Doing well in a Cardiothoracic Surgery Rotation

Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.

Approaching the Rotation

The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.

The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):

• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient

 

In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care. 

Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia,  how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.

After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student. 

In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon. 

The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.

This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care  of these patients.

Internship or PGY-1

After graduation was complete and I had finished filling out all of those thank-you notes for presents and good thoughts, I turned my attention to making preparations for my move to my residency location. Over my four years of medical school, I had accumulated loads of books and papers. The first thing that I did was toss out any papers that would not be helpful to my little sibs back at medical school. The next thing I did was get rid of the rest of my books and USMLE Prep materials. My little sibs split the lot of them.

We started packing on a small scale but quickly realized that we still had too much “junk”. I even had boxes of things that I had accumulated and had left unpacked for my previous move that had taken place at the beginning of my third year of medical school. I had moved to be located closer to the clinical affiliated hospitals to shorten my commute. A forty-five minute commute was OK for medical school because I could study on the subway but I wanted to spend no more than 20 minutes if I was going to drive.

I made a couple of trips to the location of my residency. I took one of my best friends so that we could scout out some great places to live. She helped me pick out a wonderful three-bedroom home that was located in a wooded area with plenty of jogging and bike trails. Since I have a couple of dogs, I wanted a spot where they could get some exercise and I could get outside. I found the perfect place and I loved living about 1,000 feet from a beautiful lake with woods and streams all around.

After the move, I had one day to get to orientation. I was still in the midst to unpacking on orientation day. I had completed my criminal background check and drug testing. I had also finished completing the materials for my license and smooth move to the local medical society. Orientation started early with mugs of strong coffee and plenty of folks who looked as scared as I was. We received our pagers, our lab coats and our directories. The second day of orientation is where we received our departmental information including our rotation schedule.

I started with Vascular Surgery. These patients are among the sickest in the hospital. I quickly got into the routine of rounding in the early morning (0400h), getting my notes written and then getting ready for rounding with the team. The team, which consisted of the fellows, the surgical chief resident, a mid-level resident, two interns and four medical students would then round. It was the duty of the interns to write every order and plan after we presented our pre-round findings to the fellow and chief.

The residents and students would head off to the operating room while the interns would get orders and discharges done. We would follow up on all labs and studies and then get the discharges completed. I quickly learned to “pre-discharge”, get the orders ready and then make one click to send them to the computer. The computer would print all instructions and prescriptions for me to sign. My dictations would be done at that time too.

Once the daily ward work was underway, one of us would try to get some OR cases while the other intern waited for new admissions and post-ops back from the OR. We would also follow up on all information that came from consultants and all studies as the patients returned. When the patients came back from the OR, it was my job to get them settled in and follow up on what had taken place during surgery. I would look at the OR reports, anesthesia notes and any history and physical information. I would also start a note sheet for tomorrow’s note and check all orders.

By the evening, the fellow would leave and I would report all studies and findings to the chief resident. He or she would add orders or give me the plans for the next day. If anyone was headed for surgery, they would need to have preoperative orders placed for things like nothing by mouth after midnight. Periodically during the day, I would visit each room and find out how the patient was getting along. I would also do things like debride (clean off dead tissue) wounds and follow vital signs and labs. If I was not on call, I would leave the hospital around 6pm after reporting to the on-call intern. If I was on-call, I would receive report from the services that I covered.

I had the unique opportunity of covering cardiac, thoracic and vascular when I was on call. The other interns only covered one other service and their own. At first, the cardiac patients were scary but later, I fell into taking care of them just as I took care of my own vascular patients. My patients were the sickest patients on the three services and I knew them best.

After vascular, I rotated as intern through surgical oncology and colo-rectal surgery. My program director was very impressed with my work so he decided to change my schedule to include a month as Surgical Intensive Care Unit resident. Usually, this rotation would go to a second year resident but a couple of interns managed to get this rotation. I was fortunate because the other two residents on this rotation with me were second year anesthesia residents. They taught me how to place internal jugular central lines and to float Swan-Ganz catheters. The nephrology fellow taught me to place temporary hemodialysis catheters and how to calculate fluid balance. I already know loads about mechanical ventilation but I learned even more from the critical care specialists. It was a great month for me.

I was then invited to spend a couple of months at the Veterans hospital. This was an away rotation that was totally awesome because there was so much operative experience. I honed my surgical skills and could hold my own in the ICU. My chief resident was very comfortable with my work and left me in charge of the service (as an intern no less) when he needed to go out of town. At first, it was scary but I learned that I could trust my instincts. My attending physicians were great teachers and things hummed along for me.

I went through another rotation on Vascular and then Thoracic. I made a deal with the other interns in that I would do all of the dictations and discharges if they would pull chest tubes and work out discharge planning. They hated to dictate and I had become very efficient at getting these things taken care of thanks to the VA hospital. My fellows were great to work with also. I was very comfortable calling them at home and updating. One of the most demanding fellows turned out to be one of my best teachers. He showed me how to sew down grafts.

I finished my year as Night Float intern. I covered all of the General surgery patients. There was an intern for Trauma who took care of the Trauma patients and did all admissions. If he or she was busy, I would admit patients and follow up on studies. I learned to anticipate problems and get them taken care of. I also learned to do make things happen that needed to happen. I made great friends with the night radiography technicians who would get studies completed for me and placed in front of the radiologists before I could get down to the department. They were great folks to work with.

As I headed into second year, I knew that second year would be my worst year. As a more senior resident, I would expected to play bigger role in keeping the service running. Since I would still somewhat junior, I still had a huge learning curve too. All in all, my intern year was great. Some of my chief residents and fellows were very difficult to work with but I always stepped up to the plate and got the job done.

Being a good intern is being anal about every detail of your patient’s care. It took a few months to learn the “ins and outs” of good patient care but I took careful notes and operated every chance that I could. The nursing staff also gave me high marks for getting things done and keeping the services under control. The hours are long and sometimes the work seemed endless but there was a learning point to every task. Intern year went quickly but I felt in control of my learning.