Katedra i Klinika Chirurgii Ogólnej, Transplantacyjnej i Wątroby Warszawskiego Uniwersytetu Medycznego w Warszawie
INFORMATION FOR ENGLISH DIVISION STUDENTS 3RD YEAR
OF THE IV YEAR ACADEMIC PROGRAM (COURSE DURATION: 2 WEEKS)
CLASS STARTS AT 09.00AM AND ENDS AT 12.00PM
09-10. Introduction – Kobryń Konrad/M.Skalski
10-11 Surgical scrubbing K.Dudek/Konrad Kobryń
11-12 Surgical instrumentarium K.Dudek/Konrad Kobryń
09-10 Surgical infections and prophylaxis – M.Krawczyk
10-11 Electrolytes and fluid administartions – Konrad Kobryń/R.Stankiewicz
11-12 Multitrauma + shock – M. Nowosad/Konrad Kobryń
9-10.30 gr.A – Endoscopy – S.Kozieł/J. Pertkiewicz
Gr. B – ICU (OITCh) – W.Figiel
10.30-12 gr.A – Suturing basics – J.Ligocka/W.Hołówko
Gr. B – Ward round – M.Grodzicki
9-10 Acute abdominal pain – M.Skalski
10-11 Acute gynecological problems in surgical patients – Eliza Kobryń (M.Skalski)
11-12 Radiological diagnostic in patients with acute abdominal pain – Krzysztof Kobryń (M.Skalski)
9-10 Surgical anatomy and types of surgical acces - M.Krasnodębski
10-11Principles of surgical diagnosis – O. Kornasiewicz
11-12 Bowel obstruction – O.Kornasiewicz
9-10 Laparoscopy equipment – P.Kalinowski/M.Przybysz
10-11 Endoscopy equipment – M.Przybysz/P.Kalinowski
11-12 Aseptic and Antiseptic – M.Przybysz/M.Kotulski
9-10 Use of molecular values and markers in surgery – J.Ligocka/W. Hołówko
10-11 Surgical bedside procedures in the unit – W.Hołowko/J.Ligocka
11-12 Venous thromboembolic disease and prophulaxis – Ł.Nazarewski/M. Krasnodębski
9-10.30 gr.B – Endoscopy – S.Kozieł/J. Pertkiewicz
Gr. A – ICU (OITCh) – W.Figiel
10.30-12 gr.B – Suturing basics – W.Hołówko/J.Ligocka
Gr. A– Ward round – M.Kotulski
9-10 Blood Transfusion – B.Cieślak/M.Skalski
10-11 Modern equipment for cutting and coagulation – R.Stankiewicz/B.Cieślak
11-12 Management of GI bleading – M.Grąt/M.Grodzicki
9-10 MCQ Test Konrad Kobryń/M.Skalski
10.30 -11.30 - Discussion
Identify patient with acute gastrointestinal bleed
List common causes of GI bleeds
Justify selection of standard diagnostic and therapeutic studies
Describe signs and symptoms of hemodynamic instability
Describe various operations and treatment strategies used to control GI bleeds
Describe what blood products to transfuse and when
Identify patients with complete and partial bowel obstructions
List common causes of bowel obstruction
Understand usual diagnostic labs and studies
Describe management and treatment options to deal with bowel obstruction
Evaluate patient with suspected bowel obstruction
Complete a thorough abdominal and rectal exam
Interpret evaluation results and physical findings
Demonstrate proper insertion of Nasogastric tube (NGT)
Post-Op Management, Complications
List common post-operative management points
Justify selection of post-operative labs, diagnostic studies and radiographic studies
Describe possible post-operative complications and their signs and symptoms
Specifically describe evaluation of low urine-output, hypoxia and confusion in the post-operative patient
Describe common doses, uses and modalities of narcotic and non-narcotic pain management
Identify risks of colorectal cancer
Justify standard diagnostic evaluations
Describe signs and symptoms of colorectal cancer
Describe various operations and treatment strategies for colorectal cancer
Observe colonoscopy, proctoscopy and sigmoidoscopy
Acute Abdominal Pain
Identify patient with acute abdominal pain
List common causes of abdominal pain
Differentiate potentially life threatening abdominal pain from other types of abdominal pain
Describe standard evaluation labs and studies for acute abdominal pain based on presumed diagnosis
Recognize a 'surgical abdomen' based on presentation, history and physical exam
Describe appropriate algorithm for abdominal pain evaluation and work-up
Perform thorough abdominal exam including rectal exam
Identify patient with pancreas, liver and biliary disease
List common types of biliary, hepatic and pancreatic disorders
Describe signs and symptoms of biliary, hepatic and pancreatic dysfunction
Justify selection of standard diagnostic and therapeutic studies
Describe various operative and treatment strategies to deal with diseases of the biliary system, liver and pancreas
Verbalize interpretation of study results
Observe ERCP and evaluate cholangiogram results
Identify patient with hernia (e.g., inguinal, umbilical, incisional, ventral, hiatal)
List common causes and types of hernia
Describe signs, symptoms and complications of hernias
Describe both surgical and non-surgical treatment modalities for hernias
Perform physical exam for hernia based on location.
Trauma, Burns & Shock
Identify patient with burns that require medical attention
Identify patient with signs and symptoms of shock
List common causes of shock
Describe various types and pathophysiology of burns and shock
Justify common laboratory and radiographic studies for burn or shock evaluation
Describe standard operations and treatments for various types of burn
Describe various operations and treatment for various types of shock
Perform estimation of burned body surface area
Calculate burn resuscitation requirements
Interpret pulmonary artery catheter data
Observe or perform central venous catheter placement
Fluid / Electrolytes / Nutrition
Identify patient with fluid, electrolyte or nutritional abnormality
Describe common causes of fluid, electrolyte or nutritional imbalances
Describe various treatments for fluid, electrolyte or nutritional problems
Order appropriate laboratory evaluations for fluid, electrolyte or nutritional abnormality
Interpret laboratory findings
Order fluid, electrolyte and nutritional replacements specific to patient
Interpret follow-up laboratory findings after intervention
Identify patient with endocrine disease
Describe common causes and types of endocrine disorder
Justify standard diagnostic, laboratory and radiographic studies to work-up endocrine problem
Understand complications associated with endocrine diseases with operative therapy
Describe life-saving therapies
Describe other operative and treatments available for endocrine disease
Recognize signs and symptoms of atherosclerotic disease (carotid, aortic, and peripheral vascular) and aneurysmal disease.
Differentiate between underlying vascular disease and other etiologies with similar presentations
Describe standard evaluation steps and studies (including specific physical exam maneuvers)
Describe various operations and treatment strategies used to treat patients with vascular disease
Order appropriate labs and diagnostic studies
Interpret results from above studies
Demonstrate ABI (Ankle Brachial Index) exam
Most surgical teams round twice a day. Surgeons spend the majority of their time in the operating room and clinic. As a result, there are rounds before the day begins to set plans for the inpatients and afternoon rounds to follow up on the day’s events. With that in mind, rounds typically start at 7:15am on weekdays. The only way this can be done successfully is for the team to work together. Teamwork enables us to be efficient and accurate. So, here are some tips to help you be a part of the team and make rounds run smoothly.
Each student is generally expected to follow 3-4 patients. You should know everything about why these patients are in the hospital, what their relevant past medical history is, and where they are in the course of their work-up, treatment, and recovery. It is best to follow patient’s whose surgeries you saw or people you saw in clinic who were admitted. Obviously, this cannot take place in the beginning of the rotations, but should be how you pick up patients without residents having to assign them to you.
You will generally be expected to pre-round on your patients. This includes gathering vitals and recent labs and evaluating your patients with a directed history and physical exam. Gathering vital signs and labs for your patients is not scut work. This is something you will be expected to do as an intern in any field you choose to go into, so it helps to start learning efficient ways to do this as a student.
All post-operative patients and patients with abdominal complaints should be asked about pain, nausea, vomiting, flatus, bowel movements, and activity (e.g. have they been out of bed?). If you have questions about what to ask you patients or what physical exam findings are important, talk to the intern or junior resident on your service and they can help give you tips when you are on specialty services. For example, on vascular surgery it is always important to check pulses on your patient.
Vitals are presented as Tmax, Tcur, HR, BP, RR, Sat or pulse ox, and ins and outs, including Urine Output and Drain Output (usually presented as over last 24 hours and over last 8 hours).
Try to review new labs prior to presenting. Knowing trends is important (e.g. is the WBC increasing or decreasing?).
A directed physical examination should include the heart, lungs, abdomen, surgical wound, extremities. Although you should definitely examine all of these areas, you may be asked to only present the most relevant on rounds.
Know diets, antibiotics, cultures, and IV fluid status for all of your patients.
NEVER use terms if you don’t know what they mean. This means if your patient has a diagnosis you don’t understand, has had a procedure with which you are not familiar, or is on a medication you haven’t heard of, then you should look them up or ask someone before rounds.
Dress professionally for rounds; only wear scrubs when you are post-call.
Be on time and ready to go when the chief arrives.
Surgery is all about teamwork so help the team gather charts,
Try to be brief and organized.
If you are not presenting, help take down/change dressings.
Carry some dressing supplies with you such as scissors, gauze, and tape.
Pay attention to your colleagues when they are presenting. You are expected to have a basic idea what is going on with all patients on the service.
If there is something you don’t understand, such as a term or a treatment plan, find the appropriate time and ask someone
· Keep everyone informed. If you find out information that you think may be really important, let a resident know right away. There is no need to wait until rounds. For example, if your patient has worrisome symptoms or physical exam findings or a new worrisome test result, mention it to someone before rounds. It may need to be dealt with quickly. This is a very important way that you can contribute to patient care.
This is what your surgical rotation is all about. The OR can provide some very memorable experiences, from seeing rare cases to getting a chance to suture at the end of the case. The key to getting the most out of each case is being prepared. The Teamwork concept is stressed here again. It is extremely difficult to perform a surgery without the appropriate help. This begins from the time the patient enters the OR until the patient reaches the recovery room. There are opportunities for valuable procedural experiences for the medical student. But, as noted above, just being present is not sufficient; you must be prepared to help with the case. So here are a few tips to help you get the most out of each trip to the operating room.
Know what case you are going to do the next day!
Divide up the cases amongst the students on the team as early as possible.
Each service has an OR schedule that can help, but you must check the main OR board the night prior and frequently throughout the day to get the most up to date changes.
There will be times when the schedule changes and you end up in cases you hadn’t planned to be in. We understand this, but you need to be flexible and prepare as best you can.
Read about the patients – specifically know their presenting complaints, diagnosis, indication for surgery, and procedure being performed.
Review appropriate anatomy for the case – these are the most popular pimp questions.
Be on time for each case. You should arrive with the patient or even before. Cases typically start at 8:30, except on Wednesdays when they start at 9:00 because of the radiology meet. You are not expected to be on time to the first case as you have class, but you are expected to show up after your lecture.
Try to meet the patient preoperatively in the Pre-Care area
Wear appropriate attire – scrubs, scrub hat, mask, eye protection, and shoe covers
Always get your gloves out for the scrub nurse/tech. Ask if they need an extra gown for you.
This is a great time for procedures – learn to place a foley, start an IV, prep the patient, etc. Again simply being present may not be enough. If there is something you would like to learn how to do, ASK.
Be attentive during the case – how much you can help is directly related to your being aware of what is going on.
At the end of the case, you can help the resident close and then help get the patient transferred to the Recovery Room – this includes getting the bed, helping move the patient, and learning to write post-op orders and prescriptions.
Introduce yourself to the OR staff.
Help the resident position the patient.
Remove jewelry before scrubbing.
You are a part of the team. Ask questions and be ready to participate. The team is counting on you and will get you actively involved.
Understand that there is a time for questions and a time to be silent. If the situation seems tense or the team brushes you off, this may mean it is the wrong time for questions. Hold onto your questions, though, and ask them later.
Emergency Duties are extra-curricular. This is a great opportunity to see the urgent and emergent cases that rest at the heart of surgery. This is also a great time to pick up patients for your write-ups. Medical students should not 'hang out' in the call rooms.
The on-call/emergency rooms are on the ground floor in block D.
The more you show yourself to be interested, the more people will involve you. By asking questions and asking for opportunities to participate, you show that you are interested in learning. People respond positively to this and whether intentionally or not, they will end up involving you more. If you don’t know where you are supposed to be, ask someone. Your residents are always around and can help give instructions or suggestions about where you might learn the most.
Remember that we see all 200+ medical students over the course of the year. Sometimes we forget what we have taught to a particular medical student. This is why it is important to ask questions and remind us how we can help you learn.
Ultimately, you are responsible for your learning. You are not given a detailed syllabus for third year like you were for first and second year. This does not mean you don’t need to read and study. It simply means you will need to do directed reading. Think about what you do and don’t know well and read to fill in the gaps.
Even if you have no interest in surgery as a career, there is a lot to learn on your surgery clerkship. Every type of physician will interact with surgeons in some way. If you have no interest in surgery, figure out what you need to know about surgery for your career and use this to motivate and drive your learning during your surgery clerkship. For example, ask yourself what you need to learn in order to know when to call a surgical consult. Or, ask yourself what you need to know about pre-operative clearance of patients for surgery or management of post-operative surgical complications.
Surgeons work closely with many types of physicians. Your surgery clerkship may be your only exposure to many of the smaller subspecialty fields. If you are interested in Pathology or Radiation Oncology or Interventional Radiology or Anesthesia, look for opportunities where you can gain exposure to these fields. For example, if your patient is going for a procedure in Interventional Radiology (VIR), ask if it would be okay if you go watch the procedure. Or, ask if it would be okay for you to follow the specimen to Pathology if one is sent for an intraoperative evaluation. Or, show up early to the case and ask the anesthesia resident or nurse anesthetist if you can shadow them as they prepare the patient for surgery. There may be times when the answer is “No, you are needed elsewhere.” But, more often than not, the answer will be “Sure go ahead.”
Ask for feedback on your performance at least once during your rotation. This is another great way to show you are interested in learning. Don’t accept “don’t worry about it, you’re doing fine” as an answer. There are things that even the best clinicians can do to take their learning to the next level. Be prepared, though, when you ask for feedback, you may get some negative feedback. This is not intended to hurt you or put you down. This is intended to be constructive and to help you find ways to improve as a clinician and as a team member.
Respect the non-physician staff. The truly successful medical student will quickly learn that everyone involved in patient care can be a valuable resource for learning. Often other staff will have more time for teaching than the physicians. In general, you will find that if you ask, almost anyone will be happy to teach you.
Morning rounds begin at 07:15 everyday from the Surgical Intensive Care Unit.
Morning briefing begins at 08:00 everyday in the conference room (6th floor block B).
VI year students (I Wydział Lekarski) are asked to join morning rounds. All other groups are to start at the appointed time according to your class schedule.
English Division Students are kindly asked to wait in the Seminar room (6th floor, Block B - in the Department).
Class starts every morning at 09:00!
Didactics Coordinators for VI year students (I WL): Dr hab. n. med. Krzysztof Dudek
Didactics Coordinators for IV year students (I WL):: Dr n. med. Piotr Remiszewski, lek. Małgorzata Nowosad
Didactics Coordinators for English Division: Dr hab. n. med. Oskar Kornasiewicz, Dr n. med. Michał Skalski, lek. Konrad Kobryń
Odpowiedzialny za dydaktykę dla studentów WNoZ: Dr n. med. Piotr Smoter
Department of General, Transplant and Liver Surgery
Medical University of Warsaw