Plastic Surgery

Goals of the Rotation

There are two primary focal points of the rotations on the General Surgical Services. The first focal point is experience in preoperative, operative and postoperative management of patients who present to the General Surgical service. The second focal point is the primary component of General Surgery. Specifically, it is the goal that each resident have experience in operative and non-operative lesions of the head and neck, skin soft tissue and breast, alimentary tact and the abdomen, vascular diseases, endocrine diseases, and surgical endoscopy. Beginning with the PGY-1 year resident extending through the PGY-2 year, it is the goal of this service this service to offer the resident exposure in the preoperative diagnosis and medical management of patients with this category of diseases. Residents will participate in the operative management fitting within these categories, and finally, residents at each level of training will be expected to play a role in the postoperative management and follow-up of these patients. He/she will address educational issues and present at Grand Rounds on areas represented in the primary components of General Surgery. He/she will establish treatment strategies in the preoperative and postoperative management and care of patients in this area, and assist in the operative training and education of subordinate residents and students.

Objectives Learned

The PGY-1 and PGY-2 year residents are expected to gain experience and instruction in the foundations for preoperative evaluation and the post operative management of patients who present to the hospital with disorders in the primary components of General Surgery. Although some operative experience is likely in the first two years, the focus of these years is primarily in evaluation and management of patients. Thus, the resident has exposure to the appropriate laboratory and imaging techniques involved in defining diseases within the primary components, for example interpretation of CT scan of the abdomen or mammogram for breast diseases. The skills required to perform history and physical exam will be emphasized. Experiences overlap between hospitalized patients and clinic patients, and much of the diagnostic experience is obtained during clinic evaluation. After operation, the first-and second-year residents review the ongoing medical management of patients in the postoperative period, including laboratory and imaging information. Pathology reports will be discussed in order to strengthen the ability of interpreting carefully the implications of these findings. These data form the basis for the appropriate follow-up of patients. Finally, PGY-1 and PGY-2 residents gain exposure to the long-term clinic follow-up of patients after operation and after discharge from the hospital including such features as possible side effects of operative intervention and recognizing anticipated outcomes of specific operative procedures. Operative experience is progressive, with less time assisting and more time operating as surgeon in the PGY-2 years.

Goals of the Rotation

Rotation through the Surgical Intensive Care Unit (SICU) is intended to introduce PGY-2 residents to the evaluation and care of critically ill surgical patients. Through practical supervised experience residents are expected to establish a baseline knowledge and competency that will be utilized and further enhanced in the remainder of the residency.

Objectives Learned

After completion of the two-month rotation, residents are expected to have achieved the following educational goals:

1. The ability to perform an initial evaluation and stabilization of new SICU patients including proposing and implementing the means necessary;
2. ability to recognize and initiate appropriate treatment of common acute problems in the SICU including, but not limited to, respiratory distress; shock, whether hypovolemic, septic, neurogenic or cardiogenic; renal failure; arrhythmias; nosocomial infections;
3. ability to assess nutritional need and formulate and institute a rational plan to address them;
4. competence in troubleshooting and interpreting commonly used monitoring equipment;
5. competence in ventilator management including working knowledge of commonly used modes of ventilator support;
6. demonstrated competence in endotracheal intubation, insertion of central lines, insertion of arterial lines and placement of pulmonary artery catheters; and
7. competence in daily management of critically ill patients including assessment, formulation of a management plan and its implementation.

Goals of the Rotation

The goal of the rotation in Pediatric Surgery is to expose the resident to the preoperative evaluation of pediatric patients with surgical disorders. This will include expertise in evaluation of laboratory and imaging information as well as history and physical examination. Specific attention is given to fluid management and acid base status of very young patients as well as working with adjustments in hydration and in pharmaceutical management of pediatric patients of varying sizes and metabolisms. Acquisition of operative skills in simple and progressively complex pediatric surgical procedures is also a goal and finally the postoperative management and long-term follow-up of patients with specific pediatric surgical diseases is achieved.

Objectives Learned

The PGY-1 resident receives guidance and instruction regarding evaluation of common disorders such as appendicitis and somewhat more complex disorders such as necrotizing enterocolitis or congenital anomalies. The PGY-3/4 resident participates in the supervision of the PGY-1 resident and interfaces directly with the assigned faculty in Pediatric Surgery. The resident is offered an opportunity to learn skills in the operative management of simple pediatric surgical diseases and refines his/her skills in the postoperative management of patients with these diseases. A complete understanding of the diagnostic and therapeutic strategy for each of these patients is achieved by exposure to the spectrum of pediatric surgical diseases seen during his/her rotation. By virtue of our own pediatric hospital within our complex, it is possible to anticipate that the rotation in Pediatric Surgery will expose the resident to the entire spectrum of pediatric surgical diseases An important unique feature of this rotation includes development of skills for interdisciplinary management of patients by sharing the clinical decisions with representatives form General Pediatrics and specialty divisions of Pediatrics, including Pediatric Intensive Care and Neonatology. A broad program using extracorporal using extracorporal membrane oxygenation offers the resident significant experience in critical care management of neonatal patients. Cognitive information is obtained by means of weekly pediatric surgical conferences as well as periodic conferences in the Department of Pediatrics, which require significant contributions by the representatives from Pediatric Surgery. The resident supervises and participates actively in the outpatient clinics for Pediatric Surgery.

Goals of the Rotation

The Trauma Service is the primary setting for surgical trainees to learn the continuum of principles involved in the care of injured patients, and in addition, provides significant exposure to the assessment and care f patients with non-traumatic emergent surgical conditions. The resident assignments are designed to provide a graduated increase in responsibility for each level trainee - PGY-1, PGY-2, and PGY-4.

Objectives Learned

The PGY-1 rotation is one month in duration and is designed to teach the principles of routine patient care including the identification of those at risk for iatrogenic complications and meticulous attention to detail in their avoidance. The PGY-1 rotation provides the trainee with the opportunity to learn the indications for and technical aspects of basic procedure including: thorough physical examination, phlebotomy, intravenous access, insertion of nasogastric and urinary catheters, splinting of injured extremities, suturing of lacerations, and thoracostomy tube insertion. PGY-1 trainees routinely perform appendectomy and herniorrhaphy while on the Trauma/Emergency Surgery rotation under the supervision of the senior resident and the attending physician.

The PGY-2 rotation is designed to provide an increased level of responsibility for initial assessment of acutely injured and ill patients. The PGY-2 is responsible for performing the initial assessment of trauma patients and is also responsible for the non-trauma surgery emergency consultations. Through the intense exposure to a large number of patients with a diverse spectrum of illness, the PGY-2 develops increased clinical diagnostic skills and is able to develop plans of action, including the decision on the need for operative intervention in conjunction with the senior resident and the surgical faculty. The PGY-2 rotation provides for significant ICU exposure and responsibility in the management of critically injured patients, with a daily ICU load of 2-8 patients/day. The PGY-2 rotation provides the trainee with the opportunity to learn the indications for an technical aspects of more advanced techniques and procedures including: the use of mechanical ventilators, the insertion and use of pulmonary artery catheters, diagnostic peritoneal lavage, interpretation of abdominal CT scans and abdominal ultrasound. PGY-2 trainees routinely perform emergency operations under the supervision of the senior resident and the attending faculty.

Goals of the Rotation

Goals of the Transplant Service rotation are to develop a working knowledge of transplantation including the actual transplant procedures (living and cadaveric donor and transplant recipient procedures), the immunosuppression used to maintain the organs, and the complications, both procedural and medication induced, that may occur and how to deal with these problems.

The following intellectual objectives are taught during resident rotation of this service: what organs can be transplanted, rationale for donor choice, rationale/workup for recipient eligibility, immunosuppression (what drug are used, how do they work, side effects), immunobiology of rejection and tolerance, complications post-transplant, primary caretaker concerns for transplanted patients (all-fever and neurologic complaints, kidney-abdominal/graft pain and elevated creatinine, pancreas-elevated glucoses). Residents are evaluated on their examination skills (renal, pancreas, liver, and heart), radiologic interpretational skills (VCUG, renal scan, ultrasound of the transplanted kidney and pancreas, donor arteriograms), and procedural skills (central lines, paracentesis, first assisting with transplant surgeries, creating vascular anastomosis). The following exceptional objectives are also evaluated: ongoing research, small bowel, new immunosuppressants and islet cells.

Goals of the Rotation

The goal of the rotation on the Vascular Surgery service are to accurately evaluate, correctly diagnose and adequately treat patients with vascular disease. It is imperative for the resident ot understand the risk factors for atherogenesis, the associated diseases which occur in vascular patients the natural history of vascular disorders, with and without treatment, and the treatment alternatives available.

Objectives Learned

There are three residents on the Vascular Surgery service at any given time: one chief resident (PGY-5), one junior resident (PGY-2) and one intern (PGY-1). The goals for the PGY-2 resident during the rotation are to accurately evaluate, diagnose and treat vascular patients with vascular diseases. Performing vascular consultations on patients in the Emergency room and inpatient setting attains these goals. The junior resident also evaluates out-patients in the clinic setting and performs some vascular surgical procedures including placement, thrombectomy and revision of dialysis access grafts, construction of AV fistulas for dialysis, saphenous vein harvesting, and portions of other major arterial Reconstructive operations. The goals for the PGY-1 include performing an adequate history and physical examination of the patient with vascular disease, helping to manage the in-patient with vascular disease, and evaluating clinic patients with vascular diseases, and performing debridements and amputations in the vascular surgery patient. Faculty members always perform these functions at each resident level under direct supervision with training in vascular surgery.

Goals of the Rotation

The Cardiothoracic Surgery rotation provides a primary setting for the surgery resident to learn the principals and practice of preoperative, intraoperative and postoperative care of general thoracic surgical problems. The General Surgery resident in direct collaboration with the Cardiothoracic surgery resident is expected to evaluate a patient for a general thoracic problem by history, physical exam, laboratory data and non-invasive tests to determine the appropriateness of operative intervention or invasive radiology care. The resident should be able to describe the appropriate invasive approach and the information required. These goals are achieved by daily discussion and review with the attending physician. The Surgery resident is also responsible for all General Thoracic Surgery consults and for participating in our weekly multiple disciplinary lung cancer and thoracic surgery clinic in collaboration with weekly multiple disciplinary lung cancer and thoracic surgery clinic in collaboration with Pulmonary Medicine, Pathology, Radiation Therapy and Interventional Radiology.

Objectives Learned

The educational objective of the Surgery resident is to evaluate the problems concerning chest wall, lungs and pleura, trachea and bronchia, mediastinum and pericardium, diaphragm and esophagus, as well as understanding the basics of acquired heart disease thoracic trauma. The residents are exposed to congenital heart disease and cardiac transplantation as well as the mechanisms of cardiopulmonary bypass. The minor procedures which a General Surgery resident is expected to master include bronchoscopy, mediastinoscopy and tube thoracostomy.

Goals of the Rotation

Goals include learning assessment and classification of burn wounds, including estimation of burn size, depth and reduction of related morbidity and mortality; gaining an appreciation stress response to acute burn injury, including hemodynamic, metabolic, nutritional and immunologic sequelae; learning initial management of the acute burn patients, including fluid resuscitation, nutritional support, wound care and ventilatory management; learning wound management of burn patients, including an understanding of wound healing, wound sepsis, topical antimicrobial agents, biological dressings and skin substitutes, and skin grafts developing fundamental surgical skills in treatment of burn patients, including wound debridement, wound dressing and splinting, skin grafting, and scar contracture release; gaining an appreciation for burn rehabilitation, including physical/occupational therapy, psychosocial support and reconstructives needs; improving communication and leadership through interactions and coordinated discussions with patients and their families, attending physicians, medical personnel, medical students and fellow residents; learning principles of management of injuries of a special nature, including inhalation injuries, chemical injuries, electrical injuries and dermatologic conditions necessitating the wound and surgical care that only a burn center can provide.

Goals of Rotation (PGY-3)

The resident will return to the Burn service for progressive experience with the evaluation and treatment of acute burns. The resident is expected to supervise the PGY-1 and PGY-2 residents and serve as back up for them. The resident will help educate the students and the more junior residents in the evaluation and treatment of the acute burn including fluid management. The resident will become more experienced with the operative debridement and resurfacing for acute burn. The resident will become more adept in recognition and treatment of burn complications, particularly infections. The resident will be adept at running a fluid resuscitation and evaluating the patient for smoke inhalation, compartment syndrome, and related trauma.

Objectives Learned

Successful management of the acute burn patient requires prompt aggressive fluid resuscitation, metabolic/nutritional support, control of bacterial infection, anticipation and prevention of complications, timely closure of the burn wound and early initiation of rehabilitation therapy. Burn shock must be adequately treated. Post-burn malnutrition must be prevented. In the post-burn stress response, all major organ systems are affected. Closure of the wound is essential for correction of the pathophysiologic post-burn derangements. In essence, management of the burn patient is a race against time, as rapidity of wound closure is inversely related to complications and mortality. This race must be tempered with thoughtful considerations of ultimate function, cosmesis and quality of life.

Goals of the Rotation

The goal of this rotation is to provide the PGY-1 resident with the ability to evaluate and be familiar with the treatment of urologic problems.

Objectives Learned

The resident will attend the outpatient clinic and the emergency room and become familiar with the evaluation and management of common urologic problems such as benign prostatic hypertrophy, renal or Uro-lithiasis, urologic trauma, and benign and malignant neoplasms. The resident will learn the inpatient care of operative and non-operative patients by participation in the service. The resident will attends the operating room and is familiar with the anatomy and physiology pertinent to urologic patients.

Goals of the Rotation

The goal of this rotation is to provide the PGY-1 resident with the ability to evaluate and be familiar with the treatment of neurosurgery problems.

Objectives Learned

The resident will attend the outpatient clinic and the emergency room and become familiar with the evaluation and management of common neurosurgery problems. The resident will learn the inpatient care of operative and non-operative patients by participation in the service. The resident will attend the operating room and be familiar with the anatomy and physiology pertinent to neurosurgery patients. The resident will learn the emergency room evaluation and management of cranial and spinal head trauma. The resident will learn outpatient evaluation of acquired neurosurgical problems such as vascular malformations and other neoplasms, and participate in the operative and post-operative care of these patients.

Goals of the Rotation

The resident will become familiar with the induction and monitoring of patients who have general or regional anesthetics.

Objectives Learned

The resident will participate in the preoperative evaluation, intraoperative management, and post operative evaluation of patients who are undergoing general or regional anesthetics. The resident will learn to evaluate the patient for their anesthetic risk and properly monitor these patients. The resident will become familiar with the pharmacology of a variety of anesthetic agents. The resident will learn common anesthetic procedures both of monitoring and induction of anesthetic, including intubation.

Goals of the Rotation

The goals of the rotation in Otolaryngology are to provide the resident with experience in the care of patients with head and neck oncology and pediatric otolaryngologic problems.

Objectives Learned

The resident will spend two separate rotations on this service. The first will provide experience in head and neck oncology. The resident will learn to evaluate and stage head and neck tumors, will participate in the outpatient evaluation and care as well as the inpatient management, including the surgical procedures. The second component of the rotation will provide the resident with experience in pediatric otolaryngology. Particular emphasis will be placed on pediatric airway management and otologic problems such as are part of the care of cleft palate children.

Goals of the Rotation

The goals of the PGY-2 rotation on Orthopaedic Surgery are to familiarize the resident with the evaluation and treatment of adult musculoskeletal trauma.

Objectives Learned

The resident will participate in emergency room evaluation and treatment of musculoskeletal adult fractures and dislocations by taking call with the residents in Orthopaedics. The resident will assist in the inpatient management and outpatient clinic setting of evaluation and management of adult Orthopaedic problems. The resident will participate in the combined cases with Plastic Surgery to evaluate and treat patients requiring soft tissue coverage after such trauma. The resident will participate in the surgical care of these patients. The resident will become familiar with possible Orthopaedic complications such as neurovascular compromise and compartment syndrome.

Goals of the Rotation (PGY-1)

The major goal and objective of a one month rotation on Plastic Surgery during the PGY-1 is to provide experience with the subset of patients that are treated by the specialty of Plastic and Reconstructive Surgery. During that time, the PGY-1 will be able to obtain far more the five cases in the area of plastic surgery that the Surgery Residency Review committee requires.

Objectives Learned and Method of Teaching (PGY-1)

During the one month rotation the duties of the PGY-1 would include:

1. primary responsibility for a set of in patients on the Plastic Surgery service with duty shared by the other Plastic Surgery residents. This means that there will be histories and physicals, patient orders, management and diagnostic plans, participation as the assistant surgeon or the surgeon on that particular surgical case for each patients, monitoring of the patient by being familiar with pertinent laboratory studies and vital signs, and other duties as assigned by the chief resident on that service;
2. primary assessment and evaluation of the outpatient which is done in the clinic or the emergency room. This will be monitored by a resident and then faculty evaluation of the same patient with discussion of the management plan and diagnosis;
3. call rotation will be taken at the same frequency as the junior Plastic Surgery residents and in accompaniment with the junior Plastic Surgery resident. This will mean responsibilities for the in house patients, return of patient calls an Emergency Room duty with care rendered either in the Emergency Room or the operating room during the call;
4. the PGY-1 will round with the surgical team members, attend clinic, the operating room and all conferences with the service;
5. the PGY-1 will be the surgeon of record for the following types of cases: placement of tissue expanders, removal of tissue expanders with advancement or rotation of the subsequent flap; harvesting and placement of composite grafts, full thickness grafts, or split thickness skin grafts; placement of allograft material; debridement and closure of pressure sores; scar revision by direct excision, or local flap rotation; repair of lacerations of the face, hand, and other body parts;
6. during this rotation the resident will obtain additional exposure, but not as surgeon, to the following types of cases: cleft lip, palate, or nasal deformity repair; transfer of skin, musculocutaneous, or free flaps.

Goals of the Rotation

This rotation will provide the resident with progressive experience in plastic surgery. Emphasis is placed on the pediatric rotation.

Objectives Learned

The resident will take call in rotation with the second year residents. This will allow progressive experience with patient evaluation and management both in the emergency room and in the hospital setting. The resident will be assigned to the Pediatric Plastic service at UTMB (Galveston). There the resident will learn the evaluation and treatment of congenital and traumatic pediatric plastic surgical problems. The resident will participate in the cleft Palate clinic every Wednesday and in the operative experience. The resident will learn the evaluation and management of the cleft lip and palate and the use of the entire Cleft Palate Team. The resident will participate in the evaluation operative and postoperative treatment of the children with craniofacial anomalies, myelomeningocele and traumatic injuries.

Goals of the Rotation

The resident will develop progressive understanding and independence in the evaluation and management of adult plastic surgery resident. The PGY-3 resident will become independent in the Emergency room evaluation of Plastic Surgical patients, with back up from the faculty. The resident will participate in the outpatient evaluation and treatment of Adult Plastic surgical problems, including reconstructive surgery of the breast, trunk, upper and lower extremities, head and neck.

Objectives Learned

The resident will perform procedures more complexes than at the PGY-1 or 2 levels. The resident will instruct the medical students. The PGY-4 rotation will provide the resident with more autonomy in the operating room. The resident is expected to be able to develop an operative or non-operative treatment plans and be able to execute the more simple procedures. The resident may be called upon to assist a PGY-3 resident in a surgical procedure. The resident will have greater responsibility for surgical procedures of the breast and trunk.

The PGY-5 rotation provides the plastic surgery resident with senior responsibility. The resident will serve as second call (back up) for the junior residents. The resident is more autonomous in the operating room and is expected to be able to develop a treatment plan for even the most complex and unusual plastic surgical adult problems. The resident will serve as the chief Administrative Resident and as such is responsible for ensuring the smooth running of the patient service as well as administrative responsibilities for conferences and call.

Goals of the Rotation

The two-month of research in the 5th year will provide the resident with the opportunity for a clinical or basic science project. The project must be cleared with Dr. Philips prior to beginning this rotation.

Objectives Learned

The resident may pursue an area of inquiry within or without the Division of Plastic Surgery, but located geographically at UTMB (Galveston). The resident will learn to be critical of research techniques and be able to criticize other research.

Goals of the Rotation

The PGY-3 rotation will provide the resident with greater autonomy with pediatric plastic surgery patients.

Objectives Learned

More simple procedures will allow them to become surgeons. The resident will become proficient in the outpatient evaluation and treatment of pediatric surgical problems, including congenital and traumatic injury. The resident will be expected to instruct the medical students and assist the faculty or chief resident on the service.
The PGY-5 rotation allows the resident senior responsibility. The resident will organize the service obligations and the residents on that service. The resident is expected to develop a treatment plan for the patient in conjunction with the faculty and be able to execute this plan, whether surgical or non-surgical. The resident is expected to be able to correct cleft lips, cleft palates and participate in the correction of myelomeningocele and craniofacial deformities.

Goals of the Rotation

This month long rotation provides the resident with concentrated exposure to complex microsurgical reconstruction for oncologic problems.

Objectives Learned

The PGY-4 resident is expected to participate in the care of these patients and serve as surgeon or assistant surgeon in these free tissue transfers. The resident has particular exposure to head and neck reconstruction. The resident will become more adept at microvascular surgical planning and techniques, postoperative monitoring, and treatment of complications.

Goals of the Rotation

The PGY-4 resident will spend four months learning principles and techniques of reconstructive surgery for burns.

Objectives Learned

The resident will learn to evaluate the defect, the available donor sites, and constructs a surgical treatment plan. The resident will participate in the out patient evaluation and treatment as well as the in patient management and surgical procedures. The resident will serve as surgeon for most procedures, assistant surgeons on those that are more complex. The resident will also participate in the care of the patients with congenital vascular lesions and other pediatric plastic problems as accepted into the Shriners Hospital system. The resident will learn to apply techniques such as skin graft or flap releases, ear reconstruction, tissue expansion for burn alopecia, laser treatment for vascular lesions and use of osseointegrated implant. The resident will help to instruct medical students on this service, coordinate this service, and serve as the administrator for the clinical care of these patients.

Goals of the Rotation

The PGY-5 resident will serve in a semi autonomous position to evaluate and treat the patients in the Texas Department of Criminal Justice setting on campus at UTMB (Galveston).

Objectives Learned

The resident will evaluate and manage the patients in both the in-patient and out-patient setting, the resident is expected to be able to develop a surgical or non surgical treatment plan and be able to execute this independently. This rotation allows the resident to work with a PA student for whom the resident is responsible to educate and coordinate the activities of the service. In addition, the resident will serve to instruct medical students as appointed to the service.

Goals of the Rotation

The rotation will allow the PGY-5, working with the new plastic surgery hand faculty, to evaluate, and treat more complex hand problems.

Objectives Learned

The resident will learn to evaluate acute and non-acute hand problems, traumatic and otherwise acquired, as well as congenital. The resident will treat long-term complications of flexor and extensor tendon injuries, Dupuytren's contractures, arthritides, nerve compression syndromes, bifid or syndactylized digits, and other congenital disease. Working with faculty, the resident will develop operative and non-operative management plans and be able to execute these.