This is a general outline of the daily routine of an Acute Care Surgeon- it does not represent a universal experience, because every facility and every team is unique. Daily schedules vary between the different services. Some facilities have a small enough volume that all three aspects are covered by one surgeon. However, for busy facilities, there can be up to 5-6 surgeons covering the different services. There can be multiple ICU teams to manage, each requiring a surgeon. In-coming trauma might require the full attention of one surgeon, while another surgeon takes care of inpatients and scheduled cases. This is not a guide for how to set up a department- it's just a peek into what we do during the day.
The day typically starts with morning report, where overnight events are discussed. This can include trauma and ICU admissions, as well as operative cases. Other significant events such as patients who required transfer to a higher level of care are also discussed.
Following morning report, the different services diverge to meet with their teams, either in the OR, in the ICU, or on the inpatient wards.
Trauma Service
Rounds [the process of evaluating and examining patients currently in the hospital]
- Residents typically see the patients first, review their blood work and their x-rays, examine them and ask them pertinent questions to report to their chief resident/ attending. The attending and the chief resident/ senior resident discuss the patients and visit patients in person. There are different practice patterns, and flexibility is required. If the same team is also covering new trauma consults from the emergency department (ED), rounds might be staggered or split based on staffing and patient volume.
- Patient evaluation focuses on monitoring patients in the postoperative period, including assessment of bowel function (have you passed gas or had a bowel movement?), nutrition and oral intake (hungry, eating 1/2 of meals, nauseated), pulmonary function (performing breathing exercises), pain control, activity (working with physical therapy, walking laps, breathing exercises), examining wounds, and ruling out surgical complications. Care for patients recovering from trauma also entails communication with subspecialists, such as orthopedics or neurosurgery.
Procedures
- Emergent operations on new admissions- exploratory laparotomy for intra-abdominal injuries (bowel injury, severe bleeding), thoracotomy for intra-thoracic injuries (severe bleeding, wound to the heart), repair of vascular injuries (bleeding from a blood vessel).
- Scheduled operations for patients on the trauma service.
Consultations and New Admissions
- The majority of patient consults for trauma originate in the ED. Rarely, a patient who is currently admitted to the hospital may be diagnosed with an occult injury (meaning it wasn't found on initial assessment) or a patient may sustain an injury while in the hospital.
Surgical Critical Care
Rounds
- See “What happens during Surgical Critical Care (SICU) Rounds? for details.
Procedures
- Tracheostomy- creation of a connection directly through the neck to the trachea (airway) to allow removal of the endotracheal tube (breathing tube) from the mouth.
- Percutaneous endoscopic gastrostomy tube (PEG)- creation of a connection directly through the anterior abdominal wall into the stomach to allow feeding without requiring a tube in the patient’s nose.
- Bronchoscopy- use of a small camera (think of a really skinny colonoscopy) to examine the airways of the lungs, take a specimen for culture or remove obstruction.
- Central line placement- placement of a large catheter into a large vein in the neck, under the clavicle (collarbone), or in the groin. The purpose is similar to an IV (intravenous) line, which is commonly placed to provide medication, fluids, or draw blood. A central line is larger- more drips can be connected to it, it can be kept in place longer than a peripheral IV, and it can allow delivery of special medications.
- Arterial line placement- similar to an IV, this is a skinny catheter, but instead of being in a vein, it’s placed in an artery. This allows continuous monitoring of blood pressure and allows repeat labs, specifically arterial blood gas to assess respiratory status
Consultations and New Admissions
- Scheduled or semi-scheduled surgical cases such as complex vascular procedures (aortic surgery, carotid surgery), transplant surgery (patients receive a new liver or kidney), resection of head and neck cancer with a need for management of tracheostomy, and monitoring of muscle flap.
- Emergent surgical cases such as a ruptured abdominal aortic aneurysm (thinning of the wall with eventual rupture with bleeding), bowel perforation (hole in the intestine), or any of a variety of surgical catastrophes.
- Severely injured trauma patients, including patients who require close monitoring of hemodynamics (low blood pressure, high heart rate) or pulmonary status (ability to take deep breaths with severe trauma to the chest), or patients with head injuries requiring intubation.
- Non-ICU patients in lower acuity units that require ICU admission for deterioration in clinical status (respiratory distress, altered mental status, hemodynamic instability).
Emergency General Surgery
Rounds
- Similar to trauma patients as above. For patients who haven’t had surgery (uncomplicated diverticulitis or small bowel obstructions secondary to adhesive disease), close monitoring for changes in clinical status is vital.
Procedures
- Emergent operations on new admissions- laparotomy for bowel ischemia/ perforation (decreased blood flow to the bowel or a hole in the bowel).
- Scheduled operations for patients on the emergency general surgery service, for example, reversal of an ostomy. Patients who undergo emergent surgery for trauma or bowel ischemia/ perforation sometimes require creation of an opening on the skin to allow stool to pass outside into a bag. These can be “reversed”, meaning the bowel is reconnected (so the patient will now pass stool normally) and the skin opening is closed.
Consultations and New Admissions
- Patient consults typically originate in the ED. Everything from abdominal pain to rectal pain to massive intestinal bleeding can prompt a phone call/ page/ text message to the Emergency General Surgery service.
- Patients admitted for non-surgical diseases can develop a surgical emergency during their hospital admission. This includes diagnoses that typically prompt a visit to the ED (appendicitis, cholecystitis), but there are a host of other diagnoses that are more frequent in the hospital setting, such as C. difficle colitis.
In addition to daily responsibilities, there are weekly or monthly department-wide events.
- Staff Meetings
- Trauma Morbidity and Mortality- discuss outcomes from trauma cases.
- General Surgery Morbidity and Mortality- discuss outcomes from general surgery cases.
- Grand Rounds- lectures from subject matter experts on various surgical topics.