EPA: Small Bowel Obstruction

EPA: Small Bowel Obstruction

Evaluatee Name (Last, First)*

Enter resident starting with last name. Once a form has been submitted, the resident will receive a copy of the evaluation.

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Rotation*

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Evaluator Name (Last, First)*

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Date of Assessment*

Phase of Care*

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

OBTAINS H&P with cultural humility and identifies SBO in a patient; DEVELOPS DIFFERENTIAL that includes hernia or adhesions, but MAY NEED ASSISTANCE CONSIDERING CLOSED-LOOP OBSTRUCTION OR INTERNAL HERNIA.

EVALUATES & INTERPRETS IMAGING (identifies ischemic bowel, pneumatosis, thickened bowel wall, intra-abd fluid, transition point). Understands significance of prior surgery but NEEDS ASSISTANCE to identify closed- loop or internal hernia on imaging.

RECOGNIZES IMAGING FINDINGS OF POSSIBLE INTERNAL HERNIA OR CLOSED LOOP OBSTRUCTION (eg, swirl sign, decompressed proximal and distal bowel).

Demonstrates COMPREHENSIVE KNOWLEDGE of the various presentation & identifies unique populations (prior R-Y gastric bypass, closed-loop SBO, Crohn’s, or malignant obstruction) that impact NONOPERATIVE & OPERATIVE TREATMENT decision-making.

Not applicable/not observed

Preoperative: Management*

REQUIRES GUIDANCE for fluid resuscitation, correction of electrolyte/acid-base derangements. Considers use of NGT but uncertain when it is indicated or associated risks (incorrect placement, dislodgement, clogging/dysfunction, increased aspiration risk).

INITIATES RESUSCITATION when needed, addressing electrolyte/acid-base derangements. MANAGES PRESUMED PARTIAL SBO OR ILEUS W/O URGENT SURGICAL INDICATION, including using GGF challenge consistent w/ guidelines, managing the NGT & safely advancing the diet.

Develops PLAN FOR MANAGING HEALTHY PT W/ SBO & identifies when surgery is req. Identifies when clinical condition changes (concern for ischemic bowel) & ADAPTS PLAN accordingly. Seeks assist to manage SBO 2nday to frozen abd or malignant obstruction

SYNTHESIZES INFORMATION TO DEVELOP A PLAN TO MANAGE A COMPLEX SBO, identifying the dynamic nature of SBO, when plan needs to be adjusted, and need to engage other specialists. Identifies potential need for immune-modulating medication in Crohn’s and SBO.

Not applicable/not observed

Preoperative: Communication with Patient*

Respectfully communicates BASIC PLAN for initial management but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES & audio/visual aids. If operation is indicated, communicates INFORMED CONSENT discussion BUT OMITS SOME ELEMENTS when documenting discussion

Respectfully communicates BASIC FACTS about dx & USES APPLICABLE LANGUAGE SERVICES & audio/visual aids. Verbalizes consideration for nonop management of malignant obstruction & engages palliative care team; req assist to engage in shared decision- making

Respectfully communicates the medical condition of an uncomplicated patient across barriers (eg, literacy, language, and cultural differences) to ELICIT A PERSONALIZED CARE PLAN, using shared decision-making and teach-back to ensure understanding

FACILITATES DIFFICULT CONVERSATIONS with a patient/caregiver(s) in the setting of SBO with a frozen abdomen or malignant obstruction & engages the palliative care team or an ethics consult as indicated

Not applicable/not observed

Case Difficulty

Straightforward

Moderate

Complex

Intraoperative: Anatomy*

Identifies common abdominal wall hernia but does not evaluate for an internal hernia

Demonstrates UNDERSTANDING OF ANATOMIC AND ACQUIRED FINDINGS that may be encountered intraoperatively during an abdominal exploration for SBO. Demonstrates understanding of the IMPACT OF PRIOR INCISIONS AND DILATED BOWEL ON PORT PLACEMENT

Identifies tissue planes; identifies and DISSECTS RELEVANT NORMAL ANATOMY. Demonstrates KNOWLEDGE OF POST–R-Y GASTRIC BYPASS ANATOMY and the need to explore for INTERNAL HERNIA.

MANAGES COMPLEX FINDINGS such as internal hernia (eg, Petersen, foramen of Winslow), malignant obstruction, enterotomy, and frozen abdomen

Not applicable/Not observed

Intraoperative: Steps of Operation*

1. Needs prompting for basic room setup & steps for abdominal entry (such as laparotomy w/ careful entrance into peritoneum to avoid injury of dilated bowel &, in the reop setting, entrance into undissected plane, identifying when MIS approach is safe).

2. Actively retracts and assists during the procedure and identifies some structures. Proceeds tentatively with adhesiolysis and has difficulty consistently identifying tissue planes, requiring redirection to avoid serosal injury or enterotomies.

3. Moves the operation forward and discerns when sufficient adhesiolysis has been achieved to relieve the SBO.

4. Performs a complex lap adhesiolysis and identifies when to convert to an open procedure for failure to progress.

Intraoperative: Technical Skills*

Centers the operative field (anatomy and instruments) with the camera with frequent adjustments and reminders. Displays coordinated hand movements for simple maneuvers, though inefficiently and under direct instruction.

Performs basic surgical tasks such as tying mesentery & deploying linear stapler w/ instruction. Some instrument coordination but inconsistent 2-handed tissue handling, esp laparoscopically; needs frequent camera adjustments to triangulate instruments.

Consistently demonstrates careful tissue handling when mobilizing small bowel and releasing adhesions. Safely places ports, treats a single-band adhesion, and runs the small bowel laparoscopically.

Demonstrates careful tissue handling and avoids injury in an open or MIS approach.

Intraoperative: Decision-Making*

Identifies adhesions and tissue planes with guidance and retraction but needs the supervisor to guide the entire adhesiolysis

Requires prompting to determine the need for bowel resection or repair of serosal injury once adhesiolysis is complete. Assesses bowel viability before closure

Demonstrates understanding that when serosal injury is extensive, resecting the affected bowel is the best option. Identifies bowel that is not viable and should be resected

Assesses bowel viability and makes decisions regarding restoration of intestinal continuity and abdominal closure based on intraoperative findings, including hemodynamic stability

Postoperative: Complications*

Identifies S&S of COMMON POSTOP COMPLICATIONS (ileus, infxn, or bleeding), REQUIRES GUIDANCE TO MANAGE. Demonstrates BASIC KNOWLEDGE OF TREATMENT STRATEGIES for common complications encountered (managing electrolyte abnormalities, minimizing opiate use).

Initiates MANAGEMENT FOR A COMMON POSTOP COMPLICATION (ileus, infxn, or bleeding)

Identifies and MANAGES POSTOP PROBLEMS W/ COMPLEX CONDITION (kidney failure, CHF, cirrhosis). Manages the postop course (with assistance as needed) & engages other specialty services as indicated for postop management of complex findings (cancer, IBD).

INDEPENDENTLY IDENTIFIES, DIFFERENTIATES, AND MANAGES COMPLEX POSTOP COMPLICATIONS such as ileus, early postop bowel obstruction, fistula formation, anastomotic failure, fascial dehiscence, and ostomy dysfunction.

Not applicable/not observed

Postoperative: Communication with Patient*

PROVIDES UPDATES to a patient/caregiver(s) regarding progress with SBO.

Engages with a patient/caregiver(s) to ensure they UNDERSTAND SHORT- AND LONG-TERM CARE for an ostomy, fistula, or wound.

ENGAGES IN SHARED DECISION- MAKING with a patient/caregiver(s) regarding long-term care plans in the setting of SBO and a frozen abdomen or malignant obstruction.

Communicates with a patient/caregiver(s) and members of the health care team with CULTURAL HUMILITY REGARDING COMPLICATIONS, LONG- TERM CARE NEEDS for an ostomy or fistula, or palliation as indicated.

No applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

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