Imagine you're a third year medical student. It's dark 'o thirty on week one of your surgery rotation. Your team has just finished rounds, and your notes and tasks have been diligently completed. It's off to the operating room!
Hot lights, blue drapes, everyone moving briskly and efficiently, making jokes and slapping metal instruments into palms, a square of human flesh draped out on a table -- it's all a little unreal. The attending surgeon turns to you and asks you some tidbit of anatomy that has been covered in a thick layer of dust. Your life flashes before your eyes as you struggle to picture your coffee stained Netter's atlas from MS1. It's your time to shine...or sink.
So, how do you prepare for the OR?
First of all, preparation is key. Ask the junior-most resident on the team to help get you a copy of the cases for the week; gently remind them when they forget-- or at least find some way to know what to prepare for. Sometimes you'll be assigned to cases; other times you'll have more freedom to choose. If you've been following a patient preoperatively, make an effect to be involved in their operation.
Once you have the schedule, review these things:
1. Know the patient
Read the H&P!
- Why is this person having an operation?
- Why *this* operation? (For example, a person with inflammatory breast cancer gets a modified radical mastectomy. A person with less invasive cancer may get a lumpectomy or simple mastectomy.)
- What comorbidites / past surgeries have they had? (No meds, no past surgical histories, or did they have to delay getting their 18th surgery because of the latest myocardial infarction?)
Hint: Attendings often put their favorite pimp questions in the H&P; enjoy those freebies. "What's the risk of X complication, med student?" "It's 2%, sir!"
*BONUS* The first words out of an attending's mouth at the scrub sink to the resident will un-doubtedly be: "So did you look at their films?" You want to be able to say "Yes, sir/ma'am. [And insert description of relevant pathology or abnormality]"
2. Know the operation
Okay, if you're a resident, you should shrive to know the operation well enough that if your attendings vanished mid-case, you could muster on without them.
If you're a medical student, you need to know enough to know what the heck is going on.
- Read a broad description of the operation in any surgical text. Break it down into bite size steps and write them out. (Cholecystectomy: Access abdomen, insuflate with gas. Place 4 ports. Dissect out a critical view of safety. Ligate cystic artery and cystic duct. Remove gallbladder from hepatic fossa. Pull gallbladder out. Close.)
- Now look up those relevant structures! Know your anatomy first and foremost. 95% of your average MS3 pimp questions will be anatomy. The rest will be either basic physiology or common postop complications.
- Surgical Recall somehow magically has all the good pimp questions. I highly recommend it earn a place in your white coat or ipad.
The Rapid Review
"I'm working with a different team today and found out that we're doing a Whipple today. I have 10 minutes before the case starts. What do I study??"
- 1 min: Skim the H&P. (46 yo W with Pancreatic cancer. No nodes. HTN. Hysterectomy in the past. Former smoker. Got it.)
- 3 min: Know the indications for the operation. (UpToDate or Surgical Recall in a pinch). (Ask yourself: Why is this patient getting an operation? In this case, because a Whipple can extend life or even cure patients with pancreatic adenocarcinoma with a 25% 5 yr survival)
-7 min: Anatomy! (Go back to basics. What's the blood supply to the pancreas? What are the branches of the celiac and SMA? etc.)
If you're prepared for the OR, it'll be easier to understand what's going on, ask intelligent questions, and actually learn something. You might find yourself enjoy the cases more as you become more involved, and studying becomes much easier when you directly apply it in the operating room.
Hope this helps -- Good luck!
Til next time,
Petite Surgeon
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