Rounds and presenting

Pre-rounding

The quiet hour before the team gathers, when you see your patients, gather their data, and decide what you think. Done properly it is the difference between presenting and reciting.

Arrive early enough to see every patient you are following before rounds. Work the same way each time so nothing is missed under time pressure. Pull the overnight events and the new vitals and labs from PowerChart, then go to the bedside, because the chart does not tell you that the foot is now cool or the dressing is soaked. Form an assessment and a plan for each patient before you present, even if it turns out to be wrong. The attending is teaching you to think, not to read a screen back to them.

1. Get the list and the overnight story. Note events overnight, new consults, and anyone who went to or came back from the OR, the angiography suite, or the CTV ICU.
2. Pull the numbers. Vitals and trends, ins and outs, morning labs, and the status of any drips or drains. Gather them before you walk in so the bedside visit is for examining, not charting.
3. See the patient and the limb. Lay eyes on them, examine the relevant vascular bed, Doppler the pulses if they are not palpable, and look under the dressing if a wound or incision needs checking.
4. Decide what you think. Frame each patient in one line, then an assessment and a plan. Walk in ready to commit to a recommendation.

The numbers to get

Every service wants vitals and labs. A vascular team also wants the limb, the lines, and the anticoagulation, because those are what change the plan. Collect these on every patient, every morning.

Vitals, with the trend

Temperature, heart rate and rhythm (atrial fibrillation matters here), blood pressure and oxygen. Report the trend, not just the last value, and note blood pressure in both arms when carotid or subclavian disease is in play.

Ins and outs

Fluid balance and especially urine output, which matter after open aneurysm repair, after contrast, and in anyone whose kidneys are at risk. Falling urine output is an early warning.

Labs

Hemoglobin and platelets (a falling platelet count raises the question of HIT), the basic metabolic panel for creatinine after contrast and potassium after revascularization, and coagulation studies if the patient is on heparin.

Lactate

Only if ischemia is possible. A rising lactate in the right setting points to ischemic tissue, whether a threatened limb or threatened bowel.

The limb

Pulses at each level, the Doppler signal where pulses are not palpable, capillary refill, and the look of the foot. This is the heart of a vascular exam and it should be specific.

The wound

Incision or ulcer appearance, drainage, the dressing or wound vac, and fasciotomy sites. Look under the dressing when it matters rather than reporting yesterday's finding.

Lines, drains and access sites

Arterial and central lines, drain outputs, and the puncture site after any catheter procedure: hematoma, bleeding, or a new bruit.

Anticoagulation

Is the heparin drip therapeutic, and at what rate? Is the patient on aspirin and a statin? Was anything held for a planned procedure? These change the plan most mornings.

The basics

Pain control, diet, mobility and disposition. The plan for going home or to rehab starts being built on day one.

Presenting a patient

A vascular presentation is organized around a vessel and the tissue it feeds. Lead with the vascular bed and how threatened it is, then build the rest of the story around that.

The attending wants to know how worried to be and how quickly, so your first two sentences should locate the problem and grade it. Move from the one-liner, through the vascular symptom and the pulse exam, to the hemodynamic and cardiac status, then the imaging framed as inflow, outflow and target, and finish with a clear assessment and plan.

1. One-line summary. Age, the relevant risk factors (smoking, diabetes, prior revascularization), and the problem framed by severity. Say “68-year-old smoker with rest pain and a non-healing toe ulcer, so tissue-loss CLTI,” not “leg pain.”
2. The symptom, in vascular terms. For arterial disease, claudication versus rest pain versus tissue loss. For an aneurysm, asymptomatic, symptomatic or ruptured. For carotid disease, symptomatic or asymptomatic, and when the event was.
3. The pulse and perfusion exam. Pulses at each level, graded consistently, the ABI or toe pressures, capillary refill, the skin and ulcer description, and the other side for comparison. This is the part that earns credibility.
4. Hemodynamic and cardiac status. Because the vascular patient is a cardiac patient: blood pressure, heart rate and rhythm, and any active cardiac, pulmonary or renal issue that bears on operative risk.
5. Imaging, then the plan. Summarize the duplex, CTA or angiogram as inflow, outflow and target, then close with an assessment and a plan rather than trailing off. Ending on a recommendation is what separates a strong presentation from a weak one.

Writing the note

A good vascular progress note reads the way the team thinks. It is short, it is current, and it puts the limb and the perfusion exam near the top.

• Open with the operative day and the operation. “POD 2, right fem-pop bypass” orients every reader in five words.
• Put the focused vascular exam high. Pulses by level, Doppler signals, the wound or incision, and the access site. This is what the team makes decisions on.
• Report numbers that are true today. Re-pull the vitals, the ins and outs and the labs. Never copy yesterday's exam forward.
• State the anticoagulation plan explicitly. Whether the heparin drip is therapeutic, whether aspirin and a statin are on board, and whether anything is held for a procedure.
• Close with a problem-based assessment and plan. Tie each plan to inflow, outflow or conduit where it applies, and name the disposition target.

Copy-ready progress note, consult note and post-op check templates are on History, exam and charting.

In the operating room

Your job as a student or junior is to be useful, unobtrusive and anticipatory: protect the field, follow the flow of the case, and be ready half a step before you are asked.

• Scrub, glove and stay sterile. Hands above the waist and in front of you, never turn your back to the field, and say so immediately if you think you have contaminated rather than hoping no one noticed.
• Hold retraction steadily and without complaint. Exposure is the operation. A still, well-placed retractor that gives the surgeon a view of the anastomosis is a genuine contribution. Keep the tension you were given until you are asked to change it.
• Follow the rhythm of the case. Expose, control proximal and distal, heparinize, clamp, do the anastomosis or endarterectomy, flush, unclamp, and confirm flow. Knowing the sequence tells you why each instrument is being asked for.
• Anticipate heparin, clamps and flushing. Systemic heparin precedes clamping, the team checks an activated clotting time, and flow is restored in an order that flushes debris away from the brain or the distal bed.
• Know the anatomy of the case you are in. Read the operation the night before and be able to name the structures in the wound. Answering in the room is far more impressive than answering in the workroom.
• Manage the small things. Cut suture at the length the surgeon prefers, keep the field dry with suction when asked, and handle tissue gently. Rough handling of an artery or a vein graft has real consequences.

The common consults

A handful of consults make up most of the pages to a vascular service, and each has a predictable workup. Knowing the first few moves lets you start before the senior arrives. In every case the questions are how acute it is, how threatened the tissue is, and what the perfusion exam and imaging show.

The acutely cold, painful leg

Treat this as acute limb ischemia until proven otherwise; it is the most time-sensitive vascular consult. Run the six Ps, establish the onset and whether the patient is in atrial fibrillation or has prior claudication, examine and Doppler both legs, and start systemic heparin immediately unless contraindicated. Then grade the limb with the Rutherford acute ischemia categories to decide whether there is time for imaging and catheter-directed therapy, or whether a category IIb limb demands the operating room now.

The non-healing foot ulcer

Frame it around neuropathy, ischemia and infection, because management hinges on which are present. Examine pulses and get an ABI and toe pressures (diabetic vessels can be falsely noncompressible), probe the wound for deep infection or osteomyelitis, and look for the rocker-bottom deformity of Charcot. The plan runs three threads in parallel: offload and debride, treat infection, and revascularize if perfusion is inadequate.

The asymptomatic aneurysm found on imaging

Two questions: how big, and is it symptomatic? Confirm the diameter, ask specifically about back or abdominal pain and tenderness that would reclassify it as symptomatic, and apply the repair thresholds (about 5.5 cm in men, 5.0 cm in women, rapid growth, or symptoms). Below threshold the work is surveillance and risk-factor control, principally smoking cessation and cardiovascular optimization.

The carotid bruit or asymptomatic stenosis

First decide whether the patient is symptomatic: a stroke, TIA or amaurosis fugax in the matching territory. Get a carotid duplex to grade the stenosis and make sure the patient is on best medical therapy (antiplatelet, statin, blood pressure control, smoking cessation) whatever else is decided. Symptomatic stenosis of 50 to 99 percent generally warrants intervention, ideally within about two weeks of the event; asymptomatic disease is treated more selectively.

The venous consult

A swollen leg, a DVT on duplex, or a question about an IVC filter. Confirm the extent of thrombus (calf, femoropopliteal or iliofemoral), check for phlegmasia, and confirm anticoagulation has been started if there is no contraindication. The questions for the vascular team are usually whether an extensive iliofemoral DVT needs thrombus removal and whether a filter is truly indicated.

The overnight versions of these calls, and the floor calls that come with them, are on On call and cross-cover.