The Department of Surgery and its faculty emphasize student proficiency and expertise in the following areas during this 8-week clerkship. Many of these areas are fundamental building blocks for any sound medical practice and, for the student interested in surgery, will serve as a solid foundation for the acquisition of advanced knowledge in the field of surgery.
1. The student will gain knowledge of surgical problems through patient care (H&P's, daily rounds, clinics, operating room experience).
2. The student will gain an understanding of the etiology, pathophysiology, epidemiology, clinical manifestations, diagnostic work-up and appropriate treatment options for a wide variety of diseases. (see appendix 1)
3. The student will display the ability to use both textbooks and the medical literature.
4. The student will be given an introduction to the operating room including proper scrubbing and gowning technique, basics concepts of sterile technique and instruction in various surgical procedures. The student is expected to be present in the OR for interesting cases and for those patients whom he/she has worked up.
5. The student will be expected to achieve the following operating room objectives:
Demonstrate the proper technique for surgical scrubbing and assisted and unassisted gowning and gloving.
Demonstrate knowledge of aseptic technique and discuss the microbiological principles involved.
Identify areas in the operating room, which are considered part of the sterile field.
Demonstrate the ability to function as an assistant in the operating room environment.
6. The clerkship period will allow for the familiarization of the student with post-anesthetic recovery routine including sophisticated monitoring techniques such as blood gases, arterial pressure and pulmonary artery pressure monitoring. In this setting there will be instruction and experience in writing appropriate postoperative orders.
7. By following an individual patient through surgery, the student will be able to assess the accuracy of his/her decision making process by seeing the disease in its natural state and following up on the histological interpretation. During monthly tumor board students have the opportunity to view histological slides and hear pathology discussions about pertinent cases.
8. The student will be able to recognize complications of surgical procedures such as atelectasis, urinary tract infection, and pulmonary embolism. He/she will be able to institute effective therapy as well as recognize complications that are unique to specific operations.
9. The student will participate in the postoperative care of the patient in the ICU, on hospital floors and in the outpatient clinics. The student will document his/her role in the preoperative, operative and postoperative care of the patient in the medical record.
10. The student will learn the various surgical procedures and treatments that can be effectively utilized on an outpatient basis. Concepts such as same day outpatient surgery will be stressed, along with their rationale, safety and cost effectiveness.
11. Through his/her exposure to the Emergency Department, the student will become knowledgeable in the principles of diagnosis and treatment of acute illness and injury, and distinguish priorities of care in the emergency setting.
12. During the clerkship, emphasis will be placed on the improvement of existing skills as well as introducing new manual skills. All of these skills will be acquired under close housestaff or faculty supervision. An initial surgical practicum will provide the student with the opportunity to perform suture closure of operative wounds using a variety of techniques. (see appendix 2)
13. The student will learn the basic principles of nutrition in the surgical patient including the assessment of caloric and protein needs, the choice between enteral and parenteral routes, choice of route of delivery, and assessment of the adequacy of nutrition. There will be an emphasis on the stressed and injured patient.
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1. The student will be expected to show competence in obtaining an accurate clinical history and performing a complete physical examination focused on areas of surgical concern; i.e., eyes, ears, nose, throat, respiratory system, cardiovascular system, the abdomen, the peri-rectal area, the musculoskeletal system, the breast, etc.
2. The student will display the ability to construct a complete problem list and formulate a differential diagnosis.
3. The student will be able to develop an appropriate diagnostic and therapeutic plan. If applicable, the student will demonstrate knowledge in alternative non-surgical approaches to the patientís problems.
4. The student will show the ability to implement the appropriate diagnostic work-up with indicated laboratory and radiological tests as well as the ability to interpret them and understand their relative accuracy in various surgical diseases including the rationale behind the choice of tests, their proper sequence in the clinical investigation, and their cost effectiveness.
5. The student will demonstrate knowledge of, the indications for and interpretation of the following tests ;
Ultrasonography, arteriography, Doppler studies, computed tomography (CT), liver/spleen scans, gallium scans, bone scans, biliary excretion scans (HIDA, PIPIDA), endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, fistulogram/sinogram, UGI, LGI, intravenous pyelography, and magnetic resonance imaging (MRI)
6. The student will be expected to develop proficiency in the preoperative evaluation of the surgical patient with particular concern for those areas that directly affect operative risk; namely, the pulmonary, cardiac, genitourinary and hematologic systems, as well as distinct disease states such as diabetes mellitus, bleeding disorders, etc.
7. The student will participate in the post-operative care of the patient in the ICU, on hospital floors and in the outpatient clinics. The student will document his/her role in the preoperative, operative and postoperative care of the patient in the medical record.
8. Using elements of the history, physical examination, laboratory tests and radiographic studies, the student will be able to determine resuscitation needs, establish a working diagnosis, and institute proper therapy for the patient in the emergency department.
9. Through patient management, lectures and seminars, the student will be able to assess degree and extent of burn injuries, and institute appropriate resuscitative measures. He/she should also comprehend the rationale behind the various therapeutic modalities and be aware of the use of topical and systemic antibiotics and the diagnosis and treatment of burn complications. The long-range effects of major burns to the individual and the reconstructive techniques used to restore function to burned tissues will be emphasized.
10. The student will learn how to deal with end of life issues as they present in surgical patients. This might include intimate discussions with the patient and/or family, a multidisciplinary meeting, or an ethics conference.
11. The student will learn how to approach pain relief in the injured patient or in the post-operative patient.
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1. The student, with proper resident or attending supervision, will receive instruction in writing admitting and/or preoperative orders. All orders written by students must be reviewed by a physician and counter signed.
2. Each student during the clerkship will be expected to present their patients, including x-ray and laboratory findings, to his/her peers and instructors to help develop public speaking ability and to nurture the concept of peer discussion of difficult cases.
3. The student will demonstrate an understanding of the elements of surgical admission orders by writing complete, concise and clear orders.
4. The student will demonstrate an understanding of the necessary elements in the preoperative evaluation of a patient by writing a preoperative assessment note.
5. The student will be able to construct preoperative orders to provide guidance for nursing service, laboratory or other paramedical personnel who will assist in preparing the patient for surgery.
6. The student will demonstrate an understanding of a surgical procedure by recording the relevant information in a brief operative note.
7. The student will demonstrate an understanding of the immediate postoperative care of the surgical patient by writing orders which give complete, concise, clear directions for management.
8. The student will demonstrate an understanding of the progress of the postoperative patient and a knowledge of potential complications by preparing progress notes outlining the patient's clinical course.
9. The student will demonstrate good communication skills with the patients and their families.
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1. The student will display the highest standard of professional, ethical and moral conduct when caring for patients, interacting with families and healthcare workers and when functioning as a member of the surgical team.
2. The student will display proper dress, grooming, punctuality, honesty and respect for patient's confidentiality at all times.
3. The student will recognize his/her own limitations in knowledge and clinical skills and commit to continuous improvement in knowledge and ability.
Practice Based and Lifelong Learning
1. The student will understand and apply basic evidence-based knowledge in the patient care setting.
2. The student will show the ability to learn from past mistakes and to accept constructive criticism.
3. The student will display a basic understanding of some of the areas of controversy in patient care and medical practice.
Social and Community Context of Healthcare
1. The student will display a knowledge of the healthcare system and identify resources for patient care.
2. The student will recognize how social factors can influence the course of a patient's disease as well as the outcome.
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Surgical Diseases and Problems
1. Esophagus: esophageal cancer, esophageal stricture, gastroesophageal reflux, achalasia, esophageal injury/perforation
2. Stomach: UGI bleeding, gastric cancer, gastric ulcer, injury, perforation, gastric outlet obstruction, hiatal hernia
3. Duodenum: duodenal ulcer, perforation, bleeding, injury, tumor
4. Small Intestine: tumor, Crohn's disease, polyps, arterio-venous malformations, Meckel's diverticulum, short bowel syndrome, vascular insufficiency, small bowel obstruction, injury to small bowel, appendicitis
5. Colon: Crohn's disease, ulcerative colitis, cancer, polyps, diverticular disease, obstruction, volvulus, colon injury, LGI bleeding
6. Rectum/Anus: tumors, hemorrhoids, anal fissure, fistula-in-ano, peri-rectal abscess, injury
7. Gall Bladder & Biliary Tract: cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, tumors
8. Pancreas: tumors, pancreatitis, injury
9. Liver: tumors, injury, transplant
10. Spleen: injury, hematologic disorders, tumors
11. Adrenal Gland: tumors, acute adrenal insufficiency
12. Thyroid & Parathyroid Glands: tumors, infection/inflammation, hyperthyroidism, hyperparathyroidism
13. Breast: benign tumors, malignant tumors, infection
14. Heart: coronary artery disease, valvular disease, congenital disease, injury
15. Lungs/Pleura: tumors, pneumonia, abscess, empyema thoracis, injury, pneumothorax, hemothorax
16. Cerebral Circulation: atherosclerotic disease, aneurysm, injury
17. Arterial Disease of the Lower Extremity: atherosclerotic disease, aneurysm, injury
18. Aorta & Iliac Arteries: atherosclerotic disease, aneurysm, injury
19. Venous Disease: venous stasis, varicosities, deep venous thrombosis
20. Trauma: initial management, primary and secondary survey, resuscitation, identification and treatment of injuries (head, chest, abdomen, pelvis, extremities)
21. Burn: resuscitation and initial management, treatment of burn wounds, supportive care, rehabilitation
22. Newborn Physiology: lung development and pulmonary hypertension, fluid/electrolyte/glucose management, temperature regulation
23. Congenital Anomalies: abdominal wall defects, congenital diaphragmatic hernia, tracheoesophageal fistula/esophageal atresia, inguinal hernia/hydrocele, newborn bowel obstruction, malrotation of the intestines
24. Skin and Soft Tissues: melanoma, squamous cell carcinoma, basal cell carcinoma, sarcoma
25. Hernias: inguinal, femoral, diaphragmatic, umbilical
26. Critical Care: respiratory failure (acute lung injury, acute respiratory distress syndrome), acute renal failure, shock, spesis
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1. Discuss the purpose of a nasogastric tube and list the risks, indications, and contraindications for insertion and removal.
2. Given an actual patient, demonstrate the ability to intubate the stomach with a nasogastric tube, including proper positioning and secure taping.
3. Demonstrate proper care of a nasogastric tube and describe the care of other gastrointestinal tubes, including gastrostomy tubes, T-tubes, and jejunostomy tubes.
4. List the indications, contraindications, and possible complications of passage of a urethral catheter.
5. Demonstrate the ability to insert a urethral catheter and provide daily catheter care and maintenance necessary for preventing stricture formation and retrograde urinary infection.
6. Demonstrate proper technique for sampling urine (through a catheter or a spontaneously voided specimen).
7. Describe the types of surgical drains, including their advantages and disadvantages; describe the indications for drain placement, advancement and removal, as well as possible complications associated with their use. Define the differences between therapeutic and prophylactic drainage.
8. Appropriately advance and remove surgical drains, including Penrose drains, Hemovac drains, sump drains, NG tubes and foleys.
9. List the indications, contraindications, and complications associated with the insertion of central venous catheters, pulmonary artery catheters and peripheral arterial catheters and participate in their placement.
10. Demonstrate the ability to insert intravenous catheters for the delivery of IV fluids and medications.
11. Demonstrate the routine maintenance of central venous catheters, including care and management of the tubing and solution containers.
12. Perform venipuncture for blood sampling.
13. Demonstrate the ability to sample arterial blood by performing arterial puncture.
14. Identify, describe and manage complications secondary to venipuncture and arterial puncture.
15. Appropriately place and remove skin sutures and staples.
16. Appropriately care for open wounds, including dressing changes, minor debridements; demonstrate ability to recognize infected, poorly healing and healthy granulating wounds.
17. List the indications, contraindications and complications associated with pleural aspiration; participate in or observe this procedure.
18. List the indications, contraindications and complications associated with placement of chest tubes; participate in the placement and removal of the same.
19. Observe or perform the following additional procedures:
incision and drainage of superficial skin abscess
colostomy and ileostomy care
proctoscopic examination and biopsy
application of casts, traction, ace bandages
leg wrapping for venous disease
dressings of the hand and head
construction of flow charts and their use
hyperalimentation techniques and procedures
Doppler examination of veins and arteries
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2001 Loyola University Chicago Stritch School
of Medicine. All rights reserved