Medicine From The Trenches

Experiences from medical school and residency.

Typical Day on Pediatric Surgery

When I was a PGY-3 general surgery resident, I was one of four senior residents on an away pediatric surgery rotation. The pediatric hospital where I rotated for peds surgery was located away from my base hospital. It was a large tertiary referral center for the sickest children from a tri-state area. General Surgery residents from other hospitals and programs rotated with me. This hospital had a burn unit, that was managed by surgery, in addition to all of the other things that a very strong pediatric surgery department would cover like trauma and surgical emergencies.

Pediatric surgery is the one surgical subspecialty that covers every surgical aspect of their population. Pediatric surgeons create fistulas for hemodialysis access in the pediatric population. A pediatric surgeon will ligate a patent ductus arteriosus (persist vessel between the pulmonary artery and aorta). A pediatric surgeon will perform hepatic resections and resections of choledochal cysts in addition to removing lung tumors and repairing chest wall abnormalities. Pediatric surgeons will also remove thyroglossal cysts and cystic hygromas (neck malformations). Pediatric surgeons will perform skin grafts, tracheotomies and transplants in infants and children. In short, pediatric surgeons perform procedures in children that would be performed by surgical subspecialists in adults.

A pediatric surgeon first completes five years of a General Surgical residency. Most complete two years of dedicated research in addition to the five years of residency making a total of seven years of training just to get to the pediatric surgical fellowship. In addition, the fellowship is two additional years making a total of 7-9 years of training beyond medical school to enter pediatric surgery.

Landing a pediatric surgical fellowship is no easy task either. There are presently about 23 fellowships nationally which means that applicants for pediatric surgical fellowship will apply to all fellowship programs and hope for enough interviews to be able to land a fellowship. Criteria for selection are scores on the American Board of Surgery In-Traning Examination (ABSITE) and a high level of performance in general surgical residency. The small number of fellowships nationwide in addition to the fairly large candidate population makes obtaining a pediatric surgical fellowship one of the most competitive if not the most competitive that any physician can obtain. In short, pediatric surgeons are the elite among all surgeons.

My pediatric surgery attendings fit the mold of pediatric surgeons completely. All four did fellowship in top programs in the United States and Canada. They all were extraordinary teachers and all had amazing surgical technique. It was a joy to stand across the table and see not a single wasted motion or miscue. They were equally gifted in teaching both the craft and the art of all aspects of surgery not to mention being some of the most professional folks to work with in the operating room. They treated the OR staff and the resident staff with great respect and made learning quite enjoyable. Here were four individuals who were the absolute best of the best among surgeons and they were just wonderful to learn from and work with and were the “least malignant” personalities I have ever met. Some of my best times in the OR were on the pediatric surgery service as both intern and chief resident.

On a typical day, after finishing up cases in the OR (around 4pm) I would receive sign-out from the folks who were not on call. I would be responsible for checking all post operative patients to make sure that they did not have problems urinating or had adequate pain control. I also carefully checked all vital signs and dressings to make sure that there were no problems that needed to be taken back to the OR. In addition, the attending surgeon that was on call with me would check in before he left for the day, just to make sure that the house was good for the night. If there was an impending admission, he would let me know when the patient would arrive.

I could generally grab a bit of dinner from the cafe and then head off to check the burn unit and emergency department. I would also check for any patient who might need pre-operative orders. Most surgical patients were either emergency admissions, who would go to surgery that night or AM admissions who were still at home. Many nights, trauma patients would be flown in by helicopter from neighboring counties and thus would have to be cared for by my service (me alone after 5pm). The best thing was that most children are not out after 10 pm so traumas after 10pm were rare in pediatric hospitals and more common in adult hospitals.

By midnight, I would be napping in the call room. My naps would be punctuated by calls and questions from the nursing staff. In general, few things needed my presence at bedside if I had done my post op checks thoroughly. Usually, questions would be renewals of orders or an extra pain medication dose. I usually covered my post operative patients with something for nausea with a call to me before it was administered.

Often a first-year pediatric resident and a couple of medical students would take call with me. It was my duty to be sure that this resident and the medical students got the best experience. If I received a routine call from the emergency department, I generally didn’t awaken my staff unless there was something that was going to the OR that night. I preferred to perform my own history and physical exams but I always gave the students a chance to check and observe the incoming pathology.

Patients who had been burned would be sent directly to the Burn Triage area and would not stop in the Emergency Department. Usually the Burn Triage nurse would let me know if a patient was coming. I would check over the burns, write the necessary orders and the nurses would take care of the patients. Again, adequate pain management was usually the most important aspect of burn care along with very strict attention to wound care.

My most memorable case was placing a newborn on Extra Corporeal Membrane Oxygenation or ECMO. This patient had been born with a diaphragmatic hernia that allowed abdominal organs to form in the chest cavity causing the patient’s lungs not to develop properly. When these children are born, ECMO allows the hypoplastic lung to grow and takes over oxygenation for the child. Two large bore vascular catheters are placed in a neck vein and artery. I jumped at the chance to participate in this procedure because ECMO is rarely used. It had been 2 years before that ECMO had been done at this hospital. The resident that was on call had no interest in the procedure but I was thrilled to do this. Later I participated in the definitive repair of the hernia with a good recovery from a potentially lethal congenital defect. It was awesome.

I also participated in a liver resection in an 8-month old with cancer. Again, I had a chance to participate in a fairly rare case with very interesting pathology. This patient also did well after a week-long stay in the Pediatric Intensive Care Unit. The power of regeneration in the liver is nothing short of remarkable. In a pediatric patient, the physiology of these cases are amazing. Liver anatomy is also very interesting as are the techniques used in liver surgery. My favorite surgical instrument is the Argon Bean Coagulator which is used to coagulate the raw edge of the resected liver. This is literally a plasma scalpel.

By 4am, I am usually up, showered and making my early AM rounds. I try to get my notes written so that work rounds are not rushed before we start AM cases. I am required to be out of the hospital by 12 noon on my post-call day but usually, I am done by 9am. I try to make sure that my patients are taken care so that the incoming call resident is not weighted down carrying my patient load and his. For me, it’s all about planning. I usually give a very complete signout with anything that needs to be watched and what I would do if there is a problem. The on-call resident only has to look at my sheet to be able to jump in and do what may be needed.

Another interesting aspect of pediatric surgery is seeing the patients in clinic. In general, the attending who is on call is in office while I am on call at the hospital. This made getting over to clinic more difficult but I did get some clinic time. It is good to see the patient in clinic, do the work-up, perform the surgery and post-op care and then see the patient back in clinic. I love to see how my closures worked and the patient pain-free. Clinic was always interesting.

I thoroughly enjoyed my pediatric surgery rotation because the patients are great fun to take care of and because peds surgery pushes the limits of a surgeon’s diagnostic capability. A surgical abdominal problem in a pediatric patient present far differently than in an adult patient. Even hernia repairs in pediatric patients are more fun than adults because the anatomy is seldom distorted.

I also always keep in mind two quotes: One from Alfred Blalock, the late chairman of surgery at Johns Hopkins. He said, “It’s takes arrogance to cut open a human being.” and the other from one of my pediatric surgical attendings who said, “You wouldn’t hand the keys of your car to a total stranger, yet these parents hand over their child to you, the total stranger. You have been given a great trust.”

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4 February, 2007 - Posted by | general surgery residency, on-call, pediatric surgery

6 Comments »

  1. Is it possible for an IMG/FMG from India to match into a general surgery residency programme? If yes , what steps would make us a strong candidate likely to be chosen by a good programme ?

    Comment by charoo iyer | 27 May, 2014 | Reply

    • To charoo.iyer:
      Yes, it’s possible for an IMG/FMG to match into a general surgery residency but do realize that getting a categorical surgical match in the United States is becoming rarer and rarer for an IMG/FMG. In terms of a “good programme”, any program that you are able to match into is going to be a good program because the number of American medical graduates has increased but the number of residency programs have stayed static. Since residency programs are funded by Medicare (paid for by US taxpayers), American medical graduates are going to be given preference meaning that there are fewer slots in any specialty residency program for IMG/FMGs. General Surgery residency programs have been very reluctant to match IMG/FMGs and overwhelmingly have selected American graduates for categorical slots. Those general surgery programs that have match IMG/FMGs have been community (not university) programs but even now, community programs are filling with American medical graduates leaving very few slots for IMG/FMGs.

      Things that enhance your chances of selection by any residency program are excellent scores on all USMLE steps with no failures + published research in a US peer-reviewed medical/surgical journal + good letters of recommendation by American surgeons who are well known to residency program directors. This means that you need to make strong contacts here in the United States and you need to make sure that your letter writers are well-known (university surgery professors who have a national reputation). Having research that has been presented at the American College of Surgeons is also a good step because most residency program directors will attend that meeting.

      Categorical general surgery (once you start, you will finish the program provided you pass each year) is competitive for American medical graduates thus you need to be ready to take a preliminary position (you only get one year to prove yourself and must reapply after that one year) and should apply for some of these positions. Often if you can’t match into a categorical position, you can gain valuable experience in a preliminary position and match the next year into a categorical slot as there is always some attrition (less now than previously) in surgical residency programs. If you match into a preliminary program, you need to be prepared to do extremely well on the ABSITE and you need to do extremely well clinically.

      Comment by drnjbmd | 27 May, 2014 | Reply

  2. I’m writting a romance novel, one of my character is a female peadiatric surgeon who gets to do a complicated ped surgery on an 8yr old girl who is the daughter of a man who once broke her heart, what type of case can i use that will get her coming off as a heroine, this case has to see the child going into OR twice. plus what is a personal timetable of a ped surgeon like?
    thanks.

    Comment by Ube | 22 May, 2013 | Reply

    • To Ube:
      I do not understand what you mean by “personal timetable”? A pediatric surgeon would spend 4 years as an undergraduate (college) + four years in medical school + 5 clinical years in residency + 1 year research + 2 years pediatric surgery fellowship. A typical day of a pediatric surgeon would be morning rounds from 5:30- 6:30 AM then 7AM-2:30 PM in the OR then office 3PM – 5PM (reverse if not operating early + conferences/ER) home around evening rounds 5:30 to 6:30 PM or later. Any pediatric case has the potential for heroics since a child’s life is involved. General pediatric surgeons do not perform heart surgery so leave the “open heart” cases out if you are trying to be realistic. Pediatric heart cases are performed by pediatric cardiothoracic surgeons. A trauma (auto collision) where the pediatric surgeon finds a life-threatening tumor would fit your storyline. Also, keep in mind that many general surgeons would not have a problem operating on an 8-year-old (an 8-year-old child does not specifically need to see a pediatric surgeon). Typical cases that only pediatric surgeons would handle would be intussuseption, pyloric stenosis, biliary atresia, liver tumors,tracheo-esophageal fistula, nephroblastoma, neuroblastoma and complicated hernia-like entities such as gastroschisis/omphalocele in typical age group of generally under age of 6. Also keep in mind that 8-year-olds generally do not need surgery (outside of things like appendicitis-not common in school-aged children) unless there is something highly unusual such as a rare abdominal tumor or the entities mentioned above which would involve much younger children. If an 8-year old had appendicitis, the appendix would be removed through a tiny incision or via laparoscope which would not engender particularly “heroic” feelings (more like found the problem and solved it).

      If you make your character a pediatric cardiothoracic surgeon, they would typically have the 4 years of undergraduate, 4 years of medical school, five clinical years of surgical residency + 1 year of research, two years of cardiothoracic fellowship + 1 year of pediatric cardiothoracic surgical fellowship. A typical day would be pretty much the same as with the pediatric surgeon but the cases would be surgical correction of congenital heart defects. The typical age of patients could be infant to around age 14 with most defects being corrected around age 2 (child has to be able to go in a heart-lung machine). The heart defect repairs may be done in stages with possibly a shunt at birth + definitive repair around age 2. In general an 8 year-old might have an injury (can get some heroics here) that needed repair or something missed at birth like an atrial septal defect but picked up later (not particularly heroic but definitely a problem that needs to be solved).

      Contrary to what you see on the telly, there isn’t a huge amount of “heroics” in any type of medicine/surgery. Most of us do this because we love to solve problems and make a difference in our patients’ lives and health. There is much heroism in helping a diabetic patient keep their blood sugar under control (meaning avoidance of early heart disease, strokes, blindness and kidney disease) and no surgery needed to do this. There is much heroism in helping a young patient who is suicidal, solve their problems and live a long productive life. When it comes to surgery, most of us use surgery to correct problems or fix something that is injured. We love when everything is routine; without “heroics” and fanfare. When “heroics” are involved, there is much potential for bad outcomes which tend to overshadow the heroics.

      Comment by drnjbmd | 22 May, 2013 | Reply

  3. Good read. This makes peds surgeons out to be far more personable and pleasant than their adult counterparts.

    Comment by Jennifer | 1 August, 2012 | Reply

    • To Jennifer:
      It’s probably a good idea not to stereotype any specialty as stereotypes show narrow-minded thinking. After all, there have plenty of stereotypes about women, minorities and plenty of people who are different in many ways. Pediatric surgeons are as diverse as any other group of people in personality, ability and any of the other characteristics that make humans individuals.

      Comment by drnjbmd | 1 August, 2012 | Reply


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