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17. A positive ANA, RF, SS-a, and SS-b and an elevated erythrocyte sedimentation rate
are suggestive of Sjögren’s syndrome, but the definitive diagnosis is made by a minor
salivary gland biopsy in the lower lip, which will show glandular atrophy with an
abundance of lymphocytes and histiocytes.
18. The most common parotid viral infection is mumps. Less common are cytomegalovirus,
coxsackievirus, and Epstein-Barr viruses. Bacterial sialadenitis is commonly associated
with coagulase-positive Staphylococcus aureus, but S. pneumoniae, Escherichia coli,
H. influenzae, and oral anaerobe infections may also occur.
19. Infection of the danger space between the alar fascia and the prevertebral space can
lead to mediastinitis and death if not appropriately treated.
20. The most common landmark for identification of the facial nerve during parotidectomy
is the tympanomastoid suture line.
21. Biopsies of the possible primary sites should be obtained, including the nasopharynx,
tongue base-valleculae, pyriform sinus, and tonsils, during diagnostic work-up in
patients with unknown primary with malignant lymph node in the neck.
22. Radiotherapy is more effective when given concomitantly with chemotherapy in
treatment of head and neck squamous cell carcinomas.
23. Phenol, when used as a skin-resurfacing chemical agent, can be cardiotoxic, hepatotoxic,
and nephrotoxic. Steps must be taken to minimize the risk for these toxicities.
24. When using carbon dioxide laser in skin resurfacing, a yellow-chamois color indicates
that one has reached the reticular dermis.
25. Rhytidectomy can only correct wrinkling in the lower two-thirds of the face and the neckline.
26. A patient with a glasgow coma scale (GCS) score of 8 or less requires intubation.
27. Forced duction testing is a simple and direct method to detect extraocular muscle
entrapment, which may occur with orbital blowout fractures.
28. If given in the setting of mononucleosis, amoxicillin or penicillin can cause a salmon-
colored rash.
29. Erb’s point is on the side of the neck where applied pressure on the roots of the fifth
and sixth cervical nerves causes paralysis of the brachial muscles. Muscles involved
are of the upper arm (e.g., deltoid, biceps, brachialis anterior).
30. The level of reduced hemoglobin at which a patient becomes cyanotic is 5 g/dL.
31. Anisocoria refers to inequality of the pupils. It is a common normal variation of pupil
size but can be an indication of pathology.
32. Amide local anesthetics are metabolized mainly by the liver (microsomal enzymes),
whereas the ester types are metabolized by the plasma (pseudocholinesterase). An
easy way to remember how the most commonly used local anesthetic is metabolized
is lidocaine and liver.
33. The lipid solubility determines the potency of a local anesthetic. A greater lipid solubility
produces a more potent local anesthetic. The degree of protein binding of a local
anesthetic agent determines the duration of a local anesthetic. A greater degree of
protein binding at the receptor site will create a longer duration of action. The pKa of a
local anesthetic determines its speed of onset. The closer the pKa of a local anesthetic
is to the pH of tissue (7.4), the more rapid the onset.
34. Morphine, codeine, and meperidine (Demerol) cause histamine release, resulting in
vasodilation and possible hypotension. Fentanyl, sufentanil, and alfentanil do not
stimulate histamine release.
35. Plasma cholinesterase is produced in the liver and metabolizes succinylcholine (SCh)
as well as ester local anesthetics and mivacurium, a nondepolarizing neuromuscular
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blocker (NMB). A reduced quantity of plasma cholinesterase, such as occurs with
liver disease, pregnancy, malignancies, malnutrition, collagen vascular disease, and
hypothyroidism, may prolong the duration of blockade with SCh.
36. Fluid resuscitation is preferable with 5% dextrose in water (D5W) over lactated Ringer’s
solution for symptomatic hypernatremia. Otherwise D5W is rarely indicated because
the glucose load may induce osmotic diuresis.
37. In pediatric patients younger than ages 10 to 12, tracheostomy is the preferred
emergency surgical airway. The small 3-mm-wide cricothyroid membrane and poorly
defined anatomic landmarks make cricothyrotomy all but impossible in children.
38. Malignant hyperthermia (MH) is a hypermetabolic state involving skeletal muscle that
is precipitated by certain anesthetic agents in genetically susceptible individuals.
The incidence of MH is <0.5% of all patients who are exposed to anesthetic agents.
The major clinical characteristics of MH are (1) acidosis, (2) rigidity, (3) fever, (4)
hypermetabolism, and (5) myoglobinuria.
39. Creatinine is used as a sensitive, indirect measurement of glomerular filtration rate
(GFR) because it is filtered by the glomeruli, but it is minimally secreted or reabsorbed.
40. Analysis of human data shows that fetuses of <16 weeks who had an acute exposure
of 0.5 Gy had a higher risk of growth restriction, microcephaly, and mental retardation.
During the fetal period, the fetus becomes less sensitive to radiation but retains CNS
sensitivity that may lead to growth restriction at term. Diagnostic radiographs that
deliver <0.05 to 0.1 Gy are not believed to be teratogenic. Virtually all plain film and CT
scan irradiation delivers <0.01 Gy to the fetus.
41. Fresh frozen plasma (FFP) is used for replacement of deficiencies of factors II, V, VII, IX,
and XI when specific component therapy is not available or desirable. In an averagesize adult, each unit of FFP increases the level of all clotting factors by 2% to 3%, and
most bleeding can be controlled by transfusion of FFP at a dose of 10 mL/kg of body
weight.
42. Cis-atracurium is the best choice muscle relaxant to use in a patient with liver dysfunction
because it is eliminated by Hofmann elimination and is independent of liver function.
43. Staphylococcus aureus and Staphylococcus epidermidis are most commonly
cultured from infected prosthetic joints because the majority of infections involving
prosthetic joints are caused by staphylococcal contamination during the placement of
the prosthesis. The bacteria that have been identified in cases of infected prosthetic
joints arising by hematogenous spread of infection to the prosthesis from oral sites of
infection are Streptococcus viridans and Streptococcus sanguis.
44. Ludwig’s angina is bilateral, brawny, boardlike induration of the submandibular,
sublingual, and submental spaces due to infection of these spaces. The term angina
is used because of the respiratory distress caused by the airway obstruction. This
obstruction can occur suddenly owing to the possible extension of the infection from
the sublingual space posteriorly to the epiglottis, causing epiglottic edema.
45. Erysipelas is a superficial cellulitis of the skin that is caused by beta-hemolytic
streptococcus and by group B streptococcus. It usually presents with warm,
erythematous skin and spreads rapidly from release of hyaluronidase by the bacteria.
It is associated with lymphadenopathy and fever and has an abrupt onset with acute
swelling. It may affect the skin of the face. Treatment consists of parenteral penicillin.
46. Vertical maxillary excess (VME) can be treated with orthodontic intervention early in life
(8 to 12 years) with high-pull head gear or open bite Bionater to control vertical growth
of the maxilla. If successful, such treatment may resolve the skeletal abnormalities, and
ultimately the soft tissues and other facial structures grow accordingly. However, when an
adult presents with this condition, it usually is treated with Le Fort I osteotomy and superior
repositioning of the maxilla. Recently, with use of skeletal anchorage, skeletal open bite can
be closed with orthodontic treatment alone through intrusion of the posterior teeth.
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47. Neurosensory deficits of the inferior alveolar nerve following bilateral saggital split osteotomy
(BSSO) is one of the most significant concerns with this procedure. Complications occur
in 20% to 85% of surgeries. However, the incidence is only 9% at 1 year after surgery. This
complication is more common in patients older than age 40 and in patients who undergo
simultaneous genioplasty.
48. Transverse expansion of the maxilla is the most unstable orthognathic procedure. The
greatest relapse is seen in the second molar region with an average of 50% loss of
surgical expansion. After 1 year, inferior maxillary positioning and mandibular setbacks
were also found to be less predictable than in other surgical techniques.
49. Mandibular prognathism may be present in the following syndromes: basal cell nevus
syndrome (Gorlin’s syndrome), Klinefelter’s syndrome, Marfan’s syndrome, osteogenesis
imperfecta, and Waardenburg’s syndrome. The following syndromes may be associated
with midface deficiency: achondroplasia, Apert’s syndrome, cleidocranial dysplasia,
Crouzon’s syndrome, Marshall’s syndrome, Pfeiffer’s syndrome, and Stickler’s syndrome.
50. Surgical repair of cleft lip is generally carried out at 10 to 14 weeks of age. However,
the time of repair of cleft lip often is based on the Rule of Tens. According to this rule,
cleft lip can be closed when the infant is 10 weeks old, the hemoglobin is 10 g/dL, and
the infant’s weight is 10 lb.
51. Rapid tumor growth or a sudden growth acceleration in a long-standing salivary
mass, pain, and peripheral facial nerve paralysis are some of the signs and symptoms
suggestive of salivary gland malignancy. However, it has been reported that peripheral
facial nerve paralysis can be associated with acute suppurative parotitis, nonspecific
parotitis with inflammatory pseudotumor, amyloidosis, and sarcoidosis of the parotid.
52. Sialoliths in the early stage of development are small and not adequately mineralized to
be visible radiographically. It has also been reported in the literature that 30% to 50% of
parotid and 10% to 20% of submandibular sialoliths are radiolucent. These radiolucent
sialoliths can be visualized indirectly by the imaging defect that they produce on
sialography, or directly through sialoendoscopy.
53. Fine-needle aspiration (FNA) biopsy is an efficacious modality in the diagnosis of
salivary gland pathology. The specificity of the procedure ranges from 88% to 99% and
the sensitivity is 71% to 93%.
54. Sublingual salivary gland tumors comprise <1% of all salivary gland neoplasms.
These tumors are predominantly malignant (>80%) and are usually adenoid cystic or
mucoepidermoid carcinomas.
55. Syndromes that can affect the salivary glands are primary Sjögren’s syndrome, which
is usually characterized by parotid and lacrimal gland enlargement, xerostomia, and
xerophthalmia; secondary Sjögren’s syndrome, which involves autoimmune parotitis
that occurs with rheumatoid arthritis, lupus, systemic sclerosis, thyroiditis, primary
biliary cirrhosis, and mixed collagen disease; and sarcoidosis, which may involve the
parotid gland. Sarcoidosis of the parotid gland along with fever, lacrimal adenitis,
uveitis, and facial nerve paralysis is called Heerfordt’s syndrome. Recently, a sicca
syndrome-like condition has been recognized in HIV-positive children. This condition
presents with parotid gland enlargement, xerostomia, and lymphadenopathy.
56. The most common benign tumor of minor and major salivary glands is pleomorphic
adenoma.
57. The most common malignant tumors of minor and major salivary glands are
mucoepidermoid carcinoma in the parotid gland and adenoid cystic carcinoma in the
submandibular, sublingual, and minor salivary glands.
58. The methods that have been used for the surgical management of drooling include
bilateral submandibular duct relocation to the posterior tonsillar pillar (most preferred);
bilateral parotid duct relocation to the posterior tonsillar pillar; bilateral parotid duct
diversion with autogenous venous grafts; bilateral submandibular duct relocation
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plus parotid duct ligation; bilateral submandibular and parotid duct ligation; bilateral
submandibular gland excision with parotid duct ligation, if the problem is very severe; and
chorda tympani neurectomy (only as an adjunct procedure in carefully selected cases).
59. The incidence of development of cystic lesions around retained, asymptomatic,
impacted mandibular third molars is 0.3% to 37%.
60. Thyroglossal duct, dermoid, and epidermoid cysts are the most common soft
tissue cysts in children. The most common benign soft tissue tumor in children is
hemangioma. Odontoma is the most common benign odontogenic intraosseous tumor
in children; ossifying fibroma is the most common nonodontogenic tumor in children.
61. A Sistrunk procedure is a surgical procedure used for the excision of thyroglossal duct
cysts. In this operation, the central portion of the hyoid bone is always excised. The
retrohyoid cyst tract is dissected and excised at the base of the tongue together with
the area of the foramen cecum.
62. The most common anatomic sites for oral cancer are the tongue and floor of the
mouth. Other sites might be more common in different parts of the world because of
certain predisposing ethnic, cultural, or other factors.
63. The sentinel node is any lymph node receiving direct lymphatic drainage from a primary
tumor site.
64. The most common laser used in the OMS practice is the carbon dioxide (CO2) laser.
Because of their high affinity for tissue water found in the epidermis and dermis, the CO2
and Er:YAG lasers are the most common lasers used for skin resurfacing techniques.
65. Wound infections from human bites are frequently caused by Streptococcus and
Staphylococcus organisms. Serious infections may also be associated with Eikenella.
Prophylactic antibiotic coverage with penicillin or amoxicillin-clavulanic acid is
recommended. Unlike human bites, 50% to 75% of infections in animal bites are
caused by Pasteurella multocida. Amoxicillin-clavulanic acid is recommended for
prophylaxis in animal bites. Tetanus immunization is required for all bites, and rabies
prophylaxis may be required when animals exhibit suspicious behavior.
66. In general, for most oral and maxillofacial bony defects, 10 mL of noncompacted
corticocancellous bone is required for every 1 cm of defect to be reconstructed.
67. The seven anatomic structures that attach to the anterior iliac crest are the fasciae
latae, inguinal ligament, tensor fasciae latae, sartorius, iliacus, and internal and external
abdominal oblique muscles.
68. Defects of approximately one-third of the lower lip and one-quarter of the upper lip can
be closed primarily without resulting in a significant microstomia.
69. The location of the oral defect determines where a tongue flap is based (whether it
should be an anteriorly based or posteriorly based flap). For defects of the soft palate,
retromolar region, and posterior buccal mucosa, a posteriorly based flap is used.
Anteriorly based flaps are used for hard palate defects, defects of the anterior buccal
mucosa, anterior floor of the mouth, or lips.
70. The incidence of osteoradionecrosis (ORN) ranges from 1% to 44.2% with an overall
incidence of 11.8% in most studies published before 1968. Recent studies showed
incidences of 5% to 15% with an overall incidence of 5.4%. ORN has a bimodal
incidence, peaking at 12 months and again at 24 to 60 months. However, it can occur as
late as 30 years later. It is often related to traumatic injuries such as preirradiation extraction
(4.4%), postirradiation extraction (5.8%), and denture trauma (<1%). ORN may occur
spontaneously (albeit rarely) owing to progression of periapical or periodontal disease.
71. Hyperbaric oxygen therapy is an administration of 100% oxygen via head tent, mask,
or endotracheal tube within a special chamber at 2.4 atmospheric absolute (ATA)
pressure for 90 minutes each session. The treatment should be delivered once a day,
five times (dives) a week.
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72. Submental liposuction is performed at the supraplatysmal plane, a distinct layer of
subcutaneous fatty tissue located below the dermis at which the procedure is safely
performed in a near bloodless field. The area treated from the submental incision is
bounded by the anterior border of the sternocleidomastoid muscle, inferior border of
the mandible, and superior border of the thyroid.
73. The chemical properties and interface chemistry of dental implants are determined by
the oxide layer and not by the metal of the implant. Therefore the dense oxide film of
a titanium implant, for example, is about 100 angstroms (Å) thick. This is considered a
normal space between implant and bone in an osseointegrated titanium implant.
74. Torque testing can be done to check for osseointegration at the time of implant
uncovering. Ideally, one should be able to place a force of 10 to 20 N/cm without
unscrewing an implant if it is successfully osseointegrated. Other clinical subjective
signs of integration are percussion and immobility when placing a fixture mount or
impression coping on the implant. When a lateral force of 5 lb is applied, no movement
should be seen. Horizontal mobility of >1 mm or movement <500 g of force indicates a
failed implant.
75. The most useful radiographic sign of implant failure is loss of crestal bone. Early crestal
bone loss is a sign of stress at the permucosal site. At least 40% of the trabecular
bone must be lost to be detected radiographically. Rapid progressive bone loss
indicates failure. This will usually be accompanied by pain on percussion or function.
76. Magnetic resonance imaging (MRI) and CT scans are not contraindicated in patients
with pure titanium implants. Most CT scanners can subtract titanium and other metals
from the image and eliminate the scatter images.
77. The average size of the maxillary sinus is 14.75 mL, with a range of 9.5 to 20 mL. On
average, the width is 2.5 cm; height, 3.75 cm; and depth, 3 cm.
78. Split-thickness skin grafts (STSGs) can be of varying thickness. An STSG is composed
of the epidermis layer and part of the dermis layer. The STSG can be classified as thin,
intermediate, or thick, based on the amount of dermis included. STSGs are between
0.010 and 0.025 inch.
79. The thinner a skin graft, the more the contraction. A thin STSG contracts more than an
intermediate STSG, which contracts more than a thick STSG. Full-thickness skin grafts
hardly contract at all. Primary contraction is caused by elastic fibers in the skin graft
as soon as it has been cut. This can be overcome when a graft is sutured in place.
Secondary contraction begins about postoperative day 10 and continues for up to
6 months.
80. Plasmic imbibition is the process by which a skin graft absorbs a plasma-like fluid
from its underlying recipient bed. It is absorbed into the capillary network by capillary
action. This process is the initial means of survival for a skin graft and continues for
approximately 48 hours.
81. Obstructive sleep apnea (OSA) is characterized by repetitive, discrete episodes
of decreased airflow (hypopnea) or frank cessation of airflow (apnea) for at least
a 10-second duration in association with >2% decrease in oxygen hemoglobin
saturation. Obstructive events occur during stages III and IV and the rapid eye
movement (REM) stage, which are the deeper stages of sleep. Pharyngeal wall
collapse is more common during these stages because the muscles are most
relaxed.
82. Respiratory disturbance index (RDI) represents the number of obstructive respiratory
events/hr of sleep. The RDI, along with oximetry, is the primary clinical indicator in
the diagnosis of obstructive sleep apnea syndrome (OSAS). RDI is calculated as
RDI = apnea + hypopnea/total sleep time × 60. An RDI of 5 is the upper limit of normal.
83. For every 1° C rise in body temperature, there is a corresponding 9 to 10 beats/min
increase in the patient’s heart rate.
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84. The most common cause of dysuria in the immediate postoperative period is related
to the agents incorporated in the administration of general anesthesia that can inhibit
the micturitic reflex, and the patient can suffer bladder distention, which itself may
inhibit the ability to micturate. Treatment of postoperative dysuria should begin simply
by having the patient stand by or sit on the toilet while running water in the sink. If this
does not help and there is no evidence of a hypovolemic state, then the patient should
be catheterized. If the residual measures >300 mL, then the catheter should be left in
overnight.
85. A surgical wound infection or surgical site infection (SSI) is an infection that occurs
typically 12 hours to 7 days postoperatively but can occur within 30 days of surgery
unless a foreign body is left in situ. In the case of implanted foreign material, 1 year
must elapse before surgery can be excluded as causative.
86. The four conditions other than asystole that can lead to a flat line tracing on
electrocardiogram (ECG) are (1) fine ventricular fibrillation, (2) loose electrode leads, (3)
no power, and (4) signal gain is turned down.
87. Drugs that can be administered through the endotracheal tube are lidocaine,
epinephrine, atropine, and Narcan (L-E-A-N). Administer all tracheal medications at 2
to 2.5 times the recommended IV dosage, diluted in 10 mL of normal saline or distilled
water. Tracheal absorption is greater with distilled water as the diluent than with normal
saline, but distilled water has a greater adverse effect on PaO2.
88. Kiesselbach’s plexus of septum arterioles is the source of 90% of nosebleeds. Four
anastomosed arteries make up this plexus: the sphenopalatine, anterior ethmoidal,
greater palatine, and superior labial arteries. The nasopalatine branch of the
descending palatine artery anastomoses with septal branches of the sphenopalatine
artery, the anterior ethmoidal artery, and superior lateral branches of the superior labial
branch of the facial artery. Traumatic nasal bleeding can be caused by laceration of the
nasal mucosa, and any of the nasal vessels can be the source of the bleeding.
89. The nasolacrimal duct lies within the thin, bony wall between the maxillary sinus and
the nasal cavity. The duct ends at the inferior nasal meatus through the valve of Hasner.
The position of the nasolacrimal duct beneath the inferior turbinate is 11 to 14 mm
posterior to the piriform aperture and 11 to 17 mm above the nasal floor.
90. The sebaceous glands of the eyelid are called the glands of Zeis. The sweat glands of
the eyelid are called the glands of Moll.
91. Crocodile tears is a condition that results after injury to the fibers of the facial nerve
carrying parasympathetic secretory fibers that normally innervate the salivary gland.
The injury causes the fibers to heal in contact with fibers supplying the lacrimal gland,
leading to crying when the patient eats.
92. All facial muscles except the mentalis, levator angularis superioris, and buccinator
receive their innervation along their deep surfaces. However, because these three
muscles are located deep within the facial soft tissue and lie deep to the plane of the
facial nerve, they receive their innervation along their superficial surfaces. All other facial
muscles of expression are located superficial to the plane of the facial nerve and, thus,
receive their innervation along their deep or posterior surfaces.
93. The anulus of Zinn, or common tendinous ring in the orbit, is the fibrous thickening of
the periosteum from which the rectus muscles originate.
94. Tenon’s capsule is a fascial structure that subdivides the orbital cavity into two halves—
an anterior (or precapsular) segment and a posterior (or retrocapsular) segment. The
ocular globe occupies only the anterior half of the orbital cavity. The posterior half of the
orbital cavity is filled with fat, muscles, vessels, and nerves that supply the ocular globe
and extraocular muscles and provide sensation to the soft tissue surrounding the orbit.
95. The inferior alveolar nerve is most often located buccal and slightly apical to the roots
of a mandibular third molar. The root of the tooth that is most often dislodged into
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the maxillary sinus during an extraction procedure is the palatal root of the maxillary
first molar. The most reliable signs of a potential nerve injury during extraction of an
impacted mandibular third molar are diversion of canal, interruption of canal borders,
and darkening of roots.
96. Tinel’s sign is a provocative test of regenerating nerve sprouts in which light percussion
over the nerve elicits a distal tingling sensation. It is used as a sign of small fiber
recovery but is poorly correlated with functional recovery and easily confused with
neuroma formation.
97. The incidence of inferior alveolar, lingual, and, less frequently, long buccal nerve injury
during mandibular third molar removal ranges between 0.6% and 5.0%. In general,
the incidence of inferior alveolar nerve (IAN) injuries is higher than that of the lingual
nerve. Factors such as age, surgical technique, and proximity of the nerve to the tooth
influence the incidence of these injuries. More than 96% of patients with lingual nerve
injuries recover spontaneously.
98. The average rate of an injured axon’s forward growth is approximately 1 to 2 mm/day.
99. The sural nerve graft is the best donor site for an interpositional graft for an inferior
alveolar nerve defect of approximately 25 mm. The sural nerve can provide up to
30 mm of graft harvest. It provides sensation to the posterior and lateral aspect of
the leg and foot. It also has up to 50% fewer axons and smaller axonal size than the
inferior alveolar nerve. Because of primary contracture, the length of the harvested
nerve should be at least 25% longer than the defect.
100. More than 50% of mandibular fractures are multiple. For this reason, if one fracture is
noted along the jaw, the patient should be examined closely for evidence of additional
fractures. Radiographic films must be scrutinized carefully for discrete fracture lines.
Also, associated injuries are present in 43% of all patients with mandibular fracture,
most of whom were involved in vehicular accidents. Cervical spine fractures were
found in 11% of this group of patients. It is imperative to rule out cervical neck
fractures, especially in patients who are intoxicated or unconscious.
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Patient evaluation
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ARE YOU READY FOR YOUR
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SURGERY ROTATION?*
Tabetha R. Harken, Alden H. Harken
Surgery is a participatory, team, and contact sport. Present yourself to patients, residents, and attendings
with enthusiasm (which covers a multitude of sins), punctuality (type A people do not like to wait), and
cleanliness (you must look, act, and smell like a doctor). Make sure to knock on the door (or ask for permission) to come into the room, and introduce everybody with you (who may not have introduced themselves)
and what status they are (attendings, residents, or students). Remember that taking care of a patient is a
privilege—to you and not to the patient.
1. Why should you introduce yourself to each patient and ask about his or her chief
complaint?
Symptoms are perception, and perception is more important than reality. To a patient, the chief
complaint is not simply a matter of life and death—it is much more important. Patients routinely are
placed into compromising, uncomfortable, embarrassing, and undignified predicaments. Patients
are people, however; they have interests, concerns, anxieties, and a story. As a student, you have an
opportunity to place your patient’s chief complaint into the context of the rest of his or her life. This
skill is important, and the patient will always be grateful. You can serve a real purpose as a listener
and translator for the patient and his or her family.
Patients want to trust and love you. This trust in surgical therapy is a formidable tool. The more
a patient understands about his or her disease, the more the patient can participate in getting better.
Recovery is faster if the patient helps. Similarly, the more the patient understands about his or her
therapy (including its side effects and potential complications), the more effective the therapy is (this
principle is not in textbooks). You can be your patient’s interpreter. This is the fun of surgery (and
medicine).
2. What is the correct answer to almost all questions?
Thank you. Gratitude is an invaluable tool on the wards.
3. Are there any simple rules from the trenches?
• Get along with the nurses. The nurses do know more than the rest of us about the codes,
routines, and rituals of making the wards run smoothly. They may not know as much about
pheochromocytomas and intermediate filaments, but about the stuff that matters, they know a lot.
Acknowledge that, and they will take you under their wings and teach you a ton!
• Help out. If your residents look busy, they probably are. So, if you ask how you can help and they
are too busy even to answer, asking again probably would not be very high yield. Always leap at the
opportunity to shag X-rays, track down lab results, and retrieve a bag of blood from the bank. The
team will recognize your enthusiasm and reward your contributions.
• Get scutted. We all would like a secretary, but one is not going to be provided on this rotation. Your
residents do a lot of their own scut work without you even knowing about it. So if you feel like scut
work is beneath you, perhaps you should think about another profession.
• Work hard. This rotation is an apprenticeship. If you work hard, you will get a realistic idea of what
it means to be a resident (and even a practicing doc) in this specialty. (This has big advantages
when you are selecting a type of internship.)
• Stay in the loop. In the beginning, you may feel like you are not a real part of the team. If you are
persistent and reliable, however, soon your residents will trust you with more important jobs.
• Educate yourself, and then educate your patients. Here is one of the rewarding places (as
indicated in question 1) where you can soar to the top of the team. Talk to your patients about
everything (including their disease and therapy), and they will love you for it.
CHAPTER 1
* Reprinted from Harken TR, Harken AH, Swift UMB, Harken AH: Are you ready for your surgery rotation? In Harken AH,
Moore EE, editors: Abernathy’s surgical secrets, ed 6, Philadelphia, 2009, Elsevier.
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