Surgery: An Introductory Guide PDF
Preview Surgery: An Introductory Guide
Umut Sarpel Surgery An Introductory Guide 123 Surgery Umut Sarpel Surgery An Introductory Guide Umut Sarpel Department of Surgery Division of Surgical Oncology Icahn School of Medicine at Mount Sinai New York , NY , USA ISBN 978-1-4939-0902-5 ISBN 978-1-4939-0903-2 (eBook) DOI 10.1007/978-1-4939-0903-2 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014940052 © Springer Science+Business Media New York 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduc- tion on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analy- sis or material supplied specifi cally for the purpose of being entered and exe- cuted on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provi- sions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accu- rate at the date of publication, neither the authors nor the editors nor the pub- lisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword Simple can be harder than complex : You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there , you can move mountains . — Steve Jobs Reading this book is like being “scrubbed in” an operation at the elbow of an expert surgeon. This surgeon loves her work. And she has high expectations of you, but she doesn’t leave it at that. She is aware of what you have learned so far and what you have not yet encountered. She guides your thinking to enable you to grow into the excellent clinician you aspire to be. Since most students who complete a surgery clerkship will not go on to practice surgery, this may be your only immersion into how to think like a surgeon. Pay attention. This is important. D r. Umut Sarpel introduces and demystifies the rhythms and routines of a busy surgical suite, including OR schedules, protocols, and personnel, guiding students to understand the jargon, where and why to focus their attention, how to respond to questions, and quite literally what to do with their hands. Like a good travel guide to an exotic land she trans- lates the colloquial idioms, making the new arrival feel famil- iar and “semantically competent.” This comfort and guidance is critical to learning. Without guidance a medical student may not figure out what or how to learn in the operating room. Most surgeons highly value the apprenticeship model in the OR, in which trainees learn by doing real-world work alongside an expert. But this model has limits in practice because the master prac- titioner often fails to speak aloud the hard-earned tacit knowledge critical to understanding the operation. This makes what they do seem mysterious or magical to the novice v vi Foreword medical student who is often struck dumb by the foreignness, complexity, and emotional intensity of what is going on. The educational limits of a classic apprenticeship are exacerbated when students, hoping to mimic their teachers, prepare for the OR with what is referred to as “foreground information” rather than ensure that they have mastered the basic back- ground knowledge. This is most noticeable when the student comes to the bedside or operating room having read the lat- est published literature on surgical technique but can’t articu- late the indications for the surgery in this patient, the pathophysiology of the disease process, or how to prevent or prepare for the most likely surgical complications. Skipping the basics can have significant consequences. This is because, as cognitive psychologists have elucidated, the accuracy of clinical decision-making is predicated on the learning of mental models called schemas or scripts. These scripts are foundational structures or patterns of information that are initialized through learning the basics and then become more sophisticated with deliberate practice. Scripts enable the seasoned clinician to instantly and accurately rec- ognize key clinical situations, even when subtle or atypical. Experts have highly detailed and rich scripts, novices very sparse and spotty ones. Without developmentally appropriate scaffolding provided by teachers to ensure these basic scripts are laid down solidly, learning is slowed and some novices may never develop accurate clinical decision-making capac- ity for the most common surgical diseases. In this eloquently efficient book, Dr. Umut Sarpel has done the difficult work of simplifying the complex. Ideal instructional materials use text and pictures, are engaging to read, and are aimed just above the current knowledge level of the intended reader—not too low or too high. Sarpel’s book does just this. She frames the material in words, images, classic cases, and bulleted lists to help the clinical clerk pre- pare to learn in the operating room. But this book is not just for students. I believe all surgical educators, especially newly minted ones, need to take a page from this playbook. In fact it would make a great text for faculty development, preparing Foreword vii surgical educators to teach novices about a particular surgical procedure. In addition, all health care professional students such as nurses, physician assistants, and technicians will learn a great deal from this book, which simplifies and explains the most challenging of learning environments. Umut Sarpel and I have been colleagues and friends for many years. Over that time, I have known her to be a skillful and compassionate physician, wise scholar, and enthusiastic educational leader, but until now I did not have the privilege of knowing her as a teacher. Reading this book, as a General Internist who hasn’t been in the OR (except on the table) since I was a clinical clerk in 1982, I have been reminded once again of how challenging it is to learn medicine in complex clinical environments. My respect has redoubled for her com- passion and empathy for our students who face a learning challenge akin to drinking from a fire hose. With so many competing demands on their limited time and cognitive ener- gies, many students falter and waste precious time. This book serves as a drinking cup. In the best tradition of academic surgeons, Umut identified an unmet need and then meticu- lously created this resource. Our students and our patients are better off as a result. New York, NY Adina Kalet, M.D., M.P.H. Arnold P. Gold Professor of Humanism and Professionalism Director of the Research on Medical Education and Outcomes Unit Program on Medical Education Innovation and Research New York University School of Medicine Pref ace A surgical mentor of mine used to advise his medical students “Don’t act like tourists!” He wanted them to get deeply immersed in their surgical clerkship, to view themselves as vital members of the surgical team, rather than be passive observers who simply watched surgeons work. Of course, this is easier said than done. The tempo of a surgical service is fast and the rotation is already over by the time you figure out how everything runs. The operating room—the heart of a medical student’s sur- gical experience—is perhaps the most inscrutable and intimi- dating aspect of the entire rotation. You will be assigned to cases and will be expected to “read-up” on the operation before scrubbing in. Although this sounds like a simple instruction, in my experience, most students do not really understand how to prepare for a case. Often a student will arrive to my OR having read the latest phase III clinical trial on the disease, but with little knowledge about the patient or understanding of the operation at hand. Participating in an operation has the potential to be one of the most profound learning experiences in all of medical school, but often seems to pass by in a blur. So, how can you get the most out of your time in the OR? What does it mean to “read-up” on a case? It means that you should know the patient’s story, be prepared to discuss the pathophysiology of the disease, understand why this proce- dure is being performed, be familiar with the main steps of the case, recognize the key anatomy, and be aware of the most common complications of the operation. This task requires you to pull together information from several different ix x Preface sources: texts on anatomy and pathology, surgical atlases, and clinical guidebooks. But even this type of diligent preparation does not take into account last-minute changes in the OR schedule. Surgery is a fast-paced field and it is not unusual to be suddenly reassigned to a new operation or to have an emergency case arise. T he concept of this book was to bring together those vari- ous pieces of information that a medical student needs to critically understand an operation, and present it in a unified, concise, efficient, and portable format. Throughout the book, the emphasis is on the use of keywords, diagrams, and illustra- tions in order to enhance your ability to quickly absorb and retain the relevant information. Each chapter consists of several sections, including: Introduction: Just-enough information is presented on each of the common indications for an operation and the relevant pathophysiology. The emphasis is on clinical knowledge over basic science facts, and the aspects that are important to sur- gical decision-making are stressed. Keywords are placed in bold throughout the text, allowing you to quickly find the information you need. Surgical Technique: Most surgical manuals target the surgical resident, providing technical information that is far too detailed for the needs of a medical student. Nevertheless, some knowledge of the steps of an operation is important for a student to understand the progression of a procedure. In this work, the main steps of each operation are listed, allowing you to follow the case, and interact with your surgical team. Complications : Perhaps the most important aspect of an operation is what might happen after the skin has been closed. What are the most common complications and how do they present? Despite its significance, this information is rarely covered in medical school texts. Classic Case: Each chapter ends with a classic case, since a patient story often sticks in the memory longer than does didactic text. These scenarios describe how a patient’s
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