View Full Version : Surgery Core at Flushing Hospital Medical Center

06-15-2011, 02:11 PM
Howdy folks! Meant to do this earlier, but when I started I realized it was waaaay tooooo looooong… sorry about that. Here’s the (hopefully) more succinct version. :cool:

Facility, locale: Oldish hospital in Flushing, Queens. Neighborhood felt safe for walking (although see Slevit’s comments on the OB/GYN review regarding parked cars). Surgery service does not have a trauma service, so you shouldn’t see trauma here. Also, they really don’t have a hepatobiliary service either; the one case we had was from OB/GYN, and we just stabilized the patient until we could send her to Bellevue. There isn’t a surgery residency at Flushing: residents come from Brookdale or Peninsula, and a surprisingly high number of them are DO vs. MD. There is, however, a transitional year program at Flushing, and those interns do rotate through surgery. (Keep in mind that as the residents rotate in and out, they may not be aware of what the policies are for medical students. Be sure to let them know firmly and politely if they step out of line.)

Residents (including a lot of medicine residents) hang out in the lounge on the 1st floor near the cafeteria, and that’s a good place to leave your bag and hang your coat. It has a refrigerator (admittedly it smelled terrible by the time I finished), a microwave, and a coffee machine. It also has two tables with plenty of chairs, a sofa, and two recliner chairs. Two computers there are where you and residents update patient information on a single “list” and take care of other responsibilities. You can choose to sleep in the lounge when on call (residents come and go and answer their pagers in their though) or you can stay in the on-call rooms down in the basement near the morgue. My preference was the on-call rooms; it’s one big room with three curtained alcoves, each containing a bed, a chair, and that’s about it, but it was much more comfortable than crashing on a couch, and a lot quieter too.

Note that the preceptor specifically doesn’t want students hanging out in the lounge during the day (except to eat lunch, work on the computers, or meet with the PAs or residents); there’s a library available on the fourth floor if you want to study. We largely ignored that restriction, but we were also largely busy enough not to be down there often.

Documentation and charting is still a strange mix of paper and electronic records, and really gets to be a pain when you’re on call (see below). You’ll need to bring $60 cash on the first day to loan a pager, and if you want, you can bring an additional $40 cash to loan the Washington Manual for Surgery. I ended up finding myself not having enough time to read that book, so I returned it early.

Transportation: 7 train stops at Main Street, from which you can take the Q26 or Q72 buses, or you can just hoof it for about 20 minutes. Private hire cabs are available in plenty (although hard to find early in the morning when you’d probably most want it). Parking is available on nearby streets but can be a battle to find a spot (I never drove, so I can’t speak to this personally).

Rotation setup: Six students are in each group (although I understand the current group has only five students); mine was five from AUC, one from SGU (the one before mine was all SGU). This is a 12-week rotation, split up into two-week stints on various services: general surgery (twice), SICU, wound care clinic, GU, and orthopedics. The service schedule is assigned to you on the first day by the preceptor; call is q6 and the students determine how to divide the call schedule up. Note: call begins that very first day! One of you must come prepared to stay on call that night. There are no short call days; all calls are 24 hours. Dress code was scrubs (we never wore professional attire, even for M&M, and there were no specifications on what color scrubs were required.)

Teaching: Overall, teaching was actually quite good on this rotation, with conferences or lectures almost every morning and infrequent short-notice lectures in the afternoon by preceptors. (These are mandatory, by the way: don’t let the residents bully you into doing anything that would prevent you from going to lectures.) Three of the services (SICU, GU, and orthopedics) are led by PAs, so you’ll interact with the directly while on those services (and they’re rather good at teaching). Residents are often too busy to really take the time to teach, but if you catch a decent resident on call (possibly on the weekend) they’ll be happy to answer questions and show you procedures.

Student expectations, workday: This depends heavily on what service you’re on, so I’ll break it up based on that, starting first with the on-call responsibilities. (Make sure you never leave before 3:00 pm, though!)

On-call: once you’ve finished your responsibilities for the service you’re on, take a look at the OR board and see if you need to jump into a case. You can do your fellow students a favor by helping them get out of the hospital earlier by jumping into cases that they would otherwise have to stay for. Otherwise, make sure the “list” in the lounge is as up-to-date as possible (a tedious chore indeed). Basically, you’ll have to update all the lab values, imaging studies results, and path reports for all the patients on the list. This is a task that can easily take a dedicated two hours or more assuming no interruptions, so if you’re not on call, it would help the on-call student if you started working on the list throughout the day (and in any case, the residents really want the list ready for sign-out at some undefined time in the afternoon). We rarely had the list ready for sign-out, so don’t worry too much about it, but the earlier you have it done the earlier you can get to sleep. There will be three residents on call with you: an intern covering the floor, a 2nd year or higher covering consults, and a chief doing pretty much nothing (unless they want to scrub in on any overnight cases). Throughout the day, the consult resident will have accumulated consult sheets, and those patients will need to be added to the list as well (and all their labs updated too… see where this gets tiring?) Consults usually slow down by 11:00 pm or earlier, so you can usually get the list more or less updated by midnight, and off to sleep you go. Invariably one or two consults will come in during the night, but almost always the consult resident will just take care of it and leave the consult sheet next to the computer for you. For some strange, strange reason the nursing floors start moving patients overnight. I have no idea why they do this, but it means you’ll need to check and see if the patients on your list are where they’re supposed to be. Depending on how busy the service is (i.e., 40 patients is probably the cut-off for busy, and four ICU patients), you’ll want to wake up around 3:30 am (earlier if the service is busy), update the list one more time with any new consults and room number changes. Now the fun part: print off a copy of the list, take it with you and write down the latest VS and 24-hour I/O for every patient on the list. Every floor has a different way of documenting these values, and it makes no sense whatsoever. You’ll just have to get used to it, and get used to the fact that some units simply do not document VS or I/O consistently. Try your best to find the data, and if it takes more than a few minutes to do, then just write “undocumented” on the list. Don’t forget to check patients who stayed overnight in PACU and are still in the ER without a room assignment. After 5:00 am you can get the OR list for the day from the ambulatory office; make enough copies of that list plus your updated service list (20 should do) and go up to the ICU. Unfortunately, you need the most-updated VS and I/O for the ICU patients, which means you’ll literally be scrambling to write those down at 6:00 am in time for 6:30 am rounds. Also, you’ll need to write down the lab values for the ICU patients… and for SICU patients, the latest values come up around 4:00 am. 20 copies of that, all stapled together, and you’re rocking.
All that’s just for a quiet night. There’s every possibility you’ll have a super busy service and have to get up really early, maybe with an ICU that’s stuffed to the gills, and have to scrub into a couple of overnight cases (usually an appendectomy or small bowel obstruction). Not only that, but you have to stay for rounds and morning lecture after that, but once lecture is done get you home and into a bed for a much-deserved day off!
Speaking of morning rounds…. Students are responsible for the dressing change bag. This is kept in the 1st floor lounge, and you can stock it up with supplies from the ICU supply closet. It really, really helps though if you and the other students on rounds carry a bunch of 4x4 gauze pads, drain sponges, ABD pads, and tape on you (maybe even scissors or a suture removal kit too). You’ll rarely be pimped on rounds, but you’ll do every single dressing change. Residents will expect you to anticipate these dressing changes and start pulling them off before they enter the room (but make sure you know which ones are being changed). After a while you learn to look ahead on the list and see that the next patient had a bowel resection two days ago… likely needing a wet-to-dry dressing, so get it ready and get started! The whole point is to get rounds done and over with quickly, and dressing changes are a surefire way to hold that up.

General surgery: There will be two of you at a time rotating on this service. Start at 6:30 am with morning rounds in the ICU, then proceed to the OR board after morning lecture. You’ll be responsible for pre-op H&Ps on patients needing medical clearance (you will probably be paged during rounds for 8:00 cases), and you’ll be asked to assist on a number of common cases (cholecystectomy, appendectomy, hernia, and thyroid, with occasional bowel resection and vascular cases). Outside of that, you’re free to observe any cases you like (of course, always introduce yourself to the patient and attending surgeon first). Do your best to update the list between cases. There is a general surgery clinic on Wednesday afternoons that you’ll cover. You basically grab a chart, see the patient for a brief history, present the patient to the attending, and that’s it. You might write a note, usually not though. Otherwise, the only notes I wrote on this service were the occasional post-op notes and orders. Day ends whenever the cases are completed or covered by the on-call student.
By the way, the preceptor is a breast specialist and she expects to have a student as first assistant rather than a resident for her breast excision cases in the OR. Great opportunity to learn how to suture! Make sure a student is available for these cases! Also, she runs a breast clinic on Tuesday mornings, so if you’re free, try to get to this (usually you’re not though).

SICU: One student on this service. Start at 6:30 am with morning rounds, and then report to the PA after morning lecture. The chair of vascular surgery also covers the SICU patients, so do your best to round with him and the PA. The PA will assign a patient for you to write a progress note on; this will be the lengthiest note you’ll write on surgery (but still shorter than internal medicine notes). Be sure to be present for any procedures on ICU patients (femoral line, IJ line, feeding tube, etc.), and if any ICU patients go down for surgery, you’ll be expected to scrub in. Although there’s no clinic specifically assigned to SICU, you’re expected to help out on the Tuesday morning breast clinics. Other than that, fairly chill service, and I usually left at 3:00 or shortly thereafter.

GU: One student on this service. Start at 7:00 am in the lounge with the PA, who will assign one or two patients for you to write notes on before morning lecture. See those patients, write very focused notes, and after lecture, meet with the PA again. Usually she prefers you go into any cases so she can stay on the floor and see consults, so this is a service where you’ll get to act as first assistant a lot (in fact, I did a circumcision case myself here). A lot of the cases, such as ESWL and TURP, don’t need an assistant at all, so you don’t have to see them if you don’t want to. Clinic is on Thursday afternoon every other week, and unless you have cases to scrub into, you should go to the breast clinics on Tuesday mornings. This is definitely the easiest service, and I had a lot of free time to work on the list and study. The PA is super-relaxed and easy-going, so take advantage of this service as a chance to breathe from some of the harder ones!

Ortho: One student per service (you’ll also have two PA students as well). Start at 7:00 am in the lounge with the PA, and go over the service patients. Pay attention to which patients need dressing changes, and then go upstairs and see patients, writing notes on the ones you’ve seen. Note that the PA students don’t go to lectures with you, so they keep on seeing patients when you nip out for those. Naturally that means you miss a lot of cases in the OR too, since they tend to start early while you’re in lecture. The two PAs work 8-hour shifts overlapping during the day, so usually you’ll end up following one while the PA students follow the other, seeing consults on the floor and in the ER. Clinic is on Wednesday afternoon every week, with a pediatric subspecialty clinic on (I think… can’t remember) Thursday mornings. One attending literally bangs out a couple dozen knee and shoulder arthroscopies on Friday mornings, and you’ll be busy doing pre-op H&Ps on those patients. Expect to spend Wednesday or Thursday evening preparing paperwork for these cases with the PA. You’re expected to stay until 7:00 pm each day…. The PAs are pretty cool, the attending surgeons are great guys, and doing reductions in the ER is pretty neat, but the hours just wear on you and if, like me, you have Saturday call in the middle of this service… it sucks, let me tell you.

Wound care clinic: One student on this service. Report for morning lecture and then show up to clinic at 9:00… the luxury!!! Patients are all variations on the theme of chronic venous stasis ulcers, diabetic feet, and decubitus ulcers. The name of the game is remove the dressing, cleanse the wound, scrape and scrape some more, dress it up, and send them out the door. You actually learn quite a lot on this service, and you have a different attending every morning and afternoon (no residents). The nurses are fun and love to have someone around who doesn’t mind helping out, the attendings love to teach, and the patients themselves are usually interesting.
While on this service, you are first assistant to the chief of plastics (who only does hands these days), so you’ll scrub with him in the OR. He is a really entertaining guy although he has absolutely no sense of time (be prepared to wait literally hours for him to show up for his first case), but you sure can’t beat sitting down in the OR to do a delicate hand case, and then suturing up afterward. You’ll also attend his clinics, which are on Tuesday and Friday afternoons (again, don’t be surprised if a patient or two leaves because they’re tired of waiting two hours to see him). He also loves to teach almost as much as he loves to tell jokes. Although you start later in the morning than any other service, you’ll probably find yourself staying much later than 3:00 just because of this surgeon, but it evens out. You’ll also be expected to help out in breast clinic on Tuesday mornings.

Student evaluation: I’m adding this here because from what the preceptor was saying, she’s going to start doing an oral exam at the end of the rotation. Also, another preceptor gave us a written exam based on her lectures (although I don’t think it counted towards a grade), so be prepared for that and keep her lecture handouts.

Impression: I have to be careful when giving my impression of this rotation, because I was going on three rotations (medicine, OB/GYN, and surgery) in a row without a break… and my last service on surgery was ortho (with a Saturday call between weeks), so I was pretty burned out! However, in speaking with other students doing surgery elsewhere I have to say Flushing is about middle of the pack in terms of work demands and call schedule. I generally got more sleep than my counterparts at other hospitals (not having a trauma service helps tremendously), and I still got a lot of hands-on experience both in the OR and the clinics. If you’re looking to do surgery as a career though, this may not be the best place for you to rotate, since you’ll be limited in not having a trauma experience. Otherwise, you’ll get a broad enough experience here with plenty of good teaching to hold you in good stead.

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