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Surgical Algorithms

Surgical Algorithms. Session # 1. Surgical Algorithms. Consults Patient Transport Rounding Turnover/Sign-out Stress Integrity. Consults. Consults “The Question”. Has the question been clearly communicated / documented? Does it appear in the consultation request, progress notes?

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Surgical Algorithms

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  1. Surgical Algorithms Session # 1

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

  3. Consults

  4. 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.

  5. Consults

  6. 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!!!

  7. Consults

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

  9. Consults

  10. Consults

  11. 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

  12. Consults

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

  14. Consults

  15. 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

  16. Consults

  17. 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

  18. Consults

  19. 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

  20. Consults

  21. 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

  22. Consults

  23. 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

  24. Consults

  25. 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

  26. Transport

  27. Transport

  28. 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!!!

  29. Transport

  30. Transport

  31. Transport

  32. 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!!!

  33. 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????

  34. Transport

  35. 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

  36. 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??

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

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

  39. 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!!!

  40. 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

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

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

  43. TurnoverSocial setting • Mutually acceptable • Conducive to exchange

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

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