Category: Rotation 9 – Surgery

Rotation 9 – Rotation Reflection

Even before starting PA school, I had a strong interest in surgery. I would “follow” and subscribe to accounts on websites such as Youtube, Instagram and Facebook that showed content of surgeries. I also would actively seek out television shows that covered before, during, and after surgeries. To get my healthcare hours, I had searched on Linkedin to find a surgical PA, and had written to her to ask if I could shadow her, as well as observe procedures in the OR. I was excited that York PA school offered a rotation in surgery, and I made sure to let our clinical coordinator know that I wanted to be placed in a hospital that would offer me the best exposure to this specialty. This led me to my surgical rotation at QHC. It was initially meant to be my 5th rotation. However with COVID, it got pushed all the way to being my last rotation. I was nervous about the hours, and about being burnt out when reaching my last rotation. Also since this rotation was one I was looking forward to from the start, I was afraid that it would not meet my expectations. After completing the rotation, I realized that my fears were unfounded, and confirmed that I really did enjoy the surgical PA position.

I originally thought that the rotation only consisted of assisting in surgeries. However, only my first day of orientation, my preceptor already told us that seeing the surgeries was the least of his concerns, and he cared more for the students to see surgical consults, as well as work in the surgical clinics. Eventually I was able to appreciate why he said what he said. It was helpful to see the patients come in with a complaint in the ED, and to learn what is considered a surgical emergency, versus what could be dealt with in outpatient. In the clinics, it was good to see patients coming in to see if they needed to have surgery performed, as well as those returning to clinic after their surgery was completed. I would see the difference between good healing scars versus bad healing scars. From that, I also learned how to care for the wound, or what may need additional surgical intervention. This rotation gave me a holistic understanding of what surgical cases look like, what a surgical department does, as well as how PAs play an integral part in it.

During the rotation, I especially enjoyed those cases where I met patients when they first came in, participated in their surgeries, followed along with their recovery on the floor, and finally was able to see them get discharged from the hospital. One such patient was a man in his late 60s, who was diagnosed with colon cancer on his right side, with possible liver metastases. His surgery was being performed since the colon cancer was close to causing an obstruction. I was able to scrub-in for his right hemicolectomy with primary anastomosis, and liver biopsy. It was the first large open surgery I had the opportunity to participate in. When the patient was placed on the floor for recovery, he was encouraged to practice early ambulation. I was amazed to see how he went from being in such severe pain and needing constant encouragement to walk enough steps to leave his room; to him having minimal pain and voluntarily walking up and down the hallways within days. I was extremely happy for and proud of him. There was a point during his recovery, however, when he was being advanced from NPO to clears, and he started having coffee-ground emesis. This caused a setback in his recovery, where he had to have an NG tube replaced, and restart his NPO/diet regimen. I found this part difficult, where it was unknown how the patient’s recovery was going, and when he would be returning home.

I hope that my preceptor and the staff noticed the way I worked differently from the other students. I went in everyday enthusiastic to learn, and wanting to participate in patient care. When some students would pout about going on small surgical consults, I would openly accept the opportunity to see the patients. For the 24 hour call days, I accepted it as a greater opportunity to learn, which I think made the time go by faster. I felt like I also had great compassion when caring for patients. In surgeries, I made sure to understand why some steps/procedures would be performed over another, and was not afraid to ask. One resident had commented during a surgery that I had good “intuition” when I was handing different instruments. It felt good to be seen and praised for how I performed naturally as a student. When I was taught to do something another way, I was also good at accepting criticism and not letting it get to my head.

Rotation 9 – Site Visit Summary

For my surgery site evaluations, I decided to prepare SOAP notes. This choice made the most sense, since everyday’s patient contact mostly consisted of the time spent during the morning rounds. Writing these notes were indeed quicker than the usual H&P’s I would prepare for my other rotations, but it was initially challenging since I needed to revisit how to write them. In the first evaluation, we reviewed my 4 SOAP notes together. I learned that a lot of the notes I put together were excessive, compared to how short and to-the-point they were allowed to be. The main parts of the note to mention were if the patient had any complaints, vital signs, focused physical examination, how clean the wound/incision sites were, any relevant I&Os, pain control, and the plan. The patients I presented on were POD#1 s/p Laparoscopic converted to open cholecystectomy, and Cholecystostomy tube removal, POD#2 s/p Laparoscopic appendectomy, POD#5 s/p Exploration Laparotomy, Enterotomy Evacuation of Phytobezoar, and an evaluation for Appendicitis.

For the second site evaluation, I had prepared an additional 4 SOAP notes, as well as 10 pharmacology cards, and 1 journal article. This time I received better feedback on my SOAP notes, as I knew better as to what were pertinent versus excessive details. I presented on POD#8 s/p Debridement of perineum (Left groin Fournier gangrene), POD#5 s/p Exploration Laparotomy with Resection Hemicolectomy  and Primary Anastomosis, with Liver Biopsy, a patient Hospital Day #2 admitted for RLQ Abdominal Pain (resolved SBO), and a patient s/p Amputation of 4th Toe of Right Foot (6 days ago), I&D of Right Foot Abscess (5 days ago), Debridement of Lower Extremity (4 days ago), and Debridement of Lower Extremity (3 days ago). These were big cases that I found interesting in the latter half of my rotation. For the journal article, it was a Systematic review and Meta-analysis that compared the outcomes between laparoscopic versus open appendectomies. Its conclusion showed a larger benefit in laparoscopic surgery, with the only con of a higher incidence of intra-abdominal abscesses.

Rotation 9 – Journal article

Laparoscopic versus open surgery for suspected appendicitis (Review)

Jaschinski T, Mosch CG, Eikermann M, Neugebauer EAM, Sauerland S

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517145/pdf/CD001546.pdf

Within the first week of my surgery rotation, I have already come across 3 laparoscopic appendectomies. Since it seems to be such a common issue I decided to find a journal article regarding its surgical management. I came across an interesting Systematic review and Meta-analysis article published in Cochrane Library comparing 2 different approaches as described in its title: “Laparoscopic versus open surgery for suspected appendicitis”. Its objective was to compare the benefits and harms of laparoscopic appendectomy (LA) versus open appendectomy (OA). The article searched through multiple journal databases, looking for randomized controlled trials that compare the two methods, in patients with signs and symptoms consistent with acute appendicitis. The primary outcomes looked at were the pain scale on the first day, wound infections within 14 days of the surgery, and intra-abdominal abscesses formed within 14 days of the surgery.  Secondary outcomes included the length of hospital stay, days until patient was able to return to normal activities, and quality of life within the 1 year of having the surgery. In total, 85 studies with a total of 9765 subjects were included in the study.

Pain intensity after surgery was less in LA (0.75/10 less than OA). In the studies that compared into the use of analgesic doses needed, 13/24 studies saw no difference between methods, but 11/24 studies show less analgesia needed in LA. LA showed half the amount of wound infections than OA, but higher incidence of intra-abdominal abscesses. In a majority of the articles, the length of hospital stay was less in LA versus OA by 0-5 days. Patients with LA returned to normal activity roughly 5 days faster than OA. Quality of life was better in LA vs OA, when measured on questionnaires that followed up  on the patients 2-6 weeks after the surgery.