History and Physical Write Up
Journal Article
This article was published very recently back in October of this year. It was published in the Journal of Laparoendoscopic & Advanced Surgery Techniques. This was a systematic review and meta-analysis aimed at comparing the clinical outcomes in infants/children with intestinal malrotation who were treated by laparoscopic or Open Ladd’s procedures. Very relatable to my patient who underwent the same procedure. RCTs and retrospective studies were used in comparing laparoscopic vs open Ladd’s procedures. 14 studies were included in the study totaling 444 patients who underwent laparoscopic Ladd’s procedure and 1,422 patients underwent open Ladd’s procedure. Results of the study are as follows: the laparoscopic group had shorter operative time, shorter hospital stays, shorter time to full feeds, less post-operative adhesive SBOs, and overall lower incidences of post-operative complications. However, the laparoscopic group was associated with more post-operative volvulus. There was no difference in reoperation rates between the two groups.
The patient I was following underwent an open Ladd’s procedure where she unfortunately developed a prolonged ileus requiring PICC line placement for nutrition. We can see why laparoscopic procedures are highly favorable.
Site evaluation: My summary
I presented a who was a 6-year-old, female, with no significant PMH, with a prior admission in July 2021 for abnormal electrolytes in the setting of vomiting. Patient presented to the ED today complaining of vomiting x 3 episodes. Patient had 2 episodes of vomiting yesterday and one today, non-bloody and non-bilious. She also has not had a bowel movement in 3 days nor has she been able to pass gas. She has tried MiraLAX at home with no improvement. Patient does endorse some achy, non-specific, 8/10 abdominal pain as well where nothing makes the pain better or worse. As per mother, patient with intermittent episodes of vomiting for the last several months associated with constipation. She has not tried any new foods and has not eaten nor drank anything all day. Her last meal was a two slices of pizza yesterday. Patient has been referred to GI but has not been seen by them yet. Patient denies fever, chills, cough, congestion, sore throat, ear pain, diarrhea, chest pain, SOB, diarrhea, or hematochezia. She denies sick contacts or recent travels.
She presented to the ER afebrile and normotensive but in sinus tachycardia to the 120s. Patient initially treated with 1L NS and Zofran 4mg PO. Observed at bedside for initial response to treatment. Surgery was consulted.
CT scan was ordered after X-ray imaging which showed massively dilated stomach and proximal duodenum with midgut volvulus. Patient was then taken the OR for emergent exploratory laparotomy and Ladd’s procedure. I was able to follow the patient where she unfortunately had a 2 week post operative period of ileus. It felt great to see her finally go home after being in the hospital for so long.
My site evaluator Andrea Pizzaro was very helpful and gave me feedback on my HP as it pertained to a surgery patient. She has been working in surgery for a very long time and she emphasized the importance of a differential diagnosis and the inclusion of patient education in our HPs. I believe the patient education aspect is very important because patient may state that they understand what is going on and what they have to do but in reality they may feel embarrassed/or have language barrier, that may prevent them from admitting to not having a true understanding of what the situation entails. Some patient require follow up afterwards or new medications etc, so it is very important to explain to our patients what is to be expected. In this case, the patient education aspect revolved around explaining the diagnosis and the surgery that is to be performed if the parents agreed to it. Risks and benefits are always thoroughly explained to these patients so they will not be surprised if an adverse event occurs. I thank Andrea for her constructive criticism and will incorporate this new knowledge as I will most likely pursue a career in some type of surgical field where all of this will benefit me.
Typhon postings
RT 9 – Surgery Typhon Postings
Self reflection
Exposure to new techniques or treatment strategies
I enjoyed my surgery rotation a lot because I was able to do a lot of hands-on things where other rotations there were really not many hands on procedures or interactions. I was changing dressings daily, changed a wound-vac, JP drains, assisting in procedures, learned new suturing techniques and surgical knot-tyings, and overall just exposed to the process of a patient checking in pre-operatively, then being prepped for surgery, undergoing surgery, then the post-operative recovery process in the PACU. Some would be discharged if it were an elective procedure while others needed to be admitted and observed either in the SICU or on the surgical floors. The more surgeries I got to participate on, the more I was able to help out and work on my skills. Before this, I really did not put much Foleys in but this rotation I was putting them in a lot of patients before the surgery started. Surgery may be intimidating, but it was a great experience overall.
Types of patients you found challenging in this rotation and what you learned about dealing with them?
Patients I found challenging were patients who would complain of severe pain even though they are on loads of pain medication. As a provider, we have to understand that these patients underwent surgery and are expected to have pain and it is our job to control that pain, maybe not make it go away completely, but make it very tolerable. In school we are taught about the hesitancy in prescribing opioids for severe pain, however, they were readily distributed amongst the surgery patients as a means to control their pain levels. I witnessed a patient with a PCA pump who I believed was actually addicted to the pain medication as he would be very combative against trying to ween him off the pain meds and eventually try to D/C him from the hospital. Could he have had a addiction to these medications beforehand? Absolutely, however, he could have also developed a tolerance and addiction throughout the hospital stay as he was admitted for over 8 weeks. These are patients that I believe are difficult to deal with because you are obligated to treat their symptoms but then you are simply adding to their addiction issue. It is an interesting spot to be in as a provider working with these patients and I learned that it is different on a case to case basis and it just comes with experience on how to deal with these types of patients. Quite eye opening if I do say so myself.
How your perspective may have changed as a result of this rotation | What did you learn about yourself during this 5-week rotation?
I am going to answer these questions together as my experience relates to both of them. I was fortunate/unfortunate to have my final rotation to be my surgical rotation. Hearing the reports from my classmates and their experiences in surgery was making me a little nervous. Many of the rotation schedules prior to my final rotation were 3-12 hour shifts weekly. This was very doable and I was able to study and complete assignments much more easier compared to my 60 hours/week schedule these past 5 weeks. I thought I was going to be drained and have no motivation to do anything what so ever besides sleep, surgery, and repeat Mo-Fri. My perspective changed a lot. The phrase “Do not judge a book by its cover” is readily preached for a reason. My rotation was not as bad as I thought it would be and it was actually fun and peeked my interest even more as I was able to rotate through general surgery, urology, and neurosurgery. What I learned about myself is that I have to stop doubting myself when I in fact do know the answers to questions or suggested treatment plans. Surgery as a topic, surgeons as individuals, and surgical residents can all be intimidating, but I have to remember, I have spent the last 2.5 years studying and grinding each and every day. If I was not meant to be here, I probably would not have made it this far. It is okay to say “I don’t know, but I will look it up.” As a future PA, or even any clinician/provider, it is important to know your limitations because engaging in something that you are not familiar with can be devastating to the patient. I believe patients would much rather prefer someone who can guide them to another clinician to make the appropriate arrangements compared attempting to figure something out that you are not well versed in. I will take with me the knowledge that I have gained about surgery as well as the knowledge I have gained about myself.
