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--- intern:pgy2-pgy3_off-service [2019/08/12 13:26] – [UCH Copper] jonathan
+++ intern:pgy2-pgy3_off-service [2020/06/11 18:39] (current) – old revision restored (2019/09/22 15:14) jonathan
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 ==== DH Red Surgery ====
+Hello,
+Welcome to Blue Surgery! Below is some important information and tips for this rotation.
+Contact information:
+Attendings:\\
+Dr. Mitch Cohen, General Surgery, Director of Surgery\\
+Dr. Barry Platnick, General Surgery, Director of Trauma Services\\
+Dr. Charles Fox, Chief of Vascular Surgery\\
+Dr. Kshama Jaiswal, Breast Surgery\\
+APPs:\\
+Nupur Sehdev, General Surgery PA (supporting Dr. Cohen and Dr. Platnick). Cell:  347-685-6444, Office: 2-1801\\
+Steffanie Durkin, Vascular Surgery PA (supporting Dr. Fox). Cell: 970-402-1687, Office: 2-1862\\
+Pam Crawford, Breast Surgery NP (supporting Dr. Jaiswal). Cell: 303-917-8712 Office: 2-1267\\
+Nurses:
+Katie Stoekle, Vascular Surgery RN, ext: 2-7632\\
+Brenda Colburn, General Surgery RN, ext: 2-5791\\
+Kipenda Ritcherson, Vein clinic and Breast RN ext: 2-7592\\
+OR scheduler:
+Rachel Fryc, ext: 2-7588\\
+Contact Rachel for OR scheduling for Dr. Cohen and Dr. Platnick. Contact Steffanie for OR scheduling for Dr. Fox.  That is for elective cases, for urgent cases that are to be done within the next 24 hours, call the OR bridge at 2-1061\\
+Clinic Tips:
+-For clinic days, residents should dress professionally (No scrubs).\\
+-Vascular clinic and Blue Surgery clinic are both on Tuesday, at the same time and in the same bullpen. All residents are to come to clinic on Tuesday, starting at 8:20am.\\
+-There is an Epic Tipsheet that is also attached, please print this and bring to clinic to help you navigate how to write a note, complete an encounter, complete a pre-op, etc.\\
+-Pre-op’s: See the Epic Tipsheet and/or ask Nupur/Steffanie to show you how to properly pre-op a patient. In addition, when you pre-op an open inguinal hernia repair for Dr. Platnick (only for Dr. Platnick), the patient will also need a pain catheter. When you are putting in the orders for pre-op, make sure to order “on-q-pump”\\
+Inpatient Tips:
+-At the end of each day, send an email with the day’s discharged patients who need follow up appts. Send this email to both of the nurses (Katie and Brenda) as well as cc Nupur and Steffanie. Please indicate their diagnosis and which clinic the patient is to be seen in. All of Dr. Fox’s patients are to be scheduled in “Vascular Clinic” (regardless of diagnosis). All of Dr. Platnick’s and Dr. Cohen’s patients are to be scheduled in “Blue Clinic”.\\
+-Any inpatient who is admitted with rib fractures and/or pneumothorax will need to be discharged with a 2 week follow up appt in clinic (Blue or Vascular depending on the attending) and will also need a CXR on day of clinic appt. You must put in the order for’ Ambulatory CXR’ and instruct the patient to arrive 30 minutes early to their clinic appt in order to stop by Radiology for the CXR prior to their clinic appt. Make sure to write this on their discharge summary prior to patient leaving.\\
+- CCMF patients (incarcerated patients): All CCMF patients need a doc to doc report with the provider at the inmate’s facility. Ask the CCMF nurse which jail they belong to and phone number and call to give signout to the jail provider. Make sure to indicate in their discharge summary when the patient needs to return for follow up in CCMF clinic.\\
+- All wound vac and home health care orders need a signature by an attending. The social worker will usually ask the resident to sign and then they will track down the attending for a signature.\\
+- Prescriptions or any other paperwork can be completed by and signed by the PA (Steffanie or Nupur depending on the attending)\\
+-FMLA paperwork cannot be completed by residents at DH. Provide this to Steffanie or Nupur and they will take care of it.\\
+Weekly schedule: Below is a brief overview of what to expect each day of the week.
+Everyday:\\
+-Sign-out is at 6am everyday (including weekends) unless your team was on call the night before (ie; if a blue attending was on call). Whichever team was on call the night before must arrive for sign-out by 5:45am.\\
+-Interns are expected to attend social work rounds on Mondays and Wednesdays from 8:45-9:15am\\
+Monday:
+Nupur is off on Mondays\\
+Grand Rounds/Teaching Conference 7:00-8:00am. If you plan to attend this, Steffanie and/or Pam are available to hold the pager from 7:00-8:00am\\
+Clinic: Monday morning is Vein clinic with Steffanie, 8:20am-11:40am. The intern is expected to report to clinic after morning rounds and social work rounds are done.\\
+OR cases:  Dr. Jaiswal (Breast) has OR block time on Mondays. Dr. Platnick does not have block time on Mondays, but typically adds cases when time is available. You can expect OR cases with Dr. Platnick on most Mondays. The midlevel resident and chief resident are expected to cover these cases.\\
+Tuesday:
+Clinic, 8:20am-4:00pm. This includes both Blue Surgery and Vascular Surgery. All residents are expected to come to clinic for the entire day. Attached is a tipsheet for clinic. Please review this and print it to bring to clinic with you.\\
+(Interns do not need to prepare clinic notes for the team. Nupur and Steffanie will prepare a list of who is coming to clinic and why. This will be available in clinic on Tuesday and/or emailed out ahead of time.)\\
+OR cases: None.\\
+Wednesday:
+Steffanie is off on Wednesdays\\
+Breakfast with Barry, 7:00-8:00am. Nupur will take the pager in order for residents to attend this conference.
+Interns must attend social work rounds from 8:45-9:15am.\\
+Clinic: CCMF clinic (jail clinic). This is a rotating responsibility between all surgery teams, Nupur or the chief resident will let you know if you need to be present for CCMF.\\
+Breast clinic, 8:00-5:00pm. The intern or midlevel resident is expected to attend breast clinic. Do not bring the floor pager to breast clinic, give this pager to a fellow Blue resident for the time you are in breast clinic.
+OR cases:  There is no official block time for Blue on Wednesdays, but occasionally cases will be added if time is available\\
+Thursday:
+M&M conference, 7:00-8:00am\\
+Clinic: None\\
+OR cases: Dr. Fox has OR block time in Pav A on Thursdays. You can expect a full OR day\\
+Friday:
+Pam is off on Fridays\\
+Burlew Chapter Club, 7:30-8:30am (You can pick up the assigned reading near the surgery administrative offices on 3A. It is usually available for pick-up by Monday or Tuesday each week). Nupur is available to hold the pager during this conference\\
+ICU attending/teaching rounds, 11:00am\\
+Clinic: None\\
+OR cases: Dr. Fox has OR block time in Pav M. You can expect a full OR day, this is usually vein cases. Steffanie will be there to assist the cases\\
+Other Important numbers:
+-602-7600  -Surgery clinic front desk number, this is the number to provide to patients\\
+-602-7609 -Surgery clinic front desk (back line), for you to call to schedule appts for patient follow up (do NOT give this number to patients)\\
+-436-4949 -Denver Health Appointment Center, for any scheduling needs. Please provide this number to patients who need to schedule other appts or get a new PCP.\\
+I have also attached a sheet of helpful phone numbers and an Epic Tipsheet for clinic\\
+**EPIC TIPSHEET – BLUE AND VASCULAR SURGERY CLINIC**
+. Seeing the patient:\\
+-Patients are marked with a GREEN dot once they are roomed and ready to be seen by a provider. Their chart (stickers) will be placed in the clear rack by the door\\
+-Turn the dot YELLOW when you grab the chart and go to see the patient\\
+-RED if the patient is a pre-op in need of RN teaching\\
+-BLUE if you need labs\\
+-GREY if you are done with the patient and they have left.\\
+-WHITE if you need the RN to schedule f/u appts, imaging, etc\\
+-Review/update the “ROOMING” tab (visit info, hx, meds, allergies, etc)\\
+-Review/update the “PLAN” tab (visit diagnosis, problem list, etc)\\
+. Create a Note\\
+-For a regular progress note:\\
+-Type “DH GEN VASC” in the small box that states “insert smart text” and this will pull up the vascular template options. You are welcome to use any other template options you are familiar with and would like to use\\
+-For a Pre-op H&P:\\
+-Type “DH SUR H&P” in the small box that states “insert smart text” to write a formal H&P. this should be done if the surgery is within 30 days\\
+. How to Pre-op a patient, Pre-op H&P, and enter the Case Request\\
+-Obtain an OR date from Steffanie or Dr. Fox for vascular surgery patients and obtain an OR date from Rachel Fryc (OR scheduler) for Dr. Platnick or Dr. Cohen for general surgery patients.\\
+-Obtain a consent for surgery (If the surgery date is within 30 days)\\
+-In the “WRAP UP” section of the note, add the following information: OR date, Pavilion, Surgery to be done, Dispo and Pre-anesthesia needs\\
+-Flag the patient with a RED dot and go find the RN to inform them of the pre-op\\
+-Select the “PREP FOR CASE” tab on the left\\
+    *if this tab is not present, select the “MORE” tab at the bottom left. Select “Quick Navigators” there is the “Prep for case” tab. Select the yellow star to the right of this tab to move it to your toolbar.
+-In the “Order Sets and Pathways” section, type “Sur Vascular” to bring up the vascular order set
+**Make sure you check the yellow case request “Second Sign” box and add the attending who will sign the order*** This must be done for the case to properly be added to the OR schedule\\
+. Referrals\\
+-To place a referral to any other service, select the “PLAN” tab on the left and in the “orders” section, type “Amb Referral to…” and indicate which specialty and reason for referral.\\
+-if this is a referral to outside of Denver Health, open the referral order and change the “Class” from “internal referral” to “outgoing referral”\\
+. Write a Work Note\\
+-Select the “COMMUNICATIONS” tab on the left\\
+-Click “New Communication” and select your note type “work/school, release, etc”\\
+. To close/sign all encounters\\
+-if no f/u is needed and the patient is ready to leave, print out the AVS and give to patient and tell them they may leave. Turn their dot GREY\\
+-If f/u is needed, fill out the “Patient Instructions” under the “WRAP UP” tab, inform the nurse of the f/u needed and turn their dot WHITE\\
+-To close the encounter:\\
+-Under the “WRAP UP” tab, select “Need LOS” as their LOS charge\\
+-In the far left bottom corner, hit the “sign encounter/visit” tab and assign the appropriate attending as the cosigner\\
 ==== DH TACS ====
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 Surgery Clinic Charge RN – Meghan Amiot (x27582)\\
+We look forward to working with you in the STICU.
+I want to make you aware of the website that contains all of the protocols and guidelines used in the UCH STICU.\\
+http://www.ucdenver.edu/academics/colleges/medicalschool/departments/surgery/divisions/Trauma/Trauma-at-UCH/Pages/Welcome.aspx
+On the left hand you will find links to the STICU protocols as well as the TACS Service protocols and the STICU curriculum. The only link that is protected is the curriculum. The user name is criticalcare and the password is cusurgery.com.\\
+I want to make a special note to the Department Guidelines at the bottom of the page of STICU protocols. There you will find surgeon specific guidelines. As example, there is a protocol for the liver transplant patient care during the first 48 hours after transplant.\\
+While on service, you will participate in the resident critical care curriculum, managed by Drs. Martin Krause and Lauren Steward, including:\\
+)      Critical Care Didactic Lecture Series – 3pm on Monday, Tuesday, Wednesday, Friday\\
+)      Critical Care Grand Rounds – 12pm on 1st/3rd Thursday\\
+)      Ultrasound M&M Conference – 12pm on 2nd Thursday *free pizza\\
+)      Critical Care Journal Club – 12pm on 4th Thursday (residents will be assigned manuscripts for presentation) *free pizza\\
+While on service, please refrain from eating food in patient care areas and nurses’ stations. Also, all liquids must be kept in a closed container with a lid.\\
+If you have questions please feel free to contact me or Jason Brainard.\\
+Further if you have any suggestions about the protocols, interest in developing a new one, interest in a QI project, or other observations about the STICU education please let us know.\\
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 ==== UCH Burn ====
-Cover the ICU on Wednesdays when the ED resident is off and a weekend day
+Burn Service Information:\\
+General Information on how service runs:\\
+  * Usually Monday is your 24 hr call and Tuesday you are post-call day but check the schedule. Sometimes if they cannot find enough moonlighters they will change it up.
+  * Typically first Monday of rotation they will want you to round on all patient so that you know service.
+  * When you work overnight you can leave at 6am, you don’t have to stay for rounds!
+  * When the EM resident isn’t there then it is your responsibility to pick up the pager from the night intern and then go get sign-out from the ICU resident. On these days I would usually show up around 5:30 - 5:45, so I could try my best to get the night person from the ICU out by 6.
+  * You typically work one weekend day each week rather than blacks/golds because the EM residents complained because they apparently have to have one day off for every 7.
+  * On the days there is an EM resident (usually every day except Wednesday and the weekend day) I often would get to work between 6-6:30am.
+  * When both you and an EM resident are there, you go to the OR and are not responsible for the ICU. You do have to see any patient who is going to the OR  that day and write their note prior to the OR.
+  * During the day, between cases you need to be consenting people and putting in their pre-op orders for the next day. The EM resident and APPs will not do this so it falls on you to order blood, hold heparin drips and make sure people are NPO. Consent patient’s for everywhere they could possibly be operated on. Usually type and cross between 2-4 units of blood per case.
+  * Anyone who has a protected airway (ET tube or trach) can keep their tube feeds running prior to and during the OR.
+  * When you are in the ICU (when the ED resident is off) you often carry 6-12 patients. You always carry the ICU/stepdown patients but also any other patients the APPs tell you to. They usually divide the list evenly (even though you carry icu patients which are a lot more work than their floor patients but it is what it is). When there are two APPs, it usually ends up being 6ish patients and when there is only one it ends up being more. There is always only one APP on the weekends so it’s usually more patients then.
+  * On the weekends, once you and the APP have finished all the work on the floor patients you can go sign out to the crosscover intern and then you only have to cover the icu/stepdown people until 6 when the night moonlighted comes in.
+  * Overnight, you should go to the burn alerts/activations but if a burn alert is stable the intern should admit/work it up. The activations will almost always come to you but Jess and/or the attending will always come in for those so you won’t be alone.
+  * When an alert/activation come, go down to the ED and take initial photos and send to attendings. You will then have to fill out a Lund and Browder.\\
+ In the OR:\\
+  * Wear shoe covers and eye protection always the cases are messy
+  * Takedown whatever dressings you are dealing with then all attendings prep with a chlorhexidine soap on lap pads that the scrub will have in a bucket for you. Prep limbs circumferentially and torso to bed (if involved in the excision). Dr. Wiktor likes you to prep the donor area with a chloraprep stick. Dr. Duffy does not use hand table (Wiktor and Wagner both do).
+  * Drape using blue towels and a million half sheets. The scrubs are pretty helpful with this.
+  * They put tumescence in everything with Pitkin’s solution. Bleeding is typically stopped with Thrombin spray then epinephrine soaked telfas. Dr. Wagner and Dr. Duffy are ok with VERY judicious use of the bovie (spray saline/GU solution on area of bleeding and then stop bleeding. Dr. Wiktor does NOT like the bovie and puts Vicryl stitches in anything bleeding.
+  * Grafts are put into place using Artiss spray and occasionally staples. The dressing for grafts are:
+  * Limb:  Mepitel 1, bacitracin (+/- Medihoney), kerlix and Ace if on a limb
+  * Front or Back: Mepitel 1, bacitracin (+/- Medihoney), burn pad, therabond
+  * Dressing from Graft donor site typically is Mepitel transfer Ag, kerlix, ace
+  * Cover the ICU on Wednesdays when the ED resident is off and a weekend day
 hour in-house call on Mondays
+{{ :intern:burn_rotation_resident_orientation_ppt.pdf |}}
+[[https://podcasts.apple.com/us/podcast/traumaburn/id1434771181?mt=2]]
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 ==== UCH Vascular ====
 Great experience with getting to sew vessels. Be in the OR as much as you can with any of the surgeons especially the open procedures (AVF, bypass)
+**UCH VASCULAR TEAM DELEGATIONS**
+__
+WEEKLY SCHEDULE__
+  * Monday
+:30 – Core curriculum (Conference center)\\
+:00 – Grand rounds (Conference center)\\
+:00 – Aortic conference (Conference center)\\
+  * Tuesday
+Jacobs – clinic all day\\
+:00 – Vascular conference (AO1 5th floor conference room)\\
+  * Wednesday
+Wohlauer – OR\\
+Nehler – clinic all day\\
+  * Thursday
+Jacobs – OR\\
+Wohlauer – clinic all day\\
+  * Friday
+:00 – Multidisciplinary vascular conference (IR conference room)\\
+Jacobs – every other Friday OR/clinic (half day)\\
+Nehler – OR\\
+**BASIC DUTIES of the R1**
+  * Work up and medical management of all admitted floor patients – shared duty with NP
+  * Write all daily orders of floor patients – shared duty with NP
+  * Write all daily progress notes of floor patients – shared duty with NP
+  * Vascular consults – shared duty with R2/NP
+  * Attend all vascular conferences/lectures/rounds
+  * Communicate daily events and follow up plans with team for floor patients
+  * Disposition planning for all vascular patients – shared duty with NP
+  * Hold vascular pager – shared duty with R2/NP
+  * Attend clinic as directed by fellow (GOAL: 2-3 days/week)
+  * Scrub on surgical cases (3rd tier and double scrubbed) (GOAL: 1-2 days/week)
+  * Preoperative orders and consents on patients when assigned cases
+  * Postoperative orders on all cases when scrubbed
+  * Weekend rounding – shared duty with R2
+**BASIC DUTIES of the R2**
+  * Work up and medical management of all admitted ICU patients (including floor status patients)
+  * Communicate all plans with the respective ICU teams by 7:00 am daily
+  * Preoperative orders and consents on all patients
+  * Vascular consults – shared duty with R1/NP
+  * Attend all vascular conferences/lectures/rounds
+  * Communicate daily events and follow up plans with team for ICU patients
+  * Hold vascular pager – shared duty with R1/NP
+  * Attend clinic as directed by fellow (GOAL: 1-2 days/week)
+  * Scrub on surgical cases (3rd tier and double scrubbed) (GOAL: 2-3 days/week)
+  * Postoperative orders on all cases when scrubbed
+  * Case presentations and didactics as assigned by fellow for Monday meeting
+  * Weekend rounding – shared duty with R1
+**BASIC DUTIES of the R4**
+  * The R4 is expected to act as if they are running the service with or without the fellow; role of the fellow is   to be more of a junior attending than service chief
+  * Direct AM vascular rounds with team – shared duty with fellow
+  * Discuss all medical/ surgical plans with attendings – shared duty with fellow
+  * Available to communicate with ICU teams as needed for issues – shared duty with fellow
+  * Postoperative orders on ICU cases – shared duty with ICU team
+  * Sign out in person to ICU practitioner for any ICU status postoperative patient
+  * See and staff vascular consults with attending – shared duty with fellow
+  * Attend clinic as directed by fellow (GOAL: 0.5-1 day/week)
+  * Scrub on surgical cases (1st/2nd tier and double scrubbed) (GOAL: 4-5 days/week)
+  * Take senior call – shared duty with fellow
+  * Attend all vascular conferences/lectures/rounds
+  * Present appropriate cases at M&M
+  * Case presentations and didactics as assigned by fellow for Monday meeting
+**BASIC DUTIES of the VASCULAR FELLOW**
+  * Direct AM vascular rounds with team – shared duty with R4
+  * Discuss all medical/ surgical plans with attendings – shared duty with R4
+  * Available to communicate with ICU teams as needed for issues – shared duty with R4
+  * Postoperative orders on ICU cases – shared duty with ICU team
+  * Sign out in person to ICU practitioner for any ICU status postoperative patient
+  * See and staff vascular consults with attending – shared duty with R4
+  * Assign and scrub on surgical cases, direct junior residents as appropriate through 2nd/3rd tier cases
+  * Take senior call – shared duty with R4
+  * Coordinate presentations for M&M (biweekly)
+  * Attend all vascular conferences/lectures/rounds
+  * Assign and present weekly cases/didactics for Monday conference
+  * Preoperative chart review for operative schedule
+  * Compile and distribute weekly schedule for vascular service with duty assignments
+  * Call schedule for R4 and fellows
+**BASIC DUTIES of the NURSE PRACTITIONERS**
+  * Work up and medical management of all admitted floor patients – shared duty with R1
+  * Write all daily orders of floor patients – shared duty with R1
+  * Write all daily progress notes of floor patients – shared duty with R1
+  * Communicate with Vascular social worker and case manager, daily 8:30 am
+  * Interface plans with bedside nurse daily
+  * Responsible for discharge coordination of care including FMLA and other patient documentation
+  * Prepare for all weekend discharges
+  * Primary responsibility for discharge summaries during week
+  * Arrange appropriate follow up appointments and vascular testing
+  * Available for rounds with attendings mid-day and PRN
+  * Hold vascular pager – shared duty with R1/R2
+  * Vascular consults – shared with R1/R2
+  * Attend clinic as needed (GOAL: 1-2 days/week)
+  * Tuesday PM – operative schedule review with patient communication as appropriate
+  * Attend all vascular conferences/lectures/rounds
+**GENERAL RULES OF ENGAGEMENT**
+  * All cases should be double scrubbed if team members available
+  * All plans must be communicated to attendings by R4/fellow and referred back to the team by 7:30 am, prior to first scrubbed cases
+  * All ICU plans should be communicated by R2 (or in their absence R4/fellow) to ICU team member by 7:30 am, prior to first scrubbed cases
+  * ANY EMERGENT OR URGENT QUESTIONS SHOULD BE COMMUNICATED IN PERSON (either via phone call or come to the OR if R4/fellow scrubbed)
+  * If unable to obtain a response from R4/fellow please communicate directly with attending to ensure timely response to consults
+  * Leave appropriate pager number for communications in all consult notes, H&Ps, and progress notes
+  * Primary contact for all floor questions is the vascular pager/R1
+  * Primary contact for all ICU questions is the R2 pager
+  * Primary contact for all dispo questions is the vascular pager/R1
+  * Pre-surgery order set should be completed the day before all operations
+  * Preoperative antibiosis
+  * NO heparin and NO SCDs usually; ask fellow or attending for exceptions
+  * Labs within 30 days for major cases
+  * Postoperative orders
+  * Utilize vascular order sets for patient orders
+  * Vascular Surgery Floor Postoperative Order Set
+  * Vascular Surgery ICU Postoperative Order Set
+  * Extended Stay PACU Carotid Endarterectomy Order Set
+  * Extended Stay PACU EVAR Order Set
+  * Clarify anticoagulation plan prior to leaving OR
+  * Clarify bedrest, pulse checks, etc. prior to leaving OR
+  * Clarify need for postoperative imaging prior to leaving OR
+  * Clarify all imaging/studies on patients prior to ordering
+  * “Vasc Dx” orders for any vascular lab studies
+  * All CTAs with 1 mm cuts – specified within order comments
+  * Generally NO PO CONTRAST unless specifically requested by R4/fellow or attending
+  * Consults should be staffed with a senior (R4/fellow) within 1 hour of receiving the call with communication back to consulting team
+  * All consults requested by our team should be followed up on within that day
+  * Every day, R1/R2/NP should communicate with social work and case management to identify disposition needs
+  * Clarify anticoagulation, clinic visit, and follow up imaging plans prior to D/C and include this information in patient’s D/C summary
+  * Discharge summaries should be completed within 24 hours of discharge, including the weekends
+  * Strive to make communication efficient in any group messaging thread in order to minimize “lost” or “missed” messages
+  * Communications that do not need to be shared with the entire team should be done separately
+  * Limit to important updates, not general “FYIs” throughout the day
+  * Questions that need urgent response are best posed in a directed fashion to the appropriate person
+  * All ICU cases must be signed out in person to the ICU team within 15 minutes of leaving the OR
+  * Daily PM rounds should be performed by the R1/R2/NP prior to leaving for the day
+  * If available, the R4 or fellow should attend
+  * If scrubbed, please report to the OR to discuss with the R4 or fellow
+  * Weekday notes should be assigned to surgical attending, while weekend notes should be assigned to on-call attending
+  * List should be constantly updated and include ACCURATE pulse/signal exam
+  * Days off/schedule changes should be requested 4 weeks in advance and be in accordance with CU surgical residency policies with appropriate approvals
+  * Signout should be given to the call team by Friday afternoon
+  * Method of signout (verbal, in-person, written email) is determined by preference of person on call receiving signout
@@ Line 371: / Line 698: @@
 Friday is breast conference. There are cases presented and pimped on. Know the studies sent out at the beginning of the rotation. Additionally you may be asked to present an article.
+**Basics:**
+Conferences:\\
+Monday-grand rounds\\
+Tuesday-MM\\
+Friday-GI conf at 645 and breast conference 730-9 (same room)\\
+For breast conference several attendings will be present. They may present cases and ask questions about management/next steps or have you present a paper. Knowing the papers sent out is helpful for this.\\
+Attending preferences:\\
+Ahrendt: Your role in cases will primary be to retract. In exchange, you also don't have much expectation in clinic. You'll go see patients and present to Ahrendt. She will almost always have the note prewritten. She prefers that you do not write a note if she already has. Know the studies that she sends out for her weeks and for her clinic have a plan for each of the patients based on literature.\\
+Kounalakis: The opposite. She lets you do most of the case and in exchange she wants you to do as much as possible in clinic. Specifically, she wants you to fill out the EPIC staging questions in the problem list. In your note, she wants you to include the stage and who referred the patient. For melanomas, she wants you to include the depth, ulceration, LVI, mitotic rate.\\
+Murphy: I only worked with her a couple times. She works almost exclusively at Lone Tree unless she is doing a combined case with plastics. Watch out for that as you make the schedule. She expects you to write notes in clinic. Lets you do progressively more in the OR\\
+Tevis: So far she has only had clinic. She wants you to write the notes. Bring a stethoscope as she expects a full exam.\\
+Serenity: On days when there is nothing else going on (Fridays) expect to go to her clinic. She does some benign breast and initial breast mass work-up.\\
+Other things:\\
+It's helpful for the 3 to write and send out a schedule, the attendings will read it.\\
+There is a post-op admit breast mastectomy order set. Just add valium.\\
+It's a pretty great and chill month. For the combo plastics cases, the breast DIEP flaps go to the plastics service. The tissue expanders go to the breast service. For their discharge, just touch base with plastics on whether they want antibiotics or not. They usually go home with valium for muscle relaxation as well.\\
 ==== UCH SICU ====
@@ Line 378: / Line 742: @@
 Splitting into two teams so unclear how this will affect things.
 Less acute than DGICU but more time for didactic education
+==== UCH CTICU ====
+CT ICU Rotation Survival Guide & Expectations\\
+CT ICU APPs: Caitlin Blaine (lead), Alexis Keyworth, Beth Devine,, Erin McIntyre, Lisa Bauers\\
+__Monday-Friday__
+Night resident responsibilities for list (to be done prior to 06:00)- write in 24 hour drain outputs,
+gtts and gtt doses, ECMO/VAD numbers, am SVO2 off VBG and other appropriate labs that do
+not print off. On conference days, please write in the most recent PA cath numbers and vital
+signs as well. *Ranges of HRs, BP, spo2, temps NOT necessary to copy down on
+non-conference days. This takes too long and results in the list not being ready by 0600*
+:00 - list is updated and printed. Receive brief systems signout on non-cardiac patients from
+night resident and split patients among providers. On Tuesdays and Wednesdays, fellow rounds
+start at 6am SHARP (see below), be prepared with list and numbers!
+:30 - Fellow rounds (except for on Tuesdays/Wednesdays as below). Overnight resident
+presents CARDIAC patients only to fellow. 3 dayshift providers need to each have computer so
+that one can put in orders, one pulls up CXRs, and one pulls up the adult comprehensive lab to
+review BP and PA cath numbers. This starts at 6:30 sharp.
+● Tuesday is cardiac conference and Wednesday is thoracic conference. Each start at
+:30 in specified locations and usually end at 7am. On conference days, fellow rounds start at
+am SHARP!
+**Anesthesia residents DO NOT need to attending conference.
+**Surgical residents MUST attend conference.
+:00-07:30- Providers caring for lung transplants will pre-round on lung transplant patients prior
+to presenting at 07:30
+:30- Providers who are caring for lung transplants will present on rounds with the intensivist,
+pulm transplant attending + pulm transplant team (fellow, pharmacist, social work), and the
+thoracic surgeon.
+:00-08:30am- pre-round on all other patients, finish getting handoff from night resident, get
+transfer orders in on those transfering off unit.
+:30/9am - ICU rounds. The overnight resident is expected to stay and present any active
+patients or new admits from overnight. Providers not presenting need to have a computer for
+CXRs and orders.
+:00am (ish)- finish rounds, pull drains/wires as soon as rounds are completed (do not wait
+until the afternoon), finish putting in transfer orders, complete procedures , update list, write
+notes.
+:00-15:30- Resident ICU Lecture in the STICU Conference Room (does not occur on
+Thursdays)
+:00- have list updated with day’s events and major events added to the hospital course. Be
+ready to sign out to the night resident and make afternoon rounds
+:00-18:00- complete notes. If you have already finished your notes and tasks for the day, you
+may leave only after ALL patients are signed out to the night resident.
+__Weekend & Holidays__
+Similar responsibilities for night resident in terms of list updating, but have to be ready by 0700
+instead of 0600.
+:00 – Overnight resident presents all patient to fellow and ICU attending. Typically ICU
+attending will be present for 07:00 rounds but sometimes attending comes in later and will have
+to round again. WIll need 2 computers similar to fellow rounds- one on CXRs/orders, one on
+Adult Comprehensive tab
+:00- Lung transplant rounds
+__Admissions__
+An APP comes in at 12:00 M-F for admissions. We call this the A2 shift. However, if
+admissions arrive before 12:00 or there is no admitting APP due to staffing issues or if multiple
+admission in short time span, then all providers are expected to help take admissions.
+Delegation starts with zoning (i.e., if patient admitted to room 222 and XYZ provider taking care
+of rooms 218, 219, 221, 223, then XYZ provider will admit/care for patient. If there is a provider
+with very low acuity patients or multiple move outs, then consideration for them to take patient).
+*When admitting patients, please avoid side conversations prior to formal sign-out. Nursing
+staff will alert the admitting provider (resident or APP) that the patient is rolling or here. Sign-out
+will occur when the admitting nurse is ready and the patient has safely been transferred onto the
+bed and vitals are on the monitor. Once the nurse is ready, the surgical fellow will go first to
+give report, followed by anesthesia. Always make sure to the get the patients LV and RV
+function and reasoning for any gtts and if these gtts can be weaned or not.
+**New Update for resident criteria regarding admissions** : In the first 2 weeks you are on
+service, you will have 2 shifts where you will admit with the A2 APP. You will still come in at
+am for your typical day and leave after 4pm signout, and will be given patients to present on
+rounds. Please let the A1 APP know that you would like to admit that day, so you will be able to
+take the less acute or fewer patients to allow for some of your energy to be focused on admitting
+with the A2 APP. The reason for this change is that some residents have expressed regret not
+getting more experience with admissions, as these patients are more dynamic and there is
+typically more autonomy in decision making. This will also help when it comes to night shifts and
+weekends when you are alone and need to admit.
+● Cardiac Surgery Admissions\\
+o Place orderset depending on admission type (post op vs MCS vs OSH admit, etc)\\
+o Write H&P or progress note\\
+o Add to list\\
+● Thoracic Surgery Admissions\\
+o Post op orders are written by fellow. If transfer from OSH or floor, talk to fellow\\
+regarding placing orders\\
+o Add to list\\
+o Write progress note or H&P\\
+● Vascular Surgery Admissions\\
+o Post op orders and admission orders are written by VSurg Fellow\\
+o Add to list\\
+o Write progress note\\
+**Transferring Patient Out of ICU
+On all transferring patients, please add/modify the following orders:
+-dc all central lines/aline that are no longer indicated\\
+-dc foley if no longer indicated\\
+-dc IV pain meds if no longer indicated\\
+-dc q 1 hour vitals/PA cath monitoring\\
+-Please add vital signs (q4 for floor, q2 for stepdown), continuous pulse ox, telemetry\\
+-For cardiac patients please add a “notify physician” order with the following written in:
+“please page cardiac floor resident at 4316 when patient arrives to floor”\\
+-**If cardiac surgery patient, please add patient to the cardiac surgery floor list (epic
+and signout) immediately after transfer orders are placed**\\
+● Cardiac Surgery Patients
+o Transfer to MS PCU (floor or stepdown), CPCU Stepdown for LVAD/OHT patients\\
+o **Report MUST be called to the Cardiac Surgery Floor resident (266-4316) at the
+time patient physically moves out of ICU**\\
+▪ Please do not call report prior to patient receiving bed assignment\\
+o Place patient on Cardiac Surgery Floor signout list & EPIC list\\
+o ICU providers continue to write notes and care for cardiac surgery patient while still in
+ICU awaiting stepdown or floor assignments\\
+● LVAD and OHT patients
+o Cardiac surgery is primary when in the CTICU immediately postop\\
+o When patients transfer to the stepdown unit (always CPCU), Heart Failure becomes\\
+the primary service (attending and service need to be updated on the “transfer patient”
+order. This transfer of service does not occur until the patient physically leaves the unit.\\
+o Calling patient out to the Heart Failure team is appreciated and considered a courtesy\\
+o **Calling out and giving report to the CT surgery team however is still\\
+MANDATORY. Please also add these patients to the cardiac surgery floor epic and
+signout list when transfer orders are placed.\\
+*For all Cardiac Surgery patients who transfer out of the unit to the floor or
+step-down, we must always call the CT surg resident (pager 4316) to give report
+EVEN IF THE PATIENT IS TRANSFERRING SERVICES (ie Heart failure or TACS
+becomes primary)\\
+**
+● Thoracic Surgery Patients
+o Transfer to Pulm Floor (9)\\
+o No need to call report to Thoracic Surgery Floor resident or place on Thoracic
+Surgery list\\
+o ICU providers continue to write notes and care for thoracic surgery patients while still
+in ICU awaiting floor bed assignment\\
+● Vascular Surgery Patients
+o Transfer to MS PCU (floor or stepdown). VSurg team will designate location\\
+o Clarify with Vasc Surg R2 regarding who will place transfer orders\\
+o Once patient has been downgraded, ICU team no longer writes notes or cares for
+patient. Direct all RN questions to Vasc Surg R2.\\
+● Pulm Transplant Patients
+o Transfer to Transplant Floor (6th floor, no step down status)\\
+o ICU providers continue to write notes and care for lung transplant patients while in ICU
+awaiting floor bed assignment\\
+**Who to call when things go down at night:**
+**Cardiac patients:**
+As a rule of thumb if you are dealing with any of the following issues:
+-adding new vasoactive infusions (pressors or inotropes)
+-uptitrating vasoactive infusions significantly
+-significant drain output (ie >200ml/hour for more than 2 hours)
+-worsening acidosis
+Make sure you call the cardiac fellow on call AS WELL AS the CTICU attending. If there is a
+critical care fellow rotating and on call that night, a courtesy page to them is appreciated, but
+does not substitute calling the cardiac surgery fellow.
+If dealing with primarily critical care issues (ie sepsis, afib with RVR, hypoxia), most CT fellows
+will state that this is something the CTICU attending should get a call for in the middle of the
+night, and that they can personally just be updated on in the morning. But anything remotely
+surgical or dealing with the heart function, warrants a page to the CT fellow AND CTICU
+attending.
+Thoracic patients:
+For any decompensating thoracic surg patient, please alert the thoracic surgery fellow and
+CTICU attending.
+Vascular patients:
+As above, anyone decompensating warrants a page to the vascular fellow or in some cases the
+attending (ie Kuwayama likes personal pages or calls if his patients aren’t doing well), as well as
+the CTICU attending.
+Pulm transplant patients:
+Must alert the intensivist as well as the pulm transplant attending and the thoracic fellow for all
+major issues including worsening shock, hypoxia, need for reintubation, bleeding, etc as above
+====  UCH STICU  ====
+Here is a very brief and candid rundown of the STICU. You show up every morning at 0600 and get sign out from the night person. Essentially you just claim whomever - the APPs will be there to tell you who you should take on the first day and then you can try to pick up the same patients on the days thereafter. The night person will present and write notes on all the new patients but you will "claim" them and take over their care once the night person has left. You get ~2 hours to prep your patients - which is usually more than enough time. The note template is ""Create in NoteWriter" and type "Progress" and then choose "ICU Progress (Systems) UCH IP".\\
+You will begin rounds at 0800 and usually the night person goes through all their patients first and then will break off to go write their notes and then the day team finishes rounding. In an average day the team will consistent of 1-2 residents, 2-3 APPs, and 1 fellow. There is a Gyn Onc fellow there right now as well and she essentially acts similar to the residents or APPs. Some mornings she isn't there because of other Gyn Onc obligations. In addition, you have your attending, pharmacy (usually Bonnie), and nutrition (Caitlyn).\\
+Presentations are you give a brief summary of the patient and state overnight events. Then nursing goes through their portion. Then you run the patient head to toe. Some attendings (i.e. Ferrigno) like you to list the pertinent vitals or labs. Some attendings want to know I&Os whereas others just want to know relevant outs (i.e. drains, tubes, urine). Usually the attendings will tell you ahead of time what they like, otherwise it's just learning by trial and error.\\
+You will get random admissions throughout the day. Usually they have a general idea of which patients will be coming to the unit and then of course there are any TACS patients that pop up that might need to come in. The APPs DO NOT admit after 0300. After rounds, you get work done - procedures, notes, consults, etc.\\
+At 0300 there is lecture most days. They are actually pretty useful and are usually given by the fellows or APPs. They last about 30 minutes and there is no pre-reading. Once a month there is grand rounds on a Thursday that is at noon. You do not have lecture that day.\\
+For night shift, you have to show up at 0300 and then usually go to lecture and then get sign out. If there is no lecture you still have to show up at 0300 and get sign out then. At night you'll occasionally be on with a fellow but not always. Most attendings want to be called or texted about admissions, starting someone on pressors, massive transfusion, or unstable patients in general. Otherwise you have some free reign to manage patients if you feel comfortable. The one exception is transplant patients.. as you know they are very particular so I would usually just default to calling them.\\
+TACS Tuesdays are always super fun :/. The TACS second year presents the patients to a giant team of lots of people of whom I know only half. It sucks for the second year on TACS because they usually aren't super privy to what's happening in the unit. But nice for you because you just write the note and don't have to present.\\