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.

Physical Diagnosis (You get to play with your toys!)

Most medical students take a Physical Diagnosis class during their second year. This course teaches history taking and the skills necessary for performing a complete physical examination. Back in my second year of medical school, I found this course a bit intimidating in terms of what the syllabus outlined for us to accomplish in a few short weeks. Little did I realize that I had most of the tools that I needed to do well in this class, namely, an insatiable curiosity, a good ear, two good hands and total interest in my patients.

 The first lecturer emphasized that we would get 90% of what we needed to make a diagnosis from a good patient history. “Good” was the operative word here because as one sits and reads the “how-to” of taking a medical history, it seems that there is an abundance of information that we must obtain in the patient interview while writing a couple of notes here and there. How would I remember every detail? What happens if I forget something important? What if the patient lies to me? How am I going to figure out what a comatose patient needs? Those were just a few of my concerns in addition to looking at my opthalmoscope and trying to figure out how I would ever get the “hang” of making this forbidding tool useful in my practice.

One day of the week, we would spend the afternoon in the hospital with our preceptors. My upperclassmen friends looked at the name on my paper and said that I had “hit the jackpot” with my preceptor assignment. My preceptor was a master diagnostician and an excellent teacher too. He was an endocrinologist who specialized in metabolic syndrome, a disorder that runs largely unchecked in most medically under-served populations because of poor diet and lack of physical activity. I was excited to get my practical knowledge underway with  my new preceptor. My preceptor had two medical students assigned to his service at the same time. It turned out later that the other student rotating with me was my rotation partner for all of third year so we were great friends and become even closer.

We met our preceptor in his office and he led us to one of the medicine floors in the hospital. He had made a short list of his patients who were willing to have us use them for our history-taking practice. I entered the room of a middle-aged gentleman who was hospitalized for jaundice. I quickly went thorough my script of questioning this very soft spoken man who lay quietly in bed. I came to find out that he was a physician who had been diagnosed with a biliary disorder that would kill him without a liver transplant in the next two weeks. He was kind and patient as I asked all of those questions about family history, social history, medications and the like. He asked me to stop by later that evening and read my historical write-up back to him. When I stopped by, he helped me organize the information and provided invaluable assistance in thinking about how to question patients. We chatted off and on for a week, until he received the word that he was being transferred for his liver transplant. I saw him three weeks later when he was ready to leave the hospital with a new liver, a new life and such joy!

I practiced with  my stethoscope on my own chest. It became very satisfying to lie in bed at night and listen to my own heart sounds. I listened to each sound appreciating the tones and timing. I also listened to my breath sounds, over the trachea, over the bronchi and over the lung parenchyma. I practiced listening to each heart valve and learned to appreciate the subtle differences between the sounds a the pulmonic site versus the sounds at the mitral site. I appreciated the split in my second heart sound with my respiratory cycle. If I could appreciate the subtleties of my own chest, I would be able to pick out abnormalities on my patients.

That pesky opthalmoscope was the biggest hurdle that I had to cross. The first thing that I did was learn to operate the light and aperture. Since I have no visual defects, I always start with the diopter setting on 0. I also quickly learned the utility of performing this examination in a dim room as bright light makes the patient’s pupils quite constricted. A dilated pupil is easier to examine. The other useful piece of information is to start with the opthalmoscope light dim so that you don’t blind the patient while you are attempting to examine the retina. At first, I could just pick out the “red reflex”. Soon, I found a vessel and later, I learned to focus sharply on those vessels and follow them to the optic disks. In short, there is a learning curve that is most quickly overcome if you force yourself to examine the retinas of every patient that comes into your office. If you don’t practice, you won’t learn to do an adequate examination. I would wager that most physicians out in practice today, other than the ophthalmologists and neurologists, do not perform an adequate retinal exam.

When it came to learning the rectal, pelvic and breast exams, we were taught by professional “patients”. These people knew the exams and used their own bodies to teach medical students. On the pelvic exam demonstrations, one of the demonstrators indicated that she was in the middle of her menstrual cycle. One of the male students in my group, left the room and never returned. I never found out how or if he learned to perform a pelvic examination but those demonstrators were excellent. They allowed us to practice and pointed out landmarks and hints that were invaluable. I found myself thinking about the type of person who is willing to become a professional demonstrator of breast, pelvic and rectal exams. While the job pays well, I would have to cross it off of my list of things to do if I needed loads of money quickly.

The neurological examination is the most fun to perform and write up. I found myself collecting an odd assortment of instruments to test sensations of hot and cold (I used capped test tubes filled with tap water); vibration (tuning fork), smell (alcohol pads, nail polish remover pads); color sensation (photos); light touch (feathers of various colors) and sharp versus dull (paper clip). I had a small bell and a small stuffed kitten as objects for my patients to name. I also collected a tape measure for lesions and an assortment of cotton swabs and tongue blades for cranial nerve testing.

I learned to perform my history while I was performing my physical examination. I would start with the head and ask about problems with headache, earache and vision. I would examine the eyes and nose while asking about sinus problems. I went from head to toe asking questions as I moved along. I always save invasive exams like pelvic and rectal for the end of the exam. While the patient is getting dressed, I would jot down my pertinent positive findings and spend the rest of the time chatting with the patient and explaining my findings. At this point, my preceptor would usually join me and we would discuss the treatment plans for the patient together.

The most important thing that I learned in this class was the value of communicating with your patient. I probably learned more from my patients than they learned from me. I learned to listen to their words and put their words and my physical findings into a cogent clinical plan for treatment. I also learned the importance of just getting to my patient’s fears, concerns, likes and dislikes. When a physician touches a patient, there is a relationship of trust that is begun. Your patient trusts that you will use everything that you have learned in biochemistry, anatomy, pathology, pharmacology and physiology to figure out what you can do to get them healthy and keep them healthy. There is a puzzle and the pieces must be fit together for the good of the patient.

I also came to appreciate the sanctity of the apprentice-mentor relationship that I had developed with my preceptor. In no other profession is that relationship so important than the attending physician/medical student. My preceptor was indeed a master and I was a very willing student. He led me through the maze of various patient encounters and kept me coming back for more. It was truly magical in many ways.

Finally, I mastered that opthalmoscope during the last week of my Physical Diagnosis class. I was quite comfortable with my exam and I appreciate the art of being able to make a diagnosis. While this class seemed to be quite intimidating at first, it became one the the sentinel courses in my medical school experience. After five plus years of practice and thousands of patients later, I wonder if my preceptor knows how many thousands of patients he has touched through all of his students.

Surgical Clerkship 101 (Part 2)

This is the second of a three-part series to help you get the most out of your third-year surgical clerkship. Since this is one of the most important required clerkships, I thought I would spend some time on this one. The subject matter of this essay will be scrubbing and assisting in the OR along with handling some of the “pimp” questions that frequently come during the cases.

Your first tour at the scrub sink need not be intimidating as long as you keep a couple of things in mind. First, you need to be dressed properly. By proper dress, I mean clean hospital scrubs with no T-shirt sleeves below the level of the scrub sleeve. You need to have your hair completely covered (no bangs sticking out ladies) by scrub cap or “shower-type” cap.  These caps should be clean and ideally, disposable. You need to have eye protection that covers all around. The goggle-type glasses are the best but you can pick up the disposable “Angel Frames” which are better than nothing at all. Blood spatters in the eyes are no laughing matter and you need to be protected. After your eye protection is in place, you must don a mask that completely covers your mouth and nose. If you have a beard or large bushy mustache, you can wear one of the hooded type devices that serve as both cap and mask. Finally, you need to don shoe covers that completely cover your shoes including the laces. Blood and other fluids often drip down onto your shoes. If you have shoes without laces, so much the better. I have shoes that I do not wear outside the OR that I cover with two pairs of shoe covers. When I am done with the case, I dispose of the outer cover and keep the inner cover for the recovery room.

You need to put on your hat and shoe covers before you enter the operating suite. These are usually at the door or near the door of the locker room and within easy reach. You need to be sure that your scrubs are clean before you leave the locker area (no blood or coffee). At the scrub sink, you need to don your mask and eye shields. Make sure that your mask is under the rim of your eye shield and tight. If moisture gets through, your eye shields will fog during the case and you won’t be able to see. Place a small piece of tape if you can’t crimp the mask for a custom fit. (Some people will tie a face shield-type mask upside down on their forehead to prevent fogging. This works well and you don’t need the eye shields if you do this. Another advantage of the upside-down face shield is that the rolled up mask part acts like a wick if you sweat or are doing a peds case in a very warm room. Before you begin to scrub, go into the operating suite, introduce yourself to both the circulator and scrubbed personnel and write your name on the board and your level (MS-III). Also, if you are wearing a pager, place this on the desk with a pen/small note pad clipped to it. You can’t answer your pages when you are scrubbed in a case. Obtain your gloves and gown and place them on the table where the circulator can open them and hand off to the scrubbed assistant. Be sure to obtain both pairs because you want to be double gloved. Be sure you have chosen the correct size (have one of the nurses/techs size you if you don’t know). I wear size 7.5 gloves (big hands) I place my 8 undergloves next to my skin and put size 7.5 on top. Gloves that are too tight will be miserable on a long case. Gloves that are too loose do not permit good tactile skills such as suturing.

Once your mask, hat and eye protection are in place, you should be standing in front of the scrub sink. There are two types of soap solutions available (the waterless and water requiring). If you use the waterless scrub, make sure that you have done at least one water-based scrub before you use this material. On vascular cases, I never use the waterless scrub alone and usually do a full scrub between cases. If a graft gets infected, the patient usually dies from that infection. I take no chances and always err on the side of caution. If you are allergic to iodine (and I am allergic to iodine) don’t use the povidine solution for scrubbing. You should have gone through a “scrub class” before you actually scrub but the short version is here.

Take the nail cleaner and scrub brush from its packet. Turn on the water with your foot (may be automatic) and wet your hands and arms starting with the hands and going up to the elbows. Be careful not to touch the faucet. Use the nail cleaner to clean under each nail and dispose of it. Scrub each surface of each finger with plenty of soap and the brush. Divide your arms into four quadrants and clean them using 25 strokes for each finger surface, the nails of each hand, the surface up to the elbow. Once you have scrubbed an area, don’t re scrub. Toss the brush into the trash can and rinse starting with the hands and letting the water drip at the elbows. Keep your hands up at all times. If you accidentally touch the faucet, start over with the scrub.

You will drip water but hold your hands up and open the door of the operating room with your rear end. The scrubbed person will give you a sterile towel. Allow them to drape this towel over your wet hands. Grasp the towel at one end with one hand and dry from hand up to elbow. Take the other end and do the same. Drop the towel across the laundry hamper or where you are told to drop it. You hands should be dry and continuously held up. The scrub person will hand you a gown or drape a gown over your shoulders (stand still and close enough) pulling up the sleeves. The circulator will tie the gown. The scrubbed assistant will place your under glove on your right hand (left first at Mayo) and then you use your index and long finger to stretch the second glove so that you can place it on your second hand. This is repeated for you outer glove.

 You then “spin” and tie the outside ties of your gown. At this point, if you are not doing anything, cross your arms and stand out of the way. The resident and attending surgeon will be draping the patient and will tell you where to stand and what to do. Keep your arms folded and once you are in place, keep your hands “in the case” meaning let them rest on the OR table in complete view of the scrubbed assistant. When the surgeon gives you a retractor, hold it as instructed and try not to move. Keep your mind on the case, step by step (you should review the procedure before entering the OR). The surgeon may ask you to do a couple of ties or throw some sutures. Be sure that you are totally familiar with whatever you are asked to do. If it’s your first time, speak up and someone will talk you through. Try to close the skin at the end of the case. At this point, you and the resident can share this duty and it’s a good time to learn.

If you are driving camera on an laparoscopic case, try to keep the instruments in the center of the visual field. Believe it or not, you have the most important job on the case. Good camera drivers usually get excellent evaluations from the residents and attendings so learn this important skill. In the event of an emergency and you lose gas pressure, remove the camera as quickly as possible. The light on the end of the camera can cause a very serious burn so you need to be sure that you don’t touch any tissue with the light and that you remove the camera efficiently if told to do so. Keep your eyes in the case and listen to instructions. If you make a mistake, correct it but don’t take anything personally. When a case isn’t going well, surgeons can get frustrated. It isn’t personal and don’t let it throw you.

At the end of the case, help the anesthesiologist, resident and technician move the patient to the stretcher and push the stretcher to the recovery room. Again, just do what you are told if you don’t know. Step up and volunteer your assistance if needed. Watch tubes and IV lines on transfer and remember that the anesthesiologist directs the move because he/she is in charge of the airway. Be sure to thank the OR scrub staff when you leave the OR for the recovery room. It’s just common courtesy. Once in the recovery room, be ready to write the ”Brief Op Note”. You can get all of the components from the anesthesiologist and the OR nurse. At the beginning of your rotation memorize the components of the Brief Op Note and be efficient at getting this note written. Again, ask to do this and ask the resident to help you if you can’t find something. Don’t leave this note incomplete. When I am dictating the case, I will use this note in my dictations so listen to the resident’s dictation (I dictate my cases in the RR at the end of each case) if nothing else.

Every patient that you assist on that is coming to your service will be your patient. If you have seen the case, you know what the incision looked like at the close of the case and you know what went on during the case. Keep these things in mind as you follow your patient. Be sure to read the anesthesia notes on your patient and ask questions if you don’t understand something. These notes can be invaluable in terms of fluid management of your patient post-op.  

Answering those “pimp” questions. Most questions asked during a case will be directly related to the pathology of the patient or the anatomy of the region that involves the pathology. Be sure that you have reviewed these things before scrubbing the case. It’s a good idea to review the anatomy of the biliary system, the GI system and the chest before you start your rotation. Be sure to read and review common emergency cases such as appendicitis, acute abdomen  and vascular anatomy.  After that, read about the types of patients that you will be seeing on your service. Finally, cover trauma (unless you are on trauma service). Again, the Lawrence text is great for reading and total mastery of this book can take you a long way toward doing well on your shelf exam.

You also need to be sure that you skills are adequate. Practice with a knot-tying board until you can tie a secure two-handed knot without thinking about it. Be sure to bone up on your fluid and electrolyte information as pimp questions will frequently come for this subject matter. Stick close to your resident and don’t whine. If you are tired, your intern and resident is more tired. There will be times where you are just exhausted. The first thing you should grab is a bottle of water (dehydration makes exhaustion worse). Stay away from loads of caffeine and sugar and learn to “cat-nap”. Be upbeat and remember that no matter how bad the rotation, the clock is ticking and it will be over soon. For most people, this is their only brush with surgery and the most important thing to take away from the rotation is a solid knowledge of when to consult a surgeon.  Next essay, when things go wrong and how to do “damage control”.