INTRODUCTION

Medicine Consultation is an evolving field.  Patients with a wide range of medical conditions undergo surgeries of varying levels of risk.  We believe that teamwork between internists, surgeons, and anesthesiologists improves patient care.  This handbook was created to provide useful information, advice, and guidelines, based on a combination of clinical experience and evidence-based medicine.  It is designed with a medical resident in mind, but may very well prove useful for anyone taking care of perioperative patients.

As with any handbook, this is simply a guide, and is no substitute for clinical judgment and appropriate supervision.

General Guidelines for Being an Outstanding Medical Consultant
Approach
Medicine is still medicine, whether a patient has just undergone, or is about to undergo, a surgery.  Creating a differential diagnosis, weighing risks and benefits, providing timely treatment—none of these skills disappear when you see a patient in the perioperative setting. 

There are however a few key characteristics of postoperative patients:

• Most patients should get better if their case is uncomplicated.
• Many patients are NPO and medications may be restricted, at least for a period of time, to those that may be given PR, sublingual, IV, or transdermal, or inhaled.
• Most patients receive pain medications and are at risk for complications (delirium, respiratory depression, constipation, urinary retention).
• Most patients have received some sort of sedation and remain at risk of delirium or other complications from the sedating medications.
• Patients may have more lines and tubes than medical patients, but are expected to have them removed as they recover.
• Patients undergoing abdominal surgery are usually third-spacing and intravascularly volume depleted initially.

Although much information in this handbook is tailored to the postoperative patient, many questions can be answered by simply asking yourself, “How would I ideally manage this patient were he/she on my medicine service?”  This applies also to the patients on non-surgical services for whom you may be consulting (e.g. psychiatry, rehabilitation).

Communication
Communication is vital as a consultant. 

Keep up a dialogue with the surgical team, and always call with critical recommendations.  Don’t wait for them to discover an important recommendation you made on morning rounds when they make evening rounds at 10 PM.  Know the habits of your primary team—different surgeons round at different times; surgery teams have varying compositions—some have several R1s, while others rely heavily on ARNPs and PAs.

Communication with families:  in general it is acceptable to discuss your recommendations with the patient and family.  However, be careful when discussing issues specific to the surgery—these are usually best left to the surgeon.  There may also be recommendations that are pending discussion with the surgeon—it is preferable to wait until that discussion has taken place prior to speaking with the family.

Documentation in the medical record is essential.  You may have communicated very important recommendations verbally but if they are not in the chart, they are not official.  It is best to document your recommendations immediately after seeing the patient.

Initial consults:

• Dictate or directly enter new consults.
• Make sure consult request and reason for consult is documented in the chart. (e.g. “Medicine Consult requested for diabetes recommendations.”)
• Format for initial consult notes, both inpatient and outpatient:

Requesting Physician (Avoid the word “referral”) Chief Complaint Date of Surgery (if applicable)           PCP name (phone # is helpful)                          HPI: For a preop eval, summarize but do not go into the exquisite detail that you would for a medical presentation.  The work-up has already been done.  You are being asked to help with the next step. Active and Past Medical Problems:  Focus on the ones requested, e.g. diabetes and hypertension, but be complete. Past Surgical History: Past Surgical Complications: Drug Sensitivities: Medications:

Family History: Social History: Habits: Review of Systems:  Exercise Tolerance:  • No. of blocks • No. of flights of stairs Physical Exam: Studies: Assessment:  Include: • Problem List • Risk Stratification e.g. “2 Clinical risk factors for high risk surgery” Recommendations: • Be specific (doses of drugs, etc) and concise.   • Include preventative measures, e.g. DVT prophylaxis and incentive spirometry, etc.

*** For inpatient consults, make sure your Assessment & Recommendations are online immediately so that they are available for patient care. 

Initial postop note:
• Your first postop note should start “Follow up of preop consultation on (date)”, to distinguish it from a new consultation.

Follow up notes:

• In general, a note should be written every day in the chart.
• If you plan to follow the patient less frequently than daily, you should communicate this in the chart: “I will follow up with the patient after surgery” or “My colleagues will be on call this weekend and will see the patient if called.  I will follow up with the patient on Monday.”
• Assessments should be by diagnosis, not organ system:  e.g. “Diabetes”, not “Endocrine.”  Start with the most important medical diagnosis, e.g. “Atrial fibrillation”, instead of “Postop AAA repair”.
• In most cases, you should also communicate with the team verbally.  A note is no substitute for good communication.

 

Knowing your role

• Avoid recommendations on these subjects except in unusual circumstances:

• Type of anesthesia or use of PA catheters (let the anesthesiologist decide)
• Per rectum (PR) meds in any surgery with bowel manipulation (including abdominal surgery, cystectomy, gynecologic surgery)
• Diet orders in patients with abdominal surgery

• Think carefully before making recommendations or writing orders on these subjects—the services tend to feel strongly about them for various reasons (ask your attending for details):

• DVT prophylaxis (good to recommend, but not to write as an order—bleeding risk needs to be discussed with the surgery team)
• Anticoagulation (same reasoning)
• Pain medications (often handled by the Acute Pain Service)
• Transfusions
• Antibiotics
• Postop fever workup, especially within the first 48 hrs.  (See “Postoperative Fever”)

 

 

 

Updated May 2011