Welcome to UCLA Department of Surgery - Los Angeles, CA



Welcome to your Endocrine Surgery rotation.

A couple of tips on how to do well on this rotation:

1. Come to clinic. This is where you will learn the answers to most of the board questions you will encounter in your near future. Gotta know this stuff. In a word, imparting this knowledge to you is why Dr. Hiatt hired me in the first place. My assistant Yasmin has the schedule. But generally this is Monday from 10A onward (most new pts starting at 1PM, that's when things get really busy), plus the 1st and 3rd Fridays of each month from around 9A-1P. We always need at least 1 upper level resident present for things to function smoothly; 2 is gravy and will allow more time for teaching. I love med students and interns, but they are unable to function with any independence in this setting and thus do not count toward the clinic workforce. They are invited purely for educational purposes.

2. Show up to cases early and prepare thoroughly for each case. Arrive at least 15 min before the start time. Sometimes anesthesia does us a favor by rolling back early. Be in the OR before I get there. Know the calcium, PTH, hyperparathyroid symptoms, size of the tumor, lymph node status, etc. Know the imaging results and have the most relevant images pulled up on the computer. Do this every time. You are preparing to be the attending - the time will be here before you know it. You need at least 15 minutes, probably closer to 30 until you get more experienced, to immerse yourself mentally in a case and get completely focused for peak performance. That is what patients and their families legitimately expect of us during surgery. Think of a pitcher warming up in a bullpen, or a ballerina stretching before a show. They would never blunder onto center stage at the last moment and neither should we. I know there is always other work, but believe me, there is no one who needs your full attention more at that moment than the patient on the table.

3. Read. You should perform at least 1 pubmed search per day on endocrine topics. Each patient and every operation brings up management issues that are dealt with in the literature. I am in the business of delivering evidence-based care and you should strive to understand the data that underlies even the most minute clinical decision. So ask me why. Tackling the literature can be daunting, so I will suggest articles to you. Don't wait until the end of the rotation to read them. Read them in between cases and after we are done with each work day. Apply your newly acquired knowledge to our next case together. It will make you a better surgeon.

4. Reflect. Why is it that I can perform the same number of operations with two different residents and end up with one resident who can operate independently at the end, and another who struggles with basic maneuvers? The answer is reflection. After we have finished a day of operating, review the cases mentally before you go to bed that night. Play them back in your mind. Recall the sequence of moves. Remember what you did well that day and what you need to work on. Don't make the same mistakes repeatedly. That is a waste of your time and mine. If you hear me repeating the same instructions to you in the OR day after day, then something is wrong. In order for you to progress, we must create a forward ratchet by conquering your technical challenges and progressively moving on to bigger prey. Reflect on these each night and come back the next day a different surgeon. Watching residents develop as surgeons is one of the most satisfying parts of this job, so let's do it together.

Please note that Dr. Harari has different protocols. Do not give calcium post op to anyone without speaking to her. In addition, she draws post op labs (ca, PTH, phos) at 6 hours and in the AM.

Things to remember:

1. All dictated notes should be sent to me for co-signature within 24 hours of the patient encounter.

2. All discharge summaries are to be done by NP Jennifer Isorena (p28502).

Below you will find useful information to help throughout this rotation…

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The article to accompany this clinical pathway can be found at-

ENDOCRINE MEDS

CYTOMEL (LIOTHYRONINE)

Synthetic T3

Half-life: 2.5 days

Max pharmacologic effect: 2-3 days

Rx for patients who will receive RAI s/p thyroidectomy for CA.

This is a very potent medication and must be dosed carefully - easy to cause palpitations/afib, esp in patients who are elderly, physically small, or have heart disease.

Increases catabolism of Vit K dependent clotting factors.

Patients with DM may need to increase hypoglycemic meds.

RE cytomel dosing, we probably give more than people need.

 

Pills come in 5, 25, and 50 mcg.

 

Big guy dose: 25 qAM, 25 qPM

Average medium to large young woman: 25 and 12.5 - this is the most frequent dose I give

Small woman: 12.5 and 12.5

Elderly: 10 and 10, or even 10 and 5

 

Cytomel should be taken at 7AM and PM dose no later than 5PM or else it causes insomnia.

SYNTHROID (LEVOTHYROXINE)

Synthetic T4

Long half-life

Max pharmacologic effect: 4-6 weeks

Rx for patients who had total thyroidectomy and will not be receiving RAI (e.g., resection of MNG)

In general, dose should be equal to body weight in lbs.

Pills come in 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg.

Always err on the side of lower dosing. Ok for the patient to be slightly hypothyroid and have his/her endocrinologist increase the dose by checking TSH at 4-6 weeks.

DECREASE dose in elderly patients (> 65), patients with CAD (can precipitate arrhythmias).

Single daily dose, ½ to 1 hr before breakfast.

For post-op Graves’ patients, typically no thyroid replacement until they follow up with their endocrinologist. Continue B-blocker (propanolol) post op.

TITRATION OF PREOP MEDS FOR PHEO

#1: Start alpha blockade. Take patients off other BP meds.

Phenoxybenzamine 10 mg PO BID. Take BP and HR Q day. Every 72 hrs, titrate dose up by 10 mg/day until goal SBP reached ( ................
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