RESUMEN
We describe surgical repair of a Stanford Type A aortic dissection with concurrent aortic valve Streptococcus equi endocarditis in the setting of subarachnoid hemorrhage and disseminated intravascular coagulation. Multidisciplinary collaboration among specialists from a variety of disciplines is essential when treating acutely ill cardiovascular patients with multisystem involvement. (Level of Difficulty: Beginner.).
RESUMEN
We present the case of a 63-year-old woman with intracystic papillary carcinoma of the breast who presented with a palpable mass, one year after a negative mammogram. Sonography showed a complex mass and ultrasound-guided aspiration cytology was negative, and the patient returned 6 months later with a recurrent mass. Excisional biopsy revealed invasive intracystic papillary carcinoma. Intracystic papillary carcinoma is a rare malignancy of the breast primarily affecting postmenopausal women. As opposed to invasive micropapillary carcinoma, intracystic papillary carcinoma is a low-grade carcinoma with a favorable prognosis.
RESUMEN
OBJECTIVE: The 80-hour workweek has forced surgical training programs to employ physician extenders to reduce work hours and improve the educational environment. The purpose of our study was to document objectively the specific workload provided by physician extenders and to evaluate any objective or subjective benefit provided to the residency program. METHOD: Over 4 consecutive months, all orders written by 2 physician extenders associated exclusively with the general surgery residency program at our institution were reviewed. They were categorized as daytime or evening orders and were subdivided into admission, routine preoperative and postoperative, acute care, daily laboratories, pain medications, Pro re nata (PRN), wound care, and discharge orders. Acute care issues and PRN orders were individually examined and subdivided. The appropriateness, total volume, and the orders for each category were totaled and reviewed. RESULTS: Overall, 3101 total orders (1128 daytime and 1973 nighttime) were reviewed in a 4-month time period. On average, physician extenders at night wrote 35 orders per shift, compared with only 18.8 orders during the day. During the night, admission orders totaled 547 (27.7%), preoperative orders 442 (22%), acute care issues 324 (16.4%), PRN orders 239 (12%), and pain medication and PRN sleeping pills 156 (8%). During the day, routine postoperative orders totaled 305 (27%), daily laboratories 184 (16%), and discharge orders 253 (22%). CONCLUSION: Physician extenders wrote appropriate orders and reduced resident workload. Educational opportunities increased because fewer residents left conference for acute patient care issues, and 1 fewer resident was absent during the day secondary to 1 less resident being sent home postcall. Performance on the American Board of Surgery In-Training Examination (ABSITE) increased dramatically for a focused group of residents. As the expense of each extender is approximately $90,000, justification to administration is dependent on the institutional support and efficiency of the residency program. A clear simple outcome is that by improving standing orders and clinical pathways, and by using an electronic medical record system, noneducational work hours can be reduced significantly.
