UB Surgery Intern Guide 2015-16

General Expectations
General Intern Duties
o Daily orders
o Checking labs
What to do with abnormal values
Choice of IV fluids
Special notes on ESRD patients
o Pre-ops
o Post-op checks
o Admissions
o Discharges
o Follow-up
o Families
o Common floor calls
Pain
Nausea
Vital abnormalities
Tachycardia
Hypertension
Hypotension
Desaturation
Fever
Low urine output
Chest pain
Altered mental status
Itching
Anxiety
Insomnia
Whats the plan
Abnormal labs
Other calls
Codes/Rapid Responses
Patient deathpronouncement, paperwork, etc.
o Trauma at ECMC
o List maintenance
o Good sign-out
o Consults
o Training and teaching students
o Keeping the team informed
Templates for dictations & notes
o H&P/Consult
o Admission/Post-op orders
o Pre-op Note
o Brief Op Note
o Operative Dictation
o Discharge Summary
General Advice
o Advice for the OR
o Introduction to each hospital
BGH
Millard Fillmore Suburban
ECMC
Other hospitals

Disclaimer: EVERYTHING in this guide is subject to change, and much is based on opinion as much as fact. Use it as
such. Good luck!

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General Expectations

Be on time and available

o This means if your chief expects to start at 6 that you are ready to go at 6, not pulling in the parking lot at
6.
o This means we dont have to go looking for you during the day. Update your seniors as much as possible
throughout the day
o This means you check in with your colleagues and your senior before you leave for the day to be sure
they dont need anything else.
Adhere to work hours
o We cannot afford work hours violations. The schedules are as such that this should not be an issue.
However, if you find that you are getting close to breaking work hours, it is imperative that you talk to
your senior about it so that a plan can be made to keep you compliant for that week as well as fix any
future problems with the schedule. The onus is on you first to monitor and we will then assist in
maintaining compliance.
Get your work done
o We will expect you are familiar with your duties as outlined in this packet. Ask for help if you are
struggling with time management. We have all been there and can help you find a way to get the work
done without breaking hours and while still making it into the OR.
Scrub in
o Look for opportunities to scrub. If you are free and not assigned cases, look for cases to double scrub.
Find opportunities to learn
o Look for opportunities to do bedside procedures and help with consults. Once you have gotten
comfortable with intern-level duties, it is time to start getting comfortable with more upper level
activities. Ask to be walked through procedures that you havent done yet. If you receive a page for a
consult, ask the consult resident if you can see it and present it to them.
Be honest
o We shouldnt have to remind you of this.
Do not get in over your head
o See below bump it up
o Make sure you have appropriate supervision/permission for whatever you are doing
Know your patients
o Take ownership of the patients you operate on and the patients on your service. Think of them as YOUR
patients and you will automatically do a better job.
Keep up with the expected administrative paperwork of logging hours, logging cases, and anything else that the
department asks of you. They view this as your professionalism.
Read
o Your patients are relying on your knowledge. Read for conference, read for your cases, and read as part
of a regular reading plan.

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General Intern Duties

Note: at any point, you might notice someone more senior doing one or more of these duties. Dont assume
that they have completely taken care of anything. They might look at labs for their own knowledge but not
replace them. They might order pre-op labs and studies but not actually pre-op the patient. You can NOT
assume that theyve done anything unless you check for yourself or if they tell you they fully took care of it. If
they do, thank them and dont assume theyll always take care of it. Remember, it is ultimately YOUR
responsibility to make sure these things are taken care of as everyone else has other responsibilities of their own
that they are accountable for.
Daily orders
o Most patients get daily labsCBC w/diff, BMP, Mg, others as appropriate (PT/INR for pts on Coumadin,
etc). It is bad form to leave for the day without ordering labs for the next day. Labs help create plans for
patients and the seniors and attendings expect to have this data readily available in the morning.
o Renew things like IVFs, TPN (still written orders), foley (needs to be renewed daily), etc.
o When a patients diet is advanced
Adjust pain meds (ie: strictly dilaudid/morphine IV or PCA lortab PO + dilaudid IV for
breakthrough). Add colace.
Switch other meds to PO (ie: protonix IV zantac PO)
Resume home meds.
o PT/OT and D/C planning for patients that will need it (start EARLY)
When a patient goes to the OR or is transferred from the ICU to the floor, PT/OT needs to be re-
ordered
Constant and daily communication with the discharge planner moves your patient out of the
hospital, the faster your team can stop rounding on patients who are just discharge planning issues
the happier you will make your seniors
Checking labs
o For which patients:
Nearly all patients get daily labs since most of our patients are acutely ill. Make sure to have labs
on anyone that is immediate post-op (unless it would have been an ambulatory procedure),
anyone that is NPO, and anyone else that has acute issues.
We definitely over-order labs, but when in Rome
Make sure to check labs as early as possible in the morning (should be by 10am at the
latest). It is NOT acceptable to learn at 5pm that the pt is in acute renal failure or is acutely
anemic, or has a K of 2.8.
o How to deal with abnormalities
Abnormal CBC
If Hb is acutely low, see what the pts vitals are and if they are symptomatic. If yes, then
get your senior involved. They may need transfusion. Dont just do it by yourself!
o Most of the time you should re-check it regardless.
o Hb<7.0 we transfuse most people.
o Hb<10 we transfuse most people with CAD or h/o MI
o For people with Hb trending down and likely still bleeding, we might transfuse at
8 or 9. Regardless, get your senior involved. Attending would likely decide.
They may also need more definitive treatment (back to OR, scope, etc).
o If dropping/trending down, look for the source. Check the patients wounds,
abdomen, extremities, and ask about their urine and BMs.
o If you are writing the order for transfusion of any blood products, consider that
the pt may need lasix (20mg IV) in between units to avoid fluid overload.
o Ordering blood products and transfusing the patient are two separate orders, both
orders need to be completed for the transfusion to happen.
If WBC is acutely high (or acutely markedly low), look for sources of infection (see
below, fever work up). Also make sure to look at the diff. Normal or low WBC with

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 left shift and or bandemia is still significant (if not more so) and is commonly found in
very sick elderly.
If platelets are low, look at the trend. If they have dropped considerably (technically
>50%), need to consider HIT. Talk to your senior and consider sending PF4 antibodies
as well as stopping heparin/lovenox and starting argatroban (IV drip with special order
sheet) or fondaparinoux (SQ, call pharmacy for dosing). Alternatively, if platelets are
acutely high, consider the cause reactive thrombocytosis? s/p splenectomy?, talk to
your seniors about giving daily aspirin.
Abnormal Electrolytes
If K>6 get EKG and give 10 units insulin IV with one amp of D50 and one amp of Ca
gluconate. If they are having BMs, also give them kayexalate 30gm PO. Get your senior
involved if critically high or EKG changes are present.
o If their K has been normal or low and this is significantly deviated, consider
rechecking it first. The sample may be hemolyzed.
Common replacements:
o We generally replace to keep K > 4, Phos > 3 and Mg > 2
o If the value is really low, or if the pt is NPO, replace with IV. If they are taking
PO diet then use PO replacements when possible or a combination of PO and IV.
Below are a few common suggestions but there are many other options. Call
pharmacy if needed.
o Potassium
KCl 10 meq IV x up to 4 runs (pharmacy will require a repeat BMP if
you want to do any more than 4 runs)keep in mind it burns
KCL 10-80 meq POkeep in mind it tastes like garbage if its the liquid
stuff
Expect K level to increase ~0.1 for each 10 meq IV of K given, and less
of an effect with PO.
For K<3.2 make sure to replace with IV and repeat BMP after runs
Dont replete K in ESRD pts without talking to a senior (see below)
o Magnesium
Mg Sulfate 1-4 gm IV
Mg Oxide 400-800 mg PO
o Phosphorus
KPhos 5-30 mmols IV
NaPhos 5-30 mmols IV
NutraPhos 1 packet PO TID x24 hours
o Calcium
Note that we rarely worry about hypocalcemiaconsider that most
patients albumin levels are low and so when the total calcium is
corrected with that in consideration, it is rarely low
Ca Gluconate one-two amps IV
CaCO3 PO
CaCl IV only in ICU situations
Look at the IVFs the pt is on with respect to their labs
Definitions:
o Resuscitative (isotonic) fluids: NS, LR
o Maintenance fluids: D5 NS +/- 20 KCl
o Adjustments +/- D5 for any fluid, +/- KCl for any fluid
If they are needing resuscitation (came in sick, dehydrated, vomiting, diarrhea, etc), use
isotonic IVFs at maintenance rate (recall 4-2-1 rule or wt in kilos + 40) or higher +/-
boluses
Post-op, continue isotonic fluids for 24 hours then switch to maintenance if U/O
adequate etc.
For basic maintenance, start with D5 NS + 20 KCl and adjust as appropriate based on
labs while NPO or poor PO intake
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 If potassium is climbing (>4.5), consider decreasing/removing K from IVFs (this may
include switching LR NS)
If sodium is high or low, consider changing from NS NS or vice-versa, respectively
If pt looks dry (BUN > 20*Cr; Cr climbing, low u/o), use isotonic fluids, increase rate
If they have a high u/o consider decreasing rate or HTIV (hep trap IV) if taking enough
PO
If they have any potential insults to kidneys (IV contrast, HIDA scan, vanco, rhabdo, etc),
consider keeping them on adequate IVFs
If they are tolerating a diet and labs have been normal, you can usually discontinue IVFs
IVFs need to be renewed daily (and if you dont, youll probably get an annoying page
around MN asking if you want them renewed)

Beware of renal failure patients

A classic intern mistake is to replete K in a pt on dialysis or late-stage kidney failure.
Keep in mind they are unable to clear any additional K. Dont even think of touching
their potassium unless it is below 3, and even then you should probably talk to your
senior
Dont fluid-overload these people. They usually go on NS or NS at a very low rate
when they are NPO. Nephrology should hopefully be involved with their care.
Avoid K in their fluids (this may also include avoiding LR)
They need a STAT BMP the day of surgery for nearly all cases (or anesthesia will have a
cow)
Avoid PICC lines and unnecessary lines in them when possible. Do not attempt to access
a dialysis catheter unless they are coding or if you have special permission.
Renal protection for angio
o Mucomyst 600 mg PO BID
o 3 amps NaHCO3 in 1L D5W run at maintenance cc/hr
o Note this is NOT necessary if the kidneys are already dead!
Pre-ops
o Make sure to check the OR schedule for the next day to see if any attendings added anyone in house onto
the list. Sometimes they will without notifying us & expect the patient to be pre-oped.
o Pre-Op Note
Includes: Diagnosis, Procedure, Labs, CXR, EKG, Blood, Meds (optional), Clearance (optional),
Consent
These forms are to be done on the EMR
o Consent
Ask your senior or the attending exactly what they want the patient consented for.
Explain the procedure, why its being done, the alternatives, and what risks are involved.
Have them sign and get it witnessed by RN or family member. Other physicians and medical
students cannot witness. Phone consents require 2 witnesses.
For most procedures undergoing general anesthesia (even appys and choles), have them consent
for blood.
If you are not familiar with the procedure, look it up first!
o Labs & Tests
Labs within the past week or so: CBC with Diff, BMP, Mg, Coags, UA
T&S (usually good for just 3 days)
HCG for females age 9-65 (day before)
Stat AM BMP the day of surgery for any ESRD pts
Studies within the past 30 days (unless they are young and healthy): CXR and EKG
o Review the patients PMH for need for clearance
o Review the patients medications
If possible, ASA and plavix should be stopped days in advance, but for some patients, this is not
an option. Find out why they are on it!
Coumadin usually needs to be reversed to INR <1.5.

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 Therapeutic lovenox needs to be held, usually the morning of surgery.
A heparin drip needs to be held, usually 6 hours preop
Sometimes lovenox or heparin used for DVT prophylaxis is held that morning (for procedures
likely to bleed), and sometimes not (for long procedures and cancer patients). If you are not sure,
ask your senior.
Look for other medications that may pose problems. For example, if a patient is chronically on
steroids, they will need a stress dose for surgery.
o Look at the labs and studies critically
If there is sign of infection (fever, elevated WBC, or positive UA or CXR) for a clean elective
case, it will need to be addressed or the case postponed.
If Hb is low or borderline (around 8 for most pts or around 10 for cardiac pts), pt may require
transfusion or type and cross blood.
If the INR>1.5, PTT elevated, or plts <50-100, pt may need vit K & transfusion of FFP (fresh
frozen plasma) or SPP (super packed platelets), respectively.
If electrolytes are wacky (ie: Na, K, Mg, Ca), correct them so anesthesia doesnt have a cow.
If the EKG shows any changes pt may need further work-up or cardiac clearance.
For all of the above, let a senior know
o Pre-Op Orders
NPO at midnight. Make sure the pt knows too.
IVFs starting at midnight. For renal failure or CHF pts on another service, it is usually better to
write IVFs at MN per primary service. Let the primary team know you are taking their patient
to the OR the next day and they will be NPO after MN and any meds that you may have stopped
or held.
Type and screen or type and cross x units of blood, depending on the case
Bowel prep if necessary. Again, ask a senior what bowel prep the attending prefers and when to
start it (usually around or before dinner time is safest). For the patients convenience order a
commode to bedside. Also make sure they are on adequate IVFs & check PM electrolytes after
theyve started.
o Sign out
Make sure the over-night team knows about any studies or labs that are pending. Also any
clearance that needs to be followed up on.
Make sure they are aware of any corrections to INR and Hb in case they need to follow up on labs
and transfuse more FFP etc.
Make sure they are aware of any bowel preps that need to be checked on. Starting around MN -
2am they should start checking with the pt or the nurse to see if BMs are clear yet. They may
need to encourage the pt to drink or they may need to order enemas or more bowel prep if the pt
has already finished but is still not clear.
Post-op checks
o Dont just trust the sign-outs. Make sure to check on all the cases that were performed that day by our
attendings and make sure to bed-check all the patients that may have stayed.
o Generally 4-6 hours after the procedure
o Check for pain control, N/V, U/O, vitals, drain outputs (amount and consistency/color). Check
incisions/dressings (dont remove dressings unless concerned about the wound). Document your
findings.
o Encourage incentive spirometry, ambulation. Prep d/c if they will go home next day.
Admissions
o You will be responsible for admitting patients that are direct admits, admissions from ER & clinic.
o If you get a call from the floor this direct admit arrived and we need admission orders, that doesnt just
mean admission orders. It means see the pt, do an H&P, do admission orders, and speak with a
senior so that one of you will call the attending and confirm the plan.
o Applies to direct admits, admissions from ER & from clinic.
o Consider type of admission: regular vs. telemetry floor, or ICU.
o For every patient:
H&P
Orders

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 Make sure to order labs that are needed for that day and the next
Be sure to consider if they need pain meds, antibiotics, GI px, DVT px, anything else
If they are diabetic make sure to include finger-sticks and sliding scale coverage
If they drink substantial alcohol, consider thiamine, folate, and DT prophylaxis
Medication Reconciliation
Consider which home meds should be continued and which should be held taking into
consideration PO status, likelihood of going to OR, how critical the meds are, and their
vitals.
Do your best to continue psych meds!!!
Also continue seizure meds and convert to IV if needed and possible. You may even
consider sending a level on meds when it is available (ie: dilantin)
If the patient does not have a list of their medications, ask them which pharmacy they go
to and call. It is not acceptable to leave a patient off of their home meds without an
adequate effort to look into what they are on.

Discharge paperwork and summaries

o For every patient
D/C instructions
Usually a form to fill out re: activity, diet, wound care, etc
Medication Reconciliation
Consider what home meds the pt should or should not continue
Also consider any meds started in hospital that pt should continue
Scripts
Make sure they have all necessary information on themattending, DEA, etc
Generally no refills on meds
Any wound care or ostomy supplies
Dictation
If going to another facility (rehab, nursing home, etc) will need to be done beforehand
If going home, can do after d/c, but make sure to do it within 24 hours. If they pile up,
you WILL hear about it.
o Try to do this stuff a day ahead of time for people you anticipate being d/ced, especially when you will be
post-call the next day.
o Touch base with the discharge planners each daythey can give you a heads up regarding things that
will hold people back from D/C and they will give you valuable information regarding when people will
be able to go that your chief will appreciate.
o If going to another facility, make sure you know at least a day in advance anything the pt will need.
o Make sure to start days in advance if pt needs special arrangements (ie: home wound vac/TPN/IV
abx/nursing/PT)
o If you will be post-call the next day and there is no other intern on your team, make sure to prep any
discharges you know will be leaving. This also goes for if you know that everyone will be in the OR in
the morning and wont be able to take care of it until later in the day.
o D/C to home requires D/C instructions, medication reconciliation, scripts as needed, and dictation within
24 hours. May require VNA home care. Talk to D/C planner.
o D/C to another facility or service usually requires dictation and some sort of medication reconciliation (in
Kaleida system called KTP). Always talk to the D/C planner.
Follow up on the days events (consults ordered, etc)
o Generally we should call in consults (physician to physician if possible) in addition to just ordering
themthat will go further to ensure the patient is seen that day, as well as give you an opportunity to
speak with the consultant and get some initial advicemake sure to make note in the chart of who you
spoke with and any initial recommendations they made.
o Make note of any procedures that were done and the results. Some will show up in the computer and
some you will need to check the chart.
o Make sure to look at all images yourself. Just telling your seniors about the reads without having
seen the images is weak, and you wont learn.

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 o Check labs on all of your patients and any team whose intern is post-call/off and do replacements/ change
fluids as appropriate. Most seniors will want you to write out everyones labs and pretty much every
hospital has a template that you can print and fill in with labs. See above for things to look for with labs.
Touch base with patients and families as needed about the plans
o Its very tempting to brush off requests from family that want to speak with you, especially when youre
not very familiar with the patient/plan and when youre busy. Keep in mind how you would feel if that
was your loved one. Try to make the time to take a few minutes to review the chart and give them at least
a little bit of face time/information. If you are covering for a particular patient, let the family know that
you are covering and you have reviewed the chart, offer them any information you can and let them know
when the primary team will be able to answer any further questions they have.
First call for floor issues
o Key pieces of information to ask for with most calls:
Whose patient it is (Is surgery the primary team? Who is the attending? Is it as patient that you
are currently responsible for?) Dont give orders for patients that are not admitted to one of OUR
attendings unless the orders are directly related to what we did for the patient.
Youll also get calls for patients we have nothing to do with (ortho, cardiothoracic, etc)
just because well, they had surgery. Politely tell them to call the proper
team/physician.
New vs. recurrent problem
What was done before if it is a recurrent problem
Full vitals (dont just ask, are they stablethe answer might be yes with a HR of 125 and BP
95/40)
Urine output if applicable
Recent surgery
What is their current diet

o COMMON CALLS
Pain: Most common call.
Questions to ask:
o Make sure to know why they are in painRecent procedure? Is this expected?
Is this a new issue for them or has it been a chronic issue? For example, if they
were doing great and now just started having pain that would be more ominous
than if they have been a chronic pain issue.
o What is their current regimen? Do they need a one-time dose of Dilaudid or does
their regimen need to change? Are they going home soon? Is the primary team
trying to stick to PO? Dont make major changes on another teams patients.
o Is this pain what would be expected with their procedure/ diagnosis? For
example if they are now having pleuritic chest pain after their abdominal
procedure, that requires a full assessment.
o If anything is suspicious, make sure to see the patient and evaluate them.
Nothing would be worse (for you AND more importantly, the patient) than to get
in trouble b/c you gave them several one-time doses of dilaudid over the phone
and missed the development of an acute abdomen or PE or MI or DVT.
Typical pain regimens:
o PCA: there is a form to fill out (depends on which hospital). Usually Dilaudid
0.2 mg q6-10 mins or morphine. Make sure to have a breakthrough shot 1 mg IV
q2-3 hrs. The breakthrough is important for when theyve fallen asleep and
havent hit their button in a while and need to catch up. Some attendings are OK
with a basal rate of 0.2mg Dilaudid.
o Dilaudid: 0.5-2 mg SQ or IV q2-4 hrs
o Morphine: 2-6 mg SQ or IV q2-4 hrs (sometimes people dont tolerate dilaudid
well but do fine with Morphine)
o Lortab: 5 or 7.5 or 10/500 one tab every 4 hours PO or you can do one Q4 or
two Q6

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 o Toradol (ketorolac) 30mg IV Q6H x48-72 hours. This is usually written as a
standing/around-the-clock dose. NOT to be given in patients with bleeding
issues (intracranial hemorrhage, hematoma elsewhere etc), or with renal
insufficiency. It can be very effective for pain control but check with senior or
attending before writing it.
When they get converted to PO pain meds, make sure to add Colace 100mg PO BID
(unless they are having diarrhea)
Nausea: another very common call
Find out why they are nauseous. Questions to ask:
o Recent procedures? What is their diagnosis? Is the nausea related to either of
these?
o Did they recently get any pain meds or other nauseating meds? If they did and
they attribute their nausea to that, then one-time Zofran 4 mg IV would be
appropriate
o What is their diet? Have they been passing gas and having BMs? Are they
distended? If they have an ileus or SBO then no amount of nausea medication
will take care of what an NGT will do. If necessary, get an abdominal series or
AXR. Make sure to lay hands on the patient. Make them NPO +/- drop the
NGT if you have to.
Dont give Reglan to a pt with SBO or that may have SBO. Remember it is a pro-kinetic
and can make the problem worse.
For people with motility disorders, on the other hand, Reglan 10mg IV x1 can be very
appropriate.
Avoid the temptation to write a standing PRN order for Zofran or Reglan, except in very
particular circumstances. If someone is nauseous, we want to know about it. It could be
that we are advancing their diet too fast. It could be that we are giving them meds that
make them nauseous that they wont tolerate at home. Regardless, we dont want to
mask a problem that we should know about.
Abnormalities with vital signs
For any abnormality, make sure to find out what ALL the remaining vitals are,
particularly the HR and BP
Tachycardia
o Follow your ACLS flowchart/guidelines.
o Are they symptomatic?
o What is the BP? If it is high, then is pain an issue? If it is low, then is volume an
issue? What is their urine output?
If they are dry, fluid bolus with LR or NS, 250-1000 mL over 1-2 hrs
depending on their age and co-morbidities
o How high is the HR? Is this new? Tachycardia can be common post-op
secondary to pain or stress but first eliminate ominous causes.
o Are their sats ok? Are they short of breath? Do you need to worry about PE?
o Do they have a history of afib?
o Get an EKG. If they are in afib with RVR then order 25 mg cardizem IV (or 5
mg metoprolol IV if they are on BBs for rate control) to bedside and call your
senior. Youll need to push it but dont do it alone the first few times you have
to deal with this. Make sure they are on a monitor/telemetry. If they are on a
floor without monitors, put them in for a tele/unit bed and get some sort of
monitor on them. Every floor should have both a pulse ox machine with
continuous HR and pulse ox readings and also a code cart with a monitor on it.
Make something work.
o Get labs (CBC with diff, BMP, Mg, trops)
Check for electrolyte abnormalities that can be corrected
Check for anemia or acute leukocytosis or bandemia
R/O MI
o Get a CXR if they are in afib. Recall, fluid overload can precipitate afib.
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 o Are they febrile? Is there leukocytosis? Tachycardia can come with fever or
sepsis. Fluid boluses here are key. May need abx too & cultures before starting
them. Also, remember that some patients will not mount a fever and infection
may only be indicated by a left shift (especially elderly).
o See the patient!!!
o They might ultimately require transfer to the unit for a cardizem or amiodarone
drip. Your senior should DEFINITELY be involved by this point.
o It is NOT OK to ignore a persistent HR>120 in any patient.
Hypertension
o Are they symptomatic?
o What is the HR? Is pain an issue?
o Is this a common issue for them? Do they have a h/o HTN? What is their home
regimen? What is their diet? Can their home regimen be restarted? (If so, write
first dose now)
o Has this happened already? What was given and did it work?
o If their BP is dangerous (SBP>180, DBP>100) give them something fast-acting
to prevent stroke. Options include nitropaste 1-2 inches or clonidine 0.1-0.2 mg
PO. Make sure to have it rechecked. If they dont respond or if they are
symptomatic make sure to see the patient and get your senior involved. Also
make sure they arent using a small cuff on a large patient. You might also
consider hydralazine, labetolol, or metoprolol IV but you usually need to push
these yourself.
o If they are always hypertensive consider changing their regimen or signing that
out to their primary team after dealing with the acute issue.
Hypotension
o Are they symptomatic?
o What is their HR? What has their urine output been? Is volume an issue?
Should they be bolused?
If they are dry, fluid bolus them with LR or NS, 250-1000 mL over 1-2
hours depending on their age and co-morbidities
o If their HR is low/normal check if they are on a beta-blocker; this could blunt the
reflex tachycardia they would get when hypovolemic and they may still need
fluid.
Make sure there are holding parameters for HR and BP on all anti-
hypertensives, especially beta-blockers
o What have they been running? What is their baseline?
o Check in both arms-sometimes there can be an outflow issue from stenosis in one
arm and it is OK to go with the higher reading. Check manually.
o If there is any deviation from their norm, see the patient!
o If they are symptomatic and not responding to fluid boluses get your senior
involved ASAP. Also consider they may need EKG, trops, labs, etc.
o Include in your differential MI, sepsis, acute anemia, hypovolemia, adrenal
insufficiency, etc.
o They might ultimately require transfer to the unit and pressors. Pressors are
typically required for MAP <60. Your senior should DEFINITELY be involved
by this point.
Desaturation
o Are they symptomatic? Is there a good wave-form?
o See the patient!!!
o What are their other vitals? If tachycardia, do you need to consider PE? Do they
have chest pains?
o What is their RR? If it is >30 then the possibility of needing intubation may
need to be entertainedget your senior involved ASAP as you are starting a full
workupABG, labs, CXR, EKG, trops.

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 o Why are they desatting? Recent procedures? Are they not taking deep breaths
(atelectasis)? Have they been laid up for a long time and may have DVT/PE?
o What is their medical history? COPD? Asthma? CHF?
o What is their exam? If wheezing, they may need duonebs. If crackles, they may
need lasix (check CXR). If they have rhonchi, they may need incentive
spirometry, chest PT, deep breathing.
o What has been done? Are they on nasal cannula? Put them on venti-mask or
non-rebreather. Make sure the equipment is functioning. Make sure they are on
a monitor or portable pulsox.
o Unless they respond immediately and get back above 90% on a reasonable NC or
RA, this requires more of a workup. Have a low threshold for getting ABG (on
the floor, you may need to do it yourselfmany times, nurses cannot). Also
consider CXR, EKG, trops, and other labs. Get your senior involved ASAP.
If big A-a gradient on ABG, you will need to consider CTA chest to r/o PE.
o It is NOT acceptable to let a patient sit with worsening respiratory distress
as they can decompensate very quickly.
Fever
o We generally only consider 38C or higher to be fever.
o What are the vitals? Any concern for sepsis or developing sepsis?
o Have they already been cultured? Are they on abx? Generally >38.5 may
require blood cultures & fever w/u.
o Fever workup generally includes blood cultures x2, UA & UCx, CXR, possibly
Cdiff & culture of other accessible body fluids. Also make sure to look at the
wound! If more than 4-5 days post-op from abdominal surgery may also need to
consider CT abd/pelvis to r/o abscess.
o Immediate post-op low grade temp is likely atelectasis. Dont go crazy with a
work-up.
o If pt has high fever acutely post-op, may need to consider a necrotizing
infection. It is rare but if they look sick then make sure to take down the
dressing and get your senior involved right away. (A few years back a patient
developed a necrotizing infection just hours after a routine appendectomy which
landed her back in the OR just 2 hours post-op. She may have died if they had
not checked her wound.)
o Usually ok to give Tylenol 650 mg PO or PR x1 for high temps when there is
already a source known or a workup in place, but dont do this if pt has low-
grade temp, as you would like to see if it increases higher and requires culturing.
Low urine output
o What are the vitals? Are they intravascularly depleted?
o Have their labs been ok? Are they dry?
o Do they have any baseline renal failure? Other co-morbidities?
o How are we keeping track of U/O? Do they have a foley? If U/O stays low, they
likely need a foley for closer HD monitoring.
o Has the foley been flushed?
o If they dont have a foley, the pt may need a bladder scan, particularly post-op.
If the scan is >250-300 they likely need a foley placed.
o What are they getting for IVFs and diet?
o Keep in mind 0.5-1 mg/kg is ideally the minimum for adults. Usually we are
comfortable with >30cc/hr
o Likely, they need a bolus. You can start with 250ml-1L of NS or LR depending
on their age and co-morbidities.
Chest Pain
ALWAYS see the patient
Many times it will be atypical chest pain that does not sound cardiac at all. However,
most of the time, you should still work it up.
ORDER:
11
 o EKG
o CBC w/diff, BMP, Mg, Trops, CK
o CXR
o Possibly ABG if any issues with SOB
o Consider cardiac and non cardiac causes. Dont forget PE as possible cause.
Make sure to think cardiac when you get calls about indigestion and heart burn, as
well. Residents (and patients) have gotten burned with Mylanta being ordered for an MI
before.
Follow-up on your work-up. Tell your senior any time you are doing a chest pain work-
up.
Altered Mental Status
Examine the patient. Get a new set of vitals.
o Are they hypotensive? Is their oxygenation poor?
o Get them on a monitor/tele with pulse ox
o Check a glucose fingerstick
If low, order an amp of D50 IV and if awake enough, have them drink
juice/eat crackers
Start a work-up
o CBC w/diff, BMP, Mg, Trops, CK
o CXR
o EKG
o Possibly ABG if any issues with SOB/oxygenation
Do a neuro exam (if the pt will cooperate). Are there any localizing signs? Consider
CT head.
Review the patients medications for meds that cause AMSpain meds, relaxants,
benadryl, psych meds. D/C what you can.
o If related to pain meds, try Narcan 0.4 mg IV, repeat as necessary q2-3 mins.
What is their past medical hx? Any pscyh issues? Dementia? What is their baseline?
See if that nurse or another nurse has taken care of them before. Call a family member if
necessary.
Do they drink EtOH? Consider withdrawal if the timing is appropriate and give Ativan
IM if they are agitated.
If they have lines or tubes or are a threat to themselves or others, use restraints as
needed.
Consider Ativan or Haldol for agitation/acting out only after you have ruled out organic
causes of their AMS
Itching
Between the laundry detergent used for the bedding and meds like dilaudid, itching is
actually a very common complaint. You can usually give Benadryl 25-50 mg IV for
itching over the phone without any problem. Make sure the pt is not having any other
issuesvitals ok, no swelling of throat or tongue etc. Check for new concerning rashes.
Beware in elderly of giving too much Benadrylstart with a small dose.
Anxiety
What are the vitals? Could they be calling something anxiety that is actually
tachycardia and desaturation and needing to be worked up?
Are they on anything at home? Reinstate that.
Is pain actually the issue?
If there are any red flags, see the patient. If you know the patient and know they are the
anxious type, then you can usually give Ativan 0.5-1 mg IM or PO or Xanax 0.25 mg PO
without issues. Alternatively, Benadryl might help to make them sleepy. Talk to your
senior if you have any concerns.
Insomnia
Are they on anything at home? Reinstate that.

12
 If you have no other concerns about the pt (vitals ok, etc), then you can usually give
Benadryl 25-50 mg IV or PO or Ambien 5-10 mg PO for sleep.
Beware of either of these meds in elderly. It can still be done, but they sometimes react
differently.
What is the plan
OR? Discharge? Diet?
o Dont promise anything you arent certain of. If you are able to find out answers
to the questions, give them.
Speaking with patients and families
o Again, keep in mind how you would feel if this was your loved one.
Abnormal labs
Look at the whole lab set. Is everything wacky? A common problem is when they draw
labs off of a line with TPN or D5 NSyou will end up with diluted labs, a low Na, a
high K, and a really high glucose. Redraw.
See above for discussion of how to deal with individual abnormal labs
Other calls
Be careful to think critically. Dont brush off minor things. Heartburn may warrant
Maalox, but it also may warrant a chest pain work-up. Talk to the patient.
There are plenty of other things you will get called for. Some dont make any sense at all
or will be extremely trivial. Try to be patient with the caller. Some will be for other
serious issues not discussed here.
There are a lot of good pocket handbooks that address the most common things you will
have issues about on the wards. Scope these out and have one with you especially for
your first few months. One suggestion: The Surgical Intern Pocket Guide by Ronald
Chamberlain. Make sure to carry the pocket guide that we give you, as this covers a lot
of the basics discussed here and how your senior residents will expect you to address
these issues
Any time you see a patient for something you are called about, make sure to leave at
least a brief note in the chart. Make sure to also state who you discussed the patient
with, if applicable.
Codes/Rapid Responses
Anytime you hear overhead Code Blue or Rapid Response or RRT, phone that
floor to find out who the patient is. If it is a surgical patient that any of our teams
cover, go see it or make sure that someone else is doing so. Do your best to make sure
that a senior from that patients team is aware of what is going on ASAP. Any of these
events on a surgical patient require at least one person from the surgical team to be
present.
Generally, you will not end up running codes your first year. However, you should still
go and be an active participant. Assist with compressions and drawing bloods and the
airway. Pay attention to how the senior is running the code.
When a patient dies
Your senior should already be involved by this point!!!
Duties
o Pronounce the patient
Gently try to arouse the patientcalling name, gentle shake etc
Listen for heart sounds and respirations
Feel for carotid pulse
Check for pupillary reflex. Confirm pupils fixed and dilated.
Declare Time of Death--____ out loud
o Notify next of kin if not already present
o Notify attending (may be attending on call or attending of patientask your
senior if you are not sure)
o Call UNYTS (or find out if a nurse already has). Write down WHO was spoken
to.

13
 o Call medical examiner. They will ask questions about the patient to determine
if it is an ME case. Write down who you spoke with and their decision
o Fill out the death certificate, if given to you by the floor. Ask them
SPECIFICALLY which sections to fill out because it will need to be done over if
you fill out sections you arent supposed to.
o Ask the nurse or floor manager if there is any other paperwork they need you to
fill out.
o Write a death note in the chart. Document pertinent events leading up to the
patients death and interventions made. Document that all of the above were
completed including time of death, who was notified, etc.
o Dictate a death summary. This follows the same format of the discharge
summary, summarizing the patients hospital course, but of course does not
include discharge instructions.
Keep in mind this is a legal process. Make sure to be thorough and accurate. Your senior
should be involved.
Trauma at ECMC
o Dont let your senior residents beat you to the traumas and ER consults. Thats weak! Get there right
away and begin assessing the patient and obtaining the story and pertinent information from EMS.
o Make sure the students have a role, as well. Get them involved with the foley, NGT, checking labs,
making sure the second set of labs is drawn, helping with rolling the patient, helping with transporting
them to CT, etc.
o First, prioritize taking care of the patient and initial assessments. After the initial wave of activity has
waned, begin filling out the H&P. Dont let a senior beat you to the H&P! That is embarrassing!
o Follow the process you learned in ATLS
o Primary Survey
Airway-chin lift, conversing? need for intubation?
Breathing-listen bilaterally, eval for PTX/hemothorax
Circulation-sources of outward bleeding, BP, HR, 2 large bore IVs
Disability-gross neuro deficits, maintain c-collar and logroll precautions during exam until
cleared
Exposure-cut away all clothing, evaluate entire body surface area for deformities and skin lacs for
further possible underlying injuries; team to roll pt to get them off board, do rectal exam for tone,
blood, and prostate
o Adjuncts to Primary Survey
Place foleynecessary for HD monitoring; if blood at meatus or high riding prostate get RUG
and call uro
Place NGT, especially if AMS (OGT if facial fxs)
Nurses getting blood
Cordis (introducer catheterlarger bore shorter length central catheter) if unstable
CXR & PXR asap to eval for gross PTX or HTX or widened mediastinum and gross pelvic fxs
causing internal hemorrhage
FAST exam to be done by ER for free fluid
2 liters of fluid wide open via large bore IVs
Gather info from EMS: mechanism of injury, GCS and events at scene, LOC, speed, seatbelt
usage, other fatalities, helmet usage, damage to vehicle or scene, length of time since event
o CT scan & x-raysneed to be accompanied by resident
o Assessment & Planmake sure all injuries are listed on H&P and appropriate services consulted,
follow up on their plans; determine plan and & dispo (home vs. floor vs. ICU); consent for any
procedures necessary, and pre-op as necessary
o On the teams post-call day and pre-call day make sure to follow up on the final reads for all traumas that
came in on the last call. The final reads will often pick up on additional injuries that may have been
missed in the virtual read. Also follow up on final plans from all consultants. Make sure PT/OT is
ordered. Work on DC planning.
These findings and reads should be documented in the Trauma Tertiary Survey in a timely
fashion. Also, a full physical exam should be done on all trauma patients the next day and

14
 sometimes serial physical exams if you are worried about something in particular. If there are
any new findings or complaints, your senior should be notified.
List maintenance
o As the intern of the team, you are the record keeper, and one of our most important records is our list.
The format is basically the same at every hospital. Youll find that some chiefs are very particular about
keeping everything on the list up to date dailyincluding diets, meds (specifically antibiotics, GI px,
DVT px, other blood thinners, and other things important to their care like steroids). Make it a habit to
update the list daily with all of these things (do it throughout the day), as well as diagnoses, pertinent
PMH, and procedures. Not only will it keep the chiefs happy but it will also keep the whole team
organized and keep important things from being missed. While other team members may help with
keeping the list up to date, it is ultimately the interns job to make sure the list is up to date every
day, including meds and diets.
o Generally, you should not expect students to update the list. More often than not they will make errors
and you will be the one held responsible.
o The cardinal sin is dropping a patient off the list. It happens WAY more easily than you may realize.
Make sure to cut, insert when moving pts, not cut, paste.
Good sign-out
o When you leave pre-call and post-call, you will need to sign out to the on-call intern. This applies
whether you are on the same team (MFSH) or different teams (ECMC, BGH) and even applies when you
still have team members like a second-year in house (BGH).
o At MFSH, this is usually easysimply run the list with the on-call intern so that they know what has
been done and what still needs to be done. They already know the patients.
o At hospitals like BGH and ECMC where they are on a different team, you should give a run-down of
your patients highlighting explicitly anything that needs to be done and anything they are likely to get
calls about.
Follow-up: if they need to follow up on studies/labs, make sure they know why the test was done,
what to look for, and what to do with the results.
Post-op checks: anyone on your service that you know is going to the OR
Likely calls: if they are likely to get calls about pain control or nausea or other issues that youve
been dealing with for a patient, make sure they know about the patient and what your goals are
with the patient (ie: if wanting to D/C the pt home the next day, make sure they know to try to
stick to PO pain meds, etc).
Patients to watch carefully: if you have patients you are worried about, make sure they know so
that they will go see the patient rather than give a verbal order for pain etc.
o Do your best to avoid signing out things like pre-ops and discharges that you could/should have
done. If you are pre-call, try to post-op check anyone that you operated on, if possible. Remember, look
out for each other, and your colleague will likely return the favor.
o Make sure your list is updated before you leave since that may be the only information your colleague has
about your patients.
Consults
o At some hospitals, you will see the consults first. Surgery consults are usually expected to be done
promptly (within an hour or so unless stat which really does mean immediately for us).
o Always let your senior know that you are headed to see the consult. They may decide to come with
you on the first look. They will also size up how sick the patient sounds and determine if they should
come with you or if you can handle the initial work up yourself.
o If the patient looks unstable or sick at all, make sure to get your senior involved early.
o Do the normal H&P, look through labs and imaging. Write it up and present it to your senior. Likely
they will be the ones to call the attending, although sometimes you might actually call the attending on
occasion. Youll learn which ones dont mind a call from an intern.
When you see the consult, make sure to think through a plan before presenting it to your
senior. Dont just regurgitate a medicine H&P to them. Summarize thoughtfully and present a
plan. Your plan may be shot down, but that doesnt matter. That is how you will learn to think
critically and it is practice for when you are a senior calling attendings.
o Leave at least a note in the chart if you dictate. Otherwise leave your write-up. Make sure to document
who you discussed the case with.
15
 Training and teaching the students
o The students tend to cling to interns since they are the closest in experience to them. Do your best to get
them involved in anything you are doing, particularly procedures. Emphasize what they need to know
for their SHELF exams and future careers, as well as for their intern year. Quiz them as appropriate.
Occasionally, you might be able to have them see consults first for non-critical and non-urgent consults.
o Keep in mind that their notes dont count and their H&Ps/Consults dont count. They are allowed to
write in the chart, but nothing they write can be used for billing. Encourage them still to write notes etc
for practice and for them to get noticed by attendings.
o Do NOT have them fill out an H&P (particularly at ECMC) and then sign it yourself. Previously,
residents have gotten into big trouble for this. If you train them properly, however, they can assist with
things like D/C paperwork or scripts that you then sign.
o Keep in mind that having them fill out things like orders, paperwork, scripts etc IS educational for them
(but you need to review it with them and also check it over for accuracy and completeness). Students
have often commented that they wished they were more comfortable with orders and whatnot when they
finished the rotation. There is no reason for that!
o Give the students a particular role on the team where they know how they are expected to contribute (ie:
getting vitals, writing out labs, etc). This will make them feel included and part of the team and
encourage them to get involved further, as well as having some responsibility. Keep in mind, however,
that you are still ultimately responsible for these activities. Its weak to blame the student when you are
not able to start on time, even if it is their fault.
o Dont simply scut the students out with non-educational work. Make sure that anything you have them
do (except for maybe collecting vitals) has some educational basis. Even if you have them write out the
labs for you, make sure to take some time to educate them on what we look for in the labs and what we do
about them. Emphasize the importance of accurate work no matter how small the task (ie: the problem if
they collect the wrong vitals and miss a high fever or tachycardia/hypotension that we arent aware of). If
they are simply copying the numbers without any meaning, then they are learning nothing.
o Generally speaking, students should be in the OR as much as possible. Encourage this and get them
involved and excited about it. Make sure they know to see the patient ahead of time and look up the
surgeries they are going into and the diagnoses that the surgeries are treating.
o Update students about the plans. The best students will pay attention when we run the list and make
themselves useful with floor work too. To some, it just comes naturally. Work as a team with these
studentsyou will get much more done and they will get much more out of their rotation.
Keep the team in the know
o Generally, as an intern, you are protected from severe consequences. However, that is assuming that you
are doing your job to keep everyone else aware of what is going on. It is your job to notify your senior
of anything worrisome going on. You should work hard to help your senior and in turn, they will
protect you. Document who you speak to on issues. Do NOT assume that they have taken care of
anything that is your responsibility unless they specifically told you not to worry about it. Even then,
trust but verify.

16
REFERENCE: Templates for Dictations & Notes

H&P/Consultation Dictation Template

Date of Admission/Consult
Attending/Consulting Physician
Admitting/Consulting Service
Reason for Consultation/Admission
Chief Complaint
HPI
PMH
PSH
Allergies
Meds
SH
FH
ROS
Physical Exam
Labs
Imaging
Assessment/Plan
**Make sure to mention who you saw the patient with and who you discussed the patient/plan with.

ORDERS
As more hospitals are moving to computer orders, the following will probably become less and less used; however, it is
still important to know these basic pneumonics/templates for when computer systems are down or even for when you are
doing computer orders but need to be sure you dont miss something.

Admission Orders/Post-Op Orders Pneumonic: ADC VAN DIML (memorize it or something similar)
Admit to: service, surgeon, floor/bed type
Diagnosis
Condition
Vitals: qshift/q4H/per routine
Activity: OOB ad lib vs. bedrest
17
 Nursing: SCDs BLLEs, IS 10x/hr while awake, foley to gravity, NG to gravity, JP/drain to self-suction, O2 by NC
for sats>93% etc
Diet: NPO/NPO x meds/Reg/Clears/Full liquids
IVFs or HTIV
Meds: pain meds, antibiotics, GI px, DVT px, anything else; dont forget home meds!!!
Labs & Tests: admission labs if needed, labs for next morning, x-rays or other imaging
Call HO for T>38.5, 100>SBP>160, DBP>100, 50>HR>110, etc

Modifications for Ambulatory Surgery Patients

Admit to: PACU/ASU
Diagnosis: s/p ___
Condition: stable
Vitals: per routine
Activity: OOB ad lib
Nursing: SCDs BLLEs until ambulating
Diet: Clears when fully awake then ADAT to regular/low fat
IVFs: continue current IVF @ maintenance or KVO until adequate PO then HTIV
Meds: pain meds, antiemetics (OK in this case for post-anesthesia)
Labs & Tests: post-op labs or CXR if indicated (ie: mediport)
Ok to d/c home when criteria met

Pre-Op Note
Diagnosis
Procedure
Labs
CXR
EKG
Blood
Meds (optional)
Clearance (optional)
Consent

Brief Op Note (Pneumonic: PPP SAFE DSCC)

Pre Op Dx
Post Op Dx
Procedure
Surgeon(s)
Anesthesia
Findings
EBL/Fluids
Drains
Specimens
Complications
Condition

Operative Dictation
Date of Procedure:
Pre-op Dx:
Post-op Dx:
Procedure Performed:
Attending Surgeon:
Resident Surgeons:
Anesthesia:
EBL:

18
 Specimens:
Complications:
Findings:
Indications for Procedure: The patient is a __-year-old (fe)male here with a _(timeframe)_ history of _(problem)_.
(S)he was seen in ER/clinic/etc on _(date)_ and __(course of action/work-up/plan)_. The patient has agreed to proceed
with surgery today. (S)he was consented in the clinic/pre-op area & understands the risks of bleeding, infection, and
damage to nearby structures such as _____ (and any other complications unique to this procedure).
Description of Procedure: The patient was met in the preoperative holding area and greeted by the _____ surgery
service including the attending physician. The procedure was discussed, and consent was verified. The patient was
agreeable to proceed with surgery. (The site was marked with a marking pen.) The patient was brought into the
operating room and placed in the ___ position. It was confirmed that the appropriate padding was in place, and SCDs
were placed on his/her legs bilaterally for DVT prophylaxis. Anesthesia was induced via _(ET/LMA)_. The patient
was administered preoperative antibiotic prophylaxis. (Hair was clipped from the __ area.) The patient was then
prepped and draped in standard sterile technique for the _(procedure)_. A timeout procedure was performed,
verifying the correct patient, procedure site, equipment, and surgery. (Local anesthesia was infiltrated along the
incision site.) (Proceed with procedure specifics)
At the conclusion of _(the procedure)_, the wound was copiously irrigated and excellent hemostasis was obtained.
(Details about closurelayers closed, suture material and fashion of suturing)The skin was then closed with(ie:
3 interrupted 3-0 sutures for a deep dermal stitch, and a subcuticular 4-0 Monocryl was then used to close the skin).
(Details about dressingie: Dermabond or steri-strips or island dressing).
At the end of the procedure, the lap/sponge counts, instrument counts, and needle counts were all correct. Dr.
_(attending)_ was scrubbed, present, and active during the duration of the procedure. (The patient was liberated from
anesthesia and was transferred to the PACU uneventfully.or other dispo)

Discharge Summary Dictation Template

Date of Admission
Date of Discharge
Attending Physician on Admission
Attending Physician on Discharge
Admitting Diagnosis
Discharge Diagnosis
Chief Complaint
HPI
PMH
PSH
Allergies
Meds
SH
FH
ROS
Physical Exam
Labs
Imaging
Hospital Course
Procedures Done
Consults Obtained
Condition at Discharge
Discharge Instructions
-Activity/Diet/Wound care etc
-Meds
-Follow-up

**Write down job ID number

**IF they have a dictated H&P, you can sometimes refer to that in the dictation for some of the items above
rather than repeating them. Do not do that for transfers to facilities.

19
General Advice

Your reputation
o Whether you like it or agree with it or believe it or not, you will form a reputation in just the first few
months of residency. You wont make yourself into an all-star at this time, but this is when people will
determine if you are A) reliable, B) a hard worker, C) safe, D) efficient, and E) honest. Work
especially hard your first few months, ask questions, and play it safe with patientsalways see them and
take things to the appropriate senior.
o There is no room for feelings of entitlement or bad attitude in surgery residency. This is a great way
to form a bad reputation very fast. Remember, this is now your employment, and there is as much a
component of service as there is a component of learning. If you work hard, you will learn more.
o Show up on time. If McDonalds wont tolerate their employees being late, we certainly dont. People
depend on you. On time means earlyearly enough to account for delays in traffic or other hiccups on
your way in, and early enough to take off your coat and be ready to work.
o Be honest. Nothing will ruin your credibility quicker than lying. If you make something up or guess
on something and realize you were wrong, make sure to own up to it right away before it becomes bigger.
o Answer all of your pages. Follow up on everything to the best of your ability. Many times when we try
to do something, a barrier will be thrown up. Rather than just saying it couldnt be done, make sure you
have talked to anyone that may be able to help and sought out other options first. Know WHY it couldnt
be done (since that is the first question your senior will ask). Youll come off much stronger if youve
pulled off something that wouldnt have otherwise been able to happen or if you at least have exhausted
your resources trying. Document everything.
o Interestingly, peoples reputations can follow them through to their chief yeara good reputation can
allow others to look over minor mistakes you make, whereas a bad reputation will cause people to not
trust you, constantly second guess you, and look for errors. Later on, when you are a senior presenting
your plan to an attending, particularly in the middle of the night, it is definitely in your best interest for
them to already have a long record of trusting your work ethic, clinical abilities, and judgment.
Smile
o Intern year can be miserable. Period. But there are also a lot of exciting things too. Focus on these. If
you are enjoyable to be around, people will like you more and it will work out to your benefit in the long
and short run. Youll get to do more in the OR, and while it probably wont change how much work is
dumped on you, other people WILL be more apt to give you a hand.

20
 o On the same note, be nice to the nurses and ancillary staff. If you have time, tell them about important
orders you are putting in. If they seem like weird orders, explain them and also explain the rationale
behind them. These people can be infuriatingly frustrating at timesif they dont follow orders properly,
if they call you for useless things, if they dont call you for important things. It is very easy to want to get
snarky with them. However, keep in mind a few things. First, they have done this much longer than you
and will probably be here long after you have finished your training. It is not in your best interest to burn
bridges your intern year. Also, they are often the ones who have the choice of whether to call at 3am you
for something that could easily wait. Finally, they have many connections that you dont know about.
Attendings will occasionally ask nurses or other ancillary staff about you when they do your evaluations.
Nurses also wont hesitate to tell senior residents or attendings about junior residents they have issues
with.
Bump it up
o There will be INNUMERABLE things that you dont know or havent encountered yet. As an intern, you
are generally protected from really bad consequences, because ultimately, you are not held responsible.
You may hear it from your seniors, but ultimately, they are the ones bearing responsibility. That said, if
you try to handle something over your head without help, you can get into some big trouble fast.
Especially in the first months, ask your next higher up (2nd, 3rd, 4th year, whatever) for any issues that you
have that might be concerning. Document who you discuss things with. THIS IS YOUR
PROTECTION. Load the boatat least when it sinks, youre not alone!
Write everything down
o No matter how simple something sounds, no matter how easy it seems to be to remember, write down
everything that you are told to do. Before you know it, your work will pile up, or you will get distracted
by a page, or something else will happen and it will leave your mind only to come back when the senior
resident asks you if it was done.
Knowledge vs. productivity
o While knowledge is important your first year (and you definitely dont want to come off as a dunce),
generally youll be rewarded more for productivity. Ultimately, hard work and getting stuff done is
whats expected of an intern rather than a super-large knowledge base. Focus first on having your work
done, and then do your best to get some reading in.
o Since youre so strapped for time, make sure to prioritize in the time you spend reading/studying for
things that may actually be noticed
Conferences
the topic for Dayton rounds will always be announcedmake sure to do a little reading
about the workup, differential diagnosis, and treatment for that topic
weekly Grand Rounds as well as second and third hour will be following a schedule with
themed weeks and months so make sure to be following with that topic in a textbook or
in the SCORE curriculum
M&M Conferences: look up stuff about the cases you did that week
ABSITE: spend as much time as you can the few months before ABSITE working on books like
Rush Review, Fiser, and Absite Killer. ABSITE is important for advancement as well as
fellowships down the road. Take it seriously and start early.
Textbook: try to make a reading plan (easier said than done) in one of the major texts like
Schwartz or Greenfield. Both of these are available on Hubnet (UBs internet library resource)
for free, so no excuses there!
Prioritize
o Learn what needs to be done pronto, what needs to get done early in the day, and what can wait until
evening. Find ways to multi-task. At first you may feel like there is always an impossible amount of
work to do. Later in the year, you will be amazed how much you can do in a day.
o General suggestions for a priority list after running the list in the morning with the team:
After sign out see any patients with concerns discussed in sign-out and put in their orders first.
Write orders for other patients. Writing orders can be done quickly and doing them right away in
the morning will help to ensure that things happen during business hours.
FYI don't assume that orders were carried out, you will learn in due time which nurses to trust.
Start checking labs. No need to check labs a hundred timesthey will generally not be back
before 9AM. You should plan to have them done by about 10AM though.
21
 If you find abnormalities in labs that are concerning call someone senior and inform
them. If they are tied up in the OR go and talk to them down there, don't page them in the
OR--it's annoying.
If they are not back by 10AM start bugging the nurses.
Order lab replacements as you check labs.
Get discharges ready. If you have a lot to do, you can save the discharge summaries for later but
make sure to do them the same day.
Everyone needs to have lunch--stop and eat. Hypoglycemia clouds your mind :)
This, however, does not mean to take a one hour lunch break. You can eat on the run and
should do so when there is a lot of work to be done. If we see you in the cafeteria sitting
and hanging out, we assume everything is done on the floor. Bring food to keep in your
pockets so there is no need to stop when you are busy.
In the afternoon, talk to DC planners and try to get patients ready to go for the next day.
At 4 pm go around and make afternoon rounds. That is your opportunity to get acclimatized to
rounding and to talk to families. Update them on progress. Check on stuff ordered in the morning
like whether tolerating diet advancement, response to fluid etc.
Update list and find a senior to let them know about patient progress. If they are in the OR, go
down and talk to them.
o Realize that at any time, your day may be disrupted by a sick patient, an ER/floor consult, a last minute
case to cover, or a trauma. It happens, but youre still expected to get the work done. This is why you
need to take advantage of every minute you have, and do not put off something for later that you have
time to do now.
Youll also learn how to get things done from a distance and in down-time. Carry discharge
paperwork with you to fill out while youre waiting to transport a patient. Call in orders that
dont require seeing the patient. Make nice with the nurses so that they are willing to do you
favors down the road by checking on things or keeping you abreast of updates.
o One of the biggest differences between a good intern and a superstar is time management. If you get the
work done early go to the OR and double scrub on cases. Attendings love when interns get work
accomplished and come to the OR. This is especially true at ECMC during your pre-call and post-call
days. Instead of getting your work done and leaving early, get your work done and go to the OR, find
cases to double scrub. Even if you arent doing anything in the OR except retracting or watching, the
attending will notice and it will make a difference for you down the road. It also allows your seniors to
do more in the OR if there is an extra hand and they will be thankful for it.
o Remember you are a surgeon. Go to the OR and scrub even if you are holding hook. Remember you will
be making decisions at some point, and you will be expected to know how to deal with things in the OR
that you have not dealt with before; you learn a lot from observing.
Keep up with all the administrative paperwork
o They will suffocate you with paperwork, particularly first year. Additionally, there will be numerous
online activities to complete. It is very easy to fall behind in these and more difficult to get caught up.
They notice when people slack off and will quickly flood email inboxes with friendly and less-than
friendly reminders of who hasnt done what. They also, on the other hand, do notice when people are on
top of their game with completing things. Do yourself a favor first year and keep administration happy
make it a priority to do everything on time.
o Make sure to keep up with logging OR cases (see discussion below).
o Know which procedures you need for credentialing so you remember to log them on E-value. Make sure
to keep up with your credentialing. These can be a pain and some are for very trivial things (dressing
changes, suture removal, etc). However, there are legal aspects to the credentialing process as well as just
plain keeping administration happy as addressed above. Try to get them all done as early as you possibly
can to make your life easier.
The hierarchy
o Yes, surgery is hierarchical. You probably got used to it as a student, but its even more prevalent as a
resident. Its not as big of a deal here as it may be at some programs, but keep it in mind as you interact
with senior residents and attendings. Always be respectful. Remember that they were in your shoes too
and have gone through everything that you are going through.

22
 o In most situations, when you have an issue with a patient, you should go to the next higher up (ie: go to
your 2nd year before going to your chief). This is not only because of the hierarchy but it is also for the
sake of educationthe second year residents need to learn how to field these questions and will be able to
address most of the issues you have. They will tell you when to bump it up higher. In critical situations,
on the other hand, you may need to go to whoever is available quickest.
Look out for each other
o Look out for your fellow interns and senior residents. Dont point out inconsequential mistakes in front
of other residents or attendings. Help each other to get out on time or early when there is a good day.
Dont dump work on each other (discharges when you are post-call, etc) when you are able to avoid it.
Tidy up your service before you leave for the day. Share the load and keep things fair without keeping
score. Teach each other. Protect your seniors by keeping them informed about any troubles on the
service. They will hopefully return the favor by pointing out when you do a nice job to the higher-ups,
and teaching more, and helping you with the workload.
Shake it off
o You will probably want to cry several times this year. Thats normal. You could have been an all-star
student and next thing you know you feel 2 millimeters tall. That is normal. Even the best of the best
have terrible days and make mistakes and hear about it. Or they dont make a mistake but still hear about
something. We deal with very critical patients and situations and that can also sometimes make people
short with you. Dont take it personally. For every situation, try to find what you can learn from it.
Your reputation, your success in residency, and ultimately your career will NOT be affected by one
good day or one bad day, one mistake or one smooth move. However, your pattern of reactions to
situations will drastically affect how people look at you. Remind yourself daily that this is a marathon,
not a race.

Advice for the OR

You will have OR time

o Our program is very good for getting us plenty of exposure to the OR. The majority of the time you will
be the only resident scrubbed, and you will get a good number of index cases to code as primary surgeon.
It is not uncommon to average 4-6 cases a week. That said, it is also not uncommon to have a week with
none, or a week with more than 10. Much is hospital dependent (Millard Fillmore Suburban > BGH >
ECMC). Sometimes it is chief-dependent. If you have a dry spell, dont be discouraged; you will have
more cases before you know it.
Preparation before starting residency
o Practice: The primary thing you can do is practice knot-tying. One and two handed. Do them in your
sleep. Practice with gloves. Practice in the bottom of a hole. Practice, practice, practice. An intern who
can confidently tie dependable knots will feel more confident in the OR, will be noticed and will see more
action. On the flip-side, nothing is more sweat-inducing than fumbling with suture trying to make a knot
and then ending up with an air knot in an important spot. Do whatever you can to practice other skills
like suturing, as well.
o Read: Reading a surgical atlas on some of the more common procedures may give you a different
perspective than you had as a student when you primarily observed. It would also be helpful to read the
initial chapters in the atlas that have to do with overall operative strategy, hemostasis, etc.
Learn to play the coding game
o How the cases count
Index cases: these are the best. They are major cases that are indexed into defined categories and
have letters like AB or SS&B in the index column to denote what category. There are minimums
for each category so the sooner you finish them off, the better.
Major cases: these still count towards your total number of cases, so if you cant have something
index, this is next best.
Minor cases: the heading for these will read something like Miscellaneous or Not for Major
Credit. These dont count towards your total number of cases so really theyre not very
valuable; however, you should still make sure to document them for good records.
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 Case remapping. The CPT code just underwent a huge remapping which made a lot of cases
index that werent before but also took away some index cases. This is very likely to happen
again, and you never know what will become index so you want to document everything. You
can also change how you code something later, so having a good personal record of what youve
done that can be self-audited for upgrades is helpful.
o You will be given an electronic copy of the CPT codes which is several hundred pages. It is tempting to
find the first thing that matches what you did and put that down. However, oftentimes, you can find an
index case code that closely matches what you did and counts a lot more than if it were coded as a
miscellaneous procedure. Take some time to peruse through the listing.
o Keep up with coding and keep a thorough record for yourself. It is important for both your own benefit
and for professionalism to keep an accurate record of what you have done. Do them on time so that you
dont miss or forget about any.
o Dont forget about bedside procedures. Code all of your bedside procedures. You might be surprised
how many can actually count as index cases. It is also in your benefit to even code for things like lines
b/c down the road when it comes to getting privileges at various hospitals, this can serve as a solid record
of what you have actually done.
In the OR
o Attendings preferences: Each attending is different so you will need to ask around about what they like
and feel it out. Some prefer for residents to be aggressive and confident and take some initiative in the
operation even as an intern. Others prefer to run the show and expect you to just stand there and look
pretty as you quietly hold the retractor. The key thing is just to be ready to help in any way possible.
o A good assistant: The thing that changed my perspective most was when an attending asked me, Do you
know how we can tell what resident will be a good surgeon? I expected the answer to have to do with
knot-tying or suturing etc. However, the answer was, how good of an assistant they are. Anticipate
the surgeons move. This shows you are paying attention and understand the case. Be ready to dab or
suction or move the retractor or adjust the light or tie the knot or cut the suture. Keep both hands in the
action. If your hands are already in the game, you will be more likely to do more.
o Making comparisons: Dont be discouraged if you dont feel like you are doing a lot. Especially dont
be discouraged if it sounds like your classmates are doing more than you. First of all, people talk a lot
and tend to embellish. Secondly, one persons definition of doing the surgery can be completely
different from someone elses. Early on in residency when you are involved with the majority of things
cautery, suturing mesh, cutting, dissecting, etc.you are going to feel like a million bucks, like you did
the surgery. It is not until you get further along that you realize just how much the surgeon taking you
through the case did to give you just the right plane, to set you up in just the right view, to show you
exactly what to cut/sew/bovie. It is a process. No matter what point you are at, make sure you are
learning. Even if you dont feel like you did anything, there is still much to be learned in technique
from observation and how things are approached, and also from seeing the same anatomy in many
different bodies.
Follow your patients.
o Even if the patient gets admitted to a different team, take ownership of the patients that you operated on.
Patients that you have operated on will go to your teams list. If possible, do your own post-op checks
it makes more sense since you were in the case and knew exactly what was done, and it also shows youre
responsible (and your fellow interns will appreciate it too). Keep tabs on how they are doing for your
own personal knowledge. Follow up on their path results (for your own education and for your records).
As you do more and more in cases, you will feel more and more personal responsibility for these
patients. Start good habits now.

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An Introduction to Each of the Hospitals

BGMC: Buffalo General Medical Center (part of the Kaleida system)

Where to go: Third floor D building down the hall with the chairmans office (across from D building elevators).
Last door on left before the chairmans office is the resident room. Code is 5-1-4.
Day starts: Be there by 5:50amget signout from the overnight team on any issues from your patients as well as
any new patients added to the list
Rounding: The team rounds as a group at 6am. The overnight intern should have gotten vitals for the service so
most chiefs will want to be walking to the first patient room as close to 6am as possible.
List: Located in the I DriveSurgeryBGH (youll need access to the surgery folder so if you dont have access
before you start, ask someone else to print you a list or give you their log in info).
Call schedule for interns: There are three teams at BGH. The intern schedule will be posted prior to your start.
o When on-call/overnight, you will likely end up helping with consults and you will be expected to post-op
any patients that went to the floor. Ideally, the interns there during the day will have post-opped any
patients from their teams. However, the on-call/overnight intern is still ultimately responsible to make
sure that they were all done.
The division of duties:
o Chief or PGY4: runs the team, back-up for everyone, the go-to person in serious situations, occasionally
helps with consults
o PGY2: takes consults from the floor and ER, handles post-op checks in unit and calls from unit, they are
second-call for floor issues
o PGY1: first call for floor issues, does all floor post-op checks, does typical intern-duties, helps with
consults if PGY2 is getting a lot
Where to find the post-op list
o Go to the PACUthey will have a list hanging that includes all planned surgeries as well as all add-ons.
Sift through it for ALL surgeries done by our attendings. They will also have a clipboard that lists where

25
 each patient wentwrite down their room numbers. If they went to ASU, that means they went home. If
they went to the ICU then they will not be on this list because they did not come through the PACU.
The division of patients:
o Patients are divided onto several teamsRed (vascular), Blue/White (General/Colorectal/Hepatobiliary),
Gold (UGI/Bariatric)
o Interns are first-call for any floor patients
o The on-call intern covers for any teams whose intern is no longer in the building (so by evening, the on-
call or night float intern should have received sign-out from every team)
Weekly activities/call
o Wednesday 7-8:30am M&M on second floor D building in conference room across from elevators. No
need to dress up for interns. Everyone needs to go.
o Thursday 6:45-10am Grand Rounds in Swift Auditorium at BGH on first floor. Everyone attends.
DRESS UP!!! Night float interns and residents should remember to bring dress clothes to change into
prior to conference.
o Thursdays 4:30 or 5pm Professors Rounds at location TBA. Students should be dressed up but residents
dont need tostudents present a patient and a faculty member goes through the case with various
teaching points
o Weekends: you should expect to work one shift on the weekend and which day will depend on when other
team members are working as well as other interns
o Clinic: assigned on a weekly basis based on call schedules and services.
Call rooms
o The location of call rooms and the codes are posted on the bulletin board in the resident room. Work it
out with the other residents on call as to who will use each one.
Parking
o There is a resident lot on the corner of Michigan and E. North Aves. Usually you have to swipe into it
with your ID card though so youll need to wait until you have that. Until then, you can pay to park in
one of the lots or you can find a street to park on.
Patient records
o Labs: on powerchart and infoclique
o Dictations: on powerchart and infoclique
o Radiology: images on PACS, reads on powerchart and infoclique
o Vitals and Is&Os: on powerchart
o Progress notes: EMR
o Orders: will be in powerchart by the time you start
Paperwork
o Nametags: the office is in the basement with really random limited hours. Make it a priority to get there
asap.
o Dictation ID: call medical records and they will guide you through the process. It is the same one as at
Suburban but it needs to be activated. A generic ID that might still work is 1200. Just make sure to
dictate your name.
o Scripts: get them at the pharmacy on the 8th floor. Scripts are now printed from the computer but its
good to have a script pad just in case the computer system is down.
o Computer access: should ideally be set up before you start. Youll need access to the computers (the
Kaleida network), infoclique, PACS, and Powerchart. Theres a special form on the computers that you
need to fill in to get access to the Surgery folder on the network and also the OR schedule in infoclique.
Call 859-7777.
o Case logging: needs to be done weekly. They will explain to you how to do it online.
o Tally sheet: the Kaleida system requires a tally sheet of all consults, admissions, cases, and complications
for your team for each week running from Friday morning to the following Thursday evening,
inclusively. Usually the intern is expected to turn this in.

Millard Fillmore Suburban Hospital (part of the Kaleida system)

Where to go: Park around the rear of the building (go past the ER entrance) and go in the back door entrance (you
will need to swipe in if it is before 6am so youll probably need someone to let you in the first day). Your call
26
 room is a back room on 3 West. The nurses can point you in that direction and you can leave your stuff there
before meeting with the team. Most teams will meet in a conference room on the first or second floor prior to
rounds and this is chief dependent.
Day starts: Be ready by 5:50am
Rounding: The overnight team will usually see the ICU patients and prepare the notes so that rounds can start at
6am and be brief and efficient
List: Located in the J DriveSurgerySuburban (youll need access to the surgery folder so if you dont have
access before you start ask someone else to print you a list or give you their log in info.)
Call schedule for interns: Not yet determined at the time of this writing
The division of duties:
o Generally you work as a team, but you are first call for everythingparticularly floor issues and consults.
The senior is usually first call for unit issues. If you get a consult let your senior know that you are going
to see it. In interest of time, some seniors will just go and see it with you. Some will have you see it first
and then they will only see it after youve written it up.
Where to find the post-op list
o Go to the PACUthey will have a book that includes all surgeries done and where the patient went,
except for patients going to the ICU. Sift through it for ALL surgeries done by our attendings. Write
down their room numbers. If they went to ASU, that means they went home.
The division of patients:
o All of the general surgery patients are taken care of by one team. You do not generally cover colorectal
patients (Visco, Attuwabi, or Butler) unless a resident scrubbed the casethey have a fellow. We often
cover plastics (Schultz, Graff), but not if we are strapped really thin. We give priority to DSG (Delware
Surgical GroupEvans, Adams, Barone, Falvo, Huff), Buffalo Medical Group (Berndtson, Talhouk),
Buckley, and Silva. When resources allow, we cover both Dr. Panchals and Odonnell.
Weekly activities/call
o Wednesday 7-8:30am M&M at BGH. This may eventually change to a separate conference at MFSH
o Thursday 6:45-10am Grand Rounds in Swift Auditorium at BGH on first floor. Everyone attends.
DRESS UP!!! Night float interns and residents should remember to bring dress clothes to change into
prior to conference. It has been expected the night team sees all of the patients prior to conference and
then attends.
o Weekends: you should expect to work one shift on the weekend and which day will depend on when other
team members are working as well as other interns
o Clinic: To be determined
Call rooms
o The intern call room is behind the nurses station on 3 West. It is usually locked and there are keys which
should be passed along from the previous interns.
Parking
o There is a physician lot that you can swipe into that is directly behind the building. If your card isnt
activated yet, there is another lot just behind that that you dont need to swipe into and dont need a
parking pass for.
Patient records
o Labs: on powerchart and infoclique
o Dictations: on powerchart and infoclique
o Radiology: images on PACS, reads on powerchart and infoclique
o Vitals and Is&Os: on powerchart
o Progress notes: EMR
o Orders: entered in powerchart
Paperwork
o Nametags: you can use the same nametag as you got at BGH. If you didnt go to BGH yet then ask
around where you can get your name taglikely youll get it at orientation
o Dictation ID: call medical records and they will guide you through the process. It is the same one as at
BGH but it needs to be activated. There is no generic ID so if you need to dictate and dont have a
number yet, use someone elses.
o Scripts: not necessary as scripts can all be printed out from powerchart now and you should learn that in
your computer training
27
 o Computer access: should ideally be set up before you start. Youll need access to the computers (the
Kaleida network), infoclique, PACS, and Powerchart. Theres a special form on the computers that you
need to fill in to get access to the Surgery folder on the network and also the OR schedule in infoclique
o Case logging: needs to be done weekly. They will explain to you how to do it online.

ECMC: Erie County Medical Center

Where to go: Seventh floor make a right off of the elevators; one of the doors on the right before the patient
hallways is the surgery resident/conference room (labeled). Code is 9-8-0-4.
Day starts: Be there by 5:50am. Someone will need to get vitals from the computer before the team rounds at 6 so
if your students arent trained to do this properly then youll need to get there early to do it yourself. Also, at
ECMC we used pre-formed notes that are printed out before rounds. Someone will need to show you how to do
this on Meditech and you will be responsible for having these ready before rounds (or you can train your students
to do it).
Rounding: Generally youll round as a team at 6 sharp.
List: Located in the G DriveNursingSurgery
Call schedule for interns: on call every third day.
o On call, you will likely end up helping with consults and you will be expected to post-op any patients that
went to the floor. Ideally, the interns there until 6pm will have post-oped any patients from their teams.
You will also be responding to all of the traumas, and managing these patients. However, the on-call
intern is still ultimately responsible to make sure that they were all done.
Call schedule for seniors: strictly q3
o On call days start at 6am and end at ~9am on the next day
The division of duties when on call:
o Chief, PGY4: back-up for everyone, the go-to person in serious situations, usually runs the service and
the traumas
o PGY3: takes consults from the floor, may alternatively run the traumas & the service as well
o PGY2: TICU resident
o PGY1: takes all other floor calls, does all other post-op checks, does typical intern-duties, helps with
consults if PGY3 is getting a lot
o Call is taken as a team; any ER consults or traumas get sent to everyones pager and generally everyone is
expected to show up until it is clear that the situation is under controlthen anyone not needed can split
off and get back to work
Rotators: there is often a 3rd year ER resident rotator or a 1st year ER/ortho/prelim rotator on the service. The 3rd
year ER rotators are hit-or-miss. Some will help a lot with the floor and others may just hang out in the ED all
day/night and only help with the traumas. Generally speaking, the 1st year rotators should be helping with the
team doing the same duties as all interns. However, beware: ultimately the categorical will be the one to hear
about it if something gets missed or messed up.
Where to find the post-op list
o Go to the PACUthey will have a book that includes all surgeries done and where the patient went,
except for patients going to the ICU. Sift through it for ALL surgeries done by our attendings. Write
down their room numbers. If they went to ASU, that means they went home.
The division of patients:
o Patients are divided onto several teamsA, B, C, and D, primarily based on which senior resident
operated on the patient and if the patient was recently admitted or consulted on by another team. Teams
A, B, and C rotate for call. Team D is primarily vascular patients and head & neck patients. This team is
made up of a 2 and a PGY4 senior who do not take call and thus are available until 4-6ish each day.
o Interns are first-call for any floor patients for their team and any teams they are covering at that time.
o The on-call intern covers for any teams whose interns are not in the building (so by 8pm the overnight
intern should have received sign-out from every team)
Weekly activities/call
o Tuesdays 7-8:30am M&M on third floor in Smith auditorium. No need to dress up for interns. Everyone
needs to go. Your seniors will get grilled about all of the patients that your team operated on so make
sure that you tell them about the cases that you did.
28
 o Wednesdays 7-8am Trauma rounds in the TICU on the first floor. A second year will present a case and
the attendings will pimp random people from the crowd about various aspects of the case. Everyone
goes.
o Thursday 6:45-10am Grand Rounds on UB campus. People who are pre-call attend. Post call people are
also expected sign out in time to attend and need to remember to bring dress clothes to change into.
DRESS UP!!! On call residents do NOT attend in personThursdays on call still start at 6am, but they
meet in a room where it is tele-conferenced.
o Weekends: to be determined. When the team is pre-call, it is often just an intern rounding with
attendings.
o Clinic: Wednesday, Thursday, and Friday mornings. The on-call team staffs the clinic but whoever is not
busy, especially interns, are expected to show up and staff clinic as well.
Call rooms
o The senior call rooms are across from the TICU. The code for that hallway is 3-9-0-1
o Interns and medical students can sign out call rooms from the ground floorgo to security and they will
give you a key for a room that you can sign out for the night.
Parking
o You can park in the parking garage behind the hospital. Usually you have to swipe into it with your ID
card though so youll need to wait until you have that. After you have your name tag, you will have to get
it activated at Security. Until then you can pay to park in one of the lots (Lot C or D) or you can park in
the lot that is WAY down by the 33 freeway and is free without a gate.
Patient records
o Labs: on meditech
o Dictations: on meditech
o Radiology: images on AMICAS and meditech, reads meditech
o Vitals and Is&Os: on meditech. For ICU patients, they are located on flowsheets
o Progress notes: EMR
o Orders: handwritten in the charts at the nurses stations; make sure to flag the charts
Paperwork
o Nametags: go to Human Resources on the first floor. They will do your name tag. You will then need to
go down the hall to security to get it activated for parking.
o Dictation ID: call medical records and they will guide you through the process. The dictation ID is
usually the last 4 of your SSN. A generic ID that probably still works is 9999. Just make sure to dictate
your name.
o Scripts: get them at the pharmacy on the ground floor across from Human Resources
o Computer access: should ideally be set up before you start. Youll need access to Meditech.
o Case logging: needs to be done weekly. They will explain to you how to do it online.
o Case log sheet: this also needs to be turned into Liz every Monday morning. Fill it in with the patient
information including the indication for the operation as well as the outcomes and pathology. The easiest
way to do this for you (and for Liz) is to type it out in the Excel/Word document (found on the desktop in
the residents room) and email it to her. Also make sure to turn in a copy of this as well as a copy of the
H&P, Operative Report, and Path report for each operation to your senior residents that will need to
prepare for conference.

Women & Childrens Hospital (part of the Kaleida system)

Where to go: Residents meet with the fellow(s) in the conference room on the second floor at the end of the
surgery hall in the Hodge building.
Day starts: Be ready by 6am. You meet with the fellow in the morning prior to rounding.
Rounding: The team will round together starting in the NICU. The list will be run with the whole team and notes
written on the computer.
List: Located in the common drive Pediatric Surgery Residents Patient Lists follow to the appropriate
year/month/date (youll need to request access to the pediatric surgery folder before you start. You may do this by
calling IT or simply requesting online as done at other Kaledia centers.)
Call schedule for interns: The pediatric fellow will assign the schedule.
29
 The team make up:
o There is one third year resident, one second year resident, and one intern, as well as one accredited fellow
possibly in addition to research fellows that help with call. They are also multiple midlevels. Learn to
use them well.
The division of patients:
o All of the general surgery patients are taken care of by one team.
Weekly activities/call
o Thursday 6:45-10am Grand Rounds in Swift Auditorium at BGH on first floor. Everyone attends.
DRESS UP!!! Night float interns and residents should remember to bring dress clothes to change into
prior to conference. It has been expected the night team sees all of the patients prior to conference and
then attends.
o Weekends: you should expect to work one shift on the weekend and which day will depend on when other
team members are working.
o Clinic: varies by week
Call rooms
o The resident/intern call room is on 9th floor just before entering V9, on the left. The code should be 4-1-3
Parking
o There is a lot on West Utica with a walk way they courses along the parking ramp to get you to the main
hospital. Youll need to get swipe access to the lot from security. Until you have that, pay to park or find
parking on a street.
Patient records
o Labs: on powerchart and infoclique
o Dictations: on powerchart and infoclique
o Radiology: images on PACS, reads on powerchart and infoclique
o Vitals and Is&Os: on powerchart to be recorded as cc/kg/hr
o Progress notes: in the chart at the nurses station
o Orders: entered in powerchart
Paperwork
o Nametags: you can use the same nametag as you got at BGH. If you didnt go to BGH yet then ask
around where you can get your name taglikely youll get it at orientation
o Dictation ID: call medical records and they will guide you through the process. It is the same one as at
BGH but it needs to be activated. There is no generic ID so if you need to dictate and dont have a
number yet, use someone elses.
o Scripts: available from the pharmacy on the 5th floor
o Computer access: should ideally be set up before you start. Youll need access to the computers (the
Kaleida network), infoclique, PACS, and Powerchart. Theres a special form on the computers that you
need to fill in to get access to the Surgery folder on the network and also the OR schedule in infoclique
o Case logging: needs to be done weekly. They will explain to you how to do it online.
o Every morning, the UB surgery office needs an updated list, a copy of every consult that was completed
in the previous 24 hours, and list of all cases performed in the last 24 hours.

VA Medical Center

Where to go: Residents meet in the resident room on the 5th floor, across from the back elevators at 6am. Code is
3-4-5
Day starts: Be ready by 5:50am
Rounding: Intern and/or second year will need to get vitals prior to starting rounds. Round as a team at 6am and
then notes are done on the computers after.
List: Located on the G drive
Call schedule for interns: Schedule to be made by the chief on service.
The team make up:
o There will be a chief, 4, 2, and 1.
The division of patients:

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 o All of the general surgery patients are taken care of by one team.
Weekly activities/call
o Thursday 6:45-10am Grand Rounds in Swift Auditorium at BGH on first floor. Everyone attends.
DRESS UP!!!
o Weekends: you should expect to work one shift on the weekend and which day will depend on when other
team members are working. Alternatively, it may be worked out for everyone to have power weekends.
o Clinic: there are several, all of which will be divided up appropriately.
Call rooms
o Should not be required as there is no in-house call
Parking
o You can park across Bailey in the UB lot and will need a UB parking pass for that. Alternatively, security
might provide you with a parking pass for the VA lot.
Patient records
o Everything is on their computerized system
Paperwork
o Nametags: youll get a name tag from security
o Scripts: rarely needed as everything is electronic, but in the rare instance where you have to write one out,
there are usually some in the resident room
o Computer access: should ideally be set up before you start. Contact Glenda Wood.
o Case logging: needs to be done weekly. They will explain to you how to do it online.

Other Hospitals
We also rotate through Roswell Park but not as interns

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