Attendings

Baird Mallory, MD	Jeffrey M. Halter, MD	Christopher G. Turner, MD
Kartikey A. Pandya, MD	Meredith A. Baker, MD

Expectations

Pediatric Surgery Rotation

Hello and welcome to the Pediatric Surgery rotation at MMC, we are excited to have you! The information below should help you with the daily organization of the service and general expectations.

Pediatric Surgery is a broad specialty, and we hope that you come to appreciate that children are not just small adults. We do not expect you to know how to take care of these delicate patients from day 1; we expect you to ask for help! Our hope is that you will gain comfort in the management of kids in a variety of different surgical disease processes by the end of your rotation, and truly enjoy this rewarding field.

Staff: Drs. Baker, Halter, Mallory, Pandya, Turner, Tara Hadlock PA-C and Emily Sweeney NP. Carrie LaPierre is our physician scheduler and Melissa Belanger RN is our clinic nurse.

Orientation

Please find attending on call on your first day for an orientation to the service. You’re also welcome to reach out to Drs. Turner or Pandya.

Didactic resources and practice guidelines

The Not-a-Textbook is a good resource for residents and medical students. It does not require a subscription. Our protocols and practice guidelines are here.

Pediatric Trauma pathways are with the adult pathways.

Communication

All members of the pediatric surgery division respond to Epic text messages, text pages, phone calls and pages. Most times, a phone or in-person conversation is the most efficient and safe way to communicate.

If you do not receive a response after a few minutes from person you're trying to reach do one of the following:

1. Call them.
2. Page them.
3. Find them in the office/clinic/OR.

Repeatedly texting them while you have a clinical question or consult is not efficient and delays patient care.

You will be provided with each member's contact information when you arrive on service.

Daily Rounds

Morning rounds start with a conference call at 7:00 am (6:50 am on Monday’s and Thursday’s due to conferences) in the 3rd floor NICU conference room (occasionally in the BBCH Treatment Room, discuss with the team if you’re unsure where to go). The morning phone call is a quick run through of our list and is meant to discuss major management decisions for our patients. You do not have to present patients in detail during the morning call but should have details and numbers available if asked.

Please pre-round and have pertinent labs and imaging ready to view prior to team rounds.

Patient presentation on rounds is part art and science. There are many ways of discussing patients, but core components should include:

1. One liner of why the patient is in the hospital and their post-operative day i.e “8 yr old male, POD 2 from lap appy for perforated appendicitis…”
2. An update of events from prior rounds i.e. “…had nausea overnight and continues to require IV pain medications…”
3. Total intake/out X mL, Fluids X mL/kg/day (“ckd”), Calories X kcal/kg/day (“kkd”), calories from enteral, and calories from parenteral nutrition.
4. Formula, concentration, volume, frequency (ie Similac 20cal PO 60 mL q3hr) and goal rate
5. Emesis/day and character
6. Urine output # mL/kg/hr, # stools/day or # mL/kg/hr
7. Drain/Tube output # mL and character
8. Review medications (especially antibiotic days), if they’re being used, if they’re still appropriate etc.
9. Focused physical exam.
10. Have a plan and be comfortable describing the plan by systems (neuro/pain, pulmonary, cardiac, access, FEN, endo, MSK etc.)

Afternoon rounds (variable time): PM rounds will occur with the APP(s) and surgeon on call to assure care progresses as planned. Please run the list with the team as needed throughout the day to follow up on plans, labs or radiology studies ordered. If there is no report, go find the radiologist please.

You may be asked to round without the attending on call and run the list dependent on the on-call attending’s OR/clinic schedule.

Weekend rounds: The attending on that weekend will discuss with you what time rounds will start, usually at 7 am.

Notes

Daily progress note template can be found at .psurgprogressnote.

Progress notes are an efficient way to communicate patient status and should be written thoughtfully. Please avoid the temptation to “copy-forward” and not review narrative that is propagated.

We do not want to see notes saying “POD2, AVSS, CSM.” Consults

• Please see them promptly. Medical students can be (with proper supervision) helpful in seeing consults. They are not meant to REPLACE a resident in evaluating a patient. While a ward or emergency room consult will be appropriate for a medical student, an ICU patient may not (these must be supervised).
• Please use the pediatric surgery consult note template .psurgconsultnote
• All consults/admissions require a Full History and Physical including past medical/surgical history, accurate medication list, allergies, social history, family history, and a full physical exam.
• If the consult is an inpatient, or will be admitted, please add to the list!
• Do not wait until the end of the day to review consults please. They should be reviewed after being seen, come find us in the OR if needed, or find the staff.
• If you have several consults to see, ask the other team members to help!
• If the consult will be admitted to us (ie the ER calls with a confirmed appy), then do your consult note, and then on the H&P just write a few short lines and say “see admission note.”

Pediatric Surgery SmartPhrases

Other templates are available by searching “.psurg…”

Medical Student and AI Expectations

We welcome medical students and acting interns to our service. You are a valuable member of the team and can provide direct patient care and comfort. A few ways to make the most of your time:

General patient care expectations:

1. Show up on time (rounds, conferences, chalk talks, clinic, OR’s etc.).
2. Be prepared to contribute to the team (like helping the residents prepare for rounds).
3. Present patients and see consults with the resident on service.
4. Know where you need to be (discuss OR and clinic coverage plans with the surgery resident).
5. Prepare for surgical cases and clinic patients.
6. Work with residents and APP’s when seeing consults.
7. You are expected to come to at least 2 clinics during your 1 week rotation.
8. In clinic let the surgeon or NP you are working with know you are there.
9. Read up on any cases you know are coming in (a good activity between patients or waiting for them to be roomed).
10. Offer to see the patients: especially for new consults it is helpful if you do a brief history and physical exam (budget yourself around 10 minutes) and then present this to the attending. Ask if you should do the exam or wait until the surgeon comes and do it together.
11. You cannot wear scrubs over to the clinic.
12. Please present on at least one topic from the “Pediatric Surgery Topics.”

Conduct and expectations in the OR

1. Prepare for the case by reading notes ahead, reviewing anatomy and understand basic steps of the procedure.
2. Introduce yourself to the OR team and write your name on the whiteboard. Notify them of your glove size.
3. Do not violate sterile technique. If you’re unsure about something, please ask. If you notice a violation of sterility by you or someone else, please speak up.
4. Practice knot tying and suturing in the surgical learning center (the OR is not a place for practice).
5. Help with patient transfer and accompany them to the recovery room.
6. Seek out opportunities to learn (you can learn a lot from many people in the OR, including anesthesiologists, nurses and surgical technologists).

Some people hate the OR/faint. If that is you, let us know and we can find cases that are in line with your interests or shorter.

Some people love the OR. If that’s you, great. Come as often as possible but remember that the other aspects of patient care/education should not be neglected. Enjoy your rotation!

Schedule

Orders

• Pediatric surgery order sets are found in Epic and change periodically.
• All meds and fluids are WEIGHT based. But you need to think about this…once 50 kg = adult dosing! So please do not give a 75 kg child 7.5 mg of morphine!
• If you’re not sure, ask.

Unit Goals and Objectives:

Resident goals and objectives vary based on competency, PGY year and exist on a continuum.

Medical Knowledge & Patient Care:

1. Utilize provided and acquired knowledge resources (Pediatric Surgery Protocols, Pediatric Trauma Protocols, and curated readings).
2. Understanding of general principles of care of children with surgical conditions (changes in anatomy, physiology, thermoregulation, pain control, fluid management etc.).
3. Understand role of enteral and parenteral nutrition in perioperative patients.
4. Understanding of pathophysiology of common surgical conditions in infants and children including (pyloric stenosis, intestinal obstruction, appendicitis, foreign body of esophagus and airway, etc.)
5. Management of critically ill children (including trauma resuscitation and management).
6. Evaluation and management of stable neonate.
7. Understanding of pathophysiology of surgical conditions in neonates and older children including congenital and acquired conditions (see list of conditions below).

Patient Care Skills:

1. Performing physical exams on patients across the age spectrum and recognizing normal and abnormal findings (i.e. abdominal pain, respiratory conditions, congenital abnormalities etc.).
2. Trauma evaluation and management (airway, circulation, disability).
3. Performing burn assessment, debridement and dressing changes.
4. Obtaining peripheral and central venous access in younger children.
5. Interpretation medical imaging (x-rays, upper GI series, barium enema, CT scan, MRI, and Radionuclide scans).
6. Assisting and performing (with graded supervision) common and rare pediatric surgery cases (including appendectomy, pyloromyotomy, gastrostomy tube placement, indwelling central venous access, hernia repair etc.)
7. Greater independence with on-call duties, functioning as senior resident, both with patient assessment and in the operating room.

Systems-based Practice:

1. Understanding and development of a system to provide cost-efficient surgical care. 2. Considering coordination of resources (family and hospital) when caring for children.
2. Utilizing outpatient clinic messaging successfully to coordinate patient’s outpatient care and follow up.
3. Coordination with patient care team (APP’s, case managers, social workers, primary and consulting services) to optimize patient’s length of stay.

Practice-based Learning & Improvement (PBLI), Interpersonal & Communication Skills Continuity of Care:

1. Writing thoughtful clinical documentation to optimize care team communication (including primary care physician, attending surgeon and clinic team).
2. Prompt evaluation of patients when requested in the in-patient and out-patient settings.
3. Coordination with other team members to reduce time-to-evaluation for patients.
4. Clear, concise communication about patients during all care team interactions (morning conference call, discussing consults with attendings, sign-out and task delegation between residents/APP’s).
5. Keeping an organized list with updated and accurate problem lists.
6. Prompt documentation of surgical procedures (brief OP note, OP report when asked for by the attending), filling out of evaluation tools.
7. Respond to pages in a timely manner by proactive communication with nurses, other members of the pediatric surgery service and with OR staff (if scrubbed for a case).
8. Ensure pediatric surgery resident and APP patient coverage in case of absence from service (planned vacation or leave on short notice).
9. Communicate any request to cover non-pediatric surgery services or cases while on the pediatric surgery service with the attending and APP’s on that day.
10. Conduct age-appropriate conversations with patients regarding their surgical conditions and plans (i.e. a discussion about needing surgery for a child should not occur in the absence of a guardian).
11. Regularly utilize the available pediatric surgery clinical practice guidelines (general surgical cases, trauma, perioperative management etc.).
12. Routinely search literature for optimal care of pediatric surgery patients.
13. Review topics from list below and discuss with attending on call “chalk talks.”
14. Participate in the education of patients, families, students, residents, and other health professionals.
15. Incorporate formative evaluation feedback into daily practice.

Professionalism:

1. Consistently display professionalism in communication, patient care, and care coordination with patients and care team.
2. Demonstrate sensitivity to vulnerable populations (understand social determinants of health).
3. Ensure patient privacy and autonomy.
4. Demonstrate honesty in patient care discussions and demonstrate high ethical standards. Maintain high standards of ethical behavior in all professional activities.
5. Demonstrate self-care and communicate with the remainder of the care team if there is a need for time away.

Pediatric Surgery diseases/conditions:

Below is a list of common and rare pediatric surgical conditions. Some are unique to pediatric patients while others can be found in adult patients with different management paradigms.

1. Anorectal malformations
2. Appendicitis
3. Biliary atresia
4. Choledochal cysts
5. Congenital diaphragmatic hernia
6. Cryptorchidism
7. Duodenal atresia
8. Esophageal atresia / Tracheoesophageal fistula
9. Gastroschisis / Omphalocele
10. Hirschsprung's disease
11. Hypertrophic pyloric stenosis
12. Inguinal Hernia
13. Intussusception
14. Malrotation
15. Meckel’s diverticulum
16. Neuroblastoma
17. Necrotizing enterocolitis
18. Tracheal / Esophageal foreign body
19. Umbilical hernia

Hand offs and Absences

A clear and concise hand off process is essential to patient care. Please practice active listening when receiving service hand off and provide clear patient summaries when handing off to the night team covering the pediatric surgery service. Minimizing hand offs is essential to avoiding errors in patient management. Ensure the serviced is tucked when handing off to the night or weekend team.

If you will be away for teaching/conference or are sick, please give us advance notice or call us to let us know! Also let your colleagues know so that coverage can be arranged.

Outpatient clinic

Carrie LaPierre is our physician scheduling coordinator and can be reached via Epic staff messages (off hours), via Epic Chat (office hours) and via phone at 207-662-5867. It is helpful to coordinate outpatient follow-up for patients by contacting Carrie. During day of discharge, clarify follow up (in-person or telehealth) with the primary attending or attending on call and notify Carrie.

Melissa Belanger RN is our clinic nurse and can be reached via Epic and 207-662-6224. Melissa can assist with outpatient issues and provide background on patients directed from the clinic/home to the ER/hospital.

End of rotation

We try to make the rotation as useful and educational as possible and appreciate your thoughts on how to improve the rotation. Please seek out the on call attending for a debriefing.

Schedule