The bread and butter procedures in general surgery include hernias, appendectomies, and laparoscopic cholecystectomies. However, one of the most important bread and butter procedures for a surgical intern is actually the admission of the patient. Do not be mistaken into thinking this is “scut work” or a mindless task. Admissions are an opportunity to learn the most important lesson a surgeon can learn—whom to operate on and why.
Each surgical admission should be approached in a systematic manner. Particular regard should be given to triage, time management, communication, entering orders, and avoiding common mistakes.
Choosing which patient to see first is not necessarily based on the order the pages came in or on the disease the patient has. It is the severity of each patient’s condition that dictates the order in which he or she is seen. In other words, patients are triaged.
It is helpful to know the most common diagnoses for each rotation you are on and how to work them up. However, when triaging patients, knowing the management of every surgical disease is not as important as being able to recognize several important signs of a severely ill person. These signs include fever, hypotension, and tachycardia. It goes without saying that a patient with unstable vitals needs urgent attention. However, surgery patients are the most fickle patients in the hospital. They will look good one minute and be on their way down the next. It is the ability to pick up the subtleties that make the difference. For example, an elderly patient with a heart rate of 90 does not fall into the textbook definition of tachycardia. However, when considering that the patient is on a β-blocker and his baseline heart rate is 50, this person can be considered to have a relative tachycardia and may be quite sick. Triaging patients is a skill that will improve with time, but only if it is practiced with attention to detail.
Occasionally, people have no major abnormalities of their vital signs, but there is other information that affects their priority. There are 3 “trigger words” that should raise a patient’s level of triage regardless of the vital signs. Peritonitis, free air, and ischemia should never be neglected.
Patients with the physical exam finding of peritonitis (diagnosis symptom, not a diagnosis!) are the exclusive domain of the surgeon. These patients demand prompt surgical evaluation if not immediate surgical intervention. It is important to remember that a normal computed tomographic (CT) scan in a person with a clinical exam of peritonitis is not reassuring. These patients are sick regardless of what the radiograph shows.
The same can be said for patients with free air. This is essentially synonymous with a gastrointestinal perforation, and demands a surgeon guiding the care of this patient. Patients with free air may have a relatively benign exam and stable vitals; ...