# Clinical Cases: The Role of the Surgery Sub-Intern ## Case 1: Managing a Postoperative Patient Panel ### Patient Presentation **Demographics:** 58-year-old male **Chief Complaint:** Post-operative day 2 following open right hemicolectomy for cecal adenocarcinoma **History of Present Illness:** You are the surgery sub-intern covering a panel of 8 patients on the general surgery service. Mr. Johnson underwent open right hemicolectomy two days ago for a cecal mass found on screening colonoscopy. Your attending expects you to pre-round on all patients before 6 AM rounds and present concise one-liners. **Overnight Events:** - Temperature max 38.1C at 0200 - Required additional doses of IV morphine for pain (total 12mg overnight) - No flatus or bowel movement yet - Urine output adequate at 0.6 mL/kg/hr **Physical Examination:** - Vitals: T 37.4C, HR 88, BP 128/76, RR 16, SpO2 97% RA - General: Alert, appears tired but comfortable - Abdomen: Soft, mildly distended, midline incision with staples intact, no erythema or drainage, minimal tenderness, bowel sounds hypoactive - JP drain: 45 mL serosanguinous output over 24 hours - Extremities: SCDs in place, no calf tenderness **Current Orders:** - NPO - IVF: LR at 100 mL/hr - Morphine PCA 1mg q8min demand - Incentive spirometry q1hr while awake - Enoxaparin 40mg SQ daily - Ambulate with assistance TID ### Clinical Questions 1. **Construct a one-liner presentation for this patient:** - "Mr. Johnson is a 58-year-old male, POD 2 from open right hemicolectomy for cecal adenocarcinoma, progressing well with low-grade fever, adequate pain control on PCA, and awaiting return of bowel function." 2. **What are the key post-operative milestones you should monitor?** - Return of bowel function (flatus, then bowel movement) - Adequate pain control with transition to oral medications - Ambulation independence - Tolerating oral diet - Wound healing without infection - Resolution of low-grade fever (common POD 1-2 from atelectasis) 3. **The patient develops a temperature of 38.5C on POD 3. Using the "5 W's," what is your differential?** - **Wind (POD 1-2):** Atelectasis - encourage incentive spirometry, deep breathing - **Water (POD 3-5):** UTI - check UA and culture if symptomatic - **Wound (POD 5-7):** SSI - examine wound for signs of infection - **Walking (POD 5-7):** DVT/PE - check for leg swelling, consider duplex - **Wonder drugs:** Drug fever - review medication list 4. **What information must be included in your sign-out for overnight coverage?** - Current status and POD - Anticipated issues: may develop ileus, monitor for anastomotic leak signs - Contingency plans: "If temp >38.5, obtain blood and urine cultures, pan-culture and CXR" - Code status - Contact information for responsible resident ### Clinical Image ![Laparoscopic appendectomy showing inflamed appendix](https://upload.wikimedia.org/wikipedia/commons/5/5a/Acute_Appendicitis.jpg) *Image: Intraoperative view of acute appendicitis. Source: Wikimedia Commons. License: CC BY-SA 3.0. This image demonstrates the surgical field during appendectomy, a common procedure the sub-intern may assist with.* **Image Attribution:** Acute appendicitis surgical specimen. Available at: https://commons.wikimedia.org/wiki/Category:Appendicitis. Licensed under Creative Commons. --- ## Case 2: First Assist in the Operating Room ### Patient Presentation **Demographics:** 34-year-old female **Chief Complaint:** Right lower quadrant pain for 18 hours **History of Present Illness:** Ms. Garcia is scheduled for laparoscopic appendectomy after CT confirmed acute uncomplicated appendicitis. This is your first case as first assist, and the chief resident has asked you to prepare for the OR. **Preoperative Assessment:** - ASA Class I, no medical problems - No prior surgeries - Labs: WBC 14,200, otherwise normal - CT: Dilated appendix 11mm, periappendiceal fat stranding, no perforation or abscess **Your Pre-OR Responsibilities:** - Review anatomy and surgical steps - Verify consent is signed and correct - Confirm NPO status (last ate 16 hours ago) - Check if antibiotics have been ordered ### Clinical Questions 1. **What anatomy should you review before this case?** - Blood supply: appendicular artery (branch of ileocolic artery) - Location of appendix and McBurney's point - Mesoappendix and its relationship to the cecum - Port placement for laparoscopic approach - Critical view of safety principles 2. **Describe your intraoperative roles during laparoscopic appendectomy:** - Camera driving: maintain level horizon, center instruments, anticipate dissection direction - Retraction: steady, appropriate pressure to maintain exposure - Suction: follow the action, keep field clear without obstructing surgeon's view - Specimen retrieval bag handling - Trocar site closure assistance 3. **The attending asks you to drive the camera. What are key principles?** - Keep the horizon level - Center the area of dissection in the field - Use smooth, controlled movements - Anticipate where the dissection is heading - Keep the lens clean (wipe on gauze or use anti-fog) - Communicate if you need to readjust 4. **After the case, what should you do to maximize learning?** - Thank the team and help with patient transfer - Review the pathology when available - Read about the procedure, including complications - Reflect on what went well and what could improve - Ask for feedback from the chief resident ### Operative Details for Review **Standard Laparoscopic Appendectomy Steps:** 1. Patient positioning (supine, left arm tucked) 2. Insufflation via Veress needle or open (Hasson) technique 3. Port placement (typically 3 ports: umbilical, suprapubic, LLQ) 4. Identification of appendix and mesoappendix 5. Creation of window in mesoappendix 6. Division of mesoappendix (stapler, LigaSure, or clips) 7. Division of appendix at base (stapler or endoloop) 8. Specimen retrieval in bag 9. Irrigation and hemostasis check 10. Closure of port sites >10mm ### Clinical Image ![Laparoscopic view of appendix](https://upload.wikimedia.org/wikipedia/commons/3/37/Appendectomy.jpg) *Image: Laparoscopic appendectomy surgical view. Source: Wikimedia Commons. License: Public Domain/CC BY-SA.* **Image Attribution:** Appendectomy specimen. Available at: https://commons.wikimedia.org/wiki/Category:Appendectomy. Licensed under Creative Commons. --- ## 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:** 1. Ongoing recovery from septic shock 2. AKI resolving 3. Pain management transition 4. Diet advancement 5. Ostomy education 6. Discharge planning - will need SNF ### Clinical Questions 1. **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 2. **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 3. **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 4. **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 ![Surgical team during rounds](https://upload.wikimedia.org/wikipedia/commons/thumb/d/d6/Surgeon_operating%2C_Fitzsimons_Army_Medical_Center%2C_circa_1990.JPEG/800px-Surgeon_operating%2C_Fitzsimons_Army_Medical_Center%2C_circa_1990.JPEG) *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 1. **Pre-rounding essentials:** See every patient before rounds, know all vital signs, I/Os, drain outputs, exam findings, and have a plan 2. **One-liner components:** Age, sex, POD, procedure, indication, current status 3. **SOAP brevity:** Lead with the most important information, know exact numbers, have a plan 4. **OR preparation:** Review anatomy, surgical steps, and potential complications before every case 5. **Communication:** Be honest about what you don't know, follow up promptly on missing information 6. **Professionalism:** Punctuality, preparation, and positive attitude are non-negotiable