Surgery Rotation

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​ Ah, the surgery rotation. Gowning and gloving? Long hours? Sterile field? Alright..let’s take it one step at a time. 
 
Loved my surgery rotation & sometimes still miss being in the OR. Be prepared for long hours, but the joy of this rotation comes from it being hands-on. I never found myself checking the clock because everything was so fascinating. I’ve collaborated with Anthony Gauthier, Ortho Surgical PA-C who has been practicing for 10 years (#goals). I’ll say what I have to say quickly so you can get onto reading his expert tips later in this post.
 
General tips:

• Be sure to know/spend time studying or practicing: 
  • Anatomy—this is a must! Surgeons & preceptors just love asking questions (“pimping”) during a case. What is this structure? What is it innervated by? What percentage of people have this anatomical variation?
  • Names of the Surgical Instruments--also a must! Army/Navy, Deaver retractor, Allis Clamp, Kelly clamp. Nothing else says noob status more than handing the surgeon the wrong instrument because you don't actually know the instrument names. This happened to a friend (jk..this "friend" was me. *facepalm*). Learn the instrument names prior to your first day!
  • How to properly gown and glove—Most programs have a surgical principles course, learn as much as possible here. If you still have questions, YouTube is your best friend!
  • Different suture techniques— practice at home. The first day I was handed a needle driver & some sutures and was told to “show them what I got.” Luckily they were happy with my skills & it set the tone for the rest of the rotation.
  • Different suture material--was asked about this almost daily. Know the types & where each is best suited for
• Most places have schedules for the cases you’ll be working on the next day. Not familiar with the surgery? Research it the night before, there’s tons of videos on YouTube. Even if its not the same technique the next day, at least you’ll have a talking point. “I’ve seen this done in this manner…why do you prefer this method?"

Books I recommend: 

• Surgical Recall--highly recommend.Good for classic 'pimp' questions & EOR studying). Just an FYI: the book is written in Q&A format
• Anatomy: Netter’s, Color Atlas of Anatomy

Podcast:

• Surgery 101

Miscellaneous: 

• Compression socks—personally love Comrad socks
• Comfortable shoes
  • People swear by Danskos. If you already have them, use them. I couldn’t get myself to spend ~$200 for them (poor student here) so I used Clarks + my custom orthotics. Worked well for me! No matter what, just be sure they’re shoes that have enough support for 10+ hours

Alright, now it's Anthony's part...

Surgery Rotation tips 
​By: Anthony Gauthier, PA-C
Instagram: @journey_to_pa_school

It is time for your surgery rotation and you are determined to do so well, even Dr. Richard Webber would be calling you to offer you a job (if Grey’s Anatomywas ever hiring PAs).
 
In general:

• Sleep as much as possible leading up to your surgery rotation. I don’t know who decided to make the schedule this way, but Surgeons do not value sleep as much as everyone else. The days start early and can run into the late evening. Some locations may even have you take overnight call (as if didactic year didn’t already destroy your circadian rhythms enough)
• Get a pocket notebook and write notes about everything you encounter on your rotation. Your future PA-C self will thank you for it

  
Rounding: This is the time spent evaluating the patients that are currently admitted. They may be immediately post op, waiting to be medically maximized and cleared to have surgery, or a new consult added to the never ending list. Rounding is typically done very early in the morning.
 
Get there early for pre-rounding (say what???). In order to have a good understanding of each patient you need to take time reviewing the chart. Make sure you have a piece of paper or the patient list, then spend time reviewing the chart notes to know the specifics of each patient

Important items to have listed:

• Changes in status/symptoms (increase pain, constipation, etc)
• Labs values such as CBC, CMP, culture results.
• Current medications and if any adjustments need to be made. Make sure they are on some form of DVT prophylaxis
• Are there drains? How much is it putting out per shift and when will it need to be pulled.
• Was the dressing changed and when will it need to be changed again?  
• What are the plans for discharge? Will they need more intervention or ready for home (some may be transferred to skilled nursing facility

Other rounding tips

• Always introduce yourself to the patient and everyone in the room. Nothing upsets a family more than a random person walking in addressing only the patient and walking out. The family is not only there for support, but will be the ones helping once the patient is home. Make sure you include them in the treatment plan.
• Have extra dressings, paper tape and a pair of good scissors in your white coat pocket. Nothing is worse than checking a wound and realizing you don’t have anything to cover it back up (it never fails as the supply station for that area will always be out of the stuff you need).
• Make it a requirement that you touch base with the nurse taking care of the patient. Nurses work their tail off with the patient all day and night. They want to know the game plan as it will help them answer patient questions when you are not around. By discussing the plan and allowing time for the nurse to ask questions you just saved yourself from getting multiple pages and calls about the patient.
• Understand what a surgical consent is and how to properly inform a patient about the risks and benefits of surgery.

 Now that you are ready to round let the pimping begin...

 “Pimping:" Pimping is being asked questions on the spot, as a form to improve learning. The questions are typically esoteric and asked in hopes to stump you or think deeper about a situation. 
 
Some places will have you round as a team with the Attending Physician present. While discussing the patient the Attending may ask you specific and detailed questions about the patient or their disease state

• If you do not know the answer, don’t make it up. Attending's can sense BS a mile away, making things only worse. It is best to reply, “I am not aware of the answer but will research it and get back to you.” Just make sure you actually look it up, because if asked a second time and still unsure, you can kiss that good grade good bye

 
The Operating Room
Get there early!

• Rule number 1: Do Not Touch Anything that is sterile.The worst thing you can do is contaminate something in the OR. It’s a great way to make enemies. A lot of work goes into preparing everything for surgery and by contaminating the field you just added extra work to everyone’s day.
• Know the proper way to scrub your hands for surgery. Pay attention to how the Attending is doing it. Most likely they will consider their way the correct way and you want to follow their lead.
• Learn how to gown and glove yourself. If you can do this well, you will be able to save the staff time and show you are self-sufficient. Bonus points, try to pick and open your own gloves and gown. The Surgical tech will appreciate this.
• Have an understanding of the surgery that is going to be performed for the patient. You don’t need to know every step and detail, but by having a general understanding you can anticipate the next step making you more valuable when assisting.
• Remember you are the assist. Do not make any moves or place retractors unless told to do so. The surgeon has steps to the way they perform the procedure, if you try to add your own steps you will alter their flow.
• Ask the right questions. You don’t have to be quiet during the entire surgery, unless the surgeon asks for no talking. But you don’t want to be asking so many questions they get annoyed by you.  Be prepared to be asked questions, questions like “What structure is this?” are common during your surgery rotation

Closing Time:

• Learn the basics on suturing and wound closure
• Make sure you know how to tie knots with a 2 hand tie or single hand tie
• Practice suturing so if handed over the needle driver and pick ups you can impress them, instead of hands that are so shaky they think you have a movement disorder
• Know how to close skin with a simple interrupted suture as well as a running suture

 
Final note:
Many consider the surgery rotation as stressful but once you know what to expect and what the routine is, surgery becomes their favorite rotation. Like any other rotation you get back what you put in. Always be willing to stay late or help on as many cases as possible.
 
Taking night call is not fun, so if you can, volunteer to stay to help the evening call person. This will help you get remembered and you never know, going the extra mile during rotations can very well help you land your first job out of PA school!
 
That's all! As always, if we've missed something, please let us know!  If this was helpful, share it with your buddies/classmates. Enjoy your rotation! ​

-Melody, PA-C, MPH & Anthony, Ortho Surgical PA-C