vital Signs q15 min first hour, q30 min next 2 hours, then vital signs routine thereafter

    1. O2 nasal cannual @ 2L/min

  • Transfer from PACU to 9B Floor

  • Acute Pain Service consult for pain management

  • Sips to Diet as tolerated

  • WBAT and AAT

  • Incentive spirometry every hour while awake

  • No VTE prophylaxis

  • Discharge when tolerating regular diet, WBAT independently, and pain well controlled on PO pain meds

Jane Langhorn, PA-S2
Clinical Clerk, General Surgery

In service of: Dr. ______

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Surgery Progress Note for a Post-Op Patient

A surgery progress note (when rounding on your patients) should follow the SOAP format and include the following information:

• ID: post op day (POD) # (number of days from surgery), reason for admission, surgery performed

• Subjective: problems identified overnight by the patient and overnight nursing staff (such as changes in vital signs, pain, or complications)

  • Diet: This refers to the patient's current dietary status and any restrictions or modifications that have been made

  • Pain/analgesia: This refers to the patient's level of pain and the medications being used to manage it

  • Urine output: This refers to the amount of urine the patient is producing, which can be an indicator of fluid balance and kidney function

  • GI function (flatus/BM): This refers to the patient's gastrointestinal function, specifically whether they have been passing gas or having bowel movements

• Objective:

  • Focused physical exam: This includes a targeted physical examination to assess the patient's current condition. Comment on surgical incision site, dressing.

  • New labs/imaging: Any new laboratory tests or imaging studies that have been ordered or obtained should be documented

• Assessment and Plan: Your overall assessment and current management plan. This refers to the current plan for the patient's care, including any changes that have been made since the last rounding.

ID: 54M POD#2 Lap Cholecystectomy for acute cholecystitis (DOS: January 15, 20__ by Dr. ___)

S:
- Mild incisional pain, well controlled with Acetaminophen
- No nausea/vomiting
- Diet returned to baseline
- passing gas, and BM earlier today
- Urinary output adequate

O:
On exam:
AVSS
- Incision clear, dry, intact - with no signs of infection
- No erythema, drainage or tenderness
- Bowel sounds present in all four quadrants
- Able to WBAT without assistance

Ix: Hb 104 (pre-op 120). Lytes otherwise normal.

A/P: Recovering well.

1. Pain: Continue Acetaminophen PO for pain

2. Activity: Continue WBAT

3. Diet/Fluids: Increase fluid intake as tolerated

4. Disposition: Discharge home in 1 day. Follow-up in clinic 2 weeks post-op for stitch removal and re-assessment

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VII. Writing Surgery Orders

Writing a surgery order means providing clear and detailed instructions to the surgical team about the patient's specific surgical procedure and details/instructions for patient’s care before, during and after surgery. This may include medications, labs/investigations, consultations with different services, blood products, fluids, activity level and more.

These orders can be “hand written”, or inputted electronically in an electronic medical record system. Surgery orders can also be part of an order set which is a pre-established set of orders and protocols. Order sets can be used as “checklists” to ensure all steps are taken to optimize patient outcomes and minimize complications.

Examples of Surgery Orders include:

• Admission/Pre-operative orders: These orders are written prior to the patient undergoing surgery and are designed to prepare the patient for the operation.

  • Admission orders typically include orders for diagnostic tests (e.g. bloodwork, imaging studies), consultations with other specialists (e.g. cardiology, pulmonology), and medications (e.g. antibiotics, prophylactic anticoagulation).

  • Pre-operative orders typically include orders for fasting, bowel preparation, and medications that may be required before the surgery (e.g. sedatives, anxiolytics).

• Post-op Orders: These orders are written after the patient has undergone surgery and are designed to manage the patient's post-operative care. Post-op orders typically include orders for pain management (e.g. analgesics), nausea/vomiting management (e.g. antiemetics), deep vein thrombosis (DVT) prophylaxis (e.g. compression stockings, anticoagulants), wound care, and mobilization orders. The orders will vary depending on the type of surgery performed and the patient's medical condition.

• Discharge orders: These orders are written when the patient is ready to be discharged from the hospital. Discharge orders typically include instructions for wound care, medications that the patient will need to continue taking at home, follow-up appointments with the surgical team, and any activity restrictions. The discharge orders should also include clear instructions for the patient on what to do if they experience any complications or concerns after they leave the hospital.

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Admission Orders (AD DAVID mnemonic)

ADDAVID is a mnemonic that can be used to remember the essential components of admission orders for a patient in the hospital setting. Each letter in the mnemonic represents a different component of the orders:

• Admit

• Diagnosis/DNR

• Diet

• Activity

• Vitals

• Investigations

• IV fluids

• Drugs: 5 P’s: pain (analgesic), puke (antiemetic), prophylatic (anticoagulants), pus (antibiotic), previous meds.

Example Admission Orders for Acute Cholecystitis requiring Imminent Surgery

1. Admit to General Surgery service floor 9B , under MRP: Dr. ____ (Admission)

2. Dx: Acute cholecystitis (Diagnosis)

3. Diet: NPO (Diet)

4. AAT (Activity Restrictions)

5. Vital signs routine q4h (Vital Signs)

6. Ix: CBC, extended lytes (redraw potassium if abnormal), POCT Glucose, ESR, CRP, Abdo XR (Investigations)

7. IV NS 75 cc/hr (IV Fluids)

8. Tx:
   (Drugs, 5 Ps)

   1. Ibuprofen 800 mg PO one dose on admission (Pain)

   2. Antiemetic (Puke - antiemetic)

   3. 2g IV Ancef one dose to be administered on induction (Pus - antibiotic prophylaxis)

   4. Continue home meds including [list home meds with dosages, frequency] (Previous Home Meds)

Jane Langhorn, PA-S2
Clinical Clerk, General Surgery

In service of: Dr. Y

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VIII. How to Study during your General Surgery rotation

Review Materials

At the beginning of your rotation, review the core materials and textbooks that are relevant to General Surgery. This will help you establish a strong foundation of knowledge and familiarize yourself with common surgical procedures and conditions.

Here’s a checklist of what to review:

• Approach to undifferentiated Abdominal Pain (History taking)

• Common surgical conditions: such as appendicitis, cholecystitis, diverticulitis, and bowel obstruction. See the first section for a comprehensive list.

• Surgical Anatomy and Common Surgical Procedures: Read about relevant anatomy, and purpose of the surgeries. Be sure to read around indications, contraindications and potential complications.

• Physical Examination

  • Abdomen

  • Pelvic exam (females)

  • Testicular exam (males)

• Post-operative care: including wound care, pain management, and monitoring for complications.

• Suturing skills: See tips below on how to practice!

• On-Call Surgical Problems: Read around issues you may be paged about when on-call, this can include: abdominal pain, bowel function (constipation, diarrhea), chest pain, drug reactions, dysrhythmias, falls, fever, fluid, electrolyte and acid-base balance, GI bleeding, glucose management, nausea vomiting, pain management, SOB, syncope, tubes and drains, urine output changes and wound complications.

Reading Around Cases

As you encounter patients with various surgical conditions, take the opportunity to read around the cases to deepen your understanding of the pathophysiology, diagnosis, and treatment options. This will help you contextualize the information you're learning and apply it to real-world scenarios.

Attend Teaching Rounds

If your institution offers lectures and conferences related to General Surgery, take advantage of them to supplement your knowledge and learn from experts in the field.

Seek Feedback and Guidance

Throughout your rotation, seek feedback and guidance from your supervising physicians and other healthcare providers. This will help you identify areas for improvement and tailor your learning experience to your individual needs.

Learning to Suture

Suturing is one of those skills where you learn by doing. See if you can obtain some suturing equipment and tools during your surgery rotation, or you can grab a suturing kit online that you can use to practice at home.

• Observe and practice: Observe experienced surgeons, residents, fellows or other experienced staff as they suture, and ask them to provide feedback as you practice. You can also use online resources, such as videos and tutorials, to supplement your learning.

• Start with basic suturing techniques: Begin by learning simple interrupted sutures and progress to more complex techniques, such as continuous sutures and subcuticular sutures, as you become more proficient.

• Use the right equipment: Ensure that you have the correct instruments, such as a needle holder and forceps, and the appropriate suture material for the type of tissue you are suturing. You can ask the perioperative nurses if there’s any extra suturing tools you can take home to practice (e.g. expired sutures).

• Practice on a variety of materials: Practice suturing on a range of materials, such as foam blocks, chicken breasts, and pig feet, to simulate different tissue types.

• Build muscle memory: Repetition is key to building muscle memory and improving your suturing skills. Practice consistently and regularly to build your confidence and proficiency.

• Get feedback and reflect: Seek feedback from experienced surgeons or colleagues to help identify areas for improvement. Reflect on your performance and adjust your technique accordingly.

• Attend suturing workshops: Attend suturing workshops and surgical skills courses to supplement your learning and gain hands-on experience in a supervised setting.

IX. Favourite Resources in General Surgery

General Surgery Apps

• Teach Me Surgery Mobile App: encyclopedia covering over 400 surgical topics in a visual and easy to read format. Includes topics on General Surgery and Basic Surgery Concepts.

• UptoDate: If your school or institution has access, see if you can get this set up on your phone!

• MDCalc (free): Over 275 calculators for health care providers to calculate algorithms, scores and risk.

• Firstline (Institution specific antimicrobial approach/Antibiotic Steward): An app which provides guidelines on which antibiotic to use against certain pathogens based on profile of your area. You can look up data and guidelines including biogram data by antibiotic, dosing (afdults and peds), and by pathogen. (e.g. Firstline is used by a few hospitals in Alberta Health Sciences, Manitoba, CHEO - Ottawa, SickKids - Toronto, Joseph Brant Hospital - Burlington and more).

Surgery Pocket-Medical Reference

• On Call Surgery by Adams: An easy to follow approach to common on-call ward issues you may need to respond to as a clinical clerk on-call for General Surgery. It includes items specific to General Surgery including Pre-Op preparation, and antibiotic prophylaxis for common surgical procedures.

• Surgical Recall: Helpful for clinical clerks during a General Surgery rotation, as it provides a quick review of high-yield surgical knowledge and commonly asked pimping questions.

• Case Files Surgery: This book presents clinical cases in a format that mimics patient presentations, thereby allowing clinical clerks to develop clinical reasoning skills and learn key concepts in surgery.

Surgery Textbooks

In general, you do not have to obtain large surgery textbooks to get through your rotation.

However if you do have access to these books through your university or hospital library (electronic or physical copies), try to find these texts:

• Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice: provides an in-depth understanding of the basic and advanced principles of surgery

• Schwartz's Principles of Surgery: comprehensive textbook that covers the fundamental principles of surgery.

• Current Diagnosis and Treatment: Surgery: is a comprehensive resource that provides a concise overview of surgical diseases and treatments, making it helpful for quick reference and review during a General Surgery rotation.

Online Resources

• Best Practices in Surgery by University of Toronto: Clinical Practice Guidelines in Surgery: Provides guidelines on treatment of surgery patients including pre-op fasting, enhanced recovery after surgery, surgical site infection and different implementation tools.

• Medscape Surgery (free with login): A comprehensive online resource for surgical news, articles, and medical education covering common surgical conditions of the abdomen, colorectal, glands, head and neck, lymphatic system, thorax and wounds.

• The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): Offers a wide range of resources on minimally invasive surgery.

• Teach Me Surgery: Cover core concepts like basic surgical skills, peri-operative care, clinical exams, and foundations in General Surgery.

Journals

• Annals of Surgery: A leading surgical journal featuring peer-reviewed research and expert commentary.

• Journal of the American Academy of Physician Associates (JAAPA): Surgery Collection: A monthly peer-reviewed medical journal that focuses on providing up-to-date clinical information, research, and professional development for physician assistants (PAs) and other healthcare professionals. Here PAs share experiences and insights on clinical practice, education, and research.

• Journal of the American College of Surgeons (JACS): Covers all aspects of surgery, including clinical and basic science research, education, and advocacy.

Final notes

General Surgery is a demanding specialty that requires a strong foundation of knowledge, attention to detail, and effective communication skills.

By prioritizing patient care, seeking guidance and feedback from experienced clinicians, and taking advantage of the many resources available to you, you can emerge from your clerkship with a solid understanding of the specialty and the confidence to take on new challenges!