Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 3: Communication Challenges on Rounds
Patient Presentation
Demographics: 71-year-old male
Chief Complaint: POD 5 from Hartmann procedure for perforated sigmoid diverticulitis
Scenario: During morning rounds, the attending asks you to present Mr. Williams. You know the patient well but are nervous about presenting in front of the large team. The patient has multiple active issues.
Current Status:
- End colostomy functioning with moderate output
- Required SICU stay POD 0-2 for septic shock, now on floor
- Transitioning from IV to oral pain medication
- Started on clear liquid diet yesterday, tolerating
- Low-grade fevers resolved
- Creatinine trending down from AKI (peak 2.1, now 1.4)
Active Issues:
- Ongoing recovery from septic shock
- AKI resolving
- Pain management transition
- Diet advancement
- Ostomy education
- Discharge planning - will need SNF
Clinical Questions
- Construct a concise surgical SOAP presentation:
One-liner: "Mr. Williams is a 71-year-old male, POD 5 from Hartmann procedure for perforated diverticulitis with septic shock, now recovering on the floor with functioning ostomy, resolving AKI, and tolerating clears."
Subjective: "Patient reports improved pain on oral medications, no nausea. Stoma nurse visited, patient receptive to teaching."
Objective: "Vitals stable, afebrile x48 hours. Abd soft, stoma pink and viable with moderate output. Labs show improving creatinine at 1.4, down from 2.1. Wound clean and dry."
Assessment: "Progressing well, appropriate for diet advancement."
Plan:
- Advance to regular diet
- Continue oral pain regimen, wean as tolerated
- Continue ostomy teaching
- PT/OT evaluation for SNF placement
- Anticipate discharge POD 7-8 if continues to progress
- The attending interrupts to ask about stoma output. You don't remember the exact number. How do you respond?
- "I don't have that exact number, but I'll get it immediately after rounds and update you."
- Do NOT make up numbers
- Write it down and follow up promptly
- A family member approaches you after rounds with questions about the surgery. What is appropriate?
- Answer factual questions within your knowledge
- Defer complex prognostic questions to the resident or attending
- Offer to arrange a formal family meeting if needed
- Document significant conversations
- How do you handle a disagreement with a resident's plan?
- Present your reasoning respectfully and with evidence
- Defer to the resident's decision unless it's a safety concern
- If safety is at risk, escalate appropriately through the chain of command
- Learn from the discussion regardless of outcome
Clinical Image
Image: Surgical team in the operating room demonstrating teamwork and communication. Source: Wikimedia Commons, U.S. Army. License: Public Domain.
Image Attribution: Surgical team operating. Source: U.S. National Archives. Public Domain.
Summary Points
- Pre-rounding essentials: See every patient before rounds, know all vital signs, I/Os, drain outputs, exam findings, and have a plan
- One-liner components: Age, sex, POD, procedure, indication, current status
- SOAP brevity: Lead with the most important information, know exact numbers, have a plan
- OR preparation: Review anatomy, surgical steps, and potential complications before every case
- Communication: Be honest about what you don't know, follow up promptly on missing information
- Professionalism: Punctuality, preparation, and positive attitude are non-negotiable