Surgery Rotation: H&P’s

Journal Article Summary

After being in multiple cases where there was a choice made between using a  ureteral stent or a percutaneous nephrostomy tube, I was curious to know if there was a gold standard, or if it was truly just provider preference. The article I looked at compared the optimal methods of drainage for obstructive urolithiasis – comparing percutaneous nephrostomy (PCN) with a double J ureteral stent. Both methods appeared to have high success rates with no major complications. Typically, it seemed that PCN was more often chosen for larger stones or more proximal stones. The stent seemed more likely to be chosen for smaller, more distal stones. Overall, success was reached in almost all patients in both groups. When deciding between the two, it’s important to consider factors like anatomic difficulties, location of the stone, size of the stone, and patient preference. In the patients I saw, it seems that stent was chosen more often, but that could be related to the fact that the majority of stones we saw were distal and fairly small – 3mm.\

Site Evaluation Presentation

For my surgery rotation, I presented a 72 year-old patient who presented to the emergency department with abdominal pain in the right lower quadrant. The patient had a 3mm obstructing calculus in the distal right ureter as well as a UTI, and later became septic. Because of this, he was taken to the OR for an emergent stent placement. This case allowed me an opportunity to see a presentation of sepsis, as well as evaluate the SIRS/sepsis criteria with a real patient to determine the appropriate next steps. On the urology team, I was able to follow this patient post-operatively and continue to monitor for signs of sepsis. I learned more about sepsis and how it actually presents, which can often be in patients with nephrolithiasis and UTIs – in fact, that combination is a urological emergency. I was able to observe stent placements and cystoureteroscopies that allowed me to have a better idea of the urinary tract and how these problems could come about. Because of many medical conditions including a liver transplant and atrial fibrillation, as well as the current presentation, this patient was split between the urologic surgery team and the medicine team, which was interesting to see how the two worked together. Upon presenting, I learned more about how I can better create a plan specific to the team I’m on, and what things fall under a surgical plan compared to a medicine plan. I also learned more about the process of creating an assessment and plan for a patient with sepsis or possible sepsis. 

Self-Reflection

During my rotation, I learned so much about the OR, surgical PAs, and just the field of surgery in general. I have not really been exposed to surgery prior to this, so everything was very new. It was definitely an adjustment to get used to prepping patients, scrubbing in, remembering the sterile field, and being part of surgery as a whole. It was a great experience to see all the different teams that work together in surgery – from the nurses to the scrub techs to the anesthesiologists to the surgeons – each person plays a huge role in making the surgery go seamlessly. I was also able to see the whole experience- a patient going from pre-op, to surgery, to the PACU, to the floor for follow up, and then rounding on those surgical patients the next couple of days until discharge. It really is a fulfilling experience to follow the patient’s entire journey, and I liked that aspect of surgery a lot. I found neurosurgery and urology to be the most interesting to me. I was able to see how imaging was used in both of those specialities within surgery. I also saw how PAs participated in surgery in various ways – on some teams, they were more on the floor, monitoring patients post-operatively for however long they stayed. Some PAs specifically only worked in the OR managing the robotic surgeries, and some PAs, like the neurosurgery PAs, were the first assist in the surgeries. It was exciting to see that there are a lot of different roles available to PAs just in the surgery field alone. Personally, I enjoyed my time the most when I was doing ED consults with the surgery team or working with patients post-operatively, because you were able to see the patients and interact with them a little bit more. One memorable experience I had was seeing a urological consult in the ED where there was hematuria with urinary retention. I was able to put in a coudet foley and then assist the PA to evacuate 17 syringes full of blood and clots from the patient’s bladder. While it was excruciating at times for the patient, I learned exactly how much we could help someone who was in pain, and how specific urologic knowledge is critical when consulting on and treating patients. I think I learned a lot about patient management and care. I became much more confident in placing foleys and drawing blood – those are some of the skills I practiced the most this rotation. I want to improve on my IV placement skills as well as my suturing, so those are things I will look for opportunities to do in future rotations. I tried to actively ask to do things this rotation, which is why I think I got more practice, and I want to do that more in the future to keep learning and practicing until I feel comfortable with these skills. One thing that was difficult for me during this rotation was writing SOAP notes that were the high level required for surgery. This is my first rotation and so there’s a lot of a room for improvement, and luckily my preceptors were really helpful in teaching me where I could improve and helping me see things I missed. I received a lot of good feedback, and I plan to incorporate that into my notes in the future to continue to improve.