Surgical sub-intern

Make the most of your surgical rotation

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The general surgery program director at my school said they look for three things in any potential resident: integrity, compassion, and passion. I completely agree that success or failure depends on those qualities.

Prep before surgery

• Know anatomy. Flip through your text or google images for some quick refresher. Know major arteries, nerves, and veins. If for every case you spend not even five minutes reviewing, you will soon have seen the relevant anatomy repeatedly and it will no longer be as necessary to review.

• Know the indication for surgery. Know why this patient is on the table. If it’s a biopsy, what is the differential diagnosis? Know 2-3 items and some interesting fact about each. Example: from imaging alone meningiomas also look like hemangiopericytomas.

• Prepare for pimping. Surgical Recall has classic responses for pimping

Case setup

• Introduce yourself until it gets ridiculous. Keep introducing yourself to every new team member – circulators, anesthesia, scrub techs, attendings, etc. – until it’s almost laughable. You want everyone to be crystal clear on who you are and what your level is (medical student), so they know what to expect and what you’re capable of. Remember everyone’s name, be humble and quiet. Work “from the edges inward” – meaning as you find yourself working with someone new at the periphery of the room, introduce yourself. If you’re walking into a room and don’t know anyone, start by introducing yourself to the circulator (who records your presence in the computer). Knowing people and saying hello in the morning pays dividends: everyone feels more comfortable, everyone remembers who you are, what you’re capable of, and it simply adds to a more friendly environment.

• Watch what the circulator does. They do a hundred small tasks that you can help with. Bair-hugger, foley, bovie ground pad, SCDs, etc. Watch and learn so you can start taking these on one by one. The circulator will love you and sing your praises, but more importantly he will look out for you and do anything he can to help you in the OR. Life is easier for everyone if everyone helps.

• Put in the Foley. This is a time consuming task – only minutes but longer than most simple equipment tasks that the circulating nurse handles. You can place the foley while she completes other tasks in parallel. If it’s the first time you’ve worked with her, ask permission and also invite her to supervise. It’s her neck if there’s a UTI. Better yet, watch her do it and mimic her steps. Nothing will make her more comfortable than you doing exactly what she does, quirks and all.

• Placing the foley. Adequately unwrap the sterile package so your field is wide and doesn’t fall back on itself. Take time to unwrap/uncap every item before touching the patient: hook up the sterile flush syringe very tight so it doesn’t pop when you start pushing, unwrap the catheter and stick it into the gel, loosen up the Foley bag and tubing so it doesn’t get caught as you’re advancing. Once your “dirty hand” touches the genitals, there’s little your sterile hand can do except start advancing the catheter. Be sure your clean hand does not contact anything dirty as you advance the catheter: your dirty hand stays on the genitalia, your clean hand stays on the sterile catheter, and never shall these two cross.

• Keep the Foley bag clean. After inserting the Foley catheter, use your sterile hand to hold the Foley canister off the field while your dirty hand (the one holding the genitalia) gathers up all the trash and drapes. Do everyone a favor who comes behind you and handles it: don’t touch the canister with your dirty hand.

• Get gloves, for you and the resident. Always get your own gloves and gown. The scrub tech likely has enough gowns for you, but never hurts to walk over to the table with gloves and gown. After handing those off in a sterile manner, ask if you can get anything else. Often the scrub tech has been busily organizing the back table while scrubbed in and there’s one or two items on his mind to pull from the stock room; you can fetch things. Memorize your resident’s gloves and offer to pull those.

• Setup the bair hugger warmer. Drag it into position, plug it into power, plug it into the blanket (do not turn it on yet). Same with the sequential compression devices: put them on (if not already on from pre-op), plug them in, but go ahead and turn them on.

• Position the patient. Hold the head while resident pins, remove the head of bed and place the Mayfield frame, while resident holds the head you tighten to ensure teeth lock as you go in order from head to bed. At end of case, undue first from head then just drop the handle (skip middle lock). If “tucking the arms”, then start gelpadding the arms while using 4x4 gauze to pad any plastic IV attachments that might hurt. Tape the arms, but put some folded excess that can be popped if there’s too much inspiratory resistance. When done, you yourself go along the entire body (head to toes) and ensure pressure points are relieved, joints are not extended, fingers are relaxed, breasts are not smashed, etc.

• Tie and spin gowns. Before you scrub in, stand ready in the wings to help tie the scrub tech’s or resident’s gown and spin them.

• Streamline the prep. Whatever you can do to help speed prep, do it. Each institution and attending has their own preferences and protocols, but watch and learn to anticipate. Get the electric razor ready. Get tape to pick up stray hairs. When the resident reaches for the razor, you ready some tape. Soak some cotton in alcohol. Whatever you observe being doing routinely, get it primed. Tie the resident’s gown and spin them. Prime the chloraprep sticks so when the resident is ready they are already soaking. Get a kick bucket under the head for drip; consider tossing down a temporary blue towel over the Mayfield frame. I often wait to be the last person scrubbed in and in the mean time do everything I can to speed up the work of scrub tech and resident. Do everything you can to help setup and start prepping. Do everything you can to streamline their process.

• Do not contaminate anyone. Do not contaminate yourself, but more importantly do not contaminate the attending, resident, or scrub tech. Watch what you touch. Don’t back up; your back is not sterile.

• Move slow around the sterile field. Don’t jump quickly to help reach for something; you’ll unnerve everyone with sudden unpredictable movements, even if you’re just trying to be helpful. Think before you act.

• Don’t reach over someone’s head while gowned. You’ll likely hit their head. They’ll look up to see what’s going on above them. Don’t put on the light covers until the field is setup.

• Build your sterile field from incision outward. Don’t skip steps, e.g. don’t reach to put on light covers until field underneath is ready, otherwise you might hit someone’s head or the bed with your gown as you’re reaching. Go in the same order every time.

• Watch the scrub tech. Watch how they gown and glove people. There will come a time when they are busy and another surgeon wants to be gowned and gloved. Be ready to confidently step up to bat when that day comes.

• Learn to gown and glove yourself. When things are busy, you can’t always expect the scrub tech to help you gown and glove. If the scrub tech has bloody gloves, they need to get a fresh pair (ie. waste). Grab an unused area of table to setup your gown and gloves so you can do it all yourself. Go very slow and deliberate so you don’t contaminate. Scrub techs gown and glove themselves all the time; watch and learn.

During surgery

• Know what’s next. They ask for suture, you ask for scissors; they finish opening incision, you get the bovie and raytec ready; they are wrapping up galea stitches, you get scissors ready to cut; after galea stitches, you wipe the wound with raytec and hand them the monocryl for skin closure; for a biopsy when they finish opening galea, you get navigation ready for them to reorient trajectory. If they ask for flowseal, you use the bayonet to ready a cotton pad. If they pick up a leksell, rongeur, kerrison punch, etc., then you pick up a raytec to grab scraps and clean tips. If they put away the bovie after charring some tissue, you pull it back out briefly so you can clean off the tips for next use.

• Guess what’s next. While you’re watching what they are doing, always ask yourself ‘What is next?’ If you keep checking your predictions against what actually happens then you will evolve quickly; actively guessing wrong will teach you faster than passively watching. The emotional flash of getting it wrong will help your amygdala enhance the memory.

• Don’t touch what you can’t see. If you can’t see into a hole, don’t stick the suction or irrigate. Always be able to see the tip of your instruments or the effect of your action.

• Give the surgeon elbow room. Never stand or lean where you might fall into their arm and push their instrument into the brain. Don’t balance on your tippy toes or lean over to get a better view. Don’t do anything unnatural. Make sure you are firmly planted.

• Respect the scrub tech and his domain. When you start a case with a scrub tech with whom you’ve not yet worked, don’t be too helpful from the start. Observe his routine, layout, methods, and quirks. The mayo stand is their domain and responsibility. Don’t assume you can touch, hand instruments, rearrange, etc. start slow by watching. If the surgeon asks for something and the tech is at the back table, go ahead and help, but slowly. A few small successful helpful moments will build trust. By the end of the case the tech will relax and let you handle instruments and more. Subsequent cases will go smoothly. But start by building trust and showing respect.

• Always be thinking of the anatomy. Keep yourself oriented. What’s in view? What’s nearby? This will keep you engaged but more importantly safe.

• Recognize when it’s a crowd. When there’s not much elbow room, step away and watch. When the scrub tech, attending, and one or two residents are present, you likely need to just step way back and watch until someone scrubs out.

• Don’t bovie the skin. After opening incision, you’ll use a bovie to stop any superficial bleeding. If you bovie the epidermis, the wound will not heal properly in that spot. There are no vessels right up under the dermis that need cautery–only under the subcutaneous–so you shouldn’t need to bovie that close anyway. If you’re coming close to skin, switch to “cut” mode (not “coag”) for less charge dispersal. Some people use this setting to extend the skin incision, but it’s poor form because it causes unnecessary scarring. In those cases, just ask for the knife back.

• Active bleeding means shut up. When there is active bleeding in the field, keep quiet. Pause conversation; let the surgeons work.

• Watch what the surgeons are watching. Can you see what they are doing? If there is blood or other fluid obscuring their view of a tissue edge or a screw head, you should suction or dab with raytec. If there is bone dust, you irrigate.

• Suction. Keep the important things visible. If everyone has their hands full and there’s a suction unused, pick it up and be ready. Early on I would suck up any blood I noticed anywhere on the field, but eventually I realized that I shouldn’t waste time sucking up clots randomly. Focus on the area where the surgeons are working, ignore everything else unless there is active arterial bleeding (ignore oozing). If you keep sucking up every random clot and puddle, you’ll distract the surgeons and keep agitating those areas to keep them from clotting off.

• Avoid knee jerk answers to pimping. In my eagerness to answer a question, I often speak before thinking. The surgeon points to some basic anatomy asking what is it, I respond in knee-jerk fashion, and as soon as the words are out I realize I’m wrong. If only I had taken a breath and slowly processed before answering. Train yourself: when asked a question, take a full breath, then answer. No one is going to jump in to answer before you. Slow down and think.

Closing

This is the time when you will likely get the opportunity at bat. After a long case, the resident is tired and they will appreciate that you patiently watched and helped along the way. They tell you to close. Here are tips for doing this right. I highly recommend this video from Duke on various knots.

• Good suturing starts with watching. Obsessively watch the senior residents and attendings stitch. Watch where they place galea stitches: how much galea do they grab, at what depth, how many times they grab the needle with each stitch, where they grab the needle in each phase of stitch, how they pop off the needle, how they hand back the driver with spent needle, etc. Mimic them.

• Practicing tying knots during lectures. Carry some silk suture around. Remove needles or use the multi-pack of silk ties. After a surgery, ask the scrub tech if you can keep any left over clean suture. You can do all tying with either one-handed or instrument technique. Pick some fixed or heavy object and keep tying back and forth so you get the flow. This has the added benefit of keeping you awake.

• Consistency in placement. Watch carefully that you enter and exit the skin at the same depth and inset on both sides of the incision. For running sutures, use the same run length on both sides.

• Closing galea. Make sure you actually grab galea. Give the suture a little tug: subcutaneous tissue rips out, galea is firm. Start the stitch from deep under the galea, then cross the incision superficial, and pierce down through the galea on the other side. Make sure to have consistent depth on both sides. Only grab 3-4 mm of galea inset on each side: more and you’ll pucker up the skin and subcutaneous fat will stick out, too little and it risks ripping out.

• Avoid a stitch abscess. Each stitch increases your chances of an abscess. You want to balance having enough stitches to hold and not so many that you necrose the skin or too superficial that it erodes through and spits out of the dermis.

• Don’t button-hole the skin. That’s where you come out the back side of the skin.

• Subcutaneous. Learn to start and end with the stitch buried. Open with a deeper anchor stitch, bury the knot as you come back to the apex, then start your run. Use an Aberdeen to bury the knot at the end.

• Start and end with short runs. At the start and end corners of the incision, travel only a short distance with each stitch. This way takes more time but does better at keeping the incision smooth. In the middle is where you travel longer to make up time.

• Watching your suture tail. Avoid getting tangled. If the resident is already supervising you place each stitch, ask her to “follow you” (they hold the tail out of your way while you stick the needle).

• Use fewer touches for speed. Use the driver to run the needle through tissue, use the pickups to pull it out on other side and immediately reload on the driver at proper angle/position. Reload the driver while still near the incision, right after you came through the tissue; do not pull stitch through and then load it with your hands by your face. Keep it down by the wound. When coming out on last side you use the pickup to load onto needle driver in such a way that you can pull up and pop off in one swoop. The fewer touches, the faster you go.

• Breaking stitches. Be careful as you tie that you don’t cause too much friction as the knot comes together; if there is friction then the suture will cut itself as you cinch it down. Be gentle but make sure the knot is firmly seated.

• Cut out bad knots immediately. Don’t sheepishly move on. Your resident will notice any bad stitch. Better you see it first, cut it out, and repeat. Do not ignore it and sheepishly move on. These will haunt you.

• Evert the dermis. This maximizes the amount of dermis in apposition which enhances granulation and healing.

After surgery

• Drapes in the trash. As the medical student, while gowned you move the dirty drapes to the trash. The scrub tech is packing up instruments and moving away the back tables. The resident is breaking scrub to write orders. You take down the dripping drapes and carefully gather all cords. Tie a knot in any distal suction lines so they don’t leak as you take down drapes, carefully pop the bovie and bipolar plugs out, ensure you don’t dump the cranial drainage bag, etc. Do this dirty work while still gowned and after you’ve helped apply bandages. You’re dirty now, so don’t return to bandaging the patient – go ungown.

• Don’t check your phone. Look for ways to help wrap up and get the patient out of the room sooner. Help unwrap and move the patient.

• Warm blankets. Learn where these are and grab them as soon as the patient is settled and waiting to wake up – this might be after moving to the new bed. There should be a natural lull where the patient is being unwrapped and when you can grab warm blankets.

• Mask on while extubating. Often patients cough when the tube is coming out, don’t get hit in the face.

• Help cleanup. After the patient is warming and waking, start tearing down and cleaning up. Put bed linens in the laundry, pick up any trash on the floor, use any remaining blue towels or linens to sop up any floor spillage.

Hours

• Arrive 5-10 minutes early. Whatever time they tell you to be there, arrive at least five minutes before that. Ten is comfortable.

• Leave when dismissed. When the resident directly tells you that you may go home, thank them and leave. If there is clearly something going on that you want to watch or that you might be able to help with, offer that you stay to the end of that and then leave. The resident likely has a lot of paperwork or crap to do that you can only hinder by making small chat. Leave them to work in peace. Don’t be that idiot who overstays your welcome. They are dismissing you for a reason: either you’re so incompetent that you’re only holding them up, or they genuinely believe you’re better off going home.

• Never ever ask “Can I go home?” You can ask the alternate “Is there anything I can help with?” That might prompt the resident to suggest you go home.

• Falling asleep. Do not be seen dozing off to sleep. Activity is key to staying awake. Keep moving in very small, unseen ways: bounce your foot, gently tap out a beat with your finger, pinch yourself so hard you flinch. Stand up; if you need to be less obvious, excuse yourself to the restroom, and when you come back just stand in the background instead of resuming your seat. Drink water. Chew gum. Write notes, anything that is being said, whatever comes to mind, just keep scribbling words. Anything to force you to move and stay engaged.

Call room etiquette

• Never sit while a resident stands. You are the last person to relax in a chair. If they haven’t taken the chair after several minutes, then you might have it.

• Study when there’s a lull. There is likely a decent neurosurgery atlas or textbook laying around that you can thumb through during down moments. Instead of randomly flipping it to a new chapter each time you pick it up for a minute or two, toss a bookmark in it so you can make actual progress through chapters. An atlas is better than a dense textbook; always a good idea to freshen up on anatomy.

• Know when to keep quiet. If the residents are busily writing notes or doing any kind of work that involves thought, use conversation sparingly so you don’t distract. Know when it’s a bad time to tell that new joke you learned.

Excelling During an Away Rotation, Reddit: Preparing for a sub-i in neurosurgery