Protocols alone cannot keep patients safe, we need a culture (of safety)

Emergency General Surgery (R2) - VUMC

EGS Service OverviewThe Emergency General Surgery (EGS) service is comprised of faculty in the Department of Surgery, residents at the PGY-5, PGY-2, and PGY-1 levels, as well as dedicated Nurse Practitioners. The EGS service evaluates nearly 1,200 patients each year, and serves as the primary consult service for acute general surgical diseases from within Vanderbilt University Medical Center as well as surrounding communities. The primary mission of the EGS service is to provide timely surgical assessment and operative management of the patient with an acute general surgical problem.

Core competencies as defined by the ACGME form the basis of resident evaluations.

1) Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

For PGY-2 residents on the EGS service, this will largely take place in the context of perioperative care with the support and guidance of chief residents and faculty. The PGY-2 resident functions as the main consult resident for the service. The PGY-2 should also continue learning to interpret imaging studies such as plain radiographs, ultrasound, and CT scan of the abdomen. Morning report provides a forum to discuss new patients and review imaging studies with faculty and other residents. Operative skills are further developed during the PGY-2 year with increasing participation in a variety of operations as detailed below.

2) Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

The Surgical Council on Resident Education (SCORE) has defined an excellent curriculum for the traditional 5 year General Surgery training program. This has been further grouped to aid in sequencing the material by PGY year. For the PGY-2 year grouping, diseases and conditions which may be encountered on the EGS rotation include:

• Choledocholithiasis • Biliary Pancreatitis • Acalculous Cholecystitis and Biliary Dyskinesia • Iatrogenic Bile Duct Injury • Small Bowel Obstruction and Ileus • Acute Mesenteric Ischemia: Arterial, Venous, and Nonocclusive • Lower Gastrointestinal Bleeding • Diverticular Bleeding • Diverticular Fistulae • Colonic Polyps • Colonic Cancer • Gallstone Ileus • Gallbladder Polyps • Mesenteric Cyst • Miscellaneous Hernias • Hepatic Abscess • Mallory-Weiss Syndrome • Peptic Ulcer Disease with Bleeding • Peptic Ulcer Disease with Perforation • Peptic Ulcer Disease with Obstruction

• Gastric Ulcer • Stress Gastritis • Volvulus • Appendiceal Neoplasms • Antibiotic-Induced Colitis • Meckel's Diverticulum • Intussusception • Malrotation • Pneumatosis • Addisonian Crisis • Incidental Ovarian Mass-Cyst • Cervical Lymphadenopathy • Necrotizing Fasciitis • Gastrointestinal Failure • Hepatic Failure • Renal Failure • Coagulopathy • Neurologic Dysfunction • Endocrine Dysfunction

One of the most effective ways to retain knowledge while at the same time improving the care of your surgical patients is to read about the diseases and conditions faced by patients as you encounter them.

3) Practice-based Learning and Improvement

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

A good technique to achieve this objective is to review evidence-based guidelines (e.g. Cochrane Reviews: http://www2.cochrane.org/reviews/ ), as well as critical reading of relevant articles in the surgical literature. Self-evaluation as it relates to patient care is best performed in real-time by seeking feedback and discussion from senior residents and faculty. (i.e. What could I have done differently?)

4) Interpersonal and Communication Skills

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Residents are expected to conduct themselves in a courteous and professional manner when interacting with patients, families and nursing staff. Good communication is critical to patient care, particularly in the emergency setting. Examples of specific elements which are of value throughout surgical training and practice include:

• Discussion of risk/benefit/nature of the operation with patients and families in the setting of informed consent.

• Communication with the surgical team. While a “Time-out” is performed before every invasive procedure or operation, the communication ideally begins much sooner (i.e. with anesthesia re: anticipated need for antibiotics, blood products, etc, with scrub/circulating nurses regarding nature of the operation, needed equipment/suture etc).

• Transition of patient care, i.e. “sign out”

• Communication with consultants and nursing staff

• End-of-life discussions

5) Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

(a) compassion, integrity, and respect for others

(b) responsiveness to patient needs that supersedes self-interest

(c) respect for patient privacy and autonomy;

(d) accountability to patients, society and the profession; and,

(e) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

(f) high standards of ethical behavior, and

(g) a commitment to continuity of patient care

6) Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

7) Technical Skills

PGY-2 residents will learn essential clinical skills in the evaluation and treatment of EGS patients. Time spent in the operating room in a critical part of training, regardless of whether or not one is “doing” the operation. During the PGY-2 year, you will function as the operating surgeon for many cases. In some cases, the Chief Resident may function as a teaching assistant with faculty supervision. PGY-2 residents should also strive to participate in “Chief Cases” (i.e. sick, complicated patient in which the Chief Resident functions as the operating surgeon with the faculty member assisting.)

Operations/Procedures included in the SCORE curriculum likely to be encountered by the EGS PGY-2 include:

Diagnostic Laparoscopy Exploratory Laparotomy Open drainage of abdominal abscess Incarcerated or strangulated hernias Open and laparoscopic cholecystectomy Open and laparoscopic appendectomy Laparoscopic CBD exploration Partial and subtotal colectomy Muscle and lymph node biopsies Debridement for necrotizing infections

Pancreatic debridement Pseudocyst drainage procedures Open and percutaneous tracheostomy Open, laparoscopic and percutaneous gastrostomy Repair of duodenal perforation Partial gastrectomy Enterolysis Enterectomy Ileostomy Colostomy

 

8) Education

Sign out and communication the most important parts of an EGS day, the morning report system allows for patient sign-out, case assignment, debate, and time for instruction. are critical with restricted work hours to ensure appropriate continuity of care. In order to provide additional educational benefit, it is expected that all members of the team be prepared to discuss patients, physiology, and surgical options, appropriate to his/her level of experience. 

source: vanderbit