Clerkship: General Surgery

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

General Surgery Rotation

  • Location: St. Joseph’s Hospital, Hamilton, Ont
  • Length: 6 weeks in total
  • Surgical specialty selective: Urology (2 weeks)

A typical shift

Rounding starts around 6:30 or 7:00AM depending on when the residents want to start.

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This becomes helpful to know…

Rounding = assessment of every patient on the ward under your team!  Clerks have to be there 15 minutes early to check bloodwork results on all the patients we will be rounding. Patients can be on the service floor, ICU, etc. It takes about 1-3 hours depending on how efficient/how complicated the patients are.

Then, the residents will go to the OR, sometimes they’ll take a clerk with them if they’re short a pair of hands. The other clerks will go to the clinic, or wait to be paged for a consult.

Consults, in my opinion, are fun to do! It’s like detective work. You’re given a clinical question like “Query Appendicitis”. The emergency department (where most consults come from) usually have some investigations completed already. As a surgical consulting service, we look at if the patient is a suitable candidate for surgery (and sometimes make sure the patient does indeed have appendicitis and not something else).IMG-20160228-WA0012

Calls are overnight (5PM-about 7AM, the weekend is 24 hours from 7AM-7AM) with a post call day (go home and sleep!). During my 6 weeks, I had 6 call shifts where I worked with the junior resident. He/she carried the team pager and texted me when there’s a consult or interesting case on the ward. Calls are the best in my opinion – there’s so much learning and since I was the only learner, I get to do everything!

Teaching sessions every Wednesday back at the main campus with the medical students. I found these sessions were invaluable to my learning. We had great presenters who spoke about relevant topics encountered in surgery. We also had mandatory online modules to complete, which I also found super helpful!

IMG-20160304-WA0003
St. Joes call room

My Team

  • Surgeon, Chief/Senior resident, Junior residents, a Physician Assistant, medical students (at least 2 during my rotation)

Common surgical conditions I encountered

  • Cholecystitis (my favourite!)7b884433dffe4284675c12e4aaeb9109
  • Pancreatitis
  • Appendicitis
  • Bowel Obstruction
  • Incarcerated Hernias

Surgeries I participated in

  • Cholecystectomy
  • Appendectomy
  • Hemicolectomy
  • Loop colostomy
  • Hernia repair with mesh
  • Bariatric Surgery – Roux en Y gastric bypass
  • Renal Transplant
  • Observed: nephrolithotripsy, nephrectomy

Surgeries are great to observe and I made sure I was able to see at least one of each. As a PA, I know I would not necessarily be participating in these surgeries but noIMG_20160301_160251w I can describe to patients what their surgery entails. As an observer, I wrote the OR note, post-op orders and help transfer the patient to the recovery room.

Always scrub in! As long as I am scrubbed in, I can take advantage of any opportunities to assist. In the laparoscopic procedures, I held the camera and closed ports. In open surgeries (eg. the renal transplant), I helped with retraction. The resident also supervised me closing the pelvis with a stapler. For the lithotripsy and nephrectomy, I was allowed to put in the catheter.

Procedures I learned/performed

  • Admission, Pre and Post op orders
  • Insertion of foley catheter
  • Removal of drains (NG, JP)
  • Suturing

chap9-fig3Some of my most memorable cases

  • Renal Transplant – The most interesting surgery I was involved in!
    • This is an open surgery completed under a high-stress environment. The surgery I was involved with, the kidney was just harvested from a deceased donor the night before. Once the external iliac vein and artery is located and clamped down, the surgeon only has about 30 minutes to hook up vasculature of the donor kidney to it. The ureter is then anastomosed to the bladder.
  • Bariatric surgery – Roux-en-Y Gastric Bypass
    • St. Joe’s hosts one of the bariatric programs. I was working with one bariatric surgeon and his fellow for a bariatric surgery. These are done laparoscopically so I was mostly assisting with camera and port closures. It took a few RYGB for me to orientate myself.

rygb

IMG_20160226_095222

  • Acute Pancreatitis
    • I met a patient who is the epitome of “Don’t Mess with the Pancreas”. He was a fairly young patient, in his 40’s, who had gallstone pancreatitis. He developed an ileus, an NG tube to decompress his stomach. He was initially in the step-down unit but had to be transferred to the ICU. On the way to the ICU, he coded (blue) twice. In the ICU, he had worsening ARDS. Due to his increasing abdominal pressure, he developed abdominal compartment syndrome requiring surgical decompression in the OR.

Overall

Despite the early mornings, I had a good experience during this rotation. However, because I did it in a big city hospital, there was an abundance of learners. I wasn’t able to participate as much as I would like (eg. not enough work for everyone to do). The residents at St. Joe are great teachers and actually spent time going over cases with us.

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