Evaluate a patient with right lower quadrant pain and manage appendicitis

Expected Behaviors of Residents Entrustable to Perform this EPA by Observation Only (Level 0):

Preoperative Phase of Care: When evaluating and managing a patient with right lower quadrant pain,
residents at this level have a rudimentary understanding of both the anatomy and pathophysiology of
the appendix and other organs in the right lower quadrant. Their lack of knowledge prevents the
development of an appropriate differential diagnosis with both errors of omission and commission
when a patient presents with signs and symptoms of appendicitis, resulting in an inability to initiate the
expected cost-effective workup. They order multiple diagnostic studies in a shotgun approach or rely too
much on a single approach such as a CT scan. They are unfamiliar with published guidelines regarding
the workup and management of appendicitis and other common causes of right lower quadrant pain
that may masquerade as appendicitis. They are unable or unwilling to obtain adequate informed
consent.

Intraoperative Phase of Care: In the operating room (OR), these residents are not able to describe how
to locate the appendix and its anatomic variants. They do not know where to look for alternative
pathology when the appendix appears normal. They lack spatial awareness when attempting to navigate
laparoscopic instruments and cannot target with an instrument without watching the instrument as it
enters the abdomen. These residents frequently risk tearing or injuring bowel on grasping it. These
residents may apply cautery well in advance of contact with the target tissue. Their movements are
rough and lack smoothness, and they usually cannot coordinate their hands. If forced to “go open,”
these residents often cannot describe the layers of the abdominal wall in the right lower quadrant. They
are hesitant with the Bovie and are not able to contribute to the case if a bleeding vessel is encountered.

Postoperative Phase of Care: These residents fail to prepare the patient for common postoperative
issues. They do not recognize concerning signs of a postoperative complication such as a deep space
wound infection, bleeding, or bowel obstruction. They fail to communicate the patient’s complaint and
symptoms or change in status to their senior resident or faculty surgeon.

Vignette of a Resident Entrustable to Perform this EPA by Observation Only (Level 0):

Dr. Christine Bell, a resident, is sent to the emergency department (ED) to evaluate Ai Tanaka, a 32-year-
old woman who presents with a 24-hour history of right lower quadrant pain. Christine performs a brief
history and begins ordering tests. She is focused on distinguishing possible appendicitis from pelvic
inflammatory disease (PID) because the patient had an episode of PID 1 year ago. ED physicians have
already ordered laboratory testing and a CT scan, so Christine decides that a pelvic examination is not
necessary. She does not ask any questions in the history that might lead to alternative diagnoses such as
inflammatory bowel disease or ectopic pregnancy. She asks only some limited questions about the onset
of the pain and is fixated on the fact that the patient vomited once. She then calls her chief resident, Dr.
Sarah Miller, to tell her about the consult. Christine’s presentation is disorganized and she is unable to
tell Sarah whether Ms. Tanaka has had a history of previous abdominal pain or anything that could
inform alternative diagnoses besides appendicitis and PID, but Christine is totally convinced that this is
appendicitis based on the patient’s single episode of vomiting. She has not done a rectal examination,
pelvic examination, or put Ms. Tanaka through any advanced maneuvers such as trying to demonstrate
an obturator or Romberg sign. Christine does not know if a beta human chorionic gonadotropin has
been ordered. When asked about the Alvarado score, she has no idea what it is. It is ultimately
determined that the patient actually does have acute appendicitis based on the CT scan and a more
thorough history, physical, and laboratory assessment done by Sarah when she comes down to the ED.
When Christine goes to obtain informed consent, she tells Ms. Tanaka “just sign here,” and when Ms.
Tanaka asks questions about the procedure, Christine replies, “I don’t know. Just sign, and I’ll check
later,” while repeatedly checking her beeper.

A decision is made to take Ms. Tanaka to the OR. In the OR, Sarah and the faculty surgeon, Dr. Dan
Lopez, ask Christine about the two options for entering the abdomen for a laparoscopic operation and
the risks of each. She is unable to answer this question. During the operation, Christine is initially given
the job of driving the scope and has significant difficulty with depth perception. She strays from the
target, drifts constantly, and generally has trouble following the case even with very direct instructions.
Christine keeps fogging the scope by running it into bowel. She is unable to answer questions about the
anatomy of the appendix and what the surgeons should do if the appendix appears normal when they
get there. She does not know how they would expose a retrocecal appendix. Christine is allowed to try
to run the stapler after Sarah and Dr. Lopez identify and expose an acutely inflamed appendix and
develop a window in the mesoappendix. Christine has to give up the scope to do this because she is
unable to use both hands at once with the scope and the stapler.

The next morning, Christine sees Ms. Tanaka on rounds and tells her that she is being discharged. When
Ms. Tanaka asks about what she should be concerned about, what she can eat, and how to take care of
her wounds, Christine tells her, “it’s all on the after-visit summary—just read it,” but the after-visit
summary that Christine creates is generic and lacks any of these instructions. She never checks the
nursing note that documents that Ms. Tanaka vomited her entire breakfast, and the nursing staff does
not like to call Christine because she is always so unpleasant on the phone. So Ms. Tanaka is discharged.
One week later, Christine happens to be in the office with Dr. Lopez when he mentions that Ms. Tanaka
is in the office. Christine volunteers to see her first. When Christine goes in to see Ms. Tanaka, she is
focused on the subcuticular closure of the port sites, which she did. Christine briefly asks Ms. Tanaka
how she is doing; when she complains of night sweats, a poor appetite, and continued nausea, Christine
reassures her that it sometimes takes a while to get better after surgery and anesthesia. When reporting
back to Dr. Lopez, Christine mentions the poor appetite but not the chills and sweats. She talks a lot
about the port site incisions and one that is slightly red, wondering if could be infected. She makes no
suggestion for workup other than “maybe to keep an eye on her and see her again next week.”

******************

Expected Behaviors of Residents Entrustable to Perform this EPA with Direct Supervision (Level 1):

Preoperative Phase of Care: When evaluating and managing a patient with right lower quadrant pain,
residents at this level have a basic understanding of both the anatomy and the pathophysiology of the
appendix and other organs in the right lower quadrant. Their basic knowledge allows only the
development of a limited differential diagnosis with both errors of omission and commission when a
patient presents with signs and symptoms of anything other than a classical presentation of
appendicitis, resulting in an inability to initiate the expected cost-effective workup. They order multiple
diagnostic studies in a shotgun approach or rely too much on a single approach such as a CT scan.
Although they are aware that there are published guidelines regarding the workup and management of
appendicitis, they lack any familiarity with them. They cannot diagnose common problems that can
masquerade as appendicitis. These residents can start a straightforward informed consent but need
support to answer any kind of complex question.

Intraoperative Phase of Care: In the OR, these residents are not able to describe how to locate the
appendix besides noting that it is attached to the cecum in the right lower quadrant. They do not know
how to locate anatomic variants such as a retrocecal appendix. They cannot identify a systematic
approach to exploring alternate pathology when the appendix appears normal. These residents struggle
to target with a laparoscopic instrument and frequently need to withdraw the scope to get a wider view
to find the instrument. They frequently risk tearing or injuring bowel on grasping it. Their movements
are rough and lack smoothness, and they can only coordinate their hands for simple maneuvers and
under direct instruction. If forced to “go open,” these residents can describe the layers of the abdominal
wall in the right lower quadrant but have trouble identifying them in practice. They are hesitant with the
Bovie and are able to contribute to the case if a bleeding vessel is encountered only with clear, simple
instructions.

Postoperative Phase of Care: These residents can prepare a straightforward patient for discharge. They
do not recognize deviations from the postoperative course that might indicate the early signs of a
complication. They can recognize obvious postoperative complications such as atelectasis, deep vein
thrombosis, and superficial site infections. They can begin to consider concerning signs of a
postoperative complication such as a deep space wound infection but likely cannot generate a
differential diagnosis and initiate a cost-effective workup. Communication of the patient’s complaint to
the senior resident or faculty surgeon is undertaken but is poorly organized and without a clear
algorithmic plan.

Vignette of a Resident Entrustable to Perform this EPA with Direct Supervision (Level 1):

Dr. Alex Rogozov, a junior resident, is sent to the ED to evaluate Ai Tanaka, a 32-year-old woman who
presents with a 24-hour history of right lower quadrant pain. Alex performs a detailed history and
physical examination focused on establishing the diagnosis of appendicitis. He asks about migration of
the pain and its onset as well as associated symptoms. He takes a sexual history and notes that Ms.
Tanaka had an episode of PID 1 year ago. He elicits a Romberg sign and an obturator sign and performs a
rectal and pelvic examination. He is somewhat confused after all this, because the patient’s history and
physical examination does not fit neatly with any diagnosis. He then calls his chief resident, Dr. Sarah
Miller, to tell her about the consult. Alex’s presentation is well organized but he cannot put the pieces
together to give a ranked differential diagnosis beyond appendicitis, PID, and ectopic pregnancy. The
only plan that he can come up with is to get a CT scan. When asked about the Alvarado score, he knows
that it is a scoring system for appendicitis and some of the components but does not understand how to
best use it. It is ultimately determined that Ms. Tanaka actually does have acute appendicitis based on
the CT scan and a more thorough history, physical examination, and laboratory assessment done by
Sarah when she comes down to the ED; however, the presentation is not classic. Sarah is able to
elucidate a better history that suggests that inflammatory bowel disease is high on the differential,
something that Alex had dismissed early on when the patient denied bloody diarrhea. A decision is
made to take Ms. Tanaka to the OR. When Alex goes in the patient’s room to obtain informed consent,
he adjusts the lights, gets the patient’s glasses off the nightstand so she can read the document, and
carefully goes through each section. When she asks some questions about laparoscopic versus open
approaches, he replies, “Good question–I’m not really sure. Let me go find my senior resident or the
attending,” and he does so and brings the physician into the room to complete the process.

In the OR, Sarah and the faculty surgeon, Dr. Dan Lopez, ask Alex about the two options for entering the
abdomen for a laparoscopic operation and the risks of each. He can name the approaches but does not
know the pros and cons. They start with Sarah assisting Alex and Dr. Lopez supervising. Alex has some
trouble locating the site of the other trocar incisions and coordinating both hands but gets all the trocars
in safely. To do this, he does need to repeatedly withdraw his scope to get a wide view. Sarah takes over
driving the scope and Alex takes the two trocars. He repeatedly paws at the bowel and is alternatively
too rough and then too timid to gain exposure of the appendix. When asked how to locate the appendix
or how to uncover a retrocecal appendix, he cannot say more than, “find the large bowel and then the
appendix attached to it.” Sarah has to take one of the trocars in addition to the scope and guide Alex to
the base of the appendix and make a window in the mesoappendix. Dr. Lopez occasionally reaches over
to move Alex’s hand, which is now retracting as Sarah is doing most of the active part of the case. When
they find an acutely inflamed appendix, Alex is asked what he would have done if it had been normal.
Alex is able to mention looking at the ileum and ovary but forgets about Meckel diverticulum. Alex is
given the stapler, and with direct instruction he is able to staple across the appendiceal stump and
coordinate his hands to remove the appendix. On the way out, Dr. Lopez asks Alex where a Rockey-Davis
incision would go if they had decided to do an open appendectomy and what layers of the abdominal
wall they would encounter. Alex is only able to generally point in the right lower quadrant and, although
he names the layers of the abdominal wall correctly, he is confused about their orientation. He then
completes the trocar closure.

In rounds the next morning, Alex tells Ms. Tanaka that she is being discharged. He reviews the expected
postoperative course with her. When she tells him that she is still feeling nauseated, does not have an
appetite, and has vomited her breakfast, he reassures her that it is “just the anesthesia and you’ll feel
better at home.” One week later, Alex happens to be in the office with Dr. Lopez when Dr. Lopez
mentions that Ms. Tanaka is in the office. Alex volunteers to see her first. When Alex goes in to see her,
he briefly asks her how she is doing. When she complains of night sweats, a poor appetite, and
continued nausea, he follows up with questions about voiding, closely examines her wounds, does a
good pulmonary examination, and probes her legs looking for a Homan sign. He comes back to speak
with Dr. Lopez and recommends workup based on “wind, wound, and water,” but he never considers
deep space infection.

******************

Expected Behaviors of Residents Entrustable to Perform this EPA with Indirect Supervision (Level 2):

Preoperative Phase of Care: When evaluating and managing a patient with right lower quadrant pain,
residents at this level have a good understanding of both the anatomy and the pathophysiology of the
appendix and other organs in the right lower quadrant. Their knowledge allows the development of a
differential diagnosis that encompasses all of the most common pathology seen, including unusual
presentations of appendicitis. They can initiate a cost-effective workup but may overuse or underuse
technology when the diagnosis is in doubt. Although they are aware that there are published guidelines
regarding the workup and management of appendicitis, they are unaware of nuances and exceptions to
the guidelines. They consider other conditions that can masquerade as appendicitis but are unsure
about how to diagnose these problems in complicated cases. These residents can complete a
straightforward informed consent.

Intraoperative Phase of Care: In the OR, these residents can describe how to locate the appendix but
might struggle to do so, especially in the face of significant inflammation. They understand where to
locate anatomic variants, such as a retrocecal appendix. They can identify a systematic approach to
exploring alternate pathology when the appendix appears normal but often do not undertake
appropriate changes in trocar and patient position in order to do so. These residents can target with a
laparoscopic instrument with only an infrequent need to withdraw the scope to get a wider view to find
the instrument. These residents handle normal tissue appropriately but risk tearing or injuring bowel on
grasping it when applying differential pressure in inflamed tissue. They do not recognize tissue planes in
the face of scarring and inflammation. Their movements lack economy of motion but are starting to
develop some smoothness. They can coordinate their hands for simple maneuvers without prompting. If
forced to “go open,” these residents can describe the layers of the abdominal wall in the right lower
quadrant and can identify them. They can contribute to the case if a bleeding vessel is encountered.
Postoperative Phase of Care: These residents can prepare a patient for discharge and can customize
discharge plans based on the hospital course. They recognize deviations from expected postoperative
care but may not know how to pursue these past simple therapeutic maneuvers. They recognize and
initiate management of common postoperative complications such as atelectasis, deep vein thrombosis,
and superficial site infection. They can recognize concerning signs of a postoperative complication (such
as a deep space wound infection), generate a differential diagnosis, and initiate a simple cost-effective
workup. However, these residents struggle to develop a comprehensive management plan for more
involved complications such as deep organ space infection. Communication of the patient’s complaint to
the senior resident or faculty surgeon is organized but lacks detail and nuance, especially in terms of
management recommendations.

Vignette of a Resident Entrustable to Perform this EPA with Indirect Supervision (Level 2):

Dr. Lori Picotte, a junior resident, is sent to the ED to evaluate Ai Tanaka, a 32-year-old woman who
presents with a 24-hour history of right lower quadrant pain. Lori performs a thorough history and
physical examination focused on establishing the diagnosis of appendicitis while carefully considering
other diagnoses. She asks about migration of the pain and its onset as well as associated symptoms. She
takes a sexual history and notes that Ms. Tanaka had an episode of PID 1 year ago. She elicits a Romberg
sign and an obturator sign. She does a rectal and pelvic examination. She notes that this patient’s history
and physical examination do not fit neatly with any diagnosis. She then calls her chief resident, Dr. Sarah
Miller, to tell her about the consult. Lori’s presentation is well organized, and she believes that the most
likely diagnosis is appendicitis but systematically goes through alternative diagnoses with Sarah. Lori
volunteers an Alvarado score. Sarah probes Lori to see what she really knows about the score and what
options she would recommend to confirm the diagnosis and initiate management. Lori knows how the
score is obtained but has not read the papers to understand why it was developed and when it might be
fallible. She does not espouse the routine use of CT for diagnosing appendicitis but cannot really say why
or discuss the specificity and sensitivity of different imaging studies in appendicitis. It is ultimately
determined that Ms. Tanaka actually does have acute appendicitis based on the CT scan; this is Sarah’s
assessment when she comes down to see the patient, although she comments that she has not really
elicited any new information over and above what Lori had collected. A decision is made to take Ms.
Tanaka to the OR. When Lori goes into the patient’s room to obtain informed consent, she adjusts the
lights, gets Ms. Tanaka’s glasses off the nightstand so she can read the document, and carefully reviews
each section. When she asks some questions about laparoscopic versus open approaches, Lori sits down
and lists the pros and cons of both. She offers to get a more senior resident or the attending physician if
her explanation was not adequate, but the patient feels that she is comfortable with the procedure and
signs the document.

In the OR, Lori conducts the “time out” with everyone present. Sarah and the faculty surgeon, Dr. Dan
Lopez, ask Lori about the two options for entering the abdomen for a laparoscopic operation and the
risks of each. She can name the approaches and discuss the pros and cons but states that she only has
experience with one technique. They start with Sarah assisting Lori and Dr. Lopez supervising. Lori
efficiently establishes access and gets the scope and trocars in place. She asks anesthesia to roll the
patient and put Ms. Tanaka in the Trendelenburg position. She carefully uses the grasper to move some
normal bowel out of the way. She volunteers her plan to identify the colon and follow the taenia to the
base of the appendix and also notes that the CT suggested that the appendix is retrocecal. These
preparatory steps go smoothly until the surgeons get to the cecum and find significant inflammation and
confirm that this is a retrocecal appendix. Lori starts to become more timid when trying to retract the
colon and, when encouraged to be more aggressive, she tears the serosa. Lori loses her way when
exchanging instruments at this point and asks Sarah to bring the scope back so she can follow the
scissors in, the first time she has needed to do this. Lori says that this is “the most inflamed appendix
I’ve ever seen” and wonders out loud whether they ought to be considering “going open.” Dr. Lopez
asks her how she might do this, and Lori suggests a right lower quadrant incision and accurately
describes what to do. At that point, poor control of the tips of Lori’s scissors provokes Sarah to take over
briefly in order to complete the dissection and get back into the appropriate avascular plane and they
continue laparoscopically. Lori regains her equilibrium and starts dissecting the mesoappendix. It is
thickened and inflamed and they “get into some bleeding.” Sarah sees Lori becoming flustered again
and takes control of the dissection, but with direct instructions, she is helpful in controlling the bleeder.
They are then able to complete the case. Dr. Lopez asks Lori what she would do if the appendix had
been normal. She is able to describe a systematic approach to an abdominal operation, but when Dr.
Lopez asks her to demonstrate, Lori struggles and never considers changing trocar positions or
repositioning the patient. She then completes the trocar closure.

In rounds the next day, Lori visits Ms. Tanaka and tells her it is time to go home. She goes over the
expected postoperative course with her. When Ms. Tanaka tells her that she is still feeling nauseated,
does not have an appetite, and has vomited her breakfast, Lori reconsiders the plan and tells the nurse
to cancel the discharge as she wants to “watch her a little bit.” When Ms. Tanaka is able to keep her
lunch down, Lori goes ahead and discharges her, telling her to keep to clear liquids until she feels better
at home. One week later, Lori happens to be in the office with Dr. Lopez when he mentions that Ms.
Tanaka is in the office. Lori volunteers to see her first. When Lori goes in to see her, she briefly asks her
how she is doing and when she complains of night sweats, a poor appetite, and continued nausea, Lori
follows up with questions about voiding, closely examines her wounds, does a good pulmonary
examination, and probes her legs looking for Homans sign. She comes back to speak with Dr. Lopez and
recommends a workup based on “wind, wound, and water,” but she notes that the timing and
symptoms could also be signs of a deep space organ infection and recommends a CT scan as soon as
more minor etiologies are ruled out.

******************

Expected Behaviors of Residents Entrustable to Perform this EPA in Unsupervised Practice (Level 3):

Preoperative Phase of Care: When evaluating and managing a patient with right lower quadrant pain,
residents at this level have a good understanding of both the anatomy and the pathophysiology of the
appendix and other organs in the right lower quadrant. Their knowledge allows the development of a
differential diagnosis that encompasses all of the most common pathologies seen, including unusual
presentations of appendicitis. They can initiate a cost-effective workup and utilize available technologies
to maximize efficiency when the diagnosis is in doubt. They are familiar with published guidelines and
scoring systems regarding the workup and management of appendicitis. They consider other problems
that can masquerade as appendicitis and can elucidate a cost-effective workup and obtain consultation
from other specialties as necessary. These residents can complete a straightforward informed consent
and customize it for the clinical condition. They can anticipate logistical issues in the OR.

Intraoperative Phase of Care: In the OR, these residents can describe and locate the appendix, even in
the face of inflammation or past scarring. They know where to locate anatomic variants, such as a
retrocecal appendix, and always find it in uncomplicated cases but may struggle and need guidance in
the face of inflammation and perforation. They can identify a systematic approach to exploring alternate
pathology when the appendix appears normal and will suggest repositioning of trocars and patient
position to accomplish this. They can elucidate the appropriate initial therapy for pathology other than
appendicitis but may lack experience in undertaking that therapy. These residents consistently target
with a laparoscopic instrument. They handle normal bowel with respect on grasping it. They are
occasionally risk injuring bowel in difficult, inflamed cases. They can identify tissue planes but may
struggle when the plane becomes bloody or too stuck. Their movements are mostly smooth but do lack
some economy of motion in difficult cases. They can coordinate between their two hands for most
maneuvers. These residents are capable of recognizing when to abandon a laparoscopic approach, but
their secondary plan may be vague and lack detail. If forced to “go open,” these residents can describe
the layers of the abdominal wall in the right lower quadrant and identify them. They are able to
contribute if a bleeding vessel is encountered and can gain exposure but may need guidance to optimize
exposure.

Postoperative Phase of Care: These residents can prepare a patient for discharge and customize
discharge plans based on the hospital course. They recognize deviations from expected postoperative
care and can initiate a cost-effective workup of those problems. They recognize and manage common
postoperative complications, such as atelectasis, deep vein thrombosis, and superficial site infection.
These residents also recognize concerning signs of more serious postoperative complications (such as a
deep space wound infection), can generate a differential diagnosis, and can initiate a cost-effective
workup. They consider alternative management strategies to more serious complications and can
initiate these strategies. Communication of the patient’s complaint to the senior resident or faculty
surgeon is organized and contains clear recommendations for management.

Vignette of a Resident Entrustable to Perform this EPA in Unsupervised Practice (Level 3):

Dr. John Mossell is sent to the ED to evaluate Ai Tanaka, a 32-year-old woman who presents with a 24-
hour history of right lower quadrant pain. John performs a thorough history and physical examination
focused on establishing the diagnosis of appendicitis while carefully considering other diagnoses. He
elicits a Romberg sign and an obturator sign. He asks about migration and onset of the pain, as well as
associated symptoms. He takes a sexual history and notes that Ms. Tanaka had an episode of PID 1 year
ago. He does a rectal and pelvic examination. He notes that this patient’s history and physical does not
fit neatly with any diagnosis. John then calls his chief resident, Dr. Sarah Miller, to tell her about the
consult. His presentation is well organized, and he believes that the most likely diagnosis is appendicitis
but systematically goes through alternative diagnoses with Sarah. He volunteers an Alvarado score.
Sarah probes John to see what he really knows about the scoring system and what options he would
recommend to confirm the diagnosis and initiate management. John knows about the system and has
read the studies detailing its usefulness and problems. He has carefully considered a range of workup
and management options, including nonoperative management, but believes that it is best to move
forward with a CT scan. It is ultimately determined that Ms. Tanaka actually does have acute
appendicitis based on the CT scan, and Sarah’s assessment when she comes down to see the patient is
completely in agreement with John. A decision is made to take Ms. Tanaka to the OR. When John goes
into the patient’s room to obtain informed consent, he adjusts the lights, gets Ms. Tanaka’s glasses off
the nightstand so she can read the document, and carefully reviews each section. When she asks some
questions about laparoscopic versus open approaches, he sits down and lists the pros and cons of both
and gives a detailed explanation of why he believes the laparoscopic approach is best for her case.

While Ms. Tanaka is still in the holding room, John goes into the OR to brief the team. He makes sure
both 0-degree and a 30-degree laparoscopes are in the OR. He lets anesthesia know how he thinks the
case will proceed. In the OR, John conducts the “time out” and Sarah and the faculty surgeon, Dr. Dan
Lopez, ask John about the two options for entering the abdomen for a laparoscopic operation and the
risks of each. He can name the approaches and discuss the pros and cons, and he states he prefers the
Veress needle. They start with Sarah assisting John and Dr. Lopez supervising. John efficiently establishes
access and gets the scope and trocars in place. He asks anesthesia to roll the patient and put her in a
Trendelenburg position. He carefully uses the grasper to move some normal bowel out of the way. He
volunteers his plan to identify the colon and follow the taenia to the base of the appendix, and he also
notes that the CT suggested that the appendix was retrocecal. These preparatory steps go smoothly
until they get to the cecum and find significant inflammation and confirm that this is a retrocecal
appendix. John slows down and becomes more careful, while still making steady progress. He gets out of
the correct plane while working behind the cecum and “gets into some bleeding.” He does not panic,
but Sarah needs to take a more active role to help control the bleeder and she makes a few suggestions
for getting back on track, which John does. Dr. Lopez asks John at what point he might consider
abandoning a laparoscopic approach and “go open.” John is able to defend staying laparoscopic at this
time but is vague about what might make him consider changing his mind. John starts dissecting the
mesoappendix. It is thickened and inflamed and again runs into some bleeding. This time, he is able to
direct Sarah to help him control the bleeder. As he places the stapler on the base of the appendix, John
asks Sarah and Dr. Lopez a couple of times if they think it is all right to staple where he is. They are then
able to complete the case. Dr. Lopez asks John what he would do if the appendix had been normal. John
is able to describe a systematic approach to an abdominal operation, including how he might alter the
exposure, if needed. He then completes the trocar closure.

On rounds the next day, John visits Ms. Tanaka and tells her it is time to go home. He goes over the
expected postoperative course with her. When she tells him that she is still feeling nauseated, does not
have an appetite, and has vomited her breakfast, John immediately cancels the discharge and tells the
nurse that he wants to “watch her a bit.” He comes back to see Ms. Tanaka after lunch and when she
complains of nausea, even though she kept lunch down, he reexamines her, paying close attention to
her wound as well as to her chest and abdomen. He decides to keep her another night and check
laboratory tests in the morning. The next day, Ms. Tanaka is somewhat better and John discusses the
case with his senior resident and attending, and they decide to send her home with explicit instructions
about what to watch for and to have her return for follow-up promptly. One week later, John arranges
to be in the office with Dr. Lopez expecting to see Ms. Tanaka; Dr. Lopez had mentioned that she had
called and was coming in early. John volunteers to see Ms. Tanaka first. When John goes in to see her,
he briefly asks her how she is doing and when she complains of night sweats, poor appetite, and
continued nausea, he follows up with questions about voiding, closely examines her wounds and
abdomen, does a good pulmonary examination, and probes her legs looking for Homans sign. He comes
back to speak with Dr. Lopez and states that he thinks Ms. Tanaka might have an abscess. He has already
arranged for a chest x-ray and urinalysis, with a CT scan to follow.

******************

Expected Behaviors of Residents Entrustable to perform this EPA by Supervising Others (Level 4):

Preoperative Phase of Care: When evaluating and managing a patient with right lower quadrant pain,
residents at this level have a good understanding of both the anatomy and the pathophysiology of the
appendix and other organs in the right lower quadrant. Their knowledge allows the development of a
differential diagnosis that encompasses all of the most common pathology seen, including unusual
presentations of appendicitis. They can initiate a cost-effective workup and utilize available technologies
to maximize efficiency when the diagnosis is in doubt. They are familiar with published guidelines and
scoring systems regarding the workup and management of appendicitis. They consider other problems
that can masquerade as appendicitis, can elucidate a cost-effective workup, and obtain consultation
from other specialties as necessary. These residents can supervise more junior residents in the workup
for patients with right lower quadrant pain and can delegate given the different strengths and
weaknesses of members on their team. They can complete an informed consent and customize it for the
clinical condition. They can anticipate logistical issues in the OR and they can delegate and supervise
these tasks to other members of the team.
Intraoperative Phase of Care: In the OR, these residents can describe and locate the appendix even in
the face of inflammation or past scarring. They know where to locate anatomic variants, such as a
retrocecal appendix, and always find it, both in uncomplicated cases and in the face of inflammation and
perforation. They can identify a systematic approach to exploring alternate pathology when the
appendix appears normal and suggest repositioning of trocars and patient position to accomplish this.
They can elucidate the appropriate initial therapy for pathology other than appendicitis and can
undertake that therapy. These residents consistently target with a laparoscopic instrument. They handle
normal and inflamed bowel with respect on grasping it. They can identify tissue planes and can work
through when the plane becomes bloody or stuck. Their movements are smooth and exhibit economy of
motion. They can coordinate their hands for most maneuvers. If forced to “go open,” they can decide
between a midline approach and a right lower quadrant approach based on the operative findings.
These residents can describe the layers of the abdominal wall in the right lower quadrant and identify
them. They can control bleeders and gain appropriate exposure independently. They can lead a more
junior resident through uncomplicated cases of appendicitis both verbally and by helping improve
exposure.

Postoperative Phase of Care: These residents can prepare a patient for discharge and can customize
discharge plans based on the hospital course. They recognize deviations from expected postoperative
care and can independently carry out a cost-effective workup of those problems. They recognize and
manage common postoperative complications, such as atelectasis, deep vein thrombosis, and superficial
site infection. They also recognize concerning signs of more serious postoperative complications (such as
a deep space wound infection), can generate a differential diagnosis, and can initiate a cost-effective
workup. They consider alternative management strategies to more serious complications and can
undertake these strategies independently. Communication of the patient’s complaint to the faculty
surgeon is organized and contains clear recommendations for management. These residents can
supervise a more junior resident in the postoperative care of a patient after appendectomy or surgical
management of a masquerading pathology.

Vignette of a Resident Entrustable to perform this EPA by Supervising Others (Level 4):

Dr. Sarah Miller is a chief resident responsible for the emergency general surgery team when the team is
consulted about Ai Tanaka, a 32-year-old woman, with right lower quadrant pain of 24 hours’ duration
in the ED. Although Sarah’s consults are usually handled by her PGY-3 resident, she asks a few questions
and decides that this would be a good time to have her PGY-1 resident, Dr. Jonah Hunter, gain some
experience with consults and be the first person to evaluate right lower quadrant pain. Jonah goes to
see the patient and calls to report his findings. His presentation is well organized but “bare bones,” and
he struggles to lay out a clear differential diagnosis beyond appendicitis and a plan. Sarah examines Ms.
Tanaka herself and brings Jonah with her. She probes several areas that the intern never thought of and
demonstrates aspects of the physical examination, including how to elicit a Romberg or obturator sign.
Her provisional diagnosis of appendicitis is confirmed by a CT scan and she preps Jonah to call the
attending by having him practice his presentation again, with her listening. A decision is made to go to
the OR, and Sarah tells Jonah that she will accompany him as he goes to obtain consent. They go in
together and when Jonah launches into an explanation to Ms. Tanaka of what is going to happen, Sarah
stops him, adjusts the light, and gives the patient her glasses. When Jonah struggles to answer some of
Ms. Tanaka’s questions, Sarah steps in and helps.

When Ms. Tanaka is in a holding room, Sarah notices that Jonah is distracted, trying to take care of some
last-minute floor issues, so she decides to go into the OR and brief the team herself. She makes sure that
both 0-degree and -degree laparoscopes are in the OR. She lets anesthesia know how she thinks the
case will go. In the OR, they start with Sarah as teaching assistant, her intern as surgeon junior, and the
attending, Dr. Dan Lopez, supervising. She asks Jonah what he wants to get out of the case and before
they get started, probes his level of experience with laparoscopic appendectomies, and asks him to
describe his intraoperative plan. Once satisfied, Sarah conducts a “time out” and they begin. Her intern
rapidly and efficiently establishes access and places the trocars. He instructs anesthesia to roll the
patient and place Ms. Tanaka in the Trendelenburg position. He has the trocars, Sarah has the scope,
and she is letting him proceed. When they get to the cecum and encounter some inflammation, Sarah
has Jonah stop and gauges his level of comfort and assesses whether he can continue safely. He is
struggling to find the proper plane and to dissect out what is a retrocecal appendix. Sarah takes over
one of the trocars with her free hand in order to better guide him. He still struggles, so she has him take
over the scope and she then takes primary control over the operation. The appendix is very stuck and
inflamed, but she is able to identify the proper plane and slowly chip away while demonstrating respect
for tissue and economy of motion. Once the appendix is out from behind the cecum, she turns one of
the trocars back over to Jonah while she takes the scope, and together they dissect through a thickened
mesentery. They get into a small bleeder and Sarah gives him direct instruction while they control it
together. The appendix is removed and after the case, Sarah sits down and discusses with her intern
what went well and what did not go so well. She reviews what they might have done if the appendix had
been normal, as well as what things might have prompted her to “go open.” Dr. Lopez swings by and
comments that he felt redundant during the case.

On rounds the next morning, Jonah tells Sarah that Ms. Tanaka is ready to go home. Sarah stops by
before discharge and notices that although he has properly prepared the patient to go home, Ms.
Tanaka is still nauseated and vomited her breakfast. Sarah cancels the discharge and calls Jonah and
questions him. He had thought the nausea was from the anesthesia but had not done anything more to
be sure. They discuss a plan that involves reexamining Ms. Tanaka after lunch. After lunch, he calls Sarah
and reports that Ms. Tanaka is better but still nauseated. They decide to keep her overnight. The next
morning, they send her home with explicit instructions of what to watch for, and they make plans to
bring her back early the next week. One week later, Sarah has arranged to be in the office with one of
Dr. Lopez’s partners because she had heard that Ms. Tanaka was coming into the office early because
she has not been feeling well. Sarah tells the attending that she knows Ms. Tanaka well and will take
care of it. Sarah sends a different intern, Dr. Dipayan Acharya, in to see Ms. Tanaka, after first giving him
a concise summary of the patient’s hospital course. Dipayan comes back and reports that he is
concerned that Ms. Tanaka is complaining of chills, lack of appetite, and anorexia. He recommends a
fever workup based on “wind, wound, and water.” Sarah goes back into the room with Dipayan and is
more concerned with the possibility of a deep organ space infection, given that there are no signs of a
urinary tract infection, pulmonary process, or superficial wound infection, based on her history and
physical examination. She explains her thinking to Dipayan and then oversees him as he orders the
appropriate studies, including a CT with contrast, and then she goes to find Dr. Lopez’s partner to inform
him what she is doing.