Work & Life
The last time you stepped inside an operating room may have been the third year of medical school, but during residency you will care for many patients who require surgery, either elective or emergent. Calling a surgical consult can be daunting or intimidating, especially if the problem or situation is outside your comfort zone. The following advice can help you feel more prepared and knowledgeable when calling a surgical resident or attending.
Know the patient’s recent relevant exam: This may sound obvious, but often a consult is handed off from the night team to the day team or vice versa, and sometimes a busy doctor may call the consult without personally seeing the patient. However, a patient’s exam can change in the span of an hour, and it is always good practice to examine the patient yourself.
Tips for a good exam:
Chest: Check lung sounds, recent oxygen requirements, and oxygen saturations; note scars on the chest indicating prior surgery that can make placement of a chest tube more difficult
Abdomen: Note scars; assess softness/firmness, distention, tenderness, rebound, and guarding
Vascular: Check pulses in both limbs if concerned about an ischemic limb (use a Doppler if you cannot palpate a pulse); surgical scars can indicate that the patient has had prior vascular procedures
Have a specific question in mind: Sometimes we really don’t know what is happening with a patient and need a consult to help make sense of the situation. However, it’s good to have a specific question in mind when you call a consult. Do you think the patient has cholecystitis and needs a cholecystectomy? Are you suspicious of a potential surgical problem and started a basic workup but don’t know the correct imaging test to order? Formulating a differential diagnosis helps ensure that you call the right consultant, and having a specific question saves time. Begin by stating the reason for the consult (e.g., “I’m calling a consult for Mr. Jones for a cold leg” or “I’m worried about acute mesenteric ischemia in Mr. Smith, but I’m not sure about the best test to order because he has a creatinine level of 3”).
Know the patient’s medical history, especially past surgeries: It is extremely important for surgeons to know a patient’s prior surgical and medical history (including cardiac or pulmonary disease that may increase surgery and anesthesia risk). Prior surgeries often relate to the current problem or can make an operation more difficult due to scar tissue and altered anatomy. Hint: If the history cannot be elicited from the patient or medical record, look for surgical scars, including small scars from laparoscopic or thorascopic surgery. Remember that cesarean section counts as prior surgery.
Maintain appropriate fluid and electrolyte balance: Patients with an acute surgical problem are often dehydrated, with electrolyte abnormalities from nausea, vomiting, diarrhea, infection, or sepsis. Patients headed to surgery need to be adequately resuscitated, with electrolytes replenished; otherwise, hypovolemia and electrolyte imbalance can cause intraoperative problems with anesthesia induction or prolonged surgery. Often, insertion of a Foley catheter can help guide fluid resuscitation or signal clinical deterioration.
Know when the patient last ate or drank: If you think there is a possibility that the patient needs to go urgently to the operating room, make them NPO (nothing by mouth) before you call the consult.
Know if the patient is receiving anticoagulation therapy and obtain recent coagulation study results: Reversal of anticoagulation can delay surgery. Therefore, knowing whether a patient is receiving anticoagulants is crucial and ordering a blood type and screen test is a good idea if you think the patient is headed to surgery.
Assess the patient’s feelings about having surgery and know the patient’s code status: Patients are often unaware that a surgeon has been called and can be blindsided when a consultant arrives and announces, “Hi, I’m Dr. Johnson from surgery.” What you consider routine surgery can be a major event for patients. Inform patients that you requested a surgical consult and ask how they feel about the possibility of undergoing surgery. It is not your job to talk patients into surgery or explain the risks and benefits, but it is helpful to have a general idea about their feelings regarding the possibility of undergoing surgery. If a patient is hesitant to have surgery, it is still very reasonable to get a surgical consult and let the surgeon explain the process to the patient. A do-not-resuscitate (DNR) order is not a contraindication for surgery — it can be reversed perioperatively — but it is important information for the surgical consultant.
Know if the patient is receiving immunosuppressants: Immunocompromised status can affect the presentation of patients with an acute abdomen, so let the consultant know if the patient is receiving immunosuppressants (e.g., prednisone, tacrolimus, cyclosporine), has recently undergone chemotherapy, or has other risk factors for immune suppression.
Start the workup and management of a potential surgical problem:
If you suspect intra-abdominal bleeding, establish intravenous access with two large-bore IVs, order an immediate complete blood count (stat CBC), order blood typing and crossmatch and order blood, insert a Foley catheter, and order appropriate imaging tests (e.g., such as a kidney, ureter, and bladder study [KUB] CT or MRI).
For potential thoracic problems, start with chest radiograph followed by CT scan, depending on the problem.
Use a simple pulse exam to diagnose vascular problems. Other adjunct studies include pulse volume recordings (PVR) performed in a vascular lab or with duplex ultrasound. Some patients may require a CT angiogram to make the diagnosis.
Do not let an unstable patient go to imaging without you: Patients are often left unattended while waiting for imaging or transport.
If the consult is urgent or emergent, just call the surgical consultant.
Most important, do what is right for the patient. Surgeons are busy but happy to help, especially in emergent situations. Use consults as learning opportunities and ask consultants to explain their thought process and the details of surgery.