Thankfully this rotation came after a much-needed break (pretty much slept for the entire week). Early mornings were what I dreaded the most about surgery, especially not having a car and having to commute. I never really considered surgery, but I did shadow general surgery briefly in my second year.
Surgery ran for a total of 8 weeks; the first week was orientation and didactic teaching, followed by 3 weeks of a surgical subspecialty which we ranked by preference, 3 weeks of general surgery, with the last week for exam prep.
Plastic Surgery
I felt I had a relatively good idea of what other surgical specialties were like except for plastic surgery, which is the main reason I ranked this first.
Rounds
pre-round · vital signs · dressing changes · post-op progress
Mornings were early, the average start time was 5:30 am, mainly because we had to round on patients before teaching at 7 am. I was primarily responsible for pre-rounding, which just meant charting patients’ vital signs as well as any major nursing updates overnight. Pre-rounding was a little challenging because the hospital I was at primarily charted these on paper and our patients were scattered all over the hospital (got a lot of steps in). I also gathered equipment for dressing changes that needed to be done. After teaching, we updated patient progress notes and I was usually assigned to an OR with a resident for the day.
OR
breast reconstruction after lumpectomy – flap vs. implant reconstruction · microsurgery · nipple reconstruction · tissue expansion · carpal tunnel release · nerve transfer for upper brachial plexus injuries · cranioplasty · nasal reconstruction surgery · orbital floor fracture surgery · open reduction +/- internal fixation for TMJ fracture
Despite the pandemic, I would say I got to spend a reasonable amount of time in the OR. There were three main types of surgeries: hand, breast, and craniofacial. While it was cool to watch these surgeries, one practical goal I had for myself was to try to get as much suturing experience as possible and I couldn’t have picked a better specialty. Other cool things I got to do other than retract, was separating breast tissue from surrounding skin and assisting with skin grafting.
Inpatient ward/ED Consult
hand injuries – cat bites, lacerations · pyoderma gangrenosum · skin grafts · nasal septal fracture · TMJ fracture · LeForte fractures (facial bone fractures) · aural hematoma
I spent the most time here when I was on-call (overnight, weekend). Sometimes patients admitted under other services such as orthopedics and vascular surgery, require plastic surgery consultation and/or follow-up for certain things. For example, orthopedics might need plastic surgery for skin grafting of a large fasciotomy wound. ED consults were mainly for trauma patients (craniofacial injuries), hand injuries (i.e., cat bites), and post-operative complaints (i.e., infection of a breast implant following breast reconstruction surgery). Depending on the presentation, the residents had to decide whether the patient needed surgery and if so, how quickly the surgery needed to happen. Depending on the acuity of the patient’s presentation, I usually got to do a history and physical, review with the resident who then ordered necessary imaging and bloodwork before reviewing with staff.
Clinics
breast cancer · basal cell carcinoma (BCC) · squamous cell carcinoma (SCC) · melanoma · scaphoid fractures · boxer’s fracture · mallet finger · boutonniere deformity · hand extensor laceration · carpal tunnel syndrome
Spent one day out of the week at the Cancer Center, most patients were either being seen for breast cancer, SCC, BCC, and melanoma mainly on the face and scalp. Other members of the team usually included general surgery, radiation oncology, medical oncology, and dermatology. We also had other clinics during the week such as hand, craniofacial and breast clinics. This is where we saw new patients who were referred on an outpatient basis, i.e., patient splinted in ED for a possible scaphoid fracture or a patient with a new diagnosis of breast cancer who is followed by general surgery for mastectomy/lumpectomy and who is a candidate for breast reconstruction surgery. Staff also saw patients in these clinics for post-op surveillance. As a clerk, I took history, performed physical exams, put in and remove sutures/staples (was probably way too excited to take sutures/staples out lol), and assisted with minor procedures (i.e., extensor tendon repairs). This was the first time I had to dictate my notes, let me tell you, dictating requires more finesse than typewritten notes.
This rotation was more wholesome than I had expected it to be, especially because my hospital site was both a trauma and an academic center. Based on what is often publicized about plastic surgery, I will admit that I expected it to be mostly elective cosmetic procedures, but this perception does a huge disservice to this specialty – for example, imagine being able to regain some of your life back after a disfiguring injury (due to trauma, cancer, etc.). This is what makes this specialty so meaningful to me.
General Surgery
Spent a week on each of these services; hepatobiliary, breast cancer, and ACCESS (Acute Care Emergency Surgery Service). Pretty much consisted of rounds, OR, consults, and clinics.
Hepatobiliary
cholangiocarcinoma · pancreatic cancer · hepatic cancer · bile duct resection · liver resection · transarterial chemoembolization (TACE) · Whipple procedure
Surprisingly OR time was quite affected by the pandemic. There were only 3 surgeries scheduled during the week I was there, and I probably only got to suture once. Since OR time was limited, we didn’t have many patients to round on, so I didn’t have to pre-round and mornings started at 7 am. I usually printed the patient list and wrote progress notes. I was assigned to a virtual clinic for a day – took a history, reviewed with staff, and dictated notes. I didn’t see any ED consults on this service, as ACCESS was generally expected to cover this.
Breast cancer
breast cancer · lumpectomy · mastectomy · sentinel lymph node biopsy · axillary lymph node dissection
Again, OR time was limited and there were a lot of residents and fellows, so it wasn’t very hands-on for me. I spent most of my time in the clinic, evaluating new breast cancer patients and following up with post-op patients. No rounding or ED consults on this service at my hospital site.
ACCESS
appendicitis – appendectomy · cholecystitis – cholecystectomy · diverticulitis · bowel obstruction · anorectal disease · colectomy · sigmoidectomy
Rounding was loooong as there were lots of patients on our list. Usually saw patients with the residents and debriefed with staff afterward. Lots of patients to round on means lots of progress notes to write, having a PA student meant we could split these which was so helpful.
Most of our patients were either post-op or awaiting surgery. If there was an OR scheduled, this was a priority for the residents after rounds. The PA student and I were usually sent to ED for new consults as they came up. Again, clinics were post-op patients. Saw lots of action on overnight and weekend call because ACCESS was part of the trauma response team, so we got to respond to things like gunshot wounds, motor vehicle accidents/collisions.
My respect for surgery increased by the end of this rotation and I got to see how much of a profound impact it has on patients' lives.
~GoldRimMD